Mixed Flashcards by Doc JdP

Underlying condition most likely cause for non-smoke related COPD

α1-Antitrypsin deficiency

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Initiation of Proscar for BPH requires PSA of …

> 1.5 or evidence of prostate enlargement

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Male patient w/ hypogonadism, low testosterone. Next test to get is …

FSH and LH

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Child presents w/ constipation, first line therapy is …

MiraLAX (Poly Glycol)

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Acne appearing in this age range should indicate testing for underlying disease

Mid-childhood ~5yo

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Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum
levels of …

TSH

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Nursemaid’s Elbow Dx, next step …

Attempt to perform Reduction of Radial Head Subluxation

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A patient who uses intravenous drugs and has a fever without a clear source must be evaluated for …

Infectious Endocarditis, get Blood Cx

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Most appropriate first-line therapy for primary dysmenorrhea is …

NSAIDs

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Tremor characterized by an abrupt onset, spontaneous remission, changing characteristics, and extinction with distraction.

Psychogenic Tremor

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ASx Ped Patient w/ positive TB skin test, Dx and Tx is …

Latent TB, Isoniazid x9mo (6mo for adults)

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Prophylaxis for Pt w/ shellfish allergy getting IV-contrast, no Hx of IV allergy

NONE

Pt w/ Hx, Corticoidsteroids

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Positive Lift-Off Test and Internal Rotation Test indicates tear at …

subscapularis

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External Rotation test indicates tear at …

Infraspinatous, Teres Minor

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Suspect stable Peds Pt has suspected acute appendicitis, next order …

ABD-US

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Labs indicating SIADH

Hyponatremia
Low Serum Osmo
High Urine Osmo

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HTN in AA or Hispanic Pt, first-line med is …

Thiazide or CCB

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Hospice eligibilty based off of …

Life Expectency, <6mo

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DM medication associated w/ reduction of cardiovascular events

Victoza (Liraglutide) GLP-1

Jardiance (Empagliflozin) SGLT-2

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African-Americans 2-16yo with a history of sickle cell disease need screening with …

Transcranial Doppler ultrasonography d/t increase risk of stroke.

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Signs of Fetal Alcohol Syndrome

FC-FLIGHTS
•Flexion Defects (camptodactyly)
•Curved Fifth Digit (clinodactyly)
•Flat Philtrum
•Limb Dislocation
•Intellect Deficits
•Growth Retardation
•Heart Defects
•Thin upper lip
•Small Palpebral Fissures

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Otherwise healthy child presents with OME, Tx w/…

Nothing, f/u 3 mo

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Tx of subacute low back pain

Muscle relaxer and NSAID

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Peripheral Neuropathy with Macrocytic Anemia, eval for…

B12 Deficiency

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Pulmonary Dz and Stone cutting, sand blasting, mining, or quarrying expose. Dx…

Silicosis

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Pulmonary Dz and High-tech electronic industry, Dx…

Berylliosis

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Pulmonary Dz and Agricultural dust, Dx…

Farmers Lung, hypersensitive pneumonitis

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Hormone that activates release of corticotropin

ACTH from pituitary

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Ped Pt w/ N/V and mild dehydration, Tx w/…

Half-strength juice and food on demand

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Pt w/ Hypertrophic Cardiomyopathy, refer to cardio and give Rx for …

Metoprolol.

Verapamil if B-Blocker not tolerated.

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Alzheimer Pt w/ behavioral issues, Tx w/ …

Non-pharm intervention
then Atypical Antipsychotics

ZQ-ORCA
•Ziprasidone
•Quetiapine
•Olanzapine
•Risperidone
•Clozapine
•Aripiprazole

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Reversible Tx for abnormal anovulatory uterine bleeding

Levonorgestrel releasing IUD (Mirena) or 21-day Progestin

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First-line anti-emetic in pregnancy

Doxylamine (Unisom) and pyrodoxine (B6)

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Pt is on long term antacid, and needs calcium. You Rx …

Calcium Citrate, carbonate if not on antacid

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Obtunded Pt with hyponatremia, confusion and seizures. Your next step is to start …

Hypertonic Saline +/- furosemide

Goal increase serum Na 1-2mEq/dL/hr

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Euvolemic/Hypervolemic Hyponatremia, no seizures. Next step is to give …

Conivaptan

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Pt wants to stop smoking by using Wellbutrin, but should avoid if Hx of …

Seizures

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Leading cause of injury in adults >65yo is …

Falls

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Pt w/ Chronic Respiratory Dz is concerned about ambient air quality. General advice w/ being outdoors should include …

Avoid areas w/ busy roads

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Pt is recovering alcoholic and taking naltrexone. They require pain medication, you give …

Ketorolac

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You suspect a spinal cord lesion, the imaging to order is …

MRI

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Most effective imaging to determine RV Dysfunction and Pulmonary Artery pressure.

Echocardiography

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Pt w/ symptoms and physical findings consistent with chronic fatigue syndrome.

CBC, metabolic panel, TSH level, C-reactive protein level, rheumatoid factor test, antinuclear antibody test, and phosphorus level are all normal. Comorbid diagnoses of chronic pain, depression, and sleep disturbance, which are all negative.
Your first line Tx is …

CBT, graded exercise, or both.

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Primary Prevention is …

To screen at risk patients to prevent disease.

Example
•Childhood vaccination
•Water fluoridation
•Antismoking programs
•Education about safe sex.

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Secondary Prevention is …

To screen Pt that have an asymptomatic disease to prevent complications.

Example:
Routine Papanicolaou 
Screening for hypertension
Diabetes mellitus screen
Hyperlipidemia screen

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Tertiary Prevention is …

Screening Pt w/ symptomatic disease to limit/ avoid future complications.

Example:
•Microalbumia UA for DM Pt
•Rigorous treatment of DM
•Post MI prophylaxis w/ β-blocker + ASA

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After IUD placement, how long should the Pt abstain from sex/use back up method?

Placed w/n 7 days of start of menses: none

After 7 days of menses: 7 days

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Elderly Pt taking HCTZ for hypertension develops trigeminal neuralgia and you start her on carbamazepine (Tegretol). They are at risk for what metabolic consequences

Hyponatremia (SIADH 2/2 Carbamazepine)

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Rx to reduce nightmares in a PTSD Pt

Prazosin

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Pt has been treating his plaque psoriasis with high-potency topical corticosteroids for several years. He comes to your office to discuss other options since the lesions on his trunk and extremities are becoming resistant to this therapy. Next step is …

Add topical calcipotriene (Dovonex, Sorilux)

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Elderly Pt presents for a routine health maintenance examination and is concerned about a gradual loss in his vision during the past year. He has smoked 1 pack of cigarettes per day for the past 60 years. He has no other medical problems. Amsler grid testing he notes distorted grid lines. Next step recommendation is

Smoking cessation to slow Age Related Macular Degeneration

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Pt w/ severe pancreatitis admitted to hospital. After hydration, nutrition should be addressed by …

Continuous NG Enteral Nutrition.

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Rash on his arms and legs that has been present for the last several weeks. It seems to be spreading gradually. A physical examination reveals excoriated erythematous papules on both forearms and both lower legs that drain a small amount of serous fluid. The Rash is itchy. No lesions are present on the scalp, hands, thorax, or groin.
Dx?

Bedbugs

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First line, COPD, GOLD standard A

SAAC or SABA

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First-line, COPD, GOLD standard B or worse

LAAC or LABA

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First-line, COPD, GOLD standard C or worse

ICS

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Rx for severe refractory COPD

Theophylline

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A 24-year-old asymptomatic female has a chest radiograph that incidentally shows bilateral hilar adenopathy. Additional evaluation supports a diagnosis of sarcoidosis. Next step is…

Monitor

Steroids if Tx indicated

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Pt has carotid ultrasonography at a local health fair showed a 50% occlusion of his left proximal internal carotid artery. No PmHx, never had a TIA or stroke.

You Rx a healthy diet, exercise, as well as …

Statin therapy, and repeat ultrasonography in 1 year

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Pt presents w/ upper abdominal pain and dysphagia.
An upper GI series reveals no significant reflux, esophagogastroduodenoscopy shows ringed esophagus.
Bx reveals >15 eosinophils/hpf. Helicobacter pylori testing is negative.
Dx and Tx …

Eosinophilic Esophagitis (EoE)
Budesonide (Pulmicort) oral suspension, 1 mg BID

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Tx for PTSD

Venlafaxine (Effexor) or SSRI

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Pt needs PCN, but has Hx of PCN allergy. Next step should be …

Hx of mild reaction: Amoxicillin challenge under Obs

Hx of mod reaction: Skin test. If negative, follow w/ Amoxicillin challenge under Obs

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Elderly Pt presents w/ OA, first line Tx to reduce pain is …

Supervised Exercise, then NSAIDs

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The majority of U.S. women who unintentionally become pregnant choose to …

Carry the pregnancy to term and keep the baby

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Elderly Pt taking Phenytoin is ay risk for …

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Meds that can cause OA …

Antiepileptic drugs (Phenytoin)
Long-term Heparin
Cyclosporine
Tacrolimus
Aromatase inhibitors
Glucocorticoids
Gonadotropin-releasing hormone agonists, Thiazolidinediones (Glitazones)
Levothyroxine
PPI
SSRIs
Parenteral nutrients
Medroxyprogesterone
Contraceptives
Methotrexate
Aluminum Antacids (Mylanta)

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Largest Risk of AAA

Smoking

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Tx for head Lice

Permethrin (Nix)

Washing clothes/bedding in hot water, dry with hot air

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Pulmonary Node found on CXR, what characteristics indicate malignancy

>6mm
Non-Solid Ground Glass
Non-Calcification
Irregular Borders
Double in size/volume >1 month, <1 year

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Pts with Joint contractures do not benefit from this type of PT

Stretching

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Pt has IBS, this dietary option has little to no therapeutic effect

Fiber

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Tx for IBS

Exercise
Probiotics
ABx
Antispasmodics
Antidepressants
Psychological treatments
Peppermint oil
Tricyclic antidepressants

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Pt has suspected PID based on clinical findings. Next step should be …

Empiric Tx, do not wait for labs

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Common adverse effects of stimulant therapy in adult ADHD

Insomnia
Dry mouth
Weight loss
HA
Anxiety

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Contraindications to stimulant therapy in adult ADHD

HTN
Aggravate psychosis
Tics

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Pt presents w/ stroke and HTN, acute intervention is needed in the first 24hr if BP exceeds …

220/120 mmHg

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Preferred place for emergency airway

Cricothyroid Membrane

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Pt w/ HTN starts this medication that reduces BP, bone loss and risk of hip fracture.

HCTZ

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Ped Pt presents w/ pain of the hip. He refuses to bear weight or move the LE. Pt is afebrile. Next step is …

XR, CBC and ESR to eval for septic arthritis or transient synovitis.
If negative, get an MRI

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Clinical/lab findings of septic arthritis

Fever >38.7°C (101.7°F)
Refuses to bear weight on the affected leg
WBC >12,000 cells/mm3
ESR >40 mm/hr.

