Clinical Reasoning — MCQs

Q: A 50-year-old woman presents with severe abdominal pain. Past medical history is significant for a peptic ulcer. Physical examination is limited because the patient will not allow abdominal palpation due to the pain. The attending makes a presumptive diagnosis of peritonitis. Which of the following non-invasive maneuvers would be most helpful in confirming the diagnosis of peritonitis in this patient?

Forced cough elicits abdominal pain. ***Forced cough elicits abdominal pain*** - A forced cough increases **intra-abdominal pressure**, which in turn stretches the inflamed peritoneum. - Elicitation of pain with coughing is a highly sensitive and specific sign for **peritoneal irritation** and helps confirm the diagnosis of peritonitis. *Rectal examination shows guaiac positive stool* - **Guaiac positive stool** indicates the presence of blood in the stool, which is a sign of gastrointestinal bleeding. - While a peptic ulcer can cause bleeding, this finding does not directly confirm **peritonitis** or peritoneal inflammation. *Hyperactive bowel sounds are heard on auscultation* - **Hyperactive bowel sounds** are often associated with conditions like gastroenteritis or partial bowel obstruction. - In peritonitis, bowel sounds are typically diminished or absent due to **ileus**, not hyperactive. *Bowel sounds are absent on auscultation* - While **absent bowel sounds** can be a sign of peritonitis due to paralytic ileus, this finding is not as specific or immediately helpful as eliciting pain with coughing in confirming the primary diagnosis in a patient already presumed to have peritonitis. - The absence of bowel sounds can also be seen in other conditions and may take longer to develop consistently. *Pain is aroused with gentle intensity/pressure at the costovertebral angle* - Pain at the **costovertebral angle (CVA)** typically indicates inflammation of the kidney or surrounding structures, such as in pyelonephritis. - This finding is specific to **renal pathology** and not directly related to generalized peritonitis.

Q: A 45-year-old man comes to the physician because of a 6-month history of a slowly enlarging nodule on the left upper eyelid that has persisted despite treatment with warm compresses. He also reports heaviness of the eyelid and mild blurring of vision in the left eye. Vital signs are within normal limits. Visual acuity is decreased in the left eye. Ophthalmic examination shows a solitary, rubbery, nontender nodule on the central portion of the left upper eyelid. The lesion is better seen on eversion of the left eyelid. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

Biopsy. ***Biopsy*** * The **persistence** of the eyelid nodule for 6 months despite warm compresses, along with its **atypical presentation** (solitary, rubbery, nontender), raises concern for **malignancy**, such as sebaceous cell carcinoma. * A biopsy is essential to obtain a **histopathological diagnosis** to differentiate between benign lesions (e.g., chalazion) and malignancy, guiding subsequent appropriate management. *Local tetracycline* * **Tetracycline** is an antibiotic and would be used for **bacterial infections** like a bacterial hordeolum (stye), which typically presents with acute pain and redness, unlike this chronic, painless nodule. * While some topical antibiotics may have mild anti-inflammatory properties, they are not indicated for **chronic, non-infectious nodules** that have already failed conservative measures. *Mohs micrographic surgery* * **Mohs surgery** is a specialized procedure for skin cancers with high cure rates, particularly for difficult-to-treat or recurrent lesions, but it is a **treatment** and not a diagnostic step. * It would be considered *after* a definitive diagnosis of malignancy has been established through a biopsy. *Cryotherapy* * **Cryotherapy** uses extreme cold to destroy abnormal tissue and is a treatment modality, not a diagnostic one. * It is typically used for certain **benign or superficial malignant lesions**, but a diagnosis must first be confirmed via biopsy to ensure appropriate treatment selection. *Eyelid hygiene* * **Eyelid hygiene** (e.g., warm compresses, gentle scrubbing) is appropriate for chronic inflammatory conditions like **blepharitis** or initial management of a **chalazion** or **hordeolum**. * Since the nodule has persisted for 6 months despite warm compresses, it indicates that routine eyelid hygiene is insufficient and a more definitive diagnostic and therapeutic approach is needed.

Q: A 19-year-old woman presents to the family medicine clinic for evaluation of a sore throat. The patient states that she does not have a runny nose, cough or itchy throat. The patient has no past medical history but she did have an appendectomy when she was 8 years old. She takes acetaminophen when she gets a headache and does not smoke cigarettes. Her vitals include: blood pressure 112/68 mm Hg, heart rate 72/min, respiratory rate 10/min and temperature 39.2°C (102.6°F). Physical examination reveals a patient who is uncomfortable but alert and oriented. Upon palpation, the physician notices swollen anterior cervical nodes. Inspection of the pharynx and tonsils does not reveal any erythema or exudate. Which of the following is the most appropriate next step for this patient?

Rapid strep test. ***Rapid strep test*** - The patient exhibits several Centor criteria: **fever (>100.4°F)**, **tender anterior cervical lymphadenopathy**, and **absence of cough**, making **Group A Streptococcus (GAS) pharyngitis** a strong possibility. - A rapid strep test is the most appropriate initial diagnostic step to quickly confirm or rule out GAS infection due to the high index of suspicion. *Strep culture* - While a **strep culture** is the **gold standard** for diagnosing GAS pharyngitis, it takes **24-48 hours** for results, which delays treatment and increases the risk of complications if the rapid strep test is negative but GAS is still suspected. - It is typically reserved for cases where the rapid strep test is negative but clinical suspicion remains very high, or if there is a concern for false-negative rapid strep results. *Symptomatic treatment* - Providing **symptomatic treatment alone** without ruling out GAS pharyngitis could lead to complications such as **acute rheumatic fever** or **post-streptococcal glomerulonephritis**. - While supportive care is important, it should not be the sole intervention when strep throat is highly suspected. *Antibiotics* - Prescribing **antibiotics empirically** without confirming GAS infection can contribute to **antibiotic resistance** and expose the patient to unnecessary side effects. - Antibiotics are appropriate only after a positive diagnostic test for GAS pharyngitis. *Ultrasound of neck* - An **ultrasound of the neck** is not indicated at this stage as there is no suspicion of an abscess or other structural issues. - The patient's symptoms are consistent with an infectious process, not a mass or fluid collection requiring imaging at this point.

Q: A 39-year-old man comes to the physician for evaluation of hearing loss. He reports difficulty hearing sounds like the beeping of the microwave or birds chirping, but can easily hear the pipe organ at church. He works as an aircraft marshaller. A Rinne test shows air conduction greater than bone conduction bilaterally. A Weber test does not lateralize. Which of the following is the most likely underlying cause of this patient's condition?

Destruction of the organ of Corti. ***Destruction of the organ of Corti*** - This patient's **selective hearing loss** (difficulty with high-pitched sounds like chirping and beeping, but normal hearing for low-pitched sounds like an organ) combined with his occupation as an **aircraft marshaller** strongly suggests **noise-induced hearing loss**. - **Noise-induced hearing loss** primarily damages the **hair cells** in the **organ of Corti**, particularly those sensitive to high frequencies, leading to a **sensorineural hearing loss**. *Excess endolymphatic fluid pressure* - This is characteristic of **Ménière's disease**, which typically presents with a triad of **fluctuating sensorineural hearing loss**, **tinnitus**, and **vertigo**. - The patient's symptoms do not include vertigo or tinnitus, and his hearing loss pattern is more suggestive of noise exposure rather than endolymphatic hydrops. *Immobility of the stapes* - This suggests **otosclerosis**, a cause of **conductive hearing loss**. - In conductive hearing loss, the **Rinne test** would typically show **bone conduction greater than air conduction (BC>AC)** in the affected ear, which contradicts the given finding of air conduction greater than bone conduction bilaterally. *Perforation of the tympanic membrane* - A **perforated tympanic membrane** causes **conductive hearing loss**. - Similar to immobility of the stapes, this would result in **BC>AC** on the Rinne test, which is not what is observed in this patient. *Compression of the vestibulocochlear nerve* - This could be caused by an **acoustic neuroma** (vestibular schwannoma), which typically presents with **unilateral progressive sensorineural hearing loss**, **tinnitus**, and balance issues. - The patient's symptoms describe a **bilateral hearing loss** pattern consistent with chronic noise exposure rather than a unilateral nerve compression.

Q: A 33-year-old woman presents to her primary care physician complaining of right jaw pain for the last 3 weeks. She first noticed it while eating a steak dinner but generally feels that it is worse in the morning. She describes the pain as deep and dull, with occasional radiation to the ear and back of her neck. She denies any incidents of jaw locking. The patient also states that her husband has noticed her grinding her teeth in her sleep in the last several months. She has a past medical history of depression, for which she takes fluoxetine, and carpal tunnel syndrome, for which she uses a wrist brace. The patient works as a secretary. Her father passed away from coronary artery disease at the age of 54, and her mother has rheumatoid arthritis. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 135/81 mmHg, pulse is 70/min, and respirations are 14/min. On exam, there is no overlying skin change on the face, but there is mild tenderness to palpation at the angle of the mandible on the right. Opening and closing of the jaw results in a slight clicking sound. The remainder of the exam is unremarkable. Which of the following is the next best step in management?

