Internal Recalls All Subjects

 A 69-year-old male is brought to the ER due to a first episode of compressing  pain at the anterior chest for several hours. On examination – no distress, clear lungs, normal heart sounds without murmurs. Pulse 80/min regular,  blood pressure 120/80 mmHg, room air saturation 97%. ECG – normal sinus  rhythm, troponin on admission 564 ng/ml (NL up to 7). Antiplatelet therapy is initiated with the diagnosis of non-ST elevation myocardial infarction  (NSTEMI). Which of the following is correct with regards to antiplatelet  treatment in NSTEMI patients?

A 55-year-old female is evaluated before gynecological surgery. No past medical history or any complaints. On examination – blood pressure 120/80
mmHg, pulse 76/min regular, wide and constant S2 split. No other abnormal findings.
Below is her ECG.

Which of the following is the most likely diagnosis?

A 45-year-old female is evaluated for abdominal pain and diarrhea. Her complaints started 3 days ago. Initially her stool was soft and later she  noticed fresh blood remains in her stool. History taking reveals that 5 days before her symptoms she attended a picnic and ate a hamburger with potato salad and mayonnaise. She also reports that two other guests developed diarrhea. On examination – looks well, tachycardic 115/min, hyperperistalsis with diffuse abdominal tenderness. Labs – WBC 17,400, creatinine 1.2 mg/dl, positive blood in stool.
Which of the following pathogen is the most likely  cause of her symptoms?

A 42-year-old healthy male is referred to the ER due to fever of 39.5°C and malaise. COVID 19 swab is negative.
On chest X-ray – left lower lobe infiltrate consistent with left lobar pneumonia.
He was treated accordingly with levofloxacin with no improvement after 3 days of treatment.
Which of the following is reasonable?

A 43-year-old male arrives to the ER with high fever, chills, and swelling and pain of his right leg. He denies chest pain or dyspnea. Past medical history is positive for type 2 diabetes. Past surgical history is positive for right foot varices ligation. On examinant – fever 38.7°C, pulse 99/min, blood pressure 138/72 mmHg, well defined erythematous warm area at the right leg. Fungi between the fingers of the feet.  Which of the following is the recommended  treatment?

A 70-year-old male is admitted to the ER following right lower limb burns from an oven several days ago. Pain is severe. Past medical history – diabetes and hypertension. On examination – pulse regular 100/min, blood pressure 80/50 mmHg, T 39°C, room air saturation 99%. On examination of the foot – purple vesicles and severe tenderness. Right lower limb CT – soft tissue gas. Which of the following is correct?

female, Israeli native, nursing school student, is on clinical rotation and undergoes a Mantoux test. Result is 10 mm and she is asymptomatic. Chest X-ray is normal.
What is the recommended treatment?

Which of the following is correct regarding Q fever?

A 75-year-old male resides at a nursing home following CVA. His past medical history includes several myocardial infarctions and systolic heart failure due to ischemic heart disease and type 2 diabetes. He is referred to the ER due to acute deterioration, fever, chills, and confusion. On examination – delirium, fever 38.5°C, saturation 90% with oxygen, systolic blood pressure 80 mmHg, pulse regular 115/min. His limbs are cold, lungs clear, abdomen is soft without peritonitis, no skin rash, no meningeal signs. Chest X-ray is normal. COVID-19 swab negative on PCR. Preliminary Gram stain of urine demonstrates Gram negative bacillus.

Which of the following is the first step in management?

A 19-year-old soldier is referred due to three days of maculopapular rash over the upper and lower limbs including his palms, fever 38°C and headache severity of 3/10. He reports that the symptoms began several days after raining and sleeping outdoors in the northern part of the country. Examination is normal except for the rash in the photos below.

Labs – leukopenia, thrombocytopenia, hyponatremia, and mildly elevated liver function tests. 
Which of the following is the next step in treatment?

Recently the world is dealing with the corona pandemic that is caused by the SARS-CoV-2 virus and causes COVID pneumonia and acute respiratory distress syndrome (ARDS).

 Which of the following is an ARDS criterion?

