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49 Cards in this Set

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A 77 yo M is hospitalized for CHF.
During his 3rd day of his hospital stay he complains of palpitations and double vision.
He appears to be very agitated and confused during the PE.
An ECG shows prolonged PR intervals, depressed (scooped) ST segments, and alterations in T wave morphology.
The most likely diagnosis is:
Renal failure
Sick sinus syndrome
Second-degree heart block
Atrial fibrillation
Medication overdose
Medication overdose

This pt has symptoms and ECG findings consistent with DIGOXIN TOXICITY (visual disturbances, mental status changes, palpitations, prolonged PR interval, scooped ST segments, T wave alterations).

Sick sinus syndrome often presents with alternating arrhythmias of tachycardia and bradycardia
A 77 yo M is hospitalized for CHF.
During his 3rd day of his hospital stay he complains of palpitations and double vision.
He appears to be very agitated and confused during the PE.
An ECG shows prolonged PR intervals, depressed (scooped) ST segments, and alterations in T wave morphology.
Which of the following electrolyte abnormalities has been shown to be a predictor of morbidity and mortality in patients diagnosed with this condition?
Hypokalemia
Hypocalcemia
Hypomagnesemia
Hyperkalemia
Hypercalcemia
Hyperkalemia

Hyperkalemia has been shown to be a solid predictor of morbidity/mortality in pts with digoxin toxicity as a sign of inactivation of the Na/K-ATPase pump

Hypokalemia can result in digoxin toxicity with ease and is a major precaution; however, it is not a predictor of morbidity/mortality
A 77 yo M is hospitalized for CHF.
During his 3rd day of his hospital stay he complains of palpitations and double vision.
He appears to be very agitated and confused during the PE.
An ECG shows prolonged PR intervals, depressed (scooped) ST segments, and alterations in T wave morphology.
The best treatment option at this time is:
Activated charcoal
Digoxin Fab fragments
CCBs
Cardioversion
Transcutaneous pacing
Digoxin Fab fragments

Digoxin toxicity is best treated with digoxin Fab
A 77 yo M is hospitalized for CHF.
During his 3rd day of his hospital stay he complains of palpitations and double vision.
He appears to be very agitated and confused during the PE.
An ECG shows prolonged PR intervals, depressed (scooped) ST segments, and alterations in T wave morphology.
Care should be taken to avoid giving:
Sodium bicarbonate
Magnesium sulfate
Hydralazine
Esmolol
Diltiazem
Diltiazem

CCBs are strictly prohibited in pts suffering from digoxin toxicity because of the likelihood of causing increased digoxin levels in the blood
A 22 yo M presents to your clinic complaining of bleeding from his anus.
Screening labs show: Hb14.2, Hct 42.6, PLT 432, normal PT and increased PTT, bleeding time is normal.
A factor assay shows a factor VIII level of 0.8%.
He is treated with factor VIII.
How often should factor VIII be dosed?
Every 36 hrs
Every 24 hrs
Every 12 hrs
Every 8 hrs
Every 4 hrs
Every 12 hrs

Factor VIII has a half life of 12 hours
A 34 yo F complains of hearing loss for the past 6 mos.
Otoscopic exam is normal.
Rinne test indicates that bone conduction is audible longer than air conduction for both ears.
Her mother also suffers from hearing loss.
Which of the following additional findings is most likely?
Her semicircular canals contain dislodged otoconia
Symptoms of ear fullness and tinnitus
Autosomal recessive inheritance
Damage to CN VIII
Loss of stapedial reflex
Loss of stapedial reflex

Conductive hearing loss in a young woman with a family history of hearing loss is indicative of OTOSCLEROSIS.
Otosclerosis causes overgrowth of the middle ear bones, which would lead to loss of the stapedius muscle reflex

Damage to CNVIII would result in sensineural hearing loss (think Aminoglycoside toxicity)
Otosclerosis is AD
Ear fullness and tinnitus is indicative of Meniere's disease, which is a sensineural hearing loss (tx = Acetazolamide)
Semicircular cancals containing dislodged otoconia describes Benign Positional Vertigo, which isn't associated with hearing loss
A 78 yo F with a 35 pack year smoking Hx is brought to the hospital by her daughter after developing worsening SOB.
Upon exam, the pt has a pink complexion and is very thin.
Decreased breath sounds and audible expiratory wheezing are noted with auscultation of the chest.
Pulmonary function testing of this pt would most likely show:
Decreased TLC, Decreased FRC, Increased FEV1/FVC, Decreased DLCO
Increased TLC, Increased FRC, Decreased FEV1/FVC, Decreased DLCO
Increased TLC, Increased FRC, Decreased FEV1/FVC, Increased DLCO
Decreased TLC, Increased FRC, Increased FEV1/FVC, Increased DLCO
Increased TLC, Decreased FRC, Normal FEV1/FVC, Decreased DLCO
Increased TLC, Increased FRC, Decreased FEV1/FVC, Decreased DLCO

