Subcommittee Members Alan Gindoff, DHSc, MPAS, PA-C Ryan J unsay, MSPA, PA-C Susan King-Barry, BSN, BSM, MPAS, PA-C Marc Maller, MD
DEDICATION
This examination would not have been possible without the years of commitment of the MR. TIB Development Committee. Numerous PA educators from across the nation provided their experience and insight as questions for MR. TIB. It has been this data bank that served as the building blocks for PACKRAT.
PAEA is proud to be able to continue in the tradition of quality fostered by the forerunners of the self- assessment examination for physical assistants. It is our honor to dedicate PACKRAT to:
J esse C. Edwards, MS Claire S. Parker, PhD University of Nebraska, Physician Assistant Program
Copyright 2009. Physician Assistant Education Association 2
PHYSICIAN ASSISTANT EDUCATION ASSOCIATION
Physician Assistant Clinical Knowledge Rating and Assessment Tool (PACKRAT)
Form 14
Directions and Explanations
TABLE OF CONTENTS
I. Introduction 1
II. Explanation of the Score Report 2
Page 1: Scores Your total Score and Group Comparisons 2 Page 2: Your STRENGTHS, Weaknesses, and Quality of Responses 2 Page 3: Your Individual and Correct Responses 2 Page 4: Your Responses by Task and Category 2 Page 5-6: Your Profile Comparison: Demographic Profile 2
III. Recommendations for Using the Feedback Package 3
IV. Study Resources 5
V. Answer Key 7
VI. Examination Explanations 8
VII. Comment Form 82
Copyright 2009. Physician Assistant Education Association. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy or recording, or any information and retrieval system, without permission in writing from the Physician Assistant Education Association.
Copyright 2009. Physician Assistant Education Association 3
PHYSICIAN ASSISTANT CLINICAL KNOWLEDGE RATING AND ASSESSMENT TOOL (PACKRAT)
I. Introduction
The Physician Assistant Clinical Knowledge Rating and Assessment Tool (PACKRAT) was developed by a volunteer committee of experts and is based on the content outline of a nationally recognized competency examination. The following is a description of the content of PACKRAT:
Additionally, questions also apply to the following clinical specialties:
A. Cardiology I. Neurology B. Dermatology J . Obstetrics/Gynecology C. Endocrinology K. Orthopedics/Rheumatology D. ENT L. Pediatrics E. Ophthalmology M. Psychiatry/Behavioral Medicine F. Gastrointestinal/Nutritional N. Pulmonology G. Geriatrics O. Surgery H. Hematology P. Urology/Renal
The task and specialty categories for each item are listed in the answer key on page 5; your feedback package contains a breakdown of responses by the task and clinical specialty category. Pay particular attention to the questions you answered incorrectly and determine the specialty for that question and use this information to identify weaknesses.
The PACKRAT provides a detailed feedback report of performance and it is available to anyone at any time. Explanations were developed for all the questions to provide a rationale for correct, as well as incorrect, answers. This information will help determine strengths and weaknesses with respect to the PACKRAT content outline. If you have weaknesses in specific areas, you may need to obtain additional clinical experience in those areas.
Additionally, questions also apply to the following clinical specialties:
A. Cardiology J . Obstetrics/Gynecology B. Dermatology K. Orthopedics/Rheumatology C. Endocrinology M. Psychiatry/Behavioral Medicine F. Gastrointestinal/Nutritional N. Pulmonology H. Hematology P. Urology/Renal I. Neurology Q. Infectious Diseases
Copyright 2009. Physician Assistant Education Association 4
This booklet is designed to explain and interpret the information contained in the accompanying computerized score report. You can use the report package to learn more about your abilities.
II. Explanation of the Score Report
This section provides an interpretation of each page of the computerized score report you received. You should have your computer score report in front of you. Begin on page 1 of the report and read the following information.
Page 1: Scores Your Total Score and Group Comparisons
Page 1 is an overview of the PACKRAT feedback report. Toward the bottom of the page is your examination score. This score shows the number of questions you answered correctly out of a possible 225. The average score for all first-year and second-year candidates who have taken the PACKRAT to date is also given.
Page 2: Your Strengths, Weaknesses, and Quality of Responses
Page 2 of the score report gives an overview of the content area in which your performance is categorized as Strong, Satisfactory, or Needing Improvement. These areas are based on the examination matrix on page 1.
In each content area, your answers have been classified as correct, acceptable, unsatisfactory, or harmful. A definition of these classifications is also provided on this page. Pay particular attention to the areas under Needing Improvement, as these areas should be noted for further study. Also check the answer key for the specialty area of these items. If you selected a harmful answer in any content area, it will be automatically placed in the Needing Improvement category, regardless of the number of correct answers selected. Carefully review these questions and their explanations and specialty classifications in Section VI to help you understand why your answers were correct.
Page 3: Your Individual and Correct Responses
Page 3 lists your answers to all questions. When your answer differs from the correct one, the proper response appears in parentheses. Use Section VI with this page to review the rationale for each option that is provided in the explanations, which are referenced to the study resources. The explanations may help you understand why one answer is more appropriate than another, or not the best answer, and why some of your answers may have been incorrect. If the option you chose was judged potentially harmful to the patient or others, an asterisk (*) appears before your answer. Options classified as potentially harmful may identify serious weaknesses. Go over these questions carefully and read the explanations for the correct answers. You may be able to identify areas where you need further study.
Page 4: Your Responses by Task and Specialty Category
Page 4 lists your responses by both specialty and task category. You will be able to identify the areas of the content outline where you may have difficulty. The numbers reflect how many items you answered correctly out of the total possible correct within each task and specialty area. Categories 1 through 7 identify the task areas and A-P the clinical specialty areas. If you missed a significant number of items in an area, check the key and go over the explanations for the items in these areas.
Page 5-6: Your Profile Comparison: Demographic Profile
Page 5 is the beginning of the Demographic Profile Comparison for programs. This profile shows the reported demographic information and compares your students information to the entire group of individuals who have taken the PACKRAT to date. The demographic data are based on the information your students provided when answering the demographics questions. The summary demographic information shown reflects all the data compiled for either first or second-year students who taken the PACKRAT.
RESPONDENT DEMOGRAPHIC INFORMATION Copyright 2009. Physician Assistant Education Association 5
C. Number of months of clinical rotations completed at the time of this exam?
Your response: All Second-year Respondents:
( ) 1. None ( 0% ) ( ) 2. Less than 3 months ( 5% ) ( ) 3. 3 to 6 months ( 15%) ( ) 4. 7 to 9 months ( 20%) ( ) 5. 10 to 12 months (45%) ( ) 6. Greater than 12 months (15%)
Programs can utilize this information in order to compare the characteristics of their first year students and second year students to the national demographics of first year and second year students who have taken the PACKRAT test.
III. Recommendations for using The Feedback Package
As a current physician assistant student, PACKRAT can be a useful self-evaluation tool. Through careful review of question explanations, noting specific tasks and content areas, you will be able to assess your current strengths and weaknesses. You will be able to identify particular areas in which to concentrate more effort as you continue your studies. By concentrating your effort on the areas in which you did not do well, you may improve your performance, and you may have a better chance of passing the proctored examination. However, PAEA cannot guarantee that this will occur, since the conditions under which you attempted the PACKRAT may have been different from those in a standardized administration of a proctored examination. Use the explanations in Section VI to analyze why you chose various options. Again, pay particular attention to the options that were judged potentially harmful or unsatisfactory. Look at the question and the four options again to see why the answer you chose was incorrect. If there appears to be a deficit in your exposure to a particular clinical specialty, perhaps further study would make you more familiar with these situations. Once you have completely reviewed your score report and this booklet, PAEA hopes you will use this information to improve your overall performance, either on the job or on future certification examinations. Should you wish to provide suggestions about PACKRAT to PAEA, you will find a comment form on the last page of this booklet.
IV. Study Resources
A variety of textbooks are currently available to assist candidates in preparing for the certification examination. For additional information, you may contact a faculty member at an educational program or an experienced colleague if you need help determining which references to review in a specific content area. A short list of general textbooks is below. All examination questions are related to material found in these resources.
Please note that the books on this list are not available from PAEA. This is not intended as an all-inclusive list, and the materials listed below are suggested study materials only.
1. Andreoli TE, et al (eds). Cecils Essentials of Medicine. 7th ed. Philadelphia, PA: WB Saunders, an Elsevier company, 2007. 2. Ballweg R et al. Physician Assistant: A Guide to Clinical Practice. 4 th ed., WB Saunders, an Elsevier company, 2008. 3. Bickley, LS. Bates Guide to Physical Examination and History Taking. 9th ed. Philadelphia, PA: J B Lippincott Co., 2007. 4. Beckmann CR, et al. Obstetrics & Gynecology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006. 5. Behrman RE, et al. Nelsons Textbook of Pediatrics. 18th ed. Philadelphia, PA: WB Saunders, an Elsevier company, 2007. 6. Berkowitz, C. Pediatrics: A Primary Care Approach, 3 rd ed. Philadelphia, PA: WB Saunders, an Elsevier company 2008. 7. Fauci AS, et al (eds). Harrisons Principles of Internal Medicine. 17th ed. New York, NY: McGraw- Hill, Inc., 2008. 8. DeCherney AH & Pernoll ML (eds.) Current Obstetric & Gynecological Diagnosis & Treatment, 10 th ed., Norwalk, CT: Appleton & Lange, 2006 Copyright 2009. Physician Assistant Education Association 6 9. Ellsworth AJ , et al. (eds). Mosbys Medical Drug Reference. Philadelphia, PA: Mosby, 2007. 10. Wolf K, J ohnson RA, and Surmond D. Fitzpatricks Color Atlas and Synopsis of Clinical Dermatology. 5th ed. New York, NY: McGraw-Hill, Inc., 2005. 11. Goldman J and Bennet J C. Cecil Textbook of Medicine. 23 rd ed. Philadelphia, PA: WB Saunders. 2008. 12. Goroll, AH, Mulley, AG, & May, LA. Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 6 th ed., Lippincott Williams &Wilkins, 2009 (To be released). 13. Hay WW, et al. Current Pediatric Diagnosis and Treatment. 19 th
ed. Norwalk, CT: McGraw Hill, 2008. 14. Kaplan HI and Sadock BJ (eds). Synopsis of Psychiatry. 10 th ed., Philadelphia, PA: Williams & Wilkins, 2007. 15. Katzung BG. Basic and Clinical Pharmacology. 10th ed. Stamford, CT: Appleton & Lange, 2006. 16. Mandel GL, Bennett J E, and Dolin R. Principles and Practice of Infectious Disease. 6th ed., Philadelphia, PA: Churchill Livingston, an Elsevier company, 2005. ISBN#0443066434 17. Marx, J ., Hockberger, RS, and Walls, RM. Rosens Emergency Medicine: Concepts and Clinical Practice. 6 th ed., Philadelphia, PA: Mosby, 2005. 18. McPhee SJ , et al. Pathophysiology of Disease. 5 th
ed., McGraw Hill, 2005. 19. Mercier LR, et al. Practical Orthopedics. 6th ed. Philadelphia, PA: Mosby, an Elsevier company, 2008. ISBN#9780323036184 20. Mettler FA, et al. Primary Care Radiology. Philadelphia, PA: WB Saunders, Co., 2000. (In PAEA library 2/07) 21. Howland RD nad Mycek MJ . Lippincotts Illustrated Reviews: Pharmacology. 4 th ed. Baltimore, MD: Williams & Wilkins, 2008. 22. Noble J , et al. Textbook of Primary Care Medicine. 3rd ed. Philadephia PA: Mosby, 2001. (In PAEA library 2/07) 23. Riordan-Eva, P. and Whitcher, J P. Vaughn & Asburys General Ophthalmology. 17 th ed., McGraw Hill, 2007. 24. Sacher RA and McPherson RA. Widmann's Clinical Interpretation of Laboratory Tests. 11th ed. FA Davis Co., 2000. (In PAEA library 2/07) 25. Schwartz SI, et al. Principles of Surgery. 8th ed. New York, NY: McGraw-Hill, Inc., 2004. 26. Skinner HB (ed.) Current Diagnosis & Treatment in Orthopedics. 4 th ed., Norwalk,CT:Appleton & Lange, 2008. 27. Steinberg GG. Orthopedics in Primary Care. 3 rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 3 rd ed, 1999. 28. Tierney LM, et al. Current Medical Diagnosis and Treatment. 48 th
ed. Stamford, CT: Appleton & Lange, 2009. 29. Tintinalli J E, Kelen GD, and Stapezynski J S. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill, Inc., 2004. 30. Townsend CM. Sabistons Textbook of Surgery. The Biological Basis of Modern Surgical Practice. 18 ed. Philadelphia, PA: WB Saunders, an Elsevier company, 2008. 31. Doherty GM. Current Surgical Diagnosis and Treatment. 12 th
ed., McGraw Hill, 2005. 32. Wilson WR. Current Diagnosis and Treatment in Infectious Disease. Norwalk, CT: Appleton & Lange, 2001.
Copyright 2009. Physician Assistant Education Association 7
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8 PHYSICIAN ASSISTANT EDUCATION ASSOCIATION
Physician Assistant Clinical Knowledge Rating and Assessment Tool
(PACKRAT) Form 14
EXPLANATIONS
1. History & Physical/Cardiology When performing a pre-participation sports physical in the adolescent population, a murmur with which of the following qualities indicates a risk for sudden death during exercise? A. Increases with the Valsalva maneuver B. Increases with squatting maneuver C. Associated with a mid-systolic click D. Mid-systolic without radiation to the carotids Explanations (c) A. Hypertrophic cardiomyopathy (HCM) is a known cause of sudden death during or just after physical exertion and competitive sports. The murmur associated with HCM is worsened by conditions that cause reduced ventricular volume such as the Valsalva maneuver, sudden standing, and tachycardia. (u) B. Typical systolic flow murmurs will become accentuated with maneuvers which increase venous blood flow to the heart and these murmurs do not place athletes at risk for sudden cardiac death. (u) C. Mitral valve prolapse is the most common type of heart murmur that is associated with a mid-systolic click. Mitral valve prolapse does not place the patient at risk for sudden cardiac death. (u) D. A mid-systolic heart murmur that fails to radiate into the carotids is most commonly associated with a benign systolic flow murmur and does not place the athlete at risk for sudden cardiac death. Ref: (7)
2. Scientific Concepts/Obstetrics/Gynecology At the time of ovulation in a normal menstrual cycle, there is a peak in the serum concentration of which of the following? A. Luteinizing hormone B. Prostaglandin C. Progesterone D. Prolactin Explanations (c) A. Luteinizing hormone is responsible for ovulation and, therefore, peaks at that time. (u) B. Prostaglandin is likely associated with the production of vasospasm, vascular necrosis, and menstrual flow, not ovulation. (u) C. The majority of progesterone is secreted by the corpus luteum and, therefore, peaks after ovulation has occurred. (u) D. Prolactin is an anterior pituitary hormone, and although important in reproduction and pregnancy, it is not present in high levels at the time of ovulation. Ref: (8)
9 3. Diagnostic Studies/Hematology A positive direct Coombs' test may be seen in which of the following conditions? A. G6PD deficiency B. Sickle cell anemia C. Hereditary spherocytosis D. Autoimmune hemolytic anemia Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. A positive direct Coombs' test indicates that antibody has attached to an antigen on the RBC which causes agglutination. Autoimmune hemolytic anemia results when the patient has antibodies against their own RBCs. G6PD deficiency does result from an antibody antigen reaction. Sickle cell anemia is caused by a defective hemoglobin which detected by hemoglobin electrophoresis. Hereditary spherocytosis is detected utilizing the osmotic fragility test. Ref: (28)
4. Health Maintenance/Urology/Renal In order to prevent the progression of diabetic nephropathy which of the following medications should be instituted? A. Lisinopril (Prinipril) B. Propanolol (Inderal) C. Verapamil (Calan) D. Hydrochlorothiazide (Diuril) Explanations (c) A. All patients should be started on an ACE inhibitor to prevent the progression of proteinuria. ACE inhibitors appear to improve glomerular hemodynamics by decreasing glomerular pressure. (u) B. Beta blockers are not indicated for the treatment of microalbuminuria. (u) C. Calcium channel blockers are not indicated for the treatment of microalubuminuria. (u) D. Thiazide diuretics are not indicated for the treatment of microalbuminuria. Ref: (28)
5. Diagnosis/Pulmonology A 5 year-old male presents with a history of recurrent episodes of acute bronchitis, characterized by fever and productive cough. He has no known significant past medical history. His pulmonary examination reveals crackles in the bilateral lower lobes. The remainder of his physical examination is normal. Chest x-ray demonstrates platelike atelectasis and dilated, thickened airways in the middle and lower lungs. Which of the following is the most likely diagnosis? A. Acute bronchitis B. Bronchiectasis C. Pneumonia D. Tuberculosis Explanations (u) A. Barring underlying pulmonary pathology, the chest x-ray in acute bronchitis should be normal. (c) B. Bronchiectasis typically presents as recurrent episodes of acute bronchitis. Platelike atelectasis and dilated and thickened airways, sometimes described as tram lines, are common radiographic findings. (u) C. While the history may suggest pneumonia, the radiographic findings do not support this diagnosis. (u) D. Tuberculosis would present with cavitating granuloma formation more commonly at the apices. Ref: (5)
10 6. History & Physical/Orthopedics/Rheumatology Which of the following clinical characteristics is associated with bicipital tendonitis? A. Aggravated by resisted supination of the forearm B. Bulging appearance to the proximal arm C. Weakness of the arm with internal rotation and adduction D. Pain that awakens the patient at night Explanations (c) A. Supraspinatus tendonitis will be aggravated by resisted supination of the forearm. (u) B. Biceps rupture may present with a bulging appearance of the proximal arm. (u) C. Weakness of the arm with internal rotation and adduction is characteristic of pectoralis major rupture or tear. (u) D. Night pain is characteristic of rotator cuff tear or tendonitis. Ref: (26)
7. Clinical Therapeutics/Cardiology Which of the following antiarrhythmic drugs can be associated with hyper- or hypothyroidism following long-term use? A. Quinidine B. Amiodarone C. Digoxin D. Verapamil Explanations (u) A. See B for explanation. (c) B. Amiodarone is structurally related to thyroxine and contains iodine, which can induce a hyper- or hypothyroid state. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (7)
8. Diagnostic Studies/Neurology An 18 year-old male is involved in a motor vehicle accident with a question of cervical spine fracture. What is the imaging test of choice to initially evaluate this patient and clear his cervical c-spine? A. Positron emission tomography B. Magnetic resonance imaging C. Computed tomography D. Lateral radiograph Explanations (u) A. There is no role for positron emission tomography in suspected cervical spine injury. (u) B. MRI and CT of the spine may be performed in the setting of acute cervical spine injury when a major fracture or dislocation is identified. (u) C. See B for explanation. (c) D. Cervical spine x-rays are most commonly used as the initial screen for cervical spine injury. A cervical spine series consists of a lateral view, anteroposterior (AP) view, and an odontoid view. The lateral view detects up to 80% of traumatic spine injuries. Ref: (29)
