A 34-year-old man is seen in the office for consultation one day after spontaneous rupture of the tympanic membrane. While camping two days ago, he developed acute otitis media of the right ear. Yesterday, he had spontaneous relief of ear pain along with some bloody purulent discharge from the right ear canal. He has no subjective loss of hearing. Physical examination of the ear shows residual dried blood in the auditory canal, and a clot overlying a small perforation site in the pars tensa of the tympanic membrane. Which of the following is the most appropriate advice to give this patient regarding his condition?
A. Arrange for transportation to the emergency department for urgent evaluation
B. Daily insertion of an ear wick soaked with aminoglycoside otic solution for one week
C. Irrigate the ear canal daily in a shower to remove residual debris
D. Keep the ear canal dry to allow the perforation to heal spontaneously
E. Schedule an appointment with an otolaryngologist for tympanostomy tube placement
A 32-year-old man with diabetes comes to the emergency department with two days of intense, deep ear pain and a purulent drainage from the left ear. Physical examination reveals an erythematous and edematous canal which contains some debris and granulation tissue. The tympanic membrane is barely visible but appears intact. The surrounding external ear is also indurated and erythematous. The patient has a fever of 102.1F. Which of the following is the next best step in the care of this patient?
A. Prescribe ciprofloxacin/dexamethasone ear drops, and counsel patient to keep the ear canal dry for at least a week
B. Prescribe oral amoxicillin, and schedule a follow up visit for two weeks to make sure infection has cleared
C. Refer the patient to an otolaryngologist in one week
D. Admit the patient to the hospital for intravenous antibiotics
E. Admit the patient for hyperbaric oxygen therapy
D) Admit the patient to the hospital for intravenous antibiotics
A. Prescribe ciprofloxacin/dexamethasone ear drops, and counsel patient to keep the ear canal dry for at least a week
While this regimen is an appropriate treatment for acute otitis externa, this patient is at an increased risk for malignant necrotizing otitis externa due to his history of diabetes and presence of fever.
B. Prescribe oral amoxicillin, and schedule a follow up visit for two weeks to make sure infection has cleared
This is an appropriate treatment for acute otitis media. Otitis media is characterized by a painful ear, fever, and hearing impairment. On physical examination, a bulging, erythematous tympanic membrane will be present, with reduced mobility. Otorrhea is usually only present if the tympanic membrane has ruptured.
C. Refer the patient to an otolaryngologist in one week
This patient should be seen by an ENT for further studies and management, but this should not precede the initiation of treatment. In cases which are refractory to medical treatment, surgical debridement of the bone by an ENT may be indicated.
D. Admit the patient to the hospital for intravenous antibiotics
In diabetic or immunocompromised patients, the risk of malignant otitis externa (osteomyelitis of the skull base) is high, and treatment should begin immediately with IV anti-pseudomonal antibiotics. Ciprofloxacin is the first-line antibiotic. A CT may also be done to evaluate for bone erosion.
E. Admit the patient for hyperbaric oxygen therapy
Hyperbaric oxygen therapy can be used as an adjunct in the treatment of malignant otitis externa, though studies have been conflicting in determining benefit.
A 2-year-old boy is brought to the office by his mother because she has noticed that the vision in his left eye has progressively deteriorated over the past month. Physical examination of the eye shows a white pupillary reflex in response to light. Funduscopic examination shows a white mass projecting from the retina. Which of the following is the most likely diagnosis?
A. Congenital cataract
B. Macular degeneration
C. Ocular melanoma
D. Retinitis pigmentosa
E. Retinoblastoma
E. Retinoblastoma
Retinoblastoma is the most common primary malignant intraocular tumor in children. It originates from the retina, and can be unilateral or bilateral. It most commonly occurs in children less than 5 years of age. Whitening of the red reflex is the most common presentation for retinoblastoma.
A 54-year-old man comes to the emergency department because he recently had sudden onset of black and gray specks floating in his left eye along with what he describes as a curtain being pulled over his peripheral vision.On slit-lamp examination, the retina appears to be separated from the normal structure of the eye.This patient is at increased risk for which of the following complications the longer this condition goes untreated?
