ChatGBT Questions Flashcards

Question

A 45-year-old man with a history of hyperlipidemia presents with sudden onset of shortness of breath, right-sided chest pain, and hemoptysis. He recently returned from a long car trip. His oxygen saturation is 89% on room air. What is the most appropriate diagnostic test to confirm the suspected condition?** - A. Chest X-ray - B. D-dimer assay - C. CT pulmonary angiography - D. Echocardiogram

Answer 1

C. CT pulmonary angiography ## Footnote The clinical scenario is highly suggestive of a pulmonary embolism. CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism and should be performed immediately given the symptoms.

Answer 2

C. Observation and reassurance ## Footnote In a patient with mitral valve prolapse who is experiencing occasional PVCs but no other signs of hemodynamic instability, the most appropriate management is observation and reassurance. PVCs are common and often benign.

Answer 3

C. Acute decompensated heart failure ## Footnote The presence of an S3 gallop and an enlarged cardiac silhouette on chest X-ray in a patient presenting with dyspnea and cough suggests acute decompensated heart failure.

Answer 4

B. Cardiac catheterization ## Footnote Cardiac catheterization can help assess the severity of aortic stenosis and guide decisions about timing for surgical valve replacement, which may be necessary given her symptom of syncope.

Answer 5

A. Acute myocardial infarction ## Footnote New T-wave inversions in leads II, III, and aVF are suggestive of ischemia in the inferior wall of the heart, indicating an acute myocardial infarction, especially given his significant smoking history.

Answer 6

B. Complete heart block ## Footnote the presentation of severe dizziness, weakness, hypotension, bradycardia, and wide QRS complexes is consistent with complete heart block, a serious condition requiring immediate pacing.

Answer 7

D) Arthrocentesis ## Footnote In a patient with rheumatoid arthritis presenting with acute knee pain, swelling, and signs of inflammation, arthrocentesis is critical to exclude septic arthritis, a potential emergency. An X-ray, while useful, would not provide immediate information regarding potential joint infection.

Answer 8

C) Anterior shoulder dislocation ## Footnote The description of anterior fullness and a squared-off deltoid contour is classic for an anterior shoulder dislocation, common in contact sports injuries.

Answer 9

B) MRI of the lumbar spine ## Footnote MRI is the best choice for visualizing soft tissue details needed to diagnose herniated discs and nerve root impingement, likely in this case given the sciatica symptoms.

Answer 10

A) Pelvic X-ray ## Footnote Pelvic X-rays are the first-line diagnostic tool for suspected hip fractures, especially after a low-energy trauma in an osteoporotic patient

Answer 11

B) Gout ## Footnote Acute gouty arthritis is likely given the rapid onset, severe pain, and association with alcohol consumption, commonly affecting the great toe (podagra).

Answer 12

B) Systemic lupus erythematosus ## Footnote The combination of joint symptoms, a butterfly rash, and systemic symptoms like fatigue strongly suggests systemic lupus erythematosus.

Answer 13

B) Ankle X-ray ## Footnote The Ottawa ankle rules suggest an X-ray is required in cases of ankle pain with bone tenderness and an inability to bear weight immediately after injury and in the emergency department.

Answer 14

B) Avascular necrosis of the femoral heads ## Footnote Chronic steroid use and smoking are risk factors for avascular necrosis, which can present with hip pain and reduced range of motion

Answer 15

D) Fat embolism syndrome ## Footnote Fat globules in synovial fluid following trauma without a visible fracture suggest intra-articular fat, indicative of a bone marrow embolism potentially from a non-displaced bone fracture.

Answer 16

A) Wrist X-ray ## Footnote Tenderness in the anatomical snuffbox after trauma is highly suggestive of a scaphoid fracture. An initial X-ray is appropriate to evaluate for this common injury.

Answer 17

B) Lateral malleolus fracture ## Footnote Given the tenderness over the lateral malleolus and the inability to bear weight, a fracture is highly probable, particularly in the setting of an acute inversion injury. An X-ray would confirm this diagnosis according to the Ottawa ankle rules.

Answer 18

C) Prescription NSAIDs and muscle relaxants ## Footnote This presentation is consistent with acute lumbar strain. Initial management includes NSAIDs and muscle relaxants. Bed rest is discouraged as it may delay recovery, and imaging or surgical referral is not indicated unless neurological deficits are present.

Answer 19

A) X-ray of the hip ## Footnote An X-ray is the first-line imaging study in patients presenting with symptoms suggestive of exacerbation of osteoarthritis, as it can reveal joint space narrowing, bone spurs, and other changes associated with the disease

Answer 20

C) Immediate MRI ## Footnote With clinical suspicion of a scaphoid fracture and negative initial X-rays, an MRI is indicated as it can detect occult fractures not visible on X-rays. This ensures appropriate management to prevent complications like avascular necrosis.

Answer 21

A) Patellar tendinitis ## Footnote Known as 'jumper's knee,' patellar tendinitis is common in athletes and presents with localized pain aggravated by activities that load the knee joint, such as jumping

Answer 22

A) Acute rotator cuff tear ## Footnote Chronic steroid use is a risk factor for tendon degeneration, which can lead to an acute rotator cuff tear, particularly under sudden stress. This diagnosis is supported by weakness in abduction, suggesting a tear involving the supraspinatus tendon.

Answer 23

B) Administer analgesia and order a wrist X-ray ## Footnote Initial management should focus on pain control and diagnostic imaging to assess the extent of the injury, which is critical for determining the appropriate intervention, including potential need for reduction or surgery.

Answer 24

A) Meniscal tear ## Footnote The inability to fully extend the knee, often referred to as a 'locked knee,' is a classic sign of a meniscal tear, particularly following a twisting injury during sports.

Answer 25

C) MRI of the cervical spine ## Footnote An MRI is appropriate given the symptoms of radiating pain, which may indicate nerve root compression or other soft-tissue injuries not visible on X-rays or CT scans

Answer 26

A) Hip fracture ## Footnote Given her age and the mechanism of injury, a hip fracture is highly likely and requires immediate X-ray imaging to confirm the diagnosis and guide further management.

Answer 27

C) Anterior cruciate ligament (ACL) tear ## Footnote A 'popping' sound followed by immediate swelling and a positive Lachman test (which indicates anterior translation of the tibia relative to the femur) are classic indicators of an ACL tear.

Answer 28

B) Distal radius fracture ## Footnote A fracture through the radial styloid typically indicates a distal radius fracture, often referred to as a Chauffeur's fracture, common in falls on an outstretched hand.

Answer 29

A) NSAIDs and physical therapy ## Footnote This scenario suggests acute nonspecific low back pain, best managed initially with non-opioid analgesics such as NSAIDs and physical therapy to encourage mobility and strengthen the back.

Answer 30

B) Patellofemoral pain syndrome ## Footnote Patellofemoral pain syndrome is common in young athletes, especially females, presenting with pain localized to the anterior knee, exacerbated by activities that increase patellofemoral joint stress, such as running and stair climbing

Answer 31

B) Metastatic prostate cancer ## Footnote Patients with a history of prostate cancer presenting with new severe back pain and lytic lesions on radiograph are highly suggestive of metastatic disease to the spine.

