Emergency Medicine Practice Exam 1: Part 2 of 4

Shifting dullness: free ascitic fluid moves to the dependent side, so the border between tympany and dullness shifts when the patient rolls over, while gas-filled bowel floats to the top. It is one of the more sensitive bedside signs of ascites, but ultrasound is the most accurate way to confirm it.

Board-Level Insight: For new ascites, do a diagnostic paracentesis. A serum-ascites albumin gradient (SAAG) of 1.1 g/dL or more means portal hypertension, most often cirrhosis.

Why the other options are wrong:

• To shift the internal organs so percussion is easier: Turning the patient moves free fluid, not solid organs; that movement of fluid is what the test detects.
• To elicit pain with movement: Pain with movement suggests peritonitis, not ascites.
• To bring out caput medusae: Caput medusae are dilated periumbilical veins from portal hypertension; they are seen on inspection, not with this maneuver.

Audio review:

The umbilicus is the T10 dermatome. Useful landmarks: T4 at the nipples, T6 at the xiphoid, T10 at the umbilicus, and L1 at the inguinal ligament. A sensory level on the trunk points to a spinal cord lesion at or above that segment.

Board-Level Insight: A new sensory level with leg weakness or bladder dysfunction is spinal cord compression until proven otherwise; get an emergent MRI.

Why the other options are wrong:

• T6: T6 lies at about the level of the xiphoid process.
• T8: T8 lies at about the level of the costal margin.
• T12: T12 lies just above the inguinal ligament.

Audio review:

Illness anxiety disorder (formerly hypochondriasis) is a preoccupation with having or getting a serious illness despite minimal or no symptoms, lasting at least 6 months, with repeated checking or care-seeking that reassurance does not relieve.

Board-Level Insight: Manage with regularly scheduled visits with one clinician, rather than symptom-driven visits, and cognitive behavioral therapy; avoid unnecessary testing, which reinforces the fear.

Why the other options are wrong:

• Conversion disorder: Conversion disorder causes neurologic symptoms or deficits, such as weakness or nonepileptic seizures, without a medical explanation.
• Malingering: Malingering is intentional faking of symptoms for external gain, such as money or avoiding work.
• Somatic symptom disorder: Somatic symptom disorder involves distressing physical symptoms with excessive thoughts and behaviors about them; here the symptoms are minimal and the fear of disease dominates.

Audio review:

For immune thrombocytopenia that does not respond to or relapses after corticosteroids, preferred second-line options are a thrombopoietin receptor agonist (eltrombopag, romiplostim, avatrombopag) or rituximab. These stimulate platelet production or reduce antibody formation without surgery.

Board-Level Insight: Treat ITP based on bleeding and platelet count: most adults are treated when platelets are below about 30,000/µL. IVIG is used when a rapid rise is needed, such as active bleeding or before surgery.

Why the other options are wrong:

• Aspirin: Aspirin impairs platelet function and would increase her bleeding risk.
• Intravenous immunoglobulin alone: IVIG raises the platelet count quickly but only for a few weeks; it is a short-term bridge, not long-term therapy.
• Splenectomy: Splenectomy works but is usually deferred for at least 12 months after diagnosis because many patients remit, and it carries lifelong infection risk.

Audio review:

Staphylococcus aureus food poisoning comes from a preformed, heat-stable enterotoxin in foods left at room temperature (custards, mayonnaise-based salads, ham). Symptoms start 1 to 6 hours after eating, with prominent vomiting and cramps, and resolve within 24 hours. Treatment is supportive.

Board-Level Insight: Short incubation with vomiting = preformed toxin: S. aureus or Bacillus cereus (reheated fried rice). Longer incubation with diarrhea = organisms that multiply in the gut.

Why the other options are wrong:

• Symptoms beginning 48 hours after eating a mayonnaise-based salad: Staphylococcal food poisoning is caused by a preformed toxin and starts within 1 to 6 hours, not 2 days.
• Bloody diarrhea with mucus for a week: S. aureus toxin does not invade the bowel wall, so there is no blood or mucus.
• High fever lasting a week: Fever is usually absent; illness resolves within a day.

Audio review:

Compression duplex ultrasound is the test of choice for suspected deep vein thrombosis: a vein that does not collapse under probe pressure contains clot. It is noninvasive, accurate for proximal DVT, and widely available.

Board-Level Insight: Use pretest probability (Wells score): if DVT is unlikely, a normal D-dimer rules it out without imaging; if likely, go straight to ultrasound.

Why the other options are wrong:

• Contrast venography: Venography is invasive and has been replaced by ultrasound.
• Arteriography: DVT is a venous problem, so arterial imaging does not help.
• Impedance plethysmography: Plethysmography is largely obsolete and misses nonocclusive clots.

Audio review:

Hives and flushing plus respiratory symptoms after a sting is anaphylaxis. Give intramuscular epinephrine (1 mg/mL) 0.3 to 0.5 mg in the anterolateral thigh right away, repeated every 5 to 15 minutes as needed, then transfer for observation.