A 30-year-old male is admitted with severe anterior chest pain that radiates  to the neck and left shoulder. The pain is exacerbated by deep breaths and  position changes. In examination – in pain, blood pressure 110/70 mmHg,

pulse 90/min regular, T 37.9°C, room air saturation 96%. No jugular vein  distention. Sinus normal heart sounds without murmurs. Lungs – bilateral  normal breathing sounds without rales or wheezes. Labs – leukocytosis with

left shift. ECG is given below.

 Which of the following is the most appropriate  treatment?

Which of the following bacteria is most likely to cause infective endocarditis

over normal endotel without structural cardiac defects?

Which of the following patients can be diagnosed with acute myeloid leukemia?

A 75-year-old female is admitted to fever with anemia, thrombocytopenia, and acute renal failure. The physician on call suspects disseminated intravascular coagulation (DIC).
Which of the following practically rules out (almost 100%) this possibility?

A 55-year-old male underwent mechanical prosthetic mitral valve replacement today. Permanent anticoagulation therapy is considered. Which of the following is correct?

A 20-year-old HIV female patient is admitted due to confusion and fever of 38.4°C. Labs- Hb 8.2 gr/dl, Platelets 16,000, Urea 60 mg/dl, Creatinine 2.5 mg/dl, Total Bilirubin 5.5 mg/dl, Direct Bilirubin 0.5 mg/dl, Indirect Bilirubin 5.0 mg/dl, LDH 1150 U/l, PT 13 sec, INR 1.08, PTT 30 sec, Control PTT 30 sec, Fibrinogen 300 mg/dl. Schistocytes (fragmented red cells) are noted on peripheral blood smear.

Which of the following is the most likely diagnosis?

A 60-year-old male is an active smoker. On routine CBC – Hb 19, Hct 55, WBC 8,500, Platelets 300,000, MCV 88.

Which of the following is the next step in evaluation of this patient?

A 60-year-old male is referred due to malaise. His past medical history is positive for ischemic heart disease and diabetes. On examination – distinct pale skin and sclera, ulcers at the side of the mouth, and koilonychia. Labs – Hb 6.5.

 Which of the following is the expected patient’s MCV?

A 67-year-old healthy male, complains of increasing fatigue and back pain in the past 3 months. The only medication he has been taking is  acetaminophen. On examination – tenderness over the spine and + pitting  edema at the ankles. No other abnormal findings. Spine X-ray demonstrates compression fracture of L1. Labs – Hb 8 g/dL; WBC 4,000; Platelet 300,000;  Albumin 2.7 g/dL; Total Protein 9.2 g/L; Calcium 13.4 mg/dL; Creatinine 2.1  mg/dL.
Which of the following is correct?

Which of the following direct oral anticoagulants (DOACs) is athrombin  inhibitor?

A 77-year-old male complains of increasing malaise over the past year. On examination – splenomegaly. Labs – Hb 7.6 (NL 12-16); WBC 11,000 (NL 4,300-10,800); PLT 104,000 (NL 150,000-450,000 ); haptoglobin 201 (NL 50- 150). Coombs test is negative. Peripheral blood smear – teardrop shaped red cells and nucleated red cells. Bone marrow – dry tap.

Which of the following is the most likely diagnosis?

Patients with atrial fibrillation are at risk for systemic arterial emboli and

stroke. Which of the following patients is considered to have the lowest risk  for embolic CVA?

A 48-year-old male is admitted due to increasing abdominal pain and night sweats over the past 6 weeks. On examination – bilateral axillary lymphadenopathy up to 2 cm and diffuse abdominal tenderness without rebound. Abdominal pelvic CT scan demonstrated retroperitoneal and mesenteric lymphadenopathy. Axillary lymph node biopsy demonstrates diffuse large B-cell lymphoma. PET CT demonstrates axillary, mesenterial, and retroperitoneal lymph node enlargement. Bone marrow biopsy is normal.
Which of the following is the most appropriate treatment?

What is the most common cause of death in a 70-year-old male with CKD

stage 4?

