Pance Questions 2

Question 1

26. A 34-year-old man arrives in the emergency department after being hit in the face. He complains of double vision. You notice bruising around his right eye. On x-ray, you see a “teardrop sign.” Which muscle is likely affected?
    a. Inferior rectus
    b. Superior oblique
    c. Lateral rectus
    d. Superior rectus

Answer 1

26. A: Inferior rectus. A blowout fracture involves the bones surrounding the eye, usually caused by blunt trauma. Inferior fractures are the most common. The inferior rectus muscle can become entrapped, causing limited motion of the eye and changes in vision. The “teardrop sign” is the orbital contents and muscle protruding into the sinus cavity.

Question 2

27. A generally healthy 20-year-old man has had 1 week of pruritus that seems to be worse at night. His girlfriend has been having the same problem. On exam, you notice erythematous papules and scaly lines between his fingers and also around his waistline. How do you treat this? a. No medications now, reevaluate in 3 days
    b. Oral doxycycline for 1 week
    c. Permethrin cream applied to the whole body
    b. Miconazole on the affected areas

Answer 2

27. C: Permethrin cream applied to the whole body. The patient described has scabies, which is caused by the mite Sarcoptes scabiei. The mites burrow in the skin and cause severe itching. It is easily transmitted through contact. Diagnosis is usually based on history and observation but can also be confirmed through skin scrapings. The permethrin cream is applied all over and washed off after several hours. Treatment should be repeated in 1 week, and all personal items should be washed.

Question 3

28. All of the following x-ray findings would raise suspicion for abuse EXCEPT:
    a. 9 year old with distal radius fracture
    b. 13 year old with rib fracture
    c. 5 year old with spiral fracture of the femur
    d. 2 year old with skull fracture across a suture line

Answer 3

28. A: 9 years old with distal radius fracture. This is a common injury usually due to falling on an outstretched hand. For the other x-rays listed, the forces involved to break those bones are much more than would be expected in a simple childhood accident

Question 4

29. A 16 year old wakes up in the middle of the night with left testicular pain. He comes to the emergency department where he is found to have a fever and an absent cremasteric reflex on the affected side. What is the most likely diagnosis?
    a. Varicocele
    b. Testicular cancer
    c. Testicular torsion
    d. Hydrocele

Answer 4

29. C: Testicular torsion. This condition occurs mostly in teenagers and can be spontaneous or as a result of trauma. It is considered an emergency because of the strangulation of blood supply. Ischemia and necrosis will occur if not promptly treated. A varicocele is not necessarily painful and may feel like a “bag of worms” on exam because of enlarged veins in the scrotum. Testicular cancer would not present with such acute pain. Hydroceles are painless collections of fluid in the scrotum.

Question 5

30. What would you expect with a positive obturator sign when performing an exam on a patient with suspected appendicitis?
    a. Increased pain when passively extending the right hip
    b. Increased pain when passively flexing and externally rotating the right hip
    c. Increased pain when passively extending the left hip
    d. Increased pain when passively flexing and internally rotating the right hip

Answer 5

30. D: Increased pain when passively flexing and internally rotating the right hip. Several tests can be useful when evaluating a patient for appendicitis. McBurney point is where the right lower quadrant pain is best elicited. Rovsing sign is when pain is felt in the right lower quadrant when the left lower quadrant is palpated. Psoas sign is described in answer choice A, which increases pain due to stretching the iliopsoas muscle.

Question 6

31. A 30-year-old man arrives in the emergency department with left ankle pain, which started during a basketball game when he landed after going up for a shot. You determine that he has a sprain and would like to prescribe tramadol for short-term management of his pain. However, you need to counsel him on drug interactions because he is also taking which of the following other medications?
    a. Omeprazole
    b. Ibuprofen
    c. Sertraline
    d. Valacyclovir

Answer 6

31. C: Sertraline. Tramadol should be used with caution when combined with selective serotonin reuptake inhibitors (SSRIs) because of the increased risk of seizures and serotonin syndrome. This also applies to serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), and triptans.

Question 7

32. A 3-year-old girl has sneezing, watery eyes, and a worsening cough. She has been having bouts of coughing followed by high-pitched deep inspirations. She has started to vomit as well. Swab shows gram negative coccobacilli. What is the causative organism?
    a. Moraxella catarrhalis
    b. Bordetella pertussis
    c. Streptococcus pneumoniae
    d. Staphylococcus aureus

Answer 7

32. B: Bordetella pertussis. This disease is also known as whooping cough and can be prevented through immunization. It is very contagious and affects mostly children. Symptoms are generally nonspecific but the coughing itself has a characteristic “whoop” sound afterwards when the child inspires. Pertussis is treated with macrolide antibiotics. Hospitalization may be required as complications of the disease can be serious.

