9 Flashcards
Which of the following conditions would cause a positive Kussmaul’s sign on physical examination?
Answers
A. Left ventricular failure
B. Pulmonary edema
C. Coarctation of the aorta
D. Constrictive pericarditis
(u) A. Left ventricular failure results in the back-up of blood into the left atrium and then the pulmonary system so it would not be associated with Kussmaul’s sign.
(u) B. Pulmonary edema primarily results in increased pulmonary pressures rather than having effects on the venous inflow into the heart.
(u) C. Coarctation of the aorta primarily affects outflow from the heart due to the stenosis resulting in delayed and decreased femoral pulses; it has no effect on causing Kussmaul’s sign.
(c) D. Kussmaul’s sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.
Anginal chest pain is most commonly described as which of the following?
A. Pain changing with position or respiration
B. A sensation of discomfort
C. Tearing pain radiating to the back
D. Pain lasting for several hours
(u) A. Pain changing with position or respiration is suggestive of pericarditis.
(c) B. Myocardial ischemia is often experienced as a sensation of discomfort lasting 5-15 minutes, described as dull, aching or pressure.
(u) C. Tearing pain with radiation to the back represents aortic dissection.
(u) D. Chest pain lasting for several hours is more suggestive for myocardial infarction.
Eliciting a history from a patient presenting with dyspnea due to early heart failure, the severity of the dyspnea should be quantified by
A. amount of activity that precipitates it.
B. how many pillows they sleep on at night.
C. how long it takes the dyspnea to resolve.
D. any associated comorbidities.
(c) A. The amount of activity that precipitates dyspnea should be quantified in the history.
(u) B. Orthopnea or paroxysmal nocturnal dyspnea can be quantified by how many pillows a patient needs to sleep on to be comfortable.
(u) C. How long dyspnea takes to resolve or associated comorbidities has no bearing on quantifying the severity of dyspnea.
(u) D. See answer C above.
A 25 year-old female presents with a three-day history of chest pain aggravated by coughing and relieved by sitting. She is febrile and a CBC with differential reveals
leukocytosis. Which of the following physical exam signs is characteristic of her problem?
A. Pulsus paradoxus
B. Localized crackles
C. Pericardial friction rub
D. Wheezing
(u) A. Pulsus paradoxus is a classic finding for cardiac tamponade.
(u) B. Localized crackles are associated with pneumonia and consolidation, not pericarditis.
(c) C. Pericardial friction rub is characteristic of an inflammatory pericarditis.
(u) D. Wheezing is characteristic for pulmonary disorders, such as asthma.
A 65 year-old white female presents with dilated, tortuous veins on the medial aspect of
her lower extremities. Which of the following would be the most common initial complaint?
A. Pain in the calf with ambulation
B. Dull, aching heaviness brought on by periods of standing
C. Brownish pigmentation above the ankle
D. Edema in the lower extremities
(u) A. Patients with deep venous thrombosis (DVT) may present with complaints of pain in the calf with ambulation. Secondary varicosities may result from DVT’s.
(c) B. Dull, aching heaviness or a feeling of fatigue brought on by periods of standing is the most common complaint of patients presenting initially with varicosities.
(u) C. Stasis Dermatitis and edema are most suggestive of chronic venous insufficiency.
(u) D. See C for explanation.
A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of
A. pulmonary edema.
B. wide pulse pressure.
C. distended neck veins.
D. an early diastolic murmur.
(u) A. Pulmonary edema may result with low output states as seen with myocardial contusions, but it is not strongly suggestive of tamponade.
(u) B. Wide pulse pressure is seen in conditions of high stroke volume such as aortic insufficiency or hyperthyroidism. Narrow pulse pressure is seen with cardiac tamponade.
(c) C. Cardiac compression will manifest with distended neck veins and cold clammy skin.
(u) D. The onset of diastolic murmur is suggestive of valvular disease, not tamponade.
A patient presents with a rash, characterized by red macules and edematous papules with a clearing center. This best describes which of the following?
A. erythema marginatum
B. erythema multiforme
C. varicella
D. impetigo
(u) A. Erythema marginatum is associated with rheumatic fever and is characterized by macular to maculopapular lesions. A clearing center is not found in the rash.
(c) B. Target lesions, also termed iris lesions, are characteristic of erythema multiforme. The rash may be recurrent but typically resolves over 3-6 weeks.
(u) C. The rash of varicella typically has maculopapules, vesicles, and scabs in various stages of development. A clearing center is not found in the rash.
(u) D. The lesions of impetigo are pustules that form a honey-colored crust after rupturing.
In a patient suspected of having seborrheic dermatitis, the most common site of involvement would be the
A. upper extremities.
B. thighs.
C. scalp.
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The most common site of involvement of seborrheic dermatitis is the scalp. Other common sites include the eyebrows, eyelids, nasolabial fold, and ears.
(u) D. See C for explanation.
A 26-year-old obese female complains of a 3-4 month history of discrete erythematous plaques on the pretibial areas of her legs. The lesions have increased in size, become darker, and are painful. She is concerned because the centers of the lesions have become ulcerated. This patient should be screened for which of the following?
A. Hypothyroidism
B. Diabetes mellitus
C. Melanoma
D. Scleroderma
(u) A. In hypothyroidism the skin of the pretibial area may thicken leading to edema. This is a diffuse finding, involving the face and eyelids, without discrete lesions.
(c) B. The description of the skin lesions is characteristic of necrobiosis lipoidica diabeticorum, one of the dermatologic manifestations of diabetes mellitus.
(u) C. The lesions of melanoma are typically not painful and do not ulcerate.
(u) D. Scleroderma is marked by thickening of the skin, with swelling of the fingers and hands. The swelling may involve the forearms and face; the lower extremities are relatively spared.
A 40 year-old male presents to your clinic complaining of nontender, yellow patches on both eyelids. He states his brother and uncle have similar growths. He denies any visual changes or other complaints. Your primary suspicion is
A. gout.
B. lipoma.
C. hyperlipidemia.
D. seborrheic dermatitis.
(u) A. Tophaceous gout may appear as yellow skin lesions but they usually occur around the joints and helix of the ear.
(u) B. Lipomas tend to be flesh-colored and are not usually bilateral.
(c) C. Xanthelasmas, along with xanthomas, are common findings in familial hypercholesterolemia.
(u) D. Eyelids are a common location for seborrheic dermatitis but the lesions are not yellow in color.
A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis?
A. Croupy cough and drooling
B. Thick gray, adherent exudate
C. Beefy red uvula, palatal petechiae, white exudate
D. Inflammation and medial protrusion of one tonsil
(c) A. A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained.
(u) B. Thick gray adherent exudate is suggestive of diphtheria.
(u) C. Beefy red uvula, palatal petechiae, and white exudate are findings suggestive of streptococcal pharyngitis.
(u) D. Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.
Which of the following are normal findings in a Weber test?
A. The tympanic membrane is movable with pneumatic otoscopy.
B. The tympanic membrane is pearly gray with a sharp cone of light with apex at the umbo.
C. Sound is heard equally in both ears when a vibrating tuning fork is placed on the mid forehead.
D. Air conduction is greater than bone conduction when a vibrating tuning fork is moved from the mastoid bone to close to the ear canal.
(u) A. A movable tympanic membrane indicates there is no effusion, and is not the Weber test.
(u) B. The tympanic membrane is evaluated by direct observation with an otoscope, and is not the Weber test.
(c) C. A normal Weber test means there is no lateralization of sound perception when a vibrating tuning fork is placed on the mid forehead.
(u) D. A normal Rinne test means that tuning fork vibration is heard longer through the air than the bone.
Which of the following is diagnosed by use of the cover/uncover test?
A. Adie’s pupil
B. Strabismus
C. Glaucoma
D. Myopia
(u) A. Adie’s pupil is a sluggish pupil reaction to light and accommodation, evaluated by papillary reaction to light.
