Pance Questions 5

Question 1

87. What of the following medications would not be advised for use in a patient with glaucoma?
    a. Amitriptyline
    b. Levothyroxine
    c. Montelukast
    d. Travoprost

Answer 1

87. A: Amitriptyline. This medication is a tricyclic antidepressant, which can have significant anticholinergic side effects such as constipation, weight gain, dizziness, urinary retention, and blurred vision. Amitriptyline may worsen glaucoma and should be used with caution in elderly patients.

Question 2

88. You are seeing a patient who likely has gout for the first time, but you want to be sure. What do you order to confirm diagnosis?
    a. Uric acid level
    b. Arthrocentesis
    c. X-ray
    d. Erythrocyte sedimentation rate (ESR)

Answer 2

88. B: Arthrocentesis. Gout occurs when monosodium urate crystals deposit into tissue. Patients usually present with a painful, warm, red metatarsophalangeal joint. Uric acid levels may be elevated, but not all people with elevated uric acid levels develop gout. An x-ray may be more useful when identifying tophi in chronic gout. ESR is not specific for gout. Definitive diagnosisis done by arthrocentesis, which will show monosodium urate crystals in the synovial fluid.

Question 3

89. Which of the following is NOT true regarding the physiology of cirrhosis?
    a. Progression of fibrosis varies among individuals
    b. New interconnecting vessels form that contribute to portal hypertension
    c. Loss of hepatic function can lead to liver failure
    d. Growth regulators cause hepatocellular hypoplasia

Answer 3

89. D: Growth regulators cause hepatocellular hypoplasia. Cirrhosis occurs because of chronic liver disease. Normal hepatic structure progresses to fibrosis and disorganization of tissue. Cytokines and growth regulators actually induce hepatocellular hyperplasia in response to injury. This produces regenerating nodules and angiogenesis.

Question 4

90. Which of the following is true regarding end-of-life issues with cystic fibrosis patients?
    a. Most patients will live into their 50s or 60s.
    b. Lung transplantation is not an option.
    c. Palliative care should be discussed.
    d. All of the above

Answer 4

90. C: Palliative care should be discussed. Cystic fibrosis is an inherited disease that primarily affects the respiratory and GI systems. Treatment is supportive, including infection prevention, chest physical therapy, diet changes, and management of associated conditions. Transplantation often becomes necessary, although the patient should be given options and information regarding quality of life. The median survival age is in the late 30s.

Question 5

91. How would you counsel patients regarding prevention of oral cancer?
    a. Advise them to avoid spicy foods.
    b. Educate them about how this condition is primarily genetic.
    c. Tell them to avoid smoking as this is the biggest risk factor.
    d. Recommend yearly biopsies for screening.

Answer 5

91. C: Tell them to avoid smoking as this is the biggest risk factor. Oral squamous cell carcinoma may occur on the floor of the mouth, tongue, lip, or palate. Smoking and alcohol use are the biggest risk factors for development of this condition. It can be detected early by screening, with biopsiesof suspicious areas. It is treated with surgery and/or radiation.

Question 6

92. A 36-year-old woman arrives in the emergency department with complaints of progressive bilateral lower extremity weakness and tingling over the past week. She says that she had an upper respiratory tract infection 3 weeks ago. On exam, you cannot elicit patellar reflexes. What is the most likely diagnosis?
    a. Stroke
    b. Myasthenia gravis
    c. Amyotrophic lateral sclerosis
    d. Guillain-Barré syndrome

Answer 6

92. D: Guillain-Barré syndrome. This condition is an inflammatory neuropathy that presents as muscle weakness and sensory loss. The cause it thought to be autoimmune, with an infection sometimes being the trigger. Most patients improve within several months. A stroke would usually cause weakness just on one side of the body. Myasthenia gravis also presents with weakness, although the symptoms worsen with exertion. Amyotrophic lateral sclerosis, also known as Lou Gehrig disease, presents with more asymmetric weakness.

