Pance Questions 13

Question 1

292. You are about to perform a lumbar puncture on a patient with suspected meningitis. Between which vertebral levels should you insert the needle?
     a. L3 and L4
     b. L1 and L2
     c. S1 and S2
     d. S3 and S4

Answer 1

292. A: L3 and L4. The needle can be inserted between L3 and L4 or between L4 and L5— these sites are below the termination of the spinal cord. The patient is placed in the lateral or prone position. The needle is passed in between the spinous processes into the epidural space, and further advancement punctures the dura and arachnoid matter. The needle enters the subarachnoid space and usually pushes away the spinal nerve roots without problems. Then cerebrospinal fluid can be aspirated for analysis.

Question 2

293. A 45-year-old woman has a painless lump in her neck. On exam, you note a thyroid nodule. Biopsy reveals thyroid cancer. What is the most likely type?
     a. Follicular
     b. Papillary
     c. Medullary
     d. Anaplastic

Answer 2

293. B: Papillary. This accounts for 70% to 80% of thyroid cancers. It is usually seen in women 30-60 years of age. Most thyroid cancers present as asymptomatic nodules, and diagnosis is by fine-needle aspiration biopsy. Treatment is by surgical removal. Follicular and anaplastic carcinoma are more common among elderly patients. Medullary carcinoma is often familial.

Question 3

294. A 72-year-old woman arrives for routine follow-up. You notice that her height has actually decreased over the past few years. On exam, the mid to upper part of her back has a “hump” deformity. What does this patient have?
     a. Scoliosis
     b. Lordosis
     c. Swayback
     d. Kyphosis

Answer 3

294. D: Kyphosis. This is an abnormal curvature of the vertebral column in the thoracic region. It can be caused by osteoporosis in elderly patients, producing a “dowager’s hump.” Scoliosis is an abnormal lateral curvature along with a rotational element. It may be present at birth or be a manifestation of a nerve condition, tumor, or disc protrusion. Lordosis is an abnormal curvature in the lumbar region, which is also called a swayback deformity.

Question 4

295. Which medication can be used to treat moderate pulmonary cryptococcosis in an immunocompromised patient?
     a. Fluconazole
     b. Nystatin
     c. Terbinafine
     d. Selenium

Answer 4

295. A: Fluconazole. Cryptococcosis is a fungal infection usually seen in AIDS patients and other immunocompromised patients. Pulmonary infection may present with fever, cough, and shortness of breath. The infection can disseminate to the skin, meninges, joints, and internal organs. It is diagnosed by culture. The antifungal medications fluconazole or amphotericin B are used in treatment depending on the severity and spread of disease. Patients who are immunocompetent may not require treatment for localized pulmonary infection.

Question 5

296. What does ocular tonometry evaluate for?
     a. Glaucoma
     b. Strabismus
     c. Cataract
     d. Retinoblastoma

Answer 5

296. A: Glaucoma. Tonometry is used to measure intraocular pressure. Different types of tonometers are used by eye care professionals. Glaucoma is a disease of the optic nerve related to abnormal drainage of aqueous humor, which can cause increased ocular pressure. This results in decreased vision in the peripheral fields and potential blindness.

Question 6

297. A 24-year-old woman arrives in the emergency department. She reports having food poisoning and says that she has been vomiting for the past 3 days, but today she noticed blood in her vomit. Upper endoscopy shows a superficial tear in the esophagus but no active bleeding. How do you treat this patient?
     a. Prescribe omeprazole
     b. No other intervention needed at this time
     c. Order a barium esophagography
     d. Laparotomy

Answer 6

297. B: No other intervention needed at this time. This patient likely has a Mallory-Weiss tear, which is a superficial tear at the gastroesophageal junction caused by vomiting. The bleeding will usually stop on its own and will not require intervention.

Question 7

298. What is the approximate therapeutic range for lithium?
     a. 5.2– 5.8 mEq/ L
     b. 3.5– 4.5 mEq/ L
     c. 1.5– 3.0 mEq/ L
     d. 0.6– 1.2 mEq/ L

Answer 7

298. D: 0.6– 1.2 mEq/ L. Lithium is used in the treatment of bipolar disorder. Serum lithium levels must be monitored to avoid toxicity. The lab should be drawn 8-12 hours after the patient’s last dose. Thyroid and renal function should also be monitored.

Question 8

299. A 21-year-old man has discharge from his penis and painful urination. You do a urethral swab wet mount and see flagellated pear-shaped organisms under the microscope. What does this signify?
     a. Chlamydia
     b. Trichomoniasis
     c. Giardiasis
     d. Gonorrhea

Answer 8

299. B: Trichomoniasis. This is a sexually transmitted infection with the protozoan Trichomonas vaginalis. Men are usually asymptomatic, or they may have urethritis resulting in discharge or dysuria. The organism is harder to detect in men than women. It is treated with metronidazole. Giardiasis is also caused by a flagellated protozoan, but this organism causes infection of the gastrointestinal tract.

