Pre-Test: Acute Complaints

Question 1

An 80 yo man presents with mild, crampy bilateral lower quadrant pain, decreased appetite, and low-grade fever for about 48 hours. Which of the following is the most likely dx?

a. SBO
b. Appendicitis
c. Constipation
d. IBS
e. Pancreatitis

Answer 1

b. Appendicitis

Advanced age can change the presentation and perception of abdominal pain. Only 22% of elderly patients with appendicitis present with classic symptoms.

SBO & constipation may cause bilateral lower quadrant pain and decreased appetite, but fever indicates something different. IBS is chronic and generally not associated with fever.

Question 2

A 56 yo is complaining of gnawing abdominal pain in the center of her upper abdomen associated with a sensation of hunger. She has a long history of alcohol abuse, and notes darker stool over the last 3 weeks. Which of the following is the most likely cause of her illness?

a. Alcoholism
b. NSAID abuse
c. H pylori infection
d. Gallstones
e. Gastroparesis

Answer 2

c. H pylori infection

The patient describes the classic px for PUD. Infection with H pylori is the leading cause of PUD, with the use of NSAIDs the second most common.

Alcoholism and gallstones can cause pancreatitis, but that presents differently.

Gastroparesis may cause dyspepsia, but is less likely cause for ulcer disease.

Question 3

What is the gold standard for dx and tx of choledocholithiasis?

Answer 3

ERCP

U/S shows stones, but is less sensitive for choledocholithiasis or for complications (abscess, perforation, and pancreatitis). CT or MRI is better for those.

Question 4

You are seeing a 53 yo man who was hospitalized for pancreatitis. His admission laboratory studies include a WBC count of 18,000/mm3, glucose of 153 mg/dL, LDH of 254 IU/L, and AST of 165 U/L. According to Ranson criteria, which of these factors suggest a poor prognosis in this patient?

a. Age
b. WBC count
c. Glucose
d. LDH
e. AST

Answer 4

b. WBC count

Ranson’s criteria assess the severity and prognosis of pancreatitis. On admission, five criteria are considered. It is a poor prognostic sign if:

• Age > 55
• WBC > 16,000
• Glucose > 200 mg/dL
• LDH > 350 IU/L
• AST > 250 U/L

Question 5

You are evaluating a pt new to your practice who is complaining of abdominal pain. The pain has been present on and off for more than 2 years, and has been present more often than not for the preceding 6 mo. She reports that her pain is related to defecation and is associated with diarrhea. Which of the following is true regarding diagnostic testing for her condition?

a. A normal CBC is necessary for dx
b. A normal ESR is necessary for dx
c. A colonoscopy is necessary for dx
d. Normal stool cultures are necessary for dx
e. No tests are necessary to dx this condition

Answer 5

e. No tests are necessary to dx this condition

IBS is typified by symptoms of abdominal pain or discomfort associated with disturbed defecation. Diagnostic criteria for IBS are symptom, not laboratory-based. The criteria include symptoms that are present for at least 12 weeks in the previous 12 months, and pain that is characterized by two of the following three features:

(1) relieved by defecation,
(2) onset is associated with a change in stool frequency, or
(3) onset is associated with a change in the form or appearance of stool.

Question 6

Next step for the following situations:

1. Pap smear: ASCUS, HPV testing: negative
2. Pap smear: ASCUS, HPV testing: positive

Answer 6

Next step for the following situations:

1. Repeat Pap smear in 1 year
2. Perform colposcopy (definitive test for assessing Pap smear abnormalities)

Question 7

You are caring for a 34 yo generally healthy woman. She is sexually active and currently in a monogamous relationship with her husband using oral contraceptives. You recently completed her annual exam. Her Pap smear reports “atypical glandular cells,” but does not specify if those cells are endocervical or endometrial in origin. She has not had any abnormal vaginal bleeding. Which of the following is the most appropriate next step?

a. Repeat the Pap smear immediately
b. Repeat the Pap smear in 4 to 6 mo
c. Repeat the Pap smear in 1 yr
d. Perform colposcopy
e. Peform endometrial biopsy

Answer 7

d. Perform colposcopy

When the results of a pap smear are reported as “atypical glandular cells,” the physician should proceed to colposcopy. Colposcopy involves endocervical sampling and it will help to further identify the glandular cell abnormality noted on the Pap smear.

Question 8

A laboratory analysis of one of your patients reveals a microcytic anemia. The RDW is elevated. Which of the following is the most likely dx?

a. Iron deficiency
b. Sideroblastic anemia
c. Thalassemia
d. Aplastic anemia
e. Chronic renal insufficiency

Answer 8

a. Iron deficiency

Causes of microcytic anemias include iron deficiency, anemia of chronic disease, thalassemia, and sideroblastic anemias. In iron deficiency, the RDW would be elevated due to variation in cell size. In sideroblastic anemia, the MCV would be normal, high, or low, but the red cells are dimorphic. In thalassemia, the RDW would be normal because the red cells are uniformly small.

Question 9

You are caring for a person who presents with severe symptoms. He started with fatigue, myalgias, arthralgias, headache, and low-grade fever several weeks ago. He also noted a “rash” on his upper back near the R scapula that looked “like a bull’s eye.” That rash has since resolved. Currently, he complains of musculoskeletal pain and attacks of joint pain and swelling for the past week, and today he reports pleuritic chest pain. On exam, he has lymphadenopathy, tenderness in his joints, and R axillary adenopathy. You also notice a friction rub. What is the best treatment for this condition?

a. Doxycycline for 14 to 21 days
b. Amoxicillin for 14 to 21 days
c. Tetracycline for 2 to 3 days after patient becomes afebrile
d. Ceftriaxone IV for 2 to 3 weeks

Answer 9

d. Ceftriaxone IV for 2 to 3 weeks

The patient has Lyme disease based on his early constitutional symptoms and rash consistent with erythema chronicum migrans. Based on his current symptoms, he likely has early disseminated disease. This is characterized by multiple system involvement, lymphadenopathy, musculoskeletal pain, arthritis, and pericarditis.

Treatment is dependent on the stage of disease. Early localized disease can be treated with oral abx (amoxicillin or doxycycline) for 14 to 21 days. Early disseminated disease is treated with IV therapy for 2 to 3 weeks. Ceftriaxone or cefotaxime and chloramphenicol are options.

