1.

A homeless 45-year-old man with a past medical history of AIDS and intravenous
drug use is brought in by his friend with altered mental status. The friend states that
he has had subjective fevers, nausea, and vomiting for the past two weeks. He also
recently developed right-sided weakness. Which of the following tests is most likely
to diagnose this patient's condition?
A.
Lumbar puncture
B.
CT head
C.
Brain MRI
D.
Electroencephalogram

A 22-year-old woman is planning a trip with friends to La Paz in Bolivia and

presents for advice about managing the high altitude. When she previously visited
the Himalayas with her family, she experienced headaches, nausea, fatigue, and
difficulty sleeping for several days after arriving. Her past medical history includes
an appendectomy three years ago. She has no allergies and takes no regular
medications. The clinician prescribes a drug that increases renal bicarbonate
excretion and decreases blood pH. What side effect is this patient most likely to
experience when taking this drug?

A.
Metallic taste
B.
Dry mouth
C.
Excess salivation
D.
Gum hypersensitivity

 Acetazolamide is a carbonic anhydrase inhibitor (CAI) that increases renal

bicarbonate excretion, thereby decreasing blood pH.

 It is indicated for altitude sickness prophylaxis and glaucoma and idiopathic

intracranial hypertension treatment.

 Common reported side effects of acetazolamide include metallic taste,

abdominal pain, vomiting, and diarrhea.

 Dry mouth is a common side effect of anti-muscarinic drugs, such as

atropine, oxybutynin, and solifenacin. Excess salivation, or sialorrhea, can be
experienced by patients taking drugs with a pro-cholinergic effect, such as
clozapine, risperidone, and pyridostigmine.

3. A 17-year-old boy presents to the emergency department with difficulty

breathing, slight dizziness, and generalized itching. He reports being stung
by a bee a few minutes ago. Vital signs are temperature 99 F (37.2 C),
heart rate 106 bpm, blood pressure 100/70 mmHg, and respiratory rate 26
 breaths/min. The general physical examination reveals a visible sting mark
on the left arm, with local erythema. On chest auscultation, wheeze is found
to be present bilaterally. Treatment is initiated with inhalational oxygen.


 Which of the following would be the most important in the patient's initial
management?
 Well done!You answered successfully
 A.
 Antihistamines
 B.
 Epinephrine
 C.
 Corticosteroids
 D.
 Albuterol

 Epinephrine is the drug of choice for anaphylaxis. The usual dose is 0.5 mg,
intramuscular.

 The dose may be repeated every 5 minutes with continuous blood pressure,
respiratory rate, and heart rate monitoring. Other drugs that are used include
chlorpheniramine and hydrocortisone. To counter hypotension, 0.9% normal
saline should also be administered.

 Epinephrine is a potent vasoconstrictor but can also cause tachycardia. So,

the repetition of the dose should be made with care.

 Epinephrine is available as an autoinjector that may be carried by people

who have allergies to pollen or bee stings.

4. A 36-year-old patient presents to the clinic with shortness of breath for 6 months
that is progressive, aggravated by walking, and relieved with resting. Her medical
history is significant for erythema nodosum six months ago. On examination, his
blood pressure is 110/80 mm Hg, heart rate is 77 bpm, respiratory rate is 17
breaths/min, and she is afebrile. Chest X-ray shows bilateral hilar lymphadenopathy
and pulmonary opacities. Laboratories showed elevated 1, 25-dihydroxy vitamin D
level and calcium. Which other lab abnormality may be seen?

A.
Elevated serum ACE
B.
Elevated liver function tests
C.
Polycythemia
D.
Sulfasalazine

 The patient has interstitial pulmonary fibrosis secondary to

sarcoidosis. Sarcoidosis is a multisystem disorder of unknown etiology that
mostly affects young adults worldwide and presents with noncaseating
granulomas in various organs. Characteristically, it presents with bilateral
hilar lymphadenopathy and reticular opacities in the lungs.

