SmartyPANCE Daily Questions (INC)

Question 1

Which term is used to describe the characteristic concave or “spoon-shaped” nails of iron deficiency anemia?

A. leukonychia
B. koilonychia
C. clubbing
D. onycholysis
E. paronychia

Answer 1

B: Koilonychia

Koilonychia is a spoon-shaping of the nail itself. It is usually a result of iron deficiency anemia. Leukonychia is often associated with hypoalbuminemia that causes partial or complete white discoloration of the nails. Leukonychia may also appear as a rare side effect of systemic chemotherapy in some oncological patients but may also be present with arsenic poisoning, renal failure, pneumonia, or heart disease. Clubbing of the nails is an actual thickening or elevation of the nail bed - it is a sign of a release of TNF associated with pulmonary disorders (tissue necrosis factor) typically found in bronchiectasis, lung cancers, and cystic fibrosis (the nails are NOT necessarily cyanotic.) Onycholysis is a painless separation of the nail from the nail bed. Several or all nails are usually affected - there are many causes. Paronychia is an infection of the nail bed and nail margin, usually from trauma or more commonly, nail-biting.

Question 2

A 52-year-old male presents complaining of urinary frequency, with hesitancy, and nocturia for the past few months. During his physical examination, you note a nontender, non-enlarged prostate with an isolated right posterior lobe nodule. Which of the following options is most appropriate?

A. Order a serum acid phosphatase level
B. Initiate prazosin and schedule a follow-up appointment in 6 weeks
C. Refer the patient for an ultrasound of the prostate and order a PSA level
D. Reassure the patient and schedule a follow-up appointment in six months
E. Initiate norfloxacin therapy for 7 days and schedule follow-up in two weeks

Answer 2

C. Refer the patient for an US of the prostate and order a PSA level.

This patient has an isolated nodule of the prostate gland — cancer until proven otherwise. You should order an ultrasound and a PSA. BPH will present as a diffuse enlargement, and not a discrete nodule.

Question 3

Which of the following is NOT a characteristic feature of the nephrotic syndrome?

A. proteinuria
B. hematuria
C. hypoalbuminemia
D. hyperlipidemia
E. generalized edema

Answer 3

B. Hematuria

Hematuria is present in NEPHRITIC syndrome. Nephrotic syndrome characteristically includes proteinuria (>3.5 gm/day), with resulting low serum albumin, hyperlipidemia, hypertension, hypercoagulability, and generalized edema (from oncotic third-spacing)

Question 4

A patient describes a history of recurrent bouts of uveitis. Her chemistry panel reveals elevated serum calcium and uric acid levels. Her anergy screen is negative. Her chest x-ray demonstrates bilateral hilar adenopathy. Which diagnosis is most likely?

A. Silicosis
B. Sarcoidosis
C. Alpha-1 antitrypsin deficiency
D. Histoplasmosis
E. Tuberculosis

Answer 4

B. Sarcoidosis

Sarcoidosis typically presents with hilar lymphadenopathy and noncaseating granulomas of the lungs (and other organs). In addition, patients may have eye involvement (uveitis). Elevations of ACE, Calcium and uric acid are frequently seen.

Question 5

A 34-year-old female presents complaining of symmetrical redness and swelling of the small joints of her hands (PIPs and MCPs). She has noted that the symptoms are worst in the morning. Her erythrocyte sedimentation rate is elevated and her rheumatoid factor is negative. Which of the following diagnosis is most likely?

A. progressive systemic sclerosis
B. CREST syndrome
C. osteoarthritis
D. rheumatoid arthritis
E. ankylosing spondylitis

Answer 5

D. Rheumatoid Arthritis

In spite of the negative RF, Rheumatoid arthritis is the most likely diagnosis. RA characteristically includes small joint symmetrical arthritis, with an elevated ESR (therefore inflammatory, and not OA). 80% of patients with RA will have a positive RF, but 20% will be negative. PSS involves squamous cell thickening and sclerosis causing taut skin of the face and hands and difficulty with esophageal motility. CREST syndrome is a subset of PSS; Ankylosing spondylitis would have an elevated ESR and negative RF, but mainly involves the SI joint and lumbar/thoracic spine fusion (bamboo spine)

Question 6

A 27-year-old nulliparous female presents because she’s been trying to get pregnant for two years, but has failed. She relates a history of a misdiagnosis of appendicitis that lead to abscess formation when she was 14 years old. Which of the following diagnostic studies would be most helpful at this point in her evaluation?

