Emergency Medicine Rotation Exam With Audio Explanations (Exam 2)

Question 1
To further assess ascites in a patient, the physician assistant instructs the patient to turn onto one side while performing percussion. Which of the following is the reason for this maneuver?
A
Testing for shifting of dullness on percussion
B
Shifting of internal organs making percussion easier
Hint:
In ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while tympany shifts to the top as the gas-filled organs float to the top of the ascitic fluid.
C
Trying to elicit any pain while moving
Hint:
Pain with movement is associated with peritonitis and not ascites.
D
Trying to produce a caput medusa
Hint:
Caput medusa is the dilation of the superficial abdominal veins due to increased intraabdominal fluid accumulation. It is visible with the patient standing and does not need a special maneuver for identification.
Question 1 Explanation: 
In ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while tympany shifts to the top as the gas-filled organs float to the top of the ascitic fluid.
Review Topic: Cirrhosis
Question 2
A patient complains of loss of sensation at the level of the umbilicus. Which of the following dermatomes is affected?
A
T6
Hint:
The dermatome T10 is at the level of the umbilicus
B
T8
Hint:
The dermatome T10 is at the level of the umbilicus
C
T10
D
T12
Hint:
The dermatome T10 is at the level of the umbilicus
Question 2 Explanation: 
The dermatome T10 is at the level of the umbilicus
Question 3
A 25-year-old female graduate student presents to the student health center for the eighth time in three weeks to be sure she does not have meningitis. She read that there was a student on campus who had meningitis last month, and now she has headaches and is requesting to be tested to make sure she does not have meningitis. She has been evaluated at each visit, and physical examination has been completely normal each time. Which of the following is the most likely diagnosis?
A
Conversion disorder
Hint:
Conversion disorder is characterized by onset of symptoms or deficits mimicking neurologic or medical illness, but the etiology is psychological.
B
Illness anxiety disorder
C
Malingering
Hint:
Malingering is the intentional production or feigning of physical or psychological signs and symptoms for some gain
D
Somatization disorder
Hint:
Somatization disorder is characterized by complaints of pain, often related to gastrointestinal and sexual dysfunction, and pseudoneurological symptoms.
Question 3 Explanation: 
Hypochondriasis is the chronic preoccupation with the idea of having a serious disease, which is usually not amenable to reassurance.
Review Topic: Psychiatry EOR: Illness anxiety disorder
Question 4
A 29-year-old patient with idiopathic thrombocytopenia purpura (ITP) is treated with prednisone therapy. Despite therapy, platelet counts remain consistently below 20,000/microliter over the course of 6 weeks. Which of the following is the most appropriate intervention for this patient?
A
Aspirin
Hint:
Aspirin inhibits platelet function and could lead to significant bleeding and death of this patient.
B
Intravenous immunoglobulin
Hint:
Intravenous immunoglobulin can be utilized for short-term treatment, but the platelet count is likely to return tobaseline within a month.
C
Danazol (Danocrine)
Hint:
Danazol is typically reserved for ITP that fails to respond to splenectomy.
D
Splenectomy
Question 4 Explanation: 
Persistently low platelet counts (less than 20,000) require effective long-term treatment, and splenectomy is the treatment of choice.
Review Topic: Idiopathic thrombocytopenic purpura
Question 5
Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus aureus?
A
Ingestion of mayonnaise-based salads 48 hours earlier
Hint:
A preformed toxin causes staphylococcal food poisoning; it has a short incubation period of 1-8 hours.
B
Bloody diarrhea with mucus for one week
Hint:
Because Staphylococcus aureus does not invade the mucus, blood and mucus are not seen with this noninflammatory cause of food poisoning.
C
Abdominal cramps and vomiting for 48 hours
D
High fever for 1 week
Hint:
Staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature.
Question 5 Explanation: 
Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with staphylococcal food poisoning.
Review Topic: Infectious Diarrhea
Question 6
Which of the following diagnostic tests should be ordered initially to evaluate for suspected deep venous thrombosis of the leg?
A
Venogram
Hint:
Venogram has been replaced by noninvasive tests due to discomfort, cost, technical difficulties, and complications, such as phlebitis.
B
Arteriogram
Hint:
Thrombophlebitis is a venous problem, not an arterial one. Any unnecessary invasive procedure is potentially harmful.
C
Duplex ultrasound
D
Impedance plethysmography
Hint:
Impedance plethysmography is equivalent to ultrasound in detecting thrombi of the femoral and popliteal veins,but it may miss early, nonocclusive thrombi.
Question 6 Explanation: 
Ultrasound is the technique of choice to detect deep venous thrombosis in the leg.
Review Topic: Venous thrombosis
Question 7
A 26-year-old man is stung by a bee, and shortly thereafter, a wheel 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
A
transfer him to a local hospital emergency department
Hint:
Systemic (anaphylactic) reactions can rapidly become life-threatening. Delay in treatment may cause death.
