EOR practice exam

Question 1

An HIV-positive patient presents with worsening dementia, fever, HA, and right hemiparesis. CT of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. What is the treatment of choice for this condition?

Answer 1

Sulfadiazine and pyrimethamine

Toxoplasmosis is commonly noted in HIV-positive patients and presents with multiple ring-enhancing lesions. Sulfadiazene is a sulfa Abx and pyrimethamine is an anti-parasite.

Question 2

What is toxoplasmosis?

Answer 2

parasitic protozoa

• Triad of: encephalitis + chorioretinitis + intracranial calcifications

in AIDS patients with CD4 < 100

• pregnant female with exposure to cat feces (reason we tell pregnant mothers not to change cat litter)
• Congenital toxoplasmosis is part of ToRCH syndrome (infection of developing fetus or newborn by any of a group of infections: (T)oxoplasmosis, (o)ther agents, (R)ubella, (C)MV, and (H)erpes Simplex

Question 3

Diagnosis of Toxoplasmosis

Answer 3

CT of the brain shows ring-enhancing lesions

enzyme linked immunoassay (ELISA) positive for anti-toxoplasma IgG and IgM

Question 4

A 52 yo female comes to the office because of black stools for the past 3 days. She is afebrile and has no pertinent PE abnormalities. What is the most appropriate initial diagnostic study?

Answer 4

stool for occult blood

(Melena suggests a source of bleeding proximal to the ligament of Treitz, not a lower GI bleed; sigmoidoscopy is used to evaluate only lower GI bleeds)

Question 5

What is an example of pre-renal azotemia?

Answer 5

Renal hypoperfesuion

is the cause of prerenal azotemia which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored

azotemia (azo, “nitrogen” + -emia, “blood condition” ) is characterized by abnormally high levels of nitrogen-containing compounds (urea, creatinine, various body waste compounds)

Question 6

a 65-year old patient with steroid-dependednt COPD presents with a HA that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever but has had photophobia and a stiff neck. What is the most likely diagnosis?

Answer 6

Cryptococcosis

Cryptococcosis is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients.

Question 7

What is cryptococcosis?

Answer 7

caused by fungus cryptococcus neoformans, common in AIDS and immunocompromised patients. It is considered an AIDS defining illness. Budding yeast found in soil contaminated with pigeon/bird droppings.

transmitted through inhalation and causes illness in patients with cellular immune deficiency such as HIV, cancer, or long-term corticosteroid therapy

• meningocephalitis: most common cause of fungal meningitis (may present with AMS, HA, or meningismus)
• Pneumonia: cough with little sputum and pleuritic chestpain

Question 8

Diagnosis of Cryptococcosis

Answer 8

Diagnose with CSF and serum serology

• India ink stain may be positive
• CSF shows pleocytosis (predominantly lymphocytes), increased opening pressure, INCREASED protein, and DECREASED glucose
• Computed tomography (CT) or MRI is indicated if cryptococcoma is suspected

Question 9

Treatment of Cryptococcosis

Answer 9

Amphotericin B + Flucytosine for 2 weeks

followed by Fluconazole for 10 weeks

Prophylaxis if CD4 < 100 with Fluconazole

Question 10

Axial T2-weight MRI shows clustered hyperintensities in the left caudate; these are consistent with enlarged Virchow-Robin spaces caused by small cryptococcomas

Answer 10

Question 11

What is a common symptom associated with laryngotracheobronchitis (viral croup)?

Answer 11

Barking cough

viral croup is characterized by a history of upper respiratory tract sx followed by onset of a barking cough and stridor

Question 12

A 23 yo female with a history of asthma for the past 5 years presents with complaints of increasing SOB x 2 days. Her asthma has been well controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler q4 - 6hrs. She is normally very active, however yesterday did not complete her 30 minute exercise routine due to increased dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. What initial diagnostic test is most appropriate prior to initiation of treatment?

Answer 12

peak flow

A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.

Question 13

a 3 yo boy is seen in the office with a 5-day history of fever, erythema, edema of hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is:

Answer 13

cardiac

The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of the disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.

Kawaski Syndrome: fever > 5 days and 4 of the following

• 1. conjunctivitis*
• 2. rash*
• 3. mucosal changes*
• 4. edema of hands/feet*
• 5. cervical adenopathy*

Question 14

How do you diagnose and manage Kawasaki Syndrome?

Answer 14

Diagnosis

îESR/CRP, leukocytosis, reactive thrombocytosis (î platelets). Normochromic normocytic anemia. Sterile pyuria. Echo and angiography may be needed if heart involvement is suspected.

Management

INTRAVENOUS IMMUNE GLOBULIN + HIGH-DOSE ASPIRIN

• lowers fever, joint pain, & prevents coronary artery thrombosis/aneurysm*
• corticosteroids if refractory*

Question 15

What are the five axes of DSM-IV?

Answer 15

Axis 1: describes clinical disorders and “other conditions which may be a focus of clinical attention”.

Axis 2: focuses on personality disorders and contains a rating scale for mental retardation.

Axis 3: labels any general medical conditions. (sometimes psychological problems can be the byproduct of an illness such as diabetes or heart disease)

Axis 4: specifies “psychosocial and environmental problems” such as poverty dysfunctional families, and other factors in the patient’s environment that might have some impact on the person’s ability to function

Axis 5: labeled the “Global Assessment of Functioning Scale”. it is an overall rating of person’s ability to cope with normal life. Rating goes from low scores such as 10 (“persistent danger of severely hurting self or others”) to 100 (“superior functioning in a wide range of activities”)

Question 16

A 53 yo female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the LLL. a CXR is unremarkable and an EKH reveals sinus tach. What is the most likely diagnosis?