Question 8

33. Which of the following conditions would require the most immediate treatment?
    a. Chalazion
    b. Entropion
    c. Peritonsillar abscess
    d. Aphthous ulcer

Answer 8

33. C: Peritonsillar abscess. Out of the listed conditions, this infection has the potential to be the most serious. It occurs when bacteria in the throat spread to the soft tissues. Patients may present with sore throat, “hot potato” voice, difficulty swallowing, fever, or earache. It is diagnosed with needle aspiration, and the abscess will need to be drained. Hospitalization may be required. A chalazion is a swelling of the eyelid caused by meibomian gland obstruction—it can improve spontaneously over time. Entropion is gradual inversion of the eyelid usually seen in elderly patients. Aphthous ulcers are also known as canker sores in the mouth.

Question 9

34. According to the United States Preventive Services Task Force, screening for abdominal aortic aneurysm could be appropriate for all of the following patients EXCEPT:
    a. 65-year-old man with history of smoking
    b. 72-year-old man with no history of smoking
    c. 74-year-old man with history of smoking
    d. 68-year-old woman with history of smoking

Answer 9

34. D: 68-year-old woman with history of smoking. The major risk factors for development of abdominal aortic aneurysm (AAA) include male sex, smoking history, and age 65 or older. For men ages 65-75 with a smoking history, the benefits of screening outweigh the harms and the USPSTF gives this a “B” recommendation. For men ages 65-75 with no history of smoking, the USPSTF gives no recommendation for or against screening. The USPSTF recommends against screening for AAA in women since there are few AAA-related deaths in this population.

Question 10

35. A 34-year-old woman has fatigue, fever, headache, and joint pain. She reports that she just returned from camping in Maryland. On exam, you notice a large macule on her back with central clearing. What is the most likely diagnosis?
    a. Rocky Mountain spotted fever
    b. Erythema infectiosum
    c. Lyme disease
    d. Syphilis

Answer 10

35. C: Lyme disease. This infection is transmitted by ticks and is seen in those living in wooded areas. The rash is known as erythema migrans and is usually the first sign of infection. Rocky Mountain spotted fever is also a tick-borne illness that can occur in the United States. It presents with the same generalized symptoms, but the rash begins at the extremities and would include smaller macules. Erythema infectiosum is also known as fifth disease and is usually seen in children.

Question 11

36. What are the characteristics of an indirect inguinal hernia?
    a. Congenital protrusion through the inguinal ring into inguinal canal
    b. Protrusion through weak spot of inguinal canal
    c. Occurs below inguinal ligament at weak spot of femoral canal
    d. Occurs at umbilical ring through abdominal wall

Answer 11

36. A: Congenital protrusion through the inguinal ring into inguinal canal. Answer choice B describes a direct inguinal hernia. Answer choice C describes a femoral hernia, and answer choice D describes an umbilical hernia.

Question 12

37. According to the American Congress of Obstetricians and Gynecologists (ACOG), which of the following average risk patients should have a Pap smear now?
    a. 18 year old who has been sexually active for the past year
    b. 28 year old who had a normal Pap smear 1 year ago
    c. 60 year old who had a normal Pap smear 5 years ago
    d. 66 year old whose last 3 Pap smears in 10 years have been normal

Answer 12

37. C: 60 years old who had a normal Pap smear 5 years ago. The ACOG recommends that screening for cervical cancer should begin at age 21 regardless of when the patient became sexually active. For women ages 21-29, screening through cytology should occur every 3 years. Women ages 30-65 can be screened every 3 years through cytology or every 5 years with both cytology and HPV testing. Women older than 65 can stop screening if they have had 3 consecutive normal cytology tests and no abnormal results in the p

ast 10 years.

Question 13

38. You are seeing a patient whose thyroid-stimulating hormone (TSH) is 6.3 and free T4 is 0.4. What is your next step?
    a. Use beta-blockers to control symptoms
    b. Start iodine therapy
    c. Refer to surgery
    d. Start levothyroxine

Answer 13

38. D: Start levothyroxine. In patients with primary hypothyroidism, free T4 is low and TSH is elevated. Levothyroxine is given to replace the thyroid hormone. The other answer options describe treatments for hyperthyroidism, in which the TSH would be low and free T4 would usually be increased.