11 9. Clinical Intervention/ENT/Ophthalmology A 4 year-old boy presents with pain and irritation of his left ear. Otoscopic examination reveals an insect in the left auditory canal. The tympanic membrane is not completely visualized. Which of the following is the most appropriate management of this patient? A. Debrox insertion with suction removal B. Irrigation with room temperature saline C. Insertion of 2% lidocaine solution with suction or forceps removal D. Polymyxin drop insertion via wick Explanations (u) A. Debrox is used for cerumen impaction not foreign body removal. (u) B. Irrigation with room temperature saline is useful for small particle removal only if the tympanic membrane is well-visualized and without perforation. It is not indicated in the removal of an insect. (c) C. Two percent lidocaine solution will paralyze the insect and provide topical anesthesia for suction or forceps removal. (u) D. Polymyxin B is indicated in otitis externa and administered via a wick when there is significant edema of the auditory canal. It is not indicated in the removal of a foreign body. Ref: (29)
10. Diagnosis/Gastrointestinal/Nutritional A 62 year-old male is brought to the emergency department with acute hematemesis. The patient denies a previous history of vomiting. His wife states he has chronic liver disease. Physical examination reveals a distended abdomen without rebound, guarding or organomegaly. There is a fluid wave. Which of the following is the most likely diagnosis? A. Esophageal varices B. Mallory-Weiss tear C. Arteriovenous malformation D. Perforated duodenal ulcer Explanations (c) A. Esophageal varices are dilated submucosal veins that develop in a patient with underlying portal hypertension. The most common cause of portal hypertension is cirrhosis. (u) B. A patient with a Mallory-Weiss tear would have a history of retching but would not have a distended abdomen. (u) C. Most arteriovenous malformations are asymptomatic. If symptomatic they would have symptoms of a slow bleed. (u) D. A patient with perforated duodenal ulcer would have rebound and guarding on examination. Ref: (1)
11. Scientific Concepts/Dermatology Which of the following is characterized by epidermal hyperplasia and an increase in the epidermal turnover? A. Atopic dermatitis B. Tinea corporis C. Ecthyma D. Psoriasis Explanations (u) A. Inflammation in atopic dermatitis results in lichenification of the skin from itching, which leaves the skin dry and scaly when it resolves. The inflammation is the result of elevated T-lymphocyte activation, defective cell- mediated immunity, and IgE overproduction. Epidermal hyperplasia is not involved in atopic dermatitis. (u) B. Tinea corporis is a fungal infection and does not have epidermal hyperplasia. (u) C. Ecythma is the result of an infection from group A beta-hemolytic streptococcus and contaminated with staphylococci. Like atopic dermatitis and tinea corporis, ecthyma has no epidermal hyperplasia. (c) D. Psoriasis is characterized by an increased epidermal cell turnover, increased numbers of epidermal stem cells, and an abnormal differentiation of keratin. This leads to the classic scale associated with psoriasis. Ref: (10) 12 12. History & Physical/Pulmonology On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause? A. Asthma B. Pneumonia C. Pneumothorax D. Pleural effusion Explanations (u) A. Asthma is characterized by decreased tactile fremitus, but would have resonant to hyperresonant percussion, not dullness. (u) B. Lobar pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus. (u) C. A pneumothorax is characterized by decreased to absent tactile fremitus, but would have a hyperresonant percussion note, not dullness. (c) D. Decreased tactile fremitus and dullness to percussion would be found in a pleural effusion. Ref: (1)
13. Clinical Therapeutics/Psychiatry/Behavioral Medicine Which of the following is the treatment of choice for benzodiazepine intoxication? A. Flumazenil (Romazicon) B. Naloxone (Narcan) C. Chlordiazepoxide (Librium) D. Clonidine (Catapres) Explanations (c) A. Flumazenil is the treatment of choice for benzodiazepine intoxication. (u) B. Naloxone is used for the treatment of opioid intoxication and withdrawal. (u) C. Chlordiazepoxide is used for alcohol detoxification. (u) D. Clonidine is an alpha blocker that is often used for withdrawal from opioids, alcohol, benzodiazepines, or nicotine. Ref: (14)
14. Diagnosis/Cardiology A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg to be cool to the touch and the toes to be cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities have 2+/4+pulses throughout. Given these findings what is the most likely diagnosis? A. Venous thrombosis B. Arterial thrombosis C. Thromboangiitis obliterans D. Thrombophlebitis Explanations (u) A. See B for explanation. (c) B. Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (28)
13 15. Clinical Intervention/Obstetrics/Gynecology An 18 year-old G1P0 female presents for her 35 week prenatal visit with complaints of headache, blurred vision and right upper quadrant discomfort. Vital signs show BP of 170/100 mmHg and brisk patellar reflexes. Urinalysis shows 3+proteinuria. Fetal heart tones are 150. What is your next step in the care of this patient? A. Admit to hospital and prepare for delivery B. Admit to hospital with antepartum fetal surveillance and close monitoring of maternal conditions C. Order bed rest at home with daily fetal movement counts and twice weekly antepartum care D. Order bed rest at home with administration of prophylactic magnesium sulfate Explanations (c) A. Severe preeclampsia mandates hospitalization. Delivery is indicated if gestational age is 34 weeks or greater. (u) B. Antepartum fetal surveillance and close monitoring in hospital is appropriate for pregnant female with unfavorable cervix and mild preeclampsia. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (8)
16. Health Maintenance/Orthopedics/Rheumatology Which of the following risk factors is the most predictive for the development of osteoarthritis? A. Age B. Major joint trauma C. Prior inflammatory joint disease D. Repetitive stress Explanations (c) A. Age is the most significant risk factor for osteoarthritis. Prevalence and severity increase with age. Ninety percent of people greater than the age of 40 have degenerative changes of the weight bearing joints. Major joint trauma, prior inflammatory joint disease, and repetitive stress are additional risk factors but not as predictive as age. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (28)
17. Diagnostic Studies/Urology/Renal A 48 year-old female presents to the clinic complaining of hematuria. The patient states that she was found to have hematuria during an insurance physical examination. The patient denies dysuria or frequency. She also denies pain in the abdomen, flank or meatus. She denies any history of previous nephrolithiasis. Urinalysis reveals the urine to be yellow and slightly hazy with a positive dipstick for hemoglobin. Microscopic reveals 5-7 RBCs/HPF without WBCs, bacteria, casts, or crystals. What is the next diagnostic study this patient should undergo? A. CT urography B. Intravenous pyelogram C. Abdominal ultrasound D. Cystoscopy Explanations (c) A. CT urography with and without contrast should be done to evaluate the upper and lower urinary tract for neoplasms, and benign conditions such as urolithiasis. This has replaced IVP for imaging of the upper tracts. Abdominal ultrasound will not help in this scenario and the role of renal ultrasound in evaluation of hematuria is unclear. Cystoscopy will help to assess the bladder and urethra but will not help with evaluation of the upper urinary tract. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (28) 14 18. Scientific Concepts/Infectious Diseases The pathologic process responsible for the renal damage in post-streptococcal glomerulonephritis is which of the following? A. Immunologic B. Vascular C. Hormonal D. Genetic Explanations (c) A. The antigen-antibody complex that occurs as a result of streptococcal infection is the result of an abnormal immunologic response. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (16)
19. History & Physical/Cardiology A 25 year-old female presents with a three day history of chest pain aggravated by coughing and relieved by sitting and leaning forward. She is febrile and a CBC with differential reveals leukocytosis. Which of the following physical examination signs is characteristic of her problem? A. Pulsus paradoxus B. Localized crackles C. Pericardial friction rub D. Wheezing Explanations (u) A. Pulsus paradoxus is a classic finding for cardiac tamponade. (u) B. Localized crackles are associated with pneumonia and consolidation, not pericarditis. (c) C. Pericardial friction rub is characteristic of an inflammatory pericarditis. (u) D. Wheezing is characteristic for pulmonary disorders, such as asthma. Ref: (28)
20. Clinical Therapeutics/Gastrointestinal/Nutritional Which of the following medications is most useful in maintaining remission in a patient with ulcerative colitis? A. Oral corticosteroids B. Corticosteroid enemas C. Sulfasalazine D. Macrodantin Explanations (u) A. Corticosteroids, given orally or via enema preparations, are used for acute flare-up of ulcerative colitis but are not effective when given as prophylactic agents. (u) B. See A for explanation. (c) C. Sulfasalazine, olsalazine, and mesalamine are effective in maintaining remission in patients with ulcerative colitis. (u) D. Long-term antibiotic therapy with Macrodantin is used as a prophylactic agent to prevent urinary tract infections and has no role in the treatment or prevention of ulcerative colitis. Ref: (7)
15 21. Diagnosis/Endocrinology An adult presents with a three month history of progressive severe muscle cramps, extremity paresthesias and lethargy which began shortly after a thyroidectomy for a malignant thyroid lesion. Which of the following is the most likely diagnosis? A. Hypoparathyroidism B. Hypothyroidism C. Hyperparathyroidism D. Hyperthyroidism Explanations (c) A. Hypocalcemia secondary to hypoparathyroidism is commonly seen as a complication of thyroidectomy. (u) B. Hypothyroidism is possible without replacement therapy after thyroidectomy but would not result in the tetany- like symptoms and hypocalcemia. (u) C. Hyperparathyroidism will have a different constellation of symptoms and will be typified by elevated serum calcium. (u) D. Hyperthyroidism is not likely status post thyroidectomy though possible with over-aggressive replacement therapy. Symptoms with low serum calcium are the factors that move away from this being the diagnosis. Ref: (28)
22. Clinical Intervention/Pulmonology A 22 year-old patient complains of sudden onset of chest pain accompanied by shortness of breath. The patient appears dyspneic. On examination, the trachea is deviated to the left, breath sounds are faint on the right, and the right chest is hyperresonant to percussion. The preferable treatment for this patient would be A. a tracheostomy. B. insertion of a chest tube with underwater seal, left 2nd intercostal space. C. needle thoracotomy right 2nd intercostal space D. a lung scan for pulmonary embolus and begin heparin sodium (Heparin) therapy. Explanations (u) A. Tracheostomy is indicated for upper airway obstruction, not spontaneous pneumothorax. (h) B. This patient has a tension pneumothorax on the right, and insertion of the chest tube on the left would be life threatening. (c) C. Decreased breath sounds and hyperresonance are noted on the side of the pneumothorax; tracheal deviation to the opposite side indicates development of a tension pneumothorax. Treatment consists of inserting a chest tube on the side of the pneumothorax and connecting to an underwater seal. (u) D. Pulmonary embolus may present with chest pain and dyspnea, but physical examination findings do not include decreased breath sounds with hyperresonance and tracheal deviation. Ref: (28)
23. Diagnostic Studies/ENT/Ophthalmology A patient presents with acute eye pain and photophobia after putting in his contact lens. The patient states he removed his contact which he noted to be torn. Which of the following is the diagnostic study of choice in this patient? A. Funduscopic examination B. Applanation tonometry C. Fluorescein staining D. Schirmer Test Explanations (u) A. Funduscopic examination allows for evaluation of the optic disc and retinal circulation. It is not the best diagnostic study for a patient with suspected corneal abrasion. (u) B. Applanation tonometry is used in the evaluation of intraocular pressure in patients with suspected glaucoma. (c) C. Fluorescein staining is done in patients to evaluate for corneal abrasion which commonly presents with severe eye pain and photophobia. (u) D. The Schirmer test is used to evaluate the quantity of tears produced in patient with conditions such as keratoconjunctivitis sicca. Ref: (29) 16 24. History & Physical/Psychiatry/Behavioral Medicine A 24 year-old female presents to your office for a physical examination. She is dressed in a low cut blouse and a short skirt. She is dramatic, emotional and sexually provocative. She complains of difficulty being intimate with men. On further questioning, she seems to overemphasize the severity of her current cold. After a full history and physical examination you suspect what personality disorder? A. Histrionic B. Borderline C. Narcissistic D. Antisocial Explanations (c) A. Patients who are histrionic are attention seekers, and exaggerate their thoughts and feelings, they are often sexually provocative. (u) B. Borderline patients have unstable behavior and mood. They often have feelings of aloneness and self- destructive behavior. (u) C. Narcissistic patients are grandiose, envious, and have a sense of special entitlement. They lack empathy. (u) D. Antisocial patients are unwilling to conform to social norms and do not learn from prior experiences. Ref: (14)
25. Diagnosis/Cardiology During physical examination an elderly patient is noted to have a painless, brown-colored ulceration in the area of the medial malleolus. Which of the following is the most likely diagnosis? A. Arterial ulcer B. Venous ulcer C. Arterial insufficiency D. Diabetic ulcer Explanations (u) A. Arterial ulcers typically are the last in the sequence of events of peripheral arterial disease; which include decreased or absent pulses distal to the blockage, muscle atrophy, hair loss, thickened nails, smooth and shiny skin, reduced skin temperature, pallor, cyanosis, ulcers, and gangrene. Arterial ulcers typically occur on the feet in the areas of pressure points. (c) B. Venous ulceration develops in the lower extremity secondary to venous incompetence and chronic edema. The medial aspect of the ankle is the most common location. (u) C. Arterial insufficiency is most likely to present with symptoms of claudication prior to the development of skin ulcers. When these ulcers do occur, they are most commonly seen as arterial ulcers and not venous ulcers. (u) D. Diabetic ulcers typically occur due to atherosclerosis and arterial insufficiency along with diabetic peripheral neuropathy. These ulcers are more likely to occur on pressure points on the foot and fail to heal because of poor circulation to these areas. Ref: (7)
26. Health Maintenance/Obstetrics/Gynecology A 30 year-old female presents to the clinic for her 6 week post partum examination. She was diagnosed with gestational diabetes mellitus during her pregnancy and was successfully treated with diet alone. Which of the following patient education statements is most appropriate for this patient? A. The risk of gestational diabetes occurring in future pregnancies is very low. B. The risk of developing diabetes in 10-15 years is relatively low. C. Lifestyle modification, diet & exercise will not prevent her from developing diabetes D. Glucose testing every 1-3 years is recommended Explanations (u) A. The risk of recurrence in future pregnancies is 60%. (u) B. She has a 50-60% risk of developing diabetes within 10-15 years. (u) C. Lifestyle modification may delay or prevent developing diabetes. (c) D. Those with normal glucose should be reassessed every 3 years; those with prediabetes should be assessed annually. Ref: (8) 17 27. Clinical Therapeutics/Neurology A patient with known relapsing-remitting multiple sclerosis (MS) presents to the hospital with an exacerbation of MS symptoms. What is the recommended treatment? A. Baclofen (Lioresal) B. Interferon C. Glatiramer acetate (Copaxone) D. Methylprednisolone Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Acute relapses of MS are treated with a short course of IV methylprednisolone followed by oral prednisone. This regimen reduces the severity and shortens the duration of attacks. All other drugs listed are used to reduce the attack rate of relapsing remitting multiple sclerosis. Ref: (1)
28. Clinical Intervention/Dermatology A 3 year-old child playing in an abandoned shed is bitten by a black widow spider. The mother rushes the child to the emergency department within 20 minutes of the incident. Which of the following if the best initial intervention? A. Intramuscular steroids B. Administration of antivenin C. Immediate immersion in a cold bath D. Hospital admission for symptomatic care Explanations (u) A. The bite of this spider does not cause an inflammatory reaction; therefore, steroids are not indicated. (u) B. Administration of antivenin should be administered to patients with severe envenomation manifested as seizures, respiratory failure, or hypertension. (u) C. Application of an ice pack initially would be helpful for pain relief, however, immersion in a cold bath may cause hypothermia. (c) D. Hospital admission for symptomatic care should be considered in children, pregnant women, and patients with preexisting cardiovascular disease. Ref: (17)
29. Diagnostic Studies/Orthopedics/Rheumatology The most accurate way to determine the exact degree of spinal curvature in a child with scoliosis is by which of the following? A. Calculation of the Cobb angle B. Measurement of waist asymmetry C. Measurement of rib hump deformity D. Calculation using a scoliometer Explanations (c) A. The scoliotic curve is measured by the Cobb method using AP and lateral x-ray films of the entire length of the spine. (u) B. While waist asymmetry and rib hump deformity may be observed on physical examination of the patient with scoliosis, none of them can be used to determine the exact degree of the spinal curvature. (u) C. See B for explanation. (u) D. A scoliometer or inclinometer measures distortions of the torso and is good for screening angle of rotation, but is not exact to determine exact degree of curvature. Ref: (26)
18 30. Scientific Concepts/Urology/Renal Which of the following is the portion of the nephron responsible for the absorption of 90% of the ultrafiltrate? A. Proximal convoluted tubule B. Loop of Henle C. Distal convoluted tubule D. Collecting duct Explanations (c) A. The majority of the ultrafiltrate 90% is reabsorbed in the proximal convoluted tubule. (u) B. The loop of Henle is responsible for the concentration of solutes within the nephron. (u) C. The distal convoluted tubule is responsible for some water and sodium reabsorption. (u) D. The collecting duct is responsible for the final concentration of the urine. Ref: (1)
31. Health Maintenance/Cardiology Which of the following is a proven risk factor for the development of abdominal aortic aneurysm? A. Infective endocarditis B. Diabetes mellitus C. Cigarette smoking D. Alcohol abuse Explanations (u) A. Infective endocarditis is not associated with the development of abdominal aortic aneurysm. (u) B. Diabetic patients do have a higher rate of atherosclerosis, but there is no clear causal evidence of diabetics being at higher risk for the development of abdominal aortic aneurysm. (c) C. Cigarette smoking is the primary risk factor for the development of aortic aneurysms. (u) D. Alcohol abuse is not related to development of abdominal aortic aneurysm. Ref: (30)
32. Clinical Therapeutics/Pulmonology A 22 month-old male infant presents with one day of barking cough preceded by three days of cold symptoms. On physical examination, his axillary temperature is 100.4F and he has no stridor at rest. Inspiratory stridor is evident when he becomes agitated during the examination. There are no signs of respiratory distress or cyanosis. Which of the following is the most appropriate treatment for this patient? A. Nebulized albuterol B. Nebulized epinephrine C. Oral amoxicillin D. Oral dexamethasone Explanations (u) A. Viral croup is an upper airway disease and there is no role for bronchodilator therapy. (u) B. Nebulized racemic epinephrine is only indicated in the treatment of croup in cases of moderate to severe rest stridor, respiratory distress, or hypoxia. (u) C. Croup is almost always a viral illness and antibiotics have no role in the treatment of this condition. (c) D. Corticosteroids are beneficial in the treatment of croup. Intramuscular administration has shown no benefit over oral administration. Ref: (5)
19 33. History & Physical/ENT/Ophthalmology A patient with history of hypertension and dyslipidemia presents for routine follow up. On funduscopic examination you note moderate sized fluffy white lesions with irregular borders. This is most consistent with which of the following? A. Drusen B. Cotton-wool patches C. Hard exudates D. Preretinal hemorrhages Explanations (u) A. Drusen are tiny to small yellowish round spots with hard or soft edges that are often seen in age-related macular degeneration. (c) B. Cotton-wool patches are fluffy white or grayish ovoid lesions with irregular borders. They are typically moderate in size and seen in patients with hypertension. (u) C. Hard exudates are yellowish bright lesions with well-defined borders. They are often small and round. (u) D. Preretinal hemorrhages obscure the underlying retinal vessels and are seen as a horizontal line of demarcation with plasma above and cells below. Ref: (3)