(c) B. The cover/uncover test is used to diagnose strabismus.
(u) C. Tonometry is used to measure intraocular pressure to evaluate for glaucoma.
(u) D. Myopia is evaluated by using a Snellen chart.
A patient is known to have end stage liver disease due to cirrhosis. Which of the following physical examination findings would commonly be seen in this patient?
A. Testicular hypertrophy
B. Muscular pseudohypertrophy
C. Gynecomastia
D. Hepatomegaly
(u) A. Testicular atrophy, wasting of the muscles of the lower extremity, spider angiomas, caput medusa and gynecomastia are physical examination findings associated with end stage liver disease associated due to cirrhosis.
(u) B. Muscular pseudohypertrophy is seen in muscular dystrophy.
(c) C. See A for explanation.
(u) D. Patients with end stage liver failure who have cirrhosis have a small shrunken liver from the ongoing cellular destruction and fibrosis.
Which of the following is the most consistent physical examination finding in a patient with duodenal ulcer?
A. Flank tenderness
B. Right upper quadrant tenderness
C. Epigastric tenderness
D. Rebound tenderness
(u) A. Flank tenderness is caused by urologic disorders such as pyelonephritis and renal lithiasis.
(u) B. Right upper quadrant tenderness on palpation is a typical feature for cholecystitis.
(c) C. Epigastric tenderness is a key feature of duodenal ulcer.
(u) D. Rebound tenderness is a feature of peritonitis from rupture of a hollow viscus and is not seen with just the presence of duodenal ulcer.
The initial sign or symptom of iron poisoning in a 3 year-old child is usually
A. vomiting and bloody diarrhea.
B. convulsions and tetany.
C. somnolence and coma.
D. ataxia and colicky abdominal pain.
(c) A. Iron causes localized necrosis and hemorrhage at the point of contact in the GI system resulting in abdominal pain, vomiting, bloody diarrhea, and hematemesis.
(u) B. Convulsions and tetany are symptoms of hypocalcemia.
(u) C. Somnolence and coma are not initial findings in iron ingestion.
(u) D. Ataxia and colicky abdominal pain are consistent with lead poisoning.
A classic skin finding seen in patients with inflammatory bowel disease would be
A. erythematous plaques on the extremities.
B. poorly healing, indolent ulcers on the lower extremities.
C. pretibial myxedema.
D. purple striae.
(u) A. Granuloma annulare is seen with diabetes mellitus. It consists of erythematous plaques on the extremities or trunk.
(c) B. Pyoderma gangrenosum is classically seen with inflammatory bowel disease and is rarely seen in the absence of inflammatory bowel disease.
(u) C. Pretibial myxedema is the skin manifestation of hyperthyroidism.
(u) D. The dermatologic manifestations of Cushing’s disease are purple striae and a supraclavicular fat pad.
A 55-year-old non-smoking male presents with a hemoglobin of 18.5 g/dl and a hematocrit of 56%. Which of the following physical examination findings is the most likely to be noted with this patient?
A. Splenomegaly
B. Cheilosis
C. Purpura
D. Decreased vibratory sense
(c) A. Patients with polycythemia vera present with elevated hemoglobin and hematocrit. On physical examination plethora, engorged retinal veins, and splenomegaly are common.
(u) B. Cheilosis is noted in iron deficiency anemia.
(u) C. Purpura is typically noted in bleeding disorders.
(u) D. Decreased vibratory sense is noted in vitamin B12 deficiency.
A 73 year-old male presents to the clinic with his wife. His wife has noticed that he has developed a resting tremor in his right hand and a shuffling gait over the last year. What finding on physical examination would support your suspected diagnosis?
A. Chorea
B. Dystonia
C. Masked facies
D. Hyperreflexia
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The patient symptoms are consistent with Parkinsonism. Physical exam findings include masked facies, micrographia, decreased arm swing, and monotonous speech.
(u) D. See C for explanation.
A patient with an upper motor neuron lesion would exhibit which of the following
findings?
A. Fasciculations
B. Areflexia
C. Muscular atrophy
D. Spasticity
(u) A. Fasciculations, areflexia and muscle atrophy are consistent with lower motor neuron lesions.
(u) B. See A for explanations.
(u) C. See A for explanation.
(c) D. Spasticity is an upper motor neuron lesion finding.
On examination of a pregnant patient the physician assistant notes a bluish or purplish discoloration of the vagina and cervix. This is called
A. Hegar’s sign.
B. McDonald’s sign.
C. Cullen’s sign
D. Chadwick’s sign
(u) A. Hegar’s sign is the softening of the cervix that often occurs with pregnancy.
(u) B. McDonald’s sign is when the uterus becomes flexible at the uterocervical junction at 7-8 weeks.
(u) C. Cullen’s sign is a purplish discoloration periumbilical and noted in pancreatitis.
(c) D. Chadwick’s sign is a bluish or purplish discoloration of the vagina and cervix.
On examination of a pregnant patient the physician assistant notes the fundal height is at the level of the umbilicus. This corresponds to what gestational age?
A. 16 weeks
B. 20 weeks
C. 24 weeks
D. 28 weeks
(u) A. See B for explanation.
(c) B. At 20-22 weeks the fundal height is typically at the level of the umbilicus.
(u) C. See B for explanation.
(u) D. See B for explanation.
Which of the following is the most common manifestation of polycystic ovarian syndrome?
A. Desquamation
B. Hirsutism
C. Galactorrhea
D. Rebound tenderness
(u) A. Desquamation is noted in toxic shock syndrome.
(c) B. The patient with polycystic ovarian syndrome typically presents with hirsutism or infertility.
(u) C. Galactorrhea is noted in hyperprolactinemia.
(u) D. Rebound tenderness is noted in conditions causing peritonitis.
Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle?
A. Supraspinatus
B. Infraspinatus
C. Teres minor
D. Subscapularis
(c) A. Abduction against resistance tests the supraspinatus.
(u) B. Lateral rotation against resistance tests the infraspinatus and teres minor.
(u) C. See B for explanation.
(u) D. Medial rotation against resistance tests the subscapularis.
A 22 year-old male presents to the ED after sustaining a blow to the knee during football practice. The knee exam demonstrates significant forward translation of the tibia when the knee is in 15 degrees of flexion and external rotation at the hip. Which of the following knee maneuvers does this represent?
A. Abduction stress test
B. Anterior drawer sign
C. Lachman test
D. McMurray test
(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears while applying valgus stress.
(u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; however the patient is supine, hips and knees flexed, and feet are flat on the table.
(c) C. The Lachman test is performed to evaluate the anterior cruciate ligament. The knee is placed in 15 degrees of flexion and external rotation of the hip.
(u) D. The McMurray test is performed to evaluate medial and lateral meniscal tears while rotating the lower leg internally and externally.
A 12 year-old female presents for a routine sports physical. The physical exam reveals asymmetry of the posterior chest wall on forward bending. This is the most striking and consistent abnormality of which of the following?
A. Spondylolysis
B. Spondolisthesis
C. Scoliosis
D. Herniated disc
(u) A. Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles.
(u) B. Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis.
(c) C. Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis.
(u) D. Herniated disc presents with lumbar muscle spasm and a positive straight leg test.
Physical exam findings in a 4 year-old child that include blue sclerae and recurrent fractures indicates which of the following?
A. Ehlers-Danlos syndrome
B. Marfan syndrome
C. Achondroplasia
D. Osteogenesis imperfecta
(u) A. Physical exam findings in Ehlers-Danlos include laxity and hypermobility of joints, mitral valve prolapse, and associated degenerative arthritis.
(u) B. Children with Marfan syndrome have hypotonia, arachnodactyly, joint laxity and dislocations.
(u) C. Children with achondroplasia are below normal standards on growth charts. They have difficulty balancing their large heads when beginning to walk.
(c) D. Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures and presenile deafness.
Which of the following historical factors differentiates post-traumatic stress disorder from acute stress disorder?