Answer 32

C) Splint and follow-up in one week ## Footnote With clinical suspicion of a scaphoid fracture and an initially negative X-ray, it is appropriate to splint the wrist and arrange for close follow-up. An MRI may be considered if symptoms persist or worsen.

Answer 33

D) Trapezius muscle injury ## Footnote Explanation: Inability to shrug the shoulder against resistance with a dropped shoulder appearance typically indicates a trapezius muscle injury, possibly involving the accessory nerve.

Answer 34

B) Perform a reduction in the emergency department ## Footnote Clinical signs suggest a dislocated ankle, which requires immediate reduction in the emergency department to restore alignment and minimize vascular compromise.

Answer 35

D) Splint and re-evaluate in 10-14 days ## Footnote With tenderness in the anatomical snuffbox and an inconclusive initial X-ray, it is prudent to splint the wrist and schedule a follow-up, including a repeat X-ray, to rule out a scaphoid fracture, which can often be initially occult.

Answer 36

D) Insufficiency fracture ## Footnote In elderly patients, particularly those with underlying conditions that may weaken bone (like COPD with long-term steroid use), an insufficiency fracture may occur even with minimal trauma and can be initially radiographically occult. MRI or CT may be needed to confirm the diagnosis.

Answer 37

B) Acute pancreatitis ## Footnote The patient’s history of alcohol abuse combined with the classic symptom of epigastric pain radiating to the back and elevated lipase confirms the diagnosis of acute pancreatitis. Acute cholecystitis and peptic ulcer disease typically do not cause pain that radiates to the back, and GERD does not correlate with elevated lipase levels.

Answer 38

B) Perform a CT scan of the abdomen ## Footnote The clinical presentation is suggestive of acute appendicitis. A CT scan is the diagnostic tool of choice in adults to confirm the diagnosis and rule out other causes of right lower quadrant pain.

Answer 39

A) Diverticular disease ## Footnote Given the patient's age and history of chronic constipation, diverticular disease with possible acute diverticulitis is likely, presenting with left-sided abdominal pain and altered bowel habits. Ischemic bowel disease typically presents with pain out of proportion to physical findings.

Answer 40

D) Campylobacter jejuni ## Footnote Campylobacter jejuni is a common cause of bacterial enteritis, particularly in young adults and is often associated with consumption of contaminated water or food and recent travel or outdoor activities, such as camping.

Answer 41

C) Administration of IV fluids and blood transfusion ## Footnote This patient is presenting with signs of hypovolemic shock due to upper gastrointestinal bleeding, likely from a peptic ulcer. Immediate resuscitation with IV fluids and blood transfusion is necessary before further diagnostic steps such as endoscopy.

Answer 42

C) ERCP ## Footnote The presentation is suggestive of cholestasis, possibly due to a biliary obstruction. ERCP (Endoscopic Retrograde Cholangiopancreatography) is appropriate for visualizing the biliary tree and identifying any obstructive lesion such as stones or tumors.

Answer 43

C) Gallstones with acute cholecystitis ## Footnote This classic presentation of right upper quadrant pain with a positive Murphy’s sign and systemic symptoms such as fever strongly suggests acute cholecystitis, typically associated with gallstones.

Answer 44

D) Oral vancomycin ## Footnote The patient’s history of recent antibiotic use and symptoms are suggestive of Clostridium difficile infection. Oral vancomycin is the treatment of choice for C. difficile infection.

Answer 45

D) Molar pregnancy ## Footnote The unusually high hCG levels and presentation of abdominal pain in a pregnant woman raise the suspicion of a molar pregnancy, which is characterized by abnormal trophoblastic growth.

Answer 46

B) Administer vitamin K ## Footnote The patient has an elevated INR and symptoms of gastrointestinal bleeding, indicating warfarin over-anticoagulation. Vitamin K is used to reverse the effects of warfarin rapidly to manage the bleeding.

Answer 47

B) Acute pancreatitis ## Footnote The patient's presentation of severe epigastric pain that improves on leaning forward, along with a history of risk factors such as chronic smoking and alcohol use, strongly suggests acute pancreatitis. This condition often presents with pain that radiates to the back and is alleviated by sitting up and leaning forward.

Answer 48

B) Giardia lamblia ## Footnote Giardia lamblia, a protozoan parasite, is commonly contracted through contaminated water, which fits the patient's history of drinking untreated water during a trip to South America. It presents with diarrhea, cramps, and sometimes fever.

Answer 49

C) Perform endoscopic retrograde cholangiopancreatography (ERCP) ## Footnote Given the findings of gallstones and a dilated common bile duct in a patient presenting with jaundice and right-sided abdominal pain, ERCP is indicated to remove any obstructing stones in the bile duct and alleviate the obstruction.

Answer 50

B) Drug-induced liver injury ## Footnote Methotrexate is known to potentially cause hepatotoxicity, especially in patients with pre-existing liver conditions or prolonged use, leading to symptoms like jaundice and pruritus. This patient’s symptoms are consistent with a drug-induced liver injury.

Answer 51

B) Oral vancomycin ## Footnote The presence of pseudomembranes seen during colonoscopy and a history of recent antibiotic use suggest Clostridium difficile infection. Oral vancomycin is the treatment of choice for moderate to severe cases.

Answer 52

B) Diverticulitis ## Footnote Diverticulitis often presents with sudden onset of pain in the left lower quadrant, especially in a younger patient without a clear precipitating factor like trauma. The episode of coughing may have increased intra-abdominal pressure, triggering a diverticular rupture or inflammation.

Answer 53

B) Esophagogastroduodenoscopy (EGD) ## Footnote EGD is indicated for an elderly patient presenting with melena and a history of NSAID use, as it is the best initial diagnostic test to evaluate for upper gastrointestinal bleeding, likely caused by peptic ulcer disease.

Answer 54

C) Acute cholecystitis ## Footnote The patient’s symptoms of severe pain after a fatty meal and a positive Murphy’s sign are classic for acute cholecystitis, an inflammation of the gallbladder often caused by gallstones.

Answer 55

A) Refer to a dietitian to review dietary compliance ## Footnote Before considering further invasive testing or treatments, it is crucial to ensure that the patient is strictly adhering to a gluten-free diet as non-compliance is a common reason for lack of improvement in symptoms of celiac disease.

Answer 56

C) Biliary dyskinesia ## Footnote Biliary dyskinesia can present with symptoms similar to gallstone disease but without visible stones on imaging studies. It should be considered especially when other common causes have been ruled out and there is a recurrent pattern of symptoms.

Answer 57

C) Administer intravenous fluids and packed red blood cells ## Footnote The patient presents with signs of an upper gastrointestinal bleed and hemodynamic instability, indicated by coffee-ground emesis and hypotension. Immediate fluid resuscitation with IV fluids and blood transfusion is critical to stabilize the patient before further diagnostic and therapeutic measures.

Answer 58

B) Bowel obstruction ## Footnote The presentation of acute abdominal pain, fever, and a rigid abdomen in a patient with a history of multiple abdominal surgeries strongly suggests a bowel obstruction, possibly due to adhesions. The lack of recent food intake is consistent with an obstruction.

Answer 59

B) Esophagogastroduodenoscopy (EGD) ## Footnote The patient's history of alcoholism and presentation with melena (black, tarry stools) suggest an upper gastrointestinal source of bleeding, most likely related to gastropathy or esophageal varices. EGD is the appropriate initial diagnostic test to visualize the upper gastrointestinal tract.

