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History & Physical/Orthopedics/Rheumatology
Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle?
Answers
A. Supraspinatus
B. Infraspinatus
C. Teres minor
D. Subscapularis

Explanations
(c) A. Abduction against resistance tests the supraspinatus.
(u) B. Lateral rotation against resistance tests the infraspinatus and teres minor.
(u) C. See B for explanation.
(u) D. Medial rotation against resistance tests the subscapularis.

History & Physical/Orthopedics/Rheumatology
A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 15 degrees of flexi

Explanations
(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress.
(u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however the patient is supine, h

Diagnostic Studies/Orthopedics/Rheumatology
In a trauma patient who has a suspected cervical spine injury, the x-ray view that will identify the majority of significant injuries is
Answers
A. lateral.
B. oblique.
C. anteroposterior.
D. odontoid.

Explanations
(c) A. The lateral view shows 70-80% of significant injuries. It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology.
(u) B. The oblique view is usually not included in the ini

Diagnostic Studies/Orthopedics/Rheumatology
A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, th

Explanations
(u) A. X-rays of the lower leg and ankle will only determine bone placement.
(u) B. Doppler studies will confirm the presence of a decreased pulse.
(u) C. A bone scan is not indicated in the evaluation of compartment syndrome.
(c) D. Compartm

Diagnosis/Orthopedics/Rheumatology
A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical exam the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low

(u) A. Gout and pseudogout are excluded by the failure to find crystals on synovial fluid analysis.
(u) B. See A for explanation.
(u) C. Acute rheumatic fever commonly involves multiple joints.
(c) D. Leukocytosis and a low synovial glucose are indicative

Diagnosis/Orthopedics/Rheumatology
A 32-year-old male presents with migratory arthralgias and profound malaise and fatigue. He states that one week ago he returned from a hunting trip in Pennsylvania. He is also complaining of a lesion on his left thigh t

Explanations
(u) A. Rheumatoid arthritis is a symmetrical arthritis that commonly affects the proximal interphalangeal and metacarpophalangeal joints. It is not associated with the rash of erythema migrans.
(u) B. Kawasaki disease is an acute febrile, mul

Diagnosis/Orthopedics/Rheumatology
A 22 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on. Physical exam reveals pain to palpation over the posterior tibia

Explanations
(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.
(u) B. See A for explanation.
(u) C. Osgood-Schlatter disease is an injury occurring at the insertion of

Diagnosis/Orthopedics/Rheumatology
A patient who demonstrates pain on the radial aspect of the wrist with abrupt ulnar movements while the thumb is flexed into the closed palm most likely has
Answers
A. carpal tunnel syndrome.
B. radial tunnel syndrome.
C

Explanations
(u) A. Carpal tunnel is diagnosed by a positive Tinel's or Phalen's maneuver.
(u) B. Radial syndrome is demonstrated by simultaneously extending the patient's wrists and fingers while the examiner passively flexes the patient's long finger, w

Clinical Intervention/Orthopedics/Rheumatology
A 32 year-old medical transcriptionist presents with burning and tingling in her right wrist and hand for the past month. On physical exam, Phalen's test is positive; however, there is no atrophy of the thena

Explanations
(c) A. The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve.
(

Clinical Intervention/Orthopedics/Rheumatology
Which of the following is the correct treatment for a Grade II ankle sprain resulting from an inversion injury?
Answers
A. Corticosteroid injection
B. Rest, ice, compression, elevation
C. Moist heat and a wal

Explanations
(u) A. See B for explanation.
(c) B. The majority of ankle sprains are treated with RICE (rest, ice, compression and elevation). Corticosteroid injections, moist heat, and a walking cast provide no benefit. Surgical intervention for repair of

Clinical Intervention/Orthopedics/Rheumatology
A 4 year-old boy presents to the ED after sustaining a crush injury to his distal third phalanx. Physical exam reveals an associated nail bed injury. Which of the following is the appropriate management?
A. R

(u) A. Rest, ice, and elevation are only palliative measures and not appropriate management
(c) B. Distal phalanx fracture should be immobilized and if there is an associated nailbed injury the fracture is considered "open" and the patient should be given

History & Physical/Orthopedics/Rheumatology
Which of the following clinical characteristics is associated with bicipital tendonitis?
A. Aggravated by resisted supination of the forearm
B. Bulging appearance to the proximal arm
C. Weakness of the arm with

Explanations
(c) A. Supraspinatus tendonitis will be aggravated by resisted supination of the forearm.
(u) B. Biceps rupture may present with a bulging appearance of the proximal arm.
(u) C. Weakness of the arm with internal rotation and adduction is char

Clinical Intervention/Orthopedics/Rheumatology
A 53 year-old female massage therapist presents with new onset of sudden swelling involving the right elbow. She denies previous episodes similar to this. On physical examination, the patient is afebrile. The

Explanations
(c) A. Rest and NSAID is the most appropriate initial intervention in a patient with olecranon bursitis.
(u) B. Surgical excision is reserved for chronic bursitis and is not indicated in this acute initial presentation.
(u) C. Incision and dr

Diagnosis/Orthopedics/Rheumatology
A 30 year-old male sustains a blow to his right lateral leg during a soccer game. He complains of pain with weight bearing. Examination reveals tenderness along the lateral aspect of the right lower leg, but no point ten

Explanations
(u) A. Anterior cruciate ligament injury would have a positive drawer test and mechanism of injury can be due to a direct blow to the knee or as a result of sudden deceleration and rotation of the knee.
(c) B. Isolated fibular fractures can o

Scientific Concepts/Orthopedics/Rheumatology
During the stages of fracture healing which of the following is responsible for producing collagen?
A. Osteoclasts
B. Chondrocytes
C. Glycosaminoglycans
D. Fibroblasts

Explanations
(u) A. Osteoclasts are responsible for removing necrotic bone.
(u) B. Chondrocytes make up the articular cartilage.
(u) C. Glycosaminoglycans help form the osteon or vascular canal.
(c) D. Fibroblasts produce collagen during the inflammation

Clinical Therapeutics/Orthopedics/Rheumatology
Which of the following medications inhibits prostaglandin synthesis in a patient with rheumatoid arthritis?
A. Methotrexate
B. Infliximab (Remicade)
C. Probenecid (Benemid)
D. Aspirin

Explanations
(u) A. Methotrexate inhibits the enzyme dihydrofolate reductase.
(u) B. Infliximab (Remicade) neutralizes cytokine tumor necrosing factor.
(u) C. Probenecid blocks the tubular reabsorption of filtered urate and is used to reduce serum uric ac

History & Physical/Orthopedics/Rheumatology
Which of the following mechanisms of action is most commonly associated with meniscal tears?
A. Hyperextension
B. Axial loading and rotation
C. Hyperflexion
D. Valgus force to the lateral knee

Explanations
(u) A. Hyperextension injuries usually result in ACL and PCL injuries.
(c) B. Axial loading and rotation most likely result in meniscal injuries.
(u) C. Hyperflexion injuries result in PCL injuries.
(u) D. Valgus force to the lateral knee mor

Diagnosis/Orthopedics/Rheumatology
A 14 year-old patient, who fell on his outstretched hand, complains of pain along his entire arm. There is point tenderness and swelling over the midshaft of the radius. There is significant pain with limited flexion of

Explanations
(c) A. Galeazzi's fracture/dislocation involves a fracture of the mid or distal radial shaft with distal radioulnar joint dislocation.
(u) B. A scaphoid fracture is a fracture of the scaphoid bone and would not cause pain in the elbow joint.

Diagnostic Studies/Orthopedics/Rheumatology
Which of the following x-ray views will show the presence of a "Scotty dog" deformity seen with spondylolysis?
A. Lateral
B. Oblique
C. Anteroposterior
D. Open-mouth odontoid

Explanations
(u) A. The lateral view is the most appropriate for evaluation of the possible presence of spondylolisthesis, not spondylolysis.
(c) B. Spondylolysis results from a defect through the pars interarticularis, which is seen as a defect in the ne

Clinical Intervention/Orthopedics/Rheumatology
An x-ray taken on a patient complaining of wrist pain after being hit by a baseball reveals a non-displaced mid-shaft ulnar fracture. Which of the following splints is most appropriate for treatment?
A. Thumb

Explanations
(u) A. Thumb spica splints are used for scaphoid fractures.
(c) B. Sugar tong splints are best used to immobilize the elbow, wrist and forearm.
(u) C. Cock-up wrist splints may be useful in some situations unrelated to fractures, such as to i

Diagnosis/Orthopedics/Rheumatology
A 12 year-old male presents with pain in his left leg that is worse at night. Aspirin relieves the pain and the patient denies injury. On examination, there is point tenderness over the tibia, and the patient has a sligh

Explanations
(u) A. Osteosarcoma and Ewing sarcoma are malignant bone tumors that present with pain and swelling. No improvement is noted with conservative therapy.
(u) B. Legg-Calve-Perthes disease is avascular necrosis of the hip affecting boys ages 4-1

Clinical Intervention/Orthopedics/Rheumatology
Which of the following interventions is initially indicated for helping to relieve the symptoms of plantar fasciitis?
A. Steroid injections
B. Short leg walking cast
C. Arch supports
D. Surgical release

Explanations
(u) A. Steroid injections can be used to relieve symptoms but may be harmful by causing rupture if given in the plantar tendon greater than 3 or 4 times.
(u) B. Short leg walking cast may be used for severe cases refractory to initial treatme