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Plan-Do-Check-Act (PDCA) describes what

The cycle of continuous quality improvement

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Pt w/ a 2wk Hx of postprandial right upper abdominal pain.
Associated Sx of N/V
The patient does not use tobacco or drink alcohol, and takes no medications. 
Labs show: 
lipase 105 IU/L (N 14–51)
amylase 155 U/L (N 36–128)
t-bili 1.5 mg/dL (N 0.0–1.0)
AP 200 IU/L (N 33–96)

First imaging to order is …

Transabdominal ultrasonography

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First line Tx for OA of the knee

NSAIDs/PT

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What are the high intensity statins

Atorvastatin (Lipator) 40-80mg/day

Rosuvastatin (Crestor) 20-40mg/day

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Pt presents w/ Subclinical Hyperthyroid. Tx is indicated if they also have

Osteoporosis
HF
AF

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Dix-Hallpike pos finding

Nystagmus when vertigo is elicited

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Elderly Pt with depression, first line medication

Escitalopram (Lexapro)

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The dietary herbal supplement with the highest risk for drug interactions is …

St. John’s wort (Hypericum perforatum

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First line for social anxiety

SSRI/SNRI

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Ped Pt w/ persistent asthma. Currently on a SABA, but having to use it more frequently. Next step is…

ICS

If that doesn’t work then LABA or Leukotiene Inhibitor

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Pretibial Mysedema is a skin manifestation of …

Graves Disease

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Stable Pt w/ cc of hoarseness for 3 mo w/o associated Sx, next step …

Laryngoscopy

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USPST guideline for AAA screen

Men 65-75 who have ever smoked

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Breathing and GI Sx, CXR shows b/l infiltrates, Dx is …

Legionella Dz

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First line Tx for HTN for CAD Pt

Beta-blocker

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You see a 55-year-old female for the first time. She has a 2-year history of chronic daily cough; thick, malodorous sputum; and occasional hemoptysis. She has been treated with antibiotics for recurrent respiratory infections, but is frustrated with her continued symptoms. She has never smoked. Her FEV1/FVC ratio is 60% and CT shows bronchial wall thickening and luminal dilation. Dx is …

Bronchiectasis

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Multiple myeloma Sx include …

organ damage or other abnormalities, including renal insufficiency, elevated calcium, anemia, and bone pain

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Recommended duration of thromboprophylaxis following total hip arthroplasty, starting from the day of surgery and including outpatient prophylaxis

35 days

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Pt presents w/ COPD Sx, initial testing include …

CXR and Spirometry

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Pt w/ severe Preeclampsia is treated w/ Mg and develops apnea and areflexia, you immediately give …

Calcium Gluconate

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New onset palpitations that affect ____ needs to be evaluated for cardiac cause

sleep

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Corynebacterium minutissimum infection fluoresces …

coral red/pink

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Pseudomonas fluoresces …

pale blue

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Vitiligo fluoresces …

White

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Tinea infections fluoresces …

Yellow

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Age range for a Pap smear without HPV testing

21-29yo, q3yrs

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Pt w/ BP 180/105, otherwise ASx, presents in clinic, next step is

30 min rest, recheck BP (HTN Urgency)

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Labs for pre-op clearance

CBC and CMP (Renal Fxn)

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Stress fracture of second metatarsal, getting worse, Tx with …

No weight bearing x3 days&raquo_space;Walking boot x3 days»Rigid shoe 4-6wks

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Ped athlete presents w/ proteinuria, next step …

Spot protein/creatine ration on first morning urine

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A patient with moderately severe Alzheimer’s disease has been taking quetiapine (Seroquel), 50 mg daily at bedtime, to manage behavioral symptoms related to the dementia. The patient’s symptoms have been stable on the quetiapine for 6 months. The patient’s spouse is the primary caregiver and is not aware of any adverse effects. The patient does not have a history of other psychiatric diagnoses such as schizophrenia or bipolar disorder.
Next intervention is …

Tapering Seroquel to cessation because Sx have stabilized

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Pt is getting TB tested prior to travel, upon return she should …

get retested w/ TB/Interferon-Gamma 8-10wks after return

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Pt presents w/ hypothyroid Sx and tender thyroid, no nodules. Next step …

Start Levothyroxine and recheck TSH 6-8wks

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ASx Ped Pt presents w/ HTN, next step is …

Fasting CMP, Lipid and UA

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ASx Sarcardosis Pts need annual screening of …

the eyes

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A 43-year-old female complains of easy bruising. She is otherwise asymptomatic. A CBC reveals a platelet count of 23,000/mm3 (N 150,000–450,000). A peripheral smear reveals giant platelets. A workup is negative for autoimmune causes, including Graves disease, HIV, Epstein-Barr virus, cytomegalovirus, varicella zoster, hepatitis C, and Helicobacter pylori. She is on no prescription or over-the-counter medications and denies alcohol or drug use.
Initial Tx is …

Corticosteroids

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In addition to a thorough history and physical examination, the routine evaluation of patients presenting with syncope should include …

Orthostatic blood pressure measurements and an EKG

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A 57-year-old male presents with left posterior heel pain that started several weeks ago. An examination reveals a nodular appearance at the site of insertion of the Achilles tendon to the calcaneus, and local tenderness of the distal tendon. Initiate Tx with …

PT, eccentric exercises

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F Pt presenting w/ decreased sexual arousal after starting an antidepressant, Tx w/ …

Wellbutrin 150mg BID

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A 67-year-old male presents to your office for evaluation of chronic redness, flaking, and discomfort of his eyelids. Additionally, his eyes feel irritated, dry, and sandpapery at times. He has had difficulties with these symptoms on and off throughout his life but they have worsened lately. He has not had any vision changes and does not wear contact lenses.

On examination his eyelids appear red and mildly swollen with yellow crusting at the bases of the eyelashes. You note bilateral mild conjunctival injection. Visual acuity is intact, as are pupil reactions and extraocular movements.
Tx w/ …

Warm compresses and gentle cleansing with a mild shampoo

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DM guideline for use of sweeteners

Nonnutritive sweeteners are acceptable to use

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Pt presents with a 4-month history of nasal drainage, congestion, and loss of her sense of smell. She reports having a cold about 4 months ago that never resolved. On examination the nasal turbinates are swollen and you note mucopurulent drainage on the right.
Dx …

Chronic Rhinosinusitis

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Major risk factor of suicide

Access to lethal means

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Usually begins in the teens or twenties and is characterized by multiple unexplained physical symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical history. These patients also commonly abuse alcohol, narcotics, or other drugs.

Somatic Sx Disorder

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Pt needs a statin but failed high-intensity statins, so you Rx

Mid-Intensity Stain (Ezetimibe/Simvastatin)

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Tx of Dupuytren Contracure >30 degrees of DIP or any of PIP

Surgical release

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Travelers Diarrhea Tx

Z-Pak

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Morbidities that lead to high risk mortality in CAP

RR >30/min,
hypotension
confusion/disorientation
BUN >20 mg/dL
 >65 years
Male 
HF
COPD

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Acute change in elderly behavior, screen w/

PHQ-9

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First line drug for cellulitis

Vanc

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First line drug for motion sickness

Scopolamine

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Pityriasis rosace birth complication

Spontaneous Abortion

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Otherwise healthy male/female can’t conceive, test for

Luteal Phase Progesterone in female

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Cramping diarrhea following distal ileum resection, Tx w/ …

Cholestyramine

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All women of reproductive age should take

Folic Acid 0.4-0.8mg/day

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Test to assess for ACL tear

Lachman

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Proper use of interpreter

talk to patient directly

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Tx for tinnitus to improve quality of life

CBT

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PCOS Pt w/o hirturism but has irregular menses, Tx w/ ….

IUD placement

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Elderly Pt w/ syncope is taking Donepezil (Aricept), beware of

Bradycardia and prolonged PR interval

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Tx of viral bronchiolitis

Supportive Care

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Elderly women need to be careful taking PPI d/t risk of …

Bone Fracture

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Tx of mild concussion

Initial complete cognitive and physical rest followed by an individualized graded return to activity

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School nurse discovers head lice, when may the child return to school

Immediately

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First Dx step in non-massive Hemoptysis

CXR

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Pt w/ recurrent anterior uveitis, evaluate for …

Sarcoidosis

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Acute vision change occurs in a Pt, next step is …

urgent referral to ophthalmologist

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Main risk factors for Esophageal Adencarcinomas

Obesity and GERD

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Pt w/ aortic stenosis and systolic murmur, a concerning PmHx finding would be …

Exertional Dyspnea

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Cancer patient develops new, unrelenting pain.

Next step …

order an MRI

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Signs a dementia Pt is unable to make their own decisions

Inconsistent answers to questions

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MME scoring

<12: Severe
13-20: Moderate
21-24: Mild
>25: Normal

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Test to Dx Pulmonary HTN

Echocardiogaphy

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Athlete w/ pain 1cm distal to medial joint line of the knee

Pes Anserine Bursitis

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A 52-year-old female sees you because of a vaginal discharge. An examination reveals a malodorous, greenish-yellow, frothy discharge, and inflammation of the cervix and vagina.
Most likely Dx

Trichomoniasis

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Concerning sequela of mumps in an otherwise healthy male

Orchitis, can lead to infertility

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DM medication that increases risk of candidiasis

SGLT-2 (-flozins)

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Rx that increase survival post Acute Coronary Event

Ace-i
Beta-Blockers
Statins

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Infants that solely breastfeed should supplement w/

400 I/U of Vitamin D starting at 2 mo unless eating >1 L of formula/day.

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Cobb angle of ____ indicates a referral to a specialist

20 degrees or greater

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Preggo Pt presents w/ general pruitis w/o rash. Next step

LFTs and Bile Acid Lvl

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Rx naloxone when morphine equivalent/day exceeds

50MME/day

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PTH and Phosphorus levels in hypocalcemia 2/2 CKD

both elevated

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Obese DM Pt with swollen foot and neuropathy. No further Sx. Dx and Tx

Charcot Neuroarthapthy

Immobilization

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Pt presents w/ asthma Sx, but spirometry is normal. Next step is

Methacholine Challenge

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Tx of ASx PAD

Stains and Walking program

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Elderly dementia Pt presents w/ weight loss >5%. Initial intervention is

Remove dietary restrictions

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Current definition of HTN

BP >130/80

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Sevelamer MOA

Blocks phosphate absorption, which lowers PTH secretion

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Acute OE Tx

Fluoroquinolone and steroid ear drops

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Ped Pt w/ Tonsillar Hypertrophy w/ Sleep Apnea. Tx w/

Tonsillectomy

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Dietary Tx of Struvite/Calcium Phosphate Kidney Stones.

Cranberry Juice, acidify urine

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Heel pain in a Ped Pt on passive doriflexion, otherwise ASx

Calcaneal Apophysitis (Sever Dz)

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Tx for Anemia of Chronic Dz

Tx underlining Dz

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First line test for endometriosis

Trans Vag US

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Neonate is brought to your office with a 2-week history of increasing dyspnea, cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note conjunctivitis, and a chest examination reveals tachypnea and crackles. A chest film shows hyperinflation and diffuse interstitial infiltrates and a WBC count reveals eosinophilia
Dx …

Chlamydia Trachomatis

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Mild Acne, Rx to start …

Topical Retinoids

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Elderly Pt presents w/ vaginal prolapse, Tx w/

ring pessary

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Safest NSAID post MI

Naproxen

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Ped Pt w/ CAP, Tx w/

HD Amoxicillin

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Pt w/ sudden painless vision loss, you suspect Retinal Vein Occlusion, especially b/c of this on fundoscopic exam

Tortuous Retinal Veins

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First-line Tx for Keloid

Steroid injection

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Fasting glucose goal for preggo Pt

<95

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Pt in a small town in Massachusetts. He has fevers, chills, and muscle and joint aches. He does not have any joint swelling, numbness, tingling, headache, or chest pain. He says he was working outside last Saturday and his wife removed a tick from his back that evening.

On examination he is febrile and appears moderately ill. The examination is notable for an erythematous patch on his back. The remainder of the examination is unremarkable.

Which one of the following would be the most appropriate next step

Doxy 100mg x 10 days

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Following direction is a milestone at what age

18mo

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Persistant recurrent URI indicate to

formal allergy testing

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Pt on long term steroids, avoid OA with

Alendronate (Fosamax)

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Initial Tx of Scaphoid Fracture

Spica Splint

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A 54-year-old male develops chest pain while running. He is rushed to the emergency department of a hospital equipped for percutaneous coronary intervention. An EKG shows 3 mm of ST elevation in the anterior leads. He is diaphoretic and cool with ongoing chest pain. His blood pressure is 80/50 mm Hg, his pulse rate is 116 beats/min, and his oxygen saturation is 98% on room air.