A. The inability of the person to recall an important aspect of the event.
B. Avoidance of stimuli that invokes recollections of the event.
C. A belief that their future has been foreshortened because of the event.
D. The presence of sleep disorder.
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Post-traumatic stress disorder and acute stress disorder have many of the same characteristics. A sense of a foreshortened future, such as not expecting a normal life span or a career due to the trauma, distinguishes post-traumatic stress disorder from an acute stress disorder. The other answers are common to both disorders.
(u) D. See C for explanation.
A patient with obsessive-compulsive disorder would most likely have which of the following findings?
A. Raw, red hands
B. Priapism
C. Memory impairment
D. Abdominal pain
(c) A. Common manifestations of obsessive-compulsive disorder include phobias of germ and contaminants, which results in frequent hand washing leading to chafe and reddened hands. The other answers are inconsistent with obsessive-compulsive disorder.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a “cold” for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient?
A. spoken “ee” heard as “ay”
B. hyperresonant percussion note
C. wheezes over the involved area
D. vesicular breath sounds over involved area
(c) A. This patient most likely has a bacterial pneumonia with consolidation, which would produce egophony, where a spoken “ee” is heard as “ay.”
(u) B. Consolidation from bacterial pneumonia causes findings of dullness to percussion, late inspiratory crackles and bronchial breath sounds over the involved area.
(u) C. See explanation B.
(u) D. See explanation B.
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 history of an upper respiratory tract symptoms followed by onset of a barking cough and stridor.
A foreign body lodged in the trachea that is causing partial obstruction will most likely produce what physical examination finding?
A. stridor
B. aphonia
C. inability to cough
D. progressive cyanosis
(c) A. An inspiratory wheeze is called stridor, which indicates a partial obstruction of the trachea or larynx.
(u) B. Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of the trachea, not partial obstruction.
(u) C. See B for explanation.
(u) D. See B for explanation.
On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause?
A. asthma
B. consolidation
C. pneumothorax
D. pleural effusion
(u) A. Asthma is characterized by decreased tactile fremitus, but would have resonant to hyperresonant percussion, not dullness.
(u) B. Consolidation from pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus.
(u) C. A pneumothorax is characterized by decreased to absent tactile fremitus, but would have a hyperresonant percussion note, not dullness.
(c) D. A decreased tactile fremitus and dullness to percussion would be found in a pleural effusion.
A patient with a 15-year history of type 2 diabetic mellitus presents for follow-up. Labs reveal a BUN 100 mg/dl, serum creatinine 9.2 mg/dl, and serum glucose 164 mg/dl. Which of the following would you expect to find on physical examination?
A. Pruritus
B. Hypotension
C. Macroglossia
D. Suprapubic tenderness
(c) A. Hypertension, pruritus and xerosis are common findings in the uremic patient.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. Suprapubic tenderness is associated with urinary tract infection or acute obstructive uropathy.
When performing a rectal examination, prostatic massage is contraindicated in
A. prostatodynia.
B. non-bacterial prostatitis.
C. chronic bacterial prostatitis.
D. acute bacterial prostatitis.
(u) A. Prostatodynia is an inflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement.
(u) B. Non-bacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are cultured, and the cause is unknown.
(u) C. Prostate massage can be performed in the absence of fever. Expressed prostatic secretions are cultured to help identify the organism.
(c) D. Vigorous manipulation of the prostate during rectal examination may result in septicemia. This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain.
Which of the following is typically noted on physical examination in a patient with diphtheria?
A. Papular rash on trunk
B. Supraclavicular adenopathy
C. Pharyngeal pseudomembranes
D. Splenomegaly
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The classic exam finding noted in diphtheria is a gray pharyngeal pseudomembrane. Rash, splenomegaly, and supraclavicular adenopathy are not noted in diphtheria.
(u) D. See C for explanation.
Cardiac nuclear scanning is done to detect
A. electrical conduction abnormalities.
B. valvular abnormalities.
C. ventricular wall dysfunction.
D. coronary artery patency/occlusion.
(u) A. An EKG is used to determine electrical conduction abnormalities.
(u) B. An echocardiogram is a non-invasive test used to determine valvular abnormalities and wall motion.
(c) C. Visualization of the cardiac wall can be done with cardiac nuclear scanning. This is done to determine hypokinetic areas from akinetic areas.
(u) D. Patency or occlusion is assessed with cardiac catheterization (invasive).
A 72 year-old male with a new diagnosis of congestive heart failure and atrial fibrillation, develops episodes of hemodynamic compromise secondary to increased ventricular rate. A decision to perform elective cardioversion is made and the patient is anticoagulated with heparin. Which test should be ordered to assess for atrial or ventricular mural thrombi?
A. Electrocardiogram
B. Chest x-ray
C. Transesophageal Echocardiogram
D. C-reactive protein
(u) A. Electrical conduction will not assess for mural thrombi.
(u) B. A chest x-ray will not visualize the left atria and ventricles to assess for mural thrombi.
(c) C. Transesophageal echocardiography allows for determination of mural thrombi that may have resulted from atrial fibrillation.
(u) D. C-reactive protein is not going to give you any information regarding thrombi. This test is used to identify the presence of inflammation.
A 64 year-old patient with known history of type 1 diabetes mellitus for 50 years has developed pain radiating from the right buttock to the calf. Patient states that the pain is made worse with walking and climbing stairs. Based upon this history which of the following would be the most appropriate test to order?
A. Venogram
B. Arterial duplex scanning
C. X-ray of the right hip and L/S spine
D. Venous Doppler ultrasound
(u) A. See B for explanation.
(c) B. Given the patient’s long history of type 1 diabetes mellitus the patient most likely has vascular occlusive disease. Evaluation of arterial blood flow is assessed using the duplex scanner. X-ray of the L/S spine and right hip while not harmful may give information regarding bony structures. Venous Doppler ultrasound will not give information of arterial perfusion.
(u) C. See B for explanation.
(u) D. See B for explanation.
A 36 year-old male complains of occasional episodes of “heart fluttering”. The patient describes these episodes as frequent, short-lived and episodic. He denies any associated chest pain. Based on this information, which one of the following tests would be the most appropriate to order?
A. Holter monitor
B. Cardiac catheterization
C. Stress testing
D. Cardiac nuclear scanning
(c) A. Holter monitoring is a non-invasive test done to obtain a continuous monitoring of the electrical activity of the heart. This can help to detect cardiac rhythm disturbances that can correlate with the patient symptoms. Cardiac catheterization is an invasive procedure done to assess coronary artery disease. Stress testing and cardiac nuclear scanning are non-invasive testing maneuvers done to assess coronary artery disease.
A patient with a mitral valve replacement was placed post-operatively on warfarin (Coumadin) for anticoagulation prophylaxis. To monitor this drug for its effectiveness, what test would be used?
A. PTT
B. PT-INR
C. Platelet aggregation
D. Bleeding time
(u) A. PTT is a reflection of the intrinsic clotting system and is used to monitor heparin administration.
(c) B. PT-INR is a reflection of the extrinsic and common pathway clotting system. Coumadin interferes with Vitamin K synthesis which is needed in the manufacture of factors II, VII, IX, X which are part of the extrinsic clotting pathway.
(u) C. Platelet aggregation tests are utilized to assess platelet dysfunction.
(u) D. Bleeding time is used to assess platelet function.
A 26 year-old male complains of intense itching, especially at night and after hot showers, for the past 4 days. On physical examination he has a few red papules and areas of excoriation on his volar wrists, between his fingers, and around his waist. Proper diagnosis should include which of the following tests?
A. KOH prep
B. Gram stain
C. Skin scraping microscopy
D. Tzanck prep
(u) A. A KOH prep would be used to examine for evidence of a fungal infection.
(u) B. A Gram stain would be used for a bacterial infection and would be inappropriate in this situation.
(c) C. The history and exam is consistent with a scabies infection. Scrapings from the burrows should be examined for the presence of mites, eggs, and feces.
