Packrat 11 Flashcards
- Clinical Therapeutics/Hematology A 6 year-old male presents with hemarthrosis of the left knee. Coagulation studies reveal the following results: PT 12.5 seconds (normal range 12-14 seconds), INR 1.0, aPTT 58 seconds (normal range 18-28 seconds), platelet count 430,000/microliter (normal range 150,000-450,000/microliter), and bleeding time 4 minutes (normal range 2-12 minutes). Which of the following is the best treatment option for this patient? A. Desmopressin acetate B. Corticosteroids C. Vitamin K D. Cryoprecipitate
A. Desmopressin acetate is indicated in von Willebrand’s disease, which presents with a prolonged bleeding time. B. Corticosteroids are indicated in immune-mediated thrombocytopenia. C. Vitamin K deficiency will prolong the PT greater than the aPTT. Vitamin K supplement is not indicated in this patient. ***D. Hemophilia A presents with a prolonged aPTT and normal platelet count and function. Hemophilia A is treated with factor VIII concentrate or cryoprecipitate.
- Clinical Therapeutics/Infectious Diseases An HIV positive patient presents with worsening dementia, fever, headache, and right hemiparesis. MRI of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. Which of the following is the treatment of choice? A. Sulfadiazine and pyrimethamine B. Trimethoprim-sulfamethoxazole C. Radiation therapy D. Ventricular shunt placement
***A. Toxoplasmosis is commonly noted in HIV positive patients and presents with multiple ring-enhancing lesions. Treatment of choice for possible toxoplasmosis is sulfadiazine and pyrimethamine. B. Trimethoprim-sulfamethoxazole is used for prophylaxis of toxoplasmosis, but not for treatment of acute infection. C. Radiation therapy is indicated in CNS lymphoma, which typically presents with a single lesion. D. Shunt placement is not indicated in patients with toxoplasmosis.
- History & Physical/Obstetrics/Gynecology 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
A. Hegar’s sign is the softening of the cervix that often occurs with pregnancy. B. McDonald’s sign is when the uterus becomes flexible at the uterocervical junction at 7-8 weeks. C. Cullen’s sign is a purplish discoloration periumbilical and noted in pancreatitis. ***D. Chadwick’s sign is a bluish or purplish discoloration of the vagina and cervix.
- Diagnostic Studies/Gastrointestinal/Nutritional A 52 year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study? A. Stool for occult blood B. Stool cultures C. Sigmoidoscopy D. Abdominal CT scan
***A. Occult bleeding, as evidenced by the patient’s history of black stools, is initially verified by a positive fecal occult blood test. B. Stool cultures are indicated in the evaluation of acute diarrhea and not for the evaluation of acute GI bleeding. C. Melena suggests a source of bleeding that is proximal to the ligament of Treitz, not a lower GI bleed. Sigmoidoscopy is used to evaluate only lower GI bleeding sources. D. Abdominal CT scan is indicated for evaluation of obscure bleeding in order to exclude a pancreatic or hepatic source of bleeding if endoscopy fails to identify the source.
5.. Health Maintenance/Dermatology Which of the following is considered a risk factor for the development of malignant melanoma? A. male gender B. inability to tan C. Japanese ethnicity D. brown-haired individuals
A. Incidence of malignant melanoma is equal in males and females. ***B. Inability to tan and propensity to burn are risk factors for developing malignant melanoma. C. Malignant melanomas are most common in Caucasians and are rarely seen in the Japanese population. D. Red hair and freckling is one of the major risk factors for malignant melanoma, not brown hair.
- Clinical Intervention/Neurology A 43 year-old data entry clerk presents with a one-month history of pain and tingling in the right thumb, index finger, and middle finger. Tinel’s sign and Phalen’s maneuver are positive. The most appropriate intervention at this time is A. methylprednisolone (Medrol) dose pack. B. splint in neutral position. C. observation. D. surgery.
A. A Medrol dose pack will have no affect on carpal tunnel syndrome. ***B. Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal tunnel. C. Observation will not improve symptoms. D. Surgical intervention is reserved for cases unresponsive to conservative therapy.
- Which of the following is a cause of prerenal azotemia? A. Infection B. Renal toxins C. Poor renal perfusion D. Urinary tract obstruction
A. Infection is associated with interstitial nephritis, which is considered a cause of intrinsic renal azotemia. B. This is one of the causes of intrinsic renal azotemia. ***C. Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored. D. Urinary tract obstruction is the cause of postrenal azotemia.
- Scientific Concepts/Cardiology Which of the following is the most common cause of secondary hypertension? A. Renal parenchymal disease B. Primary aldosteronism C. Oral contraceptive use D. Cushing’s syndrome
***A. Renal parenchymal disease is the most common cause of secondary hypertension. B. Primary aldosteronism can cause secondary hypertension, but it is not the most common cause. C. Oral contraceptives can cause small increases in blood pressure but considerable increases are much less common. D. Cushing’s disease is a less common cause of secondary hypertension.
- Health Maintenance/Gastrointestinal/Nutritional A newborn weighs 8 pounds at birth. On average, what should the infant weigh at 1 year of age? A. 16 pounds B. 20 pounds C. 24 pounds D. 28 pounds
A. See C for explanation. B. See C for explanation. ***C. An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age. D. See C for explanation.
- History & Physical/ENT/Ophthalmology The most reliable sign of acute otitis media (AOM) is A. bulging of the tympanic membrane. B. loss of tympanic membrane mobility. C. reddening of the tympanic membrane. D. air bubbles behind the tympanic membrane.
A. Bulging and air bubbles behind the TM represent OM with effusion. ***B. Loss of tympanic membrane mobility during pneumoinsufflation is the most reliable sign for diagnosing acute otitis media. C. Reddening of the eardrum is not reliable as it may be due to crying or other vascular changes. D. See A for explanation.
- Diagnosis/ENT/Ophthalmology Which of the following is a staphylococcal infection characterized by a localized red swollen and acutely tender abscess of the upper or lower eyelid? A. Hordeolum B. Uveitis C. Chalazion D. Dacryocystitis
***A. Hordeolum (stye) is a staphylococcal infection characterized by a localized red swollen and acutely tender abscess of the upper or lower eyelid. B. Uveitis is an intraocular inflammation involving the uveal tract. C. Chalazion is a granulomatous inflammation of the meibomian gland. D. Dacryocystitis is an infection of the lacrimal sac due to obstruction of the nasolacrimal system.
- Scientific Concepts/Obstetrics/Gynecology Progesterone influence on the breast tissue prior to menstruation causes A. proliferation of the mammary ducts. B. growth of the lobules and alveoli. C. proliferation of Cooper’s ligaments. D. increase in the number of glands of Montgomery.
A. Proliferation of the mammary ducts is under the influence of estrogen. ***B. Growth of the lobules and alveoli is under the influence of progesterone. Prior to menses, the breast swelling that women notice is a result of the progesterone which is secreted from the corpus luteum. During menses, the swelling subsides. C. See B for explanation. D. See B for explanation.
- Clinical Therapeutics/Psychiatry/Behavioral Medicine A 36 year-old man has a 30 pack-year history of smoking cigarettes and wants to quit. He is otherwise healthy at this time. Which of the following drugs would be appropriate for him? A. Amitriptyline (Elavil) B. Bupropion (Wellbutrin) C. Fluoxetine (Prozac) D. Venlafaxine (Effexor)
A. See B for explanation. ***B. The only two approved drugs for aiding smoking cessation are nicotine and bupropion. C. See B for explanation. D. See B for explanation.
