Figure 107.1. Image of the skin rash from the patient described in Question 2.

What is the most likely diagnosis?

    A. Inadequately treated Lyme disease

    B. Babesiosis

    C. Malaria

    D. Rocky Mountain spotted fever

    E. Drug reaction to doxycycline

QUESTION 3. A 31-year old nanny recently diagnosed with acute myelogenous leukemia is admitted to the hospital 12 days after her first cycle of high-dose cytarabine consolidation chemotherapy with febrile neutropenia. She is appropriately treated with intravenous ceftazidime. Seven days into her hospitalization all blood cultures have been negative, and the patient’s WBC count is beginning to recover. She now develops a new fever to 101°F, cough, and pleuritic chest discomfort. Her serum galactomannan and beta-glucan are both elevated. The patient’s chest computed tomography (CT) is shown in Figure 107.2.

    What is the likely diagnosis?

    A. Pulmonary histoplasmosis

    B. Disseminated Candida albicans infection

    C. Invasive aspergillosis

    D. Cryptococcal infection

    E. Pulmonary embolism with lung infarction

QUESTION 4. A 62-year-old female had her thyroid- stimulating hormone (TSH) checked after presenting with weight gain and tachycardia. The thyroid examination was normal.

    TSH 0.011 mIU/L (normal 0.5–5 mIU/L)

    Free T₄ 1.5 ng/L (normal 0.8–1.8 ng/L)

    What is the optimal approach to this patient?

    A. Reassurance

    B. Treat with Levoxyl

    C. Treat with methimazole

    D. Obtain a thyroid ultrasound

QUESTION 5. A 36-year-old male in generally excellent health presents to the emergency room with “palpitations” for 3 to 4 days in duration. He denies chest pain or dyspnea. He also complains of right hip pain and generalized fatigue for several weeks and recalls a vague rash on his right leg 1 month ago. Examination is notable for heart rate of 45 beats per minute and mildly limited range of movement in right hip. An electrocardiogram (EKG) is obtained, and a telemetry strip is shown in Figure 107.3.

    What is the next appropriate treatment step?

    A. Placement of permanent pacemaker

    B. Placement of permanent pacemaker and implantable cardiodefibrillator (ICD)

    C. Temporary pacemaker and initiation of intravenous corticosteroids

    D. Temporary pacemaker and initiation of intravenous ceftriaxone

    E. Aspirin plus heparin bolus and drip

QUESTION 6. A 59-year-old man with a medical history that includes a prior deep vein thrombosis (DVT) and chronic kidney disease requiring hemodialysis is admitted to the hospital for elective knee replacement. His coumadin had been stopped a few days prior, and he is started on intravenous unfractionated heparin on admission. On his sixth hospital day, his platelet count falls to 75,000/µL from 195,000/µL the day prior. In addition to discontinuing the intravenous heparin, you should do which of the following?

    A. Await the results of an anti-PF4 assay before restarting anticoagulation

    B. Transfuse platelets to prevent postoperative bleeding

    C. Start subcutaneous Lovenox immediately

    D. Start subcutaneous fondaparinux immediately

    E. Start intravenous argatroban immediately

QUESTION 7. A 78-year-old female with diabetes is admitted to the hospital with signs, symptoms, and urinalysis consistent with a urinary tract infection. On initial evaluation in the emergency department, the blood pressure is 70/30 mm Hg but improves briskly with intravenous fluids, and the patient is admitted to the medical floor. Her complete blood count (CBC) revealed a mild leukocytosis but is otherwise normal. Shortly after admission, she begins experiencing lower abdominal cramping and passes several stools with evidence of dark blood.

    Which of the following is the most like explanation for her gastrointestinal bleeding?

