I get knocked down
While playing basketball, a 22-year-old male was running down the court, stopped to shoot, and felt a tearing pain in his knee. He was unable to continue playing and his knee swelled within 15 minutes. On exam, he had a knee effusion but no pain over the joint line. Which of the following is the most sensitive physical exam test to diagnose his condition?
A. Anterior drawer
B. Lachman
C. Posterior drawer
D. McMurray
E. FABER
B. Lachman
The mechanism of injury is a forward displacement of the femur on the stopped tibia. This is the classic mechanism for an ACL injury. The effusion of the knee happened so quickly that the fluid had to be blood and therefore a tear occurred instead of a strain. The Lachman is a more sensitive test for an ACL tear than is the anterior drawer (both are PE test used for ACL tear). The posterior drawer is for a PCL tear, the McMurray for a meniscus tear, and the FABER (flexed, abducted and externally rotated) for sacroiliac pathology. While a meniscus tear could be possible, no rotational force is present in the mechanism of injury and no pain over the joint line makes this less of a possibility.
A 62-year-old patient had a fasting blood glucose of 160 and a Hgb A1c of 7.5. Which of the following would this patient be expected to display?
C. High triglycerides
The patient has diagnostic criteria of DM2 which is part of the IRS (insulin resistance syndrome). Other parts of this syndrome can include: central obesity, hypertension, low HDL, high triglycerides, DM2, high uric acid levels, NASH (fatty liver), PCOS (in females), and OSA.
According to the USPSTF, which of the following persons should be screened for osteoporosis?
C.
The USPSTF recommends screening women at age 65 with no risk factors or women less than 65 who have risks that equal or are greater than a woman at age 65. Repeat tests after negative screens have never proven to be useful. There is insufficient evidence to recommend screening for men (I recommendation).
Which of the following increases a woman’s risk of developing gestational diabetes?
E. Obesity
The risk factors for gestational diabetes are obesity, personal history of gestational diabetes, family history of DM2, maternal age >25 years, and previous baby weighing >9 lb.
A 64-year-old male with a history of HTN and metabolic syndrome presents with a 3-day history of progressively worsening epigastric pain that radiates to the back. He has a poor appetite and the pain is worse with food. He denies fever or bowel changes. His heart and lung exam are normal. He has moderate-to-severe tenderness in the epigastric area which feels very firm and he guards that area. He does not have any rebound tenderness. What is the next best treatment step?
D. Urgent CT
This patient has red flags for a possible serious intra-abdominal problem including moderate-to-severe pain that radiates to the back with both voluntary and involuntary guarding. This presentation is most consistent with pancreatitis although other disorders can present similarly. An urgent abdominal CT would be important in evaluating this and ruling out other possibilities. Blood work including a CMP, CBC with differential, and lipase/amylase should be done as well. An Ultrasound could be useful, but it is not the best test to evaluate the pancreas. There is also need for urgent evaluation. An EGD may be useful in subsequent workup but not in the initial workup of this patient. It is not appropriate to simply start a PPI without workup in a patient with abdominal red flags.
A 22-year-old female was jogging and slipped off a curb and suffered an inversion injury to her ankle. She presents to the ER requesting an X-ray to rule out a fracture. Which of the following would be an indication for an X-ray?
D.
Ottawa ankle rules:
1. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
2. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
3. Bony tenderness at the base of 5th metatarsal
4. Bony tenderness at the navicular
5. Inability to bear weight both immediately after injury and for 4 steps during initial evaluation
A 57-year-old patient has been diagnosed with DM2. Which of the following is the most potent therapy for patients with Type 2 DM?
A. Insulin
B. Metformin
C. Weight loss
D. Amylin analog
E. Sodium glucose cotransporter 2 inhibitor
C. Weight loss (lifestyle changes, diet, exercise, bariatric surgery) is the most potent therapy for Type 2 DM. None of the medications are as potent as weight loss. Insulin is the most potent medication, but not the most potent therapy.
