Pance Questions 10

Question 1

216. A 56-year-old man with a history of smoking and congestive heart failure has worsening shortness of breath. On exam, you note dullness to percussion and decreased breath sounds on the side of the left lung. What is likely going on here?
     a. Pleural effusion
     b. Acute bronchitis
     c. Pneumothorax
     d. Emphysema

Answer 1

216. A: Pleural effusion. This is an accumulation of fluid within the pleural space. There are many causes, including heart failure, cirrhosis, pneumonia, malignancy, pulmonary embolism, tuberculosis, or trauma. Chest x-ray can confirm the diagnosis. Effusions can be classified as transudates or exudates. Pneumothorax is air in the pleural space and would cause hyperresonance to percussion instead of dullness.

Question 2

217. Which of the following is NOT associated with a diagnosis of macular degeneration?
     a. Presence of drusen
     b. Loss of peripheral vision
     c. Development of scotomas
     d. Deteriorating vision in elderly patients

Answer 2

217. B: Loss of peripheral vision. Atrophy of the macula is a common cause of worsening vision in elderly patients. The macula is the spot near the center of the retina. Small yellow deposits form under the macula called drusen. Central visual acuity is lost slowly, and central blind spots are called scotomas. Peripheral vision is usually not affected. Macular degeneration is diagnosed by funduscopy and can be treated with laser.

Question 3

218. You are asking a new 32-year-old male patient about his medical and surgical history. He says that he had previously sustained a rotator cuff injury. Which one of the following muscles might have been affected?
     a. Deltoid
     b. Teres minor
     c. Rhomboideus major
     d. Teres major

Answer 3

218. B: Teres minor. Injuries of the rotator cuff include strains, tendinitis, and partial or complete tears. The muscles of the rotator cuff are the supraspinatus, infraspinatus, teres minor, and subscapularis. They help stabilize the humerus in the scapula. The rotator cuff cannot be palpated directly, but there are different maneuvers that can be used in the physical exam to test specific muscles for weakness or pain.

Question 4

219. A 45-year-old woman arrives in the emergency department with a blood pressure of 207/ 134. A family member says that she has not been taking any of her medications for the past few weeks. The patient is found to be confused with elevated creatinine. How do you best treat this patient?
     a. IV nicardipine
     b. Oral nitroglycerin
     c. IV furosemide
     d. Oral clonidine

Answer 4

219. A: IV nicardipine. This is considered a hypertensive emergency due to a diastolic reading of over 120 and target-organ damage. This can include encephalopathy, preeclampsia, left ventricular failure, MI, renal failure, aortic dissection, and retinopathy. Treatment is with short-acting IV drugs used to progressively lower blood pressure with titration. Nicardipine is a calcium channel blocker and acts as a vasodilator. Other drugs used include nitroprusside, labetalol, and fenoldopam. Onset is more variable with oral drugs.

Question 5

220. Which of the following would you NOT expect when performing a physical examination of a patient with myasthenia gravis?
     a. Diplopia
     b. Ptosis
     c. Muscle weakness
     d. Decreased deep tendon reflexes

Answer 5

220. D: Decreased deep tendon reflexes. Myasthenia gravis is an autoimmune neuromuscular disease characterized by muscle fatigability. Antibodies block acetylcholine receptors, so it is treated with acetylcholinesterase inhibitors. Patients have weakness of the eye muscles and of the limbs. More severe disease can affect the respiratory muscles. Deep tendon reflexes are usually preserved.

Question 6

221. A 26-year-old man arrives in the emergency department with periumbilical pain that has been present for the past 3 hours. On exam, you note abdominal guarding and tenderness at McBurney point. What is your next step?
     a. Order a right upper quadrant (RUQ) ultrasound
     b. Call surgery
     c. Discharge with pain medications
     d. Advise a high fibre diet

Answer 6

221. B: Call surgery. This patient is presenting with appendicitis, which is most common in teenagers and patients in their 20s. Patients usually have periumbilical pain at first, which then shifts to the right lower quadrant. McBurney point is located at one-third of the distance from the anterior superior iliac spine to the umbilicus. Gangrene and perforation can occur if left untreated, so it is considered an emergency.

