Pance Questions 8

Question 1

166. You are interviewing a patient with bipolar disorder who is currently having a manic episode. Which of the following best describes what you would include when documenting the mental status examination?
     a. Disheveled, guarded, looseness of associations
     b. Pressured speech, grandiose, flight of ideas
     c. Psychomotor retardation, blunted affect, suicidal ideation
     d. Tremulous, poor eye contact, obsessive ruminations

Answer 1

166. B: Pressured speech, grandiose, flight of ideas. The mental status examination is used in the field of psychiatry to describe the characteristics of patients through observation and questioning. It includes documentation of appearance, attitude, motor activity, speech, affect, mood, thought process, perception, insight, and judgment. Patients with bipolar disorder in a manic state likely have high energy, irritability, delusions of grandeur, and decreased need for sleep. Answer choice A is more descriptive of a patient with a psychotic disorder. Answer choice C describes a depressed patient, and answer choice D describes an anxious patient.

Question 2

167. You have been seeing a patient with anxiety and depression who has tried many selective serotonin reuptake inhibitors (SSRIs) over the years. He would like to switch to a different medication and prefers to take something at night. One of his main symptoms is decreased appetite. Which of the following would be the best choice?
     a. Bupropion

b. Venlafaxine
c. Mirtazapine
d. Citalopram

Answer 2

167. C: Mirtazapine. This medication works for both depression and anxiety symptoms and is best taken at night because sedation is a common side effect. Mirtazapine is also known to increase appetite. Bupropion is a norepinephrine-dopamine reuptake inhibitor, and venlafaxine is a serotonin-norepinephrine reuptake inhibitor. Both of these medications can also help depression/ anxiety, but are best taken in the morning because they can cause activation or insomnia. Citalopram is another SSRI.

Question 3

168. A 25-year-old woman arrives in the emergency department with severe headache and nausea. She is tachycardic and diaphoretic, with a blood pressure of 174/109. She has had episodes like this before and recalls a relative with a similar problem. Her plasma metanephrine is elevated. What is the most likely diagnosis?
     a. Essential hypertension
     b. Secondary aldosteronism
     c. Cushing syndrome
     d. Pheochromocytoma

Answer 3

168. D: Pheochromocytoma. This is a cause of secondary hypertension. It is a tumor of the adrenal glands that secretes catecholamines and leads to persistent hypertension. It usually occurs in patients between 20 and 40 years of age. There is a hereditary component for some types. Patients have paroxysmal hypertension, clammy skin, palpitations, headaches, nausea, and shortness of breath. Diagnosis is by measuring catecholamine products in the blood or urine.

Question 4

169. A chalazion involves dysfunction of what structure?
     a. Sebaceous gland of Zeis
     b. Tear duct
     c. Meibomian gland
     d. Iris

Answer 4

169. C: Meibomian gland. A chalazion usually presents as a painless lump on the upper eyelid. It is due to a blocked meibomian gland. The meibomian glands are also known as tarsal glands located within both the upper and lower eyelid. Chalazion are different from styes, also known as hordeolum, which are usually seen on the lower eyelid and caused by infection. Chalazion generally goes away on its own within months and can be treated with hot compresses.

Question 5

170. How long should a patient with latent tuberculosis be treated with isoniazid?
     a. 2-4 weeks
     b. 1-3 months
     c. 3-6 months
     d. 6-9 months

Answer 5

170. D: 6-9 months. Tuberculosis is caused by acid-fast Mycobacterium. Patients may go for periods of time without active infection and have a positive purified protein derivative (PPD) test. Active infection can present with shortness of breath, productive cough, malaise, and night sweats. An upper lobe lung cavitation is characteristic of TB, and diagnosis is by sputum culture. Patients with active infection should avoid spreading disease by covering coughs and avoiding contact with others. For patients with latent infections, Isoniazid (INH) can be given for 6-9 months in order to prevent acute infection.

Question 6

171. A 63-year-old man reports worsening nighttime urinary frequency. On exam, you note an enlarged, rubbery prostate. Urinalysis and prostate-specific antigen (PSA) are normal. How do you treat this patient?
     a. Ampicillin
     b. Terazosin
     c. Vardenafil
     d. Oxybutynin

Answer 6

171. B: Terazosin. This patient has benign prostatic hypertrophy (BPH). The prevalence increases with older age. Patient experience urinary frequency, urgency, dysuria, and nocturia. Terazosin is an alpha-blocker, which means that it blocks the action of adrenaline and relaxes smooth muscle leading to decreased blockage. Dizziness can be a side effect. Oxybutynin can also treat urinary frequency, but is usually used in urge incontinence.