You would immediately administer …

dual antiplatelet therapy and an anticoagulant

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A 67-year-old male presents to your office because of fatigue and a syncopal episode. His vital signs in the office are normal. An examination reveals a harsh systolic murmur best heard over the second right intercostal space radiating to the neck. Echocardiography confirms your suspected diagnosis.

Which one of the following is the only treatment that improves mortality with this condition?

Aortic Valve Replacement

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Citalopram Tx anxiety and what GI Disorder

IBS

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A 15-year-old male sees you after injuring his right index finger while playing volleyball. He has pain and a flexion deformity at the distal interphalangeal (DIP) joint.
What finding would suggest further eval before splinting

The patient is unable to passively fully extend the joint

Tx for pleuritic Chest Pain

IBU

Pt should stop ____ after 1 year of drug eluting stent

Clopidogrel

Pt >65yo w/ CKD should receive this vax if not already recieved

pneumococcal 13 and 23

Tx of Bells Palsey

Steroids and valacyclovir

Pt postpartum w/ fatigue and irregular, heavy menses. First test is …

Beta-HCG

Test to confirm Cushing Syndrome

Urinary free cortisol

Most specific and sensitive test for HSV

PCR

Polyuria and polydipsia in a Pt taking lithium, suspect Dx of …

DM insipidus

GERD Tx

PPI for 4-8wk

Tx for high attitude sickness

Acetazolamide and hydration

Pt has CAP and stable AAA, do not give this ABx

Levofloxacin

Most appropriate management of stress-induced (Takotsubo) cardiomyopathy after discharge

A diuretic, ACE inhibitor, and β-blocker until his symptoms and the abnormalities seen on the echocardiogram resolve

A 46-year-old female with a history of hyperthyroidism controlled with methimazole (Tapazole), 10 mg daily, returns to your office after an absence of several years. She has new symptoms of palpitations, heat intolerance, and hoarseness. A physical examination reveals an enlarged thyroid and a radioactive iodine uptake scan shows accumulation of tracer in multiple areas.
Definitive Tx will be …

Thyroidectomy

This population has the highest prevalence of syphilis

Men who have sex w/ men

Pt has new onset Hyperthyroid, Tachycardia, enlarged thyroid w/o nodules. Tx w/ …

Methimazole

Pt with a BMI of 41 kg/m2 is interested in weight loss. His medical history includes adequately controlled type 2 diabetes mellitus, well-controlled hypertension, hyperlipidemia, and obstructive sleep apnea. He has no history of coronary artery disease or COPD.

Most effective for long-term weight loss in this patient

Bariatric surgery

Pt with no significant past medical history presents to your office with 2 weeks of worsening pain in her right arm. For the past 2 months she has worked on a plastics manufacturing assembly line. A physical examination reveals no swelling and a normal range of motion. She has normal strength in the upper extremity but she experiences increased pain with extension of her right wrist against resistance. Palpation reveals marked tenderness over the lateral epicondyle of the right arm.

What will most likely to improve the patient’s long-term outcome

Modifying her work routines

Elderly Pt w/ CHF, he is on proper meds, what will decrease hospital admissions

Case management by a heart failure specialist nurse

Which serologic test would be most helpful for detecting left ventricular dysfunction

B-type natriuretic peptide

Weekend warrior presents w/ back pain, Tx w/

Muscle Relaxer

ABx for GBS Preggo Pt that has an allergy to PCN

Cefazolin

Pt w/ pancreatitis, initiate ____ to reduce complications

Enteral Feedings

Pt w/ Tinnitus should get a MRI if

Unilateral

Use these labs to assess severity of pancreatitis

CBC and CMP

You must report Child Abuse if

you suspect child abuse

Sickle cell Pt presents w/ signs of DM but A1c <6.5. This lab will help assess DM and monitor glycemic control

Serum Fructosamine Level

Pt presents with a 2-week history of lower extremity edema. He is in good health and does not take any medications. You note weight gain, and mild dyspnea with exertion. An examination is unremarkable except for 2+ to 3+ pitting edema of the lower extremities to his knees bilaterally. A CBC and metabolic panel are unremarkable except for a low albumin level. A urinalysis reveals 3+ protein on the dipstick with no microscopic findings.
Most appropriate next step

A spot urine protein/creatinine ratio

De Quervain’s tenosynovitis Tx

Spica Splint and NSAIDs for 1-4 wks

Pt w/ Hx of MI, Stable CAD, and A-Fib, anti-coag w/ …

NOAC

An otherwise asymptomatic 7-year-old male has a blood pressure above the 95th percentile for gender, age, and height on serial measurements. Next step is …

Renal ultrasonography

Pt w/ Hx of seizures has renal colic, what med may be the cause

Topiramate (Topamax)

A 30-year-old female presents with pain over the proximal fifth metatarsal after twisting her ankle. Radiographs reveal a nondisplaced tuberosity avulsion fracture of the fifth metatarsal.

The most appropriate initial management

A compressive dressing with weight bearing and range-of-motion exercises as tolerated

A 48-year-old male presents with psychogenic erectile dysfunction in conjunction with depression. You decide that treatment of his underlying mood disorder is the best initial step. Rx …

Bupropion (Wellbutrin)

A 14-year-old male sees you for a well child examination. He had one dose of HPV vaccine at his last well child examination 1 year ago. Best practices for HPV vax …

Give second dose today, no further intervention

Indication for ablation in AFib

Persistent AFib despite medication Tx

An otherwise healthy 42-year-old male presents to your office with low back pain that started a week ago after he lifted a heavy box. Since the time of his injury he has been having consistent pain, numbness, and tingling that radiates down the back of his right leg to his calf.
Next step is …

No imaging, conservative Tx

ASx Pt was bitten by a cat, initial Tx is …

Augmentin (Amoc/Clav)

Long term Tx for Achilles Tendinapathy

Eccentric calf exercises

A 55-year-old male veteran sees you for a routine health maintenance visit. He is up to date on recommended immunizations. His father was diagnosed with colon cancer at age 70 and his family history is otherwise negative. The patient underwent a colonoscopy at age 50 and has a copy of his pathology results, which describe a single hyperplastic polyp taken from the rectum.

The most appropriate screening for colorectal cancer in this patient

Repeat colonoscopy at age 60

4½-year-old otherwise healthy Pt w/ lesion that appeared at about 4 weeks of age, continued to grow until he was about 5 months of age, and then began to flatten, shrink, and fade. The lesion appears telangiectasia, fibrofatty tissue, dyspigmentation, and scarring where involution has occurred.
The most appropriate management is …

Surgical excision

Pt has HTN, takes lisinopril, but HTN is persistent, next Rx

CCB

Physical findings of precocious puberty

Secondary Sexual Characteristics

Tx for mild SLE

Hydroxychloroquine (Plaquenil)

Stable Pt w/ Anemia, transfuse if HgB drops below …

7.0

BNP is falsely elevated if CMP shows increased

Creatinine

In the development of clinical guidelines, this type of study rated as the strongest and highest-quality evidence

Evidence from randomized, placebo-controlled studies

Best way to quit smoking

Chantix and Counseling

An anxious 30-year-old white female comes to the emergency department with shortness of breath, circumoral paresthesia, and carpopedal spasms.
Expected ABG and Dx

Ph high, CO2 low, PO2 nl-high

Resp Alkalosis

In frail elderly patients, starvation can be distinguished from cachexia by

A reversal of changes with refeeding in starvation

A mother brings her 6-year-old son to your office for evaluation because she found a lump in his neck below the jaw on the right side. She first noted it a week ago, about a week after he had recovered from an upper respiratory infection. She reports that her son feels well and is back to full, unrestricted activity.

When you examine the child you find an enlarged lymph node in the right anterior cervical chain of nodes. It measures 2 cm in diameter and is somewhat firm, mobile, and nontender. The remainder of the examination is normal.
Best next step …

Follow-up examination in 1 month

The leading cause of human death in the world as a whole

Ischemic heart disease

Only this type of Hyperthyroid will present w/ high radioactive iodine uptake on thyroid scan

Graves

A healthy 49-year-old female presents to your office for a routine health maintenance visit. Since her last visit a year ago she has had only two menstrual periods. She reports sudden sensations of extreme heat in her face, neck, and chest that last just a few minutes but occur throughout the day. These symptoms are very bothersome and interfere with the quality of her sleep.

You recommend this to relieve her symptoms

Combined estrogen and progesterone

A 30-year-old female presents for follow-up after an emergency department visit for an episode of symptomatic supraventricular tachycardia that was diagnosed as Wolff-Parkinson-White syndrome.

The most appropriate for the initial long-term management of this patient

Catheter ablation

A 7-year-old male received one dose of trivalent inactivated influenza vaccine at another health care facility 5 weeks ago. This was the first time he received influenza vaccine, and it resulted in soreness at the injection site. His mother reports that he has had mild hives after eating peanuts and eggs in the past. Your office has stocked only quadrivalent inactivated influenza vaccine.

Next step is …

Immunization now with quadrivalent inactivated vaccine

2x doses for 6mo-8yr even w/ egg allergy

A 43-year-old female presents to your office with a 3-month history of left low back and posterior hip pain. She does not recall an injury but says she was very active during a move to a new home prior to the onset of the pain. An examination reveals that her gait, lower extremity strength, straight leg resistance, and hip and knee range of motion are normal. A log roll test is also normal. A flexion, abduction, external rotation (FABER) test produces posterior pain.

Most likely diagnosis…

Sacroiliac joint dysfunction

Three weeks after he had knee surgery, a 64-year-old male presents for follow-up of an emergency department visit for a pulmonary embolism. He has no previous history of pulmonary embolism and is otherwise in good health. He is being treated with apixaban (Eliquis).

The recommended duration of anticoagulation therapy for this patient is

3 months

21-year-old male presents to your office with excessive sweating in the axillae, palms, and soles. This has been a problem for several years and interferes with his ability to participate in daily activities without discomfort and embarrassment. After ruling out possible secondary causes you diagnose primary focal hyperhidrosis.

First-line treatment …

Topical 20% aluminum chloride (Drysol)

24-year-old male presents with swelling of the right testicle. The pain started yesterday and has persistently worsened. A physical examination reveals swelling on the right side of his scrotum. His entire testicle is painful, and elevation of the scrotum improves his pain. Ultrasonography reveals hyperemia, swelling, and increased blood flow to the testis and epididymis.

The most appropriate management …

Doxycycline plus ceftriaxone

An otherwise healthy 32-year-old female sees you for a routine health maintenance examination after having required laboratory screening at work. She has no significant past medical history and the physical examination is normal. Laboratory results are unremarkable except for an elevated alkaline phosphatase level.

Most appropriate next step

A gamma-glutamyl transferase level

A 72-year-old male has newly diagnosed systolic heart failure due to hypertensive cardiomyopathy. The patient has an estimated left ventricular ejection fraction of 30% and was dyspneic at rest and with minimal exertion at the time of diagnosis.

This medication is indicated to reduce mortality in this patient …

Lisinopril (Prinivil, Zestril)

A 65-year-old female develops gram-negative septicemia from a urinary tract infection. Despite the use of fluid resuscitation she remains hypotensive, with a mean arterial pressure of 50 mm Hg.

The most appropriate treatment for this patient …

Norepinephrine (Levophed)

Recommended time during menses to place IUD (LARC)

Anytime during the cycle

59-year-old plumber presents with swelling of his left elbow. An examination reveals swelling over the olecranon but no erythema or warmth. His uric acid levels are normal and he has no history of inflammatory disease. He has not had a fever. The swollen area is not painful and he has a normal range of motion.

Most appropriate next step

Padding, ice, and elevation

60-year-old male presents with a 6-week history of worsening bilateral shoulder, upper arm, and neck pain. He has morning stiffness that lasts at least an hour. The review of systems is otherwise negative. There is no localized tenderness or motor weakness on physical examination. His erythrocyte sedimentation rate is 55 mm/hr.