This pt has EMPHYSEMA ("PINK PUFFER") based on her appearance of pink complexion and thin build
Bronchitis pts are usually obese and blue ("blue bloaters")
Emphysema and bronchitis are both obstructive lung diseases and differ only by the DLCO in their PFTs
DLCO is the measure of the thickness of the alveolar membrane and is DECREASED in EMPHYSEMA and INCREASED in BRONCHITIS
A 23 yo F presents to your clinic for a prenatal visit.
Looking at her chart you see that she has a Hx of IV drug use, syphilis, genital herpes, and has had multiple sexual partners over the past year.
During teh visit, you recommend an HIV test to screen for the disease.
The most appropriate test to offer at this time would be:
PCR
Western blot
Northern blot
ELISA
RNA viral load testing
ELISA

ELISA is the initial test for HIV
ELISA is followed up with a confirmatory Western blot

PCR and RNA viral load are used to track the progress of HIV once confirmed
A 66 yo M presents to your office complaining of pain in the lower extremities that is associated with walking a relieved by rest.
PE of the legs demonstrates atrophic changes with diminished pedal pulses.
The pt is morbidly obese and has a positive smoking Hx.
What is the best initial treatment?
Pedal pumping
Revascularization of the extremities
Conservative treatment
Clopidogrel
Metoprolol
Conservative treatment

Smoking cessation, weight loss, exercise, DM/HTN/Dyslipidemia control
This pt has claudication

Clopidogrel would be used as an adjunct
Revascularization is reserved for emergent situations
A 78 yo M presents to the hospital following a syncopal episode when going from a supine to standing position.
A few months ago he had a medication change for his depression.
He can't remember the name, but remembers reading that it is used for panic attacks and enuresis.
You suspect which of the following medications is responsible for his syncopal episode?
Trazodone
Venlafaxine
Sertraline
Imipramine
Nortriptyline
Imipramine

Imipramine is a TCA that has a high likelihood of orthostatic hypotension.
It is also used to treat enuresis

Nortriptyline is a TCA with the least likelihood of developing orthostatic hypotension
A 43 yo M presents to your office with his sister.
The pt's sister tells you that her brother can no longer remember their family member's names and frequently forgets to eat and bathe.
PE of the man shows epicanthic folds, a flat facial profile, macroglossia, and a single palmar crease.
What is the gene responsible for this pt's current presentation?
Huntington
Tau
Presenilin 2
Presenilin 1
APP
APP

This pt has Down's Syndrome which has progressed into Alzheimer's.
Alzheimer's caused by Down's is due to an over expression of Amyloid Precursor Protein (APP), which is carried on Chromosome 21
APP is converted to beta-amyloid which is neurotoxic

Tau protein is involved in the pathogenesis of AD.
A 13 yo F with a Hx of asthma is brought to her pediatrician's office for evaluation.
Her father reports that her asthma attacks have recently increased to about 3 times per week.
During the past month she has had 4 night time attacks.
She has an albuterol inhaler at home, which she only uses when needed during attacks.
Vitals are stable.
On PE, she has diffuse inspiratory and expiratory wheezing.
This pt's asthma is classified as:
Status asthmaticus
Severe persistent
Moderate persistent
Mild persistent
Mild intermittent
Mild persistent

Classification of asthma is based upon the # of attacks a person has per week and the # of night-time attacks a person has in a month

Mild intermittent: <2 attacks per week, <2 nocturnal attacks per month
Tx = PRN short acting B-2 ag.

Mild persistent: >2 per week, >2 nocturnal
Tx = Daily inhaled low dose steroid or leukotriene modifier + PRN short acting B-2 ag

Moderate Persistent: Attacks daily, >1 nocturnal attack PER WEEK
Tx = Daily inhaled HIGH dose steroid + LAB (Salmeterol) + PRN short acting B-2 ag +/- Theophylline

Severe persistent: Continuous symptoms, frequent nocturnal attacks
Tx = Oral steroids + HIGH dose inhaled + LAB + PRN short acting B-2 ag

Status asthmaticus is a life-threatening asthma exacerbation that requires intubation
A 6 yo girl is in need of an emergetn blood transfusion following a shark-attack which severed her left arm.
THe parents refuse to sign the consent for blood, stating that they are Jehovah's Witnessess and this violates their beliefs.
They are fully aware of the deadly consequences that will occur if the child doesn't receive blood products.
The most appropriat course of action is to:
Comply with the parent's wishes
Give PLTs
Give whole blood
Consult the hospital clergy
Set up a meeting with the hospital ethics committee
Give whole blood