Question 10

A 22 yo woman is seeing her physician with complaints of breast pain. It is associated with her menstrual cycle and is described as a bilateral “heaviness” that radiates to the axillae and arms. Exam reveals groups of small breast nodules in the upper outer quadrants of each breast. They are freely mobile and slightly tender. Which of the following statements is most accurate?

a. The patient has bilateral fibroadenomas and reassurance is all that is necessary.
b. The patient has bilateral fibrocystic changes and reassurance is all that is necessary.

Answer 10

b. The patient has bilateral fibrocystic changes and reassurance is all that is necessary.

Fibrocystic changes are the most common benign condition of the breast. Cysts may range in size from 1 mm to more than 1 cm in size.

Fibroadenomas are usually rubbery, smooth, well-circumscribed, nontender, and freely mobile.

Mammograms are not necessary for women younger than 30 years of age, as they are less sensitive in younger women with denser breast tissue.

Question 11

You are evaluating a 21 yo woman with an erythematous, tender, and edematous hand. She reports that while playing with her cat 3 days ago, he bit her and punctured the skin. The area around the bite is inflamed, and there is a purulent discharge from the puncture site. Which of the following is the most likely infecting organism?

a. Clostridium perfringens
b. S. aureus
c. S. pyogenes
d. Pasteurella multocida

Answer 11

d. Pasteurella multocida

Hand cellulitis often follows puncture wounds, and cat bites may often produce infection with P multocida.

Most skin infections are due to Staph or Strep pyogenes. Clostridium perfringens may produce gas, and should be considered as a cause for cellulitis that can lead to gangrene, especially if crepitus is found on clinical exam.

Question 12

You are seeing a 28 yo woman who is complaining of constipation. She reports that her symptoms have been present since she can remember, and no dietary changes have seemed to benefit her. She has never tried pharmacologic therapy in the past. Which of the following would be the best first-line therapy for her?

a. Psyllium (Metamucil)
b. Magnesium hydroxide
c. Bisacodyl (Dulcolax)
d. Saline enemas

Answer 12

a. Psyllium (Metamucil)

Question 13

You are treating a 52 yo woman with a 40 pack year hx of smoking. She reports a productive cough that has been present for the last 3 to 4 months, beginning in the fall. She remembers having the same symptoms last fall, and attributed it to a “cold that she just couldn’t kick.” She does NOT have fevers, reports mild dyspnea when walking up stairs, and denies hemoptysis. Which of the following is the most likely dx?

a. Irritation of airways from cigarette smoke
b. Chronic bronchitis
c. Postnasal drainage due to seasonal allergies
d. Lung cancer
e. Asthma

Answer 13

b. Chronic bronchitis

B/c the patient reports a productive cough for at least 3 months of the year for a least 2 consecutive years, she meets the criteria for chronic bronchitis. This is the most common cause of chronic cough in smokers.

The most common cause of chronic cough in nonsmokers is postnasal drainage, but since this patient has a significant smoking hx, chronic bronchitis is more likely.

Question 14

What is the treatment for pertussis?

Answer 14

5 day course of azithromycin

or

14 day course of erythromycin

Question 15

A 30 yo man returned from a vacation in Mexico 1 day ago. He spent the last 3 days of his trip with loose, more frequent bowel movements that are continuing without resolution. He has not had bloody stool or fever. His exam is normal, except for midly diffuse lower abdominal pain. Which of the following is the best empiric tx option for this condition?

a. Erythromycin
b. Ciprofloxacin
c. Metronidazole
d. Doxycycline
e. Vancomycin

Answer 15

b. Ciprofloxacin

Most cases of travelers’ diarrhea are due to ETEC. The abx of choice is a fluoroquinolone (ciprofloxacin, ofloxacin) with TMP/SMX or azithromycin being acceptable alternatives.

Question 16

A 42 yo woman is seeing you to follow up with a new complaint of “dizziness.” She reports that symptoms first began several months ago. At that time, she reported a subjective hearing loss and a ringing in her left ear only. Symptoms were mild, and her physical exam was normal, so you elected to follow her. Since that time, her symptoms have progressed to include dizziness and some facial numbness. Which of the following is her most likely dx?

a. Vestibular neuronitis
b. Benign positional vertigo
c. Acoustic neuroma
d. Meniere disease
e. Cerebellar tumor

Answer 16

c. Acoustic neuroma

Acoustic neuroma typically presents with unilateral tinnitus and hearing loss. The symptoms are constant and slowly progressive. With continued tumor growth, symptoms of vertigo, facial weakness, and ataxia can occur.

Vestibular neuronitis presents with an acute onset of severe vertigo lasting several days, with symptoms improving over several weeks.

BPV typically involves symptoms with position changes only.

Meniere disease (inner ear disorder) presents with discrete attacks of vertigo lasting for several hours, associated with nausea and vomiting, hearing loss, and tinnitus.

A cerebellar tumor would typically present with dysequilibirum as opposed to tinnitus.

Question 17

What is the first-line therapy for treating a peripheral vestibular disorder?

Answer 17

Antihistamines

Once diagnosed with a peripheral vestibular disorder, antihistamines are the first-line therapy for symptomatic relief. They suppress the vestibular end-organ receptors and inhibit activation of the vagal response. Meclizine (Antivert) and diphenhydramine (Benadryl) are commonly recommended choices.

Question 18

You are evaluating a 71 yo male patient with the complaint of SOB. It mainly occurs with exertion. He also complains of fatigue, and needs to sleep propped up on two pillows. On exam, you note a large apical impulse and JVD. He has fine crackles in the bases of both lungs with decreased breath sounds. Which of the following would be the most appropriate treatment?

a. Bronchodilators
b. Abx
c. Steroids
d. Anticoagulants
e. Diuretics

Answer 18

e. Diuretics

The pt is presenting with signs and symptoms of CHF. These include abnormal heart sounds, cardiomegaly, JVD, basilar rales, and edema.

Bronchodilators would be appropriate for asthma or bronchitis.

Antibiotics may be appropriate for pneumonia.

Steroids would be helfpul with an asthma or COPD exacerbation.

Anticoagulation may be papropriate for DVT.

