Pance Questions 6

Question 1

112. A 41-year-old man was admitted to the psychiatry unit for treatment of alcohol dependence. What medication do you use to treat acute withdrawal symptoms?
     a. Lorazepam
     b. Clozapine
     c. Divalproex
     d. Methadone

Answer 1

112. A: Lorazepam. Alcohol withdrawal can be potentially fatal. Symptoms of withdrawal are usually 12-48 hours after last drink. Patients may have stomach upset, tremor, weakness, and sweating. Delirium tremens (DTs) can occur within 48-72 hours and include increasing anxiety, confusion, hallucinations, and autonomic lability. Benzodiazepines are used to treat alcohol withdrawal because they are CNS depressants, like alcohol. They should not be continued after the detoxification period because of their risk of dependence as well.

Question 2

113. What medication can be given to a premature infant with a patent ductus arteriosus?
     a. Pregabalin
     b. Peginterferon
     c. Epinephrine
     d. Indomethacin

Answer 2

113. D: Indomethacin. Patent ductus arteriosus (PDA) is when the aorta and pulmonary artery are still connected after birth. Infants may be poor feeders and have tachycardia and tachypnea. A murmur can be heard. For premature infants, indomethacin may close the PDA since prostaglandin E2 is responsible for keeping the ductus patent. Indomethacin is a prostaglandin synthesis inhibitor/ NSAID. If indomethacin is ineffective, surgery can be done.

Question 3

114. You order a hearing test for an elderly patient who you suspect suffers from presbyacusis. Which frequencies would you expect to be affected?
     a. Low
     b. Medium
     c. High
     d. None

Answer 3

114. C: High. Presbyacusis is bilateral, symmetric, sensorineural hearing loss due to normal aging. It usually affects the highest frequencies (18-20 kHz) and can impair speech comprehension. High-frequency hearing loss is also caused by noise damage. The results of a hearing test are displayed in an audiogram, which shows the level that sounds are detected at each frequency.

Question 4

115. Which of the following is true regarding both dilated and restrictive cardiomyopathies?
     a. Systolic dysfunction is predominant.
     b. There are numerous potential etiologies.
     c. Only the left ventricle is affected.
     d. Patients have chest pain.

Answer 4

115. B: There are numerous potential etiologies. Dilated cardiomyopathy leads to heart failure due to enlargement of the ventricles. Systolic function is mainly affected. There are many potential causes of this condition, including coronary artery disease (CAD) and viruses. Patients have shortness of breath, fatigue, and peripheral edema. Restrictive cardiomyopathy means that the ventricular walls are noncompliant and diastolic filling is limited. Causes of restrictive cardiomyopathy include amyloidosis, sarcoidosis, and hemochromatosis. Patients have shortness of breath on exertion and fatigue.

Question 5

116. A 35-year-old man arrives in the emergency department with intermittent severe back pain, dysuria, and nausea. He is afebrile. Microscopic hematuria is seen on urinalysis. What is the most likely diagnosis based on this information?
     a. Benign prostatic hypertrophy
     b. Pyelonephritis
     c. Prostatitis
     d. Nephroliathiasis

Answer 5

116. D: Nephrolithiasis. Patients with kidney stones may have sudden onset of unilateral flank pain, hematuria, abdominal pain, nausea, urgency, frequency, or dysuria. Pyelonephritis is an infection of the kidney. Patients may also have dysuria, flank pain, and nausea, but they would also have fever and an elevated white blood cell count. Patient with BPH have urinary frequency and urgency, but would not typically have back pain or hematuria. Prostatitis would likely present with urinary frequency and urgency, fever, and sometimes testicular or perineal pain.

Question 6

117. A 25-year-old generally healthy woman has a cough, runny nose, and sore throat. She denies headache or itchy eyes. She is afebrile and lung sounds are normal. Mild erythema is seen in the posterior pharynx. What is the most likely diagnosis?
     a. Allergic rhinitis
     b. Sinusitis
     c. Acute bronchitis
     d. Pneumonia

Answer 6

117. C: Acute bronchitis. Coughs and bronchitis are usually caused by viruses and do not require antibiotics for treatment. The upper airway is inflamed and fever may not be present, unlike pneumonia in which the lungs are involved and patients have fever. Allergic rhinitis presents with congestion, sore throat, cough, and itchy/ watery eyes. “Cobblestoning” may be seen in the pharynx due to postnasal drip, and eyes may be affected. Sinus infections are usually accompanied by facial pain and headache.