Question 7

172. A 58-year-old woman arrives in the emergency department with palpitations and weakness. On auscultation, you note a regular rhythm. ECG shows a “sawtooth” pattern. What is the most likely diagnosis? a. Atrial fibrillation
     b. Wolff-Parkinson-White syndrome
     c. Atrial flutter
     d. Sinus node dysfunction

Answer 7

172. C: Atrial flutter. Atrial flutter is similar to atrial fibrillation in that they are both rapid atrial rhythms and have similar symptoms, but atrial flutter is regular instead of irregular. ECG shows a “sawtooth” pattern. Treatment involves rate control and prevention of thromboembolism. Wolff-Parkinson-White syndrome is a supraventricular tachycardia and “delta waves” are seen on ECG.

Question 8

173. Oral cancer is most prevalent in which of the following patient populations?
     a. Patients who smoke and drink
     b. Patients with a history of syphilis
     c. Elderly patients because of chronic fluoride exposure
     d. Patients with skin cancer

Answer 8

173. A: Those who smoke and drink. Around 90% of patients with oral squamous cell carcinoma are smokers. Risk is also increased with heavy alcohol use. Carcinoma of the tongue may be due to syphilis or chronic trauma. Most carcinomas start on the mouth floor or tongue. Detection with screening is important because early lesions may not cause symptoms.

Question 9

174. A 45-year-old man arrives for routine follow-up. He reports a persistent cough for the past 2 months. On exam, you do not find signs of infection or inflammation. With further questioning, he remembers that the cough started when a new medication was added. Which medication is likely the culprit?
     a. Lisinopril
     b. Furosemide
     c. Losartan
     d. Diltiazem

Answer 9

174. A: Lisinopril. This medication is an ACE inhibitor that is often used in the treatment of high blood pressure. Cough is a common side effect. For patients who cannot tolerate this, they are usually switched to angiotensin receptor blockers instead. Other potential side effects of lisinopril include dizziness, headache, diarrhea, nausea, and hyperkalemia.

Question 10

175. A 21-year-old male college student arrives in the emergency department with headache and fever since yesterday. On exam, Brudzinski sign is positive. What is the mostly likely diagnosis based on this information?
     a. Encephalitis
     b. Subdural empyema
     c. Acute transverse myelitis
     d. Bacterial meningitis

Answer 10

175. D: Bacterial meningitis. It involves inflammation of the meninges around the brain or spinal cord. Bacterial meningitis is seen in college age patients due to living in close quarters like dormitories. It is usually caused by meningococci and pneumococci. Vaccine should be considered for students about to leave for college. The classic triad of symptoms is fever, headache, and stiff neck. Brudzinski sign is when hip or knee flexion is induced by neck flexion.

Question 11

176. Which of the following labs would you include in a typical workup for dementia?
     a. CK
     b. B12
     c. AFP
     d. ESR

Answer 11

176. B: B12. Dementia is a clinical diagnosis, and distinguishing the type or cause can be difficult. Labs and imaging are ordered to identify treatable causes such as infection, vitamin deficiencies, or toxins. Dementia should also be distinguished from depressive symptoms. Diagnosis of dementia includes one of the following: aphasia, apraxia, agnosia, or executive dysfunction. Other labs that should be ordered in a workup include CBC, CMP, TSH, HIV, RPR, and folate. CT or MRI can also be helpful. Vitamin B12 deficiency can cause cognitive impairment.

Question 12

177. Which of the following vitamins should be recommended for patients with alcohol dependence?
     a. Niacin
     b. Thiamine
     c. Vitamin C
     d. Vitamin K

Answer 12

177. B: Thiamine. Also known as vitamin B1, thiamine is readily available in a regular diet. However, patients with alcohol dependence are at increased risk for deficiency due to decreased intake, impaired absorption, or increased demand. Thiamine deficiency can lead to polyneuropathy and heart failure. IV glucose can worsen thiamine deficiency, so IV thiamine should always be given first with alcoholic patients.

