question:
A 60-year-old-female with hypertension and diabetes is in the emergency department complaining of 3 days of worsening back pain. The pain is located at the site of a surgery 2 weeks ago for a herniated disc. She has also been experiencing one day of fevers, chills, and fatigue. Her vital signs are as follows: temperature 38.4°C (101.1°F), heart rate 96/min, respiratory rate 18/min, blood pressure 152/92 mm Hg. On her physical exam, the patient is alert and oriented, but appears acutely ill and is unable to lie supine due to discomfort. Her lungs are clear to auscultation in all fields, her heart rate is tachycardic with no audible murmurs, rubs, or gallops. Pulling aside her hospital gown, you see an area of erythema over the midline of her spine at the level L3/L4 at the site of her recent surgery that is exquisitely tender to gentle palpation. You place orders for this patient to include blood work of a CBC, blood cultures, CMP, ESR and CRP, imaging for a CT scan and MRI, request IV fluids, broad-spectrum antibiotics and call the spinal surgeon who performed her previous surgery as a consult. As you wait for each of these components of her work up to be undertaken, you consider what osteopathic techniques you have learned that might help your patient in this situation, and what might be appropriate given her possible diagnosis. Which of the following is true regarding the relevant indications or contraindications for such a case?
Answer Choices: (A) Indirect techniques to increase lymphatic drainage would be contraindicated in this patient who presents with an acute fever and whose workup is not complete (B) Due to its gentle and rhythmic application, direct articulation of the involved joint would be indicated as it would provide the most beneficial response (C) The presence of a red reflex visible over her lumbar region is an indication that HVLA should be directed towards that area (D) Articulatory treatment to the lumbar spine would be contraindicated due to the possibility of an acutely inflamed lumbar joint space (E) Any patient experiencing a fever in the post-operative period like this patient indicates that rib raising should be performed due to the high likelihood of atelectasis or pneumonia (F) Counterstrain techniques targeting the lumbar region would be indicated to alleviate the acute inflammatory response (G) Myofascial release techniques are contraindicated in the presence of post-operative fever and erythema over the surgical site (H) Lymphatic pump techniques should be prioritized to address systemic inflammation and fever (I) HVLA is contraindicated in this patient due to the possibility of underlying infection or abscess formation (J) Facilitated positional release targeting the lumbar spine is the optimal choice for managing acute post-operative inflammation

options:
Indirect techniques to increase lymphatic drainage would be contraindicated in this patient who presents with an acute fever and whose workup is not complete
Due to its gentle and rhythmic application, direct articulation of the involved joint would be indicated as it would provide the most beneficial response
The presence of a red reflex visible over her lumbar region is an indication that HVLA should be directed towards that area
Articulatory treatment to the lumbar spine would be contraindicated due to the possibility of an acutely inflamed lumbar joint space
Any patient experiencing a fever in the post-operative period like this patient indicates that rib raising should be performed due to the high likelihood of atelectasis or pneumonia
Counterstrain techniques targeting the lumbar region would be indicated to alleviate the acute inflammatory response
Myofascial release techniques are contraindicated in the presence of post-operative fever and erythema over the surgical site
Lymphatic pump techniques should be prioritized to address systemic inflammation and fever
HVLA is contraindicated in this patient due to the possibility of underlying infection or abscess formation
Facilitated positional release targeting the lumbar spine is the optimal choice for managing acute post-operative inflammation

medical_task: Treatment

body_system: Skeletal

question_type: Reasoning


question:
A 29-year-old woman presents to the emergency department with a 1-day history of fever. She says that it started spontaneously and that it hasn't gotten any better with either rest or acetaminophen. Her past medical history is significant for homelessness, unprotected sexual intercourse with multiple partners, and substance use disorder with multiple substances. Her temperature is 103.5°F (39.5°C), blood pressure is 100/70 mmHg, pulse is 112/min, respirations are 18/min, and oxygen saturation is 93% on room air. On physical exam, a murmur is heard along the left mid-sternal border. The pulmonary exam reveals minor bibasilar crackles. The patient's upper limbs demonstrate many bruises and scars in the antecubital fossa. The patient is started on vancomycin and gentamicin and sent for echocardiography. Based on the results of the echocardiogram, the patient undergoes surgery to remove multiple vegetations from the tricuspid valve. Vancomycin and gentamicin are continued over the next 5 days. On postoperative day 5, the patient presents with bleeding from her gums, oozing from her surgical sites, and recurrent epistaxis. Lab values are obtained as seen below:
Serum:Na+: 135 mEq/L
Cl-: 90 mEq/L
K+: 4.4 mEq/L
HCO3-: 23 mEq/L
BUN: 20 mg/dL
Glucose: 110 mg/dL
Creatinine: 1.0 mg/dL
Ca2+:  10.1 mg/dL
AST: 9 U/L
ALT: 9 U/L
Leukocyte count and differential:
Leukocyte count: 6,000 cells/mm^3
Lymphocytes: 20%
Monocytes: 1%
Neutrophils: 78%
Eosinophils: 1%
Basophils: 0%
PT: 27 seconds
aPTT: 84 seconds
D-dimer: < 50 µg/L
Hemoglobin: 14 g/dL
Hematocrit: 40%
Platelet count: 150,000/mm^3
Mean corpuscular volume: 110 fL
Mean corpuscular hemoglobin concentration: 34 g/dL
RDW: 14%
Which of the following is the most likely cause of this patient's current symptoms?
Answer Choices: (A) Bacterial infection of the bloodstream (B) Defect in von Willebrand factor (C) Acquired hemophilia A (D) Factor VIII deficiency (E) Coagulation cascade activation (F) Disseminated intravascular coagulation (G) Vitamin K deficiency due to antibiotic use (H) Immune-mediated thrombocytopenia (I) Antibiotic therapy (J) Hypersensitivity reaction to antibiotics

options:
Vitamin K deficiency due to antibiotic use
Hypersensitivity reaction to antibiotics

medical_task: Diagnosis

body_system: Other / NA

question_type: Reasoning


question:
A 55-year-old man is brought to the emergency department after a witnessed tonic-clonic seizure. There was no trauma during the seizure. The patient’s medical history includes hypertension, coronary artery disease, and type 2 diabetes. His current medications are hydrochlorothiazide, atenolol, metformin, and aspirin. According to his family, he smokes a pack of cigarettes and consumes 6 to 8 beers daily but does not use recreational drugs. His last alcohol consumption occurred approximately 36 hours before presentation.

