Pance Questions 12

Question 1

267. A 67-year-old obese man arrives for routine follow-up. He does not have any specific complaints today. As you are performing an abdominal exam, you note a small bulge around the umbilicus that seems to reduce in size with pressure. What is the likely problem?
     a. Hernia
     b. Abscess
     c. Tumor
     d. Cyst

Answer 1

267. A: Hernia. This is a protrusion of the abdominal contents through a weakness in the abdominal wall. This patient has an umbilical hernia. They are usually asymptomatic and can be treated with elective surgery. Sometimes umbilical hernias can be painful because of strangulation (compromise of the blood supply to its hernial contents).

Question 2

268. How can you treat acute bronchiolitis?
     a. Antibiotics
     b. Corticosteroids
     c. Oxygen
     d. Aspirin

Answer 2

268. C: Oxygen. Bronchiolitis is an inflammation of the bronchioles, usually caused by viruses such as RSV. The virus causes epithelial necrosis and leads to obstruction and air trapping. It mostly affects children younger than 18 months. Patients can have coughing, wheezing, dyspnea, ray would show hyperinflation. Treatment is supportive and can include oxygen and hydration. There is some evidence that epinephrine may provide relief as a bronchodilator. Antibiotics are not indicated unless there is an overlying bacterial infection suggested.

Question 3

269. What is a potential complication of thyroidectomy?
     a. Hyperthyroidism
     b. Hoarseness
     c. Hyperparathyroidism
     d. Loss of taste

Answer 3

269. B: Hoarseness. This is due to damage of the recurrent laryngeal nerve, which ascends between the trachea and esophagus and passes near the thyroid gland to enter the larynx. Removal of the thyroid gland can result in hypothyroidism depending on the extent of the surgery. It can also cause hypoparathyroidism because the parathyroid glands are close by and may be damaged.

Question 4

270. Approximately how many weeks does it take after egg fertilization for a urine pregnancy test to have a positive result?
     a. 7-8
     b. 5-6
     c. 3-4
     d. 1-2

Answer 4

270. D: 1-2. Urine pregnancy tests check for the presence of human chorionic gonadotropin, which is produced in a growing placenta after implantation. The time it takes for a fertilized egg to implant in the uterus varies among women. It usually takes 6-12 days. Urine pregnancy tests are best done in the morning so that the urine is most concentrated. Tests can be falsely negative if done too early after conception. Blood pregnancy tests can usually show results earlier than urine pregnancy tests.

Question 5

271. A 54-year-old obese male patient with hypertension arrives for routine follow-up. He reports that he is not sleeping well at night and that he feels tired during the day. His wife says that he snores loudly. What is the next best step in management of this patient?
     a. Prescribe zolpidem for insomnia
     b. Encourage daytime naps
     c. Order a sleep study
     d. Prescribe modafinil to improve wakefulness

Answer 5

271. C: Order a sleep study. This patient likely has obstructive sleep apnea (OSA) that can be diagnosed with polysomnography. This is an interruption of breathing while sleeping. Apnea causes a suffocating sensation that does not usually wake the patient, but is enough to let breathing begin again. Risk factors include obesity and family history. OSA is associated with hypertension and diabetes. Patients with OSA often report snoring, gasping/choking sensation during the night, and daytime fatigue. Treatment is with positive airway pressure. Use of the sedative zolpidem can worsen untreated sleep apnea. Modafinil acts as a stimulant and can improve daytime fatigue, but underlying OSA should be treated first.

Question 6

272. You are reviewing the chart of a patient that has been receiving psychiatric treatment for years; the patient has requested to switch providers for the third time. You note a history of childhood abuse, low distress tolerance, substance abuse, and multiple suicide attempts. Which personality disorder is this patient likely diagnosed with?
     a. Paranoid
     b. Antisocial
     c. Avoidant
     d. Borderline

Answer 6

272. D: Borderline. This personality disorder is in Cluster B on Axis II, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability and impulsiveness. Patients make efforts to avoid abandonment, have unstable relationships with extremes between idealization and devaluation, feel empty, and make recurrent suicidal gestures.

