Cardiology
A 52-year-old woman is evaluated during a follow-up visit. She was discharged from the hospital 3 weeks ago following a small non–ST-elevation myocardial infarction treated with drug-eluting stent placement in the right coronary artery. An echocardiogram obtained during hospitalization showed normal left ventricular function and normal valvular function. Her hospital course was uncomplicated. Since discharge, she has had shortness of breath. Medical history is significant for hyperlipidemia. Medications are aspirin, ticagrelor, lisinopril, metoprolol, and atorvastatin.
On physical examination, vital signs are normal. Oxygen saturation is 99% breathing ambient air. The estimated central venous pressure is normal. Cardiac examination reveals no S3 or murmurs. The lungs are clear to auscultation.
A chest radiograph is normal. An electrocardiogram is unchanged from those obtained in the hospital.
Which of the following is the most likely cause of this patient's dyspnea?
A. Heart failure
B. In-stent restenosis
C. Stent thrombosis
D. Ticagrelor-mediated side effect
E. Ventricular septal rupture
Ticagrelor-mediated side effect
A 40-year-old woman seeks advice on whether she should undergo breast cancer screening with mammography. Her family history is negative for breast and ovarian cancers, and she has no other risk factors for breast cancer.
On physical examination, vital signs and the remainder of the examination are normal.
The patient is engaged in a discussion of the potential benefits and harms of initiating mammography now, including the potential for false-positive results and overdiagnosis. After the discussion, she states that she is not overly concerned about her risk for breast cancer but is anxious about the potential harms associated with screening.
Which of the following is the most appropriate screening test for this patient?
A. Breast self-examination
B. Breast tomosynthesis
C. Screening mammography
D. No testing
No testing
A 45-year-old woman is evaluated for management of type 2 diabetes mellitus diagnosed 3 months ago. She was asymptomatic at diagnosis with an initial hemoglobin A1c value of 9.7%. Her initial interventions included lifestyle modifications with weight loss and metformin. She is motivated to continue to lose weight. Medical history is significant for hypertension, hyperlipidemia, and frequent vulvovaginal candidiasis. She has no family history of thyroid or pancreatic malignancy. Medications are metformin, lisinopril, and atorvastatin.
On physical examination, vital signs are normal. BMI is 30. The remainder of the examination is unremarkable.
Results of laboratory studies show a hemoglobin A1c level of 9.1%. Chemistry panel and creatinine levels are normal.
Which of the following is the most appropriate management for this patient's diabetes?
A. Initiate empagliflozin
B. Initiate glipizide
C. Initiate insulin glargine
D. Initiate liraglutide
Initiate liraglutide
Which one of the following initial treatments is most appropriate for a previously healthy 27-year-old woman who developed cough and itching after being stung by a honeybee and is found to be tachycardic and tachypneic with localized redness and swelling at the site of the sting?
Answer choices
A. Intramuscular epinephrine
B. Intravenous methylprednisolone
C. Nebulized albuterol
D. Intravenous glucagon
E. Intravenous diphenhydramine
Intramuscular epinephrine
Key learning point: The treatment of choice for an anaphylactic reaction is intramuscular administration of epinephrine.
What County is Inverness found in?
Inverness is a city in Citrus County, Florida, United States.
A 68-year-old woman is evaluated in the emergency department for acute-onset dyspnea, palpitations, and chest pain. The symptoms began shortly after her dog was attacked by another dog. She is otherwise healthy and takes no medications.
On physical examination, the patient is afebrile, blood pressure is 150/78 mm Hg, and pulse rate is 88/min. Cardiac examination reveals no evidence of increased central venous pressure. There is no heart murmur, but an S3 is present. The lungs are clear to auscultation.
Laboratory studies are significant for a serum troponin I level of 5.2 ng/mL (5.2 µg/L).
An electrocardiogram demonstrates sinus rhythm and anterior hyperacute T-wave elevations suggestive of an ST-elevation myocardial infarction. Cardiac catheterization shows normal coronary arteries.
Which of the following is the most likely diagnosis?