Clinical Therapeutics/Orthopedics/Rheumatology
When injecting a corticosteroid into a joint to help relieve pain, which of the following would most commonly be mixed in the syringe?
A. Hyaluronic acid
B. Ketorolac
C. Chondroitin sulfate
D. Lidocaine

Explanations
(u) A. Hyaluronic acid is usually injected by itself in patients with osteoarthritis.
(u) B. Ketorolac is an NSAID that is given orally and not intra-articularly.
(u) C. Chondroitin sulfate is taken orally and thought to improve symptoms in o

Scientific Concepts/Orthopedics/Rheumatology
Which of the following is the underlying pathogen for the development of Lyme disease?
A. Borrelia burgdorferi
B. Bartonella henselae
C. Rickettsia rickettsii
D. Coxiella brunetti

Explanations
(c) A. Lyme disease is a tick-borne illness caused by the spirochete B. burgdorferi.
(u) B. Bartonella henselae is the spirochete that causes cat scratch fever.
(u) C. Rickettsia Rickettsii is the spirochete that causes Rocky Mountain Spotted

Diagnosis/Orthopedics/Rheumatology
A mother brings her 14 month-old son to your clinic. Earlier today she lifted her son by grabbing him by the wrists and pulling him up off the floor. The child is sitting in his mother's lap with his left forearm is exte

Explanations
(c) A. This clinical history is classic for radial head dislocation or nursemaid's elbow.
(u) B. There is no edema, deformity or erythema to suggest a fractured wrist.
(u) C. Osteochondritis dissecans is avascular necrosis of subchondral bone

History & Physical/Orthopedics/Rheumatology Topic: 2 Author: Christine Bruce
A patient presents with chronic back pain. On physical examination testing, the patient is found to have abnormalities of proprioception and vibration discrimination. Which of th

Explanations
(u) A. The lateral spinothalamic tract affects pain and temperature sensation.
(u) B. The ventral spinothalamic tract affects pressures and touch sensations.
(c) C. The posterior column affects proprioception (position sense) and vibration se

Scientific Concepts/Orthopedics/Rheumatology T
In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis?
A. Femur
B. Humerus
C. Vertebral spine
D. Tibia

Explanations
(u) A. Long bones are most commonly affected with osteomyelitis in children.
(u) B. See A for explanation.
(c) C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach
the well-perfused v

Clinical Therapeutics/Orthopedics/Rheumatology
Intraarticular injection of hyaluronic acid has been approved for treatment of patients with which of the following conditions?
A. Rheumatoid arthritis of the knee
B. Osteoarthritis of the knee
C. Olecranon b

Explanations
(u) A. See B for explanation.
(c) B. Intraarticular injection of hyaluronic acid has been approved recently for treatment of patients with osteoarthritis
of the knee that have failed other therapies. Although the onset of action of this medic

Diagnosis/Orthopedics/Rheumatology
A 25 year-old presents with pain in the proximal ulna after falling directly on the forearm. X-ray shows fracture of the
proximal 1/3rd of the ulna. There is an associated anterior radial head dislocation. What is the pr

Explanations
(u)A. A Galeazzi fracture is a fracture along the length of the radius with injury to the distal radioulnar joint. (c) B. A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head.
(u) C. A Colles' f

Diagnosis/Orthopedics/Rheumatology
A 75 year-old female presents with medial knee pain that worsens with stair climbing. Physical examination reveals swelling and point tenderness inferior and medial to the patella and tenderness overlying the medial tibi

Explanations
(c) A. The pes anserine bursa underlies the semimembranosus tendon and may become inflamed or painful owing to trauma, overuse, or inflammation. It is a common cause of knee pain and it is often misdiagnosed in adults.
(u) B. Prepatellar burs

Diagnosis/Orthopedics/Rheumatology
A 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorph

Explanations
(u) A. Rheumatoid arthritis usually involves more than one joint, primarily affecting metacarpophalangeal and wrist joints initially. Synovial fluid analysis would show moderate leukocytosis (< 50,000) with higher glucose levels.
(c) B. Septi

Diagnosis/Orthopedics/Rheumatology
A 53 year-old patient presents with severe pain at the base of the thumb and no other finger involvement. The pain is worse with activity and lasts a short period of time following rest. There is no specific history of t

Explanations
(u) A. Rheumatoid arthritis typically involves the MCP and PIP joints of the digits for the second through fifth fingers. The thumb is classically spared.
(c) B. The base of the thumb is typically involved with osteoarthritis as are the DIP j

Clinical Intervention/Orthopedics/Rheumatology
Which of the following is the treatment of choice for a torus (buckle) fracture involving the distal radius?
A. Open reduction and internal fixation
B. Ace wrap or anterior splinting
C. Closed reduction and c

Explanations
(u) A. See B for explanation.
(c) B. A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as
painful as unstable fractures. They heal uneventfully in 3-4 weeks.
(u) C. See B for explana

Clinical Therapeutics/Orthopedics/Rheumatology
An 80 year-old female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with osteoporotic compression fracture. Which of the following treatment mo

Explanations
(c) A. Calcitonin has the ability to cause analgesia when used for acute compression fracture of the vertebral body.
(u) B. Alendronate is effective in building new bone for a patient with osteoporosis but has no associated analgesic effect.

Diagnostic Studies/Orthopedics/Rheumatology
Which of the following views on plain films is preferred to identify spondylolysis?
A. Anterior
B. Posterior
C. Oblique
D. Lateral

Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films.
(u) D. See C for explanation.

Clinical Intervention/Orthopedics/Rheumatology
A 15 year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal jo

Explanations
(u) A. See B for explanation.
(c) B. The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via
splinting for 6 to 8 weeks.
(u) C. See B for explanation.
(u) D. Short arm casting is indicate

History & Physical/Orthopedics/Rheumatology
A 75 year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be

Explanations
(c) A. The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance.
(u) B. Axillary nerve injury results in numbness over the deltoid muscle; this nerve is mor

Clinical Therapeutics/Orthopedics/Rheumatology
A 55 year-old female presents with complaints of stiffness, aching, and pain in the muscles of her neck, shoulders, lower back, hips, and thighs. There is no associated weakness associated with the stiffness

Explanations
(c) A. This patient has polymyalgia rheumatica and treatment with glucocorticoids can relieve discomfort and prevent the associated ischemic temporal arteritis, which threatens vision.
(u) B. Cyclophosphamide is an immunosuppressant used in t

Clinical Intervention/Orthopedics/Rheumatology
An 18 year-old male presents with pain in his wrist after he fell off of a moving motor cycle. Physical examination reveals tenderness in the anatomic snuffbox. No fracture is noted on plain radiography of th

Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Even with normal initial radiographs, patients with a consistent history and tenderness in the anatomical snuffbox are treated as a stable fracture with immobilization in a th

Diagnostic Studies/Orthopedics/Rheumatology
A 53 year-old male is seen in the emergency department following a motor vehicle collision in which his knee impacted against the dashboard. The patient has a posterior knee dislocation that is promptly reduced

Explanations
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. Compartment pressures are performed in cases of suspected compartment syndrome, not to determine the patency of the popliteal artery.
(c) D. The popliteal artery is at risk fo

Health Maintenance/Orthopedics/Rheumatology
Which of the following preventive strategies against osteoporosis-associated vertebral fractures has a known side effect of increasing the incidence of hot flashes when used in a perimenopausal female?
A. Calcit

Explanations
(u) A. Calcitonin does not have any estrogen effects on the body and serves as an analgesic when used in the management of vertebral fractures.
(u) B. Alendronate is a bisphosphonate that does not have any hormonal effects on the body.
(u) C.

History & Physical/Orthopedics/Rheumatology
A 65 year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foo

Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soles muscles, a

Health Maintenance/Orthopedics/Rheumatology
Endotracheal intubation should be performed with caution in patients with which of the following underlying conditions due to the propensity to cause subluxation of C1 on C2?
A. Rheumatoid arthritis B. Osteoarth

Explanations
(c) A. Patients with advanced rheumatoid arthritis will have synovitis of the atlantoaxial joint (C1-C2) which may damage the transverse ligament of the atlas, producing forward displacement of the atlas on the axis (atlantoaxial subluxation)

History & Physical/Orthopedics/Rheumatology
A 55 year-old secretary presents with ongoing pain and numbness in her hand. These symptoms are worse at night and she must shake her hand to regain feeling in it. Which of the following physical examination sig

Explanations
(u) A. Hypothenar atrophy may occur with aging and disuse but it is not part of the median nerve involvement that occurs with carpal tunnel syndrome.
(u) B. Finger abduction weakness is associated with ulnar nerve injury, which does not occur

Scientific Concepts/Orthopedics/Rheumatology
Which of the following rotator cuff tendons is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the

Explanations
(c) A. A critical zone exists for the supraspinatus tendon due to its superior insertion site. It is susceptible for injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is m

Clinical Therapeutics/Orthopedics/Rheumatology
Which of the following is the treatment of choice for stage one Lyme disease in a patient less than 12 years of age?
A. doxycycline
B. amoxicillin
C. chloramphenicol
D. azithromycin

Explanations
(u) A. See B for explanation.
(c) B. Amoxicillin is first line therapy in a patient less than 12 years of age due to the harmful effects of doxycycline on teeth and bones in children.
(u) C. Chloramphenicol is only indicated in disseminated d