B
apply a cold compress to site of the sting
Hint:
This is only supportive local therapy and does not address the need to treat the systemic reaction present.
C
administer intramuscular epinephrine
D
administer oral albuterol
Hint:
Albuterol is indicated in the presence of bronchospasm (suggested by the presence of chest tightness), but would be delivered by an aerosol, not an oral, route.
Question 7 Explanation: 
Epinephrine Hydrochloride 1:1000, 0.2 to 0.5 mL IM is indicated for the initial treatment of this systemic reaction. Additional injections may be given 5 to 15 minutes after the first injection or every 20 to 30 minutes if needed.
Review Topic: Envenomation and arthropod bite reactions
Question 8
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 meatus and a Foley catheter was placed. The urine was positive for blood on the dipstick. Which of the following is the most appropriate diagnostic test?
A
Retrograde urethrography
Hint:
A retrograde urethrogram should be performed when blood is found at the external urinary meatus prior to insertion of a catheter.
B
CT scan of abdomen and pelvis
C
Serum haptoglobin
Hint:
A decreased serum haptoglobin is seen in hemolysis and does not provide information on renal status.
D
Urine myoglobin
Hint:
A positive test for blood in the absence of red blood cells on urine examination suggests myoglobinuria and should be confirmed by electrophoresis.
Question 8 Explanation: 
CT scan of the abdomen and pelvis is indicated in blunt trauma including those resulting in hematuria or when a renal injury is suspected.
Question 9
A 52-year-old male with a history of hypertension and hyperlipidemia presents with acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient?
A
Coronary artery bypass grafting (CABG)
Hint:
Percutaneous coronary intervention is a better, less invasive alternative to CABG for single vessel coronary artery disease.
B
Streptokinase
Hint:
Streptokinase is not commonly used for treatment of acute myocardial infarction because it is ineffective at opening the occluded artery and reducing mortality. Streptokinase would be harmful because it would increase the risk of bleeding.
C
Percutaneous coronary intervention (PCI)
D
Warfarin (Coumadin)
Hint:
Warfarin is used to prevent thrombosis and not for acute treatment.
Question 9 Explanation: 
Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis.
Review Topic: Acute myocardial infarction (PEARLS)
Question 10
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 the wrist. Which of the following is the recommended treatment for this patient?
A
Ace wrap of the wrist
Hint:
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 thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures.
B
Closed reduction of the fracture site
Hint:
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 thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures.
C
Thumb spica cast application
D
Open reduction of the fracture site
Hint:
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 thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures.
Question 10 Explanation: 
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 thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures.
Review Topic: Fractures and dislocations of the forearm, wrist and hand
Question 11
Early clues to impending delirium tremens include
A
Agitation and decreased cognition
B
Visual hallucinations and diaphoresis
Hint:
Mental confusion, tremor, sensory hyperacuity, visual hallucinations, autonomic hyperactivity, diaphoresis, dehydration, electrolyte disturbances, seizures, and cardiovascular abnormalities are common signs and/or symptoms of full-blown delirium tremens.
C
Autonomic hyperactivity and dehydration
Hint:
Mental confusion, tremor, sensory hyperacuity, visual hallucinations, autonomic hyperactivity, diaphoresis, dehydration, electrolyte disturbances, seizures, and cardiovascular abnormalities are common signs and/or symptoms of full-blown delirium tremens.
D
Mental confusion and sensory hyperacuity
Hint:
Mental confusion, tremor, sensory hyperacuity, visual hallucinations, autonomic hyperactivity, diaphoresis, dehydration, electrolyte disturbances, seizures, and cardiovascular abnormalities are common signs and/or symptoms of full-blown delirium tremens.
Question 11 Explanation: 
Anxiety, decreased cognition, tremulousness, increasing irritability, and hyperactivity are common early clues to impending delirium tremens.
Review Topic: Substance-related and addictive disorders
Question 12
A 36-year-old woman admits that her husband has abused her for over ten years. You should inform the woman that she is at most risk for injury or death
A
Just before a holiday
Hint:
See B for explanation
B
Just after leaving an abusive spouse
C
When an abusive spouse arrives home after work
Hint:
See B for explanation
D
When an abusive spouse has been drinking heavily
Hint:
See B for explanation
Question 12 Explanation: 
Women are more likely to be assaulted or murdered when attempting to report the abuse or leave the abusive relationship; up to 75% of domestic assaults occur after separation.
Review Topic: Domestic violence
Question 13
A patient presents with an acutely painful and cold left leg. Distal pulses are absent. Leg is cyanotic. There are no signs of gangrene or other open lesions. Symptoms occurred one hour ago. Which of the following treatments is most appropriate?
A
Vena cava filter
Hint:
Vena cava filters are used in the management of venous thromboembolic disease when anticoagulation cannot be done.
B
Embolectomy
C
Amputation
Hint:
Amputation is done only when no viable tissue is present. Cutting off a viable limb is never a good idea.