34. Diagnosis/Gastrointestinal/Nutritional A 50 year-old male with history of alcohol abuse presents with acute, severe epigastric pain radiating to the back. The patient admits to an episode of coffee ground emesis. On examination he is ill-appearing with a rigid, quiet abdomen and rebound tenderness. Which of the following is the most likely diagnosis? A. Abdominal aortic aneurysm B. Perforated duodenal ulcer C. Acute myocardial infarction D. Cholecystitis Explanations (u) A. A patient with an abdominal aortic aneurysm may present with pain radiating to the back, however would not have coffee ground emesis or an acute abdomen. (c) B. Perforation of a duodenal ulcer causes sudden, severe pain, with rebound tenderness and rigid abdomen on physical examination. It is often associated with coffee ground emesis. (u) C. A patient with an acute myocardial infarction may have pain radiating to the back, however would not have hematemesis or an acute abdomen. (u) D. Cholecystitis presents with right upper quadrant pain and is not typically associated with coffee ground emesis or rebound tenderness. Ref: (1)
35. Clinical Intervention/Endocrinology A 58 year-old female presents with acute onset of 105 degrees F fever, chills, delirium and tachycardia. Laboratory analysis reveals a TSH of 0.08 mcU/L (0.4-6.0 mcU/L), total T3 of 400 ng/dL (95-190 ng/dL)and a total T4 of 180 mcg/dL (5-11 mcg/dL). What is the initial treatment of choice to normalize this condition? A. Hydrocortisone B. Propylthiouracil C. Digoxin D. Levothyroxine Explanations (u) A. The use of steroids is common in thyroid storm, but it is not the best initial treatment. (c) B. Propylthiouracil is the preferred initial drug in patients with thyroid storm. (u) C. Digoxin is not the treatment of choice for symptoms related to thyroid storm. It could be used if heart failure was associated. (h) D. Levothyroxine would actually worsen this condition. Ref: (29) 20 36. Clinical Therapeutics/Cardiology When instituting diuretic therapy for patients with heart failure, which of the following is considered the treatment of choice as first-line therapy in a failing kidney due to its improved sodium clearance? A. Hydrochlorothiazide (Diuril) B. Bumetanide (Bumex) C. Spironolactone (Aldactone) D. Acetazolamide (Diamox) Explanations (u) A. Thiazide diuretics may have better hypertension control than the short acting loop diuretics but they are generally ineffective when the glomerular filtration rate falls below 30-40 mL/min. (c) B. Loop diuretics remain active in severe renal insufficiency and are the most effective type of diuretics used in the management of heart failure symptoms. These agents have a rapid onset and result in natriuresis due to their activity in the ascending limb in the Loop of Henle. (u) C. Potassium-sparing diuretics have very weak diuretic properties and are useful as adjunctive therapy in patients with Stage 3 or Stage 4 heart failure who are already on a first-line diuretic and other agents. (u) D. Acetazolamide is a carbonic anhydrase inhibitor and works by causing a metabolic acidosis with loss of bicarbonate in the failing kidney. It is a weak diuretic and does not work in the setting of a failing kidney. Ref: (28)
37. History & Physical/Hematology A female patient presents with weakness and fatigue for the past three months. A CBC was ordered and revealed the following values:
On physical examination which of the following would be a consistent finding for this type of anemia? A. Paresthesia of the hands and feet B. Hepatosplenomegaly C. Tachycardia D. J aundice Explanations (c) A. Neurological manifestation is the earliest type most commonly seen with megaloblastic anemia most commonly from vitamin B12 deficiency. (u) B. Hepatosplenomegaly and jaundice are commonly seen in hemolytic anemias. (u) C. This compensatory mechanism is common in any type of anemia due to the hypoxemic effects of the anemia. (u) D. See B for explanation. Ref: (28)
38. Scientific Concepts/Pulmonology A 20 year-old male presents with 3 weeks of constitutional and upper respiratory symptoms, including malaise, sore throat, dry cough, and fever. Lung auscultation demonstrates diffuse crackles bilaterally. What is the most likely infectious agent involved? A. Respiratory syncytial virus B. Influenza virus C. Mycoplasma pneumoniae D. Streptococcus pneumoniae Explanations (u) A. RSV is characterized by wheezing on auscultation and the course is typically 3-7 days. (u) B. Influenza pneumonia is characterized by a more precipitous onset and fulminant course. 21 (c) C. The indolent course suggests an atypical pneumonia and Mycoplasma is the most common atypical agent. (u) D. Pneumococcal pneumonia is typically characterized by a more severe illness and more fulminant course. Ref: (7)
39. Diagnostic Studies/Obstetrics/Gynecology A 30 year-old female presents to the emergency room having passed out at home 30 minutes prior to arrival. Her last menstrual period was 6 weeks ago and pregnancy test was reported positive 5 days ago. She started having vaginal bleeding last night. Vital signs are BP 70/40 mmHg, P 140 bpm, R 22. She is pale and diaphoretic. The next step in the evaluation of this patient's condition should be which of the following? A. Abdominal ultrasound B. Culdocentesis C. Laparotomy D. Magnetic resonance imaging Explanations (u) A. Abdominal ultrasound is not the test of choice in this patient. (u) B. Culdocentesis has been replaced by transvaginal ultrasound as diagnostic procedure for suspected ectopic pregnancy. (c) C. Laparotomy is indicated with presumptive diagnosis of ectopic pregnancy in an unstable patient. (u) D. MRI is useful in cases of unusual ectopic locations in stable patients. Ref: (8)
40. Diagnosis/ENT/Ophthalmology A 35 year-old patient presents with a sudden onset of fever, dysphonia, drooling, and difficulty drinking a few hours ago. Physical examination reveals a temperature of 102 degrees F. The patient appears ill and is sitting forward. Inspiratory retractions are noted and there is a soft stridor. Which of the following is the most likely diagnosis? A. Angioedema B. Foreign body aspiration C. Epiglottitis D. Bacterial pharyngitis Explanations (u) A. Angioedema would present with swelling of the mouth and upper airway. Patient would not have fever or inspiratory retractions. (u) B. Patients with foreign body aspiration are unlikely to appear acutely ill or be febrile. (c) C. Epiglottitis is characterized by fever, dysphonia, drooling, and dysphagia. Patients often appear ill and sit up leaning forward in an attempt to breathe. (u) D. Bacterial pharyngitis is not associated with stridor or inspiratory retractions. Ref: (28)
41. Clinical Intervention/Orthopedics/Rheumatology A 53 year-old female massage therapist presents with new onset of sudden swelling involving the right elbow. She denies previous episodes similar to this. On physical examination, the patient is afebrile. There is a 4 cm fluid-filled mass that is tender to palpation overlying the tip of the elbow with no evidence of erythema or warmth. Which of the following is the most appropriate intervention? A. Rest and NSAIDs B. Surgical excision C. Incision and drainage D. Aspiration and corticosteroid injection Explanations (c) A. Rest and NSAID is the most appropriate initial intervention in a patient with olecranon bursitis. (u) B. Surgical excision is reserved for chronic bursitis and is not indicated in this acute initial presentation. 22 (u) C. Incision and drainage is not recommended as it may cause a chronic drainage sinus tract. (u) D. Aspiration of the bursa and corticosteroid injection are second-line therapy in a patient with olecranon bursitis who fails rest and NSAIDs. Ref: (28)
42. History & Physical/Gastrointestinal/Nutritional A patient presents with nausea, vomiting, and fever for one day. She describes periumbilical abdominal pain which has settled in her right lower quadrant. On examination she has right lower quadrant pain with deep left lower quadrant palpation. This finding is known as which of the following? A. Psoas sign B. Rebound tenderness C. Rovsing's sign D. Obturator sign Explanations (u) A. Abdominal pain with flexion of the right hip against pressure is a psoas sign. (u) B. Right lower quadrant pain with quick withdrawal of the right lower quadrant palpation is rebound tenderness. (c) C. Right lower quadrant pain with deep left lower quadrant palpation is Rovsing's sign. (u) D. Right lower quadrant pain with internal rotation of the right hip while both the hip and knee are flexed is obturator sign. Ref: (3)
43. Clinical Therapeutics/Urology/Renal A 66 year-old male patient has both hypertension and benign prostatic hypertrophy. Which of the following medications would most likely benefit both conditions? A. Finasteride (Propecia) B. Verapamil (Calan) C. Propanolol (Inderal) D. Prazosin (Minipress) Explanations (u) A. This drug could help to relieve the symptoms of benign prostatic hypertrophy (BPH) however it has no benefit for hypertension. (u) B. This drug could help the HTN however it would have no benefit of helping the BPH. (u) C. See B for explanation. (c) D. This drug has antihypertensive properties as well as properties to relieve the symptoms of BPH. Ref: (28)
44. Diagnostic Studies/Cardiology High ventricular filling pressures are indicated by a rise in which of the following? A. Brain natriuretic peptide B. Troponin C. Myoglobin D. Creatinine Explanations (c) A. Brain natriuretic peptide (BNP) is a hormone released from the myocardium when stretched such as with high ventricular filling pressures from CHF. It can indicate or be used as prognostic evaluation in patients with acute CHF. (u) B. Troponin is a marker for cardiac muscle damage as in an acute myocardial infarction or ischemia. (u) C. Myoglobin is a byproduct of muscle destruction or damage from ischemia or other causes of skeletal muscle damage. Myoglobin may rise with high ventricular pressures, however it is nonspecific. (u) D. Creatinine is a marker of renal function. Ref: (28) 23 45. Health Maintenance/Infectious Diseases Which of the following prophylactic interventions is recommended in all individuals with HIV regardless of disease stage? A. Oral polio vaccine B. Pneumococcal vaccine C. Fluconazole for fungal infections D. Isoniazid for tuberculosis reactivation Explanations (u) A. Oral polio vaccine is contraindicated in HIV patients because it is a live attenuated vaccine. (c) B. All HIV-positive individuals should receive prophylaxis against pneumococcal pneumonia. (u) C. Prophylaxis against fungal infection would be indicated for those HIV-positive individuals with CD4 less than 50 cells/L. (u) D. Isoniazid is indicated for those with positive PPD and normal chest x-ray. Reactivation would require a multidrug regimen. Ref: (1)
46. Diagnosis/Dermatology A 60 year-old male presents with a slowly developing facial lesion first noticed 4-5 months ago. He describes it as non-painful and non-pruritic but notes it to be extremely scaly. He denies a history of similar lesions or dermatologic disease. Examination reveals a one centimeter, firm nodule at the right temple with heavy keratinization. There is no fluctuance or skin discoloration. Which of the following is the most likely diagnosis? A. Actinic keratosis B. Squamous cell cancer C. Granuloma annulare D. Merkel cell carcinoma Explanations (u) A. Actinic keratosis lesions can be very scaly but are generally flat in appearance not nodular. (c) B. This is a very typical scenario for a squamous cell cancer occurring in a sun exposed area, with slow development and heavy keratinization. (u) C. Granuloma annulare is a self-limited dermatosis occurring primarily on the distal extremities is more common in young adults and children. (u) D. Merkel cell carcinoma lesions are typically discolored and non-keratinizing. Ref: (10)
47. Clinical Intervention/Psychiatry/Behavioral Medicine A 25 year-old male on a behavioral medicine unit is given haloperidol (Haldol) IM for a violent psychotic outburst. Initially he quiets down, but about an hour later develops confusion, an inability to open his mouth, and a temperature of 40 degrees C. Initial treatment should consist of which of the following? A. Additional Haldol B. Corticosteroid C. Benzodiazepine D. Dantrolene Explanations (h) A. This patient is exhibiting symptoms of neuroleptic malignant syndrome (NMS) and an additional dose of a antipsychotic will be harmful, and potentially deadly with a 20% mortality if untreated. (u) B. Steroids will not reduce the symptoms of NMS. (h) C. Benzodiazepines will not reduce the symptoms of NMS. (c) D. In addition to supportive treatment, the most commonly used medications for neuroleptic malignant syndrome are dantrolene (Dantrium) and bromocriptine (Parlodel). Ref: (14)
24 48. History & Physical/Endocrinology Which of the following is the most characteristic physical examination finding with Grave's disease? A. Diffuse thyroid gland enlargement B. Single thyroid gland nodule C. Unilateral thyroid lobe enlargement D. Multiple thyroid gland nodules Explanations (c) A. Diffuse thyroid gland enlargement is the typical presentation for Grave's disease. (u) B. Single thyroid gland nodule would be more worrisome for thyroid malignancy. (u) C. Unilateral thyroid lobe enlargement is an atypical presentation for any thyroid malady. (u) D. Multiple thyroid gland nodules are more suggestive of a metabolic disorder. Ref: (3)
49. Diagnostic Studies/Pulmonology Which of the following chest x-ray abnormalities would most likely be seen in a patient with hypersensitivity pneumonitis? A. Lobar consolidation B. Apical infiltration C. Granulomatous inflammation D. Diffuse nodular densities Explanations (u) A. Lobar consolidation is seen in community-acquired pneumonia. (u) B. Apical infiltration is seen in tuberculosis. (u) C. Granulomatous inflammation is seen in sarcoidosis. (c) D. Diffuse nodular densities are seen in hypersensitivity pneumonitis. Ref: (7)
50. Clinical Therapeutics/Obstetrics/Gynecology A 32 year-old female complains of severe irritability and emotional lability accompanied by weight gain, breast tenderness, and headache starting mid-cycle each month and abating with the onset of menses. She has tried relaxation therapy, exercise, dietary changes and over the counter pharmacologic interventions with minimal relief of her symptoms. Which of the following prescription medications is the best choice to relieve her symptoms? A. Alprazolam (Xanax) B. Fluoxetine (Prozac) C. Oral contraceptive pill (Ortho-novum 1/35) D. Spironolactone (Aldactone) Explanations (u) A. Anxiolytics have shown to be effective however its potential for dependency makes it not the best choice. (c) B. SSRI's provide symptom improvement for patients with premenstrual syndrome (PMS). (u) C. Studies have found little difference between women taking a low dose birth control and women who do not take pills; currently not recommended for PMS. (u) D. Spironolactone is used for cyclic edema, not the best choice for PMS. Ref: (8)
25 51. Diagnosis/Orthopedics/Rheumatology A 30 year-old male sustains a blow to his right lateral leg during a soccer game. He complains of pain with weight bearing. Examination reveals tenderness along the lateral aspect of the right lower leg, but no point tenderness over the tibia. There is full active range of motion at the ankle, knee, and hip joints. There is no swelling or tenderness of the ankle or knee joints. Which of the following is the most likely diagnosis? A. Anterior cruciate ligament tear B. Fractured fibula C. Tibial stress fracture D. Gastrocnemius contusion Explanations (u) A. Anterior cruciate ligament injury would have a positive drawer test and mechanism of injury can be due to a direct blow to the knee or as a result of sudden deceleration and rotation of the knee. (c) B. Isolated fibular fractures can occur with direct or indirect trauma to the fibular shaft. X-ray films of the leg are mandatory for any patient with a history of trauma and pain on ambulation to rule out this potentially overlooked injury. (u) C. A tibial stress fracture is more likely to present without acute injury and with tenderness over the tibia rather than the lateral aspect of the leg. (u) D. A contusion does not cause pain with weight bearing. Ref: (29)
52. Health Maintenance/Neurology What is the recommendation for primary prevention of stroke in a patient under sixty years of age with atrial fibrillation? A. No therapy is needed B. Aspirin C. Warfarin D. Maze procedure Explanations (c) A. No therapy is recommended for primary stroke prevention in this patient. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (1)
53. Clinical Intervention/Cardiology Which of the following is first-line treatment for a symptomatic bradyarrhythmia due to sick sinus syndrome? A. Permanent pacemaker B. Radiofrequency ablation C. Antiarrhythmic therapy D. Anticoagulation therapy Explanations (c) A. Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome. (u) B. Radiofrequency ablation is used for the treatment of accessory pathways in the heart. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (28)
26 54. Scientific Concepts/ENT/Ophthalmology Which of the following is the most common cause of conductive hearing loss in an adult patient? A. Head trauma B. Cerumen impaction C. Otosclerosis D. Diabetes mellitus Explanations (u) A. Head trauma and diabetes mellitus are causes of sensorineural hearing loss. (c) B. Cerumen impaction is the most common cause of conductive hearing loss in an adult patient. (u) C. Although a cause of conductive hearing loss, otosclerosis is not the most common cause. (u) D. See A for explanation. Ref: (28)
55. History & Physical/Urology/Renal A newborn male infant is seen by the PA prior to discharge home. On examination it is noted that the meatal opening is on the dorsal surface of the penile shaft just behind the coronal sulcus. The testicles are descended bilaterally. This physical examination finding is called which of the following? A. Penile epispadias B. Penile hypospadias C. Glandular epispadias D. Glandular hypospadias Explanations (c) A. This is a penile epispadias which can develop anywhere along the penile shaft to the pubic bone. It is caused by displacement of urethra/meatal opening on the dorsal surface of the penis. If the opening occurs in the glans penis then it would be a glandular epispadias. If this abnormality occurs on the ventral surface of the penis or glans penis then it is known as a hypospadias. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (33)
56. Diagnostic Studies/Gastrointestinal/Nutritional Which of the following is the study of choice to diagnose upper gastrointestinal malignancy? A. Abdominal CT B. Upper endoscopy C. Barium swallow D. Abdominal ultrasound Explanations (u) A. See B for explanation. (c) B. Upper endoscopy is the study of choice to diagnose gastroduodenal ulcers, erosive esophagitis and upper gastrointestinal malignancy. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (28)
27 57. Clinical Therapeutics/Pulmonology A 17 year-old girl uses an albuterol inhaler to treat her asthma. She uses the inhaler as needed and reports symptoms occurring 3-4 days per week. She experiences symptoms at night no more than once a month. Her spirometry during her most recent office visit is normal. What is the appropriate medical management of this patient? A. Add an inhaled long-acting bronchodilator B. Add an inhaled steroid C. Add an inhaled long-acting bronchodilator and steroid D. No change to her medical regimen Explanations (u) A. See B for explanation. (c) B. Symptoms occurring more than twice a week but less than daily meet severity criteria for mild persistent asthma. The appropriate next step in her therapy is to add an inhaled steroid. Adding an inhaled long-acting bronchodilator is only recommended for moderate persistent asthma and only after an inhaled steroid has been added. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (28)
58. Diagnosis/Psychiatry/Behavioral Medicine Topic: 1d Author: Kathleen Ehrhardt A 24 year-old male presents to the emergency room via ambulance. He was found by the police walking naked on the highway. His speech is minimal but disorganized and he appears to be responding to auditory hallucinations. With further questioning, he is preoccupied with the delusion of the FBI listening in on his conversations. His mother tells you that he has been acting bizarre for two months now. What is the most likely diagnosis? A. Schizophrenia B. Schizophreniform disorder C. Schizoaffective disorder D. Schizotypal personality disorder Explanations (u) A. Schizophrenia occurs with the above symptoms of greater than six months duration. (c) B. Schizophreniform disorder is characterized by the same features as schizophrenia except the total duration of the illness is at least one month and less than six months. (u) C. Schizoaffective disorder has the features of both schizophrenia and a mood disorder. (u) D. Patients with schizotypal personality disorder are strikingly odd or strange. They have magical thinking and derealization. Ref: (14)