- History & Physical/Orthopedics/Rheumatology Topic: 2 Author: Christine Bruce A patient presents with chronic back pain. On physical examination testing, the patient is found to have abnormalities of proprioception and vibration discrimination. Which of the following portions of the spinal column are most likely affected? A. Lateral spinothalamic tract B. Ventral spinothalamic tract C. Posterior column D. Transection of the cord
A. The lateral spinothalamic tract affects pain and temperature sensation. B. The ventral spinothalamic tract affects pressures and touch sensations. ***C. The posterior column affects proprioception (position sense) and vibration sense. D. Patients with transection of the cord will have loss of sensation distal to the area of injury along with paralysis and hyperactive reflexes in the area distal to the transection.
- History & Physical/Endocrinology A 44 year-old female presents for follow-up results of her lipid profile. She is asymptomatic and has a past medical history of hypothyroidism treated with levothyroxine and hypertension controlled with atenolol (Tenormin). She drinks an average of 6 alcoholic beverages a day and smokes 1 pack per day for the last 32 years. Her family history is unremarkable for premature coronary artery disease. Her fasting blood glucose is 98 mg/dL, total cholesterol is 198 mg/dL, LDL cholesterol is 132 mg/dL, HDL cholesterol is 56 mg/dL and triglycerides of 90 mg/dL. Excluding LDL cholesterol levels, how many major risk factors for coronary artery disease does this female possess? A. 2 B. 3 C. 4 D. 5
***A. This patient’s major cardiac risk factors are smoking and hypertension in addition to the elevated LDL cholesterol. B. See A for explanation. C. See A for explanation. D. See A for explanation.
- Diagnosis/Infectious Diseases A 65 year-old patient with steroid-dependent chronic obstructive lung disease presents with a headache that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever, but has had photophobia and a stiff neck. Which of the following is the most likely diagnosis? A. Transient ischemic attack B. Bacterial meningitis C. Migraine headache D. Cryptococcosis
A. Transient ischemic attacks present with focal neurological findings rather than headaches. (a)B. Bacterial meningitis is typically acute in onset and causes fever, but immunocompromised patients may have a slower onset and no fever. C. Migraines generally do not begin in this age group, and are not accompanied by nuchal rigidity. ***D. Cryptococcus is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients.
- Diagnostic Studies/Obstetrics/Gynecology A 40 year-old female presents with a 1.5 cm well-circumscribed mass noted on mammography in the right upper, outer quadrant. Which of the following procedures is most appropriate and should be done next? A. Fine needle aspiration B. BRCA 1 and BRCA 2 genetic testing C. Serum CA-125 D. Radiation therapy
***A. Fine needle aspiration is fairly accurate, easily performed, and has minimal morbidity. B. Although BRCA 1 and BRCA 2 genetic tests are used in the risk assessment for possible breast and ovarian cancer, it would not replace the need to perform a more definitive evaluation of an identified breast mass. C. Serum CA-125 is a tumor marker for ovarian, not breast, cancer. D. Radiation therapy is only indicated after a diagnosis of breast cancer is proven and may be used as adjunctive therapy.
- History & Physical/Obstetrics/Gynecology 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
A. See B for explanation. ***B. At 20-22 weeks, the fundal height is typically at the level of the umbilicus. C. See B for explanation. D. See B for explanation.
- History & Physical/Pulmonology 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
A. Drooling and a “hot potato” voice are seen with epiglottitis, not viral croup. B. Fever is usually absent or low-grade in patients with viral croup. C. See A for explanation. ***D. Viral croup is characterized by a history of upper respiratory tract symptoms followed by onset of a barking cough and stridor.
- Diagnostic Studies/Pulmonology A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30 minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A. Chest x-ray B. Sputum gram stain C. Peak flow D. Ventilation-perfusion scan
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. B. A sputum gram stain is performed in patients who you suspect have an infectious process, such as pneumonia. ***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. 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.
- Health Maintenance/Pulmonology A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future? A. Asthma B. Tinea pedis C. Squamous carcinoma D. Systemic lupus erythematosus (SLE)
***A. Up to 50% of patients with atopic dermatitis develop asthma and/or allergic rhinitis in the future. B. Patients with atopic dermatitis are more likely to get superimposed viral or bacterial infections such as herpes simplex or staphylococcal, but they are not more at risk for fungal infections. C. Patients with atopic dermatitis are at no greater risk for any skin cancer. D. Lupus is a connective tissue disorder of the immune system, but unrelated to atopic dermatitis.
- Clinical Intervention/Infectious Diseases A 3 year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is A. renal. B. cardiac. C. pulmonary. D. hepatic.
A. See B for explanation. ***B. The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved. C. See B for explanation. D. Children with Kawasaki syndrome may have associated hydrops of the gallbladder, but liver involvement is not part of this disorder.
- Clinical Therapeutics/Cardiology Which of the following medication classes is the treatment of choice in a patient with variant or Prinzmetal’s angina? A. Calcium channel blockers B. ACE inhibitors C. Beta blockers D. Angiotensin II receptor blockers
***A. Calcium channel blockers are effective prophylactically to treat coronary vasospasm associated with variant or Prinzmetal’s angina. B. ACE inhibitors are not a treatment for coronary vasospasm. (h)C. Beta blockers have been noted to exacerbate coronary vasospasm potentially leading to worsening ischemia. D. Angiotensin II receptor blockers are not a treatment for coronary vasospasm.
- Clinical Therapeutics/Obstetrics/Gynecology Pharmacologic treatment of a patient with gestational diabetes should consist of which of the following? A. Oral hypoglycemic agents B. Regular insulin C. Oral corticosteroids D. Glucagon
(h)A. Oral hypoglycemic agents have no role in the treatment of gestational diabetes as these drugs may cross the placenta and harm the fetus. ***B. Regular insulin is the drug of choice as this will maintain the mother’s blood sugar but not cross the placenta. (h)C. Oral corticosteroids have no role in the treatment of gestational diabetes. Corticosteroids will cause the blood glucose to increase. D. Glucagon is given to patients when their blood glucose is abnormally low. Glucagon stimulates gluconeogenesis.
- Health Maintenance/Gastrointestinal/Nutritional Which of the following is an indication for vaccination against hepatitis A? A. Illicit drug users B. Health care workers C. Renal dialysis patients D. Routine vaccination starting at birth
***A. Hepatitis A vaccine is recommended for illicit drug users, anyone living or traveling to endemic areas, sewage workers, food handlers, homosexual and bisexual men, animal handlers, patients with a history of chronic liver disease or a clotting factor disease as well as children and workers in day care settings and institutions. B. Health care workers, renal dialysis patients and routine vaccination starting at birth are some of the recommendations for vaccination against hepatitis B, not hepatitis A. C. See B for explanation. D. See B for explanation.
26.. History & Physical/Psychiatry/Behavioral Medicine The DSM-IV classifies mental disorders by using five axes in completing the process. Axis III is used to identify which of the following? A. Clinical disorders and other conditions that may be the focus of clinical attention B. Any physical disorder or general medical condition that is present in addition to the mental disorder C. The psychosocial and environmental problems that have had a significant contribution to the development or exacerbation of the disorder D. Personality disorders and/or mental retardation
A. Axis I identifies clinical disorders and other conditions that may be the focus of clinical attention. ***B. Axis III identifies any physical disorder or general medical condition that is present in addition to the mental disorder. C. Axis IV identifies the psychosocial and environmental problems having a significant contribution to the disorder. D. Axis II identifies personality disorders and mental retardation.