Nighttime bite guard. ***Nighttime bite guard*** - The patient's symptoms (jaw pain worse in the morning, grinding teeth at night, tenderness at the angle of the mandible, clicking sound) are highly suggestive of **temporomandibular joint dysfunction (TMD)**, specifically related to **bruxism**. - A nighttime bite guard is a common and effective initial treatment for bruxism-related TMD, helping to reduce clenching and grinding, thereby alleviating symptoms. *Plain radiograph of the jaw* - While imaging might be considered for persistent or atypical symptoms, **plain radiographs are generally not the first-line diagnostic tool** for TMD related to bruxism, as they primarily evaluate bony structures rather than soft tissue or joint dynamics. - The patient's presentation does not suggest a fracture, dislocation, or severe degenerative changes that would necessitate immediate radiography. *Surgical intervention* - Surgical intervention for TMD is typically reserved for **severe cases unresponsive to conservative treatments** or for structural abnormalities requiring repair. - Given this is a new onset of symptoms highly suggestive of bruxism, conservative management is the most appropriate initial approach. *MRI of the brain* - An MRI of the brain would be indicated if there were concerns for neurological causes of facial pain, such as tumors or nerve compression. - The patient's symptoms are localized to the jaw and directly linked to jaw movements and teeth grinding, making a neurological etiology highly unlikely in this context. *Electrocardiogram* - An electrocardiogram (ECG) assesses cardiac activity and is performed to rule out cardiovascular causes of chest pain or systemic symptoms. - The patient's symptoms are clearly localized to jaw pain and are not consistent with cardiac issues, making an ECG irrelevant to the immediate complaint.

Q: A 17-year-old girl presents to an urgent care clinic after waking up in the morning with a left-sided facial droop and an inability to fully close her left eye. Of note, she is currently on oral contraceptives and escitalopram and smokes half a pack of cigarettes per day. Her temperature is 98.2°F (36.8°C), blood pressure is 110/68 mmHg, pulse is 82/min, and respirations are 12/min. On exam, she has generalized, unilateral left-sided drooping of her upper and lower face, and an inability to move the left side of her mouth or close her left eye. Her extraocular movements and swallow are intact. She has no other neurologic deficits. Which of the following interventions would most likely address the most likely cause of this patient's symptoms?

Prednisone alone. **Prednisone alone** - The patient's presentation of **unilateral facial droop**, inability to close the eye, and intact extraocular movements points to **Bell's palsy**, an idiopathic peripheral facial nerve paralysis. - **Corticosteroids like prednisone** are the mainstay of treatment for Bell's palsy, significantly improving the chances of full recovery, especially when started early. *Head CT without contrast* - A head CT is primarily for detecting **central causes of facial weakness** (e.g., stroke, tumor), which would spare the forehead and present with other neurological deficits. - Since the patient has **generalized facial weakness** (affecting both upper and lower face) and no other neurological signs, a central lesion is less likely. *Implantation of gold weight for eyelid* - This is a **surgical intervention** to help with **lagophthalmos** (inability to close the eyelid) and prevent corneal damage. - It is typically considered for **persistent Bell's palsy** or severe cases not responding to medical therapy, not as an initial treatment. *Valacyclovir alone* - **Antiviral agents like valacyclovir** are sometimes used in conjunction with corticosteroids if there's a suspected viral etiology (e.g., herpes simplex virus), but their benefit as monotherapy is not established. - The **evidence for their benefit** even as adjunctive therapy is mixed and less robust than for corticosteroids. *Intravenous immunoglobulin* - **IVIG** is used for various immune-mediated neurological conditions, such as **Guillain-Barré syndrome**. - There is **no evidence** to support the use of IVIG for Bell's palsy.

A 53-year-old man presents with a 2-year-history of dull, nonspecific flank pain that subsides with rest. His past medical history is significant for hypertension, hypercholesterolemia, and type 2 diabetes mellitus. He has no allergies and takes no medications. His father died of kidney disease at the age of 51, and his mother has been treated for ovarian cancer. On presentation, his blood pressure is 168/98 mm Hg, and his heart rate is 102/min. Abdominal examination is significant for palpable bilateral renal masses. His laboratory tests are significant for creatinine of 2.0 mg/dL and a BUN of 22 mg/dL. Which of the following tests is most recommended in this patient?

A 50-year-old woman presents with severe abdominal pain. Past medical history is significant for a peptic ulcer. Physical examination is limited because the patient will not allow abdominal palpation due to the pain. The attending makes a presumptive diagnosis of peritonitis. Which of the following non-invasive maneuvers would be most helpful in confirming the diagnosis of peritonitis in this patient?

A 63-year-old retired teacher presents to his family physician for an annual visit. He has been healthy for most of his life and currently takes no medications, although he has had elevated blood pressure on several visits in the past few years but declined taking any medication. He has no complaints about his health and has been enjoying time with his grandchildren. He has been a smoker for 40 years–ranging from half to 1 pack a day, and he drinks 1 beer daily. On presentation, his blood pressure is 151/98 mm Hg in both arms, heart rate is 89/min, and respiratory rate is 14/min. Physical examination reveals a well-appearing man with no physical abnormalities. A urinalysis is performed and shows microscopic hematuria. Which of the following is the best next step for this patient?

A 73-year-old man comes to the physician because of a 4-kg (9-lb) weight loss over the last month. During this time he has not been able to eat more than one bite without coughing immediately and sometimes he regurgitates food through his nose. His symptoms are worse with liquids. One month ago he had a stroke in the right middle cerebral artery. He has a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications include aspirin, amlodipine, metformin, and simvastatin. Examination of the oropharynx, chest, and abdomen shows no abnormalities. Neurological examination shows facial drooping on the left and decreased strength in the left upper and lower extremities. Which of the following is the most appropriate next step in management?

A 27-year-old woman presents to her primary care physician for minor aches and pains in her bones and muscles. She states that these symptoms have persisted throughout her entire life but have worsened recently when she moved to attend college. The patient is physically active, and states that she eats a balanced diet. She is currently a full-time student and is sexually active with 1 partner. She states that she has been particularly stressed lately studying for final exams and occasionally experiences diarrhea. She has been taking acyclovir for a dermatologic herpes simplex virus infection with minimal improvement. On physical exam, the patient exhibits 4/5 strength in her upper and lower extremities, and diffuse tenderness over her limbs that is non-specific. Laboratory values are ordered as seen below: Serum: Na+: 144 mEq/L Cl-: 102 mEq/L K+: 4.7 mEq/L HCO3-: 24 mEq/L Ca2+: 5.0 Urea nitrogen: 15 mg/dL Glucose: 81 mg/dL Creatinine: 1.0 mg/dL Alkaline phosphatase: 225 U/L Aspartate aminotransferase (AST, GOT): 11 U/L Alanine aminotransferase (ALT, GPT): 15 U/L Which of the following is most likely associated with this patient’s presentation?

A 45-year-old man comes to the physician because of a 6-month history of a slowly enlarging nodule on the left upper eyelid that has persisted despite treatment with warm compresses. He also reports heaviness of the eyelid and mild blurring of vision in the left eye. Vital signs are within normal limits. Visual acuity is decreased in the left eye. Ophthalmic examination shows a solitary, rubbery, nontender nodule on the central portion of the left upper eyelid. The lesion is better seen on eversion of the left eyelid. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old woman presents to the family medicine clinic for evaluation of a sore throat. The patient states that she does not have a runny nose, cough or itchy throat. The patient has no past medical history but she did have an appendectomy when she was 8 years old. She takes acetaminophen when she gets a headache and does not smoke cigarettes. Her vitals include: blood pressure 112/68 mm Hg, heart rate 72/min, respiratory rate 10/min and temperature 39.2°C (102.6°F). Physical examination reveals a patient who is uncomfortable but alert and oriented. Upon palpation, the physician notices swollen anterior cervical nodes. Inspection of the pharynx and tonsils does not reveal any erythema or exudate. Which of the following is the most appropriate next step for this patient?

A 39-year-old man comes to the physician for evaluation of hearing loss. He reports difficulty hearing sounds like the beeping of the microwave or birds chirping, but can easily hear the pipe organ at church. He works as an aircraft marshaller. A Rinne test shows air conduction greater than bone conduction bilaterally. A Weber test does not lateralize. Which of the following is the most likely underlying cause of this patient's condition?