Scientific Concepts/Orthopedics/Rheumatology
Which of the following leads to retropatellar pain?
A. increased Q angle
B. increased quadriceps tone and strength
C. Osgood-Schlatter Disease
D. hamstring stretching

Explanations
(c) A. Patients with an increased Q angle have more force directed laterally during knee flexion and are at greater risk of patellofemoral pain syndrome.
(u) B. Quadriceps strengthening aids in restoring patellofemoral tracking.
(u) C. Osgood

Clinical Intervention/Orthopedics/Rheumatology
A 34 year-old female, with a past medical history of irritable bowel syndrome and migraines, presents with fatigue, generalized aching and stiffness of the trunk, hip, and shoulder girdles. She complains of p

Explanations
(u) A. Corticosteroids have no role in the management of fibromyalgia.
(c) B. A carefully planned and individualized exercise program has been proven effective for the management of fibromyalgia.
(u) C. Opioids are not first-line agents in th

Diagnosis/Orthopedics/Rheumatology
A 14 year-old male who is overweight presents with complaints of left knee and anteromedial thigh pain for the past month. He states the pain gets better with rest and denies any known trauma. On examination of the gait,

Explanations
(u) A. Genu valgum is a knock-knee deformity of the knees and would be detected on physical examination.
(u) B. Legg-Calve-Perthes presents in a younger population.
(u) C. Osgood-Schlatter disease is characterized by local pain, swelling, and

Diagnostic Studies/Orthopedics/Rheumatology
A 23 year-old female presents with ongoing arthralgias with intermittent flares of arthritis. She is found to have a malar rash and an abnormal urinalysis. Serum ANA and anti-double-stranded DNA antibodies are p

Explanations
(u) A. CBC may reveal anemia, leukopenia and thrombocytopenia, but these are not the cause of thrombotic events and spontaneous abortion in SLE.
(u) B. The PT/INR should not be altered in SLE.
(u) C. Bleeding time measures platelet function,

Scientific Concepts/Orthopedics/Rheumatology
Which of the following fractures is associated with the greatest risk of avascular necrosis of the femoral head?
A. intertrochanteric
B. femoral neck
C. subtrochanteric
D. pelvic rim

Explanations
(u) A. See B for explanation.
(c) B. Femoral neck fractures lead to the greatest disruption of arterial blood supply to the femoral head.
(u) C. See B for explanation.
(u) D. See B for explanation.

History & Physical/Orthopedics/Rheumatology
A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 20 degrees of flexi

Explanations
(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress.
(u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however the patient is supine, h

History & Physical/Orthopedics/Rheumatology
Which of the following would demonstrate rotational misalignment in a patient with a fracture of the fourth metacarpal?
A. base of the ring fingernail and index fingernail line up in the partially closed hand
B.

Explanations
(u) A. Failure of the planes of the fingernails in the partially closed hand to line up indicates rotational misalignment.
(u) B. Fingernails of the open hand normally form an asymmetric arc.
(c) C. All fingernails should point to the same sp

Clinical Intervention/Orthopedics/Rheumatology
A 32 year-old medical transcriptionist presents with burning and tingling in her right wrist and hand for the past month. On physical exam, Phalen's test is positive; however, there is no atrophy of the thena

Explanations
(c) A. The treatment of carpal tunnel syndrome is aimed at relieving the pressure on the median nerve. This is best accomplished by having the patient wear a wrist splint during the activities that increase the pressure on the median nerve.
(

Diagnostic Studies/Orthopedics/Rheumatology
An x-ray reveals a break in the cortex of one side of the ulna shaft without a separation or break of the opposite cortex describes what type of fracture?
A. greenstick
B. transverse
C. torus (buckle)
D. epiphys

Explanations
(c) A. A greenstick fracture is a break in the cortex of one side of bone shaft without a break in the opposite cortex. (u) B. A transverse fracture is a complete fracture of both cortices.
(u) C. A torus fracture is a bowing, bending, or buc

Clinical Therapeutics/Orthopedics/Rheumatology
A 67 year-old female presents with progressive pain in her left knee that is worse with activity and relieved with rest. She notes stiffness of the knee that last about 20 minutes after activity is resumed. S

Explanations
(u) A. Naprosyn is contraindicated in patients with abnormal renal function.
(u) B. Oral prednisone is not appropriate for the long-term management of osteoarthritis.
(c) C. Acetaminophen is recommended as first-line pharmacotherapy in patien

Diagnosis/Orthopedics/Rheumatology
An 18 year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following

Explanations
(u) A. Avascular necrosis is a late complication of fracture resulting from disruption of the blood supply to the bone.
(u) B. Myositis ossificans occurs primarily in muscles post-traumatically and may not arise for several months after an in

Diagnosis/Orthopedics/Rheumatology
A 58 year-old male presents complaining of anterior right shoulder pain the day after performing extensive yard work. The pain is localized over the anterior proximal humerus with distinct point tenderness. There are no

Explanations
(u) A. Supraspinatus tendonitis, subacromial bursitis and rotator cuff tear usually present with pain in the area of the deltoid muscle, limited abduction and are reproduced through impingement tests that narrow the space between the acromium

DiagnosticStudies/Orthopedics/Rheumatology
The most reliable site from which to identify the causative organism in cases of osteomyelitis is the
A. base of ulcer.
B. blood.
C. sinus tract.
D. bone.

Explanations
(u) A. See C for explanation.
(u) B. While blood cultures are indicated in acute cases of osteomyelitis, they are only positive in 25-50% of pediatric hematogenous osteomyelitis and 10% of other forms of bone infection.
(u) C. Taking specimen

Diagnosis/Orthopedics/Rheumatology
A 20 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer practice but now it is present earlier on during practice. Physical exam reveals pain to palpation over the

Explanations
(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.
(u) B. See A for explanation.
(u) C. Osgood-Schlatter disease is an injury occurring at the insertion of

Clinical Intervention/Orthopedics/Rheumatology
A 36 year-old male has a history of recurrent low back pain. When lifting a stack of books yesterday, he experienced sudden, severe pain in the lumbar area. He denies radicular pain. His lower extremity exami

Explanations
(u) A. The patient can be managed conservatively by a primary care provider since there are no neurological deficits.
(c) B. Continuation of activities as tolerated is recommended during the acute phase. After symptoms resolve, an exercise pr

Clinical Therapeutics/Orthopedics/Rheumatology
A 42 year-old female experiences pain on the plantar surface of her left foot in the area of the third metatarsal head. The pain is associated with wearing tight shoes and is relieved by removing shoes. Exami

Explanations
(u) A. Casting the foot in a patient with Morton's neuroma is not effective therapy.
(u) B. Physical therapy has not been shown to be of benefit in treating Morton's neuroma.
(c) C. Steroid injection is the treatment of choice for Morton's ne

History & Physical/Orthopedics/Rheumatology
Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle?
A. Supraspinatus
B. Infraspinatus
C. Teres minor
D. Subscapularis

Explanations
(c) A. Abduction against resistance tests the supraspinatus.
(u) B. Lateral rotation against resistance tests the infraspinatus and teres minor.
(u) C. See B for explanation.
(u) D. Medial rotation against resistance tests the subscapularis.

Diagnostic Studies/Orthopedics/Rheumatology
A 26 year-old male who is an avid swimmer has been experiencing right shoulder pain for the past month. On examination, pain is elicited with palpation below the anterior acromion. Anterior shoulder pain is also

Explanations
(u) A. This patient is experiencing mild impingement syndrome and, although plain films may demonstrate bone spurs on the undersurface of the acromion, his age and relatively recent onset of symptoms suggest that this study would likely be no

Scientific Concepts/Orthopedics/Rheumatology
A 22 year-old female complains of worsening pain, swelling, and tenderness in her left heel for 1 week. She sustained a penetrating injury to the heel two weeks ago when she stepped on a nail while running in t

Explanations
(u) A. While gram negative enteric organisms can be a cause of osteomyelitis, E. coli is rarely seen outside of the neonatal period.
(u) B. Streptococcus pyogenes is an uncommon (~10 %) cause of acute osteomyelitis. The mechanism of injury su

Clinical Intervention/Orthopedics/Rheumatology
A 60 year-old female injured her right wrist when she slipped and fell onto her outstretched hand. Radiographs show a fracture through the metaphysis of the distal radius with dorsal displacement and angulati

Explanations
(u) A. The dorsal forearm splint is best used as an alternative to the ulnar or radial gutter splint for protection of fractures of metacarpals two through five.
(u) B. Ulnar gutter splints are best for treatment of stable fractures and dislo

Diagnosis/Orthopedics/Rheumatology
A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical examination the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with

Explanations
(u) A. Gout and pseudogout are excluded by the failure to find crystals on synovial fluid analysis.
(u) B. See A for explanation.
(u) C. Acute rheumatic fever commonly involves multiple joints.
(c) D. Leukocytosis and a low synovial glucose a

Diagnostic Studies/Orthopedics/Rheumatology
An obese 15 year-old male presents with complaint of a limp and right knee pain for two weeks. He denies recent trauma or history of previous injury. Physical examination of the right knee is unremarkable. Exami

Explanations
(c) A. This patient has slipped capital femoral epiphysis (SCFE) and the classic x-ray findings will demonstrate displacement of the femoral head rotation of the femoral neck anteriorly.
(u) B. Irregularity and fragmentation of the joint spac

Clinical Intervention/Orthopedics/Rheumatology
A 57 year-old male presents with acute bilateral lower extremity weakness and urinary incontinence that began after he fell earlier today. His examination is significant for bilateral lower extremity sensory

