Which of the following is not a relative contraindication to an arthrocentesis?
Anticoagulant usage
Bacteremia
History of arthrocentesis
Infection of the overlying skin
Prosthetic joints
Correct Answer ( C )
Explanation:
A history of a previous arthrocentesis (C) is not considered a contraindication to joint aspiration.
Known bacteremia (B) is considered a relative contraindication as are bleeding diatheses. Anticoagulation (A) use is con
Question: What is the most common source of septic arthritis?
Answer: Hematogenous spread.
Rapid Review
Arthrocentesis
Contraindications: overlying skin infection, bleeding diathesis, bacteremia
Ankle: medial to the anterior tibial tendon and directed toward the anterior edge of the medial malleolus.
Elbow: lateral
Which of the following clinical scenarios in a patient with chronic ethanol use should prompt admission to the hospital?
Fever, tachycardia, hypertension
Intoxication with vomiting
Mild tachycardia, tongue fasciculations
Normal vital signs, one seizure si
Correct Answer ( A )
Explanation:
The spectrum of illnesses related to chronic alcohol use is quite broad and frequently encountered in the ED. Acutely intoxicated patients are common in urban settings and require monitoring for clinical sobriety and safe
Question: Before what day of abstinence is it rare for delirium tremens to develop?
Answer: Day three.
Rapid Review
Ethanol Withdrawal
Autonomic hyperactivity (? HR, ? BP, diaphoresis)
Visual, tactile hallucinations
Seizures
Delirium tremens: autonomic hyperactivity, psychosis, peaks 2-5 days after cessation
Tremulousness ? hallucination
A patient presents with chest pain and the ECG seen above. Which of the following medications is contraindicated in this patient's management?
Aspirin
Clopidogrel
Heparin
Nitroglycerin
Correct Answer ( D )
Explanation:
This patient presents with an inferior ST elevation myocardial infarction (STEMI) and the use of nitroglycerin is relatively contraindicated in management. In patients with myocardial ischemia or infarction, nitrates are
Question: Which coronary artery most commonly supplies the inferior wall with blood?
Answer: The right coronary artery.
Rapid Review
Inferior ST-Elevation Myocardial Infarction
RCA occlusion
ST elevations: II,III, aVF
RV infarction
ST elevations: V4R and V5R
JVD, hypotension
Rx: IVF
NTG contraindicated
A 39-year-old man presents to the ED complaining of general weakness. He has signs of an upper respiratory infection on exam. His rhythm strip is seen above. Which of the following is the most appropriate next step in management?
Administer 325 mg aspirin
Correct Answer ( D )
Explanation:
The ECG denotes first degree AV heart block. This is due to prolonged conduction of atrial impulses without the loss of any single impulse. On the ECG, the PR interval will be >200 ms. This type of block is often a normal
Question: Are QRS complexes dropped in first degree heart block?
Answer: No, P wave conduction is delayed but not actually blocked, so no QRS complexes are dropped.
Rapid Review
Heart Block: First-Degree
Delayed AV node conduction
PR interval > 0.2 seconds
No specific rx
A 28-year-old woman who has been breastfeeding her baby for approximately 3 months visits her physician complaining of breast tenderness and fevers. After assessing the patient, the physician believes that she is experiencing mastitis. The patient is star
Correct Answer ( B )
Explanation:
This mother is experiencing mastitis and should be counseled to continue breastfeeding from the affected breast, which decreases the progression of mastitis to breast abscess. Nursing-associated mastitis typically occurs
Question: What is the preferred antibiotic treatment for mastitis infections?
Answer: Cephalosporins or dicloxacillin are the preferred antibiotics.
Rapid Review
Mastitis
Patient will be a breastfeeding mother
Complaining of breast erythema, tenderness, fever
Most commonly caused by Staph. aureus
Treatment is warm compresses, diclo
A patient experiences painless bright-red blood per rectum after bowel movements. Perianal examination reveals no abnormalities. You diagnose non-strangulated, large internal hemorrhoids, and then prescribe topical anesthetics and stool softeners. Three w
Correct Answer ( D )
Explanation:
Hemorrhoids can occur internally and externally. Internal hemorrhoids occur above the dentate line, and as such, do not cause cutaneous pain, but can still prolapse, bleed, become strangulated and necrotic, and cause peri
Question: Operative hemorrhoidectomy results in what rate of recurrence?
Answer: 2-5%.
Rapid Review
Hemorrhoids
Internal
Proximal to dentate line
Painless bleeding
External
Below dentate line
Visible
Painful
Initial rx: WASH (Water (sitz bath), Analgesics, Stool softeners, High fiber diet)
Thrombosed hemorrhoid rx: excision wi
Which of the following imaging studies is most appropriate to diagnose toxic megacolon?
Colonoscopy
Computed tomography
Plain radiography
Ultrasound
Correct Answer ( C )
Explanation:
Toxic megacolon is a complication of infectious colitis or inflammatory bowel disease and is potentially lethal. Patients with toxic megacolon present with signs of systemic toxicity and a nonobstructive colonic dilatatio
Question: True or false: Toxic megacolon most commonly affects young adults (aged 20-40 years)?
Answer: False.
Rapid Review
Toxic Megacolon
Most common cause: inflammatory bowel disease
Colon dilated > 6 cm on radiographs
Systemic toxcity
High risk of perforation
Rx: IVF, ABX, IV corticosteroids, emergent surgical consultation
A 32-year old woman and her 2 children present to your office with a 4-day history of intense itching that is worse at night. They specifically complain of pruritus under their arms and in between their fingers and toes. They deny any changes in household
Correct Answer ( C )
Explanation:
Based on the history and physical exam, this patient and her children most likely have scabies. Human scabies is an intensely pruritic skin infestation caused by the host-specific mite Sarcoptes scabiei hominis. Bite dist
Question: For non-crusted scabies, how should permethrin cream be applied?