Answer 60

A) Intravenous antibiotics and urgent cholecystectomy ## Footnote This patient's symptoms and ultrasound findings are indicative of acute cholecystitis. The appropriate management is intravenous antibiotics to cover potential bacterial infection and an urgent cholecystectomy to remove the inflamed gallbladder.

Answer 61

B) Celiac disease ## Footnote The symptoms of diffuse abdominal pain, diarrhea, and weight loss worsening after meals suggest a malabsorptive disorder like celiac disease, where ingestion of gluten leads to intestinal inflammation and nutrient malabsorption.

Answer 62

B) Acute appendicitis ## Footnote Although the patient has a history of IBS, the presence of fever and rebound tenderness is suggestive of a more acute inflammatory process, such as appendicitis, which requires immediate surgical evaluation.

Answer 63

A) Immediate surgical consultation ## Footnote The presence of a pulsatile abdominal mass with hypertension and severe pain suggests an abdominal aortic aneurysm (AAA), possibly ruptured. This is a surgical emergency requiring immediate consultation and intervention.

Answer 64

B) Acute pancreatitis ## Footnote The patient's symptoms of nausea, vomiting, back pain, fever, leukocytosis, and elevated lipase are highly indicative of acute pancreatitis, which can be exacerbated by factors like hyperglycemia in diabetics.

Answer 65

A) Ovarian torsion ## Footnote The acute onset of severe, localized pain and ultrasound findings of a complex ovarian mass with free fluid suggest ovarian torsion, a gynecological emergency caused by the rotation of the ovary, potentially compromising blood supply.

Answer 66

C) Choledocholithiasis ## Footnote The triad of abdominal pain, jaundice, and pale stools (acholic stools) along with the lab findings suggests an obstruction in the biliary tract, most likely due to stones (choledocholithiasis), commonly seen in patients with a history of gallstones.

Answer 67

C) Perform a CT pulmonary angiogram. ## Footnote The presentation suggests a high probability of pulmonary embolism (PE), given the risk factors (smoking, prolonged flight) and symptoms (dyspnea, pleuritic pain). An elevated D-dimer supports this suspicion. A CT pulmonary angiogram is indicated to confirm diagnosis and guide treatment.

Answer 68

D) High-dose inhaled bronchodilators. ## Footnote The patient is experiencing an acute asthma exacerbation triggered by allergen exposure. Immediate treatment with high-dose inhaled bronchodilators is indicated to relieve bronchoconstriction. Inhaled corticosteroids and oral corticosteroids may be considered as part of ongoing management, but the initial focus should be on reversing the acute obstruction.

Answer 69

B) COPD exacerbation. ## Footnote This patient's symptoms are consistent with an acute exacerbation of COPD, characterized by an increase in baseline dyspnea, cough, and/or sputum production. The change in sputum color and presence of fever suggest a possible infectious cause.

Answer 70

A) Left-sided pneumothorax. ## Footnote The sudden onset of sharp, unilateral chest pain and dyspnea following a coughing spell, along with diminished breath sounds on one side, strongly suggests a pneumothorax, likely due to the rupture of a subpleural bleb during coughing.

Answer 71

A) Chest X-ray. ## Footnote The patient's symptoms and physical findings suggest community-acquired pneumonia, particularly given the description of rusty sputum. A chest X-ray is essential to confirm the presence of an infiltrate indicative of pneumonia.

Answer 72

C) Lupus pneumonitis. ## Footnote Given her history of lupus, the acute presentation with hemoptysis and hypoxia may indicate lupus pneumonitis, an inflammation of the lung tissue associated with systemic lupus erythematosus, though pulmonary embolism should also be considered due to overlapping symptoms.

Answer 73

A) Therapeutic thoracentesis. ## Footnote Therapeutic thoracentesis is indicated to relieve symptoms and to analyze pleural fluid, helping to determine the cause of the effusion (e.g., parapneumonic, malignant, heart failure).

Answer 74

C) Streptococcus pneumoniae. ## Footnote Streptococcus pneumoniae is the most common cause of community-acquired pneumonia, presenting with symptoms like fever, productive cough, and consolidation on imaging, especially in a smoker.

Answer 75

D) Pneumomediastinum. ## Footnote The presence of subcutaneous emphysema, particularly after trauma, suggests pneumomediastinum, where air leaks into the mediastinal area, a condition that can occur independently or alongside a pneumothorax.

Answer 76

A) Sputum acid-fast bacilli (AFB) stain. ## Footnote Given the clinical presentation and epidemiological risk factors, testing for tuberculosis with a sputum AFB stain is crucial for rapid identification and confirmation of active tuberculosis, which is necessary to initiate appropriate isolation and treatment.

Answer 77

B) Lung cancer with obstructive pneumonia ## Footnote In a smoker with a new mass-like opacity and signs of consolidation on imaging, the primary concern should be lung cancer with post-obstructive pneumonia. This requires immediate further investigation with imaging and likely biopsy to confirm the diagnosis and begin appropriate management.

Answer 78

C) Drug-induced pneumonitis ## Footnote Drug-induced pneumonitis is a potential side effect of methotrexate, particularly in patients with underlying risk factors such as autoimmune diseases. The presentation with a dry cough, progressive dyspnea, and bibasilar crackles supports this diagnosis over more acute conditions such as pneumonia or pulmonary embolism.

Answer 79

C) Provide supplemental oxygen and initiate bronchodilators. ## Footnote The patient's symptoms suggest acute bronchospasm, possibly triggered by drug use. Initial management should focus on stabilizing the airway and breathing with supplemental oxygen and bronchodilators to relieve wheezing and improve ventilation.

Answer 80

A) Pleurisy ## Footnote The patient's symptoms of pleuritic chest pain and low-grade fever, in the context of an unremarkable chest X-ray, suggest pleurisy. Although pulmonary embolism could present similarly, the absence of other risk factors or signs makes primary pleuritic inflammation more likely.

Answer 81

C) Sputum acid-fast bacillus stain and culture ## Footnote The patient's history of IV drug use, systemic symptoms, and cavitary lesions on X-ray are highly suggestive of tuberculosis. The priority is to confirm this with a sputum acid-fast bacillus stain and culture, which are specific for Mycobacterium tuberculosis.

Answer 82

C) CT pulmonary angiogram ## Footnote The clinical presentation is highly suggestive of a pulmonary embolism, particularly following prolonged immobilization like a long car drive. An urgent CT pulmonary angiogram is indicated to confirm the diagnosis and facilitate immediate management.

Answer 83

A) Asthma ## Footnote Given the history of allergic rhinitis and the symptom pattern of night-time worsening, the diagnosis of asthma is most likely. This is supported by physical findings of diffuse wheezing, indicating reversible airway obstruction typical of asthma.

Answer 84

A) High-dose loop diuretics ## Footnote The patient's symptoms and signs suggest acute exacerbation of heart failure. Immediate treatment with high-dose loop diuretics is indicated to reduce fluid overload and pulmonary edema, thereby improving respiratory function and symptoms.

Answer 85

C) Chest tube placement ## Footnote The presence of a pneumothorax in a symptomatic patient typically requires active intervention. Chest tube placement is the appropriate management to re-expand the collapsed lung and prevent recurrence of the pneumothorax.