Best treatment option for this patient at this time

Prednisone, 10–20 mg once daily

20-year-old male college student comes to your office to ask what he can do to prevent meningitis. His roommate was just hospitalized with invasive meningococcal disease. The patient has no symptoms at this time, a physical examination is normal, and he received meningococcal vaccine at the recommended times. He lives in a campus dormitory that houses 22 students.

Most appropriate recommendation

Treat him and the rest of the students in the dormitory with a single dose of ciprofloxacin (Cipro)

A 43-year-old female presents with marked proximal muscle weakness, dysphagia, and pain in the shoulders and hips, all beginning within the past 5 weeks. She reports difficulty getting out of a chair. On examination she has a violaceous rash involving the periorbital skin, and macular erythematous lesions over the anterior chest and upper lateral thighs.

What additional findings would you expect

Macules over the extensor surfaces of her joints

In the hospital setting, the use of atypical antipsychotics is most appropriate for what hospital condition

ICU-associated delirium

The specificity of a screening test is best described as the proportion of persons

without the condition who test negative

A 44-year-old African-American female reports diffuse aching, especially in her upper legs and shoulders. The aching has increased, and she now has trouble going up and down stairs because of weakness. She has no visual symptoms, and a neurologic examination is normal except for proximal muscle weakness. Laboratory tests reveal elevated levels of serum creatine kinase and aldolase. Her symptoms improve significantly when she is treated with corticosteroids. Dx …

Polymyositis

A 24-year-old gravida 4 para 2 with mild chronic hypertension and an uncomplicated pregnancy has just delivered a vigorous male by spontaneous vaginal delivery. She is noted to have heavy vaginal bleeding and a bimanual examination reveals a soft, poorly contracted uterus. Her temperature is 37.1°C (98.8°F), blood pressure 158/92 mm Hg, pulse rate 105 beats/min, and oxygen saturation 95% on room air.

Which one of the following uterotonic agents is CONTRAINDICATED

Methylergonovine

A 30-year-old female presents to your office as a new patient and requests a refill of sulfasalazine (Azulfidine) tablets for maintaining remission of her ulcerative colitis. The initial presentation of her disease was in her teenage years and involved inflammation of the entire colon. She was then started on sulfasalazine, which has worked well for controlling her symptoms. She had one flare when she ran out of medicine 7 years ago. She has not seen a gastroenterologist for many years.

Next step in appropriate management

Continue sulfasalazine and arrange for colonoscopy to screen for colon cancer

Tramadol should be avoided in Pt w/ Hx of …

Seizures

For patients on lithium monotherapy for bipolar disease, monitoring should include periodic blood levels of lithium, creatinine, and

TSH

A 48-year-old male presents with a 4-week history of rectal pain associated with minimal rectal bleeding. On examination there is a small tear of the anorectal mucosa at the 6 o’clock position.

The most appropriate initial treatment would be topical …

Nitroglycerin

A 54-year-old male sees you for a 6-month follow-up visit for hypertension. He feels well, but despite the fact that he takes his medications faithfully, his blood pressure averages 150/90 mm Hg. He has had an intensive workup for hypertension in the recent past, with normal repeat laboratory results, including a CBC, serum creatinine, an electrolyte panel, and a urinalysis. His medications include chlorthalidone, 12.5 mg daily; carvedilol (Coreg), 25 mg twice daily; amlodipine (Norvasc), 10 mg daily; and lisinopril (Prinivil, Zestril), 40 mg daily. He has been intolerant to clonidine (Catapres) in the past.

What Rx change should be made

Adding spironolactone (Aldactone)

Condition typically seen w/ delirium terminus but not in lesser AWS

Fever

A 62-year-old African-American male is admitted to the hospital for the third time in 6 months with heart failure. He has dyspnea with minimal activity. Echocardiography reveals an ejection fraction of 40%.

Long term manage w/

Hydralazine plus isosorbide dinitrate

A heroin overdose is most likely to cause acute

Pulmonary edema

You suspect that a 28-year-old female patient may have a somatic symptom disorder, specifically a conversion disorder. Most appropriate pharmacologic treatment of this disorder

Sertraline (Zoloft)

A 30-year-old gravida 2 para 1 in her second trimester is evaluated for hypothyroidism. The normal TSH range in pregnancy is

lower than in the nonpregnant state

A 69-year-old male presents for an annual health maintenance examination. His medical history is significant for hypertension and worsening back pain over the last 6 months. Laboratory studies reveal a hemoglobin level of 8.6 g/dL (N 14.0–18.0) and a mean corpuscular volume of 88 μm3 (N 80–94). The remainder of the CBC is normal. A peripheral smear and a ferritin level are both normal. A comprehensive metabolic panel is normal except for a serum creatinine level of 1.6 mg/dL (N 0.7–1.3).
Most appropriate next step in the evaluation of this patient

Serum protein electrophoresis

The sensitivity of a test is defined as

the percentage of patients with the disease who have a positive test result

Injection site for steroids into the shoulder

Subacromial space

Most reliable measure to protect children from lead toxicity in the United States

Eliminating the sources of lead in the community

In patients with COPD, this inhaled medications has been shown to reduce exacerbations and exacerbation-related hospitalizations

Tiotropium (Spiriva)

A 52-year-old male sees you for a routine health maintenance examination. He does not take any medications, does not drink alcohol, and is feeling well. A physical examination is normal with the exception of a BMI of 33 kg/m2. Routine laboratory studies reveal mild elevations of ALT (SGPT) and AST (SGOT), which remain elevated on repeat testing 2 months later. Hepatitis B and hepatitis C testing are negative.

In addition to ultrasonography of the liver, which laboratory studies should be ordered to further evaluate this patient

Serum ferritin

A 23-year-old female presents with menstrual irregularity, increased facial hair, and acne. Your evaluation leads to a diagnosis of polycystic ovary syndrome.
First-line management for her constellation of symptoms

Hormonal contraceptives

GBS in unknown, give ABx if gestation less than

<35wks

A patient with advanced dementia is bed-bound and requires total assistance with all activities of daily living. She was treated recently for pneumonia, which has raised concerns that she is aspirating. Her oral intake has decreased and is not adequate for the patient’s nutritional requirements. She does not have an advance directive. You schedule a family conference.

Recommended approach to this problem

Hand Feedings

A U.S. Preventive Services Task Force “D” recommendation indicates

moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits

Antidepressant that should not be abruptly dc

Venlafaxine

A 72-year-old male with a serum creatinine level of 1.8 mg/dL (N 0.6–1.5) requires a contrast dye study.
Give this prior to the administration of contrast to reduce the risk for contrast-induced renal failure

N-acetylcysteine

Sodium bicarbonate fluid

The most common cause of proteinuria in children is

Orthostatic proteinuria

Elderly Pt taking levothyroxine is at risk for

Bone Fractures

A 25-year-old female at 31 weeks gestation presents to the labor wing with painful uterine contractions every 3 minutes. On examination her cervix is 3 cm dilated and 50% effaced. Her membranes are intact and fetal heart monitoring is reassuring. She is treated with tocolysis,betamethasone, antibiotics, and intravenous hydration, and cultured for group B Streptococcus. The neonatal intensive care unit is notified, but the contractions ease and eventually stop. After 2 days of observation, her cervix is unchanged and she is discharged home.
One week later, the patient presents with contractions for the last 8 hours. Her cervical findings are unchanged. Her group B Streptococcus culture was negative.

Most appropriate next step in the management of this patient

Expectant management

A 29-year-old female presents with redness of her left eye. She has just returned from a summer
beach vacation with her children and woke up with a red eye. Your examination reveals a watery
discharge, a hyperemic conjunctiva, and a palpable preauricular lymph node. Her cornea is clear
on fluorescein staining.

Most appropriate for this patient

Reassurance only

A 47-year-old female presents to your office with a complaint of hair loss. On examination she has a localized 2-cm round area of complete hair loss on the top of her scalp. Further studies do not reveal an underlying metabolic or infectious disorder.

Most appropriate initial treatment

Intralesional triamcinolone (Kenalog)

The preferred antibiotic treatment for community-acquired pneumonia in a young adult in the ambulatory setting is

azithromycin (Zithromax)

Major risk factor for intermittent claudication

Diabetes mellitus

While making rounds on the rehabilitation floor of your hospital, you see a 62-year-old female who was recently transferred from the acute-care section of the hospital where she was admitted for urosepsis. She is a liver-transplant recipient and her specialist has been tapering her immunosuppressive drug regimen for the last 2 months. According to the nursing staff the patient became hypoxic suddenly and had a low-grade fever and cough. You note that she looks ill and uncomfortable, and has an increased respiratory rate. A chest radiograph reveals diffuse bilateral interstitial infiltrates.

Most likely diagnosis

Pneumocystis pneumonia

A 34-year-old male presents with low back pain and stiffness that has been slowly worsening over the past 6 months. It is especially bothersome at night and in the morning when he gets out of bed. It improves with physical activity. He has taken ibuprofen, 400 mg several times a day, which provides moderate pain relief but is not working as well as it used to. He does not have any other joint pain, there is no history of trauma, and he is otherwise well. His BMI is 24 kg/m2. Radiographs of the lumbar spine show mild degenerative changes of the lumbar vertebrae without other abnormalities.

Additional tests would most likely lead to a specific diagnosis

HLA-B27

A 50-year-old female with significant findings of rheumatoid arthritis presents for a preoperative evaluation for planned replacement of the metacarpophalangeal joints of her right hand under general anesthesia. She generally enjoys good health and has had ongoing medical care for her illness.

Most important for preoperative assessment of this patient’s surgical risk

Cervical spine imaging

A 38-year-old female presents to the emergency department with an acute onset of fever, chills, and rapidly progressive right lower extremity redness. She reports being in her usual state of health until a few hours ago when she developed shaking chills and noted a fever of 103.0°F (39.4°C).

Shortly after she arrives she complains of right lower extremity pain and a bright red skin discoloration from her ankle to her right knee. She is also noted to have a heart rate of 123 beats/min and a WBC count of 22,000/mm3 (N 4300–10,800). Her past medical history is significant for congenital arthritis, a recent bilateral hip replacement, and recurrent lower extremity cellulitis.

Which organisms should you be most concerned about

Group A Streptococcus (GAS)

A 30-year-old male is treated with topical medications for his papulopustular rosacea with only partial improvement.

Preferred ABx

doxycycline

A 75-year-old male with a history of hypertension, TIA, and atrial fibrillation sees you for follow-up. Ten days ago he was on vacation in another state when he developed chest pain. He went to a local hospital where he was diagnosed with an ST-elevation myocardial infarction (STEMI) and was taken immediately for cardiac catheterization. He had a drug-eluting stent placed in his left anterior descending artery. He brings some discharge paperwork with him, including a medication list, but has not yet seen a local cardiologist. He is concerned that he is taking too many blood thinners. He feels well and does not have any chest pain, shortness of breath, or excessive bleeding or bruising.

Prior to his STEMI the patient was taking lisinopril (Prinivil, Zestril), 10 mg daily; warfarin (Coumadin), 2.5 mg daily; and metoprolol succinate (Toprol-XL), 25 mg daily. Upon discharge he was instructed to continue all of those medications and to add clopidogrel (Plavix), 75 mg daily, and aspirin, 81 mg daily.

The patient’s vital signs and physical examination are normal except for an irregularly irregular rhythm on the cardiovascular examination. His INR is 2.5.

Most appropriate at this time

Continue the current regimen

A 25-year-old male presents to your office after recently being diagnosed with HIV infection at the health department. You obtain blood work and note that his CD4+ count is 180 cells/mm3.