Answer: Apply all over body overnight once and reapply in 14 days if mites are still present.
Rapid Review
Scabies
Patient will be complaining of severe pruritus that is worse at night
PE will show small papules, vesicles and burrows in the webbed spaces
A 60-year-old missionary woman is being evaluated for dementia. She also has diarrhea. She was recently treated for tuberculosis with isoniazid. Physical examination shows a symmetric hyperpigmented rash on both arms. Deficiency of which of the following
Correct Answer ( C )
Explanation:
A patient presenting with dementia, dermatitis, and diarrhea, who was recently treated with isoniazid, strongly suggests niacin (vitamin B3) deficiency. The most characteristic finding of niacin deficiency (pellagra) is t
Question: In addition to isoniazid, what other drugs can lead to niacin deficiency?
Answer: 5-fluorouracil, pyrazinamide, 6-mercaptopurine, hydantoin, ethionamide, phenobarbital, azathioprine, and chloramphenicol.
A woman in her second trimester of pregnancy develops a left lower extremity deep vein thrombosis. Which of the following is the most appropriate choice of anticoagulation for this patient?
Apixaban
Low molecular weight heparin
Unfractionated heparin
Warf
Correct Answer ( B )
Explanation:
Low molecular weight heparin is recommended at this stage of this woman's pregnancy for prevention of thromboembolism from her deep vein thrombosis. Pregnancy is a hypercoaguable state, and anticoagulation during pregnanc
Question: Which heparin should be avoided in patients with severe renal insufficiency?
Answer: Low molecular weight heparin is almost exclusively renally cleared and should be avoided with creatinine clearance < 30 mL/min.
Rapid Review
Deep Vein Thrombosis (DVT)
Patient with a history of smoking, long distance travel, surgery, oral contrace
A 70-year-old woman presents to your office with a complaint of difficulty having bowel movements. She tells you that she has a bowel movement every 2-3 days, the stool is hard and she has to strain. Which of the following is the most appropriate initial
Correct Answer ( B )
Explanation:
Constipation is a common complaint seen in the primary care setting and has a number of possible etiologies. Patients should be evaluated for systemic disorders or medications that may be causing the complaint. Once secon
Question: What is the recommended initial treatment in patients with severe constipation?
Answer: Suppositories.
A 29-year-old man presents with gradually worsening right testicular pain over the last four days. He is sexually active. On examination, his cremasteric reflex is normal. The testicle has a normal lie. There is tenderness focally over the epididymis. Whi
Correct Answer ( B )
Explanation:
Epididymitis is the most common inflammatory condition within the scrotum. The epididymis is a tubular structure on the posterior aspect of the testicle where sperm mature. The epididymis becomes infected when retrograde
Question: What is sign on physical examination associated with torsion of the testicular appendage?
Answer: Blue dot sign.
Rapid Review
Epididymitis
Patient will be complaining of gradual onset unilateral scrotal pain
PE will show increased color flow on doppler, relief with testicular elevation (Prehn's sign)
Most commonly caused by
< 35 yo: C. trachom
A 7-year-old girl with no past medical history presents with fever, cough and runny nose. She is well appearing with normal vital signs. Exam reveals clear lungs, nasal congestion and a red, bulging tympanic membrane. What treatment is indicated?
Ceftriax
Correct Answer ( C )
Explanation:
This patient presents with an upper respiratory infection and signs of an otitis media (OM). OM is the most common diagnosis made by US physicians in patients <15 years of age but is most common in children <36 months of
Question: What are the complications of otitis media?
Answer: Hearing impairment, TM perforation, labyrinthitis, facial nerve palsy, meningitis, extradural abscess, mastoiditis, and lateral venous sinus thrombosis.
Rapid Review
Acute Otitis Media
Patient will be an infant or young child
Complaining of ear pa
Which of the following is the most common type of migraine headache?
Basilar-type migraine
Migraine with aura
Migraine without aura
Ophthalmoplegic migraine
Correct Answer ( C )
Explanation:
Migraine headaches tend to be familial and affect women twice as often as men. The underlying pathophysiology is thought to be vasogenic inflammation. The first headache usually occurs in an individual in the teens or twe
Question: What is status migranosus?
Answer: A severe migraine headache that persists >72 hours. Associated symptoms are usually debilitating and hospitalization may be required.
Rapid Review
Migraine Headache
Gradual onset, unilateral > bilateral, throbbing, pulsating
First episode: < 30 ye
A 15-year-old boy presents to the emergency department with lower back pain. He reports heavy lifting three weeks ago, with gradual onset of pain and no relief with symptomatic care. The pain is localized to the paraspinal muscles over his lumbar back. He
Correct Answer ( A )
Explanation:
This patient has acute renal failure (ARF), exhibited by his elevated creatinine level. The common causes of ARF can be subdivided into three categories: prerenal, intrinsic renal, and postrenal. Intrinsic renal pathology
Question: Which disease is characterized by intrinsic acute renal failure, microangiopathic hemolytic anemia, and thrombocytopenia?
Answer: Hemolytic uremic syndrome (HUS).
