- A 45-year-old woman is concerned that she has developed some varicose veins over the past several months. How do you counsel this patient?
a. Tell her that nothing can be done since it is strictly genetic.
b. Advise use of compression stockings since she is on her feet all day.
c. Tell her that elevating her legs can worsen the discomfort.
d. Recommend that she see a surgeon since this will be a definitive cure.
- B: Advise use of compression stockings since she is on her feet all day. Varicose veins are dilated veins seen in the lower extremities. They can be painful and due to a number of causes, including venous insufficiency, genetics, prolonged standing, and pregnancy. Elevation of the legs can provide temporary relief. Some patients opt for injection therapy or surgery, which can also be helpful from a cosmetic standpoint, although the problem can recur.
- Which of the following is true about Tourette disorder?
a. Diagnosis includes motor tics and at least one vocal tic
b. It is a hereditary condition and more common in males
c. Comorbid conditions include ADHD and OCD
d. All of the above
- D: All of the above. Tourette disorder is a tic disorder that is usually first seen in childhood. It is a spectrum disorder and must be distinguished from transient tics or other conditions. Tics can be simple such as blinking or sniffing, or more complex such as vocalizations. For a diagnosis of Tourette disorder, multiple motor tics and at least one vocal tic must be present for a year. The tics are only temporarily suppressible. Treatment can include medications such as antipsychotics.
- A 17 year old arrives in the office with left eye pain and redness. He feels like something is in his eye. He says that he has been sleeping in his contacts for the past week, but took them out earlier this morning. You use fluorescein staining and notice an abrasion but do not see a foreign body. How do you treat this patient?
a. Immediate copious irrigation
b. Eye patch for 1 week
c. Antibiotic ointment for 5 days
d. Ophthalmic corticosteroids
- C: Antibiotic ointment for 5 days. This patient has a corneal abrasion, likely from improper use of contact lenses. Abrasions can present with a foreign body sensation. Antibiotic ointment is recommended to prevent infection. Irrigation is used when a foreign body is suspected or visualized. Eye patches and steroids are not used because they can worsen the condition.
- A 28-year-old woman has wrist pain on the thumb side. The Finkelstein test is positive. The tendons of which muscles are affected in this syndrome?
a. Abductor pollicus longus and extensor pollicus brevis
b. Extensor carpi radialis brevis and extensor carpi radialis longus
c. Abductor pollicus longus and extensor pollicus longus
d. Extensor digitorum and extensor pollicus longus
- A: Abductor pollicus longus and extensor pollicus brevis. The patient described has De Quervain syndrome, which is a tenosynovitis usually occurring due to overuse. These two muscles form the bulge on the lateral side of the wrist near the thumb, and the tendons form the lateral border of the anatomical snuffbox. A positive Finkelstein test elicits pain when adducting the wrist with the thumb tucked in the palm.
- Hepatitis C is most commonly transmitted through which of the following?
a. Breastfeeding
b. Sex
c. Blood
d. Feces
- C: Blood. Infection is commonly transmitted with IV drug use, along with tattoos or body piercings. Transmission during sex and breastfeeding are relatively rare. Transmission of hepatitis B usually occurs through blood and sex. Hepatitis A spreads primarily by fecal-oral contact.
- A 25-year-old woman reports that she and her husband have been trying to conceive. They have been having unprotected intercourse for the past 6 months with no resulting pregnancy. How do you help this patient?
a. Set her up an appointment with an infertility specialist.
b. Counsel her that infertility is not diagnosed until after 1 year of unprotected intercourse.
c. Advise that her husband come in for testing.
d. Order a hysterosalpingography.
- B: Counsel her that infertility is not diagnosed until after 1 year of unprotected intercourse. In the United States, women are not considered infertile until they have been trying to conceive for 12 months without contraception. It is generally recommended that women younger than age 30 wait until then to undergo further testing. Infertility can be due to factors in the female, male, or both.