Question 7

93. A 27-year-old generally healthy woman has mildly painful/itchy clusters of pustules around her nose and mouth. Honey-colored crusts are present over an erythematous base. How do you treat this patient?
    a. Hydrocortisone cream
    b. Mupirocin ointment
    c. Oral nystatin
    d. Retinol cream

Answer 7

93. B: Mupirocin ointment. Based on the information given, this patient likely has impetigo—a bacterial skin infection usually caused by staphylococci or streptococci. It commonly begins as a sore near the nose or mouth, with pus leading to formation of a honey-colored crust. It may be itchy and is highly contagious. Mupirocin is an antibiotic.

Question 8

94. What is a potential finding in a CT scan of a patient with schizophrenia?
    a. Decreased volume of third ventricle
    b. Larger amygdala
    c. Reduction in brain volume
    d. Increased gray matter

Answer 8

94. C: Reduction in brain volume. Schizophrenia is a complex mental disorder characterized by psychosis, disorganization, flattened affect, and cognitive deficits. There is a genetic component, although the full cause is unknown. Some studies have shown that patients with schizophrenia have a reduction in brain volume along with enlarged lateral and third ventricles.

Question 9

95. Where does a Wilms tumor occur?
    a. Kidney
    b. Liver
    c. Pancreas
    d. Colon

Answer 9

95. A: Kidney. Wilms tumor, also known as nephroblastoma, is an embryonal cancer of the kidney. It usually presents in children younger than 5 years. Patients may have a painless abdominal mass with hematuria, fever, nausea, and vomiting. It is diagnosed with CT and biopsy. Treatment includes surgery, chemotherapy, and radiation.

Question 10

96. What is a common manifestation of multiple myeloma?
    a. Liver insufficiency
    b. Skin rash
    c. Shortness of breath
    d. Bone Pain

Answer 10

96. D: Bone pain. Multiple myeloma is a malignancy in which abnormal plasma cells accumulate in bone marrow, leading to bone pain, renal insufficiency, and anemia. Lytic bone lesions may be seen on x-ray. The breakdown of bone leads to hypercalcemia. Patients are more susceptible to infections due to decreased production of immunoglobulin. It is treated with chemotherapy and stem cell transplantation.

Question 11

97. A 22-year-old man has dysuria and penile discharge. He had unprotected sex about a week ago. What do you prescribe this patient?
    a. Azithromycin
    b. Nitrofurantoin
    c. Vancomycin
    d. Bacitracin

Answer 11

97. A: Azithromycin. This patient likely has chlamydia, which is a common sexually transmitted infection. Infected men will present with urethritis and a clear or cloudy discharge. Sexual partners should be treated as well. Azithromycin is a macrolide antibiotic. Untreated chlamydia can lead to more serious health problems.

Question 12

98. When may a surgical consult be appropriate for management of hemorrhoids?
    a. After hemorrhoid has been present for 6 months
    b. With patients who have external hemorrhoids hemorrhoids
    c. When hemorrhoids fail to respond to more conservative measures
    d. After patient begins experiencing pain

Answer 12

98. C: When hemorrhoids fail to respond to more conservative measures. Hemorrhoids are dilated veins in the rectum that can be asymptomatic or cause pain and bleeding. Hemorrhoids can be internal or external, sometimes protruding from the anus. They can thrombose, resulting in painful swelling. Patients should use stool softeners, take warm baths, apply anesthetic ointments, and take OTC medications for pain. Incision/evacuation, injection sclerotherapy, and ligation are also treatment options. Hemorrhoidectomy is done for patients who do not respond to these other therapies.

Question 13

99. A 56-year-old woman arrives in the emergency department with left lower quadrant pain and fever. On exam, you note abdominal tenderness and guarding. WBC is elevated. Based on this information, what do you suspect is wrong with this patient?
    a. Cholecystitis
    b. Diverticulitis
    c. Appendicitis
    d. Colon cancer

Answer 13

99. B: Diverticulitis. Patients with low-fiber diets may have diverticulosis, which consists of outpouchings of the colon. When these become inflamed or perforate, patients develop diverticulitis, which usually presents with pain in the left lower quadrant and fever. Patients may develop abscesses or bowel obstructions. Patients with severe symptoms are hospitalized and given IV fluids and antibiotics. Surgery may be necessary in patients with perforation.