Explanations
(h) A. While epidural steroids can be effective in treating lumbar disc herniation, in the case of cauda equina syndrome, immediate surgical decompression is mandatory.
(h) B. NSAIDs may be beneficial in some cases of lumbar muscle strain and

History & Physical/Orthopedics/Rheumatology
Which of the following is the most sensitive to determine whether there is a small effusion in the knee?
A. Compress the patella and move it against the femur, noting any crepitus
B. Flex the knee to about 90 de

Explanations
(u) A. Crepitus without pain is not significant and does not indicate an effusion.
(u) B. Tenderness over the joint line indicates a meniscal injury, but does not demonstrate an effusion.
(c) C. A small bulge of returning fluid after milking

Diagnosis/Orthopedics/Rheumatology
A 41 year-old female complains of 3 weeks of gradually worsening pain at the base of the thumb and radial aspect of the wrist. She and her husband have been renovating their home for the past 2 months and it has become i

Explanations
(u) A. Carpal tunnel syndrome typically presents with pain and paresthesias in the median nerve distribution.
(c) B. deQuervain's tenosynovitis typically results from repetitive activity involving pinching the thumb while moving the wrist. Th

Scientific Concepts/Orthopedics/Rheumatology
A football player complains of burning pain, numbness, and tingling extending from the left shoulder down into the hand after he tackled a player. These symptoms resolved spontaneously in minutes. Following res

Explanations
(u) A. Acute cervical muscle strain might result from the mechanism of injury described but symptoms would not quickly resolve.
(u) B. Concussion involves generalized symptoms such as loss of consciousness but would not affect one limb exclus

Diagnosis/Orthopedics/Rheumatology
A 13 year-old girl reports two weeks of worsening right knee pain with no history of antecendent injury or recent trauma. She reports frequent episodes of nighttime awakening with knee pain in the past two weeks. Examina

Explanations
(c) A. The distinctive feature of Ewing sarcoma is the radiographic appearance of a periosteal "onion skin" reaction.
(u) B. This benign tumor typically presents as a painless mass and appears in plain film radiographs as a stalk or broad-bas

Clinical Therapeutics/Orthopedics/Rheumatology
A 52 year-old male presents with a severely painful, swollen right great toe. He denies recent trauma, but reports several similar episodes of toe pain and swelling over the past two to three years. He has a

Explanations
(u) A. Calcium-channel blockers, such as diltiazem, are not associated with increased risk of hyperuricemia and gout.
(c) B. Thiazide diuretics, such as hydrochlorothiazide, are associated with increased risk of hyperuricemia and gout.
(u) C.

Clinical Intervention/Orthopedics/Rheumatology
A 22 year-old male presents several hours after sustaining a hand injury when he punched a wall. X-rays of the hand demonstrate fracture of the fifth metacarpal neck with 65 degrees dorsal angulation and a cl

Explanations
(u) A. Antibiotic treatment would be appropriate if the skin was broken and the injury was sustained in a fist fight with the potential for introduced oral flora.
(u) B. Reduction followed by splinting is recommended for fifth metatarsal frac

History & Physical/Orthopedics/Rheumatology
The neuromuscular hallmark of polymyalgia rheumatica is
A. asymmetric muscle pain and stiffness.
B. distal paresthesias.
C. muscle weakness.
D. proximal muscle pain and stiffness.

Explanations
(u) A. Polymyalgia rheumatica is associated with pain and stiffness but typically occurs in a symmetric distribution.
(u) B. Peripheral neurons are unaffected by polymyalgia rheumatica and is not associated with neuropathic symptoms.
(u) C. A

Diagnostic Studies/Orthopedics/Rheumatology
A 74 year-old male presents with one month history of right shoulder pain without any known precipitant. His pain involves an area from the right paraspinous musculature to the right deltoid with occasional radi

Explanations
(u) A. Although electromyography and nerve conduction studies would be helpful in localizing the nerves involved, this is not an appropriate first-line diagnostic test.
(u) B. Although there is pain in the shoulder, this patient presents with

History & Physical/Orthopedics/Rheumatology
A 30 year-old diabetic female complains of persistent numbness in her right thumb and forefinger that has been awakening her from sleep for the past week. She is right hand dominant and denies any history of act

Explanations
(u) A. EMG may be performed in a patient who is being considered for surgery.
(u) B. Nerve conduction test may be performed if operative intervention is being planned.
(c) C. The Phalen maneuver is used to reproduce the symptoms of carpal tun

Diagnosis/Orthopedics/Rheumatology Topic
A 42 year-old male sustained a closed left tibial fracture in a fall two days ago. He was treated with a cast for immobilization. Acutely, he developed severe pain in his left leg. Examination reveals the anterolat

Explanations
(c) A. One of the earliest signs of compartment syndrome is severe pain that occurs with extension of the involved muscles.
(u) B. DVT below the knee usually occurs in the posterior compartment and, while potentially painful, should not produ

Clinical Therapeutics/Orthopedics/Rheumatology
A 27 year-old male presents with gradually worsening low back pain and stiffness for the past two years. His symptoms are worse upon awakening and gradually improve throughout the day. Lumbosacral flexion is

Explanations
(c) A. NSAIDs, such as indomethacin, are the mainstay of therapy in ankylosing spondylitis (AS).
(u) B. Methotrexate is beneficial in treatment of rheumatoid arthritis, but there is little evidence that it changes the course of disease in ank

Health Maintenance/Orthopedics/Rheumatology
A 23 year-old male presents to the emergency department with severe right shoulder pain. He is holding his shoulder in internal rotation. Which of the following would increase your suspicion that he has a poster

Explanations
(u) A. This is a common mechanism for anterior glenohumeral dislocation.
(c) B. Tonic-clonic seizures can create severe contraction of the internal rotator muscles of the shoulder.
(u) C. This is a classic finding associated with anterior dis

cientific Concepts/Orthopedics/Rheumatology
A 33 year-old male presents to your office with a complaint of right knee injury associated with pain and swelling. He states he was running after his loose dog and suddenly stopped, hyperextended his knee, hear

Explanations
(u) A. Medial collateral ligament injuries often occur with rotational injuries or direct impact to the lateral knee. Tenderness medially with laxity with valgus (medial) stress is noted.
(u) B. Lateral collateral ligament injury causes pain

Diagnosis/Orthopedics/Rheumatology
A 60 year-old right hand dominant male presents to your office complaining of right shoulder pain and progressively worsening arm weakness. His symptoms are aggravated when working above the shoulder level. On physical e

Explanations
(c) A. Rotator cuff tears are associated with full passive range of motion but have pain and weakness during active abduction.
(u) B. Subacromial bursitis causes pain with raising hand above head and has mild degree of weakness.
(u) C. Adhesi

Health Maintenance/Orthopedics/Rheumatology
A 57 year-old male with history of hypertension presents with acute gouty arthritis. Which of the following anti- hypertensive classes should be avoided in this patient?
A. Thiazide diuretics
B. Beta-blockers
C.

Explanations
(c) A. Thiazide diuretics are common causes of increased urate levels causing gout attacks.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.

History & Physical/Orthopedics/Rheumatology
Bony and cartilaginous enlargement of distal interphalangeal joints is commonly seen in which of the following medical conditions?
A. Rheumatoidarthritis
B. Osteoarthritis
C. Psoriatic arthritis
D. Gouty arthrit

Explanations
(u) A. Findings in Rheumatoid arthritis include skin nodules, pannus formations and symmetric joint involvement sparing the distal interphalangeal joints.
(c) B. Heberden's nodes are commonly seen in primary osteoarthritis.
(u) C. Psoriatic a

Diagnostic Studies/Orthopedics/Rheumatology
A 26 year-old male was lifting a heavy object two weeks ago when he felt a sudden onset of low back pain. He describes pain in the low mid back at the belt line aggravated with movement. Radicular symptoms are n

Explanations
(u) A. See B for explanation.
(c) B. MRI is the diagnostic study of choice in a patient with suspected disc herniation.
(u) C. See B for explanation.
(u) D. See B for explanation.

Clinical Intervention/Orthopedics/Rheumatology
A 22 year-old male presents to the emergency department complaining of right hand pain after punching a brick wall. His pain is noted at the ulnar aspect of his hand and worsens with touch and movement. On ex

Explanations
(u) A. Fixation is warranted for displaced fractures, angulated fractures beyond 40 degrees, or extensor lag.
(u) B. A long finger splint would not immobilize the joint above and below and may not offer enough immobilization.
(c) C. An ulnar

Diagnosis/Orthopedics/Rheumatology
A 41 year-old male with a history of intravenous drug abuse presents to your office with acute, nontraumatic right knee pain, chills, and sweats starting 2 days ago. On physical examination, his temperature is 102.9 degr

Explanations
(u) A. See B for explanation.
(c) B. This patient's signs and symptoms are most consistent with septic arthritis. IV drug abuse places this patient at even greater risk.
(u) C. See B for explanation.
(u) D. See B for explanation.