(u) D. A Tzanck prep would be used to examine for giant multinucleated cells characteristic of a herpes infection.
A 35 year-old female who recently returned from a backpacking trip complains of fatigue, malaise, fever, chills, and arthralgias. Physical examination reveals a 6 cm annular lesion with a red border and a clear center on her mid-back. Which of the following laboratory tests would support your diagnosis?
A. KOH prep of skin scrapings
B. Blood cultures
C. RAST testing
D. Serologic antibody testing
(u) A. Although the skin lesion may resemble a fungal infection, a fungal dermatophyte would not present with systemic symptoms.
(u) B. Culturing of <i>Borrelia burgdorferi</i> from clinical specimens, with the exception of skin biopsies at the site of the lesion, have resulted in low yields.
(u) C. RAST testing is utilized in evaluation of allergies and is not indicated in this situation.
(c) D. Most people with Lyme Disease will have a positive serologic test after the first few weeks of infection and this would support the diagnosis.
A patient complains of fatigue, tremors, palpitations, and heat intolerance. The thyroid is diffusely enlarged and firm on palpation. Which of the following laboratory findings is the most consistent with this presentation?
A. Low T4
B. Low TSH
C. Decreased bilirubin
D. Normal radionuclide scan
(u) A. See B for explanation.
(c) B. The presentation is consistent with hyperthyroidism. Laboratory findings include low TSH, elevated free and total thyroid hormone levels, and an increased uptake on radionuclide scan. There may also be elevated bilirubin, liver enzymes, and ferritin levels, along with anemia and thrombocytopenia.
(u) C. See B for explanation
(u) D. See B for explanation
A solitary thyroid nodule is noted on physical examination. The TSH level is normal. The next step in the evaluation is
A. measurement of T4 and free T3 levels.
B. a radionuclide thyroid scan.
C. a fine needle biopsy.
D. a surgical excision.
(u) A. Measurement of T4 and T3 levels would not be of benefit in the evaluation of a solitary thyroid nodule with a normal TSH level.
(u) B. A thyroid scan would be the next step if there were a low TSH level.
(c) C. Fine needle aspiration (FNA) is the first step in the evaluation of a solitary nodule with a normal TSH level. FNA has a high level of accuracy in diagnosing benign versus malignant nodules in this setting.
(u) D. Surgical excision would be the final step after determination of malignancy or suspicion of malignancy by FNA.
A 32 year-old carpenter complains of right eye irritation all day after driving a metal stake into the ground with his hammer. He states that “something flew into my eye.” Visual acuity is 20/20. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact. There is minimal right corneal injection. No foreign body is noted with lid eversion. Fluorescein stain reveals a tiny pinpoint uptake in the area of the corneal injection. Which of the following is the most appropriate diagnostic test at this stage?
A. MRI
B. X-ray orbits
C. Applanation tonometry
D. Fluorescein angiography
(h) A. MRI should never be used when there is suspicion of an iron-containing intraocular foreign body.
(c) B. Orbital x-rays or CT scan will be most helpful in identifying an intraocular metallic foreign body.
(u) C. Tonometry is used to evaluate intraocular pressure, but not the presence of intraocular foreign bodies.
(u) D. Fluorescein angiography is used to evaluate vessels of the eye, not intraocular foreign bodies.
A 45 year-old male complains of loss of hearing in his left ear. He also complains of
ringing in the ear, and has had occasional dizziness. On exam, there is unilateral left-
sided sensorineural hearing loss and a diminished corneal reflex. Neuro exam is
otherwise normal. TMs are normal, and canals are clear. Neck is supple, without
adenopathy. Oropharynx is normal. Of the following, the best diagnostic study to identify the cause of this patient’s complaints is
A. auditory brainstem evoked response.
B. gadolinium-enhanced MRI.
C. acoustic reflex testing.
D. vestibular testing.
(u) A. See B for explanation.
(c) B. MRI has replaced auditory brainstem evoked response and acoustic reflex testing in the evaluation of patients for acoustic neuromas.
(u) C. See B for explanation.
(u) D. Vestibular testing is not a useful screening test for acoustic neuromas.
Which of the following laboratory abnormalities is most commonly seen acutely in a patient who has a massive GI bleed?
A. Increased BUN level
B. Hypercalcemia
C. Hyponatremia
D. Increased AST
(c) A. Blood in the gut will cause a considerable increase in the BUN that is independent of decreased renal perfusion or intrinsic renal dysfunction. BUN rises as a result of catabolism and absorption of blood protein with a resultant increase in nitrogenous waste.
(u) B. Acute blood loss does not result in a change in the calcium level unless multiple transfusions are given.
(u) C. Massive GI blood loss acutely results in blood volume contraction without acutely changing the sodium concentration until intravenous therapy is given
(u) D. Increases in the serum AST is the result of hepatocyte injury or inflammation and does not occur as a result of GI bleeding.
Primary biliary cirrhosis will have which of the following laboratory results?
A. Decreased haptoglobin
B. Anticholinesterase antibodies
C. Antimitochondrial antibodies
D. Elevated ceruloplasmin
(u) A. Haptoglobin is a glycoprotein that is made in the liver that acts as a scavenger molecule to recapture iron after hemolysis occurs. Its levels decrease with active bleeding or cell destruction as seen in hemolytic anemia.
(u) B. Anticholinesterase antibodies are evaluated in patients suspected of having myasthenia gravis.
(c) C. Antimitochondrial antibodies are seen in patients with primary biliary cirrhosis, a chronic, progressive cholestatic disease of the liver that is characterized by destruction of the extrahepatic bile ducts.
(u) D. Ceruloplasmin elevations are seen with Wilson’s disease, a disease that is due to a disordered copper metabolism.
Which of the following diagnostic tests is considered to be the best initial test to order in a patient with suspected gallbladder disease?
A. Ultrasound
B. Hepatic iminodiacetic acid (HIDA) scan
C. Flat plate of the abdomen
D. Endoscopic retrograde cholangiopancreatography (ERCP)
(c) A. Ultrasound of the abdomen is the best test for checking the extra-hepatic biliary tree for ductal dilatation and choledocholithiasis.
(u) B. HIDA scan is usually ordered to assess gallbladder function. It is mostly ordered if initial ultrasound is normal and there is still a high index of suspicion for gallbladder disease.
(u) C. Flat plate of the abdomen will only identify about 10 to 15% of gallstones.
(u) D. ERCP is performed to remove gallstones that have become lodged in the common bile duct. It is not an initial study that is performed.
An 8-year-old presents with splenomegaly. CBC results reveal the following: WBC-6,300/microliter, Hgb- 10.5 g/dl, Hct- 31%, MCV- 87 fL, MCHC- 39 g/dl, MCH- 28 pg, and platelets- 317,000/mL. Examination of the RBC morphology reveals 80% spherocytes. Which of the following would be most helpful in confirming the diagnosis?
A. Direct Coombs test
B. Osmotic fragility
C. G-6-PD level
D. Serum ferritin
(u) A. The direct Coombs test would be negative and would not be helpful in diagnosing hereditary spherocytosis.
(c) B. Hereditary spherocytosis presents with a normocytic, normochromic anemia and many spherocytes. Diagnosis is confirmed with a positive osmotic fragility test.
(u) C. G-6-PD deficiency presents with minimal or no RBC morphologic abnormalities and is diagnosed by measuring G-6-PD enzyme activity level.
(u) D. Iron deficiency anemia typically presents with microcytic, hypochromic red blood cells and is diagnosed with a serum ferritin.
What test is the single most useful test in establishing the diagnosis of multiple sclerosis?
A. Cerebral spinal fluid cell count and protein level
B. Cerebral spinal fluid immunoglobulin studies
C. Evoked potentials
D. Magnetic Resonance Imaging
(u) A. While cerebral spinal fluid cell count, protein levels, and immunoglobins may be abnormal they are not specific for multiple sclerosis.