 Symptoms are variable; typically, patients present with a persistent dry

cough, fatigue, and shortness of breath. Other symptoms include painful red
lumps on the skin, uveitis with the blurring of vision, hoarseness of voice, and
palpable lymph nodes at multiple sites.

 Laboratory abnormalities include hypercalcemia (10-13%), elevated ACE

levels (60%), 1, 25-dihydroxy vitamin D, serum amyloid A, soluble
interleukin-2 receptor, and the glycoprotein KL-6.

 None of these markers are diagnostic. Biopsy shows noncaseating

granulomas.

 A 16-year-old boy with a seizure disorder presents to the hospital with a

history of severe joint pain, fever, and fatigue. On examination, he has a low-
 grade fever, and his vitals are blood pressure 135/85 mmHg, heart rate 89
bpm, and respiratory rate 19 breaths/min. His seizures have been
controlled with phenytoin for the past few years. The autoimmune assay is
positive for ssDNA, anti-histones, and ANA. What is the most likely
diagnosis?
 Well done!You answered successfully
 A.
 Drug-induced lupus erythematosus
 B.
 Systemic lupus erythematosus
 C.
 Purple glove syndrome
 D.
 Rheumatoid arthritis

 Given the patient's history, prolonged phenytoin use, and antibody assay, the
disorder is of an autoimmune origin. Positive ssDNA, anti-histones, and ANA
point toward drug-induced lupus erythematosus (DILE). Other drugs
classically associated with DILE are isoniazid, hydralazine, and
procainamide.

 Drug-induced lupus erythematosus is less severe than systemic lupus

erythematosus (SLE). SLE is an autoimmune disorder typically seen in
middle-aged women, and a common symptom is photophobia.

 Purple glove syndrome is a rare side effect of intravenous administration of

phenytoin.

 Rheumatoid arthritis is an autoimmune disorder associated with the HLA-

DR4 subtype.

 A 3-year-old boy presents with possible foreign body ingestion. His mother
found him playing with numerous coins as well as the television and stereo
 remote controllers but is unsure if all of the batteries can be accounted for.
He eats fruits, cereals, and rice, meets all developmental milestones, and all
vaccinations are up to date. He has no significant history. Vital signs are
normal. The physical examination shows a calm and playful boy. An oral
cavity exam reveals no lacerations or foreign bodies. Lungs are clear to
auscultation without stridor, and the abdomen is soft and non-tender. A plain
X-ray is shown in the image. What is the next step in management?

(Click Image to Enlarge)


 Well done!You answered successfully

 A.
 Emesis with ipecac.
  B.
 Endoscopic removal.
 C.
 Reassurance that this blunt object will pass through the digestive system.
 D.
 Serial X-rays to ensure passage of the foreign body.

A 3-year-old boy presents with possible foreign body ingestion. His mother found
him playing with numerous coins as well as the television and stereo remote
controllers but is unsure if all of the batteries can be accounted for. He eats fruits,
cereals, and rice, meets all developmental milestones, and all vaccinations are up
to date. He has no significant history. Vital signs are normal. The physical
examination shows a calm and playful boy. An oral cavity exam reveals no
lacerations or foreign bodies. Lungs are clear to auscultation without stridor, and the
abdomen is soft and non-tender. A plain X-ray is shown in the image. What is the
next step in management?

(Click Image to Enlarge)

 Well done!You answered successfully
A.
Emesis with ipecac.
B.
Endoscopic removal.
C.
Reassurance that this blunt object will pass through the digestive system.
D.
Serial X-rays to ensure passage of the foreign body.

A 38-year-old man who smokes cigarettes presents with fever, productive cough,
and malaise. His medical history is significant for non-ischemic cardiomyopathy,
with a left ventricular ejection fraction (LVEF) of 45%. He is on an angiotensin-
converting enzyme inhibitor and furosemide. Vital signs are temperature 98.6 °F (37
°C), heart rate 120 bpm, respiratory rate 30 breaths/min, oxygen saturation 93% on
room air, and blood pressure 96/60 mm Hg. Physical examination reveals mild
respiratory distress and bilateral wheezing without egophony or bronchophony. The
chest X-ray is reported as "cardiomegaly, and no infiltrates." The serum B-type
natriuretic peptide (BNP) is 250 pg/mL. The EKG shows sinus tachycardia and no
ST-T segment changes. Which of the following statements is correct in making a
diagnosis of pneumonia?