Diagnostic Studies/Orthopedics/Rheumatology
A 62 year-old female presents to the emergency room with significant back pain without radiation after lifting a box weighing approximately 15 pounds. She denies any previous trauma or injuries. Past history inc

Explanations
(u) A. CT of the spine should be reserved for fractures that remain symptomatic or progress after treatment.
(u) B. MRI is a good tool in evaluation of union versus non union fractures and should be reserved for fractures that remain symptoma

Diagnosis/Orthopedics/Rheumatology
A 34 year-old female construction worker presents with episodic blanching of her fingers when exposed to cold weather. The physical examination of her extremities and digits is normal at this time. Which of the following

Explanations
(u) A. Sjogren syndrome is a secondary cause of Raynauds, but it is not the disorder causing the symptoms.
(u) B. Scleroderma is a secondary cause of Raynauds, but it is not the disorder causing the symptoms.
(c) C. Raynauds phenomenon is cau

Scientific Concepts/Orthopedics/Rheumatology
Which of the following types of hip fracture has the highest risk for avascular necrosis and nonunion?
A. Femoral neck
B. Intertrochanetric
C. Subtrochanteric
D. Greater trochanteric

Explanations
(c) A. Fractures involving the femoral neck typically disrupt the blood supply to the femoral head and may cause avascular necrosis and nonunion.
(u) B. Intertrochanteric fractures usually do not cause avascular necrosis and nonunion due to t

History & Physical/Orthopedics/Rheumatology
Which of the following histories best describes spinal stenosis?
A. Gradual onset of back and thigh pain exacerbated by walking and alleviated by sitting
B. Acute onset of low back pain with radiation of pain to

Explanations
(c) A. Spinal stenosis typically presents as back pain and thigh pain aggravated by ambulation and relieved by sitting.
(u) B. Spinal stenosis is gradual in onset and is improved by sitting.
(u) C. Spinal stenosis, unlike polymyalgia rheumati

Diagnosis/Orthopedics/Rheumatology
A 13 year-old female presents to the office with right knee and thigh pain and the inability to bear weight since waking yesterday morning. The mother states the child had a fever of 100.9 degrees F this morning and cont

Explanations
(u) A. Plain x-rays may aid in diagnostic suspicion, usually after a week or two, but do not aid in treatment choice.
(u) B. ASO titer is not indicated in a patient with osteomyelitis.
(u) C. MRI will detect the early inflammation of osteomye

History & Physical/Orthopedics/Rheumatology
A 14-year old male active in sports, has been complaining of intermittent anterior right knee pain for several months. He denies any specific injuries. On examination, there is no erythema, swelling, deformities

Explanations
(u) A. Discoid meniscus causes clicking over the lateral meniscus during flexion. This disorder is mostly painless and occasionally may cause mild aching or effusion.
(c) B. Osgood-Schlatter disease causes pain at the tibial tubercle and it i

Clinical Intervention/Orthopedics/Rheumatology
A patient is 12 hours post-closed reduction of a tibial fracture and is in a long leg cast. Despite pain medication the patient complains of unrelieved pain and cannot move his toes. Which of the following is

Explanations
(u) A. This measure may be used while the necessary equipment is obtained to bivalve the cast, but it will not treat the underlying condition.
(c) B. The cast for this patient is too tight and the pressure needs to be released. Bivalving the

Clinical Intervention/Orthopedics/Rheumatology
A 30 year-old female presents with left wrist pain after slipping on the ice while walking to her car. On examination, pain is noted on palpation over the anatomical snuff box. X-ray of her wrist shows no ide

Explanations
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Tenderness in the snuff box should be treated as a suspected scaphoid fracture. The patient should be treated as if it is fractured and placed in a splint with a referral to a

Clinical Therapeutics/Orthopedics/Rheumatology
A 25 year-old female with irritable bowel syndrome presents with complaint of upper and lower extremity discomfort. The patient has pinpoint muscle tenderness over the shoulder girdle, low back and hips. Whic

(u) A. Opioid medication is not effective in the treatment of fibromyalgia.
(c) B. Amitriptyline is the treatment of choice for fibromyalgia and is typically administered at bedtime.
(u) C. Methotrexate is not effective in treating fibromyalgia.
(u) D. NS

A 62 year-old male is brought to the emergency department with acute hematemesis. The patient denies a previous history of vomiting. His wife states he has chronic liver disease. Physical examination reveals a distended abdomen without rebound, guarding o

(c) A. Esophageal varices are dilated submucosal veins that develop in a patient with underlying portal hypertension. The most common cause of portal hypertension is cirrhosis.
(u) B. A patient with a Mallory-Weiss tear would have a history of retching bu

A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg to be cool to the touch and the toes to be cyanotic. The popliteal pulse is absent by palpation a

(u) A. See B for explanation.
(c) B. Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse.
(u)

A 3 year-old child playing in an abandoned shed is bitten by a black widow spider. The mother rushes the child to the emergency department within 20 minutes of the incident. Which of the following if the best initial intervention?
A. Intramuscular steroid

(u) A. The bite of this spider does not cause an inflammatory reaction; therefore, steroids are not indicated.
(u) B. Administration of antivenin should be administered to patients with severe envenomation manifested as seizures, respiratory failure, or h

A 30 year-old female presents to the emergency room having passed out at home 30 minutes prior to arrival. Her last menstrual period was 6 weeks ago and pregnancy test was reported positive 5 days ago. She started having vaginal bleeding last night. Vital

(u) A. Abdominal ultrasound is not the test of choice in this patient.
(u) B. Culdocentesis has been replaced by transvaginal ultrasound as diagnostic procedure for suspected ectopic pregnancy.
(c) C. Laparotomy is indicated with presumptive diagnosis of

A 24 year-old male presents to the emergency room via ambulance. He was found by the police walking naked on the highway. His speech is minimal but disorganized and he appears to be responding to auditory hallucinations. With further questioning, he is pr

(u) A. Schizophrenia occurs with the above symptoms of greater than six months duration.
(c) B. Schizophreniform disorder is characterized by the same features as schizophrenia except the total duration of the illness is at least one month and less than s

An 18 month-old female presents to the Emergency Department having possibly swallowed a hearing aid battery within the past hour. She is drooling and appears anxious but parents have noticed no stridor or dyspnea. She has no history of previous esophageal

(h) A. Batteries must be removed as they can induce mucosal injuries in as little as one hour of contact time.
(c) B. Esophagoscopy is the procedure of choice for acutely ingested foreign bodies.
(u) C. A barium swallow is a diagnostic option but will not

A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6

(c) A. High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain.
(u) B. Appendicitis presents with nausea, vomiting and periumbilical pain that moves to the right lower qua

A 26 year-old man presents to the emergency room complaining of shortness of breath, palpitations, and tingling of the lips and fingers. He appears anxious and describes a sensation of impending doom. His ECG and plain chest radiograph are normal. Which o

(u) A. These values are consistent with a respiratory acidosis.
(u) B. These values fall within the normal range.
(c) C. This patient is suffering an acute anxiety attack and resultant hyperventilation and respiratory alkalosis. Labs show alkaline pH, dep

An elderly appearing adult male patient is transported to the emergency room with unconsciousness for an underdetermined amount of time. There is no family and the only history is provided by the paramedics. The patient arouses to verbal and painful stimu

(c) A. Since the patient was found unconscious for an undetermined amount of time and the blood alcohol is elevated the patient has been in a state of prolonged immobilization resulting in muscle ischemia resulting in myoglobinuria. This is responsible fo

A stuporous patient is brought to the emergency room with a five day history of progressive lethargy and confusion along with polyuria and polydipsia. On examination the patient is dehydrated and is without Kussmaul respirations. Serum glucose is 1200 mg/

(u) A. The extreme hyperglycemia eliminates primary hyperaldosteronism as the primary diagnosis.
(u) B. The lack of acidemia, ketones and Kussmaul respiratory pattern help to eliminate this as the primary diagnosis.
(u) C. The lack of a Kussmaul respirato

A 23 year-old male being treated for an acute bacterial prostatitis has been taking antibiotics for less than 24 hours. He presents to the emergency room today with acute urinary retention for 12 hours. Which of the following is the most appropriate next

(h) A. Urethral catheterization, or any form of instrumentation is contraindicated in the presence of acute bacterial prostatitis.
(h) B. Diuretic therapy is contraindicated in the treatment of acute urinary retention.
(u) C. See A for explanation.
(c) D.

A patient is brought to the emergency room with acute onset of dyspnea and tachypnea. He has a long history of alcoholism and was involved in a motor vehicle accident two days ago. He is hypoxic with crackles auscultated bilaterally. Chest radiography rev

(c) A. Tracheal intubation with lowest level of PEEP is required to maintain the PaO2 above 60mmHg or SaO2 above 90% in a patient with ARDS.
(u) B. See A for explanation.
(u) C. Fluids are the preferred treatment initially for hypovolemia. Type-specific p

A 68 year-old male with a history of atrial fibrillation treated with warfarin (Coumadin) presents to the emergency department after vomiting large amounts of bright red blood. INR is 3. Which of the following is most appropriate to rapidly lower the pati

(u) A. This will not immediately reverse the effects of warfarin.
(c) B. Fresh frozen plasma is the most rapid way to lower the patient's INR.
(u) C. Protamine sulfate is used to neutralize heparin sulphate not warfarin.
(h) D. Heparin administration woul

A 25 year-old male presents to the emergency department for evaluation of a wound on his hand. He cut his hand while tearing down a chicken coop. On examination of his right hand you note a dirty 3cm jagged laceration. The patient is unaware of his tetanu

(c) A. Td or Tdap with TIG is recommended as tetanus prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.