Question 19

What does BNP evaluate for? (normal is 0-100 pg/mL)

Answer 19

Evaluates for presence of CHF

Studies indicate that a value less than 80 has a high (99%) negative predicative value and helps rule out CHF

Question 20

One of your patients is dying of end-stage breast cancer. She is complaining of dyspnea. Which of the following treatment options would be most beneficial?

a. Bronchodilators
b. Steroids
c. Anxiolytics
d. Opioids
e. Pulmonary rehabilitation program

Answer 20

d. Opioids

Many studies have shown that opioids relieve dyspnea in patients with cancer, but the mechanism is unknown. Bronchodilators are better in the setting of COPD and asthma, as are steroids.

Question 21

A 23 yo sexually active woman visits a free clinic with sudden onset of dysuria that began 2 days ago. On further questioning, she also reports urinary frequency, some back pain, and a pink discoloration in her urine.

She denies vaginal discharge or irritation and has been afebrile. The clinic has no microscope or urine dipsticks available. Based on her hx, what is her most likely dx?

a. Acute bacterial cystitis
b. Urethritis
c. Pyelonephritis
d. Interstitial cystitis
e. Vulvovaginitis

Answer 21

a. Acute bacterial cystitis

Four factors correlate significantly with a dx of acute bacterial cystitis: frequency, hematuria, dysuria, and back pain

In addition, four factors decrease the likelihood of UTI (absent dysuria, absent back pain, hx of vaginal discharge, hx of vaginal irritation). Women with any combination of the positive and negative sx have more than 90% probability of a UTI.

Urethritis is more likely with a gradual onset.

Pyelonephritis often have fever.

Interstitial nephritis tends to be more chronic in nature and not associated with back pain.

Vulvovaginitis is a common cause of dysuria, but is associated with irritation or discharge.

Question 22

What is the acceptable prophylactic measure for patients with frequent UTIs?

Answer 22

Single-dose abx therapy after sexual intercourse

Question 23

When hematuria is present, interstitial cystitis should be suspected. Interstitial cystitis is generally diagnosed through ____________, based on presence of ________ and __________ in the bladder mucosa and the absence of ______________.

Answer 23

Interstitial cystitis is generally diagnosed through cystoscopy, based on the presence of ulcerations and fissures in the bladder mucosa and the absence of bladder tumors.

Question 24

You are seeing a 34 yo man with urinary symptoms. He reports frequency, urgency, and moderate back pain. He is febrile and acutely ill. He has no penile discharge. His urinalysis shows marked pyuria. He has never had an episode like this before, and has no known urinary abnormalities. Which of the following is the most likely dx?

a. Gonococcal urethritis
b. Nongonococcal urethritis
c. Acute bacterial cystitis
d. Pyelonephritis
e. Acute prostatitis

Answer 24

e. Acute prostatitis

In men with urinary symptoms and a normal urinary tract, cystitis and pyelonephritis are uncommon.

Urethritis would be unlikely to cause this systemic illness. The patient described above has acute bacterial prostatits.

Acute prostatitis is most commonly seen in 30- to 50- year old men, and symptoms include frequency, urgency, and back pain. The patient generally appears acutely ill, and has pyuria. The prostate exam would reveal a boggy, tender, and warm prostate.

Question 25

You are seeing a 25 yo patient complaining of a left-sided ear ache. She describes the pain as deep, and it worsens with eating. Her ear exam is normal, but she has tenderness and crepitus during palpation of the L TMJ. Which of the following is the most appropriate next step?

a. Abx therapy
b. Treatment with NSAIDs
c. Dental referral
d. MRI of the TMJ
e. Obtaining an ESR

Answer 25

b. Treatment with NSAIDs

The pt has TMJ dysfunction, a common cause of referred otalgia. First-line therapy includes NSAIDs, heat, and referral to dentist if there is no improvement in 3-4 weeks.

Question 26

You are seeing a 6 yo patient whose mother brought him in for severe ear pain and fever. On exam, he is febrile with a temperature of 102.5 F and bulging TM. Which of the following would be the best initial tx?

a. A weight-adjusted dose of Tylenol
b. A weight-adjusted dose of amoxicillin
c. A weight-adjusted course of amoxicillin-clavulanate

Answer 26

c. A weight-adjusted course of amoxicillin-clavulanate

This picture represents acute otitis media. The child should be treated with a first-line abx. In most cases, amoxicillin is used as first-line.

However, in patients with severe illness (moderate to severe otalgia and/or fever > 102 F), therapy should be initiated with high-dose amoxicillin-clavulanate.

Question 27

You are seeing a 16 yo student complaining of ear pain that has been present for 2 days. He denies fever and has no symptoms of upper respiratory infection. On exam, his ear canal is erythematous, and swollen. His tympanic membrane is obscured by discharge and debris. Which of the following is the treatment of choice in this pt?

a. Flushing of the ear with hydrogen peroxide
b. Acetic acid washes
c. Topical abx
d. Systemic abx
e. Oral steroids

Answer 27

c. Topical abx

Fundamental to the tx of external otitis is protection from additional moisture and avoidance of further mechanical injury from scratching. Otic drops containing abx and corticosteroids are very effective.

Question 28

You are seeing a 45 yo obese diabetic woman who reports bilateral lower extremity peripheral edema. In addition to diabetes, she has arthritis, HTN, and depression. Which of the following medications is the likely cause of her edema?

a. Fluoxetine
b. Metformin
c. Naproxen
d. Lisinopril
e. HCTZ

Answer 28

c. Naproxen

Antihypertensives such as CCBs are well known to cause peripheral edema.

Other drugs: vasodilators, beta blockers, centrally acting agents, antisympathetics, rosiglitazone, hormones, corticosteroids, NSAIDs

Question 29

What would bilateral vs. unilateral lower extremity edema indicate?

Answer 29

Bilateral: CHF

Unilateral: DVT

Question 30

You are evaluating a 63 yo diabetic man who noted unilateral lower extremity edema. He denies dyspnea or recent trauma. On evaluation, you note pitting edema on the R with well-demarcated erythema from the ankle to the mid thigh. Which of the following is the best treatment option?

a. Vascular surgery referral
b. Diuresis
c. Compression stockings
d. Anticoagulation
e. Antibiotics

Answer 30

e. Antibiotics

Unilateral edema is suspicious for a DVT. However, if there is a hx of recent trauma, or evidence of inflammation, a Doppler U/S is usually not necessary.