A. Anterior uveitis
B. Cataracts
C. Corneal abrasion
D. Nearsightedness
E. Permanent vision loss
E. Permanent vision loss
(Pt has retinal detachment)
Which of the following physical examination characteristics best differentiates oral candidiasis from oral leukoplakia?
A. Ability to scrape off patch
B. Color of patch
C. Induration of patch
D. Location of patch
E. Particular shade or hue of white
A. Ability to scrape off patch
A 46-year-old woman is seen in the office for evaluation of numbness and tingling in her legs, and decreased taste sensation in her mouth for the past month. She denies urinary or fecal incontinence. She has a past medical history of epilepsy, for which she takes phenytoin. She adheres to a strict vegan diet. Her last normal menstrual period was three weeks ago. Her periods are regular, and generally last six days. Temperature is 37.0°C (98.6° F), pulse rate is 74/min, and blood pressure is 112/76 mmHg. Physical examination shows a smooth, beefy red tongue. Neurologic examination shows absence of ankle reflexes bilaterally, presence of Babinski reflex, and positive Rhomberg test. The remainder of the examination shows no abnormalities. Finger stick blood analysis of hemoglobin was 9.0 g/dL.
Which of the following best explains the cause of her anemia?
a) Alcoholism
b) Lead toxicity
c) Menorrhagia
d) Phenytoin use
e) Vegan diet
e) Vegan diet
This patient has macrocytic anemia from B12 deficiency. Vitamin B12 is often lacking in vegan diets since the primary sources of the vitamin are dairy, fish and meat. Neurologic symptoms including paresthesias, numbness, and loss of vibration and position sense can occur. In severe cases dementia and psychosis may occur. Atrophy of the tongue mucosa results in a loss of taste sense.
An 8-year-old girl is brought to the emergency department by her parents because of continuous, gnawing dental pain for the past week. Her mother reports that the pain is worse when she eats something cold, or if she touches the tooth. On physical examination you see the attached image, with exquisite tenderness when you tap the associated tooth with a tongue blade. What is the next best step in the management of this patient?
A. Order CT face and admit for cancer workup
B. Discharge home with clinic follow up for biopsy
C. Order antibiotics and dental consultation
D. Admit with orders for a soft diet and monitor over the next 24-48 hours
E. Discharge home with a prescription strength pain reliever
C. Order antibiotics and dental consultation
This is the correct course of action if a dental abscess is suspected. Untreated abscesses could lead to local cellulitis or Ludwig angina (an infection of the submandibular space). Infections usually involve anaerobes. Pediatric dental abscesses may need to be admitted for procedural sedation for incision/drainage of the abscess or may be taken care of in an appropriate dental office.
A 5 y/o boy is brought to the office by his mother because she has noticed a persistent lump in his neck for the past month. PE shows a midline 2 cm rubbery mass located just inferior to the hyoid bone. When he is asked to swallow or protrude his tongue, the mass transiently moves upward.
Which is the most likely diagnosis?
A. Branchial cleft cyst
B. Goiter
C. Normal contents of the carotid sheath
D. Submental lymph node
E. Thyroglossal duct cyst
E. Thyroglossal duct cyst
Thyroglossal duct cysts are the most common congenital neck cyst. They are typically located in the midline (~70% are located within 2 cm of the midline), and are the most common midline neck mass in young patients. Thyroglossal duct cysts typically present during childhood (90% before the age of 10), or remain asymptomatic until they become infected. They account for 70% of all congenital neck anomalies, and are the second most common benign neck mass, after lymphadenopathy. Presentation is typically either as a painless rounded midline anterior neck swelling or, if infected, as a red warm painful lump. It may move with swallowing, and classically elevates on tongue protrusion. Thyroglossal duct cysts are epithelial lined cysts that form from failure of normal developmental obliteration of the thyroglossal duct during development (8th-10th gestational week), and can thus occur anywhere along the course of the duct.
What is the most common cause of viral conjunctivitis?
A. Coronavirus
B. Influenza virus
C. Adenovirus
D. Parainfluenza virus
E. Human herpes virus
C. Adenovirus
A 35-year-old man began drug therapy with isoniazid one month ago for treatment of latent tuberculosis. Which of the following laboratory studies is the most important to obtain in monitoring this patient for black box warning adverse effects of this medication?
A. Blood urea nitrogen
B. Complete blood count
C. Creatinine
D. Liver function tests
E. Sodium
D. Liver function tests
Severe and sometimes fatal hepatitis associated with isoniazid therapy has been reported and may occur or may develop even after many months of treatment. The risk of developing hepatitis is age related. The risk of hepatitis is increased with daily consumption of alcohol. Therefore, patients given isoniazid should be carefully monitored and interviewed at monthly intervals. For persons 35 and older, in addition to monthly symptom reviews, hepatic enzymes (specifically, AST and ALT [formerly SGOT and SGPT, respectively]) should be measured prior to starting isoniazid therapy and periodically throughout treatment. Isoniazid-associated hepatitis usually occurs during the first three months of treatment.
Which of the following types of anemia has hypochromic, microcytic red blood cells, and low plasma ferritin levels?
A. Anemia of chronic disease
B. Aplastic anemia
C. Hemolytic anemia
D. Iron deficiency anemia
E. Megaloblastic anemia
D. Iron deficiency anemia
Iron deficiency anemia is a hypochromic, microcytic anemia with low plasma ferritin levels.
A 23-year-old woman with a history of anxiety and depression comes to your office because of an itchy rash on her abdomen that she has had for years. Physical examination reveals various lichenified plaques spread over the abdomen and onto the flanks. There is some evidence of excoriation, but no telangiectasias or signs of infection are present. Which of the following is the most likely diagnosis?
A. Actinic keratosis
B. Lichen planus
C. Lichen simplex chronicus
D. Pityriasis rosea
E. Psoriasis
C. Lichen simplex chronicus
Lichenified plaques due to chronic, excessive scratching, especially in someone with psychological factors, leads to lichen simplex chronicus. Thickened plaques are typically present with excoriations. The rash only occurs on areas that can be reached by the patient. Treatment involves cessation of scratching and topical corticosteroids.
Which of the following signs or symptoms would you expect to find at the bite site of a patient infected with rabies?
A. Purulent discharge
B. Paresthesias and fasciculations
C. Epithelial necrosis
D. Cellulitis and abscess formation
E. Rabies is not associated with signs or symptoms at the bite site
Stevens-Johnson syndrome is most commonly linked to exposure of which of the following medications?
Levofloxacin
Glucophage
Phenytoin
Amiodarone
Acetaminophen
Phenytoin
A 66-year-old woman, diagnosed with primary biliary cirrhosis two years ago, is being evaluated in the office for vitamin K deficiency because of fat malabsorption. An abnormality in which of the following studies is most likely to indicate significant vitamin K deficiency in this patient?
A. C-reactive protein
B. Erythrocyte sedimentation rate
C. Ferritin
D. Prothrombin time
E. Red blood cell distribution width
D. Prothrombin time
A 4-year-old Somali-American boy is brought to the pediatrician’s office by his parents following three days of fever, loss of appetite and malaise. A non-productive cough began this morning. His parents state that other children in their apartment building also have similar symptoms. Temperature is 40°C (104°F). On physical examination the patient appears fatigued. Tympanic membranes are grey, translucent, and mobile with air insufflation. The sclera are injected bilaterally and there is redness, swelling and warmth of the eyelid margins. Nasal drainage is present. Lungs are clear to auscultation, and the abdomen is soft and non-tender. Which of the following additional physical examination findings is most likely to be present?
A. Bright red rash on bilateral cheeks
B. Fine papular rash on chest and abdomen
C. Swelling of the parotid glands
D. Vesicular eruption on the mouth, hands and feet
E. White specks on the buccal mucosa
E. White specks on the buccal mucosa
Koplik spots, white or bluish-gray specks on a red base seen on the buccal mucosa, are pathognomonic for measles (rubeola). They are also described as looking “like a grain of salt.” Measles is caused by a virus from the paramyxovirus family. The classic maculopapular rash seen in measles occurs 1-2 days following the emergence of Koplik spots. The classic triad of cough, coryza, and conjunctivitis is also seen with measles. Inflammation of the eyelid margin in cases of measles is known as the Stimson line. The United States has experienced pockets of outbreaks in recent years in communities with low vaccination rates. While the diagnosis of measles can be made on the basis of the clinical picture, laboratory diagnosis via reverse-transcriptase polymerase chain reaction and IgM or IgG titers are necessary for outbreak control.
What is the most common cause of pneumonia in elderly pts (>65 y/o)?
Influenza virus
Which of the following is the earliest EKG change seen in hyperkalemia?
A. U wave
B. QRS widening
C. Sine-wave pattern
D. Peaked T waves
E. Loss of P wave
D. Peaked T waves
A nurse frantically calls you because one of your patients lost consciousness with the following rhythm on the cardiac monitor. As you are speaking with her, the patient becomes pulseless with the same rhythm. Which of the following is the initial treatment of choice in this patient?
A. Magnesium sulfate
B. Implantable defibrillator
C. Defibrillation
D. Amiodarone
E. Metoprolol
C. Defibrillation
This cardiac monitor demonstrates torsades de pointes. In unstable patients, the first step in management is nonsynchronized defibrillation. In stable patients, one may try magnesium sulfate. Overall, the underlying cause of torsades de pointes needs to be identified and addressed (eg hypokalemia, drug-induced). Prolonged QT interval is a risk factor and contributory to the underlying electrophysiologic mechanism.
Which of the following is the most common type of thyroid cancer?
A. Anaplastic
B. Follicular
C. Lymphoma
D. Medullary
E. Papillary
E. Papillary
Papillary thyroid carcinoma is the most common form of well-differentiated thyroid cancer, and the most common form of thyroid cancer to result from exposure to radiation. Papillary carcinoma appears as an irregular solid or cystic mass or nodule in a normal thyroid parenchyma. Despite its well-differentiated characteristics, papillary carcinoma may be overtly or minimally invasive. These tumors have a propensity to invade lymphatics, but are less likely to invade blood vessels. Life expectancy of patients with this cancer is related to their age. The prognosis is better for younger patients than for patients who are older than 45 years. Fine-needle aspiration biopsy is considered the best first-line diagnostic procedure for a thyroid nodule. Surgery is the definitive management of papillary thyroid cancer. Approximately 4-6 weeks after surgical thyroid removal, patients may have radioiodine therapy to detect and destroy any metastasis and residual tissue in the thyroid.
An indirect hernia is most likely to pass through which of the following structures?
A. Femoral canal
B. Hesselbach triangle
C. Inguinal canal
D. Obturator foramen
E. Spigelian fascia
C. Inguinal canal
Indirect inguinal hernias arise lateral and superior to the course of the inferior epigastric vessels (lateral to Hesselbach triangle), and then protrude through the deep (internal) inguinal ring into the inguinal canal. It passes inferomedial to emerge via the superficial ring and, if large enough, extends into the scrotum.
A 54-year-old man is being evaluated in the hospital after being admitted from the emergency department with a diagnosis of encephalitis. Which of the following is the most likely etiologic agent of this patient’s condition?
A. Herpes simplex virus
B. Measles virus
C. Mumps virus
D. Rabies virus
E. Tuberculosis
A. Herpes simplex virus
Herpes simplex virus (HSV), varicella-zoster virus (VZV), and enterovirus are three of the most commonly identified etiologic agents in acute encephalitis. These should be routinely screened for in the cerebrospinal fluid.
An infant who sits with only minimal support, who attempts to attain a toy beyond reach, and who can roll from supine to prone, but does not display a pincer grasp, is at which of the following developmental levels?
A. 2 Months
B. 4 Months
C. 6 Months
D. 9 Months
E. 12 Months
C. 6 Months
During the acute hemolysis of red blood cells, which one of the following sets of serum findings would be most supportive?
A. Elevated haptoglobin and creatinine; metabolic alkalosis
B. Elevated potassium and LDH; reduced haptoglobin
C. Reduced potassium; elevated haptoglobin and LDH
D. Reduced haptoglobin, potassium and LDH
E. Reduced haptoglobin; elevated sodium and chloride
B. Elevated potassium and LDH; reduced haptoglobin
During acute hemolytic states – the serum potassium and LDH levels are classically elevated; serum haptoglobin levels are reduced