Which of the following is an indication for urgent dialysis in a patient that has

been unsuccessfully treated conservatively?

A patient with recent diagnosis of chronic renal failure is evaluated by a renal
ultrasound that demonstrates large kidneys. Which of the following  diagnoses can explain this finding?

A 75-year-old male started treatment with IV acyclovir due to herpes infection involving the eye and nose. Before treatment the patient had high fever and barely ate or drank. On examination – blood pressure of 100/60 mmHg, pulse 100/min, T 38°C, no other abnormal findings.
Which of the following is this patient most likely to develop?

A healthy 55-year-old male with no medications is admitted to the ER due to multiple vomiting of stomach content for 3 days. No fever or diarrhea. On examination – dry mucosa, decreased skin turgor, pulse 110/min, blood pressure 130/85 supine, 100/50 standing. Labs – pH 7.45, bicarbonate 32

mEq/dl. Which of the following is the most expected in this patient?

A 20-year old male with Alport syndrome causing terminal renal failure is admitted to the ER due to chest discomfort and dyspnea over the past two days. On examination – pericardial friction rub, lungs are clear. Chest X-ray – cardiomegaly with no infiltrates or edema. He reports starting hemodialysis a month ago, twice weekly for 3 hours each.
Which of the following is the most appropriate treatment?

47-year-old female is treated for 1 week with cefalexin (Ceforal) for right leg cellulitis. She complains of systemic fever and diffuse maculopapular rash. Labs – creatinine 2.4 mg/dl (baseline 0.9) and BUN 39 mg/dl, absolute
eosinophilia 2100. On urine sediment – red blood cells and white blood cells casts.
Which of the following is the next step?

A 67-year-old male is referred by an occupational physician due to suspected significant occupational exposure in his past. His chest X-ray demonstrates “calcified pleural plaques”. To which of the following substances was he most  likely exposed?

An 80-year-old male is admitted to internal medicine department due to new left pleural effusion.
 Which of the following is diagnostic of exudative fluid?

 A 78-year-old male with morbid obesity and uncontrolled hypertension and  diabetes is brought to the ER due to compressing chest pain and significant malaise that lasted 30 minutes. On admission – blood pressure 80/40 mmHg, irregular pulse 123/min. Below is his ECG.

All of the following are acceptable treatments, except:

An Israeli native is treated with amiodarone due to atrial fibrillation and develops thyroid dysfunction.

Which of the following is most likely?

A 65-year-old COPD male smokes 2 packs a day for 30 years. He is admitted due to disease exacerbation and is known to the team for repeated admissions, latest one 4 months ago. Lately he almost never leaves his house and is treated with maximum inhalations. Which of the following is recommended upon discharge?

Which of the following is not considered a risk factor for developing chronic obstructive pulmonary disease?

A 70-year-old male is admitted to the ER with fever for a month, lack of appetite, weight loss, and prolonged cough.
X-ray is below.

Which of the following is the most likely diagnosis?

In which of the following the highest residual volume is expected?

A 35-year-old female complains of a year of pruritus and rigidity of the skin over her fingers that has spread beyond her elbows and involves the chest. She also reports finger cyanosis especially during cold temperatures. Labs – normocytic normochromic anemia around 10, elevated CRP, creatinine 0.8, normal urine. Anti-scl-70 (anti topoisomerase 1) positive.

 Which of the  following extra-cutaneal is expected in this patient?

A 21-year-old male is rushed to the ER after being stung by a bee and became dyspneic. He complains of nausea, abdominal pain and difficulty in breathing. On examination – respiratory distress, pulse 100/min, erythematous diffuse skin rash, expiratory wheezes over both lungs.

Which of the following is the first step in treatment?

A 65-year-old male with nephrolithiasis, hypertension, dyslipidemia, renal failure with creatinine around 2. He is evaluated due to severe foot pain that started 24 hours prior to his admission and increased to the point that he cannot step on his leg. This is his first episode. On examination – the photo below.

 Which of the following is the most appropriate treatment?

Which of the following is the most commonly involved joint in calcium pyrophosphate dihydrate arthropathy
(CPPD arthropathy)?