Question 9

300. You are examining a patient who has yellowing of the eyes, an enlarged spleen, spider angiomas, and a rounded firm abdomen with enlarged veins. What does this patient likely have?
     a. Cirrhosis
     b. Hepatitis A

c. Cholecystitis
d. HIV

Answer 9

300. A: Cirrhosis. This is a liver disorder that can be confirmed histologically. It is characterized by widespread fibrosis due to cell damage. Causes include long-term alcohol abuse, chronic hepatitis B or C infection, biliary obstruction, and malnutrition. Increased pressure in the portal vein leads to splenomegaly and varicose veins. Progressive liver failure leads to fluid retention producing ascites. The inability to break down blood products manifests as jaundice. Patients are more at risk of bleeding because of decreased production of clotting proteins.

Question 10

Q–15 Infectious Diseases The most common pathogen causing community acquired pneumonia (CAP) is

a. Streptococcus pneumoniae
b. Mycoplasma pneumoniae
c. Hemophilus influenza
d. Klebsiella pneumoniae

Answer 10

A–15 (A) Streptococcus pneumoniae causes 20–50% of the cases of CAP; Mycoplasma pneumoniae is responsible for 10–30%; Hemophilus influenza 5–10%; and Klebsiella pneumoniea 1–3% of the cases.

Question 11

Q–16 Emergency Medicine The diagnosis of appendicitis is MOST likely to be missed in which age group?

a. 1–6 years
b. 11–20 years
c. Over 65 years
d. Both (A) and (C) are correct.

Answer 11

A–16 (D) Young children have difficulty in expressing their symptoms clearly and elderly patients may have a reduced inflammatory reaction, making diagnosis more difficult in these age groups. Appendicitis reaches its peak between the ages of 10 and 20, and approximately 80% of cases occur before the age of 45.

Question 12

• *Q–17 Women’s Health/Reproductive** Which of the following antibiotics are known to cause fetal harm if given to a pregnant woman?
  a. Azithromycin
  b. Clindamycin
  c. Gentamicin
  d. Ceftriaxone

Answer 12

A–17 (C) Gentamicin and other aminoglycosides may be ototoxic to a fetus. The other drugs listed have no overt toxicity reported to date.

Question 13

• *Q–18 Infectious Disease** In a sulfonamide allergic patient who has an uncomplicated cystitis due to Escherichia coli, the drug of choice is
  a. bactrim DS
  b. ampicillin
  c. metronidazole
  d. cephalexin

Answer 13

(B) Ampicillin is the drug of choice when the patient is allergic to sulfa drugs. Bactrim contains sulfamethoxazole. Neither metronidazole nor cephalexin would be considered in this patient.

Question 14

Q–19

Cardiovascular Homocysteine is derived from the breakdown of essential amino acids and if elevated elevated > 12 mmol/L is an independent risk factor for heart and blood vessel disease. Elevated levels may be seen in patients taking

a. metformin
b. carbamazepine
c. oral contraceptives
d. all of the above

Answer 14

A–19 (D) All of the drugs listed may elevate homocysteine to > 15 mmol/l, which is a dangerous level.

Question 15

Q–20 General Medicine/Radiology Increased whiteness on a CT scan is referred to as “hyperdensity” or high attenuation. All of the following are causes of hyperdensities EXCEPT

a. calcification
b. ossification
c. acute hemorrhage
d. fat

Answer 15

(D) Fat shows as increased darkness and is referred to as “hypodensity” or low attenuation. All the others show as hyperdensities.

Question 16

Q–21 Neurology/Radiology Subarachnoid hemorrhage is most often due to a

a. ruptured aneurysm
b. laceration of the middle meningeal artery
c. trauma
d. either (A) or (C)

Answer 16

(D) Subarachnoid hemorrhage most often follows trauma to the head or a ruptured aneurysm. An acute epidural hematoma may result from laceration of the middle meningeal artery (choice B).

Question 17

• *Q–22 Musculoskeletal** All of the following deformities are associated with rheumatoid arthritis EXCEPT
  a. Heberden’s node
  b. swan-neck
  c. boutonniére deformity
  d. ulnar deviation

Answer 17

A–22 (A) Heberden’s nodes may be found with osteoarthritis. The other choices occur in patients with a diagnosis of rheumatoid arthritis.