Question 14

100. Which of the following is a long-acting insulin used in the treatment of diabetes?
     a. Aspart
     b. Glargine
     c. Lispro
     d. NPH

Answer 14

100. B: Glargine. Diabetes can be treated by administration of exogenous insulin, due to the patient no longer producing insulin internally or the patient being insulin resistant. Glargine has a duration of action of roughly 18-26 hours. Aspart and lispro are fast-acting insulins, and NPH is an intermediate-acting insulin.

Question 15

101. A 36-year-old man has had fever and fatigue for the past week. He had a dental procedure 2 weeks ago. On exam, you note splinter hemorrhages under the nails and a heart murmur. What do you suspect?
     a. Acute bacterial endocarditis
     b. Pericarditis
     c. Aortic aneurysm
     d. Hypertrophic cardiomyopathy

Answer 15

101. A: Acute bacterial endocarditis. This patient likely has an infection of the endocardium, which is the inner layer of the heart. IV drug use, recent dental procedures, and prior heart valve issues increase the risk of developing endocarditis. Usually caused by streptococci or staphylococci, “vegetations” form on the heart valves. Patients present with fever, heart murmur, and evidence of emboli from the infected material on the valve. It is diagnosed by blood culture and echocardiography. It is treated with IV antibiotics and may require surgery.

Question 16

102. An 18 year old arrives in your office because she has never had a menstrual period. She has never been pregnant. What could be happening with this patient?
     a. Excessive luteinizing hormone (LH) secretion
     b. Decreased gonadotropin secretion
     c. Excessive estrogen level
     d. Decreased testosterone level

Answer 16

102. B: Decreased gonadotropin secretion. This patient has primary amenorrhea, which is the absence of menarche by age 16. Gonadotropins are hormones such as LH and follicle-stimulating hormone (FSH) that are secreted by the pituitary gland and act on the ovaries. Decreased gonadotropin secretion results in estrogen deficiency—this is the most common reason for amenorrhea. Increased testosterone may also lead to amenorrhea, as may be seen with polycystic ovary syndrome.

Question 17

103. A 45-year-old woman arrives in your office with complaints of a progressive growth on her right eye. She reports foreign body sensation. On exam, you see a triangular shaped growth from the nasal side of her right eye extending to the edge of her cornea. Her vision is intact. What test do you need to order for confirmation of diagnosis?
     a. MRI
     b. ESR
     c. Herpes simplex virus (HSV)
     d. None of the above

Answer 17

103. D: None of the above. Based on the information provided, this patient has a pterygium, which is a benign growth of the conjunctiva. It is diagnosed by physical examination and does not require any specific tests. The pterygium may eventually spread across the cornea and distort vision. It can be removed to improve vision or for cosmetic purposes.

Question 18

104. You have a patient who takes isosorbide dinitrate for angina pectoris. Which of the following medications would be contraindicated for this patient?
     a. Aspirin
     b. Metoprolol
     c. Sildenafil
     d. Esomeprazole

Answer 18

104. C: Sildenafil. This medication is a phosphodiesterase type 5 (PDE5) inhibitor that is used to treat erectile dysfunction, but it is contradicted when patients are already taking nitrates. Isosorbide dinitrate and sildenafil are both vasodilators and can cause hypotension when used in conjunction.

Question 19

105. According to the Centers for Disease Control and Prevention, at what age should a healthy nonsmoking adult receive the pneumococcal vaccine if they received their first dose as a child?
     a. 65
     b. 60
     c. 55
     d. 50

Answer 19

105. A: 65. The most common bacterial cause of pneumonia in the United States is Streptococcus pneumoniae, also known as pneumococcus. Symptoms include fever, cough, and shortness of breath. Elderly patients are at greater risk for pneumococcal disease. The pneumococcal vaccine (PCV13) is routinely given to infants in a series of four doses. The pneumococcal vaccine (PPSV) is recommended for all adults 65 years and older if they received their first dose before age 65 and if it has been 5 or more years since their first dose. Older children and adults younger than 65 are also vaccinated if they have certain medical conditions.