(u) B. See A for explanation.
(u) C. Evoked potentials are most useful in the detection of subclinical involvement of neuropathways in MS, but does not establish the diagnosis.
(c) D. The presence of plaques on MRI is a key finding in establishing the diagnosis of MS.
A 22 year-old male presents to the clinic complaining of excessive daytime somnolence and strong desires to sleep at inappropriate times. He came in today because he had an episode of “feeling paralyzed” as he was falling asleep yesterday. What is the most appropriate diagnostic test to confirm this patient’s diagnosis?
A. MRI of the brain
B. Electroencephalogram
C. Multiple sleep latency test
D. Overnight polysomnography
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Multiple sleep latency test is required to observe the abrupt transition to REM sleep and establish the diagnosis of narcolepsy.
(u) D. See C for explanation.
A 25 year-old female presents with vulvar pruritus and a thick, white vaginal discharge. Which of the following tests will be most helpful in making the correct diagnosis?
A. KOH prep
B. Gram stain
C. Tzanck smear
D. FTA-ABS
(c) A. KOH prep is used to assist in the diagnosis of vaginal candidiasis, which presents with vulvar pruritus and white curd like, cheesy vaginal discharge.
(u) B. Gram stain is used in the diagnosis of bacterial infections.
(u) C. Tzanck smear is used to diagnose herpes infections.
(u) D. FTA-ABS is used to diagnose syphilis.
A 25 year-old presents with pelvic pain and uterine bleeding. Her Beta-HCG was 1200 mIU/L six days ago. Her current Beta-HCG is 1600 mIU/L. What is the next best test in the evaluation of this patient?
A. Laparoscopy
B. Culdocentesis
C. Dilation and curettage
D. Transvaginal ultrasound
(u) A. The use of laparoscopy in the diagnosis of an ectopic pregnancy has decreased, but is still useful when a definitive diagnosis is difficult.
(u) B. Culdocentesis is used in the diagnosis of intraperitoneal bleeding, which may or may not be present in an ectopic pregnancy.
(u) C. Dilation and curettage may confirm or exclude intrauterine pregnancy but is not the next best test in the evaluation of ectopic pregnancy.
(c) D. Transvaginal ultrasound is the best test to separate ectopic from intrauterine pregnancy.
A couple presents having not been able to conceive over the past 12 months. Evaluation of the male has been normal. The female has had regular menses. Ovulation can be confirmed with mid-luteal phase measurement of which of the following?
A. Thyroid stimulating hormone
B. Luteinizing hormone
C. Progesterone
D. Prolactin
(u) A. TSH is used only if signs of thyroid disease are present.
(u) B. LH, FSH, and prolactin are used to confirm ovulation in patients with irregular menstrual cycles.
(c) C. Ovulation can best be confirmed by measuring serum progesterone levels in the mid-luteal phase.
(u) D. See B for explanation.
A 65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine?
A. Radiolucent lesions
B. Demineralization
C. Chondrocalcinosis
D. Subperiosteal resorption
(u) A. Paget’s disease of bone presents with bone pain, kyphosis, bowed tibias, large head, and deafness. The initial lesions are destructive and radiolucent. Paget’s disease has a normal serum calcium and phosphate, but the serum alkaline phosphatase is elevated.
(c) B. Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. X-
ray findings demonstrate demineralization in the spine and pelvis.
(u) C. Chondrocalcinosis is the presence of calcium-containing salts in articular cartilage and is commonly seen in hyperparathyroidism, diabetes, hypothyroidism, and gout.
(u) D. Hyperparathyroidism is frequently asymptomatic. Serum parathyroid hormone and serum calcium are elevated. X-ray findings include demineralization, subperiosteal resorption of bone especially in the radial aspects of the fingers.
In a trauma patient who has a suspected cervical spine injury, the x-ray view that will identify the majority of significant injuries is
A. lateral.
B. oblique.
C. anteroposterior.
D. odontoid.
(c) A. The lateral view shows 70-80% of significant injuries. It is important to visualize all seven cervical vertebrae and the upper margin of T1 to avoid missing possible pathology.
(u) B. The oblique view is usually not included in the initial set of x-rays taken. Bilateral supine oblique is a view that may be ordered if all seven cervical vertebrae are not seen on the lateral view.
(u) C. Anteroposterior view shows < 1% of significant injuries.
(u) D. The odontoid view reveals 10% of significant injuries.
A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient “yells” in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done?
A. X-ray of the lower leg and ankle.
B. Doppler studies.
C. Bone scan.
D. Compartment pressure
(u) A. X-rays of the lower leg and ankle will only determine bone placement.
(u) B. Doppler studies will confirm the presence of a decreased pulse.
(u) C. A bone scan is not indicated in the evaluation of compartment syndrome.
(c) D. Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency.
A 19 year-old female presents with complaints of intermittent abdominal pain associated with recent, frequent episodes of regurgitation of food for the past several months and worsening over the past 12 hours. She maintains a normal weight for her height however she seems obsessed with losing weight. On examination the physician assistant notes multiple dental caries, bilateral tenderness of the parotid glands and mild epigastric tenderness. Which of the following findings would you expect to find on laboratory tests to support your suspected diagnosis?
A. hypokalemia
B. hypocalcemia
C. hyperchloremia
D. hypermagnesemia
(c) A. This patient most likely has bulimia nervosa - purging type. Self-induced vomiting is the most common method of purging and this is supported by the physical examination findings noted in this patient. Laboratory findings to support this diagnosis include hypochloremia with subsequent hypokalemia due to renal compensatory mechanisms, hypomagnesemia and metabolic alkalosis.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A divorced female patient presents for an employment physical. She states she has had a “run of bad luck” with jobs and has not been able to hold any job for longer than 2-3 months. She also states she has been arrested several times for getting into fights when she is out with the girls. She states she drinks an occasional beer, but denies any significant problems with alcohol. Which of the following laboratory findings would support your suspected diagnosis?
A. decreased triglycerides
B. decreased serum uric acid
C. increased LDL cholesterol
D. increased mean corpuscular volume
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. The primary lipid abnormalities demonstrated with alcoholism are increased triglycerides and increased HDL cholesterol, not LDL cholesterol.
(c) D. This patient most likely has alcohol abuse as evidence by her social, occupational and legal issues. Laboratory tests will reveal the presence of an elevated mean corpuscular volume, triglycerides, serum uric acid and liver function tests.
Which of the following is essential to make a diagnosis of cystic fibrosis?
A. Positive family history
B. Elevated sweat chloride
C. Recurrent respiratory infections
D. Elevated trypsinogen levels
(u) A. Cystic fibrosis is a genetic disease, but a positive family history in and of itself is not enough to diagnose the condition.
(c) B. The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test or demonstration of a genotype consistent with cystic fibrosis.
(u) C. While recurrent respiratory infections are a classic presentation of cystic fibrosis, the diagnosis relies on confirmation, as noted in explanation B.
(u) D. Trypsinogen levels are used as a neonatal screening test and if elevated should be followed by more definitive testing to confirm the diagnosis.
An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. Which of the following is the most appropriate interpretation of this test result?
A. positive
B. negative
C. active infection
D. falsely negative
(c) A. A reaction size of greater than or equal to 5 mm in a HIV positive patient is considered a positive tuberculin skin test reaction.
(u) B. See A for explanation.
(u) C. A positive PPD identifies patients that have been infected with Mycobacterium tuberculosis, but does not indicate whether the disease is currently active or inactive.
(u) D. See A for explanation.
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 and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes 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 patient presents with a history of progressive worsening of dyspnea over the past several years. He gives a history of having worked as a ship builder for over 50 years. He denies any alcohol or tobacco use. On examination you note clubbing and inspiratory crackles. Which of the following chest x-ray findings support your suspected diagnosis?