A 35-year-old meat cutter comes to your office with persistent symptoms of nausea, vomiting, and diarrhea, which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His wife was sick during the first 2 days of the cruise with similar sym
Correct Answer ( C )
Explanation:
Recent reports of epidemics of gastroenteritis on cruise ships are consistent with Norovirus infections due to waterborne or foodborne spread. In the United States these viruses are responsible for about 90% of all epidem
Question: What population has a high fatality rate if infected with Hepatitis E?
Answer: Pregnant women during the second and third trimesters.
Rapid Review
Norovirus
Patient with a history of recent travel on a cruise ship
Complaining of nausea, vomiting, and diarrhea
Treatment is supportive
Comments: most common cause of viral gastr
A 28-year-old woman presents to your office complaining of three days of fever, odynophagia, trismus, and a gradual change in her voice. On examination of her oral cavity, you see an edematous, exudative tonsil with contralateral uvular deviation. She den
Correct Answer ( D )
Explanation:
This patient's history and physical is consistent with a diagnosis of peritonsillar abscess (PTA), which is a collection of microbial pustular fluid within the tonsil. Most often, peritonsillar abscesses affect children a
Question: What is the most commonly isolated pathogen from a peritonsillar abscess?
Answer: Streptococcus pyogenes.
A 63-year-old woman with a history of a recent viral upper respiratory infection presents with vertigo that started this morning after she woke up. Throughout the day, she experienced intense spinning associated with head movements. She reports nausea and
Correct Answer ( D )
Explanation:
Vertigo is a challenging chief complaint that can stem from the central nervous system or the peripheral nervous system. Vertigo is a perception of movement when there is none. Central vertigo is most often due to a cereb
Question: If vesicles are noted in the external ear canal of a patient with vertigo, what is the appropriate therapy?
Answer: Acyclovir for herpes zoster oticus (Ramsay Hunt Syndrome).
Rapid Review
Labyrinthitis
Patient with a history of recent upper respiratory infection
Complaining of sudden and persistent onset of vertigo and hearing loss lasting several days to a wee
A 17-year-old boy is seen in the clinic because of a skin lesion. He first noted a bump on his penis that became ulcerated. He denies any pain. He admits he is sexually active and has had multiple sexual partners. He denies the use of contraception. On ph
Correct Answer ( D )
Explanation:
A boy has a single, painless ulcer that is suspicious for primary syphilis. Syphilis is a chronic infection caused by the bacterium Treponema pallidum. Transmission of T. pallidum usually occurs via direct contact with an
Question: What is reported to be the most common ulcerative sexually transmitted disease in the US?
Answer: Genital herpes.
Rapid Review
Primary Syphilis
Patient will have been sexually active 2 to 3 weeks ago
Complaining of bump on his penis
PE will show painless, "punched out" lesion
Diagnosis is made by dark field microscopy
Most commonly caused by T
A 1-year-old boy is brought to the emergency department for severe abdominal pain, vomiting, and diarrhea. His mother says he has had several episodes of intermittent abdominal pain occurring about every 15 to 20 minutes. He appears to be in distress and
Correct Answer ( C )
Explanation:
The constellation of severe intermittent abdominal pain, vomiting, diarrhea, and a "sausage-shaped" abdominal mass most likely suggests intussusception. Intussusception refers to the invagination (telescoping) of a part o
Question: What chromosomal abnormality is Hirschsprung disease commonly associated with?
Answer: Down syndrome (trisomy 21).
Rapid Review
Intussusception (Telescoping Bowel)
Patient will be a child 5 months - 3 years old
Complaining of colicky abdominal pain, vomiting and bloody stools (currant jelly)
Diagnosis is made by ultrasound ("target
A 74-year-old man presents to the ED with chest pain radiating to the jaw and dyspnea. His past medical history is significant for hypercholesterolemia, hypertension and diabetes. He denies illicit drug use. His blood pressure is 210/122 mm Hg. Physical e
Correct Answer ( B )
Explanation:
A hypertensive emergency is a severe elevation in blood pressure with evidence of end-organ damage. This requires immediate lowering of blood pressure. There is no specific blood pressure at which hypertensive emergency o
Question: What is malignant hypertension?
An outdated term which has been replaced by hypertensive emergency.
Rapid Review
Hypertensive Emergency
Hypertension with acute end-organ system injury
Encephalopathy, cardiac ischemia, renal ischemia
Objectives: reduce MAP 25% in first hour, normalize BP
A 43-year-old man comes to the clinic complaining of a 3-week history of a "burning" sensation in his chest and nocturnal cough. He says he wakes up several times at night coughing and wheezing. He weighs 350-lbs and has a BMI of 48. If this patient's con
Correct Answer ( A )
Explanation:
This patient most likely has gastroesophageal reflux disease (GERD). GERD typically presents with heartburn, regurgitation, non-cardiogenic chest pain, and nocturnal cough. Complications from longstanding GERD can result
Question: What is the precursor lesion to the development of esophageal adenocarcinoma?
Answer: Barrett's esophagus.
Rapid Review
Esophageal Neoplasm
Patient will be a man
With a history of weight loss or chronic GERD
Complaining of progressive dysphagia to solid foods
Diagnosis is made by endoscopy with biopsy
Most common type adenocarcinom
A 6-week-old newborn is being evaluated for projectile vomiting and failure to thrive. The mother tells you the infant vomits immediately after every feeding. The vomitus appears to be nonbilious. Palpation of the right upper quadrant of the abdomen revea
Correct Answer ( D )
Explanation:
Nonbilious projectile vomiting in a 6-week-old newborn, is highly suggestive of infantile hypertrophic pyloric stenosis (IHPS). Pyloric stenosis is a narrowing between the distal portion of the stomach (pylorus) and the p
Question: What is the definitive form of treatment for infantile hypertrophic pyloric stenosis?
