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Flashcards in UWorld Deck (1353):
1

An elderly pt presenting with progressive memory impairment along with impaired vibration sense, positive romberg sign, spastic paresis and hyperreflexia most likely suffers from ..

Vitamin B deficiency

(dementia with subacute combined degeneration)

2

A pt with vitamin B 12 deficiency presenting with elevated lactate dehydrogenase, low haptoglobin, and indirect hyperbilirubinemia most likely suffer from ...

Hemolytic anemia secondary to ineffective erythropoesis

(defective DNA synthesis in new RBCs results in hemolysis when pt has vitamin B deficiency)

3

An elderly pt presenting with dementia, cognitive fluctuations, visual hallucinations, parkinsonism (bradykinesia, rigidity, gait abnormalities), vivid dreams, and/or neuroleptic hypersensitivity most likely suffers from ...

Lewy Body Dementia

4

What treatment for Lewy Body Dementia can exacerbate the pt's visual hallucination symptoms?

dopamine agonist

(lewy body dementia treated with cholinesterase inhibitors and anti-parkinson medications)

5

A pt presenting with a unilateral headache, ipsilateral miosis (small pupil), and ipsilateral ptosis (eyelid drooping) most likely suffers from ...

Carotid Artery Dissection

(in setting of trauma/ connective tissue disease/ smoking/ neck manipulation/ hypertension/ 3-point restraint belts in car accidents)

6

What is the most appropriate next step in management of a pt presenting with unilateral headache, ipsilateral miosis (small pupil), and ipsilateral ptosis (eyelid drooping)?

Head and Neck CT angiography

(detect carotid artery dissection)

7

An alcoholic pt presenting with confusion, ataxia and nystagmus (leading to ophthalmoplegia) most likely suffers from ...

Wernicke's Encephalopathy

(due to thiamine deficiency; tx with IV/ IM thiamine)

8

An alcoholic pt presenting with amnesia (anterograde and retrograde) and confabulation most likely suffers from ...

Korsakoff's syndrome

(due to thiamine deficiency)

9

Administration of what substance prior to thiamine in an alcoholic with Wernicke's encephalopathy can precipitate progression into Korsakoff's syndrome?

Glucose

(do not give glucose before thiamine)

10

What part of the brain is affected in alcoholic patients with Wernicke-Korsakoff syndrome?

mammillary bodies

11

What are three major reversible causes of dementia that should be ruled out before diagnosing a pt with Alzheimer's?

1. hypothyroidism (perform thyroid function test)
2. Vitamin B12 deficiency
3. depression

(consider vitamin B1 in alcoholic and severely malnourished)

12

A pt presenting with rapidly progressive dementia, periodic sharp wave complexes on EEG, and presence of 14-3-3 protein in CSF most likely suffers from ...

Creutzfeldt-Jakob disease

13

What is the best initial treatment for Alzheimer's disease?

acetylcholinesterase inhibitors

(donepezil better than tacrine b/c once daily and more improvement in behavioral and cognitive domains)

14

What part of the brain has been associated with the decreased levels of acetylcholine in Alzheimer's?

degeneration of basal nucleus of Meynert (along with diffuse deficiency of choline acetyltransferase)

15

A pt presenting with unilateral onset of symptoms consisting of bradykinesia, resting tremor, and rigidity with a persistant asymmetry in the symptoms, and develops postural instability most likely suffers from ..

Parkinson's Disease

(dx: clinical)

16

Other than physical exam, what diagnostic test can be used to diagnosis Parkinson's disease in a pt whose symptoms are suggestive but pt not responding to initial therapy?

Striatal Dopamine Transporter Scan

(low uptake of ioflupane-123 in striatal region)

17

What is the best initial treatment for Parkinson's Disease?

if > 65 years and severe: levodopa
if less than 65 years and mild: dopamine agonist

(prevent use of levodopa as long as can)

18

What is the clinical criteria for brain death? (3)

1. imaging evidence of devastating cause
2. absence of confounding factors (endocrine, electrolyte abnormalities, drug intoxication)
3. hemodynamically stable (temp > 36; sbp > 100)

19

An elderly pt presenting with dementia along with hyponatremia, macrocytosis (high MCV), and bradypsychia (slowed thought process)/ cognitive slowing most likely suffers from..

Hypothryoidism

(obtain thryoid function testing)

20

A pt presenting with progressive flaccid ascending paralysis (progressive lower extremity weakness), areflexia (absent deep tendon reflexes), and possibly difficulty breathing weeks after an upper respiratory or gastrointestinal infection most likely suffers from ..

Guillian Barre Syndrome

(intubate if signs of respiratory compromise)

21

What diagnostic test is most useful in determining the degree of respiratory impairment in a pt with Guillian Barre Syndrome?

bedside vital capacity measurements

22

What is the mainstay of therapy for Guillian Barre Syndrome (after triaging the severity and providing appropriate respiratory support)?

plasmapheresis and/or IVIG (IV immunoglobulin)

23

A pt presenting with a tremor (usually in distal upper extremities) that becomes more pronounced with outstretching of the arm/ end of an activity or movement in the setting of a family member having had similar symptom and alcohol improves symptoms most likely suffers from ..

Benign Essential Tremor (Familial Tremor)

(normal life expectancy, no significant disabilities/ neurologic problems)

24

What is the best initial treatment for benign essential tremor (familial tremor) that is significantly impacting a pt's life?

beta blockers (propanolol)

25

What is the next best step in management of a pt who meets all clinical criteria of brain death (clinical/imaging evidence of devastating cause, absence of confounding factors, hemodynamic stability)?

Neurologic examination

(cerebral and brain stem reflexes including motor response to pain, pupillary, oculocephalic, oculovestibular/ caloric, cough reflex with tracheal suctioning, corneal, gag, suckling, swallowing, extensor posturing)

26

What is the next best step in management of a pt who meets all clinical criteria of brain death (clinical/imaging evidence of devastating cause, absence of confounding factors, hemodynamic stability) and has abnormal neurologic findings (coma, absent motor response to pain, absent pupillary light reflex, absent corneal and oculocephalic reflexes, absent cough reflex with tracheal suctioning)?

Apnea Testing

(pre-oxygenated and then disconnect ventilator)

(absence of respiratory response for 8-10 minutes with PaCO2 > 60 or > 20 from baseline, and final arterial pH of less than 7.28

27

What are the three conditions in which ancillary testing (EEG showing electrocerebral silence or absence of somatosensory/ brainstem-evoked potentials; absent intracranial blood flow on brain imaging) for suspected brain death should be performed?

1. don't meet all clinical criteria
2. difficult to evaluate neuro exam or pt paralyzed
3. difficult to interpret or inconclusive apnea test

28

A pt presenting with loss of pupillary reaction bilaterally, vertical gaze paralysis (impaired upward gaze), loss of optokinetic nystagmus and ataxia in the setting of progressively worsening headache most likely suffers from ...

Parinaud's syndrome

(pineal tumor that can secrete HCG)

29

A male pt presenting with headaches, pulsating rhythmic sound in ears when bent over, papilledema, and progressive optic atropy leading to vision problems (possibly blindness) while on retinoic acid derivative treatment for acne most likely suffers from ...

Pseudotumor Cerebri

(Idiopathic intracranial hypertension)

30

What spinal cord level is responsible for the cremasteric reflex?

L1-L2

(can be absent if pt suffering from diabetic neuropathy)

31

An adolescent presenting with generalized tonic clonic seizure and an EEG showing bilateral polyspike and slow discharge in the setting of a history of myoclonic jerks of the upper extremity within the first hour of waking and history of anxiety most likely suffers from ...

Juvenile Myoclonic Epilepsy

32

What is the best initial treatment for Juvenile Myoclonic Epilepsy?

Valproic Acid (Depakote)

33

A pt presents with a history of unsteady gait rapidly progressing to ascending paralysis within hours to days of spending time in a wooded area along with loss of deep tendon reflexes, normal CSF findings, and absence of fever/ pupillary abnormalities most likely suffers from ...

Tick Paralysis

(dx: skin examination to assess for tick attachment)

34

What is the best initial treatment for pt presenting with Tick Paralysis?

remove tick carefully (improvement immediately, may worsen initially)

35

What is the best initial step in management for a pt with suspected epidural spinal cord compression (i.e. pt with cancer history presenting with thoracic radicular pain wrapping around abdomen with associated weakness and sensory changes in lower extremities)?

High Dose corticosteroids (reduce inflammation and swelling) followed by spinal MRI (to confirm diagnosis and assess extent)

36

What is the definitive treatment for epidural spinal cord compression secondary to tumor metastasis?

radiation: if stable spine, minimal neuro symptoms or highly radiosensitive tumor
surgical decompression: if radioresistant or unstable spine

37

What diagnostic tests are included in a routine dementia work-up before diagnosing a pt with Alzheimer's? (6)

1. CBC (rule out anemia)
2. Serum glucose (rule out hypoglycemia)
3. electrolytes (rule out electrolyte disturbance)
4. calcium level (rule out hypo/ hypercalemia)
5. creatinine (rule out renal failure)
6. TSH (rule out hypothryoidism)

38

What Mini-Mental Status Exam score indicates dementia? What score indicates benign forgetfulness of senility?

dementia: less than 20
benign: greater than 25

39

What is the prognosis of Alzheimer's disease?

irreversible, medication slows progression but there is no cure

40

A pt who presents to the ER unconscious, unresponsive to verbal and tactile stimuli, has symmetric decrease in muscular tone, normal deep tendon reflexes, and a normal response to the caloric stimulation (transient conjugate slow deviation of gaze to side of stimulus followed by saccadic correction to midline after irrigation of the external auditory canal with cold water) most likely suffers from ...

Psychogenic Coma

41

What is the net clinical benefit of a medication? (in reference to studies)

measure of possible benefit minus its possible harm

42

... is when participants in trials are analyzed in the groups to which they were randomized, regardless of whether they received or adhered to the allocated intervention and regardless of whether they withdrew from treatment

Intention-to-treat analysis

(purpose is to maintain randomization)

43

.... is the practice of monitoring the safety of medication or devices after they have been released on the market due to the fact that clinical trials have ....

Postmarketing surveillance; inadequate power (short follow-up times, underrepresented populations, too few participants to detect rare and serious side effects)

44

A pt presenting with sticking sensation in the throat (dysphagia) accompanied by heartburn and esophageal manometry showing absence of peristaltic waves in the lower two-thirds of the esophagus and significant decrease in lower esophageal sphincter tone most likely suffers from ...

Scleroderma

(results in esophageal dysmotility)

45

What are the esophageal manometric findings in Achalasia?

significant decrease/ absence of peristaltic waves and increased lower esophageal sphincter tone

46

A pt with history of treated cancer (especially Hodgkin lymphoma) presenting with myocardial ischemia, restrictive cardiomyopathy with diastolic dysfunction, sclerotic and calcified valves with associated stenosis/ regurgitation, and ostial narrowing of the coronary arteries most likely suffers from ...

Radiation Induced Cardiotoxicity

47

What is the next best step in management of a pt with suspected active TB (travel to endemic area, cough for more than 2-3 weeks, fever, night sweats, weight loss) after chest x-ray is performed (showing infiltrate or cavitary lesion)?

3 sputum specimens for acid fast bacillus smears and culture (within 8-24 hours intervals, and at least 1 early morning)

48

A pt with active TB (travel to endemic area, cough for more than 2-3 weeks, fever, night sweats, weight loss, imaging showing infiltrate or cavitary lesion) with 3 negative sputum specimens is considered ...

noninfectious

49

What is the formula for the NNT (number needed to treat; number of patients who need to be treated in order to prevent on additional bad outcome)?

NNT = 1/ (control group rate- experimental group rate)

NNT = 1/ (absolute risk reduction)

50

What are the two most common causes of diaphragmatic paralysis (decreased movement of rib cage and abdominal flattening)?

1. birth injury (Erb's palsy secondary to shoulder traction)
2. cardiothoracic injury

51

A pt presenting with easy fatigability, pallor of conjunctiva, pallor of oral mucosa, low hemoglobin, microcytosis (low MCV), anisocytosis on blood smear and serum ferritin level ( less than 30) most likely suffers from ...

Iron Deficiency Anemia

(likely due to GI bleed in males so perform fecal occult blood test)

52

What is the typical prognosis for an infant suffering from hypertrophic cardiomyopathy (i.e. hypertrophic interventricular septum) as a result of being born to a diabetic mother with poor glycemic control during gestation?

does well with conservative medical therapy and the abnormality corrects itself (resolves spontaneously b/c no longer exposed to maternal hyperglycemia leading to excessive glycogen within myocardium)

53

What is the likely cause of isolated gastric varices in a pt with a history of chronic recurrent pancreatitis?

splenic vein thrombosis
(runs along posterior surface of pancreas and gets directly inflamed and thrombosed due to recurrent pancreatic inflammation)

54

What is the likely cause of gastric varices with esophageal varices in a pt with a history of chronic recurrent pancreatitis?

portal vein thrombosis
(leads to prehepatic/ noncirrhotic portal hypertension)

55

What is the benefit of smoking cessation in a pt who is age 60 or older?

mortality risk will fall below current smokers within 5 years

(can result in initial temporary increase in cough during first few weeks after cessation, followed by improvement)
(reduces risk of COPD exacerbation and developing lung cancer)

56

What is the most reliable physical exam finding for excluding severe aortic stenosis?

normal splitting of second heart sound (increased splitting of aortic and pulmonic components during inspiration)

57

What are three physical exam findings that indicate severe aortic stenosis?

1. soft, single S2 (no normal splitting)
2. delayed and diminshed carotid pulse (parvus and tardus)
3. loud and late-peaking systolic murmur

58

What is the most immediate step in management for an infant presenting with bilateral flame shaped retinal hemorrhages suggestive of shaken baby syndrome?

CT scan of head

(ultrasound can be used if fetus or infant with open fontanelles but not as accurate)

59

What are the four indications for head CT after a head trauma in a kid?

1. glascow coma score equal to/ less than 14
2. signs of basilar skull fracture (battle sign- mastoid ecchymoses, raccoon eyes- orbital ecchymoses, CSF rhinorrhea or otorrhea, hemotympanum, cranial nerve deficits)
3. altered mental status
4. symptomatic pt with bleeding disorder

60

A type 1 diabetic who presents with recurrent hypoglycemic episodes evenly distributed throughout the day while on stable insulin dose (signs of decreasing insulin requirement) in setting of weight loss, weakness, eosinophilia, hyperkalemia, mild anion gap acidosis, prerenal azotemia, and low blood glucose most likely suffers from ...

Adrenal Failure (secondary to autoimmune disease)

(if pt has one autoimmune disease, predisposed to get another)

61

What is the best initial screening test when a pt is suspected of having pheochromocytoma (episodic headaches, diaphoresis and tachycardia, early onset/ refractory hypertension, paroxysmal hypertension)?

24 hour fractionated urinary metanephrines and catecholamines or plasma free metanephrine levels

62

What is the next best step in management for a pt with symptoms and biochemical confirmation of pheochromocytoma?

Abdominal CT or MRI

63

What is the next best step in management for a pt who develops hypotension during surgical removal of adrenal tumor responsible for pheochromocytoma?

normal saline bolus followed by continous normal saline infusion

(pressors if needed)

64

What is the next best step in management for a pt who develops hypoglycemia during surgical removal of adrenal tumor responsible for pheochromocytoma?

IV dextrose infusion

(due to decrease catecholamine supression of insulin secretion leading to hyperinsulinemia)

65

What is the next best step in management for a pt who develops cardiac tachyarrhythmias during surgical removal pheochromocytoma?

IV lidocaine or esmolol

(due to increase catecholamine release from adrenal gland handling)

66

What is the next best step in management for pt who develops acute severe hypertension during surgical removal of pheochromocytoma?

IV phentolamine/ nitroprusside/ nicardipine

(due to increase catecholamine release from intubation and adrenal gland manipulation)

67

What is the best next step in management for a pt with an ECHO confirmed bicuspid valve?

ECHO screening in first degree relatives (autosomal dominant with incomplete penetrance or sporadic)

68

What is the next best step in management for a pt with suspected osteomyelitis (foot pain, swelling and erythema along with elevated WBC and ESR) but negative foot X-rays (lack periosteal reaction and osseous lucency)?

MRI of foot

(non-invasive modality with highest accuracy for diagnosing osteomyelitis)

69

A pt presenting with hyperthyroid symptoms, nontender thryoid goiter, elevated T3 and T4, low TSH, positive TPO antibody and diffusely decreased radioiodine uptake study in the setting of immunotherapy treatment (interferon for hep C) or lithium treatment most likely suffers from..

Painless Thyroiditis/ Silent Thyroiditis/ Subacute lymphocytic thyroiditis

(autoimmune induced proteolysis of thyroglobulin leading to thyroid hormone release until stores depleted)

70

What treatment can be used in painless/ silent/ subacute lymphocytic thyroiditis during the hyperthyroid state?

propanolol (beta blockers)

71

What is the best initial step in management prior to treating a sexually active female of reproductive age for a UTI?

urine beta-hCG (pregnancy test)

72

What is the best initial treatment for UTI's in a pregnant patient?

nitrofurantoin (and first generation cephalosporin)

73

What is the influenza vaccination protocol in a pt with egg allergies in which the reaction is limited to hives?

administer inactivated influenza vaccine and observe for at least 30 minutes

74

.... is a measure of the likelihood that an outcome will occur in the presence of a particular exposure compared to the likelihood that the outcome will occur in the absence of that exposure

Odds Ratio

OR = ad/ bc

(if greater than 1: exposure associated with high odds of outcome)
(if less than 1: exposure associated with lower odds of outcome)

75

An asthmatic pt presenting with history of recurrent fever, malaise, cough with brownish mucoid expectoration, wheezing, symptoms of bronchial obstruction, eosinophilia and bilateral upper lobe parenchymal infiltrates on CXR most likely suffers from ...

Allergic Bronchopulmonary Aspergillosis (ABPA)

76

What is the initial screening test for suspected allergic bronchopulmonary aspergillosis in an asthmatic pt?

skin prick test for aspergillus
(if negative, unlikely diagnosis)
(if postive, perform serum total IgE level and precipitating serum antibodies to Aspergillus fumigatus)

77

What is the best initial treatment for allergic bronchopulmonary aspergillosis (ABPA)?

oral prednisone (corticosteroids)

78

A pt presenting with fragmented sleep, hypnagogic hallucinations (seeing/hearing things as fall asleep), recurrent lapses into sleep or napping multiple times within the same day occuring at least 3 times weekly for 3 months along with at least one of the following symptoms (cataplexy-conscious brief episodes of sudden bilateral muscle tone loss precipitated by emotions or spontaneous abnormal facial movements without emotional triggers; hypocretin 1 deficiency by CSF analysis; rapid eye movement sleep latency less than 15 minutes) most likely suffers from ..

Narcolepsy

79

What is the diagnostic test of choice for suspected narcolepsy?

Polysomnography (Sleep Study)
(shows multiple spontaneous awakenings, reduced sleep efficiency, reduced latency of rapid eye movement sleep)

80

What is the best initial treatment for narcolepsy?

Modafinil (stimulant) along with behavioral intervention (good sleep hygiene, scheduled naps)

81

What is the best treatment for cataplexy (sudden onset of muscle weakness triggered by intense emotional episodes) associated with narcolepsy?

serotonin-norepinephrine reuptake inhibitor (venlafaxine)

(can also use SSRI, TCAs, sodium oxybate- restricted due to abuse potential)

82

A pt presents with respiratory difficulty, cough, sputum, fever, chills, and infiltrate on CXR 1-5 days after choking most likely suffers from ...

Aspiration Pneumonia

83

What is the best initial treatment for aspiration pneumonia (gram positive cocci, gram negative rods, anaerobes)?

Clindamycin (or beta lactam and beta-lactamase inhibitor combination)

84

What is the best step in management in a hospitalize pt who develops acute renal failure to distinguish between prerenal azotemia and acute tubular necrosis?

fluid challenge
(if improved urine output, then prerenal azotemia)
(if no improvement in urine output, then acute tubular necrosis)

85

A pt who develops oliguria after hypotension with an elevated BUN and creatinine but a normal BUN to creatinine ratio (10-15), anion gap acidosis, and oliguria does not improve with fluid challenge most likely suffers from ...

Acute Tubular Necrosis

(muddy brown casts, high fractional excretion of sodium > 2%)

86

What is an important diagnostic test that should be performed in all high-risk pts being treated for aspiration pneumonia?

speech and swallow evaluation by speech therapist (to assess for need for diet modification)

87

What is the best initial treatment for insomnia secondary to bereavement in the elderly patients?

behavioral therapy and relaxation techniques

(elderly at increased risk of falls and bone fractures at night and reduced daytime alertness if use medications for insomnia)

88

What are the indications for adding antibiotic therapy to incision and drainage for a skin abscess in kid? (6)

1. diameter > 5 cm
2. multiple abscesses
3. extensive surrounding cellulitis
4. systemic signs of infection
5. immunocompromised
6. age less than 6 months

89

What is the best step in management for a pt with a septate uterus (septum within the uterus) and non-obstructing fallopian tubes who experiences recurrent miscarriages?

metroplasty via hysteroscopy (surgery to decrease risk of future miscarriage)

90

A pt who develops hyperactive deep tendon reflexes, muscle cramps and possibly convulsions during or shortly after surgery (especially if extensive transfusions were required) most likely suffers from ...

Hypocalcemia

(due to volume expansion and hypoalbuminemia)

91

A pt with sarcoidosis presenting with acute onset red eye, photophobia, blurring of vision, and mild to moderate pain most likely suffers from ..

Anterior Uveitis

(most common ocular manifestation of sarcoidosis)

92

A pt presents with a papular lesion that slowly grows in size and eventually ulcerates with non-purulent discharge along with similar lesions along the lymphatic channels proximal to the original lesions after an outdoor activity/ occupation most likely suffers from ..

Sporotrichosis

(Sporothrix schenckii inoculated in skin or subcutaneous tissue)

93

What is the treatment for lymphocutaneous sporotrichosis?

itraconazole for 3-6 months

94

A pt who develops intense pain which increases with passive stretch accompanied by paresthesia (ant crawling sensation, burning sensation), tightness of extremity, weakness, and rapidly increasing and tense swelling after extremity thromboectomy most likely suffers from ...

postischemic Compartment Syndrome

(due to interstitial edema and intracelluar swelling following tissue ischemia and subsequent reperfusion)

95

What is a diagnostic test used to confirm compartment syndrome?

measuring tissue pressures
(compartment pressure more then 30 mmHg or delta pressure (diastolic bp - compartment pressure) less than 20-30 mmHg)

(time to surgical intervention is most important factor of prognosis; fasciotomy is tx)

96

What is the management step of choice to prevent deep venous thrombosis complication in a pt with a hip fracture?

low-molecular weight heparin (start at time of fracture, hold at time of surgery, then continue for at least 10 days post-op)

97

What is the initial and subsequent treatment options for mild- moderate functional constipation in children?

initial: dietary modification (increase fiber, decrease dairy)
subequent: mild laxative (magnesium hydroxide aka milk of magnesia)

98

What is the recurrence risk after having an infant with Turner's syndrome (dorsal feet and hands edema, short webbed neck, cardiac murmur, wide spaced nipples)?

no increased recurrence risk (same as general population)

99

A pt presenting with a pervasive, lifelong pattern of suspiciousness and distrust in home and work relationships, hypervigilience, hostility, interpreting others' motives as malevolent, controlling in personal relationship, and pathologically jealous most likely suffers from ...

Paranoid Personality Disorder

100

A pt presenting with pattern of excessive emotionality, attention seeking behavior, inappropriate and sexually seductive/ provocative behavior, shallow/shifting/ dramatic emotions, easily influenced behavior, impressionistic/ vague speech and considers relationships more intimate than they really are most likely suffers from ...

Histrionic Personality Disorder

(often attempt to manipulate doctor-patient relationship through seduction and dramatic descriptions of new symptoms)

101

What is the next best step in management of a pt who decides to take herbal medications against medical advice?

counsel pt on side effects, document discussion and refusal to discontinue, continue to follow-up pt's health

102

A pt presenting with recurrent episodes of wheezing, dyspnea, cough and chest tightness that occurs especially at night and early morning hours and cough is induced when the pt is asked to do a forced expiration most likely suffers from ..

Asthma

103

What is the best test to diagnosis a pt with asthma who is currently asymptomatic?

Pulmonary function testing with methacholine challenge

(obstructive pattern/ FEV1 decreased by more than 20% with methacholine challenge)

104

What are the arthritic swellings of the distal interphalangeal joints in a pt with osteoarthritis called?

Heberden's nodules

105

What are the arthritic swellings of the proximal interphalangeal joints in a pt with osteoarthritis called?

Bouchard's nodules

106

What is the next best step in management for a pt diagnosed with diphtheria (pharyngitis, cervical lymphadenopathy, fever, pharyngeal erythema with exudate and membrane formation)?

Diphtheria Antitoxin

(have epinephrine available in case of anaphylaxis or serum sickness because made with horse serum)

107

What is the best initial test for diagnosing acute cholecystitis (gallbladder inflammation presents with ill appearance, right upper quadrant tenderness with guarding, positive murphy sign)?

Ultrasound

(shows gallstones, gallbladder wall thickening/ edema, sonographic murphy's sign)

108

What is the next best step in management for suspected acute cholecystitis (gallbladder inflammation presents with ill appearance, right upper quadrant tenderness with guarding, positive murphy sign) when ultrasound findings are unclear (i.e. small stones without gallbladder edema/ ultrasonographic murphy's sign)?

HIDA scan

(positive if no visualization of gallbladder)

109

What is the best initial treatment for a well-differentiated adenocarcinoma in the head of a pedunculated colonic polyp without involvement of the stalk or resection margins?

endoscopic removal

110

What is the next best step in management after endoscopic removal of a well-differentiated adenocarcinoma in the head of a pedunculated colonic polyp without involvement of the stalk or resection margins?

follow-up colonoscopy 2-3 months later (followed by 1 year, 4 years and 9 years later)

111

A pt with a history of an autoimmune disorder (type 1 diabetes, hypothyroidism) presenting with macrocytic anemia, loss of proprioception and vibration sense, ataxia, spasticity, weakness and loss of reflexes most likely suffers from ...

Pernicious Anemia

(due to autoimmune destruction of parietal cell leading to decreased intrinsic factor leading to decreased vitamin B12 absorption)

112

What should be monitored during the first few days of treatment with vitamin B12 for vitamin B 12 deficiency associated megaloblastic anemia?

potassium level

(formation of new RBCs can causes hypokalemia)

113

What is the first line, second line and third line treatment for a patient with significant obesity (BMI greater than 35) with comorbid conditions?

1. dietary changes, behavioral therapy, exercise
2. Orilstat (medical therapy)
3. Bariatric surgery

114

A pt presenting with fever, otalgia (ear pain), tympanic membrane erythema, bulging of tympanic membrane (TM inflammation) and limited tympanic membrane motility on insufflation (middle ear effusion) most likely suffers from .... and the likely causes are.... (3)

Acute Otitis Media

1. Strep pneumoniae
2. nontypeable H. influenzae
3. Moraxella pneumoniae

115

What is the most likely cause of concurrent otitis media and purulent conjunctivitis?

Nontypeable H. influenzae

116

What is the first line treatment for acute otitis media? What is the best treatment for repeat infection within one month of initial treatment?

first: high dose amoxicillin
repeat: amoxicillin-clavulanic acid (due to beta-lactamase resistance)

117

What is the best step in management to maximize the viability of donor organs in a brain dead patient? (2)

1. achieve hemodynamic stability
2. maintain normothermia with blankets (using warm air blankets and warm IV if body temp less than 35 C)

118

What is the inheritance status of a daughter born to an affected father and normal mother in the case of an X-linked recessive disorder (i.e. hemophila)?

carrier (received 1 affected X from dad and 1 normal X from mom)

119

What is the hemoglobin threshold level for red blood cell transfusion in a hemodynamically stable pt with an upper GI bleed and no comorbidities?

hemoglobin less than 7 g/dl

120

What is the hemoglobin threshold level for red blood cell transfusion in a hemodynamically stable pt with an upper GI bleed and a risk for morbidity in setting of severe anemia such as unstable coronary artery disease?

hemoglobin equal to or less than 9 g/dl

121

A pt presenting with chronic intense rash with excoriated lichenified plaques and a possible history of asthma/ allergic rhinitis most likely suffers from ...