Board-Level Insight: Prescribe an epinephrine auto-injector and refer to an allergist; venom immunotherapy greatly lowers the risk of future systemic reactions.

Why the other options are wrong:

• Transfer him to a hospital emergency department: Anaphylaxis can become fatal within minutes; transfer comes after epinephrine, not instead of it.
• Apply a cold compress to the sting site: A cold compress treats only the local reaction.
• Oral albuterol: Inhaled albuterol can help bronchospasm as an adjunct, but it does not treat anaphylaxis, and the oral form is too slow.

Audio review:

In a hemodynamically stable patient with blunt abdominal trauma and hematuria, the test of choice is CT of the abdomen and pelvis with IV contrast, including delayed images. It grades renal injury and identifies other solid-organ injuries.

Board-Level Insight: Imaging is indicated for gross hematuria, or microscopic hematuria with shock or a high-energy deceleration mechanism. CT cystography evaluates bladder injury.

Why the other options are wrong:

• Retrograde urethrography: Retrograde urethrography is done before catheterization when there is blood at the meatus or other signs of urethral injury.
• Serum haptoglobin: Haptoglobin evaluates hemolysis, not trauma to the urinary tract.
• Urine myoglobin: Myoglobinuria shows a positive dipstick without red cells; this patient has visible blood.

Audio review:

Primary percutaneous coronary intervention (PCI) with stenting is the reperfusion treatment of choice for STEMI when it can be done promptly. It opens more arteries, with less bleeding, reinfarction, and death than fibrinolysis.

Board-Level Insight: Goal is first medical contact to device in 90 minutes or less at a PCI-capable hospital. After PCI: dual antiplatelet therapy, a high-intensity statin, a beta-blocker, and an ACE inhibitor when EF is reduced.

Why the other options are wrong:

• Coronary artery bypass grafting: CABG is preferred for left main or multivessel disease, especially with diabetes, not single-vessel disease.
• Streptokinase: Fibrinolysis is used only when timely PCI is not available; PCI is superior and he is already in the catheterization lab.
• Warfarin: Warfarin is not an acute reperfusion treatment.

Audio review:

Snuffbox tenderness after a fall on an outstretched hand is a scaphoid fracture until proven otherwise, even with normal x-rays, because early films miss many of these fractures. Immobilize in a thumb spica splint or cast and repeat x-rays in 7 to 14 days, or get an MRI for an earlier answer.

Board-Level Insight: The scaphoid's blood supply enters distally, so proximal pole fractures are at high risk of avascular necrosis and nonunion when missed.

Why the other options are wrong:

• Elastic bandage wrap: An elastic wrap does not immobilize a possible scaphoid fracture.
• Closed reduction: There is no displaced fracture to reduce.
• Open reduction and internal fixation: Surgery is for displaced or proximal pole scaphoid fractures, not a suspected occult fracture.

Audio review:

Delirium tremens typically starts 48 to 96 hours after the last drink. Early warning signs are anxiety, agitation, irritability, tremulousness, and subtle decline in cognition. Full DTs adds disorientation, hallucinations, and autonomic instability (tachycardia, hypertension, fever, sweating).

Board-Level Insight: Treat withdrawal early with symptom-triggered benzodiazepines (guided by the CIWA-Ar score) to prevent progression, and give thiamine before glucose.

Why the other options are wrong:

• Visual hallucinations and diaphoresis: Hallucinations and sweating occur in established withdrawal and in full delirium tremens, not as the earliest clue.
• Autonomic hyperactivity and dehydration: Marked autonomic instability is a feature of full delirium tremens.
• Mental confusion and sensory hyperacuity: Frank confusion means delirium has already developed.

Audio review:

The most dangerous time in an abusive relationship is when the victim leaves or tries to leave, as the abuser loses control. Many intimate partner homicides happen around separation. This is why leaving should be planned with a safety plan and advocacy support.

Board-Level Insight: Screen all women of reproductive age for intimate partner violence privately, document injuries carefully, assess lethality (firearm access, strangulation, escalating violence), and connect her with a domestic violence advocate or hotline.

Why the other options are wrong:

• Just before a holiday: Holidays can raise stress, but they are not the period of greatest danger.
• When the partner arrives home from work: This is not the period of greatest danger.
• When the partner has been drinking heavily: Alcohol increases risk, but separation is the period of greatest danger.

Audio review:

Acute limb ischemia from an arterial embolus (often from atrial fibrillation) presents with the 6 Ps: pain, pallor, pulselessness, poikilothermia (cold), paresthesia, and paralysis. Start IV heparin immediately, then restore flow with embolectomy (or catheter-directed thrombolysis) as quickly as possible, ideally within 6 hours.

Board-Level Insight: Sensory loss and weakness mean the limb is threatened; paralysis and fixed mottling mean it may be past saving. Watch for reperfusion injury and compartment syndrome after revascularization.

Why the other options are wrong:

• Inferior vena cava filter: IVC filters prevent pulmonary embolism from venous clots; this is an arterial embolus.
• Amputation: Amputation is for a nonviable limb with irreversible ischemia.
• Aspirin alone: Aspirin does not restore blood flow to an acutely occluded artery.