Answer 86

C) Initiate inhaled bronchodilators and corticosteroids ## Footnote This presentation is indicative of an acute COPD exacerbation, likely triggered by an infection given the change in sputum color. Initial treatment should include both inhaled bronchodilators to address airway constriction and corticosteroids to reduce inflammation.

Answer 87

C) Pulmonary embolism ## Footnote The patient's history of recent surgery, combined with symptoms of pleuritic chest pain and shortness of breath, raises the suspicion of a pulmonary embolism. The postoperative state increases the risk of venous thromboembolism, making this the most likely diagnosis.

Answer 88

B) Chest X-ray ## Footnote The presentation of a smoker with new onset wheezing, hemoptysis, and clubbing is concerning for a possible lung cancer. A chest X-ray is an essential first step to evaluate for any mass, consolidation, or other abnormalities that could indicate a malignancy.

Answer 89

A) Asthma induced by aspirin ## Footnote Aspirin-exacerbated respiratory disease (AERD) is likely in this case, where aspirin intake leads to bronchospasm in susceptible individuals. This condition can present similarly to asthma and is triggered by aspirin or other NSAI

Answer 90

A) Intravenous furosemide ## Footnote This patient is showing signs of acute decompensated heart failure with pulmonary edema and peripheral edema. Immediate administration of intravenous furosemide is appropriate to reduce fluid overload and improve respiratory status.

Answer 91

B) Pneumocystis jirovecii ## Footnote Pneumocystis jirovecii pneumonia (PCP) is common in patients with HIV, especially those with CD4 counts below 200 cells/μL. The presentation of a dry cough, low-grade fever, and diffuse interstitial infiltrates on X-ray is characteristic of PCP.

Answer 92

C) Pneumomediastinum ## Footnote Pneumomediastinum is likely, given the history of neck manipulation followed by acute respiratory symptoms and subcutaneous emphysema. Air escaping into the mediastinal space can occur due to a sudden change in intrathoracic pressure.

Answer 93

B) Perform a diagnostic thoracentesis. ## Footnote A diagnostic thoracentesis is necessary to determine the cause of the pleural effusion, particularly in a patient on immunosuppressive therapy where the differential includes infection, rheumatoid effusion, or even malignancy.

Answer 94

C) Perform a ventilation-perfusion scan. ## Footnote Despite a negative leg ultrasound, her risk factors (including the use of oral contraceptives) and symptoms still warrant further investigation for a pulmonary embolism. A ventilation-perfusion scan is appropriate if a CT pulmonary angiogram is contraindicated or inconclusive.

Answer 95

A) Mycoplasma pneumoniae ## Footnote Mycoplasma pneumoniae is a common cause of community-acquired pneumonia in younger populations such as college students, often presenting with a less acute illness characterized by cough and malaise.

Answer 96

B) Azithromycin ## Footnote This patient is likely experiencing an acute exacerbation of COPD with signs of a bacterial infection suggested by the change in sputum color. Azithromycin is effective for typical pathogens involved in COPD exacerbations and has anti-inflammatory properties beneficial in this setting.

Answer 97

B. CT scan of the head without contrast ## Footnote A CT scan of the head without contrast is the initial diagnostic test of choice in patients suspected of having a subarachnoid hemorrhage, which is likely in this patient presenting with sudden severe headache, vomiting, and signs of meningeal irritation.

Answer 98

A. Epidural hematoma ## Footnote The presentation of an acute loss of consciousness, followed by a lucid interval, and subsequent neurological deterioration (evidenced by confusion and anisocoria) suggests an epidural hematoma, commonly associated with arterial bleeding, typically from the middle meningeal artery.

Answer 99

C. Vestibular neuritis ## Footnote Vestibular neuritis is characterized by acute onset vertigo, nausea, and imbalance with nystagmus, typically without auditory symptoms, distinguishing it from Meniere's disease and differentiating it from central causes like stroke.

Answer 100

A. Intravenous thrombolysis ## Footnote Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) is indicated within 4.5 hours of onset in patients with ischemic stroke, provided no contraindications exist and hemorrhage has been ruled out by CT.

Answer 101

D. Perform a lumbar puncture ## Footnote This presentation is suggestive of meningitis, potentially bacterial or viral. A lumbar puncture, after excluding increased intracranial pressure with a CT if indicated, is essential for diagnosis and guiding treatment.

Answer 102

B. Obtain a non-contrast CT of the head ## Footnote The immediate priority is to differentiate ischemic from hemorrhagic stroke via a non-contrast CT scan before considering thrombolytic therapy.

Answer 103

B. Viral encephalitis ## Footnote The combination of fever, stiff neck, first-time seizure, and CSF findings of lymphocytic pleocytosis strongly suggests viral encephalitis, possibly herpes simplex virus, which requires prompt antiviral therapy.

Answer 104

D. Brain abscess ## Footnote In a patient with alcoholism presenting with new onset seizures and a mass lesion, a brain abscess is highly probable, particularly if there is an associated infection source or immunocompromised state.

Answer 105

A. High-dose corticosteroids ## Footnote This presentation is consistent with acute transverse myelitis, likely post-infectious. High-dose corticosteroids are the initial treatment of choice to reduce spinal cord inflammation.

Answer 106

C. Transient ischemic attack (TIA) ## Footnote This classic description of sudden onset neurological deficits that resolve completely within a short period is indicative of a transient ischemic attack (TIA), a warning sign of potential future cerebrovascular events.

Answer 107

B. Amaurosis fugax ## Footnote Amaurosis fugax, often caused by a temporary blockage of blood flow to the retina, presents as transient monocular vision loss ("curtain coming down") and is associated with vascular risk factors like hypertension and hyperlipidemia.

Answer 108

C. MRI brain with and without contrast ## Footnote Given the recent infection and new-onset seizure, an MRI with and without contrast is indicated to evaluate for possible spread of infection to the brain or other structural abnormalities.

Answer 109

B. Subdural hematoma ## Footnote Despite no visible hemorrhage on CT, the clinical picture suggests a subdural hematoma, which can have delayed or subtle findings especially in patients on anticoagulation, and might require further imaging like MRI for confirmation.

Answer 110

D. Administer intravenous thrombolysis ## Footnote Despite her history of migraines, the sudden onset of aphasia and unilateral weakness strongly suggests an ischemic stroke, requiring immediate assessment for intravenous thrombolysis after excluding hemorrhage with CT.

Answer 111

A. Guillain-Barré syndrome ## Footnote Guillain-Barré syndrome, a post-infectious polyneuropathy, presents with ascending weakness and areflexia. The recent diarrheal illness and clinical features support this diagnosis.

Answer 112

B. Lumbar disc herniation ## Footnote The acute presentation with radicular pain and foot drop, along with sensory loss in a dermatomal pattern, suggests a lumbar disc herniation at the L5 level.

Answer 113

D. Hospital admission for observation and workup ## Footnote Given the transient nature and resolution of symptoms, a transient ischemic attack is suspected. Hospital admission for observation and a comprehensive stroke workup including imaging and possibly carotid Doppler is warranted.