A. Acute myocarditis
B. Giant cell myocarditis
C. Tachycardia-mediated cardiomyopathy
D. Takotsubo cardiomyopathy
Takotsubo cardiomyopathy
A 67-year-old man is evaluated for a 2-year history of worsening pain in his feet. He describes the pain as long-standing aching and burning. The pain is persistent, sometimes waking him from sleep. Medical history is otherwise significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Medications are insulin glargine, insulin aspart, valsartan, aspirin, and simvastatin.
On physical examination, vital signs are normal. The feet are insensate to monofilament testing, and vibratory sensation is absent in the feet and ankles. No evidence of skin breakdown is noted.
Which of the following is the most appropriate treatment?
A. Oral duloxetine
B. Oral hydromorphone
C. Oral lamotrigine
D. Oral tramadol
E. Topical diclofenac
Oral duloxetine
A 33-year-old man is evaluated for fatigue, headache, loss of appetite, and nausea for 6 months' duration. He has lost 9.1 kg (20 lb). Medical history is unremarkable, and he takes no medications.
On physical examination, temperature is normal, blood pressure is 118/70 mm Hg sitting and 98/68 mm Hg standing, pulse rate is 88/min sitting and 106/min standing, and respiration rate is 18/min. BMI is 19. The remainder of the physical examination is normal.
Laboratory studies:
Potassium
5.6 mEq/L (5.6 mmol/L)
Sodium
136 mEq/L (136 mmol/L)
Adrenocorticotropic hormone (ACTH )
450 pg/mL (99 pmol/L)
Cortisol , 8 AM
2.6 µg/dL (71.8 nmol/L)
Which of the following is the most appropriate next test?
A. Cosyntropin stimulation test
B. 21-Hydroxylase antibody measurement
C. Pituitary MRI
D. Serum aldosterone measurement
21-Hydroxylase antibody measurement
A 50-year-old man with allergic rhinitis since childhood presents during autumn with worsening symptoms of rhinorrhea, sneezing and nasal pruritus. He takes loratadine 10 mg daily, which provides inadequate symptomatic relief.
Which for the following treatment options is most appropriate for this patient?
Answer choices:
A. Oral prednisone for 3 days at onset of symptoms
B. Oral pseudoephedrine
C. Daily ipratropium nasal spray
D. Daily fluticasone nasal spray
E. Immunotherapy
Daily fluticasone nasal spray
Key learning point: If allergic rhinitis symptoms are not relieved by antihistamines, the next line of therapy is a nasal glucocorticoid.
The city of Inverness was originally named:
A. "Tompkinsville"
B. Barnesville
C. Titusville
D. Klumpville
E. Noveckville
Settlement of the area dates back to 1868.[9] A. D. Tompkins, later known as "Uncle Alf", started the community.
A 64-year-old man is evaluated in the office 7 days after discharge from the hospital for non–ST-elevation myocardial infarction. He was treated with percutaneous coronary intervention using a radial artery approach. Right femoral artery access was initially attempted, but the catheter guidewire could not be passed. During the procedure, an abdominal aortogram was obtained (shown). He has not had any symptoms of claudication. Medical history is significant for hyperlipidemia. He is a current smoker with a 40-pack-year history. Medications are low-dose aspirin, ticagrelor, metoprolol, and atorvastatin.
On physical examination, vital signs are stable. The right femoral pulse is faint, and a bruit is heard over the right femoral artery. No foot or toe ulceration is noted.
In addition to aggressive risk factor modification, which of the following is the most appropriate management?
A. Cilostazol
B. Cardiac rehabilitation
C. Endovascular iliac stenting
D. Vorapaxar
Cardiac rehabilitation
A 49-year-old man is scheduled for total right knee arthroplasty. Medical history is otherwise unremarkable. He takes no medications.
On physical examination, vital signs are normal. The right knee demonstrates bony hypertrophy and crepitus with passive movement.
Low-molecular-weight heparin and intermittent pneumatic compression will be initiated and continued during the hospital stay.
Which of the following is the recommended duration of low-molecular-weight heparin prophylaxis for this patient?
A. Total of 10 days
B. Total of 14 days
C. Total of 35 days
D. Until fully ambulatory
E. Until hospital discharge
Total of 35 days
A 23-year-old woman is seen in follow-up for evaluation of amenorrhea of 4 months' duration. Her only other medical problem is schizophrenia treated with risperidone.