- Diagnostic Studies/ENT/Ophthalmology A 2 month-old infant presents for a routine health maintenance visit. The mother has been concerned about the infant’s hearing since birth. Physical examination reveals no apparent response to a sudden loud sound. Which of the following is the most appropriate diagnostic evaluation? A. audiometry B. tympanometry C. acoustic reflectometry D. auditory-evoked potentials
A. Pure tone audiometry can be used to screen for hearing deficits in children over the age of 3 years. B. Tympanometry is used to identify an effusion as the cause of hearing loss, but in infants over the age of months. C. Acoustic reflectometry measures the spectral gradient of the tympanic membrane, but is not used clinically due to concerns about its reliability. ***D. Brainstem auditory-evoked potentials evaluate the sensory pathway and identify the site of any anatomical disruption. The test does not require any active response from the patient and is useful in the evaluation of suspected hearing loss in an infant.
- Diagnosis/Pulmonology A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals sinus tachycardia. Which of the following is the most likely diagnosis? A. Atelectasis B. Pneumothorax C. Pulmonary embolism D. Myocardial infarction
A. Small atelectasis is commonly asymptomatic, while large atelectasis may produce signs of dyspnea and cough. Exam reveals absence of breath sounds in the area involved and dullness to percussion. A chest x-ray would reveal various findings dependent on the location of the atelectasis, but would not be normal. B. While a pneumothorax commonly presents with pleuritic chest pain and dyspnea, exam would reveal the presence of diminished breath sounds and hyperresonance on the involved side. A chest x-ray would reveal presence of a pleural line on the expiratory chest x-ray. ***C. This patient’s risk factors for pulmonary embolism include advanced age, surgery, and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult to make due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal. D. While a myocardial infarction usually presents with dyspnea, the chest pain is not usually pleuritic in nature. An EKG would commonly reveal ST segment changes which would be consistent with ischemia or infarct.
- Health Maintenance/Pulmonology Which of the following is an independent risk factor for development of a mesothelioma? A. Cigarette smoking B. Asbestos exposure C. Radon gas exposure D. Chronic obstructive lung disease
A. There has not been any evidence of association between cigarette smoking and the development of mesothelioma. ***B. Studies confirm the association of asbestos exposure to the development of mesothelioma. C. After cigarette smoking, radon gas is the second most common risk factor for development of bronchogenic lung cancer, not mesothelioma. D. Chronic obstructive lung disease is associated with an increased risk of bronchogenic lung cancer, not mesothelioma.
- Clinical Therapeutics/Pulmonology A 34 year-old female with a history of asthma presents with complaints of increasing asthma attacks. The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. Which of the following is the most appropriate intervention at this time? A. Oral prednisone B. Oral theophylline (Theo-Dur) C. Salmeterol (Serevent) inhaler D. Beclomethasone (Qvar)inhaler
A. Oral corticosteroids, such as prednisone, are added to therapy in severe persistent asthma. While a course of oral corticosteroids may be needed for mild exacerbations of asthma, they are not added until inhaled corticosteroids have failed to control the symptoms. B. Due to its safety profile, oral theophylline is now considered a third or fourth line treatment option for asthma. C. Long acting inhaled beta2-agonists, such as salmeterol, are not added to the treatment regimen until the symptoms indicate a moderate persistent asthma. Long acting inhaled beta2-agonists should also not be used in place of inhaled steroids. ***D. This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control.
- Scientific Concepts/Pulmonology Which of the following mechanisms leads to a primary pneumothorax? A. Penetrating or blunt trauma forces B. Underlying lung cancer C. Pressure of air in the pleural space exceeds room air pressure D. Rupture of subpleural apical blebs due to high negative intrapleural pressures
A. Penetrating or blunt trauma force is responsible for a traumatic pneumothorax. B. A pneumothorax that results from an underlying lung disease is classified as a secondary pneumothorax. C. When pressure of air in the pleural space exceeds room air pressure, it leads to a tension pneumothorax. ***D. A primary spontaneous pneumothorax is thought to result from a rupture of subpleural apical blebs secondary to high negative intrapleural pressures.
- Clinical Therapeutics/Obstetrics/Gynecology What is the initial treatment of choice for hyperthyroidism in a 10-week pregnant patient? A. No treatment is necessary. B. Propylthiouracil (PTU) C. Radioiodine treatment D. Subtotal thyroidectomy
A. Although thyroid function tests are altered in pregnancy true hyperthyroidism can occur and should be treated. ***B. This is the initial treatment of choice. C. Radioiodine treatment is contraindicated in pregnancy. D. Subtotal thyroidectomy is an option for pregnant patients during the second or third trimesters. Surgery is not indicated for first-trimester pregnancies.
- Diagnosis/ENT/Ophthalmology A patient presents with eye pain and blurred vision. Snellen testing reveals vision of 20/200 in the affected eye and 20/20 in the unaffected eye. Fluorescein staining reveals the presence of a dendritic ulcer. Which of the following is the most likely diagnosis? A. Viral keratitis B. Fungal corneal ulcer C. Acanthamoeba keratitis D. Bacterial corneal ulcer
***A. Herpes Simplex virus is a common cause of dendritic ulceration noted on fluorescein staining. B. Fungal corneal ulcers have an indolent course with intraocular infection being common but fluorescein staining is negative for a dendritic pattern. C. Acanthamoeba keratitis has a waxing and waning course over several months and has no fluorescein staining in a dendritic pattern. D. Bacterial corneal ulcers can progress aggressively resulting in corneal perforation. Fluorescein staining does not occur in a dendritic pattern.
- Clinical Therapeutics/Cardiology A 63 year-old female with history of diabetes mellitus presents for blood pressure follow-up. At her last two visits her blood pressure was 150/92 and 152/96. Today in the office her blood pressure is 146/92. Recent blood work shows a Sodium 140 mEq/L, Potassium 4.2 mEq/L, BUN of 23 mg/dL, and Creatinine of 1.1 mg/dL. Which of the following is the most appropriate initial medication in this patient? A. Terazosin (Hytrin) B. Atenolol (Tenormin) C. Lisinopril (Zestril) D. Hydrochlorothiazide (HCTZ)
A. Alpha blockers are not the treatment of choice in a diabetic with hypertension. B. Patients with hypertension and diabetes may require a Beta blocker, but it should be added to an ACE inhibitor if the ACE inhibitor is ineffective on its own. ***C. ACE inhibitors should be part of the initial treatment of hypertension in diabetics because of beneficial effects in diabetic nephropathy and is the most appropriate initial medication. D. Patients with hypertension and diabetes mellitus may require a diuretic, but it should be added to an ACE inhibitor if the ACE inhibitor is ineffective on its own.
- Diagnostic Studies/Cardiology What is the EKG manifestation of cardiac end-organ damage due to hypertension? A. Right bundle branch block B. Left ventricular hypertrophy C. Right ventricular hypertrophy D. ST segment elevation in lateral precordial leads
A. Right bundle branch block is caused by a delay in the conduction system in the right ventricle. It may be caused by right ventricular hypertrophy or conditions with higher pulmonic resistance such as cor pulmonale. Hypertension, however, is likely to cause changes in the left ventricle rather than the right ventricle. ***B. Long-standing hypertension can lead to left ventricular hypertrophy with characteristic changes noted on EKG. C. See A for explanation. D. ST segment elevation is a sign of acute myocardial infarction not hypertension.
