Pance Questions 4

Question 1

61. For patients who have frequent clots or cannot take anticoagulants, where are Greenfield filters implanted in order to prevent pulmonary emboli?
    a. Superior vena cava
    b. Femoral vein
    c. Inferior vena cava
    d. Pulmonary artery

Answer 1

61. C: Inferior vena cava. Greenfield inferior vena cava (IVC) filters, also known as venous filters, are implanted in patients with recurrent clots or in those who cannot take anticoagulants. The filter is cone-shaped and allows blood to flow around it, while trapping clots from the lower extremities before they reach the lungs.

Question 2

62. A 29-year-old man has had right elbow pain for the past 3 weeks. On exam, you note pain with wrist extension and tenderness over the lateral humeral epicondyle. There is no edema. What is the most likely diagnosis based on this information?
    a. “Golfer’s elbow”
    b. Olecranon bursitis
    c. Ulnar collateral ligament tear
    d. “Tennis elbow”

Answer 2

62. D: “Tennis elbow.” This is another name for lateral epicondylitis, which is caused by repetitive wrist extension. It involves the tendon for the extensor muscles of the wrist and hand. “Golfer’s elbow” is also known as medial epicondylitis— pain would increase with wrist flexion. An ulnar collateral ligament tear would involve pain over the medial elbow.

Question 3

63. You are seeing a 55-year-old man for routine follow-up. He has diabetes mellitus (DM) and peripheral vascular disease (PVD), and is a smoker. What is his low-density lipoprotein (LDL) goal?
    a. < 5.5 mmol/L
    b. < 7.2 mmol/L
    c. < 8.9 mmol/L
    d. < 10.5 mmol/L

Answer 3

63. A: < 5.5 mmol/L. In this patient, presence of DM and PVD are considered coronary heart disease equivalents, and he also has risk factors of being a cigarette smoker and older than 45 years. His LDL goal is < 100 mg/ dL. For levels equal to or greater than 100 mg/ dL, lifestyle changes should be initiated. For LDL levels equal to or greater than 130 mg/ dL, drug therapy should be considered, although drug therapy is considered for some patients at a level of 100 mg/ dL as well.

Question 4

64. A 49-year-old man with a history of diabetes mellitus arrives in the emergency department with shortness of breath and chest pain. He had knee surgery 1 week ago. He is tachycardic and hypotensive, and you note crackles with auscultation of the lungs. Chest x-ray and troponin are normal. What is the most likely diagnosis based on this information?
    a. Pneumonia
    b. Pulmonary embolism (PE)
    c. Acute myocardial infarction (MI)
    d. Congestive heart failure (CHF) exacerbation

Answer 4

64. B: Pulmonary embolism. Risk factors include immobilization, recent surgery, malignancy, smoking, age, pregnancy, and diabetes. Most PEs involve the lower lobes. Chest x-ray may be normal or show atelectasis, pleural effusion, or infiltrate. A positive D-dimer is sensitive but not necessarily specific. The other answer choices listed could present similarly to this patient, but all of the factors combined, especially with recent surgery, make PE more likely. Pneumonia or CHF would likely have an abnormal chest x-ray. Acute MI would have elevated troponin.

Question 5

65. You diagnose a 10-year-old girl with influenza and prescribe oseltamivir. She has had symptoms for 1 day. How do you counsel the patient’s mother with regard to expectations for the medication?
    a. The duration of symptoms will be reduced by 1 day.
    b. Acetaminophen cannot be given concurrently.
    c. The patient will never need to have another influenza vaccine.
    d. The patient should be cured after 1 day.

Answer 5

65. A: The duration of symptoms will be reduced by 1 day. Oseltamivir is also known as Tamiflu and is a neuraminidase inhibitor, which competitively inhibits the surface viral protein. It is used for both prophylaxis and treatment. It can reduce the duration and severity of symptoms when initiated on the first day of illness. Patients should also undergo symptomatic therapy, such as using medications for fever and headache.

Question 6

66. A 25-year-old generally healthy white man has dull testicular pain present for the past 2 weeks. He denies penile discharge, and the scrotum is nonerythematous. He is negative for sexually transmitted diseases. What do you suspect?
    a. Spermatocele
    b. Epididymitis
    c. Hydrocele
    d. Testicular cancer

Answer 6

66. D: Testicular cancer. It usually occurs in white males between the ages of 18 and 30. It can progress rapidly, so diagnosis cannot be missed. A testicular mass can be felt that can be confirmed through ultrasound. Hydroceles are collections of fluid within the scrotum and usually painless. Spermatoceles are accumulations of sperm with no known etiology that are painless. Epididymitis usually presents with pain, edema, and erythema. In males younger than 35 years, epididymitis is usually concurrent with STDs.