D
Aspirin
Hint:
Antiplatelet agents such as aspirin appear to reduce the risk of atheroembolic events and are generally recommended for patients with coronary artery disease equivalents (ie, peripheral artery disease, aneurysmal disease). Aspirin has no role in the treatment of peripheral arterial embolism.
Question 13 Explanation: 
Embolectomy within 4 to 6 hours is the treatment of choice.
Review Topic: Arterial embolism/thrombosis
Question 14
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 currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory?
A
Anterior plain film of knee
Hint:
The popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pedal pulses.
B
Sunrise view of the knee
Hint:
The popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pedal pulses.
C
Measurement of compartment pressures
Hint:
Compartment pressures are performed in cases of suspected compartment syndrome, not to determine the patency of the popliteal artery.
D
Angiography
Question 14 Explanation: 
The popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pedal pulses.
Review Topic: Fractures and dislocations of the knee
Question 15
A 70-year-old presents with headache and neck stiffness. On physical exam, the patient is febrile, Kernig's sign is present, and no rash is noted. A spinal tap reveals a white count of 250/cm3 with 100% neutrophils, total protein 250 mg/dL, and glucose 35 mg/dL. Which of the following is the most appropriate treatment?
A
Acyclovir (Zovirax)
Hint:
Acyclovir is used to treat meningitis secondary to herpes. Viral meningitis presents with increase number of lymphocytes and elevated glucose in the CSF .
B
Fluconazole (Diflucan)
Hint:
Fluconazole is used to treat fungal meningitis. Fungal meningitis, typically noted in immunocompromised hosts, presents with increase number of lymphocytes in the CSF.
C
Ampicillin and ceftriaxone (Rocephin)
D
Penicillin and chloramphenicol (Chloromycetin)
Hint:
Penicillin and chloramphenicol is used to treat bacterial meningitis, secondary to Neisseria meningitidis.
Question 15 Explanation: 
Ampicillin and ceftriaxone is used to treat bacterial meningitis, secondary to Listeria monocytogenes , which is common in the elderly. Ceftriaxone will cover other common etiologic agents such as Streptococcal pneumonia.
Review Topic: Meningitis
Question 16
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 did state that her mother sounded a little confused this morning. The patient's left pupil is dilated. Which of the following diagnostic studies should be ordered first?
A
MRI of the brain
Hint:
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 blood than an MRI.
B
CT scan of the brain
C
Skull x-ray
Hint:
Skull x-rays would not be helpful because they evaluate bony, not soft tissue, injury.
D
Lumbar puncture
Hint:
A lumbar puncture is contraindicated because of the potential for brain herniation.
Question 16 Explanation: 
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 blood than an MRI.
Review Topic: Intracranial hemorrhage
Question 17
Seizures that first manifest in early to middle adult life should be considered suspicious of which of the following causes?
A
Cerebrovascular disease
Hint:
Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.
B
Encephalitis
Hint:
Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.
C
Tumor
D
Idiopathic epilepsy
Hint:
Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.
Question 17 Explanation: 
Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.
Review Topic: Seizure disorders
Question 18
A 32-year-old presents with a 3-day history of diarrhea. The patient denies blood, mucus, or night awakening with diarrhea. He recently returned from a business trip to Canada. On physical examination, the patient is afebrile and vital signs reveal BP 115/80, pulse is 76, and respirations are 14. The abdominal examination reveals hyperactive bowel sounds, but is otherwise unremarkable. Which of the following is the most appropriate initial intervention?
A
Stool for culture, ova, and parasites
Hint:
Stool culture and examination for ova and parasites are indicated when the diarrhea has persisted longer than 3 weeks or is associated with abdominal pain, fever, and/or bloody stools.
B
Proctosigmoidoscopy
Hint:
Proctosigmoidoscopy is indicated when inflammatory bowel disease is suspected on the basis of fever, bloody diarrhea, or abdominal pain.
C
Metronidazole (Flagyl)
Hint:
Metronidazole is indicated with a confirmed diagnosis of Giardia lamblia or amebic disease.
D
Supportive treatment
Question 18 Explanation: 
Symptomatic treatment, including dietary management and over-the-counter antidiarrheals, is indicated for afebrile patients with watery diarrhea of less than 5 days duration.
Review Topic: Infectious Diarrhea
Question 19
A 62-year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise unremarkable. Which of the following is the most likely diagnosis?
A
Viral hepatitis
Hint:
While viral hepatitis may cause jaundice, the liver is enlarged and tender.
B
Pancreatic cancer
C
Acute cholecystitis
Hint:
While acute cholecystitis may present with jaundice and an enlarged gallbladder, the pain is classically colicky and located in the right upper quadrant. On physical examination with deep inspiration and palpation of the right subcostal area increased pain and respiratory arrest (Murphy's sign) is usually seen.
D
Gilbert's syndrome
Hint:
Gilbert's syndrome is the most common of the hereditary hyperbilirubinemias. It is most often diagnosed near puberty or adult life based on results of a comprehensive metabolic panel.