Atopic Dermatitis (Eczema)

122

What are treatments for atopic dermatitis (eczema)? (5)

1. avoid excessively hot/ dry environments
2. avoid harsh soaps and detergents
3. oral antihistamines
4. regular use of emollients (to maintain hydration)
5. steroid cream if severe (short term)

123

What is the best treatment for atopic dermatitis involving the face, eyelids, flexural areas if symptoms persist after avoiding irritants and using emollients?

topical calcineurin inhibitors (tacrolimus)

124

A pt presenting with wrist pain radiating to palmar surface of thumb and first 2 fingers, associated with numbness and tingling sensation in same distribution, worse at night and can awaken from sleep, provoked by flexing/ extending wrist or raising arms (typing, driving), improved by flicking wrist (flick sign) or warm running water, symptoms reproduced with full flexion at wrist with elbow in full extension or by tapping on wrist most likely suffers from ...

Carpal Tunnel Syndrome

(risk factors: diabetes, rheumatoid arthritis, hypothryoidism, wrist trauma, obesity, end stage renal disease, pregnancy)

(due to median nerve entrapment in the carpal tunnel)

125

What is the best initial treatment for carpal tunnel syndrome?

nocturnal wrist splinting

(followed by steroid injection followed by surgery)
(also surgery if motor weakness or atrophy of thenar eminence)

126

What medications should a pt with a recent myocardial infarction be taking? (5)

1. antiplatelet (aspirin and clopidogrel/ prasugrel/ ticagrelor)
2. beta blocker (metoprolol/ atenolol/ bisoprolol except if severe asthma/ COPD/ CHF/ hypotension/ bradycardia)
3. statin (lipid lowering)
4. ACE inhibitor/ ARBs
5. aldosterone antagonist (eplerenone if LV ejection fraction less than 40%)

127

What is the next best step in management of an intoxicated pt who was brought in for threatening suicide attempt or suicidal ideation but is dismissing attempt as due to intoxication?

keep for observation in ER and perform suicide assessment when pt is completely sober

128

What is the strongest predictive risk factor for suicide?

prior history of attempted suicide

129

What are the four protective factors for suicide?

1. social support/ family consciousness
2. pregnancy
3. parenthood
4. religion and participation in religious activities

130

What is the best anticoagulation regimen for a pregnant patient requiring anticoagulation throughout pregnancy (i.e. for mechanical valve presence)?

replace warfarin with unfractionated heparin or low molecular weight heparin during the first trimester (warfarin teratogenic at 6-12 weeks gestation) and prior to delivery (heparin easily reversible in cases of bleeding; otherwise on warfarin (for 2nd and 3rd trimester)

131

What is the most important factor in perioperative adverse drug reaction in the elderly population?

multiple medication use

132

A child presenting with hypopigmented skin lesions, seizure like activity, developmental delay, and possible autistic like behavior most likely suffers from ...

Tuberous Sclerosis

(benign tumors throughout body: skin, CNS, heart, kidney)

133

What diagnostic tests should be performed in a child with suspected tuberous sclerosis? (5)

1. thorough skin exam (ash leaf spots, angiofibromas of malar region, shagreen patches)
2. fundoscopy
3. brain MRI (glioneuronal hamartomas)
4. EEG (for baseline/ seizure activity)
5. abdominal imaging

134

What is the predominant cause of death in patients with tuberous sclerosis?

Progressive neurologic impairment (uncontrollable seizures, aspiration pneumonia, obstructive hydrocephalus)

135

When can low-risk pts (few CVD risk factors, controlled HTN, asymptomatic LV dysfunction, successful revascularization of clinically significant lesions > 50-60%) initiate/ resume sexual activity after a myocardial infarction?

once they can perform light intensity exercise without symptoms (within weeks of MI)

136

A pt presenting with nightmares, flashback of an event, avoids distressing thoughts/ feelings/ external reminders of event, have persistent feeling of horror/ anger/ guilt, have negative belief about self or world, decreased interest in activities, emotional detachment, amnesia of event, sleep disturbance, hypervigilence, and impaired concentration lasting for more than 1 month after exposure to a life threatening trauma most likely suffers from ..

Post Traumatic Stress Disorder (PTSD)

137

What is the best medical treatment for nightmares associated with PTSD (post-traumatic stress disorder)?

prazosin

138

An infant presenting with constipation followed by lethargy, poor sucking, weak cry and impaired gag reflex after being fed honey most likely suffers from ..

Infant Botulism

139

An HIV pt who has a recent history of severe pain in mouth, throat and epigastric region and then develops ocular pain, photophobia, scotomas (large glistening off-white lesions with indistinct borders on funduscopy) and fever most likely suffers from ..

Candida endophthalmitis

(risk factors: central venous catheter, TPN, broad spectrum antibiotics, prior abdominal surgery, neutropenia, steroid therapy, IV drug abuse)

140

What is the best medical therapy for candida endophthalmitis?

systemic amphotericin B or fluconazole

(also vitrectomy if vitreal involvement)

141

In a normal distribution graph, 68% of all observations lie within ... standard deviations of the mean, 95% of all observations lie within .... standard deviations of the mean, and 99.7% of all observations lie within ...standard deviations of the mean..

1 (68%); 2 (95%); 3 (99.7%)

142

What type of study involves a group of subjects being selected and their exposure status is initially determined before being followed for a certain period and observed for development of the outcome?

Prospective Cohort Study

143

What type of preventative medicine strategy is defined as the prevention of risk factors for a disease?

Primordial prevention

144

What type of preventative medicine strategy is defined as an action that attempts to halt the progression of a disease at its initial stage before irreversible pathological changes take place, thus preventing complications?

Secondary prevention

145

What type of preventative medicine strategy takes place when the disease process has advanced beyond early stage and all actions available are taken to limit impairments and disabilities?

Tertiary Prevention

146

What type of preventative medicine strategy is an action taken before a patient develops the disease and acts to prevent the occurrence of the disease itself?

Primary Prevention

147

... is when a test is able to diagnose more patients that actually have the disease (more true positives and less false negatives) such that less "sick" pts will have negative test results

Sensitivity

(sensitivity = a/ (a+c))

(associated with high negative predictive value)

148

... is when a test is able to identify pts who are actually healthy (more true negatives and less false positives) such that less "healthy" patients will have a positive test result

Specificity

(specificity = d/ b+d)

(SpIn= specificity rules in disease)

149

When determining which test to use as a screening test, what is more important for the initial test used as a screening test: specificity or sensitivity?

sensitivity (use more sensitive test first then more specific test as confirmation)

150

What physical activity is strictly prohibited in pregnancy?

scuba diving (risk of decompression injury and gas emboli in fetus)

151

What is the next best step in management of a pt presenting with symptomatic normocytic, normochromic anemia?

reticulocyte count (to distinguish between hemolytic disorder and disease of decreased RBC production)

low retic count: disease of decreased RBC production
high retic count: hemolysis

152

What is the typical interval for breastfeeding a newborn?

every 2-3 hours (no more than 4 hours overnight)

(feed early if signs of hunger: rooting, hand/ finger sucking, arm movement toward mouth)

153

What type of drug test is the preferred screening test to identify recent drug use in the emergency setting?

Urine immunoassay

(antibodies to opioids, cocaine, marijuana, phencyclidine, amphetamines and alcohol used in last 1-3 days)

154

A girl presenting with cyclic pelvic/ abdominal pain with primary amenorrhea, appearance of bluish tissue bulging between labia and a small rounded palpable mass in the suprapubic area in the setting of secondary sexual characteristics adequately developed for age most likely suffers from ..

Imperforate Hymen (hematocolpos)

155

What is the best initial step in management of a pt with non-suicidal self-injury (cutting behavior)?

inform relatives that pt is not in danger, screen for suicidal ideation and perform comprehensive psychiatric evaluation

156

An HIV pt not on medication presenting with rapidly progressive focal neurologic deficits such as cognitive impairment, hemiparesis, aphasia, ataxia, visual field deficits, seizure activity and a brain biopsy reveling oligodendrocytes with intranuclear inclusions, demyelination and astrogliosis most likely suffers from ..

Progressive Multifocal Leukoencephalopathy (PML)

(tx: HAART therapy prolongs life for 2 years but not cure)
(prognosis: without treatment, most die within 3-6 months)

157

What is the best step in management of a battery ingestion in which the battery is lodged in the esophagus? What is the best step in management of a battery ingestion in which the battery has made it to the stomach?

esophagus: immediate endoscopic removal

stomach: outpatient management (pass on own)

158

A pt with syncopal episode and an EKG showing short PR interval with delta wave (initial slow upstroke of QRS) and prolonged QRS most likely suffers from ..

tachyarrhythmia secondary to Wolff- Parkinson-White syndrome

(pre-excitation syndrome due to accessory pathway)

159

What is the best treatment for symptomatic pts with Wolff-Parkinson White syndrome?

catheter ablation therapy

160

What is the most common complication of bacterial conjunctivitis (unilateral eye redness with mucopurulent discharge)?

Keratitis (inflammation of cornea)

(presents as foreign body sensation, photophobia, corneal opacity/ ulceration especially in contact wearers)
(tx: antibiotics and urgent optho consult/ referral)

161

What is the best initial treatment for bacterial conjunctivitis (due to Strep penumoniae, Moraxella catarrhalis, H. influenzae)? (3)

1. erythromycin ointment
2. sulfa drops
3. polymixin/ trimethoprim drops

162

When can a pt with bacterial conjunctivitis return to work/ school?

after 24 hours of antibiotic therapy (but should wait until discharge has resolved if can)

163

When is it acceptable to disclose genetic information to relatives?

if disclosure serves to ameilorate/ prevent a highly likely and forseeable harm to relative
(Huntington's does not do this bc get disease regardless)

164

What is the most appropriate next step in management if a pt with positive genetic testing results for a serious hereditary illness refuses to disclose the information?

discuss with pt the reason for decision and document counseling and pt's refusal to disclose in chart

165

What is the next best step in management of a pt who is competent and refusing appropriate health care?

identify possible barriers to accepting appropriate health care by asking pt why he/she is refusing

166

What is the finding in an aspiration of an affected joint associated with a diagnosis of gout?

negatively birefringent needle-shaped crystals

167

A pt on cyclosporin who presents with acute swelling of the first metatarsophalangeal joint associated with erythema, warmth and tenderness most likely suffers from ..

Gout

(cyclosporin causes hyperuricemia via decreasing urate excretion)

168

What is the best initial treatment of gout in a pt with renal failure or post- renal transplant?

intra-articular glucocorticoids (avoids systemic effect of steroids) or increase dose of systemic steroids if on them

169

What is the best initial treatment for prolactinomas (erectile dysfunction, galactorrhea, sexual dysfunction, visual changes, amenorrhea, hot flashes, decreased bone density) regardless of size?

Dopaminergic receptor agonist (bromocriptine, cabergoline)

(use trans-sphenoidal surgery if pt fails medical therapy especially if have significant neuro symptoms)

170

What is the best initial step in management of a pt with symptomatic bradycardia?

IV atropine

171

What is the next best step in management of symptomatic bradycardia if there is no response to atropine?

transvenous cardiac pacing

172

A pt presenting with decreased hearing, history of aural irrigation for removal of cerumen, otalgia (ear pain), purulent drainage/ discharge from the ear (otorrhea), ear lobe tenderness, and visible granulation tissue on floor of external auditory canal at osseocartilaginous junction most likely suffers from ..

Malignant Otitis Externa

(usually in elderly pt with diabetes, HIV pt, immunocompromised)
(due to Pseudomonas aeruginosa)

173

What is the treatment for malignant otitis externa?

IV antibiotics initially then switched to oral to complete 6-8 weeks
1. IV ciprofloxacin
2. IV piperacillin/ ticarcillin with/ without aminoglycoside
3. IV ceftazidime

174

A pt presents with fever, malaise, hydrophobia (water triggers pharyngeal spasms causing pt to fear drinking), aerophobia (fear of fresh air), agitation, ascending flaccid paralysis, aphasia, drooling and lethargy after an encounter with an animal most likely suffers from ..

Rabies

(bats especially is spelunking/ cave exploration, raccoons)

(once symptomatic, poor prognosis)

175

Why should selective estrogen receptor modulators (raloxifene, tamoxifen) be discontinued 4 weeks prior to surgery?

risk of venous thromboembolism

176

What other treatments should be given to a pt who is on chronic glucocorticoid therapy? (2)

1. calcium
2. vitamin D

(b/c longterm steroids increase risk of osteoporesis via decrease intestinal absorption of calcium, increase renal excretion of calcium and acclerated bone resorption)

177

A pt presenting with symmetric polyarthritis involving MCP and PIP joints, associated with morning stiffness lasting more than 30 minutes for several weeks most likely suffers from ..

Rheumatoid arthritis

(dx: rheumatoid factor and anti-cyclic citrullinated peptide/ CCP, X-rays)

178

What is the first line treatment for rheumatoid arthritis?

NSAIDs (ibuprofen)

(use disease modifying antirheumatic drugs if higher risk of disease progression: multiple inflamed joints, functional limitation, extraarticular disease, bone erosion on X-ray, markedly elevated RF, positive anti-CCP)

179

What is the first line disease modifying anti-rheumatic drugs (DMARDs) used for rheumatoid arthritis?

Methotrexate

180

What P-value signifies statistical significance in studies?

P- value less than 0.05

181

What is a major side effect of Ginko Biloba used for memory enhancement?

increased bleeding risk

(bleeding and platelet dysfunction)

182

What is a major side effect of Ginseng used for improved mental performance?

increased bleeding risk

183

What are major side effects of Saw Palmetto used for benign prostatic hyperplasia? (2)

1. Hypertension
2. increased bleeding risk

184

What are major side effects of Black Cohosh used for post-menopausal symptoms (hot flashes, vaginal dryness)? (2)

1. hepatic injury
2. increased bleeding risk

185

What are major side effects of St John's Wort used for depression and insomnia? (2)

1. drug interactions (with antidepressants causing serotonin syndrome, OCP, anticoagulants causing decreased INR, digoxin)
2. hypertensive crisis

186

What is a major side effect of Kava kava used for anxiety and insomnia?

severe liver damage (hepatotoxicity)

187

What are major side effects of Licorice used for stomach ulcers and bronchitis/ viral infections? (2)

1. hypertension (due to inhibition of 11-beta hydroxysteroid dehydrogenase leading to elevated cortisol)
2. hypokalemia

188

What is a major side effect of Echinacea used for treatment and prevention of cold and flu?

anaphylaxis (more likely in asthmatics)

189

What are major side effects of ephedra used for treatment of cold and flu and for weight loss and improved athletic performance? (4)

1. hypertension
2. arrhythmia/ MI/ sudden death
3. stroke
4. seizure

190

What cell type is responsible for acoustic neuromas observed in patients with neurofibromatosis?

Schwann cells

191

What is the best initial screening test for Down's syndrome detection during pregnancy?

integrated test

(ultrasound measurement of nuchal translucency thickness at 10 weeks, PAPP-A level in first trimester, and in second trimester alfa-fetaoprotein, HCG, unconjugated estriol, dimeric inhibin-A levels)

192

What is the most accurate test for detecting Down's Syndrome in a fetus during pregnancy?

fetal karyotyping from CVS or amniocentesis

193

What mode of inheritance is associated with all children of an affected mother being affected; however no children of an affected father being affected?

Mitochondrial

194

What is the next best step in management for a pt with short duration syncopal episodes triggered by prolonged standing/ emotional distress/ painful stimuli and associated with prodrome with dizziness/ nausea/ pallor/ diaphoresis/ abdominal pain/ generalized sense of warmth if an EKG is normal and there is no orthostatic hypotension?

no further testing

(Vasovagal Syncope is clinical diagnosis; can use tilt table test if uncertain)

195

Is a retroverted uterus a possible etiologic cause of spontaneous abortions in a woman experiencing recurrent miscarriages?

No

196

What is the next best step of management for a female pt older than 45 years old who experiences periods of amenorrhea followed by irregular unpredictable bleeding (anovulatory bleeding) with associated hot flashes and sleeping difficulties?

Endometrial Biopsy

(symptoms suggestive of menopausal transition/ perimenopause )
(to assess for endometrial hyperplasia and cancer)

197

A pt presenting with shoulder pain associated with ipsilateral ptosis, miosis, enophthalmos and anhidrosis, as well as weight loss, supraclavicular lymph node enlargement, and weakness/ atrophy of intrinsic hand muscles along with pain and paresthesisa of 4th finger, 5th finger, medial arm, and forearm most likely suffers from ...

Pancoast Tumor

(superior pulmonary sulcus tumor is subset of non-small cell lung cancer and affects paravertebral sympathetic chain and inferior cervical ganglion)

198

What is the most worrisome findings in the setting of a pt having a Pancoast Tumor?

low back pain and asymmetric lower-extremity deep tendon reflexes (hyper-reflexia on affected side)

(suggest spinal cord compression)

199

A pt with history of atherosclerotic disease (cartoids, coronary, HTN, diabetes)/ vasculitis/ hematologic disease presenting with painless acute vision loss in 1 eye, an afferent pupillary defect, retinal whitening/ cherry red spot in macula and diffuse ischemic retinal pallor on funduscopy most likely suffers from ..

Central Retinal Artery Occlusion

(cherry red spot due to preserved circulation via posterior ciliary arteries)

200

What is the treatment for central retinal artery occlusion? (4)

1. urgent ophthalmology consult
2. lower intraocular pressure (ocular massage, anterior chamber paracentesis, IV acetazolamide, mannitol)
3. intra-arterial thrombolytics if needed
4. long term atherosclerosis risk factor modification (statin, antiplatelet agent)

201

A pt presenting with acute painless vision loss in 1 eye and tortuous and dilated veins, diffuse hemorrhages, disk swelling and cotton wool spots on funduscopy most likely suffers from ..

Central Retinal Vein Occlusion

202

How should difficult patient encounters due to situations beyond the physician's control (i.e. long waiting times) be managed?

apologize, acknowledge the delay and pt's frustration, provide brief explanation

203

A young pt or pt with history of Paget's disease who develops hypercalcemia in the setting of low PTH and normal vitamin D levels (1,25 Vitamin D may be low) while in the hospital most likely has hypercalcemia due to ..

Immobilization

(excessive bone resorption leads to hypercalcemia)

204

How do you correct the calcium level in the setting of hypoalbuminemia?

for every 1 g/dl decrease in serum albumin below 4 g/dl, add 0.8 mg to the total calcium level

(corrected calcium = measured total calcium + 0.8( 4- measured serum albumin))

205

What is the treatment for akathisia (subjective feeling of inner restlessness and the urge to move) due to antipsychotic medications?

Beta blocker (propanolol)

206

What is the best initial step in management to establish the cause of a syncopal episode?

through history and physical with an EKG

207

What is the next best step in management of a patient presenting with substernal chest discomfort that is relieved by nitroglycerin and has an EKG with findings of ST depression suggesting acute coronary syndrome (unstable angina/ non-ST elevation MI)? (6)

1. dual antiplatelet therapy (aspirin and P2Y12 receptor blocker- clopidogrel/ prasugrel/ ticagrelor)
2. nitrates
3. beta blockers
4. statins
5. anticoagulant therapy (unfractionated/ LMW heparin, fondaparinux)
6. oxygen

208

What is the best initial step in management for a female pt who has just become menopausal to prevent osteoporesis? (3)

1. regular weight bearing and anti-gravity exercises
2. 1200 mg of calcium (dietary and/or supplemented)
3. 600-800 IU of vitamin D (dietary and/or supplemented)

209

When should postmenopausal women aged less than 65 years old undergo a bone density screening? (5)

1. body weight less than 58 kg (127 lbs)
2. chronic steroid use
3. smoking
4. malabsorptive disorders (cystic fibrosis)
5. parental hx of hip fracture or personal hx of low-impact fracure

210

A pt presenting with expanding, painless lesions with central clearing, headache, fatigue, malaise, myalgias, and fever after spending time in woods most likely suffers from ...

Early Limited Lyme Disease

(dx with initial ELISA followed by confirmatory western blot if history and physical not clear)

(transmitted by brown tick)

211

What is the treatment for Early Limited Lyme Disease?

oral doxycycline/ amoxicillin/ cerfuroxime

212

A pt presenting with history of cramping with volitional movements in early morning (i.e. stretching in bed), asymmetric weakness in distal extremity progressing to muscle wasting, atrophy, twitching and fasciculations that then spreads to multiple limbs with associated hyperactive deep tendon reflexes, spastic resistance to passive movement and difficulty chewing and swallowing most likely suffers from ...

Amyotrophic lateral sclerosis (ALS)

213

What treatment has been shown to be beneficial in pts with amyotrophic lateral sclerosis (ALS)?

Riluzole

(glutamate inhibitor prolongs survivial and delays tracheostomy)

214

What is the risk of developing type 1 diabetes in an offspring of a parent with type 1 diabetes?

if mother has it: 3%
if father has it: 6%

215

What is the next best step in management for medication induced psychosis once the minimum effective dose of anti-parkinsonian medication has been established in a pt with parkinson's disease (i.e. development of psychosis while on minimum effective dose of levodopa)?

add quetiapine (low dose antipsychotic)

(second line is clozapine)

216

A pt presenting with asymptomatic mild hypercalcemia, normal vitamin D level, PTH level within normal range but at upper limit of normal, urine calcium less than 100 mg/day and a family history of hypercalcemia most likely suffers from ..

Familial Hypocalciuric Hypercalcemia

(mutation in calcium sensing receptor in parathyroid gland and kidneys)

217

A pt presenting with asymptomatic mild hypercalcemia, normal vitamin D level, PTH level within normal range but at upper limit of normal, urine calcium more than 200 mg/day most likely suffers from ..

Primary Hyperparathyroidism

218

What are the procedures that warrant antibiotics prophylaxis in patients with high risk cardiac conditions? (4)

1. dental procedures w/ manipulation of gingiva/ periapical region of tooth/ perforation of oral mucosa
2. respiratory tract procedures with incision/ biopsy
3. GI or GU procedure in pt with established infection
4. procedures on infected skin/ musculoskeletal tissue

219

What is the next best step in management for a pt diagnosed with familial adenomatous polposis after finding more than 100 colonic adenomatous polps on colonoscopy (especially in setting of positive family history)?

proctocolectomy or total colectomy with ileoanal anastomosis

(otherwise inevitably progresses to colorectal cancer by 50 years old)

220

A pt presenting with asymmetric oligoarthritis that is inflammatory (elevated WBC on synovial aspiration) yet sterile (culture negative), circinate balanitis (painless, shallow penile ulcers)/ uveitis/ conjunctivitis/ oral ulcers/ keratoderma blennorrhagicum/ achilles enthesitis (pain at ligament/ tendon insertion site), dactylitis in the setting of a history of chlamydia infection 1-4 weeks ago most likely suffers from ....

Reactive Arthritis

(can also be associated with gastroenteritis from Shigella, Salmonella, Clostridium, Yersinia, Campylobacter)

(associated with positive HLA- B27)

(can't see, can't pee, can't climb a tree)

221

What is the next best step in management in a pt with new onset reactive arthritis that have a history of chlamydia infection?

repeat chlamydia testing (urinary nucleic acid amplification for Chlamydia trachomatis)

222

What is the treatment for reactive arthritis from recurrent chlamydia infection?

antibiotics with naproxen (NSAID for symptomatic relief)

223

An african american pt presenting with dry cough, weight loss, fever, maculopapular rash, erythema nodosum (tender erythematous nodules on shin), bilateral hilar adenopathy and interstitial infiltrates on CXR, uveitis, lymphadenopathy, polyarthritis, hypercalcemia, suppressed PTH, increased urinary calcium, elevated alkaline phosphatase, hepatomegaly, and central diabetes insipidus most likely suffers from ..

Sarcoidosis

(non-caseating granulomas)

224

What is the cause of hypercalcemia in a pt with sarcoidosis?

calcitriol (1,25-OH Vitamin D) overproduction

(noncaseating granulomas produce 1-alpha hydroxylase which converts 25-OH Vitamin D to 1,25-OH Vitamin D to increased calcium absorption in GI tract)

225

What is the best treatment for hypercalcemia secondary to sarcoidosis?

glucocorticoids (steroids)

226

A pt presents with a persistent cough (lasting more than 5 days up to 3 weeks) after a respiratory illness with associated wheezing, rhonchi and chest wall tenderness but lacking fever and chills most likely suffers from ..

Acute Bronchitis

(ts: symptomatic with NSAIDs and bronchodilators)

227

What area of the heart is supplied by the left circumflex artery?

lateral and posterolateral wall of the left ventricle

(affected if left main coronary artery occluded b/c branches off left main)

228

What area of the heart is supplied by the left anterior descending artery?

anterior wall of the left ventricle

(affected if left main coronary artery occluded b/c branches off left main)

229

What area of the heart is supplied by the right coronary artery?

1. inferoposterior wall of left ventricle
2. right ventricle

230

What is the next best step in management of a pt with signs of hepatic encephalopathy (hallucinations, wax and waning of consioucness) in the setting of spontaneous bacterial peritonitis (more than 250 neutrophils in ascitic fluid)?

lactulose (for hepatic encephalopathy) and antibiotics (for bacterial peritonitis)

231

What parameters are most useful in predicting a patient's 90-day mortality from liver disease?

1. bilirubin
2. INR
3. serum creatinine

(MELD score = 3.8 [Ln bilirubin] + 11.2 [Ln INR] + 9.6 [Ln creatinine])

232

What MELD score in a patient with liver disease correlates with a good outcome from placement of a transjugular intrahepatic portosystemic shunt (TIPS procedure)?

MELD score less than 14 (have high survival likelihood)

233

A pt presenting with diarrhea, fever, abdominal pain and leukocytosis in the setting of recent antibiotic use most likely suffers from ..

Clostridium difficile associated colitis

(tx: metronidazole)

234

What is the next best step if there is a high clinical suspicion for C. difficile colitis but laboratory testing is negative (negative PCR or enzyme immunoassay of stool)?

limited colonoscopy or sigmoidoscopy

(detect pseudomembranous colitis- raised yellow plaques over the sigmoid mucosa)

235

What are the most common antibiotics associated with causing C. difficile colitis? (4)

1. fluoroquinolones (ciprofloxacin)
2. enhanced spectrym penicillins
3. cephalosporins
4. clindamycin

236

What is the cervical cancer screening guidelines for patients age 21-29 years old?

Pap smear every 3 years

237

What is the cervical cancer screening guidelines for patients aged 30-65 years old?

1. Pap smear every 3 years
or
2. Pap smear with HPV testing every 5 years

238

What is the cervical cancer screening guidelines for immunocompromised patients (HIV, lupus, organ transplant)?

start at onset of sexual intercourse performing every 6 months for 2 years and then annually

239

What is the next best step in management for a patient with clinical signs (gait disturbance- wide based and magnetic, dementia/ cognitive decline, urinary incontinence) and brain imaging (ventriculomegaly out or proportion to sulcal enlargment) suggestive of normal pressure hydrocephalus?

Miller Fisher test/ Lumbar tap test

(evaluate gait speed, stride length, verbal memory, visual attention before and after removal of 30-50 ml of CSF; if improvement after removal than will respond to VP shunt)

240

What is the best prognostic indicator for the severity of acute pancreatitis?

APACHE II score
(12 variables used at time of admission and daily)
(if score greater to or equal to 8, pt should have CT scan at 72 hours to evaluate for necrosis)

241

What is the next best step in management of a dog bite on the hand (not other places on body)?

cleaned, irrigated with normal saline, debrided and left open to drain with close observation
(high risk of infection, similar with any cat/ human bite and puncture wounds)

242

What intervention most significantly improves the quality of patient handoffs?

systemiatic sign out checklists and templates

(pt identifying info, DNR/ do not intubate status, hospital course and recent events, acuity/current conidtion, anticipatory info, plan and tasks by organ system)

243

A pt presenting with fatigue, paroxysmal nocturnal dyspnea, orthopnea, jugular venous distension, rales/ crackles, presence of S3, increased cardiac silhouette and pulmonary congestion on CXR, bilateral lower extremity edema, nocturnal cough, dyspnea on exertion and hepatomegaly most likely suffers from..