- Which of the following drugs has been linked most strongly with the adverse effect of aplastic anemia? a. Phenylephrine
b. Gentamicin
c. Cyclobenzaprine
d. Carbamazepine
- D: Carbamazepine. Aplastic anemia occurs when there is a loss of blood cell precursors. The cause is unknown in most cases, but radiation, chemicals, and medications have been linked to the condition (benzene, certain antineoplastics, antibiotics, NSAIDS, and anticonvulsants). Carbamazepine is used as an anticonvulsant and mood stabilizer. Chloramphenicol is a rarely used antibiotic that has been associated with aplastic anemia.
Women’s Health/Reproductive
Which of the following combinations accurately describes the normal progression of labor?
A Stage I usually lasts no longer than 6–8 hours and is characterized by Braxton-Hicks contractions.
B Stage II is active labor lasting from 4–6 hours. The cervix is dilated to approximately 8 cm and contractions are 3–5 minutes apart.
C Stage III lasts 15 minutes to 1.5 hours. The cervix dilates to 10 cm and contractions are 60 to 90 seconds long and 2–3 minutes apart. Delivery is expected soon.
D None of the above statements are true.
(D) Braxton-Hicks contractions that are perceived by the patient occur late in pregnancy but are not associated with dilation of the cervix. Stage I is the interval between the onset of labor and full cervical dilation (10 cm). Stage II encompasses complete cervical dilation with delivery of the baby. Stage III begins immediately after delivery of the baby and ends with delivery of the placenta. The final stage is Stage IV which is the immediate postpartum period of approximately 1 to 4 hours after delivery of the placenta.
A 32-year-old white male presents for an insurance physical. He is asymptomatic and denies significant past medical history. His physical examination is essentially normal except that he has a blood pressure of 140/90 mm Hg in both arms. What is the most appropriate intervention at this time?
A No diagnosis: Return in 2 weeks to recheck the blood pressure.
B No diagnosis: Obtain an electrocardiogram, complete metabolic panel, and urinalysis and return in 2 weeks to recheck the blood pressure.
C Stage I primary hypertension: Obtain labs mentioned in (B) above and begin nonpharmacologic therapy.
D Stage I primary hypertension: Obtain labs mentioned in (B) above and begin pharmacologic therapy.
(A) This appears to be a healthy 32-year-old gentleman according to the history. He should not be classified as hypertensive unless he has a proven sustained elevation of his blood pressure. It would be appropriate to instruct the patient to measure his blood pressure at home daily (or twice daily), keep a record of the readings, and return for an office visit in two weeks. The JNC-7 report classifies a well-documented sustained blood pressure of 140/90 as Stage I hypertension and recommends initiation of pharmacologic therapy along with lifestyle modifications.
Cardiovascular
Which antihypertensive agent would be most preferred in a patient with coexisting diabetes mellitus?
A Thiazide diuretic
B Calcium channel blocker
C Beta adrenergic blocker
D ACE inhibitor
(D) Placebo controlled trials in diabetic patients have shown the efficacy of ACE inhibitors, diuretics, and beta blockers as initial therapy in lowering blood pressure. However, ACE inhibitors have also been shown to slow progression of diabetic nephropathy, making this the best first line choice. Studies have also shown that the use of ACE inhibitors in high risk hypertensive patients slows the occurrence of cardiovascular events, i.e., stroke, coronary artery disease, etc.
Pulmonary
Which process most accurately reflects the current understanding of the pathogenesis of asthma?
A Chronic airway inflammation
B Activated macrophage release of leukotrienes and tumor necrosis factor alpha
C inhalation of dust
D An imbalance between protease and antiprotease activities in the lungs
(A) Asthma is defined as a chronic inflammatory disorder of the airways. Choices (B) and (C) are more pathogenic of emphysema, and pneumoconiosis results from inhalation of various kinds of dust particles. Imbalances between protease and antiprotease activity is being studied as a cause for alveolar wall destruction.
Pulmonary
Bronchial breathing, egophony, whispered pectoriloquy, diminished fremitus, and dullness to percussion are most consistent with which diagnosis?