An 18 year-old female with diabetes presents to the emergency department with altered level of consciousness, deep breathing and fruity odor to her breath. Which of the following medications is indicated for this patient?
A. NPH insulin
B. Metformin (Gluc

(h) A. NPH insulin has a slower onset of action than regular insulin, and should not be administered intravenously. Onset is 2-4 hours and in a patient with diabetic ketoacidosis the onset needs to be rapid.
(h) B. Metformin and glyburide are oral hypogly

A 49 year-old female presents complaining of several episodes of chest pain recently. Initial ECG in the emergency department shows no acute changes. Two hours later, while the patient was having pain, repeat electrocardiogram revealed ST segment elevatio

(c) A. This patient is most likely having coronary artery spasm. This can be treated prophylactically with calcium channel blockers such as nifedipine.
(h) B. Beta-blockers may exacerbate the symptoms of coronary vasospasm.
(u) C. ACE inhibitors are not e

A 6 year-old male, a recent immigrant from Latin America, is brought to the emergency department with difficulty swallowing and breathing. On physical examination you note a gray-tan pseudomembrane in the back of the pharynx. There is also tender cervical

(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Diphtheria most commonly presents with sore throat, adherent tonsillar, pharyngeal, or nasal pseudomembrane
and low grade fever. The pseudo-membrane is most specific for diphtheria.
(u) D.

A 25 year-old female with a history of diarrhea presents to the emergency department with Guillian-Barre syndrome. What is the most likely causative pathogen in this patient?
A. Shigella dysenteriae
B. Yersinia enterocolitica
C. Entamoeba histolytica
D. C

(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Campylobacter jejuni is a Gram-negative bacteria that has been linked to the subsequent development of Guillain-Barr� syndrome (GBS). GBS usually develops two

A 23 month-old male presents to the office with his father who reports the patient has had an acute onset of severe pharyngitis, fever of 103.5 degrees F and what sounds like harsh, high-pitched breath sounds. His dad states the child has started drooling

(h) A. See B for explanation.
(c) B. Epiglottitis requires endotracheal intubation to maintain the airway but should be performed only in the operating room or emergency room with a competent physician prepared to place an endotracheal tube or less often

A 55 year-old male with history of hypertension and diabetes mellitus presents to the emergency department. The patient's wife states that the patient developed progressive irritability and confusion today after complaining of a headache. Physical examina

(u) A. Resistant hypertension is the failure to reach blood pressure control in patients who are compliant with a 3 drug regimen including a diuretic.
(u) B. Hypertensive urgency is a systolic BP > 220 or a diastolic BP > 125 in a patient who is asymptoma

A 22 year-old male presents to the emergency department complaining of right hand pain after punching a brick wall. His pain is noted at the ulnar aspect of his hand and worsens with touch and movement. On examination, you notice obvious swelling and tend

(u) A. Fixation is warranted for displaced fractures, angulated fractures beyond 40 degrees, or extensor lag.
(u) B. A long finger splint would not immobilize the joint above and below and may not offer enough immobilization.
(c) C. An ulnar gutter splint

A 62 year-old female presents to the emergency room with significant back pain without radiation after lifting a box weighing approximately 15 pounds. She denies any previous trauma or injuries. Past history includes hysterectomy at age 42 and a 49 pack y

(u) A. CT of the spine should be reserved for fractures that remain symptomatic or progress after treatment.
(u) B. MRI is a good tool in evaluation of union versus non union fractures and should be reserved for fractures that remain symptomatic or progre

You are evaluating a 67 year-old Asian male in the emergency room for acute onset right eye pain. He states he was at the evening premier of a newly released movie when the pain started. He had acute, profound visual loss in the affected eye. The pain was

(u) A. The major risk from contact lens wear is bacterial, amebic, or fungal corneal infection, potentially a blinding condition. In this condition the eye may appear red, however the cornea would be clear, and the globe would not be tense.
(u) B. Past se

A 53 year-old man who had previously been in good health presents to the emergency department with a history of passing approximately 300 cc of bright red blood from the rectum 45 minutes ago. From which of the following anatomical sites is the bleeding m

(c) A. Rectosigmoid is the most common site leading to hematochezia.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.

A patient involved in a minor motor vehicle crash is brought to the emergency department by a family member who was riding in the car, but was unhurt. The family member states that the patient was unconscious for about 2 minutes,
but seems "okay" now. Wha

(c) A. A head CT scan would provide evidence of fractures and demonstrate intracranial hemorrhage and cerebral
edema if present.
(u) B. A lumbar puncture would not be immediately indicated, but if the patient worsens it might be a consideration.
(u) C. Sk

A 48 year-old alcoholic, whose last drink was 6 days ago, presents to the clinic complaining of palpitations and intermittent abdominal pain. On physical examination, blood pressure is 170/110 mm Hg, pulse 124/min, respirations 22/min, and temperature 100

(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. This patient is exhibiting the signs and symptoms of alcoholic withdrawal characterized by delirium, autonomic
hyperactivity, perceptual distortions, and fluctuating levels of psychomotor

A patient presents with chest pain. ECG done in the emergency department reveals ST segment elevation in leads II, III, and AVF. This is most consistent with a myocardial infarction in which of the following areas?
A. anterior wall
B. inferior wall
C. pos

(u) A. Anterior wall myocardial infarction is characterized by ST segment elevation in 1 or more of the precordial (V1-V6) leads.
(c) B. Inferior wall myocardial infarction is characterized by ST segment elevation in leads II, III, and AVF.
(u) C. Posteri

Which of the following may precipitate acute angle-closure glaucoma?
A. metoclopramide
B. timolol
C. glyburide
D. acetazolamide

(c) A. Metoclopramide and other drugs with high anticholinergic effects may precipitate acute angle-closure glaucoma from pupillary dilation.
(u) B. Timolol, a beta-antagonist, is used in the treatment of acute angle-closure glaucoma.
(u) C. Glyburide has

A 75 year-old man with a long history of COPD presents with acute onset of worsening dyspnea, increased
productive cough, and marked agitation. While in the emergency department he becomes lethargic and obtunded. His ABG's reveal a PaO2 40 mmHg, PaCO2 65

(u) A. Supplemental oxygen and positive pressure ventilation are inadequate for patients with overt respiratory failure.
(u) B. See A for explanation.
(c) C. This patient is in severe respiratory arrest with markedly impaired mental status; conventional m

A 36 year-old male developed a sore throat and was treated with IM penicillin. Within 20 minutes, he felt faint and became dyspneic. Upon entry to the emergency department, he was pale and apprehensive. He had a thready pulse, and systolic blood pressure

(u) A. Dopamine is not indicated in the treatment of allergic reactions.
(c) B. Epinephrine is the drug of first choice for emergency use and should be given as soon as anaphylactic shock is suspected or diagnosed.
(u) C. Hydrocortisone should be given as

A 17 year-old patient presents to the emergency department with agitation and hallucinations, and has one seizure. He admits to using "some drugs" but does not know what they were. On physical examination, temperature is 103 degrees F, BP 140/90, pulse 12

(a) A. Although a drug screen may identify specific drugs, the results will not alter the care of this patient.
(u) B. Urine dipstick is not sensitive for myoglobinuria.
(u) C. This patient is at risk for myoglobinuria, and a complete blood count will not

A 30 year-old female presents to the emergency department with a syncopal episode. She has a history of irregular menstrual cycles and infertility. She has scanty, persistent vaginal bleeding and sharp pelvic pain. A left adnexal mass is palpated. The mos

(u) A. This is primarily a third trimester cause of vaginal bleeding.
(c) B. Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis.

A known alcoholic presents to the emergency department with altered level of consciousness and a blood glucose level of 35 mg/dL. Which of the following best explains this glucose result?
A. Excess pancreatic insulin release
B. Rapid carbohydrate discharg

(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Alcohol-related hypoglycemia results from hepatic glycogen depletion and impaired gluconeogenesis and not due to antibody formation, excessive insulin release

A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg.

(h) A. Decreasing the oxygen flow rate would be harmful as it would decrease the amount of oxygen delivered to the patient.
(u) B. Administration of steroids is an important treatment modality but this patient is in respiratory failure and needs more imme

A 45 year-old female presents to the emergency department with generalized, hot, erythema of the skin. Physical exam reveals an oral temperature of 102 degrees Fahrenheit, purulent conjunctivitis, and mucosal erosions. Her skin is painful and separates fr

(c) A. Medications are most frequently implicated in toxic epidermal necrolysis. These usually include, analgesics (NSAIDs), antibiotics (Ampicillin) and anticonvulsants (Carbamazepine).
(u) B. Systemic glucocorticoids may be used early in the treatment o

A 26 year-old man is stung by a bee, and shortly thereafter, a wheal develops at the site of the sting. He soon feels flushed and develops hives, rhinorrhea, and tightness in the chest. He is seen in the urgent care center. Immediate therapy should be to

(u) A. Systemic (anaphylactic) reactions can rapidly become life-threatening. Delay in treatment may cause death.
(u) B. This is only supportive local therapy and does not address the need to treat the systemic reaction present.
(c) C. Epinephrine hydroch

A 26 year-old female arrives in the emergency department with friends who say she was standing in front of her church, dressed in a white bathrobe, claiming to be the Virgin Mary and handing out $100 bills to all passers-by. Her friends noted that she had

(c) A. Treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.). Lithium, valproate, and olanzapine are considere

A 19 year-old patient was involved in a motor vehicle crash and brought to the emergency department fully
immobilized. The patient sustained multiple blunt injuries to the chest and abdomen. During the trauma assessment, there was no blood at the urethral