Congestive Heart Failure

(dx: clinical- 2 major- goes up to CXR and 2 minor criteria)

244

A pt presenting with pain and swelling behind an ear after a recent otitis media infection most likely suffers from

Acute mastoiditis

(infection of mastoid air cells)

245

A pt presenting with acute onset of upper abdominal pain radiating to the back, associated nausea and vomiting, blunting of left costophrenic angle on CXR most likely suffers from ...

Acute Pancreatitis

(dx: lipase and amylase levels)

246

What is the treatment for acute pancreatitis?

aggressive IV fluids (prevent hypovolemia from third spacing), morphine (pain control), NPO

247

What is the next best step in management of a pt with acute pancreatitis after initiating treatment?

Obtain liver function tests (if not done already), abdominal ultrasound, lipid panel, assess alcohol use, calcium level

(assess cause of pancreatitis: gallstones, alcohol, hypertriglyceridemia)

248

What is the next best step in management of a pt with acute pancreatitis who was initially hemodynamically stable but deteriorates several days later?

contrast- enhanced CT scan of abdomen (assess for pancreatic necrosis or infection)

249

A pt with hyponatremia, low plasma osmolality, elevated urine osmolality and high urinary sodium (greater than 40 mEq/L) with normal renal, adrenal and thyroid function test most likely suffers from ..

Syndrome of Inappropriate ADH secretion (SIADH)

(due to CNS disorders, HIV, tumors- small cell lung cancer, carbamazepine, cyclophosphamide, SSRIs, post-op pts)

250

What antibiotics have an increased risk of seizure in the setting of renal insufficiency/ older age/ pre-existing CNS disease/ use of proconvulsant drugs?

beta-lactams and fluoroquinolones
(penicillins, cephalosporins, monobactams, carbapenems- imipenem)

251

An african american child presenting with painful swelling of the hands and feet (dactylitis or hand-foot syndrome), peripheral cyanosis, unlocalized pain, hemolytic anemia, howell-jolly bodies on smear and crying most likely suffers from ..

Vaso-Occlusive Painful Crisis of Sickle Cell Disease

(dx: hemoglobin electrophoresis)

252

What is the best screening test for suspected sarcoidosis (primarily in African American, Puerto Ricans, Irish, Scandinavians)?

Chest X-ray (bilateral hilar adenopathy/ mediastinal widening and interstitial infiltrates)

253

What is the best test to confirm sarcoidosis?

biopsy if easily accessible lesion

(fiberoptic bronchoscopy with transbronchial lung biopsy if no accessible lesion)

254

In a non-inferiority trial, if the test variable's mean and confidence interval is to the right of the non-inferiority margin line, what does that mean?

the test drug is non-inferior to the control drug
(new drug is not unacceptably worse than the control drug in reference to the variable)

255

In a non-inferiority trial, if the test variable's confidence interval crosses the zero line, what does that mean?

the test drug is not superior to the control drug

(if confidence interval is to right of zero line, test drug is superior to control)
(if confidence interval is to left of zero line, test drug is inferior to control)

256

A pt preseting with small, rough, erythematous and keratotic papules on sun-exposed areas that show signs of chronic photodamage (dyspigmentation, wrinkling, thinning, telangiectasia) in the setting of spending lots of one's life in the sun most likely suffers from ..

Actinic Keratosis

(tx: liquid nitrogen cryotherpy, surgical excision, curettage)

(biopsy if diagnosis unclear/ lesion greater than 1 cm in diameter/ lesion indurated/ ulceration rpesent/ tenderness present/ rapidly growing lesion/ fails to respond to therapy)

257

What disease is there an increased risk for if a pt has actinic keratosis?

Squamous Cell carcinoma

258

A pt presenting with an enlarging fleshy nodule with ulceration on sun-exposed skin in the setting of spending lots of one's life in the sun most likely suffers from..

Basal Cell Carcinoma

259

A young female athlete presenting with chronic anterior knee pain that worsens with squatting/ running/ prolonged sitting/ using the stairs (activities that require quadricep contraction) and has crepitation and pain on extension of the knee with anterior patellar compression most likely suffers from ..

Patellofemoral pain syndrome

(tx: exercises to stretch and strengthen the thigh muscles and avoid activities that aggravate pain)

260

An athlete who plays sports that involve alot of jumping (volleyball/ basketball) presenting with episodic anterior knee pain and tenderness at the inferior patella most likely suffers from ..

Patellar tendonitis
(jumper's knee)

261

An adolescent athlete who recently underwent a growth spurt presenting with anterior knee pain that worsens while playing sport and is relieved by rest, and has tenderness and swelling at the tibial tubercle most likely suffers from ...

Osgood-Schlatter syndrome

262

A pt presenting with periodic vertigo (room spinning), unilateral hearing loss and tinnitus most likely suffers from ...

Meniere's syndrome

263

An elderly pt who withdraws from social life, avoids leaving home to avoid conversation, listens to the radio/ TV at high volumes, and failing the whispered voice test most likely suffers from ..

Presbycusis

(age-related hearing loss)

264

A pt presenting with joint pain and restriction of joint movement, elevated alkaline phosphatase, normal calcium level, thickening of outer cortex of the bone on X-ray and increased uptake on technetium bone scan most likely suffers from ...

Paget's Disease of bone

(tx: bisphosphonates)

(dx: radionuclide bone scan)

265

What is the treatment for Paget's Disease and when is it indicated? (5)

Bisphosphonates (alendronate, risedronate, pamidronate)

1. intolerable pain
2. involves weight bearing bones
3. neuro involvement
4. hypercalcemia/ hypercalciuria
5. CHF

266

A pregnant pt presenting with pruritic erythematous papules within the striae gravidum most likely suffer from ..

Papular urticarial papules and plaques of pregnancy (PUPPP)

(tx: topical steroids)

267

A pregnant pt presenting abdominal pruritis that develops into papules and vesicles surrounding the umbilicus most likely suffers from ...

Herpes gestationis (pemphigoid gestationis)

(autoimmune disorder)

268

What is the best treatment for herpes gestationis (pemphigoid gestationis)?

corticosteroids (use systemic if fail topical)

269

What is the next best step in management of an asymptomatic pt with an incidental findings of Actinomyces while using an intrauterine device (IUD)?

advise pt to call if she develops pelvic infection symptoms

(Actinomyces is normal flora of vagina but is associatd with infection in IUD users)

270

What is the first line treatment for primary dysmenorrhea (crampy lower abdominal pain with the onset of menstrual bleeding, may have associated nausea and vomiting)?

NSAIDs (naproxen)

271

What is the second line treatment for primary dysmenorrhea (crampy lower abdominal pain with the onset of menstrual bleeding, may have associated nausea and vomiting)?

combined hormonal contraceptive pills

(if fail to improve, evaluate for secondary causes)

272

A pt presenting with a severe and sudden onset headache different from previous headache patterns (or described as worst headache of life) associated with nausea, vomiting, brief loss of consciousness, focal neuro deficits or meningismus especially in the setting of having hypertension/ being a smoker or heavy alcohol drinker most likely suffers from ...

Subarachnoid Hemorrhage

(due to ruptured saccular aneursym)

273

What is the preferred initial test for establishing a diagnosis of subarachnoid hemorrhage?

Head CT without contrast

(if negative or equivocal, then do lumbar puncture- xanthochromia)

274

If a head CT without contrast is negative but history and physical is suggestive of subarachnoid hemorrhage, what is the next best step in management of the pt?

Lumbar puncture (assess for elevated opening pressure, xanthrochromia- pink/yello tint of CSF due to hemoglobin degradation products), consistently elevated RBCs in all tubes)

275

A pt with the history of celiac sprue presenting with abdominal pain, weight loss, diarrhea, and anemia despite being adherent to gluten-free diet most likely suffers from ...

Intestinal T cell Lymphoma

276

What treatment in a pregnant woman lowers the risk of having an infant with spina bifida?

folic acid

277

A newborn with muscular weakness of the lower extremities and the presence of a protrusion of tissue in the midline lumbar region consisting of a sac of fluid most likely suffers from ...

Myelomeningocele

(no imaging, immediate neurosurgical eval and surgical closure within 24-48 hours)

278

A pt with skin that has a leathery appearance with coarse, deep wrinkles and furrows, variable pigmentation, clusters of dilated capillaries and venules, and scattered flesh-colored scaly patches with slightly irregular margins most likely suffers from ...

Photoaging

(tobacco smoking is associated)

279

What is the best treatment for photoaging of skin?

tretinoin (all-trans retinoic acid)

280

What is the next best step in management for a pt diagnosed with rhabdomyolysis (muscle tenderness, increased muscle tone, renal failure, hyperkalemia, hypocalcemia, hyperphosphatemia, elevated creatine kinase in the setting of cocaine/ alcohol intoxication/ severe trauma/ neuroleptic malignant syndrome)?

aggressive IV isotonic saline (followed by alkalinication of urine)

281

What is the next best step in management of a pt with loud snoring without other alarming symptoms (daytime hypersomnolence, nocturnal choking/ gasping/ apnea with oxygen desaturations, hypertension)?

lose weight, stop smoking, avoid alcohol near bedtime

282

What is the first line treatment for Raynaud phenomenon (fingers get numb and turn blue when exposed to cold)?

Dihydropyridine calcium channel blockers (nifedipine and amlodipine) and diltiazem

283

What is the next best step in the treatment of a pt with Raynaud's phenomenon who is resistant to treatment with calcium channel blockers and has arthralgias and myalgias?

obtain ANA and rheumatoid factor (along with chemistries U/A and complement levels)

284

What are favorable prognostic factors for schizophrenia? (10)

1. female
2. older age of onset (older than 40)
3. acute onset of symptoms
4. identifiable precipitant
5. mostly positive symptoms (hallucinations, delusions)
6. presence of mood symptoms
7. goo pre-morbid functioning
8. no family history of schizophrenia
9. good family support
10. shorter duration of active symptoms

285

A young to middle aged woman presents with painless hepatomegaly and incidentally found elevated AST and ALT with normal alkaline phosphatase and normal bilirubin and may have a history of arthritis/ thyroiditis/ pericarditis most likely suffers from ..

Autoimmune hepatitis

(dx: ANA and anti-smooth muscle antibodies)

286

What is the antithrombotic guideline for patients with mechanical heart valves and no risk factors for thromboembolism?

aspirin (75-100 mg/day) with warfarin with INR goal of 2-3

287

What is the antithrombotic guideline for patients with mechanical heart valves and risk factors for thromboembolism (a-fib, severe LV dysfunction with ejection fraction less than 30%, prior thromboembolism, hypercoagulable state)?

aspirin (75-100 mg/day) with warfarin with INR goal of 2.5-3.5

288

A pt presenting with progressively worsening back pain with morning stiffness which improves with exercise for more than 3 months, reduced range of forward flexion of lumbar spine on Schober testing, and reduced chest expansion most likely suffers from ..

Ankylosing Spondylitis

(exercise improves overall functional status, no reduced life expectancy)

289

What is the best initial step in a pt with suspected ankylosing spondylitis?

X-ray of sacroiliac joint (sacrolitis, erosion of ischial tuberosity and iliac crest, squaring of vertebral bodies)

290

What is used to monitor the disease progression in a pt with ankylosing spondylitis?

X-rays (AP and lateral views of lumbar spine, lateral view of cervical spine, pelvic X-ray) and acute phase reactants

291

What are extraarticular manifestations of ankylosing spondylitis? (4)

1. Restrictive lung disease (due to limited costovertebral joint motion & development of apical pulmonary fibrosis)
2. anterior uveitis
3. aortic regurgitation
4. IgA nephropathy

292

What screening test should be performed in a pt who is diagnosed with familial adenomatous polyposis (FAP)?

upper GI endoscopy (to assess for extracolonic neoplasms such as gastric and duodenal adenomas/ carcinomas)

293

What is the next best step of management for a female pt presenting with spontaneous, unilateral nipple discharge that is guaiac positive/ grossly bloody who may have the presence of paplable lump/ skin changes?

Mammography with ultrasound)

(to assess for possible papillary tumor- most common cause of pathologic nipple discharge)

294

What is the next best step of management for a female pt presenting with bilateral/ multiple duct involving nipple discharge that is milky and nonbloody and lacking palpable lump/ skin changes? (3)

1. urine beta-HCG
2. TSH
3. prolactin

295

What is the first line therapy for acute gout attack?

NSAIDs (indomethacin or ibuprofen) or colchicine

296

What is the best anti-hypertensive medication for treatment of hypertension in a pt with gouty arthritis?

ARBs (angiotensin receptor block- "sartans")

(has uricosuric effect and antihypertensive)

297

What is the best treatment for a pt presenting with mild symptoms of acute otitis externa (minor discomfort, pruritus and minimal canal edema)?

gently clean canal using wire loop followed by topical acidifiers (acetic acid, domeboro)

(can add topical steroids to relieve itching and pain)

298

What is the best treatment for a pt presenting with moderate to severe symptoms of acute otitis externa (moderate pain, pruritis, partial/ complete canal occlusion from edema)?

gently clean canal using wire loop followed by topical antibiotics, wick placement if canal is completely occluded

(can add topical steroids to relieve itching and pain)

299

A pt presenting with ear pain, ear pruritis, erythema and edema of ear canal, and discharge along with pain caused by tragal pressure or traction on the auricle most likely suffers from ...

Otitis Externa

(swimmer's ear due to Pseudomonas or S. aureus)

300

What is the best preoperative management of type 1 diabetic during labor and cesarean section?

normal insulin dose on the night before surgery followed by insulin drip and infusion of D5 1/2 NS with 40 mEq of KCl to keep the blood glucose below 160 mg/dl during procedure

(insulin requirement significantly decreases following delivery of pregnant diabetic)

301

What is the formula for relative risk (RR)?

relative risk = risk of exposed group/ risk of unexposed group

(risk ratio comparing risk of an outcome among the exposed to that among the unexposed)

302

What is the formula for attributable risk percent (ARP)?

ARP = (risk in exposed - risk in unexposed) / risk in exposed

ARP = (relative risk -1)/ relative risk

(measure of excess risk and estimates the proportion of disease among exposed subjects that is attributed to exposure status)

303

What is the formula for population attributable risk percent (PARP)?

(Q ID: 5206)

PARP = (risk in total population - risk in unexposed)/ risk in total population

risk in total population = (risk of exposed) (proportion of exposure in population) + (risk of unexposed) (proportion of exposure in population)

PARP = (prevalence) (relative risk - 1)/ [ (prevalence) (relative risk -1) + 1]

(measure of excess risk in the total population that is attributed to exposure status)

304

A pt with sudden onset confusion, lethargy, bradycardia, skin flushing, miosis, wheezing and garlic like odor of clothing most likely suffers from ..

Organophosphate poisoning

(tx: atropine and pralidoxime- cholinesterase activator)

305

What diagnostic test is used to confirm the diagnosis of organophosphate poisoning?

RBC cholinesterase activity level

(used to diagnosis and assess severity)

306

What medical condition is saw palmetto most commonly used to treat?

Benign Prostatic Hyperplasia (BPH)

(improves urinary symptoms scores, nocturia, peak urine flow)

307

What medical condition is garlic most commonly used to treat?

Hypercholesterolemia

308

What medical condition is glucosamine and/ or chondroitin used to treat?

Osteoarthritis

309

What is the most effective parameter for preventing central-line associated bloodstream infections?

fully draping the body during insertion

(also use maximal barrier precautions, avoid femoral site, skin cleansing with chlorhexidine, prompt catheter removal when no longer needed)

310

What is the next best step in management of a pt who is not competent to make decisions and whose family members can not agree on the approach to the pt's medical care?

involve hospital's ethics committee in decision-making and mediation process

311

What is the next best step in management for a pt with a lab finding of isolated elevation of anti-HBc (total core antibody including IgG and IgM)?

measure IgM anti-HBc and liver enzymes
(after repeating hep B serologies to rule out false positive)

312

What does a finding of elevated liver enzymes and positive IgM anti-HBc in a pt who was previously found to have isolated elevation of anti-HBc (total core antibody) mean?

window period of acute hepatitis B virus infection

(HBsAg has fallen but anti-HBs has not risen yet)

313

What does a finding of normal liver enzymes and negative IgM anti-HBc in a pt who was previously found to have isolated elevation of anti-HBc (total core antibody) mean?

years after recovery from acute Hep B virus infection

314

What is the next best step in management for pt with abnormal liver function tests or evidence of chronic liver disease with negative IgM anti-HBc after having been found to have isolated elevation of anti-HBc (total core antibody)?

HBV DNA level (if detectable, chronic disease)

315

What is the main long-term complication of IVC (inferior vena cava) filter placement?

recurrent deep venous thrombosis (DVTs)

316

What is the initial best step in management for a pt with suspected idiopathic intracranial hypertension/ pseudotumor cerebri (obese women, headache, visual problems, on OCPs)?

ophthalmoscopic exam
(assess for papilledema before brain imaging)

317

What is the best treatment for a large retrosternal goiter that is causing compressive symptoms (dysphagia)?

surgical removal via cervical approach

318

What diagnostic test consists of hyperflexion of both wrists to reproduce characteristic symptoms of Carpal Tunnel Syndrome?

Phalen's test

(more sensitive than tinel sign)

319

What diagnostic test consists of tapping or percussing over the region of the median nerve at the carpal tunnel to reproduce characteristic symptoms of Carpal Tunnel Syndrome?

Tinel sign

320

What diagnostic test can be used to confirm the diagnosis of carpal tunnel syndrome?

nerve conduction study
(shows slowed conduction along median nerve at level of carpal tunnel with normal conduction velocity proximally; along with reduced amplitudes)

321

What is the first line treatment for nongonococcal urethritis (dysuria, watery urethral discharge, many neutrophils with absence of bacteria on urethral swab in sexually active pt)?

Azithromycin 1 gm single dose (or doxycycline 100 mg PO BID for 7 days)

(chlamydia is most common cause)

322

What is the first line treatment for gonococcal urethritis (dysuria, purulent urethral discharge, many neutrophils with gram negative diplococci on urethral swab of sexually active pt)?

Injection of ceftriaxone

323

What is the likely cause of nongonococcal urethritis (dysuria, watery urethral discharge, many neutrophils with absence of bacteria on urethral swab in sexually active pt) in a pt who does not respond to azithromycin despite being compliant and not having repeated sexual exposures?

Trichomonas vaginalis

(tx: metronidazole)

324

A pt presenting with erythematous, scaling plaques and patches with indistinct margins on the scalp, central face, ears, chest, upper back, axilla, and pubic area along with dandruff of the scalp most likely suffers from ...

Seborrheic dermatitis

(should suspect HIV infection if new onset and severe)

325

A pt presenting with a well circumscribed erythematous patch on skin/ mucous membrane that rapidly worsens and evolves into nodular patches marked by hemorrhage, ulceration and necrosis in a pt with an indwelling catheter/ central venous catheter or following infection of traumatic/ surgical infection most likely suffers from ...

Ecythma gangrenosum

(usually due to Pseudomonas aeruginosa bacteremia)

326

What is the treatment for ecythema gangrenosum?

IV antibiotics (aminoglycoside with extended spectrum antipseudomonal penicillin/ antipseudomonal cephalosporin) for 7-10 days after catheter has been removed

(for 14 days after neutrophil count returns to normal in neutropenia pt)

327

What is the best management step for providing nutrition to a pt with oropharyngeal dysphagia who has failed oral feeding modifications?

gastrostomy tube feeding

328

... is when pt views another individual as perfect and flawless and is unable to tolerate any evidence to the contrary; often occuring in pts with borderline personality disroder when interacting with a "savior" (person who cared for him/her in time of crisis)

Primitive Idealization

(type of splitting)

329

What is the best treatment for borderline personality disorder?

dialectical behavior therapy

330

According toe Light's criteria, what type of pleural fluid has a pleural fluid protein/ serum protein ratio greater than 0.5, a pleural fluid lactact dehydrogenase/ serum LDH ratio greater than 0.6, and/ or pleural fluid LDH > 2/3 the upper limit of normal for serm LDH?

Exudative Pleural Fluid

(associated with autoimmue, esophageal rupture, infection, malinancy, pancreatitis, post CABG, pulmonary embolism)

331

What is the primary treatment for hepatic hydrothorax (right sided transudative pleural effusion in pt with cirrhosis and ascites)?

Sodium restriction and Diuretics

(second line is TIPS- transjugular intrhepatic portosystemic shunt)

332

A pt with history of alcohol abuse presenting with flank dullness, positive fluid shift, hypoalbuminemia and transudative pleural effusion most likely suffers from ...

Hepatic Hydrothorax

333

What is the first line, second line and third line treatment for nocturnal enuresis (urinary incontinence at night in a child 5 years old or older)?

1. behavior modification (void immediately before bed, minimize fluid intake prior to bedtime, reward system) for 3- 6months
2. enuresis alarm (best long term outcome)
3. desmopressin (immediate improvement but high relapse)

334

A pt presenting with headache, nausea, malaise, and dizziness in the setting of other family members with similar symptoms most likely suffers from ...

Carbon Monoxide Poisoning

(dx: carboxyhemoglobin level)

335

What is the next best step in management of a simple breast cyst if the mass completely disappears after fine needle aspiration and discharge is nonbloody?

ultrasound breast tissue in 4-6 weeks

(if discharge bloody, perform mamogram and excision)

336

A pt with Raynaud phenomenon and GERD who presents with severe hypertension and associated symptoms (headache, papilledema, blurred vision) most likely suffers from ..

Scleroderma renal crisis
(due to renal arteriole wall thickening and narrowing leading to ischemia and renin-angiotensin activation)

337

What is the first line treatment for scleroderma renal crisis?

captopril (ACE inhibitor)

(add IV nitroprusside if malignant HTN with CNS manifestations)

338

A pt presenting with right upper quadrant pain, fever and jaundice along with elevated levels of direct bilirubin and alkaline phosphatase without rise in aminotransferases most likely suffer from ..

Acute Cholangitis

(tx: blood cultures, antibiotics, fluid hydration, vital sign monitoring)

339

What is Reynold's pentad?

1. right upper quadrant pain
2. jaundice
3. fever
4. confusion (due to sepsis)
5. hypotension (due to sepsis)

(suggests suppurative cholangitis)

340

What is the pathophysiologic mechanism behind toxic shock syndrom?

bacterial exotoxin production leading to widespread T cell activiation (releasing cytokines)

341

What is the treatment for toxic shock syndrome?

remove foreign body, extensive IV fluids, antibiotics (clindamycin with antistaphylococcal antibiotic)

342

What are the two major risk factors for pediatric dental caries?

1. nighttime bottle feeding (especially with juice)
2. frequent exposure to sugary snacks

(use fluoride toothpast 2x a day, exam teeth as soon as erupt)

343

What is the treatment for diabetic ketoacidosis?

normal saline bolus given over an hour followed by insulin drip and potassium containing IV fluids (if pt has low to normal potassium level)

344

A pt presenting with glucose greater than 200 mg/dL, bicarbonate less than 15 mEq/L, venous pH less than 7.3 and an anion gap greater than 14 most likely suffers from ..

Diabetic Ketoacidosis

(polyuria, polydipsia, polyphagia, kussmaul respirations- deep rapid breathing, dehydration, vomiting, abdominal pain, fatigue, altered mental status)

345

What are pts with diabetic ketoacidosis at greatest risk of developing (which is why they should be admitted to ICU)?

cerebral edema

346

An immigrant presenting with weight loss, abdominal pain, and diarrhea who is found to have eosinophilia most likely suffers from ..

Helminthiasis
(infection with nematodes- round worm, hook worm, whipworm)

(tx: albendazole/ mebendazole)

347

What is the next best step in management of depression if the pt is intolerant of an SSRI?

Switch to another SSRI

(different SSRIs can have different side effect profiles)

348

A pt being treated for diabetic ketoacidosis who then develops fever, facial swelling, maxillary pain and tenderness, foul smelling nasal discharge, ophthalmoplegia and headache most likely suffers from ..

Mucomycosis (due to infection with Zygomycetes)

349

What is the treatment for mucomycosis?

debridement of necrotic tissue and amphotericin B

350

When is valvular surgery for mitral regurgitation advised?

if presence of symptoms (exertional dyspnea, fatigue, overt heart failure) and LV ejection fraction less than 60%

351

An HIV pt (or immunocompromised pt) who presents with multiple, discrete flesh to red colored papules with central umbilication on the face and/or trunk most likely suffers from ..

Cutaneous Cryptococcosis

(assess for systemic involvement via CXR, blood and CSF cultures, india ink stain of CSF, cryptococcal antigens of serum and CSF)

352

What is the diagnostic test of choice for cutaneous cryptococcosis?

biopsy of skin lesion using Periodic Acid Schiff and Gomori's methenamine silver nitrate

(granulomatous inflammation with multinucleated giant cells, histiocytes, lymphocytes, neutrophils and plasma cells with numerous yeast like organisms)

353

What allergen is most frequently associated with asthma?

house dust mites

354

What disease/ disorder is suggested to be the cause of a young patient with diabetes, osteoporesis, hypertension, hypokalemia and metabolic alkalosis?

Cushing's syndrome

(dx: 24 hour urinary free cortisol or overnight dexamethasone suppression test- cortisol level greater than 3 in the morning)

355

A child presenting with sudden acceleration of growth prior to puberty that is out of sequence (not testicular followed by penis followed by pubic hair followed by growth spurt) along with severe cystic acne most likely suffers from ...

Severe androgen excess (likely secondary to late-onset congenital adrenal hyperplasia)

(precocious pseudo-puberty)

356

How long should a pt wait before starting an MAO inhibitor after discontinuing SSRI use?

at least 5 weeks

357

A pt presenting with mental status changes, autonomic dysregulation (diaphoresis, tachycardia, hypertension, hyperthermia), and neuromuscular hyperactivity (hyperreflexia, tremor, myoclonus, ocular clonus) in setting of using an SSRI and MAO inhibitor most likely suffers from ...

Serotonin syndrome

(tx severe cases with cyproheptadine)

358

What is the formula for standardized incidence ratio (SIR)?

SIR = observed cases/ expected cases

(determines if occurrence of disease in a small population is high or low relative to an expected value derived from larger comparison population)

359

A pt who develops facial asymmetry after a recent upper respiratory infection most likely suffers from ...

Bell's palsy

360

A pt who presents with perioral numbness, muscle cramps, carpopedal spasm, positive chvostek sign (ipsilateral contraction of facial muscles on tapping of angle of jaw) and positive Trousseau's sign (rapid development of carpopedal spasm on occlusion of blood supply to upper extremity) most likely suffers from ...

Hypocalcemia

361

What is Hungry Bone Syndrome?

sudden withdrawal of PTH in pts with severe hyperparathyroidism causes increased influx of calcium into bone 2-4 days after parathyroid surgery

362

A pt presenting with early diastolic murmur at the left sternal border (aortic regurgitation), long extremities (especially arms), long fingers, tall stature, flat feet and scoliosis/ pectus deformity/ kyphosis and family member with similar problems most likely suffers from ..

Marfan's syndrome

(autosomal dominant defect in fibrillin-1)
(ectopia lentis, aortic root dilation/ regurgitation/ dissection)

363

What diagnostic test is essential to detect the major cause of death in a pt with Marfan's syndrome?

transthoracic ECHO (at diagnosis and every 6 months to assess aortic root and ascending aorta)

(replace aortic root if diameter greater than 50 mm)

364

What size induration on a tuberculin skin test is considered positive in a normal healthy pt? What size induration on tuberculin skin test is considered positive in moderate risk pt (immigrant, IV drug user, employee at high risk setting, kids less than 4 years old, homeless, prisoner)?

healthy: greater than 15 mm

high risk: greater than 10 mm

365

What size induration on a tuberculin skin test is considered positive in a high risk pt (HIV, recent contact of known TB case, CXR with nodular/ fibrotic changes, transplant, immunocompromised)?

greater than 5 mm

366

What is the next best step in management of a pt who presents with gross hematuria without signs of glomerular disease (red cell casts, dysmorphic red cells), older than 40 years old, and has a smoking history?

Cystoscopy (to visualize lower urinary tract) and CT urogram (to visualize upper urinary tract)
(assess for suspected urinary tract malignancy)

367

A young healthy pt presenting with lymphadenopathy and white plaques on the buccal mucosa and palate that can be easily scraped off revelaing hyperemia most likely suffers from ...