A Pneumothorax
B Upper lobe atelectasis
C Consolidated pneumonia
D Pleural effusion
(B) The findings are consistent with upper lobe atelectasis. If it were lower lobe atelectasis, the patient would have diminished or absent breath sounds. Pneumothorax presents with diminished to absent breath sounds, diminished or absent whispered voice sounds, and hyperresonance to percussion. It usually occurs in one lung only. Consolidated pneumonia presents with a variety of crackles and/or rhonchi along with bronchial breath sounds, egophony, whispered pectoriloquy, and increased fremitus in the area of consolidation. Pleural effusion presents with diminished or absent breath sounds, bronchophony, whispered pectoriloquy, an occasional friction rub, and dullness to percussion.
Women’s Health
Which diagnosis must ALWAYS be excluded in a female patient with an acute abdomen?
A Ectopic pregnancy
B Ovarian cyst
C Endometriosis
D Appendicitis
(A) Ectopic pregnancy (implantation outside the uterine cavity) is incompatible with continuing the pregnancy and carries the risk of catastrophic bleeding if it erodes into blood vessels or ruptures through the fallopian tube. Ovarian cysts usually resolve spontaneously or may be managed by pharmacological agents. Endometriosis causes a wide variation in symptoms with pelvic pain being the most common finding. It is not usually associated with an acute abdomen. Acute appendicitis typically produces pain in the right lower quadrant of the abdomen and is a cause of an acute abdomen. In the female of childbearing potential, however, the best answer to the question is selection (A).
infectious Diseases
The most common pathogen causing community acquired pneumonia (CAP) is
A Streptococcus pneumoniae
B Mycoplasma pneumoniae
C Hemophilus influenza
D Klebsiella pneumoniae
(A) Streptococcus pneumoniae causes 20–50% of the cases of CAP; Mycoplasma pneumoniae is responsible for 10–30%; Hemophilus influenza 5–10%; and Klebsiella pneumoniea 1–3% of the cases.
Emergency Medicine The diagnosis of appendicitis is MOST likely to be missed in which age group?
A 1–6 years
B 11–20 years
C Over 65 years
D Both (A) and (C) are correct.
(D) Young children have difficulty in expressing their symptoms clearly and elderly patients may have a reduced inflammatory reaction, making diagnosis more difficult in these age groups. Appendicitis reaches its peak between the ages of 10 and 20, and approximately 80% of cases occur before the age of 45.
- A 21-year-old woman has symptoms of dysuria and frequency for the first time. She is not pregnant, and there is no costovertebral angle (CVA) tenderness. The urine dipstick is positive for leukocyte esterase and nitrites. What is the most likely causative organism?
a. E. coli
b. Enterobacter
c. Serratia
d. Pseudomonas
- A: E. coli. This patient has cystitis, also known as a lower urinary tract infection. E. coli is responsible for roughly 90% of first infections in women. Klebsiella, Enterobacter, Proteus, Pseudomonas, and Serratia are also common. Culture is considered the gold standard for diagnosis but may not always be necessary.
- Which of the following is NOT a sign of Cushing syndrome?
a. Thin skin with striae
b. Central obesity
c. Decreased hair growth
d. “Moon face”
- C: Decreased hair growth. Cushing syndrome is due to adrenal hormone excess. Central obesity, “moon face,” and thin skin with striae are due to changes in protein and fat metabolism. Patients with Cushing syndrome have excess hair growth due to changes in sex hormones, along with irregular periods and impotence.
- A 26-year-old man has 3 to 4 cm depigmented irregular patches on his fingertips that have been present for the past 2 months and seem to be growing. What is likely happening to this patient?
a. Acute infection with a virus
b. Too much sun exposure
c. Chronic fungal infection with underlying disease
d. Loss of skin melanocytes with unclear cause
- D: Loss of skin melanocytes with unclear cause. This patient likely has vitiligo. It may be an autoimmune condition, although the true cause is unknown. There is a genetic component. Loss of skin melanocytes causes progressive areas of skin depigmentation. It commonly occurs on the face, digits, and flexor surfaces.