 A 33-year-old male is evaluated at the ER due to headaches and right eye pain for the past 5 days. He also reports painful ulcer in the scrotum. He denies fever or joint pain. He also complains of intermittent oral ulcers in the past 5 years. No regular medications. On examination – T 36.8°C, pulse 85/min, blood pressure 130/76 mmHg, five oral mucosal ulcers, no nuchal rigidity, 1 cm ulcer over his scrotum. Labs – Hb 11.1; WBC 15,600. Normal head CT. lumbar puncture – 13 leukocytes/µL, 100% lymphocytes, negative Gram stain.
Which of the following is the most likely diagnosis?

A 50-year-old healthy male is admitted due to bloody cough accompanied by dyspnea for the past two days. He also reports bloody urine in the past 24 hours. His history is positive for joint pain at the hands and knees with morning rigidity and no swelling. On examination – dyspnea 24/min, blood pressure 136/80 mmHg, pulse 105/min, T 37.6°C, decreased bilateral breathing sounds with diffuse crackles over the lungs, normal heart sound, soft abdomen, no organomegaly, elevated purpureal rash over the shins. Labs – normocytic mild anemia 10, creatinine 2.5 mg/dl (normal at baseline), urine erythrocytes with little protein, urine sediment – dysmorphic red cells and casts. Elevated erythrocyte sedimentation rate 60, positive cytoplasmic antineutrophilic cytoplasmic antibody (c-ANCA). Which of the following is the most likely diagnosis?

A 64-year-old male with diabetes, hypertension, and smoking complains of 6 months of compressing chest pain on moderate exercise, radiating to the left arm and accompanied by dyspnea. On examination – wide split of S2, a 3/6 holosystolic murmur at the apex, radiating to the axilla. Which of the following is most probable to be found on physical examination?

A 50-year-old female with hypothyroidism is treated medically. She is  admitted due to fatigue, malaise, and scleral jaundice. On examination –oriented to time and place, hemodynamically stable, no fever, mild skin and  scleral jaundice, mild right upper quadrant tenderness. No other abnormal  findings. Labs – AST 300 (NL 5-40)., ALT 370 (NL 14-63), ALP 120 (NL 30-115),  GGT 55 (NL 5-60), bilirubin 3 (NL <1) of which 2 is direct. History taking – no  new medications, viral evaluation is negative, liver ultrasound in the past was  normal without bile duct dilation. Antinuclear antibodies (ANA) and antismooth muscle antibodies (ASMA) are positive. Which of the following is the most likely diagnosis?

A 24-year-old male undergoes gastroscopy due to abdominal pain and antrum gastritis is demonstrated with positive helicobacter pylori.

Which of the following is the most appropriate treatment?

Which of the following is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP)?

A 23-year-old female was diagnosed with ulcerative colitis several months ago and treated with 5-ASA with no improvement. She is admitted due to severe colitis exacerbation and is treated with IV steroids with no improvement.
Which of the following is the next step in treatment?

A 60-year-old male with a history of atrial fibrillation is treated with rivaroxaban (Xarelto). Normal kidney function tests. He is scheduled for a colonoscopy for polyp removal that was previously demonstrated and not resected since.
Which of the following is the recommended approach regarding rivaroxaban?

Which of the following is not a recommended treatment in hepatic encephalopathy?

A 60-year-old male with atrial fibrillation is treated with amiodarone. He is brought to the ER after being found unconscious. On admission – pulse 40/min regular, blood pressure 130/96, rectal temperature 35.3°C, room air saturation 94%. Stupor, cold and dry skin, delayed reflex relaxation. ECG – sinus bradycardia.

 Which of the following is the most appropriate treatment?

45-year-old male is evaluated for frequent urination in the past several months. He is usually healthy and otherwise asymptomatic and is not on any  current medication. Both his parents had type 2 diabetes. His physical  examination is normal. Labs- fasting glucose 220 mg/dl and HBA1C 8%.
Which  of the following is the first line of treatment in this patient?