Question 7

118. Which of the following conditions will have a positive Murphy sign?
     a. Cholecystitis
     b. Pancreatitis
     c. Appendicitis
     d. Peptic ulcer disease

Answer 7

118. A: Cholecystitis. Inflammation of the gallbladder presents with pain in the upper right quadrant. A positive Murphy sign is when this pain can be elicited with patient inspiration when the examiner’s hand palpates under the ribs on the right side.

Question 8

119. How do you manage a patient with abruptio placentae at 35 weeks who presents with vaginal bleeding and with fetal distress?
     a. Prompt delivery
     b. Magnesium
     c. Bed rest
     d. Oxygen

Answer 8

119. A: Prompt delivery. Abruptio placentae is when the placenta prematurely separates from the uterus during late pregnancy. Patients can present with bleeding and pain. Severity depends on the degree of separation, but it can lead to fetal distress and maternal shock. It is diagnosed clinically or with ultrasound. Mild symptoms may be treated with bed rest, but prompt delivery is more appropriate when the life of mother or fetus is threatened.

Question 9

120. Which of the following drug classes is most likely responsible for a patient developing Stevens-Johnson syndrome?
     a. Antipsychotics
     b. Antibiotics
     c. Antihypertensives
     d. Antivirals

Answer 9

120. B: Antibiotics. Stevens-Johnson syndrome is a potentially life-threatening hypersensitivity reaction in which patients present with ulcers, widespread macules, and blistering. It can be caused by drugs (sulfa drugs, antiepileptics, antibiotics), infections, or vaccinations. Treatment is supportive.

Question 10

121. A 78 year old with dementia is brought in the office by his daughter for routine follow-up. He is disheveled and smells of urine. You notice several bruises on his back. What is the most important step in management of this patient?
     a. Referring to a social worker
     b. Ordering home health services
     c. Educating daughter on care of patient
     d. Contacting Adult Protective Services

Answer 10

121. D: Contacting Adult Protective Services. All of these answer choices are appropriate steps to take in management of this patient; however, contacting APS is obligatory for health care professionals who suspect that a patient is being abused or neglected. This patient is at risk because of dementia, and there are signs of abuse/ neglect such as bruising and poor hygiene.

Question 11

122. A 10-year-old girl arrives for an annual physical accompanied by her mother. She is generally healthy although describes anal itching that is worse at night. How do you treat this patient based on your suspected diagnosis?
     a. Fluconazole
     b. Hydrocortisone
     c. Mebendazole
     d. Amoxicillin

Answer 11

122. C: Mebendazole. This medication is an antihelminthic. This patient has pinworms, which is an intestinal parasitic infection common in children. It is transmitted from human to human by contamination and ingestion. It presents as anal itching, usually worse at night because this is when the female pinworm migrates to lay eggs around the anus. Sometimes the worms are visible upon inspection.

Question 12

123. What is the physiology of hyaline membrane disease in neonates?
     a. Chronic lung injury due to mechanical ventilation
     b. Aspiration of meconium
     c. Bacterial infection of the trachea
     d. Deficiency of pulmonary surfactant

Answer 12

123. D: Deficiency of pulmonary surfactant. Hyaline membrane disease is also known as neonatal respiratory distress syndrome. The risk for this condition depends on how premature the infant is. Surfactant diminishes the surface tension of lung alveoli, increasing pulmonary compliance and preventing lung collapse. Infants with deficiency of surfactant become hypoxemic and have more difficulty breathing.

Question 13

124. Which of the following is true regarding ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI)?
     a. Emergency percutaneous coronary intervention is always necessary.
     b. Patients present with the same symptoms.
     c. Both involve transmural ischemia.
     d. All of the above

Answer 13

124. B: Patients present with the same symptoms. For both STEMI and NSTEMI, patients can present with the same symptoms of angina, shortness of breath, fatigue, diaphoresis, and nausea. NSTEMI has subendocardial ischemia, where STEMI has transmural ischemia that extends through the whole thickness of the heart muscle. For NSTEMI, emergency percutaneous coronary intervention (PCI) is not necessarily indicated unless patient is high risk— with hemodynamic instability or elevated cardiac markers.

Question 14

125. How do you counsel a patient with gout about how to prevent flare-ups?
     a. Avoid alcohol.
     b. Eat more red meat.
     c. Avoid NSAIDs.
     d. Decrease physical activity.

Answer 14

125. A: Avoid alcohol. Gout is due to monosodium urate crystals precipitating into tissue. Increased use of alcohol and red meats tend to make the condition worse. NSAIDs can actually prevent and provide relief for gout attacks. Physical activity does not necessarily make gout worse, and it has shown to be helpful.