A. TSH level
B. hysterosalpingogram
C. laparoscopy
D. PAP smear
E. pelvic ultrasound

Answer 6

B. Hysterosalpingogram

While I would disagree that an invasive procedure like HSG should be done first-line, the thing to remember in this question is that the patient has reason to have tubal scarring from adhesions (and there is no better answer listed to choose), so, for a board exam I would choose this answer. The TSH level would not be indicated (she has not had a pg loss), lap could diagnose the tubal scarring but would be done after an abnormal HSG. Pap smear is screening for cervical cancer and not indicated in this case of infertility, and the pelvic US would yield nothing diagnostically about the tubes.

Question 7

A 14-year-old is experiencing a severe asthma attack. Although he is using accessory muscles to breath, auscultation of his chest reveals no audible wheezing. His heart rate is 160 and his respiratory rate is 52. Which of the following arterial blood gases represents the worst prognosis?

A. pH = 7.52; pC02 = 28; p02 = 80
B. pH = 7.44; pC02 = 38; p02 = 70
C. pH = 7.60; pC02 = 18; p02 = 60
D. pH= 7.40; pC02 = 40; p02 = 60
E. pH = 7.27; pC02 - 62; p02 = 64

Answer 7

E

This patient has a respiratory rate of 52. If he is ventilating, he is blowing off C02 (an acid) and would be alkalotic and should have a low C02. A pH that is acidic with a pC02 which is elevated means that he is no longer ventilating at all (she needs mechanical ventilation or she will die).

Question 8

A 48-year-old nurse with a body mass index of 31 presents for an evaluation of back pain. She relates that historically, she had a positive PPD test a year ago and did not follow-up as directed. She has recently been experiencing night sweats and coughing. An x-ray of her lumbar spine reveals osteopenia and cortical breakdown of vertebral bodies L4 and L5. Which of the following diagnosis is most suspect?

A. compression fractures secondary to obesity
B. degenerative joint disease
C. Potts disease
D. compression fractures secondary to osteoporosis
E. spondylolisthesis

Answer 8

C. Pott’s Disease

Pott’s disease is TB of the spine. She could have any of the other diseases, but the question states that she had a positive PPD and did not take meds…that is the clue that she has active TB in the spine.

Question 9

While suturing a wound, you opt to use lidocaine with epinephrine. The rationale for your choice is:

A. an increase in the absorption of the lidocaine.
B. an increase in the diffusion of the lidocaine into the nerve’s myelin sheath.
C. an increase in the blood flow to the area of injection.
D. an increase in the duration of anesthesia.
E. a decrease in the risk of infection at the site of injection.

Answer 9

D

Lidocaine with epinephrine both increases the duration of anesthesia and decreases blood flow to the area of injection-i.e. penis, nose, fingers, toes

Question 10

An EKG demonstrates a PR interval of 0.16 seconds, a P to QRS relationship of 1:1, a variable heart rate and an R to R interval that is noted to accelerate ad decelerate during the respiratory cycle. What is the diagnosis?

A. Wenckebach
B. third degree heart block
C. atrial fibrillation
D. sinus arrhythmia
E. atrial flutter

Answer 10

D. Sinus arrhythmia

This is sinus arrhythmia. Wenckebach & third-degree AVB would have a nonconducted P wave. A-fib would have no P waves and an irregularly irregular rhythm. A flutter would have “flutter waves” or a regular rhythm of 150.

Question 11

A 42-year-old female presents after finding a firm, painless bump in her right eyelid. On examination, you note a 6 mm mass within the tarsus of the right eye. The skin is freely movable over the mass. The remainder of the ophthalmoscopic examination is unremarkable. Which of the following is the most likely diagnosis?