A patient with routine labs – thyroid stimulating hormone (TSH) 8 mU/L (NL 0.4-4); T3 and T4 normal. Thyroid peroxidase (TPO) antibodies are negative. The patient is asymptomatic with no past medical history.

 Which of the following is the most appropriate approach?

A 35-year-old female with type 1 diabetes diagnosed at the age of 5 years is controlled and treated with insulin pump. In the last few days – fever, diarrhea, and vomiting. On examination – pale, very weak, altered consciousness, blood pressure 90/60 mmHg, pulse 110/min regular, room air saturation 99%. Labs – Hb 15; WBC 20,000; glucose 5500 mg/dl; sodium 130 mEq/L; potassium 5.5 mEq/L; chloride 100mEq/L; creatinine 1.1 mg/dl; HCO3 12 mEq/L; pH 7.12.

which of the following is part of the initial treatment?

A 28-year-old male complains of dyspnea on moderate and intense exercise.  On examination – blood pressure 130/80 mmHg, pulse regular 84/min. Heart – sinus, 3/6 holosystolic murmur over the heart base and left sternal border. ECG – sinus rhythm with left ventricle hypertrophy. Echocardiography –hyperdynamic systolic function with LVEF of 70%, hypertrophy of ventricular septum, systolic anterior motion (SAM) of the mitral valve, and dynamic obstruction of the left ventricle outlet.

Which of the following is a risk factor for sudden death in the patient and therefore ICD defibrillator implantation  should be considered?

A 55-year-old male undergoes abdominal CT due to right lower quadrant pain. An incidental left adrenal 3 cm mass is demonstrated. Which of the following is not part of the evaluation?

A 40-year-old drug abuse male is admitted due to a fever of 38.5°C without any other symptoms. Chest X-ray demonstrates left lower lobe infiltrate. Echocardiography – large tricuspid valve vegetation. Labs – positive
rheumatoid factor. Blood cultures are pending.
Which of the following is most probable to grow on blood cultures?

A 60-year-old male is brought to the ER due to an episode of palpitations and dyspnea two hours prior to his arrival. On examination – respiratory distress, diaphoretic, diffuse rales over the lungs, irregular rapid heart sounds, pulse 160/min, blood pressure 80/50 mmHg, oxygen mask saturation 85%. ECG below.

Which of the following is the most appropriate management?

Direct oral anticoagulants (DOACs) are recommended to which of the following patients?

A 64-year-old male with diabetes, hypertension, and smoking history, complains of 6 months of compressing chest pain during exercise that radiate to the left arm and are accompanied by shortness of breath. On examination – wide S2 split, 3/6 holosystolic murmur at the apex that radiates to the axilla. Which of the following is most likely to be found on physical examination?

A 64-year-old male, with known mitral valve prolapse and moderate valve regurgitation, is asymptomatic. He can climb 5 floors and swims about 1000 meters with no restrictions. Which of the following is an indication for valve intervention if the regurgitation deteriorates?

 An 18-year-old male complains of prolonged purulent cough. On chest CT – suspected tram track sign and signet ring sign (photo below).

Which of the flowing is the most likely diagnosis?

A 70-year-old male, who is a heavy smoker with 100 pack years, complains of shortness of breath on mild exercise. You suspect his complains are associated with COPD. Which of the following is correct regarding lung volumes in COPD patients?

A patient with left pleural effusion undergoes thoracentesis. Which of the following defines exudate?

A 60-year-old heavy smoker male is evaluated for dyspnea. Spirometry is consistent with COPD. Which of the following prolongs longevity in COPD patients?

A patient is brought to the ER with room air saturation of 80% that does not change significantly with 100% oxygen. Which of the following is the most likely explanation?

A patient with asthma is treated with bronchodilators PRN. He is admitted due to exacerbation. After he improves is asking about the need for treatment with omalizumab (anti IgE). Which of the following is correct?