Question 20

106. You are examining a 67-year-old patient who has had a progressive hand tremor. You note a bilateral, slow tremor that is absent at rest. How can you treat this patient?
     a. Phenytoin
     b. Primidone
     c. Terazosin
     d. Levodopa

Answer 20

106. B: Primidone. This medication is an anticonvulsant. This patient has essential tremor, which is benign and usually associated with older age. It may be hereditary. It can also be treated with beta-blockers, such as propranolol. A tremor associated with Parkinson disease would be present at rest and decrease with activity.

Question 21

107. A 31-year-old woman has a 2 cm soft, round swelling on the dorsal side of her left wrist. She does not remember any specific trauma but reports that it has increased in size over the past few months. What is the most likely diagnosis?
     a. Gout
     b. Tenosynovitis
     c. Colles fracture
     d. Ganglion cyst

Answer 21

107. D: Ganglion cyst. These usually occur on the dorsal aspect of the hand or wrist. They are more common in women between 20 and 50 years of age. The cause is unknown. The cysts are usually attached to tendon sheaths and joint capsules. They may be removed surgically. Tenosynovitis would not present with a well-circumscribed mass. With gout, the joint would be red and painful.

Question 22

108. What is a risk factor for the development of actinic keratosis?
     a. Smoking
     b. Frequent sun exposure
     c. Long-term use of retinoid medications
     d. Poor hygiene

Answer 22

108. B: Frequent sun exposure. Actinic keratosis is a condition usually seen in fair-skinned people with frequent sun exposure. It is considered to be premalignant, meaning that the areas could progress to squamous cell carcinoma. Patients will have scaly/crusty, pink areas of skin usually on sun-exposed areas such as the face. It can be treated with medications, laser resurfacing, or cryotherapy.

Question 23

109. Which of the following patients is most likely to develop mastitis?
     a. 18-year-old woman who has fibrocystic disease
     b. 58-year-old woman with remote history of breast cancer
     c. 44-year-old man with gynecomastia
     d. 26-year-old woman who is breastfeeding

Answer 23

109. D: A 26-year-old woman who is breastfeeding. Mastitis is an inflammation of the breast, usually with infection by staphylococci, streptococci, or E. coli. It is a common maternal complication of breastfeeding due to engorgement and blockage. Patients present with fever and a red, swollen, painful area of the breast. Treatment includes antibiotics and continued breastfeeding in order to empty the breast.

Question 24

110. A discrete 1 cm lung nodule is incidentally found on the chest x-ray of a 46-year-old nonsmoking man. There are no other x-rays for comparison. The patient is asymptomatic. What is the best next step?
     a. Oncology referral
     b. Chest CT
     c. Lung biopsy
     d. X-ray in 1 year

Answer 24

110. B: Chest CT. There are many causes for solitary pulmonary nodules, including cysts, arteriovenous malformations, tuberculosis, hematomas, and neoplasms. Lesions may be benign or malignant. Risks factors for lung cancer include age, smoking, asbestos exposure, and family history. Certain lesion characteristics, such as an irregular border, may be indicative of a malignancy. It is best to evaluate risk factors for each patient and do a thorough history/physical. It is helpful to compare with old imaging if available to determine if the lesion has grown. A chest CT is a reasonable next step for this patient in order to better characterize the lesion. If there is concern for malignancy, then excision or biopsy would be done.

Question 25

111. A 70-year-old woman was found to have osteoporosis on dual-energy x-ray absorptiometry (DEXA) screening. You do not want this patient’s condition to worsen, so you recommend all of the following EXCEPT:
     a. Taking a calcium and vitamin D supplement
     b. Decreasing physical activity
     c. Minimizing caffeine and alcohol intake
     d. Starting a bisphosphonate medication

Answer 25

111. B: Decreasing physical activity. Osteoporosis is a condition in which bone density is decreased, which can lead to fractures. It is more common in women and elderly patients. White and Asian patients are at higher risk, along with those who have a family history of osteoporosis. Exercise is actually recommended because the weight-bearing and stress are necessary for bone growth. Goals with treatment are to preserve bone mass, prevent fractures, and decrease pain. Bisphosphonates work by inhibiting bone resorption.