Cards
Ortho/MSK/MISC
Pulm
General
ID
100
A 16 year old girl presents to office for a new complaint of recurrent syncope over the past several months. She is on no meds and has a normal neuro exam. Lytes are normal. EKG is below. Based on this tracing, you should initiate therapy with which of the following?
A. High dose ASA
B. Nadolol
C. Glucose insulin drip
D. Fludrocortisone
E. Amiodarone
Nadolol
100
A 16 yo boy c/o worsening left elbow pain. following examination, he is diagnosed with tennis elbow. Which of the following clinical findings is most consistent with diagnosis?
A. Pain and point tenderness upon palpation around lateral epicondyle
B. Dull, poorly localized lateral elbow pain with decreased ROM
C. Deep, dull ache distal to the lateral epicondyle that is worse at night.
D. Excess fluid within the bursa, which is easily visible on direct observation.
E. Pain and point tenderness upon palpation around the medical epicondyle.
Pain and point tenderness upon palpation around lateral epicondyle
100
A 12-year-old male with mild persistent asthma develops cough and wheezing. he has no fever, chest pain, sore throat, or diarrhea. His normal peak flow is 320 L/min and today is 220 L/min. He is able to speak in complete sentences. He is breathing 24 x per min. After reviewing the asthma action plan, his mom calls the office for advice. She reports that they have a 5-day supply of oral glucocorticoids at home along with inhaled steroids and albuterol. he does not use any daily medications.
A. 1-2 puffs of inhaled steroids and 2-4 puff of short acting beta agonist
B. 2-4 puff of short acting beta agonist and inhaled ipratropium
C. 2-4 puff of short acting beta agonist and oral steroids
D. schedule same day visit
E. send the patient to the ED
1-2 puffs of inhaled steroids and 2-4 puff of short acting beta agonist
100
A mom of a 9-month-old came for well visit. She wants to know if he is on target developmentally. He should be able to do which of the following?
A. Understand no
B. Get to a sitting position and sit without help
C. Call a parent "mama" or "dada" or another special name
D. Stack at least 2 objects well
E. Follow 1 step direction
Get to a sitting position and sit without help
100
A 16 yo girl presents to the ED for fever, chills, myalgia, vomiting, and severe left ankle pain. on exam, she is lethargic, oriented, temp 103, BP 95/45. A small area overlying the lateral malleolus and lateral portion of the foot is cellulitic, near razor nick. Despite aggressive fluids, she is hypotensive and gets admitted to PICU. she is now on inotropes. 2 days later, cultures from the wound grow GAS. Pt has NKDA. Following positive identification of the organism, which of the following is the most appropriate treatment?
A. PCN G and clinda
B. Metronidazole
C Vanco and Clinda
D. Meropenem
E. PCN G plus IVIG
PCN G and clinda
200
A 63 yo male is evaluated during a follow up exam for rheumatic aortic valve disease. He is asymptomatic and has not exercise limitations. He has no other medical problems. On exam, BP is 134/32. Grade 3/6 holo diastolic murmur is heard best at LSB. Peripheral pulses are bounding. No evidence of heart failure. TTE showed L EF of > 55% and tricuspid aortic valve with severe aortic regurgitation. the left ventricular end systolic dimension is elevated 45 mm.
Which of the following is the most appropriate Management?
A. Repeat eval in 6 months
B. Surgical aortic valve replacement
C. Transcatheter Aortic valve implantation
D. TTE
Repeat eval in 6 months
200
a 68 year old mane is evaluted in the ED for worsening of chronic right hip pain and difficulty walking over the past 3 days. the pain is most intense in the posterior hip and buttocks and is non radiating. It worsens with rising from a chair, ambulation, and prolonged standing. it improves with lying down.
On exam, VSS. BMI 30, antlgic gait, pain in the buttocks and FADIRof right hip and reduced active flexion are observed. no pain is elicited with palpation of the lumbar spine or over the SI joint. The remainder of the exam is normal.