On physical examination, vital signs and physical examination are normal.
Laboratory studies:
Prolactin
220 ng/mL (220 µg/L)
Thyroid-stimulating hormone
2.2 µU/mL (2.2 mU/L)
Thyroxine (T4), free
1.2 ng/dL (15.5 pmol/L)
Urine human chorionic gonadotropin
Negative
Which of the following is the most appropriate next step?
A. Obtain a pituitary MRI
B. Start cabergoline
C. Start an oral contraceptive
D. Stop risperidone
Obtain a pituitary MRI
A healthy 25-year-old woman drinks a smoothie from a new juice bar. 10 minutes later, she develops a generalized urticarial rash. She is immediately brought to the emergency department, where she was noted to have normal vital signs, clear lungs, a clear oropharynx and diffuse hives and itching.
Which one of the following initial treatments is most appropriate for this patient?
Answer choices:
A. Intramuscular epinephrine and an oral antihistamine
B. Intramuscular epinephrine alone
C. An oral antihistamine alone
D. Intramuscular epinephrine and oral prednisone
E. Oral prednisone alone
Answer: An oral antihistamine alone
Key learning point: The treatment of choice for an acute allergic reaction without systemic symptoms is an oral antihistamine.
In 1961 the historic courthouse downtown was used to film the courtroom scene of:
A. "Follow That Dream" featuring Elvis Presley
B. "Forest Gump" featuring Tom Hanks
C. "County men" featuring Ringo Star
D. "The Dreamer" featuring Tina Turner
E. "The Suncoast" featuring Neil Armstrong
A. "Follow That Dream" featuring Elvis Presley
An 80-year-old woman was hospitalized for chest pain and findings of a lateral ST-elevation myocardial infarction. She underwent percutaneous coronary intervention of a marginal branch of the left circumflex artery 16 hours after symptom onset. On hospital day 3, her cardiac examination is normal, but 3 hours later, she develops sudden-onset chest pain and loses consciousness. She is found to have pulseless electrical activity. Heart sounds are significantly diminished.
Which of the following is the most likely diagnosis?
A. Aortic dissection
B. In-stent restenosis
C. Ventricular free wall rupture
D. Ventricular septal defect
Ventricular free wall rupture
A 23-year-old woman is evaluated for depression as she prepares for discharge from the hospital to home hospice care. She was diagnosed with metastatic ovarian cancer 2 years ago, and she progressed through four lines of chemotherapy, a trial of immunotherapy, and a failed attempt at a phase 1 clinical trial. Her life expectancy is measured in weeks. She is currently hospitalized with volume depletion, and after consultation with her oncologist and palliative care team, she has decided to be discharged home with hospice care.
On physical examination, the patient exhibits substantial fatigue and poor concentration. She has a flat affect except when intermittently tearful. Previously upbeat despite all of the setbacks, she is now withdrawn and describes feeling hopeless. She has pervasive guilt over the burden she believes she has caused her family. Medications are a fentanyl patch, oxycodone, ondansetron, polyethylene glycol, senna, and zolpidem.
Which of the following is the most appropriate treatment?
A. Citalopram
B. Cognitive behavioral therapy
C. Methylphenidate
D. Sertraline
Methylphenidate
A 22-year-old woman is evaluated for loss of appetite and fatigue and 4.5-kg (10-lb) weight loss over the past 6 months. Medical history is otherwise unremarkable, and she takes no medications.
On physical examination, blood pressure is 100/70 mm Hg and pulse rate is 94/min. Other vital signs are normal. BMI is 22. The patient looks tanned, even in areas not exposed to the sun, and has buccal and palmar hyperpigmentation.
Laboratory studies:
Potassium
5.3 mEq/L (5.3 mmol/L)
Sodium
134 mEq/L (134 mmol/L)
Adrenocorticotropic hormone (ACTH )
650 pg/mL (143 pmol/L)
Cortisol
2.8 µg/dL (77.3 nmol/L)
Which of the following is the most appropriate treatment?