Question 19 Explanation: 
Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer.
Review Topic: Pancreatic neoplasms
Question 20
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 foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected?
A
L3-L4
Hint:
See C for explanation
B
L4-L5
Hint:
See C for explanation
C
L5-S1
D
S1-S2
Hint:
See C for explanation
Question 20 Explanation: 
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 soleus muscles, and the abductor hallucis and gluteus maximus muscles.
Review Topic: Herniated nucleus pulposus
Question 21
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 fifteen miles a day, and on weekends also bicycles forty to fifty miles. Her LMP was six months ago. On exam, she is 5' 6" tall and weighs 98 pounds. Temp 98 degrees F, pulse 100, respirations 18, BP 98/60. EKG shows sinus tachycardia. Laboratory findings include Na 138 mEq/L, K 2.8 mEq/L, Cl 91 mEq/L, BUN 35 mg/dL, Creatinine 1.1 mg/dL. Which of the following is the next most appropriate treatment?
A
Propylthiouracil (PTU) and individual psychotherapy
Hint:
Propylthiouracil is used to treat hyperthyroidism, not anorexia nervosa.
B
Hormone replacement and cognitive therapy
Hint:
Hormone replacement is not indicated for the amenorrhea of anorexia nervosa, but nutritional support may help
C
Weight restoration and family therapy
D
IV hydration and antidepressant therapy
Hint:
Antidepressant therapy may be useful in bulimia nervosa.
Question 21 Explanation: 
Anorexia nervosa requires a comprehensive, multidisciplinary approach to treatment that integrates medical management, individual psychotherapy, and family therapy. Currently, the best results have been shown with weight restoration accompanied by family therapy for patients with adolescent-onset anorexia nervosa and individual therapy for patients with onset after 18 years of age. Inpatient treatment is often required.
Question 22
Which of the following is the most common cause for acute myocardial infarction?
A
Occlusion caused by coronary microemboli
Hint:
Coronary microemboli occlusion is a rare cause of acute myocardial infarction.
B
Thrombus development at a site of vascular injury
C
Congenital abnormalities
Hint:
Congenital abnormalities are rare causes of acute MI.
D
Severe coronary artery spasm
Hint:
Severe coronary artery spasm is more likely to result in Prinzmetal's angina rather than true infarction.
Question 22 Explanation: 
Acute myocardial infarction occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion.
Review Topic: Acute myocardial infarction (PEARLS)
Question 23
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 acromion and coracoacromial ligament?
A
Supraspinatus
B
Infraspinatus
Hint:
See A for explanation
C
Teres minor
Hint:
See A for explanation
D
Subscapularis
Hint:
See A for explanation
Question 23 Explanation: 
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 most commonly seen with the supraspinatus tendon, the long head of the biceps tendon and/or the subacromial bursa.
Review Topic: Disorders of the shoulder (PEARLS)
Question 24
A 13-year-old boy with leukemia presents with epistaxis for two hours. The bleeding site appears to be from Kiesselbach's area. The most appropriate intervention is
A
Electrocautery of the bleeding site
Hint:
Cautery is not used because the edges of the cauterized area may begin to bleed.
B
Silver nitrate application
Hint:
Silver nitrate is not used in children because it increases the risk for nasal septal perforation.
C
Posterior nasal packing
Hint:
Posterior nasal packing is indicated for posterior bleeds in the inferior meatus.
D
Intranasal petrolatum gauze
Question 24 Explanation: 
Petrolatum gauze will provide pressure to the bleeding point while the cause of bleeding is corrected.
Review Topic: Epistaxis
Question 25
Which of the following is the most common cause of arterial embolization?
A
Rheumatic heart disease
Hint:
Rheumatic heart disease is a rare cause of embolization
B
Myxoma
Hint:
Myxoma is a rare cause of embolization
C
Atrial fibrillation
D
Venous thrombosis
Hint:
Venous thrombosis may be a cause of embolization paradoxically, but is uncommon.
Question 25 Explanation: 
Atrial fibrillation is present in 60-70% of patients with arterial emboli and is associated with left atrial appendage thrombus.
Review Topic: Atrial fibrillation/flutter
Question 26
A 25-year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is
A
acyclovir (Zovirax)
Hint:
Acyclovir is an antiviral used in the treatment of herpes esophagitis.
B
omeprazole (Prilosec)
Hint:
Omeprazole is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease with esophageal ulceration and peptic ulcer disease and is not indicated in the treatment of infectious esophagitis.
C
fluconazole (Diflucan)
D
penicillin G
Hint:
Penicillin G is an antibiotic and is not effective against fungal infections.
Question 26 Explanation: 
The patient has Candida esophagitis and the treatment of choice is fluconazole.
Review Topic: Candidiasis
Question 27
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 important information?
A
Serum TSH
Hint:
While hyperthyroidism can cause tremor and sometimes hunger, it is not associated with a dysphoric mood. It also generally occurs in early adulthood.