Which of the following is the most likely diagnosis?
A. Acetabular labrum injury
B. Hip osteoarthritis
C. Lumbar radiculopathy
D. SI joint dysfunction
Hip osteoarthritis
200
a 24 year old woman is evaluated for intermittent cough, wheezing, and chest tightness x 1 month. she reports worsening with exercise and exposure to cats. Exam and vitals are normal. she has end expiratory wheezing. Heart exam is normal. On spirometry, FEV1 is 75% of predicted and improves after inhaled Albuterol. Which of the following tests will help predict this patient's responsiveness to inhaled glucocorticoids?
A. Bronchial challenge test
B. Diffusing capacity for CO
C. Fractional exhaled NO
D. Pulse ox
Fractional exhaled NO
if NO levels are above 50, it correlates with eosinophilic airway inflammation and predicts response to inhaled steroids. It is NOT to be used for diagnostic tool for asthma.
200
A 54 year old asympatomatic woman is evaluated during a wellness visit. she has a 35 pack year smoking history but quit smoking 12 years ago. She has no medical history or meds. Exam and vitals are unremarkable. Which of the following is the most appropriate lung cancer screening strategy for this patient?
A. Annual chest film
B. Annual low dose CT of chest
C. one-time low dose Ct of the chest
D. No screening is indicated.
Annual low dose CT of chest
RF- > 50 years old with at least 20 pack year hx
200
A 45 yo woman is evaluated in the ED for a human bite to the hand. it occurred by a toddler in her day care class. She has DM2 and had anaphylactic shock to PCN. she received the Tdap 1 year prior. meds are metformin and Empaglifozin. On exam, VSS. A few tiny puncture wounds with minimal erythema are noted over the dorsum of the left hand. Films show no foreign body, gas, or bone involvement. The wound is irrigated and evaluated by hand specialist. no surgery is needed. Which of the following is the most appropriate treatment?
A. Amox/clav
B. Levofloxacin and Metronidazole
C. Tetanus Vax
D. Observe
Levofloxacin and Metronidazole
300
An infant with severe cyanosis presents. For which of the following conditions would a balloon atrial septostomy be helpful?
A. A large VSD
B. TGA
C. Anomalous pulmonary venous return without obstruction
D. Truncus arteriosis
E. Tetralogy of Fallot
TGA
300
a 57 old male is evaluated for 2 month hx of neck pain and stiffness accompanied by unsteadiness on his feet, especially while climbing up or down stairs. He is otherwise healthy and takes no meds. on exam, VS are normal. Muscle strength is 4/5 for b/l hip flexors and arm flexors. Hyperreflexia and clonus are present in the lower extremities, as are b/l upgoing extensor reflexes in the toes. Diminished reflexes are present in the upper extremities. Forward flexion of the neck produces electric shock like pain that radiates from the neck to the arms.
Which of the following is the most likely diagnosis?
A. Cervical myelopathy
B. Cervical radiculopathy
C. Cervical sprain
D. Myofascial pain
E. Whiplash injury
Cervical myelopathy
combined upper and lower motor neuron findings indicate disease in spinal cord. cervical cord produces lower motor weakness in arms/hands and upper motor weakness in legs.
300
A 35-year-old man is evaluated in the ED 4 hours after being rescued from his burning home by firefighters. He initially refused transportation to the hospital but now desires an eval. he reports tracheal irritation with breathing, sore throat, and change in his voice. on exam, he is alert and in moderate pain. Temp 37.5, BP 144/90, HR 100, RR 26. O2 sats 96% on ambient air. He has dysphoria. There is no soot in the nares or the oral pharynx or burns on his face, neck, or thorax. Non obstructing edema on oropharynx is noted. Heart exam reveals a regular rhythm. Chest is clear to auscultation. there is no stridor.
PH 7.45, Pc02 = 35 and P02 95
which of the following is the most appropriate management?
