1) An 80-year-old woman comes to the urgent care clinic with dyspnea on exertion. On physical examination, her blood pressure is 100/70 mm Hg, and her pulse is 75. She has no pulsus paradoxus. Her jugular veins are distended, and she has distant heart sounds. In addition, she has extra third and fourth heart sounds. Her liver is enlarged, and she has pedal edema. She has occasional premature ventricular contractions on her electrocardiogram. A chest x-ray reveals clear lung fields with a dilated cardiac silhouette. Her echocardiogram reveals ventricular walls with a "speckled pattern." Which of the following is the most likely diagnosis?

A) Alcoholic cardiomyopathy
B) Amyloidosis
C) Hemochromatosis
D) Tuberculosis
E) Viral myocarditis

The correct answer is B. In amyloidosis, the left ventricular wall appears speckled on the echocardiogram, and there is a restrictive cardiomyopathy. In such a condition, ventricular filling is impaired, and the cardiac silhouette may be mildly enlarged. An ECG may reveal a host of nonspecific arrhythmias. Primary cardiac amyloidosis usually develops into diastolic dysfunction.

 Alcoholic cardiomyopathy (choice A) is typically the cause of a biventricular dilated cardiomyopathy, which leads to both right- and left-sided heart failure. An S3 will be heard. An echocardiogram will show enlarged left and right ventricles. The walls of the ventricles may appear very thin and stretched, consistent with volume overload.

Hemochromatosis (choice C) also may cause a restrictive cardiomyopathy, as seen in amyloidosis. However, the speckled pattern mentioned above would be absent. Other noncardiac features include bronzing of the skin and diabetes.

Tuberculosis (choice D) may cause a chronic tuberculous pericarditis that can manifest clinical symptoms similar to those seen in constrictive cardiomyopathy. The presentation is similar to that seen with restrictive features. However, patients tend to have normal ventricular wall thickness on echocardiogram, pericardial calcification, an absent S3, and S4.

Viral myocarditis (choice E), like alcohol, can lead to a dilated cardiomyopathy. Unfortunately, such conditions may progress to complete left and right ventricular failure, ultimately requiring cardiac transplantation in refractory cases.

A) Escherichia coli
B) Haemophilus influenzae
C) Klebsiella pneumoniae
D) Mycobacterium tuberculosis
E) Mycoplasma pneumoniae

The correct answer is B. This patient, with a long history of chronic obstructive pulmonary disease (COPD), has evidence of a community-acquired pneumonia. The common organisms causing pneumonias in patients with COPD are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

This patient has no other history suggestive of Escherichia coli (choice A) infection elsewhere (such as in the urinary tract), and primary E. coli pneumonia is rare. Klebsiella pneumoniae (choice C) is typically found in alcoholic patients and it may cavitate. There is no evidence of tuberculosis (choice D) by history. Tuberculosis usually presents with a more chronic presentation. Furthermore, it would generally be found as an upper lobe infiltrate, consistent with reactivation tuberculosis.

Much less commonly, tuberculosis may present as a primary infection, but this is generally seen in patients with an underlying immunocompromised state. In the setting of primary tuberculosis, a lower lung field pneumonia is in fact possible. Mycoplasma pneumoniae (choice E) does not present with a lobar consolidation and is generally a disease of younger people who present with fever, malaise of at least several days duration, and a nonproductive cough. The chest x-ray film in a patient with Mycoplasma pneumonia would classically reveal faint bilateral  interstitial infiltrates.

3) A 41-year-old man comes to the clinic complaining of a chronic cough over the past 4 months, which has now been accompanied by hemoptysis. He denies smoking or any past medical history. On physical examination, his head and neck examination is normal. His lungs have diffuse bilateral rales. Cardiac examination is normal. Laboratory findings reveal a sodium of 142 mEq/L, a potassium of 4.3 mEq/L, a chloride of 110 mEq/L, a bicarbonate of 24 mEq/L, a BUN of 39 mg/dL, and a creatinine of 2.9 mg/dL. Urinalysis reveals microscopic hematuria and 4+ proteinuria. Which of the following serologic blood tests would most help confirm the suspected diagnosis?