B
Urine drug screen
C
Minnesota Multiphasic Personality Inventory (MMPI)
Hint:
The MMPI is an objective personality assessment instrument. There is no indication for its use here.
D
Electroencephalogram (EEG)
Hint:
While an EEG might be useful later (assuming the drug screen was negative), there is no history to indicate use of this test early on.
Question 27 Explanation: 
A drug screen would be helpful for many drugs of abuse that might cause these symptoms, but may not be definitive for amphetamines.
Review Topic: Candidiasis
Question 28
A 75-year-old woman presents to the office with complaint of vision loss. Examination reveals a palpable cord in the temporal region. Which of the following is the most helpful initial test to order on this patient?
A
Carotid ultrasound
Hint:
See D for explanation
B
Chest x-ray
Hint:
See D for explanation
C
Complete blood count
Hint:
See D for explanation
D
Erythrocyte sedimentation rate
Question 28 Explanation: 
The patient is suspected of having temporal arteritis. This disease is most commonly noted in patients over age 50 and should be suspected in patients with sudden vision loss and a palpable cord in the temporal region. Erythrocyte sedimentation rate is almost always increased in this disease.
Review Topic: Giant cell arteritis
Question 29
A 53-year-old male with history of hypertension presents complaining of recent 4/10 left-sided chest pain with exertion that is relieved with rest. He states the pain usually lasts approximately 4 minutes and is relieved with rest. Heart examination reveals regular rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute changes. Which of the following is the most appropriate initial step in the evaluation of this patient?
A
Cardiac catheterization
Hint:
This patient has signs and symptoms consistent with stable angina. Noninvasive diagnostic testing is preferred in this patient
B
CT Angiogram of the chest
Hint:
CT angiogram may be useful for the evaluation of chest pain, however its role in routine practice has not been established.
C
Echocardiogram
Hint:
This patient has signs and symptoms of stable angina. There are no signs of valvular heart disease on examination. While an echocardiogram may be performed at some point, it is not the best initial diagnostic step to determine the etiology of the patient's angina.
D
Nuclear stress test
Question 29 Explanation: 
Nuclear stress testing is the most appropriate initial diagnostic study in the evaluation of a patient with signs and symptoms consistent with stable angina.
Review Topic: Angina pectoris (PEARLS)
Question 30
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, heard a pop and noticed immediate swelling. On physical examination, the Lachman test and anterior drawer test demonstrates joint laxity. Which of the following ligaments is most likely injured?
A
Medial collateral
Hint:
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.
B
Lateral collateral
Hint:
Lateral collateral ligament injury causes pain mostly on the lateral aspect of the knee and patients can experience knee buckling with normal gait. Tenderness laterally with laxity with varus (lateral) stress is noted.
C
Posterior cruciate
Hint:
Posterior cruciate ligament injuries occur with an outside directed force, often a posterior directed force such as a knee striking a dashboard. The patients often do not hear a pop. A posterior drawer test or posterior sag test can be useful in the diagnosis.
D
Anterior cruciate
Question 30 Explanation: 
Anterior cruciate ligament injuries occur with sudden deceleration injuries. Patients often hear a pop and the diagnosis is aided by assessing the anterior drawer test and Lachman test. The immediate swelling as well as laxity with anterior drawer test and Lachman test should raise suspicion of anterior cruciate ligament injury.
Review Topic: Soft tissue injuries of the knee
Question 31
A 22-year-old woman comes to the office because her urine is cola-colored and she has not urinated since yesterday morning. Her past medical history is significant for pharyngitis two weeks ago. Her mother and grandmother have type II diabetes. Her blood pressure is 146/92 mmHG. On physical examination, she has edema of her face and hands. Which of the following is the most likely diagnosis?
A
Glomerulonephritis
B
Acute tubular necrosis
Hint:
Acute tubular necrosis is caused by acute kidney injury, such as a nephrotoxin, and is associated with uremic symptoms which include nausea, vomiting, malaise, and altered mental status. Granular casts are nonspecific and may be seen in acute tubular necrosis.
C
Nephrolithiasis
Hint:
Nephrolithiasis usually presents as a sudden onset of colicky flank pain with associated nausea and vomiting. Urinalysis often reveals gross or microscopic hematuria.
D
Diabetic nephropathy
Hint:
Diabetic nephropathy is the most common cause of end stage renal disease in the United States. Urine examination reveals albuminuria.
Question 31 Explanation: 
Glomerulonephritis presents with hematuria, cola-colored urine, oliguria, and edema of the face and eyes in the morning. Urinalysis reveals red blood cells, mild proteinuria and red blood cell casts. Glomerulonephritis can occur 1-3 weeks after a strep infection.
Review Topic: Glomerulonephritis
Question 32
A 15-year-old girl is hit in the right eye by a golf ball. There is swelling and ecchymosis of the orbit. She complains of double vision. The right eye does not move with downward gaze or right lateral gaze. Which of the following diagnostic tests will provide the most accurate information regarding this injury?