Question 7

67. Metronidazole can be used to treat which of the following conditions?
    a. Lichen sclerosis
    b. Vulvovaginal candidiasis
    c. Trichomoniasis
    d. Atrophic vaginitis

Answer 7

67. C: Trichomoniasis. This condition is primarily sexually transmitted. Patients can present with vaginal discharge, pruritus, and dyspareunia. “Strawberry cervix” may be seen during pelvic exam, and parasites would be visible under the microscope. Metronidazole is an antibiotic that works well for protozoa. The partner must be treated too.

Question 8

68. A 32-year-old generally healthy man has had a rash over his back for the past week with itching. On exam, you note multiple rose-colored oval papules spread over the back in a “Christmas tree” distribution. The lesions are somewhat scaly. With further questioning, he remembers initially seeing a single larger lesion on his trunk about a week ago. How do you treat this patient?
    a. Antibiotics for 5 days
    b. Topical antifungal applied over the whole body
    c. No treatment necessary as it will go away on its own
    d. Immmunomodulatory drugs long term

Answer 8

68. C: No treatment necessary as it will go away on its own. Pityriasis rosea usually affects patients between ages 10 and 35. This condition usually begins with a “herald” patch, and then oval papules will appear within 1 to 2 weeks. It may resemble ringworm. Lesions can be distributed in a “Christmas tree– like” pattern over the back. The condition will usually go away within 5 weeks without specific treatment.

Question 9

69. Which of the following is true regarding primary hypertension?
    a. Roughly 1 in 3 Americans has it.
    b. Prevalence increases with age.
    c. It occurs more often in black patients.
    d. All of the above

Answer 9

69. D: All of the above. Hypertension can be primary (no known cause) or secondary (identifiable cause, usually renal disorders). It is defined as greater than or equal to systolic BP of 140 and/ or diastolic BP of 90. Primary hypertension is believed to be due to multiple factors, including heredity and environment.

Question 10

70. You encounter a patient with “saddle anesthesia,” which you determine as cauda equina syndrome. Between what vertebral levels is the cauda equina located?
    a. L2 to coccyx
    b. L3 to S5
    c. L5 to coccyx
    d. L1 to S2

Answer 10

70. A: L2 to coccyx. The cauda equina (“ horsetail”) consists of the spinal nerves in the area below the conus medullaris (at level L1) of the spinal cord. An injury at L1 or above will damage the spinal cord itself. Cauda equina damage can include motor loss, diminished sensation in the perineal region, and bowel/ bladder impairment. It may be caused by trauma, spinal stenosis, ruptured disk, or tumor. It requires urgent surgical treatment.

Question 11

71. What is the mechanism of action for ranitidine?
    a. H1 receptor agonist
    b. H2 receptor antagonist
    c. H1 receptor antagonist
    d. H2 receptor agonist

Answer 11

71. B: H2 receptor antagonist. Ranitidine is used in the treatment of gastroesophageal reflux disease (GERD) and peptic ulcer disease. It blocks histamine on parietal cells in the stomach and thus decreases acid production. In the United States, it is now available over the counter. Antihistamines used for allergy symptoms are H1 receptor antagonists.

Question 12

72. In a patient with congestive heart failure (CHF), what might you find on chest x-ray?
    a. Kerley B lines
    b. Decreased heart size
    c. Ground glass appearance
    d. Silhouette sign

Answer 12

72. A: Kerley B lines. These markings on chest x-ray signify pulmonary edema. They appear as short parallel lines at the edges of the lungs or costophrenic angles, and they indicate thickening of the septa. With CHF, you would expect the heart to be enlarged. Ground glass appearance is usually seen with interstitial disease. Silhouette sign is when the border of a structure cannot be viewed, like with atelectasis when the lung lobe obscures the heart.