Question: What is the definitive form of treatment for infantile hypertrophic pyloric stenosis?
Answer: Surgery (pyloromyotomy).
Rapid Review
Pyloric Stenosis
Patient will be 2-6 weeks old
Complaining of nonbilious projectile vomiting after feeding and ea
A 32-year-old previously healthy man presents to the ED with a 4-hour history of palpitations. He denies chest pain, shortness of breath, or history of similar palpitations. He does admit to heavy alcohol use in the past week, drinking 1 pint of vodka and
Correct Answer ( B )
Explanation:
This patient has holiday heart syndrome, which can produce atrial fibrillation, atrial flutter, or atrial tachycardia after excessive alcohol use. Patients generally present with palpitations. The rhythm tends to spontane
Question: What type of cardiomyopathy is most common in patients who consume alcohol?
Answer: Dilated cardiomyopathy.
Rapid Review
Atrial Fibrillation
Observe when initiated by alcohol
Irregularly irregular
No P waves
Narrow QRS unless conduction block or accessory pathway
Unstable: cardioversion
Stable:
<48 hours duration: cardiovert to s
A 19-year-old man presents with headache and a peripheral cranial nerve seven palsy. He states that he was recently hiking in Connecticut and had numerous tick bites. What CSF finding is most sensitive for Lyme meningitis?
Borrelia burgdorferi antibody
De
Correct Answer ( A )
Explanation:
B. burgdorferi antibody is the most sensitive test for Lyme meningitis and will be present in 80-90% of patients. Lyme disease is the most common tick borne illness in the US. The disease is caused by Borrelia burgdorferi
Question: What is a Jarisch-Herxheimer reaction?
Answer: The onset of fever, myalgias, headache, tachycardia and tachypnea after initiation of antibacterial treatment of a spirochete illness.
Rapid Review
Lyme Disease
NE USA
Campers/hikers
Ixodes tick harbors Borrelia burgdorferi
Stage I: erythema migra
A 43-year-old man presents with pain, swelling, and redness to his left leg for 2 days. He denies fever or history of similar presentations in the past. He was hospitalized a month ago for 3 days. Vital signs are unremarkable. Physical examination reveals
Correct Answer ( D )
Explanation:
This patient presents with signs and symptoms of cellulitis requiring antibiotic treatment covering the most likely pathogens. Cellulitis is a soft tissue infection involving the skin and subcutaneous tissue. It is charac
Question: What are criteria for admitting a patient with cellulitis on outpatient antibiotics?
Answer: Failure to improve or worsening cellulitis after 48-72 hours of appropriate therapy.
Rapid Review
Cellulitis
Patient will be complaining of pain, redness, swelling
PE will show tenderness, erythema with poorly demarcated borders, lymphedema
Most c
What is the most likely underlying chronic medical problem in the patient with the following ECG?
Cardiomyopathy
COPD
Hyperthyroidism
Mitral stenosis
Correct Answer ( B )
Explanation:
This electrocardiogram demonstrates multifocal atrial tachycardia, a form of atrial tachycardia diagnosed on the electrocardiogram by three distinct p-wave morphologies. In approximately 60% of cases, patients have underl
Question: What is the treatment for multifocal atrial tachycardia?
Answer: Most commonly, treat the underlying cause which will often improve the dysrhythmia. Nodal agents are not as effective as in other dysrhythmias.
Rapid Review
Multifocal Atrial Tachycardia
Irregularly irregular
? 3 different P waves
Rate: 100-180
No
You have made a new diagnosis of polycystic kidney disease in one of your primary care patients. Proper maintenance of normal blood pressure should be obtained with which of the following medications?
Furosemide
Losartan
Metoprolol
Verapamil
Correct Answer ( B )
Explanation:
In a patient with polycystic kidney disease, the development of hypertension signifies disease progression. Therefore, it is clinically necessary to maintain proper blood pressure in these patients. Target levels for adul
Question: What is the recommended treatment protocol for acute pyelonephritis/cyst infection in those with polycystic kidney disease?
Answer: Hospital admission, blood and urine cultures and intravenous fluoroquinolones.
Rapid Review
Autosomal Dominant Polycystic Kidney Disease
Autosomal dominant
Bilateral cysts ? progressive renal failure
Flank pain
Hematuria
HTN ? berry aneurysm, intr
A 32-year-old man presents to the office with a rash on both of his hands. The rash appeared a couple days after completing yard work. He wore gloves while working and reports no similar rashes in household contacts. There are pink patches with multiple t
Correct Answer ( B )
Explanation:
Dyshidrotic eczema is an intensely pruritic, chronic recurrent dermatitis, typically involving the palms and soles. It starts as an episode of intense itching, followed by the formation of small vesicles. The vesicles are
Question: What is the recommended treatment for dyshidrotic ecematous dermatitis?
Answer: Steroids can be administered topically, intralesionally or systemically depending on the severity. PUVA (psoralen and UVA light) may also be beneficial.
Rapid Review
Dyshidrotic Eczema
Patient will be complaining of intense pruritus on their palms
What is the most common cause of lens opacity?
Cataract
Glaucoma
Hyphema
Optic neuritis
Correct Answer ( A )
Explanation:
Nuclear sclerosis cataract is the most common cause of lens opacity. Cataracts are common and, as a result, cataract surgery is the most common U.S. surgery performed. A cataract causes opacity to the lens that decreases
Question: Which condition is associated with bilateral central vision loss and is the leading cause of permanent blindness in the elderly?