A) Anti-glomerular basement membrane antibodies
B) Anti-mitochondrial antibodies
C) Anti-neutrophilic antibodies
D) Anti-parietal cell antibodies
E) Anti-smooth muscle antibodies

The correct answer is A. The combination of hematuria and hemoptysis should always raise the possibility of Goodpasture syndrome. Anti-glomerular basement membrane antibodies are pathognomonic for this diagnosis.

Anti-mitochondrial antibodies (choice B) are found in patients with primary biliary cirrhosis.

The anti-neutrophilic cytoplasmic antibodies (choice C) are found in patients with Wegener granulomatosis. Wegener granulomatosis may also present with pulmonary and renal involvement but will have associated upper respiratory tract findings, e.g, sinusitis and sinus abscesses.

Anti-parietal cell antibodies (choice D) are found in patients with the autoimmune disease known as pernicious anemia.

Anti-smooth muscle antibodies (choice E) are found in patients with autoimmune hepatitis.

4) The parents of a 9-year-old girl bring their daughter to the emergency department. For the last 12 hours, the child has suffered severe nausea and vomiting, as well as diarrhea and abdominal cramps. Further discussion with the child indicates that she suffers from blurred vision and headache. The parents originally were worried about bringing the child to the emergency department because they feared deportation since the family are illegal immigrants employed to pick strawberries on a nearby farm. On direct questioning, the parents admit that the child was assisting with spraying crops with pesticides the previous day. None of the family members was wearing any protective clothing. Her blood pressure is 88/48 mm Hg, pulse is 90/min, respirations are 33/min, and temperature is 38 C (100.3 F). The child appears sweaty and confused. Auscultation of the lungs reveals a diffuse wheeze bilaterally. Pupils are miotic, and the child has diffuse muscle weakness. Which of the following interventions is the most appropriate treatment for this child's condition?

A) Atropine
B) Charcoal
C) Glucagon
D) Naloxone
E) Pralidoxime

The correct answer is E. Pesticide exposure should prompt one to think of organophosphate poisoning. Organophosphate poisoning inhibits cholinesterase, resulting in an accumulation of acetylcholine. This results in cholinergic excess at muscarinic sites (salivation, arrhythmia, bronchoconstriction) and peripheral nicotinic sites (such as sweating and weakness). Pralidoxime activates acetylcholinesterase, reversing the effects of most, but not all, organophosphates. In contrast, atropine (choice A), which competes with acetylcholine only at muscarinic receptors, will not reverse the nicotinic effects of any organophosphates.

Charcoal (choice B) is inappropriate in this situation. Most pesticide exposure is topical, and thorough surface decontamination (skin, clothing, contacts), but not gastric decontamination, is warranted.

Glucagon (choice C) will reverse beta-blocker overdose and can be used to treat severe hypoglycemia.

Naloxone (choice D) is used to reverse the effects of opioids. It has no use in treating pesticide overdose.

5) A 5-year-old boy suddenly begins coughing while eating peanuts. He is choking and  agging. When he is brought to the emergency department, but he is awake and is able to give his name. On physical examination, his vital signs are stable. On examination of the chest, inspiratory stridor and intercostal and suprasternal retractions are apparent. Which of the following is the most appropriate initial step in management?

A) Allow patient to clear foreign object by spontaneous coughing
B) Clear oropharynx with multiple blind sweeps with finger
C) Position patient and perform back blows
D) Stand behind patient and perform abdominal thrusts
E) Perform emergency tracheostomy and take to surgery

The correct answer is A. Since the patient can cough and breathe, he should be allowed to clear the foreign object spontaneously, if possible. In the management of foreign object obstruction, if the patient can cough and breathe, it is best to initially observe and allow spontaneous resolution, since intervention may actually be damaging.

Often, blind finger sweeps (choice B) may remove the foreign object and resolve the symptoms. Also, this will need to be done if the patient is to be intubated. The next step would be performing back blows if the patient was less than 1 year of age (choice C). If the patient were over 1 year old, abdominal thrusts would be the next management
option (choice D).