Answer 16

Pulmonary Embolism

The patient’s risk factors for pulmonary embolism include advanced age, surgery, and prolonged bed rest. While the dx of PE is difficulty to make due to nonspecific clinical findings, the most common Sx include pleuritic CP, dyspnea associated with tachypnea. CXR and EKG are usually normal.

Hint: small atelactasis is commonly asymptomatic while large atelactasis may produce signs of dyspnea and cough. Exam revelas absence of breath sounds in the area involved and dullness to perussion. A CXR would reveal various findings dependent on the location of the atelactasis, but would NOT be normal.

Question 17

Clinical Manifestations of Pulmonary Embolism

Answer 17

Dyspnea MC symptom & Tachypnea MC sign***

History:

classic triad, dyspnea + pleuritic chest pain + hemoptysis

Classic Presentation:

post-op patient with sudden onset tachypnea, tachycardia + cough or hemoptysis

Factor V Leiden is the MC predisposing condition

Physical Exam:

Pulmonary Exam is usually normal; may have rales or pleural friction rub

+ Homan’s sign (calf pain with dorsiflexion is a classic but nonspecific sign)

Question 18

What is the best initial test for suspected PE?

Answer 18

Helical CT Scan (CT-PA)

PULMONARY ANGIOGRAPHY IS GOLD STANDARD DIAGNOSIS: ordered if HIGH SUSPICION & negative CT or VQ scans

others:

V/Q Scan: low probability only rules out PE in patients with low clinical suspicion

Doppler US: 70% of patients with with PE will be + for lower extremity DVT. can miss pelvic DVTs. serial US may be performed to increase diagnostic specificity.

Question 19

Ancillary Evaluation Tests for PE

Answer 19

1. CXR: most often normal. A normal CXR in the setting of hypoxia is highly suspicious for PE

classic (but rare) signs on CXR:

Westermark’s Sign: avascular markings distal to the area of the embolus

Hamptons Hump: wedge-shaped infiltrate (represents infarction)

2. ECG: sinus tachycardia % nonspecific ST/T changes MC*

S1Q3T3 most specific for PE: wide deep S in lead I, isolated Q and T wave inversion in lead III

3. ABG: initially respiratory alkalosis (2ry to hyperventilation) ⇒ respiratory acidosis may occur with time. îA-a gradient

4. D-dimer: helpful ONLY if negative & low suspicion for PE (high sensitivity, poor specificity)

Question 20

Management of Pulmonary Embolism

Answer 20

1. Anticoagulation
   * Low Molecular Weight Heparin (LMWH) or Unfractionated Heparin (UFH)

need to monitor PTT with UFH but not needed with LMWH

Higher risk of Heparin Induced Thrombocytopenia (HIT) with UFH

• Warfarin (COUMADIN) for at least 3 months–should be overlapped with Heparing for at least 5 days AND INR 2.0 to 3.0 at least 24 hours
• Novel Anticoags–LMWH followed by Dabigatran (direct thrombin inhibitor) or Edoxaban (Factor Xa inhibitor) can be used instead of Warfarin and may be preferred

2. IVC FILTER: hemodynamically stable patients in whom anticoagulation is contraindicated or is unsuccessful*

3. THROMBOLYSIS OF CLOT: streptokinase, urokinase, alteplase

IND: massive PE, hemodynamically unstable PE. resolves emboli within 24 hours. usually preferred over embolectomy

CI: CVA or internal bleed w/i 2 months

4. THROMBECTOMY/EMBOLECTOMY: unstable/massive PE if thrombolysis is contraindicated or ineffective

Question 21

Pulmonary Embolism Prophylaxis

Answer 21

the single most important step in managing PE. Prophylaxis is warrranted preoperatively in patients undergoing surgery with prolonged immobilization, pregnant women, history of prior DVT/PE.

Early Ambulation: low risk, minor procedures in patients < 40 yo

Elastic stockings/pneumatic compression devices/venodyne boots: moderate risk

Low Molecular Weight Heparin: patients undergoing orthopedic or neurosurgery, trauma

Question 22

PERC Criteria for Pulmonary Embolism

(Pulmonary Embolism Rule Out Criteria)

Answer 22

If all the following is negative, you can effectively rule out PE if there is low suspicion for PE:

Age < 50 yo

Pulse < 100 bpm

O2 Sat > 95%

No prior PE

No recent trauma or surgery

No hemoptysis

No use of exogenous estrogen

No unilateral leg swelling

Question 23

34 yo female with h/o asthma presents with complaints of increasing sthma attcks. patient states she has been well controlled on abuterol until one month ago. since that time she has had to use her inhaler 3 - 4 times a week and also has had increasing nighttime use averaging about 3 episodes in the past month. Spirometry reveals > 85% predicted.

What is the most appropriate intervention at this time?

Answer 23

the patient has progressed to mild persistent asthma. in addition to her beta-2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled Corticosteroids (ICS) such as beclamethasone are preferred for long-term control.

Question 24

definition of intermittent, mild persistent, moderate persistent, and severe persistent asthma

Answer 24

Question 25

In adults and IV drug abusers, which bone is most commonly affected with acute osteomyelitis?

Answer 25

**vertebral spine** bones of the vertebral spine are MC affected in a patient with osteomylitis. organisms reach the _well-perfused vertebral body via spinal arteries_ and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. the infection may originate in the urinary tract and IV drug use carries an increased risk of spinal infection

Question 26

a 43 yo asymptomatic diabetic female is found to have an elevated total calcum level of 12.4 mg/dL. Which test must be assessed in order to evaluate this lab abnormality?

Answer 26

**serum albumin** since approximately _50% of calcium is protein bound_, total calcium levels should be i_nterpreted relative to albumin levels_

Question 27

Which condition would cause a positive Kussmaul's sign on PE?