A 33-year-old woman presents to her primary care physician complaining of right jaw pain for the last 3 weeks. She first noticed it while eating a steak dinner but generally feels that it is worse in the morning. She describes the pain as deep and dull, with occasional radiation to the ear and back of her neck. She denies any incidents of jaw locking. The patient also states that her husband has noticed her grinding her teeth in her sleep in the last several months. She has a past medical history of depression, for which she takes fluoxetine, and carpal tunnel syndrome, for which she uses a wrist brace. The patient works as a secretary. Her father passed away from coronary artery disease at the age of 54, and her mother has rheumatoid arthritis. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 135/81 mmHg, pulse is 70/min, and respirations are 14/min. On exam, there is no overlying skin change on the face, but there is mild tenderness to palpation at the angle of the mandible on the right. Opening and closing of the jaw results in a slight clicking sound. The remainder of the exam is unremarkable. Which of the following is the next best step in management?

Q10

A 17-year-old girl presents to an urgent care clinic after waking up in the morning with a left-sided facial droop and an inability to fully close her left eye. Of note, she is currently on oral contraceptives and escitalopram and smokes half a pack of cigarettes per day. Her temperature is 98.2°F (36.8°C), blood pressure is 110/68 mmHg, pulse is 82/min, and respirations are 12/min. On exam, she has generalized, unilateral left-sided drooping of her upper and lower face, and an inability to move the left side of her mouth or close her left eye. Her extraocular movements and swallow are intact. She has no other neurologic deficits. Which of the following interventions would most likely address the most likely cause of this patient's symptoms?

Clinical Reasoning US Medical PG Practice Questions and MCQs

Question 1: A 53-year-old man presents with a 2-year-history of dull, nonspecific flank pain that subsides with rest. His past medical history is significant for hypertension, hypercholesterolemia, and type 2 diabetes mellitus. He has no allergies and takes no medications. His father died of kidney disease at the age of 51, and his mother has been treated for ovarian cancer. On presentation, his blood pressure is 168/98 mm Hg, and his heart rate is 102/min. Abdominal examination is significant for palpable bilateral renal masses. His laboratory tests are significant for creatinine of 2.0 mg/dL and a BUN of 22 mg/dL. Which of the following tests is most recommended in this patient?

A. Chest X-ray
B. Genetic testing for polycystic kidney disease
C. CT scan of abdomen and pelvis
D. 24-hour urine protein collection
E. Renal ultrasound (Correct Answer)

Explanation: ***Renal ultrasound*** - This patient presents with classic features of **autosomal dominant polycystic kidney disease (ADPKD)**: bilateral palpable renal masses, hypertension, elevated creatinine, and a strong family history (father died of kidney disease at 51). - **Renal ultrasound is the first-line imaging test** for diagnosing ADPKD due to its **non-invasiveness, no radiation exposure, high sensitivity for detecting cysts, and cost-effectiveness**. - Ultrasound can establish the diagnosis using **established diagnostic criteria** (Pei-Ravine criteria based on age and number of cysts) and is recommended by **KDIGO guidelines** as the initial imaging modality. - In this patient with clear clinical features and palpable masses, ultrasound will readily confirm the diagnosis by demonstrating multiple bilateral renal cysts. *24-hour urine protein collection* - This test quantifies **proteinuria** to assess for glomerular damage. - While proteinuria can occur in ADPKD, it is not a diagnostic test and would not help identify or characterize the bilateral renal masses in this presentation. *Chest X-ray* - A chest X-ray evaluates the **lungs and heart**. - It provides no diagnostic information regarding renal masses or kidney pathology and is not indicated in this case. *Genetic testing for polycystic kidney disease* - **Genetic testing** (for PKD1 or PKD2 mutations) can confirm ADPKD definitively and is useful for family counseling and cases with uncertain imaging findings. - However, it is **not the first-line test** and is typically performed *after* imaging has established the diagnosis, or in specific situations (e.g., young patients, potential living kidney donors, atypical presentations). - In this patient with clear clinical and anticipated imaging findings, genetic testing is unnecessary for initial diagnosis. *CT scan of abdomen and pelvis* - CT scan provides excellent anatomic detail and is useful in ADPKD for **evaluating complications** such as cyst hemorrhage, infection, suspected malignancy, or for **preoperative planning**. - However, it is **not the first-line diagnostic test** due to higher cost, radiation exposure, and the fact that ultrasound is equally effective for initial diagnosis. - CT would be reserved for situations where ultrasound is inconclusive or when complications are suspected.

Question 2: A 50-year-old woman presents with severe abdominal pain. Past medical history is significant for a peptic ulcer. Physical examination is limited because the patient will not allow abdominal palpation due to the pain. The attending makes a presumptive diagnosis of peritonitis. Which of the following non-invasive maneuvers would be most helpful in confirming the diagnosis of peritonitis in this patient?

A. Rectal examination shows guaiac positive stool
B. Forced cough elicits abdominal pain (Correct Answer)
C. Hyperactive bowel sounds are heard on auscultation
D. Bowel sounds are absent on auscultation
E. Pain is aroused with gentle intensity/pressure at the costovertebral angle

Explanation: ***Forced cough elicits abdominal pain*** - A forced cough increases **intra-abdominal pressure**, which in turn stretches the inflamed peritoneum. - Elicitation of pain with coughing is a highly sensitive and specific sign for **peritoneal irritation** and helps confirm the diagnosis of peritonitis. *Rectal examination shows guaiac positive stool* - **Guaiac positive stool** indicates the presence of blood in the stool, which is a sign of gastrointestinal bleeding. - While a peptic ulcer can cause bleeding, this finding does not directly confirm **peritonitis** or peritoneal inflammation. *Hyperactive bowel sounds are heard on auscultation* - **Hyperactive bowel sounds** are often associated with conditions like gastroenteritis or partial bowel obstruction. - In peritonitis, bowel sounds are typically diminished or absent due to **ileus**, not hyperactive. *Bowel sounds are absent on auscultation* - While **absent bowel sounds** can be a sign of peritonitis due to paralytic ileus, this finding is not as specific or immediately helpful as eliciting pain with coughing in confirming the primary diagnosis in a patient already presumed to have peritonitis. - The absence of bowel sounds can also be seen in other conditions and may take longer to develop consistently. *Pain is aroused with gentle intensity/pressure at the costovertebral angle* - Pain at the **costovertebral angle (CVA)** typically indicates inflammation of the kidney or surrounding structures, such as in pyelonephritis. - This finding is specific to **renal pathology** and not directly related to generalized peritonitis.

Question 3: A 63-year-old retired teacher presents to his family physician for an annual visit. He has been healthy for most of his life and currently takes no medications, although he has had elevated blood pressure on several visits in the past few years but declined taking any medication. He has no complaints about his health and has been enjoying time with his grandchildren. He has been a smoker for 40 years–ranging from half to 1 pack a day, and he drinks 1 beer daily. On presentation, his blood pressure is 151/98 mm Hg in both arms, heart rate is 89/min, and respiratory rate is 14/min. Physical examination reveals a well-appearing man with no physical abnormalities. A urinalysis is performed and shows microscopic hematuria. Which of the following is the best next step for this patient?

A. Perform intravenous pyelography
B. Reassure the patient and recommend lifestyle modifications for his hypertension
C. Perform a cystoscopy
D. Perform a CT scan of the abdomen with contrast (Correct Answer)
E. Repeat the urinalysis

Explanation: ***Perform a CT scan of the abdomen with contrast*** - This patient has **asymptomatic microscopic hematuria** with significant risk factors: age >60 years and **40-year smoking history** (major risk factor for urothelial malignancy). - According to **AUA guidelines**, patients with risk factors and microscopic hematuria require complete evaluation including **upper tract imaging (CT urography preferred) AND cystoscopy**. - CT urography is the gold standard for detecting **renal cell carcinoma, urothelial carcinoma, and structural abnormalities** of the upper urinary tract. - In high-risk patients like this, proceeding directly to imaging is appropriate rather than waiting to confirm persistent hematuria. *Repeat the urinalysis* - Repeating urinalysis is appropriate for patients with **transient causes** of hematuria (vigorous exercise, menstruation, urinary tract infection, recent instrumentation). - This patient has **no evidence of transient causes** and has significant risk factors requiring immediate workup. - Delaying evaluation in a high-risk patient could miss early malignancy when it is most treatable. *Perform a cystoscopy* - **Cystoscopy** is indeed part of the standard hematuria workup and evaluates the bladder and urethra for malignancy. - However, it should be performed **in conjunction with upper tract imaging**, not alone, as it cannot visualize the kidneys or ureters. - Both cystoscopy and imaging are needed for complete evaluation; imaging is typically done first to identify upper tract pathology. *Reassure the patient and recommend lifestyle modifications for his hypertension* - While addressing **hypertension** is important, ignoring microscopic hematuria in a high-risk patient is inappropriate. - **Smoking and age** make this patient high-risk for genitourinary malignancies that require prompt investigation. - This approach could result in dangerous delays in diagnosing serious conditions like **renal cell carcinoma or bladder cancer**. *Perform intravenous pyelography* - **Intravenous pyelography (IVP)** is an outdated imaging technique largely replaced by **CT urography**. - CT urography provides superior sensitivity for detecting **renal masses and urothelial abnormalities** with better anatomical detail. - IVP has lower diagnostic accuracy and higher radiation exposure compared to modern CT imaging.