Well done!You answered successfully

A.
A chest x-ray is not indicated when there is an equal likelihood of an alternative diagnosis.
B.
In patients with symptoms and signs suggestive of pneumonia, empiric therapy is
indicated even when an initial chest X-ray does not show an infiltrate.
C.
When combined, history and physical exam have a high sensitivity and specificity for the
diagnosis of pneumonia.
D.
The growth of the pathogen in sputum culture confirms the diagnosis of pneumonia.

 All patients suspected of pneumonia should get a chest X-ray.

  Clinical diagnosis using symptoms and signs alone has suboptimal sensitivity
and specificity due to regional variability in the prevalence of pneumonia.

 A follow-up chest X-ray may show an infiltrate in dehydrated patients with

pneumonia whose initial chest X-ray did not show an infiltrate.

 Laboratory tests such as WBC counts, C-reactive protein, erythrocyte

sedimentation rate, or sputum studies, by themselves, are not adequate to
make a pneumonia diagnosis. An elevated serum procalcitonin increases the
predictive value of chest X-rays for pneumonia in patients with an equal
likelihood of alternate diagnosis.

A 62-year-old woman presents with worsening agitation as well as frequent mood

swings. A history of present illness obtained from her daughter reveals that she has
been developing progressive forgetfulness and has frequently been getting lost on
her way back home while driving on familiar routes. She also has had brief but
frequent periods of confusion characterized by nonsensical speech. Other reported
symptoms include excessive daytime sleepiness as well as difficulty sleeping during
the night. Over the past 12 months, the patient has had increasing visual
hallucinations and paranoid behavior accompanied by agitation and restlessness.
Her medical history is significant for mild depression, and her only medication is
sertraline. Her vital signs are temperature 37 °C (98.6 °F), blood pressure 125/80
mm Hg, heart rate 78 bpm, respiratory rate 18 breaths/min, and oxygen saturation
96% on room air. Her general physical examination findings are unremarkable.
Neurologic examination shows an agitated and restless female with masked facies,
a soft voice, postural instability, and a slow gait. She scores 24/30 on the mini-
mental state examination, where she lost points on orientation to time and place,
delayed recall, and figure drawing. A depression screen is negative for depressed
mood. The patient receives haloperidol in the emergency department to treat the
agitation, which results in the worsening of her symptoms with associated limb and
neck stiffness. Which of the following is the most likely diagnosis?

Well done!You answered successfully

A.
Alzheimer dementia
B.
Dementia with Lewy bodies
C.
Bipolar disorder with psychosis
D.
Major depression with psychosis

 This patient most likely has dementia with Lewy bodies, which is the second
most common cause of dementia. The classic findings of dementia with
Lewy bodies include fluctuating attention and alertness; recurrent, well-
formed visual hallucinations; and spontaneous parkinsonism. Sensitivity to
neuroleptic medications such as haloperidol is commonly seen. The patient's
presenting symptoms, as well as associated sensitivity to haloperidol, all
point towards the possibility of dementia with Lewy bodies.

 Sensitivity to neuroleptic medications is less common in Alzheimer disease

compared with Lewy body dementia.

 Delirium typically has a more rapid onset, unlike this patient where symptoms
have been present for a year.

 Bipolar disorder with major depression is less likely in this patient with the
above constellation of findings.

A 9-month-old male from Central America is brought to the emergency department

with a 6-hour history of intermittent, inconsolable crying and hugging his knees to
his abdomen. He has had two bloody stools and vomiting. The infant is irritable with
a temperature of 38.5 C. The abdomen seems tender, and the child continues
crying. What is the best initial diagnostic test?