A 56-year-old female, with anxiety and hypertension, is brought to the ER due to severe exhaustion and left hemiparesis for the past two hours. Vital signs are normal. Glucocheck- 37 mg/dl. The patient immediately recovers with glucose infusion and her neurological symptoms resolve. Head and neck CTA is normal. The patient reports that in the past 3 months she gained 5 Kg with increased appetite. Her weight is 80 Kg and her height is 168 cm. She is taking enalapril and fluoxetine regularly. Heart and lung examination is normal. Below are her labs before any treatment.

Which of the following is the most likely etiology of her symptoms?

A 30-year-old female is evaluated for hypertension. She is now asymptomatic but reports episodes of very high blood pressure accompanied by headache and cold sweat. She denies abdominal pain or diarrhea. Her mother had thyroid cancer and her grandmother died of cerebral hemorrhage secondary to very high blood pressure. Physical examination is normal. 24-hour urine collection demonstrates normetanephrines and noradrenaline four times the normal range. CT scan demonstrates 4X5 cm right adrenal mass with enhancement on iodine injection.

Which of the following is the most appropriate next step?

A 76-year-old male is admitted due to large left lung mass with left hilar lymphadenopathy and dehydration. Labs – serum calcium 16.8 mg/dL (8.4-10.2); serum phosphorus 3.6 mg/dL(2.3-4.7); serum creatinine 2.1 mg/dL; serum blood urea nitrogen (BUN) 80 mg/dL. Which of the following is the most appropriate first line of treatment?

A healthy female who is two weeks after labor complains of worsening shortness of breath and lately sleeps with 3 pillows. On examination – bilateral inspiratory rales, S3 on auscultation. Which of the following is considered a risk factor for this clinical presentation?

A 34-year-old healthy female is evaluated due to palpitations, resting hand tremor, weight loss, and increased sweating. Her mother and grandmother had hypothyroidism at young age. On examination – non-nodular goiter, hyperreflexia, without ophthalmopathy. Hyperthyroidism on thyroid function tests (decreased TSH with high T4).
Which of the following is the most appropriate next step?

A 35-year-old female, with diabetes mellitus type 1, complains of severe abdominal pain and multiple vomiting for the past 4 hours. On examination – regular pulse 110/min, temperature 37.5°C, blood pressure 90/60 mmHg, diaphoretic, and decreased consciousness. No other physical findings.

Which of the following labs is most likely to be found in this patient?

Which of the following is the most correct sentence regarding pre-diabetes in type 2 diabetes?

A 65-year-old female is brought to the ER due to symptomatic anemia and hemoglobin 6 g/dl. She is treated with 1 unit of blood. Shortly after the blood infusion is started the patient develops acute dyspnea, fever, chills, and flank pain. Urinalysis is positive for hemoglobin. Which of the following is the most correct statement?

A 35-year-old female, with a history of Crohn’s disease, complains of increasing malaise over the last few months. During the past year her disease is well-controlled with antitissue necrotizing factor (anti TNF). Her hemoglobin decreased from 11 to 8 g/dl with MCV of 70 (both values are lower than a few months ago). Blood smear demonstrates hypochromia and microcytosis. Which of the following is the most likely cause of her anemia?

Which of the following increases the risk to develop lymphoma?

A 37-year-old female is brought to the ER with decreased consciousness. She recently started chemotherapy for Burkitt’s lymphoma. Her sister reports that she complained of vomiting and diarrhea following the treatment. There are no further details. On examination – disoriented, normal breathing and heart sounds. Labs are below.

Which of the following is the most likely etiology?

75-year-old male is brought to the ER due to fatigue and malaise. On examination – pallor, lymphadenopathy at the neck, axilla, and groin. Splenomegaly palpated 6 cm under the ribs. Labs are below.

Which of the following is the most likely diagnosis?

A 55-year-old male is brought to the ER due to dizziness and unstable gait for the past two days. On examination – disoriented and decreased consciousness that limits the neurological examination. Multiple skin petechia. Labs – hemoglobin 7 g/dl, thrombocytopenia 17,000, schistocytes on peripheral blood smear.
Which of the following is the most appropriate treatment?

A 30-year-old female, pregnant on her third trimester, is diagnosed with pulmonary  embolism.

 Which of the following is the recommended treatment upon discharge?