Audio review:

A knee dislocation injures the popliteal artery in a large share of cases, because the artery is tethered above and below the joint. Palpable pulses do not exclude an intimal tear that can thrombose hours later. Every patient needs an ankle-brachial index (ABI); an ABI below 0.9 or any hard sign of vascular injury requires CT angiography or vascular surgery consultation.

Board-Level Insight: Many knee dislocations reduce spontaneously before arrival. A knee with multiple torn ligaments after high-energy trauma should be treated as a dislocation, with full vascular and peroneal nerve assessment.

Why the other options are wrong:

• AP x-ray of the knee: Post-reduction films are obtained, but they do not evaluate the popliteal artery, which is the dangerous injury.
• Sunrise view of the knee: A sunrise view evaluates the patellofemoral joint.
• Compartment pressure measurement: Compartment pressures are checked when compartment syndrome is suspected; they do not assess the artery.

Audio review:

CSF with many neutrophils, high protein, and low glucose means bacterial meningitis. In adults over 50, empiric therapy is vancomycin plus ceftriaxone (for Streptococcus pneumoniae and Neisseria meningitidis) plus ampicillin to cover Listeria monocytogenes. Give dexamethasone with or just before the first dose.

Board-Level Insight: Do not delay antibiotics for imaging or the lumbar puncture: draw blood cultures and treat first if CT is needed (immunocompromise, focal deficit, papilledema, seizure, or altered mental status).

Why the other options are wrong:

• Acyclovir: Acyclovir treats herpes simplex encephalitis; viral CSF shows lymphocytes with normal glucose.
• Fluconazole: Fungal meningitis is subacute in immunocompromised patients and shows lymphocytes.
• Penicillin and chloramphenicol: This outdated regimen misses resistant pneumococci and is not used.

Audio review:

A fall followed by progressive confusion, hemiparesis, and an ipsilateral dilated pupil in an older adult suggests a subdural hematoma with uncal herniation. Noncontrast head CT is the first test: fast, widely available, and highly sensitive for acute blood.

Board-Level Insight: Older adults and those on anticoagulants or antiplatelets can develop subdural hematomas after trivial falls, with symptoms days to weeks later. Reverse any anticoagulation and get neurosurgery involved.

Why the other options are wrong:

• MRI of the brain: MRI takes longer and is less practical in an unstable patient; noncontrast CT is the first test for suspected intracranial bleeding.
• Skull x-ray: Skull films do not show intracranial bleeding.
• Lumbar puncture: An LP is contraindicated with a mass effect because it can trigger herniation.

Audio review:

Causes of new seizures depend on age. In early to middle adult life, think structural lesions (especially brain tumor), trauma, and alcohol or drug use or withdrawal. In older adults, stroke is the leading cause. Every adult with a new seizure needs neuroimaging, ideally MRI.

Board-Level Insight: Also check glucose, sodium, calcium, magnesium, a toxicology screen, and pregnancy status in women.

Why the other options are wrong:

• Cerebrovascular disease: Stroke is the most common cause of new seizures after about age 60, not in early to middle adulthood.
• Encephalitis: Encephalitis causes seizures with fever and altered mental status; it is not a typical cause in an otherwise well adult.
• Idiopathic epilepsy: Idiopathic (genetic) epilepsies usually begin in childhood or adolescence.

Audio review:

Acute watery diarrhea in a well-appearing, afebrile adult without blood is usually viral or toxin-mediated and self-limited. Treat with oral rehydration and diet as tolerated; loperamide is safe when there is no fever or blood. No testing is needed.

Board-Level Insight: Red flags that call for stool studies and possibly antibiotics: fever, bloody stools, severe dehydration, immunocompromise, recent hospitalization or antibiotics (C. difficile), or duration over 7 days.

Why the other options are wrong:

• Stool culture and ova and parasites: Stool testing is for fever, bloody stools, severe dehydration, immunocompromise, or diarrhea lasting more than 7 days.
• Flexible sigmoidoscopy: Endoscopy is for suspected inflammatory bowel disease or chronic or bloody diarrhea.
• Metronidazole: Metronidazole treats confirmed Giardia or amebiasis; empiric antibiotics are not needed for mild watery diarrhea.

Audio review:

Painless (or vague) jaundice with a palpable, nontender gallbladder (Courvoisier sign) suggests malignant obstruction of the distal common bile duct, most often pancreatic head adenocarcinoma. Obstruction causes conjugated hyperbilirubinemia and itching from retained bile salts.

Board-Level Insight: Next test: contrast-enhanced CT with a pancreatic protocol. CA 19-9 supports the diagnosis and is used to follow treatment, but it is not a screening test.

Why the other options are wrong:

• Viral hepatitis: Hepatitis causes jaundice with a tender liver and markedly elevated transaminases, not a palpable gallbladder.
• Acute cholecystitis: Cholecystitis causes fever, right upper quadrant pain, and a positive Murphy sign; the gallbladder is tender.
• Gilbert syndrome: Gilbert syndrome causes mild unconjugated hyperbilirubinemia without itching or a palpable gallbladder.