A. Bronchoscopy
B. Methylprednisolone
C. Nebulized Epinephrine
D. NIPPV
Bronchoscopy
300
a 32-year-old woman is evaluated for hidradenitis suppurativa. She has had a tender, foul smelling draining nodules in the axillary folds for 4 years. Doxy and topical clindamycin have not achieved satisfactory improvement. She has a 10-pack year smoking history. on exam, VSS. BMI 30. left axilla is shown.
Behavioral counseling for smoking cessation and pharmalogical treatment are offered. The patient agrees to see a nutritionist for weight loss counseling. Which of the following is the most appropriate additional treatment?
A. Acitretin
B. Adalimumab
C. Methotrexate
D. Narrow band UVB phototherapy
Adalimumab
Hidradenitis suppurativa- is associated with smoking, obesity, metabolic syndrome. Adalimumab is approved for moderate to severe hidradenitis with diffuse nodules and scar formation.
300
A 36 yo woman is hospitalized 3 days ago for fever x 4 dads. Hx of significant for IVDA. she is on no meds. Exam is notable for temp 38.9, BP 108/70 and HR 100. RR is 20. Empiric Vanco and Ceftazidime are started. Today, she is better and VSS. cultures are + for MRSA with Vanco MIC 1ug/mL). Vanco trough level is 18. Ceftazidime is d/c. Echo shows a TV vegetation. Which of the following is the most appropriate management?
A. Add Gent/Rifampin
B. Area under the curve vanco guided dosing
C. Switch to Daptomycin
D. Switch to Telavancin
Area under the curve vanco guided dosing
400
A 38 yo male undergoes pre op eval before repair of torn ACL. His cardiac hx includes repaired Tet of fallot. He has no other symptoms. on exam, VSS. JVD and prominent a waves are noted. A RV heave is present. A single S2 is heard as is a grade 1/6 early systolic murmur localized to the left 2nd ICS and a grade 2/6 diastolic murmur best heard in the left 2nd and 3rd IC spaces. The diastolic murmur increases with inspiration.
Which of the following is the most likely diagnosis?
A. Aortic coarctation
B. Aortic regurgitation
C. Mitral stenosis
D. Pulmonary regurgitation
Pulmonary regurgitation
400
a 29-year-old woman is evaluated for a 2-week history of left sided back pain. the pain begins in the lumbar spine and radiates through the left buttock and hip into the thigh. the pain is sharp and shooting. She is 19 weeks pregnant with her first kid. the pregnancy is uncomplicated. her only meds is prenatal. On exam, she walks with a limp favoring the left leg. ROM is normal. no pain with hip flexion, abduction or external rotation. There is left sided hip and leg pain with straight left raise of both the left and right legs. There is no pain with flexion or extension of the lumbar spine. Which of the following is the most likely diagnosis?
A. OA of the hip
B. Radiculopathy of the sciatic nerve
C. Round ligament pain
D. Sacroiliitis
Radiculopathy of the sciatic nerve
400
A 29 yo man is evaluated in the ED after transport by EMS. He was found sitting on the garage floor, lethargic, and an empty container of coolant nearby. On exam, temp is 37.4, BP 108/58, HR 118 and RR 26. sats 99% on room air. he arouses briefly to loud voice but is not interactive.
Labs: Cr 1.3, glucose normal, Na 138, K 4.8, Cl 104, HCO3 12, Lactate normal, osmolal gap is increased.
ABG: 7.25/CO2 28, O2 98
Which of the following is the most appropriate treatment?
A. Ethanol
B. Fomepizole
C. Fomepizole and HD
D. Lorazepam
Fomepizole and HD
Ethylene glycol and Methanol tox are treated with Fomepizole
HD is severe AGMA and end organ involvement.
400
A 62-year-old woman is evaluated for a 6-month history of intermittent, painful sores on the back of her hands that worsen with sun exposure. She has no other medical problems. she is on no meds. Skin findings are below. skin punch biopsy results are pending. Which of the following is the most appropriate diagnostic test?