59. History & Physical/Dermatology What is the most common examination finding in a patient diagnosed with mumps? A. Occipital lymph node swelling B. Parotid gland tenderness C. Splenic enlargement D. Testicular tenderness Explanations (u) A. Lymph node swelling can occur secondary to facial edema but can be variable and more often involves the submandibular and cervical lymph node chains. (c) B. Parotid gland tenderness and swelling are the hallmark findings of mumps. (u) C. Splenic enlargement is not a common exam finding even in extra-salivary disease. (u) D. Testicular tenderness can occur in as many as 40% of post-pubescent men but it is not the most common finding considering all cases of mumps. Ref: (28)
28 60. Scientific Concepts/Cardiology What is the most likely mechanism responsible for retinal hemorrhages and neurologic complications in a patient with infective endocarditis? A. Metabolic acidosis B. Embolization of vegetations C. Hypotension and tachycardia D. Activation of the immune system Explanations (u) A. See B for explanation. (c) B. The vegetations that occur during infective endocarditis can become emboli and can be dispersed throughout the arterial system. (u) C. See B for explanation. (u) D. Glomerulonephritis and arthritis result from activation of the immune system. Ref: (7)
61. Health Maintenance/Endocrinology A patient with adrenal insufficiency is taking hydrocortisone 25 mg daily. What should the patient do with the hydrocortisone dose when they develop a minor illness such as a cold? A. Stop the hydrocortisone until the illness resolves. B. Continue the current dose that the patient is taking. C. Increase the dose to 50 mg daily until the illness resolves. D. Increase the dose to 250 mg daily until the illness resolves Explanations (h) A. Stopping the hydrocortisone would cause adrenal crisis. (u) B. See C for explanation. (c) C. To better mimic the normal physiologic response the baseline dose should be doubled for the duration of the illness. Doses should be increased 5-10 fold with major events such as surgery. (u) D. See C for explanation. Ref: (1)
62. Diagnosis/Neurology A 30 year-old female presents to the office complaining of generalized weakness and reduced exercise tolerance that improves with rest. On physical examination you note the presence of bilateral eyelid ptosis, proximal muscle weakness and normal reflexes. What is the most likely diagnosis? A. Lambert-Eaton syndrome B. Organophosphate intoxication C. Multiple sclerosis D. Myasthenia gravis Explanations (u) A. Common symptoms of Lambert-Eaton syndrome are proximal muscle weakness of lower limbs, cranial nerve findings, and depressed or absent reflexes. Patients commonly have a malignancy. (u) B. Patients with organophosphate intoxication have seizures, excessive secretions, wheezing and diaphoresis. (u) C. Patients with multiple sclerosis have multiple lesions in time and space. (c) D. Common symptoms of myasthenia gravis are fatigable weakness, ptosis, diplopia, and proximal muscle weakness. The disease is more common in women in the 2nd and 3rd decade and in men older than 60. Ref: (1)
29 63. History & Physical/Obstetrics/Gynecology During a routine prenatal visit, the fundal height is found to be at the umbilical level. The number of weeks gestation is estimated to be A. 10 to 12. B. 16 to 18. C. 20 to 22. D. 26 to 28. Explanations (u) A. At 12 weeks, fundal height is palpable just above the pubic symphysis. (u) B. At 16 weeks, fundal height is midway between the pubic symphysis and umbilicus. (c) C. At 20 weeks, fundal height is at the umbilicus. (u) D. At 26 weeks, fundal height is above the umbilicus. Ref: (8)
64. Clinical Intervention/Gastrointestinal/Nutritional An 18 month-old female presents to the Emergency Department having possibly swallowed a hearing aid battery within the past hour. She is drooling and appears anxious but parents have noticed no stridor or dyspnea. She has no history of previous esophageal injury. Physical examination is unremarkable. Chest radiograph reveals a radiopaque round object at the distal esophagus. Which of the following is the most appropriate treatment option? A. Observation for 24 hours B. Esophagoscopy for removal C. Barium swallow D. Bronchoscopy Explanations (h) A. Batteries must be removed as they can induce mucosal injuries in as little as one hour of contact time. (c) B. Esophagoscopy is the procedure of choice for acutely ingested foreign bodies. (u) C. A barium swallow is a diagnostic option but will not provide treatment. (u) D. Bronchoscopy would be the procedure of choice for an airway foreign body, not esophageal. Ref: (29)
65. Diagnostic Studies/Cardiology Which of the following is a non-invasive quick method of evaluating a patient with suspected lower extremity arterial insufficiency? A. Ankle-Brachial Index B. Striker Tonometry C. CT Angiography D. Lower extremity arteriography Explanations (c) A. The single most useful index is the ankle pressure. This can be obtained with an Ankle-Brachial Index (ABI) which the severity of signs and symptoms of arterial insufficiency are correlated to the findings on the ABI. It is a non-invasive study that can be performed in an office setting. (u) B. Striker Tonometry is used to evaluate compartment pressures. (u) C. CT angiography is an invasive test involving radiation and contrast that cannot be done in an office setting. (u) D. Lower extremity arteriography is an invasive test involving radiation and contrast that cannot be done in an office setting. Ref: (1)
30 66. Clinical Therapeutics/ENT/Ophthalmology A patient presents complaining of left eye discharge and eyes that were matted shut this morning. The patient denies changes in visual acuity, but states that he is afraid to put his contacts in. On physical examination you note erythematous conjunctivae and mucopurulent discharge of the left eye. The cornea is clear. Which of the following topical agents is the treatment of choice in this patient? A. Aminoglycoside (Tobrex) B. Olopatadine (Patanol) C. Cycloplegic D. Prednisolone acetate Explanations (c) A. Topical aminoglycoside or fluoroquinolones are indicated in contact lens wearers with conjunctivitis to cover for Pseudomonas infection. (u) B. Patanol is indicated in patients with allergic, not bacterial, conjunctivitis. (u) C. Topical cycloplegic agents and corticosteroids are not indicated in the treatment of bacterial conjunctivitis. (u) D. See C for explanation. Ref: (29)
67. Diagnosis/Hematology A 69 year-old female presents to the clinic complaining of fatigue. Physical examination reveals lymphadenopathy, splenomegaly and pale conjunctiva. The remainder of the examination is unremarkable. CBC reveals a normochromic normocytic anemia. White blood cell count is 45,000/mm3, with a differential of 77% mature lymphocytes, 3% eosinophils, 18% segmented neutrophils and 1% basophils and monocytes. Platelets appear adequate in number. What is the most likely diagnosis? A. Acute myelocytic leukemia B. Acute lymphocytic leukemia C. Chronic lymphocytic leukemia D. Chronic myelocytic leukemia Explanations (u) A. Acute leukemias present with circulating blast cells with pancytopenia. (u) B. See A for explanation. (c) C. Chronic lymphocytic leukemia typically occurs after age 50 presenting with lymphocytosis with lymphocytes that appear small and mature. (u) D. See C for explanation. Ref: (28)
68. Health Maintenance/Pulmonology A 62 year-old female is admitted to a nursing home during an outbreak of influenza. In review of her records, you note that she did not receive the flu vaccine this year. Which of the following is the most appropriate drug of choice for influenza prophylaxis in this patient? A. Ciprofloxin (Cipro) B. Oseltamivir phosphate (Tamiflu) C. Clarithromycin (Biaxin) D. Alpha-2b interferon (Avonex) Explanations (u) A. Ciprofloxin is indicated for postexposure prophylaxis of anthrax. (c) B. Either oseltamivir or zanamivir are indicated for prophylactic use against influenza A or B. (u) C. Clarithromycin is indicated for prophylaxis against disseminated Mycobacterium avium complex. (u) D. Alpha-2b interferon is indicated for treatment of several disorders, such as chronic hepatitis B & C, but has no role in prophylactic treatment of any condition. Ref: (28)
31 69. Diagnostic Studies/Psychiatry/Behavioral Medicine What laboratory test must be monitored frequently in patients who are taking clozapine (Clozaril)? A. Thyroid stimulation hormone B. White blood cell count C. Platelet count D. Aspartate aminotransferase Explanations (u) A. See B for explanation. (c) B. Leukopenia, granulocytopenia, and agranulocytosis occur in approximately 1% of patients on this medication, clozapine should not be dispensed without proof of monitoring. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (14)
70. Scientific Concepts/Orthopedics/Rheumatology During the stages of fracture healing which of the following is responsible for producing collagen? A. Osteoclasts B. Chondrocytes C. Glycosaminoglycans D. Fibroblasts Explanations (u) A. Osteoclasts are responsible for removing necrotic bone. (u) B. Chondrocytes make up the articular cartilage. (u) C. Glycosaminoglycans help form the osteon or vascular canal. (c) D. Fibroblasts produce collagen during the inflammation stage of healing. Ref: (26)
71. History & Physical/Cardiology Which of the following is the earliest symptom for patients with left ventricular failure? A. Dependent edema B. Dyspnea on exertion C. Congestion D. Chest pain Explanations (u) A. Right ventricular failure is manifested by dependent edema and congestion in the lungs. (c) B. Patients with left ventricular heart failure may be comfortable at rest and may experience their first symptoms with dyspnea with conversation or with mild exertion. (u) C. Right ventricular failure is manifested by congestion in the lungs with cough being a possible manifestation of this congestion. (u) D. Patients who have on-going left ventricular failure may have underlying coronary heart disease. When the heart failure is progressing, chest pain (manifested by angina) and myocardial infarction may be manifestations of ongoing, progressive heart failure. Acute decline in heart failure may lead to acute myocardial infarction but this tends to be a very late symptom. Ref: (28)
32 72. Clinical Therapeutics/Endocrinology 34 year-old female status-post trans-sphenoidal resection of pituitary adenoma presents with worsening polydipsia of 10-12 liters daily and polyuria within four days of discharge. A urinalysis reveals a specific gravity of 1.004 (1.001- 1.035) and shows decreased urine osmolality but is otherwise normal. Labs reveal mild hypernatremia. What is the treatment of choice for this patient? A. Glyburide B. Methylprednisolone C. Desmopressin D. Quinapril Explanations (u) A. Glyburide is not indicated because this patient has diabetes insipidus, not diabetes mellitus. (h) B. Use of steroids in diabetes insipidus will actually worsen renal free water secretion. (c) C. The main treatment for diabetes insipidus is Desmopressin. (u) D. Quinapril is not indicated due to the lack of diabetes mellitus and overt renal failure/insufficiency. Ref: (28)
73. Diagnosis/Urology/Renal A 9 year-old boy who has had cold-like symptoms for the past few days is brought to the clinic by his mother who states that her son had gross hematuria this morning. Prior to the cold-like symptoms the boy has been in excellent health. He is up-to-date on all of his immunizations. The patient does not have any edema, hypertension or purpura. Urinalysis reveals the urine to be cola-colored with a 2+positive protein and 2+hemoglobin. Microscopic analysis reveals 50-100 RBCs/HPF, no WBCs, bacteria, casts or crystals. What is the most likely diagnosis? A. Post streptococcal glomerulonephritis (PSGN) B. IgA nephropathy C. Minimal change disease (MCD) D. Membranous nephropathy Explanations (u) A. PSGN usually presents 2-3 weeks after a streptococcal infection (pharyngeal or skin) and usually presents with nephritic symptoms (edema, hypertension, cola-colored urine). This is due to trapping of the streptococcal antigen within the glomerulus (c) B. IgA nephropathy presents after an upper respiratory illness with deposition of IgA within the mesangium of the glomerulus. (u) C. MCD is the most common nephrotic presentation (edema, hypoproteinemia, hyperlipidemia, >3.5 gms. of proteinuria in 24 hours) in children following an upper respiratory illness. This patient is not exhibiting any of these signs at this time. (u) D. Membranous nephropathy is the most common cause of adult nephrotic syndrome. Ref: (28)
74. Clinical Intervention/Neurology A 50 year-old male presents to the ER with a complaint of severe headaches. These headaches are unilateral and he describes the headache pain as steady and non-throbbing. He also complains of nasal congestion and rhinorrhea. He also mentions that alcohol often triggers these headaches. What do you recommend for this patient? A. High flow oxygen B. Massage C. Ibuprofen D. Propranolol Explanations (c) A. This a description of a cluster headache (migrainous neuralgia), these headaches respond to oxygen by mask 7-10 L/min for 15 minutes. (u) B. Massage may be effective for patients with tension headaches. (u) C. Ibuprofen is helpful for the treatment of tension type headaches. (u) D. Propranolol is a preventative medication used for migraine headaches. Ref: (1) 33 75. Diagnostic Studies/Dermatology An 8 year-old child is brought in by his mother with a two day history of spreading, non-pruritic red rash. The rash was preceded by moderate fever, sore throat and rhinorrhea. Examination reveals a moderately ill appearing child with a fine, macular-papular rash on an erythematous base spread diffusely over the trunk with some accentuation in the skin folds. The face is flush with perioral pallor. There is palpable anterior cervical lymphadenopathy. Which of the following is the most appropriate diagnostic study to establish the diagnosis? A. Shave biopsy B. Epstein-Barr virus Ig G C. Complete blood count D. Throat culture Explanations (u) A. Disorders such as erythema multiforme (EM) minor favors the extremities while the EM major may favor the trunk and have associated oral mucosa involvement but generally has blistering lesions. Direct immunofluorescence studies are negative in these disorders. (u) B. Epstein-Barr virus Ig G would not be helpful in that it screens for prior exposure to this virus or illness such as mononucleosis. (u) C. Though a complete blood count is commonly ordered and may be helpful in stratifying illness in this case it would not be diagnostic as to the etiology. (c) D. Scarlatina rash is due to infection with group A strep. A throat culture would be the most appropriate diagnostic study to establish the diagnosis in this patient. Ref: (13)
76. History & Physical/Pulmonology Upon auscultation of a patient's lungs, there are harsh, hollow breath sounds which have a long inspiratory component in the region of the suprasternal notch. Throughout the periphery of the lung fields, softer breath sounds are heard. Which of the following best describes these findings? A. Normal B. Asthmatic C. Atelectasis D. Foreign body Explanations (c) A. Bronchial breath sounds are normally heard near the sternum and vesicular breath sounds are heard over the periphery of the lungs in a healthy, normal patient. (u) B. Breath sounds in an asthmatic patient are usually obscured by wheezing. (u) C. Breath sounds are usually absent over an area of atelectasis. (u) D. Foreign body aspiration can present with stridor, wheezing or decreased breath sounds depending on where it has lodged. Ref: (1)
77. Diagnosis/Obstetrics/Gynecology A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Which of the following is the most likely diagnosis? A. Ectopic pregnancy B. Appendicitis C. Crohn's disease D. Pelvic inflammatory disease Explanations (c) A. High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain. 34 (u) B. Appendicitis presents with nausea, vomiting and periumbilical pain that moves to the right lower quadrant of the abdomen. (u) C. Crohn's disease is more common in women and may present with an acute abdomen. However, pelvic examination would be normal. (u) D. In pelvic inflammatory disease the temperature is usually above 38 degrees C and pelvic pain usually follows onset of cessation of menses. Ref: (8)
78. Clinical Therapeutics/Cardiology When utilizing medical treatment for hypertension, which of the following classes of medications should be used with caution in those with elevated potassium levels or intrinsic renal disease? A. Beta blockers B. Calcium channel blockers C. Central alpha agonists D. ACE inhibitors Explanations (u) A. Beta blockers primarily work by decreasing cardiac contraction and slowing the heart rate. There is no association with hyperkalemia. (u) B. Calcium channel blockers (especially the dihydropyridines) act as vasodilators with some effect at lessening cardiac contraction. Their use is not associated with hyperkalemia. (u) C. Central alpha agonists stimulate the alpha receptors in the brain resulting in decreased vessel wall pressures. This process is responsible for causing a lowering of the blood pressure. There is little effect on the kidney and these agents do not cause hyperkalemia. (c) D. ACE inhibitors are recognized as valuable agents in the management of hypertension but they may result in hyperkalemia in patients with intrinsic renal disease. They should be used with caution in patients who are taking potassium-sparing diuretics. These agents reduce glomerular filtration pressure resulting in retention of potassium since less filtration occurs in the kidney. Ref: (28)
79. Scientific Concepts/Gastrointestinal/Nutritional A 40 year-old male presents with several months of abdominal pain and nausea. Endoscopy reveals an irregular 1 x 2 cm area of loss of rugal folds near the antrum. Biopsies show extensive mucosal and submucosal infiltration by B- lymphocytes. The patient is given appropriate treatment and the lesion resolves. Which infectious agent is most likely to be associated with these findings? A. Aspergillus fumigatus B. Helicobacter pylori C. Human papilloma virus D. Salmonella typhi Explanations (u) A. A. fumigatus would be associated with pulmonary, not gastrointestinal disease. (c) B. H. Pylori causes gastric mucosal inflammation with PMN's and lymphocytes. Infection causes nausea and abdominal pain. Inflammation may be confined to the superficial gastric epithelium or may extend deeper resulting in varying degrees of gland atrophy. Eradication of H. Pylori with appropriate therapy leads to resolution of the chronic gastritis. (u) C. Human papilloma virus is primarily a urogenital disorder. (u) D. Salmonella typhi infection would present with fevers, malaise, vomiting, and other symptoms. This diagnosis is best made with blood cultures. Ref: (28)
35 80. Clinical Intervention/Infectious Diseases A 3 year-old presents with profuse watery diarrhea for the past three days. The child vomited twice yesterday, but not today. On examination, the child is febrile, with pulse of 142, respiratory rate of 18, and blood pressure of 60/40 mmHg. The child is alert and responsive, with no focal findings. Which of the following is the most appropriate intervention? A. Antibiotic therapy B. Loperamide (Imodium) C. 3% normal saline IV infusion D. Oral rehydration Explanations (u) A. In the US, infectious gastroenteritis is most frequently due to a virus. Antibiotic therapy may be second-line in cases where the causative organism is bacterial, is identified, and symptoms continue. (u) B. Loperamide may lead to toxic megacolon. (h) C. 3% normal saline infusion may cause hypernatremia and central pontine myelinosis. (c) D. The goal of therapy for a child with severe gastroenteritis and dehydration is to restore fluid loss. Oral rehydration with an appropriate electrolyte solution is the best option if the child is not actively vomiting and is alert enough to take oral fluids. Ref: (13)
81. Health Maintenance/ENT/Ophthalmology Which of the following is considered a risk factor for retinopathy of prematurity? A. Maternal rubella infection B. Maternal alcohol abuse C. Low birth weight D. Family history of retinal detachment Explanations (u) A. While maternal rubella infection is a risk factor for ocular disease in the newborn, it is not a specific risk factor for retinopathy of prematurity. (u) B. Maternal alcohol use is associated with the development of fetal alcohol syndrome which includes craniofacial abnormalities, but does not include increased risk of retinopathy of prematurity. (c) C. Risk factors for retinopathy of prematurity include low birth weight, perinatal oxygen therapy, prematurity and sepsis. (u) D. If retinopathy of prematurity is not treated, retinal detachment causing blindness may result, but a family history of retinal detachment is not considered a risk factor for the development of retinopathy of prematurity. Ref: (13)
82. Clinical Therapeutics/Orthopedics/Rheumatology Which of the following medications inhibits prostaglandin synthesis in a patient with rheumatoid arthritis? A. Methotrexate B. Infliximab (Remicade) C. Probenecid (Benemid) D. Aspirin Explanations (u) A. Methotrexate inhibits the enzyme dihydrofolate reductase. (u) B. Infliximab (Remicade) neutralizes cytokine tumor necrosing factor. (u) C. Probenecid blocks the tubular reabsorption of filtered urate and is used to reduce serum uric acid. (c) D. Salicylates inhibit the enzymatic production of prostaglandins by inhibiting cyclooxygenase. Ref: (26)