A. hyperinflation and flat diaphragms
B. interstitial fibrosis and pleural thickening
C. cavitary lesions involving the upper lobes
D. “eggshell” calcification of hilar lymph nodes
(u) A. Chest x-ray findings of hyperinflation and flat diaphragms suggest long-standing chronic obstructive lung disease.
(c) B. This patient most likely has asbestosis, which is supported by his occupation as a ship builder and clinical presentation as noted above. Chest x-ray findings include interstitial fibrosis, pleural thickening and calcified pleural plaques on the diaphragm or lateral chest wall.
(u) C. Chest x-ray findings of cavitary lesions involving the upper lobes suggest pulmonary tuberculosis.
(u) D. Chest x-ray findings of “eggshell” calcification of hilar lymph nodes strongly supports the diagnosis of silicosis.
A 38 year-old female presents with right flank pain for several days, shaking chills, fever to 102°F, and general malaise. The flank pain has been intermittently severe, and she has a history of kidney stones. Urinalysis reveals 3+ red blood cells, 3+ leukocyte esterase, trace protein and negative glucose. Which of the following findings would most likely be seen on a renal ultrasound?
A. Small echogenic kidneys
B. Cysts
C. Hydronephrosis
D. Capsular hemorrhage
(u) A. Small echogenic kidneys bilaterally, less than 10cm, support a diagnosis of chronic renal failure.
(u) B. Cysts and capsular hemorrhage are not causes of obstructive pyelonephritis.
(c) C. Hydronephrosis, dilation of the collecting ducts, may be present due to a stone or other source of obstruction.
(u) D. See B for explanation.
A 65 year-old patient presents with hypertension and peripheral edema. Urinalysis reveals pale urine, with a specific gravity of 1.002, 2+ protein, trace glucose, and is negative for red blood cells and leukocytes. Serum electrolytes include BUN of 58 mg/dl and creatinine of 4.5 mg/dl. These are unchanged from previous results obtained 3 months and 6 months ago. Of the following, what other laboratory abnormalities would you expect?
A. Hypercalcemia
B. Metabolic alkalosis
C. Hypophosphatemia
D. Anemia
(u) A. Patients with chronic renal failure typically present with hypocalcemia, hyperphosphatemia, and metabolic acidosis.
(u) B. See A for explanation.
(u) C. See A for explanation.
(c) D. Anemia of chronic disease is associated with chronic renal failure.
An 8 year-old patient presents with fever, nausea, vomiting, and diarrhea, 12 hours after playing with a turtle. The stools are watery, non-bloody and of moderate volumes. Which of the following laboratory tests will be most helpful in making the diagnosis?
A. Stool for ova and parasites
B. Scotch tape test
C. Widal test
D. Stool culture
(u) A. The most likely diagnosis is salmonellosis, which is a bacterial infection, and this will not be diagnosed with ova and parasite studies.
(u) B. The scotch tape test is used to diagnose pinworm infections, which typically present with perianal itching.
(u) C. The Widal test detects febrile agglutinins seen in typhoid fever, but a large number of false-
positives and false-negatives make this test not useful clinically.
(c) D. Salmonellosis presents with fever, nausea, vomiting and diarrhea, 6-48 hours after ingestion of the organism. It is commonly transmitted to humans from eggs, poultry, and reptiles. Diagnosis is made by isolation of the organism via stool culture.
A 64 year-old male, with a long history of COPD, presents with increasing fatigue over the last three months. The patient has stopped playing golf and also complains of decreased appetite, chronic cough and a bloated feeling. Physical examination reveals distant heart sounds, questionable gallop, lungs with decreased breath sounds at lung bases and the abdomen reveals RUQ tenderness with the liver two finger-breadths below the costal margin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level 1.6 mg/dl, BUN 42 mg/dl, liver function test’s mildly elevated and the CBC to be normal. Which of the following is the most likely diagnosis?
A. Right ventricular failure
B. Pericarditis
C. Exacerbation of COPD
D. Cirrhosis
(c) A. Signs of right ventricular failure are fluid retention i.e. edema, hepatic congestion and possibly ascites.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities has 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis?
A. Venous thrombosis
B. Arterial thrombosis
C. Thromboangiitis obliterans
D. Thrombophlebitis
(u) A. See B for explanation.
(c) B. Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse.
(u) C. See B for explanation.
(u) D. See B for explanation.
A 48 year-old male with a known history of hypertension is brought to the ED complaining of headache, general malaise, nausea and vomiting. The patient currently takes nifedipine (Procardia)90mg XL every day and atenolol (Tenormin) 50 mg every day. Vital signs reveal temperature 98.6°F, pulse 72/minute, respiratory rate 20/minute, and the blood pressure is 168/120 mmHg. BP reading taken every 15 minutes from the time of admission reveal the systolic to run from 176 to 186 mmHg and the diastolic to run from 135 to 150 mmHg. Physical examination reveals papilledema bilaterally. There are no renal bruits noted. The EKG is normal. Based upon this presentation, what is the most likely diagnosis?
A. Meningitis
B. Secondary hypertension
C. Pseudotumor cerebri
D. Malignant hypertension
(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. Pseudotumor cerebri presents with papilledema, but not hypertension and is more common in young females.
(c) D. Malignant HTN is characterized by diastolic reading greater than 140 mm Hg with evidence of target organ damage.
A 55 year-old male is seen in follow-up for a complaint of chest pain. Patient states that he has had this chest pain for about one year now. The patient further states that the pain is retrosternal with radiation to the jaw. “It feels as though a tightness, or heaviness is on and around my chest”. This pain seems to come on with exertion however, over the past two weeks he has noticed that he has episodes while at rest. If the patient remains non-
active the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smoking history and drinks a martini daily at lunch. Patient appears overweight on inspection. Based upon this history what is the most likely diagnosis?
A. Acute myocardial infarction
B. Prinzmetal variant angina
C. Stable angina
D. Unstable angina
(u) A. Pain does not resolve in an acute MI, it gradually gets worse.
(u) B. Pain typically occurs at rest is one of the hallmarks of Prinzmetal variant angina. This patient has just started to develop pain at rest.
(u) C. Pain in stable angina is relieved with rest and usually resolves within 10 minutes. Stable angina does not have pain at rest.
(c) D. Pain in unstable angina is precipitated by less effort than before or occurs at rest.
A 60 year-old male is brought to the ED complaining of severe onset of chest pain and intrascapular pain. The patient states that the pain feels as though “something is ripping and tearing”. The patient appears shocky; the skin is cool and clammy. The patient has an impaired sensorium. Physical examination reveals a loud diastolic murmur and variation in blood pressure between the right and left arm. Based upon this presentation what is the most likely diagnosis?
A. Aortic dissection
B. Acute myocardial infarction
C. Cardiac tamponade
D. Pulmonary embolism
(c) A. The scenario presented here is typical of an ascending aortic dissection. In an acute myocardial infarction the pain builds up gradually. Cardiac tamponade may occur with a dissection into the pericardial space; syncope is usually seen with this occurrence. Pulmonary embolism is usually associated with dyspnea along with chest pain.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 42 year-old male is brought into the ED with a complaint of chest pain. The pain comes on suddenly without exertion and lasts anywhere from 10-20 minutes. The patient has experienced this on three previous occasions. Today the patient complains of light-headedness with the chest pain lasting longer. Vital signs T-99.3°F oral, P-106/minute and regular, R-22/minute, BP 146/86 mm Hg. EKG reveals sinus rhythm with a rate of 100. Intervals are PR = 0.06 seconds, QRS = 0.12 seconds. A delta wave is noted in many leads. Based upon this information what is the most likely diagnosis?
A. Sinus tachycardia
B. Paroxysmal supraventricular tachycardia
C. Wolff-Parkinson-White syndrome
D. Ventricular tachycardia
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Wolff-Parkinson-White syndrome hallmarks on EKG include a shorten PR interval, widened QRS, and delta waves. Sinus tachycardia has a normal PR interval and no delta waves. PSVT usually has a retrograde P wave or it may be buried in the QRS complex.