An 84-year-old male with ischemic heart disease, hypertension, and diabetes, is referred to the ER following a syncope episode at home. He is taking ACE inhibitors, metformin, and aspirin, On examination at the ER – fully conscious, pale, pulse 42 per minute, blood pressure 85/45 mmHg, room air saturation 92%. Labs – normal electrolytes, normal troponin (8 hours following his admission). Below is his ECG

Which of the following is most appropriate next step?

A 20-year-old male with no chronic medical history and no regular medications is brought to the ER due to epistaxis. Labs – platelets 2,000, with no other abnormalities on CBC. No schistocytes on peripheral blood smear. The patient denies any new recent medications, drug abuse, or fever disease. Platelets level was normal several years ago.
Which of the following is not an acceptable treatment?

A 25-year-old male presents to your clinic with abdominal pain, weight loss, and diarrhea over the last 8 months. After a taking the patient’s history and performing a physical examination you suspect inflammatory bowel disease (IBD). Which of the following points to ulcerative colitis rather than Crohn’s disease?

A new patient presents to your clinic, with laboratory results from a week ago including

HBsAg +, Anti HBc IgG +; HBeAg +; Anti HBs – .

Which of the following is true regarding this patient?

Which of the following is the most important complication of celiac disease?

Which of the following is true regarding trans-jugular intrahepatic portosystemic shunt  (TIPS)?

A 39-year-old patient with Crohn’s disease involving the terminal ileum, which hasn’t received treatment a long time, presents with unstable gait, sensorial deficits, and forgetfulness. Examination reveals unstable gait and deficit in sensing vibration.
Blood work is below:

Which of the following is the best explanation for the patient’s symptoms?

A 54-year-old male presents with malaise, anorexia, weight loss of 7 kg, abdominal distention, and peripheral edema over the last 6 months. His medical history is positive for hypertension treated with amlodipine, smoking, and IV drug use until recently. On examination – hemodynamically stable, with no distention of the jugular veins, he has gynecomastia and spider angiomas on his trunk. There are reduced breath sounds on both lung bases, distended non-sensitive abdomen with shifting dullness, and pitting edema +++ on both calves. Which of the following is the most likely explanation for this man’s condition?

A 40-year-old male presents with heart burn over the last 6 months. His history is  negative for dysphagia, weight loss, or familial history of gastrointestinal malignancy.

Which of the following is recommended in managing this patient?

An 82-year-old lucid and active female presents with headaches, pain, and morning rigidity in the shoulders and hips. On examination there is sensitivity over the right temple, scalp sensitivity, range of motion limitation of the shoulders and hips. Laboratory is positive for new normocytic anemia, and elevated CRP and ESR.
Which of the following is correct?

A 70-year-old male, with atrial fibrillation not treated with anticoagulation, presents to the emergency room with severe abdominal pain and bloody diarrhea. On physical examination – hemodynamically stable, abdomen is slightly distended but soft, although extremely sensitive to any touch. Laboratory results include elevated lactate, and a normal abdominal x-ray.
Which of the following is the next step in managing this patient?

A 55-year-old female, with hypertension and diabetes that are medically treated, is admitted due to anterior chest pain and diagnosed with acute anterior wall STEMI. An urgent coronary catheterization is performed with stent insertion to the LAD artery. She is discharged home with aspirin, prasugrel, bisoprolol, ramipril, spironolactone, and atorvastatin. Which of the following is an indication for implantable cardioverter defibrillator (ICD) insertion in this patient?

A 41-year-old male complains lately of malaise, sub-febrile fever of 37.5°C, recurrent sinusitis with purulent nasal discharge containing blood clots, productive purulent cough with occasional blood streaks, and recurrent subcutaneous nodular skin rash. Laboratory results include new normocytic normochromic anemia, slight thrombocytosis, elevated CRP and ESR, increase ferritin, creatinine 2m/dl, serology positive for ANCA antiproteinase-3. Urinalysis revealed protein and erythrocytes. The medical staff has decided to perform a biopsy.
Which of the following organs’ biopsy will be most appropriate for diagnosis?