This patient should receive prophylaxis against What infection

Pneumocystis

CD4 prophylaxis levels

<200: Pneumocystis
<150: Histoplasma capsulatum
<100: Toxoplasma g
<50: Mycobacterium avium-intracellulare complex

A 7-year-old female is brought to your office with a complaint of right hip pain and a limp with an insidious onset. There is no history of injury or repetitive use. Her vital signs are within normal limits and she has no history of fever or chills or other systemic symptoms. On examination you note that she cannot fully abduct her hip and she winces with pain on internal rotation. A FABER test is normal. Her right leg is 2 cm (¾ in) shorter than the left. Plain films reveal flattening and sclerosis of the proximal femur with joint space widening.

Most likely diagnosis in this patient

Legg-Calvé-Perthes disease

According to U.S. Preventive Services Task Force guidelines, what interventions is recommended after 12 weeks gestation in women who are at high risk for preeclampsia

Aspirin, 81 mg daily

When switching NOACs, check

Renal Fxn

A 42-year-old male with alcohol use disorder tells you that his last drink was 7 days ago and asks if there are any medications available to help him maintain abstinence from alcohol. He has no other medical or psychological problems.

What pharmacologic agents could help reduce this patient’s alcohol consumption and increase abstinence

Acamprosate

Cardiac pathology associated w/ Marfans

Aortic Insufficiency

A 46-year-old male with a 30-pack-year smoking history has had multiple episodes of coughing up blood that he describes as a “quarter size” amount. This has happened over the last couple of days. He has not had any chronic cough and has not been ill. A chest radiograph is negative.

Most appropriate management at this point

CT of the chest

You suspect a 45-year-old female may have irritable bowel syndrome. She has a 6-month history of crampy, diffuse abdominal pain associated with defecation. Her symptoms occur several days per week.

Associated symptom that would help in making this diagnosis is

a change in stool frequency

A 20-year-old football player presents with pain in the proximal fifth metatarsal. The pain was initially present only after practices, but now it causes push-off pain during practice. There is tenderness to palpation. Plain films show no signs of fracture.

Most appropriate at this point

Order MRI of the foot

use of Risperdal increases risk of

Mortality

Pt w/ tinnitus can improve quality of life w/

CBT

A healthy 43-year-old executive presents with problems falling asleep and staying asleep. Doxepin (Silenor) and extended-release melatonin have not helped.

In addition to behavioral interventions, which is most appropriate pharmacologic therapy for this patient’s insomnia at this time

Eszopiclone (Lunesta)

A 35-year-old gravida 2 para 2 reports diminished sexual arousal since initiating antidepressant therapy with sertraline (Zoloft). She has normal menstrual cycles and does not have any other symptoms.

What Rx would you recommend?

Bupropion (Wellbutrin), 150 mg twice daily

A 36-year-old female singer presents with a 10-day history of hoarseness. She has never smoked and does not take any medications. Her vital signs are normal. An oropharyngeal examination is normal, her chest is clear to auscultation, and there is no cervical adenopathy and no masses. She is anxious to be able to sing again as soon as possible.

You advise …

No talking, whispering, or throat clearing for 48 hours

A 50-year-old male with hypertension who is not at increased risk for gastrointestinal bleeding should begin low-dose aspirin at what 10-year risk level for cardiovascular disease

10%

A U.S. hospital or birthing center seeking to be certified as “Baby-Friendly” by the Baby-Friendly Hospital Initiative must satisfy what in addition to meeting other requirements

Providing no other food or fluids to breastfeeding infants without a medical indication (promote infant feeding and bonding)

A 50-year-old gravida 2 para 2 who is 3 years post menopausal presents with fatigue, headache, galactorrhea, and loss of libido. Your evaluation reveals elevated serum prolactin and a pituitary adenoma of 5–6 mm.

You recommend …

bromocriptine (Parlodel)

A 41-year-old male presents with a complaint of headaches for the past 6 weeks. He has severe, sharp, right-sided periorbital pain 3–4 days each week. When these headaches occur his right eye gets watery, his right nostril feels clogged, and his forehead feels sweaty. When he gets the headaches he takes four 200-mg ibuprofen tablets and goes into a dark, quiet room. The headaches usually resolve in about 90 minutes. Currently he is feeling well and his examination is completely normal.

What type of headache does he most likely have

Cluster headache

According to national and international guidelines, which is the next step for adults with asthma who require therapy with inhaled β-agonists more than three times a week?

Inhaled glucocorticoids

A 7-year-old male presents with a 3-day history of sore throat, hoarseness, fever to 100°F (38°C), and cough. Your examination reveals injection of his tonsils, no exudates, shotty lymphadenopathy, and normal breath sounds.
Next step is …

Symptomatic treatment only

Dx more common in elderly non-Hispanic whites than in the Hispanic population

Osteoporosis

When evaluating the patient, what features would be more characteristic of depression as opposed to a grief reaction

Loss of interest or pleasure in all activities

A 63-year-old male with a history of alcoholism and compensated hepatic cirrhosis asks if there are pain medications he can use to treat his chronic low back pain and knee and hand osteoarthritis. He also has occasional headaches. He has not used alcohol for several years.

What medication is CONTRAINDICATED in this patient

Naproxen

Rash that fluoresces coral red, treat w/

Erythromycin

A 21-year-old female is being evaluated for secondary causes of refractory hypertension. What test is most specific for fibromuscular dysplasia

Magnetic resonance angiography of the renal arteries

A 66-year-old female with a previous history of hypertension, stable angina, and carotid endarterectomy presents with acute upper abdominal pain, which has developed over the past 3 hours. A physical examination reveals epigastric tenderness without guarding or rebound, but does not reveal a cause for the level of pain reported by the patient. Initial laboratory findings are within normal limits, including a CBC, glucose, lactic acid, amylase, lipase, liver enzymes, and kidney function tests. You suspect acute mesenteric ischemia.

Which diagnostic imaging tests is the preferred initial evaluation for this problem

CT angiography

A 38-year-old patient wishes to start contraception. She currently takes lisinopril (Prinivil, Zestril) for hypertension and also takes sumatriptan (Imitrex) occasionally for migraines at the first sign of flashing lights or zigzagging lines in her vision. Her medical, family, and social histories are otherwise unremarkable. An examination is notable only for a blood pressure of 130/80 mm Hg and a BMI of 36 kg/m2.

OTC Rx is …

None due to her migraines

A 55-year-old male sees you for follow-up. His medical problems include morbid obesity, type 2 diabetes mellitus, hypertension, hyperlipidemia, and major depressive disorder. His medications include metformin (Glucophage), glipizide (Glucotrol XL), lisinopril (Prinivil, Zestril), aspirin, simvastatin (Zocor), and fluoxetine (Prozac). His BMI is 52.4 kg/m2 and he is struggling to lose weight.

What Rx change do you make

Canagliflozin (Invokana) instead of glipizide

A 45-year-old white female presents to your office after recent routine laboratory tests revealed a platelet count of 100,000/mm3 (N 150,000–350,000). Six months ago the patient’s platelet count was 283,000/mm3. All other indices are within normal limits. The history is negative for easy bruising, bleeding, fever, rash, or arthralgias. She has no family history of blood disorders or recent illness. Her medications include ranitidine (Zantac), fluticasone (Flonase), and inhaled albuterol (Proventil, Ventolin). She is otherwise healthy. A peripheral smear confirms thrombocytopenia.

What Rx change do you make

Stopping ranitidine and repeating the CBC in 2 weeks

An 82-year-old white male consults you following several syncopal episodes that are clearly orthostatic in nature. During the course of your evaluation you find that he has a large tongue, mild cardiomegaly, and findings that suggest bilateral carpal tunnel syndrome.

The most likely diagnosis at this time is

amyloidosis

A 60-year-old male returns for a reevaluation of his asthma that you have been working to control. In the past he has been adequately maintained with daily use of inhaled fluticasone/salmeterol (Advair), along with montelukast (Singulair). Last month he experienced an exacerbation of his asthma that responded well to oral prednisone. However, each time you have attempted to wean him off the prednisone his asthma symptoms have returned.

Most appropriate at this time

Increasing the dosage of the corticosteroid

An 82-year-old male presents to the emergency department with severe generalized abdominal pain. He has a history of paroxysmal atrial fibrillation and stopped taking rivaroxaban (Xarelto) 2 months ago because of the cost. The physical examination reveals generalized abdominal tenderness and an epigastric bruit. You suspect mesenteric ischemia.

Recommended imaging study

CT angiography

What complication would be reduced by gentle range-of-motion exercises during immobilization

Adhesive capsulitis (frozen shoulder)

A 14-year-old female with mild depression sees you for follow-up. After her last visit she began a trial of psychotherapy but her mother asks about additional treatment options. The daughter has no other significant past medical history.

Recommended as first-line pharmacotherapy for this patient

Fluoxetine (Prozac)

A 24-year-old male presents with a 1-week history of right eye redness. He says his eye hurts, especially with light exposure. He reports no history of trauma, but recalls his 2-year-old daughter having “pink eye” about a month ago. He has a previous history of ankylosing spondylitis.

On examination his conjunctiva appears injected and he has a sluggishly reacting pupil. No discharge is noted. Reduced anterior spine flexion is noted on examination of the back. Fluoroscein staining of the cornea is negative.

Most appropriate next step to manage this patient’s eye condition

Ocular corticosteroids

medications. You confirm that she is not pregnant and order additional laboratory testing. TSH, LH, and FSH levels are normal but she has an elevated prolactin level.

Most appropriate at this point to further evaluate her pituitary gland

MRI of pituitary

A 36-year-old male who participates in his neighborhood basketball league visits your office with a 3-week history of heel pain. On examination he has pain over the medial plantar region of the right heel and the pain is aggravated by passive ankle dorsiflexion.

What should you order to confirm the diagnosis

Nothing – No diagnostic imaging

An 18-month-old previously healthy infant is admitted to the hospital with bronchiolitis. Pulse
oximetry on admission is 92% on room air.

Next step in the management of this patient

Nasal suction to clear the upper airway

A 6-year-old male is diagnosed with acute bacterial sinusitis. He has a previous history of a rash 5 days after beginning penicillin treatment.

Most appropriate Rx in this patient

Cefuroxime (Ceftin) –3rd/4th Gen Cephalosporin

An 85-year-old male is brought to your office by his family because they are concerned that he may be depressed.

Most likely in a depressed patient in this age group

Somatic symptoms

A 72-year-old previously healthy male presents with a 3-week history of mild, intermittent chest pressure that occurs when he walks up a steep hill.

What EKG abnormalities would dictate the use of a pharmacologic stress test as opposed to an exercise stress test

Left bundle branch block

Most likely cause of hearing loss in newborns

Genetic disorders

What blood condition is associated with testosterone supplementation in men with hypogonadism

Polycythemia

A 53-year-old male presents for follow-up after a routine screening colonoscopy. He is healthy and takes no medications, and his family history is negative for colon cancer. During a thorough, relatively easy colonoscopy to the cecum, two rectal polyps measuring 0.7 mm were removed, both of which were found to be hyperplastic on pathologic analysis.

His next surveillance colonoscopy should be in

10yrs

This mineral is best absorbed in an acidic environment

Iron

Tx Tinea Capitis w/

oral antifungals

Tx Antiphospholipid antibody syndrome w/

Aspirin and heparin combined

A 35-year-old female sees you because she has lost her voice. She has had no recent upper respiratory infection symptoms, cough, or heartburn, and she has not done anything that would strain her voice. Findings are normal on examination of the head and neck. A review of her chart shows this has happened before, but an ear, nose, and throat evaluation found no abnormalities. She also has been seen numerous times in the past few years for headaches, chest pains, abdominal pains, rectal pressure, and vaginal symptoms. Despite several workups and referrals, no definite cause has been found and the symptoms persist.

Most reasonable plan of action

Schedule frequent office visits

A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea, cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note conjunctivitis, and a chest examination reveals tachypnea and rales. A chest film shows hyperinflation and diffuse interstitial infiltrates. A WBC count reveals eosinophilia.