Regarless of a parent's religious views, a child who is in need of a life-saving transfusion must be treated.
Physicians do not need parental consent in emergent situations
A 42 yo M presents to the ED with severe R knee pain.
The pt is subsequently diagnosed with pseudogout.
Analysis of the synovial fluid would likely show:
Bacteria on gram stain
Rhomboid-shaped crystals with negative birefringence
Rhomboid-shaped crystals with positive birefringence
Needle-shaped crystals with negative birefringence
Needle-shaped crystals with positive birefringence
Rhomboid-shaped crystals with positive birefringence

Gout = Needle-shaped crystals with negative birefringence
Septci arthritis = Bacteria on gram stain
A 17 yo M construction worker is seen in the ED 24 hrs after suffering a laceration on his forearm while at work.
He remembers getting a tetanus booster about six years ago but is unable to remember the exact date.
Otherwise, he is up to date with all immunizations.
The most appropriate course of action is to administer:
IV ABX only
Both tetanus toxoid and tetanus immunoglobulin
Basic wound care with no injections at this time
Tetanus immunoglobluin only
Tetanus toxoid only
Tetanus toxoid only

Tetauns toxoid should be given to anyone whose last dose was >5 years ago
Tetauns immunoglobulin should be given to anyone >60, or they have had <3 doses of tetanus toxoid in their lifetime
A 32 yo F presents to your clinic complaining of increasing joint pain.
X-rays shows joint destruction.
Screening labs show: Hb 14.2, Hct 42.6, PLT 432, normal PT and increased PTT.
A factor assay is performed and shows a factor XI level of 0.8%.
What is the most likely diagnosis:
Hemophilia A
Hemophilia B
Hemophilia C
Hemophilia D
Hemophilia E
Hemophili C

A = Factor VIII
B = Factor IX
C = Factor XI
D = Factor XII
E does not exist
A 32 yo F presents to your clinic complaining of increasing joint pain.
X-rays shows joint destruction.
Screening labs show: Hb 14.2, Hct 42.6, PLT 432, normal PT and increased PTT.
A factor assay is performed and shows a factor XI level of 0.8%.
The pt is treated with cryoprecipitate which doesn't decrease her bleeding episodes.
Which of the following are found in cryoprecipitate:
Factor VIII, factor XIII, vWF, fibrinogen, fibronectin
Factor VIII, factor XII, vWF, fibrinogen, fibronectin
Factor VIII, factor XI, vWF, fibrinogen, fibronectin
Factor VIII, factor X, vWF, fibrinogen, fibronectin
Factor VIII, factor IX, vWF, fibrinogen, fibronectin
Factor VIII, factor XIII, vWF, fibrinogen, fibronectin
Following stage III of delivery, a 29 yo primigravida begins to demonstrate signs of uterine atony.
The pt is found to have a BP of 182/105, pulse of 82, RR of 16, and T of 37.2.
Which of the following is a uterogonic drug and should be avoided at this time?
Ritodrine
Terbutaline
Methylergonovine
Caraboprost tromethamine
Oxytocin
Methylergonovine

Methylergonovine causes uterine smooth muscle contraction and vascular constriction, thus it should NOT be used in a woman with pre-eclamptic BPs

Oxytocin is 1st line for uterine atony and causes uterine smooth muscle contraction and vascular RELAXATION (leading to hypotension)
Caraboprost is a Prostaglandin analog that promotes uterine smooth muscle contractions and can cause N/V and bronchoconstriction (thus it must be avoided in pts with asthma)
Terbutaline and Ritodrine are both B2 selective agonists and are used to stop uterine contractions
An 8 month old M presents with Strep. Pneumonia positive bacteremia.
He has no significant medical history.
What is his most likely immunodeficiency:
Chediak-Higashi
C1 esterase
Chronic granulomatous disease
DiGeorge syndrome
Bruton's agammaglobulinemia
Bruton's

Bruton's (X-linked = Boys) is associated with B-cell deficiency, which increases the risk for encapsulated bacteria ("Kapsules Produce A Shield for SHiN" = Klebsiella, Pseudomonas, Salmonella, Strep P, Haemophilus, Neisseria)

DiGeorge's (CATCH 22) = Cardiac defects, Abnormal facies, Thymic aplasia, Cleft palate, Hypocalcemia, Chromosome 22 deletion
CGD = NADPH deficiency, leading to catalase positive bacterial invasion (Staph & Aspergillus) diagnosed with nitroblue tetrazolium test
C1 esterase = Recurrent, life-threatening angioedema
Chediak-Higashi = Albino, neutrophils with giant cytoplasmic granules
A 45 yo Caucasian M presents to your office complaining of periumbilical pain for 1 week.
The pt also reports experiencing HA, wt loss, fevers, weakness, and malaise during this time.
His vitals are BP 145/90, Pulse 86, T 37.6.
On PE you note an ill-appearing male who appears older thans his stated age.
His abdomen is diffusely tender without peritoneal signs.
Rovsing's sign and tenderness at McBurney's point are both negative.
Needle tracts of various ages are visible throughout the pt's arms.
Angiogram of the abdomen revelas multiple aneurysms in the mesenteric and renal arteries.
The confirmatory test for this diagnosis is:
P-ANCA
C-ANCA
Tissue biopsy
Ultrasound
ESR
Tissue biopsy