Answer 27

**constrictive pericarditis** Kussmaul sign is a _paradoxical rise in jugular venous pressure (JVP) on inspiration,_ or a failure in the appropriate fall of the JVP with inspiration. It can be seen in some forms of heart disease and is usually indicative of _limited right ventricular filling due to right heart dysfunction._ **_frequent finding in patients with constrictive pericarditis or right ventricular infarction_**

Question 28

What are the common clinical manifestations of constrictive pericarditis?

Answer 28

**1. _Dyspnea_ MC\*\*** **2. _Right Sided HF signs:_** increased JVD, peripheral edema, hepatojugular reflex, N/V **_Kussmaul's Sign_: increased JVD with inspiration** **3. _pericardial knock_:** high pitched 3rd heart sound due to sudden cessation of ventricular filling in early diastole from thickened inelastic pericardium

Question 29

60 yo pateint with presents with **increased sputum production.** 100 temp, RR 20, HR 88, pH 7.44, PaO2 75, PaCO2 40 PE remarkable for inreased AP diameter, diminished breath sounds without wheezes, rhonchi or other signs of respiratory distress **what would be an appropriate treatment for this patient?**

Answer 29

**broad spectrum antibiotic** sputum production is extremely variable from patient to patient but _any increase in sputum with a h/o COPD_ reported by a patient must be regarded as _potentially infectious and treated promptly_

Question 30

transudate vs exudate

Answer 30

**transudate** is fluid pushed through a capillary due to **high pressure** within the capillary. **exudate** is fluid that leaks around the cells of the capillaries caused by **inflammation**

Question 31

Which of the following conditions will produce a transudative pleural effusion? **a.** Kaposi's sarcoma **b.** bacterial pneumonia **c.** cirrhosis **d.** mesothelioma

Answer 31

**cirrhosis** the MC causes of transudative pleural effusions in the US are **_heart failure**_ and _**cirrhosis_** other conditions: severe hypoalbuminemia nephrotic syndrome acute atleactasis myxedema peritoneal dialysis obstructive uropathy end-stage kidney disease

Question 32

23 yo female with h/o palpitations presents for evaluation admits to acute onset of rapid heart beating lasting seconds to minutes with associated SOB and CP patient states she can relieve her symptoms with valsalva **What is the most appropriate diagnostic study?**

Answer 32

**electrophysiology study** useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardias (SVT)

Question 33

The finding of egophony is most consistent with:

Answer 33

**lobar pneumonia** *egophony occurs with consolidation caused by lobar pneumonia*

Question 34

A patient presents with edema, which is most noticeable in the hands and face. Lab findings include proteinuria, hypoalbuminemia, and hyperlipidemia. The most likely diagnosis is:

Answer 34

**nephrotic syndrome** Proteinuria, hyperlipidemia, and hypoalbuminemia are consistent with nephrotic syndrome

Question 35

Which of the following can be used to treat chronic bacteiral prostatitis? **a.** Penicillin **b.** cephalexin (KEFLEX) **c.** Nitrofurantoin (MACROBID) **d.** Levofloxacin (LEVOQUIN)

Answer 35

**LEVOFLOXACIN** chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of **_fluoroquinolones or trimethoprim-sulfamethoxazole_**, both of which **_penetrate the prostate._**

Question 36

25 yo male presents with h/o syncope patient admits to intermittent episodes of rapid heart beating that resolves spontaneously. Lead EKG shows delta waves and short PR interval Which of the following is the treatment of choice for this patient? **a.** radiofrequency catheter ablation **b.** verapamil (CALAN) **c.** Percutaneous coronary intervention **d.** Digoxin (LANOXIN)

Answer 36

**radiofrequency catheter ablation** TOC on patients with accessory pathways, such as WPW

Question 37

What are the types of endocarditis and what are the MC organisms associated with each?

Answer 37

**acute bacterial endocarditis:** S. aureus **subacute bacterial endocarditis:** S. viridans **Endocarditis in IV drug userse:** MRSA **prosthetic valve endocarditis:** staphylococcus epidermis

Question 38

What is the MC valve associated with acute bacterial endocarditis (NO IV DRUG USE)?

Answer 38

**mitral valve**

Question 39

What is the MC valve associated with **endocarditis in IV drug users?**

Answer 39

**tricuspid**

Question 40

What are clinical manifestations of infective endocarditis?

Answer 40

1. **\*\*fever\*\*, ECG conduction abnormalities** **2.** _Peripheral Manifestations:_ **_Janeway Lesions_**: painless erythematous macules on palms & soles (emboli/immune) **_Roth Spots_**: retinal hemorrhages with pale centers, **petechiae** (conjunctiva, palate) **_Osler's Nodes_:** tender nodules on the pads of the digits ***splinter hemorrages*** of proximal nail bed, clubbing, hepatosplenomegaly.

Question 41

What is the **"Modified Duke Criteria"** for _Infective Endocarditis?_ _need 2 MAJOR_ _or_ _1 MAJOR + 3 MINOR_ _or_ _5 MINOR_

Answer 41

**_Major_:** **Sustained Bacteremia--** **_2 + blood cultures_** by organism known to endocarditis **endocardial involvement--** documented by either a + **ECHO** (vegetation, abscess, valve perforation, prosthetic dehiscence) or clearly established **_new_** ***valvular*** **_regurgitation_** (aortic or mitral regurg) **_Minor:_** **Predisposing condition:** abnormal valves, IVDA, indwelling catheters **Fever** **_Vascular and embolic phenomena:_** Janeway lesions, septic arterial or pulmonary emboli, ICH **_Immunologic phenomena:_** Osler's nodes, Roth Spots, + RF, acute glomerulonephritis + blood culture not meeting major criteria + ECHO not meeting major criteria (ex: worsening of existing murmur)