Answer 114

A. Opioid overdose ## Footnote The presence of pinpoint pupils, decreased level of consciousness, bradycardia, and evidence of intravenous drug use strongly suggest an opioid overdose.

Answer 115

A. Tourette syndrome ## Footnote The description of involuntary, rapid, repetitive movements that the patient cannot suppress fits Tourette syndrome, which often includes both motor and vocal tics.

Answer 116

D. Cerebral toxoplasmosis ## Footnote In a patient with headache, confusion, personality changes, and ring-enhancing lesions on MRI, cerebral toxoplasmosis should be considered, especially if there is any suggestion of immunocompromise, such as undiagnosed HIV/AIDS.

Answer 117

D) Topical trifluridine ## Footnote Herpes simplex keratitis is typically treated with antiviral therapy. Topical trifluridine is preferred for dendritic ulcers as it inhibits viral replication effectively. Oral acyclovir is used for systemic symptoms, whereas topical corticosteroids are contraindicated due to the risk of exacerbating the infection. Gentamicin is an antibiotic and not effective against viral infections.

Answer 118

C) Removal of the foreign body and topical antibiotic therapy ## Footnote Immediate removal of the corneal foreign body and initiation of topical antibiotic therapy are crucial to prevent infection and promote healing. Elevation of the head and beta-blockers are appropriate for managing hyphema, but the immediate concern should be addressing the foreign body. A CT scan is indicated if there is suspicion of intraocular or intraorbital foreign bodies or fractures.

Answer 119

B) Allergic conjunctivitis ## Footnote The patient’s symptoms are classic for allergic conjunctivitis, likely related to seasonal allergens. This condition is characterized by bilateral itchy eyes, watery discharge, and conjunctival injection. The presence of nasal congestion and pale, boggy nasal mucosa also suggests a concurrent allergic rhinitis.

Answer 120

B) Immediate surgical consultation for possible drainage ## Footnote The patient's symptoms suggest a peritonsillar abscess, which is a complication of untreated or partially treated tonsillitis. Features like muffled voice, drooling, and uvular deviation are indicative of a severe infection that may require surgical drainage. This is an emergency as the abscess can obstruct the airway.

Answer 121

A) Acute angle-closure glaucoma ## Footnote The patient’s symptoms and examination findings of ciliary flush, irregular pupil, and elevated intraocular pressure are indicative of acute angle-closure glaucoma. This condition is an ophthalmic emergency requiring immediate treatment to lower intraocular pressure and prevent permanent vision loss.

Answer 122

A) Topical antibiotics and eye patching ## Footnote Corneal abrasions from metallic foreign bodies require removal of the foreign body, followed by topical antibiotic treatment to prevent infection. Patching the eye can provide comfort and support healing. Surgery is not indicated unless there is significant penetration or retained foreign material.

Answer 123

B) Acute retinal artery occlusion ## Footnote The presentation of sudden pain, blurred vision, a mid-dilated non-reactive pupil, and fundoscopic findings of a pale retina with a cherry-red spot are diagnostic of acute retinal artery occlusion. This is an ophthalmologic emergency that requires immediate intervention to attempt to restore retinal circulation and preserve vision.

Answer 124

B) Retinal detachment ## Footnote the symptoms of seeing floaters and flashes along with the examination finding of a section of the retina being elevated are indicative of retinal detachment. This requires prompt referral to an ophthalmologist for potential surgical repair to prevent permanent vision loss.

Answer 125

C) Topical antibiotics ## Footnote Corneal ulcers, particularly in contact lens wearers, are typically bacterial in origin and require aggressive treatment with topical antibiotics to prevent progression and preserve vision. NSAIDs and anesthetics are contraindicated as they can delay healing and worsen the outcome.

Answer 126

C) Retinal detachment ## Footnote The symptom of a sudden, painless loss of vision with a description of a curtain-like shadow suggests retinal detachment. This condition is an ophthalmological emergency that requires immediate referral for potential surgical intervention.

Answer 127

B) Non-contrast CT scan of the abdomen and pelvis ## Footnote Non-contrast CT scan of the abdomen and pelvis is the most effective diagnostic tool for detecting nephrolithiasis, which is highly suspected given the patient's symptoms of flank pain, nausea, and hematuria. This modality provides detailed images of the urinary tract and can detect stones that may not be visible on other studies.

Answer 128

B) Acute cystitis ## Footnote Acute cystitis is diagnosed based on the patient’s symptoms of dysuria, urinary frequency, and suprapubic pain without signs of systemic infection, making it the most likely diagnosis. This is a common urinary tract infection seen in young women.

Answer 129

A) Urinary catheterization ## Footnote This patient is exhibiting signs of acute urinary retention likely secondary to his known benign prostatic hyperplasia. Immediate bladder decompression via urinary catheterization is necessary to relieve the obstruction and prevent further complications.

Answer 130

C) Nephrotic syndrome ## Footnote Nephrotic syndrome is characterized by heavy proteinuria, hypoalbuminemia, and edema, which align with the patient's presentation. Diabetes is a common cause of nephrotic syndrome due to diabetic nephropathy.

Answer 131

D) Nausea and vomiting ## Footnote Systemic symptoms such as fever, nausea, and vomiting in addition to dysuria and back pain suggest upper urinary tract infection, or pyelonephritis, rather than simple cystitis which typically presents with localized symptoms.

Answer 132

B) Discontinue ACE inhibitor ## Footnote ACE inhibitors can cause deterioration in renal function and hyperkalemia, particularly in susceptible individuals. Discontinuing the drug is a prudent step to prevent further renal impairment and manage hyperkalemia.

Answer 133

B) Renal ultrasound ## Footnote Renal ultrasound is appropriate for evaluating suspected pyelonephritis in this patient, particularly with her history of UTIs and current symptoms indicating a likely kidney infection.

Answer 134

B) Testicular torsion ## Footnote Testicular torsion is a urological emergency characterized by sudden severe testicular pain, absent cremasteric reflex, and nausea. Immediate surgical intervention is required to salvage the testicle.

Answer 135

D) Hyperkalemia ## Footnote Peaked T waves on an EKG are indicative of hyperkalemia, which is a common complication in patients with chronic kidney disease due to decreased renal excretion of potassium.

Answer 136

A) Appendicitis ## Footnote The patient’s symptoms of acute onset right lower quadrant pain, fever, and vomiting, along with a negative urinalysis, most likely point to appendicitis as the diagnosis. An urgent surgical consultation is recommended.

Answer 137

B) Patch the eye and prescribe topical antibiotics ## Footnote Corneal abrasions require protection and prevention of infection. Patching the eye can provide pain relief and protect the area, while topical antibiotics prevent bacterial infection. Topical anesthetics are generally avoided as they may delay healing and worsen the injury.

Answer 138

B) Otitis externa (swimmer's ear) ## Footnote Otitis externa, commonly known as swimmer's ear, is characterized by inflammation of the external ear canal, often associated with water exposure. It typically presents with pain, discharge, and a feeling of ear fullness, especially in frequent swimmers.

Answer 139

A) Refer to ophthalmology for foreign body removal ## Footnote Corneal foreign bodies, especially with a rust ring, require careful removal to prevent further damage to the eye. Referral to an ophthalmologist is recommended for proper removal and management to avoid complications such as infection or corneal scarring.