(u) A. A retrograde urethrogram should be performed when blood is found at the external urinary meatus prior to insertion of a catheter.
(c) B. CT scan of the abdomen and pelvis is indicated in blunt trauma including those resulting in hematuria or when r

A 53 year-old male is seen in the emergency department following a motor vehicle collision in which his knee
impacted against the dashboard. The patient has a posterior knee dislocation that is promptly reduced in the
emergency department. The patient cur

(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. Compartment pressures are performed in cases of suspected compartment syndrome, not to determine the patency of the popliteal artery.
(c) D. The popliteal artery is at risk for injury when

A 74 year-old female is being treated for mild hypertension. She is found at home with right hemiparesis and brought to the emergency department. Her daughter states that the patient fell in her kitchen 2 days ago, but had no complaints at that time. She

(u) A. See B for explanation.
(c) B. This patient presents with a history of minor trauma and progressive neurological abnormalities consistent with subdural hematoma. Diagnosis would be confirmed by CT scan, which is less expensive and more sensitive for

A 22 year-old female presents to the emergency department with rapid heart rate. She appears quite thin and dehydrated. She denies that she is thin, stating "I am so fat that I can hardly stand myself! That is why I exercise every day." She runs twelve to

(u) A. Propylthiouracil is used to treat hyperthyroidism, not anorexia nervosa.
(u) B. Hormone replacement is not indicated for the amenorrhea of anorexia nervosa, but nutritional support may help.
(c) C. Anorexia nervosa requires a comprehensive, multidi

A mother brings her teenage daughter to the emergency department. The teenager is anxious, tremulous, and in a
dysphoric mood. She reports recent nightmares and insatiable hunger. Which of the following diagnostic tests would likely yield the most importa

(u) A. While hyperthyroidism can cause tremor and sometimes hunger, it is not associated with a dysphoric mood. It
also generally occurs in early adulthood.
(c) B. A drug screen would be helpful for many drugs of abuse that might cause these symptoms, but

A 58 year-old male who is otherwise healthy presents with chest pain and is found to have left main coronary artery stenosis of 75%. The most important aspect of his management now is
A. daily aspirin to prevent MI.
B. nitrate therapy for the angina.
C. a

(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Although medical therapy is important, revascularization is indicated when stenosis of the left main coronary artery is greater than 50%.

A 23 year-old sexually active female presents with a 4 day history of painless bilateral eye exudates which she
describes as copious. Visual acuity is 20/20, generalized conjunctival inflammation with sparing of the cornea is noted on physical examination

(c) A. With sparing of the cornea, as in this case, a single 1 gram IM dose of ceftriaxone is sufficient treatment for ophthalmic gonorrhea. If the cornea is involved, 5 days of IM ceftriaxone would be required.
(u) B. Polymixin is ineffective against gon

A patient presents with respiratory complaints. Chest x-ray reveals calcification of the hilar nodes with an eggshell pattern. Which of the following occupations is most consistent with these chest x-ray findings?
A. building demolitioners
B. coal miners

(u) A. Asbestosis is the most likely occupational risk and has an indistinct heart border appearance on CXR described as looking like "ground glass".
(u) B. The CXR of a coal miner consists of irregular opacities ranging from a reticular pattern to a nodu

A 26 year-old female required 12 units packed red blood cells during a trauma resuscitation and surgical repair of
liver and splenic lacerations. The patient is now 6 hours postoperative and has blood oozing from the suture line and IV sites. There is blo

(u) A. ABO incompatibility results in immediate hemolysis and shock.
(c) B. Disseminated intravascular coagulation is characterized by bleeding from many sites as all coagulation factors are consumed and then broken down, leading to decreased fibrinogen l

A 27 year-old G1P0 female presents complaining of painless spotting since this morning. She is known to be 12 weeks pregnant. Pelvic examination reveals the presence of blood within the vagina with a closed cervical os. The uterus is consistent with a 10-

(u) A. Vaginal bleeding and cramp-like lower abdominal pain are usually present in an inevitable abortion. The cervical os is also frequently partially open.
(c) B. Vaginal bleeding that occurs prior to the 20th week of gestation is classified as a threat

The most common pathogen identified in community acquired pneumonia (CAP) is
A. Mycoplasma pneumoniae.
B. Staphylococcus aureus.
C. Legionella pneumophila.
D. Streptococcus pneumoniae.

(u) A. M. pneumoniae, S. aureus, Legionella pneumophila are common pathogens for CAP, but do not account for a majority of the cases.
(u) B. See A for explanation.
(u) C. See A for explanation.
(c) D. S. pneumoniae accounts for a majority of cases of comm

A patient presents with abdominal pain. On deep palpation of the left lower quadrant the patient notes increased pain in the right lower quadrant. This is noted as a positive
A. Psoas sign.
B. Murphy's sign.
C. Rovsing's sign.
D. Obturator sign.

(u) A. A psoas sign is positive when the supine patient notes pain with flexion of the hip against resistance.
(u) B. A Murphy's sign is positive when the patient experiences abrupt cessation of deep breathing with palpation of the gallbladder.
(c) C. A R

A 28 year-old patient presents with complaint of chest pain for two days. The patient describes the pain as constant and sharp. It is worse with lying down, better with sitting up and leaning forward. Vital signs are BP 120/80, HR 80, regular, RR 14 and T

(u) A. Lower extremity edema is seen with heart failure or venous insufficiency, not pericarditis.
(u) B. Carotid bruits are associated with carotid artery stenosis, not pericarditis.
(c) C. This patient has signs and symptoms of pericarditis. A pericardi

A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is
strongly supported by the presence of
A. pulmonary edema.
B. wide pulse pressure.
C. distended neck veins.
D. an early diastolic murmur.

(u) A. Pulmonary edema may result with low output states as seen with myocardial contusions, but it is not strongly suggestive of tamponade.
(u) B. Wide pulse pressure is seen in conditions of high stroke volume such as aortic insufficiency or hyperthyroi

A 45 year-old female presents with complaint of lower extremity discomfort. The patient admits to dull aching of the left lower extremity. The discomfort is worse after standing for long periods of time. Examination reveals dilated, tortuous and elongated

(u) A. Heparin is used in the treatment of deep vein thrombosis not varicose veins.
(c) B. This patient has signs and symptoms of varicose veins. Initial treatment with compression stockings may prolong or avoid the need for surgery.
(u) C. This patient h

A 55 year-old male presents with complaint of sudden ripping chest pain that radiates into the abdomen. On
examination the patient is found to have diminished peripheral pulses and a diastolic murmur. EKG reveals left ventricular hypertrophy. Which of the

(u) A. Pain associated with a myocardial infarction is commonly a retrosternal pressure, squeezing, or heaviness. ST segment elevation on EKG would be expected.
(u) B. A pulmonary embolism is associated with retrosternal pain; however chest pain is not al

A 2 year-old child is brought to the office because of a cough and a fever of 102 degrees F for 2 days. The physician assistant notes the presence of hoarseness, a barking cough, and stridor. The ears and nose exam are
unremarkable. Auscultation of the ch

(u) A. Pneumonia would not produce the stridor noted on physical exam. Pneumonia would more than likely produce crackles, also not noted in this patient.
(u) B. Bronchiolitis would produce inspiratory wheezes which are absent in this patient.
(c) C. Hoars

Which of the following skin rashes is pathognomonic of rheumatic fever?
A. erythema marginatum
B. erythema nodosum
C. diffuse petechiae
D. purulent bullae

(c) A. Erythema marginatum is one of the major Jones criteria for the diagnosis of acute rheumatic fever.
(u) B. Erythema nodosum lesions are associated with many diverse causes including various infections, malignancies, drug sensitivities and inflammato

The first step in the treatment of a patient with an intestinal obstruction and no comorbid diseases is
A. nasogastric decompression.
B. invasive hemodynamic monitoring.
C. abdominal exploration.
D. administration of antibiotics.

(c) A. Nasogastric decompression is indicated in all but mild cases of obstruction to prevent distal passage of swallowed air and minimize distension.
(u) B. Invasive hemodynamic monitoring is needed only if the patient has underlying cardiac, pulmonary,

A 78 year-old patient who is in acute distress with near-syncope and lightheadedness is being examined. The
patient's pulse is 40/min and blood pressure is 90/56 mm Hg. Examination of the patient at 45 degrees of elevation
reveals cannon "a" waves. Which

(c) A. The patient is in a third-degree heart block with the atria contracting against a closed atrioventricular valve, which would be the scenario in a patient who has an escape rate of 40. Elderly patients are at risk for heart conduction problems such

A 19 year-old college student complains of a sore throat for over a week, with fever and general malaise. On exam T- 38 degrees C, P-70/minute, RR-20/minute, BP-110/76 mmHg. The skin is warm, dry, and without rash. The TMs have a normal light reflex and t

(u) A. Antibiotics are not indicated in the treatment infectous mononucleosis, or Ebstein-Barr virus (EBV) infections.
(u) B. See A for explanation.
(c) C. Acetaminophen may be used to treat fever and pain associated with infectious mononucleosis, or EBV

A patient is hospitalized with a change in mental status. Examination reveals that he is unable to maintain dorsiflexion of the wrists after pronating his arms in front of his body. Which of the following is the most likely diagnosis?
A. cocaine overdose

(u) A. Tremor and agitation are part of acute cocaine intoxication, not asterixis.
(u) B. Hyperthyroidism causes a fine resting tremor, not asterixis.
(c) C. This is the description for asterixis that is seen with hepatic encephalopathy, uremia, and carbo