- Health Maintenance/Cardiology Annual blood pressure determinations should be obtained beginning at the age of A. 3 years. B. 5 years. C. 12 years. D. 18 years.
***A. Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years. B. See A for explanation. C. See A for explanation. D. See A for explanation.
- Scientific Concepts/Orthopedics/Rheumatology T In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis? A. Femur B. Humerus C. Vertebral spine D. Tibia
A. Long bones are most commonly affected with osteomyelitis in children. B. See A for explanation. ***C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection D. See A for explanation.
- Clinical Therapeutics/Obstetrics/Gynecology Treatment of the patient with Pediculosis pubis consists of which of the following? A. Permethrin (Nix) cream B. Clotrimazole (Gyne-Lotrimin) C. Podofilox (Condylox) solution D. Selenium sulfide (Selsun) suspension
***A. Permethrin 1% cream/shampoo is used to kill the louse and remove the eggs from the hair shafts. B. Clotrimazole is an antifungal agent and is not used to treat parasitic infestation. C. Podofilox 0.5% solution is used to treat Condyloma accuminata. D. Selenium sulfide suspension is used to treat Tinea versicolor fungal infection.
- Diagnostic Studies/Endocrinology A 43 year-old asymptomatic diabetic female is found to have an elevated total calcium level of 12.4 mg/dL. Which of the following tests must be assessed in order to evaluate this laboratory abnormality? A. Intact parathyroid hormone B. Serum albumin C. 24 hour urine calcium level D. Complete blood count
A. Intact parathyroid hormone levels are only obtained for patients with true hypercalcemia with an unknown etiology. ***B. Since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels. C. Demonstration of excessive calcium in the urine does not provide any additional information regarding the increased serum calcium. D. Complete blood count has no relationship to the serum calcium levels.
- History & Physical/Cardiology Which of the following conditions would cause a positive Kussmaul’s sign on physical examination? A. Left ventricular failure B. Pulmonary edema C. Coarctation of the aorta D. Constrictive pericarditis
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. B. Pulmonary edema primarily results in increased pulmonary pressures rather than having effects on the venous inflow into the heart. 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. ***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.
- Clinical Intervention/Neurology Treatment of Bell’s palsy includes which of the following? A. Acyclovir B. Reassurance of the patient’s recovery C. Referral to a neurosurgeon D. Electromyography
A. See B for explanation. ***B. Bell’s palsy is a peripheral neuropathy of cranial nerve VII. Although it has been suggested it may be related to an activation of herpes simplex virus, there is little empiric evidence for this. Approximately 60% of cases of Bell’s palsy recover without treatment and patient reassurance of this is advised. Electromyography may provide aid in the prognosis, but not as a treatment option. A neurosurgeon has no role in the management of Bell’s palsy. C. See B for explanation. D. See B for explanation.
- Diagnostic Studies/ENT/Ophthalmology During a baseball game, a 22 year-old college student is hit in the right eye by a baseball. He complains of blurry vision in that eye. On physical exam, the physician assistant notes proptosis of the right eye, and limitation of movement in all directions. On CT scan, which of the following is most likely to be seen? A. Fracture of the medial orbital wall B. Prolapse of orbital soft tissue C. Hematoma of the orbit D. Orbital emphysema
A. Fracture of the medial orbital wall is associated with diplopia from medial rectus impingement, orbital emphysema and epistaxis. B. Prolapse of orbital soft tissue, including inferior rectus muscle, inferior oblique muscle, orbital fat, and connective tissue results in enophthalmos, ptosis, diplopia, anesthesia of the ipsilateral cheek and upper lip, and limitation of upward gaze and is seen with fractures of the orbital floor. ***C. Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma. D. Orbital emphysema is seen with fractures of the medial orbital wall or floor of the orbit into the maxillary and ethmoid sinuses respectively. It will not lead to proptosis.
- History & Physical/Cardiology Which of the following physical findings is suggestive of atrial septal defect? A. Fixed split S2 B. Increased pulse pressure C. Continuous mechanical murmur D. Difference in blood pressure between the left and right arm
***A. An atrial septal defect will cause a shunt of blood from the left to the right atrium. This will result in an equalization in the amount of blood entering both the left and right ventricles which effectively eliminates the normally wide splitting that inspiration typically causes in hearts without an atrial septal defect. B. Pulse pressures reflect the difference in aortic and left ventricular volumes that occur during ventricular systole Increased pulse pressures are seen in aortic regurgitation which is a different entity than atrial septal defect. C. Continuous mechanical murmurs are noted in patients with patent ductus arteriosus. D. Differences in blood pressure between the left and right arms are seen in conditions such as coarctation of the aorta.
- Diagnostic Studies/Pulmonology 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
A. Cystic fibrosis is a genetic disease, but a positive family history in and of itself is not enough to diagnose the condition. ***B. The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test or demonstration of a genotype consistent with cystic fibrosis. C. While recurrent respiratory infections is a classic presentation of cystic fibrosis, the diagnosis relies on confirmation, as noted in explanationB. D. Trypsinogen levels are used as a neonatal screening test and if elevated should be followed by more definitive testing to confirm the diagnosis.
- History & Physical/ENT/Ophthalmology In infants, the eyes should move in parallel without deviation by the age of A. 2 weeks. B. 3 months. C. 6 months. D. 1 year.
A. See C for explanation. B. See C for explanation. ***C. Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months. D. See C for explanation.
- History & Physical/Pulmonology Which of the following physical exam findings is consistent with moderate emphysema? A. Increased tactile fremitus B. Dullness to percussion C. Distant heart sounds D. Deviated trachea
A. Physical examination findings in emphysema include a midline trachea, diffuse hyperresonant to percussion, and decreased tactile fremitus. B. See A for explanation. ***C. Distant heart sounds are common in emphysema patients due to hyperinflation of the lungs. D. See A for explanation.
- Clinical Intervention/Gastrointestinal/Nutritional Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis? A. Weight loss B. Intractable pain C. Exocrine deficiency D. To decrease risk of cancer
A. While weight loss is common with chronic pancreatitis, it is not an indication for surgical intervention. ***B. Indications for surgical treatment of chronic pancreatitis include severe pain that limits the patient’s functioning or intractable pain despite the use of non-narcotic analgesics and absence of alcohol intake. C. While the majority of patients go on to develop diabetes mellitus 25 years after the clinical onset of chronic pancreatitis, this is not an indication for surgical intervention as it would lead to more severe exocrine deficiency. D. While the possible presence of pancreatic cancer is an indication for surgery, there is no indication for prophylactic surgery to decrease the risk of cancer.