Question 42

Treatment for the different types of **infective endocarditis**

Answer 42

**acute (native valve):** _nafcillin + gentamicin_ x 4 - 6 weeks OR _vancomycin_ (if suspected MRSA) _+ gentamicin_ **subacute (native valve):** _penicillin or ampicillin + gentamicin_ _vancomycin in IVDA_ **prosthetic valve:** _vancomycin + gentamicin + rifampin_ (for staph aureus) **fungal:** amphotericin B (treat 6 - 8 weeks) patients often need surgical intervention for fungal cases (penicillin and vancomycin have great gram + coverage. Gentamicin has great gram - coverage)

Question 43

Prophylactic regimen for circumstances that put patients at high risk for infective endocarditis: (such as prosthetic heart valves, congenital heart disease, dental procedures, respiratory procedures, and procedures involving infected skin/MSK tissue)

Answer 43

**_amoxicillin 2g_ 30 - 60 minutes** prior to procedure **_(clindamycin 600 mg_** if PCN allergic)

Question 44

Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct OR: **a.** cystic duct **b.** pancreatic duct **c.** duodenal ampulla **d.** common hepatic duct

Answer 44

**cystic duct** obstruction of the cystic duct by gallstones causes the typical symptoms of biliary colic. once obstructed the gallbladder distends and becomes edematous and inflamed. gallstones can also migrate into the _common duct through the cystic duct leading to a condition known as choledocholithiasis_

Question 45

An **elderly patient** with poorly-controlled Type 2 DM and renal disease develops a fever of **102 orally, productive cough, and dyspnea.** **RR 32, labored breathing, and rales at the left base. 90% sats.** Which of the following is the net appropriate step in the management of this patient? **a.** administer nebulized corticosteroids **b.** admit to the hospital **c.** oral antimicrobial therapy **d.** endotracheal intubation

Answer 45

**admit to hospital** CAP is the most deadly infectious disease in the US. Important risk factors for increased morbidity and mortality: advanced age, alcoholism, comorbid medical conditions, AMS, RR \> 30, hypotension, and a BUN \> 30

Question 46

An 80 yo female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with osteoporotic compression fracture. Which of the following treatment modalities has the potential to cause analgesia of the fracture site with its use: **a.** calcitonin nasal spray **b.** alendronate **c.** Raloxifene **d.** combined estrogen and progesterone (Prempro) therapy

Answer 46

**Calcitonin** Alendronate is a bisphosphonate that inhibits bone resorption and is effective in building new bone for a pt with osteoporosis but NO ANALGESIA raloxifene is a selective estrogen receptor modulator and has positive effects on bone density when used to treat osteoporosis but NO ANALGESIA combined hormonal therapy may have positive effects on bone density but NO ANALGESIA

Question 47

A patient with severe COPD presents to the ED with 3-day history of increasing SOB with exertion and cough productive of purulent sputum. ABG reveals pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen 2L/min and an IV is started. After 1 hour of treatment, his ABG reads pH 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate step in his treatment? **a.** decrease O2 flow rate **b.** administer oral corticosteroids **c.** intubate the patient **d.** administer salmeterol

Answer 47

**intubate the patient** this person has increasing respiratory failure as indicated by the raising PaCO2 levels. intubation is required at this time. admininstration of steroids is an important treatment modality but this patient is in respiratory failure and needs more immediate therapy LABA therapy such as salmeterol is not utilized for rescue therapy

Question 48

To further assess ascites in a patient, the PA instructs the patient to turn onto one side while performing percussion. Which of the following is the reason for this maneuver? **a.** testing for shifting of dullness on percussion **b.** shifting of internal organs making percussions easier **c.** trying to elicit any pain while moving **d.** trying to produce a caput medusa

Answer 48

**testing for shifting of dullness on percussion** in ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while tympany shifts to the top as the gas-filled organs float to the top of ascitic fluid

Question 49

a 25 yo female presents for the 8th time in 3 weeks to be sure she doesn't have meningitis. she read that there was a student on campus who had meningitis last month, and now she has headaches and is requesting to be tested to make sure she does not have meningitis. PE all normal. What is the most likely diagnosis? **a.** conversion disorder **b.** hypochondriasis **c.** malingering **d.** somatization disorder

Answer 49

**hypochondriasis** hypochondriasis is the chronic preoccupation with the idea of having serious disease, which is usually not amenable to reassurance conversion disorder: onset of Sx or deficits mimicking neurologic or medical illness, but the etiology is psychological. somatization disorder: complaints of pain, often related to GI and sexual dysfunction, and pseudoneurological symptoms

Question 50

Diagnostic studies and treatment for ITP (idiopathic thrombocytopenic purpura) *_autoimmune antibody reaction to platelets which results in splenic platelet destruction often after an acute infection_* easy bruising and gingival bleeding petechiae throughout chest, arms and legs platelet count of 24,000

Answer 50

**_Diagnostic Studies_** **isolated thrombocytopenia (\<100,000/uL)** and otherwise **normal CBC and peripheral blood smear** **+ Direct Coombs Test** **_Treatment_** (observation unless \< 30,000 or bleeding) **Corticosteroids** initial treatment **IVIG** for those with contraindications to corticosteroids **splenectomy** for patients with refractory ITP

Question 51

29 yo patient with idiopathic thrombocytopenia purpura (ITP) is treated with prednisone therapy. Despite therapy, platelet counts remain consistently below 20,000 over the course of 6 weeks. Which of the following is the most appropriate intervention for this patient? **a.** aspirin **b.** IVIG **c.** danazol **d.** splenectomy

Answer 51

**splenectomy** Persistently low platelent counts (\< 20,000) require effective long-term treatment, and splenectomy is the TOC *IVIG can be utilized for short-term treatment, but the platelet count is likely to return to baseline within a month*

Question 52

Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus Aureus? **a.** ingestion of mayonnaise-based salads 48 hours earlier **b.** bloody diarrhea with mucus x 1 wk **c.** abdominal cramps and vomiting x 48 hours **d.** high fever x 1 wk