- What is considered first-line therapy for hypertrophic cardiomyopathy?
a. Beta-blockers
b. Nitrates
c. Inotropes
d. Angiotensin-converting enzyme (ACE) inhibitors
- A: Beta-blockers. Hypertropic cardiomyopathy is a congenital disorder. Patients experience chest pain, shortness of breath, and syncope, and can have sudden death. It is diagnosed with echocardiography. Beta-blockers slow the heart rate, which prolongs the diastolic filling period, and ventricular diastolic function is improved. Nitrates and ACE inhibitors decrease chambersize and worsen the condition. Inotropes worsen outflow obstruction and may induce arrhythmias.
- A toddler has jaw stiffness, headache, and fever 7 days after stepping on a dirty nail. The patient has not received any immunizations. CSF is clear. Which of the following is NOT a usual component of treatment for this condition?
a. Steroids
b. Human immune globulin
c. Metronidazole
d. Diazepam
- A: Steroids. Tetanus is also known as “lockjaw” and is caused by the neurotoxin from Clostridium tetani. Patients have tonic spasms of voluntary muscles. Disease is rare in the United States because of prevention through immunization. Immune globulin neutralizes the toxin, and metronidazole prevents further toxin release. Patients are also usually sedated to control muscles spasms. The wound should be debrided as well.
- What is the most frequent complication of performing an endoscopic retrograde cholangiopancreatography (ERCP)?
a. Aspiration
b. Pancreatitis
c. Perforation
d. Cholangitis
- B: Pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that uses x-ray to view the bile and pancreatic ducts. This procedure is often done because of a gallstone blockage. The scope is inserted through the mouth, and air is introduced so that the flexible tube can go into the lower structures. Mild pancreatitis occurs in 3% to 5% of people who undergo the procedure.
- How does donepezil work in the treatment of Alzheimer disease?
a. Acetyl/ butyrylcholinesterase inhibitor
b. Acetylcholinesterase inhibitor
c. Cholinesterase and nicotinic receptor stimulation modulator
d. Glutamate antagonist
- B: Acetylcholinesterase inhibitor. Patients with Alzheimer disease have a cerebral cholinergic deficit, and donepezil increases cholinergic transmission by inhibiting the enzyme that breaks down acetylcholine. It can improve cognition, behavior, and functioning with activities of daily living. Rivastigmine is an acetyl/ butyrylcholinesterase inhibitor, galantamine is a cholinesterase and nicotinic receptor stimulation modulator, and memantine antagonizes glutamate.
- A 32-year-old woman has a 1-week history of runny nose, cough, and fever. On exam, you note tenderness to palpation of the forehead. What is the most likely diagnosis?
a. Sinusitis
b. Allergic rhinitis
c. Parotitis
d. Nasal polyps
- A: Sinusitis. This condition is an inflammation or swelling of the sinuses. Patients present with rhinorrhea, anosmia, congestion, facial pain, headache, fever, and cough. Allergic rhinitis and nasal polyps may have similar symptoms, although sinus tenderness would not be present. Parotitis is an inflammation of the parotid gland.
- A 46-year-old man arrives in the emergency department with depressed mood, insomnia, low energy, and poor concentration for the past month. He has been having intermittent thoughts about suicide, but has not thought of a specific plan. He says that he does not want to commit suicide because of his family. He also does not want to have to stay in the hospital. What is the most appropriate course of action?
a. Admit him to the hospital involuntarily since you think he is an imminent danger to himself.
b. Advise that he find a psychologist since mental health issues are not treated in the emergency department.
c. Send him home with a month’s supply of a mood stabilizer to try out for his symptoms.
d. Discharge him with a low-dose antidepressant and make a close psychiatry follow-up appointment.
- D: Discharge with a low-dose antidepressant and make a close psychiatry follow-up appointment. Involuntary commitment to a hospital would be appropriate if a patient is considered to be a danger to self or others. With this patient, although he does have intermittent suicidal thoughts, he does not have current suicidal intent or plan. He declines voluntary hospitalization, so the best course of action is outpatient management. He could be discharged with a starting dose of an antidepressant as long as an outpatient mental health appointment can be ensured within the coming days.
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