Audio review:

Pain and numbness in the posterior leg, lateral foot, and sole with a diminished ankle (Achilles) reflex point to the S1 nerve root, usually compressed by an L5-S1 disc herniation. Lumbar herniations typically affect the lower of the two roots at that level.

Board-Level Insight: Red flags needing emergent MRI: saddle anesthesia, urinary retention or incontinence, bilateral or progressive weakness (cauda equina syndrome), fever, or cancer history. Otherwise, most sciatica improves with conservative care in 4 to 6 weeks.

Why the other options are wrong:

• L3-L4: An L3-L4 herniation affects the L4 root: pain in the medial leg, weak knee extension, and a reduced patellar reflex.
• L4-L5: An L4-L5 herniation affects the L5 root: dorsum of the foot, weak great toe extension, and no reflex change.
• S1-S2: There is no S1-S2 disc; the sacral segments are fused.

Audio review:

This is anorexia nervosa (BMI about 15.8) with dangerous complications: hypokalemia, dehydration, and tachycardia, likely with purging or extreme exercise. Treatment centers on supervised nutritional rehabilitation (weight restoration) with psychotherapy; family-based treatment is most effective for adolescents. Her potassium below 3 and vital signs warrant hospital admission for medical stabilization.

Board-Level Insight: Watch for refeeding syndrome in the first 1 to 2 weeks: hypophosphatemia, hypokalemia, and hypomagnesemia with heart failure and arrhythmias. Start calories cautiously and monitor electrolytes daily.

Why the other options are wrong:

• Propylthiouracil and individual psychotherapy: PTU treats hyperthyroidism; her weight loss and amenorrhea are from starvation.
• Hormone replacement and cognitive therapy: Estrogen does not restore bone or menses in anorexia; weight restoration does.
• IV hydration and an antidepressant: IV fluids and electrolytes are part of stabilization, but antidepressants do not treat the core illness.

Most acute MIs (type 1 MI) happen when an atherosclerotic plaque ruptures or erodes, exposing thrombogenic material and triggering a thrombus that occludes the coronary artery. Plaques that rupture are often lipid-rich with thin fibrous caps and are not necessarily severely narrowing beforehand.

Board-Level Insight: Type 2 MI is a supply-demand mismatch without plaque rupture, such as with severe anemia, tachyarrhythmia, or hypotension; treatment targets the cause.

Why the other options are wrong:

• Coronary microemboli: Coronary embolism is a rare cause of MI.
• Congenital coronary anomalies: Congenital anomalies are rare causes, mainly in young athletes.
• Severe coronary artery spasm: Vasospasm usually causes transient angina rather than infarction.

Audio review:

The supraspinatus tendon passes directly beneath the acromion and coracoacromial arch and has a poorly vascularized critical zone near its insertion, so it is the tendon most often affected by impingement and rotator cuff tears. Patients have lateral shoulder pain with overhead activity and a painful arc between about 60 and 120 degrees of abduction.

Board-Level Insight: Positive Neer and Hawkins tests suggest impingement; weakness on the empty can test suggests supraspinatus tear. Weakness, not just pain, points to a full-thickness tear and MRI.

Why the other options are wrong:

• Infraspinatus: The infraspinatus lies posteriorly and is less often impinged.
• Teres minor: The teres minor is rarely injured in isolation.
• Subscapularis: The subscapularis lies anteriorly and is not caught under the acromion.

Audio review:

Most nosebleeds are anterior, from Kiesselbach plexus. Start with direct pressure and a topical vasoconstrictor. When that fails in a patient with severe thrombocytopenia, use anterior nasal packing (petrolatum gauze, a nasal tampon, or absorbable packing) to apply pressure, while correcting the cause with a platelet transfusion.

Board-Level Insight: Cautery works well for a visible, minor anterior bleed in a patient with normal clotting, but it should not be used on both sides of the septum at once because of the risk of septal perforation.

Why the other options are wrong:

• Electrocautery of the bleeding site: Cautery creates a raw area that oozes in a patient with very low platelets, and it can enlarge the bleeding surface.
• Silver nitrate cautery: Chemical cautery works poorly when bleeding is active and platelets are very low.
• Posterior nasal packing: Posterior packing is for posterior bleeds; this is an anterior bleed.

Audio review:

Atrial fibrillation is the most common source of arterial emboli. Stasis in the left atrial appendage forms thrombus that can travel to the brain (stroke), limbs, or mesenteric arteries. Other cardiac sources include left ventricular thrombus after MI, endocarditis, and prosthetic valves.

Board-Level Insight: Use the CHA2DS2-VASc score to decide on anticoagulation in atrial fibrillation; direct oral anticoagulants are preferred over warfarin except with mechanical valves or moderate to severe mitral stenosis.

Why the other options are wrong:

• Rheumatic heart disease: Rheumatic mitral stenosis can cause emboli, but it is now an uncommon source in developed countries.
• Atrial myxoma: Myxoma is a rare cause of emboli.
• Deep vein thrombosis: Venous clots reach the arterial system only through a right-to-left shunt such as a patent foramen ovale (paradoxical embolism), which is uncommon.