Answer 52

**abdominal cramps and vomiting x 48 hours** abdominal cramps, N/V, and watery diarrhea typically last 1 - 2 days with staphylococcal food poisoning * a preformed toxin causes staphylococcal food poisoning and it has a short incubation period of 1 - 8 hours* * staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature*

Question 53

Which of the following diagnostic tests should be ordered initially to evaluate for suspected DVT of the leg? **a.** venogram **b.** arteriogram **c.** duplex ultrasound **d.** impedance plethysmography

Answer 53

**Ultrasound** is the technique of choice to detect DVT in the leg

Question 54

a 26 yo man is stung by a bee, and shortly therafter, a wheal develops at the site of the sting. he soon feels flushed and develops hives, rhinorrhea, and tightness in his chest. He is seen in the urgent care center. Immediate therapy should be to:

Answer 54

**administer intramuscular epinephrine** epinephrine HCl 1:1000 0.2 to 0.5 mL IM is indicated for intiial treatment of this systemic reaction. Additional injections may be given q 20 - 30 minutes

Question 55

What is the first line treatment for symptomatic bradyarrhythmias due to sick sinus syndrome?

Answer 55

**permanent pacemaker**

Question 56

Which of the following views on plain films is preferred to identify spondylolysis?

Answer 56

**oblique** the defect in the pars articularis (usually bilateral) is best visualized on oblique projections of plain films

Question 57

a 15 yo softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray shows no associated avulsion fracture. What is the treatment of choice

Answer 57

**continuous extension of the DIP via splinting for 6 to 8 weeks** TOC for a tear in the extensor tendon of the finger

Question 58

57 yo male was working on a farm when some manure was slung hitting him in the L eye. He presents several days after with a red, tearing, painful eye. Fluorescein stain reveals uptake over the cornea looking like a shallow crater which of the following interventions would be HARMFUL opthalmic antibiotics, pressure patch, examination for visual acutiy, copious irrigation

Answer 58

**pressure patch:** patching the eye after an abrasion is associated with organic material contamination and is contraindicated due to increased risk of fungal infection *(opthalmic antibiotics and copious irrigation are indicated when treating a patient with a suspected corneal ulcer due to an infectious cause)*

Question 59

75 yo female falls on outstretched arm and sustains a humeral mid-shaft fracture. nerve impingement occurs due to the fracture, What is the most likely PE abnormality that will be encountered?

Answer 59

**inability to extend the wrist against resistance** radial nerve is most likely entrapped by this fracture *wristdrop in radial nerve injury* axillary nerve injury results in numbness over the deltoid muscle, this nerve is more commonly injure in proximal humeral fractures and anterior shoulder dislocations

Question 60

Which of the following PE findings would be conistent with a pleural effusion? hyperresonance to percussion, increased tactile fremitus, unilateral lag on chest expansion, egophony

Answer 60

**unilateral lag on chest expansion** * hyperresonance to percussion suggestive of emphysema or pneumothorax* * increased tactile fremitus and presence of egophony consistent with a consolidation*

Question 61

Bipolar patient in a manic episode. What is the most appropriate treatment?

Answer 61

**inpatient olanzapine therapy** treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.). Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants

Question 62

Clinical Manifestations of Alcohol Withdrawal

Answer 62

1. _uncomplicated alcohol withdrawal:_ 6 - 24 hours after last drink, **_increased CNS activity_**: tremors, diaphoresis, insomnia, GI (N/V/D). uncomplicated = no seizures, hallucinosis or delirium tremens 2. **_withdrawal seizures_**: 6 - 48 hours after last drink usually generalized clonic-tonic type 3. **_Alcoholic Hallucinosis:_** 12 - 48 hours after last drink visual, auditory and/or tactile hallucinations. patient has a *clear sensorium & normal vital signs* 4. **_Delirium Tremens:_** 2 - 5 days after last drink Delirium (**altered sensorium**), hallucinations, agitation **altered vital signs** (tachy, HTN, fever), often diaphoretic

Question 63

Management of Alcohol Withdrawal

Answer 63

**1. IV BZDS: Diazepam** (VALIUM), **Chlordiazepoxide** (librium), **Oxazepam** **2. IV fluids & supplementation: IV Thiamine & Magnesium (prior to glucose administration),** multivitamins (including B12/folate), IV fluids + dextrose (intoxication may cause hypoglycemia) 3. avoidance of medications that can lower seizure threshold if possible (ex: Bupropion, Haloperidol, anticonvulsants, clonidine, BB)

Question 64

Clinical Manifestations of **Opioid _Intoxication_ AND _withdrawal_**

Answer 64

**_OPIOID INTOXICATION:_** euphoria and sedation (drowsiness, slow/slurred speech, impaired memory) PE: ***pinpoint pupils (narcotics are miotics), respiratory depression***, may also develop biot's breathing (quick, shallow inspirations followed by irregular periods of apnea), **bradycardia, hypotension** **_OPIOID WITHDRAWAL:_** lacrimation, HTN, pruritus, tachycardia, N/V/D, ***piloerections*** (goosebumps), ***pupil dilation (mydriasis), flu-like Sx: rhinorrhea***

Question 65

Management of **Opioid Intoxication**

Answer 65

Acute intoxication: **Naloxone (NARCAN)** onset of action is ~ 2 minutes IV (~5 minutes IM); 30 - 60 minutes duration of action MC used in patients with respiratory depression

Question 66

Management of **Opioid Withdrawal**

Answer 66

_symptomatic control:_ **clonidine** (decreases sympathetic symptoms), **loperamide** for diarrhea, **NSAIDs** for joint pains and muscle cramps, **Buprenorphine + Naloxone** **Methadone Tapering**

Question 67

How to manage cocaine intoxication

Answer 67

**benzodiazepines** neuroleptics BP reduction

Question 68

Signs of cocaine intoxication

Answer 68

aggression, agitation hyperthermia, flushing **SYMPATHETIC STIMULATION: sweating, tachycardia, pupillary dilation, HTN** rhabdomyolysis

Question 69

Early clues to impending delirium tremens include:

Answer 69

***agitation and decreased cognition*** mental confusion, tremory, sensory hyperacuity, visual hallucinations, autonomic hyperactivity, diaphoresis, dehydration, electrolyte disturbances, seizures, and CVD abnormalities are common signs and/or symptoms of FULL-BLOWN DELIRIUM TREMENS

Question 70

A woman admits that her husband has abused her for over ten years. You should inform the woman that she is at most risk for injury or death....