Candidiasis secondary to HIV test

(dx: gram stain/ KOH prep of scrapings and HIV test)

368

What is the best step in management of hyperthyroidism during pregnancy?

use PTU (propylthiouracil) during 1st trimester (b/c methimazole is teratogenic) then switch to methimazole for second and third trimester (b/c PTU is hepatotoxic)

369

A pt who develops platelet reduction by more than 50% from baseline, arterial/venous thrombosis, necrotic skin lesions at heparin injection sites or anphylactoid reaction after 5-10 days after heparin administration most likely suffers from ...

Type 2 heparin induced thrombocytopenia (HIT)

(dx: serotonin release assy)
(tx: stop heparin and use direct thrombin inhibitor- argatroban or fondaparinux)

370

When should warfarin treatment be started after a patient has developed HIT (heparin induced thrombocytopenia) from heparin use?

after treatment with non-heparin anticoagulant and platelet recovery to more than 150,000

371

What is the treatment for Lyme arthritis (usually affecting knee)?

28 days of doxycycline (if not pregnant and older than 8 years old) or amoxicillin

(good prognosis; cured after 6-12 months)

372

What is the recommendation for pilots taking Viagra?

wait at least 6 hours after taking viagra before a flight

(due to disturbance in blue-green differentiation)
(six hours from viagra to throttle time)

373

What is the next best step for a child with a foreign body visualized to be in the stomach on imaging?

no intervention

374

A pt who develops new or worsening respiratory symptoms which include respiratry distress, diffuse crackles, hypoxemia, bilateral alveolar infiltrate on CXR, and a PaO2/ FiO2 ratio less than 300 mmHg without signs of fluid overload most likely suffers from ...

Acute Respiratory Distress Syndrome (ARDS)

375

What is the treatment for acute respiratory distress syndrome (ARDS)?

(Q ID 5307, 5308)

low-tidal volume ventilation (goal of plateau pressure less than 30 cm H2O and arterial oxygen of 55-80 mmHg or oxygen saturation of 88-95%)

(increase FiO2/ PEEP to improve oxygenation and prevent overdistension by opening collapsed alveoli)

(lower FiO2/ PEEP once overshoot oxygenation goal while continuing mechanical ventilation)

376

What is the best way to form an initial therapeutic alliance with a psychotic patient?

permit pt to maintain privacy and interpersonal distance

377

What is the next best step in management of a pt with history sytemic lupus erythematous who develops renal involvement?

renal biopsy (to determine type of renal involvement to determine treatment)

378

What substances can be measured and used to monitor the activity level of lupus nephritis? (2)

1. serum complement
2. anti- ds-DNA level

379

What substance can be measured and used to monitor the current level of immunosupression in an HIV pt?

CD4 count
(the immunologic damage that has already occured)

(viral load determines disease activity and is the damage that is about to occur)

380

What is the initial treatment for hyperkalemia with severe EKG changes (prolonged PR interval, prolonged QRS, disappearance of P wave; all more severe than peaked T waves)?

IV calcium gluconate (stabilizes myocardium membrane potential)

381

What is the next best step for a depressed pt with a partial response to monotherapy (after trial of 2 antidepressants)?

aument with second agent (second generation anti-psychotic or an antidepressant from different class)

382

A pt who develops pituitary enlargement, bitemporal hemianopsia and hyperigmentation following bilateral adrenalectomy for Cushing's disease most likely suffers from ..

Nelson's syndrome

(dx: brain MRI- pituitary microadenoma with suprasellar extension and ACTH level- high)

(tx: surgery and/or local radiation)

383

What is the best initial test for a women under 30 years old with a breast mass on clinical exam>

Ultrasound

(if solid mass with atypical features, core needle biopsy)
(if cystic mass, followup routine clinical exams or FNA if desired)

384

A pt presenting with severe anion gap metabolic acidosis, rapid and deep breathing (kussmaul's respiration), nausea, vomiting, slurred speech and ataxia most likely suffers from ...

Ethylene gylcol (anti-freeze) intoxication

385

What is the best treatmeent for ethylene gylcol (anti-freeze) intoxication?

fomepizole

386

What is the next best step in management of worsening thrombotic disease while on sub-therapeutic level of warfarin (INR less than 2-3)?

admit and start IV heparin (until can get warfarin at therapeutic level)

387

What is the best initial treatment for a pt with visible, palpable, tortuous superificial veins on the legs with leg cramping, heaviness, fatigue and leg swelling?

leg elevation, weight reduction and compression stockings

(varicose veins)

388

What other cardiac abnormality is highly associated with a bicuspid aortic valve?

aortic root and ascending aortic dilation

(screen for with ECHO)

389

A pt presenting with eye pain/ discomfort, decreased visual acuity and visualization of a floating, white layer in the anterior chamber (hypopyon), and conjunctival and lid edema and erythema most likely suffers from ...

Endophthalmitis

(ophthalmic emergency- immediate ophthalmology referral)

390

An infant presenting with staccato cough (inspiration between every single cough), history of concurrent conjunctivitis, and auscultatory and radiologic findings out of proportion to healthy appearance of child (hyperinflation, peribronchial thickening, bilateral symmetrical infiltrates on CXR), elevated eosinophil count in the setting of no fever most likely suffers from ...

Chlamydia pneumonia

(due to vaginal contact during delivery)

(tx: oral erythromycin for 14 days)

391

A pt presenting with fever, sudden onset sore throat with tonsillar erythema and exudates, tender anterior cervical nodes and palatal petechiae most likely suffers from ..

Streptococcal tonsillopharyngitis (strep throat)

(dx: rapid strep antigen test, throat culture)
(tx: penicillin or amoxicillin)

392

A pt presenting with sudden onset shortness of breath, pallor, diaphoresis, pulmonary edema, hypotension, hyperdynamic precordium/ apical impulse, and a soft low pitched decrescendo systolic murmur head best at the lower left sternal border most likely suffers from ...

Acute Mitral Regurgitation

(usualy due to ruptured mitral chordae tendineae)
(can be due to papillary muscle rupture if 2-7 days after MI)

393

A pt with joint hypermobility, recurrent joint dislocations, velvety hyperextensible skin with easy bruisabilty, anddelayed healing of atrophic scars most likely suffers from ..

Ehler's Danlos Syndrome

394

What cardiac abnormality is associated with Ehler's Danlos syndrome?

mitral valve prolapse
(that can lead to acute mitral regurgitation from rupture of chordae tendineae)

395

An infant presenting with tomatoe red papulovesicular lesions in the diaper area including the crural folds with satellite papules (usually after treatment with an antibiotic) most likely suffers from ...

Candidal diaper rash

(tx: antimycotic cream - clotrimazole or nystatin)

396

A pt presenting with excoriated, lichenified plaques that are itchy and located near the belt-line most likely suffers from ...

Allergic Contact Dermatitis

(probably secondary to nickel allergy from belt)

397

What is the next best step in a pt presenting with difficulty initiating swallowing accompanied by coughing, drooling and/or aspiration in the dysphagia was initially for solids but progresses to include liquids?

Nasopharyngeal Laryngoscopy or Barium Esophagram

(assess for mechanical obstruction leading to dysphagi)

398

What is the next best step in a pt presenting with dysphagia initially involving both solids and liquids accompanied by coughing, drooling, and/ or aspiration?

Videofluoroscopic barium swallow

(assess for neuromuscular disorder)

399

What is the most likely histopathologic type of tumor to be found in the upper esophagus?

Squamous Cell Carcinoma

(associated with chronic smoking and alcohol use)

400

What is the most likely histopathologic type of tumor to be found in the lower esophagus?

Adenocarcinoma

(associated with chronic GERD and Barrett's esophagus)

401

What are the common causes of hepatic encephalopathy? (8)

1. GI bleeding
2. hypokalemia
3. hypovolemia
4. hypoxia
5. sedatives and tranquilzers
6. hypoglycemia
7. metabolic alkalosis
8. infection (spontaneous bacterial peritonitis)

402

What are the three conditions in which potassium must be replaced immediately if hypokalemia is present? (3)

1. hepatic encephalopathy (associated with loop diuretic)
2. ventilatory failure
3. cardiac arrhythmia

403

An HIV pt who presents with sensory ataxia (falling b/c feel off balance), lancinating pain (shooting/ burning), urinary incontinence, normal pupillary constriction with accommodation but not with light, aflexia, and impaired sensations most likely suffers from ..

Late Neurosyphillis

(dx: test for treponema pallidum infection)

404

... is a measure of risk that describes the chance of events occurring in one study arm compared to another and can be calculated at multiple time intervals throughout a study period

Hazard Ratios

(HR less than 1 means decreased risk)
(HR greater than 1 means increased risk)
(HR equal to 0 means no change in risk)

(only statistically significant if 95% confidence interval does not include null value of 1)

405

What are the measures of central tendency and their definitions? (3)

mode: value that occurs most frequently
Mean: sum divided by the total number of values
median: value separating the top half from lower half of data (50th percentile)

406

What are the contraindications to using dabigatran (or other target specific oral anticoagulants like rivaroxaban, apixaban, edoxaban)? (2)

1. valvular a-fib (presence of moderate to severe valvular regurgitation/stenosis, prosthetic vallves)
2. end stage renal disease

407

What is the best treatment for asymptomatic pulmonary sarcoidosis (i.e. hilar adenopathy with erythema nodosum)?

no treatment (spontaneous remission)

408

What are the three main disorders that make up Schmidt's syndrome (polyglandular autoimmune failure type II)?

1. Addison's disease (no cortisol)
2. Type 1 diabetes
3. autoimmune thyroid disease

409

A pt with an EKG showing fast rate, narrow and regular QRS complexes with absent P waves most likely suffers from ..

Supraventricular tachycardia

410

A pt with an EKG showing regular rate and rhythm, presence of p waves, PR interval less than 0.12 sec, a slurred initial part of activation of the QRS complex and a QRS durationof about 0.12 sec most likely suffers from ..

Wolff Parkinson White syndrome

(delta wave- slurried initial part of QRS complex)

411

A pt who develops hypoxemia and increased work of breathing 2-5 days after thoracoabdominal surgery with a CXR showing small lung volumes most likely suffers from ...

Atelectasis

(due to splinting, reduced cough from abdominal pain, retained secretions and diminished lung compliance)

412

What is the colon cancer screening guideline for a pt who has a first degree relative diagnosed before age 60 with colorectal cancer or advanced adenomatous polyps?

colonscopy at age 40 years old or 10 years before age of onset in relative (whichever comes first); repeat every 3-5 years

413

What is the best initial diagnostic test for renovascular disease/ hypertension in a pt with renal insufficiency?

renal duplex doppler ultrasonography

(avoid contrast induced nephropathy with CTA and nephrogenic systemic fibrosis with MRA)

414

What is the time interval between giving a phosphodiesterase inhibitor (sildenafil) and an alpha blocker (doxazosin)?

4 hours

415

What is the next best step in management of a symptomatic pt with a EKG documented STEMI?

percutaneous coronary intervention (if within 12 hours of symptom onset and 90 minutes of initial contact)

(fibrinolysis (tpa) if cant undergo PCI)

416

A pt who develops hypotension, diaphoresis, jugular venous distension, and cold extremities with clear lungs shortly after being diagnosed with an inferior wall MI (leads II, III, avf) most likely suffers from ...

Right Ventricular MI

417

What is the best treatment for right ventricular MI?

bolus of IV fluids (increased preload)

(avoid nitrates, diuretics, opiods that lower preload)

418

What does asymmetry in a funnel plot suggest?

publication bias (studies showing opposite effect are absent as they are less likely to be published)

419

What is the best initial treatment for symptomatic (CNS symptoms) or severe hyponatremia (Na below 115)?

3% NaCl (hypertonic saline)

(goal correction rate of 1.5-2 mEq/L/hour for first 3-4 hours; no more than 12 mEq/L in first 24 hours)

420

What is the first line treatment used for torsade de pointes as well as to prevent recurrence?

IV Magnesium sulfate

(depsite normal serum Mg levels)

421

What is the next best step in management for torsade de pointes if pt does not respond to IV magnesium sulfate?

temporary transvenous pacing

422

What is the next best step in management of a pt with a palpable renal mass?

ultrasound: if low risk of cancer

CT abdomen: if high risk (older pt, smoking, elevated Hct and Hb, night sweats, weight loss)

423

A pt presenting with long standing smoking history, flank pain, flank mass, increased hematocrit and hemoglobin levels and night sweats most likely suffers from ..

Renal Cell Carcinoma

424

What conditions are associated with the presence of multiple skin tags (pedunculated, skin colored papules mostly on areas of friction)?

1. insulin resistance/ metabolic syndrome
2. pregnancy
3. crohns disease (if located in perianal region)

425

What medical condition is associated with dermatitis herpetiformis (pruritc, erythematous, grouped papuloesicular lesions that usually occur on elbows)?

Celiac disease

426

What medical condition is associated with pyoderma gangrenosum (purulent ulcer)?

Crohn's disease

427

A pt presenting with scaly patches with slight erythema in their hair with associated hair loss and cervical lymphadenopathy most likely suffers from ..

Tinea Capitis

428

What is the first line treatment for tinea capitis?

oral griseofulvin (alternative is oral terbinafine)

429

What is the most appropriate next step in management of a pt who is found to have multifocal atrial tachycardia (tachycardia with narrow QRS, 3 or more different P wave morphologies, variable PR and RR intervals)?

obtain arterial blood gas

(to assess for hypoxemia as cause of MAT which if corrected can fix MAT)
(followed by chemistries for electrlyte imbalance)

430

What are common causes of multifocal atrial tachycardia? (6)

1. hypoxia
2. COPD
3. hypokalemia
4. hypomagnesemia
5. heart disease
6. meds (theophyilline, aminophylline, isoproterenol)

431

A child presenting with emotional lability, decreased school performance, distal hand movements, facial grimacing, feet jerking, decreased strength, delayed relaxation phase of patellar reflex, and positive pronator drift sign in the setting of a history of self-resolving prior infection most likely suffers from ..

Sydenham chorea

(complication of untreated strep pharyngitis; acute rheumatic fever)

432

What is the JONES criteria and what disease is it used to diagnosed?

acute rheumati fever if have 2 major or 1 major with 2 minor criteria
major: Joints (migratory arthritis), carditis, Nodules (subcutaneous), Erythema marginatum, Sydenham chorea
minor: fever, arthalgias, elevated ESR/ CRP, prolonged PR interval

433

What is the best initial step in management of a pt diagnosed with sydenham chorea secondary to untreated strep pharyngitis?

long acting IM penicillin (until adulthood to erradicate grap A strep)

434

A pt presenting with sudden onset vertigo, nystagmus, loss of pain and temperature in ipsilateral face and contralateral body, hoarseness, ipsilateral horner's syndrome, decreased gag reflex and aspiration most likely suffers from..

Lateral Medullary Infarction

(wallenberg syndrome)
(loss of pain and temp make it lateral)
(cranial nerves 9 and 10 make it medullary)

435

What is the best initial step in management for a pt presenting with chronic diarrhea?

microscopic exam of stool
(for leukocytes, ova, parasites, occult blood, fat staining, pH, osmotic gap)

436

What are the findings on small intestinal biopsy that are suggestive of Celiac disease?

villus blunting, loss of normal villus architecture, increased lymphocytic infiltration of mucosa

437

What is the next best step in management of an HIV pt with CNS symptoms who is found to have positive syphillis test results?

Lumbar puncture

(to assess whether pt has neurosyphilis)

438

What is the treatment for late latent syphillis (more than 12 months of infection), syphilis of unknown duration or gummatous/ cardiovascular syphilis?

benzathine penicillin G IM each week for 3 weeks

439

What is the treatment for primary, secondary or early latent (less than 12 months of infection) syphilis?

single dose of benzathine penicillin G IM

440

What is the treatment for neurosyphilis?

aqueous penicillin G IV every 4 hours for 10-14 days

441

What is the treatment for congenital syphilis?

aqueous penicillin G IV every 8-12 hours for 10 days

442

A pt being treated for syphilis who develops fever, malaise, chills, headache, and myalgias within 24 hours of initiation the treatment most likely suffers from ...

Jarisch-Herxheimer reaction

(no effective prevention)

443

... is the ability of a test to correctly identify patients with the disease and therefore is best to rule out a diagnosis

Sensitivity

(SnOut= sensitivity rules out disease)

444

What is the formula for positive likelihood ratio?

positive LR = sensitivity / (1- specificity)

(independent of prevalence)

445

What is the formula for negative likelihood ratio?

negative LR = (1- sensitivity)/ specificity

(independent of prevalence)

446

... occurs when a study uses gold standard testing selectively in order to confirm a positive/ negative result of preliminary testing; therefore performing the test in a random sample of participants reduces it occurence

Verification bias

447

What is the next best step in management of a pt presenting with substernal chest pain and dyspnea relieved with sublingual nitroglycerine?

admit, EKG and serial cardiac enzymes

(takes up to 6 hours for cardiac enzymes to be positive)

448

What is the best initial intervention of an unknown dry/ powdered chemical?

brush off remaining chemical
(followed by irrigation with copious amounts of low pressure water for 15-30 minutes)

449

What is the next best step in management of an acute exacerbation that is nor responding to nebulized albuterol therapy (shortness of breath and wheezing persist)?

IV corticosteroids (systemic steroids)

(same in pregnant pt; PaCO2 greater than 35 suggests respiratory compromise in pregnant pt)

450

what is the next best step in management of a depressed pt with passive suicidal ideation (wish to go to sleep and not awake, better off dead) without a plan?

outpatient treatment with antidepressant and close follow-up

451

A pt presenting with progressive fatigue, shortness of breath, fever, systolic murmur that increases with inspiration heard at LLSB, CXR showing circumscribed round pulmonary infiltrates and tricuspid vegetation on ECHO most likely suffers from ..

IV drug use induced infective endocarditis

(right heart endocarditis: tricuspid valve abnormalities and septic pulmonary emboli)

452

What is the formula for standardized mortality ratio?

SMR = observed number of deaths/ expected number of deaths

(adjusted measure of overall mortality used in occupational epidemiology)

453

What is the latent period?

time elapsed from initial exposure to clinically apparent disease

454

.... occurs when a study fails to reject a null hypothesis that is false; in other wrose the failure to detect a difference between groups when a difference exists and it is related to the ... of a study

type II error; power (sample size)

455

A pt with history of anatomical change of GI tract/ motility disorder (scleroderma, diabetes)/ immunocompromised/ acid suppresion presenting with abdominal pain, diarrhea, bloating, excess flatulence, malabsorption, weight loss, anemia and nutritional deficiencies most likely suffers from ..

Small Intestine Bacterial Overgrowth

(lack of protective mechanisms such as bacterial degradation by proteolytic digestive enzymes, bacteria trapping in intestinal mucus layer, intact ileocecal valve preventing retrograde bacterial movement from colon, gastric acidity, peristalsis)

456

What is the most accurate test for diagnosing small intestine bacterial overgrowth?

endoscopy with jejunal aspirate showing more than 10,000 organisms/ ml

(less accurate is hydrogen breath test)

457

What is the next best step in management of a pt with rheumatoid arthritis that is resistant to methotrexate and steroid after 6 months of treatment?

switch to or add anti-cytokine (infliximab or etanercept)

(screen for TB first)

458

What is the next best step in management of a pt with rheumatoid arthritis who presents with new onset monoarticular arthritis with associated fever?

Joint Aspiration

(to assess for septic arthritis)

459

A pt presenting with recurrent and unexpected epsiodes of palpitations, sweating, shaking, and shortness of breath and have concern about having additional epsiodes/ about implications or consequences of episodes/ significant change in behavior because of episodes most likely suffers from ..

Panic Disorder

(associated with agoraphobia- fear of being in public should a panic attack occur and subsequently avoid public situations)

460

An infant who lives near farm/ construction site in California/ Pennsylvania/ Utah presenting with constipation and cranial nerve palsies (ptosis, pupillary paralysis, weak suck) followed by progressive hypotonia and loss of deep tendon reflexes most likely suffers from ..

Infant Botulism

(due to ingestion of C. botulinum spore in environmental dust; or ingestion of honey)
(good prognosis; 1-3 month hospitalization with full recovery)

461

what is the best treatment for infant botulism?

IV human derived botulism immunoglobulin
(along with ICU, NG tube feedings, laxatives, PT/OT)

462

What is the best treatment for foodborne botulism (due to ingestion of preformed C botulinum toxin)?

equine-derived botulism toxin

463

What is the best initial step in management of a man presenting with testicular swelling 9especially if painless nad negative transillumination)?

scrotal ultrasound

(assess whether intra or extra tesicular lesions and whether it is solid or cystic mass)

464

What is the next best step in management of a pt with lobular carcinoma in situ (nonmalignant lesion) on needle biopsy?

excisional biopsy

(b/c has significant associated with future development of invasive breast cancer)

465

What is the best treatment for symptomatic aortic stenosis (dysnea ofheart failure, anginal pain, syncope)?

aortic valve replacement

(marked reduction in mortality and symptoms)

466

What does non-overlapping confidence intervals suggest when comparing one group to another in a study and the P-value is significant?

significant differences between groups

467

A pt presenting with sandy sensation in eyes, dry eyes, prominent bulbar blood vessels and stringy discharge from eyes, oral candidiasis, dental caries, chronic esophagitis and dry mouth most likely suffers from ...

Sjogren syndrome

(sicca syndrome is keratoconjunctivitis- dry eyes and xerostomia- dry mouth)

468

A pt presenting with wrist swelling, decreased grip strength, pain and tenderness on the radial aspect of the wrist after falling on outstretched hand with dosifleced wrist most likely suffers from ...

Scaphoid fracture

(pain located in the anatomical snuffbox)

469

What is the next best step in management of a pt with suspected scaphoid fracture in which initial X-rays are negative? (3)

1. MRI/ CT of wrist
2. repeat X-ray in 7-10 days
3. radioscintigraphy bone scane in 3-5 days

470

What is the treatment for nondisplaced scaphoid fractures?

short arm thumb spica cast

(inadequate treatment results in nonunion and avascular necrosis)

471

An athlete presents with excruciating pain and swelling of the knee, difficulty bearing weight, tenderness at the anterior aspect of the knee, inability to actively extend the leg, and inability to maintain passive extension of knee against gravity after a traumatic injury most likely suffers from ..

Patellar Tendon Rupture

(tx: surgery)

472

What is the best initial treatment for bipolar maniaduring pregnancy?

haloperidol

473

A bone marrow transplant pt presenting with fever, cough, chest pain, localized headache, nasal bleeding and has patchy infiltrate on CXR most likely suffers from ..

Invasive Aspergilliosis

474

A pt presenting with eyelid erythema, swelling and tenderness along with proptosis, ophthalmoplegia and pain with eye movements most likely suffers from ..

Orbital Cellulitis

(tx: inpatient Iv antibiotics)

475

A pt presenting with eyelid erythem, swelling and tenderness along with fever, and leukocytosis most likely suffers from ...

Preseptal Cellulitis

(tx: oral antibiotics)

476

What are complications of orbital cellulitis?

1. orbital abscess
2. intracranial infection
3. cavernous sinus venous thrombosis

477

What is the next best step in the management of an elevated capillary lead level in a child?

obtain venous lead level
(mild: 5-44; no meds, repeat level in 1 month)
(moderate: 45-69, treat with DMSA)
(severe: more than 70; treat with dimercaprol with EDTA)

478

What is the next best step in management for a pt on amiodarone who develops abnormal thryoid biomarkers in which there is nomal to high TSH, low T3 and high T4?

repeat thryoid function testing in few weeks

(effect of decreased peripheral conversion of T4 to T3 from amiodarone usually improves after 3-4 months)

479

What is the next best step for a pt with epigastric/ abdominal discomfort and nausea worse after eating that does not respond to trial with PPI and has no alarming symptoms (age greater than 55, weight loss, anemia, gross bleeding)?

H. pylori testing (stool antigen testing or breath test)

480

What is the best initial treatment for oral candidiasis (cottony taste in mouth, white plaques on buccal mucosa that can be scraped off leaving hyperemic spots)?

nystatin suspension or clotrimazole troches

(topical antifungal)
(if associated with use of inhaler in asthma, rinse mouth out after using inhaler and proper technique)

481

What is the best initial treatment for moderate lead toxicity (lead 45-69)?

oral meso-2-3-dimercaptosuccinic acid (DMSA, succimer)

482

What is the best initial treatment for severe lead toxicity (lead 70 or greater)?

dimercaprol with EDTA (calcium disodium edetate)

483

What is the best initial diagnostic test for suspected acute diverticulitis?

abdominal CT (showing colonic wall thickening and stranding of mesenteric fat, diverticulae, as well as complications such as abscess, perforation, fistula)

484

What is the next best step in management of individuals exposed to pt with active TB whose PPD test result is negative?

repeat PPD in 3 months

(if PPD positive, monotherapy with INH for 9 months)

485

What is the best next step in management of acute aortic dissection after pain management?

IV beta blocker (esmolol- short acting)

(to slow HR, lower sBP to 100-120 mm/Hg, reduced LV contractility)

486

What is the next best step in management of acute aortic dissection if systolic blood pressure remains above 100-120 mmHg after IV beta blocker?

nitroprusside

487

A pt presenting with episode of syncope while standing that was proceeded by nausea, lightheadness, pallor and diarphoresis and recovered while supine without jerky movements, tongue biting, and incontinence most likely suffers from ...

Vasovagal Syncope (Neurocardiogenic)

488

An obese boy presenting with hip pain that may spread to the thigh and knee without recent history of trauma, and the hip is externally rotated most likely suffers from ...

Slipped Capital Femoral Epiphysis (SCFE)

(acute less than 3 weeks; chronic more than 3 weeks)
(stable can bare weight; unstable cant bare weight)

489

What is the treatment for slipped capital femoral epiphysis (SCFE)?

immediate internal fixation with pins

490

What antibiotics can be used as first line treatment for UTI in a pregnant patient? (4)

1. nitrofurantoin
2. amoxicillin
3. cephalexin
4. amoxicillin- clavulanate

491

What is the best initial treatment of pyelonephritis (fever, chills, dysuria, nausea, vomiting, CVA tenderness) in a pregnant pt?

hospitalization and IV antibiotics until afebrile for 24-48 hours and symptom improvement, then outpatient antibiotics for total of 10-14 days

(ceftriaxone, aztreonam, ampicillin with gentamicin)

492

A pt with a lumbar puncture showing elevated RBC, elevated WBC at a ratio of 1 WBC to 750-1000 RBCs, elevated protein and glucose level in the absence of xanthochromia most likely suffers from ...

Traumatic Lumbar Tap

493

An elderly pt presenting with signs of osteoporesis such as multiple fractures that is not responding to bisphosphonate therapy along with constitutional symptoms, weight loss and pallor most likely suffers from ...

Multiple Myeloma

494

What is the diagnostic test for multiple myeloma?

serum and urine protein electrophoresis

495

An IV drug abuser who presents with malaise, nausea, jaundice and right upper quadrant pain along with have elevated transaminases (10-20 times upper limit) most likley suffers from ..

Acute Hepatitis

(if anti HAV antibodies, HBsAg, anti HBsAg antibodies and anti HCV antibodies are negative, likely hep C infection prior to formation of antibodies)

496

What are the absolute contraindications to combined hormonal contraceptives? (9)

1. migraine with aura
2. smoking more than 15 cigs/ day and older than 35
3. stage 2 HTN (greater than 160/100)
4. hx of venous thromboembolic disease
5. hx of stroke/ ischemic heart disease
6. breast cancer
7. cirrhosis and liver cancer
8. major surgery with prolonged immoblization
9. less than 3 weeks postpartum

497

What type of cancer is at increased risk in a pt with Klinefelter's syndrome (hypogonadism, low testosterone, gynecomastia, karyotype of 47 XXY)?

Breast Cancer

(50x more likely compared to pt with normal karyotype)

498

What is the formula for positive predictive value (PPV)?

PPV = true positive/ (true positive + false positive)

PPV = a/ (a+b)

(probability that an individual truly has disease given a positive test result; dependent on prevalence of disease)

(increasing specificity results in increasing positive predictive value)

499

What is the formula for negative predictive value (NPV)?

NPV = true negative/ (true negative + false negative)

PPV = d / (d +c)

(probability that an individual truly does not have disease given a negative test result; dependent on prevalence of disease)

500

A pt who develops swinging fever, leukocytosis, cough and shoulder tip pain 14-21 days after abdominal surgery most likely suffers from ...