The confirmatory test for Polyarteritis Nodosa (PAN) is a tissue biopsy

C-ANCA is associated with Wegener's
P-ANCA is associated with PAN, but is a screening test

Note: PAN is associated with Heptatitis C & B in 30% of cases
A 2 yo F is brought to her pediatrician's office by her parents.
Until 5 weeks ago, the pt had met all appropriate milestones.
Her parents noted a distinct decline in the pt's ability to communicate and perform simple motor tasks.
Previously, she could use simple sentences and could demonstrate purposeful movements with her extremities.
During the exam, it is noted that, in addition to the findings that the parents report, the pt is awake and has short breath-holding spells and displays hand-wringing.
What is the most appropriate first-line treatment for this child?
Vagal nerve stimulation
Valproic acid
Multidisciplinary treatment addressing communication and motor disabilities
Diet consisting of a high level of carbs
Carbamazapine
Multidisciplinary treatment addressing communication and motor disabilities

Rett syndrome is treated, and appears, like Autism.
A 17 yo boy presents complaining of constipation.
A thorough workup reveals a mass near the illeocecal valve which is biopsied.
Biopsy reveal cells consistent with Burkitt's Lymphoma.
Which of the ofllowing blood smear descriptions is consistent with Burkitt's Lymphoma?
Sheets of lymphocytes with interspersed macrophages
Plasma cells with a fried egg appearance
Red blood cells stacked like poker chips
Giant cells with bilobular nuclei and eosinophilic nucleoli
Lacunar cells with collagen banding
Sheets of lymphocytes with interspersed macrophages

This image is often referred to as "Starry Sky" pattern.
The translation in Burkitt's is t(8;14) c-myc.
Treatment is RITUXIMAB

Lacunar cells with collagen banding = Nodular Sclerosing Hodgkin's Lymphoma (most common Hodgkin's)
Giant cells with bilobar nuclei = Reed Sternberg Cells
RBCs stacked like poker chips = Rouleaux formation of MM
Plasma cells with a fried egg appearance = MM
A 24 yo M who is unfamiliar to your practice presents with chronic stiffness in his lower back.
The pt also reports increased fatigue and states that his eyes are very sensitive to light.
This pr is demonstrating symptoms most consistent with the primary diagnosis of:
Narcotic addiction
Reiter's syndrome
Ankylosing spondylitis
Somatic dysfunction of the lumbar spine
Degenerative joint disease
Ankylosing spondylitis

AS commonly presents in males ages 15-30 with lumbar stiffness (bamboo spine), iritis (photophobia), recurrent oral ulcerations, and fatigue
HLA-B27 testing can be used as an initial diagnostic test to confirm the dx
HLA-B27 is positive in a number of inflammatory/arthritis/optic conditions: AS, Reiter's, Acute anterior uveitis, Iritis, Behcet's disease, Psoriatic arthritis, Inflammatory bowel disease

Reiter's ("can't pee, can't see, can't climb a tree") INITIALLY presents with urethritis (can't pee), then later presents with arthritis and conjunctivitis.
Although it presents similarly, urethritis is the FIRST symptom to develop
A few pt records are being reviewed because these patients developed a rare disease.
This is an example of:
Cross-sectional study
Cohort study retrospective
Cohort study prospective
Case-control study
Blinded experiment
Case-control study

Case-control studies are ONLY RETROSPECTIVE
They are great for RARE DISEASES because they can identify someone who has a rare disease and then compare them with a healthy population

Cohort studies can either be prospective or retrospective and are great for testing RISK
A 55 yo HIV-positive woman with a Hx of IV durg abuse and gonorrhea presents with a sort throat and pain with swallowing.
Her CD4 count is 250.
Her current medications include efavirenz, zidovudine, and enfuviritide.
Which of the following is the next best step?
Add acyclovir
Endoscopy
Add nystatin
Add a protease inhibitor
Add fluconazole
Add fluconazole

HIV-associated ESOPHAGITIS is typically due to CANDIDA
The tx of choice of candida esophagitis is FLUCONAZOLE

Nystatin would be used for oral candida (thrush) outbreaks, but not esophagitis
A 66 yo post-menopausal F presents to your office complianing of terrible vuvlar pruritis, which has been ongoing for the past several months.
The pt has been applying over the counter anti-fungal agents without relief.
On PE, you notice white plaques on her labia minora and majora.
You perform a punch biopsy, and atypia is not present.
The most effective treatment for this condition is:
Fluconazole
Chemotherapy
Excision
Estrogen cream
Topical corticosteroids
Topical corticosteroids

Lichen sclerosis is characterized by white, pruritic patches on the vulva, typically seen in elderly, post-menopausal women.