A 55-year-old female lawyer comes to see you for a complete physical exam. Aside from a 30-pack year history of cigarette smoking, her Past Medical History is unremarkable. Her physical exam is completely normal. You tell her that you will be making recommendations based on guidelines issued by the U.S. Preventive Services Task Force. Which of the following do you definitely recommend?
C. Colonoscopy
Per USPSTF, mammogram screening is recommended biannually NOT annually. Osteoporosis screening is not recommended in women until 65 years old unless she is at high risk. AAA screening is not recommended in women.
A 26-year-old G2P2 presents for her routine postpartum check-up. She states that breastfeeding is going well but she is anxious about her ability to care for her infant girl. Quietly she mentions she is having difficulty sleeping and has cried unexpectedly nearly every day since hospital discharge. Her boyfriend has been vocal about questioning whether or not he is really the father of the baby. She also has had decreased appetite and is not interested in activities she normally enjoys. She denies suicidal ideation or wanting to harm or abandon her daughter. Her self-reported EPDS score was 17. Which of the following are true about her diagnosis?
C. Lack of social support
Patients at risk for postpartum depression generally are younger, primiparous, have a history of depression, an unplanned pregnancy, poor social support, or be involved in an abusive relationship. The diagnosis of postpartum depression can occur at any time in the first year after delivery, and affects 8% to 15% of women. Intervention should be made by any medical professional who suspects the diagnosis. The EPDS is a nonproprietary validated test for this condition, which can be administered in a variety of healthcare settings. Her score of 17 is strongly suggestive of postpartum depression. A score of 10 or less would be considered normal.
A 38-year-old woman presents with chronic headaches that she has on most days. It is a bilateral frontal headache and is usually dull and pressing. She has slight photo/phonophobia. She denies an aura preceding the headache. She has no vision changes or weakness, denies nausea or vomiting, and weight has been stable. She takes labetalol for HTN and ibuprofen most mornings for the headache. Which of these is the best treatment to improve her headaches?
B. Discontinue Ibuprofen
Her symptoms are most consistent with a withdrawal-type headache owing to the use of the ibuprofen. Discontinuing the ibuprofen or limiting it to no more than two to three times a week will likely improve her symptoms once she gets past the acute withdrawal stage (usually within a few days). Increasing the ibuprofen to three times a day may initially help but the headaches will eventually come back and it does not solve the actual cause. Sumatriptan is used to treat migraine-type headaches, which is not consistent with this presentation. While propranolol is used in headache prophylaxis, changing the labetalol to propranolol is unlikely to significantly benefit this patient.
A 10-year-old boy presents to your clinic with right knee pain for 2 weeks. He is physically active at school and plays soccer and basket-ball. He describes pain in his knees when he runs or jumps. He denies any recent trauma.His physical examination is normal except for mild edema and tenderness over the right tibial tubercle. What is the most likely diagnosis?
(A) slipped capital femoral epiphysis
(B) Osgood-Schlatter disease
(C) patellar tendonitis
(D) iliotibial band friction syndrome
(E) septic joint
(B)Osgood-Schlatter disease is a repetitive stress injury to the inferior end of the patellar tendon at its insertion into the tibial tubercle.These patients are usually young, athletic males between the ages 10 and 15 years. The diagnosis is made when a young male presents with knee pain that increases with exercise without a history of trauma. Treatment consists of rest, activity restriction, and anti-inflammatory agents. Slipped capital femoral epiphysis occurs most commonly in African American obese adolescent males. It refers to a slipping of the epiphysis off the metaphysis. The “slipping” is caused by weakening of theperichondral ring of the growth plate, which allows the epiphysis and metaphysis to gradually or acutely displace from each other. This results in pain in the groin, thigh, or knee as well as a limp. Treatment is primarily operative internal fixation. Patellar tendonitis is caused by injury to the patellar tendon. Most of these patients have tenderness in the inferior portion of the patella and complain of chronic anterior knee pain. Iliotibial band friction syndrome causes lateral knee pain in runners.