What is the most likely etiologic agent

Chlamydia trachomatis

A local dentist contacts you for a prescription for the appropriate antibiotic dosage for one of
your patients who has an appointment for dental cleaning to eliminate a significant plaque
buildup. The patient is a 55-year-old male who has controlled hypertension and mitral valve
prolapse with mitral regurgitation. He is allergic to sulfonamides.

Most appropriate prophylaxis

No antibiotic prophylaxis

In order to facilitate wound healing in elderly, you recommend oral supplementation of

protein

High iodine content in this medication may cause hyperthyroidism

Amiodarone

Effect of DHEA on muscle strength and performance

Nothing

Sympathomimetic decongestants such as pseudoephedrine and phenylephrine can be problematic in elderly patients because they can

worsen existing urinary obstruction

Most useful static for evaluating the effectiveness of a clinical intervention

Number needed to treat

A 39-year-old female presents to your office with progressive swelling in the right leg that has spread over the past 2 days. She feels well otherwise. Her past medical history is significant for adrenal insufficiency treated with oral prednisone, 5 mg daily, and fludrocortisone, 0.1 mg daily. An examination reveals a temperature of 37.8°C (100.0°F), a pulse rate of 88 beats/min, a blood pressure of 105/62 mm Hg, and redness, warmth, and swelling in the right lower extremity. You diagnose cellulitis and prescribe appropriate antibiotics.

Most appropriate management of her corticosteroid regimen

Increase prednisone to 15 mg daily and continue fludrocortisone at the current dosage

Most appropriate definitive treatment for this patient

Thyroidectomy

A 55-year-old patient with a history of alcoholism is admitted through the emergency department with acute pancreatitis.
What test performed at the time of admission can best predict the severity of pancreatitis

Hematocrit

An obese 70-year-old male with chronic pain due to osteoarthritis complains of fatigue, anhedonia, hypersomnolence, and increased appetite.

What would be the best pharmacologic agent for this patient

Duloxetine (Cymbalta)

A 55-year-old male with diabetes mellitus is found to have asymptomatic microscopic hematuria. The rest of his urinalysis is negative. He has no other medical problems and quit smoking 10 years ago. His only medication is metformin (Glucophage). A urine culture is negative and his renal function is normal. CT urography is also negative.

Next step in the evaluation of his microscopic hematuria

Cystoscopy

A 24-year-old male who just moved to town for a new job presents to your office with a 2-week history of a rash. His previous medical records are not available. The physical examination reveals pink, scaling papules and plaques on the trunk and proximal aspect of the arms and legs. You suspect pityriasis rosea.

To complete the diagnostic evaluation you should order

a rapid plasma reagin (RPR) test

A 22-year-old male college student presents with 1–2 weeks of worsening tenesmus associated with frequent stools that are mixed with blood and mucus. He is afebrile and has no other signs of systemic illness. Initial blood and stool testing is normal.

Most appropriate test at this point to evaluate this patient for the presence of inflammatory bowel disease

Colonoscopy with biopsies

A 24-year-old gravida 2 para 1 presents to your office for her first prenatal visit at 7 weeks gestation. You review her vaccine records and note that she received Tdap 1 year ago.

When should you recommend that she get her next Tdap

Between 27 and 36 weeks gestation

Most likely cause of acute kidney injury in a patient with eosinophiluria

Acute interstitial nephritis

Empiric Tx before Cx for Neonate Pt w/ sepsis

Ampicillin and cefotaxime (Claforan)

A 77-year-old female is admitted to the critical care unit for acute respiratory failure and is on a ventilator for more than 48 hours. Stress ulcer prophylaxis is ordered.

This prophylaxis should be continued until

the patient is transferred out of the critical care unit

A 29-year-old female presents with a 1-week history of a rash on her legs. A full review of systems is significant only for regular borderline-heavy periods that lasted for 7 days during her last two menstrual cycles. She has not had any recent illness or hospitalization, and takes no medications. Her examination shows nonblanching purple macules on her upper legs.

A comprehensive metabolic panel reveals normal renal function and liver enzyme tests, and a urine pregnancy test is negative. A CBC reveals a platelet count of 27,000/mm3 (N 150,000–400,000) but is otherwise normal.

Most likely cause of the rash

Immune thrombocytopenic purpura

A 34-year-old female presents with a 3-month history of a minimally productive cough. She has never smoked. She does not have any fever, weight loss, rhinorrhea, congestion, or heartburn. She does not have a known history of allergies or asthma and has tried over-the-counter cold remedies, cough syrups, and cough drops without significant relief. She is otherwise healthy and takes no medications. On examination her vital signs are normal. An ear, nose, and throat examination is remarkable for swollen nasal turbinates. A lung examination is normal. Given the duration of the cough, you order a chest radiograph, which is normal as well.

Most appropriate at this point

A trial of an intranasal corticosteroid

A 68-year-old female presents with a history of episodic severe lower abdominal pain relieved by defecation. She has had a long history of constipation with normal to very firm stools. Her history and a physical examination are otherwise normal. A colonoscopy 3 years ago was normal. You diagnose constipation-predominant irritable bowel syndrome.

Which one of the following agents would be the most appropriate treatment for this patient?

What is the best initial management for this patient

Polyethylene glycol

A 48-year-old male presents with pain in the right antecubital fossa after lifting a trailer in his garage. On examination you note ecchymosis and tenderness in the antecubital fossa. You suspect a possible distal biceps tendon rupture.

Next step

MRI of the elbow

A 72-year-old male with type 2 diabetes mellitus sees you for routine follow-up. He takes metformin (Glucophage), 1000 mg twice daily. He is sedentary and does not adhere to his diet. His BMI is 32 kg/m2. The examination is otherwise within normal limits. His hemoglobin A1c is 9.5%.

Next step recommended by the American Diabetes Association to better control his blood glucose

Start basal insulin at 10 units/day

A 47-year-old male presents with bilateral lower extremity edema of undetermined etiology extending to the proximal lower extremities, associated with fatigue. His lipid levels were also very high on recent testing. He does not take any daily medications and his thyroid function is normal. The only significant findings on examination are lower extremity edema and some periorbital edema.

Urine test to help confirm the most likely diagnosis

Protein

You are notified by the nurse that a 66-year-old female who was admitted for pain control for her bone metastases is still having breakthrough pain. You gave her 10 mg of immediate-release oxycodone (Roxicodone) 15 minutes ago.

You are hoping to optimize pain control and minimize sedation, so you advise the nurse that the last dose will have its peak effect

1 hour after it was given

A 62-year-old female has a history of COPD graded as moderate on pulmonary function testing, with an FEV1 of 65% of predicted and a PaO2 of 57 mm Hg. Because her symptoms of dyspnea on exertion and fatigue seem out of proportion to her pulmonary function tests, you order echocardiography, which shows a pulmonary artery systolic pressure of 50 mm Hg, indicating pulmonary hypertension.

Tx most effective for decreasing mortality in this situation

Supplemental oxygen

Antihypertensive drug that may reduce the severity of sleep apnea

Spironolactone (Aldactone)

1/ARR =

NNT

ARR =

Risk before intervention - Intervention after intervention

A 25-year-old female sees you because of irregular menses, hirsutism, and moderate acne. She is sexually active in a monogamous relationship with a male, has never been pregnant, and prefers not to become pregnant at this time.

First-line therapy

Levonorgestrel/ethinyl estradiol

An 85-year-old male nursing home resident with a past history of a stroke has developed a pressure ulcer over his right greater trochanter. The ulcer is 2 cm in size and is noted to be shallow with a reddish-pink wound base. There is no evidence of secondary infection.

Best liquid for cleansing the wound

Tap water

A 26-year-old female has a 4-month history of continuous right-sided headache. The headache is associated with tearing and nasal congestion only on the right, and has not responded to over-the-counter analgesics. The patient went to the emergency department a few nights ago because of the pain, and CT of the head at that visit was normal. On examination you note conjunctival injection on the right. Findings are otherwise normal.

Which would be the most appropriate treatment at this time

Indomethacin

A 64-year-old male presents with increasing dyspnea on exertion. He feels well otherwise and has no chronic medical problems. A physical examination is normal. Pulmonary function testing reveals normal spirometry, with no evidence of an obstructive or restrictive pattern. However, his lung carbon monoxide diffusing capacity (DLCO) is low.

Based on these results, the most likely diagnosis

Chronic pulmonary emboli

A 46-year-old male with a prosthetic heart valve requests your advice regarding antibiotic prophylaxis for an upcoming dental procedure. The patient is allergic to penicillin.

Most appropriate Rx

Clindamycin (Cleocin)

Typical use, the annual failure rate of a combined oral contraceptive pill is

You see a 38-year-old male 11 days after his cat bit him on the thumb. He went to an urgent care clinic and was given a ceftriaxone (Rocephin) injection and 10 days of oral amoxicillin/clavulanate (Augmentin). He says the redness and pain in his thumb and hand have improved some, but the thumb remains very painful. He received a tetanus booster recently. His cat is well.

His vital signs are normal and examination of the thumb reveals a swollen, erythematous, tender, warm interphalangeal joint with decreased range of motion. There are healing 2-mm dorsal skin wounds over the joint.

Next step

Consultation for surgery

An 85-year-old female is admitted to the hospital for surgery and develops confusion postoperatively. The patient is a widow and lived independently prior to admission. Her daughter says the confusion is atypical for her mother. She does not have a history of memory loss, forgetfulness, or confusion prior to admission.

What cognitive assessment tests should be used to assess her acute change in mental status

Confusion Assessment Method (CAM)

Purpose of direct observational therapy (DOT) in the treatment of active tuberculosis

It decreases drug-resistant tuberculosis

Beyond short-term pain relief, local corticosteroid injection provides the best long-term improvement for

Trigger finger

A 30-year-old male presents to your office with a 10-day history of rhinorrhea, nasal congestion, cough, and headache. He initially had a low-grade fever that resolved, but over the past 2 days all of his symptoms have gotten worse. His past medical history is unremarkable and he does not smoke. On examination there is a purulent secretion noted from the right nasal cavity and tenderness over the right maxillary sinus region.

The most appropriate treatment is

amoxicillin/clavulanate (Augmentin)

A 7-month-old infant is hospitalized for the third time with lower-lobe bronchopneumonia. Findings include a weight and height below the 10th percentile. A sibling died of sudden infant death syndrome.

Laboratory testing reveals a hemoglobin level of 9.0 g/dL (N 10.5–14.0), a mean corpuscular volume of 85 μm3 (N 72–88), and a serum calcium level of 9.0 mg/dL (N 9.0–10.5). A sweat chloride level is 20 mEq/L (N <60).

Most likely cause of this infant’s failure to thrive

GERD

While on call for your group practice you are called to admit a 23-year-old female with a history of sickle cell disease who presented to the emergency department with chest pain, a cough, and shortness of breath. She has no history of recent hospitalization.
A chest radiograph shows consolidation in the right lower lobe.

In addition to oxygen, intravenous fluids, an intravenous third-generation cephalosporin, and pain management, you give

Azithromycin (Zithromax)

A 2-year-old male has a 3-day history of a runny nose and cough, and a 2-day history of fever reaching 40.0°C (104.0°F). He woke up with a rash this morning. His appetite is good and his activity level is normal. On examination the child is afebrile with normal vital signs, and has a fine, maculopapular, erythematous rash on the trunk and extremities. The remainder of the examination is normal.

Most likely Dx

Roseola infantum

A 47-year-old female is concerned about a change in her menstrual pattern. Her monthly periods continue, but for the past several months they have been heavier than usual and have been lasting a few days longer. Last month she also noted some spotting for several days prior to the onset of her menses. Her pelvic examination is normal.