Estrogen cream would be used for atrophic vaginitis
Excision is the treatment for SCC of the vulva
Chemo is necessary if the SCC has metastasised
Fluconazole would be used to treat candida
A 45 yo M with a 50 pack year history presents with a dull epigastric pain for the past 2 months.
He admits to loss of appetite and a 10 lb wt loss over the past 3 months.
His sclerae are icteric and his GB is enlarged.
PMH includes PUD and GERD.
After a thorough work-up the pt is diagnosed with carcinoma of the body of the pancreas.
Which of the ofllowing is true concerning his diagnosis?
Whipple resection is indicated as long as there are no positive lymph nodes
Chronic alcohol consumption is a significant risk factor
Chemotherapy combined with radiation has shown promising results and can induce long-term remission
Cancer restricted to the body or tail generally has a better prognosis than the head
A hard periumbilical nodule is a poor prognostic sign
A hard periumbilical nodule is a poor prognostic sign

Correctly answering this question relies on the process of elimination.
A hard, palpable, perimubilical nodule (Sister Mary Joseph's nodule) indicates advanced disease and thus a poorer prognosis

Cancer restricted to the head of the pancreas has the best prognosis
Chemo and radiation are used as palliative treatment, they haven't shown promising results
Smoking, age, obesity, and FH are significant risk factors, alcohol is NOT a risk factor for CA (it is for pancreatitis)
Whipple resection is indicated for lesions restricted to the head of the pancreas
A 25 yo G1P0 HIV-positive woman at 8 weeks gestation presents for her first prenatal visit.
She is on HAART treatment which includes Zidovudine and her last CD4 count wa 320 two months ago.
She is positive for toxoplasmosis IgG.
Which of the following is the best advice?
Vaginal delivery and no breast feeding
Toxoplasmosis prophylaxis
Cesarean section when fetal lungs are mature
Abortion because her CD4 count is so low
Abortion because HAART drugs are contraindicated in pregnancy
Vaginal delivery and no breast feeding

Vertical transmission of HIV is 25% and reduced by 20% when using Zidovudine.
Breast feeding is contraindicated for HIV-pos women.
HAART drugs aren't contraindicated.

Toxoplasmosis IgG antibodies can cross the placenta and protect the fetus.
There is no need for prophylaxis, since the antibodies serve to protect the fetus
A 77 yo F nursing home resident with a Hx of decubitis ulcer is transferred to the Ed for progressive dyspnea, tachypnea, tachycardia and increased work of breathing that has progressed over the past several hours.
The pt is difficult to ventilate with high peak airway pressures and her oxygen saturation continues to decrease despite supplemental oxygen.
A STAT CXR reveals bilateral diffuse pulmonary infiltrates.
Which of hte following best correlates with this pt's findings?
PCWP 25, PaO2/FiO2 350, PVR 350
PCWP 25, PaO2/FiO2 350, PVR 200
PCWP 25, PaO2/FiO2 150, PVR 350
PCWP 12, PaO2/FiO2 250, PVR 200
PCWP 12, PaO2/FiO2 150, PVR 350
PCWP 12, PaO2/FiO2 150, PVR 350

This pt is likely suffering from ARDS due to sepsis from an infected decubitis ulcer
PCWP < 18 indicates ARDS; wherease PCWP > 18 indicates cardiogenic edema (CHF)
PaO2/FiO2 is a measure of A-a gradient, which is LOW in ARDS due to increased permeability of respiratory epithelium leading to interstitial edema and alveolar collapse.
PVR is INCREASED in ARDS due to the destruction of endothelium-derived vasodilators (NO, prostacyclin) via activation and adhesion of PLTs, neutrophils, and monocytes
A 14 yo gymnast is brought to your office for evaluation.
She complains of stiffness in her right hip and reports a "snapping" feeling when flexing at her waist.
Osteopathic evaluation reveals a tenderpoint medial to the right ASIS and a positive pelvic shift test to the left.
Which of the following tests would be the most useful tool for further evaluation of her condition?
Ober's test
Thomas test
Bounce home test
Lachman's test
Apley's compression test
Thomas test

Thomas test is used to diagnose tight psoas muscles

Apley's compression test evaluates meniscus and ligamentous structures of the knee
Lachman's test assess the stability of the ACL
Bounce home test evaluates mechanical injury to the knee
Ober's test detects tightness in the tensor fascia lata and IT band
A 29 yo M is at your office today because he is traveling to Mexico and wants prophylaxis for traveler's diarrhea.
He has known inflammatory bowel disease and will be in Mexico for three weeks.
Based on the above scenario, the most appropriate treatment would be:
Erythromycin
Doxycycline
TMP-SMX
Ciprofloxacin
Metronidazole
Ciprofloxacin