A. Dexamethasone twice daily
B. Hydrocortisone twice daily
C. Hydrocortisone twice daily and fludrocortisone once daily
D. Prednisone twice daily
E. Prednisone twice daily and fludrocortisone once daily
Hydrocortisone twice daily and fludrocortisone once daily
A 21-year-old man presents with a persistent cough after a recent cold. The cough is exacerbated by cold air and exercise and worsens at night. Which one of the following treatments is most appropriate?
Answer choices
A. A nasal glucocorticoid spray
B. A leukotriene receptor antagonist
C. Guaifenesin
D. A long-acting beta agonist
E. As needed inhaled glucocorticoid-formoterol
Correct answer: As needed inhaled glucocorticoid-formoterol
Key learning point: The most likely cause of a chronic cough that is exacerbated by cold air and exercise and that worsens during sleep is asthma
The last full weekend in October is reserved for this festival named after this great Florida animal:
A. The Florida cooter turtle
B. Florida Panther
C. Florida Alligator
D. The Florida Rattlesnake
E. The Florida Eagle
the Great American Cooter Festival, named after the Florida cooter turtle.
A 66-year-old man has just received an aortic valve replacement with a mechanical prosthesis. He is otherwise healthy and takes no medications.
On physical examination, vital signs are normal. There is a regular rhythm with a normal S1, a mechanical S2, and no murmurs. The remainder of the physical examination is normal.
Which of the following is the most appropriate antithrombotic therapy?
A. Apixaban
B. Dabigatran
C. Warfarin
D. Warfarin and aspirin
E. No anticoagulation required
Warfarin and aspirin
A 68-year-old man is evaluated for fever, perineal pain, dysuria, frequency, and intermittent straining that began yesterday. Symptoms began 48 hours after a prostate biopsy due to an elevated prostate-specific antigen level detected during routine screening.
On physical examination, temperature is 38.7 °C (101.7 °F), blood pressure is 145/82 mm Hg, pulse rate is 105/min, and respiration rate is normal. The prostate is enlarged and boggy, and it is tender to gentle palpation. There is no penile discharge, and no scrotal pain occurs with palpation.
Dipstick urinalysis is positive for leukocyte esterase and nitrates. Urine Gram stain reveals gram-negative rods. Urine culture is pending.
Which of the following is the most appropriate treatment?
A. Amoxicillin
B. Ceftriaxone and doxycycline
C. Cephalexin
D. Trimethoprim-sulfamethoxazole
Trimethoprim-sulfamethoxazole
A 32-year-old woman is seen for follow-up evaluation of thyroid nodules. At her visit 2 weeks ago, a 3-cm right thyroid nodule and 2-cm right lateral neck mass were palpated on examination. The patient is asymptomatic. At age 12 she was treated with combination chemotherapy plus involved-field radiation for Hodgkin lymphoma. There is no family history of thyroid disease.
Laboratory studies show a serum thyroid-stimulating hormone level of 3.0 µU/mL (3.0 mU/L). Results of other laboratory studies are normal.
Thyroid ultrasound demonstrates a 3.1 × 2.8 × 1.6-cm hypoechoic solid right thyroid nodule with irregular margins. Right cervical lymphadenopathy was confirmed on ultrasonography.
Which of the following is the most likely diagnosis?
A. Benign follicular thyroid nodule
B. Follicular thyroid cancer
C. Medullary thyroid cancer
D. Papillary thyroid cancer
Papillary thyroid cancer
A 36-year-old woman who lives in the United States presents for evaluation of nasal symptoms. She reports symptoms of rhinorrhea, nasal pruritus, and ocular pruritus that occur every year for 4 to 5 weeks in the late summer and early fall. She has a cat and a dog.
To which of the following allergens is this patient most likely to be sensitive?
Answer choices
A. Grass pollen
B. Tree pollen
C. Cat or dog dander
D. Dust mites
E. Weed pollen
Correct answer: Weed pollen
Key learning point: Allergies in the late summer and early fall are most likely to be caused by weed pollen.
The Withlacoochee State Trail, which replaced a former Atlantic Coast Line Railroad line, runs between two of the chained lakes, with small bridges replacing former railroad trestle crossings. The trail offers access to 46 continuous miles of enjoyment for biking, jogging and walking. It is the longest paved recreation trail in Florida