    A. Hemolytic uremic syndrome

    B. Acute mesenteric ischemia

    C. Chronic mesenteric ischemia

    D. Ischemic colitis

    E. Bacterial colitis

QUESTION 8. A 76-year-old male patient with diabetes mellitus (DM), CKD, and a 40-pack-year smoking history presents for physical examination. He has no acute complaints. Review of systems is negative for cough, fevers, chills, night sweats, chest pain, shortness of breath, bright red blood per rectum, or genitourinary symptoms. He continues to smoke one-half pack of cigarettes each day. Which of the following are recommended for cancer screening in this patient at this time?

    A. Digital rectal examination (DRE)/prostate-specific antigen (PSA), colonoscopy

    B. Chest CT, DRE/PSA

    C. Chest CT, colonoscopy

    D. Chest CT

    E. None of the above

QUESTION 9. A 68-year-old man with a history of cardiovascular disease presents to his primary care physician asking about the need for antibiotics before he goes to the dentist to get his teeth cleaned. His past medical history includes hypertension, mitral valve prolapse (MVP) with mild regurgitation, a pacemaker placed 8 months ago, a total hip replacement 18 months ago, and two coronary artery stents placed 4 months ago.

    Which of the following should his physician recommend?

    A. Antibiotic prophylaxis because of his MVP with regurgitation.

    B. Antibiotic prophylaxis because of his recent pacemaker implantation.

    C. Antibiotic prophylaxis because of his recent joint replacement.

    D. Prophylactic antibiotics are not required for routine teeth cleaning.

    E. Prophylactic antibiotics are not required given his medical history.

QUESTION 10. A healthy 25-year-old graduate student presents to the student health clinic complaining of a sore throat, cough, and fever for the past 3 days. On examination, her throat is erythematous and without exudates. She has no neck tenderness or palpable lymphadenopathy. Which of the following is the most appropriate plan for this patient?

    A. Reassurance since she is unlikely to have streptococcal pharyngitis.

    B. Prescribe a course of antibiotics based on the result of a rapid strep test.

    C. Prescribe a course of antibiotics to take if she is no better in 3 days.

    D. Prescribe a course of antibiotics to begin taking now.

    E. Obtain a throat culture and have her stop antibiotics if it is negative.

QUESTION 11. Over the next 5 days, her throat pain worsens. She continues to have high fevers with chills and now notes painful left-sided neck swelling. Representative images from studies of her neck and chest are shown in figures 107.4–107.6. Which of the following is LEAST likely to be helpful in this situation?

    A. Urgent otolaryngology consultation

    B. Gentamycin

    C. Clindamycin

    D. Penicillin

    E. Intravenous heparin

QUESTION 12. A 28-year-old nonsmoking graduate student presents with 1 week of wheezing, cough, and yellow sputum. He has had several prior episodes of “bronchitis” in the last 2 years. Examination is notable for O₂ saturation 90% on room air and scattered wheezing and rhonchi. Laboratory values are notable for leukocytosis and eosinophilia: WBC 14.4 × 10³/µL (53 neutrophils, 20 lymphocytes, 15 eosinophils). Prior PFTs have shown a mild obstructive pattern. Small, scattered opacities are seen on chest x-ray (CXR), and the chest CT shown in figures 107.7 and 107.8 is obtained. What is the next appropriate step?

    A. Bronchoscopy

    B. Skin prick test for reactivity to Aspergillus fumigatus

    C. Strongyloides serology

    D. Induced sputum × 3 samples

    E. Prednisone taper

QUESTION 13. A 30-year-old man presents to his primary care physician with a new rash on his back and trunk (Figure 107.9). The lesions are red and raised. He says it is itchy but not painful. He has never had a rash like this before. He has used no new lotions, soaps, or medications.

    He does comment that he has a similar rash in one spot on his back a few weeks before the current eruption.

    What is the most likely outcome for this rash?

    A. It will spontaneously resolve in 6 to 10 weeks.

    B. It will resolve with steroids and recur with episodes of stress.

    C. It will resolve with calcipotriene ointment.

    D. It will resolve with benzoyl peroxide.

    E. It will require treatment with psoralens plus UVA (PUVA) and possible chemotherapy

QUESTION 14. A 57-year-old woman with no history of cardiac disease develops substernal chest pressure during her routine hemodialysis session. The episode lasts about 5 minutes and resolves spontaneously before she arrives in the emergency room. Her vital signs are normal, and her cardiac biomarkers are not elevated. Her EKG is shown in Figure 107.10.