Which U.S. population has the highest prevalence of Type 2 DM?
D. Native Americans have the highest prevalence of DM2 in the United States followed by African Americans, Latinos, Caucasians, and Asian Americans.
Which of the following is true regarding screening recommendations for adolescents or young adults?
C. Depression screening
The CDC recommends screening everyone aged 15 to 65 years for HIV. Lipid screening is recommended for adolescents by the AAP but not by the USPSTF. Universal hearing screen is not recommended for adolescents or young adults. Depression screening is recommended for all 12 years or older.
A 28-year-old G1P0 at 38 weeks 4 days presents to labor and delivery after feeling a gush of fluid. She has also been having irregular low abdominal cramps every 8 to 10 minutes. Her pregnancy has been uneventful and she is GBS positive. A fern test was positive. She was found to be dilated to 1 cm. What is the next step in management?
A. Admit for labor
There is no evidence that the patient is truly in active labor yet; however, in GBS-positive patients with confirmed rupture of membranes, penicillin must be started to reduce risk of complications in the infant. About 15% to 40% of women are colonized with Group B Strep. Appropriate treatment with two doses of penicillin prior to delivery reduces the risk of an early-onset GBS infection in the newborn. The Centers for Disease Control and Prevention recommendations and standardization of screening and treatment of GBS-positive mothers have resulted in a reduction of incidence of GBS-affected infants from 1.5 per 1,000 live births to 0.24 per 1,000 live births. She should be formally admitted to labor and delivery, and considered for induction of labor if she has no further progress in cervical dilation. With rupture of membranes, she has an increased risk for chorioamnionitis. There is no advantage to waiting for days at a time for labor to progress on its own, as she is already full-term. Minimizing cervical exams will also help reduce the potential risk of further introducing bacteria up into the uterus. There is no point to schedule hourly cervical exams in this scenario.
A 50-year-old male with a current history of smoking cigarettes presents to the Emergency Department with the new onset of chest pain and diaphoresis of 6 hours duration. To evaluate him for MI, the recommended initial serum biomarker is:
A. Troponin is released into the serum with myocardial cell damage and is the “gold standard” for determining acute MI. The level in the serum begins to rise 3 to 6 hours after myocardial injury, peaks at 24 to 36 hours, and remains elevated for 5 to 14 days. CPK and myoglobin are less specific markers of myocardial injury, as they are released with skeletal muscle injury as well. CRP and ESR are nonspecific markers of inflammation.
A 64 year old male has been suffering from lower back pain for over 10 years. You have been following him for this period. You have prescribed stretching exercises and, occasionally, an anti-inflammatory medication to alleviate his pain. Although he has had no neurologic deficits in the past, today he has shown up in your office unexpectedly, complaining of bilateral lower back pain with numbness and tingling over the dorsal aspect of both feet. His symptoms have become progressively worse over the past 2 weeks and he is now unable to stand for more than 5 minutes without developing extreme pain and numbness. His symptoms are much improved by sitting down or kneeling over a chair. He denies bladder or bowel incontinence or retention. Sensation in intact on exam in the saddle area.
What is the likely diagnosis?
(A) spondyloathropathy of the sacroilliacjoint
(B) age-related early degenerative joint dis-ease (DJD) of the hips
(C) spinal stenosis of the lumbosacral area
(D) muscle spasm of the lower back
(E) cauda equina syndrome
C. spinal stenosis.
Spinal stenosis is a degenerative disorder of the spine which normally presents after the age of 50. Neurologic symptoms, including dysesthesias and paraesthesias, and pain are often bilateral and not localized, since it commonly affects multiple vertebrae. The symptoms are improved with flexion of the spine (sitting or climbing stairs) and worsened by straightening the spine (standing). There is no localized pain in the sacrum and no bowel or bladder incontinence, so a diagnosis of cauda equina syndrome or spondyloarthopathy is less likely. Muscle spasms and early DJD should not produce such neurologic findings.