- Clinical Therapeutics/Cardiology A 29 year-old male presents with complaint of substernal chest pain for 12 hours. The patient states that the pain radiates to his shoulders and is relieved with sitting forward. The patient admits to recent upper respiratory symptoms. On examination vital signs are BP 126/68, HR 86, RR 20, temp 100.3 degrees F. There is no JVD noted. Heart exam reveals regular rate and rhythm with no S3 or S4. There is a friction rub noted. Lungs are clear to auscultation. EKG shows diffuse ST segment elevation. What is the treatment of choice in this patient? A. Pericardiocentesis B. Nitroglycerin C. Percutaneous coronary intervention D. Indomethacin (Indocin)
A. Pericardiocentesis is the treatment of choice in a patient with a pericardial effusion and cardiac tamponade, there is no evidence of either of these in this patient. B. Nitroglycerin is indicated in the treatment of chest pain related to angina. C. Percutaneous coronary intervention is the treatment of choice in a patient with an acute myocardial infarction. ***D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment of choice in a patient with acute pericarditis.
- Clinical Intervention/Dermatology As a general rule, sutures in the face should be removed in A. 3 days. B. 5 days. C. 7 days. D. 10 days.
A. See B for explanation. ***B. Sutures of the face should be removed in 5 days in order to allow for adequate healing and to limit the amount of scarring. C. See B for explanation. D. See B for explanation.
- Health Maintenance/Obstetrics/Gynecology Patient education for a 23 year-old using oral contraceptives should include which of the following? A. Rifampin may decrease the effectiveness of the oral contraceptives. B. Acetaminophen may decrease the effectiveness of the oral contraceptives. C. Oral contraceptives may provide some protection from coronary artery disease. D. Changing to the “minipill” (progestin only) will inhibit ovulation more consistently than combination oral contraceptives.
***A. Rifampin may interfere with the efficacy of the oral contraceptives. B. Acetaminophen levels or effects may be decreased by oral contraceptives. C. Coronary artery disease is a contraindication to the use of oral contraceptives. D. Progestin only oral contraceptives are less effective at inhibiting ovulation than the combination oral contraceptive.
- History & Physical/Urology/Renal When performing a rectal examination, prostatic massage is contraindicated in A. acute bacterial prostatitis. B. chronic bacterial prostatitis. C. nonbacterial prostatitis. D. prostatodynia.
***A. 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. B. Prostate massage can be performed in the absence of fever. Expressed prostatic secretions are cultured to help identify the organism. C. Nonbacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are cultured, and the cause may be unknown. D. Prostatodynia is a noninflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement.
- Clinical Intervention/Urology/Renal = A patient with prostate cancer has a nonpalpable, focal lesion, and the patient is reluctant to have surgery at this time. Which of the following would best monitor disease progression? A. Periodic rectal exams B. Transrectal ultrasonography C. Measurements of serum acid phosphatase D. Measurements of prostate-specific antigen
A. Many prostate carcinomas are contained within the gland, making it difficult to assess progression with a digital examination alone. B. Ultrasonography is used largely for staging disease, not monitoring disease progression. C. Serum acid phosphatase is more predictive of metastatic disease than PSA measurement, but its use has largely been replaced by PSA. ***D. PSA measurement correlates well with volume and stage of disease and is the recommended examination for monitoring disease progression.
- Scientific Concepts/Obstetrics/Gynecology If a woman has a normal 28-day menstrual cycle what tissue and hormonal phase occurs during the last 14 days? A. Proliferative follicular phase under the influence of estrogen. B. Secretory luteal phase under the influence of estrogen and progesterone. C. Proliferative follicular phase under the influence of estrogen and progesterone. D. Secretory luteal phase under the influence of estrogen.
A. See B for explanation. ***B. The endometrial changes seen in the latter half of the cycle are under the influence of both estrogen and progesterone from the corpus luteum. During this phase, the endometrium becomes more vascularized and slightly edematous. C. See B for explanation. D. See B for explanation.
- Diagnosis/Cardiology A 24 year-old male presents for routine physical examination. On physical examination, you find that the patient’s upper extremity blood pressure is higher than the blood pressure in the lower extremity. Heart exam reveals a late systolic murmur heard best posteriorly. What is the most likely diagnosis in this patient? A. Hypertrophic obstructive cardiomyopathy B. Patent foramen ovale C. Coarctation of the aorta D. Patent ductus arteriosus
A. Patients with hypertrophic obstructive cardiomyopathy do not present with hypertension or weak femoral pulses. B. The murmur associated with patent foramen ovale is a systolic ejection murmur heard in the second and third intercostal spaces and patients do not present with hypertension. ***C. Coarctation of the aorta commonly presents with higher systolic pressures in the upper extremities than the lower extremities and absent or weak femoral pulses. D. Patent ductus arteriosus is rare in adults and patients are noted to have a continuous rough, machinery murmur.
- Diagnosis/Dermatology A mother brings a 3 month-old infant to the office because she is concerned about a red, vascular, nodular growth on the child’s back. It appears to be enlarging slightly and the vessels are slightly dilated. It seems to cause the child no discomfort. The most likely diagnosis is A. a hemangioma. B. a pigmented nevus. C. a salmon patch (stork bite). D. a malignant melanoma.
***A. A hemangioma is a bright red to deep purple vascular nodule or plaque that often develops at birth, may enlarge, and may regress and disappear with aging. B. A pigmented nevus is not a vascular lesion. C. A salmon patch is a light red macule over the nape of the neck or the glabella. D. A malignant melanoma presents as a hyperpigmented, asymmetric lesion with irregular borders and is typically seen in the adult population.
- Clinical Therapeutics/Endocrinology A 45 year-old male with Type 1 diabetes presents with the following lipid panel: Total cholesterol 321 mg/dL; Triglycerides 225 mg/dL; HDL 30 mg/dL; LDL 155 mg/dL. The treatment of choice for this patient is A. Nicotinic acid (Niacin). B. Cholestyramine (Questran). C. Gemfibrozil (Lopid). D. Simvastatin (Zocor).
A. Niacin is not indicated in patients with diabetes as it may worsen blood sugar control. B. Cholestyramine is not indicated as it may worsen the triglyceride level in this patient. C. Gemfibrozil should be avoided as it may worsen the LDL level. ***D. Simvastatin is the drug of choice as it will decreases triglyceride level, decrease LDL, and increase HDL.
- Clinical Therapeutics/Gastrointestinal/Nutritional A 45 year-old male presents with abdominal pain and one episode of mild hematemesis, which happened days ago. On physical examination, vital signs are stable and he is in no acute distress. Hemoglobin and hematocrit are unremarkable; endoscopy reveals non-bleeding small superficial ulceration of the duodenal bulb. Rapid urease test is positive. Which of the following is the most appropriate treatment at this time? A. Schedule for a selective vagotomy and antrectomy B. Start an antacid along with omeprazole (Prilosec) C. Schedule elective ulcer excision and start sucralfate (Carafate) D. Start omeprazole (Prilosec) and antibiotic therapy against H. pylori
A. Medical therapy should be initiated prior to any consideration of surgery, which is rarely performed secondary to satisfactory ulcer healing with medical therapy. B. While proton pump inhibitors, such as omeprazole, have excellent results in healing duodenal ulcers, this regimen will not treat the H. pylori infection that is documented by the positive rapid urease test. C. While sucralfate can be utilized as a cytoprotectant agent in treatment of active ulcer disease or in maintenance of healed ulcers, surgery to remove the ulcer is not warranted as initial therapy. ***D. Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing.