Cipro is the treatment and prophylaxis of choice for traveler's diarrhea

Metronidazole is good for anaerobic and parasitic infections such as Trichomoniasis
TMP-SMX & Doxycycline used to be used as prophylaxis but resistence developed
Erythromycin is the tx of choice for neonatal conjunctivitis prophylaxis
A 32 yo G3P2 presents at 17 weeks gestation because of decreased fetal movement.
On US they are unable to detect a fetal heartbeat.
The most likely diagnosis is:
Septic abortion
Missed abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed abortion

A missed abortion occurs with a LACK OF UTERINE GROWTH OR FETAL HEART TONES.
Tx = D&E
DIC is a serious complication

Threatened = Passage of blood before 20 weeks without cervical dilation and without expulsion of POC
Inevitable abortion = Passage of blood before 20 weeks WITH cervical dilation and without expulsion of POC
Incomplete abortion = Partial passage of POC
Complete abortion = Spontaneous abortion of all POC
Septic abortion = Following an abortion a pt develops fever, elevated WBCs, lower abdominal pain
A 17 yo M presents to the hospital with severe LUQ pain that started earlier today.
He was seen by his PCP three days ago after being kicked in his left side.
Plain X-rays show fractures of the left 7th and 8th ribs.
PE shows mild diffuse tenderness and guarding.
His BP is 118/74 and his pulse is 88.
A contrasted CT scan is obtained and shows a blush sign near the spleen.
What is the most appropriate next step in management of this pt?
Rib fracture wiring
Splenic angioembolization
Exploratory surgery with posssible splenic salvation
Exploratory surgery with splencectomy
Serial CT scans and observation
Splenic angioembolization

Since the pt is hemodynamically stable, the initial step in management of splenic trauma is embolization

If the pt were unstable or if the embolization did not work, exploratory surgery with possible splenic salvation would be attempted
A 22 yo G1P0 smoker is scheduled to talk about her recent abnormal Pap smear which showed atypical squamous cells of undetermined significance (ASCUS).
She has had negative Pap smears on a yearly basis since age 16.
She has had three sexual partners and uses condoms and oral contraceptives.
Which of the following is the most appropriate next step in the management of this patient?
Repeat Pap smear in 1 year
Colposcopy with biopsy
HPV typing
Ultrasound
LEEP
HPV typing

HPV typing is the initial test for the workup of ASCUS Pap

LEEP would be indicated after colposcopy
If a high-risk HPV type were detected, then the pt would need a colposcopy with biopsy
A repeat Pap in 6 months is warranted because of the ASCUS Pap
A 35 yo F delivered a healthy baby 3 hours ago.
She has a Hx of multiple sexual partners and PID.
She is concerned about breast-feeding and seeks advice.
Which of the followign is a contraindication for breast feeding?
Hep B
Breast cancer
Positive PPD
Cyclophosphamide
Mastitis
Cyclophosphamide

Cyclophosphamide is an alkyating agent used to treat cancer and is contraindicated in pregnancy

Babie born to mothers of active Hep B must receive the vaccine and immunoglobin therapy, but breast-feeding is not contraindicated
A 74 yo nursing home pt is brought to the ED for fever, poor appetitie and altered metnal status.
Her BP is 90/70 and temp is 101.4
Her PMH is significant for depression, HTN, and DM.
Lumbar puncture shows elevated protein and low glucose.
Which of the following is the most appropriate empirical therapy?
Ceftriaxone and erythromycin
Erythromycin and vancomycin
Ceftriaxone and fluconazole
Ceftriaxone and vancomycin
Ceftriaxone, vancomycin, and ampicillin
Ceftriaxone, vancomycin, and ampicillin

This pt has bacterial meningitis
Pts of this age group must be covered for S. Pneumo (Vancomycin), Neisseria meningitidis (Ceftriaxone) and LISTERIA (Ampicillin)
Pts > 65 must be treated with these three agents for these three bugs

Adults < 65 must be treated for S. Pneumo (Vancomycin) & Neisseria M (Ceftriaxone)

Neonates <1 mo old must be treated with Ampicillin and Ceftriaxone to cover S. Aglactiae, Listeria, and E.Coli
A 62 yo M with a PMH of COPD and HTN presents to the ED complaining of a "fluttering" in his chest.
He is pale and diaphoretic and becoming increasingly confused.
Your attempts at placing a peripheral IV are unsuccessful and the pt becomes unresponsive.
Vitals are BP 90/45, HR 180, RR 18, O2 95%.
He is connected to a heart monitor and you determine his rhythm to be a SVT.
What is the best next step in management?
Synchronized cardioversion without conscious sedation
Synchronized cardioversion with conscious sedation
Administer adenosine 12 mg
Administer adenosine 6 mg
Place a central line
Synchronized cardioversion without conscious sedation

Because this pt has SVT and is unconscious and unstable, he should be synchronized immediately without sedation

If the pt were to have SVT and become unstable BUT still be conscious, then he would need synchronized cardioversion with conscious sedation