Question 13

178. You are doing a full body skin exam on a 45-year-old obese female patient. Across the back of her neck, you notice darkened pigmentation in the skin crease with a velvety texture. What diagnosis does this likely reflect?
     a. Diabetes mellitus
     b. Ulcerative colitis
     c. Pyoderma gangrenosum
     d. Hepatitis C

Answer 13

178. A: Diabetes mellitus. The darkened pigmentation is known as acanthosis nigricans, and it is most often associated with insulin resistance. Acanthosis nigricans can also occur in patients with thyroid disorders, Cushing syndrome, PCOS, or cancer.

Question 14

179. All of the following are true regarding iron supplementation for anemia EXCEPT:
     a. The usual dose is 325 mg of ferrous sulfate given once or twice daily.
     b. Parenteral iron supplementation is used for some patients.
     c. Diarrhea and constipation are uncommon side effects.
     d. The anemia is usually corrected within several months.

Answer 14

179. C: Diarrhea and constipation are uncommon side effects. Anemia is most commonly caused by iron deficiency as a result of blood loss. Blood loss can occur due to occult GI bleeds, menstruation, intravascular hemolysis, or vitamin C deficiency. The cause of anemia should be determined before beginning supplementation. Constipation and diarrhea are common side effects of iron therapy.

Question 15

180. How is acromegaly usually treated?

a. Vasopressin
b. Recombinant growth hormone
c. Ablation of thyroid gland
d. Surgical removal or radiation of pituitary adenoma

Answer 15

180. D: Surgical removal or radiation of pituitary adenoma. Acromegaly describes a condition of excessive growth hormone (GH), usually due to a pituitary adenoma. Patients may present with coarsened facial features, protrusion of the jaw, enlargement of the hands, and thickened body hair. Plasma GH levels will be elevated, and the tumor will be visible by CT or MRI.

Question 16

181. A 4-year-old boy is brought in by his mother who is concerned that her son seems to be short of breath all the time. Also, he has been complaining that his head hurts and that his legs hurt when he runs. His blood pressure is elevated today. On exam, you note that his extremities are cool to the touch with diminished femoral pulses. You can hear a bruit on auscultation in the interscapular area. ECG shows left ventricular hypertrophy. What is the most likely diagnosis?
     a. Coarctation of the aorta
     b. Tetralogy of Fallot
     c. Ventricular septal defect
     d. Tricuspid atresia

Answer 16

181. A: Coarctation of the aorta. This congenital condition is when part of the aorta is narrowed. Symptoms depend on severity and may be present at birth. It can lead to hypertension in the upper extremities, left ventricular hypertrophy, and poor perfusion. Chest x-ray and echocardiography can help the support the diagnosis. Treatment is with balloon angioplasty or surgical correction.

Question 17

182. Which of the following is true regarding barrier contraceptives?
     a. There is only one size of

diaphragm that can be used over the cervix.

b. Pregnancy rate is about 15% in a year of inconsistent condom use.
c. Nonoxynol-10 is a type of spermicide.
d. None of the above

Answer 17

182. B: Pregnancy rate is about 15% in a year of inconsistent condom use. With perfect use, pregnancy rate is about 2% in a year using condoms. Condoms also decrease the risk of sexually transmitted infections. Some condoms are lubricated with a spermicide known as nonoxynol-9. Diaphragms come in different sizes and can be fitted by a health care provider.

Question 18

183. A 55-year-old woman has pain in the area near her left cheek. On exam, you note swelling of the left side of the face near the jaw line and ear. The area is tender upon palpation, and you feel a firm lump with overlying erythema. She is febrile. What is the most likely diagnosis?
     a. Sialadenitis
     b. Temporal arteritis
     c. Ludwig angina
     d. Peritonsillar abscess

Answer 18

183. A: Sialadenitis. This is an infection of a salivary gland, which can occur because of an obstruction or dry mouth. It usually affects the parotid gland and is most commonly caused by Staphylococcus aureus. Imaging can confirm diagnosis or show an abscess. It is treated with antibiotics, and patients Ludwig angina would involve infection in the tissues below the mouth, and it is usually bilateral. A peritonsillar abscess would be more apparent when looking into the mouth, rather than seeing external signs.