A 42 year old patient with type II diabetes comes to you for routine follow up. Which of the following screening tests is indicated for a patient with diabetes without other risk factors?
A. DEXA
B. Colonoscopy
C. Urine albumin/creatinine ratio
D. Skin cancer screening
C. Screening for microalbuminuria is indicated for patients with diabetes at least yearly.
Which of the following screening recommendations is true during infancy and childhood?
D. Fluoride varnishes
The AAP recommends BP screening starting at 3 years old. TB screening is not recommended for average risk patients in the United States. The USPSTF gives screening for Autism an I rating.
You are called to see a newborn in the nursery because the nurse is concerned that the baby may have Down syndrome. Which of the following signs is associated with Down syndrome?
A. Cafe au lait spots
B. High arched palate
C. Ambiguous genitalia
D. Hypotonia
E. Club feet
The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up. Café au lait spots are associated with neurofibromatosis. High arched palates are associated with fragile X syndrome. Ambiguous genitalia are commonly seen in congenitial adrenal hyperplasia.
A 52-year-old male with a history of smoking presents for a follow-up appointment for exertional dyspnea worsening over the past 3 months. He has no history of heart problems or family history of cardiac or pulmonary disease. He has a cough that is occasionally productive of sputum, often in the morning. He denies fever, weight loss or gain, chest pain, or any other symptoms. Your initial testing including chest X-ray is normal. He presents today to follow-up after his pulmonary function testing. His results show an FEV1/FVC = 0.6 with a prebronchodilator FEV1 = 52% predicted and a postbronchodilator FEV1 = 55% predicted. You diagnose him with:
D. COPD is suspected in patients with progressive dyspnea and may be accompanied by chronic cough and a history of smoking. Initial evaluation should include an exam and chest X-ray. Pulmonary function testing will reveal an obstructive pattern on spirometry based on FEV1/FVC < 0.7. The FEV1 is not improved with bronchodilator use as it would be in asthma. Interstitial lung disease may have chest X-ray abnormalities, and spirometry results vary but often show a restrictive pattern (decreased FVC, normal or increased FEV1/FVC, and normal or decreased FEV1).
A 28-year-old professional football player presents to the urgent care clinic with a five-week history of lower back pain. He says the pain is located in the center of the lower back and radiates to the buttocks and posterior thighs. He does not recall a traumatic event. Physical examination reveals pain with lumbar hyperextension. Palpation of the lumbar spine produces mild tenderness. Which of the following is the most likely diagnosis?
A. Cauda Equina Syndrome
B. Disc Herniation
C. Spondylolisthesis
D. Vertebral fracture
E. Lumbar radiculopathy
C. spondylolisthesis
Radiating lower back pain and pain with lumbar hyperextension (> three weeks) without history of a traumatic event suggests spondylolisthesis. Spondylolisthesis results from anterior slippage of the spine forward, leaving posterior elements behind. Pain with lumbar extension is the most common physical exam finding. Patients typically present with activity-related pain. Diagnosis is typically made based on clinical exam findings and confirmed by radiographs.