36 83. Diagnosis/Psychiatry/Behavioral Medicine A 32 year-old female presents to the office with the complaint of worry which she can not control for the last six months. She tells you that she has symptoms at least four times per week consisting of sleep disturbances, difficulty concentrating and irritability. What is the most likely diagnosis? A. Panic disorder B. Generalized anxiety disorder C. Posttraumatic stress disorder D. Obsessive-compulsive disorder Explanations (u) A. Panic disorder typically involves certain situations or phobias rather than generalized symptoms. (c) B. A patient needs to have symptoms for more days than not for six months or more, need 3 of 6 symptoms to diagnose generalized anxiety disorder. (u) C. Posttraumatic stress disorder is characterized by development of symptoms after exposure to traumatic events. (u) D. In obsessive-compulsive disorder patients have symptoms of intrusive thoughts, rituals, preoccupations, and compulsions. Ref: (14)
84. Diagnostic Studies/Pulmonology A 26 year-old man presents to the emergency room complaining of shortness of breath, palpitations, and tingling of the lips and fingers. He appears anxious and describes a sensation of impending doom. His ECG and plain chest radiograph are normal. Which of the following arterial blood gas findings would you expect in this patient? A. pH 7.32 pCO2 49 mm Hg bicarbonate 24 mEq/L B. pH 7.40 pCO2 40 mm Hg bicarbonate 25 mEq/L C. pH 7.50 pCO2 23 mm Hg bicarbonate 21 mEq/L D. pH 7.52 pCO2 40 mm Hg bicarbonate 44 mEq/L Explanations (u) A. These values are consistent with a respiratory acidosis. (u) B. These values fall within the normal range. (c) C. This patient is suffering an acute anxiety attack and resultant hyperventilation and respiratory alkalosis. Labs show alkaline pH, depressed pCO2 and low to normal bicarbonate. (u) D. These values suggest metabolic alkalosis. Ref: (29)
85. Clinical Intervention/Cardiology A 60 year-old male has unstable angina, but is otherwise healthy. A 90% lesion is found in the left main coronary artery. Which of the following interventions is most appropriate? A. Thrombolysis with t-PA B. Medical management with nitrates C. Coronary artery bypass graft (CABG) D. Percutaneous transluminal coronary angioplasty Explanations (u) A. Thrombolysis is recommended in acute embolic occlusion, not chronic. (u) B. Medical management is appropriate only for patients who are not surgical candidates. (c) C. CABG is indicated in patients with stenosis of the left main coronary artery and those with three-vessel 37 coronary artery disease. (u) D. Percutaneous transluminal coronary angioplasty is not the management of choice in left mainstem artery disease because of increased potential complications and mortality. Ref: (30)
86. History & Physical/Endocrinology Which of the following descriptions is most typical of a patient with acromegaly? A. Mask-like face with decreased blinking and oily skin B. Non-pitting facial edema with dry course hair and dry skin C. Round face and red cheeks with hirsutism D. Coarsened facial features with prognathism and prominent brow Explanations (u) A. Mask-like face with decreased blinking and oily skin is usually seen in a Parkinson's disease. (u) B. Non-pitting facial edema with dry course hair and dry skin is commonly seen with myxedema. (u) C. Round face and red cheeks with hirsutism is commonly seen in Cushing's syndrome (c) D. Coarsened facial features with prognathism and prominent brow are typical findings for acromegaly. Ref: (3)
87. Health Maintenance/Gastrointestinal/Nutritional The birth weight of an infant has usually tripled by A. the second and third month. B. the fourth and fifth month. C. the seventh and eighth month. D. one year. Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. A child triples his/her birthweight by one year. Ref: (13)
88. Diagnosis/ENT/Ophthalmology A patient presents with complaint of sudden onset of recurrent episodic vertigo for one week that happens when rolling onto the left side. The patient states that this sensation lasts approximately 30 seconds and then goes away. The patient admits to associated nausea. The patient denies associated hearing difficulties or tinnitus. Which of the following is the most likely diagnosis? A. Benign positional vertigo B. Mnire's disease C. Acoustic neuroma D. Vestibular neuronitis Explanations (c) A. Benign positional vertigo is characterized by the sudden onset of vertigo when rolling onto the affected side or tilting the head up. The typical duration is less than a minute. There can be associated nausea and vomiting. There is no impact on hearing and no associated tinnitus. (u) B. Mnire's disease is characterized by a sudden onset of vertigo that lasts several hours to more than a day. Patients typically have sensorineural hearing loss and tinnitus. (u) C. Acoustic neuroma is characterized by an insidious onset of vertigo with impaired unilateral hearing and the presence of tinnitus. (u) D. Vestibular neuronitis (acute labyrinthitis) has a sudden onset of vertigo lasting hours to two weeks. There is no hearing impairment or tinnitus. Ref: (3) 38 89. Diagnostic Studies/Neurology A 21 year-old male college student is admitted to the hospital with suspected meningitis. A lumbar puncture is performed. The results of the cerebrospinal fluid (CSF) analysis reveals an elevated white blood cell count of 5,000/mcL with over 90% neutrophils, a decreased glucose level of 35 mg/dL, and elevated protein level of 150 mg/dL. What is the most likely diagnosis based on these results? A. Bacterial meningitis B. Viral meningitis C. Fungal meningitis D. Tuberculous meningitis Explanations (c) A. CSF results with bacterial meningitis reveal an elevated white count with predominance of neutrophils, a low glucose, and an elevated protein level. (u) B. CSF values in patients with viral meningitis are lymphocytic pleocytosis with normal glucose and normal or slightly elevated protein. (u) C. CSF findings in fungal meningitis include lymphocytic pleocytosis, elevated protein, and decreased glucose. (u) D. CSF findings with TB meningitis reveals elevated pressure, lymphocytic pleocytosis, elevated protein, and decreased glucose. Ref: (1)
90. Scientific Concepts/Cardiology Which of the following pathogens has been linked with the development of acute myocarditis? A. Human papilloma virus B. Rotavirus C. Human Herpes Virus 6 D. Coxsackie B virus Explanations (u) A. Human papilloma virus most commonly is associated with venereal warts and not myocarditis. (u) B. Rotavirus is primarily responsible for acute diarrhea. (u) C. Human Herpes Virus 6 is the causative organism for Roseola. (c) D. Although associated with a number of infectious and systemic diseases, myocarditis is most frequently the result of a viral infection, with Coxsackie B virus and echovirus being the most frequently implicated in the infection. Ref: (1)
91. Clinical Therapeutics/Urology/Renal Which of the following medications is most likely to cause acute tubular necrosis? A. Trimethoprim-sulfamethoxazole (Bactrim) B. Acetaminophen C. Cephalothin (Kefzol) D. Gentamicin Explanations (u) A. See D for explanation. (u) B. Acute renal failure can develop as a result of acetaminophen overdose however this is rare. (u) C. Some first generation cephalosporins may cause renal insufficiency this too is rare. Aminoglycosides are still more nephrotoxic. (c) D. In hospitalized patients up to 25% of patients receiving aminoglycosides sustain some degree of acute tubular necrosis. Gentamicin is one of the most toxic aminoglycosides, streptomycin is the least nephrotoxic of the aminoglycosides. Ref: (28)
39 92. Diagnosis/Pulmonology A 32 week preterm infant has an APGAR score of 9 at 5 minutes. Thirty minutes after delivery, tachypnea, retractions, and expiratory grunting are noted. Cyanosis and dyspnea appear with little response to oxygen. Physical examination reveals poor air movement bilaterally. A chest x-ray reveals air bronchograms and a fine reticular granular pattern. Which of the following conditions should be suspected? A. Atelectasis B. Diaphragmatic hernia C. Respiratory distress syndrome D. Pneumothorax Explanations (u) A. Small areas of atelectasis usually are asymptomatic. While larger areas may present with similar clinical findings, the chest x-ray findings are not consistent with atelectasis. (u) B. Chest x-ray in a patient with a diaphragmatic hernia would not show a fine reticular granular pattern. (c) C. Clinical findings of increasing cyanosis unresponsive to oxygen therapy and the characteristic x-ray findings are most consistent with respiratory distress syndrome. (u) D. Chest x-ray in a patient with a pneumothorax would not show a fine reticular granular pattern. Ref: (5)
93. History & Physical/Orthopedics/Rheumatology Which of the following mechanisms of action is most commonly associated with meniscal tears? A. Hyperextension B. Axial loading and rotation C. Hyperflexion D. Valgus force to the lateral knee Explanations (u) A. Hyperextension injuries usually result in ACL and PCL injuries. (c) B. Axial loading and rotation most likely result in meniscal injuries. (u) C. Hyperflexion injuries result in PCL injuries. (u) D. Valgus force to the lateral knee more than likely results in medial collateral ligament injuries. Ref: (26)
94. Clinical Intervention/Obstetrics/Gynecology A 46 year-old G4P4 African American female presents to the clinic complaining of heavy and prolonged menstrual flow over the past 6 months. Gynecological history includes menarche age 12 and LMP 3 weeks prior. Pelvic exam reveals a 14-week size, irregular uterus. Pelvic ultrasound shows the presence of a large intramural fibroid with normal endometrial lining. Which of the following is the most appropriate management for this patient? A. Oral contraceptive pill B. Levonorgestrel-releasing IUD C. Hysterectomy D. Myomectomy Explanations (u) A. Oral contraceptive pills do not treat the leiomyomas.. (u) B. A levonorgestrel-releasing IUD works for treatment of menorrhagia related to multiple smaller leiomyomas (c) C. Large leiomyomas are the most common indication for hysterectomy in this age group. (u) D. Myomectomy is not an option for this large of an intramural fibroid. Ref: (8)
40 95. Diagnostic Studies/Gastrointestinal/Nutritional A 66 year-old female presents to your office complaining of progressive difficulty swallowing over the last 6 months. Initially she had difficulty only with meats, but now she has dysphagia with other foods as well. Which of the following is the most appropriate initial diagnostic study? A. Barium swallow B. Endoscopy C. CT scan D. Urea breath test Explanations (u) A. Barium swallow may be used in the evaluation of dysphagia, but does not allow for biopsy to be performed. (c) B. Endoscopy is the diagnostic study of choice in a patient with progressive dysphagia because of its ability to obtain tissue for diagnosis. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (28)
96. Diagnosis/Cardiology A patient is having a routine physical examination. Funduscopic examination reveals AV narrowing and venous nicking. The nasal border of the optic disc appears blurred. Which of the following is the most likely underlying cause? A. Hypertension B. Macular degeneration C. Retinal detachment D. Diabetes mellitus Explanations (c) A. Hypertensive retinopathy may cause AV narrowing and venous nicking due to these blood vessels having increased pressures. (u) B. Macular degeneration is associated with the formation of Drusen and neoproliferation. (u) C. Retinal detachment is observed funduscopically by the retina being displaced from its attachment. Patients will present with complaints of floaters in the eye field or abrupt loss of vision if the detachment is complete. (u) D. Diabetes mellitus is most closely associated with neovascularization and microaneurysms as its primary manifestations. Ref: (3)
97. Clinical Therapeutics/ENT/Ophthalmology A 32 year-old female presents complaining of spiking fevers. She was seen four weeks ago with a complaint of left ear pain and was treated for otitis media. She continues to have symptoms, but now has pain behind the ear. On examination you note left post auricular tenderness and erythema. Which of the following is the treatment of choice in this patient? A. IV antibiotics B. Mastoidectomy C. IM steroids D. Ventilating tube placement Explanations (c) A. IV antibiotics are the treatment of choice in a patient with mastoiditis. (u) B. Mastoidectomy is reserved for patients with mastoiditis who fail medical therapy. (u) C. IM steroids are not indicated in the treatment of mastoiditis. (u) D. Ventilating tube placement is indicated in patients with auditory tube dysfunction and chronic serous otitis media. Ref: (28)
41 98. Health Maintenance/Dermatology Zostavax (varicella-zoster vaccine) is contraindicated in which of the following groups of patients? A. Chemotherapy patients B. Adults over 60 years of age C. Patients allergic to eggs D. Patients who have recovered from shingles Explanations (c) A. Zostavax is a live attenuated vaccine and is contraindicated in patients with immunodeficiency states, malignancy affecting the bone marrow, pregnant women, and patients taking immunosuppressive medications. (u) B. A single dose of zoster vaccine is recommended for patients over the age of sixty without other contraindications. (u) C. Patients with an anaphylactic reaction to gelatin or neomycin should not receive the Zostavax vaccine. However, egg allergy is not a contraindication to the Zostavax vaccine. (u) D. Patients who have recovered from shingles may still receive the vaccine. This may decrease recurrent varicella zoster and postherpetic neuralgia in these patients. Ref: (28)
99. History & Physical/Neurology A 75 year-old male presents to the ER with the following stroke findings: right-sided hemiparesis (face and hand more affected than leg), homonymous hemianopsia of the right half of both visual fields, and aphasia. Where is the location of his stroke? A. Anterior cerebral artery B. Middle cerebral artery C. Posterior cerebral artery D. Internal carotid artery Explanations (u) A. Patients with anterior cerebral artery stroke will have findings greater in the legs than hands. (c) B. This case is a description of a middle cerebral artery stroke. (u) C. Posterior cerebral artery stroke patients will have midbrain and thalamic or sensory findings. (u) D. Internal carotid artery stroke patients will have amaurosis fugax, visual disturbances and crossed symptoms. Ref: (1)
100. Scientific Concepts/Pulmonology Patients with long-term exposure to silica, coal dust, and asbestos may develop which of the following as complications? A. Airway hyperreactivity B. Epithelial hyperplasia C. Pulmonary fibrosis D. Upper airway obstruction Explanations (u) A. Airway hyperreactivity is classically seen with asthma and while acute exposure to occupational mineral dusts may cause airway hyperreactivity, this does not persist in long-term exposures. (u) B. Epithelial hyperplasia is one of the mechanisms involved in the pathogenesis of chronic bronchitis and is not involved in the pneumoconioses. (c) C. The principal processes in the pathogenesis of this set of diseases is inflammation and subsequent fibrosis. (u) D. The upper airway is not involved in this disease process. Ref: (7)
42 101. Diagnosis/Orthopedics/Rheumatology A 14 year-old patient, who fell on his outstretched hand, complains of pain along his entire arm. There is point tenderness and swelling over the midshaft of the radius. There is significant pain with limited flexion of the elbow joint. An x-ray will most likely show which of the following fractures? A. Galeazzi's B. Scaphoid C. Colles' D. Smith's Explanations (c) A. Galeazzi's fracture/dislocation involves a fracture of the mid or distal radial shaft with distal radioulnar joint dislocation. (u) B. A scaphoid fracture is a fracture of the scaphoid bone and would not cause pain in the elbow joint. (u) C. A Colles' fracture of the distal radius has a characteristic "silver fork" deformity, but does not involve the elbow joint. (u) D. A Smith's fracture is the reverse of a Colles' fracture, with volar angulation of the distal radius, but does not involve the elbow joint. Ref: (29)
102. Diagnostic Studies/Pulmonology You are evaluating a patient whom you suspect has asthma. You perform spirometry before and after administration of an inhaled short-acting bronchodilator. After administration of the bronchodilator, which of the following spirometry results would suggest reversibility? A. Decrease in FEV1 B. Increase in FEV1 C. Decrease in FVC D. Increase in FVC Explanations (u) A. See B for explanation. (c) B. In asthma, the airway obstruction should be at least partially relieved be a short-acting bronchodilator. This would be reflected in an increased forced expiratory volume in 1 second (FEV1). (u) C. The forced vital capacity (FVC) is not a function of obstruction and is generally normal in early mild asthma or lower than expected in severe or long-standing asthma. Either way, it is not expected to change with administration of a short-acting bronchodilator. (u) D. See C for explanation. Ref: (7 )
103. Clinical Therapeutics/Gastrointestinal/Nutritional Which of the following is considered to be the treatment of choice for the pruritus that occurs with primary biliary cirrhosis? A. Colchicine (Colzalide) B. Atorvastatin (Lipitor) C. Cholestyramine (Questran) D. Enalapril (Vasotec) Explanations (u) A. Colchicine is used to improve the biochemical abnormalities which may slow the progression of the disease. (u) B. Statins have a role in the management of hyperlipidemia but are not effective in this disease. (c) C. Cholestyramine, a bile salt sequestrant, is able to decrease the pruritus that occurs from the bile stasis and granulomas. (u) D. ACE inhibitors are effective as antihypertensives and in preserving renal function in those with proteinuria, but they have no role in the management of primary biliary cirrhosis. Ref: (7) 43 104. Clinical Intervention/Psychiatry/Behavioral Medicine A 35 year-old male patient comes back to the office for a follow-up visit. He remarks that after 5 weeks on fluoxetine (Prozac) 20 mg per day, he still feels depressed but he denies suicidal ideations. What should you do to help this patient? A. Switch to tricyclic antidepressant B. Increase the dose of fluoxetine C. Switch the patient to divalproex (Depakote) D. Admit the patient to the behavioral health unit Explanations (u) A. Tricyclics are second line in the treatment of depression. (c) B. An antidepressant should be raised to the recommended level and maintained at that level for 4-5 weeks, this patient was on too low of a dose. (u) C. Divalproex is a drug that is used to treat seizures and bipolar disorder. (u) D. This patient denies suicidal ideations, and is not in need of an admission to the behavioral health unit. Ref: (14)
105. Scientific Concepts/Endocrinology Which of the following results from hypersecretion of growth hormone in a 27 year-old patient? A. Addison's disease B. Myxedema C. Acromegaly D. Cushing's syndrome Explanations (u) A. This is a disease of low cortisol production by the adrenal cortices. (u) B. This occurs secondary to severe deficiency of T3 and T4. (c) C. This disease results from excessive growth hormone production generated by the anterior pituitary or an ectopic source. (u) D. Excessive cortisol production is the hallmark of this process. Ref: (7)
106. History & Physical/Cardiology A 33 year-old female presents to the office with a complaint of palpitations. There is no history of any significant heart disease in the past and her symptoms begin and end abruptly on their own. Which of the following is the most likely explanation for these symptoms? A. Atrial fibrillation B. Atrial flutter C. Benign supraventricular tachycardia D. Sinus tachycardia Explanations (u) A. Atrial fibrillation, the most common cause of sustained irregular heart rates, tends to present in an older population or in patients that have underlying heart disease such as mitral stenosis. (u) B. Atrial flutter is not commonly seen in young patients without underlying heart disease although it does tend to be intermittent in nature when it does occur. (c) C. Benign supraventricular tachycardia tends to occur in a young patient without pre-existing heart disease. Symptoms begin and end abruptly without therapy and occurrences happen only intermittently. It is the most likely diagnosis in this setting. (u) D. Sinus tachycardia may occur in a young patient without underlying heart disease but the palpitations and tachycardia tends to start and stop gradually rather than abruptly. Ref: (7)
44 107. Diagnosis/ENT/Ophthalmology A 66 year-old male presents complaining of 6 month history of progressive blurred vision without associated pain. On examination there is no erythema or injection of the sclera. On funduscopic examination there is an absent red reflex and a cloudy lens. Which of the following is the most likely diagnosis? A. Retinal detachment B. Chronic glaucoma C. Age-related macular degeneration D. Cataract Explanations (u) A. In retinal detachment the retina is seen hanging in the vitreous like a gray cloud. (u) B. In chronic glaucoma there will be slight cupping of the optic disc observed. (u) C. Findings in age-related macular degeneration include drusen, degenerative changes in retinal pigmentation, and subretinal neovascular membrane changes. (c) D. Cataracts present with blurred vision that progress over months to years. On examination the red reflex becomes increasingly difficult to visualize until it is finally absent and the pupil is white. Ref: (28)