A.
Stool for giardia antigen, ova, and parasites
B.
Air contrast enema with a baseline scout decubitus view
C.
Abdominal ultrasound
D.
Plain radiograph of the abdomen

 The patient, being between the ages of 6 months and 4 years, most likely
has ileocolic intussusception.

 The history is consistent with this diagnosis, and occasionally a sausage-

shaped mass can be palpated in the right upper quadrant. Plain radiographs
may be helpful to exclude perforation or when ultrasound is not immediately
available and can show characteristic bowel obstruction. The "target sign,"
consisting of two concentric radiolucent circles superimposed on the right
kidney, represents peritoneal fat surrounding and within the intussusception.
The "crescent sign" is a soft tissue density representing the intussusceptum
projecting into the gas of the large bowel, obscured liver margin, or lack of air
in the cecum.

 Air, saline, or barium enema can reduce the intussusception or make the
diagnosis but are not usually the first study ordered because there is a risk of
bowel rupture. Prior to the enema, the patient must be cleared for surgery.
There is no preparation required for an abdominal ultrasound.

 Bowel perforation must be excluded prior to radiologic intervention. Air has

the least incidence of perforation.
A 49-year-old woman presents with 8 hours of progressive epigastric pain that
worsens when recumbent and radiates to her back. The pain is associated with
nausea. Her medical history includes alcohol use disorder. Her vital signs are
temperature 100.6 °F (38.1 °C), heart rate 123 bpm, blood pressure 95/60 mm Hg,
respiratory rate 16 breaths/min, and oxygen saturation 90% on room air. The
physical examination reveals an uncomfortable and ill-appearing woman from
whom it is difficult to elicit a history as she drifts off between sentences. Breath
sounds are slightly diminished over the left posterior lung fields, and she displays
epigastric tenderness with guarding but without rigidity or rebound tenderness.
Bowel sounds are decreased but present. Laboratory results show hemoglobin of
17.0 g/dL, hematocrit of 58.0%, WBC count of 17 x 109/μL, and platelet count of
135000/μL. The metabolic panel reveals alanine aminotransferase 62 U/L,
aspartate aminotransferase 128 U/L, alkaline phosphatase 135 U/L, blood urea
nitrogen 34 mg/dL, and creatinine 1.20 mg/dL. Lipase is 2524 U/L. The chest x-
ray demonstrates mild to moderate left pleural effusion without visualization of free
air under the diaphragm. An abdominal ultrasound shows no dilatation of the
common bile duct or any stones in the visualized biliary ducts but cannot visualize
the pancreas due to overlying bowel gas. What is the next best step in
management?

Well done!You answered successfully

A.
Order CT of the abdomen with contrast to establish the diagnosis of acute pancreatitis.
B.
Admit for hydration with monitoring of fluid resuscitation with complete blood count and
metabolic panel every 6 hours.
C.
Start patient on piperacillin/tazobactam for empiric coverage of pancreatic necrosis.
D.
Administer fluid bolus and admit to keep the patient nil per os and for pain control.
Submit

Adult Lab Normals Pediatric Lab Normals Calculator Show References

Teaching Points

 The Bedside Index of Severity for Acute Pancreatitis (BISAP) score can be
used to predict mortality in acute pancreatitis and is similar in prognosticating
mortality to other more complicated scoring systems, such as Ranson's
criteria or the APACHE II score. High-scoring patients require intensive care
unit admission.
 This patient scores high on the Bedside Index of Severity for Acute
Pancreatitis (BISAP) with 4/5 points, indicating a high risk of mortality, and
the patient will require close monitoring.
 Patients with 0 points have < 1% mortality risk, while mortality increases
significantly with a score of 3 or more. A score of 5 points is associated with a
22% mortality. In this question, the patient scores 4 out of 5 points and has a
high risk for mortality.
 In severe pancreatitis, BUN and hematocrit should be followed every 6 hours
to ensure adequate fluid resuscitation. The first 12 to 24 hours of
resuscitation are crucial in improving outcomes.