Adenosine 6 mg is the initial treatment for a stable pt with SVT and WITH IV ACCESS
You are the PCP of a 72 yo M who presents to your office with insomnia, which is now causing him to take multiple naps throughout the day.
The pt states that he has difficulty falling asleep almost every night but does not awaken after he is asleep.
The most appropriate medicaiton at this time would be:
Amitryptiline
Trazodone
Zolpidem
Furazepam
Estazolam
Zolpidem

This pt suffers from sleep onset insomnia.
Sedative hypnotics like ZOLPIDEM, ZALEPLON & TRIAZOLAM work best for these patients
Sedative hypnotics should not be combined with alcohol

Pts who suffer from sleep maintenence insomnia (can't stay asleep) would benefit most from ESTAZOLAM or FLURAZEPAM because of their slow release
Both are benzos and should be avoided in pts with narrow angle glaucoma or untreated obstructive sleep apnea

Pts suffering from depression and insomnia would benefit most from TRAZODONE or AMITRYPTILINE
Pts with cardiac arrhythmias should avoid amitryptiline
A 10 yo F presents to your outpatient clinic for a follow-up visit six months status-post softball injury whereby she was struck above the left ear with a ball in the region of the pterion.
What foud bones form the pterion?
Temporal, zygomatic, sphenoid, parietal
Temporal, parietal, sphenoid, frontal
Temporal, frontal, occiput, sphenoid
Sphenoid, zygomatic, occiput, parietal
Sphenoid, frontal, mandible, parietal
Temporal, parietal, sphenoid, frontal
A 68 yo M diagnosed with mild cognitive impairment is scheduled to undergo volumetric MRI to screen for Alzheimer's disease.
The pt's daughter reports that his short-term memory has become progressively worse over recent months and he often forgets her name.
Recent evidence has suggested that patietns are at an increased risk for developing Alzhemier's disease if they have the allele for:
Apo D
Apo E4
Apo A-I
Apo B-100
Apo C-II
Apo E4

MRI images of the brains of pts' with Alzheimer's will show HIPPOCAMPAL ASYMMETRY
A 43 yo alcoholic M presents to the ER 2 days after undergoing an esophagoduodenoscopy complaining of intractable vomiting, painful swallowing and SOB.
A review of systems, complete H&P indicate the presence of Mackler's triad and a subsequent diagnosis of boerhaave's syndrome is suspected.
What is Mackler's triad?
Chest pain, vomiting, subQ emphysema
Chest pain, vomting, dyspnea
Chest pain, dyspnea, fever
Dyspnea, fever, odynophagia
Odynophagia, chest pain, fever
Chest pain, vomiting, subQ emphysema

Mackler's triad is a result of esophageal rupture/perforation (boerhaave's syndrome)
50% of boerhaave's syndrome cases are a result of endoscoping procedures
The pt with Mackler's triad develops chest pain, vomiting and subQ emphysema all due to the perforation of the esophagus
A 60 yo F presents to her gynecologist with abnormal vaginal bleeding.
She reached menopause at age 55.
She denies pain but admits to feeling weak and light-headed.
Her Hb is 10, BP is 120/70.
Which of the following is the next best step?
Colposcopy
Endometrial biopsy
Hysterectomy
Pelvic ultrasound
Transfuse packed RBCs
Endometrial biopsy

The initial test in a post-menopausal woman with abnormal vaginal bleeding is ALWAYS ENDOMETRIAL BIOPSY to rule out endometrial cancer
The most common cause of post-menopausal vaginal bleeding is atrophy of the endometrium; however, CA must be ruled out since it is the most deadly

Pelvic ultrasound would be correct if ovrain cancer were suspected
A 72 year old male is brought to the emergency department following an isolated syncopal event while getting up from his bed.
When questioned, he reports experiencing multiple episodes of dizziness when standing upright for "quite some time."
His past medical history significant for hypothyroidism, BPH, depression, and hypertension.
Physical examination reveals a standing blood pressure of 101/58 mm Hg and supine pressure of 148/81.
A positive tilt table test is noted.
Orthostatic hypotension is a physical finding defined by the American Academy of Neurology as a:
Systolic blood pressure decrease of at least 30 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 1 minute of standing
Systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of standing
Systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 5 minutes of standing
Systolic blood pressure decrease of at least 10 mm Hg or a diastolic blood pressure decrease of at least 20 mm Hg within 5 minutes of standing
Systolic blood pressure decrease of at least 30 mm Hg or a diastolic blood pressure decrease of at least 20 mm Hg within 1 minutes of standing
Systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within 3 minutes of standing
A 32 yo F with a Hx of anxiety presents to your clinic complaining of heart palpitations.
PE reveals a mid-systolic click followed by a late systolic regurgitant murmur.
Which of the following is associated with the most likely diagnosis?
Cystic medial degeneration
Defective type I and III collagen production
Plasma cell infiltrate in the vessel walls
Defective fibrillin production
Myxomatous degeneration with excess dermatan sulfate
Myxomatous degeneration with excess dermatan sulfate