108. Clinical Intervention/Pulmonology A 32 year-old male with a history of Tetralogy of Fallot with poor right ventricular function presents for evaluation of sleep apnea. There is no evidence of deviated septum. Polysomnography reveals apneic episodes of 60 seconds in duration. Oxygen saturation falls to low levels. Which of the following is the first-line treatment in the management of this patient? A. Uvulopalatopharyngoplasty B. Nasal septoplasty C. Continuous positive airway pressure D. Antidepressants and oxygen Explanations (u) A. Uvulopalatopharyngoplasty (UVVP) is a surgical procedure with resection of pharyngeal soft tissue and partial amputation of the soft palate and uvula. It is a procedure of last resort in most cases of sleep apnea. (u) B. Nasal septoplasty is performed if gross anatomic nasal septal deformity is present. (c) C. Continuous positive airway pressure prevents hypoxemia and maintains patency of the airway. (u) D. Antidepressants have no role in the treatment of sleep apnea. Ref: (28)
109. Diagnostic Studies/Obstetrics/Gynecology A 21 year-old obese woman complains of menstrual irregularity since menarche at age 17. She is 5'5" and weighs 180 pounds. Exam of her face reveals excessive hair growth as well as acne. Her abdomen shows midline hair growth and truncal obesity. A previous pelvic ultrasound shows many small fluid filled ovarian cysts bilaterally. Which of the following is the most appropriate diagnostic study to make the initial diagnosis in this patient? A. Prolactin level B. Endometrial biopsy C. Free testosterone D. Thyroid stimulating hormone Explanations (u) A. Prolactin level will not be elevated in a patient with polycystic ovarian syndrome. (u) B. Endometrial hyperplasia occurs secondary to anovulation, endometrial biopsy is mandatory for follow-up management but is not indicated at diagnosis. (c) C. Hyperandrogenism, as evidenced by elevated free testosterone, supports the diagnosis of polycystic ovarian syndrome. (u) D. An increase of TSH is suggestive of hypothyroidism. Ref: (8) 45 110. Clinical Therapeutics/Orthopedics/Rheumatology Which of the following medications used to treat rheumatoid arthritis is contraindicated in patients with chronic hepatitis? A. Sulfasalazine B. Methotrexate C. Minocycline D. Infliximab Explanations (u) A. Sulfasalazine is a second line medication that can cause neutropenia and thrombocytopenia. (c) B. Methotrexate is contraindicated in patients with chronic hepatitis. (u) C. Minocycline is used for early rheumatoid arthritis with minimal adverse effects. (u) D. Infliximab is a tumor necrosing factor inhibitor and should be used cautiously in patients with heart failure. Ref: (28)
111. History & Physical/Urology/Renal A 22 year-old male presents to the clinic complaining of scrotal pain that radiates into the groin. Patient admits to being a weightlifter and was lifting 24 hours prior to this pain developing into the scrotum. The patient admits to being sexually active with only his male partner. Examination reveals a reddened scrotum and it is difficult to distinguish the epididymis from the testes on the right side. Elevation of the right testicle brings relief of the pain. This is known as a positive A. Prehn's sign. B. Cullen's sign. C. Rovsing's sign. D. Murphy's sign. Explanations (c) A. Prehn's sign is seen in epididymitis when elevation of the scrotum with the affected epididymis to the level of the symphysis pubis brings relief from the pain. (u) B. Cullen's sign is a bluish discoloration of the umbilicus resulting from hematoperitoneum. (u) C. Rovsing's sign is seen in appendicitis when pressure on the left quadrant produces pain in the right lower quadrant. (u) D. Murphy's sign is seen in acute cholecystitis with a sharp increase in tenderness when the gall bladder touches the examining hand causing a stop of the inspiratory effort. Ref: (28)
112. Diagnosis/Cardiology A patient's EKG reveals widened P waves in lead II and large negative deflection of the P wave in lead V1. Which of the following is the most likely underlying cause for this? A. Right atrial enlargement B. Left atrial enlargement C. Right ventricular hypertrophy D. Left ventricular hypertrophy Explanations (u) A. Right atrial enlargement is found on EKG with peaked P waves in lead II and a large positive deflection on the initial P wave in lead V1. (c) B. Wide P waves in lead II and a deep negative deflection in lead V1 is due to P-mitrale which is caused by left atrial enlargement. (u) C. Right ventricular hypertrophy is noted on the EKG by having a large R wave in lead AvR along with a deep S wave in leads V5 or V6. (u) D. On an EKG, left ventricular hypertrophy is associated with tall R waves in leads V5 and V6, deep S waves in AvR and V1, and tall R waves in AvL and AvF. Ref: (7) 46 113. Scientific Concepts/Gastrointestinal/Nutritional A patient diagnosed with Barrett's esophagus is at an increased risk for the development of what type of cancer? A. Squamous cell B. Transitional cell C. Adenocarcinoma D. Atypical carcinoid Explanations (u) A. Squamous cell is not typical for esophageal cancer. (u) B. Transitional cell is a cancer of the bladder. (c) C. The most serious complication of Barrett's esophagus is esophageal adenocarcinoma. (u) D. Atypical carcinoid is more typical of lung cancer. Ref: (7)
114. Diagnostic Studies/Endocrinology A 60 year-old male presents with a two day history of acute, right great toe pain with no trauma or change of activities. He states he is healthy but started a high protein diet three weeks ago to try and lose weight. Examination reveals an erythematous, severely swollen and highly sensitive right great toe with limited range of motion at the metatarsal phalangeal joint. No other joint abnormalities are noted. Which of the following is the most appropriate to confirm the diagnosis? A. Complete blood count B. J oint fluid analysis C. Foot radiograph D. Rheumatoid factor Explanations (u) A. Normal to nonspecific findings will occur on CBC with gouty arthritis lessening this tests clinical utility. (c) B. J oint fluid analysis is needed to confirm the diagnosis of gouty arthritis and rule out other diagnoses such as a septic joint, psoriatic arthritis and other crystalline-associated arthritides. (u) C. Radiographs would only show clinically obvious swelling in cases of acute gouty arthritis. (u) D. Rheumatoid factor is not useful in diagnosing this non-autoimmune process. Ref: (7)
115. History & Physical/Dermatology In a patient with dyshidrotic eczema on which area of the body would associated vesicles be found? A. Axillae B. Intertriginous areas C. Palms D. Upper back Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Vesicles associated with dyshidrotic eczema are most commonly found on the palms with the dorsum of the hands spared. The soles may also be affected in a similar fashion. (u) D. See C for explanation. Ref: (28)
47 116. Clinical Therapeutics/Neurology What is the recommended treatment for absence (petit mal) seizures? A. Phenytoin (Dilantin) B. Carbamazepine (Tegretol) C. Ethosuximide (Zarontin) D. Gabapentin (Neurontin) Explanations (u) A. Phenytoin is used to treat tonic clonic and partial seizures. (u) B. Carbamazepine is used to treat tonic clonic and partial seizures. (c) C. Ethosuximide, valproic acid, and clonazepam are recommended treatments for absence seizures. (u) D. Gabapentin is used to treat partial seizures. Ref: (28)
117. Diagnosis/Pulmonology A 40 year-old woman presents with 3 months of dry cough and intermittent low-grade fever. She is a non-smoker and has no significant family history or past medical history. A purified protein derivative (PPD) test was recently performed at work and was negative. On physical examination she is afebrile with stable vital signs. Lung auscultation reveals crackles in bilateral upper lobes. Chest x-ray shows hilar and mediastinal adenopathy, mild interstitial disease in the upper lung zones, and several small granulomas in both lungs. What is the most likely diagnosis? A. Asbestosis B. Cryptococcosis C. Sarcoidosis D. Tuberculosis Explanations (u) A. Asbestosis typically presents as interstitial disease in the lower lungs and this patient has no known exposure to asbestos. (u) B. Cryptococcosis typically shows pleural-based nodules on x-ray and this patient has no known risk factors (HIV disease, COPD, chronic steroid use). (c) C. Sarcoidosis classically presents as a vague systemic illness with radiographic evidence of any or all of the following: granulomas, hilar and mediastinal adenopathy and interstitial infiltrate. (u) D. The patient's recent negative PPD makes tuberculosis unlikely. Ref: (7)
118. Clinical Intervention/ENT/Ophthalmology A 14 year-old male presents with complaint of worsening sore throat for two weeks. He now complains of fever, difficulty swallowing, and difficulty opening his mouth. The patient's mother states his voice seems muffled. On examination his left tonsil is bulging and the uvula is displaced to the right. Which of the following is the most appropriate management? A. Needle aspiration B. Corticosteroid administration C. Nebulized epinephrine administration D. Nasotracheal intubation Explanations (c) A. Surgical drainage by needle aspiration and antibiotic therapy is the treatment of choice for peritonsillar abscess. (u) B. Corticosteroids, nebulized epinephrine, and nasotracheal intubation are not indicated in the treatment of peritonsillar abscesses. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (5) 48 119. Health Maintenance/Cardiology According to the American College of Cardiology/American Heart Association classification of heart failure, which of the following patients fits the Stage B Classification system? A. Asymptomatic patient with no structural disease or patients who are at high risk for the development of heart failure. B. Asymptomatic patient with structural heart disease. C. Symptomatic patient with structural heart disease. D. Patients with refractory symptoms despite intervention. Explanations (u) A. According to the ACC/AHA 2005 guidelines, patients with risk factors for heart disease but who have yet to develop symptoms are categorized as Stage A. These patients have hypertension and lipid disorders treated along with lifestyle modifications. (c) B. According to the ACC/AHA 2005 guidelines, patients with structural heart disease who have not yet experienced symptoms are classified as Stage B. This is the initial stage in which medication therapy other than just ACE inhibitors are recommended. (u) C. According to the ACC/AHA 2005 guidelines, patients with symptoms and structural heart disease are classified as Stage C. (u) D. According to the ACC/AHA 2005 guidelines, patients with refractory symptoms are classified as Stage D. Ref: (28)
120. Diagnostic Studies/Orthopedics/Rheumatology Which of the following x-ray views will show the presence of a "Scotty dog" deformity seen with spondylolysis? A. Lateral B. Oblique C. Anteroposterior D. Open-mouth odontoid Explanations (u) A. The lateral view is the most appropriate for evaluation of the possible presence of spondylolisthesis, not spondylolysis. (c) B. Spondylolysis results from a defect through the pars interarticularis, which is seen as a defect in the neck of the "Scotty dog" on the oblique view. (u) C. Anteroposterior views will show the alignment of the spinous processes, but not a defect in the pars interarticularis. (u) D. The open-mouth odontoid view is used to visualize the odontoid process and the relationship between the C1 and C2 vertebrae. Ref: (26)
121. Clinical Therapeutics/Psychiatry/Behavioral Medicine You are treating a patient for her first episode of major depression. She has no medical problems and there is no family history of psychiatric disorders. In addition to psychotherapy, which class of drugs should be your first choice for the treatment of this patient? A. Monamine oxidase inhibitors (MAOIs) B. Tricyclic antidepressants (TCAs) C. Selective serotonin reuptake inhibitors (SSRIs) D. Serotonin dopamine antagonists (SDAs) Explanations (u) A. MAOIs should not be first choice in the treatment of this patient because of the concern for potentially lethal hypertension and the need for a restrictive diet. (u) B. Although, TCAs are effective in the treatment of depression, they are not considered first line and have a significant risk of death with overdose. (c) C. SSRIs are the first line treatment for depression because of ease of use, safety, and broad spectrum of treatment. 49 (u) D. SDAs or atypical antidepressants are not first line treatment for depression. Ref: (14)
122. History & Physical/Obstetrics/Gynecology A 29 year-old female G1P1 presents to the office with a one-month history of amenorrhea and a positive home pregnancy test. The first day of her last menstrual period (LMP) was April 4. Using Ngele's rule what is her EDC? A. J anuary 1 B. J anuary 7 C. J anuary 11 D. J anuary 18 Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Ngele's rule is LMP minus 3 months plus 7 days. April 4 minus 3 months equals J anuary 4 plus 7 days equals J anuary 11. (u) D. See C for explanation. Ref: (8)
123. Clinical Intervention/Gastrointestinal/Nutritional An otherwise healthy 23 year-old female presents to the student health office complaining of 3 days of frequent, watery, non-bloody stools. She denies significant abdominal pain, vomiting, fever or dark urine. Others on campus have been seen with the same presentation this week. Initial choice of treatment includes which of the following? A. Fluid intake and bowel rest B. Ciprofloxacin C. Hospital admission with IV fluids D. Atropine Explanations (c) A. Most mild diarrhea will not lead to dehydration with adequate fluids and comfort with rest to the bowel. (u) B. Empiric treatment with antibiotics is not indicated this early. (u) C. See A for explanation. (h) D. Atropine is contraindicated as an antidiarrheal due to the possibility of toxic megacolon. Ref: (1)
124. Diagnosis/Urology/Renal An elderly appearing adult male patient is transported to the emergency room with unconsciousness for an underdetermined amount of time. There is no family and the only history is provided by the paramedics. The patient arouses to verbal and painful stimuli. VS: T-97.0 degrees F rectally, P-52 bpm, R-10, BP-95/60 mmHg. Physical examination is unremarkable except for ecchymosis across his extremities. A Foley catheter is inserted draining a small amount of dark brown urine. Urine dipstick reveals 4+positive hemoglobin and protein. Microscopic urinalysis reveals no RBCs but many renal tubular epithelial cells and renal tubular casts. Drug screen is negative, blood alcohol is 2.5 mg/dL, and creatinine is 4.9 mg/dL. What is the most likely diagnosis? A. Rhabdomyolysis causing acute renal failure B. Obstructive uropathy causing acute renal failure C. Ethanol ingestion causing acute renal failure D. Methanol ingestion causing acute renal failure Explanations (c) A. Since the patient was found unconscious for an undetermined amount of time and the blood alcohol is elevated the patient has been in a state of prolonged immobilization resulting in muscle ischemia resulting in myoglobinuria. This is responsible for turning the dipstick positive without the RBCs seen on the urinary 50 microscopy. The myoglobin causes an acute tubular necrosis resulting in the sloughing of the renal tubular epithelium. Obstructive uropathy does not cause acute tubular necrosis and occurs over time. Methanol ingestion causes visual symptoms, ethylene glycol causes renal failure. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (28)
125. Clinical Therapeutics/Pulmonology A 55 year-old man with a history of chronic bronchitis presents with two days of increased dyspnea and cough with worsening purulent sputum production. He is currently using inhaled albuterol as needed. In addition to systemic corticosteroids, what pharmacologic agent is warranted at this time for treatment of this patient? A. Antibiotic B. Inhaled corticosteroid C. Long acting beta-agonist D. Theophylline Explanations (c) A. Empiric antibiotic treatment is indicated in the treatment of acute exacerbations of COPD if there are sputum changes suggestive of bacterial infection, such as increased quantity and purulence. (u) B. Inhaled corticosteroids are not indicated in the management of acute exacerbations of COPD. (u) C. Long acting beta-agonists are not indicated in the management of acute exacerbations of COPD. (u) D. Theophylline is rarely used in the management of COPD and has no place in the management of acute exacerbations of COPD. Ref: (7)
126. Diagnostic Studies/Dermatology A 26 year-old presents with two days of a generalized, non-pruritic rash with concurrent low grade fever and sore throat. He is otherwise in good health with no history of dermatologic problems other than acne and a non-painful ulceration at the base of his penis seven months ago that resolved spontaneously. Examination reveals a macular- papular rash spread diffusely over the body including the palms and soles of the feet. Shallow ulcers are noted on the buccal mucosa while the pharynx is moderately erythematous. Which of the following is the most appropriate initial diagnostic study? A. Tzanck smear of lesion B. Serum FTA-Absorption test C. Streptococcus pyogenes culture D. Epstein-Barr IgM titer Explanations (u) A. A Tzanck smear is commonly used for diagnosing herpes virus infections. (c) B. With secondary syphilis, 100% of persons test positive with serum FTA-Absorption test. (u) C. Though some attributes of the case point to a scarlatina- like rash the prior genital lesion and palmar involvement make this less likely. (u) D. Epstein-Barr IgM titer is used in the diagnosis of infections such as mononucleosis which would generally not present with this type of rash unless a penicillin had been given to the patient. Ref: (28)
51 127. Diagnosis/Cardiology A 15 year-old male presents acutely to the office. His legs are cool to the touch. Examination reveals that his pulses and blood pressure are higher in the upper extremities than the lower extremities. Femoral pulses are delayed and weakened. Which of the following is the most likely underlying diagnosis? A. Pheochromocytoma B. Conn's Syndrome C. Cushing's Syndrome D. Coarctation of the aorta Explanations (u) A. Pheochromocytoma is most commonly associated with palpitations and feelings of warmth along with episodic (later sustained) hypertension. (u) B. Conn's Syndrome, also known as primary hyperaldosteronism, is found in a patient with hypertension who has unprovoked hypokalemia. (u) C. Cushing's Syndrome is associated with hypertension but is associated with the typical appearance of sustained elevated cortisol levels such as purple striae, buffalo hump, and central obesity. (c) D. Coarctation of the aorta typically has narrowing of the aorta proximal to the left subclavian artery with resultant high blood pressure in the upper extremities and decreased run off to the lower extremities following this narrowed segment. Ref: (3)
128. History & Physical/ENT/Ophthalmology A 60 year-old patient with a history of tobacco and alcohol abuse presents for a routine physical. Which of the following physical examination findings is suspicious for oral carcinoma? A. Painful creamy-white patches overlying erythema B. Red smooth surface tongue C. Small vesicles on an erythematous base D. White lesion that cannot be removed by rubbing Explanations (u) A. Oral candidiasis is characterized by painful creamy white patches overlying erythema. (u) B. Red smooth tongue is characteristic of glossitis which is most commonly associated with nutritional deficiencies. (u) C. Small vesicles on erythematous bases are characteristic of herpetic stomatitis. (c) D. Leukoplakia, premalignant lesions, are white lesions that can not be removed by rubbing. Ref: (28)
129. Health Maintenance/Pulmonology A 33 year-old HIV-positive woman develops an 8mm area of induration following the administration of a purified protein derivative (PPD) test. Her chest radiograph shows no evidence of active tuberculosis (TB) infection. Which of the following is the most appropriate clinical intervention? A. Four-drug regimen for 4 months B. Isoniazid with Rifampin C. Observation only D. Repeat PPD and chest radiograph in 3 months Explanations (u) A. Greater than 5 mm of induration is positive in an HIV-infected patient. A positive PPD and negative chest film is considered latent TB infection and, while requiring treatment, does not require the full four-drug regimen. (c) B. Isoniazid with Rifampin is recommended in HIV positive patients with a positive PPD and a negative chest x- ray. (u) C. Latent TB infection is associated with a risk of progression to tuberculosis and observation alone is inadequate. (u) D. Repeat screening is not helpful since the diagnosis of latent TB infection has already been established. Ref: (28) 52 130. Clinical Intervention/Orthopedics/Rheumatology An x-ray taken on a patient complaining of wrist pain after being hit by a baseball reveals a non-displaced mid-shaft ulnar fracture. Which of the following splints is most appropriate for treatment? A. Thumb spica B. Sugar tong C. Cock-up wrist D. Short arm gutter Explanations (u) A. Thumb spica splints are used for scaphoid fractures. (c) B. Sugar tong splints are best used to immobilize the elbow, wrist and forearm. (u) C. Cock-up wrist splints may be useful in some situations unrelated to fractures, such as to immobilize the wrist for tendinitis or to support it in the case of wrist drop due to radial nerve palsy but not to be used in wrist fractures. (u) D. Short arm gutter splints immobilize only the wrist and the ulnar or radial half of the hand. Ref: (29)