Most appropriate at this time

Transvaginal ultrasonography

A 45-year-old male comes to the urgent care center with left foot pain that began at a ballroom dancing competition. He states that he put all of his weight on the lateral portion of his foot while on tiptoe, and felt the pain immediately. He now cannot bear weight on the foot. On examination it appears slightly edematous with a small amount of ecchymosis. A radiograph reveals a proximal fifth metatarsal metadiaphyseal fracture. The patient is eager to return to competitive dancing as soon as possible.

Best Tx Option

Surgical referral

A 4-year-old female is brought in by her mother because of a 3-day history of left ear drainage and a low-grade fever. The patient has bilateral ventilation tubes that were placed 2 months ago.

Most effective for resolving this child’s condition

Ciprofloxacin eardrops (Cetraxal)

A 55-year-old male presents with shortness of breath and abdominal pain. He has a history of diabetes mellitus, coronary artery disease, and hepatitis C. He usually is very active and continues to work at a steel plant. He smokes 1 pack of cigarettes each day and drinks alcohol daily. A chest radiograph shows a moderate right-sided pleural effusion. Thoracentesis reveals a pleural fluid protein to serum protein ratio of 0.3, and a pleural LDH to serum LDH ratio of 0.4. The pleural glucose level is 140 mg/dL and his serum glucose level is 150 mg/dL.

Most likely cause of this pleural effusion

Cirrhosis with ascites

High Trigs can have this effect on sodium

cause pseudohyponatremia

A 13-year-old female with asthma sees you for the first time in a year. The patient has a cough and you discover that she has not been taking her medications since you last saw her. She has been having symptoms 3–4 days a week and has been awakening at night about 3 times a month. Her FEV1 in the office is 90% of predicted.

This patient’s asthma should be classified as

mild persistent

A 37-year-old female who smokes 1 pack of cigarettes per day has just had her third child and requests contraception. She does not intend to have any more children.

Safest contraception option for this patient

etonogestrel implant (Nexplanon)

A 42-year-old male comes to your office with acute right flank pain that awakened him from sleep. The pain is colicky and he says it is the most intense pain that he has ever felt. The findings on a physical examination, in addition to blood on his urinalysis, make you suspect a urinary tract stone.

What imaging modality would be most appropriate for confirming your suspicion

Low-dose helical (spiral) noncontrast CT of the abdomen and pelvis

A patient returns to your office for a refill of oxycodone (Roxicodone), which he has been taking for 6 months for pain secondary to chronic osteomyelitis of his knee. His pain relief is adequate at a dosage of 10 mg every 6–8 hours. He took his prescribed dose approximately 4 hours prior to his visit. A urine drug screen using an enzyme-linked test is negative.

Next step

Order chromatography

A 15-year-old male is seen in the office for ankle pain. While playing basketball he jumped and landed on the lateral edge of his foot. He had immediate pain and did not continue playing, but was able to walk after the injury. On examination his right ankle has tenderness, swelling, and bruising over the anterior talofibular and calcaneofibular ligaments. There is no bony tenderness.

Most appropriate at this point

A lace-up ankle support

A 55-year-old male has New York Heart Association class III chronic systolic heart failure due to hypertensive cardiomyopathy.

Iontropic Rx is contraindicated

Verapamil (Calan)

What Rx used in the treatment of osteoporosis can also be used to treat the pain associated with acute and chronic vertebral compression fractures?

Calcitonin-salmon (Miacalcin)

Which DM class is most likely to cause hypoglycemia in elderly patients

Sulfonylureas – ‘rides – Glyburide (DiaBeta)

A 70-year-old white female with hypertension and atrial fibrillation has been chronically anticoagulated. A higher dosage of warfarin (Coumadin) would be required to achieve a therapeutic INR if the patient were found to have

hypothyroidism

Nutritional management strategies is associated with better outcomes in patients with mild acute pancreatitis whose pain and nausea have resolved

Early initiation of a low-fat diet

In a patient presenting with unstable angina, which findings would denote the highest risk for death or myocardial infarction

Angina with hypotension

A 72-year-old white female presents to your office with a 6-week history of “tanned skin.” She initially attributed it to having gone on a cruise 2 months ago, but noticed her skin continued to darken as time passed. She is slender and has lost 5 kg (11 lb) since her last checkup 6 months ago. She denies fever, malaise, or abdominal pain. Her only medications are hydrochlorothiazide and a baby aspirin daily.

On examination your suspicion of jaundice is confirmed by the presence of scleral icterus. You also note a single enlarged left supraclavicular lymph node which is nontender. The abdomen is soft and nontender; on deep palpation of the right upper quadrant you feel a smooth, nontender mass.

Most likely diagnosis

Carcinoma of the head of the pancreas

A 25-year-old female with asthma uses her albuterol (Proventil, Ventolin) inhaler only before
running, but reports waking up short of breath four times per month. She went to the emergency
department recently for increased dyspnea during peak ragweed season and remained overnight
until her symptoms improved.

Best treatment option now

Inhaled fluticasone (Flovent) daily

A 4-year-old female is treated at a local urgent care center with amoxicillin for acute pharyngitis. Several days after starting treatment her initial symptoms resolve. When she is 8 days into the 10-day course of her antibiotic treatment she returns to your office because she has developed a diffuse erythematous maculopapular rash starting on her torso and extending to her proximal extremities.

Best course of action at this time

Discontinue the amoxicillin and note amoxicillin as a potential allergy in her record

Define CURB-65

Confusion, BUN, RR, BP (Hypo), >65yo
0-1 = OP
2 = Hospital
3+ = ICU

A 52-year-old male presents with a swollen and tender area anterior to the left ear and extending
to below the left angle of the mandible. One week ago he had a Nissen fundoplication for
intractable GERD. This was complicated by difficulty swallowing and drinking. On examination
his tympanic temperature is 37.7°C (99.9°F), his blood pressure is 110/70 mm Hg, and his
pulse rate is 95 beats/min and regular. His left parotid gland is diffusely enlarged and tender.
Purulent material is noted coming from the left parotid duct orifice.

Most appropriate at this point

Amoxicillin/clavulanate (Augmentin)

Initial long term Tx of WPW heart defect

Ablation

HPV CDC recommendation

Two doses b/t ages 11-14, 6-12mo apart

If <6mo, or IC, third dose indicated

A 90-year-old female with severe dementia is seen in the emergency department for a left knee strain. She was at home alone for 2 hours and no fall or injury was witnessed. A radiograph of the knee is negative, and she is referred to you for follow-up the next day. At the follow-up visit the patient is confused and agitated, and cries out at any attempt to examine her. She is unable to bear weight on her left leg and it appears to be externally rotated.

Most appropriate at this point

A radiograph of the left hip

Spiritual assessment can be assessed by

the doc

A 60-year-old male with COPD returns for a follow-up visit. He has been treated twice for pneumonia in the past year and is using his albuterol metered-dose inhaler (Proventil, Ventolin) several times a day. His FEV1 is 60% of predicted.

To reduce symptoms and prevent hospitalization, the most appropriate medication to add to this patient’s treatment regimen at this time

A long-acting anticholinergic inhale (Tiotropium)

A 3-year-old female is brought to your office for a health maintenance examination, and her father expresses concern about her vision. Her visual acuity is 20/20 bilaterally on a tumbling E visual acuity chart. With both eyes uncovered during a cover/uncover test, the corneal light reflex in the right eye is medial to the pupil when focused on a fixed point, but the light reflex in the left eye is almost centered in the pupil. When the left eye is covered, the right eye moves quickly inward to focus on the fixed point, and the corneal light reflex is centered in the pupil. When the left eye is uncovered, the right eye returns to its original position. When you cover the right eye, no left eye movement is noted.

Most likely diagnosis

Strabismus

A 42-year-old previously healthy white female presents to your office with her third episode of abdominal pain. This episode began 2 hours ago, and the pain is improving. She describes colicky right upper quadrant and epigastric pain. On examination you note mild right upper quadrant tenderness, with otherwise unremarkable findings. Renal function tests are normal.

Most appropriate at this point

Ultrasonography of the right upper quadrant

A 60-year-old male has moderate anemia, with a suggestion of hemolysis on a peripheral blood smear.

Labs for LDH, Haptoglobin and Bilirubin would be

Elevated LDH, decreased haptoglobin, elevated indirect bilirubin

A 43-year-old male complains of difficulty washing his face and combing his hair with his right hand. On examination a nodule, band, and slight contracture are noted in the palm proximal to the fourth finger.

Associated Dx

Diabetes mellitus

A 75-year-old patient with underlying chronic renal failure requires cardiac catheterization.

Prep Pt w/ to help prevent acute renal failure due to contrast-induced nephropathy

Hydration with sodium bicarbonate-containing fluids

One day after a nurse performs CPR on an emergency-department patient, she learns that the patient had meningococcal meningitis.

Most appropriate chemoprophylaxis for this condition

Rifampin, 600 mg every 12 hours for 2 days

A 3-year-old male was treated for acute otitis media last month. His mother brings him in for follow-up because she believes his hearing has not been normal since then. He attends day care and has had several upper respiratory infections. On examination the tympanic membranes are not inflamed, but the membrane is retracted on the right side. An office tympanogram shows a normal peak (type A) on the left side, but a flat tracing (type B) on the right side.

Next step

Observation with follow-up

U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults

55–80 years of age who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years

A 37-year-old male complains of severe headaches that typically involve his right eye, and often cause the eye to tear. The headaches occur at about the same time each day and recur for several days in a row before remitting. He reports that he is currently experiencing a third episode of these headaches.

Therapy that will help prevent future recurrences of this patient’s headache

Verapamil (Calan, Verelan)

An 85-year-old male admitted to the hospital for shortness of breath is diagnosed with terminal lung cancer. He decides he would like to receive home hospice care. Over the course of his hospitalization he becomes increasingly confused and forgets where he is and why he is there. He appears depressed with a flat affect. He repeatedly tries to get out of bed and pulls at his IV line and catheter.

Most appropriate for treating these symptoms

Haloperidol

A 53-year-old white female with chronic hepatitis C is concerned about ulcers in her mouth. She is not currently receiving therapy. Your examination reveals several ulcers involving the buccal mucosa. The patient also points out a number of pruritic, reddish-purple plaques on her wrists, ankles, and back. Laboratory studies are within normal limits except for mildly elevated transaminases.

Lichen planus

A new serum marker has been developed for the diagnosis of pulmonary embolism. The test has a likelihood ratio of 1.

From this you can conclude

Nothing – The test can neither confirm nor rule out pulmonary embolism

Bone issue associated with bisphosphonate use for the treatment of
osteoporosis

Atypical femoral shaft fractures

A 2-week-old female is brought to the office for a well child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure.

Next step

Referral for orthopedic consultation

A 57-year-old female on dialysis for end-stage renal disease develops chronic, severe generalized pain.

Manage pain w/

Fentanyl

55-year-old male has a 3-month history of chronic shortness of breath and dyspnea on exertion. His physical examination is unremarkable except for 1+ ankle edema bilaterally and a soft systolic murmur. A stress echocardiogram is normal. Pulmonary function tests are normal except for a low diffusing capacity of the lung for carbon monoxide (DLCO).

Chronic pulmonary thromboembolism

A 55-year-old male with a 4-year history of type 2 diabetes mellitus was noted to have microalbuminuria 6 months ago, and returns for a follow-up visit. He has been on an ACE inhibitor and his blood pressure is 140/90 mm Hg.
Adding this Rx would INCREASE the likelihood that dialysis would become necessary

Losartan (Cozaar)

Which medication used to treat psychiatric disorders is associated with an increased risk of agranulocytosis

Carbamazepine (Tegretol)

Static stretching before running has been shown to

do nothing

A 66-year-old female sees you for the first time. She has a history of iron deficiency anemia and
chronic diarrhea associated with a diagnosis of celiac disease.