Question 4: A 73-year-old man comes to the physician because of a 4-kg (9-lb) weight loss over the last month. During this time he has not been able to eat more than one bite without coughing immediately and sometimes he regurgitates food through his nose. His symptoms are worse with liquids. One month ago he had a stroke in the right middle cerebral artery. He has a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia. Current medications include aspirin, amlodipine, metformin, and simvastatin. Examination of the oropharynx, chest, and abdomen shows no abnormalities. Neurological examination shows facial drooping on the left and decreased strength in the left upper and lower extremities. Which of the following is the most appropriate next step in management?

A. CT scan of the neck
B. Esophageal manometry
C. Transnasal laryngoscopy
D. Videofluoroscopy (Correct Answer)
E. Barium swallow

Explanation: ***Videofluoroscopy*** - This patient presents with symptoms highly suggestive of **dysphagia** (coughing with swallowing, nasal regurgitation, worse with liquids) following a **right middle cerebral artery stroke**, which can affect swallowing mechanisms. - **Videofluoroscopy**, also known as a **modified barium swallow study**, is the **gold standard** for evaluating oropharyngeal dysphagia, allowing direct visualization of oral and pharyngeal phases of swallowing and identifying aspiration. *CT scan of the neck* - A CT scan of the neck is primarily used to evaluate **structural abnormalities** in the neck, such as masses, lymphadenopathy, or thyroid pathology. - While it can identify some anatomical issues, it does not dynamically assess the complex process of **swallowing mechanics** or **aspiration risk** in real-time. *Esophageal manometry* - **Esophageal manometry** measures pressures within the esophagus and is used to diagnose disorders of esophageal motility, such as achalasia or diffuse esophageal spasm. - The patient's symptoms (coughing, nasal regurgitation, worse with liquids) point to **oropharyngeal dysphagia**, not primarily esophageal motility issues. *Transnasal laryngoscopy* - **Transnasal laryngoscopy** allows direct visualization of the larynx and pharynx to assess vocal cord movement, structural abnormalities, and pooled secretions. - While it can identify some anatomical or neurological deficits affecting swallowing, it does not directly visualize the **bolus transit** or **aspiration** during the act of swallowing, unlike videofluoroscopy. *Barium swallow* - A **barium swallow** (esophagram) is primarily used to evaluate the **esophagus** for structural abnormalities (e.g., strictures, diverticula) or motility disorders. - While it involves barium, it typically focuses on the esophageal phase and is less detailed for the **oropharyngeal phase** compared to videofluoroscopy, which is specifically tailored for this purpose.

Question 5: A 27-year-old woman presents to her primary care physician for minor aches and pains in her bones and muscles. She states that these symptoms have persisted throughout her entire life but have worsened recently when she moved to attend college. The patient is physically active, and states that she eats a balanced diet. She is currently a full-time student and is sexually active with 1 partner. She states that she has been particularly stressed lately studying for final exams and occasionally experiences diarrhea. She has been taking acyclovir for a dermatologic herpes simplex virus infection with minimal improvement. On physical exam, the patient exhibits 4/5 strength in her upper and lower extremities, and diffuse tenderness over her limbs that is non-specific. Laboratory values are ordered as seen below: Serum: Na+: 144 mEq/L Cl-: 102 mEq/L K+: 4.7 mEq/L HCO3-: 24 mEq/L Ca2+: 5.0 Urea nitrogen: 15 mg/dL Glucose: 81 mg/dL Creatinine: 1.0 mg/dL Alkaline phosphatase: 225 U/L Aspartate aminotransferase (AST, GOT): 11 U/L Alanine aminotransferase (ALT, GPT): 15 U/L Which of the following is most likely associated with this patient’s presentation?

A. Vitamin D deficiency (Correct Answer)
B. Fibromyalgia
C. Primary hyperparathyroidism
D. Chronic fatigue syndrome
E. Systemic lupus erythematosus

Explanation: ***Correct: Vitamin D deficiency*** - The patient presents with the **classic biochemical findings of vitamin D deficiency**: **severe hypocalcemia (Ca2+ 5.0 mg/dL, normal 8.5-10.5)** and **elevated alkaline phosphatase (225 U/L)**. - **Clinical features of osteomalacia** are present: diffuse bone and muscle pain, proximal muscle weakness (4/5 strength in extremities), and bone tenderness—all consistent with bone demineralization and secondary myopathy. - **Risk factor identified**: Recent move to college may represent lifestyle changes including reduced sun exposure, dietary changes, or increased indoor time studying. - The elevated alkaline phosphatase reflects increased osteoblastic activity attempting to compensate for undermineralized bone matrix. - Severe vitamin D deficiency also impairs immune function, which may explain the herpes simplex infection with poor response to acyclovir. *Incorrect: Chronic fatigue syndrome* - Chronic fatigue syndrome (CFS) is a **diagnosis of exclusion** characterized by persistent unexplained fatigue for at least 6 months with **normal laboratory findings**. - This patient has **significant biochemical abnormalities** (severe hypocalcemia, elevated alkaline phosphatase) that exclude CFS and point to a specific metabolic disorder. - CFS does not cause hypocalcemia, elevated alkaline phosphatase, or objective muscle weakness on examination. *Incorrect: Fibromyalgia* - While fibromyalgia presents with widespread musculoskeletal pain, it is characterized by **normal laboratory studies** including normal calcium and alkaline phosphatase. - The patient's severe hypocalcemia and elevated alkaline phosphatase exclude fibromyalgia as the primary diagnosis. - Fibromyalgia typically requires identification of specific tender points on examination, which are not described here. *Incorrect: Systemic lupus erythematosus* - SLE typically presents with **multisystem involvement** including malar rash, photosensitivity, serositis, nephritis, and hematologic abnormalities. - Laboratory findings would show **positive autoantibodies** (ANA, anti-dsDNA, anti-Smith), not isolated hypocalcemia with elevated alkaline phosphatase. - The patient's normal liver and kidney function, absence of systemic features, and specific biochemical pattern do not support SLE. *Incorrect: Primary hyperparathyroidism* - Primary hyperparathyroidism is defined by **hypercalcemia** with elevated or inappropriately normal PTH levels. - This patient has **severe hypocalcemia (Ca2+ 5.0)**, which is the **opposite** of what occurs in hyperparathyroidism. - The biochemical pattern (low calcium, high alkaline phosphatase) is consistent with hypoparathyroidism or vitamin D deficiency, not hyperparathyroidism.

Question 6: A 45-year-old man comes to the physician because of a 6-month history of a slowly enlarging nodule on the left upper eyelid that has persisted despite treatment with warm compresses. He also reports heaviness of the eyelid and mild blurring of vision in the left eye. Vital signs are within normal limits. Visual acuity is decreased in the left eye. Ophthalmic examination shows a solitary, rubbery, nontender nodule on the central portion of the left upper eyelid. The lesion is better seen on eversion of the left eyelid. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

A. Local tetracycline
B. Mohs micrographic surgery
C. Biopsy (Correct Answer)
D. Cryotherapy
E. Eyelid hygiene

Explanation: ***Biopsy*** * The **persistence** of the eyelid nodule for 6 months despite warm compresses, along with its **atypical presentation** (solitary, rubbery, nontender), raises concern for **malignancy**, such as sebaceous cell carcinoma. * A biopsy is essential to obtain a **histopathological diagnosis** to differentiate between benign lesions (e.g., chalazion) and malignancy, guiding subsequent appropriate management. *Local tetracycline* * **Tetracycline** is an antibiotic and would be used for **bacterial infections** like a bacterial hordeolum (stye), which typically presents with acute pain and redness, unlike this chronic, painless nodule. * While some topical antibiotics may have mild anti-inflammatory properties, they are not indicated for **chronic, non-infectious nodules** that have already failed conservative measures. *Mohs micrographic surgery* * **Mohs surgery** is a specialized procedure for skin cancers with high cure rates, particularly for difficult-to-treat or recurrent lesions, but it is a **treatment** and not a diagnostic step. * It would be considered *after* a definitive diagnosis of malignancy has been established through a biopsy. *Cryotherapy* * **Cryotherapy** uses extreme cold to destroy abnormal tissue and is a treatment modality, not a diagnostic one. * It is typically used for certain **benign or superficial malignant lesions**, but a diagnosis must first be confirmed via biopsy to ensure appropriate treatment selection. *Eyelid hygiene* * **Eyelid hygiene** (e.g., warm compresses, gentle scrubbing) is appropriate for chronic inflammatory conditions like **blepharitis** or initial management of a **chalazion** or **hordeolum**. * Since the nodule has persisted for 6 months despite warm compresses, it indicates that routine eyelid hygiene is insufficient and a more definitive diagnostic and therapeutic approach is needed.