An emergency tracheostomy (choice E) should be the last option and should be undertaken only by a physician trained to perform the procedure.

6) A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate  her long history of uterine fibroids. About 30 minutes after her arrival, she begins to complain of nausea and has two episodes of vomiting. The physician administers 0.625 mg of droperidol and 400 mg of acetaminophen by mouth. On follow-up evaluation, the patient's neck is involuntarily flexed to one side. She is alert, oriented, and conversant and has an otherwise normal neurologic examination. Which of the following is the most likely diagnosis?

A) Cerebral vascular accident
B) Conversion disorder
C) Dystonic reaction to droperidol
D) Munchausen syndrome
E). Seizure

The correct answer is C. The most likely diagnosis is a dystonic reaction to the droperidol. Droperidol causes its antiemetic effect by antagonizing dopaminergic receptors in the vomiting center (central chemoreceptor zone) of the brain. This antidopaminergic action can produce torticollis or other dystonias.

A cerebral vascular accident (choice A) is unlikely given that the patient is alert and oriented, has no detectable language deficit, and has an otherwise nonfocal neurologic examination.

A conversion disorder (choice B) is unlikely since the patient has no prior history of a psychiatric disorder and has a viable medical reason (dystonia from droperidol) for her neuromuscular deficit.

Munchausen syndrome (choice D) is also unlikely since the patient had valid medical reasons for her initial admission and your current visit. We are also not informed of any prior history of hospitalizations or seeking of medical attention without appropriate cause.

A seizure (choice E) is similarly unlikely since the patient has no history of a seizure disorder and is alert, oriented, and conversant.

7) A 73-year-old man comes to the emergency department complaining of abdominal pain. He describes a dull, aching, constant pain in his mid-umbilical region. The pain has persisted over the past few days with increasing intensity, and it is not relieved by changes in position or eating. The patient has a past medical history significant for hypertension and coronary artery disease. He had a myocardial infarction 3 years ago. The man has moderate peripheral vascular disease with a prior femoral-popliteal bypass graft on the left. On physical examination, his blood pressure is 180/100 mm Hg, and his pulse is 86/min. He has a loud S4, a pulsatile, midline abdominal mass and venous stasis changes bilaterally on his lower extremities. Which of the following is the most appropriate diagnostic test at this time?

A) Abdominal ultrasound (U/S)
B) Lumbosacral (L/S) spine films
C) CT of the spine
D) CT of the abdomen
E) Spinal MRI

The correct answer is A. Abdominal ultrasound (U/S) is the most cost-effective screening test for a suspected abdominal aortic aneurysm (AAA). A CT of the abdomen (choice D) with IV contrast is about twice as expensive as U/S, adds little if any benefit, and exposes the patient to unnecessary radiation.

The other choices, lumbosacral (L/S) spine film (choice B), CT of the spine (choice C), and spinal MRI (choice E) are imaging studies directed at evaluating spinal pathology, which is not suspected here. MRI provides the highest resolution and is useful for detecting abscesses or cord compression. CT is excellent for disk pathology and even bone pathology. Plain radiographs are useful for very gross visualization of the bony density and integrity.

8) A previously healthy 27-year-old man comes to the physician complaining of a cough with sputum production for the past 3 days. The cough has been keeping him up at night and it is affecting his job performance. He has no prior history of respiratory disease. His temperature is 37 C (98.6 F), blood pressure is 130/80, pulse is 70/min, and respirations are 18/min. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A) Admit to the hospital for medical management
B) Perform a chest x-ray film
C) Perform a sputum culture
D) Send home with antibiotic therapy
E) Send home with no therapy

The correct answer is E. This patient most likely has acute bronchitis. Acute bronchitis in a healthy patient with no other medical conditions is often due to a viral infection that is usually self-limited. Given that this patient has only had 3 days of symptoms, an antibiotic is not necessary and is inappropriate. If the symptoms persist for longer than 1 week, a macrolide antibiotic may be given. A chest x-ray film and a sputum culture are not indicated.