This history increases her risk for

Osteoporosis

A 66-year-old female sees you for the first time. She has a history of iron deficiency anemia and
chronic diarrhea associated with a diagnosis of celiac disease.

This history increases her risk for

Osteoporosis

An 18-month-old male is brought to your office by his mother. The patient is tugging at both ears and has a temperature of 39.0°C (102.2°F). You diagnose bilateral acute otitis media for the third time in the last 6 months. The most recent infection was 3 weeks ago and resolution of the infection was documented after 10 days of treatment with amoxicillin.

Antibiotic regimens would be most appropriate at this time

Amoxicillin/clavulanate (Augmentin), 90 mg/kg/day for 10 days

45-year-old female had myalgias, a sore throat, and a fever 2 weeks ago. She now has anterior neck tenderness and swelling, with pain radiating up to her ears. Your examination reveals a tender goiter.

What test finding would support a diagnosis of subacute granulomatous thyroiditis

Low radioactive iodine uptake (<5%

A 48-year-old female sees you for routine follow-up. She was diagnosed with type 2 diabetes mellitus 2 years ago and has been treated with metformin (Glucophage), 850 mg orally 3 times daily, and glipizide (Glucotrol XL), 20 mg orally daily, along with diet and exercise. Her other medical problems include hypertension and obesity. She has no known cardiovascular disease or microvascular complications. She came in for laboratory testing yesterday, and her hemoglobin A1c is 8.0% (N <5.7%).

What medication would help with both glycemic control and weight loss for this patient

Exenatide (Byetta) (GLP-1)

A 45-year-old female has been admitted to the hospital for an episode of acute diverticulitis.

This finding would most strongly suggest a need for surgical intervention

generalized peritonitis

An 18-month-old female with atopic dermatitis is brought to your office. She has recently had a flare-up of her condition that has been slow to resolve, and the mother says the child scratches “constantly” despite daily use of emollients.

Next step

A topical mild-potency corticosteroid

A 58-year-old female with diabetes mellitus complains of 2 years of right shoulder pain, which is worse with activity. There has been no trauma. She tells you one of her friends had a similar problem and was treated successfully with “some sort of shock wave treatments.”

This Dx diagnoses is most likely to be successfully treated with extracorporeal shock wave therapy

Calcific tendinitis

Rx for boderline personality disorder

none currently available

A 32-year-old gravida 2 para 1 with long-standing untreated hypertension presents at 8 weeks gestation for prenatal care. Her physical examination is normal except for a blood pressure of 156/114 mm Hg.

Most appropriate as initial treatment

Labetalol (Trandate)

A 26-year-old male presents to the emergency department with a fever, and he appears acutely ill. After a previously undocumented grade 3 murmur is detected on examination, a transthoracic echocardiogram is ordered and reveals a 1.5-cm vegetation on the tricuspid valve.

Most likely causative organism

Staphylococcus aureus

A 3-year-old male is brought to your office by his father for evaluation of 5 days of knee pain and fever up to 101.6°F. There was no known trauma preceding these symptoms. The pain and fever respond well to oral acetaminophen but continue to recur 4 hours after each dose.
On examination the child appears well and is afebrile. He had a dose of acetaminophen about 2 hours ago. There are no signs of upper respiratory infection. Examination of the knee reveals no redness, warmth, or swelling, and you see no other skin changes. He has full range of motion of both the knee and hip without pain. You note tenderness to firm palpation of the proximal tibia. He is able to bear weight and walk but refuses to jump due to anticipation of pain in his knee. Plain films of the knee are normal.

The next step in the evaluation of this patient should include

A CBC, a C-reactive protein level, and an erythrocyte sedimentation rate

Pt w/ hypothyroid will need higher dose of levothyroxine if they also have this condition

H. Pylori

Pt w/ CAD is treated w/ SAAB. The beta blocker and CCB are held d/t Bradycardia, start this Rx

Isosorbide Mononitrate

A 42-year-old male hair stylist presents with numbness and tingling of the right fifth finger that has been progressive over the last few months. He is particularly bothered after a long day of prolonged elbow flexion. He has no pain but has noticed some clumsiness and difficulty with fine coordination of his fingers. An examination clearly shows intrinsic muscle weakness.

Most likely diagnosis

Cubital tunnel syndrome

One of your patients recently went into atrial fibrillation and you order an echocardiogram. The diameter of this structure best predicts the likelihood that sinus rhythm will be maintained after successful cardioversion

Left Atria

A 16-year-old male is hit on his shoulder while playing football. A radiograph subsequently reveals a midclavicular fracture that is minimally displaced.

Appropriate management would be

a sling for 2–6 weeks

A 63-year-old male hospitalized for treatment of metastatic lung cancer develops a proximal deep vein thrombosis of the leg.

Which anticoagulants should be prescribed when he is discharged from the hospital

Enoxaparin (Lovenox)

A 48-year-old female is treated appropriately for MRSA bacteremia. An echocardiogram is negative for endocarditis. There are no indwelling devices such as prosthetic heart valves or vascular grafts.

Assuming that the patient improves with an excellent response to antibiotics, next dtep

Repeat blood cultures 2–4 days after the initial set and as needed thereafter

GLP-1 agonists such as exenatide (Byetta) can be used as second-line agents to help improve glycemic control in patients with type 2 diabetes mellitus.

If the Pt has this condition it is CONTRAINDICATION

Thyroid cancer

Area of the world that uses “coin-rubbing” as a Tx for illness

Southeast Asia

Pt w/ PE. if this Sx also present, there is a strong indication for thrombolytic therapy

Hypotension

Neonate exclusively breastfed, iron therapy is indicated at what age

1 m

MRSA protocol to limit spread

Strict handwashing practices by all staff, visitors, and residents

A 9-year-old female presents with a 4-week history of right knee pain with activity. There is no history of trauma or recent illness. Your examination reveals lateral patellar tracking with extension of the knee.

Patellofemoral pain syndrome

A 29-year-old mother of three young children asks your opinion on giving probiotics to her children.

Benefit of probiotics in children

They prevent antibiotic-associated diarrhea

CT of the chest shows ground-glass opacities and honeycombing of the lower lobes of the lungs.

Interstitial lung disease

A 47-year-old female with a 10-year history of type 2 diabetes mellitus is concerned about
the recent onset of swelling in her legs accompanied by a sudden weight gain of 8 lb. She
is also experiencing increased fatigue and shortness of breath with mild exertion.
On examination she has a blood pressure of 150/95 mm Hg, which is above her baseline
of 130/85 mm Hg. Her lungs are clear to auscultation and a cardiac examination is also
normal. She has no hepatosplenomegaly, but her legs are swollen to the level of the
midtibia bilaterally. You are concerned that her symptoms and examination findings may
be related to an underlying renal pathology.
To confirm your suspicion, the most appropriate diagnostic test at this time would be

a spot urine protein to creatinine ratio

A 24-year-old male presents with swelling of the right testicle. The pain started yesterday and has persistently worsened. A physical examination reveals swelling on the right side of his scrotum. His entire testicle is painful, and elevation of the scrotum improves his pain. Ultrasonography reveals hyperemia, swelling, and increased blood flow to the testis and epididymis.

Tx w/

Doxycycline plus ceftriaxone

New Pt has this on CMP, Dx is DM

A fasting plasma glucose level ≥126 mg/dL on two separate occasions

A 66-year-old male with nonalcoholic steatohepatitis, hyperlipidemia, and hypertension sees you for follow-up. He was recently diagnosed with cirrhosis. He has no new health complaints today. His medications include metoprolol, simvastatin (Zocor), and low-dose aspirin. His vital signs include a blood pressure of 120/75 mm Hg, a heart rate of 72 beats/min, and an oxygen saturation of 96% on room air. The physical examination is notable for mild ascites and trace lower extremity edema.

You make recommend this diet change

Limiting sodium intake

A 26-year-old female presents with a 3-month history of abdominal pain, lightheadedness with standing, and some hyperpigmentation. Her CBC is normal, but a basic metabolic panel reveals a slightly low sodium level and a slightly high potassium level.

Most appropriate next step in your evaluation of this patient

A corticotropin (ACTH) stimulation test

A 54-year-old male presents to your office with a 2-day history of mild right anterior chest pain with deep breathing. He reports that it has been sharp and constant and is preventing him from sleeping. He also describes shortness of breath and a cough productive of white sputum. He reports that prior to this episode he had been in good health, and he has not experienced these symptoms in the past.

On examination his blood pressure is 140/88 mm Hg, his temperature is 37.1°C (98.8°F), his pulse rate is 88 beats/min, and his oxygen saturation is 95% on room air. Heart auscultation reveals a regular rhythm with no murmur. His lungs are clear. Examination of the lower extremities reveals no edema or tenderness. A chest radiograph is normal. An EKG reveals right bundle branch block.

Next order

A D-dimer level

The fee-for-service system of medical payments establishes a reimbursement for individual care episodes provided by physicians and hospitals. Which one of the following is the term for when this reimbursement is adjusted up or down based on quality and/or efficiency measures

Value-based reimbursement

A 60-year-old female sees you because she has recently lost 20 lb without trying and is having trouble swallowing. Her other medical problems include obesity, tobacco abuse, and GERD.

Most appropriate diagnostic test in this situation

Upper endoscopy

A 22-year-old female who was diagnosed with bronchitis at an urgent care clinic 3 days ago sees you because her cough is still present. She is very annoyed by the cough and is concerned because she read online that she could have pneumonia. She asks if she should have a chest radiograph.

Indication for a chest radiograph in this patient

A respiratory rate >24/min

Diabetes mellitus medications is MOST likely to cause weight gain

Glimepiride (Amaryl)

A 62-year-old female with stage 3 chronic kidney disease and an estimated glomerular filtration rate of 37 mL/min/1.73 m2 is found to have a mildly low ionized calcium level.

What would you expect to see if her hypocalcemia is secondary to her chronic kidney disease

Elevated parathyroid hormone (PTH) and elevated phosphorus

A 30-year-old female who gave birth to a healthy infant 3 months ago has had mildly depressed moods almost daily for the last 7 weeks. She takes very little joy in daily activities and interacting with her baby. She is exclusively breastfeeding and has difficulty sleeping. She says that she felt fine during the first month after the delivery, and has not experienced any homicidal or suicidal ideations. You rule out postpartum psychosis and bipolar disorder.

Most appropriate at this point

Referral for psychotherapy

A 68-year-old female sees you for a routine health maintenance visit. She feels well and says she has been eating more carefully and exercising for 45 minutes 4 days a week for the past 6 months. Her past medical history includes controlled hypertension and osteoarthritis of the knee. Her family history is notable for a myocardial infarction in her mother at 48 years of age. Her only medication is lisinopril (Prinivil, Zestril).

The physical examination is notable only for a BMI of 36 kg/m2. Laboratory findings are notable for significant hyperlipidemia and you recommend starting a statin. She reports that she will undergo an elective total knee replacement next month and asks about the safety of starting a new medication before this surgery.

You recommend that she

start a statin immediately to decrease her risk of cardiovascular disease and perioperative mortality

A 40-year-old male presents to your office for follow-up of an abnormal clean-catch urine test performed at his employee health clinic during a preemployment screening examination. He had a positive urine dipstick for hemoglobin and 5 RBCs/hpf on microscopy. The urine was negative for protein, WBCs, and casts. A basic metabolic panel was notable for a creatinine level of 0.8 mg/dL (N 0.6–1.2) and a BUN of 15 mg/dL (N 8–23). He reports that he has been healthy and has not sought medical care in the last 5 years. He quit smoking 6 months ago and walks the dog daily for 30 minutes. A physical examination today is normal.

According to the guidelines of the American Urological Association, Next step is

Cystoscopy

NNT equation

True Negative/Negative

In women with polycystic ovary syndrome, the risk is increased the most for carcinoma of the

Endometrium

The following cardiac rhythm abnormalities is most common in patients with anorexia nervosa

Bradycardia

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