Signs of inflammation including erythema point toward cellulitis as a dx. Cellulitis should be treated with abx.

Question 31

Primary monosymptomatic enuresis

vs

Secondary monosymptomatic enuresis

Answer 31

Primary: bed-wetting without a hx of nocturnal continence and is unassociated with other symptoms

Secondary: bed-wetting after at least 6 mo. of nocturnal continence

Question 32

A 19 yo male patient presented to your office with a 3 day hx of fatigue, sore throat, and low-grade fevers. On exam, his temperature was 100.3 F and you noted an exudative pharyngitis with cervical adenopathy. You sent a throat culture and started him on amoxicillin prophylactically.

Two days later, he presents for follow-up with continued symptoms and a diffuse, symmetrical erythematous maculopapular rash. Which of the following is the most likely cause of his symptoms?

a. Scarlet fever
b. Allergic rxn to amoxicillin
c. Viral exanthem
d. Mononucleosis
e. Measles

Answer 32

d. Mononucleosis

Mononucleosis is often mistaken for streptococcal pharyngitis. Both have symptoms of sore throat, fatigue, fever, and adenopathy. If patients with mononucleosis are given ampicillin, up to 100% may develop the rash described above, sometimes confused as an allergic rxn to penicillin.

The rash of scarlet fever is more confluent, and has a sandpaper-like texture. The rash of measles starts as erythematous flat papules, first appearing on the face and neck, and then spreading to the arms and trunk in 2 to 3 days.

Question 33

Migraine prophylaxis

Migraine abortive therapy

Answer 33

Beta blockers

Triptans

Question 34

A 38 yo man comes to the office to discuss his headache symptoms. He describes the headaches as severe and intense, “like an ice pick in my eye!”

The headaches begin suddenly, are unilateral, last up to 2 hours, and are associated with a runny nose and watery eye on the affected side. He gets several attacks over a couple of months, but is symptom-free for months in between flare-ups. Which of the following is the best approach for prophylactic mgmt of the attacks?

a. SSRIs
b. Triptans
c. NSAIDs
d. CCB
e. Ergotamine

Answer 34

d. CCB

The mainstay of therapy for cluster headaches is to provide relief from the acute attacks, then use therapy to suppress headaches during the symptomatic period. Nifedipine has been shown to be effective, as has prednisone, indomethacin, and lithium. However, the medication should not be given daily, just during the symptomatic period.

Question 35

A 42 yo man that you treat suffers from cluster headaches. He would like a medication to take when he has an attack (abortive therapy). What would be best for treatment of the acute episodes?

Answer 35

100% oxygen, administered via a nasal cannula

Question 36

You are talking with a 33 yo woman who is complaining of headaches. She has had these headaches for 5 months, and they are increasing in frequency. She reports that the headaches may last anywhere from an hour to several days. They are now occurring about 5 to 10 times a month, without relationship to her menstrual cycle. She describes the headache as bilateral, and the pain is described as a pressure around her forehead. She denies nausea, is not sensitive to sound, but is sensitive to light during an attack. On exam, she has no obvious neurologic deficit. Which of the following is the best approach to take at this point?

a. Prescribe a triptan for abortive therapy
b. Prescribe NSAIDs and follow up if no improvement.
c. Order blood work to rule out secondary cause.
d. Order a CT of the brain.
e. Order an MRI of the brain.

Answer 36

b. Prescribe NSAIDs and follow up if no improvement.

Tension-type headaches (TTH) are the most frequent of all headaches encountered in clinical practice.

The episodes last from 30 minutes to several days, and headaches should occur less than 15 times per month. It requires at least two of the following characteristics:

• Pressure/tightness
• Bilateral
• Mild to moderate
• Not aggravated by activity

There is generally no nausea. Either photophobia or phonophobia may be present, but not both. If criteria for this classification of headache are met, a trial of NSAIDs may be appropriate, with follow-up if there is no improvement.

Question 37

You are caring for a patient who complains of transient insomnia. He has eliminated caffeine and has maintained effective sleep hygiene. Which of the following medications works best to maintain sleep?

a. Zolpidem (Ambien)
b. Eszopicione (Lunesta)
c. Zaleplon (Sonata)
d. Diphenhydramine (Benadryl)
e. Melatonin

Answer 37

c. Zaleplon (Sonata)

Pharmacologic agents may be used in select cases of transient sleep disorders unassociated with more serious problems.

The drugs of choice for transient sleep ONSET problems: zolpidem (Ambien) or eszopiclone (Lunesta)

For sleep MAINTENANCE problems, zaleplon (Sonata) may be used.

Question 38

You are following a patient after an acute hepatitis B infection. His serologies are shown below:

• HBsAg: Positive
• HBeAg: Positive
• IgM anti-HBc: Negative
• IgG anti-HBc: Positive
• Anti-HBs: Negative
• Anti-HBe: Negative

Which of the following terms best describes his disease status?

a. Acute infection, early phase
b. Acute infection, recovery phase
c. Chronic infection, replicating virus
d. Chronic infection, nonreplicating virus
e. Previous exposure with immunity

Answer 38

c. Chronic infection, replicating virus

The HBsAg positivity in this case indicates either chronic infection or early infection. The negativity of the IgM anti-HBc rules out an early infection. The HBeAg is correlated with replication.

Question 39

You are following a patient after an acute hepatitis B infection. His serologies are shown below:

• HBsAg: Negative
• HBeAg: Negative
• IgM anti-HBc: Negative
• IgG anti-HBc: Negative
• Anti-HBs: Positive
• Anti-HBe: Negative

Which of the following terms best describes his disease status?

a. Acute infection, early phase
b. Acute infection, window phase
c. Acute infection, recovery phase
d. Previous exposure with immunity
e. Vaccination

Answer 39

e. Vaccination

The positivity of the anti-HBs indicates either exposure with immunity, recovery phase, or vaccination.

Because the IgG anti-HBc is negative, there is no evidence of past exposure or infection.