Question 18

Q–23

Anatomy/Musculoskeletal When examining the knee, an anterior and posterior drawer test is used to identify

a. a torn medial meniscus
b. a torn lateral meniscus
c. instability of the lateral and medial collateral ligaments
d. instability of the anterior and posterior cruciate ligaments

Answer 18

A–23 (D) The drawer test is used to assess instability of the anterior and posterior cruciate ligaments. The McMurray test is used to detect a torn medial or lateral meniscus. Abduction and adduction stress, also known as Valgus and Varus stress tests, are used to identify instability of the lateral and medial collateral ligaments.

Question 19

Q–24 Orthopedics/Musculoskeletal

A positive drawer sign is present if the examiner demonstrates

• *a**. the presence of fluid in the knee when the patella is moved greater than 3 mm in either an anterior or posterior direction.
• *b**. any palpable or audible click, grinding, or limited extension of the knee.
• *c**. a locking of the knee with anterior or posterior movement of the tibia.
• *d**. anterior or posterior movement of the knee greater than 5 mm in either direction.

Answer 19

(D) Answers (A), (B), and (C) may be indicative of knee problems, but they are not used to assess instability of the cruciate ligaments.

Question 20

Q–25 Cardiovascular Which factor could result in the recording of a FALSELY ELEVATED blood pressure?

a. Sphygmomanometer bladder in excess of 100% of arm circumference
b. Concurrent use of long-acting nitrate medication
c. Both
d. Neither

Answer 20

(D) Neither of the choices is associated with a falsely elevated blood pressure reading. Using a blood pressure cuff that is too big for the patient’s arm may give a falsely low reading while using a cuff that is too narrow for the patient’s arm will result in a falsely elevated reading. A patient patient taking long-acting nitrates may have decreased venous return and a lowering of blood pressure.

Question 21

Q–26 Rheumatology/Orthopedics Risk factors for arthritis and chronic joint disease include all of the following EXCEPT

a. lower education level
b. sedentary lifestyle
c. high body-mass index
d. being male

Answer 21

(D) Females have a greater risk of developing arthritis.

Question 22

Q–27 General Medicine question applicable to any system

The difference between a patient screening interview and an assessment interview is that

a. the goal of a screening interview is to find out if a problem exists while the goal of the assessment interview is to discover more about a defined problem.

b. the screening interview places emphasis on past medical history while the assessment interview emphasizes the chief complaint.

c. the screening interview is associated with a specific set of questions, e.g., CAGE or CRAFFT, while the assessment interview encompasses the entire medical history.

d. there is no difference between a screening and an assessment interview.

Answer 22

(A) There is a difference between a screening interview and an assessment interview in that a screening interview attempts to find out if a problem exists. This is particularly true of CAGE, CRAFFT, TACE, and other questionnaires. The screening interview is only the start, and assessment goes on from there, i.e., defining the problem and coming to a definitive diagnosis.

Question 23

Q–28 Neurology

You see a 38-year-old male who had a syncopal syncopal episode 12 hours before the office visit. His family history is positive for syncope as well as sudden cardiac death. Based on this information alone, which of the following etiologies for the syncope in this patient would be the most likely?

a. Seizure disorder
b. Anxiety attack
c. Ventricular dysrhythmia
d. Hypertrophic cardiomyopathy

Answer 23

(D) A family history of sudden cardiac death, syncope, or heart failure suggests hypertrophic cardiomyopathy or long QT syndrome. A history of neurologic symptoms, such as focal motor weakness, arm or leg movement, tongue biting, or a postictal state, would suggest a seizure disorder. A history of myocardial infarction or congestive heart failure is more suggestive of a ventricular dysrhythmia. A history of anxiety along with hyperventilation would accompany a diagnosis of an anxiety attack.

Question 24

Q–29 Cardiovascular

Pulse pressure is defined as:

a. the backflow of blood to the vena cava during right atrial contraction.
b. the lowest point to which the diastolic blood pressure falls.
c. the difference between systolic and diastolic pressures
d. the systolic force exerted against the wall of arteries.

Answer 24

(C) The blood pressure falls to its lowest point during diastole and the systolic pressure is the force exerted against the wall of the arteries when the ventricles

Question 25

**Q–30 Women’s Health** All of the following statements about uterine leiomyomas are true EXCEPT **a**. they represent localized proliferation of smooth muscle cells surrounded by compressed muscle fibers. **b**. they represent a common clinical finding in women. **c**. they represent a pre-malignant uterine cancer. **d**. they are hormonally responsive to estrogen.

Answer 25

(**C) Leiomyomas are benign tumors** that are present in approximately 30% of American women. The incidence increases with age and as many as 50% of women have this condition after age 40.