A 25-year-old female complains of painful oral aphthous and a single event of uveitis.

Which of the following is missing for establishing a diagnosis of Bechet syndrome?

A 29-year-old female presents with pain and swelling of the hands and feet. The pain appears in the early morning and improves after about two hours after she is awake and active. After searching the internet, she suspects the diagnosis of rheumatoid arthritis and comes with a list of complications she is afraid of. Which of the following is the most likely?

A 57-year-old woman has hypertension treated with amlodipine, bisoprolol, and ramipril. Due to uncontrolled blood pressure she has gone through workup for secondary hypertension which did not reveal the reason for the lack of control, and was started on hydralazine with good blood pressure control. Two weeks later she presented with a skin rash, arthralgia, and fever. Examination revealed synovitis in the small hand joints including the metacarpophalangeal joint (MCP joint) and proximal interphalangeal (PIP). Antinuclear antibodies (ANA) came back high titer positive. Which of the following is correct?

A 65-year-old man presents with acute swelling of the first right metatarsophalangeal (MTP) joint, with no history of trauma. The patient consumed beer at a wedding. Medical history is positive for diabetes, chronic renal disease stage 3, and ischemic heart disease, and he is treated with chlorothiazide, atenolol, aspirin, and insulin. On examination his first right MTP is swollen, hot, red and sensitive. Which of the following is the most appropriate next therapeutic step?

A healthy 58-year-old male smoker presents with a fever of 38.6oC, productive cough, and shortness of breath over the last 2 days. On examination he is alert, answers questions on point, temperature is 38.4oC, pulse 110 beats per minute, blood pressure 130/80, 32 breaths per minute, and oxygen saturation of 91% on room air. Laboratory results are below

Chest x-ray reveals a right lower lobe consolidation consistent with pneumonia.
Which of  the following is the most appropriate therapeutic next step?

A 67-year-old male, 6 months after aortic valve replacement, presents with worsening exercise intolerance over the last months, and a fever of 38.4oC over the last few days. Multiple blood cultures obtained through out his hospital stay were positive.
Which of the following is the most likely causative agent?

Which of the following combinations was suggested for immediate identification of

patients with high risk of sepsis in the emergency room?

A 34-year-old woman, 2 days after an out of hospital abortion at 12 weeks, presents with fever and lower abdominal pain. On examination she is drowsy, but awakes to sound, blood pressure 82/52, pulse 130 bpm, temperature 38.6oC, 92% oxygen saturation in room air. Her abdomen is diffusely tender. Laboratory results are below.

Which of the following will diagnose sepsis in this woman?

A 56-year-oldmale is admitted due to pneumonia, and after 3 days of unsatisfactory improvement had a x-ray revealing moderate amount of pleural effusion. Thoracentesis was performed. Which of the following will indicate drainage of all the pleural fluid?

A 69-year-old male with diabetes, hyperlipidemia, and smoking history, is admitted due to urinary tract infection. During his admission he complains of epigastric pain and sweating. ECG demonstrates ST elevation in V1-V4 and coronary catheterization is performed with LAD artery stenting. Two days following the catheterization the patient complains of palpitation and significant malaise. Blood pressure is 80/50 and on the monitor is the photo below

What is the most appropriate next step?

A 30-year-old morbidly obese male with hypertension presents with fever, chills, and right calve edema. On examination temperature is 38.4oC, pulse 110/min, blood pressure 130/80 mmHg, respiratory rate 20/min. There is local warmth, erythema, and tenderness of the right calve without fluctuation. He arrives to the ER due to sore throat and cervical lymphadenopathy. Pharyngeal smear is negative for streptococcus. Laboratory results include WBC 12,000 with 80% neutrophils.
Which of the following is the most appropriate treatment?

A 60-year-old female presents with fever and a headache. The patient is drowsy, refuses to open her eyes, and complains of a severe headache. On examination her blood pressure is 150/90 mmHg, pulse regular 100/min, temperature 38.8oC, and difficulty moving her neck. She is not confused, nor has focal neurological symptoms. A lumbar puncture was performed. Which of the following is the most appropriate next step?