Question 7: A 19-year-old woman presents to the family medicine clinic for evaluation of a sore throat. The patient states that she does not have a runny nose, cough or itchy throat. The patient has no past medical history but she did have an appendectomy when she was 8 years old. She takes acetaminophen when she gets a headache and does not smoke cigarettes. Her vitals include: blood pressure 112/68 mm Hg, heart rate 72/min, respiratory rate 10/min and temperature 39.2°C (102.6°F). Physical examination reveals a patient who is uncomfortable but alert and oriented. Upon palpation, the physician notices swollen anterior cervical nodes. Inspection of the pharynx and tonsils does not reveal any erythema or exudate. Which of the following is the most appropriate next step for this patient?

A. Strep culture
B. Symptomatic treatment
C. Antibiotics
D. Ultrasound of neck
E. Rapid strep test (Correct Answer)

Explanation: ***Rapid strep test*** - The patient exhibits several Centor criteria: **fever (>100.4°F)**, **tender anterior cervical lymphadenopathy**, and **absence of cough**, making **Group A Streptococcus (GAS) pharyngitis** a strong possibility. - A rapid strep test is the most appropriate initial diagnostic step to quickly confirm or rule out GAS infection due to the high index of suspicion. *Strep culture* - While a **strep culture** is the **gold standard** for diagnosing GAS pharyngitis, it takes **24-48 hours** for results, which delays treatment and increases the risk of complications if the rapid strep test is negative but GAS is still suspected. - It is typically reserved for cases where the rapid strep test is negative but clinical suspicion remains very high, or if there is a concern for false-negative rapid strep results. *Symptomatic treatment* - Providing **symptomatic treatment alone** without ruling out GAS pharyngitis could lead to complications such as **acute rheumatic fever** or **post-streptococcal glomerulonephritis**. - While supportive care is important, it should not be the sole intervention when strep throat is highly suspected. *Antibiotics* - Prescribing **antibiotics empirically** without confirming GAS infection can contribute to **antibiotic resistance** and expose the patient to unnecessary side effects. - Antibiotics are appropriate only after a positive diagnostic test for GAS pharyngitis. *Ultrasound of neck* - An **ultrasound of the neck** is not indicated at this stage as there is no suspicion of an abscess or other structural issues. - The patient's symptoms are consistent with an infectious process, not a mass or fluid collection requiring imaging at this point.

Question 8: A 39-year-old man comes to the physician for evaluation of hearing loss. He reports difficulty hearing sounds like the beeping of the microwave or birds chirping, but can easily hear the pipe organ at church. He works as an aircraft marshaller. A Rinne test shows air conduction greater than bone conduction bilaterally. A Weber test does not lateralize. Which of the following is the most likely underlying cause of this patient's condition?

A. Excess endolymphatic fluid pressure
B. Immobility of the stapes
C. Perforation of the tympanic membrane
D. Destruction of the organ of Corti (Correct Answer)
E. Compression of the vestibulocochlear nerve

Explanation: ***Destruction of the organ of Corti*** - This patient's **selective hearing loss** (difficulty with high-pitched sounds like chirping and beeping, but normal hearing for low-pitched sounds like an organ) combined with his occupation as an **aircraft marshaller** strongly suggests **noise-induced hearing loss**. - **Noise-induced hearing loss** primarily damages the **hair cells** in the **organ of Corti**, particularly those sensitive to high frequencies, leading to a **sensorineural hearing loss**. *Excess endolymphatic fluid pressure* - This is characteristic of **Ménière's disease**, which typically presents with a triad of **fluctuating sensorineural hearing loss**, **tinnitus**, and **vertigo**. - The patient's symptoms do not include vertigo or tinnitus, and his hearing loss pattern is more suggestive of noise exposure rather than endolymphatic hydrops. *Immobility of the stapes* - This suggests **otosclerosis**, a cause of **conductive hearing loss**. - In conductive hearing loss, the **Rinne test** would typically show **bone conduction greater than air conduction (BC>AC)** in the affected ear, which contradicts the given finding of air conduction greater than bone conduction bilaterally. *Perforation of the tympanic membrane* - A **perforated tympanic membrane** causes **conductive hearing loss**. - Similar to immobility of the stapes, this would result in **BC>AC** on the Rinne test, which is not what is observed in this patient. *Compression of the vestibulocochlear nerve* - This could be caused by an **acoustic neuroma** (vestibular schwannoma), which typically presents with **unilateral progressive sensorineural hearing loss**, **tinnitus**, and balance issues. - The patient's symptoms describe a **bilateral hearing loss** pattern consistent with chronic noise exposure rather than a unilateral nerve compression.

Question 9: A 33-year-old woman presents to her primary care physician complaining of right jaw pain for the last 3 weeks. She first noticed it while eating a steak dinner but generally feels that it is worse in the morning. She describes the pain as deep and dull, with occasional radiation to the ear and back of her neck. She denies any incidents of jaw locking. The patient also states that her husband has noticed her grinding her teeth in her sleep in the last several months. She has a past medical history of depression, for which she takes fluoxetine, and carpal tunnel syndrome, for which she uses a wrist brace. The patient works as a secretary. Her father passed away from coronary artery disease at the age of 54, and her mother has rheumatoid arthritis. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 135/81 mmHg, pulse is 70/min, and respirations are 14/min. On exam, there is no overlying skin change on the face, but there is mild tenderness to palpation at the angle of the mandible on the right. Opening and closing of the jaw results in a slight clicking sound. The remainder of the exam is unremarkable. Which of the following is the next best step in management?

A. Plain radiograph of the jaw
B. Surgical intervention
C. Nighttime bite guard (Correct Answer)
D. MRI of the brain
E. Electrocardiogram

Explanation: ***Nighttime bite guard*** - The patient's symptoms (jaw pain worse in the morning, grinding teeth at night, tenderness at the angle of the mandible, clicking sound) are highly suggestive of **temporomandibular joint dysfunction (TMD)**, specifically related to **bruxism**. - A nighttime bite guard is a common and effective initial treatment for bruxism-related TMD, helping to reduce clenching and grinding, thereby alleviating symptoms. *Plain radiograph of the jaw* - While imaging might be considered for persistent or atypical symptoms, **plain radiographs are generally not the first-line diagnostic tool** for TMD related to bruxism, as they primarily evaluate bony structures rather than soft tissue or joint dynamics. - The patient's presentation does not suggest a fracture, dislocation, or severe degenerative changes that would necessitate immediate radiography. *Surgical intervention* - Surgical intervention for TMD is typically reserved for **severe cases unresponsive to conservative treatments** or for structural abnormalities requiring repair. - Given this is a new onset of symptoms highly suggestive of bruxism, conservative management is the most appropriate initial approach. *MRI of the brain* - An MRI of the brain would be indicated if there were concerns for neurological causes of facial pain, such as tumors or nerve compression. - The patient's symptoms are localized to the jaw and directly linked to jaw movements and teeth grinding, making a neurological etiology highly unlikely in this context. *Electrocardiogram* - An electrocardiogram (ECG) assesses cardiac activity and is performed to rule out cardiovascular causes of chest pain or systemic symptoms. - The patient's symptoms are clearly localized to jaw pain and are not consistent with cardiac issues, making an ECG irrelevant to the immediate complaint.

Question 10: A 17-year-old girl presents to an urgent care clinic after waking up in the morning with a left-sided facial droop and an inability to fully close her left eye. Of note, she is currently on oral contraceptives and escitalopram and smokes half a pack of cigarettes per day. Her temperature is 98.2°F (36.8°C), blood pressure is 110/68 mmHg, pulse is 82/min, and respirations are 12/min. On exam, she has generalized, unilateral left-sided drooping of her upper and lower face, and an inability to move the left side of her mouth or close her left eye. Her extraocular movements and swallow are intact. She has no other neurologic deficits. Which of the following interventions would most likely address the most likely cause of this patient's symptoms?

A. Head CT without contrast
B. Implantation of gold weight for eyelid
C. Prednisone alone (Correct Answer)
D. Valacyclovir alone
E. Intravenous immunoglobulin

Explanation: **Prednisone alone** - The patient's presentation of **unilateral facial droop**, inability to close the eye, and intact extraocular movements points to **Bell's palsy**, an idiopathic peripheral facial nerve paralysis. - **Corticosteroids like prednisone** are the mainstay of treatment for Bell's palsy, significantly improving the chances of full recovery, especially when started early. *Head CT without contrast* - A head CT is primarily for detecting **central causes of facial weakness** (e.g., stroke, tumor), which would spare the forehead and present with other neurological deficits. - Since the patient has **generalized facial weakness** (affecting both upper and lower face) and no other neurological signs, a central lesion is less likely. *Implantation of gold weight for eyelid* - This is a **surgical intervention** to help with **lagophthalmos** (inability to close the eyelid) and prevent corneal damage. - It is typically considered for **persistent Bell's palsy** or severe cases not responding to medical therapy, not as an initial treatment. *Valacyclovir alone* - **Antiviral agents like valacyclovir** are sometimes used in conjunction with corticosteroids if there's a suspected viral etiology (e.g., herpes simplex virus), but their benefit as monotherapy is not established. - The **evidence for their benefit** even as adjunctive therapy is mixed and less robust than for corticosteroids. *Intravenous immunoglobulin* - **IVIG** is used for various immune-mediated neurological conditions, such as **Guillain-Barré syndrome**. - There is **no evidence** to support the use of IVIG for Bell's palsy.