Audio review:

Candida esophagitis causes odynophagia and dysphagia, with white plaques on endoscopy and yeast with pseudohyphae on biopsy. It usually signals immunosuppression (HIV with low CD4, inhaled or systemic steroids, diabetes). Treatment is oral fluconazole for 14 to 21 days; topical nystatin or clotrimazole is not enough.

Board-Level Insight: In a patient with HIV and odynophagia plus oral thrush, empiric fluconazole is reasonable; endoscopy is reserved for those who do not improve within a few days.

Why the other options are wrong:

• Acyclovir: Acyclovir treats herpes esophagitis, which shows small, punched-out ulcers.
• Omeprazole: A PPI treats reflux esophagitis, not an infection.
• Penicillin G: Antibacterial drugs do not treat fungal infection.

Audio review:

Dysphoria, vivid nightmares, increased appetite, and fatigue or agitation are classic for stimulant withdrawal (cocaine or amphetamines), the "crash" after a binge. A urine drug screen is the most useful test, though it can miss some synthetic stimulants.

Board-Level Insight: Stimulant withdrawal is not life-threatening, but the depressed mood can be severe; always screen for suicidal ideation.

Why the other options are wrong:

• Serum TSH: Hyperthyroidism can cause anxiety and tremor, but not vivid dreams with a crash in mood.
• Minnesota Multiphasic Personality Inventory: A personality inventory has no role in the acute evaluation.
• Electroencephalogram: Nothing suggests seizures.

Audio review:

Giant cell (temporal) arteritis: age over 50 with new headache, jaw claudication, visual symptoms, and a tender, thickened temporal artery. The initial test is an ESR (with CRP), which is almost always elevated. Confirm with temporal artery biopsy or ultrasound.

Board-Level Insight: With visual symptoms, start high-dose glucocorticoids immediately, before the biopsy; vision loss can become permanent and bilateral within days. Biopsy remains accurate for about 2 weeks after starting steroids.

Why the other options are wrong:

• Carotid ultrasound: Carotid ultrasound evaluates atherosclerotic stenosis, not giant cell arteritis.
• Chest x-ray: A chest x-ray does not help diagnose temporal arteritis.
• Complete blood count: A CBC may show mild anemia or thrombocytosis but is nonspecific.

Audio review:

This is stable angina: predictable exertional chest pressure relieved by rest. When the resting ECG is normal and the patient can exercise, an exercise ECG stress test is a reasonable first test. Add imaging (nuclear or echo) if the baseline ECG is abnormal (LBBB, paced rhythm, LVH with strain, digoxin), and use pharmacologic stress if he cannot exercise.

Board-Level Insight: Coronary CT angiography is also a first-line option for many patients with stable chest pain and intermediate risk, especially younger patients without known disease.

Why the other options are wrong:

• Cardiac catheterization: Invasive angiography is for high-risk features or failed medical therapy, not first-line in stable symptoms.
• Serial troponins with hospital admission: His pattern is stable angina; troponins and admission are for suspected acute coronary syndrome.
• Resting echocardiogram: An echocardiogram assesses structure and function but does not detect ischemia at rest.

Audio review:

Anterior cruciate ligament (ACL) tear: a noncontact deceleration or pivoting injury, an audible pop, and a rapid hemarthrosis within hours. The Lachman test is the most sensitive examination; MRI confirms the tear.

Board-Level Insight: Rapid swelling within hours means bleeding into the joint, most often from an ACL tear; swelling that develops overnight suggests a meniscal tear.

Why the other options are wrong:

• Medial collateral: An MCL injury follows a valgus blow to the lateral knee and causes medial tenderness with valgus laxity.
• Lateral collateral: An LCL injury causes lateral pain and laxity with varus stress.
• Posterior cruciate: A PCL injury follows a blow to the front of the flexed knee (dashboard injury) and shows a positive posterior drawer or sag sign.

Audio review:

Poststreptococcal glomerulonephritis: a nephritic syndrome appearing 1 to 3 weeks after streptococcal pharyngitis (2 to 6 weeks after skin infection), with cola-colored urine, oliguria, hypertension, and edema (often periorbital). Urinalysis shows red cell casts and mild proteinuria; C3 is low and ASO or anti-DNase B is elevated.

Board-Level Insight: IgA nephropathy also follows infection, but hematuria starts within 1 to 3 days of the infection rather than weeks later, and complement is normal.

Why the other options are wrong:

• Acute tubular necrosis: ATN follows ischemia or nephrotoxins and shows muddy brown granular casts, not hypertension with edema after pharyngitis.
• Nephrolithiasis: Kidney stones cause sudden colicky flank pain with hematuria.
• Diabetic nephropathy: Diabetic nephropathy develops over years in a patient with diabetes and shows albuminuria.

Audio review:

This is an orbital floor (blowout) fracture: blunt force pushes the floor into the maxillary sinus, entrapping the inferior rectus (limited upward gaze and diplopia) and injuring the infraorbital nerve (cheek and upper lip numbness). Thin-cut CT of the orbits is the test of choice.