Question 19

184. What cranial nerve does an acoustic neuroma affect?
     a. Third
     b. Sixth
     c. Eighth
     d. Eleventh

Answer 19

184. C: Eighth. This is the acoustic or vestibulocochlear cranial nerve. An acoustic neuroma is a tumor of the eighth cranial nerve that leads to hearing loss in the affected ear. The third cranial nerve is the oculomotor cranial nerve. The sixth is the abducens, and the eleventh is the accessory.

Question 20

185. You are looking at a chest x-ray which shows small upper nodules and hilar node calcification in an “eggshell” pattern. What does this likely suggest?
     a. Asbestosis
     b. Mediastinitis
     c. Goodpasture syndrome
     d. Silicosis

Answer 20

185. D: Silicosis. This is a type of pneumoconiosis due to inhalation of silica dust. Quarry workers and sand blasters are at risk. Patients may be asymptomatic at first but eventually develop shortness of breath. Asbestosis is also a type of pneumoconiosis, but chest x-ray would show fibrosis usually in the lower lobes with “honeycombing.” Goodpasture syndrome is an autoimmune condition that can cause hemoptysis and is diagnosed by the presence of anti-glomerular basement membrane (GBM) antibodies in the blood.

Question 21

186. All of the following are used in the treatment of osteoarthritis EXCEPT:
     a. Oral steroids
     b. Acetaminophen
     c. NSAIDs
     d. Celecoxib

Answer 21

186. A: Oral steroids. These are usually not used because they do not provide real benefit and may have adverse effects. Steroid injections are sometimes used to relieve pain and increase flexibility. Celecoxib is a COX-2 selective inhibitor, which is a type of NSAID.

Question 22

187. A 40-year-old man has progressive difficulty swallowing and pain behind the sternum. He says that he also tends to regurgitate some of his food in the nighttime. Barium x-ray shows absence of progressive esophageal contractions with a narrow lower segment. What is the most likely diagnosis?
     a. Hiatal hernia
     b. GERD
     c. Achalasia
     d. Mallory-Weiss syndrome

Answer 22

187. C: Achalasia. This is a type of motility disorder characterized by lack of peristalsis and incomplete relaxation of the lower esophageal sphincter. On barium x-ray, the esophagus may appear “beaklike” near the lower esophageal sphincter. The exact etiology of achalasia is unknown. Treatment consists of balloon dilation of the sphincter.

Question 23

188. A 52-year-old man arrives after a fall he sustained several days ago. He is now having severe hip pain with walking along with limited motion. On exam, you hear a click when externally rotating the hip. X-ray shows a “crescent sign.” He is diagnosed with a hip fracture, but what else is complicating his presentation?
     a. Osteoporosis
     b. Paget disease of bone
     c. Osteomyelitis
     d. Avascular necrosis

Answer 23

188. D: Avascular necrosis. This is a bone infection that can be caused by steroid use, fractures, dislocations, alcohol abuse, tumors, and other diseases. After a trauma, blood supply can become impaired and lead to avascular necrosis (AVN). The “crescent sign” is due to subchondral lucency. The bone collapses and degenerative joint changes occur.

Question 24

189. You are monitoring a patient with atrial fibrillation who has been taking warfarin. He had laboratory tests done earlier today, and his international normalized ratio (INR) was at 3.9. What do you need to do?
     a. Increase the dose
     b. Decrease the dose
     c. Keep dose the same
     d. Discontinue medication

Answer 24

189. B: Decrease the dose. Warfarin is used to prevent thromboembolic events. The medication has potential for many interactions, and the degree of anticoagulation must be monitored closely through blood tests. The international normalized ratio (INR) value for a patient on warfarin should usually be between 2 and 3. If the value is less than 2, then the patient may not be receiving the full benefit of the medication. If the value is greater than 3, then the patient is at increased risk of bleeding.

Question 25

190. Which of the following patient populations has the highest rate of death by suicide?
     a. Elderly males
     b. Adolescent males
     c. Adolescent females
     d. Pregnant women

Answer 25

190. A: Elderly men. Men 75 years and older have the highest rate of death by suicide. Male deaths by suicide outnumber female deaths, although females attempt suicide more. The rate of attempts is high among adolescent females. Firearms are used most often in completed suicides. Factors that increase suicide risk include mental illness, family history of suicide, recent discharge from the hospital, substance use, psychosocial stressors, and previous attempts.