Question 7

222. A 22-year-old man has low-grade flank pain. He is hypertensive, and urinalysis shows blood and protein. CT shows bilateral enlarged kidneys with multiple fluid-filled spaces. What is the most likely diagnosis?
     a. Urinary tract infection
     b. Nephrolithiasis
     c. Polycystic kidney disease
     d. Pyelonephritis

Answer 7

222. C: Polycystic kidney disease. This is a progressive genetic condition that may be asymptomatic at first but patients may present with symptoms while in their 20s. It can be autosomal dominant or recessive. Patients present with flank pain, hematuria, and hypertension. It is diagnosed by CT or ultrasound. It may progress to renal failure and require dialysis or transplantation. Patients can have extrarenal manifestations such as hepatic cysts, valvular heart disorders, or cerebral aneurysms.

Question 8

223. Which medication is most suitable for treating lichen simplex chronicus?
     a. Tretinoin
     b. Nystatin
     c. Neomycin
     d. Triamcinolone

Answer 8

223. D: Triamcinolone. Lichen simplex chronicus is characterized by darkened, leathery-appearing skin due to repeated scratching. It occurs frequently in patients with anxiety disorders. Dry, scaling plaques are usually seen on the legs, arms, neck, and trunk. It may appear similarly to tinea, lichen planus, and psoriasis. Treatment is with topical steroids.

Question 9

224. You are reviewing a patient’s lymph node biopsy results which reveal Reed-Sternberg cells. What are these cells associated with?
     a. Burkitt lymphoma
     b. Multiple myeloma
     c. Hodgkin lymphoma
     d. Acute lymphoblastic leukemia

Answer 9

224. C: Hodgkin lymphoma. Also known as Hodgkin disease, this is a malignant proliferation of cells of the lymphoreticular system. Patients may present with lymphadenopathy, fever, weight loss, splenomegaly, or hepatomegaly. It is diagnosed through biopsy and treated with chemotherapy and radiation. Reed-Sternberg cells are large and binucleated— they are abnormal cells that result from clonal transformation of B lymphocytes.

Question 10

225. What is the mechanism of action for fluvoxamine?
     a. Serotonin 5-HT receptor partial agonist
     b. Serotonin-norepinephrine reuptake inhibitor
     c. Norepinephrine-dopamine reuptake inhibitor
     d. Selective serotonin reuptake inhibitor

Answer 10

225. D: Selective serotonin reuptake inhibitor. Also know as an SSRI, fluvoxamine works by inhibiting the reuptake of serotonin into the presynaptic cell so that more serotonin is available in the synaptic cleft to bind to the postsynaptic receptor. Serotonin is a neurotransmitter found in the brain that is thought to help regulate mood. SSRIs are used in the treatment of depression and anxiety. Other SSRIs include citalopram, fluoxetine, paroxetine, and sertraline.

Question 11

226. A 12-year-old girl arrives in the emergency department with nausea, vomiting, and abdominal pain. She is hypotensive and tachycardic. Glucose and ketones are present in the urine. What does this patient likely have?
     a. Addison disease
     b. Type I diabetes mellitus
     c. Multiple endocrine neoplasia
     d. Type II diabetes mellitus

Answer 11

226. B: Type I diabetes mellitus. This usually develops in children and adolescents and is considered insulin-dependent, whereas type II diabetes develops more often in adults who may or may not need insulin replacement. In type I diabetes, insulin production is absent because of autoimmune destruction of pancreatic B cells. Patients may present in diabetic ketoacidosis, which is an acute complication characterized by hyperglycemia.

Question 12

227. What is torsades de pointes?
     a. Polymorphic ventricular tachycardia associated with long QT syndrome
     b. Partial or complete interruption of impulse conduction in a bundle branch
     c. Reentrant supraventricular tachycardia triggered by an atrial premature beat
     d. Rapid regular atrial rhythm due to a reentrant circuit

Answer 12

227. A: Polymorphic ventricular tachycardia associated with long QT syndrome. In torsades de pointes, the ventricular rate can range from 150-250 beats per minute. It appears on ECG as irregular twisting of the QRS complex around the baseline. Prolonged QT interval, which is inherited or caused by medications, predisposes individuals to arrhythmias that can trigger torsades. Torsades can terminate spontaneously or may degenerate into ventricular fibrillation, which can lead to sudden death without intervention.