Subphrenic Abscess

(dx: abdominal ultrasound)

501

What is the best diagnostic test for monitoring cardiotoxicity from anthrocycline chemotherapy agents (doxorubicin, daunorubicin)?

Radionuclide Ventriculography (MUGA) to assess LV ejection fraction

(chemotherapy contraindicated if ejection fraction less than 30%; discontinue therapy if ejection fraction decreases by 10% or more)

502

What is the best initial test used to determine the cause of a couple's infertility issues (unable to conceive after 1 year of unprotected sex)?

semen analysis

(easy and detects male cause which is 20-30% of time)

503

What is the first line treatment of hypertension in a pt with bipolar depression who is being treated with lithium?

Calcium channel blockers

(avoid ACE inhibitors, ARBs, diuretics as affect renal exretion of lithium)

504

What is the best initial step in management of an adult pt with mental retardation or dementia?

ask about guardianship status

505

What is the serum-ascites albumin gradient (SAAG) formula and what is it used for?

SAAG = serum albumin - ascitic fluid albumin

used to identify presence or absence of portal HTN
(SAAG greater or equal to 1.1 is portal HTN)
(SAAG less than 1.1 is non-portal HTN - peritoneal TB or carcinomatosis, nephrotic syndrome, pancreatitis, serositis)

506

A pt who develops anorexia, weight loss, insomnia, palpitations, tachycardia, elevated BP, irritability and agitation after starting treatment for ADHD most likely suffers from ...

Methylphenidate/ stimulant toxicity

(long term: decreased height and weight)

507

What is the best initial treatment for keloids (benign fibrous growths in scar tissue secondary to overproduction of extracellular matrix and dermal fibroblasts)?

intralesional glucocorticoids

(high recurrence rate; use excisional removal if fail steroids)

508

When should a C-section be performed for an HIV positive pregnant pt?

if vial load greater than 1000 copies/ ml

(if pregnant pt on HAART therapy prior to conceiving maintain same HAART therapy during pregnancy to minimize drug resistance and loss or viral suppression)

509

What is the best management of a newborn of an HIV positive mother?

Zidovudine for 6 or more weeks with serial HIV PCR testing

(avoid breastfeeding; use formula)

510

What are maternal contraindications to breastfeeding? (6)

1. active untreated TB (can after 2 weeks of therapy)
2. maternal HIV infection
3. herptic breast lesions
4. varicella infection less than 5 days before or 3 days after delivery
5. chemotherapy/ radiation therapy
6. alcohol or drug use

511

What is the next best step in management of a pt with a pituitary lesion that was incidentally found and who lacks clinical or laboratory evidence of pituitary abnormality/ dsfunction?

repeat MRI of pituitary in 6-12 months

(incidentaloma)

512

A pt presenting with dyspnea, tachypnea, hypoxemia and hemoptysis after a blunt chest traumain which CXR shows homogenous opacification of the lung fields without a specific anatomic segment involved most likely suffers from ....

Pulmonary Contusion

513

What is the next best step in management of a pt with pulmonary contusion?

admit to hospital and monitor for 24-48 hours (for signs of clinical deterioration)

514

What is the effect of magnitude of the expected effect size (size of expected difference between the groups) on the power of a study?

the smaller the magnitude of expected effect size, the higher the power of the study needs to be to see effect
(therefore more subjects are required to see the effect)

515

An HIV pt presenting with fat tissue deposition on the back of the neck and abdomen along with thin extremities and face most likely suffers from ...

HIV lipodystrophy due to insulin resistance
(tx: metformin and "zones")

516

What is the next best step in management of an HIV pt with dyslipidemia particularly marked triglyceridemia (TGs greater than 500)?

Fibrates (gemfibrozil)

517

What is the next best step in management of an HIV pt with dyslipidemia with moderate elevation if triglycerides (TGs less than 500)?

statin

518

What are the common associated disorders of having Turner's syndrome (XO karyotype)? (4)

1. coarctation of aorta
2. bicuspid aortic valve
3. horseshoe kidney
4. streaked ovaries/ amenorrhea/ infertility

519

What is the best next step in preventing further retinal damage or peripheral neuropathy damage in a diabetic patient?

strict glycemic control (goal of HbA1c below 7%)

(improves microvascular complications of diabetes such as retinopathy, peripheral neuropathy and nephropathy)

520

What is the best next step in management of a pt who develops lithium-induced hypothyroidism (elevated TSH, fatigue, constipation) while being treated for bipolar disorder?

continue lithium and add levothyroxine

(especially if hx of severe mood episodes that respond to lithium)

521

What is the best initial diagnostic test for a pt who presents with hemoptysis?

Chest X-ray

522

What is the best next step in management of a pregnant pt at high risk of cervical insufficiency (in ability of cervix to hold pregnancy in the absence of labor resulting in increased risk of preterm birth)?

serial ultrasound cervical lengths and evaluations for cerclage placement during second trimester (16-24 weeks)

523

What are risk factors for cervical insufficiency? (5)

1. collagen abnormalities (Ehlers- Danlos)
2. uterine abnormalities (septate/ bicornuate uterus)
3. prior mechanical cervical dilation (D&C, pregnancy termination)
4. prior OB cervical laceration
5. prior cone or LEEP procedure for CIN

524

What is the most common extraneural complication of myelomeningoceles (bulging sac covered with membranes in lower back)?

Genitourinary system involvement (bladder dysfunction, urinary tract and renal dysfunction)

525

What is considered hypoglycemia?

blood sugar level less than 60 mg/dL

(normal is 70-100 mg/dL)

526

What is the target pre- meal blood sugar level in diabetic patients?

80-120 mg/dL

(if blood sugar level outside this range, adjust insulin)

527

What is Whipple's triad?

1. low blood glucose level
2. symptoms of hypoglycemia (headache, palpitations, sweating, irritability)
3. symptomatic relief with glucose administration/ eating

(suggests true hypoglycemia)

528

What is the next best step in management of exercise induced hypoglycemic episodes in diabetic patient? (2)

1. eat source of glucose before exercising
2. decrease level of basal insulin (in morning if exercise in afternoon)

529

What is a common gram negative anaerobe found in human bites?

Eikenella corrodens

530

What is the best antibiotic treatment for human bite wounds (polymicrobial with mixture of anaerobic and aerobic organisms)?

Amoxicillin- clavulanate

531

A pt presenting with episodes of well-circumscribed and raised plaques with central pallor and intensely itchy in which lesions appear and enlarge over minutes to hours before disappearing within 24 hours and episodes occur for more than 6 weeks most likely suffers from ...

Chronic Urticaria (Hives)

(dx: clinical)

(prognosis: spontaneous resolution within 2-5 years)

532

What is the best initial treatment for chronic urticaria?

second generation antihistamine (loratadine, certirizine) and avoid aggravating factors

(if fail: increase dose or add additional first generation H1 blocker like hydroxyzine/ leukotriene receptor antagonist like montelukast/ H2 blocker like ranitidine, or short course of steroids)

533

A pt presenting with knee pain, swelling and stiffness after hitting the knee on the dashboard during a motor vehicle accident most likely suffers from ...

Posterior cruciate ligament injury

(posteriorly directed force on anterior aspect of proximal tibia with knee flexed such as with athlete falling on flexed knee with foot plantar flexed)

534

A pt presenting with multiple psychotic episodes with concurrent major depressive or maniac symptoms along with at least 2 weeks of delusions or hallucinations in absence of mood symptoms most likely suffers from ...

Schizoaffective Disorder

535

What is the most common cause of hereditary/ inhertied thrombophilia?

Factor V Leiden

(increased risk of venous thromboembolism)

536

A pt who develops nightmares and flashbacks of a traumatic event, negative mood, avoids thoughts/ feelings/ external reminders of the event, sleep disturbances, irritability/ outbursts, hypervigilence, impaired concetration and exaggerated startle reflex 3 days to 1 month after a life- threatening trauma most likely suffers from ...

Acute Stress Disorder

(tx: trauma focused cognitive behavioral therapy and short term benzos for agitation/ insomnia)

537

What is the best next step in management of an infant 6 months or older with hypoplastic, hypopigmented, poorly rugated and empty scrotum with bilateral inguinal fullness without signs of torsion (tenderness, swelling, discoloration)?

elective ochiplexy


(cryptorchidism may resolve during first 6 months of life but if not surgery to bring testes down)

538

What is the most common adverse event in a hospitalized patient who is not undergoing surgery?

adverse drug events

(in surgery pts it is wound infections, bleeding and DVTs)

539

What are the 4 criteria that are used to determine whether a patient has SIRS (systemic inflammatory response syndrome- only need 2 of them)?

1. temp greater than 38.5
2. HR greater than 90
3. respiratory rate greater than 20
4. WBC greater than 12,000

540

What is the best initial step in management of a pt with SIRS (systemic inflammatory response syndrome)?

aggressive fluid resuscitation until central venous pressure is 8-12 mmHg

(use pressors if not responsive to fluids)

541

What is the mechanism responsible for exacerbated hypotension in patients on long term corticosteroids who develop septic shock?

suppression of pituitary-adrenal axis

(long term use of steroids negatively feedbacks to decrease ACTH causing decrease cortisol response to septic shock)

542

A pt presenting with episodes of chest pain and dysphagia lasting a few seconds to minutes, has a classic corkscrew esophagus on esophagogram, and manometric studies show simultaneous high amplitude peristaltic contractions with normal relaxation of lower esophageal sphincter most likely suffers from ...

Diffuse Esophageal Spasm

(tx: antispasmodics, dietary modification, psychiatric counseling)

543

A female pt presenting with complaints of food sticking in the throat, halitosis and regurgitation of food most likely suffers from ...

Zenker's Diverticulum

(tx: surgery)

544

What are the symptoms described by SMIGECAPS for diagnosis of depression?

S: sleep disorder
M: mood depressed
I: interest deficit (anhedonia)
G: guilt (worthlesness, regret)
E: energy deficit
C: concetration deficit
A: appetite changes (weight loss/gain)
P: psychomotor agitation/ retardation
S: suicidality

(depression dx requries at least 5 with 1 being depressed mood for at least 2 weeks)
(tx: SSRIs)

545

What is the next best step in management for a pt with symptoms suggestive of coronary heart disease (chest pain on exertion) with a normal EKG and inability to exercise?

adenosine myocardial perfusion imaging

(avoid if pt has asthma or hx of bronchospasm)

546

What are the recommendations for lung cancer screening?

chest CT yearly in pts aged 55-80 who have a 30 pack year smoking history and are current smokers or quit smoking within the last 15 years

(less than 10% of pts with positive CT- noncalcified nodule 4 mm or greater actually have lung cancer)

547

What is the best next step in management of a preterm labor (24 to 24 weeks gestation)?

intramuscular betamethasone or dexamethasone

(to reduce risk of infant respiratory distress syndrome and intraventricular hemorrhage)

548

What is the most important recommendation for a pt with suspected infectious mononucleosis (fever, fatigue, sore throat, tender posterior cervical lymphadenopathy, splenomegaly, atypical lymphocytes, rash after amoxicillin treatment)?

avoid sports

(to reduce risk of splenic rupture)

(rash due to circulating immune complexes; discontinue antibiotic)

549

What is the best next step in a pt with adult polycystic kidney disease who is considering peritoneal dialysis?

colonoscopy (rule out diverticula that can affect peritoneal dialysis)

550

What is the next best step in management of a diabetic pt with symptomatic multivessel coronary artery disease?

Coronary Artery Bypass Graft (CABG)

551

What is the first line treatment for hyperbilirubinemia (generally bilirubin greater than 18 mg/dL)?

Phototherapy (convert bilirubin to water soluble form)

(use exchange transfusion if phototherapy ineffective or bilirubin levels already at toxic level)

552

A female child presenting with short stature, hypogonadism, short fourth metacarpal bones, multiple nuchal folds, and wide spaced nipples most likely suffers from ...

Turner Syndrome (XO karyotype)

(cardiac abnormalities, visual and hearing deficits, horseshoe kidney, hypothyroidism, streaked gonads)

553

An adolescent found to have isolated proteinuria most likely suffers from ...

Orthostatic Proteinuria

(elevated protein excretion during day (upright) and normal excretion at night (supine))
(benign, no treatment)

554

What two diagnostic tests can be used to diagnose orthostatic proteinuria?

1. split 24 hour urine collection for protein (elevated in day, normal at night)
2. comparing urine protein- creatine ratio in urine samples collected in supine and standing positions

555

What is the next best step in management of a pt with a glasgow coma score of 8 or lower?

Intubate (to maintain adequate airway)

556

What is the best step in management of a pregnant woman who is Rh (D) negative and has an anti-D antibody screen that is negative if the father is Rh positive or status is unknown?

anti-D immune globulin at 28 weeks gestation

(as well as peripartum to reduce risk of isoimmunization due to fetomaternal transfusion during delivery)

557

What is the best step to smoking cessation in a patient with history of seizure disorder or eating disorder?

varenicline or nicotine replacement therapy (patch-plus combination: long acting with short acting)

558

What is the best initial test for suspected infectious mononucleosis?

Monospot testing

(detects heterophile antibodies that agglutinate horse RBCs)

(if monospot negative: perform EBV specific antibodies- IgM and IgG viral capsid antigen without IgG EBV nuclear antigen)

559

What is the best treatment for infectious mononucleosis (due to EBV)?

bed rest and NSAIDs

560

What is the next best step in management of a pt with infectious mononucleosis who develops shortness of breath while recumbent, pharyngeal edema and swelling of soft tissues of the nexk?

admit and start IV corticosteroids

(steroids for infectious mononucleosis with airway obstruction imminent, overwhelming infection, aplastic anemia, thrombocytopenia)

561

What is the best treatment for community acquired pneumonia (fever, cough, tachypnea, adventitious lung sounds) in a pre-school aged child or a child with focal lung findings?

high dose Amoxicilin

(likely due to strep. pneumoniae)

562

Whatis the best treatment for community acquried pneumonia (fever, cough, tachypnea, adventitious lung sounds) in older child or well appearing child with bilateral lung findings?

Azithromycin

(likely mycoplasma pneumoniae)

563

What is the sudden onset of hyperglycemia (insulin resistance) in a patient receiving total parenteral nutrition (TPN) suggestive of?

Sepsis

564

What is the next best step in management for a pt with fractures following minor trauma (ground level fall)?

Dual-Energy X-ray Absorptiometry

(DEXA scan for osteoporesis)
(T score of -1 to -2.5: osteopenia)
(T score of -2.5 or lower: osteoporesis)

565

When is treatment of osteoporesis with bisphosphonates recommended in postmenopausal women?

1. have T score of -2.5 or less
2. have hx of low-trauma hip or vertebral fracture regardless of T score

566

How should amputated body parts be transported to preserve ability to replant body part on pt?

wrap in gauze, moisten with saline and place in sealed, sterile plastic bag and place bag in containerwith ice mixed with saline/ sterile water (maintain cold ischemia)

567

What is the best initial step in management of a pt with end stage renal disease who has anemia with hemoglobin less than 10 g/dL?

erythropoietin stimualting agents (epo)

568

What is the next best step in management of a pt with end stage renal disease with anemia (hemoglobin less than 10 g/dL) with a transferrin saturation less than or equal to 30% and ferritin less than or equal to 500 ng/mL?

IV iron supplementation

569

A pt presenting with intensely itchy rash that is worse at night and located in flexor surfaces of wrist/ lateral surface of fingers/ and finger webs and looks like excoriations with multiple small crusted red papules with linear burrows most likely suffers from ....

Scabies

(dx: skin scrapings revealing mites, ova and feces under light microscopy)

570

What is the best initial treatment for scabies?

topical 5% permethrin cream or oral ivermectin

(place beeding and clothes in plastic bag for 2-3 days after cleaning to eradicate mite)

571

A pt with history of periodic restrosternal chest pain and transient dysphagia presenting with difficulty swallowing solid foods, need for prolonged and careful chewing and drinking excess liquids with meals, and swallowing small portions most likely suffers from while being young and lacking alarming symptoms ...

Esophageal Stricture

(complication of untreated GERD and erosive esophagitis)

572

What are common causes of decreased vision in elderly patients?

1. cataracts
2. macular degeneration

(associated with each other)

573

What is the next best step in managment of an infant with an elevated hematocrit (greater than 65%) on heel prick (capillary sample)?

recheck hematocrit using peripheral venous blood

(neonatal polycythemia if hct higher than 65% or Hb greater than 22 g/dL)

574

What is the treatment for symptomatic polycythemia in an infant (irritability, drowsy, poor feeding, hypotonia, abdominal distension, plethoric, hypoglycemia, jaundice, apneic)?

IV hydration and partial exchange transfusion

(problems due to hyperviscosity)

575

An elderly pt presenting with calcium elevation, renal insufficiency, anemia (normocytic), and bone pain (lytic lesions) (CRAB symptoms) along with hyperproteinemia most likely suffers from ...

Multiple Myeloma

(dx: serum and urine protein electrophoresis showing monoclonal protein and bone marrow biopsy showing greater than 10% clonal plasma cells)

576

What is the next best step in management of a pt with recent diagnosis of multiple myeloma?

complete X-ray skeletal survery (to assess for fractures, lytic lesions)

577

A pt with hx of multiple myeloma who develops nasal/ oral bleeding, blurry vision, confusion, headache and possibly heart failure most likely suffers from ...

Hyperviscosity Syndrome

(tx: plasmapheresis)

578

What should a pt with diagnosis of Marfan's syndrome and aortic root dilation/ moderate to severe mitral regurgitation/ family history of aortic dissection/ sudden death be counselled on?

avoid strenous physical activity

579

A pt presenting with acute onset chest pain, dyspnea, and fever following repeated episodes of vomiting along with pleural effusion on CXR most likely suffers from ..

Esophageal Perforation (Boerhaave's syndrome)

(associated with pneumomediastinum- radiolucent band adjacent to cardiac border and pneumothorax)
(fever suggests mediastinitis)

580

What is the best diagnostic test for esophageal perforation (Boerhaave's syndrome)?

esophagogram with water soluble contrast

(second line is barium contrast if high suspicion)

581

A pt presenting with a rash that started as a small, elevated red area and gradually involved the surrounding skin to become erythematous, itchy and painful along with new onset diabetes most likely suffers from ...

Glucagonoma

(skin rash is necrolytic migratory erythema)
(dx: glucagon level; tx: surgical removal)

582

What acne treatments are associated with the adverse effect of photosensitivity? (2)

1. benzoyl peroxide
2. tetracycline and doxycycline

583

What is the best treatement for photosenstivity rash/ sunburn?

fluid replenishment and NSAIDs (ibuprofen and indomethacin)

584

What activity should be avoided in patients who are being treated for acne with isotretinoin?

avoid alcohol consumption

(isotretinoin causes hypertriglyceridemia which increases risk of pancreatitis especially with alcohol consumption)

585

What steps in management should be taken if a female pt of reproductive age is going to have her acne treated with isotretinoin?

have 2 negative pregnancy tests before start treatment and use 2 concurrent methods of contraception 1 month before, during and 1 month after

(assess plans for possible pregnancy)

586

What is the best initial treatment for patients with hypertension and chronic kidney disease who are found to have proteinuria (in excess of 500-1000 mg/day)?

ACE inhibitor (or ARB)

(then add diuretic and then calcium channel blocker if needed)

587

A pt who presents with rapid onset unilateral facial weakness in which the pt is unable to raise the eyebrow, close the eye or wrinkle the forehead on the affected side along with drooping of the mouth corner and disappearance of the nasolabial fold with an associated funny feeling at time of onset most likely suffers from ...

Bell's Palsy

(7th cranial nerve neuropathy)
(unilateral upper and lower facial weakness)

588

What is the treatment for Bell's Palsy?

corticosteroids within 3 days of onset and eye care if poor eyelid closure (artificial tears and eye patching)

589

A pt who has a distal radius fracture possibly with shortening and dorsal displacement after falling on an outstretched hand most likely suffers from...

Colles' fracture

(associated with scaphoid fracture, ulnar styloid fracture, acute carpal tunnel syndrome and osteoporesis)

590

What is the best initial diagnostic test for routine screening for HIV?

HIV p24 antigen with HIV antibodies

(confirm with HIV-1/HIV-2 differentiation immunoassay)

591

What is the most common short term complication after cervical conization (cold knife conization and LEEP)?

bleeding

592

What is the next best step in management of a pregnant pt at less than 34 weeks gestation who has elevated blood pressure with proteinuria and without symptoms (nausea, vomiting, headache, SOB, upper abdominal pain, visual abnormalities)?

admit to hospital for further evaluation of severity of pre-eclampsia
(repeat BP measurements, lab tests, protein measurement, monitor for symptoms)

593

What is the best treatment for catatonia (immobility, unresponsiveness, catalepsy- passively allowing examiner to position pt, echolalia- mimics speech, echopraxia- mimics movement, posturing- spontanous postures against gravity, waxy flexibility- resistance to positioning, mutism, negativism- resistance to instructions)?

Lorazepam (benzos) or ECT (if fail benzo or urgent case)

(dx catatonia with lorazepam challenge test- give 1-2 mg and observe for partial, temporary relief withing 5-10 mins)

594

A pt presenting with flaky and itchy scalp associated with red, oily skin with inflammation and scaling of the scalp/ face/ upper trunk most likely suffers from ..

Seborrheic dermatitis
(dandruff)

595

What is the best initial treatment for seborrheic dermatitis?

medicated shampoo (tar-based preparations, zinc pyrithione, selenium sulfate)

596

An elderly pt with history of smoking who presents with recurrent pneumonia that responds to antibiotics most likely suffers from ...

Bronchogenic carcinoma

(tumor causes endobronchial obstruction preventing adequate clearance of secretions)

597

What is the best diagnostic test to evaluate a pt with persistent/ non-resolving pneumonia that responds to antibiotics (suggests endobronchial obstruction)?

Flexible bronchoscopy (visualize obstruction and biopsy)

(best initial test would be high resolution CT scan- persistent scar)

598

What are the effects of intermittent heavy drinking (more than 7 drinks/ week or 3 drinks at 1 time in women; more than 14 drinks/week or 4 drinks at 1 time in men) and binge drinking (4 or more drinks at once in women; 5 or more drinks in men) in a diabetic pt? (3)

1. elevated blood pressure
2. unstable glucose levels (hypoglycemia with sulfonylureas)
3. increased risk of cardiovascular disease (a-fib, dilated cardiomyopathy, coronary disease)

599

What do overlapping standard error of measurement bars in a study's results suggest?

non-statistically significant difference

600

What is the most common complication of sodium glucose contransporter 2 inhibitor use in diabetic patients?

Vulvovaginal candidiasis

(reduce hyperglycemia via promoting renal glucose excretion leading to glucosuria which increases infections)

601

A pt presenting with inability to extend the knee against resistance (quadriceps weakness), sensory loss over anteromedial aspect of thigh, medial shin and arch of foot, and decreased knee jerk reflex most likely suffers from ...

Femoral Nerve Injury

(arch of foot is saphenous nerve- branch of femoral)

602

What is the best treatment for Lyme disease in a pregnant patient?

amoxicillin or cefuroxime

603

What are the most common complications associated with silicone breast implants? (2)

1. capsular contracture resulting in pain
2. shape distorion/ implant deflation/ implant rupture

(no effect to fetus during pregnancy or to infant during breast-feeding)
(routine mamamogram screening for breast cancer and MRI every 2-3 years to screen for rupture recommended)

604

What is the best step to confirm eradication of H. pylori infection after triple therapy for H. pylori positive ulcers?

urea breath test or fecal antigen testing 4 weeks after completing therapy

605

What is the pathophysiologic mechanism responsible for heparin induced thrombocytopenia type 2?

antibodies to platelet factor 4 (PF4) complexed with heparin

606

What is the best recommendation for patients who have a history of HIT (heparin induced thrombocytopenia)?

avoid all forms of heparin (low molecular weight, unfractionated) for lifetime including heparin flushes and heparin coated catheters

(heparin allergy)

607

A pt presenting with hyperventilation (breathing heavy), tinnitus, restlessness, nausea, vomiting and mild GI distress that progresses to drowsiness and loss of consciousness, acute renal failure, elevated aminotransferases, and metabolic acidosis with elevated anion gap (especially in setting of history of drug abuse or suicide attempt) most likely suffers from ...

Salicylate (aspirin) Intoxication

(hyperventilation without dyspnea is respiratory alkalosis compensating for metabolic acidosis)

608

What is the treatment for salicylate (aspirin) intoxication?

alkalinization of urine (if salicylate level greater than 35 mg/dL), gastric lavage, activated charcoal

609

A pt who presents with history of recurrent headaches the last 30 minutes to 3 hours and assocaited with severe retro-orbital pain, lacrimation, conjunctival injection, rhinorrhea, sweating and pallor most likely suffers from ..

Cluster Headaches

(treat acutely with 100% oxygen or second line is sumatriptan, NSAIDs, ergotamine)

610

What is the best initial treatment for prevention of cluster headaches?

verapamil

(assess for cardiac effects with EKG)
(prednisone and lithium are alternatives)

611

What diagnostic test can be used to assess for the loss of vibration sense in a pt with suspected diabetic neuropathy?

tuning fork test

612

What are the three drugs that are used as first line treatment for pain associated with diabetic neuropathy?

1. duloxetine (SNRI)
2. pregabalin
3. TCAs

613

What is the best initial diagnostic test for imaging skeletal metastasis for malignancies that are primarily osteoblastic (prostate cancer, small cell lung, Hodgkin lymphoma)?

radionuclide bone scan

614

What is the best initial diagnostic test for imaging skeletal metastasis for malignancies that are primarily osteolytic (multiple myeloma, non-small cell lung, non-Hodgkin lymphoma)?

X-ray and PET scans

615

What is the best step in management of a pt with a lightening injury resulting in asytole or ventricular fibrillation?

uninterrupted CPR (continue CPR while giving epinephrine or vassopressin)

616

What medical treatment can be used before diving to prevent the incidence of ear and sinus barotrauma?

non-sedating decongestants (pseudoephedrine)

617

What factor is responsible for increased risk of transverse limb abnormality when undergoing chorionic villus sampling (CVS)?

age of gestation

(high risk if gestation less than 9 weeks)

618

What is the best follow-up procedure for a pt with autosomal dominant polycystic kidney disease?

regular blood pressure checks

(hypertension is poor prognostic factor)

619

What is the best initial treatment for hypertension in a pt with autosomal dominant polycystic kidney disease?

ACE inhibitors

620

What is the most common extrarenal manifestation of autosomal dominant polycystic kidney disease?

hepatic cysts

621

What is the next best step in management for family members of a pt with autosomal dominant polcystic kidney disease?

abdominal ultrasound

(to assess kidney- 3 to 5 cysts in each kidney)

622

What is the best preventative step in patients with chronic liver disease (chronic Hep C infection)?

Hep A vaccination in unvaccinated

(hepatic decompensation and liver failure if develop Hep A while have chronic Hep C)

623

What is the prognosis for a child who is diagnosed with attention deficit hyperactivity disorder (ADHD)?

one to two thirds of kids witll experience ADHD symptoms into adulthood but medication is symptomatically beneficial

624

True or False. Stimulant therapy for attention deficit hyperactivity disorder does increase the risk of developing substance use disorder.

False

(current research does not support increase risk)

625

What is the best initial step in management of shoulder dystocia (difficulty delivering baby's shoulder) during delivery?

BECAL(M)
B- breath, dont push; lower head of bed
E- elevate legs into McROberts position (sharp hip flexion while supine)
C- call for help
A- apply suprapubic pressure (downward and lateral)
L- enlarge vaginal opening with episiotomy
(m)- other maneuvers

626

A trauma pt presents with unilateral decreased/ absent breath sounds with ipsilateral decreased chest excursions, hypoxia, hypotension, low oxygen saturation, and shifting of mediastinal structures (trachea, heart) most likely suffers from ...

Tension Pneumothorax

(tx: needle decompresion at 2nd/ 3rd intercoastal space in mid clavicular line followed by chest tube thoracostomy)

627

A pt presenting with nasal congestion, rhinorrhea, sneezing, and postnasal drainage that began after age 20 years old, has erythematous and boggy nasal mucosa, and has no known triggers but symptoms can wrosen with seasonal changes most likely suffers from ...

Non-allergic Rhinitis

(tx: intranasal corticosteroids/ antihistamines)

628

A pt being treated for a "mood disorder" who presents with gradual onset of ataxia, sluggishness, confusion, agitation, coarse tremor, and GI distress most likely suffers from ...