Question 11: A 46-year-old woman comes to the clinic complaining of right eye irritation. The eye is itchy and red. Discomfort has been relatively constant for the last 6 months, and nothing makes it better or worse. Past medical history is significant for hypertension, hyperlipidemia, and aggressive tooth decay, requiring several root canals and the removal and replacement of several teeth. She takes chlorthalidone, fluvastatin, and daily ibuprofen for tooth pain. She has smoked a pack of cigarettes daily since the age of 20 and drinks alcohol on the weekends. She does not use illicit drugs. She cannot provide any family history as she was adopted. Her temperature is 36.7°C (98°F), blood pressure is 135/65 mm Hg, pulse is 82/min, respiratory rate is 15/min, and BMI is 27 kg/m2. A thorough eye exam is performed and shows no foreign objects. Both eyes appear erythematous and infected. Schirmer test is abnormal. Laboratory test Complete blood count: Hemoglobin 9.5 g/dL Leukocytes 12,500/mm3 Platelets 155,000/mm3 ESR 60 mm/hr Antinuclear antibody Positive What is the best next step in the management of this patient?

A. Fundoscopy
B. Artificial tears (Correct Answer)
C. Homatropine eye drops
D. Erythromycin ointment
E. Order anti-Ro/SSA and anti-La/SSB antibodies

Explanation: ***Artificial tears*** - The patient's symptoms (dry, itchy, red eyes, abnormal **Schirmer test**, aggressive tooth decay, high ESR, positive ANA) are highly suggestive of **Sjögren syndrome**, a systemic autoimmune disease characterized by *dry eyes* (keratoconjunctivitis sicca) and *dry mouth* (xerostomia). - Artificial tears are the initial and primary treatment for ocular dryness in Sjögren syndrome to alleviate discomfort and prevent corneal damage. *Fundoscopy* - **Fundoscopy** is used to examine the retina, optic disc, and retinal vessels. While an important part of a complete eye exam, it is not the most immediate or appropriate next step for addressing the patient's primary complaint of dry, irritated eyes, especially with a clear indication of a *surface issue* and an abnormal **Schirmer test**. - It would be more relevant if there were concerns for visual changes, headache, or other signs of retinal or optic nerve pathology. *Homatropine eye drops* - **Homatropine** is a *cycloplegic* and *mydriatic agent* that dilates the pupil and paralyzes the ciliary muscle, primarily used in treating conditions like uveitis to prevent synechiae formation and reduce pain from ciliary spasm. - It does not address the underlying issue of *dry eyes* or inflammation associated with Sjögren syndrome and would likely worsen discomfort by interfering with tear film dynamics. *Erythromycin ointment* - **Erythromycin ointment** is an *antibiotic* used to treat bacterial eye infections (e.g., conjunctivitis, blepharitis). - The patient's presentation of chronic eye irritation, abnormal Schirmer test, and systemic symptoms (high ESR, positive ANA, aggressive tooth decay) points away from a simple bacterial infection, and an antibiotic would not be effective for autoimmune-related dry eyes. *Order anti-Ro/SSA and anti-La/SSB antibodies* - While ordering **anti-Ro/SSA** and **anti-La/SSB antibodies** would be a crucial diagnostic step to confirm the suspected Sjögren syndrome, it is not the *best next step in management* for immediate symptom relief. - The patient is experiencing significant discomfort from dry eyes, and symptomatic treatment with artificial tears should be initiated promptly while awaiting confirmatory diagnostic test results.

Question 12: A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?

A. Second opinion from a neurologist
B. Withdraw ventilation support and mark time of death
C. Electroencephalogram
D. Repeat examination in several hours
E. Apnea test (Correct Answer)

Explanation: ***Apnea test*** - The patient exhibits classic signs of **brain death**, including a **coma**, fixed and dilated pupils, and absent brainstem reflexes (corneal, gag, cough). The next step is to perform an apnea test to confirm the absence of spontaneous respiratory drive. - An apnea test confirms brain death by demonstrating the **absence of respiratory effort** despite a rising pCO2, provided that spinal cord reflexes are not mistaken for respiratory efforts. *Second opinion from a neurologist* - While consulting a neurologist is often helpful in complex neurological cases, the current clinical picture presents such clear signs of brain death that **further confirmatory testing** for brain death (like the apnea test) is more immediately indicated before seeking additional opinions on diagnosis. - A second opinion would typically be sought to confirm the diagnosis or guide management, but establishing brain death requires a specific protocol which is incomplete without the apnea test. *Withdraw ventilation support and mark time of death* - It is **premature to withdraw ventilation** before brain death is unequivocally confirmed by all necessary clinical and confirmatory tests, including the apnea test. - Withdrawing support without full confirmation could lead to ethical and legal issues, as the patient might still have residual brainstem function, however minimal. *Electroencephalogram* - An **EEG** can show absent electrical activity, supporting brain death, but it is **not a mandatory part of the core brain death criteria** in many protocols, especially when clinical signs are clear and an apnea test can be performed. - The primary diagnostic criteria for brain death usually prioritize clinical examination and the apnea test for proving irreversible cessation of all brain functions. *Repeat examination in several hours* - Repeating the examination in several hours is typically done if there are **confounding factors** (e.g., severe hypothermia, drug intoxication) that might mimic brain death, or if the initial assessment is incomplete. - In this case, there are no mentioned confounding factors, and the immediate priority is to complete the brain death protocol with an apnea test, given the current clear clinical picture.

Question 13: A 22-year-old man presents to the emergency department with a fever and a sore throat. He has had these symptoms for the past 2 weeks and has felt progressively more fatigued. His temperature is 102°F (38.9°C), blood pressure is 120/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for tonsillar exudates, posterior cervical lymphadenopathy, and splenomegaly. Which of the following is the most appropriate next step in management for this patient?

A. No further workup needed
B. Rapid strep test
C. Amoxicillin
D. Oseltamivir
E. Monospot test (Correct Answer)

Explanation: ***Monospot test*** - The patient's presentation with **fever**, **sore throat**, **tonsillar exudates**, **posterior cervical lymphadenopathy**, and **splenomegaly** for 2 weeks is highly suggestive of **infectious mononucleosis**. - A **Monospot test** (heterophile antibody test) is the most appropriate initial diagnostic step to confirm the diagnosis of infectious mononucleosis. *No further workup needed* - This is incorrect because the patient has a constellation of symptoms and physical findings suggestive of a specific condition that warrants **diagnostic confirmation** for appropriate management and to rule out other possible causes. - Without further workup, the underlying condition remains undiagnosed, potentially leading to **mismanagement** or delayed treatment of complications. *Rapid strep test* - While a **sore throat** with exudates can suggest streptococcal pharyngitis, the presence of **splenomegaly** and **posterior cervical lymphadenopathy** in this age group makes infectious mononucleosis a more likely diagnosis. - A rapid strep test might be negative and would not explain the splenomegaly or prolonged symptoms, potentially delaying the correct diagnosis. *Amoxicillin* - Administering **amoxicillin** to a patient with infectious mononucleosis can cause a **characteristic maculopapular rash**, which is often mistaken for an allergic reaction. - Additionally, infectious mononucleosis is caused by a **virus (EBV)**, so antibiotics like amoxicillin are ineffective and not indicated for treatment unless a co-occurring bacterial infection is confirmed. *Oseltamivir* - **Oseltamivir** is an antiviral medication specifically used for the treatment of **influenza**. - This patient's symptoms are not typical for influenza, and the duration of illness (2 weeks) along with specific physical findings like splenomegaly point away from influenza and towards infectious mononucleosis.

Question 14: A 28-year-old man presents to his physician with a complaint of a 4-week history of headaches that is affecting his academic performance. Over-the-counter medications do not seem to help. He also mentions that he has to raise his head each time to look at the board when taking notes. His blood pressure is 125/75 mm Hg, pulse 86/min, respiratory rate 13/min, temperature 36.8°C (98.2°F). Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema. CT scan of the head reveals a 1.5 x 1.2 cm heterogeneous mass in the epithalamus with dilated lateral and 3rd ventricles. What other finding is most likely to be associated with this patient’s condition?