131. Diagnosis/Endocrinology A stuporous patient is brought to the emergency room with a five day history of progressive lethargy and confusion along with polyuria and polydipsia. On examination the patient is dehydrated and is without Kussmaul respirations. Serum glucose is 1200 mg/dL (75-110 mg/dL), serum sodium 150 mEq/L (136-146 mEq/L) serum pH is 7.5 and serum osmolality is 320 mosm/kg (280-300 mosm/kg). Urinalysis reveals no ketones. What is the most likely diagnosis? A. Primary hyperaldosteronism B. Diabetic ketoacidosis C. Lactic acidosis D. Hyperglycemic hyperosmolar state Explanations (u) A. The extreme hyperglycemia eliminates primary hyperaldosteronism as the primary diagnosis. (u) B. The lack of acidemia, ketones and Kussmaul respiratory pattern help to eliminate this as the primary diagnosis. (u) C. The lack of a Kussmaul respiratory pattern greatly lessens the likelihood of lactic acidosis. (c) D. Extreme hyperglycemia with normal pH and negative ketones are hallmark for this clinical picture. Ref: (28)
132. History & Physical/Infectious Diseases A two year-old male is brought into a free clinic with a fever of 102 degrees F for two days. Through an interpreter, the mother states that they are from Romania. Examination reveals that the buccal mucosa has a grainy appearance opposite the second molars. Which of the following is the most likely diagnosis? A. Rheumatic fever B. Roseola C. Rubeola D. Rubella Explanations (u) A. Rheumatic fever causes carditis, arthritis, erythema, subcutaneous nodules, and chorea. (u) B. Roseola, caused by human herpes virus VI, causes a high fever followed by a reticular rash. (c) C. Rubeola or measles causes Koplik spots which are described as the salt-like crystals opposite the second molars. (u) D. Rubella causes a macular rash starting on the face with arthralgias and low-grade fevers. Ref: (28)
53 133. Diagnostic Studies/Cardiology Which of the following valvular heart abnormalities will most likely be seen on echocardiography as a complication of acute myocardial infarction? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral regurgitation Explanations (u) A. Aortic stenosis puts additional strain on the left ventricle and contributes to a patient developing an acute myocardial infarction and does not occur as a result of one. (u) B. Aortic regurgitation is not a consequence of acute myocardial infarction and most commonly occurs as a result of an incompetent valve or dilation of the proximal aorta. (u) C. Mitral stenosis most commonly occurs as a complication of rheumatic fever and not because of an acute myocardial infarction. (c) D. In patients with acute myocardial infarction, echocardiogram can show the severity of mitral regurgitation and the presence of ventricular septal defect if one is present. Acute inferior wall myocardial infarction is associated with acute mitral regurgitation due to necrosis of the posterior papillary muscle which is supplied by the right coronary artery. Ref: (7)
134. Clinical Therapeutics/Obstetrics/Gynecology A 29 year-old female has been diagnosed with infertility due to anovulation. Her provider suggests using a medication that will block the feedback inhibition of estradiol on the hypothalamus and pituitary leading to an increase in FSH. Which of the following medications is the most appropriate for this patient? A. Leuprolide (Lupron) B. Clomiphene citrate (Clomid) C. Medroxyprogesterone acetate (Provera) D. Metformin (Glucophage) Explanations (u) A. Leuprolide inhibits gonadotropin release suppressing ovarian steroidogenesis and ovulation. (c) B. Clomiphene citrate is the agent of choice for women younger than 36 years of age who need induction of ovulation. (u) C. Medroxyprogesterone acetate inhibits pituitary gonadotropin release, it maintains a pregnancy; used for secondary amenorrhea. (u) D. Metformin decreases hepatic glucose, reduces body weight which in turn can improve ovulatory function in women with PCOS; it is sometimes used as an adjunct with clomiphene citrate in anovulation. Ref: (8)
135. Health Maintenance/Pulmonology You are seeing 62 year-old African American male for health maintenance. He is a former cigarette smoker with a 40 pack-year history. He quit smoking 10 years ago. He denies cough, hemoptysis, shortness of breath, chest pain, weight loss, or night sweats. What method of screening for lung cancer is appropriate in this patient? A. Chest radiograph B. Spiral CT of the chest C. Sputum cytology D. No screening is recommended Explanations (u) A. Screening chest radiographs have not been shown to improve outcomes when used to screen asymptomatic patients. (u) B. While CT may yet prove valuable for screening, it is cost-prohibitive and has not yet been validated as a screening modality in asymptomatic patients. (u) C. Sputum cytology is not an effective screening tool. 54 (c) D. No routine screening for lung cancer is recommended for asymptomatic smokers or former smokers. Ref: (7)
136. Clinical Intervention/Urology/Renal A 23 year-old male being treated for an acute bacterial prostatitis has been taking antibiotics for less than 24 hours. He presents to the emergency room today with acute urinary retention for 12 hours. Which of the following is the most appropriate next step? A. Insert a Foley catheter. B. Initiate diuretic therapy. C. Schedule for cystoscopy. D. Insert a percutaneous suprapubic tube. Explanations (h) A. Urethral catheterization, or any form of instrumentation is contraindicated in the presence of acute bacterial prostatitis. (h) B. Diuretic therapy is contraindicated in the treatment of acute urinary retention. (u) C. See A for explanation. (c) D. Inserting a percutaneous suprapubic tube is the treatment of choice in a patient with acute bacterial prostatitis who develops acute urinary retention. Ref: (33)
137. History & Physical/Gastrointestinal/Nutritional A 72 year-old man presents with acute left lower quadrant abdominal pain. He has nausea, vomiting, and constipation. He has a fever of 101 F and guarding and rebound tenderness in his left lower quadrant. His white blood cell count is elevated. He has no prior history of gastrointestinal disease. Which of the following is the most likely diagnosis? A. Inflammatory bowel disease B. Irritable bowel syndrome C. Viral gastroenteritis D. Acute diverticulitis Explanations (u) A. Inflammatory bowel disease typically presents in a younger population. (u) B. Irritable bowel syndrome is not associated with nausea, vomiting and fever. It usually presents in a younger population. (u) C. Viral gastroenteritis typically does not localize to the left lower quadrant. (c) D. Acute abdominal pain, fever, left lower abdominal tenderness, and leukocytosis are hallmark signs of acute diverticulitis. Ref: (28)
138. Diagnosis/Neurology You are examining a patient with right-sided extremity weakness and left-sided weakness of the face. Where is the lesion? A. Brainstem B. Cerebral hemisphere C. Cerebellum D. Basal ganglia Explanations (c) A. A patient with a unilateral sensory or weakness finding on one side of the body and contralateral finding of weakness or sensory loss of the face has a brainstem lesion. (u) B. Patients with cerebral hemisphere lesions may present with motor, sensory, visual or auditory findings depending on the lesion. 55 (u) C. Patients with cerebellum lesions present with ataxia, intention tremor, and dysmetria. (u) D. Patients with basal ganglia lesions present with bradykinesia, akinesia, and loss of postural reflexes. Ref: (1)
139. Clinical Therapeutics/ENT/Ophthalmology A 9 year-old patient presents for follow up of his allergic rhinitis symptoms. He continues to complain of nasal congestion, sneezing, rhinorrhea, and eczema despite avoidance therapy and treatment with oral cetirizine (Zyrtec) and nasal flunisolide (Nasarel). Examination reveals pale, boggy nasal mucosa and eczema of the face and lower extremities. Which of the following is the most appropriate treatment at this time? A. Ipratropium bromide B. Montelukast C. Immunotherapy D. Cromolyn sodium Explanations (u) A. Ipratropium bromide does not alleviate the sneezing and pruritus symptoms this patient is experiencing. (u) B. Montelukast is less effective than intranasal steroids in the management of allergic rhinitis. (c) C. Immunotherapy is recommended in patients with severe allergic rhinitis who fail to respond to drug therapy and allergen avoidance. This patient has failed avoidance therapy, as well as antihistamines and intranasal corticosteroids. (u) D. Cromolyn sodium is much less potent than intranasal steroids and will likely not improve the patient's symptoms. Ref: (28)
140. Diagnostic Studies/Psychiatry/Behavioral Medicine What laboratory test should be followed routinely every six to twelve months in patients taking lithium? A. Complete blood count B. Calcium C. Potassium D. Thyroid stimulating hormone Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Lithium induces hypothyroidism because of the decrease in concentration of circulating thyroid hormones. Ref: (14)
141. History & Physical/Cardiology Which of the following conditions is most closely associated with an increased intensity of the P2 heart sound? A. Atrial septal defect B. Aortic stenosis C. Ventricular septal defect D. Mitral valve prolapse Explanations (c) A. Atrial septal defect can cause a left to right shunt with resultant increased volume in the right ventricle. The net result of this is that the P2 heart sound will be accentuated because of the increased blood flow in the right ventricle and increased force of contraction in the right ventricle to remove this blood. Atrial septal defect will also cause a fixed split S2 heart sound. (u) B. Aortic stenosis primarily affects the left ventricle and causes left ventricular hypertrophy. As the left ventricle contracts harder against increased valvular resistance, a systolic ejection murmur occurs. 56 (u) C. Ventricular septal defect most commonly causes a holosystolic murmur as its most notable ausculatory finding. (u) D. Mitral valve prolapse most commonly is associated with a mid-systolic click with or without a systolic heart murmur. Ref: (3)
142. Diagnosis/Orthopedics/Rheumatology A 12 year-old male presents with pain in his left leg that is worse at night. Aspirin relieves the pain and the patient denies injury. On examination, there is point tenderness over the tibia, and the patient has a slight limp that favors the left leg. Radiographs show a 1 cm radiolucent nidus surrounded by osteosclerosis. Which of the following is the most likely diagnosis? A. Osteosarcoma B. Legg-Calve-Perthes disease C. Osgood-Schlatter disease D. Osteoid osteoma Explanations (u) A. Osteosarcoma and Ewing sarcoma are malignant bone tumors that present with pain and swelling. No improvement is noted with conservative therapy. (u) B. Legg-Calve-Perthes disease is avascular necrosis of the hip affecting boys ages 4-10. (u) C. Osgood-Schlatter disease is inflammation of the tibial tuberosity affecting mainly boys in the ages of 10-15. Commonly associated bilaterally and due to jumping. (c) D. Osteoid osteoma is a benign tumor in children age 5 to 20, presents with increasing pain, worse at night and relieved by aspirin. Ref: (26)
143. Clinical Therapeutics/Gastrointestinal/Nutritional A 25 year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema of the esophagus are noted. Silver stain is positive for hyphae. The best treatment option for this patient is A. acyclovir (Zovirax). B. omeprazole (Prilosec). C. fluconazole (Diflucan). D. penicillin G. Explanations (u) A. Acyclovir is an antiviral used in the treatment of herpes esophagitis. (u) B. Omeprazole is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease with esophageal ulceration and peptic ulcer disease and is not indicated in the treatment of infectious esophagitis. (c) C. The patient has Candida esophagitis and the treatment of choice is fluconazole. (u) D. Penicillin G is an antibiotic and is not effective against fungal infections. Ref: (7)
144. Clinical Intervention/Dermatology A 28 year-old male presents with burns sustained from hot grease splashed on his left hand earlier this afternoon. The burn extends from his palm to the volar aspect of his wrist and has an erythematous base, covered by an intact blister. There are a few small scattered blisters over the dorsum of the left hand. Which of the following is the initial intervention of choice? A. Tetanus prophylaxis B. Admission to a burn unit C. Intravenous fluid administration D. Debridement of blisters 57 Explanations (c) A. Tetanus prophylaxis should be initially considered in all burn patients. (u) B. Admission to a burn unit is not indicated for adult patients with uncomplicated partial thickness burns covering less than 15 to 20% of total body surface area (TBSA). (u) C. IV fluids are indicated for severe partial thickness burns covering more than 10% TBSA or in burns with complications. (u) D. Debridement of blisters is controversial, however blisters on the palms and soles should remain intact. Ref: (17)
145. Clinical Therapeutics/Pulmonology A patient is brought to the emergency room with acute onset of dyspnea and tachypnea. He has a long history of alcoholism and was involved in a motor vehicle accident two days ago. He is hypoxic with crackles auscultated bilaterally. Chest radiography reveals diffuse bilateral infiltrates which spare the costophrenic angle and air bronchograms, there was no cardiomegaly or pleural effusion noted. Oxygen saturation is 70%. Which of the following is the most important initial treatment? A. Tracheal intubation B. Bilateral chest tube insertion C. Type-specific packed cells D. Colloid solutions Explanations (c) A. Tracheal intubation with lowest level of PEEP is required to maintain the PaO2 above 60mmHg or SaO2 above 90% in a patient with ARDS. (u) B. See A for explanation. (u) C. Fluids are the preferred treatment initially for hypovolemia. Type-specific packed cells are given when the patient's blood type is identified. Until then O negative packed cells are administered. (u) D. Use of crystalloid solutions are preferred to avoid pulmonary edema. Ref: (28)
146. Scientific Concepts/Neurology You have just stuck yourself with a sharp needle. In order for you to be able to interpret this sensation, which of the following areas must be intact? A. Anterior spinothalamic tract, basal ganglia, and sensory cortex B. Corticospinal tract, medulla, and basal ganglia C. Pyramidal tract, hypothalamus, and sensory cortex D. Lateral spinothalamic tract, thalamus, and sensory cortex Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Sensory impulses reach the sensory cortex from the spinothalamic tract or the posterior columns. Fibers transmit this to the thalamus which sends impulses to the sensory cortex of the brain Ref: (3)
147. Diagnosis/Obstetrics/Gynecology A 22 year-old G1P0 female presents at 12 weeks gestation with 24 hours of vaginal bleeding. She complains of continued cramping and bleeding requiring pad change every two hours. Vital signs are normal. Vaginal examination shows bleeding with a dilated cervix. Which of the following is the most likely diagnosis? A. Threatened abortion B. Inevitable abortion C. Incomplete abortion 58 D. Complete abortion Explanations (u) A. Threatened abortion (AB) implies the cervix remains closed with only slight bleeding. (c) B. Abortion is inevitable when cervical effacement, dilatation and rupture of membranes is noted. (u) C. Incomplete AB implies the products of conception have partially passed causing continued bleeding, more common after 10 weeks. (u) D. Complete AB is identified by passage of the entire conceptus. Ref: (8)
148. Clinical Therapeutics/Cardiology Which of the following medication classes is considered first-line therapy for patients with Raynaud's phenomenon? A. Beta blockers B. Calcium channel blockers C. Central alpha agonists D. Oral nitrates Explanations (u) A. Beta blockers do not cause vasodilation against this vasospasm which makes them less effective as treatment. (c) B. Calcium channel blockers are first line therapy for patients who have uncontrolled symptoms related to Raynaud's phenomenon. They are vasodilating agents which may play a role in preventing the vasospasm that occurs with this disorder. (u) C. See B for explanation. (u) D. Second line agents for Raynaud's phenomenon may include topical but not oral nitrates. Ref: (28)
149. Health Maintenance/Gastrointestinal/Nutritional A 41 year-old female presents to you for medical screening advice. Her 44 year-old sister passed away recently 18 months after diagnosis of metastatic colon cancer. Which of the following is the most appropriate advice for this patient? A. Double contrast barium enema now and repeat every 5 years if normal B. Rectal occult blood testing annually until age 50 then sigmoidoscopy every 3 years C. Rectal occult blood testing annually until age 50 then screening colonoscopy every 5 years D. Screening colonoscopy now and repeat every 3-5 years if normal Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Hereditary factors are believed to contribute to up to 30% of colorectal cancers. Relative risk is 3.8 times if the family member's cancer was diagnosed at less than 45 years of age. Recommended screening in a single first degree relative with colorectal cancer diagnosed before age 60 is beginning colonoscopy at age 40 or ten years younger than age at diagnosis of youngest affected first-degree relative. Then if negative, every 5 years. Ref: (28)
150. History & Physical/Pulmonology A 27 year-old woman presents with one week of worsening productive cough, dyspnea, fever and malaise. Which of the following physical examination findings would support the diagnosis of lobar pneumonia? A. Decreased tactile fremitus B. Egophony C. Hyperresonance to percussion D. Wheeze 59 Explanations (u) A. Consolidation would increase the transmission of vocal vibrations and manifest as increased tactile fremitus. (c) B. Transmission of vocal sounds through consolidation leads to the changes heard with egophony. (u) C. Dullness, not hyperresonance, would be expected with consolidation. (u) D. Wheezing is associated with narrowing of the small airways as seen in asthma. Ref: (3)
151. Clinical Intervention/Orthopedics/Rheumatology Which of the following interventions is initially indicated for helping to relieve the symptoms of plantar fasciitis? A. Steroid injections B. Short leg walking cast C. Arch supports D. Surgical release Explanations (u) A. Steroid injections can be used to relieve symptoms but may be harmful by causing rupture if given in the plantar tendon greater than 3 or 4 times. (u) B. Short leg walking cast may be used for severe cases refractory to initial treatment. (c) C. Arch supports, NSAIDs and stretching exercises are the initial interventions to help relieve symptoms. (u) D. Surgical release of the plantar tendon is usually reserved for patients who fail all therapies. Ref: (29)
152. Diagnosis/Gastrointestinal/Nutritional A 65 year-old homeless male with a history of pancreatitis is seen in the emergency department for vomiting, upper abdominal pain, back pain and weakness. He is cachetic, pale and jaundiced. A 4-5 cm mass is palpable in the mid to right hypochondrium. What is the most likely diagnosis? A. Chronic cholecystitis B. Carcinoma of head of pancreas C. Fibrolipoma D. Primary biliary cirrhosis Explanations (u) A. Chronic cholecystitis is not typically associated with weight loss or cachexia. There would not be a palpable mass. (c) B. Seventy-five percent of pancreatic cancers are in the head. Risk factors include age, tobacco use, obesity, chronic pancreatitis, family history and previous abdominal radiation. (u) C. Fibrolipoma may present as an abdominal mass, but would not cause weight loss and illness. (u) D. Primary biliary cirrhosis most commonly presents with generalized urticaria and is not associated with an abdominal mass. Ref: (28)
153. Clinical Therapeutics/Urology/Renal A 23 year-old male presents with symptoms of irritative urethral discharge. History reveals recent unprotected intercourse with a new partner. A Gram stain of the urethral discharge is negative for intracellular diplococci. Assuming no allergies, which of the following is the drug of choice? A. Doxycycline B. Penicillin G C. Ceftriaxone D. Amoxicillin 60 Explanations (c) A. Doxycycline 100 mg orally for 7 days is indicated for the treatment of non-gonococcal urethritis. (u) B. Penicillin G is not used in the treatment of Chlamydia urethritis. (u) C. Ceftriaxone is the treatment of choice for uncomplicated gonorrhea. (u) D. Amoxicillin is not used in the treatment of gonococcal or non-gonococcal urethritis. Ref: (28)