Admission to the hospital for medical management (choice A) is inappropriate for a healthy patient with acute bronchitis.

A chest x-ray film (choice B) has no role in the diagnosis of acute bronchitis in a healthy patient.

A sputum culture (choice C) is used to identify organisms, but should only be used in elderly patients with chronic disease that fail antibiotic therapy.

Sending the patient home with antibiotic therapy (choice D) is appropriate management for acute bronchitis in an elderly patient with chronic disease. A macrolide is the treatment of choice.

9) A 63-year-old man is admitted to the hospital for fever and a productive cough. The patient reports that, over the past few days, he has had a worsening cough that has become productive of greenish-crimson sputum. The patient reports temperatures to 39.5 C (103 F) over the past 24 hours. The patient has had nothing to eat or drink for the past 36 hours. On further questioning, the man describes a prodromal period 7 days prior to the onset of the cough that was remarkable for rhinorrhea and general malaise. On physical examination, the patient appears acutely ill. His blood pressure is 130/80 mm Hg, and his pulse is 110/min and regular. Examination is remarkable for diminished breath sounds on the right lung-base with "a to e" egophony and whispered pectoriloquy. Which of the following is required for the diagnosis of pneumonia?

A) Hypoxemia on pulse oximetry
B) Infiltrates present on chest radiograph
C) Sputum Gram's stain showing gram-positive diplococci
D) Sputum Gram's stain showing neutrophils
E) Temperature to 38.6 (101.4 F)

The correct answer is B. The diagnosis of pneumonia absolutely requires that an infiltrate of some sort (whether interstitial or parenchymal, lobar or diffuse) be present on a chest radiograph.

Hypoxemia on pulse oximetry (choice A) is one possible physical manifestation of severe pneumonia but is certainly not required for the diagnosis.

A sputum Gram's stain showing gram-positive diplococci (choice C) is suggestive of a pneumonia, but it could also easily be explained by pharyngeal colonization with this organism.

A sputum Gram's stain showing neutrophils (choice D) is also highly suggestive of some pulmonary inflammatory process, although not necessarily pneumonia.

A temperature to 38.6 (101.4 F) (choice E) is clearly a nonspecific sign and can be associated with a multitude of possible etiologies.

10) A 72-year-old man with a 25-year history of emphysema comes to his physician after he develops the acute onset of fevers, rigors, and a cough productive of green sputum. The symptoms gradually worsen over 36 hours and he comes to the emergency department. He has been taking a beclomethasone inhaler twice daily, an albuterol nebulizer treatment at home four times daily, and has been taking erythromycin for a recent bronchitis. On physical examination he is 183 cm (6 feet) tall and weighs 85 kg. His temperature is 38.3 C (100.9 F), blood pressure is 162/92 mm Hg, pulse is 94/min, and respirations are 32/min. His lung examination reveals diffuse bilateral coarse rhonchi. He uses his sternocleidomastoid muscles with each inspiration. An arterial blood gas reveals a pH of 7.20, a pCO2 of 60 mm Hg, and a pO2 of 52 mm Hg. Over the next 2 hours, he becomes increasingly tachypneic, and his pCO2 rises to 74 mm Hg. The decision is made to intubate him at that point. Which of the following settings would be most appropriate for his tidal volume on the respirator?

A) 500 mL/breath
B) 600 mL/breath
C) 700 mL/breath
D) 850 mL/breath
E) 1000 mL/breath

The correct answer is D. The tidal volume for a patient is generally estimated as 10 mL/kg of weight, which for this patient would be 850 mL/breath. Giving a lower tidal volume will yield hypoventilation and be insufficient to eliminate pCO2. Providing a tidal volume greater than 10 mL/kg increases the risk of pneumothorax, particularly in a patient with longstanding emphysema who may have thin-walled alveoli.

A low tidal volume with risk of hypoventilation would be produced by choice A (500 mL/breath), choice B (600 mL/breath), and choice C (700 mL/breath).

A high tidal volume with risk of pneumothorax would be produced by choice D (1000 mL/breath).