Question 40

You are following a patient after an acute hepatitis B infection. His serologies are shown below:

• HBsAg: Negative
• HBeAg: Positive
• IgM anti-HBc: Positive
• IgG anti-HBc: Negative
• Anti-HBs: Negative
• Anti-HBe: Negative

Which of the following terms best describes his disease status?

a. Acute infection, early phase
b. Acute infection, recovery phase
c. Chronic infection, replicating virus
d. Chronic infection, nonreplicating virus
e. Previous exposure with immunity

Answer 40

b. Acute infection, recovery phase

The positivity of the IgM anti-HBc indicates early infection, and is negative in chronic infection.

If the patient were in the early phase, his HBsAg would be positive.

Question 41

What is urge incontinence and what is the best medication for a patient with this to use?

Answer 41

Urge incontinence = most common type of incontinence in the elderly… due to detrusor hyperactivity, patients often complain of a strong urge followed by an involuntary loss of urine

For urge incontinence, _anticholinergic medication_s are the drugs of choice with oxybutynin and tolteridine both indicated for symptoms

Question 42

You are treating a 45 yo man for HTN. Since beginning therapy, he complains of urinary leakage and urgency. Which antihypertensive class is most likely to cause this?

a. Thiazide diuretics
b. ACE inhibitors
c. Beta blockers
d. CCBs
e. alpha blockers

Answer 42

c. Beta blockers

Alpha blockers cause urethral sphincter relaxation and can cause urinary leakage, but not urgency.

Beta blockers inhibit bladder relaxation and therefore can cause both urinary leakage and urgency.

Question 43

You are evaluating a 5 yo girl whose mother brought her in to evaluate jaundice. Laboratory evaluation reveals a conjugated hyperbilirubinemia. Which of the following is the most likely cause of her problem?

a. G6PD deficiency
b. Gilbert disease
c. Crigler-Najjar syndrome
d. Wilson disease
e. Viral hepatitis

Answer 43

e. Viral hepatitis

In evaluating childhood jaundice, it’s important to differentiate between conjugated and unconjugated hyperbilirubinemia. If jaundice occurs in childhood and is associated with unconjugated hyperbilirubinemia, hemolytic diseases (G6PD deficiency and spherocytosis), Gilbert disease and CN syndrome should be considered.

If associated with conjugated hyperbilirubinemia, viral hepatitis is the most common cause.

Less common causes include Wilson disease and milder forms of galactosemia.

Question 44

You are evaluating a 45 yo woman with significant jaundice. Her AP is 7x normal, and her transaminases are 2x normal. You perform an ultrasound of her RUQ and it is negative for obsturction and shows no bile duct dilation. You still suspect obstruction. Which of the following should be the next step in the workup?

a. CT of the abdomen
b. Endoscopic retrograde cholangiopancreatography (ERCP)
c. Percutaneous transhepatic cholangiography (PTC)
d. Magnetic resonance cholangiopancreatography (MRCP)
e. Nuclear scintigraphy of the biliary tree (HIDA)

Answer 44

d. Magnetic resonance cholangiopancreatography (MRCP)

In the setting of suspected obstruction with normal initial testing, it is sometimes difficult to determine the next steps. When obstruction is suspected, U/S or CT scan is the appropriate initial test.

If dilated bile ducts are seen, then ERCP or PTC should be done, followed by appropriate intervention.

If bile ducts are NOT dilated but the likelihood of obstruction is low, the patient should be evaluated for hepatocellular or cholestatic liver disease.

If obstruction is still considered likely after a negative U/S or CT scan, MRCP is a reasonable next option. It has excellent sensitivity and specificity, will evaluate anatomy appropriately, and unlike ERCP, does not induce post-procedure pancreatitis.

Question 45

A 16 yo woman comes to your office complaining of unpredictable menstrual periods. She began her periods at age 14 and they have never been predictable. She denies sexual activity in her lifetime, has no systemic illness, uses no medications regularly and her physical exam is normal. Which of the following is her most likely dx?

a. Pregnancy
b. Ovulatory bleeding
c. Anovulatory bleeding
d. Uterine leiomyoma
e. Endometrial polyposis

Answer 45

c. Anovulatory bleeding

Anovulatory bleeding is caused by continuous unopposed endometrial estrogen stimulation. Since these patients do not ovulate, progesterone from the corpus luteum is not secreted, the withdrawal from which would normally cause endometrial sloughing. It is the most common cause of dysfunctional uterine bleeding in women younger than 20 years of age, accounting for about 95% of cases.

Normal menstrual bleeding in the ovulatory cycle is a result of a decline in progesterone due to the demise of the corpus luteum. It is thus a progesterone withdrawal bleeding. As there is no progesterone in the anovulatory cycle, bleeding is caused by the inability of estrogen — that needs to be present to stimulate the endometrium in the first place — to support a growing endometrium. Anovulatory bleeding is hence termed estrogen breakthrough bleeding.

Question 46

If a postmenopausal woman has menstrual spotting/bleeding, what must you do first?

Answer 46

Endometrial biopsy to r/o endometrial cancer

Question 47

You are considering tx for a 19 yo female patient with primary dysmenorrhea. Which of the following should be your first-line therapy?

a. Use of NSAIDs during menses
b. Use of NSAIDs daily
c. Use of opiates during menses
d. Use of SSRI daily
e. Use of OCPs daily

Answer 47

a. Use of NSAIDs during menses

Primary dysmenorrhea is cauesd by the release of prostaglandin from the endometrium at the time of menstruation. Treatment focuses on the. reduction of endometrial prostaglandin production.

Question 48

You are evaluating a 16 yo girl who has never menstruated. She has normal secondary sexual characteristics and her laboratory evaluation is negative. She has no withdrawal bleeding after a progestin challenge and you choose to perform an estrogen-progestin challenge. She has no withdrawal bleeding after that challenge as well. Which of the following is the most likely reason for her amenorrhea?

a. Outflow tract obstruction
b. Hypergonadotropic amenorrhea
c. Hypogonadotropic amenorrhea
d. PCOS
e. Pituitary adenoma

Answer 48

a. Outflow tract obstruction

When evaluating primary amenorrhea in patients with normal secondary sexual characteristics and a normal initial laboratory test, it is appropriate to perform a progestin challenge test.

When there is no withdrawal bleeding, it either indicates inadequate estrogen production or an outflow tract obstruction.