A. Pterygium
B. Chalazion
C. Ectropion
D. External hordeolum
E. Internal hordeolum

Answer 11

B. Chalazion

A chalazion is a painless chronic mass in the eyelid. Hordeolum are acute and red and painful. Pterygium involves the sclera. Ectropion is when the eyelid sags outwardly and the lid doesn’t close well.

Question 12

A 22-year-old patient was involved in an automobile accident and is comatose. Which of the following diagnostic modalities would be least useful in this patient’s evaluation?

A. CT scan
B. skull radiographs
C. MRI scan
D. EEG
E. PET scan

Answer 12

B. Skull radiograph

Of these choices, the skull film is LEAST useful. Whether or not the skull is fractured, any LOC in a head trauma requires imaging for bleeding. CT would be the imaging test of choice. MRI should be done for a more chronic bleed. EEG would help to establish brain activity. PET scan (while not done often) would establish physiologic function (uptake of glucose). A positive or negative plain film of the skull would supply NO FURTHER INFORMATION.

Question 13

Which white blood cell disorder is characterized by the presence of the Philadelphia chromosome in 90% of cases?

A. chronic lymphocytic leukemia (CLL)
B. acute lymphocytic leukemia (ALL)
C. chronic myelogenous leukemia (CML)
D. acute myelogenous leukemia (AML)
E. multiple myeloma

Answer 13

C. CML

Philadelphia Chromosome occurs in CML. ALL occurs in children. AML is associated with Auer rods. Multiple myeloma has Bence-Jones protein. CLL has no clear distinguishing feature except increased lymphocytes.

Question 14

Which of the following thyroid profiles is most compatible with a diagnosis of primary hypothyroidism?

A. a low TSH (thyroid stimulating hormone) level and a high T4
B. a low TSH level and a normal T4
C. a low TSH level and a low T4
D. a high TSH level and a low T4
E. a high TSH and a high T4

Answer 14

D. High TSH low T4

Low T4 is diagnostic for low thyroid function. If the pituitary is normal (as in primary thyroid disease) the TSH should be high as the pituitary tries to stimulate the failing thyroid gland.

Question 15

All of the following are factors that predispose a patient to the development of gastroesophageal reflux EXCEPT:

A. hiatal hernia
B. pregnancy
C. scleroderma
D. an incompetent esophageal sphincter
E. pernicious anemia

Answer 15

E. Pernicious Anemia

Pernicious anemia has no correlation with GERD. It is an autoimmune destruction of the gastric parietal cells that make intrinsic factor. Signs and symptoms are not present until B12 levels are very low (and include peripheral neuropathies & ataxia)

Question 16

A patient with nonsevere chronic hypertension warrants antihypertensive medication use for the duration of her pregnancy. Which of the following is the first-line antihypertensive recommended for such patients?

A. Alpha-methyldopa
B. Captopril
C. Chlorthalidone
D. Propranolol
E. Clonidine

Answer 16

A. Alpha-methyldopa

Alpha-methyldopa

For the initial treatment of high blood pressure in pregnancy, these are the most commonly used and recommended medications:

Labetalol (Normodyne, Trandate)
Nifedipine (Procardia, Adalat)
Methyldopa (Aldomet)

Methyldopa has been used for decades to treat high blood pressure in pregnancy and it appears to be safe. Labetalol has been extensively studied and has become increasingly prescribed in pregnancy. Labetalol is now commonly used as a first-line treatment choice. Nifedipine is also sometimes used in certain situations.

ACEIs (captopril) are contraindicated in pregnancy. Propranolol can be used but may cause growth restriction. Diuretics are not used in pregnancy. Calcium channel blockers and centrally acting agents (while not contraindicated) should be avoided.

Question 17

A 6-year-old child falls onto his right arm. An x-ray demonstrates a buckle in the cortices of the distal radius, proximal to the growth plate, without angulation. What is the term used to describe this fracture?

A. Salter-Harris Type III
B. Salter Harris Type IV
C. Salter Harris Type V
D. torus
E. greenstick

Answer 17

D. Torus fracture

Torus fracture

Torus or buckle fracture is most common in a child. This is proximal to the epiphyseal plate and so is not a Salter-Harris issue. Greenstick fracture is also common in children in long bones and is a fracture which “bends” the bone without fracturing it.