A
CT-Scan of head
B
Schiotz tonometry
Hint:
Schiotz tonometry is used to evaluate intraocular pressures; elevated pressure indicates glaucoma.
C
Fluorescein angiography
Hint:
Fluorescein angiography is used to evaluate retinopathies.
D
Slit lamp biomicroscopy
Hint:
Slit lamp biomicroscopy is used to evaluate lid contour, lesions, lashes, conjunctiva, sclera, cornea, anterior chamber, and lens.
Question 32 Explanation: 
A CT scan may show a blow-out fracture of the orbital floor. Such fractures may lead to oculomotor nerve entrapment or may lead to swelling that impinges on the nerve, causing decreased eye movements.
Review Topic: Blowout fracture
Question 33
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 patient's INR?
A
Discontinue warfarin
Hint:
This will not immediately reverse the effects of warfarin.
B
Administer fresh frozen plasma
C
Administer protamine sulfate
Hint:
Protamine sulfate is used to neutralize heparin sulphate not warfarin.
D
Administer heparin sulphate
Hint:
Heparin administration would increase the bleeding and be harmful.
Question 33 Explanation: 
Fresh frozen plasma is the most rapid way to lower the patient's INR.
Review Topic: Atrial fibrillation/flutter
Question 34
An 85-year-old nursing home resident presents with abrupt onset of cough, sore throat, headache, myalgias, and malaise. On examination the patient's temperature is 102 degrees F; the rest of the exam is unremarkable. Nasal smear is positive for Influenza B. Which of the following is the treatment of choice in this patient?
A
Amantadine (Symmetrel)
Hint:
Amantadine is only used to treat influenza A.
B
Oseltamivir (Tamiflu)
C
Acyclovir (Zovirax)
Hint:
Acyclovir is used to treat viral infections due to certain herpes viruses.
D
Nevirapine (Viramune)
Hint:
Nevirapine is used to treat infection due to HIV.
Question 34 Explanation: 
Oseltamivir is used to treat both influenza A and B.
Review Topic: Influenza
Question 35
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 3 cm jagged laceration. The patient is unaware of his tetanus immunization status. Besides cleaning and debriding the wound, what is the recommended clinical intervention in this patient?
A
Administer tetanus-diptheria toxoid (Td) and tetanus immune globulin (TIG)
B
Administer diphtheria, tetanus, and pertussis vaccine (DTP)
Hint:
Td or Tdap with TIG is recommended as tetanus prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status.
C
Administer tetanus toxoid vaccine (TT) and tetanus immune globulin (TIG)
Hint:
Td or Tdap with TIG is recommended as tetanus prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status.
D
No tetanus immunization or tetanus immune globulin is necessary in this patient
Hint:
Td or Tdap with TIG is recommended as tetanus prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status.
Question 35 Explanation: 
Td or Tdap with TIG is recommended as tetanus prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status.
Review Topic: Tetanus
Question 36
A 20-year-old male presents with complaint of brief episodes of rapid heart beat with a sudden onset and offset that have increased in frequency. He admits to associated shortness of breath and lightheadedness. He denies syncope. Electrocardiogram reveals a delta wave prominent in lead II. Which of the following is the most appropriate long-term management in this patient?
A
Implantable cardiac defibrillator
Hint:
Implantable cardiac defibrillators are indicated in the treatment of ventricular arrhythmias, not Wolff-Parkinson-White (WPW) syndrome.
B
Radiofrequency ablation
C
Verapamil (Calan)
Hint:
Calcium channel blockers and beta-blockers are not the best options for the long-term management of WPW. They may decrease the refractoriness of the accessory pathway or increase the refractoriness of the AV node in patients with atrial fibrillation or atrial flutter who have an antegrade conducting bypass tract. This may lead to faster ventricular rates.
D
Metoprolol (Lopressor)
Hint:
Calcium channel blockers and beta-blockers are not the best options for the long-term management of WPW. They may decrease the refractoriness of the accessory pathway or increase the refractoriness of the AV node in patients with atrial fibrillation or atrial flutter who have an antegrade conducting bypass tract. This may lead to faster ventricular rates.
Question 36 Explanation: 
Radiofrequency ablation is the procedure of choice for long-term management in patients with accessory pathways (WPW) and recurrent symptoms.
Review Topic: Paroxysmal supraventricular tachycardia
Question 37
A 26-year-old woman requests screening after her boyfriend was treated for a sexually transmitted infection recently. On examination you find a painless vulvar ulcer. Which of the following is the most likely diagnosis?
A
Herpes
Hint:
The classic presentation of herpes is a painful vesicle.
B
Syphilis
C
Chancroid
Hint:
Chancroid presents with a painful genital ulcer and tender suppurative inguinal adenopathy.
D
Granuloma inguinale
Hint:
Granuloma inguinale presents with raised, red lesions that bleed easily.