An estrogen-progestin challenge can differentiate between the two. No withdrawal bleeding after an estrogen-progestin challenge indicates an outflow tract obstruction or an anatomic defect.

Question 49

You are evaluating a 34 yo woman who reports amenorrhea for 4 months. She has never been “regular,” but has never gone this long without a period. You give her medroxyprogesterone acetate (Provera) for 7 days, and the next week, she reports having a period. Which of the following is the most likely cause of her amenorrhea?

a. Premature ovarian failure
b. Ovarian neoplasm
c. Turner syndrome
d. Asherman syndrome
e. PCOS

Answer 49

e. PCOS

The progestin challenge test separates patients with estrogen deficiency from those with normal or excess estrogen. Any bleeding in the week after administration of Provera indicates that the patient has sufficient estrogen to menstruate, and that the amenorrhea is likely due to anovulation, as in PCOS. Those with premature ovarian failure would not have withdrawal bleed.

Question 50

You are evaluating a homeless person in the ED who is displaying hyperalert confusion. Withdrawal from which of the following substances is most likely to cause this state?

a. Levothyroxine
b. Fluoxetine
c. Oxycodone/acetaminophen
d. Alcohol
e. Amphetamine

Answer 50

d. Alcohol

Question 51

You receive a telephone call from the mother of a 19 yo patient. During the day, she complained of a headache, body aches, and a low grade fever. She went to bed 30 minutes ago and her mother is now finding it difficult to arouse her. Which of the following tests would be most likely to reveal the dx?

a. Urinalysis
b. CBC
c. Tox screen
d. Pregnancy test
e. LP

Answer 51

e. LP

Bacterial or viral meningitis r/o

Question 52

A 53 yo woman is seeing you b/c of chronic nausea and vomiting. She has a 15 year hx of type 2 DM. Her symptoms are worse after eating and on occasion, she will vomit food that appears to be undigested. Her weight is stable and she does not appear dehydrated. Which of the following is the best treatment for her condition?

a. An anticholinergic medication, like scopolamine
b. An antihistamine, like promethazine
c. A benzamide, like metoclopramide
d. A cannabinoid, like dronabinol
e. A phenothiazine, like chlorpromazine

Answer 52

c. A benzamide, like metoclopramide

While all of the medications listed have antiemetic properties, the patient described has gastroparesis, likely as a result of her longstanding diabetes. Metoclopramide can improve gastric motility and help her symptoms more than the other antiemetics listed.

Question 53

You are seeing a 48 yo man who complains of nausea and vomiting. He is nauseated before breakfast, and he describes the vomiting as “severe” and “projectile.” His symptoms are associated with headache and dizziness, but improve throughout the day. Which of the following is the most likely dx?

a. Gastroparesis
b. Cholelithiasis
c. Pancreatitis
d. Vestibular disorder
e. Brain tumor

Answer 53

e. Brain tumor

The symptoms and characteristics of nausea and vomiting can often be clues to the etiology. When nausea happens before eating in the morning, likely etiologies include pregnancy, uremia, alcohol withdrawal, and increased ICP (meningitis or space-occupying lesions).

Gastroparesis and pancreatitis are usually associated with nausea AFTER eating. Cholelithiasis is associated with nausea, vomiting, and pain after eating FATTY FOODS. Vestibular disorders cause nausea without any clear association with meals or time of day.

Question 54

A 42 yo woman is seeing you to evaluate nausea and vomiting. It happens about 60 min after eating a big meal and is associated with pain in the epigastric area. Which of the following tests is most likely to be abnormal in this case?

a. Amylase and lipase level assessment
b. Hemoccult testing of the stool
c. Abdominal x-rays
d. U/S
e. Upper endoscopy

Answer 54

d. U/S

The patient described likely has cholelithiasis. Nausea, vomiting, and pain occur after eating fatty meals. The diagnostic test of choice would be a RUQ U/S to identify stones in the gallbladder.

Amylase and lipase may be positive if the patient develops 2ndary pancreatitis, but are unlikely to be elevated until that point.

Question 55

You are caring for a 51 yo man complaining of neck pain for several weeks. He denies injury or illness. The pain is aggravated by movement, worse after activities, and there is a dull ache in the interscapular region. His exam reveals limited ROM, no tenderness to palpation, no radiation, and no neurologic signs. Which of the following is the most likely dx?

a. Osteoarthritis
b. Chronic mechanical neck pain
c. Cervical nerve root irritation
d. Whiplash
e. Cervical dystonia

Answer 55

a. Osteoarthritis

Question 56

You are seeing a 66 yo man complaining of R sided neck pain. He suffers from neck stiffness and complains that his R hand has become “numb.” On exam, you confirm paresthesia of his fingers that continues up the back of his arm, and his pain worsens when he turns his head to the R. Which of the following studies, if any, should be your next step in the workup?

a. Cervical spine radiographs
b. CT scan of his neck
c. MRI of his neck
d. EMG
e. No testing is necessary

Answer 56

b. CT scan of his neck

This patient likely has spinal stenosis. He is an older individual, and describes axial stiffness and paresthesias over several dermatomes (C7-T1). In this case, a CT scan is the best choice.

C-spine radiographs are indicated after injury.

MRI provides the best anatomic assessment of disk herniation and soft tissue or spinal cord abnormalities.

EMG would help localize radiculopathy, but that is not necessary in this case.

Question 57

You are seeing a hypertensive 56 yo woman who is complaining of a “fluttering in her chest.” She describes a rapid heart rate and to her it seems irregular. She is otherwise well, and denies shortness of breath, light-headedness pedal edema, or other acute symptoms. On examination, her pulse rate is rapid and irregular. Which of the following is her most likely dx?

a. Atrial fibrillation
b. Paroxysmal supraventricular tachycardia (PSVT)
c. Stable ventricular tachycardia
d. Stimulant abuse
e. Hyperthyroidism

Answer 57

a. Atrial fibrillation

When a patient describes her heartbeat as rapid and irregular, it suggests either afib or atrial flutter.

PSVT is usually rapid and regular, as is stable vtach.