Question 18

A 55-year-old male presents complaining of “difficulty wrtiing” using his dominant hand and some “slurred” speech. He has a h/o hypertension, DM type II, and hypertriglyceridemia. Which of the following would you anticipate to find on a CT scan of his head, as the explanation for his chief complaint?

A. hemorrhage in the distribution of his posterior cerebral artery
B. hemorrhage in the distribution of the middle cerebral artery
C. hypodensity measuring 12 mm by 21 mm in the distribution of the posterior cerebral artery
D. hypodensity measuring 4 mm by 4 mm in the internal capsule
E. calcifications bilaterally, in the third ventricles

Answer 18

D. hypodensity measuring 4mm by 4mm in internal capsule

Hypodensity measuring 4 mm by 4 mm in the internal capsule

The main clue to this question is that most strokes are ischemic - especially with this patient’s history (ruling out hemorrhagic infarct - A & B). Calcifications (E) are not indicative of stroke at all. When trying to decide between C & D - the size of the area needs to correlate with the patient’s symptoms. If the patient had a HUGE infarct (12 x 21) he would have significantly more signs and symptoms than just some slurred speech and difficulty writing. (In addition, as it turns out, the internal capsule is supplied by the MCA - which is the most common vessel involved in an ischemic stroke)

Question 19

A female in her third trimester of pregnancy developed hypertension, diffuse edema, proteinuria and hyperreflexia. She was treated with intravenous magnesium sulfate and is now hyporeflexic and drowsy. What do you prescribe now?

A. calcium
B. diazepam
C. an amphetamine
D. additional magnesium
E. oxygen

Answer 19

A. Calcium

Calcium

Pre-eclampsia causes hyperreflexia. Magnesium is the treatment. The sign of magnesium toxicity is a loss of reflexes… this is treated with calcium

Question 20

This papulosquamous eruption is most common in young adults. A single oval patch is generally noted several days before a more generalized, fawn-colored rash erupts. This rash is most prevalent on the trunk, and the proximal upper and lower extremities. The rash spontaneously disappears over five to six weeks. The diagnosis is:

A. pityriasis rosea
B. tinea corporis
C. psoriasis
D. atopic dermatitis
E. sporotrichosis

Answer 20

A. pityriasis rosea

Pityriasis rosea

This is the classic presentation of pityriasis rosea. Remember that the differential diagnosis includes secondary syphilis, so if there is a positive sexual history - consider ordering a VDRL/RPR. The “herald” patch which is described is pathognomonic for pityriasis.

Question 21

A patient presents complaining of generalized swelling. Her urine is positive for protein. Her serum testing reveals hyperlipidemia and hypoalbuminemia. Which of the following is the most likely diagnosis?

A. cirrhosis
B. nephrotic syndrome
C. congestive heart failure
D. cystitits
E. pyelonephritis

Answer 21

B. Nephrotic syndrome

Nephrotic syndrome

This is a classic presentation of nephrotic syndrome.

Question 22

A patient is experiencing an acute exacerbation of asthma. Which of the following drugs would be the least useful in the management of this asthma attack?

A. albuterol
B. cromolyn sodium
C. prednisone
D. theophyline
E. epinephrine

Answer 22

B. Cromolyn sodium

Cromolyn is a mast cell stabilizer and must be present in the system PRIOR to the symptoms. It would be useless in a patient already having symptoms.

Question 23

A 34-year-old female patient presents to the ER with sharp pleuritic-type chest pain. An x-ray shows an enlarged cardiac silhouette suggestive of pericarditis. On more careful questioning, the patient admits to a polyarticular arthritis involving the small joints of her hands. Her obstetrical history is positive for two third trimester stillbirths. At this point, you would suspect which autoimmune process as the cause of her symptoms:

A. Rheumatoid arthritis
B. Systemic Lupus Erythematosis
C. Wegener’s granulomatosis
D. Sjogren’s Syndrome
E. Scleroderma

Answer 23

B. SLE

Systemic Lupus Erythematosus

40-60% of patients with SLE have serositis (pleuritis and pericarditis). That, combined with joint pains, habitual AB - should cause you to order an ANA.