    Which of the following treatment plans is most appropriate for this patient?

    A. Urgent cardiac catheterization

    B. Heparin, Plavix, aspirin, and cardiac catheterization if cardiac biomarkers become elevated

    C. Imaging stress test before considering catheterization

    D. Admission for observation and telemetry monitoring

    E. Correction of electrolyte abnormalities and reassurance

Question 15. A 46-year-old lawyer presents to the emergency department with bright red emesis. He had been on a drinking binge for several days and started vomiting food and bile last night. He was retching all night and in the morning threw up frank blood. Examination reveals a heart rate of 110 beats per minute, rising to 135 beats per minute when standing up, blood pressure of 104/76 mm Hg, falling to 80/56 mm Hg with standing. He smells of alcohol, has clear lungs, and a nontender abdomen.

    What is the first step in caring for this patient?

    A. Start an intravenous proton pump inhibitor

    B. Give fresh frozen plasma as he likely has liver disease

    C. Resuscitate patient with intravenous fluids

    D. Perform esophagogastroduodenoscopy

    E. Perform gastric lavage with nasogastric tube

QUESTION 16. Given the previous patient’s history, what is the most likely diagnosis?

    A. Dieulafoy’s lesion

    B. Peptic ulcer disease

    C. Erosive esophagitis

    D. Mallory-Weiss tear

    E. Variceal bleed

QUESTION 17. A 67-year-old woman presents with 2 weeks of progressive fatigue, dyspnea, and easy bruising. She now notes dyspnea at rest, a severe headache, and blurry vision.

    She is afebrile with a heart rate of 113 beats per minute, a normal blood pressure, and an oxygen saturation of 89% on room air. On examination, she has scattered ecchymoses, retinal hemorrhages, and bibasilar rales. Blood studies (Figure 107.11) show:

    • WBC 113,800/µL

    • Hematocrit 24.1%

    • Platelets 27,000/µL

    Which of the following treatments is it most important to start as soon as possible?

    A. Intravenous normal saline bolus

    B. Hydroxyurea

    C. Red blood cell transfusion

    D. Leukopheresis

    E. Rasburicase

Question 18. A 46-year-old male, Asian American, presents with diabetes mellitus. He reports sugars in the 300 mg/dL range and his hemoglobin A1c (HbA_1c) returns at 6.8%. You explain that these laboratory values could be secondary to all of the following EXCEPT:

    A. Glucometer malfunction

    B. Laboratory error

    C. Hemolytic anemia

    D. Polycythemia vera

    E. β-thalassemia

QUESTION 19. A 79-year-old male arrives at the emergency room complaining of right-sided facial droop and right arm weakness. His symptoms started about 3–4 hours ago during breakfast. Physical examination confirms findings consistent with a left-sided middle cerebral artery (MCA) stroke. Head CT shows no evidence of intracranial bleed. Which of the following treatments are indicated for initial therapy of this event?

    A. Intravenous tissue-plasminogen activator (tPA)

    B. Intravenous heparin

    C. Enoxaparin (low-molecular weight heparin)

    D. Aspirin

    E. None of the above

QUESTION 20. A 22-year-old pharmacy student with a history of eczema and a nut allergy presents with a painful, burning rash on her right thigh. Her symptoms began the prior evening after a day at the beach. This morning, the rash and pain are much worse. She also notes some pain on her hands, neck, and distal thigh (see Figure 107.12).

    Which activity most likely led to the development of her symptoms?

    A. Walking through brush in her swimsuit

    B. Swimming in the ocean

    C. Applying sunscreen containing zinc oxide

    D. Squeezing limes while making mojitos

    E. Taking tetracycline for facial acne

Stay updated, free articles. Join our Telegram channel

Join