Question 58

You are caring for a 23 yo woman complaining of pelvic pain. She reports one-sided pain that is diffuse and dull, but occasionally sharp. Menses have been normal. She denies fever. Based on this history alone, which of the following is the most likely cause of the pain?

a. PID
b. Ectopic pregnancy
c. Ovarian cyst
d. Uterine leiomyoma
e. Appendicitis

Answer 58

c. Ovarian cyst

Question 59

You are caring for a 21 yo woman complaining of pelvic pain. She reports a gradual onset of bilateral pain associated with fever, vomiting, vaginal discharge, and mild dysuria. Her pelvic exam demonstrates uterine, adnexal, and cervical motion tenderness. Which of the following is the best treatment option?

a. Ceftriaxone 250 mg IM in a single dose
b. Ceftriaxone 250 mg IM in a single dose + oral doxycycline 100 mg twice a day for 14 days
c. Ceftriaxone 250 mg IM in a single dose + oral doxycycline 100 mg twice a day for 14 days + oral metronidazole 500 mg twice a day for 14 days
d. Inpatient admission for parenteral abx

Answer 59

d. Inpatient admission for parenteral abx

The CDC recommended outpatient regimen is ceftriaxone 250 mg IM + doxycycline 100 mg BID for 14 days with or without metronidazole 500 mg BID for 14 days

Inpatient tx with parenteral abx is recommended for pregnant women, patients with severe illness with fever and vomiting, and cases where surgical emergencies can’t be ruled out.

Question 60

Pt has signs and sx of endometriosis. What test is most helpful in assessing?

Answer 60

MRI is sensitive for localization of endometriosis

Question 61

You are evaluating a 14 yo girl with pelvic pain. She denies being sexually active and you do not suspect abuse. On pelvic exam, you confirm that she has never been sexually active, see no discharge, and find no cervical motion tenderness, but feel an ovarian mass on the R side. Which of the following is the most appropriate next step in this situation?

a. Reassurance and use of NSAIDs for pain control
b. Reassurance and repeat pelvic exam in 6 to 8 weeks
c. Transvaginal pelvic U/S
d. CT scanning of the abdomen and pelvis
e. MRI evaluation of the pelvis

Answer 61

c. Transvaginal pelvic U/S

80% of ovarian masses in girls younger than 15 are malignant. Becuase of the high potential for malignancy, any adnexal mass should be evaluated by transvaginal U/S and referral for surgical removal.

In many women of childbearing years, adnexal masses are commonly cysts.

Question 62

You are evaluating an 18 yo male with a sore throat. It has been present for 3 days and is associated with fever, aches, and fatigue. On exam, he has an exudative pharyngitis, soft palate petechiae, and posterior cervical adenopathy. Which of the following is the most likely dx?

a. Group A strep infection
b. Group A strep colonization
c. Corynebacterium diphtheriae infection
d. Gonorrhea infection of the throat
e. Infectious mononucleosis

Answer 62

e. Infectious mononucleosis

Any of the conditions listed as answers in this question can cause an exudative pharyngitis. Palatal petechiae suggest either a group A streptococcal infection or infectious mononucleosis.

However, posterior cervical adenopathy should point to infectious mononucleosis as the correct dx.

Question 63

You are caring for a 16 yo girl with moderate acne. Her current regimen includes topical retinoids, benzoyl peroxide gel, and oral tetracycline, but after 4 mo on this regimen, she has not had improvement. You are considering treatment iwth oral isotretinoin (Accutane). In addition to ensuring that pregnancy is prevented during her therapy, which of the following must occur during her therapy?

a. She must avoid Tylenol use.
b. She must stop wearing her contacts.
c. She must stop her tetracycline.
d. She must be screened for depression every 3 months.
e. She must not use topical glucocorticoids.

Answer 63

c. She must stop her tetracycline.

Both tetracycline and isotretinoin cause pseudotumor cerebri so don’t use together.

Question 64

Treatment for rosacea

Answer 64

Oral antibiotics

Question 65

Treatment for pityriasis rosea

Answer 65

Self-limited; resolving

Can use antihistamines for itching

Question 66

Treatment for impetigo

Answer 66

Topical mupirocin

Question 67

After returning from a ski trip in the mountains, your 35 yo patient developed a rash. He has multiple erythematous pustules over his legs, arms, and chest. They are not pruritic and do not seem to be spreading. He denies any new soaps, lotions, foods, or medications. He did spend time in a hot tub on the trip. A picture of his rash is most consistent with hot tub folliculitis. Which of the following is the best tx option for this pt?

a. Reassurance and follow-up if no improvement
b. Topical steroid medication
c. Systemic steroid medication
d. Topical abx with activity against Streptococcus and Staphylococcus species
e. Oral abx with activity against Pseudomonas species

Answer 67

a. Reassurance and follow-up if no improvement

Question 68

You are seeing a 26 yo male patient complaining of a red eye who says “I think I have pink eye.” He reports increased redness, tearing, discharge, photophobia, and pain. Which of his reported symptoms would be more suggestive of something other than conjunctivitis?

a. Redness
b. Tearing
c. Discharge
d. Photophobia
e. Pain

Answer 68

e. Pain

Symptoms of conjunctivitis include increased redness, irritation, tearing, discharge, photophobia, or itching. Unfortunately, the character of the eye discharge is not useful in distinguishing bacterial from viral conjunctivitis.

Pain is suggestive of a more serious problem, possibly acute angle closure glaucoma, uveitis, scleritis, keratitis, a foreign body, or a corneal abrasion.

Question 69

A 32 yo mother of two young children presents to your office for evaluation of her left eye. She reports redness of the white part of her eye, with a watery discharge. She reports mild itching and a sensation as if something is in her eye. She denies a history of allergies and reports no concurrent allergic symptoms. Exam reveals a palpable preauricular lymph node. Fluorescein staining does not reveal corneal dendrites. Which of the following should be the tx of choice in this case?

a. Antiviral eye drops
b. Antibacterial eye drops
c. Corticosteroid eye drops
d. Combination abx/corticosteroid eye drops
e. Supportive care

Answer 69

e. Supportive care

The symptoms in this case are consistent with viral conjunctivitis. The presence of a palpable preauricular lymph node is characteristic of viral conjunctivitis. Approximately 85% of viral conjunctivitis is because of adenovirus, which is highly contagious, and is self-limited.

Only 15% of conjunctivitis is bacterial.