His blood pressure is 160/110 mm Hg, his heart rate is 98 beats per minute and regular, and his respiratory rate is 22 breaths per minute. He is afebrile but confused and diaphoretic.

A complete blood count shows mild macrocytic anemia and thrombocytopenia. A biochemical profile shows a normal glucose level, mild hypokalemia, hypophosphatemia, normal kidney function, and an elevated aspartate aminotransferase level.

Chest radiography is unremarkable. Noncontrast CT of the brain shows mild volume loss. Blood and urine drug test results are negative. An electrocardiogram is notable for sinus tachycardia and motion artifact.

Thiamine, multivitamins, folate, and electrolyte repletion are administered. Three hours later, the patient becomes increasingly agitated and confused, with incoherent speech, diaphoresis, and combative behavior that persist even after the cumulative administration of 40 mg of intravenous lorazepam. Physical restraints to prevent him from disrupting his intravenous access only contribute to his agitation.

What is the most appropriate initial management option in this patient?
Answer Choices: (A) Obtain repeat CT of the brain (B) Transfer to the intensive care unit, and initiate sedation (C) Start a continuous infusion of midazolam (D) Obtain electroencephalography (E) Start a continuous infusion of phenytoin (F) Administer phenobarbital for refractory agitation (G) Perform lumbar puncture to rule out meningitis (H) Administer haloperidol for agitation (I) Initiate propofol infusion for sedation (J) Administer dexmedetomidine for sedation

options:
Transfer to the intensive care unit, and initiate sedation
Start a continuous infusion of midazolam
Start a continuous infusion of phenytoin
Administer phenobarbital for refractory agitation
Perform lumbar puncture to rule out meningitis

medical_task: Treatment

body_system: Nervous

question_type: Reasoning


question:
A 4-year-old boy with Klippel-Feil syndrome has elevation of the left scapula since birth.  Spine radiographs shows no evidence of scoliosis.  What shoulder motion is likely to be most limited?
Answer Choices: (A) external rotation (B) adduction (C) internal rotation (D) abduction (E) extension (F) forward flexion (G) transverse flexion (H) scapular protraction (I) scapular retraction (J) circumduction

medical_task: Diagnosis

body_system: Skeletal

question_type: Understanding


question:
A previously healthy 46-year-old woman reports one week of malaise, fever, and skin rash. Her medical history is significant only for a recent case of uncomplicated acute bacterial rhinosinusitis, for which she began taking amoxicillin-clavulanate 6 days ago. Her nasal discharge and facial pain have improved. She reports no cough, abdominal pain, diarrhea, or dysuria.

On physical examination, she has a temperature of 38.3°C, a blood pressure of 148/92 mm Hg, a heart rate of 88 beats per minute, and a respiratory rate of 14 breaths per minute. A diffuse erythematous maculopapular rash is present over her chest and back. The rest of her physical examination is within normal limits.

Her serum creatinine level is 1.8 mg/dL, compared with 0.9 mg/dL one year ago (reference range, 0.6–1.1). Other laboratory results are as follows:

|  | Patient value | Reference range |
| --- | --- | --- |
| Hematocrit (%) | 37 | 36–46 |
| Leukocyte count (per mm3) | 9760 | 4500–11,000 |
| Neutrophils (per mm3) | 6800 | 1900–7600 |
| Lymphocytes (per mm3) | 2000 | 800–4100 |
| Eosinophils (per mm3) | 750 | 0–350 |
| Platelets (per mm3) | 480,000 | 150,000–350,000 |
| Sodium (mEq/liter) | 135 | 136–145 |
| Potassium (mEq/liter) | 5.3 | 3.5–5.0 |
| Blood urea nitrogen (mg/dL) | 34 | 10–20 |

Urinalysis reveals 31 to 40 white cells per high-power field (reference range, 0–2) and a urine protein-to-creatinine ratio of 1.1 mg/mg (<0.2).

Which one of the following next steps in evaluation is most appropriate for this patient?
Answer Choices: (A) Perform kidney biopsy (B) Measure antistreptolysin O titer (C) No immediate testing is necessary; discontinue amoxicillin-clavulanate (D) Assess the urine for eosinophils (E) Assess for antineutrophil cytoplasmic antigen antibodies (F) Measure serum complement levels (G) Perform renal ultrasound with Doppler studies (H) Prescribe corticosteroids immediately without further testing (I) Evaluate for systemic lupus erythematosus with ANA testing (J) Check for hepatitis B and C serologies

options:
No immediate testing is necessary; discontinue amoxicillin-clavulanate
Assess for antineutrophil cytoplasmic antigen antibodies
Perform renal ultrasound with Doppler studies
Prescribe corticosteroids immediately without further testing
Evaluate for systemic lupus erythematosus with ANA testing

medical_task: Diagnosis

body_system: Urinary

question_type: Reasoning