Question 37 Explanation: 
The primary lesion of syphilis presents as a painless ulcer or chancre. Secondary syphilis presents with a skin rash lymphadenopathy and mucocutaneous lesions.
Review Topic: Syphilis
Question 38
A 57-year-old male recently on a high protein diet presents with an exquisitely tender, erythematous, warm right great toe. Which of the following is the treatment of choice for this patient?
A
Corticosteroids
Hint:
Corticosteroids are effective in acute gout attacks but are reserved for people with non-steroidal anti-inflammatory agent allergies or contraindications.
B
Colchicine
Hint:
Low-dose oral colchicine therapy for an acute gout flare is appropriate in patients with glucocorticoid and NSAID intolerance or with absolute (or often relative) contraindications to glucocorticoid and NSAID use.
C
Allopurinol
Hint:
Allopurinol is useful in reducing uric acid levels but is not the treatment of choice in acute gouty arthritis.
D
Non-steroidal anti inflammatory agents
Question 38 Explanation: 
Nonsteroidal antiinflammatory drugs (NSAIDs) are the drugs of first choice in most settings. There is no evidence that one NSAID is superior to another in the treatment of gout. Systemic corticosteroid therapy can be used for patients with acute polyarticular gout who have not responded to other therapies as well as for patients in whom other therapies are contraindicated. Intra articular injections of corticosteroid medication are usually effective in patients with acute monoarticular gout.
Review Topic: Gout/pseudogout
Question 39
Which of the following diagnostic studies is indicated in the evaluation of an upper gastrointestinal bleed?
A
Esophageal manometry
Hint:
Esophageal manometry is not indicated in the evaluation of upper gastrointestinal bleeding.
B
Bleeding scan
Hint:
Bleeding scans are most useful to evaluate occult GI bleeding. Radioactive isotope tracing is useful to concentrate bleeding sites at a single location. It is most useful to find bleeding that is occurring in the large or small bowel rather than in the upper GI sites.
C
Upper endoscopy
D
Barium swallow
Hint:
Barium swallow is not indicated in the evaluation of upper gastrointestinal bleeding.
Question 39 Explanation: 
Endoscopy is the evaluation modality of choice in patients with upper GI bleeding. The advantage of this technique is that it can be used for both diagnostic and therapeutic purposes.
Review Topic: General Surgery: Hematemesis
Question 40
Which of the following physical examination findings would be consistent with a pleural effusion?
A
Hyperresonance to percussion
Hint:
Hyperresonance to percussion would be suggestive of emphysema or pneumothorax.
B
Increased tactile fremitus
Hint:
Increased tactile fremitus would be consistent with a consolidation.
C
Unilateral lag on chest expansion
D
Egophony
Hint:
The presence of egophony would be consistent with a consolidation.
Question 40 Explanation: 
A lag on chest expansion may be seen in the presence of a pleural effusion.
Review Topic: Pleural effusion
Question 41
A 72-year-old patient with a history of hypertension and atrial fibrillation presents with episodes of weakness, numbness, and paresthesias in the right arm. At the same time, she notes speech difficulty and loss of vision in her left eye. These symptoms come on abruptly and clear within minutes. Physical examination is normal except for the previously known arrhythmia. Which of the following is the most likely diagnosis?
A
Focal seizure
Hint:
Focal seizures usually cause abnormal motor movement rather than weakness or loss of feeling.
B
Migraine headache
Hint:
Patients with migraines commonly have a history of episodes since adolescence.
C
Hypoglycemic episodes
Hint:
Hypoglycemic episodes do not present with focal neurological findings.
D
Transient ischemic attack
Question 41 Explanation: 
This patient's symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli.
Review Topic: " target="_blank" rel="noopener">Transient ischemic attack
Question 42
A 16-year-old male involved in a fight sustained a laceration to his right upper eyelid. He is unable to open his eye, and a possible laceration of the globe is suspected. Which of the following is the next step?
A
Use a slit lamp to determine the extent of the injury
Hint:
See C for explanation
B
Use fluorescein strips to determine the extent of injury
Hint:
See C for explanation
C
Apply a metal eye shield and refer to an ophthalmologist.
D
Apply antibiotic ointment to the lid and recheck in 24 hours
Hint:
See C for explanation
Question 42 Explanation: 
Protect the eye from any pressure with a rigid metal eye shield and refer for immediate ophthalmologic consultation. Avoid unnecessary actions that would delay treatment or cause further injury.
Review Topic: Traumatic disorders of the eye
Question 43
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 encountered?
A
Inability to extend the wrist against resistance
B
Numbness over the deltoid muscle in the shoulder
Hint:
Axillary nerve injury results in numbness over the deltoid muscle; this nerve is more commonly injured in proximal humeral fractures and anterior shoulder dislocations.
C
Winging of the scapula
Hint:
Injury to the long thoracic nerve causes winging of the scapula due to its innervation of the serratus anterior muscle.
D
Weakness of the rotator cuff
Hint:
Injury to the subscapular nerve results in weakness and pain of the infraspinatus muscle; this injury is commonly seen in volleyball players from repetitive stress.