Cauda equina syndrome (A) is typically associated with marked neurologic disability. Patients typically present with bilateral leg weakness and possibly bowel, bladder, and sexual dysfunction. Disc herniation (B) typically presents with pain on lumbar flexion (not extension). Additionally, neurologic deficits can also occur with disc herniation compared to spondylolisthesis. A vertebral fracture (D) typically results from trauma and is caused by falls, sudden deceleration resulting from a motor vehicle collision, or direct injury. A vertebral fracture is not likely in this case, due to the lack of a traumatic event and only mild tenderness elicited on palpation. Lumbar radiculopathy (E) is less likely to produce bilateral radiating pains
A 49-year-old man presents to the clinic for his annual exam. He has a history of HTN, hypercholesterolemia, type 2 diabetes mellitus, and obesity. He currently takes lisinopril 20 mg daily, atorvastatin 40 mg daily, and metformin ER 1,000 mg twice daily. He denies any new concerns today. Vital signs include BP 124/68 mm Hg, HR 82 bpm, RR 18/min, T 98.9°F, and BMI of 34.0 kg/m2, which is unchanged from the last visit. Physical exam is unremarkable. His last HbA1C approximately 6 months ago was 7.7%. Today it is 8.2%. Which of the following adjunctive medications could be used to help lower his HbA1C and decrease his weight?
A.
GLP-1 receptor agonists, such as exenatide, liraglutide, and semaglutide, are diabetes medications that commonly lead to weight loss (of approximately 2 to 3 kg). They affect glucose control through several mechanisms, including enhanced insulin secretion, slowed glucagon secretion, slowed gastric emptying, and increased early satiety. Other diabetes medications that can promote weight loss include metformin, amylin mimetics, and SGLT-2 inhibitors.
Glipizide (B), a second-generation sulfonylurea, and insulin (C) are known to lead to weight gain. Pioglitazone (D), a type of thiazolidinedione, is commonly associated with edema and not likely to promote weight loss. The DPP-4 inhibitor, sitagliptin (E), is considered to be a weight-neutral diabetes medication.
Which of the following is true regarding screening for Sexually Transmitted Infections and HIV in adults?
A. HIV screening is recommended in all adults younger than 65.
Chlamydia screening is not recommended in asymptomatic men per the USPSTF guidelines. All sexually active women should be screened for chlamydia. Syphilis screening is recommended for high-risk patients regardless of geographic location.
A term infant male is born after an uncomplicated vaginal delivery. The mother’s prenatal labs were negative with the exception of being GBS positive at 36 weeks’ gestation. The mother received two doses of ampicillin prior to delivery and did not have a fever. The infant had APGAR scores of 9 at 1 minute and 9 at 5 minutes. The infant was brought to the newborn nursery and appears well.
The most appropriate management of the infant would be which of the following?
(A) Draw a CBC and blood culture, but do not start empiric antibiotics.
(B) Give the baby a prophylactic dose of ampicillin.
(C) Routine care.
(D) Cultures of blood, urine, and spinal fluid and wait for culture results before starting antibiotics.
(E) Cultures of blood, urine, and spinal fluid and begin empiric antibiotics before getting culture results.
C. Routine care
The most common bacterial infection in the newborn period is GBS. GBS is commonly cultured in the adult vaginal tract, and its vertical transmission can be interrupted with maternal antimicrobial treatment prior to delivery of the infant. Mothers are commonly treated in labor with penicillin, ampicillin, clindamycin, or azithromycin in an attempt to interrupt trans-mission to the infant while passing through the birth canal. If antimicrobial prophylaxis is initiated greater than 4 hours prior to delivery the rate of early-onset GBS disease is dramatically decreased. The current recommendation for term infants of GBS-positive women who have received antibiotics in labor (at least two doses or ≥4 hours prior to delivery) is observation without testing or antibiotics.
A patient has a history of having red, raised plaques with very easily loosened scales over most of his body for almost 20 years. He is complaining of multiple joint pains especially when he plays golf. Which of the following is a classic X-ray finding for this disease process?
D. Pencil in a cup deformity
This patient has psoriasis and psoriatic arthritis. The classic X-ray finding of psoriatic arthritis is a “pencil in a cup” deformity on hand films. A bucket handle tear is a finding in a torn meniscus, loss of joint space in osteoarthritis (although this may be present in psoriatic arthritis, it is not a classic finding as it is in osteoarthritis), subcutaneous nodules are classic in rheumatoid arthritis, and a spiral fracture is consistent with child abuse.