A. Eyes down and out
B. Pseudo-Argyll Robertson pupils (Correct Answer)
C. Sensorineural hearing loss
D. Medial strabismus
E. Conductive hearing loss

Explanation: ***Pseudo-Argyll Robertson pupils*** - The constellation of **upward gaze palsy**, **convergence-retraction nystagmus**, and **papilledema** points towards **Parinaud syndrome**, which is strongly associated with **pineal tumors**. - **Pseudo-Argyll Robertson pupils** (pupils that respond poorly to light but constrict during accommodation-convergence) are a characteristic finding in Parinaud syndrome due to dorsal midbrain compression. *Eyes down and out* - This presentation typically indicates **oculomotor nerve (CN III) palsy**, where the unopposed action of the lateral rectus and superior oblique muscles pulls the eye inferolaterally. - While cranial nerve palsies can occur with brain tumors, **CN III palsy** is not the primary or most characteristic ophthalmologic finding associated with Parinaud syndrome. *Conductive hearing loss* - **Conductive hearing loss** results from problems in the outer or middle ear, impairing sound transmission to the inner ear. - This condition is unlikely to be directly associated with a **pineal tumor** affecting the midbrain and is not part of Parinaud syndrome. *Sensorineural hearing loss* - **Sensorineural hearing loss** results from damage to the inner ear or the auditory nerve. - This is not a typical symptom of **pineal tumors** or Parinaud syndrome, which primarily involves ocular motor nuclei and pathways in the midbrain. *Medial strabismus* - **Medial strabismus**, or esotropia, usually indicates a weakness or paralysis of the **lateral rectus muscle**, controlled by the abducens nerve (CN VI). - While cranial nerve abnormalities can occur with increased intracranial pressure, **medial strabismus** is not a specific feature of Parinaud syndrome or pineal tumors.

Question 15: A 21-year-old man presents with fever, headache, and clouded sensorium for the past 3 days. His fever is low-grade. He says his headache is mild-to-moderate in intensity and associated with nausea, vomiting, and photophobia. There is no history of a sore throat, pain on urination, abdominal pain, or loose motions. He smokes 1–2 cigarettes daily and drinks alcohol socially. Past medical history and family history are unremarkable. His vital signs include: blood pressure 120/80 mm Hg, pulse 106/min, temperature 37.3°C (99.2°F). On physical examination, he is confused, disoriented, and agitated. Extraocular movements are intact. The neck is supple on flexion. He is moving all his 4 limbs spontaneously. A noncontrast CT scan of the head is within normal limits. A lumbar puncture is performed, and cerebrospinal fluid results are still pending. The patient is started on empiric intravenous acyclovir. Which of the following clinical features favors encephalitis rather than meningitis?

A. Photophobia
B. Clouded sensorium (Correct Answer)
C. Headache
D. Fever
E. Nausea and vomiting

Explanation: ***Clouded sensorium*** - **Altered mental status**, including confusion, disorientation, agitation, and clouded sensorium, is the hallmark feature that distinguishes **encephalitis** from meningitis - **Encephalitis** involves direct inflammation of the **brain parenchyma**, leading to impaired brain function and altered consciousness - While meningitis can cause irritability, profound changes in consciousness like disorientation and confusion are characteristic of **brain tissue involvement** rather than isolated meningeal inflammation - The patient's confusion, disorientation, and agitation indicate parenchymal dysfunction, making encephalitis the more likely diagnosis *Photophobia* - Photophobia is a common symptom in **both meningitis and encephalitis**, reflecting meningeal irritation - It results from inflammation of the meninges and does not indicate brain parenchymal involvement - This symptom is **not a differentiating factor** between the two conditions *Headache* - Headache is a prominent symptom in **both meningitis and encephalitis** due to meningeal inflammation and increased intracranial pressure - While often severe in meningitis, it can also occur in encephalitis when meningeal irritation is present (meningoencephalitis) - Headache alone **does not specifically favor** one diagnosis over the other *Fever* - Fever is a systemic response to infection and inflammation, present in **both meningitis and encephalitis** - It reflects the body's immune response to the infectious agent - The presence of fever **does not help distinguish** between inflammation of the meninges alone versus inflammation involving the brain parenchyma *Nausea and vomiting* - Nausea and vomiting can occur in **both meningitis and encephalitis**, often associated with meningeal irritation and increased intracranial pressure - These symptoms result from stimulation of the vomiting center and are common in many CNS infections - These symptoms are **not specific enough to differentiate** between the two conditions

Question 16: A 50-year-old man presents with a rapid onset of severe, right periorbital pain, an ipsilateral throbbing headache, and blurred vision for the past hour. The patient says he was out walking with his friend when he felt short of breath. His friend gave him a puff of his rescue inhaler because it often relieves his breathlessness, but, soon after that, the patient's eye symptoms started. No significant past medical history. His pulse is 100/min and regular, respirations are 18/min, temperature is 36.7°C (98.0°F), and blood pressure 130/86 mm Hg. On physical examination, his right pupil is fixed and dilated. Fundoscopic examination of the right eye is difficult due to 'clouding' of the cornea, and tonometry reveals increased intraocular pressure (IOP). Ibuprofen, acetazolamide, timolol, pilocarpine, and topical prednisolone are administered, but the patient's symptoms are only slightly reduced. Which of the following is the next best step in the management of this patient?

A. Perform emergency iridotomy.
B. Administer systemic steroids.
C. Anesthetize the eye and perform corneal indentation.
D. Add latanoprost.
E. Get an urgent ophthalmology consultation. (Correct Answer)

Explanation: ***Get an urgent ophthalmology consultation.*** * The patient presents with **acute angle-closure glaucoma** triggered by the **bronchodilator** (likely anticholinergic or sympathomimetic) from the rescue inhaler. Given the severity of symptoms, high IOP, and limited response to initial medical therapy, an **urgent ophthalmology consult** is crucial for definitive management, including potential laser or surgical intervention. * Although initial medications like pilocarpine and timolol were started, the patient's symptoms are only slightly reduced and **fixed, dilated pupil, and corneal clouding** indicate a persistent and severe condition requiring specialized ophthalmic care for urgent pressure reduction and prevention of **permanent vision loss**. *Perform emergency iridotomy.* * While an **iridotomy** is a definitive treatment for angle-closure glaucoma, it is a **surgical procedure** that needs to be performed by an ophthalmologist. It would not be the immediate next best step before consulting the specialist. * The decision to perform an **iridotomy** and the choice between laser or surgical approaches should be made by an ophthalmologist after a comprehensive examination and failed medical management. *Administer systemic steroids.* * **Systemic steroids** are not indicated for the primary treatment of elevated intraocular pressure in **acute angle-closure glaucoma**. * While topical steroids may be used to reduce inflammation in the eye, systemic steroids can paradoxically **increase intraocular pressure** in some individuals (steroid-induced glaucoma), making them inappropriate here. *Anesthetize the eye and perform corneal indentation.* * **Corneal indentation** is a diagnostic and sometimes therapeutic maneuver to temporarily open the angle by displacing aqueous humor and flattening the cornea, but its use is limited to situations where an immediate **definitive treatment** like laser iridotomy is not possible. * This procedure is generally performed by an ophthalmologist and is not the "next best step" in the emergency department for a patient who has already received initial medical therapy and requires definitive specialized care. *Add latanoprost.* * **Latanoprost** is a prostaglandin analog that primarily works by increasing **uveoscleral outflow** of aqueous humor and is typically used for **chronic open-angle glaucoma**. * Its onset of action is **slow (hours to days)**, making it ineffective for the acute, rapid reduction of high intraocular pressure seen in an **acute angle-closure glaucoma emergency**.

Question 17: A 62-year-old man presents to his primary care physician for a follow-up appointment. The patient was the front seat driver in a head-on collision which resulted in a femur and pelvic fracture. Although no obvious head injury was noted initially, the patient subsequently developed neurological symptoms. He was treated appropriately and spent 3 weeks in the hospital, then was discharged 2 weeks ago. The patient has a past medical history of diabetes, hypertension, and dyslipidemia. He smokes 3 packs of cigarettes per day and drinks 4 alcoholic beverages every night. The patient says that he has been attempting to engage in sexual activities with his wife but has been unable to do so. He states this has never been a problem for him before. He also reports new-onset minor headaches and trouble sleeping for which he is taking trazodone. Which of the following is the most likely diagnosis?