Answer 140

A) Acute sinusitis ## Footnote This patient's symptoms of unilateral nasal congestion, purulent discharge, facial pain, and loss of smell are typical of acute sinusitis. The tenderness over the maxillary sinus further supports this diagnosis.

Answer 141

C) Immediate referral to neurology ## Footnote These symptoms may indicate an aneurysm impacting the third cranial nerve, particularly given the patient's history of hypertension. Immediate referral to neurology for further evaluation and possible imaging is critical to rule out life-threatening conditions such as an aneurysm.

Answer 142

A) Otosclerosis ## Footnote Otosclerosis often presents with progressive conductive hearing loss, tinnitus, and sometimes dizziness. It involves abnormal bone growth around the stapes, leading to fixation and reduced sound transmission.

Answer 143

B) Patch the eye and prescribe topical antibiotics ## Footnote Recurrent corneal erosions can cause acute episodes of eye pain, photophobia, and vision changes. Management typically includes eye patching to relieve pain and prevent eyelid rubbing, along with topical antibiotics to prevent infection.

Answer 144

A) Hordeolum (stye) ## Footnote A hordeolum, or stye, is an acute infection of the eyelid glands, presenting as a painful, red, swollen nodule, often with a central pustule. It is usually caused by Staphylococcus aureus.

Answer 145

D) Immediate endoscopic evaluation ## Footnote This patient is likely suffering from an esophageal foreign body, evidenced by his symptoms of sensation of something stuck, drooling, and dysphagia. Immediate endoscopic evaluation is necessary to locate and potentially remove the foreign body.

Answer 146

D) Labyrinthitis ## Footnote Labyrinthitis is characterized by the acute onset of vertigo, nausea, and hearing loss, accompanied by nystagmus that often worsens with gaze towards the affected side. It involves inflammation of the inner ear or nerves connecting the inner ear to the brain.

Answer 147

B) Intravenous antibiotics ## Footnote The presentation is suggestive of cellulitis, particularly given the rapid expansion, systemic symptoms, and exposure history. Immediate administration of intravenous antibiotics is indicated to combat the likely bacterial infection and prevent systemic spread.

Answer 148

D) Eczema herpeticum ## Footnote Eczema herpeticum is characterized by the eruption of painful vesicles superimposed on areas of atopic dermatitis, often accompanied by fever and malaise, particularly in patients with a history of atopy such as asthma.

Answer 149

A) Discontinue the medication ## Footnote The patient's symptoms are suggestive of an allergic reaction, possibly angioedema, associated with the new medication. Immediate discontinuation of the suspected drug is crucial.

Answer 150

B) Venous stasis dermatitis ## Footnote The "cobbled" appearance and hyperpigmentation in a patient with chronic venous insufficiency are characteristic of venous stasis dermatitis.

Answer 151

C) Chancroid ## Footnote The presentation of a painful genital ulcer with lymphadenopathy in a sexually active individual suggests chancroid, a sexually transmitted infection caused by *Haemophilus ducreyi*.

Answer 152

C) Ramsay Hunt syndrome ## Footnote Ramsay Hunt syndrome involves a reactivation of the varicella-zoster virus, leading to ear pain, vesicles in the auditory canal, and potentially hearing loss due to involvement of the facial nerve.

Answer 153

C) Erysipelas ## Footnote Erysipelas is an acute infection typically caused by Streptococcus and is characterized by a bright red, raised, sharply demarcated rash, commonly on the lower extremities.

Answer 154

C) Start intravenous antibiotics ## Footnote The symptoms suggest a severe reaction to the bite, possibly progressing to cellulitis or a necrotizing infection. Immediate IV antibiotics are needed to treat the infection and prevent further complications.

Answer 155

B) Bullous pemphigoid ## Footnote Bullous pemphigoid typically presents with tense blisters and severe itching, usually in older adults. It is an autoimmune blistering disease.

Answer 156

C) Stevens-Johnson syndrome ## Footnote Stevens-Johnson syndrome, often triggered by medications, presents with a blistering rash and mucosal involvement and requires immediate medical intervention.

Answer 157

B) Hyperthyroidism ## Footnote The patient’s symptoms of palpitations, tremors, heat intolerance, weight loss despite increased appetite, and physical findings of a palpable thyroid gland, tachycardia, and exophthalmos are characteristic of hyperthyroidism. These symptoms are consistent with an overactive thyroid, which can be confirmed with further thyroid function tests.

Answer 158

B) Intravenous insulin ## Footnote This patient is presenting with diabetic ketoacidosis (DKA), evident from high anion gap metabolic acidosis, elevated blood ketones, and clinical symptoms. The first line of treatment for DKA is intravenous insulin to reduce blood glucose levels and correct ketosis.

Answer 159

B) Adrenal insufficiency ## Footnote The patient’s symptoms of generalized weakness, severe fatigue, nausea, skin hyperpigmentation, hyponatremia, and hyperkalemia are suggestive of adrenal insufficiency, where there is a deficiency in the production of adrenal hormones, particularly cortisol.

Answer 160

C) Diabetes insipidus ## Footnote The patient’s symptoms of increased thirst, polyuria, and notably high serum sodium suggest diabetes insipidus, a condition characterized by insufficient production of antidiuretic hormone (ADH) leading to dilute urine and hypernatremia.

Answer 161

D) Prescribe an antithyroid medication ## Footnote The clinical presentation and lab findings indicate hyperthyroidism. The initial management involves antithyroid medications to reduce thyroid hormone production and mitigate symptoms.

Answer 162

B) Hyperosmolar hyperglycemic state ## Footnote This patient, with type 1 diabetes, elevated blood glucose, high blood ketones, and without significant acidosis, is more likely experiencing a hyperosmolar hyperglycemic state (HHS), which is characterized by severe hyperglycemia and dehydration, more common in type 2 diabetics but can occur in type 1.

Answer 163

B) Hypothyroidism ## Footnote he symptoms of fatigue, cold sensitivity, constipation, along with the lab findings of elevated TSH and low free T4, are indicative of hypothyroidism, where there is insufficient production of thyroid hormones.

Answer 164

C) Hypercalcemia of malignancy ## Footnote In a patient with prostate cancer, the finding of a high serum calcium level is most likely due to hypercalcemia of malignancy, a common paraneoplastic syndrome associated with cancer.

Answer 165

B) Hypocalcemia ## Footnote Following thyroidectomy, this patient likely has hypoparathyroidism leading to hypocalcemia, as indicated by symptoms of tingling, muscle cramps, and a positive Chvostek’s sign.

Answer 166

C) Diabetes insipidus ## Footnote The symptoms of polyuria, dehydration, and a hypothalamic mass, along with high serum sodium and normal glucose levels, suggest diabetes insipidus, likely central, due to damage or dysfunction in the hypothalamus.

Answer 167

C. Administration of IV fluids and corticosteroids ## Footnote In the setting of a stable mother and fetus, the immediate management should include stabilization with IV fluids to ensure maternal and fetal well-being and administration of corticosteroids to accelerate fetal lung maturity in case of premature delivery. Immediate cesarean delivery (A) is reserved for cases where the fetus or mother is unstable. Therapeutic bed rest (B) and discharge (D) are inappropriate due to the risks associated with placental abruption.