(u) D. Ventricular tachycardia has a widened QRS as it originates in the ventricles.
A 63 year-old male is admitted to the hospital with an exacerbation of COPD. The electrocardiogram shows an irregularly, irregular rhythm at a rate of 120/minute with at least three varying P wave morphologies. These electrocardiogram findings are most suggestive of
A. atrial fibrillation.
B. multifocal atrial tachycardia.
C. atrioventricular junctional rhythm.
D. third degree heart block.
(u) A. Atrial fibrillation is an irregularly, irregular rhythm with no definable P waves.
(c) B. Multifocal atrial tachycardia is seen most commonly in patients with COPD. Electrocardiogram findings include an irregularly, irregular rhythm with a varying PR interval and various P wave morphologies (Three or more foci).
(u) C. Atrioventricular junctional rhythm is an escape rhythm, because of depressed sinus node function, with a ventricular rate between 40-60/minute.
(u) D. Third degree heart block presents with a wide QRS at a rate less than 50/minute and blocked atrial impulses.
A 56 year-old, right hand dominant, carpenter presents to your clinic complaining of a prolonged bruise under his left thumbnail. He states that he first noticed it one year ago. Physical examination reveals a nontender left thumb with a 6 mm macular lesion located under the distal nail bed. It is mixed dark brown and black in color, with irregular borders. The most likely diagnosis is
A. lentigo.
B. trauma.
C. melanoma.
D. nevus.
(u) A. Lentigos are typically uniform in color with well-demarcated borders.
(u) B. If the lesion was from trauma, it should have resolved well before one year.
(c) C. Acral lentiginous melanoma may occur on the palm, sole, nail bed, or mucus membrane. This lesion is suspicious for a melanoma due to its irregular borders, being variegated in color, and its size. A biopsy is required and will insure the diagnosis.
(u) D. A nevus usually has regular, well-demarcated borders.
A mother brings in her 2 year-old child stating that the child has had a 3-day history of a nonproductive cough, thick copious rhinorrhea, conjunctivitis, and a fever to 103 degrees. Physical examination reveals a well-hydrated child, with numerous 1-2 mm white papules on both buccal mucosa, normal heart and breath sounds. This presentation is most consistent with early
A. rubeola.
B. rubella.
C. varicella.
D. streptococcal pharyngitis
(c) A. Rubeola (measles) is characterized by cough, coryza, and conjunctivitis, along with a fever as a prodrome. Koplik spots appear prior to the onset of the typical erythematous, maculopapular rash and are pathognomonic for rubeola.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 30 year-old female complains of fatigue, weakness, diminished appetite, weight loss, and syncope. She denies fever, chest or abdominal pain, palpitations, changes in bowel patterns or sleep patterns. Physical examination reveals a thin female, BP 90/65 mmHg, and pulse 80 beats per minute. Pulmonary, cardiovascular, abdominal, and neurologic exam are without abnormalities. Areas of brown and bronze hyperpigmentation are noted
on her elbows and the creases of her hands. Which of the following is the most likely diagnosis?
A. Addison’s disease
B. Cushing’s disease
C. Anorexia nervosa
D. Porphyria
(c) A. Addison’s disease (adrenal insufficiency) would account for all her symptoms, the hypotension, and the hyperpigmentation of the skin.
(u) B. Cushing’s disease, the presence of an ACTH-producing adenoma, is characterized by central obesity, hypertension, moon facies, purple striae, and glucose intolerance.
(u) C. Anorexia nervosa may explain the weakness, weight loss, hypotension, and syncope, however, a normal pulse rate would be an unexpected finding along with the hyperpigmentation.
(u) D. Porphyria presents acutely with anxiety, depression, disorientation, and insomnia.
A 72 year-old female is being evaluated for recurrent kidney stones. Physical examination reveals no abnormal findings. Laboratory findings show elevated calcium and decreased phosphate levels. Which of the following is the most likely diagnosis?
A. Pheochromocytoma
B. Adrenal insufficiency
C. Hyperparathyroidism
D. Breast cancer
(u) A. Pheochromocytoma may lead to hypercalcemia but the patient does not have any signs or symptoms suggestive of pheochromocytoma, such as hypertension, headache, profuse sweating, or weight loss.
(u) B. Adrenal insufficiency, Addison’s disease, would reveal, in addition to the hypercalcemia, anorexia, nausea and vomiting, weight loss, and cutaneous hyperpigmentation, none of which are evident in this patient.
(c) C. The majority of patients with hyperparathyroidism are asymptomatic. Recurrent nephrolithiasis may be one of the presentations of primary hyperparathyroidism. Measurement of parathyroid levels would be the initial laboratory test for the evaluation of hypercalcemia.
(a) D. Hypercalcemia may be the earliest manifestation of a malignancy and this must be investigated. Most often the signs and symptoms of a malignancy will cause the patient to seek medical care. Malignancy is the second leading cause of hypercalcemia, behind hyperparathyroidism.
A 38 year-old male presents to your clinic complaining of increasing constant headaches and progressive loss of peripheral vision. His medical and family history is unremarkable. Physical examination reveals bitemporal hemianopsia but is otherwise without any abnormalities. Which of the following is the most likely diagnosis?
A. Aneurysm involving the circle of Willis
B. Migraine headache
C. Multiple sclerosis
D. Pituitary tumor
(u) A. An aneurysm involving the circle of Willis would result in CN III palsy. This would be a rare finding.
(u) B. Although a migraine headache may produce visual field defects, these defects would remit upon resolution of the migraine. It would also be unusual to have the scotomas occur bilaterally.
(u) C. Optic neuritis associated with multiple sclerosis presents with decreased visual acuity, dimness, or color desaturation in the central visual field. It would not affect the periphery.
(c) D. A pituitary tumor would account for the headaches and the loss of the peripheral vision in both visual fields. As the tumor grows, the optic chiasm will be compressed by the tumor.
A 23 year-old graduate student presents with sudden onset of severe dizziness, with nausea and vomiting for the past couple of hours. She denies hearing loss or tinnitus. She has had a recent cold. Which of the following is the most likely diagnosis?
A. Ménière’s disease
B. Vestibular neuronitis
C. Benign positional vertigo
D. Vertebrobasilar insufficiency
(u) A. Ménière’s disease is associated with hearing loss, tinnitus, and vertigo that lasts from seconds to hours.
(c) B. Vestibular neuronitis or labyrinthitis presents with vertigo, nausea, and vomiting, but not hearing loss or tinnitus. It is related to viral URIs, and develops over several hours, with symptoms worse in the first day, with gradual recovery over several days.
(u) C. Benign positional vertigo occurs with changes in position, especially rapid movements of the head. Nausea may occur, but vomiting is not significant.
(u) D. Vertebrobasilar insufficiency is usually accompanied by brain stem findings, such as diplopia, dysarthria, or dysphagia, and is not common in this age group.
A 4 year-old boy presents with purulent, foul-smelling nasal discharge for three days. He has not had any other symptoms of respiratory illness, cough, wheeze, or fever. His activity level and appetite has been normal. On exam, he is afebrile. TM’s have normal light reflex, canals are clear. Left nare is clear; there is considerable amount of purulent exudate from the right nare, and a bright reflection of light is noticed. Oropharynx is without inflammation or exudate. Neck is supple, without lymphadenopathy. Lungs are clear, with equal breath sounds and no wheezing. Heart has regular rhythm without murmurs. Which of the following is the most likely diagnosis?
A. Viral URI
B. Acute sinusitis
C. Allergic rhinitis
D. Nasal foreign body
(u) A. Viral URI does not present with foul-smelling nasal discharge.
(u) B. Acute sinusitis may present with purulent nasal discharge, but the observation of a bright light reflection suggests a foreign body.
(u) C. Allergic rhinitis is seasonal, associated with sneezing and other allergy-related symptoms.