Board-Level Insight: Entrapment with nausea, vomiting, or bradycardia (oculocardiac reflex), especially in children (white-eyed blowout), needs urgent surgery. Tell patients not to blow their nose.

Why the other options are wrong:

• Tonometry: Tonometry measures intraocular pressure; it does not show orbital fractures.
• Fluorescein angiography: Fluorescein angiography evaluates retinal blood flow.
• Slit-lamp examination: A slit lamp examines the anterior eye but cannot show the orbital floor.

Audio review:

For life-threatening bleeding on warfarin, give four-factor prothrombin complex concentrate (PCC), which replaces factors II, VII, IX, and X within minutes, plus IV vitamin K (10 mg), which sustains the reversal once the PCC wears off. Resuscitate, protect the airway, and arrange urgent endoscopy.

Board-Level Insight: For a high INR without bleeding, hold warfarin; add oral vitamin K only if the INR is over 10. Reverse dabigatran with idarucizumab, and apixaban or rivaroxaban with andexanet alfa or PCC.

Why the other options are wrong:

• Stop warfarin: Stopping warfarin alone takes days to lower the INR.
• Protamine sulfate: Protamine reverses heparin, not warfarin.
• Fresh frozen plasma alone: FFP works but is slower, needs thawing and blood-type matching, and requires large volumes; it is used when PCC is not available.

Audio review:

Oseltamivir, a neuraminidase inhibitor, treats both influenza A and B. Antivirals are recommended for anyone at high risk of complications, including adults 65 and older and nursing home residents, and for anyone hospitalized, even if more than 48 hours have passed since symptoms began.

Board-Level Insight: In a nursing home outbreak, give antiviral prophylaxis to all residents and test and treat staff, because influenza spreads quickly and is often fatal in older adults.

Why the other options are wrong:

• Amantadine: Amantadine has no activity against influenza B, and influenza A is now widely resistant to it.
• Acyclovir: Acyclovir treats herpes simplex and varicella-zoster virus.
• Nevirapine: Nevirapine is an HIV medication.

Audio review:

For a dirty or contaminated wound (soil, feces, saliva, puncture, crush, or devitalized tissue) in a patient with unknown or fewer than 3 prior tetanus doses, give both a tetanus-containing vaccine (Tdap preferred if never received, or Td) and tetanus immune globulin (TIG), at separate sites.

Board-Level Insight: Rule for vaccinated patients (3 or more doses): clean minor wound, booster if over 10 years since the last dose; dirty wound, booster if over 5 years. TIG is only for unknown or incomplete vaccination with a dirty wound.

Why the other options are wrong:

• DTaP vaccine alone: DTaP is used for children under 7, and he also needs tetanus immune globulin.
• Tdap alone: With a dirty wound and unknown or incomplete vaccination, he also needs tetanus immune globulin.
• No tetanus prophylaxis: A dirty wound with unknown vaccine history requires both vaccine and immune globulin.

Audio review:

Wolff-Parkinson-White syndrome (short PR interval, delta wave, and symptomatic tachycardias) is cured by radiofrequency catheter ablation of the accessory pathway, with high success and low complication rates. It is the preferred long-term treatment for symptomatic patients.

Board-Level Insight: Irregular, very fast, wide-complex tachycardia in a patient with WPW is atrial fibrillation conducted down the pathway: give procainamide or cardiovert. Never give AV nodal blockers.

Why the other options are wrong:

• Implantable cardioverter-defibrillator: An ICD treats life-threatening ventricular arrhythmias; it does not eliminate an accessory pathway.
• Verapamil: AV nodal blockers can speed conduction down the accessory pathway if atrial fibrillation occurs, which can lead to ventricular fibrillation.
• Metoprolol: Beta-blockers do not cure the pathway and carry the same concern if atrial fibrillation develops.

Audio review:

Primary syphilis presents as a chancre: a single painless, firm, clean-based ulcer with nontender lymphadenopathy, about 3 weeks after exposure. It heals on its own, which is why it is often missed. Diagnose with serologic testing (treponemal and nontreponemal tests) or dark-field microscopy.

Board-Level Insight: Treatment for primary, secondary, or early latent syphilis is a single dose of benzathine penicillin G 2.4 million units IM. Test for HIV and other STIs, and treat partners.

Why the other options are wrong:

• Genital herpes: Herpes causes grouped vesicles that become painful shallow ulcers.
• Chancroid: Chancroid causes a painful, ragged ulcer with tender, suppurative inguinal nodes (buboes).
• Behçet disease: Behçet disease causes recurrent painful oral and genital ulcers with uveitis.

Audio review:

Acute gout (podagra) is treated with NSAIDs, colchicine, or glucocorticoids; all are first-line, and the choice depends on comorbidities. With advanced CKD and prior GI bleeding, NSAIDs and colchicine are unsafe, so oral prednisone (or an intra-articular steroid injection for one joint) is the best choice.

Board-Level Insight: Do not stop urate-lowering therapy during a flare if the patient is already taking it. Start allopurinol for recurrent flares, tophi, or urate nephropathy, with flare prophylaxis.