A 20 year-old male presents with pain along the medial tibia. The pain initially began towards the end of soccer
practice but now it is present earlier on during practice. Physical exam reveals pain to palpation over the posterior
tibialis muscle body. Wh

(c) A. Shin splints cause pain over the posterior tibialis muscle body as opposed to discrete pain over the tibia with a stress fracture.
(u) B. See A for explanation.
(u) C. Osgood-Schlatter disease is an injury occurring at the insertion of the patellar

An 18 year-old female presents with 2-day duration of dysuria, vulvovaginal pruritis, and a frothy clear to white
discharge. Which of the following results would be expected?
A. clue cells on normal saline preparation
B. hyphae and budding yeast on a KOH

(u) A. Clue cells are seen in Gardnerella vaginalis infections, but the vaginal discharge is grayish and has an unpleasant fishy odor.
(u) B. Candida infections are diagnosed by demonstrating hyphae and budding yeast on KOH and usually present with a whit

A 36 year-old male has a history of recurrent low back pain. When lifting a stack of books yesterday, he experienced sudden, severe pain in the lumbar area. He denies radicular pain. His lower extremity examination is unremarkable, and his back examinatio

(u) A. The patient can be managed conservatively by a primary care provider since there are no neurological deficits.
(c) B. Continuation of activities as tolerated is recommended during the acute phase. After symptoms resolve, an exercise program should

Which of the following animals is the major cause of human rabies in the United States and, therefore, poses the highest risk?
A. bats
B. rabbits
C. rodents
D. dogs

(c) A. Bat rabies is found in practically every state and is the most common cause of human rabies in the U.S.
(u) B. Rabbits, rodents, and dogs are uncommon causes of human rabies in the United States.
(u) C. See B for explanation.
(u) D. See B for expla

Closure of the eyelids is mediated by which cranial nerve?
A. cranial nerve III
B. cranial nerve V
C. cranial nerve VII
D. cranial nerve IX

(u) A. Cranial nerve III is involved in extraocular movement and controls opening of the eyelids but has no control over closing the eyelids.
(u) B. Cranial nerve V controls the motor function of the temporal and masseter muscles and facial sensation. It

Which of the following is the most appropriate therapeutic agent for acute influenza?
A. azithromycin (Zithromax)
B. acyclovir (Zovirax)
C. tetracycline (Sumycin)
D. zanamivir (Relenza)

(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Zanamivir is an anti-viral agent that is active against the influenza virus.

A 23 year-old female presents with a 24-hour history of watery diarrhea, nausea and vomiting after returning from a cruise. On exam, the vitals reveal HR 120, BP 90/60, and RR 20. The abdomen is soft and non-tender, with hyperactive bowel sounds. Which of

(u) A. Loperamide is not indicated for acute infectious gastroenteritis in the vomiting patient.
(c) B. This is most likely a self-limiting viral gastroenteritis and is treated with hydration and supportive care.
(u) C. Bismuth sulfate is useful for treat

Which of the following is the treatment of choice for a nursing home patient who has asymptomatic bacteriuria with no history of diabetes or structural abnormalities of the genitourinary tract?
A. ciprofloxacin (Cipro)
B. sulfamethoxazole-trimethoprim (Ba

(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Asymptomatic bacteriuria is commonly seen in the geriatric population and no treatment is needed as long as the patient is not diabetic or has no structural a

A 68 year-old patient presents after a syncopal episode. The patient has a history of coronary artery disease and
ischemic cardiomyopathy. Echocardiogram shows an ejection fraction of 20%. Electrophysiology study reveals
inducible sustained ventricular ta

(c) A. Patients with symptomatic ventricular tachycardia (VT) or sustained VT and left ventricular dysfunction are at increased risk for sudden cardiac death. An implantable defibrillator is the treatment of choice.
(u) B. Beta blockers are used in patien

Which of the following is the most common cause of infective endocarditis in an IV drug abuser?
A. Haemophilus parainfluenza
B. Enterococci
C. Staphylococcus aureus
D. Viridans streptococci

(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. S. aureus accounts for more than 60% of all cases of endocarditis in IV drug abusers.
(u) D. See C for explanation.

A 3 year-old presents with a 24-hour history of diarrhea. The patient is afebrile and the stool is noted to be loose and watery. No blood is noted in the stool. Fecal WBC is negative. Which of the following is the most likely diagnosis?
A. viral gastroent

(c) A. Patients with viral gastroenteritis are afebrile and noted to have loose, watery, non-bloody diarrhea. Fecal WBC is negative.
(u) B. Toxic megacolon is a complication of ulcerative colitis and presents with diarrhea, fever, tachycardia, and leukocy

Which of the following is an expected finding in a patient with a diagnosis of an arterial embolism?
A. lower extremity edema
B. stasis dermatitis
C. palpable cord
D. pulselessness

(u) A. Lower extremity edema is commonly associated with venous insufficiency, not arterial embolism.
(u) B. Stasis dermatitis is commonly seen in patients with venous insufficiency, not arterial embolism.
(u) C. A palpable cord is commonly found in a pat

A 16 day-old male presents in the office with a history of vomiting after feeding for the past 2 days. The vomiting has become progressively worse and the mother describes it as very forceful, sometimes hitting the floor 6 feet away. She says the neonate

(u) A. Achalasia is uncommon under the age of 5 and the child presents with retrosternal pain and dysphagia.
(u) B. Tracheoesophageal fistula presents with increased secretions, choking, cyanosis, and respiratory distress within the first few hours of lif

A 55 year-old non-smoking male presents with a hemoglobin of 18.5 g/dl and a hematocrit of 56%. Which of the following physical examination findings is the most likely to be noted with this patient?
A. splenomegaly
B. cheilosis
C. purpura
D. decreased vib

(c) A. Patients with polycythemia vera present with elevated hemoglobin and hematocrit. On physical examination plethora, engorged retinal veins, and splenomegaly are common.
(u) B. Cheilosis is noted in iron deficiency anemia.
(u) C. Purpura is typically

A 23 year-old female complains of fever and genital pain. Examination reveals the presence of lymphadenopathy in the groin and the presence of vulvar vesicles surrounded by erythematous skin. The diagnosis may be confirmed by
A. A culture of a vesicle usi

(u) A. Herpes virus will not grow on blood agar medium.
(u) B. Herpes genitalis occurs in skin that comes into contact with the herpes virus. Usually the infection is localized.
(u) C. A Gram stain will not identify the herpes virus.
(c) D. A Tzanck smear

A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental pe

(c) A. Anticoagulation is the treatment of choice in patients with pulmonary embolism with normal ventricular function and no absolute contraindications.
(u) B. Embolectomy is not indicated as initial treatment of a pulmonary embolism in patients with nor

A blacksmith presents to your clinic after feeling like something went in his eye while he was grinding on a piece of metal. You stain the eye with Fluorescein and can visualize uptake with what appears like a deep abrasion. You are unable to visualize an

(u) A. Tetanus booster is only required every 5 years.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Intraoccular foreign body requires emergency treatment by an ophthalmologist. Patients giving a history of something hitting the eye,

A 13 year-old male with known cystic fibrosis presents to the emergency department, accompanied by his parents, with increased coughing, wheezing and low grade fever. Rales are audible on auscultation of the lungs. Treatment should target which of the fol

(u) A. Pneumocystis jiroveci is common in HIV patients, not patients with cystic fibrosis.
(u) B. Staphylococcus aureus and Haemophilus Influenzae often begin in the first few months of life even in asymptomatic infants with cystic fibrosis, but are less

A 26 year-old patient is brought to the emergency department after a head on collision. The patient complains of chest pain, dyspnea and cough. Examination reveals the patient to be tachypneic and tachycardic with a narrow pulse pressure. Jugular venous d

(u) A. Serial echocardiograms would be indicated if a patient had a small pericardial effusion and no intervention was immediately needed. This patient has signs and symptoms of cardiac tamponade and needs immediate intervention.
(c) B. Urgent pericardioc

A 55 year-old female presents to the emergency department with complaints of dyspnea, chest pain and coughing with hemoptysis. Past medical history includes breast cancer 5 years ago, currently in remission. Vital signs are Temp. 98.6 degrees F, BP 150/90

(c) A. Leg swelling and pain with palpation of the deep veins are consistent with a DVT and increase the likelihood of a PE.
(u) B. While a tachycardic rate may be present in a patient with a PE, it is not specific for a PE.
(u) C. While hemoptysis may be

A 45 year-old male presents to the Emergency Department complaining of sudden onset of tearing chest pain radiating to his back. On examination the patient is hypertensive and his peripheral pulses are diminished. Electrocardiogram shows no acute ST-T wav

(c) A. This patient has signs and symptoms of acute aortic dissection for which CT scan is the diagnostic study of choice.
(u) B. CT scan is better than transthoracic echocardiogram for the diagnosis of acute aortic dissection. Transesophageal echocardiog

A 25 year-old female with irritable bowel syndrome presents with complaint of upper and lower extremity discomfort. The patient has pinpoint muscle tenderness over the shoulder girdle, low back and hips. Which of the following medications is the most appr

(u) A. Opioid medication is not effective in the treatment of fibromyalgia.
(c) B. Amitriptyline is the treatment of choice for fibromyalgia and is typically administered at bedtime.
(u) C. Methotrexate is not effective in treating fibromyalgia.
(u) D. NS