(c) D. Nasal foreign body is suggested by unilateral nasal obstruction or discharge
A 59 year-old male complains of “flashing lights behind my eye” followed by sudden loss of vision, stating that it was “like a curtain across my eye.” He denies trauma. He takes Glucophage for his diabetes mellitus and atenolol for his hypertension. He has no other complaints. On funduscopic exam, the retina appears to be out of focus. Which of the following is the most likely diagnosis?
A. Central retinal vein occlusion
B. Retinal artery occlusion
C. Retinal detachment
D. Hyphema
(u) A. Central retinal vein occlusion causes painless, variable loss of vision. Exam shows retinal hemorrhages in all quadrants and edema of the optic disk.
(u) B. Retinal artery occlusion presents with sudden, painless loss of vision. Exam shows pale retina with normal macula, seen as a cherry-red spot.
(c) C. Patients with retinal detachment frequently complain of flashes of light or floaters that occur during traction on the retina as it detaches. This is followed by loss of vision. In small detachments, the retina may appear out of focus, but with larger detachments, a retinal fold may be identified.
(u) D. Hyphema is usually associated with trauma, and is a collection of blood in the anterior chamber.
A 64 year-old woman complains of headache and left eye pain for about a day. She says it started yesterday as a dull ache and now is throbbing. She also complains of nausea and vomiting, which she attributes to the popcorn she ate at the movie theater yesterday afternoon. On exam, the left pupil is mid-dilated and nonreactive. The cornea is hazy. A ciliary flush is noted. Which of the following is the most likely diagnosis?
A. Migraine headache
B. Temporal arteritis
C. Acute glaucoma
D. Retinal artery occlusion
(u) A. Migraine headache does not present with eye findings.
(u) B. Temporal arteritis presents with headache and systemic symptoms of fever, myalgias, anorexia, and tenderness over the temporal artery.
(c) C. Acute glaucoma often presents with abdominal complaints that may delay diagnosis. Findings of ciliary flush, mid-dilated and nonreactive pupil, and hazy cornea in a patient with severe eye pain are consistent with acute angle closure glaucoma.
(u) D. Retinal artery occlusion presents with sudden, painless, severe loss of vision. There are no systemic symptoms.
A 76 year-old female presents to the ED with the worst abdominal pain in her life. The pain began following a large meal and is located periumbilically. Although she is writhing in pain, she does not have an exacerbation of the pain on palpation of the abdomen. She has a history of coronary artery disease, asthma, and atrial fibrillation. Which of the following is the most likely diagnosis?
A. Toxic megacolon
B. Mesenteric thrombosis
C. Fulminant hepatitis
D. Acute diverticulitis with perforation
(u) A. Toxic megacolon is a complication seen with ulcerative colitis or electrolyte abnormalities in which the bowel loses its tone.
(c) B. This patient is at risk for mesenteric ischemia due to advanced age, atherosclerosis and atrial fibrillation. This is the classic presentation for this condition with pain out of proportion to physical examination findings.
(u) C. Fulminant hepatitis is most likely to cause malaise, loss of taste, lethargy, and right upper quadrant pain.
(u) D. Acute diverticulitis with perforation will cause left lower quadrant abdominal pain and severe pain on palpation due to the peritonitis that occurs from the perforation of bowel contents.
A 25 year-old Physician Assistant student is preparing for the national board certification examination. The student stays up all night and is so busy studying that he forgets to eat or drink. When he arrives at the test site, he is jaundiced but denies abdominal pain or tenderness. The jaundice disappears with rest and eating. Laboratory testing reveals an elevation in the indirect bilirubin in a fasting state but normal test results in a nonfasting state. What is the most likely diagnosis?
A. Ehlers-Danlos syndrome
B. Laennec’s cirrhosis
C. Chronic hepatitis infection
D. Gilbert’s disease
(u) A. Ehlers-Danlos syndrome is a disease affecting the connective tissues of the body.
(u) B. Cirrhosis may involve an increase in various liver function tests but these are not related to fasting and non-fasting results.
(u) C. Chronic hepatitis may cause jaundice but the results of the liver function tests are not based upon fasting and non-fasting states.
(c) D. This is an inherited, benign condition resulting in elevations in the indirect bilirubin concentration. There are no long-term liver abnormalities associated with this condition.
A patient is hospitalized with a change in mental status. Examination reveals that he is unable to maintain dorsiflexion of the wrists after pronating his arms in front of his body. Which of the following is the most likely diagnosis?
A. Cocaine overdose
B. Hyperthyroidism
C. Hepatic encephalopathy
D. Parkinson’s Disease
(u) A. Tremor and agitation are part of acute cocaine intoxication, not asterixis.
(u) B. Hyperthyroidism causes a fine resting tremor, not asterixis.
(c) C. This is the description for asterixis that is seen with hepatic encephalopathy, uremia, and carbon dioxide narcosis.
(u) D. Parkinson’s Disease has resting tremor, rigidity, akinesia, and postural hypotension, not asterixis.
A patient is found to have enlargement of both parotid glands. He is also found to have failure to thrive with anorexia, weight loss, weakness, and fatigue. On examination vital signs are BP 135/82 mmHg, pulse 74/minute, and respirations 18/minute. Physical examination is unremarkable. His hematocrit is 45%, BUN is 15 mg/dl and serum creatinine is 0.8 mg/dl. Which of the following is the most likely diagnosis?
A. Hepatorenal syndrome
B. Cirrhosis of the liver
C. Addison’s disease
D. Vitamin B12 deficiency
(u) A. Patients with hepatorenal syndrome have renal failure that occurs following liver failure. Although these kidneys would function normally if transplanted into a normal host, they lose their function as a result of liver impairment.
(c) B. This is the description of a patient who has classic clinical manifestations of cirrhosis of the liver and liver failure. Jaundice may also be seen if the liver has an inability to metabolize bilirubin.
(u) C. Addison’s disease occurs from adrenal failure to produce glucocorticoids and mineralocorticoids. The main manifestations are hypotension and skin hyperpigmentation.
(u) D. Vitamin B12 deficiency usually presents with peripheral neuropathy and other neurological signs, not wasting.
A 60-year-old presents with fatigue and splenomegaly. CBC reveals the following: WBC- 24,000/microliter, Hgb- 13.5 g/dl, Hct- 40%, MCV- 87 fL, MCHC- 34 g/dl, MCH- 28 pg, and platelets- 380,000/mL. The differential reveals neutrophils- 11%, lymphocytes- 80%, monocytes- 8%, and basophils- 1%. What is the most likely diagnosis?
A. Acute lymphocytic leukemia
B. Acute myelogenous leukemia
C. Chronic lymphocytic leukemia
D. Chronic myelogenous leukemia
(u) A. Acute lymphocytic leukemia is more common in children and presents with blasts in the peripheral blood.
(u) B. Acute myelogenous leukemia presents with pancytopenia and presence of blasts in the peripheral blood.
(c) C. Chronic lymphocytic leukemia presents with a WBC count greater than 20,000/microliter and absolute lymphocyte count of greater than 5000/microliter.
(u) D. Chronic myelogenous leukemia presents with elevated WBC count, marked left shift in the myeloid series of cells, and positive for Philadelphia chromosome.
A 54 year-old male smoker presents to the clinic complaining of frequent vague headaches with associated vomiting that awaken him from sleep occasionally and have been present upon awakening for about two weeks. The headache typically resolves about an hour into his morning routine. The patient is afebrile. What is the most likely cause of this patient’s headaches?
A. Cluster headaches
B. Depression
C. Glioblastoma
D. Giant cell arteritis
(u) A. Cluster headaches can awaken patients, but are not usually “vague”.
(u) B. See C for explanation.
(c) C. Morning headaches associated with vomiting are indicative of increased intracranial pressure and raise concern of a CNS tumor such as a glioblastoma.
(u) D. Giant cell arteritis presents in the older patient with headache in the temporal region and loss of vision.