Question 13

73. A 7-year-old boy arrives in the emergency department with rapid onset of sore throat, difficulty swallowing, and fever. On exam, you note that he is drooling, leaning over, and having a hard time breathing in. What is the most likely diagnosis?
    a. Pertussis
    b. Pneumonia
    c. Epiglottitis
    d. Respiratory syncytial virus (RSV)

Answer 13

73. C: Epiglottitis. This is a bacterial infection of the epiglottis and surrounding structures that requires emergent care because of possibility of asphyxia. It may occur in children or adults. Drooling is common, and the patient may be in a “tripod position,” leaning forward in order to breathe. Differential diagnosis could include croup, airway foreign body, and

Question 14

74. Ectopic pregnancies occur most often in which structure?
    a. Uterine interstitium
    b. Fallopian tube
    c. Cervix
    d. Pelvic cavity

Answer 14

74. B: Fallopian tube. An ectopic pregnancy is when implantation occurs anywhere outside the endometrium. Patients may present with pain and bleeding during early pregnancy. Risk increases with advanced maternal age, PID, and smoking. The second most common site is the uterine interstitium.

Question 15

75. You encounter a patient who has had several incidences of optic neuritis. What would be the best test to order so that more serious comorbid conditions can be ruled out?
    a. HIV
    b. Lumbar puncture
    c. Reticulocyte count
    d. Magnetic resonance imaging (MRI)

Answer 15

75. D: MRI. Optic neuritis is an inflammation of the optic nerve that can present with sudden vision loss and pain. The most common cause is multiple sclerosis, which can show up on an MRI as demyelination. MRI is the most sensitive test for multiple sclerosis (MS). Other less common causes of optic neuritis include infection and autoimmune disorders, such as lupus.

Question 16

76. A 9-year-old girl with asthma has shortness of breath, chest tightness, and wheezing. She was unable to participate in school sports yesterday. She has been having these symptoms 4 times a week during the day and 3 times a month during the night. She has been using a rescue beta-agonist as needed. What do you recommend next?
    a. Use of rescue beta-agonist more frequently
    b. High-dose inhaled corticosteroid daily
    c. Low-dose inhaled corticosteroid daily
    d. Long-acting beta-agonist

Answer 16

76. C: Low-dose inhaled corticosteroid daily. This patient falls into the “mild persistent” class of asthma sufferers (daytime symptoms more than 2 times per week, nighttime symptoms more than 2 times per month, exacerbations that sometimes limit activity). Treatment of asthma is a stepwise approach. For patients with mild intermittent asthma, no daily drugs are required, and rescue beta-agonists can be used as needed. For patients older than 5 years with mild persistent asthma, low-dose inhaled corticosteroids are recommended along with rescue beta-agonists.

Question 17

77. You are working with a team to monitor a patient who has been seizing for over 20 minutes. The patient has been given lorazepam, phenytoin, and valproate intravenously but there is no improvement. What is the next step?
    a. Give patient up to 30 minutes total to see if seizure will end
    b. Prepare for surgery
    c. Administration of additional anticonvulsant
    d. Intubation and general anesthesia

Answer 17

77. D: Intubation and general anesthesia. Status epilepticus is when the brain is in a continuous state of seizure for at least 5 minutes. It requires drugs to terminate the seizure and monitoring of respiratory status. If patients continue to seize after administration of lorazepam and phenytoin, they are considered to have refractory status epilepticus, and a third anticonvulsant is usually given. Intubation is necessary if the airway is compromised or if the seizure has not terminated at this point.

Question 18

78. All of the following are signs of pituitary dwarfism in children EXCEPT:
    a. Height is below the 3rd percentile.
    b. Proportions are not normal.
    c. Skeletal maturation is more than 2 years behind chronologic age.
    d. The child fails to begin pubertal development or is delayed.

Answer 18

78. B: Proportions are not normal. Hypopituitarism in children can result in short stature, also known as dwarfism. A pituitary tumor is usually the cause, but it also may be idiopathic. Growth hormone is decreased. Proportions are normal, unlike short-limbed dwarfism that is seen due to osteochondrodysplasias.

Question 19

79. You are treating a patient with quetiapine for mood stabilization and psychotic symptoms. Which of the following need to be ordered regularly?
    a. HbA1c
    b. Platelet count
    c. TSH
    d. Kidney function tests

Answer 19

79. A: HbA1c. Quetiapine is in the antipsychotic class of medications, which can be used to treat mood disorders and psychotic disorders. Other drugs in this class include risperidone, aripiprazole, ziprasidone, and olanzapine. Blood glucose, blood pressure, cholesterol, and weight need to be monitored regularly when patients on are these medications because of the potential metabolic side effects. Patients should also be monitored for abnormal movements, such as tardive dyskinesia.