Question 70

You are seeing a 32 yo nurse who was treated for bacterial conjunctivitis. Despite the appropriate use of ciprofloxacin solution over the last 4 days, her purulent discharge and erythem have not improved. What should be the next step in treatment in this pt?

a. Ciprofloxacin ointment
b. Oral ciprofloxacin
c. Oral sulfamethoxazole-trimethoprim
d. Immediate ophthalmologic referral

Answer 70

c. Oral sulfamethoxazole-trimethoprim

Bacterial conjunctivitis is most commonly caused by Strep and Staph. However, there are increasing reports of conjunctivitis caused by MRSA.

MRSA conjunctivitis manifests as bacterial conjunctivitis resistant to conventional therapy, and is treated with the same drugs used to treat MRSA in other parts of the body.

Question 71

You are treating a 43 yo woman with RA for years You and her rheumatologist have had her illness in relatively good control. She presents to you with a red eye and significant eye pain. She denies trauma. Upon further questioning, she complains of decreased vision and headache. She describes the pain as deep and boring. Her exam reveals diffuse injection of the deeper vessels with minimal discharge. Her pupils react normally. Which of the following is her most likely dx?

a. Scleritis
b. Episcleritis
c. Corneal abrasion
d. Acute glaucoma
e. Iritis

Answer 71

a. Scleritis

Scleritis is a unilateral diffuse injection of the deeper scleral vessels. Symptoms include decreased vision, deep “boring” eye pain, and a surrounding headache. It is usually associated with systemic AI diseases like RA or Wegener granulomatosis.

Episcleritis is associated with mild irritation, and is not as intense as the syndrome described above.

A corneal abrasion is associated with decreased vsion, intense pain, and tearing, but is associated with trauma.

Acute glaucoma is associated with pain, decreased vision, and rednesss, but the affected pupil is usually dilated.

Iritis also has similar symptoms, but the pupil is small.

Question 72

A 36 yo man has had recurrent bouts of sinusitis. He develops at least 3 sinus infections per year and wants to discuss prevention. Which of the following conditions is the most likely preciipating factor for his recurrent sinusitis?

a. Allergic rhinitis
b. GERD
c. Cigarette smoking
d. Environmental pollutants
e. Immunodeficiency

Answer 72

a. Allergic rhinitis

Most patients with recurrent sinusitis have an underlying physiologic or anatomic abnormality that contributes to their problem. While all of the conditions listed predispose to bacterial infections of the sinus cavities, allergic rhinitis is the most common one listed and is present in at least 60% of people with recurrent sinusitis.

Question 73

Most common organisms causing symptoms of bacterial sinusitis

Answer 73

• S. pneumo****
• H. influenzae, Moraxella catarrhalis,* group A beta-hemolytic strep

Question 74

Appropriate next steps for a shoulder dislocation

Answer 74

Immobilization for 7 to 10 days, then begin physical therapy

Question 75

A 30 yo male cyclist comes to your office complaining of knee pain. He describes lateral knee pain when he goes for a long bike ride that does not improve with activity. On exam, he has tenderness over the lateral aspect of the knee just above the joint line. Which of the following is the most likely dx?

a. Iliotibial band syndrome
b. Patellofemoral pain syndrome
c. Medial collateral ligament sprain
d. ACL sprain
e. Medial meniscal tear

Answer 75

a. Iliotibial band syndrome

Iliotibial band syndrome is the most common cause of lateral knee pain in an athlete. It is most commonly seen in athletes who participate in repetitive knee flexion activities like distance runners and cyclists. The patient will present with pain or ache over the lateral aspect of the knee that worsens with activity, and on exam has pain and tightness over the IT band.

Patellofemoral pain syndrome would present with diffuse knee pain and a positive patellar grind test.

MCL sprains, ACL sprains, and meniscal tears would not present with lateral pain.

Question 76

A pt comes to see you after a skiing accident 6 days ago. She reports twisting her L knee during a fall, feeling a “pop,” and noting significant immediate swelling. She was able to bear weight immediately, but did not ski for the rest of the trip. Her pain is now improved, and she is ambulating, but she says the knee feels unstable. On exam, she has a tense effusion in her L knee and is unable to extend her knee fully. Which of the following is the most likely cause of her symptoms?

a. Patellofemoral pain syndrome
b. ACL tear
c. PCL tear
d. Meniscal injury
e. Medial collateral ligament sprain

Answer 76

b. ACL tear

The twisting injury, feeling of a “pop,” and immediate effusion while still being able to bear weight are consistent with an ACL tear. The sense of instability also helps lead toward that diagnosis.

Patellofemoral pain would generally not occur acutely or after an injury.

The mechanism of the PCL injury is through direct force to the knee.

Meniscal injuries also cause knee pain, and are frequently associated with ACL tears, but are more likely to cause locking, catching, or giving way.

Question 77

What are the Ottawa ankle rules?

Answer 77

Useful guide to use to determine if radiographs are indicated after an ankle sprain

Films should be obtained if:

• The patient is unable to walk 4 steps immediately after the injury and in the office
• There is tenderness over the distal 6 cm of the tibia or fibula, including the malleoli
• There is midfoot or navicular tenderness
• There is tenderness over the proximal fifth metatarsal

Question 78

Working up a tremor in a patient, you found that the patient does have Parkinson disease. Which of the following medications has been shown to delay functional impairment and disease progression?

a. Selegiline (Eldepril)
b. Carbidopa-levodopa (Sinemet)
c. Bromocriptine (Parlodel)
d. Pramipexole (Mirapex)

Answer 78

a. Selegiline (Eldepril)

Question 79

You are seeing a 24 yo woman who presents to your office complaining of “wheezing.” She reports acute SOB that occurred while she was shopping, and her wheezing is associated with pleuritic pain. She is otherwise healthy, only taking OCPs. On exam, she is tachypneic, but not in acute distress. Auscultation of her lungs is normal. After the appropriate dx workup, what is the best treatment option for this pt?

a. Reassurance and observation
b. Abx therapy
c. Anticoagulation
d. Bronchodilators
e. Steroids

Answer 79

c. Anticoagulation

When a patient presents with acute SOB and an increased RR, PE must be ruled out. The patient in this case is taking OCPs, increasing her risk for PE.

After appropriate workup, anticoagulation should be initiated. An allergic rxn, asthma, or bronchitis would likely cause an abnormal lung exam.