Question 15

126. A 54-year-old man with hypertension arrives in the emergency department with sudden onset of “ripping” chest pain. Chest x-ray shows a widened mediastinum. What is the most likely diagnosis?
     a. CHF exacerbation
     b. Acute MI
     c. Pericarditis
     d. Aortic dissection

Answer 15

126. D: Aortic dissection. Tears in the layers of the aorta cause intense pain.The dissection may extend along the aorta and into other arteries. The DeBakey classification system indicates the location and extent of the dissection. Hypertension is the main risk factor for development of this condition.

Question 16

127. You treat a 30-year-old woman for a urinary tract infection with antibiotics. She comes back 2 weeks later and complains of watery diarrhea with mucus and abdominal cramping. She is febrile. What is the most likely causative organism of the diarrhea?
     a. Salmonella
     b. C. difficile
     c. Shigella
     d. E. coli

Answer 16

127. B: C. difficile. Clostridium difficile is a spore-forming gram-positive bacillus. It is the leading cause of nosocomial infectious diarrhea. The biggest risk factor for development is antibiotic use, especially fluoroquinolones and clindamycin. The antibiotics disturb the colonic flora. Individuals are also at greater risk if they are older than 65, have medical comorbidities, have irritable bowel disease, or are immunocompromised. Symptoms include fever, abdominal cramping, and watery diarrhea with mucus. Blood is not usually present.

Question 17

129. You are examining a 40-year-old woman with fair skin who has telangiectasias, and scattered pustules. She says that she often feels “flushed.” What is the most likely diagnosis?
     a. Psoriasis
     b. Rosacea
     c. Erysipelas
     d. Melasma

Answer 17

129. B: Rosacea. This is a chronic inflammatory disorder that usually affects patients between 30 and 50 years of age. Treatment involves avoidance of triggers (such as sun, stress, alcohol, wind, cosmetics) and antibiotics. Psoriasis is also an inflammatory disease, but the lesions are usually better circumscribed and have silvery scales. Erysipelas is superficial cellulitis that could present as distinct, shiny plaque lesions on the face. It is usually accompanied by fever. Melasma consists of dark, irregular macules usually occurring in pregnant women. .

Question 18

130. Which of the following patients should NOT receive the influenza vaccination? a. 9-month-old male infant
     b. 38-year-old pregnant woman
     c. 24-year-old woman with upper respiratory tract infection and fever
     d. 86-year-old man living in a nursing home

Answer 18

130. C: A 24-year-old woman with upper respiratory tract infection and fever. Influenza is a common viral infection seen between the months of October and May. Cases peak around January and February. The vaccine is not approved for infants younger than 6 months, but is otherwise universally recommended. However, if patients are moderately to severely ill with fever, they should wait to be vaccinated until after their symptoms diminish. The vaccine is especially recommended for those at greater risk of flu complications, such as those younger than 5 years, greater than 50 years, living in a nursing home, those who are pregnant, or have chronic medical conditions.

Question 19

131. What would you expect to find when reviewing lab results of a patient with untreated hypoparathyroidism?
     a. Low calcium
     b. Elevated magnesium
     c. Low TSH
     d. Elevated phosphate

Answer 19

131. A: Low calcium. Hypoparathyroidism can be caused by surgical removal or incidental destruction of the parathyroid glands. Inadequate parathyroid hormone results in hypocalcemia. Patients can have vague or neuromuscular symptoms. Chronic hypocalcemia can lead to mental status changes, cataracts, dry skin, and brittle hair/ nails.

Question 20

133. For women, what is the biggest risk factor for developing breast cancer?
     a. Family history of breast cancer
     b. Increasing age

c. Oral contraceptive use
d. Early menarche

Answer 20

133. B: Increasing age. Gender is actually the biggest risk factor, followed by increasing age. For women in their 20s, approximately 1 in 2000 will develop breast cancer, compared with 1 in 25 for women 70 years and older. Other risk factors include family history or personal history of breast cancer, estrogen exposure, earlier menarche, later menopause, fewer pregnancies, and no history of breastfeeding.

Question 21

134. A 4-year-old black boy is treated for a viral upper respiratory tract infection. He returns a week later with jaundice. Lab tests show anemia and reticulocytosis, with Heinz bodies and “bite cells” seen on smear. What is the most likely diagnosis?
     a. Autoimmune hemolytic anemia
     b. Sickle cell anemia
     c. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
     d. Hereditary spherocytosis

Answer 21

134. C: G6PD deficiency. This is an X-linked hereditary disease more common in black patients, characterized by abnormally low levels of glucose-6-phosphate dehydrogenase, which is a metabolic enzyme. Deficiency leads to reduced energy available to maintain RBC membranes. Hemolysis can occur after acute illness or use of certain medications. Heinz bodies are inclusions within RBCs composed of denatured hemoglobin. When macrophages remove the Heinz bodies, characteristic “bite cells” are left.