Answer: Macular degeneration.
Rapid Review
Cataract
Opacity of lens
Painless blurred vision
Treatment is surgical
You are called to examine a one-week-old boy in the ED for seizures. At home, the mother noticed jittery bilateral leg movements that cannot be stopped when the legs are held. The neonate was born full-term to a 25-year-old G2, P2 mother with limited pren
Correct Answer ( C )
Explanation:
The infant has an abnormal facie that presents with seizures, which is suspicious for DiGeorge syndrome. This disorder arises from a failure of migration of neural crest cells into the third and fourth pharyngeal pouches.
Question: In hypocalcemia, what do you give to stabilize the heart?
Answer: Calcium gluconate.
Rapid Review
DiGeorge Syndrome
Patient with a history of congenital heart disease
Complaining of recurrent infections
PE will show hypoplasia of thymus and parathyroids
Labs will show hypocalcemia
CXR will show absent thymic sha
A 23-year-old man presents with leg pain for 3 months and requests hydromorphone for pain. The nurse approaches you because she believes the patient is "drug seeking" as he became extremely upset when she told him that he would have to wait for the doctor
Correct Answer ( B )
Explanation:
This patient exhibits a number of features typically seen in borderline personality disorder. Borderline personality disorder is characterized by unstable relationships, self image and affect. This instability is often ma
Question: Which of the personality disorders are associated with an increased risk of suicide attempts?
Answer: Borderline and histrionic personality disorders.
Rapid Review
Borderline Personality Disorder (BPD)
Cluster B personality disorder
F > M
Splitting
Unstable mood and relationships
Self-mutilation, ? suicide risk
A 27-year-old man with a history of asthma presents to your office for his annual exam. He reports that in the past month he has experienced wheezing and shortness of breath about once per week which resulted in using his rescue inhaler. He woke up once b
Correct Answer ( A )
Explanation:
Asthma severity is determined by monitoring patient symptoms over the past 2-4 weeks, determination of the patient's current lung function and number of asthma exacerbations that require oral glucocorticoids each year. A
Question: What treatment is recommended for asthma classified as mild persistent?
Answer: Daily low-dose inhaled glucocorticoid.
Which of the following is contraindicated in children with bloody diarrhea and no confirmatory infection by stool culture?
Antibiotics
Blood transfusion
Hemodialysis
Intravenous fluid hydration with normal saline
Correct Answer ( A )
Explanation:
Antibiotics and antidiarrheal agents should be avoided in children who have hemorrhagic diarrhea because both agents may increase subsequent risk of developing HUS. Hemolytic uremic syndrome (HUS) is characterized by the
Question: What clinically distinguishes hemolytic uremic syndrome (HUS) from thrombocytopenic thrombotic purpura (TTP)?
Answer: HUS causes less change in mental status and more renal dysfunction. Patients with HUS tend to be younger, and onset is associated with bacterial gastroenteritis.
Rapid Review
TTP/HUS
HUS:
E. coli O157:H7
Autoimmune hemolysis, Renal failure, Thromb
Which of the following describes a burn that causes pressure and discomfort, extends into the dermis, and may have thick-walled blisters or be leathery white?
First-degree burn
Second-degree deep partial thickness burn
Second-degree superficial partial th
Correct Answer ( B )
Explanation:
Burn classification is based on burn depth. Second-degree burns are classified into superficial and deep partial-thickness burns. Deep partial-thickness burns extend into the reticular dermis. Skin color is usually a mixt
Question: Can succinylcholine be used for rapid sequence intubation in an acute burn patient?
Answer: Yes. The concerning change in muscle receptors that occurs from burns takes place over 7-10 days after the burn.
Rapid Review
Thermal Burns
Fire: obtain CO levels
Industrial or house fire: suspect CN toxicity
Superficial: similar to sunburn
Superf
A 67-year-old woman presents with severe unilateral pain in her face and head. She characterizes the symptoms as lasting only a few seconds and denies any associated nausea, vomiting, dizziness, or blurry vision. Her Head, Eye, Ear, Nose and Throat Exam (
Correct Answer ( B )
Explanation:
Trigeminal neuralgia manifests with unilateral facial pain characterized as lancinating paroxysms of pain in the lips, teeth, gums, and chin. The pain is often associated with triggers such as chewing, brushing the teeth,
Question: What is the medical treatment for patients with trigeminal neuralgia?
Answer: Carbamazepine (primary) or gabapentin (secondary).
Rapid Review
Trigeminal Neuralgia
Sudden unilateral paroxysms of pain in gums, cheek, chin, temporal forehead
Pain in V2 and V3 distributions, not V1
Right side > left side
Triggers: chewing, brus
An 8-year-old boy presents with a complaint of excessive thirst and urination. His mother comments that he sleeps "all the time". Which of the following test result scenarios is needed to make a diagnosis of type 1 diabetes mellitus?
Fingerstick glucose >
Correct Answer ( C )
Explanation:
Diabetes mellitus type 1 (DM1) is a condition of glucose dysregulation and hyperglycemia. It is due to an autoimmune attack on the pancreatic beta-cells. Onset usually occurs in childhood, but can also occur in adults age
Question: A focused diabetic physical examination must include, at minimum, evaluation of which areas?
Answer: Vital signs (autonomic neuropathy), fundoscopy (retinopathy) and feet (diminished pulses, neuropathy).