Question 43 Explanation: 
The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance.
Review Topic: Fractures and dislocations of the forearm, wrist and hand
Question 44
A 57-year-old male was working on his farm when some manure was slung hitting his left eye. He presents several days after with a red, tearing, painful eye. Fluorescein stain reveals uptake over the cornea looking like a shallow crater. Which of the following interventions would be harmful?
A
Ophthalmic antibiotics
Hint:
Ophthalmic antibiotics and copious irrigation are indicated when treating a patient with a suspected corneal ulcer due to an infectious cause.
B
Pressure patch
C
Examination for visual acuity
Hint:
Examination for assessment of visual acuity should be performed.
D
Copious irrigation
Hint:
Ophthalmic antibiotics and copious irrigation are indicated when treating a patient with a suspected corneal ulcer due to an infectious cause.
Question 44 Explanation: 
Patching of the eye after abrasion associated with organic material contamination is contraindicated due to increased risk of fungal infection.
Review Topic: Ocular Foreign body
Question 45
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 joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice?
A
Open reduction and internal fixation
Hint:
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.
B
Continuous extension of the DIP with splinting
C
Continuous flexion of the PIP with splinting
Hint:
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.
D
Application of short arm cast
Hint:
Short arm casting is indicated in wrist and metacarpal injuries but not in DIP extensor injuries.
Question 45 Explanation: 
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.
Review Topic: Soft tissue injuries of the forearm, wrist and hand (ReelDx)
Question 46
Which of the following views on plain films is preferred to identify spondylolysis?
A
Anterior
Hint:
The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films.
B
Posterior
Hint:
The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films.
C
Oblique
D
Lateral
Hint:
The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films.
Question 46 Explanation: 
The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films.
Review Topic: Video - Spondylolysis and Spondylolisthesis in the Adolescent Athlete
Question 47
What type of chest pain is most commonly associated with a dissecting aortic aneurysm?
A
Squeezing
Hint:
Squeezing pain is more characteristic of angina or esophageal pain.
B
Dull, aching
Hint:
Dull, aching pain is more characteristic of chest wall pain, possibly angina, or anxiety.
C
Ripping, tearing
D
Burning
Hint:
Burning pain is more characteristic of esophageal reflux, esophagitis, or tracheobronchitis.
Question 47 Explanation: 
A dissecting aortic aneurysm often presents with a very severe ripping, tearing-like pain.
Review Topic: Aortic aneurysm/dissection
Question 48
Which of the following is the first-line treatment for symptomatic bradyarrhythmias due to sick sinus syndrome (SSS)?
A
Permanent pacemaker
B
Radiofrequency ablation
Hint:
Radiofrequency ablation is used for the treatment of accessory pathways in the heart.
C
Antiarrhythmics
Hint:
Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome.
D
Anticoagulation therapy
Hint:
Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome.
Question 48 Explanation: 
Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome.
Review Topic: Sick sinus syndrome
Question 49
A 36-year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size, but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis?
A
Congestive heart failure
B
Subacute bacterial endocarditis
Hint:
Endocarditis occurs as a result of infection that primarily occurs in the blood stream. Endocarditis would present with signs of infection or seeding rather than signs of heart failure.
C
Pulmonary embolus
Hint:
Pulmonary embolus usually presents with an acute onset of chest pain, severe dyspnea, and anxiety.
D
Pneumonia
Hint:
Pneumonia is less likely since there is no fever and edema is not usually associated with pneumonia.
Question 49 Explanation: 
Given the presence of cardiomyopathy, the patient's heart has decreased functional reserve. The symptoms and chest x-ray findings are typical of congestive heart failure.
Review Topic: Heart Failure
Question 50
An 18-year-old sexually active female was seen in the student health clinic 1 week ago for a sore throat. A streptococcal antigen test was positive, and she was given a prescription for oral penicillin. After 3 days, she stopped her medication because she felt better. She now presents with a severe sore throat. On physical examination, she has a temperature of 102.6° F (39.2° C), marked pharyngeal erythema, medial deviation of the soft palate on the left, tender left anterior cervical adenopathy, and a "hot potato" voice. The rest of her history and physical examination are unremarkable. Which of the following is the most likely diagnosis?
A
Recurrent streptococcal pharyngitis
Hint:
This presentation suggests a complication of an incompletely treated streptococcal pharyngitis rather than recurrent disease.
B
Infectious mononucleosis
Hint:
Infectious mononucleosis may present with severe sore throat, fever, and cervical adenopathy in this age group, but would not cause deviation of the soft palate or the muffled voice.
C
Gonococcal pharyngitis
Hint:
Gonococcal pharyngitis usually follows a more indolent course than this patient's presentation.
D
Peritonsillar abscess
Question 50 Explanation: 
The soft palate deviation and a muffled voice are classic signs of peritonsillar abscess.
Review Topic: Peritonsillar abscess
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