Emergency Med PACKRAT questions and answers with complete solution 100% correct

An HIV positive patient presents with worsening dementia, fever, headache, and right hemiparesis. MRI of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. Which of the following is the treatment of choice? A. Sulfadiazine and pyrimethamine B. Trimethoprim-sulfamethoxazole C. Radiation therapy D. Ventricular shunt placement (c) A. Toxoplasmosis is commonly noted in HIV positive patients and presents with multiple ring-enhancing lesions. Treatment of choice for possible toxoplasmosis is sulfadiazine and pyrimethamine. (u) B. Trimethoprim-sulfamethoxazole is used for prophylaxis of toxoplasmosis, but not for treatment of acute infection. (u) C. Radiation therapy is indicated in CNS lymphoma, which typically presents with a single lesion. (u) D. Shunt placement is not indicated in patients with toxoplasmosis. A 52 year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study? A. Stool for occult blood B. Stool cultures C. Sigmoidoscopy D. Abdominal CT scan (c) A. Occult bleeding, as evidenced by the patient's history of black stools, is initially verified by a positive fecal occult blood test. (u) B. Stool cultures are indicated in the evaluation of acute diarrhea and not for the evaluation of acute GI bleeding. (u) C. Melena suggests a source of bleeding that is proximal to the ligament of Treitz, not a lower GI bleed. Sigmoidoscopy is used to evaluate only lower GI bleeding sources. (u) D. Abdominal CT scan is indicated for evaluation of obscure bleeding in order to exclude a pancreatic or hepatic source of bleeding if endoscopy fails to identify the source. 00:19 01:27 Which of the following is a cause of prerenal azotemia? A. Infection B. Renal toxins C. Poor renal perfusion D. Urinary tract obstruction (u) A. Infection is associated with interstitial nephritis, which is considered a cause of intrinsic renal azotemia. (u) B. This is one of the causes of intrinsic renal azotemia. (c) C. Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored. (u) D. Urinary tract obstruction is the cause of postrenal azotemia. A 65 year-old patient with steroid-dependent chronic obstructive lung disease presents with a headache that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever, but has had photophobia and a stiff neck. Which of the following is the most likely diagnosis? A. Transient ischemic attack B. Bacterial meningitis C. Migraine headache D. Cryptococcosis (u) A. Transient ischemic attacks present with focal neurological findings rather than headaches. (a) B. Bacterial meningitis is typically acute in onset and causes fever, but immunocompromised patients may have a slower onset and no fever. (u) C. Migraines generally do not begin in this age group, and are not accompanied by nuchal rigidity. (c) D.Cryptococcus is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients. Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)? A. Drooling B. High fever C. "Hot potato" voice D. Barking cough (u) A. Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup. (u) B. Fever is usually absent or low-grade in patients with viral croup. (u) C. See A for explanation. (c) D. Viral croup is characterized by a history of upper respiratory tract symptoms followed by onset of a barking cough and stridor. A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30 minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A. Chest x-ray B. Sputum gram stain C. Peak flow D. Ventilation-perfusion scan (u) A. A chest x-ray should be ordered in an asthmatic patient only if you are concerned about the presence of pneumonia or pneumothorax, neither of which is supported by the H&P findings noted above. (u) B. A sputum gram stain is performed in patients who you suspect have an infectious process, such as pneumonia. (c) C. A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions. (u) D. A ventilation-perfusion scan (V/Q scan) is indicated in cases of suspected pulmonary embolism. The patient above does not have any risk factors that would lead you to suspect such a diagnosis. A 3 year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is A. renal. B. cardiac. C. pulmonary. D. hepatic. (u) A. See B for explanation. (c) B. The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved. (u) C. See B for explanation. (u) D. Children with Kawasaki syndrome may have associated hydrops of the gallbladder, but liver involvement is not part of this disorder. The DSM-IV classifies mental disorders by using five axes in completing the process. Axis III is used to identify which of the following? A. Clinical disorders and other conditions that may be the focus of clinical attention B. Any physical disorder or general medical condition that is present in addition to the mental disorder C. The psychosocial and environmental problems that have had a significant contribution to the development or exacerbation of the disorder D. Personality disorders and/or mental retardation (u) A. Axis I identifies clinical disorders and other conditions that may be the focus of clinical attention. (c) B. Axis III identifies any physical disorder or general medical condition that is present in addition to the mental disorder. (u) C. Axis IV identifies the psychosocial and environmental problems having a significant contribution to the disorder. (u) D. Axis II identifies personality disorders and mental retardation. A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals sinus tachycardia. Which of the following is the most likely diagnosis? A. Atelectasis B. Pneumothorax C. Pulmonary embolism D. Myocardial infarction (u) A. Small atelectasis is commonly asymptomatic, while large atelectasis may produce signs of dyspnea and cough. Exam reveals absence of breath sounds in the area involved and dullness to percussion. A chest x-ray would reveal various findings dependent on the location of the atelectasis, but would not be normal. (u) B. While a pneumothorax commonly presents with pleuritic chest pain and dyspnea, exam would reveal the presence of diminished breath sounds and hyperresonance on the involved side. A chest x-ray would reveal presence of a pleural line on the expiratory chest x-ray. (c) C. This patient's risk factors for pulmonary embolism include advanced age, surgery, and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult to make due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal. (u) D. While a myocardial infarction usually presents with dyspnea, the chest pain is not usually pleuritic in nature. An EKG would commonly reveal ST segment changes which would be consistent with ischemia or infarct. A 34 year-old female with a history of asthma presents with complaints of increasing asthma attacks. The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. Which of the following is the most appropriate intervention at this time? A. Oral prednisone B. Oral theophylline (Theo-Dur) C. Salmeterol (Serevent) inhaler D. Beclomethasone (Qvar)inhaler (u) A. Oral corticosteroids, such as prednisone, are added to therapy in severe persistent asthma. While a course of oral corticosteroids may be needed for mild exacerbations of asthma, they are not added until inhaled corticosteroids have failed to control the symptoms. (u) B. Due to its safety profile, oral theophylline is now considered a third or fourth line treatment option for asthma. (u) C. Long acting inhaled beta2-agonists, such as salmeterol, are not added to the treatment regimen until the symptoms indicate a moderate persistent asthma. Long acting inhaled beta2-agonists should also not be used in place of inhaled steroids. (c) D. This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control. In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis? A. Femur B. Humerus C. Vertebral spine D. Tibia (u) A. Long bones are most commonly affected with osteomyelitis in children. (u) B. See A for explanation. (c) C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection (u) D. See A for explanation. A 43 year-old asymptomatic diabetic female is found to have an elevated total calcium level of 12.4 mg/dL. Which of the following tests must be assessed in order to evaluate this laboratory abnormality? A. Intact parathyroid hormone B. Serum albumin C. 24 hour urine calcium level D. Complete blood count (u) A. Intact parathyroid hormone levels are only obtained for patients with true hypercalcemia with an unknown etiology. (c) B. Since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels. (u) C. Demonstration of excessive calcium in the urine does not provide any additional information regarding the increased serum calcium. (u) D. Complete blood count has no relationship to the serum calcium levels.