Question 24

A patient with AIDS develops severe headaches. A CT scan demonstrates multiple ring-enhancing lesions of the brain. What diagnosis is most likely?

A. Toxoplasmosis
B. Histoplasmosis
C. lymphoma
D. Cytomegalovirus
E. Herpes encephalitis

Answer 24

A. Toxoplasmosis

Toxoplasmosis

Toxoplasmosis occurs commonly in HIV and is a parasitic infection causing ring-enhancing lesions (but lots of things can cause ring-enhancing lesions). CMV is common as well and typically causes retinitis. Herpes encephalitis can happen frequently too but causes a diffuse encephalitis.

Question 25

A Caucasian male has a history of a meconium ileus as a newborn, steatorrhea and a positive sweat test. What is the most likely diagnosis?

A. Von Gierke’s disease
B. Hurler’s syndrome
C. Cystic fibrosis
D. Hunter’s syndrome
E. Cri du chat syndrome

Answer 25

C. Cystic fibrosis

Cystic fibrosis

This is the classic presentation of Cystic fibrosis

Question 26

A 32-year-old male presents with dyspnea and a nonproductive cough. He is tachycardic, tachypneic, and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia and his LDH is elevated. What is the most likely diagnosis?

A. Streptococcal pneumoniae pneumonia
B. Mycoplasma pneumoniae pneumonia
C. Pneumocystis carinii pneumonia
D. Bowen’s disease
E. Steven-Johnson syndrome

Answer 26

C. PCP

Pneumocystis carinii pneumonia

Formerly PCP Pneumonia now called (PJP) Pneumocystis jiroveci. Many AIDS patients present initially with PJP. These are the classic signs and symptoms of PJP pneumonia. While mycoplasma patients can be acutely ill, they are more likely (especially on the Boards) to present as mildly ill with a normal physical exam and no hypoxia. S. pneumonia is the most common community-acquired pneumonia but would present with a focal/lobar consolidation.

Question 27

A patient describes a history of a “curtain being brought down over my right eye it stayed there for a few minutes then was lifted back up.” In which of the following arteries is the etiology of this complaint located?

A. anterior cerebral
B. middle cerebral
C. posterior cerebral
D. internal carotid
E. external carotid

Answer 27

D. Internal carotid

Internal Carotid

This is amaurosis fugax….a form of “TIA” of the optic artery — it arises from the internal carotid - most common location for occlusion in TIA.

Question 28

Upon review of an EKG you notice periodic, repetitively absent QRS complexes and “grouped beating.” Which of the following is the explanation?

A. Third degree heart block
B. Mobitz Type II heart block
C. Mobitz Type I heart block
D. first degree heart block
E. sinus tachycardia

Answer 28

C. Mobitz Type 1

Honestly sounds weird

Mobitz Type I heart block

I don’t like the wording of this question, but typically “group beating” suggests Wenckebach. The fact that there are absent QRS complexes means there is a second or third-degree AVB. In Mobitz II, the PR intervals are the same - so no “grouped” beating, in Third degree, there is no rhyme or reason to the rhythm. In Wenckebach, the rhythm “repeats”, causing a “regularly irregular” rhythm.

Question 29

A 14-month-old female is brought to your office with a 3-day history of a fever of 104 degrees rectally. Suddenly, today, the fever stopped and a rash developed. Examination reveals a diffuse, fine, maculopapular rash. Presently, the child does not appear ill. The most likely diagnosis is:

A. Rubella
B. Rubeola
C. erythema infectiosum (Fifth’s disease)
D. Roseola
E. Chicken pox

Answer 29

D. Roseola

Roseola

This is typical for Roseola. Rubella has a mild illness with a fine macular rash. Rubeola (measles) is an acute illness, the child is toxic, has conjunctivitis and Koplik spots. Fifth’s disease has mild illness with a “lacy” rash on the extremities. Chickenpox has vesicles.

Question 30

At what age does the first tooth usually erupt in an infant?

A. 2-4 months
B. 6-8 months
C. 10-12 months
D. 14-16 months

Answer 30

B. 6-8 months

6-8 months

The first tooth in an infant to erupt is the central incisor at the average age of 6-8 months.