Question 7

273. An 18-year-old generally healthy woman reports intermittent episodes where she feels like her heart is beating very fast. She cannot pinpoint any specific triggers but says this has been going on for months. She does not have a history of anxiety. On exam, you do not hear any murmurs. Her ECG is normal today. What is the best next step?
     a. Have her return in 6 months
     b. Order an echocardiogram
     c. Have her undergo Holter monitoring
     d. Order a stress test

Answer 7

273. C: Have her undergo Holter monitoring. Holter monitoring is continuous monitoring and recording of the ECG. It is useful for evaluation of intermittent arrhythmias that may not show up on a one-time physical exam. Patients wear the device for 24 hours and are also asked to record their symptoms so that they can be correlated with the data.

Question 8

274. All of the following are used to treat osteoporosis EXCEPT:
     a. Risedronate
     b. Raloxifene
     c. Zoledronic acid
     d. Carisoprodol

Answer 8

274. D: Carisoprodol. Risedronate and zoledronic acid are bisphosphonates that work by inhibiting bone resorption. Raloxifene is a selective estrogen receptor modulator that decreases bone turnover and increases bone mineral density. Carisoprodol is a muscle relaxant.

Question 9

275. Name the correct order of the connective tissue membranes surrounding the spinal cord, starting from the spinal cord and going outwards.
     a. Pia mater, subarachnoid space, arachnoid mater, dura mater
     b. Subarachnoid space, arachnoid mater, pia mater, dura mater
     c. Pia mater, dura mater, subarachnoid space, arachnoid mater
     d. Dura mater, subarachnoid space, arachnoid mater, pia mater

Answer 9

275. A: Pia mater, subarachnoid space, arachnoid mater, dura mater. The spinal canal lies within a bony canal. The anterior wall is formed by the vertebrae, discs, and ligaments. The vertebral arches and ligaments cover the other sides. Within the vertebral canal, the spinal cord is surrounded by the meninges. The subarachnoid space contains cerebrospinal fluid. Outside of the dura mater is the epidural space containing tissues, fat, and vessels.

Question 10

276. All of the following are true regarding the management of folate deficiency EXCEPT:
     a. Encourage dietary inclusion of plant foods and meats.
     b. Prescribe folic acid as a daily supplement.
     c. Advise patient that deficiency in pregnancy can lead to neural tube defects.
     d. Instruct patient to overcook food so that folate is preserved.

Answer 10

276. D: Instruct patient to overcook food so that folate is preserved. Deficiency of folic acid can be due to inadequate dietary intake, malabsorption, decreased metabolism, or drug interactions. Folate is found in citrus fruits, meats, and green leafy vegetables. Prolonged cooking actually destroys folate. Folate deficiency can cause megaloblastic anemia. Folate is important for DNA synthesis, and deficiency results in decreased RBC life.

Question 11

277. What is the function of the greater omentum in the abdominal cavity?
     a. Connects the left kidney to the spleen
     b. Walls off inflammation
     c. Absorbs nutrients

d. All of the above

Answer 11

277. B: Walls off inflammation. The greater omentum is a large double-layered membrane that attaches to the stomach and duodenum. It drapes over the intestines and colon and lies freely to “migrate” to inflamed areas and wrap itself around, adhering to diseased areas of the bowel.

Question 12

278. All of the following are located in the hilum within the root of each lung EXCEPT:
     a. Two pulmonary veins
     b. Main bronchus
     c. Two pulmonary arteries
     d. Nerves

Answer 12

278. C: Two pulmonary arteries. The root of each lung consists of structures that attach to the mediastinum. It is surrounded by pleura and this region is known as the hilum. One pulmonary artery, two pulmonary veins, a main bronchus, bronchial vessels, nerves, and lymphatics are within each lung root and located in the hilum.

Question 13

279. A 32-year-old woman has eye redness and tearing. Vision is decreased. You do fluorescein dye staining and see dendritic corneal lesions. What does this signify?
     a. Bacterial conjunctivitis
     b. Herpes keratitis
     c. Iritis
     d. Optic neuritis

Answer 13

279. B: Herpes keratitis. This is the leading cause of infectious corneal blindness in the United States. It is caused by HSV and transmitted through bodily fluids. The virus replicates in the corneal epithelium and breaks it down. Herpes keratitis produces hallmark dendritic ulcers.