Lithium Intoxication

(can ocurr with drug interaction with thiazide diuretics/ ACE inhibitors/ non-aspirin NSAIDs)
(other causes are overdose, volume depletion, elderly with low GFR)

(obtain lithium levels every 2-4 hours, IV hydration and bowel irrigation; hemodialysis if meet criteria)

629

What are the criteria for nephrology consult and hemodialysis for a pt with lithium intoxication? (3)

1. lithium level equal to or greater than 4 mEq/L
2. significant symptoms (seizures, altered mental status) with lithium level of 2.5 mEq/L or greater
3. increasing level despite IV fluids

630

A pt presenting with speech abnormalities (echolalia, aphasia, mutism), impaired executive functioning, irritablity, hyper-oral behavior, disinhibition and progressive memory loss most likely suffers from ..

Pick's Disease (Frontotemporal Dementia)

(brain imaging shows symmetric atrophy of frontal and temporal lobes)

631

A pt presenting with acute painless unilateral vision loss, increased frequency of floaters and photopsias (flashing lights with vitresou hemorrhage and marked elevation of retina on funduscopy most likely suffers from ..

Retinal Detachment

632

What factor makes it easier to detect the decreased ability to discriminate speech in elderly patients suffering from presbycusis?

noisy, distracting environemnt

(background noise)

633

A male presenting with scrotal pain accompanied by swelling and tenderness along with a decrease in pain on testicular elevation (Prehn's sign) and normal cremasteric reflex most likely suffers from...

Epididymitis

(usually due to Chlamydia trachomatis infection)

634

A male pt presenting with severe scrotal pain, absence of cremasteric reflex, and a high riding testis on palpation most likely suffers from ...

Testicular Torsion

635

A male pt preseenting with dull scrotal pain that is relieved by recumbency (laying down) and a soft scrotal mass palpated that feels like bag of worms that disappears when recumbent most likely suffers from ...

Varicocele

636

An infant (older than 6 months) presenting with symptoms of anemia with associated low hemoglobin (less than 11), low MCV and low total red bblood cell count resulting in a Mentzer index greater than 13 most likely suffers from ..

Iron deficiency Anemia secondary to breast-milk predominant diet

(breast milk low in iron for 6 month and older infant, need iron fortified foods)

637

What is the Mentzer index and what is it used for?

Mentzer index = MCV/ total RBC count; used to distinguish between iron deficiency anemia and thalassemia

(Mentzer greater than 13: iron deficient)
(Mentzer less than 13: thalassemia)

638

What is the best initial treatment for recurrent pneumonia in a cystic fibrosis patient?

2 antipseudomonal agents (tobramycin with cefepime/ amikacin/ imipenem/ piperacillin-tazobacam) with vancomycin (if have hx of MRSA)

639

What is the best initial step in management for pt with Allergic Rhinitis?

avoidance of trigger/ allergen (followed by intranasal corticosteroids)

640

.. is a potential problem in case- control studies and is a result of inaccurately reporting the exposure status by the participants in a study and leads to ....

Recall bias; misclassification of exposure

641

A female pt with history of maternal birth trauma presenting with postvoid dribbling followed by development of dysuria and dyspareunia (pain with sex) most likely suffers from ...

Urethral Diverticulum (3 D's)

(can have hematuria, recurrent UTIs, stress urinary incontinence)

642

A female pt presenting with dysmenorrhea, dyspareunia (pain with sex), dyschezia (pain with defecation), hematochezia, hematuria and premenstrual/ postemenstrual spotting along with anterior vaginal wall fullness (possibly infertility issues) most likely suffers from ...

Endometriosis

(dx: laparoscopy- visualize ectopic endometrial tissue)

(tx: NSAIDS, GnRH analogs, danazol, OCPs, surgery)

643

What are two non-invasive diagnostic tests used to diagnosis urethral diverticulum?

1. transvaginal ultrasound
2. MRI

644

What is the formula for odds ratio (used as measure of association in case-control study)?

OR = (a * d)/ (b * c)

OR = (a/c) / (b/d)

(a= disease with exposure; c= disease without exposure; b= not diseased with exposure; d= not diseased wihtout exposure)

645

What potential development is of most concern in a pt who was rescued from a burning building?

supraglottic edema (inhalation injury that can obstruct airway)

646

What is the most sensitive imaging modality for diagnosing osteonecrosis of the femoral head (avascular necrosis/ osteochondritis dissecans)?

MRI

(increased risk of disease if steroid use and excessive alcohol consumption)

647

What is the prognosis of infantile hemangiomas with no functional impairment or sign of ulceration?

proliferate during first year of life and spontaneously involute by age 7-10 years

648

What is the best initial treatment for complicated or disfiguring infantile hemangiomas (visceral location, airway location, periorbital location)?

propanolol (non-selective beta blocker)

649

A child (between 6 months and 3 years old) presenting with intermittent severe crampy abdominal pain, palpable sausage shaped mass on right side of abdomen, and currant jelly stools (bright red rectal bleeding) who may draw legs up to the abdomen during episodes of pain and vomiting most likely suffers from ..

Intussusception
(telescoping of proximal portion of intestine into distal portion)

(tx: air or water soluble enema)

650

What is the best initial diagnostic test for suspected intussusception?

abdominal ultrasound

(shows target sign of intestines)

651

What is the major complication associated with enema reduction of intussusception?

intestinal perforation

652

What is the appropriate duration and rationale for treatment of streptococcal pharyngitis?

10 days of oral penicillin to prevent acute rheumatic fever

(can give 5 day course of azithromycin to penicillin-allergic patients)

653

A male infant aged 3-6 months old presenting with non-bilious, non-bloody postprandial projectile vomiting and is immediaely hungry after vomiting along with palpable olive shaped mass in RUQ, and hypokalemic, hypochloremic metabolic alkalosis most likely suffers from ...

Pyloric Stenosis

(dx: abdominal ultrasound; can also use upper GI contrast study)

654

What is the best initial step in management of an infant with pyloric stenosis?

correct electrolyte imbalance (hypokalemic, hypochloremic metabolic alkalosis) and dehydration then pyloromyotomy

655

What antibiotics is associated with the development of pyloric stenosis?

Oral erytromycin (usually given to infant for pertussis)

656

What is the best next step in management of an acutely maniac lithium treated pt with low normal blood level of lithium?

increase lithium to achieve high normal blood level of lithium

657

What is the next best step in management of an acutely maniac lithium treated pt with high normal blood level of lithium?

augment lithium by adding antipsychotic (risperidone)

658

What is the best next step in management of a pregnant pt who has hypertension, proteinuria, hyperreflexia (brisk deep tendon reflexes), and edema?

Hydralazine (or labetalol to lower BP) and Magnesium sulfate (prevent progression into eclampsia)

(followed by delivery if term)

659

What is considered a full/ complete trial of an antidepressant therapy for a depressed pt before considering switching agents or adding agents?

at least 6 weeks on SSRIs

660

What co-morbidity has a high risk of adverse effects with the use of varenicline for smoking cessation?

Major depression (as well as unstable psychiatric symptoms, history of suicidal ideation)

(increases depressive symptoms)

661

What is the best initial treatment for H. pylori infection?

triple therapy with pantoprazole, amoxicillin (1 gram twice a day), and clarithromycin (500mg) for two weeks

662

What is the best initial treatment for H. pylori infection in a penicillin allergic patient?

triple therapy with pantoprazole, metronidazole (500 mg twice a day), and clarithromycin (500mg) for two weeks

663

What is the next best step in management of a pt with H. pylori infection who fails initial therapy with triple therapy? (2)

1. quadruple therapy (PPI, bismuth, tetracycline, and metronidazole for 2 weeks with meals)
2. use different combination of triple therapy

664

A pt presenting with decreased sensation over the anterolateral thigh (with numbess and burning sensation) without muscle weakness or deep tendon reflex abnormalities most likely suffers from ...

Meralgia Paresthetica due to lateral femoral cutaneous nerve entrapment

(dx: clinical)

665

What is the treatment for meralgia paresthetica (lateral femoral cutaneous nerve entrapment)?

reassurance, weight loss and avoid tight fitting clothes

666

What is the diagnostic workup that should be performed in a child age 5 years or older suffering from enuresis (urinary incontinence)?

1. urinalysis (assess specific gravity, glucosuria, signs of infection)
2. urologic imaging if significant daytime symptoms and history of UTIs

(rule out secondary enuresis: psychological stress, UTI, diabetes mellitus, diabetes insipidus, obstructive sleep apnea)

667

A pt presenting with skin lesions that are shiny, discrete, intensely pruritic, polyglonal shaped violaceous plaques and papules on flexural surfaces on extremities (especially wrist, mucous membranes) with an associated whitish, lacy pattern on the lesion surface (Wickham striae) most likely suffers from ...

Lichen Planus

(dx: clincial but can due punch biopsy)

668

What is the next best step in management of a pt with Lichen Planus?

obtain anti-hep C antibodies

(lichen planus is associated with hep C infection)

669

True or False. Household contacts of transplant patients and pregnant patients can be safely be vaccinated with varicella vaccine and is recommended.

True

(monitor for development of vaccine-associated rash and isolated from immunocompromised individual if present until lesions crusted over)

670

What are contraindications to varicella-zoster vaccination? (4)

1. anaphylaxis to neomycin
2. anaphylaxis to gelatin
3. pregnancy
4. immunodeficient state (congenital immunodeficiency, long term immunosuppresive therapy, HIV, hematologic/ solid tumor)

671

What is the best next step in management of a pt presenting with low back pain along with radiculopathy (sciatica symptoms) or red flags (night time pain, older than 50, unexplained weight loss, history of malignancy)?

plain X-rays of back and ESR level

(if no red flags or signs of cord compresion, conserative therapy- PT and analgesics for 4-6 weeks)

672

What is the next best step in management of a pt presenting with low back pain along with bowel/bladder dysfunction, saddle anesthesia and/ or motor weakness?

MRI of back (to assess for cauda equina syndrome)

673

A pt presenting with dyspnea and voice hoarseness with a loud S1 (first heart sound) and an opening snap followed by a low pitched mid-diastolic rumbling murmur heard best at the cardiac apex (between 5th and 6th rib at left mid-clavicular line) most likely suffers from..

Mitral Stenosis

(hoarsness from compression of recurrent larygneal nerve by enlarged right atrium)
(most common cause if rheumatic heart disease)

674

A pt with a mid-systolic ejection murmur heard best at the left upper sternal border along with a wide and fixed splitting of the second heart second, and right atrial and ventricular dilation on ECHO most likely suffers from ...

Atrial Septal Defect

(can be asymptomatic until adulthood; present with decreased exercise tolerance, pulmonary HTN, right heart failure, stroke due to paradoxical embolization, atrial arrhythmias)

675

A pt presenting with short statue, facial dysmorphism and congenital heart defect most likely suffers from ...

Noonan syndrome

676

A female pt presenting with acute abdomen (abdominal tenderness with rebound and guarding), a positive pregnancy test, and transvaginal ultrasound showing adnexal mass with empty uterus and/or echogenic fluid in the cul-de-sac, around adnexa, in Morrison's pouch most likely suffers from ...

Ruptured Ectopic Pregnancy

(tx: surgical evaluation)

677

A pt with chronic GERD symptoms along with (age older than 50, male, white, hiatal hernia, increased BMI, intraabdominal body fat distribution or tobacco use) who is found to have velvety, reddish mucosa extending from the squamocolumnar junction into the distal esophagus most likely suffers from ..

Barrett's esophagus

(metaplastic columnar epithelium in the esophagus replacing normal stratified squamous epithelium)

678

What is the next best step in the management of a pt found to have Barrett's esophaus (columnar lined esophagus) without signs of dysplasia?

endoscopic surveillance every 3-5 years

(to assess for adenocarcinoma formation)

679

What is the next best step in management of a pt found to have Barrett's esophagus (columnar lined esophagus) with signs of low-grade dysplasia?

endoscopic surveillance every 6-12 months

(to assess for adenocarcinoma formation)

680

A child presenting with a rash that starts as erythematous macules that coalesce into non-blanching, non-pruritic purple colored palpable purpura in gravity dependent areas, arthritis/ arthralgia, abdominal pain, hematuria with/ wihtout RBC casts and proteinuria, and normal platelet level most likely suffers from ...

Henoch- Schonlein Purpura

(IgA-mediated leukocytoclastic vasculitis)

(associated with intussusception, renal failure, prior URI)

681

What is the significance of the correlation coefficient in study results?

shows strength and direction (positive or negative) of linear association between 2 variables

(not causality)

682

A type 2 diabetic presenting with confusion, lethargy, markedly elevated glucose, serum bicarbonate near lower limits of normal, dry mucous membranes, acute renal failure, negative ketones, hyperkalemia and abnormal sodium most likely suffers from ..

Hyperosmolar Hyperglycemic State

683

What is the best initial step in management for hyperosmolar hyperglycemia state in a type 2 diabetic?

agressive fluid resuscitation
(isotonic saline)

684

What type of calcification pattern on pulmonary nodules are strongly suggestive of benign lesions? (3)

1. popcorn calcifications
2. central calcifications
3. diffuse homogenous calcifications

(eccentric, reticular and punctate calcifications and spiculated margins are suspicious for malignancy)

685

What is the next best step in management of a young pt who experiences a ischemic stroke in the setting of having deep venous thrombosis?

transesophageal echo (and bubble study)

(assess for intracardiac communication like patent foramen ovale or ASD allowing for paradoxical emboli)

686

What is the most common complication of transurethral resection of the prostate (TURP) used in the management of benign prostatic hyperplasia (BPH)?

retrograde ejaculation

(bladder neck fails to close allowing sperm to flow backward to bladder)

687

A pt who presents with periodic involuntary eye closure that can be provoked by external stimuli (bright light or irritants) most likely suffer from ...

Blepharospasm (focal dystonia)

688

What is the best initial treatment for blepharospasm?

botulinum toxin injections

689

... is a type of statistical analysis that is useful in studying the difference in mean values (of a continuous variable) among several groups (catergorical variables)

Analysis of Variance (ANOVA)

(homoscedasticity and normality must be true to make test valid)

690

An infant presenting with failure to pass meconium, bilious emesis, and markedly distended abdomen who is found to have multiple dilated loops of large bowel and no air in the rectum on abdominal X-ray and a normal caliber rectosigmoid colon, transition zone and dilated descending colon with constrast enema most likely suffers from ...

Hirschsprung Disease

(aganglionic intestinal disease
(dx: rectal mucosal suction biopsy)
(tx: surgical resection of aganglionic portion of bowel)

691

A pt presents with history of urge to move legs and unpleasant sensations in the legs that begins or worsens during inactivity (lying down, sitting) and is relieved by movement (walking, stretching) most likely suffers from ...

Restless Leg Syndrome

692

What is the best treatment for mild/ intermittent symptoms of restless leg syndrome? What is the best treatment for persistent/ moderate to severe symptoms of restless leg syndrom?

mild: supplement iron if ferritin less than 75 , avoid sleep deprivation, use leg massage/ heating pads/ exercise

persistent: dopamine agonists (pramipexole)

693

What diagnostic test is usedin cases of suspected restless leg syndrome?

ferritin level

(iron deficiency anemia is assocaited with restless leg syndrome)

694

A diabetic pt with history of peripheral neuropathy and labile glycemic control (multiple episodes of hypoglycemia) presents with nausea vomiting, early satiety, postprandial fullness, bloating, abdominal pain and distension and weight loss most likely suffers from ...

Gastroparesis

(dx: nuclear gastric emptying study after ruling out obstruction with upper GI endoscopy and compression with CT)

695

What is the treatment for gastroparesis?

dietary modification (small more frequent meals consisting of less fat and fiber intake)

(if fails, erythromycin or metoclopramide)

696

What is the most accurate physcial exam testto detect Achilles tendon rupture?

Thompson squeeze test

(squeeze gastrocnemius muscle and assess for lack of plantar flexion)

697

A pt presenting with fever, headache, malaise, intense muscle pain (myalgias), intense joint pain (arthalgias), retro-orbital pain, and a rash described as white sands in sea of red, petechiae formation after BP cuff placed on arm, and thrombocytopenia in the setting of recent travel most likely suffers from ...

Dengue Hemorrhagic Fever

(common complication is Shock due to increased capillary permeability leading to hemoconcentration, thrombocytoenia, prolonged fever, respiratory/ circulatory failure)

698

A pt presenting with episodic epigastric or RUQ pain described as dull with radiation to the back and right shoulder, and the episodes last less than 6 hours and can be associated with meals or occur at night along with nausea, vomiting and diaphoresis most likely suffers from ...

Biiary Colic (due to gallbladder contracting and forcing gallstones into cystic duct)

699

What is the best initial diagnostic test for biliary colic?

abdominal ultrasound

(to assess for gallstones after 8 hour fast)

700

What is the next best step in management of a pt with gallstones on abdominal ultrasound and biliary colic symptoms?

acute pain management and elective prophylactic cholecystectomy

(if pt is poor surgical candidate or refuse surgery, trial of ursodeoxycholic acid)

701

What is the next best step in mangement of a pt with biliary colic symptoms without gallstones on imaging?

cholecystokinin stimulated cholescintigraphy

(to evaluate functional gallbladder disorder- surgery if low gallbladder ejection)

702

A pt presenting with episodic epigastric or RUQ pain, described as dull with radiation to the back and right shoulder along with nausea, vomiting, diaphoresis, elevated liver function studies but normal lipase levels most likely suffer from ....

Choledocholithiasis
(common bile duct stone)

(tx: endoscopic retrograde cholangiopancreatography (ERCP)- also used to confirm diagnosis if ultrasound shows dilated common bile duct without apparant stone)

703

An infant presenting during first week of life with unconjugated hyperbilirubinemia, jaundice, and dehydration in the setting of being breast-fed most likely suffers from ...

Breastfeeding Failure Jaundice

(suboptimal breastfeeding)

704

What is the next best step in management for an infant with unconjugated hyperbilirubinemia secondary to breast milk jaundice who is gaining weight adequately and has mildly elevated bilirubin?

continue breastfeeding and consider phottherapy if levels continue to rise (especially after two weeks of life)

705

A pt presenting with limb pain with associated pallor, paresthesia, pulselessness, poikilothermia (feels cold) and paralysis most likely suffers from ...

Acute Limb Ischemia

(6 P's)

706

What charcaterizes a viable limb versus threatened limb versus nonviable limb in a pt with acute limb ischemia?

viable: mild pain, no sensory/motor deficit, cap refill intact, audible doppler pulses (tx: catether based TpA or surgicial revasularization

threatened: severe pain, mild sensory/motor deficit, delayed cap refill, inaudible pulses on arterial doppler but audible on venous (tx: emergency surgical revascularization)

nonviable: pain, severe sensory/motor deficit, absent cap refill, inaudiable doppler pulses (tx: amputation)

707

A male pt presenting with dysuria, dull aching pain in perineal region and testicles, painful ejaculation, blood in semen with a tender and boggy prostate on exam most likely suffers from ..

Prostatitis

708

What is the best initial step in mangement of a pt with suspected prostatitis?

obtain urinalysis and urine culture

709

A pt with signs and symptoms of prostatitis whose culture of the prostatic secretion shows elevated leukocytes and no bacteria most likley suffer from ...

Chronic nonbacterial prostatitis

(tx: sitz baths and anti-inflammatory meds)

710

What is the most common complication associated with endometriosis?

intestinal obstruction

(due to endometriosis involving the intestinal wall)

711

An immigrant pt presenting with chronic diarrhea, weight loss, iron deficiency anemia and eosinophilia most likely suffers from ...

Helminthic Infection (Intestinal Parasitosis)

(risk of reinfection if adequate hygenic measures are not taken)

712

What medications can result in decreased warfarin metabolism leading to over-anticoagulation in pts on stable dose of warfarin? (7)

(reduce warfarin dose by 25-50% when initiating new drug)

1. NSAIDs
2. amiodarone
3. levothyroxine
4. SSRIs
5. omeprazole
6. cranberry juice, ginkgo biloba, vitamin E
7. antibiotics/ antifungals

713

What medications can result in increased warfarin metabolism leading to under-anticoagulation in pts on stable dose of warfarin? (6)

(increase warfarin dose by 25-50% when initiating new drug)

1. rifampin
2. carbamazepine
3. OCPs
4. ginseng
5. St Johns wort
6. green vegetables (spinach)

714

What is the best management for a sickle patient experiencing an acute pain crisis (vaso-occlusive episode usually of back, chest, abdomen or extremity)?

pain med (IV morphine in ED; NSAIDS outpatient) and hydration (normal saline bolus if hypovolemic/ hypoensive; 1/4 or 1/2 NS if normal BP)

715

What is the next best step in management of a sickle cell patient with recurrent vaso-occlusive episodes?

Hydroxyurea (increased fetal hemoglobin)

716

A sickle cell pt who develops a new pulmonary infiltrate on CXR along with fever (greater than 38.5), hypoxemia, chest pain and/or respiratory distress (increased work of breathing, cough, tachypnea, wheezing) most likely suffers from ...

Acute Chest Pain

(tx: ceftriaxone and azithromycin; along with IV fluids and pain control)

717

What are the side effects of SSRIs (citalopram, fluoxetine, paroxetine, setraline)? (4)

1. fatigue/ drowsiness/ insomnia
2. weight changes
3. sexual dysfunction
4. serotonin syndrome

718

An HIV pt presenting with headache, vomiting, fever, blurry vision, neck stiffness and papilledema who has CSF findings of elevated opening pressure (greater than 250-300), lymphocytic leukocytosis that is low (less than 50), elevated protein and low glucose most likely suffers from ...

Cryptococcus Neoformans meningitis

(dx: India ink stain or cryptococcal antigen test)
(tx: amphotericin B and flucytosine for induction therapy followed by fluconazole for maintenance)

719

What is the next best step in management of a pt with cryptococcal meningitis who initial responds to treatment with amphotericin B and flucytosine but then redevelops symptoms again?

repeat lumbar puncture (to decrease the increased intracranial pressure from outflow obstruction due to the yeast)

720

What is the next best step in management of a pt with cryptococcal meningitis who clinically improves with amphotericin B and flucytosine treatment for 10-14 days?

stop amphotericin B and fucytosine therapy and start consolidation/ maintenance therapy with fluconazole

721

Why is it important not to initiate HAART therapy in an HIV pt with cryptococcal meningitis before it has been 4-10 weeks after the initiation of antifungal treatment for the cryptococcus?

can develop immune reconstitution inflammatory syndrome (IRIS) that increases mortality

722

What is the best initial step in management of a trauma pt with symptomatic intracranial hypertension (headache, vomiting, blurred vision, papilledema, bradycardia, respiratory depression, hypertension)?

endotracheal intubation

(to maintain airway before possible brain herniation)

723

A pt presenting with fever, chills, flank pain, CVA tenderness, nausea and vomiting with bacteruria and pyuria on urinalysis most likely suffers from ...

Pyelonephritis (kidney infection)

(tx: antibiotics; IV if vomiting/ fail oral/ hemodynamically unstable/ positive blood culture/ infant less than 2 months old)

724

A pt presenting with dysuria, increased urinary frequency and urgency, hematuria and suprapubic pain most likely suffers from ..

Cystitis

725

What is the earliest sign of hypovolemia?

Tachycardia

726

What is the next best step in management for a pt with Clostridium difficile colitis who has leukocytosis less than 15000 and normal creatinine (less than 1.5)?

oral metronidazole (mild-moderate colitis)

727

What is the best initial step in management for a pt with Clostridium difficile colitis who has leukocytosis greater than 15,000, creatinine greater than or equal to 1.5, or albumin less than 2.5?

Oral vancomycin (severe colitis)

(if ileus, add IV metronidazole or switch to rectal vancomycin)

728

What is the best treatment for the first recurrence of Clostridium difficile colitis? What is the best treatment for the second recurrence of C. difficile colitis? What is the best treatment for the third recurrence of C. difficile colitis?

first: repeat oral metronidazole (for mild to moderate) or oral vancomycin (for severe)

second: pulsed tapered oral vancomycin for 6-7 weeks

third: fidaxomicin and consider fecal microbiota transplant

729

What is the next best step in management of a pt with hypoparathyroidism being treated with high dose of vitamin D (calciferol) and calcium but still has borderline low serum calcium and high urinary calcium?

add thiazide diuretic (increases calcium reuptake in kidney to increase serum calcium and decrease urinary calcium)

730

A pt presenting with hypertension, hypokalemia and possibly polyuria and polydipsia most likely suffers from ...

Conn's syndrome (primary Hyperaldosteronism)

(dx: plasma aldosterone to renin ratio greater than 30)

731

what is the best initial diagnostic test for a pt who presenting with typical (crushing/ pressure lasting more than 20 minutes, provoked by exercise/ emotional upheaval and relieved with nitroglycerin or res) and/or atypical chest pain who has a normal EKG and is able to exercise?

Exercise EKG stress test

(if not normal EKG, then exercise imaging test)

732

A pt presenting with blurry vision, facial muscle weakness, bilateral ptosis, dilated pupils with sluggish reactivity to light, dysarthria and preserved sensory function after eating home-canned food most likely suffers from ...

Botulism

(results in descending weakness)

733

A pt presenting with hematuria (red-colored urine) and bilateral flank pain with dysmorphic red blood cells on microscopic exam of urine a few days after a recent upper respiratory infection most likely suffers from ...

IgA Nephropathy

734

What is kappa statistic as it relates to a study?

quantitative measure of inter-rate reliability (inter-rate concordance) when 2 different individuals are rating a diagnostic test

735

What treatment used for breast cancer targets cells that have HER-2/neu overexpression?

Trastuzumab

736

What is the best initial screening tool to identify unhealthy alcohol use?

single-item screening: asking pt how many times in the past year has he had 5 or more (she had 4 or more) drinks in a day

737

An elderly pt presenting with low back pain that worsens with extension of the spine and improves with flexion, when he sits down or bends forward (i.e. using grocery cart), pedal pulses are preserved and may have abnormal gait (spaghetti legs or walking like drunken sailor) most likely suffers from ...

Lumbar spinal stenosis

(dx: MRI of spine)

738

After stabilizing the pt, what is the best initial step in management of a pt who experienced a blunt chest trauma?

12 lead EKG

(assess for fractures, pneumothorax, hemothorax, widened mediastinum, aortic injury)

739

A pt with a mid-systolic click followed by a late systolic murmur heard best at the LLSB most likely suffers from ...

Mitral Valve Prolapse

740

A child presenting with sore throat with a non-prurtic maculo-papular and vesicular rash on the palms, soles, genitalia and butt along with vesicles surrounded by a thin halo of erythema on the hard palate/ posterior oropharynx most likely suffers from ...

Hand Foot and Mouth Disease

(Coxsackievirus infection- herpangina is vesicles on posterior oropharynx)

741

A pt presenting with squeezing or burning sensation in the retrosternal chest that radiates to the back, neck, jaw or arms, resolves spontaneously or after consumption of antacids, usualy occurs postprandially, can awaken pt from sleep and worsens with emotional stress most likely suffers from ...

Gastroesophageal reflux disease (GERD)

742

What are the indications for parathyroidectomy in a pt with refractory secondary or tertiary hyperparathyroidism (elevated PTH and calcium level)? (7)

1. calcium greater than 10.5 and not responding to therapy
2. hyperphosphatemia not responding to therapy
3. PTH level greater than 1000
4. intractable bone pain
5. intractable pruritis
6. calciphylaxis episode
7. soft tissue calcification

743

What is the next best step in management of a pregnant pt who has exposure to a HSV infected partner (active lesions)?

perform type specific IgG antibody screening for HSV-1 and HSV-2

(if positive, give acyclovir starting at 36 weeks and c-section if active lesions)

744

A male pt presenting with abdominal pain, inability to void urine, suprapubic tenderness, elevated creatinine and an enlarged smooth prostate most likely suffers from ...

Obstructive, acute renal failure secondary to benign prostatic hypertrophy

745

What is the next best step in management for a pt suffering from obstructive acute renal failure secondary to benign prostatic hypertrophy?

urethral catheterization with foley

(use suprapubic catheterization if history of pelvic/ urethral trauma, urethral strictures)

746

A female pt presenting with depression/ anxiety/ irritability, bloating and breast tenderness that occurs monthly and resolves promptly with onset of menses each month most likely suffers from ..