Rapid Review
Diabetes Mellitus Type 1
Autoimmune destruction of ? cells
<30 years old
Polyuria, polydipsia, weight loss
DKA
Insulin always neces
A 30-year-old woman with no past medical history presents to the emergency department complaining of substernal chest pain for two hours. It is not worse with exertion and was not relieved by sublingual nitroglycerin. She admits to some mild nausea. She d
Correct Answer ( C )
Explanation:
Reassurance is most appropriate for this patient as her pretest probability for coronary heart disease it is very low. An initial estimate of the likelihood of coronary heart disease is referred to as the pretest probabil
Question: What is the goal heart rate during an treadmill exercise stress test?
Answer: Goal= 85% of maximum predicted heart rate [220 - patient age].
A 16-year-old male presents with a sore throat, adenopathy, and fatigue. He has no evidence of airway compromise. A heterophil antibody test is positive. Appropriate management includes which one of the following?
A corticosteroid
An antiviral agent
Avoid
Correct Answer ( C )
Explanation:
Infectious mononucleosis presents most commonly with a sore throat, fatigue, myalgias, and lymphadenopathy, and is most prevalent between 10 and 30 years of age. Both an atypical lymphocytosis and a positive heterophil an
Question: Infectious mononucleosis is causes by which virus?
Answer: Epstein Barr Virus (EBV).
Rapid Review
Infectious Mononucleosis
Patient will be complaining of low-grade fever, headache, malaise, severe fatigue
PE will show mildly tender lymphadenopathy involving the posterior cervical chain, hepatosplenomegaly
A 55-year-old woman with a history of chronic bronchitis presents to the ED concerned about the appearance of her left eye. She denied a change in vision or any discomfort but is concerned because she noticed "blood in my eye" this morning. Evaluation of
Correct Answer ( D )
Explanation:
The patient has a subconjunctival hemorrhage. This usually occurs with trivial events such as coughing or sneezing, Valsalva maneuver, or minor blunt trauma. The hemorrhage appears flat and is limited to the bulbar conjun
Question: What injury can occur if Hemoccult drops are instilled in the eye?
Answer: Severe alkali burns can occur.
Rapid Review
Subconjunctival Hemorrhage
Coughing, sneezing, minor trauma
Under conjunctiva and stops at limbus
Reassurance
A 35-year-old woman with a known history of seizure disorder is actively seizing in the ED. Which of the following is the first-line medication and route to treat her seizure?
Intramuscular fosphenytoin
Intravenous midazolam
Oral lorazepam
Rectal diazepam
Correct Answer ( B )
Explanation:
In an actively seizing patient, attention is always directed to the airway first. A patient having a generalized tonic-clonic seizure has a suppressed gag reflex and is prone to aspiration of gastric contents. Therefore,
Question: How long until the onset of action of phenobarbital?
Answer: The onset of action is 15-30 minutes.
Rapid Review
Status Epilepticus
Seizure lasting > 5 minutes or > 2 discrete seizures without recovery of consciousness
Causes: antiepileptic therapy discontinuation, medication noncompliance
BZDs, phenytoin (s
A mother brings her 7-year-old boy into the clinic. She reports that the child has been complaining of fatigue, headache and myalgias since he returned home from a camping trip with his father. His mother points out an annular rash with central clearing o
Correct Answer ( A )
Explanation:
Amoxicillin is the first line treatment of Lyme disease in children. Early disease usually occurs a few days to one month after an Ixodes tick bite and is typically characterized by an erythema migrans skin lesion with or
Question: What is the name of the spirochete that causes Lyme disease?
Answer: Borrelia burgdorferi, which is transmitted by the Ixodes tick.
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Lyme Disease
NE USA
Campers/hikers
Ixodes tick harbors Borrelia burgdorferi
Stage I: erythema migrans (pathognomonic), viral-like syndrome
Stage II: arthritis, myocarditis
What is the etiologic agent that causes erysipelas?
Haemophilus influenzae
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pyogenes
Correct Answer ( D )
Explanation:
Erysipelas is a bacterial skin infection involving the upper dermis that characteristically extends into the superficial cutaneous lymphatics. Lymphatic involvement often is manifested by overlying skin streaking and regi
Question: What is the treatment for erysipelas for patients whom are allergic to penicillin?
Answer: A first-generation cephalosporin or macrolide, such as erythromycin or azithromycin, may be used if the patient has an allergy
A 42-year-old man presents to the Emergency Department with nausea, vomiting, and right upper quadrant abdominal pain. He drinks alcohol daily. Which of the following laboratory results would be most consistent with alcoholic hepatitis?
Alkaline phosphata
Correct Answer ( C )
Explanation:
Acute hepatitis can be the result of an infectious process (most commonly viral), toxic injury, or alcohol. Alcoholic hepatitis can range from subclinical disease to acute liver failure. Patients present with nausea, vomi
Question: Which hepatitis is caused by a defective RNA-containing virus?
Answer: Hepatitis D (delta).
A 52-year-old obese man presents to your office with a complaint of right foot pain. He admits that his alcohol consumption has been increasing over the past 5 years and he frequently eats "surf and turf" at his favorite restaurant. He takes daily aspirin
Correct Answer ( C )
Explanation:
Gout is characterized by recurrent attacks of inflammatory arthritis due to deposition of monosodium urate crystals. Risk factors for gout include male sex, increasing age, alcohol consumption, obesity, hyperlipidemia, di
Question: What medication is used to prevent attacks of recurrent gouty arthritis?
Answer: Allopurinol.
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Gout
Patient will be a middle-aged man
Complaining of acute onset of pain in the first MTP (Podagra)
Labs will show needle-shaped crystal with negative birefringence
Most commonly caused by uric acid crystals
Treatment is
Which of the following statements is true regarding gestational diabetes?