Question 14

280. A 45-year-old woman is a new patient. She has not been to a doctor in several years but does not have any specific complaints today. During your physical exam, you notice that her right breast has an area that appears like the texture of an orange peel. Why is this concerning?
     a. Fibrocystic changes
     b. Breast cancer
     c. Mastitis
     d. Herpes zoster

Answer 14

280. B: Breast cancer. This patient has what is called “peau d’orange” that means that tumor growth and lymphatic obstruction can pull on the connective tissue in the breast to give the dimpled appearance of an orange peel. Breast cancer is one of the most common malignancies in women. This patient will need to have a biopsy and staging. There is also concern for metastases because it is unknown how long the cancer has been present.

Question 15

281. A 50-year-old man with lupus has worsening peripheral edema and a report of frothy urine. The 24-hour urine collection shows protein loss of 4.2 grams. What is the most likely diagnosis?
     a. Renal artery occlusion
     b. Acute tubular necrosis
     c. Acute renal failure
     d. Nephrotic syndrome

Answer 15

281. D: Nephrotic syndrome. This is a condition in which the kidneys leak protein into the urine because of increased permeability of the glomerular capillary wall. It may be the result of kidney disease or from another systemic condition that affects the kidneys. It is diagnosed by 24-hour urine collection when excretion of protein is greater than 3.5 g. It is treated with fluid restriction, diet, diuretics, and ACE inhibitors.

Question 16

282. How can a large pleural effusion be treated if it is resulting in pulmonary dysfunction?
     a. Paracentesis
     b. Physiotherapy
     c. Thoracentesis
     d. Nebulizer

Answer 16

282. C: Thoracentesis. This is when the chest wall is punctured for aspiration of pleural fluid. Pleural effusion is an accumulation of fluid within the pleural space due to many causes. Chest x-ray can confirm the diagnosis. Thoracentesis can determine the etiology of the pleural effusion or relieve dyspnea. A paracentesis is when the peritoneal cavity is punctured, usually for relief of ascites.

Question 17

283. Which of the following is a risk factor for development of endometrial cancer?
     a. Obesity
     b. Cigarette smoking
     c. HPV infection
     d. Unopposed progesterone

Answer 17

283. A: Obesity. Endometrial cancer primarily affects postmenopausal women and typically presents with vaginal bleeding. Risk factors include obesity, diabetes, hypertension, unopposed estrogen (associated with nulliparity, early menarche, late menopause, anovulation, and estrogen therapy), family history of breast or ovarian cancer, and prior pelvic radiation therapy. Endometrial cancer is diagnosed by biopsy.

Question 18

284. All of the following conditions would show an obstructive pattern on pulmonary function tests EXCEPT:
     a. Asthma
     b. Chronic bronchitis
     c. Chest wall disease
     d. Emphysema

Answer 18

284. C: Chest wall disease. Pulmonary function tests (PFTs) are used to evaluate functional change in a patient with known or suspected lung disease. PFTs provide information on lung volumes, flow rates, and gas transfer. An obstructive pattern means that there is a decrease in rates of expiratory airflow and air trapping. This is seen with asthma, chronic bronchitis, and emphysema. A restrictive pattern is seen in neuromuscular and chest wall diseases, which means that there is a reduction in lung volume and normal expiratory airflow.

Question 19

• *285. A 46-year-old man with a history of H. pylori infection arrives for follow-up of dyspepsia. Now he says that he feels full even if he has not eaten much. He is found to be anemic with loss of weight and lymphadenopathy. What is the most likely diagnosis?
  a. Pancreatic cancer
  b. Colon cancer
  c. Liver cancer
  d. Stomach cancer**

Answer 19

285. D: Stomach cancer. Carcinoma of the stomach is a common gastrointestinal malignancy. Helicobacter pylori plays a significant role in the cause of stomach cancer. Gastric polyps can also be precursors of cancer. Symptoms can include epigastric pain, early satiety, bleeding, and obstruction. Surgical resection is possible if diagnosed early, but many patients present with advanced disease.