Premenstrual Syndrome

(premenstrual dysphoric disorder- PMDD is severe form with predominance of anger and irritability)

(increased risk of mood and anxiety disorders)

747

What is the best intiial treatment for premenstrual syndrome?

SSRIs (if one fails, can try another or use OCPS if dont want to be pregnant)

748

What is the next best step for the treatment of symptomatic rectocele (low back pain, pelvic pressure and heaviness, constipation) in a pt who refuses surgery or is not a surgical candidate?

pessary with vaginal estrogen cream

749

What is the next best step in management of a pregnant pt who is found to have active Hep B infection (positive Hep B surface antigen and Hep B core antigen)?

give mom Hep B vaccination and antiviral therapy; give baby Hep B vaccine and Hep B immunoglobulin within 12 hours of birth

750

What is the most effective emergency oral contraceptive mechanism for a pt who had unprotected intercourse?

Ulipristal (anti-progresting pill effective if taken within 5 days of intercourse)

(copper IUD is most overall effective emergency contraceptive but avoid if pelvic infection/ cervicitis/ wilson's disease)

751

What is included in post-exposure prophylaxis for sexual assault victims? (5)

1. cefitraxone (gonorrhea)
2. azithromycin (chlamydia)
3. metronidazole (trichomonas vaginalis)
4. tenofovir-emtricitabine with raltegravir (HIV)
5. hep B vaccine with/ without Hep B immunoglobulin

752

What is the next best step in managemnt of a pt with a curvilinear calcification in the right hypochondrium at the location of the gallbladder?

elective cholecystectomy (for porcelain gallbladder that has high risk of gallbladder carcinoma)

753

What is the next best step in management of a stroke patient after evaluation for intracranial bleeding with CT and bedside swallow study for possible aspiration?

subcutaneous low dose heparin or low molecular weight heparin

(for DVT prophylaxis that can lead to PE)

754

A pregnant pt who develops mild and asymptomatic thrombocytopenia late in pregnancy and has not history of thrombocytopenia outside of pregnancy or evidence of fetal thrombocytopenia most likely suffers from ..

Gestational Thrombcyotpenia

(resolves once child born)

755

What medication should be avoided in a with acute coronary syndrome/ myocardial infarction?

immediate release calcium channel blockers like immediate release nifedipine

(increases mortality via hypotension and increased sympathetic tone)

756

What is the next best step in the management of a female pt with an incidental finding of a liver lesion that is less than 5 cm, well-demarcated, hyperattenuated area on liver and the pt is asymptomatic?

discontinue OCPs (associated with hepatic adenoma)

(suspect malignancy if increases in size after discontinue OCP or elevated AFP level)

757

An infant presents with vomiting, hypotension, hyponatremia, hyperkalemia, hypoglycemia and ambiguous genitalia in girl/ precocious puberty in boy most likely suffers from ...

21 hydroxylase deficiency type congenital adrenal hyperplasia

(dx: elevated 17-hydroxyprogesterone)

(have high testosterone, low aldosterone and cortisol)

758

An infant presents with hypertension, hypernatremia, and ambiguous genitalia most likely suffers from ...

11 beta hydroxylase deficiency type congenital adrenal hyperplasia

(dx: elevated 11-deoxycorticosterone and 11- deoxycortisol)

(have high testoerone, low aldosterone and cortisol)

759

What is the best treatment for congenital adrenal hyperplasia (especially 21 hydroxylase deficiency type)?

chornic glucocorticoid and mineralocortcoid therapy

(hydrocortisone and fludrocortisone)

760

What treatment used during chemotherapeutic treatment of cancer has a side effect of akathisia, dystonia, gait abnormality, bradykinesia, and increased muscle tone/ rigidity (similiar to Parkinsons)?

Metoclopromide

(central and peripheral D2- receptor antagonist used for chemotherapy induced nausea and vomiting)

761

What is the next best step in management of a young women with premature ovarian failure with symptoms of hot flashes, vaginal dryness and low bone density?

conjugated equine estrogen with medroxyprogesterone acetate

(combination of estrogen and progesterone closely monitored; has increased risk of MI, DVT, stroke, breast cancer in older pts)

762

What is the next best step in management of a pt with fecal incontinence and evidence of fecal impaction?

enemas followed by rectal suppositories to evacuate bowel

(then caninstruct pt to increase fluid intake and dietary fiber and use stool softners as needed)

763

What is the next best step in management of a pregnant woman with severeal flesh-coloured hyperkerototic papules in the genital area at time of labor?

allow labor to continue without invention

(condyloma acuminata is HPV infection; no contraindication to vaginal delivery)

764

A sickle cell pt who is experiencing acute onset of weakness, pallor, and lethargy in the setting of acute severe anemia superimposed on chronic anemia and absent reticulocytes most likely suffers from ...

Aplastic Anemia

(transient failure of erythropoiesis)

765

An infant born premature who has gross motor delay within first year of life, early hand preference, hypotoni that progresses to spasticity, hyperreflexia, persistent primitive reflexes, scissoring gait (spastic diplegia) and toe walking most likely suffers from ...

Cerebral palsy

(due to prematurity, birth asphyxia, intrauterine infection)

(dx: brain MRI)

766

A pt presents symptomatic withnon-enlarged thyroid gland, low TSH and elevated T4, and has low serum thyroglobulin and low radioiodine uptake most likley suffers from ...

Exogenous thyroid use- hyperthryoidism

767

A female presenting with homogenous vaginal discharge, vaginal pH greater than 4.5, amine/ fish odor of vaginal discharge with potassium hydroxide application, and presence of irregularyly bordered epithelium cells with outlines obscured by sheets of small bacteria most likely suffers from ...

Bacterial Vaginosis

(tx: oral clindamycin or metronidazole to relieve symptoms)

(affects 1/3 of pregnant pts and is associated with preterm delivery, premature rupture of membranes, spontaneous abortion)

768

What is the best treatment regimen for type 1 diabetics?

basal- bolus insulin regimen

(long-acting and rapid acting in combination)

769

What is the next best step in management of an elderly pt who wears dentures and has developed erythematous painful oral lesions?

remove dentures for 1-2 weeks and re-evaluate

(if lesions dont subside, biopsy for possible malignancy)

770

A pt with history of asthma/CF who is experiencing recurrent asthma exacerbations, fever, lethargy, cough with production of brown mucus plugs, hempotysis, fleeting infiltrates on CXR, central bronchiectasis on CT, eosinophilia (greater than 500) and IgE greater than 417 most likely suffers from ...

Allergic bronchopulmonary aspergillosis (ABPA)

(tx: glucocorticoids and itraconazole)

(due to exaggerated IgE and IgG immune mediated hypersensitivity to Aspergillus)

771

What is the best initial treatment for onychomycosis (fungal infection of toenails/ fingernails resulting in thick, brittle and discolored nails)?

oral terbinafine for 6 weeks if fingernails and 12 weeks if toenails

(oral itraconaole is alternative)

772

A pt presenting with microcytic, hypochromic anemia (low MCV, low mean corpuscular hemoglobin), elevated ferritin (due to increased RBC turnover), target cells on smear and normal red cell distribution width most likely suffers from ...

thalassemia minor

(dx: hemoglobin electrophoresis)

773

What is the next best step in management of a pregnant pt with elevated alfa fetoprotein level (AFP)?

obstetric ultrasound (to get detailed anatomic survery)

774

What are the non-permanent methods of contraception that have the lowest rate of pregnancy (are most effective)? (2)

1. intrauterine devides (IUD)
2. progestin implants

775

A pregnant pt in the first trimester of pregnancy who is found to have a crescent-shaped hypoechoic area adjacent to the gestational sac most likely suffers from ..

Subchorionic hematoma

(re-evaluate with repeat ultrasound in 1 week)

776

What complication is most likely to occur in a pregnant pt with a subchorionic hematoma?

spontaneous abortion

777

What are the indications for surgery (parathyroidectomy) in asymptomatic pts with primary hyperparathyroidism? (4)

1. serum calcium greater than 1 mg/dl above upper limit of normal
2. young age (less than 50)
3. bone mineral density score of less than T -2.5
4. reduced renal function (GFR less than 60 ml/min)

(also perform if pt is symptomatic)

778

What is the next best step in management for a pt presenting with history of intimate exposure to HIV positive person and clinical symptoms of primary HIV infection (fatigue, sore throat, muscle aches, fever) but had negative ELISA and Western Blot testing results?

HIV RNA PCR assay or test for p24 antigen

779

What is the next best step in management of a pt with history of intimate exposure to HIV positive person?

HIV antibody testing at initial visit, 6 weeks, 12 weeks, and 24 weeks

(using ELISA confirmed by Western Blot)

780

How often should a newly diagnosed HIV positive pt have their immune status monitored whether on HAART therapy or not?

evaluate CD4 count and HIV viral load every 3-4 months

781

An infant who has difficulty passing meconium/ only passed small amount of thick meconium during initial 24-48 hours, has bilious vomiting, abdominal distention and on abdominal X-ray has dilated, gas filled loops of small bowel, absent air-fluid levels and a ground glass mass withing the right side of the abdomen in the setting of a family history of recurrent respiratory infections most likely suffers from ..

Cystic Fibrosis

782

What is the next best step in management of a pt who is found to have elevated, corrected serum calcium levels confirmed by repeat testing?

measure parathyroid hormone (PTH) levels

783

A pt presenting with severe hypercalcemia (calcium greater than 13), low PTH, and a long standing history of smoking most likely suffers from ...

PTH-related peptide production by malignancy (small cell carcinoma)

784

What is the next best step in mangement of a pt with hypercalcemia and suppresed/ low PTH level?

measure PTHrP, 25(OH) vitamin D, and 1,25(OH) vitamin D levels

(if PTHrP elevated then solid tumor malignancy)
(if 1,25(OH) vitamin D elevated, then perform chest x-ray to assess for lymphoma and sarcoidosis)
(if 25 (OH) vitamin D elevated, then vitamin D toxicity)
(if none elevated then, hyperthyroidism/ multiple myeloma/ adrenal tumor/ acromegaly/ vitamin A toxicity/ immobilization/ milk-alkali syndrome)

785

A pt presenting with low back pain that is brief, shooting and radiates along nerve distribution, provoked by forward bending/ coughing/ straining and dimishes with laying down most likely suffers from ...

Nerve Root Irritation (radiculopathy)

(dx: straight leg raise)

786

What is the next best step in the management of a pt with acute decompensated heart failure (acute dyspnea, orthopnea, paroxysmal nocturnal dyspnea, accessory muscle use, diffuse crackles, S3, JVD, peripheral edema) in order to improve symptoms?

reduce cardiac preload with diuretics (furosemide)

(consider IV vasodilators like nitroglycerin if normal or elevated BP)
(use IV vasopressor like norepinephrine if hypotensive/ shock)

(order pulse oximetry, CXR, and EKG)

787

What is the routine guidelines for HPV vaccination?

vaccinate females between 9-26 years old (usually start at 9-11 years old) with 3 doses of vaccine

(bivalent- time 0, 1 month, and 6 month)
(quadrivalent or 9-valent- time 0, 2 months and 6 months)
(avoid in pregnant pts)

788

What is the next best step in management of a health care worker who experiences occupational exposure (needlestick) while caring for a pt who refuses HIV testing and HIV status is unknown?

HIV post-exposure prophylaxis with 2-3 antiretroviral medications

(immediate step in cases of pt refusing HIV testing, testing results pending, HIV status unknown)

789

What preparation needs to be done prior to the lactose breath hydrogen test for lactose intolerance?

pt should fast for 8 hours before test

(during test given lactose-containing beverage and then breath into bag at set intervals over 2-3 hours and hydrogen level measure by gas chromatography; greater than 20 ppm is positive)

790

What are two common treatments that can cause an unexplained increase in TSH in a pt with hypothyroidism treated with stable dose of levothyroxine (disrupt absorption of levothyroxine)?

1. calcium
2. iron

(instruct pt to take levothyroxine on empty stomach separate from other medications)

791

What is the next best step in management of a hyperthyroid pt with symptomatic tachycardia?

beta blockers (propanolol)

(followed by PTU or methimazole for long term care)

792

What is the next best step in management of delirium associated agitation and physical aggression in elderly patients after attempting reassurance, orienting to environment, and constant supervision?

IV or IM low dose antipsychotics (haloperidol/ risperidone)

793

What is the next best step in management of a pt with gonococcal urethritis?

single dose of ceftriaxone 250 mg IM with C. trachomatis treatment (oral doxycyline 100 mg BID for 7 days or oral azithromycin 1 gram single dose)

794

What is the next best step in management of a pt with gastroenteritis due to Salmonella enteritidis infection?

supportive therapy and observation if immunocompetent and older than 12 months of age

795

What is the next best step in management of a pt presenting with fever, malaise, headache and localized pain that progresses into painful vesicular rash in the distribution of specific nerve roots?

Oral acyclovir for 7-10 days (for Shingles/ herpes zoster) and placed on contact isolation until skin lesion are dry and crusted over

(no diagnostic test for shingles)
(low recurrence risk but should have vaccine if 60 or older)

796

What is the next best step in management of a pt with renal dysfunction who presents with bleeding in the setting of normal platelet count but prolonged bleeding time?

IV desmopressin (if symptomatic or prior to surgeries)

(increases release of factor 8 and vwF from endothelium)

797

A infant (of African american/ mediterranean/ asian descent) who develops unconjugated hyprbilirubinemi, jaudince, and scleral icterus withing the first 24 hours of life and has a negative Coombs test most likely suffers from ...

G6PD deficiency

(physiologic jaundice does not appear until 24 hours after birth)

798

What is an important long term complication of donor nephrectomy (donating a kidney)?

increased risk of gestational complications in female donors of childbearing age

799

A pt presenting with painless blistering on the dorsal surfaces of the hands after being in the sun, facial hyperpigmentation, and facial hypertrichosis (facial hair growth) most likely suffers from ...

Porphyria Cutanea tarda (due to uroporphyrinogen decarboxylase deficiency)

(dx: urinary uroporphyrins)
(tx: phlebotomy or hydroxychloroquine)

800

What is the best initial treatment for a post-partum woman presenting with fever, breast pain, focal inflammation and a history of poor latching during breastfeeding?

Oral dicloxacillin or cephalexin, observe feeding for technique and position, and more frequent breastfeeding/ pumping

(treat lactional mastitis due to S. aureus)

801

What is the next best step in management for a post-partum breastfeeding woman who is being treated for lactational mastitis but returns after start of antibiotic treatment with new palpable induration and/ or fluctuance?

Ultrasound to assess for abscess formation

(antibiotics can take 2-3 days to treat normal lactational mastitis but if abscess present, then need to use ultrasound guided needle aspiration to drain)

802

A child aged 6 months to 6 years presenting with generalized tonic-clonic jerking or atony lasting less than 15 minutes in the setting of a fever (greater than 38 C) without prior history of afebrile seizures/ CNS infection/ acute systemic metabolic cause most likely suffers from ...

Febrile Seizure

803

What is the prognosis for a child who has a febrile seizure?

have an increased risk of developing another febrile seizure (30%) and less than 5% risk of epilepsy; have normal development/ intelligence

804

What is the next best step in management of pt on SSRI treatment (for depression) who develops sexual dysfunction (decreased libido, anorgasmia, delayed ejaculatio) that is distressing to the patient?

switch to bupropion or mirtazapine

805

A pt presenting with progressive symmetrical proximal muscle weakness, grossly elevated CPK levels and elevated ferritin most likely suffers from ...

Inflammtory Muscular Disorder
(dermatomyositis or polymyositis)

(tx: systemic high dose glucocorticoids- prednisone 1 mg/kg)

806

A pt on mechanical ventilation who is being given continuous glucose infusions and is unable to be weaned off the ventilator along with signs of respiratory muscle weakness and significant thinning of the diaphragm most likely suffers from ...

Hypophosphatemia

(impairs ATP generation needed by muscle)

807

A pt with an incidental finding of a small (diameter less than 10 mm; thickness less than 3 mm) densely pigmented lesion with irregular boarders on funduscopic examination most likely suffers from ...

Ocular Melanoma

(dx: ultrasound is most sensitive; MRI used to detect extrascleral extension for staging and treatment)
(if pt asymptomatic with small lesion, repeat exam in 3 months)

808

What is the next best step in management of a pt with a large (diameter greater than or equal to 10; thickness greater thn or equal to 3) ocular melanomas or pts with symptomatic ocular melanomas (eye pain, visual distubarnces)?

radiotherapy (brachytherapy or external beam radiotherapy)

(use enucleation if very large tumors or tumors with extrascleral extension)

809

What are the three prophylaxis regimens that can be used for close contacts (household members, roomates, intimate contacts, child care workers, airline travelers seated next to affected person for more than 8 hours, persons directly exposed to pt's respiratory/ oral secretions via kissing/ mouth-to mouth resuscitation/ endotracheal intubation) of individuals with neisseria meningitidis infection?

1. rifampin 600 mg BID for 2 days (avoid if person on OCPs)
2. oral ciprofloxacin 500 mg single oral dose
3. IM ceftriaxone 250 mg single dose

810

What is the next best step in management of a pt with an asthma exacerbation that is mild to moderate (FEV1 or PEF greater than or equal to 40%)?

1. oxygen until 90% or greater saturation
2. inhaled short acting beta agonist (albuterol) 3 doses/ hr
3. systemic corticosteroids if no response to albuterol/ if recent oral corticosteroid use

811

What is the next best step in management of a pt with an asthma exacerbation that is moderate to severe (FEV1 or PEF less than 40%)?

1. oxygen until 90% or greater saturation
2. oral systemic corticosteroids
3. high dose inhaled short acting beta agonist (albuterol) with ipratropium nebulizer every 20 minutes/ continously for 1 hour

812

What is the next best step in management of a pt with an asthma exacerbation with impending or actual respiratory arrest?

1. inhaled short acting beta agonist (albuterol) and ipratropium nebulizer
2. IV corticosteroids and magnesium sulfate
3. possibly SQ/ IV epinephrine or terbutaline
4. mechanical ventilation with intubation and 100% oxygen

(admit to ICU)

813

What treatment used in patients with severe congenital anemia (such as thalassemia major) can result in significant iron overload and organ damage?

Hypertransfusion regimen

814

What is the next best step in management for a pt with advance colorectal adenomas (3-10 adenomas, any adenoma that is greater than 1 cm or adenoma with high grade dysplasia or villous features) on screening colonscopy?

repeat colonscopy in 3 years

815

What is the next best step in management for a pt with 1 or 2 small (less than 1 cm) tubular adenomas on screening colonscopy?

repeat colonoscopy in 5 years

816

What is the next best step in management for pt with large (greater than 2 cm) sessile polyp removed by piecemeal exicision? What is the next best step in management for pt with polyp with adenocarcinoma (minimal invasion and greater than 2 mm margins)?

large sessile: repeat colonoscopy in 2-6 months

adenocarcinoma: repeat colonoscopy in 2-3 months

817

A pt presenting with rapid onset severe knee pain with popping sensation at the time of injury and associated with significant swelling and joint instability after pivoting on lower extremity with foot planted or rapid change in direction most likely suffers from ...

Anterior Cruciate Ligament (ACL) injury

(dx: anterior drawer test, Lachman test, MRI)
(tx: RICE- rest, ice, compression, elevation; possible surgery)

818

What is the next best step in management for a type 2 diabetic presenting with hypoglycemia secondary to accidental/ intentional overdose with sulfonylurea (glyburide) after starting dextrose infusion?

add octreotide
(decreases insulin secretion that occurs with transient hyperglycemia from dextrose infusion)

819

What is the most common micro-organism associated with corneal foreign bodies?

Coagulase negative Staphylococcus

820

What is the best initial treatment for absence seizures (kid with staring spells followed by confusion that can result in poor school performance)?

Ethosuximide

(valproate is secon line)

821

What type of shock results in elevated right atrial pressure (greater than 4 mmHg), increased pulmonary capillary wedge pressure (greater than 9 mmHg), decreased cardiac index ( less than 2.8 L/min/m2), increased systemic vascular resistance (greater than 1150 dynes*sec/ cm5) and decreased mixed venous saturation (less than 60%)?

Cardiogenic Shock

822

What type of shock results in decreased right atrial pressure (less than 4 mmHg), decreased pulmonary capillary wedge pressure (less than 9 mmHg), decreased cardiac index (less than 2.8 L/min/m2), increased systemic vascular resistantce (less than 1150 dyne* sec/cm5) and decreased mixed venous oxygen saturation (less than 60%)?

Hypovolemic Shock

823

What type of shock results in normal right atrial pressure (4 mmHg), normal pulmonary capillary wedge pressure (9 mmHg), increased cardiac index (more than 4.2 L/min/m2), decreased systemic vascular resistance (less than 1150 dynes*sec/ cm5) and increased mixed venous oxygen saturation (greater than 80%)?

Septic Shock

824

What is the next best step in management following thyroidectomy and radioactive iodine therapy for thyroid cancer (papillary and follicular)?

levothyroxine
small, low risk: with target TSH 0.1-0.5 for 6-12 months, the low normal
intermediate risk: with target TSH 0.1-0.5
large, aggressive: with target TSH less than 0.1 for several years

(suppress TSH to decreases recurrence risk but avoid increase risk of bone loss and a-fib with high dose levothyroxine)

825

A child presenting with sleep walking (with blank, staring face; unresponsive to attempts to awaken) or sleep terrors (abrupt arousal from sleep with panicked scream/ terror/ autonomic arousal, unresponsive to comfort) with little or no dream recall and amnesia regarding the episodes most likely suffers from ...

Non-REM sleep arousal disorder

(prognosis: self-limiting; spontaneous resolution over years)
(can use benzos if episodes frequent, persistent and distressing)

826

What is the next best step in management for an incidentally found cystic lesion in the pancreas on abdominal imaging?

endoscopic ultrasound and aspiration

(to determine if malignant)

827

What are the indications for group B strep prophylaxis with penicillin during labor and delivery? (4)

1. prior infant with early onset GBS disease
2. GBS bacteruria/ urinary tract infection during pregnancy
3. GBS positive within 5 weeks of labor (rectovaginal culture at 35-37 weeks gestation)
4. unknown GBS status with labor at less than 37 weeks gestation/ intrapartum fever/ rupture of amniotic membranes for 18 hours or more

(adequate prophylaxis if given 4 or more hours before delivery)

828

What is the next best step in management for a pt with back pain secondary to metastatic, advanced hormone refractory cancer (i.e. prostate cancer)?

focal external beam radiation

829

A woman of childbearing age presenting with sudden onset severe pelvic pain, unilateral and tender adnexal mass, nausea, vomiting and fever most likely suffers from ..

Ovarian/ Adnexal torsion

(dx: pelvic ultrasound with color doppler)
(tx: laparoscopy with detorsion; salpingo-oophrectomy for necrosis or malignancy)

(make sure to rule out pregnancy)

830

What is the next best step in management for halted labor after the initial baby is born vaginally in a twin gestation as long as amniotic sac intact, fetal heart rate is reassuring and baby is cephalic?

IV oxytocin

831

What is the next beststep in management for a pt with high risk sexual encouter with an HIV positive partner?

Tenofovir, emtricitabine and raltegravir for 4 weeks within 72 hours of exposure

832

What is the initial hematologic measure to respond to iron supplementation in iron deficiency anemia?

increase in reticulocyte coutn (after 1-2 weeks)

(hemoglobin and hematocrit increases after 3-4 weeks)

833

What is the best initial treatment for sarcoidosis (symptomatic pulmonary disease with fever, fatigue, and hypercalcemia)?

daily oral corticosteroids

834

A pt presenting with fever, lethargy, myalgias, and headache followed by development of petechial rash that starts on wrists and ankles and then spreads to soles, palms, and central body after outdoor activity during the spring/ early summer most likely suffers from ...

Rocky Mountain Spotted Fever

(dx: clinically)
(tx: doxycycline)

(transmitted by black tick)

835

A pt presenting with fatigue, exertional dyspnea, systolic murmur heard best at left sternal border that increases with Valsalva (decreased preload), asymmetric septal hypertrophy, systolic anterior motion of mitral leaflets and increased left ventricular outflow tract gradient with exercise most likely suffers from ...

Hypertrophic Obstructive Cardiomyopathy

836

What is the best initial treatment for hypertrophic obstructive cardiomyopathy?

Beta blockers

(can add verapmil or disopyramide)

837

What is an important predictor of work outcome for patients with occupational back pain?

Recovery expectation

(educate pt on natural history and prognosis to positively influence expectation)

838

A pt presenting with small, rough erythematous and kerototic papules that are easier to feel than to see and located on photdamaged skin (dyspigmentation, wrinkling, thinning, telangiectasia) most likely suffers from ...

Actinic Keratosis

(increase risk of squamous cell carcinoma)

839

What is the best treatment for actinic keratosis?

single lesion: cryotherpy or surgical excision
multiple lesions: field treatment with 5 fluorouracil cream

840

What is the most appropriate strategy to decrease the risk of perinatal transmission of herpes virus if pt has active lesions during pregnancy?

antiviral agents from 36 weeks to delivery with C-section if symptomatic at term

841

What intervention is used to reduced the risk of contrast induced acute kidney injury?

IV volume expansion (IV saline before and after scan to prevent renal hypoperfusion) and avoid nephrotoxic agents (NSAIDs)

842

A pt with palpitations and an EKG with absence of P waves, irregularly irregular rhythm, with varying RR intervals and narrow QRS complexes most likely suffers from ...

Atrial Fibrillation (with rapid ventricular response)

843

What is the best initial treatment for atrial fibrillation (with rapid ventricular response)?

Beta blockers (avoid if have worsening CHF, hypotension, bronchospasm) or non-dihydropyridine calcium channel blockers

844

What precautions are used to prevent spread of C. difficile colitis in hospitals?

contact isolation with soap and water hygiene

845

A pt presenting with local burning pain out of proportion to injury, temperature change, edema, and abnormal skin coloring (mottled, blue discoloration) of extremity after injury that can then progress to skin thickening, muscle wasting, limited range of motion, and bone demineralization on X-ray most likely suffers from....

Complex Regional Pain Syndrome

(dx: increase resting sweat output or MRI showing changes)
(tx: sympathetic nerve block or IV regional anesthesia)

846

What is the most common finding associated with massive pulmonary embolism with EKG findings of acute pulmonary hypertension and right ventricular strain (RBBB, atrial arrhythmias, inferior Q waves)?

Tricuspid regurgitation (and dilation of tricuspid annulus)

847

A pt presenting with acute onset (less than 6 weeks) symmetrical polyarticular joint pain and swelling of small joints, with slightly elevated rheumatoid factor after a recent upper respiratory infection most likely suffers from ...

Viral Arthritis (likely due to parvovirus)

(prognosis: self-limited and no long term sequelae)

848

What does the area under the curve of a receiver-operating characteristic curve signify?

diagnostic accuracy
(more AUC means better performance)

849

A woman who develops heart failure during last month of pregnancy or withing 5 months after delivery and has left ventricular systolic dysfunction with left ventricular ejection fraction less than 45% most likely suffers from ....

Peripartum Cardiomyopathy

(evaluate with ECHO prior to subsequent pregnancies to assess for risk of complications)

850

What is the next best step in management of an elderly pt with a hip fracture who was stable and ambulatory prior to the injury?

surgerical correction within 48 hours

851

What is the most important single risk factor for osteoporesis and osteoporetic bone fracture?

Age

852

What are male patients who had cryptorchidism (undescended testis) still at risk for even after orchipexy?

malignancy

853

A pt presenting with pitting of the nails, sharply demarcated erythematous plaques with thick silvery scales on extensor surfaces of elbows/ knees/ etc, and arthritis in joints characterized by early morning stiffness relieved by activity mainly affecting the DIP joints and axial skeleton most likely suffers from ...

Psoriasis (with psoriatic arthritis)

(mild tx: high potency topical steroids, vitamin D derivatives)
(severe tx: phototherapy, systemic therapy- methotrexate)
(facial and intertriginous tx: topical tacrolimus, low potency steroids)
(guttate tx- small salmon pink spots on skin: observation, phototherpy)

854

What is the best initial treatment for a pt with psoriasis with joint involvement or extensive disease?