Question 22

135. Name the correct order for blood flow through the heart.
     a. Right atrium, right ventricle, left atrium, left ventricle
     b. Left atrium, left ventricle, right atrium, right ventricl

c. Right atrium, left atrium, right ventricle, left ventricle
d. Left atrium, right atrium, right ventricle, left ventricle

Answer 22

135. A: Right atrium, right ventricle, left atrium, left ventricle. Blood comes into the right atrium by way of the superior vena cava and inferior vena cave. It goes through the tricuspid valve into the right ventricle, where it is then pumped to the lungs to become oxygenated. Blood returns into the left atrium and flows through the mitral valve into the left ventricle. It is then pumped throughout the body.

Question 23

136. A 40-year-old generally healthy man arrives for routine follow-up and reports that it is getting harder for him to exercise without feeling short of breath. On exam, you note a faint midsystolic murmur near the upper left sternal border. Chest x-ray shows a dilated right atrium. What is the most likely diagnosis?
     a. Coarctation of the aorta
     b. Ventricular septal defect
     c. Patent foramen ovale
     d. Hypoplastic left heart syndrome

Answer 23

136. C: Patent foramen ovale. This patient likely has a type of atrial septal defect known as a patent foramen ovale. During fetal development, the foramen ovale is open so that blood flows between the atria and bypasses the nonfunctional lungs. It is congenital, although some patients may not present with symptoms until later in life. Most small atrial septal defects (ASDs) are asymptomatic or will close within the first few years of life. With larger defects, a left-to-right shunt is present, which produces dyspnea, fatigue, and exercise intolerance.

Question 24

137. A 28-year-old man arrives in the emergency department with sudden onset of unilateral, severe headache. There has not been any trauma. You note tearing and rhinorrhea on the affected side. What do you do next?
     a. Order a head CT.
     b. Perform a lumbar puncture.
     c. Order a urine toxicology screen.
     d. Administer 100% oxygen.

Answer 24

137. D: Administer 100% oxygen. This patient is suffering from a cluster headache, which primarily affects men between 20 and 40 years of age. The exact cause is unknown. The excruciating headaches occur suddenly with autonomic symptoms on the same side. It is treated acutely with oxygen, and there are medications that patients can take to prevent the attacks.

Question 25

138. Which of the following is true regarding erectile dysfunction?
     a. It can be caused by stress or anxiety.
     b. In the United States, 5 to 10 million men are affected.
     c. It is treated with phosphodiesterase inhibitors.
     d. All of the above

Answer 25

138. A: It can be caused by stress or anxiety. Erectile dysfunction is the inability to attain or sustain an erection. The causes for ED include vascular, neurologic, hormonal, and psychological disorders. In the United States, 10-20 million men are affected. Prevalence increases with age. The treatment is with phosphodiesterase type 5 inhibitors, which prevent the degradation of cyclic GMP (cGMP). Increased cGMP results in vasodilation and increased blood flow.

Question 26

139. Which of the following women needs to receive the Rh immune globulin injection?
     a. Rh-positive mother who gave birth to an Rh-positive baby
     b. Rh-negative mother who gave birth to an Rh-negative baby
     c. Rh-positive mother who gave birth to an Rh-negative baby
     d. Rh-negative mother who gave birth to an Rh-positive baby

Answer 26

139. D: Rh-negative mother who gave birth to an Rh-positive baby. The injection of Rh immune globulin is given to Rh-negative women who deliver an Rh-positive baby. The injection prevents the mother’s immune system from forming antibodies against Rh-positive blood cells, which entered the bloodstream due to fetal circulation. The injection prevents hemolytic disease of the newborn, which can occur in subsequent pregnancies also.

Question 27

140. A 60-year-old man has been experiencing intermittent syncopal episodes. He also reports angina and shortness of breath with exertion. On exam, you hear a crescendo-decrescendo ejection murmur. What is the most likely diagnosis?
     a. Mitral stenosis
     b. Aortic stenosis
     c. Mitral regurgitation
     d. Aortic regurgitation

Answer 27

140. B: Aortic stenosis. This patient presents with the classic triad of symptoms. Aortic stenosis is when the valve is narrowed between the left ventricle and the aorta, so a murmur is heard whenever blood is flowing out to the body. Untreated, this condition can lead to heart failure and arrhythmias. Treatment is with valve replacement.