Question 14

39. A 63-year-old male Vietnam combat veteran has a 5-year history of flashbacks, extreme irritability, and increased startle response. Your working diagnosis is posttraumatic stress disorder. You expect him to report that he is doing all of the following EXCEPT:
    a. Waking up at night to check door locks and survey the house
    b. Attending more military events and talking about his experiences
    c. Having frequent nightmares about combat situations
    d. Feeling detached from family and friends

Answer 14

39. B: Attending more military events and talking about his experiences. The diagnostic criteria for PTSD include the following three symptom clusters that cause impairment for greater than a month following a traumatic event: re-experiencing, avoidance, and hyperarousal. Answer choice B does not fit with this because individuals with PTSD tend to avoid thoughts, feelings, places, and people that remind them of their trauma.

Question 15

40. In the treatment of hypertension, which of the following diuretics acts by inhibiting chloride reabsorption in the ascending loop of Henle?
    a. Furosemide
    b. Triamterene
    c. Spironolactone
    d. Acetazolamide

Answer 15

A. Furosemide. Diuretics inc urine volume. Furosemide is a loop diuretic and can cause hypokalaemia. Triamterene and spironolactone are K sparing diuretics, act by enhancing sodium excretion and retaining K in distal tubule. Acetazolamide is a carbonic anhydrase inhibitor.

Question 16

A 34-year-old woman requests a combination oral contraceptive for birth control. Which one of the following would be a contraindication to prescribing oral contraceptives for this patient?

A history of controlled hypertension

B family history of ovarian cancer

C history of thromboembolic disease

D current history of smoking

Answer 16

(C) Oral contraceptives have been associated with an increased risk of developing blood clots (thromboembolic disease) by as much as a fourfold increase. Currently available oral contraceptives (OCs) contain low doses of estrogen and do not carry the contraindications of earlier, larger doses of OCs. However, one should maintain close supervision of women who have controlled hypertension, are current smokers, have a family history of ovarian cancer, and are prescribed oral contraceptives.

Question 17

Women’s Health/Reproductive A recently married 28-year-old female presents with uncomplicated cystitis. She is otherwise healthy. She currently uses barrier birth control methods but has plans to discontinue this soon, as she wants to become pregnant. Which of the following supplemental vitamins or minerals would you advise this patient to begin taking?

A Ferrous sulfate

B Calcium carbonate

C Ascorbic acid

D Folic acid

Answer 17

(D) When planning for a pregnancy, folic acid supplementation of 400 micrograms daily beginning 3 months prior to conception is recommended to decrease the likelihood of neural tube defects in the baby. Once pregnancy is established, the mother-to-be should be prescribed a prenatal vitamin supplement to help meet the required demands of pregnancy and to assure that a steady supply of nutrients reaches the developing fetus.

Question 18

Dermatology A patient presents with a skin lesion that he describes as painless when he first noticed it, but now, about 3–4 hours later, he describes the lesion as quite painful. Physical examination reveals a ring of pallor immediately around the lesion (bleb), with a surrounding area of erythema. Your initial impression is

A erythema nodosum

B brown recluse spider bite

C toxic epidermal necrolysis

D allergic dermatitis

Answer 18

(B) Brown recluse spider venom produces both localized and systemic effects. Early symptoms include pain that develops between 2 and 10 hours after the initial bite. Soon thereafter, a ring of pallor, secondary to vasoconstriction, surrounds the bite. Beyond the pallor, the skin is erythematous. The bleb, at the center, becomes necrotic after a few days. Erythema nodosum can be due to a variety of causes and presents as tender, erythematous nodules usually seen on the shins. Toxic epidermal necrolysis is a widespread, life-threatening skin condition that frequently results from a reaction to medications. Allergic dermatitis presents as an itchy skin condition and its cause can be traced to an allergy to a specific agent or group of agents.

Question 19

EENT A 68-year-old female presents to your practice with complaints of tinnitus and a declining ability to understand speech if spoken too quickly or when background noise is present. An in-office otoscopic exam revealed no visible abnormalities. You suspect this elderly woman is suffering from

A presbycusis

B cerumen impaction

C otosclerosis

D presbyopia

Answer 19

(A) Presbycusis is a common auditory disorder in which there is bilateral sensorineural hearing loss associated with aging. It is caused by degenerative changes in the inner ear and auditory nerves. Cerumen impaction causes a blockage of the external ear canal and may cause symptoms of partial hearing loss, itching and tinnitus, along with a feeling of fullness in the ear. A diagnosis can be made by otoscopic examination of the ear. Otosclerosis is a hereditary condition usually noticed between the late teens and 30 years of age. It causes a progressive conductive hearing loss, typically of low-to-medium pitch sounds. Presbyopia describes the inability of the eyes to focus on near objects as one ages.

Question 20

Cardiovascular

From the following list, which symptoms are most likely to be

present in a patient with heart failure?