Answer 70

**just after leaving an abusive spouse** *75% of domestic assaults/murders occur after separation*

Question 71

patient presents with an acutely painful and cold L leg. Distal pulses are absent. Leg is cyanotic. No signs of gangrene or other open lesions. Symptoms occurred one hour ago. What is the most appropriate treatment?

Answer 71

**Embolectomy** within 4 - 6 hours is the TOC

Question 72

male pt seen in the ED following MVC in which his knee hit the dashboard. pt has posterior knee dislocation that is reduced in the ED. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory?

Answer 72

**Angiography** *the popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pulses*

Question 73

70 yo presents with HA and neck stiffness. On PE, patient is febrile, Kernig's sign is present, and no rash is noted. A spinal tap reveals a white count of 250/cm3 with 100% neutrophils, total protein 250 mg/dL and glucose 35 mg/dL. What is the most appropriate treatment?

Answer 73

**ampicillin and ceftriaxone (ROCEPHIN)** ampicillin and ceftriaxone is used to treat bacterial meningitis, secondary to Listeria monocytogenes, which is commonly in the elderly. Ceftriaxone will cover other common etiologic agents such as Streptococcal pneumonia.

Question 74

74 yo female is being treated for mild HTN. She is found at home with **R hemiparesis** and brought to the ED. Her daughter states the patient **fell** in her kitchen 2 days ago, but had no complains at the time. She did state her mother sounded a little **confused** this morning. The patient's **left pupil is dilated.** Which of the following diagnostic studies should be ordered first?

Answer 74

**CT scan of the brain** the patient presents with a h/o minor trauma and progressive neurological abnormalities consistent with **_subdural hematoma_** Diagnosis is confirmed with CT scan, which is less expensive and more sensitive for blood than MRI

Question 75

Seizures that first manifest in early to middle adult life should be considered suspicious of which of the following causes?

Answer 75

**tumor** seizures that develop during adolescence and adult life are predominantly due to tumor trauma druge use alcohol withdrawal

Question 76

62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise unremarkable. Which of the following is the most likely diagnosis?

Answer 76

**pancreatic cancer** Courvoisier's law (or Courvoisier syndrome, or Courvoisier's sign or Courvoisier-Terrier's sign) states that in the presence of a palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones.

Question 77

Which of the following is most common cause for acute MI

Answer 77

**thrombus development at a site of vascular injury** acute MI occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when atherosclerotic plaque fissures, ruptures or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion

Question 78

What rotator cuff tendon is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament?

Answer 78

**supraspinatus** it is susceptible to injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is MC seen with the supraspinatus tendon, the long head of the biceps tendon and.or the subacromial bursa.

Question 79

13 yo boy with leukemia presents with epistaxis for 2 hours. the bleeding site appears to be from Kiesselbach's area. The most appropriate intervention is:

Answer 79

**intranasal petrolatum gauze** this will provide pressure to the bleeding point while the cause of bleeding is corrected * posterior nasal packing is indicated for posterior bleeds in the inferior meatus* * silver nitrate is NOT USED IN KIDS because it increases the risk for nasal septal perforation*

Question 80

What is the most common cause of arterial embolization?

Answer 80

**afib**

Question 81

25 yo man presents with odynophagia and dysphagia. On endoscopin examination, small, white patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is:

Answer 81

**fluconazole** The patient has Candida esophagitis and the treatment of choice is fluconazole

Question 82

75 yo woman presents with complaint of vision loss. exam reveals a palpable cord in the temporal region. What is the most helpful initial test to order on this patient?

Answer 82

**ESR** the patient is suspected of having temporal arteritis. This disease is MC noted in patients over age 50 and should be suspected in patients with sudden vision loss and a palpable cord in the temporal region. ESR is almost always increased in this disease

Question 83

68 yo male with h/o afib treated with warfarin (coumadin) presents to the ED after vomiting large amounts of bright red blood. INR is 3. What is the most appropriate way to rapidly lower his INR?

Answer 83

administer **Fresh Frozen Plasma**

Question 84

85 yo nursing home resident presents with abrupt onset of cough, sore throat, HA, myalgias, and malaise. On examination the patient's temperature is 102 degrees F, the rest of the exam is unremarkable. Nasal smear is positive for influenza B. Which of the following is the treatment of choice in this patient?

Answer 84

**oseltamivir (TAMIFLU)** used to treat both influenza A and B

Question 85

patient with a dirty laceration from a chicken coop is unsure of his immunization status. Besides cleaning and debriding the wound, what is the recommended clinical intervention with this patient?

Answer 85

**Td or Tdap with TIG** is the recommended prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status

Question 86

20 yo male presents with complain of brief episodes of rapid heart beat with a sudden onset and offset that have increased in frequency. he admits to associated SOB and lightheadedness. Denies Syncope. ECG reveals delta waves prominent in lead II. Which of the following is the most appropriate long-term management in this patient?

Answer 86

**radiofrequency ablation** is the procedure of choice for long-term management in patients with accessory pathways (WPW) and recurrent symptoms

Question 87

26 yo woman requests screening after her bf was treated for STI. On examination you find a painless vulvar ulcer. What is the most likely diagnosis?