MVP is commonly associated with Marfan's or Ehler's danlos syndromes.
Its pathophysiology causes mysomatous degeneration with excess dermatan sulfate

Defective fibrillin production is associated with Marfan's syndrome. While Marfan's is common in pts with MVP, not all pts with MVP have Marfan's
Defective type I and III collagen production is associated with Ehler's danlos. Again while Ehler's danlos is commin in pts with MVP, not all pts with MVP have EDS
A 32 yo F with a Hx of anxiety presents to your clinic complaining of heart palpitations.
PE reveals a mid-systolic click followed by a late systolic regurgitant murmur.
Which of the following will move the audible click closer tot he S1 heart sound?
Beta blockers
Reclining
Anxiety
Sustained hand grip
Squatting
Anxiety

MVP is the dx
Things that will move the click closer to the S1 heart sound do so by decreasing preload: ANXIETY, standing, valsalva

Increased preload will cause the click to move closer to the S2 sound, including: Reclining, squatting, sustained hand grip
A 32 yo F with a Hx of anxiety presents to your clinic complaining of heart palpitations.
PE reveals a mid-systolic click followed by a late systolic regurgitant murmur.
Which of the following is the best treatment for this pt's condition?
Aspirin
Warfarin
Mitral valve replacement
Mitral valve repair
Propranolol
Propranolol

Beta blockers decrease the heart rate and force of contraction leading to less stretch and trauma to the prolapsed leaflets
A 48 year old factory worker presents to your clinic complaining of diarrhea and an inability to extend his right wrist which began a few weeks ago.
He has worked in an ammunition factory since age 18.
Physical exam shows 2/5 MMS with right wrist extension.
A urinalysis is positive for bicarbonate, amino acids, phosphate and glucose.
What is the most likely diagnosis:
Organophosphate poisoning
Cyanide poisoning
Arsenic poisoning
Mercury poisoning
Lead poisoning
Lead poisoning

Lead exposure = Pain chips, working in battery or ammunition factories, consumption of moonshine from lead-lined radiators
Presentation = "LEAD" = Lead lines on gingiva (Burton's lines), Encephalopathy or Erythrocyte basophilic stippling, Anemia (sideroblastic) or Abdominal colic, Drops (wrist and foot), Dimercaperol and EDTA
Lead may also cause peripheral neuropathy and renal failure due to Fanconi's syndrome

Mercury exposure = over-consumption of fish
Presentation = diarrhea, constricted visual fields, renal failure, tachycardia, HTN, peripheral neuropathy, hyperhydrosis
Tx = Succimer, dimercaprol, penicillamine

Arsenic exposure = Pesticides, contaminated ground water
Presentation = severe HA, abd. pain, diarrhea, delirium, convulsions, BREATH THAT SMELLS LIKE GARLIC
Tx = succimer or dimercaprol

Cyanide exposure = House fires
Presentation = coma, seizures, heart dysfunction, metabolic acidosis, BREATH TAHT SMELLS LIKE BITTER ALMONDS
Tx = Amyl nitrate and thiosulfate

Organophosphate exposure = Pesticides
Presentation = Salivation, lacrimation, urination, fecal incontinence, diaphoresis, blurry vision, HTN, bradycardia, muscle fasiculations
Tx = Atropine
A 59 year old female, who appears older than her stated age, develops a persistent productive cough with mucous plugging.
The patient has a long-standing history of asthma and has failed multiple attempts to wean from corticosteroids.
Auscultation of the chest reveals bilateral wheezing, more prominent on the left side.
A CXR shows cavitary lesions.
Based on this information, the patient is most likely suffering from:
Aspergilosis
Wegener's granulomatosis
Tuberculosis
Sarcoidosis
Histoplasmosis
Aspergilosis

The pt is suffering from allergic bronchopulmonary aspergillosis, which is typically seen in pts suffering from asthma or CF.
Symptoms include productive coughing, mucous plugging, and hemoptysis.
It should be suspected in asthmatics with poorly-controlled disease who are unable to wean from corticosteroids.

Histoplasmosis is associated with spelunkers and bat droppings and causes the lung to form a granulmoa
Sarcoidosis forms granulomas and presents with SOB, erythema nodosum, fatigue, wt loss, dry eyes, high ACE levels
which of the following defines the prevalence of a disease?
The difference in the total number of cases of the disease between major cities
The number of new cases of a disease diagnosed during a one year time period
The total number of cases of a disease in the area
The total number of existing cases of a disease divided by the total population in the area
The total number of individuals with the disease at this moment in time divided by the total number of new cases of a disease
The total number of existing cases of a disease divided by the total population in the area

Incidence = The number of new cases of a disease diagnosed during a one year time period