A Shortness of breath while lying in bed

B Pain in the left arm

C Epigastric pain

D Cough, especially at night

E Shortness of breath on exertion

A a and c

B a, b, and c

C b and d

D a, d, and e

Answer 20

(D) A person with heart failure has a cardiac disorder that impairs the ability of the ventricle(s) to function as a pump, i.e., to fill with or eject blood to meet the needs of the body. This results in a variety of signs and symptoms primarily manifested as fluid retention with subsequent shortness of breath (a and e), fatigue, and decreased exercise tolerance. Because of fluid retention in the lungs, the patient may develop a cough that worsens when the patient is supine due to the fluid shift, such as at night (d). Pain in the left arm and epigastric pain are more commonly associated with myocardial infarction.

Question 21

Neurology

Mr. Brown, age 59, is brought to the emergency department and the triage nurse suspects he has had a stroke. The family states that Mr. Brown appeared normal until about 2 hours ago when he began to have slurred speech and wanted to lie down.

Mr. Brown is now comatose. His B/P is 160/90 mm Hg; blood glucose 110 mg/dL; and ECG is WNL. The CT scan is suggestive of acute ischemic stroke. Initial treatment for this patient is:

A clopidogrel

B intravenous heparin

C intravenous rt-PA

D aspirin

Answer 21

(C) This patient meets all the inclusion criteria for administration of rt-PA and, after consent from the family, should be given a dose of 0.9 mg/kg (maximum of 90 mg) infused over one hour, with 10% of the total dose infused over the first minute. Aspirin is recommended for most acute stroke patients, however, it should be withheld for at least 24 hours after administration of thrombolytics. Clopidogrel may be used in patients allergic to aspirin, although its beneficial effects are unproven. Studies have demonstrated that IV heparin offers no appreciable benefit for most patients and should not be administered within 24 hours of thrombolytic therapy.

Question 22

Cardiovascular

The pain of chronic arterial peripheral vascular insufficiency, manifesting as intermittent claudication, has which of the following characteristics?

A It is associated with swelling of the affected extremity.

B It is increased with exercise.

C It is associated with a dilated saphenous system on the affected side.

D The patient will have a positive Homan’s sign.

Answer 22

(B) Arterial vascular insufficiency (intermittent claudication) is characterized by pain that develops with exercise and is relieved by rest. Swelling is more often present in venous insufficiency and may be evident by dilated saphenous veins. A positive Homan’s sign is indicative of venous thrombosis even though a patient may have a thrombus and not have a positive Homan’s sign.

Question 23

Cardiovascular

A 50-year-old male presents to the emergency department with a suspected myocardial infarction. Laboratory examinations helpful in making the diagnosis at the time of his arrival would be

A. electrocardiogram

B chest X-ray

C elevated CK and CK-MB enzymes

D elevated myoglobin

Answer 23

(A) All of the procedures would be obtained on a patient suspected of having a myocardial infarction, along with the cardiac specific marker for acute MI, troponin. Of the choices presented in the question, the ECG will give the most rapid information, although a patient may be having an MI and have a normal ECG.

CK and CK-MB enzymes rise after an MI but the rise is delayed for 3–4 hours usually. Also, myoglobin will rise in a person with an infarcted myocardium but it is nonspecific, being found also in skeletal muscle.

Question 24

41. An overweight 12-year-old boy has pain and swelling below his right kneecap. He does not remember a specific injury but is actively involved in sports. What is the most likely diagnosis?
    a. Slipped capital femoral epiphysis
    b. Sever disease
    c. Osgood-Schlatter disease
    d. Scheuermann disease

Answer 24

41. C: Osgood-Schlatter disease. This condition usually affects males between 10 and 15 years of age. It is thought to be caused by stress on the patellar tendon, which attaches to the tibial tuberosity. It is generally self-limited with conservative treatment. Slipped capital femoral epiphysis usually occurs in overweight adolescent boys, but affects the hip. Sever disease is also seen in young patients, but this affects the heels. Scheuermann disease affects the back.

Question 25

42. A 35-year-old man has an itchy, red rash in his armpits that has been present for the past 2 days.He often works outside in the heat and is otherwise healthy. What is the best tool to confirm diagnosis given this presentation?
    a. Potassium hydroxide wet mount
    b. Punch biopsy
    c. Tzanck smear
    d. Shave biopsy

Answer 25

42. A: Potassium hydroxide wet mount. Hyphae or budding yeast is seen under a microscope can confirm candidiasis. This type of fungal infection can occur anywhere but is common in skin folds, especially with hot weather and restrictive clothing. Biopsies are helpful when evaluating skin cancers. A Tzanck smear can help diagnose viral disease.