Answer 87

**Syphillis** the primary lesion of syphillis presents as a painless ulcer or chancre. Secondary syphillis presents with a skin rash, lymphadenopathy and mucocutaneous lesions.

Question 88

57 yo male recently on a high protein diet presents with an exquisitely tender, erythematous, warm right great toe. which of the following is the treatment of choice for this patient? **a.** corticosteroids **b.** colchicine **c.** allopurinol **d.** NSAIDs

Answer 88

**NSAIDs** are the TOC for acute gouty attacks _corticosteroids_ are used in acute gouty attacks but are reserved for people _with NSAID CI or allergy_ allopurinol is useful in reducing uric acid levels but is not the TOC in acute gouty attacks colchicine is not recommended for acute gouty attacks

Question 89

60 yo female recently discharged after an 8 day hospital stay for PNA presents complaining of pain and redness in her R arm where the IV had been placed. Patient denies fever or chills. Exam reveals localized induration, erythema and tenderness. There is no edema or streaking noted. What is the most likely diagnosis and how is it diagnosed and treated?

Answer 89

**_thrombophlebitis_** short-term venous catheterization of a superficial arm vein is commonly the cause of thrombophlebitis **venous duplex ultrasound** is the GOLD STANDARD for Dx treat thrombophlebitis (phlebitis + thrombosis) **with heparin x 1 month** (treat phlebitis with **elevation, warm or cool compresses, and NSAIDs**)

Question 90

16 yo nulliparous acutely ill female presents with bilateral lower abdominal pain. She has a temperature of 100.4 degrees F and on examination has a tender, enlarged left adnexa. Cervical culture is positive for chlamydia. US reveals a complex tubular structure in the left adnexal area. What is the recommended treatment?

Answer 90

**hospitalization with parenteral doxycycline and cefoxitin** patient has pelvic inflammatory disease and most likely tubo-ovarian abscess. It is recommended that the patient be hospitalized and treated with high dose IV antibiotic therapy. For patients with tubo-ovarian abscesses, surgical drainage is often necessary

Question 91

2 yo presents with sudden onset of cough and stridor. on examination the child is afebrile and appears nontoxic with a RR of 42. What is the next step in the evaluation of this patient?

Answer 91

**CXR** should be done FIRST when foreign body aspiration is suspected

Question 92

29 yo female with a history of IV drug abuse presents with ongoing fevers for three weeks. She complains of fatigue, worsening DOE and arthralgias. PE reveals BP of 130/60, HR 90, RR 18, unlabored. Petechiae are noted beneath her fingernails. Fundoscopic exam reveals exudative lesions in the retina. Heart examination shows RRR, with no S3 or S4. Lungs are CTAB and extremities without edema. What is the best diagnostic study of choice for this patient?

Answer 92

**transesophageal echocardiogram (TEE)** patient's signs and symptoms are consistent with infective endocarditis. **splinter hemorrhages** in fingernal beds **osler nodes**--painful lesions of fleshy portions of hands **roth spots** = retinal hemorrhages **janeway lesions** = non-tender, cutaneous evidence of septic emboli palatal or conjunctival petechiae _Duke Criteria:_ 2 MAJOR, 1 MAJOR + 3 minor, 5 minor MAJOR: 2 separate positive blood cultures, single positive culture for C. burnetii or antihase 1 IgG Ab titer positive ECHO--presence of vegetation new valvular regurgitation minor: predisposing heart condition or IV drug use fever vascular phenomena (arterial emboli, septic pulmonary infarcts, conjunctival hemorrhage, janeway lesions) immunologic phenomena (glomerulonephritis, osler nodes, roth spots, RF)

Question 93

18 yo female with DM presents to ED with altered level of consciousness, deep breathing and fruity odor to her breath. Which of the following medications is indicated for this patient?

Answer 93

**regular insulin** has a rapid onset of action when given IV and is the initial choice in patients with DKA. following the initial dose, a continuous infusion promotes a steady, slow fall of glucose levels to normal, which can then be stabilized by decreasing the insulin administer IV fluids fast administer insulin IV slow measure serum K+ ABG

Question 94

Bony and cartilaginous enlargement of distal interphalangeal joints is commonly seen in which of the following medical conditions?

Answer 94

**osteoarthritis** _Herberden's nodes_ are commonly seen in primary osteoarthritis

Question 95

68 yo male presents with jaundice, weight loss, and boring abdominal pain which radiates to the back. the gallbladder is palpable on PE. This is most consisten with what?

Answer 95

**pancreatic tumor** a large palpable gallbladder resulting from pressure from a tumor in the pancreatic head is known as Courvoisier's sign

Question 96

49 yo female presents complaining of several episodes of CP recently. Initial ECG in ED shows no acute changes. 2 hours later, while the patient was having pain, repeat ECG showed ST segment elevations in leads II, III, and AVF. Cardiac catheterization shows no significant obstruction of the coronary arteries. Which of the following is the treatment of choice for this patient?

Answer 96

**Nifedipine (PROCARDIA) CCB** the patient is most likely having a coronary artery vasospasm. This can be treated prophylactically with CCBs such as nifedipine. and nitrates as needed

Question 97

What is the most common etiology for spontaneous abortions (termination of pregnancy before 20 weeks)?

Answer 97

fetal chromosomal abnormalities

Question 98

What are the clinical manifestations of a **threatened abortion** and how do you manage it?