A. Psychologic
B. Neurologic damage (Correct Answer)
C. Increased prolactin
D. Atherosclerotic change
E. Medication changes

Explanation: ***Neurologic damage*** - The patient's **pelvic and femur fractures** from a severe head-on collision create high risk for direct **neurovascular injury** affecting erectile function, including potential damage to the **pudendal nerve**, **pelvic autonomic nerves**, or **vascular supply** to erectile tissues. - The stem explicitly states he "**subsequently developed neurological symptoms**" after the trauma, indicating documented organic neurologic injury, not just psychological distress. - The **acute onset** of ED immediately following this documented neurologic injury, combined with persistent **minor headaches**, strongly suggests an **organic neurologic etiology** (traumatic brain injury affecting neuroendocrine pathways or direct pelvic nerve injury). - The temporal relationship between documented neurologic injury and ED onset makes this the most likely primary diagnosis. *Psychologic* - **Psychological factors** (PTSD, depression, anxiety) are indeed very common causes of ED following major trauma and hospitalization. - The presence of **sleep disturbance** could support depression or PTSD. - However, the stem explicitly mentions that the patient "**subsequently developed neurological symptoms**," which points toward a documented **organic neurologic injury** rather than purely psychological distress. - While psychological factors may be contributing, the documented neurologic injury makes organic causes the primary consideration. *Increased prolactin* - Elevated **prolactin** (from pituitary adenoma or certain medications) can cause ED, but there is no evidence suggesting hyperprolactinemia in this case. - While severe **TBI** could potentially cause **hypopituitarism** or pituitary dysfunction, this would be evaluated if initial neurologic workup suggests it, and it's less common than direct nerve injury in pelvic trauma. *Atherosclerotic change* - This patient has **multiple cardiovascular risk factors** (diabetes, hypertension, dyslipidemia, heavy smoking) that predispose to **atherosclerotic ED**. - However, atherosclerotic ED typically has a **gradual, progressive onset** over months to years, not an **acute onset** immediately following trauma. - The **sudden appearance** of ED right after documented neurologic injury suggests an acute traumatic etiology rather than progression of chronic vascular disease. *Medication changes* - **Trazodone** is used for insomnia and is generally **not a common cause of ED**; in fact, it has been used off-label to treat ED in some cases. - Trazodone is more commonly associated with **priapism** (rare) rather than erectile dysfunction. - No other new medications are mentioned that would explain the acute ED onset following trauma.

Question 18: A 57-year-old woman comes to the emergency department because of severe pain around her right eye, blurred vision in the same eye, and a headache for the past 4 hours. She is nauseous but has not vomited. She can see colored bright circles when she looks at a light source. She is currently being treated for a urinary tract infection with trimethoprim-sulfamethoxazole. She appears uncomfortable. Vital signs are within normal limits. Examination shows visual acuity of 20/20 in the left eye and counting fingers at 5 feet in the right eye. The right eye shows conjunctival injection and edema of the cornea. The right pupil is dilated and fixed. Intravenous analgesia and antiemetics are administered. Which of the following is the most appropriate next step in management?

A. Perform ultrasound biomicroscopy
B. Perform fundoscopy
C. Perform gonioscopy (Correct Answer)
D. Administer topical steroids
E. Administer topical atropine

Explanation: ***Perform gonioscopy*** - This patient presents with symptoms highly suggestive of **acute angle-closure glaucoma** (severe eye pain, blurred vision, colored halos, dilated and fixed pupil, corneal edema). Gonioscopy is the **definitive diagnostic tool** to visualize the anterior chamber angle and confirm closed-angle glaucoma. - Confirming a closed angle is crucial for guiding appropriate treatment, which involves medications to lower intraocular pressure and potentially laser peripheral iridotomy. *Perform ultrasound biomicroscopy* - While ultrasound biomicroscopy can visualize anterior segment structures and the angle, it is generally **not the primary diagnostic step** for acute angle-closure glaucoma in the emergency setting. - Its use is more complex and less readily available than gonioscopy for initial diagnosis of angle closure. *Perform fundoscopy* - Fundoscopy is used to examine the posterior segment of the eye, including the **optic nerve head and retina**. While important for evaluating the optic nerve for glaucoma damage, it does not directly assess the anterior chamber angle to diagnose angle closure. - In acute angle-closure glaucoma, the immediate concern is the high intraocular pressure and its effect on the angle, not primarily the fundus appearance unless ruling out other conditions. *Administer topical steroids* - Topical steroids are used to reduce inflammation and are **contraindicated** in acute angle-closure glaucoma as they can worsen the condition by potentially increasing intraocular pressure further. - Steroids are typically used for conditions like uveitis or allergic conjunctivitis, which have a different clinical presentation. *Administer topical atropine* - Topical atropine is a **powerful cycloplegic and mydriatic agent**, meaning it dilates the pupil. Administering atropine would worsen angle-closure glaucoma by further dilating the pupil and potentially causing the iris to block the angle even more. - In acute angle-closure glaucoma, the goal is often to constrict the pupil (using miotics) to pull the iris away from the angle.

Question 19: A 37-year-old man comes to the emergency department for severe eye pain. The patient reports that he is a construction worker and was drilling metal beams when he suddenly felt a sharp pain in his right eye. Since then, the vision in his right eye has seemed blurry and his eye “has not stopped tearing.” The patient’s medical history is significant for type II diabetes mellitus and hypertension. His medications include metformin, captopril, and lovastatin. He has a mother with glaucoma, and both his brother and father have coronary artery disease. Upon physical examination, there is conjunctival injection present in the right eye with no obvious lacerations to the eyelids or defects in extraocular eye movements. Pupils are equal and reactive to light. No afferent pupillary defect is appreciated. The unaffected eye has 20/20 visual acuity. The patient refuses to participate in the visual acuity exam of the right eye due to pain. Which of the following is the best initial step in management?

A. Orbital magnetic resonance imaging
B. Topical corticosteroids
C. Patching
D. Tonometry
E. Fluorescein stain (Correct Answer)

Explanation: ***Fluorescein stain*** - The patient's presentation with sudden eye pain, blurry vision, and tearing after drilling metal beams suggests **corneal abrasion** or **corneal foreign body**. A fluorescein stain will highlight any epithelial defects or retained superficial foreign bodies on the cornea. - This is a rapid, non-invasive diagnostic step to visualize corneal damage. In cases where there is high suspicion for **intraocular foreign body (IOFB)** from high-velocity metallic injury, **orbital CT or plain radiographs should be obtained** before extensive manipulation; however, among the options provided, fluorescein staining is the most appropriate initial diagnostic maneuver. - The absence of an afferent pupillary defect and normal pupillary responses make open globe injury less likely, supporting the use of fluorescein examination as the initial step. *Orbital magnetic resonance imaging* - **MRI is absolutely contraindicated** when there is suspicion of an **intraocular metallic foreign body**, as the magnetic field can cause the object to move and cause severe damage to ocular structures, including retinal detachment or hemorrhage. - CT scan or plain radiographs would be the appropriate imaging modalities if penetrating injury with metallic IOFB is suspected, not MRI. *Topical corticosteroids* - Topical corticosteroids are **contraindicated** in acute corneal epithelial defects or suspected infection, as they **impair healing**, increase risk of superimposed infection (particularly fungal), and can lead to corneal melting. - They may be used later for inflammatory conditions after the acute injury is managed and infection is ruled out. *Patching* - Eye patching for corneal abrasions is **no longer routinely recommended** as studies have shown it does not improve healing and may increase patient discomfort. - Patching should never be applied before a thorough examination excludes penetrating injury, retained foreign body, or infection, as it can delay diagnosis and appropriate treatment. *Tonometry* - **Tonometry** measures **intraocular pressure (IOP)** and is contraindicated if open globe injury is suspected, as pressure on the globe could extrude intraocular contents. - While useful for glaucoma screening or uveitis evaluation, it is not the initial priority in acute ocular trauma with suspected corneal injury.

Question 20: A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable for hypertension and diabetes. His temperature is 99.1°F (37.3°C), blood pressure is 154/99 mmHg, pulse is 89/min, respirations are 12/min, and oxygen saturation is 98% on room air. Neurologic exam reveals right upper and lower extremity weakness and an asymmetric smile. Which of the following is the next best step in management?

A. Alteplase
B. MRI brain
C. CT head (Correct Answer)
D. Aspirin
E. CTA head

Explanation: ***CT head*** - A **non-contrast CT head** is the immediate priority to differentiate between ischemic and hemorrhagic stroke, which is critical for guiding subsequent treatment decisions. - Given the patient's acute neurological deficits (slurred speech, facial asymmetry, weakness) and vascular risk factors (hypertension, diabetes), **stroke is highly suspected**, and identifying intracerebral hemorrhage is crucial before considering thrombolytic therapy. *Alteplase* - **Alteplase** (tPA) is a thrombolytic agent used for acute ischemic stroke, but its administration is **contraindicated in hemorrhagic stroke**. - Initiating alteplase without first ruling out hemorrhage with a CT scan could lead to catastrophic bleeding. *MRI brain* - While an **MRI brain** can provide more detailed imaging of stroke, it is typically **not the initial imaging modality** in the emergency setting due to longer acquisition times and limited availability, especially when emergent differentiation between ischemic and hemorrhagic stroke is needed. - Its use is usually reserved for cases where the CT is inconclusive or for later evaluation. *Aspirin* - **Aspirin** is an antiplatelet agent used in the management of ischemic stroke, but it should **not be given until a hemorrhagic stroke has been ruled out** via CT head. - Administering aspirin in the context of an intracerebral hemorrhage could worsen bleeding. *CTA head* - A **CT angiography (CTA) head** is used to visualize the cerebral vasculature and identify large vessel occlusions, which can guide thrombectomy decisions in ischemic stroke. - However, performing a **non-contrast CT head is a prerequisite** to rule out hemorrhage before proceeding with CTA or any other advanced imaging or therapeutic interventions.

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