Answer 168

B. Ectopic pregnancy ## Footnote The presentation of hypotension, tachycardia, and positive pregnancy test strongly suggests an ectopic pregnancy leading to internal bleeding, which is a surgical emergency. Appendicitis (A) and ovarian torsion (C) are possible but less likely given the pregnancy and syncope, typically not features of these conditions initially.

Answer 169

B. Active phase of the first stage ## Footnote The active phase of the first stage of labor is characterized by strong, frequent contractions and significant cervical dilation progress. The sudden gush of fluid suggests rupture of membranes, indicating that labor has progressed beyond the latent phase.

Answer 170

C. Ceftriaxone and doxycycline ## Footnote Ceftriaxone and doxycycline are the recommended initial therapy for pelvic inflammatory disease, which this patient most likely has based on her symptoms and examination findings.

Answer 171

D. Both A and C are correct ## Footnote This patient requires immediate stabilization with blood transfusion due to suspected internal bleeding and an urgent laparoscopy to address the source of bleeding and manage the ectopic pregnancy.

Answer 172

B. Blood transfusion and IV fluids ## Footnote The primary concern is the patient's hemodynamic instability, likely due to significant blood loss. Immediate resuscitation with IV fluids and blood transfusion is necessary before any further gynecological intervention.

Answer 173

A. Preeclampsia ## Footnote The presence of hypertension, proteinuria, and symptoms such as headache and blurred vision in a pregnant woman are diagnostic of preeclampsia. Eclampsia (B) involves seizures, which have not occurred yet.

Answer 174

C. Ectopic pregnancy ## Footnote The combination of a positive pregnancy test, hypotension, and free fluid in the abdomen in the absence of an intrauterine pregnancy is highly suggestive of a ruptured ectopic pregnancy, requiring immediate surgical intervention.

Answer 175

A. Immediate cesarean delivery ## Footnote Placental abruption with signs of fetal distress requires immediate delivery, typically by cesarean section, to prevent further morbidity or mortality to the mother and fetus.

Answer 176

A. Ovarian torsion ## Footnote Given the acute presentation with pelvic pain, nausea, and an adnexal mass, ovarian torsion is the most likely diagnosis. This condition requires immediate surgical intervention to prevent further complications such as ovarian necrosis.

Answer 177

- B. Perform immediate coronary angiography ## Footnote The patient's symptoms and ECG findings are indicative of an ST-segment elevation myocardial infarction (STEMI), specifically involving the inferior wall given the leads affected. Immediate coronary angiography is crucial as it is part of revascularization therapy, which is the recommended treatment for STEMI patients to restore blood flow and minimize myocardial damage.

Answer 178

- A. Metoprolol ## Footnote Metoprolol is indicated as it helps in controlling the heart rate by slowing the AV nodal conduction, which is beneficial in atrial fibrillation with rapid ventricular response. This beta-blocker is effective in reducing symptoms and stabilizing the patient’s condition.

Answer 179

A. Start IV furosemide ## Footnote IV furosemide is appropriate for acute decompensated heart failure with signs of fluid overload as evidenced by dyspnea, rales, and peripheral edema. It provides rapid diuresis, reducing fluid congestion and improving symptoms.

Answer 180

C. Third-degree AV block ## Footnote The ECG findings and clinical presentation suggest a third-degree AV block (complete heart block), where there is no association between P waves and QRS complexes. This condition often requires urgent pacing.

Answer 181

B. Ruptured aortic aneurysm ## Footnote The presence of a pulsatile abdominal mass, hypotension, and the described symptoms are highly suggestive of a ruptured aortic aneurysm, which is a surgical emergency. Immediate imaging and surgical consultation are required.

Answer 182

B. Acute arterial occlusion, immediate surgical evaluation ## Footnote Acute arterial occlusion presents with the 'five Ps': Pain, Pallor, Pulselessness, Paresthesia, and Paralysis. Immediate surgical evaluation is crucial for possible revascularization to save the limb.

Answer 183

- A. Oral aspirin ## Footnote Aspirin is given immediately in cases of suspected myocardial infarction to reduce cardiac event-related mortality by inhibiting platelet aggregation, thus preventing further thrombus formation.

Answer 184

B. Perform defibrillation ## Footnote Immediate defibrillation is the most effective treatment for ventricular fibrillation, especially in the context of cardiac arrest following a suspected myocardial infarction.

Answer 185

B. Acute decompensated heart failure ## Footnote Given the history of rheumatic heart disease, her symptoms are indicative of acute decompensated heart failure, likely exacerbated by the onset of atrial fibrillation with rapid ventricular rate, which compromises cardiac efficiency.

Answer 186

B. CT scan of the chest with contrast ## Footnote The clinical presentation is suggestive of an aortic dissection. A CT scan of the chest with contrast is the diagnostic test of choice for confirming the presence of an aortic dissection, as it provides detailed images of the aorta and can identify the extent of the dissection.

Answer 187

B. Intravenous furosemide ## Footnote The patient presents with acute decompensated heart failure with signs of significant volume overload. Intravenous furosemide is indicated for rapid diuresis to relieve symptoms of fluid congestion and improve respiratory status.

Answer 188

A. IV adenosine ## Footnote The patient likely has supraventricular tachycardia (SVT). IV adenosine is the drug of choice for rapid termination of SVT due to its ability to transiently block the AV node.

Answer 189

B. Aortic dissection ## Footnote The combination of severe chest pain, hypotension, and a diastolic murmur suggests an aortic dissection, which may involve the aortic valve leading to acute aortic regurgitation as a complication.

Answer 190

C. Placement of a transcutaneous pacemaker ## Footnote The patient presents with symptomatic bradycardia likely due to high-grade AV block or ventricular escape rhythm. The placement of a transcutaneous pacemaker is indicated to provide stable cardiac output until a more permanent solution is implemented.

Answer 191

B. Troponin I ## Footnote Troponin I is the most specific and sensitive marker for myocardial injury and is essential for the diagnosis of myocardial infarction, especially in patients presenting with classic symptoms and ECG changes.

Answer 192

C. Obtain a spiral CT scan of the chest ## Footnote The clinical presentation is suggestive of a pulmonary embolism. A spiral CT scan of the chest is the most appropriate diagnostic test to confirm the diagnosis and guide further management, especially in a hemodynamically stable patient.

Answer 193

A. Transthoracic echocardiogram ## Footnote A transthoracic echocardiogram is the best initial test to assess the severity of aortic stenosis, evaluate valve anatomy, and measure hemodynamic parameters such as gradient and valve area.

Answer 194

B. Aortic dissection, CT angiography ## Footnote The symptoms suggest an aortic dissection. A CT angiography is the most appropriate imaging study to confirm the diagnosis as it provides detailed images of the aorta and can show the presence of a dissection flap and involvement of branch vessels.

Answer 195

C. Acute exacerbation of heart failure ## Footnote In patients with systolic heart failure presenting with chest pain and elevated BNP, acute exacerbation of heart failure should be considered as a probable cause, especially in the absence of new ECG changes.

Answer 196

B. Abdominal aortic aneurysm, urgent surgical referral ## Footnote the presence of a pulsatile abdominal mass in a patient with risk factors such as diabetes and smoking, accompanied by severe pain and high blood pressure, strongly suggests an abdominal aortic aneurysm. Urgent surgical referral is necessary as this condition can lead to rupture, which is life-threatening.