Gestational diabetes eventually evolves into Type 2 diabetes
Glitazones are the first line treatment
Preliminary screening is a blood glucose >130 one hour after a 50 gram glucose l
Correct Answer ( C )
Explanation:
Screening for gestational diabetes (GDM) is performed between 24 and 28 weeks' gestation with a 50-g oral glucose load and blood glucose measured 1 hour later (abnormal >130 mg/dL). Screening for GDM also identifies women
Question: What is the most concerning complication of a newborn born to a diabetic mother?
Answer: Hypoglycemia.
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Gestational Diabetes Mellitus
Screening between 24 and 28 weeks with 50 g glucose load (abnormal: glucose >130 mg/dL after 1 hr)
Diagnostic criteria:
Random glucose > 200 mg/DL on 2 separate occasions or
Fasting glucose
A newly diagnosed type 1 diabetic complains of severe dyspnea. The patient is diagnosed with acute bacterial pneumonia, admitted to the hospital, and started on antibiotic therapy. During the second day of admission, he develops mental status changes, inc
Correct Answer ( A )
Explanation:
The patient is suffering from diabetic ketoacidosis (DKA), which is most commonly seen as a complication of type 1 diabetes, but also can occur in ketosis-prone type 2 diabetes. Precipitants include infection, exogenous s
Question: What are three common forms of diabetic neuropathy?
Answer: Autonomic (gastroparesis, orthostasis, constipation), acute mononeuropathy (CN palsy, foot drop) and distal, symmetric, sensory > motor peripheral neuropathy.
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Diabetic Ketoacidosis
Caused by precipitating factor in known diabetic
Hype
Which of the following describes a grade 3 ankle sprain?
Complete ligamentous rupture with concomitant distal fibular fracture
Complete ligamentous rupture with considerable swelling, pain, and significant laxity
Partial tear with mild laxity and moderate
Correct Answer ( B )
Explanation:
Grade 3 sprain is a complete rupture resulting in considerable swelling, increased pain, significant laxity, and often an unstable joint. Ankle sprain involves stretching or tearing of the ligaments of the ankle. There ar
Question: High ankle sprains involve a partial tear of which ligament?
Answer: Syndesmosis.
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Ankle Sprain
Partial or complete tearing of ? 1 ligaments
Most often due to inversion mechanism
Anterior talofibular ligament (ATFL) most commonly sprained
Grade I: microscopic tear, Grade II: incomplete tear, Grade III:
Which of the following clinical findings differentiates rheumatoid arthritis from osteoarthritis?
Involvement of the proximal interphalangeal (PIP) joints
Polyarticular involvement
Presence of constitutional symptoms
Symmetric joint involvement
Correct Answer ( C )
Explanation:
Osteoarthritis (OA) and rheumatoid arthritis (RA) share a number of features but constitutional symptoms are only seen in RA. RA is a chronic inflammatory disease. Patients often present with fever, weakness and musculosk
Question: What are the unique laboratory findings of pleural effusions associated with rheumatoid arthritis?
Answer: Low glucose, low pH and high LDH.
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Rheumatoid Arthritis
Women in 20s/30s
AI destruction of synovial joints
Morning stiffness lasting > 30 minutes
MCP, PIP
Bilateral ulnar deviation at MCP
Baker's cyst
Systemic sx
Lung: interstitial fib
A 19-year-old Hispanic man with a body mass index of 32 kg/m2 presents to your office with a complaint of darkened skin. Physical exam reveals thickened, velvety, darkly pigmented plaques on the back of his neck. Which of the following is the most appropr
Correct Answer ( B )
Explanation:
Acanthosis nigricans is a dermatologic condition characterized by darkened plaques, most commonly in the intertriginous sites such as the axillae or neck. A significant percentage of patients who are obese or have diabete
Question: Which type of malignancy is most associated with malignant acanthosis nigricans?
Answer: Gastric cancer.
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Acanthosis Nigricans
Patient will be obese or diabetic
PE will show thickened, velvety, darkly pigmented plaques on the neck or axillae
Comments: Screen for diabetes in those not yet diagnosed
Which of the following is the most common congenital heart defect?
Atrial septal defect
Coarctation of the aorta
Patent ductus arteriosus
Ventricular septal defect
Correct Answer ( D )
Explanation:
Ventricular septal defect (VSD) is most common, responsible for 25% of all congenital heart defects. Most are small and close spontaneously over time. However, larger lesions may persist, eventually leading to pulmonary h
Question: What syndrome is associated with a VSD that results in right-to-left shunting?
Answer: Eisenmenger syndrome. Progressive high pulmonary vascular pressure alters flow from left to right through the VSD to right to left, leading to cyanosis.
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Acyanotic Congenital Heart Disease
ASD: fixed split S2
VSD: most common congenita
A 30-year-old man with ankylosing spondylitis presents for a routine physical. This is the first encounter that you appreciate a murmur during cardiac auscultation. You appreciate a diastolic, high pitched, blowing murmur while listening with the diaphrag
Correct Answer ( A )
Explanation:
The murmur of aortic regurgitation is best heard with the diaphragm in the left sternal border. It can be accentuated when a patient sits and leans forward. This is a diastolic murmur, as compared to the systolic stenotic
Question: What is an Austin-Flint murmur?
Answer: A variant of aortic regurgitation, the Austin-Flint murmur is best heard with the bell at the apex, is more low-pitched and rumbling, and can be presystolic or mid-diastolic.