A. ANA
B. anti TTG antibody
C. Bullous pemphigoid antibodies
D. Plasma and urine porphyrin levels
Plasma and urine porphyrin levels
Porphyria cutanea tarda-photosensitive disorder with scarring and blistering on sun exposed skin on dorsal hands. Associated with hep c, alcohol liver disease and hemochromatosis.
400
A 55 yo man is evaluated for fever, night sweats, cough with sputum production and weight loss over 2 months. he was dx with HIV infection 3 months prior but has not started treatment. He has hx of alcohol use disorder and was incarcerarated 5 years prior. Exam shows temp 38.4. rest of vitals were normal. Crakcles are heard at b/l bases.
Lab: Hb 10, WBC 11,500, HIV Antigen/Ab assay was positive, CD4 count 200, and viral load 56,000 copies. Chest film showed paratracheal lymphadenopathy and b/l intersitital infiltrates. Sputum stain and cultures are negative. Acid fast bacilli is positive, yeast is not identified.
Which of the following is the most likely cause of his infection?
A. Histoplasma capsulatum
B. Mycobacterium abscesses
C. Mycobacterium avium complex
D. Mycobacterium tuberculosis
Mycobacterium tuberculosis
500
Review this CXR in a workup for a kid with suspected CHD. It shows a "snowman sign". Which of the following best describes the anatomic anomaly typically associated with this radiographic sign?
a. Abnormal connection of the pulmonary veins
b. discordant AV and VA relationships "corrected transposition"
c. downward displacement of an abnormal tricuspid valve into the right ventricle
d. anterior deviation of the infundibular septum, resulting in vsd and subpulmonic stenosis.
e. a single arterial trunk rising from heart.
Abnormal connection of the pulmonary veins
500
A 14 yo high school studen, who is determined to attend college on full athletic scholarship, presents for physical prior to baseball. Findings on exam include BP 150/95, moderate to severe acne, and gynecomastia. When confronted, he admits that he is stacking with some pills, obtained from a local strength and conditioning club. Which of the following complications is this patient most likely to experience?
A. early epiphyseal closure
B. Heat stroke
C. Premature osteoporosis
D. Spondylolysis
E. Rhabdomyolysis.
early epiphyseal closure
500
A previously healthy teen presents with a 2-week history of malaise and persistent dry cough. On exam, bibasilar rales and decreased breath sounds without associated wheezing are noted. A chest film reveals thickened bronchial shadows, scattered streaks of interstitial infiltration, and areas of atelectasis in both lower lobes. Select the best evaluation to confirm the patient's diagnosis in this scenario.
A. Serum cold agglutinins
B. Serum Mycoplasma pneumoniae IgG
C. Throat culture for Mycoplasma pneumoniae
D. Elevated white blood cell count
E. Serum Mycoplasma Pneumonia IgM
Serum Mycoplasma Pneumonia IgM
500
A 16 year old with Stage 4 rhabdomyosarcoma returns home to begin hospice care. She is severely immunocompromised. Four other kids live in the house with the patient, mom, and dad. Mom is concerned about infection control, and she wants to make sure the other kids are properly immunized. You determine that some vaccines will need to be administered to the other kids. Which of the following vaccinations should NOT be administered, when age appropriate, to other kids in the h ouse?
A. Live flu
B. Varicella
C. MMR
D. MMRV
E. Rotavirus
Live flu
500
A 11-month-old afebrile well appearing girl, presents with a rash of one day's duration. it first began on her trunk, but is n ow characterized by widespread erythematous blanching macules that also involve the face, neck, and upper extremities. Her mom reports that her several days prior to the morning to presentation, the patient had a febrile illness with a temp as high as 39.2. she was treated with fluids and Tylenol. which of the following is often associated with the most likely cause of the patients clinical findings?
A. Palpebral and periorbital edema
B. Inguinal lymphadenopathy
C. Scleral icterus
D. Bulbar conjunctival injection
E. Swelling of one or more large joints.
Palpebral and periorbital edema