- . Diagnostic Studies/Infectious Diseases A 19 year-old female presents with a sore throat for nearly two weeks. She complains of fatigue and a low-grade fever. On physical examination, there is cervical, axillary, and inguinal lymphadenopathy, and mild splenomegaly. On review of the blood smear, which of the following would be expected? A. Atypical lymphocytes B. Hypersegmented neutrophils C. Hypochromic red blood cells D. Schistocytes
***A. The hallmark of infectious mononucleosis is the presence of lymphocytosis with atypical large lymphocytes seen in the blood smear. These are larger than normal mature lymphocytes, stain more darkly, and frequently show vacuolated, foamy cytoplasm, and dark chromatin in the nucleus. B. Hypersegmented neutrophils are seen in vitamin B12 deficiency. C. Anemia, if seen in mononucleosis, is normocytic and normochromic. D. Schistocytes are noted in hemolytic anemias.
- Health Maintenance/Urology/Renal Which of the following increases the risk of developing testicular cancer? A. Low socioeconomic status B. History of cryptorchidism C. Multiple episodes of epididymitis D. Being of African-American ethnicity
A. High socioeconomic status, not low, is a risk factor. ***B. The major predisposing risk factor is cryptorchidism unrepaired until after age two. C. Multiple episodes of epididymitis are unrelated to the development of testicular cancer. D. The incidence of testicular cancer is much lower in African-American men than in Caucasian men.
- Diagnostic Studies/Psychiatry/Behavioral Medicine A 17 year-old patient presents to the emergency department with agitation and hallucinations, and has one seizure. He admits to using “some drugs” but does not know what they were. On physical examination, temperature is 103 degrees F, BP 140/90, pulse 120, respirations 20. Remainder of the examination is unremarkable. Which of the following diagnostic studies will be of most help in managing this patient? A. Drug screen B. Urine dipstick C. Complete blood count D. Serum creatinine kinase
(a)A. Although a drug screen may identify specific drugs, the results will not alter the care of this patient. B. Urine dipstick is not sensitive for myoglobinuria. C. This patient is at risk for myoglobinuria, and a complete blood count will not alter the treatment. ***D. Serum creatinine kinase is the most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse.
- Clinical Therapeutics/Orthopedics/Rheumatology Which of the following medications is the treatment of choice for patients with chronic gout to prevent recurrence of symptoms during its quiescent phase? A. Probenecid (Benemid) B. Allopurinol (Zyloprim) C. Colchicine D. Indomethacin (Indocin)
A. Probenecid is a uricosuric medication that helps to increase the excretion of uric acid but it does not prevent the formation of uric acid making it less beneficial in chronic gout therapy. It is also not effective in patients with chronic renal disease. ***B. Allopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It is a xanthine oxidase inhibitor that is used to prevent the formation of uric acid. C. Colchicine treatment is recommended only in patients who have tophaceous deposits in the skin and is used in the acute rather than the chronic setting of gout. D. Indomethacin is used in the acute management of gout but is not effective in decreasing monosodium urate deposition in the joints.
- Diagnosis/Endocrinology A 64 year-old male presents complaining of new onset of fatigue, weight gain, constipation, erectile dysfunction, and loss of body hair. Laboratory investigation demonstrates: TSH less than 0.5 microunits/mL (normal range 0.5-5.0 microU/mL); Thyroxine (T4) 2 mcg/dL (normal range 5-12 mcg/dL); Prolactin 10 nanograms/ml (normal A. Primary hypothyroidism B. Excessive dosing of levothyroxine (Synthroid) C. Hypopituitarism D. Subacute thyroiditis
A. Primary hypothyroidism is usually associated with an elevated TSH. B. Excessive replacement of levothyroxine would result in symptoms of hyperthyroidism, not hypopituitarism. ***C. The low trophic and target hormone levels combined with symptoms of hypogonadism indicate this patient has hypopituitarism. D. The T4 level would be elevated in subacute thyroiditis due to excessive release of thyroid hormone.
- Diagnosis/Pulmonology A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is A. tuberculosis. B. mycoplasma pneumonia. C. pneumococcal pneumonia. D. staphylococcal pneumonia.
A. Most children with pulmonary tuberculosis are asymptomatic with few physical examination findings. The results of the diagnostic studies do not support tuberculosis as the most likely diagnosis. ***B. The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely. C. The clinical presentation of bacterial pneumonias in children is variable, but usually involves fever of acute onset. The WBC count is also usually elevated, making this a less likely diagnosis. D. See C for explanation.
- History & Physical/Obstetrics/Gynecology Which of the following clinical manifestations is common in candidal vulvovaginitis? A. Extreme vulvar irritation B. Firm, painless ulcer C. Tender lymphadenopathy D. Purulent discharge
***A. Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that may be malodorous. B. A firm painless ulcer is seen in syphilis. C. Tender lymphadenopathy is associated with bacterial infections and is not a feature of candidal vulvovaginitis. D. Purulent discharge is noted in gonorrhea.
- Diagnosis/Cardiology A 63 year-old female presents with a complaint of chest pressure for one hour, noticed upon awakening. She admits to associated nausea, vomiting, and shortness of breath. 12 lead EKG reveals ST segment elevation in leads II, III, and AVF. Which of the following is the most likely diagnosis? A. Aortic dissection B. Inferior wall myocardial infarction C. Acute pericarditis D. Pulmonary embolus
A. A patient with aortic dissection will complain of tearing, ripping pain. EKG is often normal, but may reveal left ventricular strain pattern. ***B. Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST segment elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction. C. Acute pericarditis presents with atypical chest pain and diffuse ST segment elevation. D. Pulmonary embolism often presents with either no EKG changes or sinus tachycardia. Classically described, rarely seen findings include a large S wave in lead I, a Q wave with T wave inversion in lead III, ST segment depression in lead II, T wave inversion in leads V1-V4 and a transient right bundle branch block.
- Diagnostic Studies/Hematology An 18 year-old woman presents to the clinic complaining of fatigue. She reports a past history of lifelong frequent nosebleeds and bleeding gums. She also has menorrhagia. Her mother and maternal grandfather have a similar bleeding history. Initial lab results are as follows: WBC 9,500/mm3, Hgb 10.9 g/dL, HCT 33%, MCV 69 fL, MCHC 26 pg and platelets 284,000/mm3. Which of the following tests should be ordered to evaluate this patient’s diagnosis? A. Hemoglobin electrophoresis B. Bleeding time and platelet aggregometry C. Bone marrow aspiration D. PT and aPTT
A. Hemoglobin electrophoresis would be utilized to evaluate microcytic, hypochromic anemias. ***B. The patient’s presentation is consistent with a congenital qualitative platelet disorder, most likely von Willebrand’s Disease, necessitating a bleeding time and evaluation of platelet function. C. Bone marrow aspiration is not utilized in the evaluation of qualitative platelet disorders. D. A PT and aPTT would be utilized to evaluate for bleeding consistent with abnormalities with the coagulation cascade.
- Clinical Therapeutics/ENT/Ophthalmology A 35 year-old patient has recurrent seasonal rhinitis and a history of mild asthma. Which of the following should be included for first-line management? A. Immunotherapy B. Decongestants C. Corticosteroid inhalers D. Cromolyn sodium (Intal)
A. Immunotherapy (desensitization) is indicated as a last resort in patients who fail to either respond to pharmaceutical management or face prolonged exposure to known allergens. B. Decongestants have a limited role in helping to decrease edema, and are generally ineffective in relieving allergic symptoms. ***C. Regular use of corticosteroid nasal spray and oral inhalers prior to the allergy season is among the best means of preventing allergies. D. Cromolyn sodium has been found to be moderately effective for some patients with allergic symptoms, but it is not usually first-line management.