Question 20

286. What is incised when performing a midline episiotomy?
     a. External urethral sphincter
     b. Perineal body
     c. Inferior pubic ligament
     d. Rectal ampulla

Answer 20

286. B: Perineal body. This is a connective tissue structure where muscles of the pelvic floor and perineum attach, including the levator ani, deep transverse perineal, superficial transverse perineal, external anal sphincter, sphincter urethrovaginalis, and bulbospongiosus muscles. The perineal body may be stretched and torn during childbirth, so an obstetrician may preemptively make an incision in the perineal body known as a midline episiotomy.

Question 21

287. Which of the following is an indication for ordering an upper GI endoscopy?
     a. Banding of varices
     b. Hematochezia
     c. Sore throat
     d. Evaluation of the ileum

Answer 21

287. A: Banding of varices. An upper endoscopy (esophagogastroduodenoscopy or EGD) is a procedure in which a tube with a camera is inserted into the patient’s mouth, in order to examine the esophagus, stomach, duodenum, and proximal jejunum. The mucosa can be directly visualized. Abnormal areas can be biopsied, and bleeding can be cauterized. Upper endoscopy can be used for banding of varices, dilation of strictures, removal of a foreign body, and surveillance of ulcers.

Question 22

288. What is the mechanism of action for montelukast?
     a. Beta-2 agonist
     b. Antihistamine
     c. Leukotriene receptor antagonist
     d. Anti-cholinergic

Answer 22

288. C: Leukotriene receptor antagonist. This medication is used for prophylaxis and long-term treatment of asthma and for prevention of exercise-induced bronchoconstriction. It is not used as primary treatment of acute attacks. It can also relieve symptoms of seasonal allergies

Question 23

289. When performing a physical examination of the lungs, what can a finding of increased tactile fremitus signify?
     a. Hyperinflation
     b. Consolidation
     c. Emphysema
     d. Bronchial obstruction

Answer 23

289. B: Consolidation. Tactile fremitus is the palpable vibration of the chest wall that results from vocalization. The patient is asked to recite numbers or words while the examiner systematically systematically palpates the chest with the ulnar aspects of the hands. Tactile fremitus is increased with the presence of fluids or a solid mass within the lungs, usually from consolidation, secretions, or tumors. Tactile fremitus is decreased because of excess air in the lungs or bronchial obstruction.

Question 24

290. A 12-year-old girl has persistent fever and loss of weight. On exam, you note pale skin, petechiae, hepatosplenomegaly, and enlarged lymph nodes. WBC is extremely elevated with blast cells seen in peripheral smear. What is the most likely diagnosis?
     a. Chronic lymphocytic leukemia
     b. Acute myelogenous leukemia
     c. Chronic myelogenous leukemia
     d. Acute lymphoblastic leukemia

Answer 24

290. D: Acute lymphoblastic leukemia. ALL is a malignant proliferation of lymphoid stem cells that occurs mainly in children. The exact cause is unknown. Patients present with fever, fatigue, weight loss, bone pain, and bleeding. Chemotherapy has a high success rate. Chronic lymphocytic leukemia (CLL), acute myelogenous leukemia (AML), and chronic myelogenous leukemia (CML) usually occur in adults older than 50 years

Question 25

291. A mother brings in her 6-year-old son with the complaint that he does not seem to be listening at school or at home. She says that he jumps from thing to thing and makes careless mistakes on schoolwork. During the appointment, he is fidgety, has a hard time staying seated, and interrupts often. How can this condition be treated?
     a. Benzodiazepines
     b. Mood stabilizers
     c. Stimulants
     d. Antipsychotics

Answer 25

291. C: Stimulants. This patient likely has attention deficit hyperactivity disorder (ADHD), which is a characterized by inattention, hyperactivity, or both. Patients have difficulty following instructions, are distractible, make careless mistakes, have a hard time organizing, and are restless. In addition to behavioral interventions and school support, stimulant medications have been shown to be helpful in reducing symptoms.