Why the other options are wrong:

• Colchicine: Colchicine needs major dose reduction in advanced CKD and carries a high toxicity risk at this eGFR, so it is best avoided here.
• Allopurinol: Allopurinol lowers urate for long-term prevention; it does not relieve an acute flare.
• An NSAID such as indomethacin: NSAIDs are contraindicated with advanced CKD and a history of a bleeding ulcer.

Audio review:

Upper endoscopy (EGD) is the test of choice for upper GI bleeding because it both finds the source and treats it (injection, clips, thermal therapy, or banding). It should be done within 24 hours, after hemodynamic resuscitation.

Board-Level Insight: Before endoscopy: two large-bore IVs, fluids, a restrictive transfusion target (hemoglobin about 7 g/dL, higher with active coronary disease), and an IV PPI. Add octreotide and ceftriaxone if varices are suspected.

Why the other options are wrong:

• Esophageal manometry: Manometry evaluates motility disorders, not bleeding.
• Tagged red blood cell scan: A bleeding scan localizes slow, intermittent lower GI bleeding, not upper GI bleeding.
• Barium swallow: Barium studies are not used for active bleeding and interfere with later endoscopy.

Audio review:

A pleural effusion causes decreased chest expansion (lag) on the affected side, dullness to percussion, decreased tactile fremitus, and decreased or absent breath sounds. A large effusion can shift the trachea away from the fluid.

Board-Level Insight: Confirm with chest x-ray (blunting of the costophrenic angle) or bedside ultrasound, which detects small effusions and guides thoracentesis.

Why the other options are wrong:

• Hyperresonance to percussion: Hyperresonance suggests pneumothorax or emphysema; an effusion is dull.
• Increased tactile fremitus: Fluid between lung and chest wall dampens vibration, so fremitus is decreased; increased fremitus suggests consolidation.
• Tracheal deviation toward the right: A large effusion pushes the trachea away from the affected side.

Audio review:

A transient ischemic attack (TIA) is a brief episode of focal neurologic dysfunction from ischemia, without infarction on imaging. Here, left eye vision loss (amaurosis fugax) plus right arm weakness and aphasia localizes to the left carotid territory. Atrial fibrillation is the likely embolic source.

Board-Level Insight: A TIA is a warning: stroke risk is highest in the first 48 hours. Evaluate urgently with brain MRI, vascular imaging of the head and neck, and cardiac monitoring; in atrial fibrillation, start anticoagulation.

Why the other options are wrong:

• Focal seizure: Focal seizures usually cause positive symptoms such as jerking or tingling that spread, not abrupt loss of function.
• Migraine aura: Migraine aura spreads gradually over minutes, is usually followed by headache, and typically begins at a younger age.
• Hypoglycemia: Hypoglycemia can rarely cause focal deficits, but it would not cause repeated left-eye vision loss with right-sided symptoms.

Audio review:

With a suspected open globe, protect the eye with a rigid shield (no pressure, no patch), keep the patient NPO and calm, give antiemetics to avoid straining, start IV antibiotics, update tetanus, and obtain emergent ophthalmology consultation.

Board-Level Insight: Signs of globe rupture: teardrop-shaped pupil, flat anterior chamber, positive Seidel sign, extruded uveal tissue, or severe subconjunctival hemorrhage. CT of the orbits can help, but do not delay consultation.

Why the other options are wrong:

• Slit-lamp examination to determine the extent of injury: Prying the lids open for a full examination can push intraocular contents out of a ruptured globe.
• Fluorescein staining to determine the extent of injury: Fluorescein is avoided when an open globe is suspected; it delays definitive care.
• Apply antibiotic ointment and recheck in 24 hours: Ointment and delayed recheck are wrong for a suspected open globe, which is a surgical emergency.

Audio review:

The radial nerve runs in the spiral groove of the humeral shaft, so it is the nerve most often injured with midshaft humerus fractures. Injury causes wrist drop (weak wrist and finger extension) and numbness over the dorsal first web space.

Board-Level Insight: Most radial nerve palsies with closed humeral shaft fractures are neurapraxias that recover within months; most shaft fractures are managed nonoperatively with a functional brace.

Why the other options are wrong:

• Numbness over the lateral shoulder: Axillary nerve injury causes numbness over the deltoid; it occurs with proximal humerus fractures and shoulder dislocations.
• Winging of the scapula: Long thoracic nerve injury weakens the serratus anterior.
• Weakness of external rotation: Suprascapular nerve injury weakens the supraspinatus and infraspinatus.

Audio review:

This is a corneal ulcer (infectious keratitis) after injury with organic material, which raises the risk of fungal and bacterial infection. Patching is contraindicated: it creates a warm, dark, moist environment that promotes microbial growth. Treat with intensive topical antimicrobials and same-day ophthalmology referral for scraping and culture.

Board-Level Insight: Never patch a corneal injury in a contact lens wearer or one involving organic material. Patching is no longer routine even for simple abrasions.