- Diagnosis/Obstetrics/Gynecology A 35 year-old female presents with multiple ulcerative lesions on her labia and perineum. A Tzanck preparation of one of the lesions reveals multinucleated giant cells. Which of the following is the most likely diagnosis? A. Herpes Simplex Virus (HSV) B. Molluscum Contagiosum Virus (MCV) C. Human Papilloma Virus (HPV) D. Syphilis
***A. The presentation seen on the Tzanck preparation is characteristic of HSV. B. See A for explanation. C. See A for explanation. D. See A for explanation.
- Scientific Concepts/ENT/Ophthalmology Small grayish vesicles and punched-out ulcers in the posterior pharynx in a child with pharyngitis is representative of which organism? A. Epstein-Barr virus B. Group C Streptococcus C. Coxsackievirus D. Gonorrhea
A. Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate. B. Group C Streptococcus presents with a red pharynx and enlarged tonsils with a yellow, blood tinged exudates ***C. Coxsackievirus presents with small grayish vesicles and punched-out ulcers in the posterior pharynx. D. Neisseria gonorrhea of the pharynx may be asymptomatic
- Health Maintenance/Neurology A 53 year-old female has a diagnosis of migraine headaches. She had been using sumatriptan (Imitrex) to abort her headaches, but she is now having one or two headaches per week. The most appropriate preventive therapy is A. zolmitriptan (Zomig). B. promethazine (Phenergan). C. propranolol (Inderal). D. fluoxetine (Prozac).
A. Zolmitriptan, another 5-HT receptor agonist, is used acutely to abort migraine headaches. B. Promethazine is an antiemetic that may be used to alleviate nausea and vomiting from an acute migraine. ***C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely. D. Fluoxetine is an SSRI that is used in the treatment of anxiety and obsessive-compulsive disorders.
- History & Physical/Neurology Topic: 3 Author: Which of the following primitive reflexes should begin to disappear at about 2 months of age in a normal infant? A. Moro B. Grasp C. Tonic neck D. Parachute
A. The Moro reflex starts to disappear at about 5-6 months of age. ***B. The grasp reflex starts to disappear at about 2-3 months of age. C. The tonic neck reflex starts to disappear at about 6-7 months of age. D. The parachute reflex remains throughout life.
- History & Physical/Cardiology A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical features? A. Chest pain B. Cyanosis C. Convulsions D. Palpitations
A. Chest pain is not a feature of tetralogy of Fallot. ***B. Cyanosis is very common in tetralogy of Fallot. C. Convulsions are occasionally seen as part of severe hypoxic spells in infancy rather than a feature of tetralogy of Fallot. D. Palpitations are uncommon in tetralogy of Fallot.
- Clinical Therapeutics/Orthopedics/Rheumatology Intraarticular injection of hyaluronic acid has been approved for treatment of patients with which of the following conditions? A. Rheumatoid arthritis of the knee B. Osteoarthritis of the knee C. Olecranon bursitis D. Gouty arthritis
A. See B for explanation. ***B. Intraarticular injection of hyaluronic acid has been approved recently for treatment of patients with osteoarthritis of the knee that have failed other therapies. Although the onset of action of this medication is slower than injected glucocorticoids, it has a sustained length of activity outlasting the injected glucocorticoids. C. Treatment of olecranon bursitis may include incision and drainage but not hyaluronic acid injections. D. Gout is treated with anti-inflammatory medications.
- Clinical Therapeutics/Psychiatry/Behavioral Medicine Which of the following drugs is first-line therapy for schizophrenia? A. Chlorpromazine (Thorazine) B. Clozapine (Clozaril) C. Haloperidol (Haldol) D. Olanzapine (Zyprexa)
A. The older, traditional antipsychotic agents, such as haloperidol and chlorpromazine have higher risk of side effects, including acute motor system side effects a long-term risk of tardive dyskinesias, and should not be considered as first-line drugs. B. Clozapine should not be considered a first-line therapy because of its hematopoietic and hepatic side effects. C. See A for explanation. ***D. Initial pharmacologic therapy of schizophrenia should begin with one of the newer, “atypical” antipsychotic drugs, such as olanzapine, risperidone, quetiapine, ziprasidone, and clozapine because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms.
- Diagnosis/Orthopedics/Rheumatology A 25 year-old presents with pain in the proximal ulna after falling directly on the forearm. X-ray shows fracture of the proximal 1/3rd of the ulna. There is an associated anterior radial head dislocation. What is the proper name for this condition? A. Galeazzi fracture B. Monteggia fracture C. Colles’ fracture D. Smith fracture
A. A Galeazzi fracture is a fracture along the length of the radius with injury to the distal radioulnar joint. ***B. A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head. C. A Colles’ fracture is a fracture of the distal radius with dorsal displacement of the radial head. D. A Smith fracture is a fracture of the distal radius with ventral displacement of the radial head.
- Diagnosis/Gastrointestinal/Nutritional A 20 year-old male presents with a mass in the groin. On examination with the patient standing, a mass is noted that extends into the scrotum. The patient denies any trauma. The most likely diagnosis is A. an indirect inguinal hernia. B. a direct inguinal hernia. C. an obturator hernia. D. a femoral hernia.
***A. An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum. B. A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. It is the result of a weakness in the inguinal 3external ring. Hernial contents may radiate anteriorly rather than into the scrotum. C. Obturator hernia’s are more commonly seen in elderly women and are rarely palpable in the groin. D. Femoral hernias are rare in males and do not typically reduce with lying down.
- Health Maintenance/ENT/Ophthalmology A patient with type 2 diabetes mellitus presents for a yearly eye exam. Ophthalmoscopic exam reveals neovascularization. Which of the following is the most likely complication related to this finding? A. Glaucoma B. Cataracts C. Vitreous hemorrhage D. Optic neuritis
A. Glaucoma occurs in about 6% of diabetics. Neovascularization of the iris can cause closed angle glaucoma. B. Cataracts can occur secondary to diabetes, but are not caused by proliferative retinopathy. ***C. Proliferative retinopathy, as evidenced by neovascularization, is associated with an increased risk of vitreous hemorrhage. D. Optic neuritis is strongly associated with demyelinating disease, like multiple sclerosis.
- Clinical Therapeutics/Endocrinology Which of the following oral hypoglycemic agents when used as monotherapy is most likely to cause hypoglycemia? A. Glipizide (Glucotrol) B. Metformin (Glucophage) C. Pioglitazone (Actos) D. Acarbose (Precose)
***A. Sulfonylureas increase insulin levels and predispose patients to hypoglycemia. B. C. D. Acarbose is an alpha glucosidase inhibitor that delays the absorption of carbohydrates in the diet. It does not cause hypoglycemia since it does not drive insulin into the cells.
- Diagnosis/Orthopedics/Rheumatology A 75 year-old female presents with medial knee pain that worsens with stair climbing. Physical examination reveals swelling and point tenderness inferior and medial to the patella and tenderness overlying the medial tibial plateau. Which of the following is the most likely diagnosis? A. Pes anserine bursitis B. Prepatellar bursitis C. Infrapatellar bursitis D. Trochanteric bursitis
***A. The pes anserine bursa underlies the semimembranosus tendon and may become inflamed or painful owing to trauma, overuse, or inflammation. It is a common cause of knee pain and it is often misdiagnosed in adults. B. Prepatellar bursitis causes swelling in the prepatellar area and is worse with kneeling. The prepatellar bursa is superficial and is located over the inferior portion of the patella. C. The infrapatellar bursa is deeper and lies beneath the patellar ligament before its insertion on the tibial tubercle. It has a midline location rather than the medial surface as described in the question. D. Trochanteric bursitis causes hip pain rather than knee pain.