Question 13

228. A 34-year-old generally healthy man has had cough, shortness of breath, pleuritic chest pain, and malaise for the past 3 days. He is febrile, and crackles are heard with lung auscultation. Chest x-ray shows multilobar infiltrates. What is the most likely causative organism?
     a. Adenovirus
     b. Histoplasma capsulatum
     c. Streptococcus pneumoniae
     d. Respiratory syncytial virus

Answer 13

228. C: Streptococcus pneumoniae. Pneumonia is an inflammation of the lungs that can be caused by bacteria, viruses, fungi, or parasites. Many pathogens present similarly in patients, and it is often difficult or unnecessary to determine the specific causative agent. Chest x-ray will usually show an infiltrate. Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, and Chlamydia pneumoniae are the most common bacterial causes. Adenovirus is a common infection but usually does not cause pneumonia. Histoplasma capsulatum is a fungus that causes infection more commonly in patients with weakened immune systems. RSV infection usually occurs in children.

Question 14

229. Epidemiologically, which one of the following patients would be the most likely to be diagnosed with sarcoidosis?
     a. 32-year-old African-American woman
     b. 16-year-old Asian male adolescent
     c. 63-year-old Caucasian woman
     d. 41-year-old Hispanic man

Answer 14

229. A: 32-year-old African-American woman. Sarcoidosis is characterized by noncaseating granulomas found in organs and tissues. The etiology is unknown. Diagnosis is usually first suspected because of lung involvement. It primarily affects people 20-40 years of age, and prevalence is greatest in northern Europeans and in people of African descent in the United States. It is slightly more prevalent in women.

Question 15

230. A growing pituitary adenoma can compress which of the following structures?
     a. Superior cerebellar peduncle
     b. Optic chiasm
     c. Pineal body
     d. Amygdala

Answer 15

230. B: Optic chiasm. The pituitary gland is located in the sella turcica, which is a fossa of the sphenoid bone. A pituitary adenoma may present with visual field defects due to compression of the optic nerve. The optic chiasm is the area where the optic nerves partially cross, making an “x.” Pressure on the optic chiasm can cause bitemporal hemianopia, which is a bilateral temporal visual field defect.

Question 16

231. Which of the following medications does NOT typically have gastrointestinal side effects?
     a. Citalopram
     b. Metformin
     c. Naproxen
     d. Albuterol

Answer 16

231. D: Albuterol. Citalopram is an SSRI used for depression and anxiety. GI upset is a common side effect, in the form of nausea, vomiting, or diarrhea. Gastrointestinal upset is common when metformin is first prescribed for treatment of diabetes. Naproxen is an NSAID and can cause heartburn and ulcers. Albuterol is used in the treatment of asthma and does not typically have GI side fx.

Question 17

232. A 70-year-old man who recently had abdominal surgery has a swollen, painful, erythematous left lower leg. He does not recall any trauma to the leg. D-dimer is positive. When doing your physical examination, what would help support your suspected diagnosis?
     a. Murphy sign
     b. Homan sign
     c. Waddell sign
     d. Tinel sign

Answer 17

232. B: Homan sign. This patient likely has a deep venous thrombosis (DVT), which is a blood clot usually occurring in a deep vein of the calf or thigh. Risk factors include recent surgery, immobilization, smoking, heart failure, trauma, obesity, malignancy, contraceptive use, and pregnancy. DVTs cause pain and swelling and can lead to pulmonary embolism. They are treated with anticoagulants. Homan sign is when ankle dorsiflexion elicits calf pain when the knee is extended. The sign is neither sensitive nor specific, but it can occur with distal leg DVTs.

Question 18

233. According to the latest guidelines from the American Congress of Obstetricians and Gynecologists, at what age should women start having annual mammograms?
     a. 55
     b. 30
     c. 47
     d. 40

Answer 18

233. C: 47.

Question 19

234. How can primary pulmonary hypertension be treated?
     a. Prostaglandins
     b. Norepinephrine
     c. Beta-agonists
     d. Antidiuretic hormone

Answer 19

234. A: Prostaglandins. The cause of primary pulmonary hypertension (PPH) is unknown. Pulmonary vessels become constricted and fibrosed, leading to right ventricular failure. Patients present with fatigue and exertional dyspnea. Tests may be obtained to rule out secondary causes. PPH is diagnosed by measuring pulmonary artery pressure. Prostaglandins are used as treatment because they dilate vessels. Some patients may require transplantation.