Answer 197

A. Acute pericarditis ## Footnote he clinical presentation of sharp pain worsening with inspiration and the presence of a pericardial friction rub strongly suggest acute pericarditis, likely precipitated by a recent viral infection.

Answer 198

A. Administer IV adenosine ## Footnote the presence of a stable, narrow complex tachycardia unresponsive to vagal maneuvers suggests SVT. IV adenosine is effective for terminating SVT by temporarily blocking the AV node.

Answer 199

B. CT angiography of the chest ## Footnote The symptoms of severe chest pain radiating to the back, differential blood pressure readings between arms, and a diastolic murmur suggest aortic dissection. A CT angiography of the chest is crucial for immediate diagnosis.

Answer 200

B. IV diltiazem ## Footnote Given her history of heart failure and presentation with atrial fibrillation with rapid ventricular response, IV diltiazem is appropriate for rate control. It helps decrease the ventricular rate without adversely affecting cardiac output.

Answer 201

C. CT pulmonary angiography ## Footnote The clinical scenario is highly suggestive of a pulmonary embolism. CT pulmonary angiography is the gold standard for diagnosing pulmonary embolism and should be performed immediately given the symptoms. ---

Answer 202

C. Observation and reassurance ## Footnote In a patient with mitral valve prolapse who is experiencing occasional PVCs but no other signs of hemodynamic instability, the most appropriate management is observation and reassurance. PVCs are common and often benign.

Answer 203

C. Acute decompensated heart failure ## Footnote The presence of an S3 gallop and an enlarged cardiac silhouette on chest X-ray in a patient presenting with dyspnea and cough suggests acute decompensated heart failure.

Answer 204

B. Cardiac catheterization ## Footnote Cardiac catheterization can help assess the severity of aortic stenosis and guide decisions about timing for surgical valve replacement, which may be necessary given her symptom of syncope.

Answer 205

A. Acute myocardial infarction ## Footnote New T-wave inversions in leads II, III, and aVF are suggestive of ischemia in the inferior wall of the heart, indicating an acute myocardial infarction, especially given his significant smoking history.

Answer 206

B. Complete heart block ## Footnote The presentation of severe dizziness, weakness, hypotension, bradycardia, and wide QRS complexes is consistent with complete heart block, a serious condition requiring immediate pacing.

Answer 207

B) Panic Disorder ## Footnote The patient's presentation with spontaneous episodes of intense anxiety featuring physiological symptoms (like hyperventilation) and fear of impending doom, occurring in a variety of settings and without specific triggers like traumatic events, is characteristic of Panic Disorder.

Answer 208

B) Schizophrenia ## Footnote This patient exhibits classic symptoms of Schizophrenia, such as paranoia (delusions of poisoning), disorganized behavior (walking in traffic), and auditory hallucinations, alongside a deterioration in his social functioning (unkempt appearance).

Answer 209

C) Admit for psychiatric hospitalization ## Footnote The presence of active suicidal ideation, even without a specific plan, alongside a deterioration in her mood symptoms after a medication change, warrants acute inpatient psychiatric admission for stabilization and safety.

Answer 210

D) Detailed psychiatric evaluation ## Footnote A comprehensive psychiatric assessment is crucial to differentiate between primary psychiatric conditions like schizophrenia or a psychotic disorder due to another medical condition. Drug use and medical causes should be ruled out through further investigation after the initial psychiatric assessment.

Answer 211

A) Oral diazepam ## Footnote This patient is likely experiencing alcohol withdrawal symptoms, which can include severe anxiety and autonomic hyperactivity. Benzodiazepines like diazepam are the treatment of choice for managing withdrawal symptoms.

Answer 212

B) Bipolar I Disorder ## Footnote The patient's symptoms of elevated mood, increased activity, decreased need for sleep, grandiosity, and impulsivity (excessive spending) are indicative of a manic episode, consistent with Bipolar I Disorder.

Answer 213

C) Perform a neurological exam ## Footnote The first step should be a thorough neurological exam to assess for any focal deficits or signs that suggest a specific cause such as stroke, which could present with sudden confusion and speech disturbance.

Answer 214

A) Schizophreniform Disorder ## Footnote Schizophreniform Disorder is diagnosed when symptoms of schizophrenia (like delusions, hallucinations, and disorganized speech) are present for more than one month but less than six months. In this case, the acute onset and duration of symptoms suggest this diagnosis.

Answer 215

D) Ensuring her physical safety and comfort ## Footnote The primary initial step in managing a sexual assault survivor is to ensure physical safety and comfort, which helps establish trust and ease the process of further necessary interventions.

Answer 216

A) Adjustment Disorder ## Footnote Adjustment Disorder is likely given the onset of depressive symptoms in response to a significant life stressor (spouse's death) occurring within three months of the event. This condition is characterized by emotional or behavioral symptoms in response to an identifiable stressor.

Answer 217

C) Hereditary spherocytosis ## Footnote Hereditary spherocytosis is characterized by hemolytic anemia, jaundice, and the presence of spherocytes on a blood smear, with a negative Coombs test indicating an intrinsic defect of the red cells rather than an autoimmune process.

Answer 218

B) Discontinue the suspected medication ## Footnote The patient's presentation is suggestive of drug-induced thrombocytopenia, a condition where certain medications can cause a severe decrease in platelet counts. The first step should be to discontinue the offending medication.

Answer 219

B) Hyperviscosity syndrome ## Footnote Polycythemia vera can lead to hyperviscosity syndrome due to increased red cell mass, which can present with symptoms such as blurred vision and headache due to impaired blood flow.

Answer 220

C) Vitamin B12 deficiency ## Footnote The combination of low hemoglobin, high MCV, and hypersegmented neutrophils suggests a megaloblastic anemia, with vitamin B12 deficiency being a common cause.

Answer 221

B) Infectious mononucleosis ## Footnote Infectious mononucleosis, caused by the Epstein-Barr virus, typically presents with fever, pharyngitis, atypical lymphocytosis, and splenomegaly in a young adult.

Answer 222

A) Lower extremity ultrasound ## Footnote Given the presentation of unilateral leg swelling and an elevated D-dimer, a lower extremity ultrasound is appropriate to assess for deep vein thrombosis, a common precursor to pulmonary embolism.

Answer 223

C) Immune thrombocytopenic purpura (ITP) ## Footnote ITP is characterized by autoimmune destruction of platelets, often presenting with symptoms like easy bruising, and a bone marrow biopsy typically shows increased megakaryocytes as the bone marrow attempts to compensate for peripheral destruction.

Answer 224

C) Bone infarction ## Footnote Patients with sickle cell disease often suffer from bone infarctions due to vaso-occlusive episodes, which can cause acute pain and sometimes fever, without the swelling typical of other conditions like DVT or osteomyelitis.

Answer 225

A) Von Willebrand disease ## Footnote Von Willebrand disease, a common inherited bleeding disorder, typically presents with mucocutaneous bleeding and may show a decrease in factor VIII activity due to its role in stabilizing von Willebrand factor.

Answer 226

A) G6PD deficiency ## Footnote G6PD deficiency can cause episodic hemolysis in response to oxidative stress, and is often hereditary. Bite cells and Heinz bodies are characteristic findings on the blood smear.