- Diagnosis/Cardiology A 23 year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis? A. Hypertrophic cardiomyopathy B. Aortic stenosis C. Mitral regurgitation D. Pulmonic stenosis
***A. Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining. B. Straining decreases the intensity of the murmur associated with aortic stenosis and squatting increases the intensity. C. Mitral regurgitation is characterized by a blowing systolic murmur that radiates to the axilla, it is not often associated with syncope. D. Pulmonic stenosis is a harsh systolic murmur with a widely split S2, and no change with maneuvers.
- Clinical Therapeutics/Gastrointestinal/Nutritional Which of the following can be a very serious consequence of using antidiarrheals in a patient with inflammatory bowel disease? A. Lymphoma B. Toxic megacolon C. Bone marrow suppression D. Delayed serum sickness-like reaction
A. There is suggestion that lymphoma may result from the use of infliximab, an anti-TNF agent, utilized in refractory cases of Crohn’s disease; however a clear link between the development of lymphoma and the use of infliximab has not been established. ***B. Antidiarrheals may cause the development of toxic megacolon when used by patients with active severe inflammatory bowel disease. C. Bone marrow suppression is a side effect of methotrexate, which is being increasingly used in the treatment of Crohn’s disease. D. Delayed serum sickness-like reaction is another potential side effect of infliximab.
- Diagnosis/Orthopedics/Rheumatology A 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear lymphocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis? A. Rheumatoid arthritis B. Septic arthritis C. Gouty arthritis D. Osteoarthritis
A. Rheumatoid arthritis usually involves more than one joint, primarily affecting metacarpophalangeal and wrist joints initially. Synovial fluid analysis would show moderate leukocytosis (
- Clinical Therapeutics/Urology/Renal When the diagnosis of gonococcal urethritis is confirmed, which of the following is the treatment of choice? A. Ceftriaxone (Rocephin) B. Amoxicillin (Amoxil) C. Penicillin G benzathine (Bicillin LA) D. Doxycycline (Vibramycin)
***A. Ceftriaxone is recommended therapy for gonococcal urethritis. B. Effective single-dose regimens for uncomplicated gonococcal urethritis include cefixime or one of the fluoroquinolones, but NOT amoxicillin due to penicillin-resistant strains of gonorrhea. C. Penicillin G benzathine is the treatment of choice for primary syphilis. D. Doxycycline is the treatment of choice for Chlamydia urethritis, not gonococcal urethritis.
- History & Physical/Dermatology Erythema nodosum is characterized by A. subcutaneous red tender nodules. B. brown pigmentation on the lower extremities. C. tender lymph nodes in the groin. D. scaling red macules.
***A. Erythema nodosum produces erythematous red tender nodules, especially on the shins. B. Brown pigmentation on the lower extremities is a feature of chronic venous insufficiency. C. Lymphovenereum granuloma is likely to produce tender lymph nodes in the groin as can acute infection in the lower extremities. D. Scaling red macules are a feature of tinea corporis.
- Clinical Therapeutics/ENT/Ophthalmology Use of systemic corticosteroids can cause which of the following adverse effects in the eye? A. Cortical blindness B. Optic atrophy C. Glaucoma D. Papilledema
A. Cortical blindness is a rare adverse effect when prescribing salicylates. B. Optic atrophy can occur as an adverse effect with lead compounds, amebicides, and MAO inhibitors. ***C. Glaucoma can be caused by the long-term use of steroids. D. Papilledema can be a side effect to many systemic medications.
- Health Maintenance/Obstetrics/Gynecology It is determined that a woman has a nonexistent rubella titer level during her first trimester of pregnancy. When should she receive the rubella vaccine? A. During the first trimester of pregnancy B. During the second trimester of pregnancy C. During the third trimester of pregnancy D. After delivery of the infant
A. See D for explanation. B. See D for explanation. C. See D for explanation. ***D. The patient should not receive the rubella vaccine during the course of her pregnancy as the possibility of transmission of the rubella virus does exist. During the time that the patient is without protective titer she should avoid anyone with active rubella infection. The proper time to receive the vaccine is after delivery of the infant.
- Health Maintenance/Cardiology A patient with which of the following is at highest risk for coronary artery disease? A. Congenital heart disease B. Polycystic ovary syndrome C. Acute renal failure D. Diabetes mellitus
A. Congenital heart disease is not an established risk factor for coronary artery disease. B. While patients with polycystic ovary syndrome have hyperinsulimemia, they do not have the same poor prognosis for coronary artery disease as patients with diabetes mellitus. C. Patients with acute renal failure are not at risk for coronary artery disease, although patients with diabetes and chronic renal disease do have this risk. ***D. Patients with diabetes mellitus are in the same risk category for coronary artery disease as those patients with established atherosclerotic disease.
- Diagnostic Studies/Orthopedics/Rheumatology A 44 year-old female presents with ongoing arthralgias and myalgias with intermittent flares of arthritis. She is found to have a malar rash that worsens with sun exposure. She is known to have progressive renal damage and has recurrent infections that are slow to respond to therapy. She takes ibuprofen (Motrin) as needed for her joint pain and takes no other medication. Which of the following tests would be the initial test recommended to screen for this diagnosis? A. Rheumatoid factor B. Antihistone antibodies C. Anti-Smith (Anti-Sm) antibodies D. Anti-nuclear antibodies (ANA)
A. Rheumatoid factor is most commonly performed in the assessment of rheumatoid arthritis and not suspected systemic lupus erythematosus. B. Antihistone antibodies are seen in drug-induced SLE rather than in spontaneously occurring SLE. C. Anti-Smith antibodies and antibodies to the double stranded DNA are fairly specific to SLE but their role is for confirmation rather than screening for SLE. ***D. ANA’s are the best screening test used in the evaluation for SLE.
- History & Physical/Neurology Upon stroking of the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan. This is a positive A. Kernig’s sign. B. Brudzinski’s sign. C. Babinski’s sign. D. Gower’s sign.
A. Kernig’s sign is positive when pain is noted on straightening the knee after flexing both the hip and knee. B. Brudzinski’s sign occurs with neck flexion resulting in resultant flexion of the hips. It is a sign of meningeal irritation. ***C. A Babinski test is performed by stroking the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan in a positive test. D. A positive Gower’s sign is noted in certain types of muscular dystrophy and is described as children rising to stand by rolling over prone and pushing off the floor with arms while the legs remain extended.
- Health Maintenance/Endocrinology Which of the following strategies promotes improved carbohydrate metabolism and is recommended for all Type 2 diabetic patients? A. Low-carbohydrate, high protein diet B. Routine aerobic exercise C. Metformin (Glucophage) D. Acupuncture
A. There is no evidence that a low-carbohydrate, high protein diet is effective in improving carbohydrate metabolism. ***B. Routine exercise improves carbohydrate metabolism and insulin sensitivity. C. Metformin is a biguanide that primarily works to decrease gluconeogenesis rather than affecting carbohydrate metabolism. D. There is no evidence that acupuncture improves carbohydrate metabolism.