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Aortic Regurgitation
Acute MCC: endocarditis
Chronic MCC: r
A 20-year-old woman presents with weakness in her left wrist. She states that she fell asleep in a chair after a night of heavy drinking. On physical examination, she is unable to extend her wrist. What nerve is compromised?
Axillary nerve
Median nerve
Ra
Correct Answer ( C )
Explanation:
This patient presents with a wrist drop caused by radial neuropathy also called "Saturday Night Palsy." The radial nerve arises from the C5-T1 roots. It controls extension of the fingers, thumb, wrist and elbow. Symptoms
Question: What upper extremity fracture often compromises the radial nerve?
Answer: Humeral shaft fracture.
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Peripheral Neuropathies
Sciatic: buttock injury, hip dislocation, ? knee flexion, foot drop, rx: ankle splint
Common peroneal: proximal fibula injury, footdrop, rx: ankle splint
Radial: crutches, wrist/finger d
A 25-year-old sexually active woman presents to the Emergency Department with a complaint of painful vulvar ulcers and a swollen inguinal lymph node. She denies dysuria and vaginal discharge. Which of the following is most consistent with the description
Correct Answer ( A )
Explanation:
Chancroid is a common sexually transmitted disease in developing nations, but is relatively rare in the United States. Chancroid is caused by Haemophilus ducreyi, a gram negative bacillus, which has an incubation period o
Question: Which organism causes condyloma latum?
Answer: Treponema pallidum (syphilis).
A 60-year-old man with a history of peptic ulcer disease presents to your office with a complaint of intense pruritus after showering. Physical exam reveals splenomegaly and injection of bilateral conjunctivae. Laboratory findings include elevated hemoglo
Correct Answer ( C )
Explanation:
Polycythemia vera is a bone marrow disease that causes chronic myeloproliferative neoplasms. Other diseases in this category include chronic myelogenous leukemia and essential thrombocytopenia. Patients often present with
Question: How long do patients with untreated polycythemia vera generally survive?
Answer: 6-18 months from time of diagnosis.
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Polycythemia Vera
Patient will be complaining of headache, dizziness, pruritus after showering
PE will show hypertension, splenomegaly
Labs will show increased RBC mass, overproduction of all cell l
Which of the following diagnostic studies has the highest sensitivity to evaluate for acute radiculopathy?
Cerebrospinal fluid analysis
Electromyography
Magnetic resonance imaging
X-ray
Correct Answer ( C )
Explanation:
Magnetic resonance imaging (MRI) should be performed when evaluating for acute radiculopathy because it is the most sensitive diagnostic tool for a herniated nucleus pulposus or other intraspinal pathology. Radiculopathy
Question: In CSF analysis, what does xanthochromia indicate?
Answer: Red blood cells in the subarachnoid space.
A previously healthy 35-year-old woman presents to your clinic with questions about breast cancer screening. She has no family history of breast cancer and wants to know when she should start screening. Per the United States Preventive Services Task Force
Correct Answer ( C )
Explanation:
Screening guidelines for cancer are developed after consideration of a number of factors including the benefits and harms of screening, scientific evidence of the risks of the condition and cost. Guidelines for breast can
Question: At what age should breast cancer screening for women without risk factors stop?
Answer: 74 years.
A ten-year-old girl presents with drooping eyelids for the past month. The patient reports some difficulty completing her schoolwork due to blurry vision and hand weakness. On initial observation, her exam is notable for bilateral ptosis. Which of the fol
Correct Answer ( A )
Explanation:
Antibodies to the acetylcholine receptor are the most common cause of myasthenia gravis. Myasthenia gravis is a chronic, autoimmune disease characterized by fatigue of striated muscle. The first clinical signs are ptosis
Question: Infants of mothers with myasthenia gravis are at risk for which disease?
Answer: Transient neonatal myasthenia gravis.
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Myasthenia Gravis
Patient will be complaining of proximal muscle weakness, ptosis, diplopia that is worse at the end of the day
PE will show ice test improves sx
Diagnosis is made by edrophonium (
Which of the following statements is true regarding the condition associated with the ECG seen above?
Pain is often relieved in the supine position
The ECG is the most reliable diagnostic tool
Thrombolytic therapy is a potential treatment
Ventricular dysr
Correct Answer ( B )
Explanation:
The ECG is representative of acute pericarditis. This may be difficult to distinguish from the ECG seen with acute MI, coronary artery spasm, or benign early repolarization. Although there is no single test that is diagno
Question: What is the most common cause of pericarditis?
Answer: Idiopathic.
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Acute Pericarditis
Idiopathic > viral (Coxsackie)
Pleuritic chest pain radiating to the back
Pain ? with leaning forward
Pericardial friction rub
ECG: diffuse STE, PR depression
NSAIDs
A 28-year-old man with a history of left renal agenesis presents to the Emergency Department with sudden onset right flank pain. Vital signs are BP 140/70 mm Hg, HR 107, RR 18, and T 98.1�F. Urinalysis is negative for nitrites and leukocyte esterase, but
Correct Answer ( C )
Explanation:
Urinary calculi are a common condition presentation to Emergency Departments. There is a 2:1 male predominance and the first episode usually occurs between 20 and 50 years of age. The majority of renal calculi are compose
Question: Which type of renal calculus is radio translucent?
Answer: Uric Acid stones.
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Nephrolithiasis
Patient will be complaining of flank pain radiating to groin
PE will show a patient that won't lay still and hematuria
Diagnosis is made by helical CT
Most commonly caused by calcium oxalate
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