Why the other options are wrong:

• Topical antibiotics: Intensive topical antimicrobials are the core treatment of a corneal ulcer.
• Visual acuity testing: Visual acuity is the vital sign of the eye and must be documented.
• Irrigation of the eye: Gentle irrigation to remove debris is appropriate.

Audio review:

This is a mallet finger: rupture of the terminal extensor tendon at the DIP joint from forced flexion of an extended fingertip. Treatment is a splint holding the DIP in continuous extension (slight hyperextension) for 6 to 8 weeks, followed by nighttime splinting. The PIP stays free.

Board-Level Insight: The splint must not come off, even for washing, without holding the finger straight; a single flexion during healing restarts the clock.

Why the other options are wrong:

• Open reduction and internal fixation: Surgery is reserved for large avulsion fragments with joint subluxation or failed splinting.
• Flexion splinting of the PIP joint: The PIP joint should be left free; the DIP is what needs to be held straight.
• Short arm cast: A short arm cast immobilizes the wrist and metacarpals, not the DIP joint.

Audio review:

Spondylolysis is a stress fracture of the pars interarticularis, usually at L5, common in adolescents in sports with repeated hyperextension (gymnastics, football linemen, diving). On oblique films the defect looks like a collar on the "Scottie dog". CT or MRI is more sensitive when x-rays are normal.

Board-Level Insight: Pain on single-leg hyperextension (stork test) suggests spondylolysis. Treatment is rest from sports, physical therapy, and sometimes bracing.

Why the other options are wrong:

• Anteroposterior: The AP view does not profile the pars interarticularis well.
• Posteroanterior: A PA view has the same limitation as an AP view.
• Lateral: The lateral view can show spondylolisthesis (slippage) but often misses a pars defect alone.

Audio review:

Acute aortic dissection causes sudden, severe, ripping or tearing pain that is maximal at onset and often radiates to the back (type B) or is felt in the anterior chest (type A). Clues include pulse or blood pressure differences between arms, a new diastolic murmur of aortic regurgitation, and a widened mediastinum.

Board-Level Insight: Confirm with CT angiography. Lower heart rate first with IV beta-blockers, then blood pressure, and get emergent surgery for type A (ascending) dissection.

Why the other options are wrong:

• Squeezing: Squeezing pressure is typical of angina or MI.
• Dull, aching: Dull, aching pain is more typical of musculoskeletal pain.
• Burning: Burning pain suggests reflux or esophagitis.

Audio review:

Sick sinus syndrome (sinus node dysfunction) causes sinus bradycardia, pauses, or arrest, often alternating with atrial tachyarrhythmias (tachy-brady syndrome). When bradycardia causes symptoms and no reversible cause is found, the treatment is a permanent pacemaker.

Board-Level Insight: Always look for reversible causes first: beta-blockers, calcium channel blockers, digoxin, hypothyroidism, and hyperkalemia. In tachy-brady syndrome, the pacemaker allows rate-controlling drugs to be used safely.

Why the other options are wrong:

• Radiofrequency ablation: Ablation treats tachyarrhythmias from accessory pathways or specific circuits, not sinus node failure.
• Antiarrhythmic drugs alone: Antiarrhythmics for the tachycardia worsen the bradycardia unless a pacemaker is placed first.
• Anticoagulation alone: Anticoagulation is needed for her atrial fibrillation stroke risk, but it does not treat symptomatic bradycardia.

Audio review:

This is acute decompensated heart failure in a patient with dilated cardiomyopathy: worsening dyspnea, fatigue, and peripheral edema, with cephalization (upper-lobe vascular redistribution) on chest x-ray, an early sign of raised pulmonary venous pressure.

Board-Level Insight: Treat congestion with IV loop diuretics. For heart failure with reduced EF, long-term therapy uses four drug classes: an ARNI (or ACE inhibitor/ARB), an evidence-based beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor.

Why the other options are wrong:

• Subacute bacterial endocarditis: Endocarditis causes fever and constitutional symptoms with a new murmur.
• Pulmonary embolism: PE usually causes sudden pleuritic chest pain and dyspnea, not bilateral leg edema with vascular redistribution.
• Pneumonia: Pneumonia causes fever, cough, and focal consolidation; it does not cause leg edema.

Audio review:

Peritonsillar abscess: a complication of tonsillitis, often after incomplete treatment, with severe unilateral sore throat, fever, trismus, a muffled "hot potato" voice, and a bulging soft palate with the uvula deviated away from the affected side. Treat with needle aspiration or incision and drainage plus antibiotics (ampicillin-sulbactam or clindamycin).

Board-Level Insight: Bedside intraoral ultrasound or CT can distinguish abscess from peritonsillar cellulitis when the examination is unclear.

Why the other options are wrong:

• Recurrent streptococcal pharyngitis: Simple pharyngitis does not cause palatal bulging, uvular deviation, or trismus.
• Infectious mononucleosis: Mono causes exudative tonsillitis and lymphadenopathy, but not unilateral palatal swelling with uvular deviation.
• Gonococcal pharyngitis: Gonococcal pharyngitis is usually mild or asymptomatic.

Audio review: