62 ABFM Family Medicine Board Exam Practice Questions

Administration of pulmonary vasodilator therapy is correct. This patient’s clinical presentation is consistent with pulmonary arterial hypertension (PAH), a condition characterized by increased pulmonary artery pressure leading to right ventricular dysfunction and eventual heart failure. The presence of symptoms such as shortness of breath, fatigue, chest pain, and syncope along with physical examination findings of jugular venous distension, a prominent P2, and a harsh holosystolic murmur suggests the possibility of pulmonary arterial hypertension (PAH). The most appropriate initial treatment for PAH is the administration of pulmonary vasodilator therapy. Medications such as endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostacyclin analogs have been shown to improve symptoms, exercise tolerance, and hemodynamics in patients with PAH. These medications target the underlying pathophysiology of PAH, promoting pulmonary vasodilation and reducing pulmonary artery pressure.

Diuretics is incorrect. While diuretics may address fluid retention in certain cases, they do not specifically target the underlying cause of pulmonary arterial hypertension (PAH).

Oral anticoagulation therapy is incorrect. Oral anticoagulation therapy is indicated for specific subgroups of patients with PAH, such as those with idiopathic PAH or PAH associated with connective tissue diseases. However, it is not the most appropriate initial treatment for all patients with suspected PAH.

Coronary artery bypass graft (CABG) surgery is incorrect. CABG is a surgical procedure used to restore blood flow to the coronary arteries in cases of coronary artery disease (CAD). While CAD and pulmonary arterial hypertension (PAH) are both cardiovascular conditions, they are distinct entities with different treatment approaches. PAH primarily involves increased pulmonary artery pressure and right ventricular dysfunction, whereas CABG is used to treat coronary artery blockages.

Referral for lung transplantation is incorrect. it is typically considered in advanced cases of PAH when medical therapy fails or if the patient is not a suitable candidate for medical therapy. It is not the initial treatment option for all patients with suspected PAH.

Coronary artery disease is correct because, based on studies, the leading cause of death in the United States and worldwide is coronary heart disease, and the risk is higher in men than in women. Given that this patient socially smokes, he had a greater risk of developing coronary artery disease than someone who does not smoke.

Lung cancer is incorrect because it is the 2nd most common cause of death worldwide. It is the most common cause of cancer-related death in men and women. This patient does smoke, but his smoking history is not significant enough to increase his risk of dying from lung cancer.

Malignant melanoma is incorrect because although this patient may have a family history of melanoma, around 10% of malignant melanomas are familial. This patient is more likely to die from another condition.

Construction accident is incorrect because accidents are the 3rd most common cause of death amongst men in the United States. This patient is more likely to die from another condition.

Prostate cancer is incorrect even though this is the most common cancer amongst men. However, it is not the leading cause of cancer-related deaths. This patient is more likely to die from another condition.

Topical ciprofloxacin solution and topical analgesics is the correct answer because the above case describes a patient with the most likely diagnosis of corneal abrasion secondary to trauma. The patient should be prescribed a topical antibiotic solution to prevent secondary bacterial infection and topical analgesics for pain relief.

Topical steroids is incorrect because topical steroids are not recommended for the treatment of corneal abrasions.

Topical ciprofloxacin solution is incorrect because although topical antibiotic solutions are usually prescribed in patients with corneal abrasion to prevent infection, it is also important to prescribe analgesics as well.

Topical ciprofloxacin solution and oral opioid analgesics is incorrect because oral opioid analgesics are not usually prescribed in patients with corneal abrasion. If the patient has severe pain or topical analgesics are not causing resolution of symptoms, oral analgesics can be prescribed.

Immediate referral to an ophthalmologist is incorrect because there is no need for a referral to an ophthalmologist at this time. However, if the symptoms do not resolve within 24 hours after the treatment is initiated, an immediate referral to an ophthalmologist is recommended.

Reassurance and regular follow-ups is the correct answer because the above case describes a patient with the complication of middle ear effusion as a sequela of acute otitis media (AOM). The middle ear effusions can take up to 3 months to settle. Therefore, the mother should be reassured and advised to follow up regularly.

Oral amoxicillin for a week is incorrect because middle ear effusions can take up to 3 months to settle. There is no need for antibiotics.

Intravenous ceftriaxone for a week is incorrect because there is no indication for antibiotic administration for middle ear effusion in this patient.

Clindamycin for a week is incorrect because antibiotics are not indicated for middle ear effusion that occurs as a sequela of acute otitis media (AOM), as it can take up to 3 months to resolve.

Refer to an otolaryngologist is incorrect because there is no need for a referral at this time. If the middle ear effusion persists for more than 3 months, the child should then be referred to an otolaryngologist.

Influenza vaccine is the correct response. This vignette describes a patient suffering from influenza virus. The most effective way to prevent influenza virus is the annual dosing of the influenza vaccine, a trivalent vaccine. The vaccine does not cover all strains of the influenza virus. Therefore, it is still possible to get infected despite vaccination. Apart from vaccines, oseltamivir is also used in the prevention and treatment of the influenza virus.

Antibiotics is incorrect because they treat bacterial infections, while influenza is a viral infection. Antibiotics have no role in the prevention of a viral disease.

Multivitamins is incorrect because they can increase immunity levels, but they do not play a significant role in preventing infectious diseases.

Antihistamines is an incorrect response because this drug is used to treat allergies, not prevent them.

Non-steroidal anti-inflammatory drugs (NSAIDS) is an incorrect response as this class of drugs is used to relieve pain, reduce inflammation and bring down high body temperatures but does not prevent viral diseases.

The ability to communicate preferred treatment is correct because a patient is assessed to possess adequate decision-making capacity when choosing and communicating a preferred treatment option.

The ability to recall all treatment options verbatim is incorrect because the patient needs to understand rather than the physician’s fundamental meaning of the information.

The ability to not stutter during the discussion is incorrect because, legally, the patient needs to communicate a clear choice, understand the information given, and engage in a rational discussion regarding preferred treatment. A stutter is not a hindrance to a patient’s decision-making capacity.

The ability to ignore the likely consequences of treatment is incorrect because the patient with adequate decision-making capacity needs to acknowledge the likely consequences of the treatment options.

The ability to apply the relevant information to his friend’s situation is incorrect because a legal component of decision-making capacity includes the ability to apply the relevant information shared by the physician to one’s situation.

Ketoacidosis is the correct option because this patient is suffering from type 1 diabetes mellitus, which is most commonly complicated by diabetic ketoacidosis. The patient is experiencing polydipsia and polyuria, which can be symptoms of hyperglycemia. The fruity smell in her breath indicates ketosis, which can progress to ketoacidosis. Diabetic ketoacidosis occurs exclusively in type 1 diabetes and is a medical emergency requiring admission to the intensive care unit for controlled rehydration and glycemic control. It may be the first presentation for most cases of type 1 diabetes.

Lactic acidosis is incorrect because it is a complication of type 2 diabetes and is unlikely in this patient.

Acute tubular necrosis (ATN) is incorrect because it is not an immediate complication that can be expected in a patient with type 1 diabetes. ATN can occur in case of well-established ketoacidosis leading to severe dehydration.

Pulmonary embolism is incorrect because it is not an immediate complication of type 1 diabetes.

Pseudomembranous colitis is incorrect because it is not associated with type 1 diabetes. It occurs as an overgrowth of clostridium difficile following prolonged use of broad-spectrum antibiotics.

Chvostek sign is the correct option because it is positive in patients with hypocalcemia. This patient is exhibiting signs and symptoms of hypoparathyroidism secondary to subtotal thyroidectomy in the past. Hypoparathyroidism leads to low calcium levels that cause muscle spasms and twitching. This can be elicited through tapping the facial nerve as it passes in front of the ear that causes involuntary twitching of the facial muscles.

Babinski’s sign is incorrect because this is performed in patients with suspected upper motor neuron lesions. Babinski’s sign is considered positive when there is dorsiflexion of the big toe; it is abnormal if it persists beyond 12 months.

Murphy’s sign is incorrect because it is used to diagnose acute cholecystitis and is considered positive when there is a tenderness in the right hypochondrium.

McMurray’s sign is incorrect because it is positive in patients with meniscal injury. It is performed by flexing and then extending and externally rotating the suspected knee while the patient lies flat on the back. A click is heard in case of a meniscal injury, which is considered a positive McMurray’s sign.

Cullen’s sign is incorrect because it is characterized by a discoloration of the central abdomen due to intraperitoneal hemorrhage.

Patient education is correct as it is a crucial step in managing an obese patient presenting with osteoarthritis. The patient should be educated about the important role he can play in his management, especially regarding weight loss. Patient education acts as one of the most efficient measures in improving symptoms and reducing disease progression.

High-dose acetaminophen administration is incorrect because the patient has a history of heavy alcohol consumption. The use of high doses of acetaminophen is cautioned against when utilized for pain relief in such a patient with osteoarthritis.

High-dose azithromycin administration is incorrect because the patient in this scenario suffers from osteoarthritis and does not display any sign of a bacterial infection requiring an antimicrobial drug for management.

Arthroscopic surgery is incorrect because in a patient presenting with osteoarthritis, as in this case, clinical trials have shown the benefit of arthroscopic surgery to be due to the placebo effect.

Joint replacement is incorrect because joint replacement is indicated in patients in whom maximal therapy cannot adequately control pain. In contrast, therapy has yet to be initiated in this scenario. Joint replacement is also indicated in those patients who suffer from malalignment or decreased joint mobility, but both of these findings are absent in this patient. Joint replacement would also require an obese patient to lose weight before surgery initiation, given the lengthy rehabilitation process.

Reactive arthritis is the correct option. This patient developed her symptoms after an episode of gastroenteritis. The triad of lower limb arthritis, ocular (conjunctivitis, uveitis), and nongonococcal urethritis point to the underlying diagnosis. Other manifestations include Achilles tendinitis, circinate balanitis, keratoderma blennorrhagicum, recurrent oral ulcers, and a geographical tongue. Treatment is supportive.

Rheumatoid arthritis is incorrect because although the patient complains of sore eyes, the absence of symmetrical involvement of small joints of the hands with associated morning stiffness makes it a less likely possibility.

Septic arthritis is incorrect because it is usually monoarticular, and the involved joint is red, hot, tender, and held in flexion because of muscle spasms. Joint and blood cultures are often positive.

Still’s disease is incorrect because it is a diagnosis of exclusion. It is characterized by fever, salmon-colored rash, lymphadenopathy, arthritis, and hepatosplenomegaly. Inflammatory markers in the blood are often markedly elevated, and rheumatoid factor and antinuclear antibody (ANA) are negative.

Jaccoud’s arthropathy (JA) is an incorrect option because it is characterized by a reversible, chronic, non-erosive, rheumatoid-like deformity of the hands associated with systemic lupus erythematosus (SLE).

Acoustic neuromas, which commonly arise from the internal acoustic canal, often exert a mass effect on the vestibulocochlear nerve (CN VIII). The resulting unilateral sensorineural hearing loss, as seen in this patient, is the most common early symptom of this condition. Other symptoms include tinnitus due to pressure on CN VIII, as well as dizziness/vertigo and gait instability due to vestibular deficits.

Cerumen impaction is associated with conductive hearing loss due to direct obstruction of the external acoustic canal. If cerumen impaction were present on the right side, the patient would have a negative Rinne test on the right and a positive test on the left. The Weber test would lateralize to the right side.

Cochlear ischemia can lead to direct cochlear nerve damage and thus, cause unilateral sensorineural hearing loss, as seen here. In a patient with right-sided cochlear ischemia, the Rinne test would be positive on both sides. However, the Weber test would lateralize to the left because of right-sided nerve damage.

Cholesteatoma does not always present with hearing loss but would cause conductive hearing loss due to erosion of the ossicles. In the case of a symptomatic cholesteatoma on the right side, this patient would have a negative Rinne test on the right and a positive test on the left. The Weber test would lateralize to the right side.

Otosclerosis is characterized by conductive hearing loss (more in the lower frequencies than in the higher), typically bilateral. It most commonly manifests in the third or fourth decade of life. If otosclerosis were present on the left side, the patient would have a negative Rinne test on the left and a positive test on the right. The Weber test would lateralize to the left.

Lyme disease is the correct option. The patient visited a forest a year ago in the endemic area of the disease. The patient had developed a pathognomonic rash, and it was associated with tick-borne illness. The symptoms of joint pain occur 2 -24 months after the development of inflammation.

Rheumatoid arthritis is an incorrect response. Although the symptoms of joint pain lead toward rheumatoid arthritis, it mimics Lyme disease. Patients with rheumatoid arthritis complain of morning stiffness and pain in interphalangeal joints, which is negative.

Osteoarthritis is an incorrect option because it is not associated with the development of a rash. Moreover, the radiographs are negative for reduced joint space.

Sarcoidosis is incorrect. Sarcoidosis is a short-lived polyarthritis similar to rheumatoid arthritis. Furthermore, it is a systemic disease.

Septic arthritis is an incorrect response. Septic arthritis is usually monoarticular, sometimes pauciarticular, and on culture, the report shows bacterial growth, which is negative in this patient’s result.

Herpes zoster ophthalmicus is the correct answer. These patients present with vesicles, swelling, erythema, painful maculopapular rash, or burning with an onset occurring over hours to days. Viral culture and molecular techniques are required to establish a definitive diagnosis, immediate diagnosis and treatment with antiviral medications are crucial to prevent progression and preserve vision.

Contact dermatitis is incorrect because patients with irritant contact dermatitis may present with symptoms of pruritus, burning, or stinging of the eyelids and periorbital area, with or without the involvement of the face and hands. Little scaling may be present in contact dermatitis.

Atopic dermatitis is incorrect because patients with eyelid atopic dermatitis may present with pruritus, edema, erythema, lichenification, fissures, or fine scaling. Affected individuals with atopic dermatitis may have a family or personal history of asthma, rhinitis, and atopic dermatitis.

Orbital cellulitis is incorrect because it has features of proptosis, decreased visual acuity, pain with eye movement, and limitation of extraocular movements, in addition to edema and erythema, and usually, patients have a history of sinusitis, fever, malaise, local trauma, impetigo, or surgery, and may have evidence of systemic infection, with fever/myalgias or even sepsis. Herpes simplex and herpes zoster ophthalmicus patients present with vesicles, swelling, erythema, painful macro-popular rash, or burning with an onset over days to hours.

Blepharitis is an incorrect answer because it is a common chronic inflammatory condition of the eyelid margins, which may anteriorly affect the base of the eyelashes or posteriorly involve the meibomian gland orifices. Erythematous and mildly edematous eyelid margins, soft, oily, yellow scaling or, rarely, brittle scaling around the lashes are typical of blepharitis that is often associated with other disorders such as rosacea, seborrheic dermatitis, and keratoconjunctivitis sicca. Itching, irritation, and burning may be present.

Echocardiography is the correct option. This patient has primary pulmonary hypertension, as evidenced by progressive dyspnea, signs of right heart failure (elevated JVP, pedal edema), and a murmur of tricuspid regurgitation. Primary pulmonary hypertension is an idiopathic disorder that affects young women who present with insidious onset of dyspnea. Echocardiography with colored Doppler will estimate the pulmonary artery pressure and demonstrate right-sided heart failure. It’s a diagnosis of exclusion, and patients may need an autoimmune profile, CT pulmonary angiogram, sleep studies, etc., to rule out secondary pulmonary hypertension.

Serum ACE levels is incorrect because it is used to diagnose sarcoidosis. These patients have a dry cough with joint pains, and a chest x-ray demonstrates bilateral hilar lymphadenopathy.

Antistreptolysin O (ASO) titer is an incorrect option because the pansystolic murmur is not due to rheumatic heart disease but because of functional tricuspid regurgitation resulting from elevated right heart pressures.

Pulmonary function tests is incorrect because although they may demonstrate airway obstruction, they will not offer any diagnostic benefit.

Methacholine challenge test is an incorrect option because it aids in the diagnosis of asthma. Although she has a strong family history of asthma and atopy, the absence of wheezing and variability of symptoms make it a less likely possibility.

Myasthenia gravis is the correct option. This patient has presented with episodic involvement of the bulbar and respiratory muscles after periods of activity and at the end of the day. Bulbar and respiratory muscle involvement may occur early and increase the risk of sudden death. Muscular weakness may not be evident unless tested repeatedly.

Anxiety is an incorrect option because her symptoms are strongly suggestive of myasthenia gravis.

Phrenic nerve palsy is incorrect because it innervates the diaphragm. Although it may cause unexplained shortness of breath, recurrent pneumonia, anxiety, insomnia with resulting excessive daytime somnolence, fatigue, and orthopnea, the symptoms are not episodic, and eye involvement (ptosis) does not occur.

Lambert-Eaton syndrome is incorrect because it is characterized by decreased muscle strength which improves after activity.

Vanishing lung syndrome is incorrect because it is a rare phenomenon in patients with systemic lupus erythematosus characterized by a loss of lung volume.

Granulomatous lymphocytic interstitial pneumonia is the correct option. It is a rare and potentially fatal complication of common variable immunodeficiency. Lung abnormalities are a recognized problem in patients with common variable immunodeficiency (CVID). Recurrent cases of pneumonia, bronchiectasis, and interstitial lung disease have all been documented. Granulomatous interstitial pneumonia occurs due to intrinsic CVID-related immune dysregulation. Treatment is mostly supportive.

Lymphoma is an incorrect option because patients present with fever, night sweats, and lymphadenopathy. High-resolution computed tomography (HRCT) of these patients may show bilateral hilar, tracheal, and paratracheal lymphadenopathy.

Streptococcus pneumonia is incorrect because it presents as fever, pleuritic chest pain, and rusty-colored sputum. A CT scan will show consolidation and air bronchograms.

Relapse of bronchiectasis is incorrect because an high-resolution computed tomography (HRCT) will show bronchial wall thickening, air trapping, tram-track sign, and signet-ring sign.

Drug-induced pneumonia is incorrect because amoxicillin rarely causes eosinophilic pneumonitis and is commonly associated with urticaria and rash. Patients may present with wheezing and have evidence of peripheral blood eosinophilia.

Obtain throat culture is correct. This patient has acute tonsillitis and no signs (conjunctivitis, hoarseness, cough, stomatitis) specifically suggesting a viral illness. The gold standard for diagnosing bacterial tonsillitis is a throat culture, which can identify the underlying pathogen and determine its antibiotic sensitivity.

Measurement of antiviral capsid antigen IgM antibody is incorrect. An antiviral capsid antigen IgM level is used to diagnose mononucleosis in patients with clinical suspicion despite a negative monospot test. Patients with mononucleosis often have tonsillitis/pharyngitis but this patient lacks further symptoms such as cervical lymphadenopathy, fever, and hepatosplenomegaly.

Reassurance and follow-up in 2 weeks is indicated for patients with viral tonsillitis. This patient requires further testing to rule out bacterial tonsillitis. Failure to treat bacterial tonsillitis in children increases the risk of rheumatic fever, post-streptococcal glomerulonephritis, and peritonsillar abscess.

Measurement of anti-streptolysin O titer is part of the workup for sequelae of streptococcal infection such as rheumatic fever. ASO titer is not useful in diagnosing acute streptococcal infection because antibody levels take about 2 weeks to rise and do not peak until 3-5 weeks after infection; antibody levels reflect past, rather than current infections. This patient has only been symptomatic for 2 days. Therefore, an ASO titer would likely be negative even if his symptoms were due to streptococcal infection.

Penicillin V therapy is the treatment of choice for in patients without penicillin allergy. This patient requires further testing before antibiotic treatment is indicated.

Community-acquired pneumonia is the correct option because it is one of the types acquired outside of a healthcare establishment. Common presenting features include dyspnea, fever, and purulent sputum. Common pathogens are Streptococcus pneumoniae, atypical bacteria, and Hemophilus influenzae.

Aspiration pneumonia is incorrect because it occurs due to inhaling or aspiring gastric contents into the lungs. It is mostly seen in patients with neurological abnormalities, reduced conscious states, or in association with certain medical procedures.

Hospital-acquired pneumonia is incorrect because it occurs 48 hours after admission. This patient has no history of recent hospitalization.

Lung abscess is incorrect because it has an indolent presentation of symptoms, including night sweats, hemoptysis, anorexia, and weight loss. Moreover, the x-ray shows cavitation of the lung.

Pneumocystis pneumonia is incorrect because it usually occurs in immunocompromised individuals, specifically in HIV patients. This patient’s clinical features suggest a different diagnosis.

Inhibition of neuraminidase is the correct option because neuraminidase inhibitors, e.g., zanamivir and oseltamivir, inhibit the budding and release of the progeny influenza virus and are used for both treatment and prophylaxis of the disease.

Inhibition of protease is incorrect because protease inhibitors are used in treating HIV infection and are not used to treat influenza.

Inhibition of proton translocation is incorrect because it is the mechanism of action of amantadine and rimantadine. This class of drugs is of no significance because of its increased viral drug resistance.

Inhibition of nucleoside reverse transcriptase is incorrect because NRTIs (e.g., zidovudine) are used in the treatment of HIV infection, not for influenza. Moreover, HIV belongs to the family of retroviruses, not orthomyxoviruses.

Inhibition of viral DNA polymerase is incorrect because guanosine analogs (e.g., acyclovir, valacyclovir), as well as foscarnet, are mainly used for the treatment of HSV infection and varicella zoster infection, not for treatment of influenza.

Supportive therapy only is correct as he is outside the window for effective medication.

Oseltamivir is incorrect in this case, as the patient has had symptoms for 3 days. It is a neuraminidase inhibitor used in the treatment of severe influenza. It has also been shown to reduce complications in elderly individuals (~60 years old). It can reduce the severity of the disease if therapy is started within the first 24-48 hours of symptom onset.

Amantadine is incorrect because it has N-methyl-D-aspartate (NMDA) receptor antagonist properties and is used in the treatment of Parkinson’s disease. It was formerly used in treating influenza, but as the virus mutates, it is no longer used.

Inactivated influenza vaccine is incorrect because it is inefficient in treating acute infection.

Protease inhibitors are incorrect because it is indicated in the treatment of HIV-infected individuals and has no role in the management of influenza.

Prolongation of QT interval is correct as it is the characteristic electrocardiogram finding of hypocalcemia. This patient presents with symptoms and signs of hypocalcemia due to hypoparathyroidism. Hypoparathyroidism occurs most commonly as a result of damage to the parathyroid glands when undergoing a thyroidectomy surgical procedure. Rare causes of hyperparathyroidism include Wilson’s disease and hemochromatosis. Hypocalcemia that is mild is asymptomatic but hypocalcemia that is severe presents with tetany, muscle cramps, twitching, and tingling sensations. A positive Chvostek sign, reflecting a classical sign of hypocalcemia, results in the twitching of the corner of the mouth when tapping the facial nerve as it crosses the parotid gland. Trousseau’s sign refers to the carpopedal spasm when the blood pressure cuff placed on the upper arm is inflated above the systolic blood pressure reading.

Broad QRS complexes on an electrocardiogram indicate hyperkalemia.

Prolongation of the PR interval on an electrocardiogram indicates first-degree atrioventricular block.

Peaked T waves on an electrocardiogram indicate moderate hyperkalemia.

Prominent U waves on an electrocardiogram indicate severe hypokalemia.

Plasma adrenocorticotropic hormone (ACTH) is correct. Plasma ACTH levels should be checked with a cortisol level to determine whether the etiology of the adrenal insufficiency is primary or secondary. Increased plasma ACTH levels indicate primary adrenal insufficiency and low to normal ACTH levels point to a secondary cause. The diagnosis of adrenal insufficiency must be confirmed with a cosyntropin stimulation test.

Random plasma cortisol is of no use in establishing the diagnosis of adrenal insufficiency. Although it is generally decreased, even normal levels may be low for severely ill patients.

Chest x-ray may be done when there is a clinical suspicion for other causes of adrenal insufficiency such as tuberculosis.

Dexamethasone suppression test is used to establish the diagnosis of Cushing syndrome which is a syndrome of hypercortisolism. This patient is exhibiting symptoms of hypocortisolism.

Urine free cortisol test should be done when initial screening tests are inconclusive and physical findings are strongly suggestive of Cushing syndrome.

Graves’ disease is the most common cause of thyrotoxicosis. Symptoms of thyrotoxicosis include weight loss (despite no changes in appetite), heat intolerance, palpitations, sweating, emotional lability, irritability, oligomenorrhea, diarrhea, infertility, and decreased libido. Palmar erythema, lid retraction, lid lag, sinus tachycardia, and systolic hypertension are the commonly seen signs in patients with thyroid hormone excess. Graves’ disease most commonly affects women aged 30-50 years and is caused by autoantibodies against thyroid stimulating hormone (TSH) receptors (thyroid stimulating immunoglobulins or TSH receptor antibodies). Diffuse goiter may or may not be present along with features of thyrotoxicosis. Features unique to Graves’ disease but not present in other forms of thyrotoxicosis include periorbital edema, exophthalmos, pretibial myxedema, and thyroid acropachy. Measurement of TSH receptor antibodies (TRAb) and thyroid peroxidase antibodies is not required in most cases if the clinical suspicion is high.

Subacute thyroiditis classically results in a tender and enlarged thyroid. It usually occurs in females aged 20-40 years after infection with mumps, adenovirus, or Coxsackie virus.

Hashimoto’s thyroiditis is the most common cause of hypothyroidism. Thyroperoxidase antibodies would be positive.

TSH-secreting pituitary adenoma is incorrect because both TSH and T4 and T3 are elevated.

Riedel’s thyroiditis is a fibrous infiltration of the thyroid gland. It clinically presents as a slowly enlarging goiter which often causes tracheal and esophageal compression.

Surgery is correct as this patient is presenting with typical features of acromegaly, an endocrine disorder caused by a growth hormone-producing adenoma in adults. Excessive growth hormone secretion results in bone and soft tissue growth. Symptoms include headache, sweating, decreased libido, amenorrhea (in women), joint pain, and back pain. Patients complain of their shoe and hat size having increased and of gaining weight. Signs include enlarged hands and feet, coarse facial features, widening of the nose, increased spacing between teeth, and skin darkening. Growth hormone stimulates the secretion of insulin-like growth factor-1. Serum IGF-1 levels are used as a screening test when the clinical features are suggestive of acromegaly. Random growth hormone (GH) levels are not reliable as GH secretion is pulsatile. The first line treatment for a growth-hormone-producing adenoma is surgical resection via the transsphenoidal route.

Radiotherapy is typically used for tumors refractory to medical and surgical management.

Bromocriptine, a dopamine receptor agonist, is not as effective as somatostatin analogs in reducing growth hormone (GH) but may be useful when prolactin levels are elevated. Some GH-secreting tumors also co-secrete prolactin.

Pegvisomant is a growth hormone receptor antagonist that is used in patients who do not respond to somatostatin analog therapy.

Octreotide, a somatostatin analog, may be used to antagonize growth hormone (GH) hypersecretion following surgical resection of the tumor.

Antithyroid peroxidase antibodies is correct. This woman presents with signs and symptoms of hypothyroidism. Once hypothyroidism is confirmed, antithyroid peroxidase antibodies or thyroglobulin antibodies should be checked.

Thyroid scintigraphy is an imaging study used to determine whether the thyroid gland is hyper- or hypofunctioning.

Fine needle aspiration cytology is the biopsy procedure used to remove tissue, cells, or fluid of thyroid nodules. The results of the cytology are reported as nondiagnostic, diagnostic, or diagnostic of malignant neoplasm (lymphoma or papillary, follicular, or anaplastic carcinoma). There is no nodule to biopsy in this patient.

Thyroid-stimulating hormone receptor antibodies are present in patients with Graves disease. Patients with Graves disease typically present with signs and symptoms of hyperthyroidism.

Thyroid ultrasonography is used to assess thyroid gland structure and thyroid nodule characteristics, which are not necessary to evaluate in this patient until laboratory results are known.

Prescribe high-intensity statin is the correct response. Lipid control is an important component of risk reduction in patients with coronary artery disease. The target goal is low-density lipoprotein (LDL) < 100 mg/dl in patients with diagnosed coronary artery disease (CAD), such as this patient with 75 % occlusion on coronary angiography. Statins significantly improve the morbidity and mortality in patients with CAD, possibly owing to their endothelial stabilizing and anti-inflammatory effects, and are recommended in all patients regardless of their lipid profile. Therefore, although his serum lipid levels fall into the target range of patients with CAD, he should be prescribed a high-intensity statin.

Prescribe warfarin is incorrect. Warfarin is reserved for patients who have contraindications for aspirin or do not respond to it.

Prescribe niacin is incorrect. Niacin is more effective in controlling triglyceride levels than low-density lipoprotein (LDL) and this patient’s triglyceride levels are within the target range (<200 mg/dl)

Prescribe angiotensin receptor blocker (ARB) is incorrect. This patient is already taking an angiotensin-converting enzyme inhibitor (ACEI), and his blood pressure is under control. ARB and ACEI have similar effects. Therefore, this patient does not require additional ARB.

Prescribe diuretic is incorrect. There is no indication for the prescription of a diuretic in this patient at this point.

Nonalcoholic fatty liver disease is associated most often with an ALT>AST. Hispanics are more prone to this form of liver disease than weight-matched Caucasians or African-Americans, probably because of genetic factors. In addition, 50% of children with nonalcoholic fatty liver disease have acanthosis nigricans, a dark rash on the nape of the neck (as seen in this patient). The best treatment in this case is diet and weight loss. There is some benefit to liver enzymes and perhaps histology, as well, from vitamin E supplementation.

Autoimmune hepatitis is incorrect as the patient has mildly elevated liver enzymes, but no jaundice. Autoimmune hepatitis is a possible diagnosis but is not the most likely. The liver enzymes are only mildly elevated, and there is no elevation of the globulin fraction of her serum protein (7.2-4.0 = 3.2). Usually in autoimmune hepatitis, there is an elevated globulin fraction (for example, 8.0-3.0.).

Covert alcohol use disorder is also incorrect due to the fact that alcoholic hepatitis is not common in teenagers. In addition, it would produce an elevation in AST as well as ALT, with the AST often higher than ALT (“A Scotch and Tonic” is the mnemonic).

Reaction to doxycycline is incorrect, as tetracycline can indeed cause cholestasis, but the bilirubin is normal. Similarly, doxycycline can cause autoimmune hepatitis, but there is no elevation in the globulin fraction on her serum protein profile.

Hepatitis B is also incorrect because while hepatitis B can be indolent and is possible, it is not the best answer given the mild elevation of the liver enzymes and asymmetric elevation (ALT>AST). Hepatitis B has a much lower prevalence in Mexico than in Asian countries.

Magnetic resonance cholangiopancreatography is correct. This patient has suspected ischemic-type biliary lesions which are not associated with anastomotic ischemia but are rather the consequence of ischemia reperfusion injury to the biliary tree during transplantation. This patient is at risk of this complication from a non-beating heart donor and magnetic resonance cholangiopancreatography is the diagnostic test for assessing this condition.

Endoscopic retrograde cholangiopancreatography is less preferred as an initial step. The noninvasive assessment by magnetic resonance cholangiopancreatography is preferred to establish a diagnosis and pathologic anatomic changes.

Liver biopsy would provide no additional information in the evaluation of large duct ischemic strictures.

Fractionated alkaline phosphatase levels is incorrect, as increased gamma-glutamyl transferase (GGT) levels already suggest that the elevation in alkaline phosphatase levels is liver related.

Computed tomography angiography of the abdomen is incorrect because it would not provide any additional information. The right upper quadrant ultrasonography results did not suggest hepatic artery thrombosis which is usually an earlier finding after transplantation.

Magnetic resonance imaging (MRI) of the shoulder joint is correct because it is the gold-standard imaging modality for diagnosing rotator cuff impingement syndrome. The syndrome is characterized by pain in the anterior shoulder that worsens with repetitive and overhead activities. A shoulder MRI will show the tendon rupture, fluid in the joint space, or bone marrow edema.

X-ray of the shoulder joint is incorrect because the scenario describes a patient with rotator cuff impingement syndrome. X-ray aids in visualizing acromial morphology and the presence of bony spurs that might contribute to the pathology. It also tells the presence of cystic changes in the humeral head, calcification of the tendons, and underlying degenerative disease.

Ultrasound of the shoulder joint is incorrect because it is not the gold-standard investigation for diagnosing rotator cuff impingement syndrome. Ultrasound is operator-dependent, and inexperienced hands may show inflammatory features like tendon bunching and excessive bursal fluid.

Computed tomography (CT) scan of the shoulder is incorrect because it does not show the underlying pathology of rotator cuff impingement syndrome, as does the MRI scan. CT shoulder is done for tumors or clots in this region.

Electromyography (EMG) is incorrect because MRI is the gold standard modality for diagnosing rotator cuff impingement syndrome.

Brachial neuritis is the correct option. It may be idiopathic or follow an infection, surgery, vaccination, or trauma. It presents with severe pain in the upper arm that is unresponsive to analgesics, followed by wasting and weakness of the deltoid, serratus anterior, supraspinatus, and infraspinatus after a few weeks. Treatment is supportive, and most patients recover spontaneously.

Polymyalgia rheumatica is an incorrect option because it is characterized by bilateral proximal muscle pain and weakness. Erythrocyte sedimentation rate (ESR) will be raised. Unilateral shoulder pain makes it an unlikely possibility.

Neoplastic brachial plexopathy (NBP) is an incorrect option because it is a rare diagnosis, and there is nothing in the history to suggest weight loss, lumps, or any features of an occult malignancy. The lower trunk is often involved, and patients present with weakness and sensory loss in C8 and T1 dermatomes.

Rotator cuff disease is an incorrect option because although patients have difficulty raising their arm overhead, an examination will reveal marked tenderness along the greater tuberosity and subacromial bursa. There is decreased active elevation with a normal passive range of movements in these patients.

Axillary nerve palsy is an incorrect option because patients have numbness in the deltoid muscle area with impaired abduction and external rotation.

Weight loss is the single most important factor in the treatment of osteoarthritis. Weight loss reduces stress on the arthritic joint, slows disease progression, and halts the destructive process. Obese patients with osteoarthritis are more likely to receive joint replacement surgery than lean patients.

Avoid caffeine is incorrect because although it halts osteoarthritis progression, it does not reduce stress on the arthritic joint, as does weight loss.

Quit smoking is incorrect because although smoking is a risk factor for developing osteoarthritis, it cannot halt the disease progression.

Strengthening exercises is incorrect because although they are an integral part of osteoarthritis management, weight loss is more important to reduce stress on the arthritic joint.

Aerobic exercises is incorrect because weight loss is the most important lifestyle advice for osteoarthritis.

Needle-shaped crystals on synovial fluid analysis is correct because arthrocentesis should always be done when acute gout is suspected. The first attack of acute gout, as in this scenario, mimics acute monoarthritis or septic arthritis, and therefore, arthrocentesis is necessary. Chalky, cloudy fluid, 10-10,000 /mm3 white cells, <50% polymorphs, and needle-shaped with negative birefringence in the synovial fluid confirms the diagnosis of acute gout.

Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) is incorrect because although they are both raised in acute gout, they are markers of inflammation and can be raised in any inflammatory condition other than acute gout.

Elevated serum uric acid level is incorrect because hyperuricemia may be present without gout. The uric acid levels are always raised in acute gout, but there are several conditions causing hyperuricemia, like diuretics, alcohol, hypothyroidism, and acute kidney injury.

Bone erosions on plain radiograph is incorrect because plain radiograph shows no acute change. Characteristic erosions can be seen on an x-ray with long-standing gout, but acute modifications cannot be visualized.

Elevated 24-hour urinary uric acid is incorrect because it helps determine therapy for long-standing gout. It does not help in the diagnosis of acute gout.

Non-steroidal anti-inflammatory drugs (NSAIDs) is correct because the scenario describes a patient with plantar fasciitis. Foot pain that is worse in the morning and on climbing upstairs strongly suggests this diagnosis. Plain radiographs are inconclusive and sometimes show calcaneal spur, which is misleading. Plantar fasciitis treatment usually includes pain relief and conservative measures, and 90% of patients respond this way. NSAIDs, heel and arch support, and physiotherapy are the basis of treatment for plantar fasciitis.

Fasciotomy is incorrect because it is required in plantar fasciitis only when conservative treatment is given for a long time and the pain does not respond to it.

Extracorporeal shockwave therapy is incorrect because it is done if the patient does not respond to conservative treatment for 6 months. The results of extracorporeal shockwave therapy are promising.

Local corticosteroid injection is incorrect because it provides short-term benefits but carries a risk of atrophy of the fat pad and rupture of the plantar fascia.

Platelet-rich plasma is incorrect because it is used only for pain control if non-steroidal anti-inflammatory drugs and conservative measures fail.

De Quervain tenosynovitis is the correct option. It is an entrapment tendinitis that causes pain during thumb motion. This patient is a daycare worker and repetitively picks up babies resulting in friction tendinitis. The Finkelstein test is used clinically to reproduce the pain and confirm the diagnosis.

Herpetic whitlow is incorrect because it is a severe infection of the fingers caused by the herpes simplex virus. Examination reveals vesicles or ulcers with surrounding erythema.

Cheiralgia paresthetica is incorrect because it is a neuropathy of the superficial radial nerve at the wrist. Although it also causes pain and burning, the pain is not associated with the movement of the hand or fingers.

Kienböck disease is incorrect because it is associated with avascular necrosis of lunate. Patients experience wrist pain, swelling, and decreased range of motion of the wrist. It is rarely bilateral, making it an unlikely diagnosis.

Add long-acting beta-agonists (LABAs) is the correct option. This patient has presented with poor control of asthma, as evidenced by her nocturnal symptoms and exercise-induced wheeze. Adding a long-acting beta-agonist to her low-dose inhaled corticosteroids will provide bronchodilation for 12 hours and better control her symptoms. Besides, counseling regarding the management of environmental factors or allergens that trigger her asthma should be done.

Modified release theophylline is an incorrect option because although it provides mild bronchodilation, improved mucociliary clearance of secretions, and anti-inflammatory effects, it has a narrow therapeutic index. It may cause toxicity, and serum levels need to be closely monitored.

Short course of oral corticosteroids is incorrect because it has been used in acute asthma exacerbations. She should proceed to step 3 of the management ladder.

Add short-acting beta-agonists (SABA) twice daily is an incorrect option because daily use is not recommended. Moreover, increased use of short-acting beta-agonists in patients indicates poor asthma control.

Add omalizumab is an incorrect option because it’s a recombinant antibody that binds to IgE. It’s offered to patients with peripheral blood eosinophilia and severe asthma who do not respond to high-dose inhaled steroids and long-acting beta-agonists.

Cystic fibrosis is the correct option. These patients present with recurrent childhood infections, malabsorption, hypoproteinemia, and ultimately develop bronchiectasis. Men are often infertile because of obstructive azoospermia. There is the congenital absence of the vas deferens, but assisted fertility is possible. Sweat chloride test and nasal transepithelial potential difference are the diagnostic tests of choice. Treatment is supportive.

Bronchiectasis is an incorrect option because although this patient has coarse crepitations with clubbing, azoospermia cannot be explained by diagnosing bronchiectasis alone.

Pulmonary fibrosis is an incorrect option because although these patients also present with shortness of breath and clubbing, chest auscultation reveals fine crepitations. Moreover, idiopathic pulmonary fibrosis is a disease of the elderly.

Primary ciliary dyskinesia (PCD) is an incorrect option because although these patients also have recurrent infections and infertility due to abnormal movement of the cilia, the sperm count is normal. The sperms are immotile due to impaired ciliary function.

Yellow nail syndrome is incorrect because it is characterized by excessively curved yellow nails, bronchiectasis, and pleural effusions.

Stress fracture is correct. It is common among ballet dancers, athletes, and military personnel. Stress fractures are caused by overuse injury and represent over 10% of sports-related injuries. Around 90% of such injuries are located in the lower limb.

Morton neuroma is a degenerative neuropathy of the interdigital nerve in the forefoot. It is caused by compression and irritation at the level of the transverse intermetatarsal ligament. Symptoms include forefoot pain that worsens with weight-bearing and palpation in the affected space.

Interdigital neuritis is also known as Morton neuroma, a degenerative neuropathy of the interdigital nerve in the forefoot. It mainly affects middle-aged women and is associated with chronic repetitive trauma and ischemia.

Tarsal tunnel syndrome is an entrapment neuropathy due to compression of the structures within the tarsal tunnel, particularly the posterior tibial nerve.

Tibialis posterior tendinopathy is the most common cause of adult-acquired pes planus deformity. Patients will complain of lowly progressive foot deformity associated with medial foot pain and weakness.

Give the patient acetaminophen is correct. This patient presents with degenerative joint disease reflective of pain in weight-bearing joints and distal and proximal interphalangeal joints. Her symptoms worsen with physical activity, and the physical examination is noted for joint crepitations and Heberden nodes. Joint space narrowing on radiographs suggests osteoarthritis. The initial management is weight loss and exercise. In addition to changes in her lifestyle, acetaminophen is recommended for her pain control.

Start the patient on triamcinolone acetonide is incorrect. Triamcinolone acetonide is a glucocorticoid used to relieve acute inflammatory conditions like gout and pseudogout, both of which are caused by crystal deposition. This glucocorticoid can be used in the management of osteoarthritis via intraarticular injections if the patient fails to respond to analgesics.

Start the patient on chondroitin sulfate is incorrect. Chondroitin sulfate is a glycosaminoglycan that is used as a supplement in the treatment of osteoarthritis. It has not been found effective for this degenerative joint disorder.

Perform a joint replacement is incorrect. Joint replacement surgery is the procedure that replaces a severely affected joint due to osteoarthritis. This patient does not have a severely affected joint for which joint replacement can be offered.

Start the patient on allopurinol is incorrect. Allopurinol is a xanthine oxidase inhibitor that is used in the management of chronic gout.

Contact the hospital chief of staff and report his concerns immediately is correct. While the subsequent reporting of the physician and assessment may come down the road, the immediate issue is one of patient safety.

Report his concerns to state authorities on Monday is not correct. Immediate action is required to avoid harm to patients. In addition, it is not clear if this is a single incident or an ongoing issue. Before reporting, assessment would be necessary.

Take his colleague aside later and discuss his concerns with her is not correct. Immediate action is required to avoid harm to patients. In addition, it is not clear if this is a single incident or an ongoing issue. Before reporting, assessment would be necessary.

No obligation to intervene is not correct. As physicians we are obligated to first do no harm to patients. Allowing an impaired physician to engage in patient care is not acceptable.

Obtain a breathalyzer to estimate blood alcohol content, is incorrect. There is no role for diagnosis. The concern for the colleague is clear based on physical signs of intoxication. Having it demonstrated by breathalyzer does nothing to prevent the physician from going to the hospital and engaging in patient care.

Systemic sclerosis is the correct answer. It is an autoimmune disease characterized by systemic fibrosis. Internal organ involvement is common and causes significant morbidity and mortality. Patients can present with various symptoms, including symmetric skin induration, sclerodactyly, Raynaud phenomenon, digital infarction, heartburn, dysphagia, dyspnea on exertion, and/or mucocutaneous telangiectasia.

Systemic lupus erythematosus (SLE) is an incorrect answer. The diagnosis of SLE is based on the presence of at least 4 of the 11 known systemic manifestations, including symptoms of rash, arthritis, serositis, renal involvement, neurological involvement in the form of psychosis, hemolytic anemia, positive anti-dsDNA, and positive antinuclear antibody (ANA). As this patient does not have 4 of the 11 symptoms, SLE is an unlikely diagnosis.

Behcet disease is an incorrect answer. It presents with aphthous ulcers, arthralgia, and uveitis. As these symptoms are not present in this patient, Behcet disease is an unlikely diagnosis.

Rheumatoid arthritis is an incorrect answer. It presents with pain in smaller joints, often in symmetrical patterns. Other symptoms include fever, weight loss, anemia, and eye involvement as scleritis or keratoconjunctivitis sicca. It presents with pain and morning stiffness that progressively worsens over time. The erythrocyte sedimentation rate (ESR) is elevated, and rheumatoid factor (RF) will be positive, making this an unlikely diagnosis.

CREST (calcinosis, Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasias) syndrome is an incorrect answer. It stands for calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. There is no lung, kidney, and heart involvement. Anti-centromere is specific for CREST syndrome, making this an unlikely diagnosis in this patient.

Toxic shock syndrome (TSS) is an unfortunate complication in postpartum patients. Patients present with fever, hypotension, and organ dysfunction, as well as diffuse erythroderma, often followed by desquamation. Historically, group A streptococcus was the most common etiological agent. However, staphylococcal TSS syndrome also occurs. Staphylococcal infections were the more common cause during the outbreak associated with super-absorbent tampons. One of the most common presentations of TSS is in the post-operative setting as well as after childbirth. Clinical criteria include fever, diffuse macular erythroderma with desquamation, hypotension, and multisystem involvement (three or more of the following: gastrointestinal, muscular, mucous membrane, renal, hepatic, or hematologic). Laboratory criteria for the diagnosis would be negative blood or cerebrospinal fluid cultures for organisms not responsible for TSS as well as negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles.

Measles is incorrect. Patients at risk for measles will have one or more of the following:

1) never vaccinated; 2) older individuals with no recent titers; 3) immunocompromised; and/or 4) potential exposure to another infected patient.

Measles infections present with fever, headache, cough, coryza, and conjunctivitis, as well as maculopapular rash that begins cranially and extends thereafter.

Rocky Mountain spotted fever (RMSF) typically presents in patients with recent outdoor exposure. Patients initially present with mild symptoms; however, symptoms rapidly progress in severity.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome usually presents with fever, rash, and organ dysfunction, as well as peripheral eosinophilia, which is absent in this patient.

Stevens-Johnson syndrome (SJS) is associated with flu-like syndrome and a diffuse rash with blisters that involves oral and genital mucosa often after exposure to a new medication (although also associated with infections including HSV and Mycoplasma pneumoniae). Patients with SJS may present with sepsis secondary to absence of mucosal barriers, as well as hypotension secondary to fluid losses.

Yergason test evaluates the biceps tendon. To administer this test, have the patient flex the affected elbow to 90°, pointing the thumb upwards. The examiner then grasps the affected side’s wrist, applying resistance to the patient’s actively supinating, and flexing the arm at the elbow. Elicited pain with the Yergason maneuver indicates biceps tendonitis.

Hawkins test is when the examiner places the patient’s arm shoulder in 90° of shoulder flexion with the elbow flexed to 90° and then internally rotates the arm. The test is considered positive for subacromial impingement and rotator cuff tendonitis if the patient experiences pain with internal rotation– sensitivity is 90%.

Neer’s test is performed by placing the arm in forced flexion with the arm fully pronated. Stabilize the shoulder blade (scapula) during this maneuver to prevent scapulothoracic motion, which would falsely weaken this test. Elicited pain with this test correlates well with subacromial impingement.

Drop arm test is asking the patient to slowly lower the affected arm from horizontal down to the waist. With a rotator cuff tear, the patient will drop the arm as it is lowered.

Apley scratch test is when the patient attempts touching the opposite scapula, resulting in obvious decreased range of motion in the context of a rotator cuff injury.

Repeat dexamethasone dose and administer nebulized epinephrine and oxygen and observe longer is correct as an observation post-treatment is recommended and if no improvement then admission to the hospital.

Repeat Dexamethasone dose and discharge home with precaution is incorrect as despite a repeat dexamethasone dose, administering nebulized epinephrine and administering oxygen is the correct management, the child needs to be observed to confirm improvement before discharging home.

Administer nebulized epinephrine and discharge with precautions is incorrect as despite a repeat dexamethasone dose, administering nebulized epinephrine and administering oxygen is the correct management, the child needs to be observed to confirm improvement before discharging home.

Administer oxygen and repeated dose of dexamethasone and discharge home is incorrect as despite a repeat dexamethasone dose, administering nebulized epinephrine and administering oxygen is the correct management, the child needs to be observed to confirm improvement before discharging home.

May discharge home now with precautions as the benefits of the dexamethasone dose can be delayed is incorrect as a 4 hours observation is a sufficient time to see improvement post dexamethasone dose. Viral croup starts like a respiratory tract infection, with coryza and low-grade fever, barking cough, stridor, respiratory retractions, and nasal flaring. Symptoms normally resolve quickly, but might be worse at night, and when the child is crying. Croup has a low mortality rate and in general is a benign condition that does not lead to high-grade fever or sick child. And in general, does not happen in children less than 3 months. 1% to 8% of children with croup get admitted to the hospital.

Azithromycin is correct as this patient is healthy and did not present with signs of severity and the optimal treatment would be an outpatient management with macrolides or doxycycline.

Clindamycin is incorrect as this is not the drug of choice for community-acquired pneumonia (CAP).

Levofloxacin and Azithromycin is incorrect as these are are more recommended for patients who require admission or had a recent antibiotics course.

Amoxicillin is incorrect as this is not the drug of choice for community-acquired pneumonia (CAP).

Piperacillin/Tazobactam is incorrect as these are are more recommended for patients who require admission or had a recent antibiotics course.

Shingles vaccination is recommended for all elders over age 65 to reduce the risk and severity of shingles and postherpetic neuralgia.

Repeat colonoscopy is incorrect. Based on this patient’s prior colonoscopy results, his next scheduled colonoscopy should occur when he turns 88, though the utility of a screening colonoscopy at that age could be debated.

Repeat pneumonia vaccine is incorrect. The United States Preventive Services Task Force recommends the pneumonia vaccine be administered once after age 65 with no boosters.

Screened for osteoporosis with a DEXA scan is incorrect. There are no recommendations for screening for osteoporosis in men, though it may be considered in individuals who may have risk factors for the development of osteoporosis (including chronic use of steroids, anticonvulsants, or presence of chronic illnesses that may contribute to osteoporosis risk including hypogonadism, vitamin D deficiency, thyroid disease). This patient does not have any risk factors, nor are there any reports of height loss which might suggest clinical osteoporosis.

Abdominal ultrasound to screen for abdominal aortic aneurysm is recommended for men aged 65-75, who currently or have ever smoked. This patient does not have a smoking history and is not actively smoking.

Retroperitoneal ultrasound is correct. The electrocardiogram and troponin are improved, there is no chest pain, and no findings of left-sided heart failure. A dreaded complication of femoral vascular access is retroperitoneal bleeding. This may occur suddenly with large volume shifts that may not be initially apparent in lab work (e.g., a complete blood count). Retroperitoneal imaging is indicated, usually by ultrasound (the choice here) or computed tomographic (CT) scanning.

Right heart catheterization would better define the hemodynamics, but not necessarily the etiology of the hypotension, and would be an invasive procedure that might otherwise delay a diagnostic test.

Ventilation/perfusion nuclear scan (VQ scan) is incorrect. While pulmonary embolism should always be considered, he has been on triple anticoagulants and there are no suggestive findings, hence a ventilation-perfusion (V/Q) scan would be less useful.

Repeat coronary catheterization is not needed. Given the dearth of post-MI findings, consideration must be given to other causes.

Transesophageal echocardiography determined left ventricular function, and no other complications of myocardial infarction were described. A transesophageal echo would not be likely to add significant information.

Recommend ferrous gluconate is correct. In iron deficiency anemia, iron is given to correct and replenish iron stores while treating the possible underlying cause. Ferrous sulfate is the best treatment for iron deficiency anemia and contains 66 mg of iron in each 325 mg tablet.

Administer iron dextran is incorrect. Parenteral iron may result in hypersensitivity reactions and is not the next best step. Parenteral iron is given when iron requirements are high (GI bleeding, chronic hemodialysis, erythropoietin [EPO] therapy, etc.) or if patients are unable to absorb iron PO (celiac disease, small bowel resection, IBD, etc.).

Prescribe desferrioxamine is incorrect because chelates removes iron.

Recommend taking ferrous sulfate with ascorbic acid is incorrect because, although ascorbic acid augments iron absorption, it may increase gastrointestinal side effects.

Administer erythropoietin (EPO) is incorrect as EPO therapy will worsen iron deficiency because it increases iron requirements.

Normal saline is correct. This man shows evidence of significant intravascular volume depletion with a low blood pressure, acute kidney injury, and an absence of edema. The volume depletion is a result of osmotic diuresis due to uncontrolled diabetes mellitus, resulting in the syndrome of hyperosmolar nonketotic hyperglycemic state. Serum osmolality is very high, but almost exclusively as a result of severe hyperglycemia. Therefore, the corrected serum Na is approximately 154 meq/L, slightly high but not sufficiently high to produce altered mental status.

Lactated Ringer’s is isotonic but has a fairly significant base load. His serum bicarbonate is already the upper limit of normal, suggesting he does not require bicarbonate replacement.

1/2 normal saline is incorrect because his very low blood pressure suggests that he would benefit from volume repletion in the form of isotonic fluid.

1/4 normal saline is incorrect because his very low blood pressure suggests that he would benefit from volume repletion in the form of isotonic fluid.

3% saline is incorrect because, although his serum Na is low, he has pseudohyponatremia. His corrected serum Na is elevated; therefore, 3% saline would not be appropriate.

Start prednisone at 60 mg daily is correct. This woman presents with new onset headaches, fevers, weight loss, hip/shoulder girdle pain, and an elevated ESR. This constellation of findings is typical for temporal arteritis. When the pretest probability for the disease is high, corticosteroids should be started immediately, even before a pathologic diagnosis is made. Therefore, this patient should be started on prednisone.

Obtain a temporal artery Doppler ultrasound is incorrect. The data on the utility of ultrasound is conflicting, so the test is not recommended at this time.

Refer for a temporal artery biopsy is incorrect. Ultimately, a temporal artery biopsy should be obtained, but the specimen should not be significantly affected by the steroids as long as the biopsy is done within 3 to 4 weeks.

Obtain a computed tomographic (CT) scan of the head is incorrect because it would be of no utility at this time.

Refer for temporal artery stent placement is generally not indicated since the temporal arteries develop an extensive network of collateral vessels. Controlling the inflammation should be the focus of treatment.

Acute bacterial pyelonephritis is consistent with her clinical picture (fever, flank pain, elevated WBC).

Struvite stones occur in individuals who have recurrent infections with urea-splitting organisms such as proteus, not E. coli.

Medullary sponge kidney will present in a similar demographic of young and middle-aged women, but with kidney stones, as well as hematuria and urinary tract infection.

Uncomplicated urinary tract infection is incorrect as the patient’s symptoms do not indicate this disease.

Acute interstitial nephritis can occur with antibiotic therapy, but the urinalysis would show eosinophils and no bacteria.

Inhaled oxygen is correct. It is the standard treatment for an acute cluster headache among the options listed here and can be prescribed for home use.

Calcium channel blockers is incorrect. They are frequently prescribed but do not act quickly.

Lithium is incorrect and also useful for cluster headaches but is not the fastest acting.

Beta-blockers is incorrect. They can be helpful in prevention. Side effects include dizziness, fatigue, and depression.

Corticosteroids is incorrect. They are also useful but have significant morbidity if used long-term.

Central retinal artery occlusion is the correct answer because it occurs due to blockage of the central retinal artery, most commonly due to thrombi, embolism, or inflammation, resulting in retinal ischemia and decreased visual acuity. The findings of a pale retina and a cherry-red spot are diagnostic for CRAO.

Acute angle-closure glaucoma is incorrect because it includes symptoms of an extremely painful red eye with raised intraocular pressure and blurred vision.

Central retinal vein occlusion is an incorrect option. Although it is another cause of painless loss of vision, the fundoscopic examination will reveal an engorged venous supply along with several dot-and-blot retinal hemorrhages.

Vitreous hemorrhage is incorrect because even though it causes painless loss of vision, especially if there is a massive hemorrhage, it involves rupture of the retinal vessels and leakage resulting in clots and a hazy vitreous on examination

Retinal detachment is incorrect because it causes a sudden loss of vision especially if it involves the macular area and physical examination will show tears between the layers of the retina along with fluid accumulation. It is usually preceded by flashing lights and spots in vision.

Topical antihistamines is correct because, along with avoidance of environmental allergens (mold spores, dust mites, animal dander), it is the mainstay of treatment.

Topical antibiotics is incorrect because these drops are used for bacterial conjunctivitis, including purulent discharge and eyelid matting.

Topical beta-blockers is incorrect because beta-blockers are used in emergency conditions such as acute angle-closure glaucoma to reduce and control the intraocular pressure

Topical mydriatics is incorrect because these drops are used in conditions such as anterior uveitis to reduce ciliary spasms and relieve pain.

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) is incorrect because even though topical NSAIDs can be used to reduce inflammation and itching in allergic conjunctivitis, it is not the most effective treatment.

Vestibular neuritis is the correct answer because it causes peripheral vertigo and is preceded by a viral upper respiratory tract infection resulting in inflammation of the vestibular nerves. The vertigo is severe, lasting for days, with no associated hearing loss or tinnitus. Since the vertigo lasts for days, this differentiates it from other disorders such as Meniere’s disease. The symptoms, although severe, run a benign course and may either resolve after days or persist for months.

Labyrinthitis is the incorrect answer because it involves hearing loss and vertigo due to inflammation of the labyrinths following effusion of the middle ear.

Meniere’s disease is incorrect because vertigo lasts for a few hours, not days, and it is associated with fullness of the ear, hearing loss, and tinnitus.

Benign paroxysmal positional vertigo (BPPV) is an incorrect answer because BPPV causes vertigo due to movements such as lying down or bending over, lasting for a few seconds with no history of hearing loss or tinnitus.

Vestibular migraine is incorrect because it is a central cause of vertigo and is associated with migraine symptoms such as aura and photophobia.

Mild persistent asthma is the correct option because, in mild persistent asthma, the symptoms are present >2 times a week during the day, and nighttime symptoms appear >2 times a month. In this type of asthma, the forced expiratory volume in one second (FEV1) remains 80%, and the predicted peak expiratory flow (PEF) variability is between 20-30%.

Mild intermittent asthma is an incorrect option because, in mild intermittent asthma, the symptoms are present <2 times a week, forced expiratory volume in 1 second (FEV1) is 80%, and predicted peak expiratory flow (PEF) variability is <20%. Moderate persistent asthma is an incorrect option because in moderate persistent asthma, the symptoms are persistent daily, and night symptoms appear >1 time a week. In this type of asthma, the forced expiratory volume in 1 second (FEV1) is >60% and <80%, and predicted peak expiratory flow (PEF) variability is >30%.

Severe persistent asthma is an incorrect option because, in severe persistent asthma, there is the presence of continuous symptoms of dyspnea and cough, and forced expiratory volume in 1 second (FEV1) is <60%, and predicted peak expiratory flow (PEF) variability is >30%.

Chronic bronchitis is an incorrect option because, in chronic obstructive pulmonary disease (COPD), there is a productive cough for 3 months for 2 consecutive years.

Benign paroxysmal positional vertigo is the correct option. It is associated with positional changes; the patient?s symptoms are triggered when she rolls in her bed, so the diagnosis is most likely benign paroxysmal positional vertigo. Epley maneuver is useful in managing symptoms of BPPV.

Labyrinthitis is an incorrect option because an infectious agent triggers it, so there should be a history of the previous infection. It is always associated with hearing loss and tinnitus.

Meniere’s disease is incorrect because it is not associated with positional changes, whereas the patients symptoms are associated with positional changes. Moreover, these patients have a history of fullness in their ears and hearing loss.

Herpes zoster oticus is an incorrect option because it presents with otalgia, vesicles in the ear, and paralysis.

Cerebellar hemorrhage is incorrect because although patients may present with vertigo, they also have incoordination, impaired heel shin test, and other cerebellar signs.

Topical antihistamines is correct as they help in reducing the allergic response and reduce symptoms like itching and congestion in allergic conjunctivitis. Histamine is a major modulator of allergic responses. Mast cell stabilizers and topical steroids(for severe cases) may also be used in conjunction. Systemic antihistamines may unmask overt disease by causing a reduction in the tear film.

Topical antibiotics is incorrect because the given scenario shows allergic conjunctivitis, and these drugs are used in active bacterial infections like conjunctivitis, keratitis, etc.

Topical antivirals is incorrect. These drugs have very limited indications for eye disorders, including herpetic cornea infections.

Topical atropine is incorrect because it has no role in allergic conjunctivitis. It may be used in iritis to prevent synechiae formation and before ophthalmologic examinations for a proper view of the eye’s posterior chamber.

Topical antifungals is incorrect. These drugs are used for fungal corneal ulcers, which present with blurring of vision, corneal opacities, and a prior history of immunosuppression or trauma by vegetative bodies.

Compression wrapping is the correct response because the patient presented with an isolated medial collateral ligament (MCL) tear in this scenario, where conservative management such as ice and a compression wrap is recommended to control the initial swelling.

Aspiration is incorrect because the presence of effusion in the affected joint is ruled out by imaging in this patient suffering from an MCL tear.

Hinged knee bracing locked in flexion is incorrect because this patient suffers from an isolated MCL tear, requiring a hinged knee brace locked in extension rather than flexion.

Surgical fixation is incorrect because the patient suffers from an isolated MCL tear for which surgical intervention is employed only once conservative management fails.

Intra-articular hyaluronic acid injection is incorrect because the patient does not suffer from osteoarthritis (OA) as revealed by imaging studies and does not require intra-articular hyaluronic acid injection, indicated for the management of OA.

Colchicine administration because the features of arthritis in a patient with suspected Behcet’s disease can be adequately managed using colchicine.

Allopurinol administration is incorrect because the patient has presented with features suggestive of Behcet’s disease rather than gout; allopurinol can be used to manage gout.

Surgery is incorrect because surgical intervention is only indicated in cases of Behcet’s disease with extensive vascular involvement that is refractory to medical management.

Acyclovir administration is incorrect because this patient most likely suffers from Behcet’s disease, while a viral etiology of the clinical features has been ruled out.

Morphine administration is incorrect because the patient presenting with the features of Behcet’s disease requires NSAIDs and corticosteroids for symptomatic relief rather than direct administration of opioids.

Anterior drawer test is correct because it is used to diagnose anterior cruciate ligament (ACL) injury. It is performed by making the patient lie supine with the knee flexed to 90° and the hip flexed to 45 degrees. The doctor sits on the patient’s foot and stabilizes the relaxed leg, holds the plateau of the tibia with both thumbs at the level of the tibial tubercle, and applies a force in an anterior direction.

Talar tilt test is incorrect because it is used to assess for ankle ligament sprains.

Posterior drawer test is incorrect because it checks for any posterior cruciate ligament injuries by assessing the posterior translation of the tibia.

Valgus test is incorrect because it is used to assess for medial collateral ligament injuries.

Varus test is incorrect because it is used to assess for lateral collateral injuries.

24-hour urine collection for metanephrines, vanillylmandelic acid (VMA), and catecholamines is the correct answer. This question stem describes a patient with a pheochromocytoma, a rare tumor developing from the chromaffin tissue of the adrenal gland. The diagnostic testing is a 24-hour urine collection for metanephrines, vanillylmandelic acid (VMA), and catecholamines, and a computed tomographic (CT) scan of the adrenal glands. A 24-hour urine collection for metanephrines, vanillylmandelic acid (VMA), and catecholamines is the screening test for a pheochromocytoma.

24-hour urine collection for aldosterone is incorrect because it is used to look for hyperaldosteronism, which is unlikely with someone with normal potassium (normal chemistry panel) and such malignant hypertension.

Captopril renogram is incorrect because it is a screening test for renovascular hypertension, which is unlikely in the patient with normal potassium, no abdominal bruit, and such malignant hypertension.

Renal artery ultrasound is incorrect, as it is a screening test for renovascular hypertension. This is unlikely in a patient with a normal potassium (normal chemistry panel), such malignant hypertension, and no abdominal bruit.

Echocardiogram is incorrect, as getting an echocardiogram would not help determine the etiology of her malignant hypertension. It would show the downstream effects (left ventricular hypertrophy) but not the etiology.

Cardiac surgery is the correct answer. This question describes a patient with acute mitral regurgitation (MR) secondary to infectious endocarditis. Acute MR is a medical and surgical emergency, especially when the patient presents with acute pulmonary edema and cardiogenic shock such as the one in the question stem. The definitive treatment is surgical intervention. The patient needs cardiac surgery to repair the mitral valve.

IV antibiotics is incorrect as antibiotics will help treat the infection but will not fix the insufficient valve and the cardiogenic shock with pulmonary edema. The patient needs surgery.

IV nitroprusside is an incorrect answer because it is a supportive measure until surgery can be done.

IV dobutamine is incorrect because it is a supportive measure until surgery can be done.

Intraaortic balloon pump is incorrect, as it is a supportive measure until surgery can be done.