Question 20

80. What would you expect to see on the ECG of a patient having an acute MI?
    a. Normal T waves
    b. ST segment abnormality
    c. PR interval elongation
    d. Ventricular premature beats

Answer 20

80. B: ST segment abnormality. An acute myocardial infarction is when coronary arteries become obstructed, resulting in cardiac ischemia. The patient’s symptoms can include chest pain, shortness of breath, and diaphoresis. An ECG will make the diagnosis, along with markers such as troponin and myocardial-bound creatine phosphokinase (CPK-MB).

Question 21

81. A 67-year-old woman has had bilateral knee pain for the past 3 months. She does not recall any specific injury. On exam, you note mild swelling and tenderness. X-rays show joint space narrowing and osteophytes. What do you prescribe this patient?
    a. Steroids
    b. Nonsteroidal anti-inflammatory drugs (NSAIDs)
    c. Narcotics
    d. Muscle relaxants

Answer 21

81. B: NSAIDs. Osteoarthritis is also known as degenerative joint disease. Patients are more likely to experience osteoarthritis as they get older. It can occur in the hands, hips, knees, and feet. Osteoarthritis begins with tissue damage, inflammation, or defects in cartilage metabolism. NSAIDs or acetaminophen can help relieve pain. Muscle relaxants and narcotics tend to cause more side effects, especially in elderly patients.

Question 22

82. What would you expect to find when evaluating a patient with known benign prostatic hyperplasia?
    a. Rubbery prostate with digital rectal exam
    b. Patient report of painful urination
    c. Hard, nodular prostate with digital rectal exam
    d. Fever and elevated white blood cell count (WBC)

Answer 22

82. A: Rubbery prostate with digital rectal exam. Benign prostatic hyperplasia can cause urinary frequency, urgency, nocturia, hesitancy, and dribbling. BPH etiology is unknown, but may be related to changes in hormones due to aging. BPH patients would have a “rubbery” prostate, whereas patients with prostate cancer may have a hard, nodular prostate. Fever and elevated white blood cell count would be more common with an infection like prostatitis.

Question 23

83. A 28-year-old man has a complaint of “bumps” on his forehead, which have been present for several months. He does not recall any trauma and says that they are not painful or particularly itchy. On exam, you note a cluster of 2 mm papules that are flesh-colored, smooth, and round, and have a central umbilication. What is the most likely diagnosis?
    a. Milia
    b. Warts
    c. Folliculitis
    d. Molluscum contagiosum

Answer 23

83. D: Molluscum contagiosum. This condition is caused by a virus and can be spread by contact. Most lesions will go away on their own. Milia are keratin-filled cysts that usually occur around the nose and eyes. Warts are also caused by a virus but are rougher in appearance and may have an irregular shape. Folliculitis is an inflammation of the hair follicles and may look more like pustules.

Question 24

85. A 46-year-old man arrives in the emergency department with severe chest pain that is worsened by deep inspiration and relieved by leaning forward. The patient is hypotensive and tachypneic, and you hear a friction rub with auscultation. Echocardiography shows an effusion. How do you treat this patient?
    a. Valvuloplasty
    b. Tube thoracostomy
    c. Pericardiocentesis
    d. Cardiac catheterization

Answer 24

85. C: Pericardiocentesis. Pericarditis is an inflammation of the sac around the heart that can be caused by MI, trauma, or infection, or the cause may be unknown. When pericarditis involves a large effusion and impairs cardiac filling, it is known as cardiac tamponade and can lead to shock and death. It is treated immediately with pericardiocentesis in order to remove fluid from around the heart.

Question 25

86. At what gestational age are low-risk pregnant women usually screened for diabetes?
    a. 10 to 12 weeks
    b. 28 to 32 weeks
    c. 12 to 16 weeks
    d. 24 to 28 weeks

Answer 25

86. D: 24-28 weeks. Gestational diabetes increases morbidity and mortality of both mother and fetus, so all pregnant women are screened with an oral glucose tolerance test. Women with risk factors such as prior gestational diabetes, unexplained fetal losses, family history of diabetes, or BMI more than 30 maybe screened in the first trimester.

Question 26

84. What is a risk factor for development of endometriosis?
    a. Lengthened menstrual cycles
    b. Delayed childbearing
    c. Short periods
    d. Multiple pregnancies

Answer 26

84. B: Delayed childbearing. Endometriosis is when tissue is implanted outside the uterine cavity, causing pain and infertility. It is diagnosed with biopsy. Incidence is increased with delayed childbearing, family history of endometriosis, shortened menstrual cycles, and abnormally long periods. Protective factors seem to be multiple pregnancies and use of contraceptives.