Methotrexate

(if mild disease: topical glucocorticoids and vitamin D derivatives like calcipotriene)

855

A pt presenting with arthalgia,intense fatigue, palpable purpura (red, non-blanching, nontender lesions), lymphadenopathy, hepatosplenomegaly, peripheral neuropathy, decreased serum complement levels and renal disease (hematuria, proteinuria, elevated creatinine) in the setting of Hep C infection most likely suffers from ...

Cryoglobulinemia

(dx: serum cyroglobulin level)
(initial short-term tx with immunosuppressive therapy)

856

What is the best long term treatment for Cryoglobulinemia?

anti-viral therapy (alpha interferon and ribavirin for Hep C)

857

What is the best initial treatment for mild gastroesophageal reflux in an infant?

thicken formula with cereal

858

What is the best treatment for chlamydia infections in a pregnant pt?

1. erythromycin base 500 mg PO QID for 7 days
2. amoxicillin 500 mg PO TID for 7 days

859

What is the best initial step in management of a pt with a thyroid nodule?

obtain TSH and ultrasound

(if no cancer risk or suspicious US finding with normal/ elevated TSH or if there are cancer risk factors or suspicious US finding, then FNA)
(if no cancer risk or suspicious US findings with low TSH, then iodine 123 scintigraphy/ radionuclide thyroid scan)

(cancer risk factors: family hx, past radiation exposure, cervical lymphadenopathy, compressive symptoms- hoarseness/ difficulty swallowing)

860

What is the next best step in management of a pt with a thyroid nodule found to be thyroid cancer on fine needle biopsy?

ultrasound of neck and cervical lymph nodes to stage cancer

(to best determine type of surgery)
(if papillary cancer less than 1 cm, lobectomy)
(if papillary cancer 1 cm or greater, then total thyroidectomy)

861

What is the best approach to diagnosing sicca syndrome (sjogrens) in a pt with clinical symptoms suggestive of the disorder?

Schirmer test (secretory deficiency) with anti-Ro/ SSA and anti-La/ SSB antibodies (as well as RF and ANA)

862

What are the exceptions to laws protecting confidentiality of adolescents with regards to pregnancy, contraception, STDs, substance use, and psychiatric illness? (4)

1. harm to self or other
2. physcial or sexual abuse
3. neglect
4. violent injuries (gun shot or stab wound)

863

What is the next best step in management of a pt on warfarin with an INR less than 5 and none/minimal bleeding?

hold warfarin for 1-2 days and monitor INR; or decrease wararin dose

864

What is the next best step in management of a pt on warfarin with an INR between 5-9 and none/ minimal bleeding?

hold warfarin and resume when INR therapeutic

(administer low dose (1-2.5 mg) oral vitamin K if increased risk of bleeding)

865

What is the next best step in management of a pt on warfarin with an INR greater than 9 with non/minimal bleeding?

hold warfarin and administer high dose (2.5-5mg) oral viatmin K

866

What is the best initial treatment for hyponatremia in a pt with congestive heart failure (CHF)?

water intake restriction

(hyponatremia in CHF due to dilutional hyponatermia from increased ADH and water intake)

(use tolvaptan- vasopressin receptor antagonist if symptomatic hyponatremia or severe hyponatremia (Na less than 120))

867

What is the best treatment for negative symptoms of Schizophrenia (alogia, flat affect, amotivation, social withdrawal)?

psychosocial intervention with social skills training

868

A pt presenting with an oblong shaped, firm and deeply seated mass thay may or may not be painful located in the trunk/extremity/ intraabdominal bowel/ messentary/ abdominal wall most likely suffers from ...

Desmoid Tumor

(high recurrence, benign agressive tumor)
(dx: CT or MRI)
(tx: surgery if symptomatic/ risk to adjacent structures/ cosmetic/ recurrent)

869

What are the criteria for cardiac resynchronization therapy with biventricular pacing device in a pt with heart failure? (3)

1. severe left ventricular systolic dysfunction with ejection fraction less than 35%
2. class 2,3 or 4 heart failure symptoms
3. left bundle branch block with QRS greater than 150msec

870

A pt who presents with fever, chills, hemoglobinuria, flank pain and discomfort at infusion site within an hour of a blood transfusion most likely suffers from ...

Acute Hemolytic Transfusion Reaction

(due to ABO incompatibility)
(tx: stop transfusion and hydrate with IV normal saline)
(dx: direct Coombs test; pink plasma)

871

What is the best initial screening test for evaluating thyroid function during pregnancy?

TSH

(first trimester: TSH 0.1-2.5)
(second trimester: TSH 0.2-3.0)
(third trimester: TSH 0.3-3.0)

(levels of free T4 and T3 unreliable during pregnancy due to high thyroid binding-globuin levels and lower albumin levels in pregnancy; so adjust levels to 1.5x normal range or measure total T4)

872

A pt presenting with nausea, headache and altered mental status after being rescued from a burning building most likely suffers from ...

Carbon Monoxide Poisoning

(dx: CO-oximetry)

873

What is the next best step in management of a pt with liver cirrhosis along with distended abdomen with shifting dullness, malaise, leukocytosis, fever and diffuse abdominal tenderness?

Abdominal paracentesis

(to assess for spontaneous bacterial peritonitis- PMN leukocyte count of greater than 250 with positive culture or gram stain)

874

What are common signs of phenytoin toxicity? (5)

1. nystagmus
2. visual disturbances (diplopia, blurred vision)
3. ataxia
4. slurred speech
5. decreased mentation

875

A pt presenting wtih signs of right heart failure (edema, JVD, hepatic congestion, hepatomegaly), Kussmaul sign (increase in JVD with inspiration), mid-diastolic knck, calcification of cardiac borders on imaging, atrial enlargment and pulsus paradoxus (decrease in systolic BP with inspiration) most likely suffers from ...

Constrictive Pericarditis

(common in pts with CABG, radiation therapy and TB)

876

What is the next best step in management of a pt who meets criteria for neurofibromatosis type 1 (two or more of following: first degree relative with NF1, more than 6 cafe-au-lait spots, presence of more than 2 neurofibromas/ lisch nodules/ optic gliomas/ bone dysplasia/ axillary freckling)?

immediate ophthalmology referral

(for early detection of optic nerve gliomas and Lisch nodules- iris hamartoma)

877

What is the best initial treatment for uterine prolapse (sensation of pressure or heaviness in pelvic area relieved by lying down and aggravated by prolonged standing/exertion, low back pain, dyspareunia, vissible mass at introitus in multiparous postmenopausal women)?

surgical correction

(use pessary if not surgical candidiate or refuse surgery)

878

What is the most important modifiable risk factor for stroke?

Hypertension

879

A pt presenting with a single/ multiple hyprkeratotic papules on the sole of the foot that consist of thrombosed capillaries (as is seen on scrapings of the lesions)most likely suffers from ...

Plantar Warts

(due to HPV via skin to skin contact; in young adults of pt who is a meat/ poulty/ fish handler)

880

What is the best initial treatment for plantar warts?

topical salicylic acid (takes to 2-3 weeks to begin to resolve; continue treatment 1-2 weeks after resolution)

(liquid nitrogen is alternative)

881

What is the best diagnostic test for diagnosing exercise- induced bronchoconstriction (shortness of breath and chest tightness 10-15 minutes after starting exercise and lasting about 30 minutes after exercise complete)?

Bronchoprovovation test with exercising or inhalation of dry, cold air

(fall in FEV1 greater than 10% is positive and greater than 15% is diagnostic)

882

A pt presenting with dyspnea, persistent cough, facial fullness and neck pain progressing into hoarseness, dysphagia, chest pain and syncope with associated findings of edema and erythema of the neck and dilated veins of the arm and neckespecially in pt with high risk of malignancy most likely suffers from ...

Superior Vena Cava Syndrome

(dx: contrast CT of chest and neck)

883

What is the best step in management of a pt with a cat or dog bite? (4)

1. local wound care
2. rabies prophylaxis (if animal status unknown)
3. tetanus prophylaxis (tetanus toxoid and IG if no recent tetanus vaccination within 5 or 10 years depending on wound dirtiness)
4. amoxicillin/ clavulanate

884

What is the next best step in management for a pt with syphilis who has a penicillin allergy?

penicillin desensitization

885

What is the next best step in a pt suffering from benzodiazepine withdrawal (restlessness, tremors, autonomic instability) while hospitalized?

IV benzodiazepines (lorazepam, diazepam) with gradual tapering

886

What is the best initial treatmnet for heat stroke (hyperthermia, tachycardia, flushed non sweating skin, headache, altered mental status)?

augmentation of evaporative cooling
(naked pt sprayed with water mist or covered with wet sheets while fans circulate air)

887

What conditions are at an increase risk for women on hormone replacement therapy (with combine estrogen-progestin therapy)? (4)

1. breast cancer
2. venous thromboembolism (DVTs and PEs)
3. non fatal myocardial infarction
4. dementia

(benefits lipids, osteoporesis, and menopausal symptoms)

888

A pt presenting with knee pain and joint effusion after injury with associated tendereness along medial joint line, pain occurs with external rotation of right tibia and moderate laxity with valgus (abducted) stress on knee most likely suffers form ..

Medial Collateral Ligament Injury

(due to valgus/ abductor stresson knee)

889

An infant with an adducted and internally rotated arm with forearm pronation and flexed wrist and asymmetric Moro reflex most likely suffers from ...

Erb's Palsy

(injury to brachial plexus- upper roots consisting of C5, C6, C7)

(progrnosis: full or near full recovery by age 1)

890

A pt presenting with lower-extremity claudication (intermittent butt/ thigh/leg pain with exertion), absent/ diminished femoral pulses and erectile dysfunction most likely suffers from ...

Leriche syndrome (due to peripheral artery disease)

(dx: ankle-brachial index less than 0.9)
(tx: phosphodiesterase-5 (PDE-5) inhibitors- "afils")

891

A multipareous women with history of prior pelvic surgery/ chronic constipation or straining presenting with abdominal discomfort, straining to defecate/ fecal incontinence with mucus, defecation requiring digital maneuvers as disease progresses, and thick protruding rectal mucosal mass with bluish discoloration thru anus with concentric rings of rectum most likely suffers from ...

Rectal Prolapse

(tx surgically if full thickness prolapse, sensation of prolapse or prolapse with fecal incontinence/ constipation)
(tx medically with fiber & fluid intake and pelvic floor muscle exercises, if non full thickness)

892

A pt with a loud, harsh holosystolic murmu heard best in the 4th left intercostal space near sternal border with an associated palpable thrill most likely suffers from ...

Ventricular Septal Defect

893

A pt with back pain, low phosphorous level, high alkaline phosphatase, and elevated PTH in the setting of bariatric surgery/ malabsorption disorder most likely suffers from ...

Vitamin D Deficiency

(dx: 25- OH vitamin D level less than 20 ng/mL)
(tx: vitamin D3/ cholecalciferol to maintain vitamin D level of 30-50)

894

A pt presenting with malodorous frothy yellow-greeen vaginal discharge, vulvar pruritus and dyspareunia most likely suffers from ...

Trichomonas vaginalis

(tx: metronidazole 2 grams PO for 1 dose)

(discontinue breastfeeding for 12-24 hours b/c enters breast milk)

895

What is the major problem that leads to difficulties finding cross-matched blood in patients with history of multiple transfusions (i.e. sickle cell anemia or myelodysplasia patients)?

alloantibodies formation

(especially to E, L, and K)

896

What are the five steps of root cause analysis (quality improvement tool used to identify what, how, and why an undesirable outcome occured)?

1. collect data
2. create causal factor flow chart
3. identify root causes
4. generate recommendations and implementation
5. measure success of changes implemented

897

A pt presenting with double vision and ptosis that worsens at the end of the day along with dysphagia. dysarthria, and proximal muscle weakness that worsen throughout the day and improves with restmost likely suffers from ...

Myasthenia Gravis

(a neuromuscular junction disease due to autoantibodies against ACh receptor)

898

What is a better measure of central tendency in a set of data that is strongly skewed distribution?

median

899

What is the best next step in management of a severely malnourished child (lethargic, hypoactive, severe wasting, symmetrical lower extremity edema) if the child is vomiting, has impaired consciousness or painful oral ulcers?

insert dobhoff tube and rehydrate/ feed

(placed beyond pylorus to reduce aspiration)

(use oral rehydration if possible)

900

A young, female healthcare professional (nurse) who presents with repeated bacteremia and sepsis with multiple different organisms most likely suffers from...

Factitious Disorder

(pt feigns illness to be pt and to assume sick role)
(pt is injecting exogenous material parenterally or ingesting drugs)

901

A young female presenting with occasional urine leakage aggravated by coughing and straining in the setting of having genitourinary surgery/ multiple pregnancies and leakage occurs when pt is asked to relax and give single vigorous cough most likely suffers from ....

Stress Urinary Incontinence

(initial tx: pelvic floor exercises)
(last resort tx: surgical correcttion)

902

What anti-hypertensive medication is associated with photosensitivity reaction (erythematous rash on exposed parts of body)?

Thiazides diuretics

(hydrochlorothiazide)

903

What is the next best step in management of a pt on pentamidine therapy who develops generalized seizure/ CNS symptoms?

finger stick blood test

(pentamidine associated with hypo/ hyper-glycemia, hyper/ hypo-kalemia, hypocalcemia)

904

What is the criteria for delayed puberty in a boy?

1. no testicular enlargement by 14 years old
2. testicles are 2.5 cm or smaller in diameter
3. delay in development for 5 years or more from onset of genitalia enlargement

905

What is the next best step in management of a pt with delay puberty?

X-ray imaging to assess bone age

906

What is the next best step in management of a pt with subclinical thyrotoxicosis (suppressed TSH and normal thyroid hormone levels)?

recheck thyroid function test in 6-8 weeks

(if no symptoms, normal heart rhythm, normal bone denisty)

907

What is the best initial test for suspected pneumothorax?

upright chest X-ray with posteroanterior view

(gas separating white visceral pleural line from parietal pleural line with no vascular markings beyond visceral pleural line)

908

What are the indications for implantable cardioverter-defibrillator placement in hypertrophic obstructive cardiomyopathy as primary prevention? (50

1. family hx of sudden cardiac death
2. syncope (recurrent or associated with exertion)
3. nonsustained VT on Holter monitoring
4. hypotensive BP response to exercise
5. extreme LV hypertophy (greater than 3 cm)

(used as secondary prevention if prior hx of cardiac arrest or sustained, spontaneous ventricular tachycardia)

909

What is the next best step in management of a male pt presenting with fever, dysuria, lower abdominal discomfort, inability to void, palpable bladder, and anterior rectal wall tenderness?

suprapubic catheterization

(relieve pt's urinary obstruction that is worsen acute prostatitis)

(avoid foley catheter and prostatic massage as can result in bacteremia)

910

What is the next best step in management of a cirrhotic pt that is hospitalized for variceal bleeding to prevent assocaited complications?

fluoroquinolone (cipro/o/nor-floxacin) for 7-days

(prevent infection such as spontaneous bacterial peritonitis)

911

What three type of patients should be treated for asymptomatic bacteriuria (bacteria greater than 10^5 colony forming units in pt without signs or symptoms of UTI)?

1. pregnant pt
2. urologic intervention pt
3. hip arthroplasty pt

(not treating others prevents drug resistance)

912

What is the most common complication of cat-scratch disease due to Bartonella henselae?

suppration of lymph nodes

(other complications are visual loss due to neuroretinitis, encephalopathy, fever, hepatosplenomegaly)

913

What is the next best step in management of a pubertal male who develops gynecomastia?

reassure and follow-up

(normal due to excess production of estrogens from testes during puberty; regresses in 18-24 months)

914

A middle aged woman presenting with elevated alkaline phosphatase levels and intense pruritus (excoriations from scratching) and may also have jaundice/ steatorrhea/ fatigue/ hyperlipidemia with xantomas/bone disease/ hyperpigmentation of exposde areas most likely suffers from ...

Primary Biliary Cirrhosis

(progressive autoimmune destruction of liver)

915

What is the best initial diagnostic test for suspected primary biliary cirrhosis?

antimitochondrial antibody level

(definitive dx is with liver biopsy)

916

What treatment can be used to slow the progression of primary biliary cirrhosis?

ursodeoxycholic acid

(definitive tx with liver transplant)

917

What is a common complication of primary biliary cirrhosis disease that should be routinely screened for?

Osteoporesis

(screen with DEXA scan, prevent with calcium and vitamin D supplementation along with bisphosphonates if needed)

918

What are significant predictors of adverse cardiovascular outcomes in pts and are considered coronary heart disease risk equivalents?

1. diabetes
2. chronic kidney disease
3. noncoronary atherosclerotic disease (carotid, peripheral artery, abdominal aortic aneurysm)

919

What diagnostic test can be performed to distinguish between a true positive tuberculin skin test and induration due to prior BCG vaccination (usualy never exceeds 15 mm)?

interferon gamma release assay

920

What is the next best step in management of a pt with positive tuberculin skin test and signs of latent tuberculosis on CXR (fibrosis)?

Isoniazid (INH) for 9 months (can be 6 months if adherence difficulties) with vitamin B6 (to prevent peripheral neuropathy)

(alternative options: Rifampin for 4 months in adults/ 6 months in kids, INH and rifampin for 4 months, or INH and rifapentine weekly for 3 months- not in HIV pts)

(to prevent conversion into active TB)
(can use rifampin for 4 months as alternative)

921

What is used to determine whether a patient with atrial fibrillation needs anticoagulation?

CHADS2 score

C: CHF (1 point)
H: hypertension (1 point)
A: age older than 75 (1 point)
D: diabetes (1 point)
S: stroke/ transient ischemic attack (2 points)

If score 2 or more, need anticoagulation
if 1, can give aspirin or anticoagulation

922

What is the next best step in management of a infant with unilateral/ bilateral palpable firm disc-like tissues under the areolae with/without galactorrhea?

Reassurance

(isolated premature thelarache due to maternal estrogen withdrawal after birth elading to prolactin production resolves within 6 months)

923

What is the most common cause of sudden death due to steering wheel injuries?

aortic injury (aortic rupture)

924

A female who develops significant postpartum hemorrhage shortly after birth in the setting of a soft uterine fundus at the level of the umbilicus most likely suffers from ...

Uterine Atony

(tx: fundal massage and oxytocin infusion)
(maintain BP with IV fluids and blood transfusion)

925

What is the next best step in management of a pt with pneumonia in the same location as recently treated pneumonia (recurrent pneumonia in same location)?

chest CT scan

(to assess for possible obstructing endobronchial neoplasma if smoker, abscess, empyema)

(if not helpful, then bronchoscopy)

926

An HIV pt who develops worsening of a pre-existing infection after starting treatment with HAART therapy and antibiotics most likely suffers from ...

Immune reconstitution inflammatory syndrome (IRIS)

(due to rapid improvement of immune function allowed by HAART therapy and subsequent inflammatory reaction at site of pre-existing infection

(reassure pt and continue treatment)

927

What is the next best step in management of an elderly pt with squamous cell carcinoma who refuses surgical excision?

radiation therapy (requires multiple visits and risk of future malignancies)

(other options are cryotherapy and elexctrosurgery but dont provide tissue for histologic exam)

928

What anti-hypertensive medications are associated with the side effect of peripheral edema?

calcium channel blockers (amlodipine and nifedipine more so than verapmil and diltiazem)
(use of ACE inhibitors with calcium channel blockers reduces risk of peripheral edema)

929

A pt presenting with a prodrome of itching and urticaria followed by outbreak of erythematous rash with tense bullae and blistering most likely suffers from ...

bullous pemphigoid

(dx: skin biopsy from edge of intact blister with assay for basement membrane antibodies)
(tx: glucocorticoids)

930

A pt presenting with cirrhosis/ liver dysfunction, diabetes mellitus, bronzed skin (golden brown skin), hook like osteophytes of the 2nd and 3rd metacarpophalangeal joints, and central hypogonadism (low LH and FSH) most likely suffers from ..

Hemochromatosis

(excessive iron accumulation in parenchymal organs)
(tx: therapetic phlebotomy- remove 1 unit of blood per week)

931

What are the common side effects of insulin secretagogues (sulfonylureas- glyburide; meglitinides- nateglinide/ repaglinide) used for type 2 diabetes? (2)

1. hypoglycemia
2. weight gain

932

What are the common side effects of thiazolidinediones ("azones") used for type 2 diabetes? (3)

1. hepatoxictiy
2. fluid retention/ heart failure/ pulmonary edema
3. bone fractures

933

What are the common side effects of metformin used for type 2 diabetes? (3)

1. GI upset
2. lactic acidosis
3. decreased vitamin B12 absorption

934

What are the common side effects of DDP inhibitors ("gliptins") used for type 2 diabetes? (2)

1. headache
2. nasopharyngitis

935

What are the common side effects of alpha-glucosidase inhibitors (acarbose, miglitol) used for type 2 diabetes? (2)

1. diarrhea
2. flatulence

936

What are the common side effects of SGLT2 inhibitors ("gliflozins")used for type 2 diabetes? (3)

1. polyuria
2. UTIs
3. hypotension

937

A newborn male born with bladder distention, bladder wall thickening, palpable bladder and weak urinary stream most likely suffers from ...

Posterior Urethral Valves

(leads to vesicoureteral reflux and hydronephrosis)
(dx: voiding cystourethrogram (VCUG))

938

An HIV pt presenting with hemiparesis and disturbance in speech, vision and gait along with multiple demyelinating, non-enhancing lesions with no mass effect on brain MRI most likely suffers from ...

Progressive Multifocal Leukoencephalopathy

(due to JC virus)
(tx: optimize HAART therapy)
(dx: confirmed by brain MRI)

939

A young healthy pt presenting with acute non-traumatic mono or oligoarthritis along with a history of unprotected sex most, tenosynovitis (painful tendonsat wrist/ fingers/ ankle/ toes), and transient pustular or vesiculo-pustular skin rash likely suffers from ...

Gonococcal arthritis

(dx: culture joint fluid, rectum, urethra, and oral cavity)

940

... is defined as a misclassification of events that can result from knowing the exposure status of a patient during a study, and it can be reduced by ...

Observer's bias; blinding

941

What is the next best step in the management of a pt with deep venous thrombosis formation secondary to reversible/ time limited risk factor (i.e. surgery, pregnancy, OCP use, trauma)?

warfarin anticoagulation for 3-6 months and then discontinue

(if DVTs develops idiopathically, then warfarin anticoagulation for 6 months then re-evalaute for long-term need)

942

What is the dietary recommendation fro a child with acute diarrhea and no signs of dehydration?

normal, age appropriate diet with limited fats and sugars

(fats and sugars can increase osmolarity of stool and delay gastric emptying which worsens diarrhea)

943

What is the next best step in management of a pt with acute cholangitis and signs of suppurative cholangitis whose abdominal pain, hypotension, fever, and mental confusion persist despite aggressive fluid resuscitation and antibiotics?

Biliary Drainage (endoscopic or percutaneous)

944

What is the causes of Cushing's syndrome (weight gain, fatigue, proximal muscle weakness, truncal obesity, buffalo hump, striae) in a pt who has increased urinary cortisol level, nonsupressible high dose dexamethasone suppression test and undecteable ACTH level?

Adrenal adenoma

(dx: CT scan of adrenals)

945

A pt presenting with vesiculation and faint erythema after topical antibiotic use for a burn most likely suffers from...

Acute Allergic Contact Dermatitis

(tx: avoid offending agent; steroids for itching and discomfort)

946

What is the next best step of management for a pt with type 2 diabetes being treated with metformin who is scheduled for a cardiac cathertization?

discontinue metformin on day of procedure and restart 2 days after procedure

(to avoid lactic acidosis from metformin use with large dose IV iodine contrast)

947

True or False. Most men with prostate cancer die from other causes rather than from prostate cancer.

True

(prostate cancer is progresses slowly)

948

What is the next best step in mangement of a hemodynamically stable pt with EKG findings of supraventricular tachycardia (regular and narrow QRS tachycardia)?

identify type of SVT by using IV adenosine or vagal maneuvers

(slows tachycardia so can unmask hidden EKG findings)

949

A pt who develops chest pain that is worse with positional changes and deep respiration along with scratchy sound heard during ventricular systole over left sternal border, EKG with diffuse ST segment elevation with PR depression and JVD 1-4 days after a myocardial infarction most likely suffers from ..

Acute Pericarditis (infarction Pericarditis)

(tx: aspirin for pain control and close observation)
(usualy transient)

950

A pt who develops fever, leukocytosis, pleuritic chest pain (worse with position and deep respiration), and pericardial rub weeks to months after and acute myocardial infarction most likely suffers from ...

Dressler's syndrome

951

An uncircumsized male pt presenting with small, flesh colored dome-topped or filiform papules positioned circumferentially around the corona or sulcus of the glans penis most likely suffers from...

Normal Variant

(not sexually transmitted, not malignant, no treatment needed)

952

A pt on long standing NSAID use who presents with unilateral flank pain radiating to groin, hematuria and unilateral CVA tenderness but CT of the abdomen shows mild dilation of the pelvicalyceal system without an obvious stone/ obstruction most likely has renal dysfunction (elevated creatinine) due to ...

Analgesic (NSAID induced) nephropathy

953

What are the two most important predictors of survival for a pt with chronic obstructive pulmonary disease (COPD)?

1. FEV1 (

954

... occurs when a screening test detects the disease at an earlier point in time (making it look like the survival rate increased), but the associated prognosis of the disease does not actually change

Lead time bias

955

A pt presenting with stearatorrhea, vitamin D deficiency, iron deficiency anemia, vitligo, dermatitis herpetiformis, peripheral neuropathy and bone pain most likely suffers from ...

Celiac Disease

(dx: anti-endomysial antibody and anti-tissue transglutaminase antibody)
(small bowel biopsy is gold standard)

956

An alcoholic who is being hospitalized and treated with fluids and glucose and then develops muscle weakness and other signs of rhabdomyolysis most likely suffers from ...

Hypophosphatemia

(due to insulin increased shifting phosphate intracellularly and unmasking compensated phosphate depletion due to poor feeding)

957

A pt older than 50 presenting with subacute diffuse muscle pain that is bilateral and associated with morning stiffness for more than 1 month and involving neck/torso/ shoulders/proximal arms/ proximal thigh/ hip and may have constitutional symptoms (fever, malaise, weight loss), on physical exam have decreased active range of motion in shoulders, hips and neck most likely suffers from ...

Polymyalgia Rheumatica

(elevated ESR and CRP)
(tx: low dose glucocrticoids/ prednisone)

958

What is the next best step in management of a female pt aged 21-24 years old with atypical squamous cells of undtermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) on Pap smear?

repeat Pap smear in 1 year

(colposcopy if pt demonstrates ASCUS or LSIL on 3 consecutive pap smear)

959

What is the next best step in management of a female pt aged older than 25 with atypical squamous cells of undtermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) on Pap smear?

HPV DNA testing

(if negative, perform HPV DNA testing with Pap smear in 3 years)

960

What is the best initial treatment for a preschool aged child (3-5 years old) who has attention deficit hyperactivity disorder (ADHD)?

parent-child behavioral therapy

(if fails, then stimulant medication (methylphenidate or amphetamines))

961

What is the best initial step in management of a pt with attention deficit hyperactivity disorder before starting pt on stimulant medication (methylphenidate or amphetamines)?

detailed cardiac and physcial examination

(atomoxetin- NE reuptake inhibitor and alpha-2 agonist are non-stimulant options for ADHD)

962

What is the next best step in management of a hospitalized pt who is found to have decreased total T3 with normal total T4 and TSH on thyroid function studies?

repeat thyroid function studies in 8 weeks

(most likely pt has euthyroid sick syndrome- TSH increases above normal when recovering from illness)

963

A pt with fever, nasal congestion/ obstruction, prurulent nasal discharge, maxillary tooth discomfort, facial pain/ pressure that is worse with bending forward as well as symptoms persist for 10 days or more without improvement/ severe symptoms with high fever (greater than 39), purulent nasal discharge or facial pain for more than 3 days/ worsening symptoms more than 5 days after an initial improving viral upper respirtaory infection most likely suffers from ...

Acute Bacterial Rhinosinusitis

(tx: amoxicillin-clavulanate)

964

What is the best initial treatment for an infant aged 28 days or less than presents with sepsis?

ampicillin with gentamicin or cefotaxime

(E. Coli and Group B strep, as well as Listeria)

965

What is the best initial treatment for an infant aged older than 28 days presenting with sepsis?