Answer 98

**MC cause of 1st trimester bleeding** bloody vaginal discharge, _+_ contractions of uterus, uterus size is compatible with dates **_Management_** ***supportive: rest @ home, return to ER if symptoms persist or passage of POC (products of conception), serial B-hCG*** to see if doubling RhoGAM if indicated

Question 99

What are the key features of an **inevitable abortion and how is it managed**

Answer 99

**_progressive cervix dilation_** \> 3cm, effaced **_+_ rupture of membranes** **_No POC (products of conception) expelled_** moderate bleeding \> 7 days **_Management:_** **Dilation and Evacuation (D&E) 2nd trimester** suction curettage in 1st trimester

Question 100

What are the key features of an **incomplete abortion and how is it managed?**

Answer 100

**_Some POC expelled, some contained_** **_DILATED\*\*_** **heavy bleeding, retained tissue, BOGGY UTERUS** **_Management:_** may be allowed to finish **_D&E_** after 1st (D&C in 1st) **Pitocin** RhoGAM if indicated

Question 101

What is the synthetic version of oxytocin that can be given to woman with **incomplete abortions** that will cause the uterus to contract and expel the rest of the POC?

Answer 101

**pitocin**

Question 102

Management of a **missed abortion**

Answer 102

**D&E (D&C in 1st)** **misoprostol** (synthetic prostaglandin E1 analog that replaces protective prostaglandins with prostaglandin-inhibiting therapies, been shown to induce uterine contractions

Question 103

25 yo female, G2P1001 presents to your office at 11 weeks gestation with vaginal bleeding, mild lower abdominal cramping, and bilateral pelvic discomfort. On examination, blood is noted at the DILATED cervical os. No tissue is protruding from the cervical os. The uterus by palpation is 8 - 9 weeks gestation. No other abnormalities are found. What is the most likely diagnosis?

Answer 103

**inevitable abortion** the gross rupture of membranes in the presence of cervical dilation

Question 104

50 yo male with h/o alcohol abuse presents with complain of worsening dyspnea. PE reveals bibasilar rales, elevated JVP, an S3 and lower extremity edema. CXR revelas pulmonary congestion and cardiomegaly. ECG shows frequent ventricular ectopy. ECHO shows LV dilation and EF 30%. What is the most likely diagnosis? **a.** hypertrophic cardiomyopathy **b.** dilated cardiomyopathy **c.** restrictive cardiomyopathy **d.** tako-tsubo cardiomyopathy

Answer 104

**dilated cardiomyopathy** often caused by chronic alcohol use. it is characterized by signs and symptoms of left-sided HF, a dilated LV and decreased EF

Question 105

What gram-negative bacteria has been linked to subsequent Guillain-Barré Syndrome?

Answer 105

**Campylobacter Jejuni** pathophys: immune-mediated demyelination & axonal degeneration slows nerve impulses --\> symmetric weakness & parasthesias. post-infection immune response cross-reacts with peripheral nerve components (molecular mimicry)

Question 106

Hallmarks of Guillain-Barré Syndrome

Answer 106

***_ASCENDING weakness and parasthesias (usually symmetric)._*** **decreased DTRs** (LMN lesion) ***_Autonomic Dysfunction_***: tachycardia, hypotension, ***breathing difficulties*** ***CSF: high protein with a normal WBC***

Question 107

How to Manage Guillain-Barré Syndrome

Answer 107

**1. Plasmapheresis:** best done if early (removes harmful circulating auto-antibodies that cause demyelination) **2. IVIG:** suppresses harmful inflammation/antibodies and induces remyelination. most recover within months **prednisone is CI in GBS because they may reduce scavengers that play a crucial role for nerve regeneration** prognosis: 60% recover within the 1st year

Question 108

Which of the following Rh genotypes in a mother and father would represent a risk for hemolytic disease of the newborn

Answer 108

mother Rh-negative and father Rh-positive if an Rh-negative woman carries an Rh-positive fetus, she may develop antibodies against Rh when fetal blood cells enter her circulation

Question 109

Low Molecular Weight Heparin (LMWH) dosage is based on which of the following: a. weight b. INR c. PT d. PTT

Answer 109

**weight** LMWH is based on a patient's weight in kilograms. INR is used to monitor anticoagulant medications PT is used to monitor warfarin efficacy PTT is used to monitor heparin use but not to determine the dosage

Question 110

What's the most common cause of ascites?

Answer 110

**portal HTN** over 80% of patients with ascites have portal HTN secondary to chronic liver disease. Infection, malignancy, and nephrotic syndrome are common causes of non-portal hypertensive ascites.

Question 111

55 yo male with h/o HTN and DM, presents to ED and wife states the patient developed progressive irritability and confusion today after complaining of a HA. PE revelas BP of 230/130 and papilledma. What is the most accurate diagnosis?

Answer 111

**Malignant HTN** is significantly elevated BP with progressive retinopathy, including papilledema, encephalopathy, and headache

Question 112

74 yo male with h/o CAD and afib presents to clinic for f/u of SOB. Patient's medications include amiodarone (CORDARONE) and metoprolol (LOPRESSOR). His **CXR reveals patchy ground-glass infiltrates.** What is the most likely diagnosis?

Answer 112

**pulmonary fibrosis** presents with ground-glass infiltrates on CXR and is often associated with certain medication use

Question 113

Household contacts of a patient with bacterial meningitis are best treated with what?

Answer 113

***Rifampin, Cipro, Levaquin, Zithromax, and Rocephin*** are the drugs of choice

Question 114

Croup is most often caused by what virus?

Answer 114

**parainfluenza virus**

Question 115

What behavior is typical for a patient with schizoid personality disorder?

Answer 115

**chooses solitary activities** persons with schizoid personalities are very withdrawn and do not seek or enjoy relationships and are indifferent to praise or criticism. They generally appear cold and unfeeling to others

Question 116

62 yo female presents to ER with significant back pain without radiation after lifting a box weighing approximately 15 pounds. She denies any previous trauma or injuries. Past history includes hysterectomy at age 42 and a 49 pack year smoking history. Current weight is 107 pounds. Lumbo-sacral spine film indicates a spinal compression fracture at level L4. Which of the following tests would you perform to further assess the patient's findings.

Answer 116

**DEXA scan**