Question 20

235. A 67-year-old woman has urinary symptoms of urgency and frequency for the past year, to the point where she leaks urine. Her urinalysis is negative for infection. Which muscle is over-active in this case?

a. External sphincter
b. Detrusor
c. Internal sphincter
d. Trigone

Answer 20

235. B: Detrusor. This muscle contracts when urinating. Involuntary bladder contractions are caused by overactivity of the detrusor muscle. This is a type of urge incontinence commonly seen in elderly women. Treatment can include bladder training, Kegel exercises, and relaxation techniques. Oxybutynin can suppress urgency symptoms.

Question 21

236. A 50-year-old man with hypertension arrives for routine follow-up. He reports that he had a 5-minute episode last week where his vision went black in one eye. On today’s exam, you do not find any visual deficits. What likely happened to this patient?
     a. Subarachnoid hemorrhage
     b. Central retinal artery occlusion
     c. Transient ischemic attack
     d. Optic neuritis

Answer 21

236. C: Transient ischemic attack. A TIA is similar to a stroke but the symptoms last less than an hour. TIAs do increase risk of stroke. This patient likely experienced amaurosis fugax, which is transient monocular blindness caused by ischemia of the ophthalmic artery. When TIAs occur, it is important to test for hemorrhage, carotid stenosis, and arrhythmias. Antiplatelet drugs are given to prevent strokes. Central retinal artery occlusions also cause unilateral blindness, but vision does not usually improve. Optic neuritis presents with pain.

Question 22

237. All of the following are associated with a diagnosis of rheumatoid arthritis EXCEPT:
     a. Radial deviation of the fingers
     b. Boutonniere deformity
     c. Keratoconjunctivitis sicca
     d. Anti-CCP

Answer 22

237. A: Radial deviation of the fingers. Rheumatoid arthritis is a chronic systemic inflammatory disease that mainly affects the joints. Patients with rheumatoid arthritis have ulnar deviation of the fingers. Boutonniere deformity is when the proximal interphalangeal joints are flexed and the distal interphalangeal joints are hyperextended. Keratoconjunctivitis sicca is eye dryness. Anti-citrullinated peptide antibodies have a high specificity and sensitivity for RA.

Question 23

238. A 40-year-old man has right ankle pain that started suddenly when he was running earlier in the day. When doing your physical examination, you find that the Thompson test is positive. What does this signify?
     a. Ankle sprain
     b. Achilles tendon rupture
     c. Talus fracture
     d. Gastrocnemius tear

Answer 23

238. B: Achilles tendon rupture. This tendon connects the calf muscles to the heel, so that the foot can be plantar flexed. Athletes or patients who have been inactive for a period may be more prone to rupture. Quinolone antibiotics have also been associated with an increased risk of rupture. A positive Thompson test means that the foot does not plantar flex when you squeeze the calf muscle while the patient is lying prone with their feet hanging off the table.

Question 24

239. You have been treating a 54-year-old male patient with simvastatin for hyperlipidemia. Recent lab results show that his LDL and HDL are at goal, but his triglycerides are still very elevated. What medication could you add to target this?
     a. Colestipol
     b. Fenofibrate
     c. Cholestyramine
     d. Rosuvastatin

Answer 24

239. B: Fenofibrate. This is a fibrate medication that works well to reduce triglycerides. Although it can potentiate muscle toxicity when used in conjunction with a statin, this combination can provide a significant therapeutic advantage for refractory hyperlipidemia. Statins work well to reduce LDL and reduce cardiovascular mortality. They also provide small increases in HDL and modest decreases in triglycerides. It would not be much more helpful to add another statin to the patient’s regimen, such as rosuvastatin. Bile acid sequestrants, such as colestipol and cholestyramine, may actually increase triglyceride levels.

Question 25

240. A 30-year-old woman has fever and neck pain that started several days ago. She says that she had just been getting over an upper respiratory tract infection. On exam, you note that her thyroid gland is tender to palpation and enlarged. Her free T4 is elevated, and TSH is decreased. Radioactive iodine uptake is decreased. How do you treat this patient?
     a. NSAIDs
     b. Levothyroxine
     c. Thyroidectomy
     d. Radioiodine

Answer 25

240. A: NSAIDs. This patient likely has De Quervain thyroiditis, also known as subacute thyroiditis. It is an acute inflammation of the thyroid likely due to a viral infection. Patients present with fever and thyroid tenderness. Thyroid function tests (TFTs) may initially show hyperthyroidism. It can be distinguished from Graves disease through the radioactive iodine uptake test, since Graves will result in increased uptake. De Quervain thyroiditis resolves within months. It is treated with high doses of NSAIDs or steroids.