154. Scientific Concepts/Cardiology Elevated levels of LP(a) (Lipoprotein a) are considered to be a risk factor for coronary artery disease through which of the following proposed mechanisms? A. Direct inhibition of HDL B. Increasing the formation of VLDL cholesterol C. Competes for binding to the plasminogen receptor D. Enhancement of naturally circulating triglycerides Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Lp(a) lipoproteins are secreted by the liver, constitute 10% or less of the total plasma lipoprotein mass, possess kringle domains homologous to plasminogen, and are associated with vascular disease risk. Having domains homologous to plasminogen, Lp(a) will compete with actual plasminogen for its receptor sites. Plasminogen activates plasmin, which facilitates degradation of fibrin and matrix components. The main component of LP (a) is LDL, a known risk factor for atherosclerosis. (u) D. See C for explanation. Ref: (1)
155. Diagnostic Studies/Endocrinology A 50 year-old female presents describing poor concentration, generalized fatigue, oligomenorrhea and severe acne outbreaks over the past year. On examination she exhibits central obesity, a round face, numerous striae and elevated blood pressure. Which of the following is the most appropriate initial diagnostic study? A. Serum thyroid stimulating hormone B. Dexamethasone suppression test C. Oral glucose tolerance test D. Antithyroperoxidase antibodies Explanations (u) A. Serum thyroid stimulating hormone would be more appropriate for hypo- or hyperthyroidism. (c) B. Dexamethasone suppression test as well as midnight serum cortisol level, late night salivary cortisol level, and urinary free cortisol used singly or in combination to diagnose Cushing's syndrome (Hypercortisolism). (u) C. Patients with Cushing's syndrome do have issues with glucose tolerance, however oral glucose tolerance test would not confirm the presence of a secondary cause of the intolerance. (u) D. Antithyroperoxidase antibodies are commonly ordered when Hashimoto thyroiditis is suspected. Ref: (28)
156. . Health Maintenance/Hematology Adult patients with a compromised immune system should not receive which of the following immunizations? A. Hepatitis A B. Pneumococcal C. Influenza D. Varicella 61 Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Varicella vaccine is a live vaccine and is contraindicated in those individuals with a compromised immune system. Hepatitis A, pneumococcal and influenza are recommended for patients with a compromised immune system. Ref: (28)
157. Clinical Therapeutics/Orthopedics/Rheumatology When injecting a corticosteroid into a joint to help relieve pain, which of the following would most commonly be mixed in the syringe? A. Hyaluronic acid B. Ketorolac C. Chondroitin sulfate D. Lidocaine Explanations (u) A. Hyaluronic acid is usually injected by itself in patients with osteoarthritis. (u) B. Ketorolac is an NSAID that is given orally and not intra-articularly. (u) C. Chondroitin sulfate is taken orally and thought to improve symptoms in osteoarthritis. (c) D. 1% lidocaine and corticosteroids are most commonly used together for joint injections. Ref: (19)
158. Clinical Intervention/Pulmonology A 4 year-old boy is sent home from day care for a severe cough following one week of cold symptoms, including sneezing, conjunctivitis, and nocturnal cough. He presents with paroxysms of cough followed by a deep inspiration, and occasional post-tussive emesis. During severe paroxysms, he exhibits transient cyanosis. What is the most appropriate treatment for exposed contacts at his day care center? A. Macrolide prophylaxis B. Isolation C. Observation and treatment only if symptomatic D. Supportive care only Explanations (c) A. All close contacts of a patient with pertussis should be treated with macrolide prophylaxis, regardless of age, immunization history, or symptoms. (u) B. Isolation of contacts is impractical and unnecessary. (u) C. Pertussis is rarely diagnosed before the paroxysmal stage, by which time exposure of contacts to the pathogen is assured. (u) D. While supportive care is essential in those contacts with symptoms, macrolide prophylaxis is mandatory in all contacts to prevent further spread of the illness. Ref: (5)
159. Clinical Therapeutics/Cardiology Which of the following medication classes is the recommended treatment for patients who have an anterior wall myocardial infarction with poor left ventricular function? A. Beta blockers B. Calcium channel blockers C. Potassium sparing diuretics D. ACE inhibitors 62 Explanations (u) A. Beta blockers need to be used with caution in a patient with severe left ventricular dysfunction as they will worsen left ventricular contractility and may make this dysfunction worse. They are used, however, in the early stages of chronic heart failure. (u) B. Calcium channel blockers have no proven mortality benefit in patients with myocardial infarctions and left ventricular dysfunction. (u) C. Although potassium sparing diuretics are part of the later stage treatment of congestive heart failure and tend to potentiate the other therapies, they are not first-line therapy in a patient with left ventricular dysfunction. (c) D. ACE inhibitors have been proven to be effective in the therapy of heart failure, especially in the setting of left ventricular dysfunction. They are considered first-line therapy in patients with symptomatic left ventricular systolic function. Ref: (28)
160. History & Physical/Obstetrics/Gynecology A 46 year-old woman describes her menstrual periods as regular (occurring every 30 days), prolonged, and with a heavy flow. You document this finding as which of the following? A. Menorrhagia B. Oligomenorrhea C. Metrorrhagia D. Hypomenorrhea Explanations (c) A. Menorrhagia describes long and heavy flow menstrual flow. (u) B. Oligomenorrhea describes menstrual periods that occur more than 35 days apart. (u) C. Metrorrhagia is bleeding that occurs at any time between menstrual periods. (u) D. Hypomenorrhea is usually light flow, sometimes only spotting. Ref: (8)
161. Diagnosis/Dermatology A 30 year-old patient is seen for a non-painful mass on the upper back which has grown slowly over the past year. He denies previous trauma, drainage from the area or history of dermatologic diseases. Examination reveals a four centimeter firm, but highly mobile subcutaneous mass with no overlying skin discoloration or punctum with drainage. Which of the following is the most likely diagnosis? A. Epidermoid cyst B. Hemangioma C. Keratoacanthoma D. Lipoma Explanations (u) A. An epidermoid cyst is a lesion of the dermis, usually with periodic expression of sebaceous material. (u) B. A hemangioma is typically a discolored elevated bed/mass of vessels penetrating to or through the epidermis. (u) C. Keratoacanthoma is rapid in its development, more common in the elderly and confined to the dermis. Resembles squamous cell carcinoma. (c) D. A lipoma is a benign fatty tumor usually developing slowly in the subcutaneous layer and generally remaining small though can become very large. Ref: (10)
63 162. Diagnostic Studies/Urology/Renal A 29 year-old male is involved in a motor vehicle crash. On the secondary survey it is noted that there is blood at the meatus and the patient is suspected of having a pelvic fracture. The patient is otherwise stable. Which of the following tests should be done to evaluate the urinary system? A. Voiding cystourethrogram (VCUG) B. Intravenous pyelogram (IVP) C. Urethrogram D. Renal arteriography Explanations (u) A. A VCUG is done to evaluate urinary reflux in children. (u) B. An IVP can be done as part of an evaluation for hematuria however it is rarely used today. (c) C. A urethrogram is the only procedure that should be done to evaluate this type of injury as urethral integrity may have been compromised secondary to the pelvic fracture. Blood at the meatus is the most important finding of suspected urethral injury. (u) D. Renal arteriography does not have any place in this scenario as there is no evidence of a renal injury. Ref: (33)
163. Clinical Therapeutics/Orthopedics/Rheumatology A 35 year-old female presents with a long standing complaint of dry, scratchy eyes and dry mouth. She also reports dyspareunia. Labs demonstrate a positive anti-nuclear antibody and Anti-La antibodies. The patient has a prolonged Schirmer test. Which of the following classes of medicines should be avoided in treating this condition? A. Antimalarials B. NSAIDs C. Glucocorticoids D. Anticholinergics Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Anticholinergics should be avoided in a patient with Sjogrens syndrome. All the other medications may be used to treat the systemic symptoms of Sjogrens. Ref: (1)
164. History & Physical/Neurology A 64 year-old right-handed woman presents to the emergency room. The patient is pleasant and cooperative, but you note that the left side of her mouth has little movement as she talks, resulting in some dysarthric speech. On physical examination, the left side of her mouth droops, eyebrows raise symmetrically, frown is symmetric, and eyes close but left offers little resistance to opening. You suspect which of the following? A. Upper motor neuron damage to CN VII (central facial palsy) in left hemisphere B. Upper motor neuron damage to CN VII (central facial palsy) in right hemisphere C. Lower motor neuron damage to CN VII (Bell's palsy) on the left D. Lower motor neuron damage to CN VII (Bell's palsy) on the right Explanations (u) A. See B for explanation. (c) B. The upper face is controlled by pathways from both sides of the face. Upper motor neuron lesions cross, findings on the left are due to lesions on the right. Lower motor neuron lesions of the face are ipsilateral. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (3)
64 165. Diagnosis/Cardiology The 35 year-old patient presents after a syncopal episode while throwing a football with his son. Examination reveals regular heart rate and EKG is normal. There were no symptoms prior to the episode. Right radial pulse is decreased. Which of the following is the most likely explanation for the syncope? A. Carotid sinus hypersensitivity B. Vasovagal episode C. Cardiac dysrhythmia D. Subclavian steal syndrome Explanations (u) A. Carotid sinus hypersensitivity typically presents with syncope that is related to turning of the head (such as backing a car out of a driveway) or from tight collars. (u) B. Vasovagal episodes may result in syncope but there would not be abnormal pulse findings. (u) C. Cardiac dysrhythmia may occur in the setting of exercise but this would not produce a decreased pulse on the affected side. (c) D. Subclavian steal syndrome occurs if the subclavian artery is occluded proximal to the origin of the vertebral artery which results in reversal in the direction of blood flow in the ipsilateral vertebral artery. Exercise of the ipsilateral arm may increase demand on the vertebral flow which produces a "subclavian steal". Ref: (28)
166. Clinical Intervention/Gastrointestinal/Nutritional Which of the following is the treatment of choice for patients with celiac disease? A. Gluten-free diet B. Small bowel resection C. Clindamycin D. Whipple procedure Explanations (c) A. Removal of all gluten from the diet is essential to therapy in celiac disease. (u) B. Celiac disease is a dietary disorder that resolves with gluten free diet. Small bowel resection is not indicated. (u) C. Antibiotics are not therapeutic for celiac disease. (u) D. Whipple procedure is used in the treatment of pancreatic carcinoma and is not indicated in the management of celiac disease. Ref: (28)
167. Health Maintenance/Psychiatry/Behavioral Medicine Who is the most likely adult to sexually abuse a child? A. School teacher B. Friend of the family C. Scout leader D. Family member Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation (c) D. Adults within the immediate or extended family perpetrate the most child sexual abuse, usually this is a trusted member of the family. Ref: (14)
65 168. Diagnostic Studies/ENT/Ophthalmology An 18 year-old male who was struck in the left eye with a baseball presents with ocular pain, periorbital ecchymosis, and restricted upward gaze. Which of the following is the diagnostic study of choice in this patient? A. Zygomatic arch x-ray B. CT scan of the orbit C. Ultrasonography D. Fluorescein staining Explanations (u) A. Zygomatic arch x-ray is not the diagnostic study of choice for a suspected blowout fracture. (c) B. CT scan of the orbit is the study of choice to evaluate a suspected blowout fracture. (u) C. Ultrasound may be helpful if there is a suspected foreign body, however it is not helpful in fracture identification. (u) D. Fluorescein staining is indicated in the evaluation of corneal abrasion, not orbital fracture. Ref: (29)
169. History & Physical/Orthopedics/Rheumatology In the neonate, unequal thigh folds may indicate which of the following? A. Coxa vara B. Legg-Calve-Perthes disease C. Developmental hip dysplasia D. Slipped capital femoral epiphysis Explanations (u) A. Coxa vara is a hip deformity that would present with a decrease in the hip angle and a shift of the femoral shaft medially. (u) B. Legg-Calve-Perthes disease presents with a painless limp in children ages 4-10 due to avascular necrosis of the femoral head. (c) C. A dislocated hip displaces proximally in developmental hip dysplasia, causing a shortening of the leg that may present as unequal thigh folds. (u) D. A slipped capital femoral epiphysis is primarily an adolescent disorder with decreased range of motion in abduction and internal rotation of the hip on physical examination. Ref: (26)
170. Clinical Therapeutics/Pulmonology A previously healthy 8 month-old boy is hospitalized for acute bronchiolitis. He has no known significant past medical or family history. On admission, he exhibits nasal flaring and retractions with a respiratory rate of 68, axillary temperature of 102.0 degrees F and O2 saturation of 86%. Which of the following medications is indicated? A. Prednisolone B. Oxygen C. Ceftriaxone (Rocephin) D. Palivizumab (Synagis) Explanations (u) A. Corticosteroids are not indicated for the treatment of previously healthy infants with bronchiolitis. (c) B. Oxygen is an important supportive therapy for hypoxemic infants with bronchiolitis. Bronchodilators would also be initiated in this patient. (u) C. Antibiotics are not indicated in the treatment of bronchiolitis unless there is a secondary bacterial infection. (u) D. Palivizumab is used only for prevention of RSV infection. Ref: (5)
66 171. Scientific Concepts/Cardiology Which of the following is the most common complication that occurs in the setting of acute pericarditis? A. Pericardial effusion B. Left ventricular failure C. Superior vena cava syndrome D. Subclavian steal syndrome Explanations (c) A. Accumulation of transudate, exudate or blood in the pericardial sac can occur due to pericardial inflammation. (u) B. Patients with acute pericarditis may have problems with filling which affects the right ventricle more than the left ventricle. (u) C. Patients with lung malignancy may develop superior vena cava syndrome as a result of tumor invasion into the superior vena cava. (u) D. Patients with subclavian steal syndrome typically present with arm ischemia and syncope and is not related to pericarditis. Ref: (1)
172. Diagnosis/Infectious Diseases A 19 year-old college student has a severe sore throat and a temperature of 102 F. On examination, there are vesicles on the soft palate with some erythema. The tonsils are not enlarged. There is mild cervical lymph node enlargement. Which of the following is the most likely diagnosis? A. Epstein-Barr virus B. Coxsackie virus group A C. Streptococcus pyogenes D. Mycoplasma pneumoniae Explanations (u) A. Epstein-Barr is accompanied by generalized lymphadenopathy. Exudative pharyngitis and tonsillitis may also occur. (c) B. Coxsackie virus group A is characterized early by petechiae or papules/vesicles on the soft palate that become shallow ulcers in about 3 days. (u) C. Streptococcus pyogenes produces an exudative pharyngitis. (u) D. Mycoplasma pneumoniae is characterized by conjunctivitis, otitis media, and atypical pneumonia. Ref: (7)
173. History & Physical/Gastrointestinal/Nutritional A 45 year-old type 2 diabetic female with history of cholelithiasis presents to the clinic with 2-3 episodes of sudden, severe epigastric pain that radiates to her shoulder. She has associated nausea and vomiting. Temperature is 101 degrees F and she is experiencing chills. Today her eyes appear yellow in color. Which of the following is the most likely diagnosis for this patient A. Postcholecystectomy syndrome B. Cholangitis C. Gastroesophageal reflux disease D. Pancreatic cancer Explanations (u) A. The patient has no history of previous gall bladder surgery. (c) B. Cholangitis is characterized by a history of biliary pain, fever, chills, and jaundice associated with episodes of abdominal pain. (u) C. Gastroesophageal reflux disease (GERD) is characterized by heartburn. Fever and jaundice are not typical features of GERD. (u) D. Pancreatic cancer, although a possibility, is characterized by chronic weight loss, epigastric pain radiating to the back, and occasional jaundice. Fever and chills are not typical features. Ref: (28)
67 174. Clinical Intervention/Endocrinology A 32 year-old male with a history of pheochromocytoma is seen in the office. The patient is scheduled for adrenalectomy, however has developed a throbbing headache and racing heart. Vital signs reveal pulse 126 bpm, blood pressure 160/115 mmHg, and respiratory rate 20. The patient appears diaphoretic and anxious. Which of the following is the most appropriate acute management in this patient? A. Oral Phenoxybenzamine (Dibenzyline) B. Hydrochlorothiazide (Diuril) C. Lisinopril (Prinivil) D. Bumetanide (Bumex) Explanations (c) A. Phenoxybenzamine is an alpha-blocker utilized to control hypertension in patient with a pheochromocytoma. (u) B. Hydrochlorothiazide is not appropriate in the management of hypertension in a patient with a pheochromocytoma. (u) C. ACE inhibitors are not indicated in the management of hypertension in a patient with pheochromocytoma. They may be used if blood pressure is difficult to control with alpha-blockers alone. (u) D. Bumetanide is not appropriate in the management of hypertension in a patient with a pheochromocytoma. Ref: (7)
175. Clinical Therapeutics/Hematology A 21 year-old male with a diagnosis of type 1 von Willebrand disease undergoes dental extraction of his wisdom teeth. The patient comes to the clinic with continued oozing of the dental sockets despite packing. Treatment should begin with which of the following? A. DDAVP B. Factor VIII C. vWF concentrate D. FFP Explanations (c) A. DDAVP causes the release of vWF and factor VIII from storage sites significantly which is needed to complete hemostasis. Factor VIII is indicated for patients with Hemophilia A. Fresh frozen plasma is indicated in Coumadin overdosage and vWF concentrate is indicated in type 2 and 3 patients with von Willebrand disease. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (28)
176. Diagnosis/Obstetrics/Gynecology Topic: 4d Author: Annette Larson A 54 year-old female comes to your office with the complaint of vaginal itching. Her last menstrual period was three years ago. On examination the patient's vulva is smooth and somewhat shiny; her vaginal mucosa is pale and thin with a mild yellowish discharge with a pH of 6.0. The most likely cause of these symptoms is which of the following? A. Lichen sclerosis B. Atrophic vaginitis C. Contact Dermatitis D. Candidiasis Explanations (u) A. Lichen sclerosis is a benign, chronic inflammatory process and the most common vulvar dermatologic disorder. During the acute phase the lesions appear red or purple and involve the non hair bearing areas of the vulva and perianal areas. Erythema and edema of the skin occur. (c) B. Atrophic vaginitis is typically caused by reduced estrogen levels producing intense itching and thin vaginal mucosa with a resultant yellowish discharge that has a pH >5.5. (u) C. Contact dermatitis is relatively common with red, edematous skin surfaces and sometimes with vesicles and secondary infection. (u) D. Candidiasis produces a white curdy discharge with a pH of <4.5. Ref: (8) 68 177. Diagnostic Studies/Cardiology Which diagnostic study is considered to be the strategy of choice for symptomatic patients with recurrent ischemia, hemodynamic instability or impaired left ventricular dysfunction? A. Stress echocardiography B. Exercise treadmill testing C. Coronary angiography D. Cardiac magnetic resonance imaging Explanations (h) A. Stress echocardiography should not be performed in the setting of a patient who is acutely symptomatic. (h) B. Exercise treadmill testing should not be performed in the setting of an unstable patient with ongoing cardiac symptoms. (c) C. Coronary or cardiac catheterization is the gold standard technique in the evaluation of patients with significant cardiac symptoms. Anatomical information along with degree of coronary artery blockages are provided and patients may be able to undergo coronary revascularization during or after this procedure. (u) D. Cardiac magnetic resonance imaging has limited availability and is not part of national guidelines for evaluation of the cardiac patient. Ref: (28)
178. History & Physical/Psychiatry/Behavioral Medicine On performing a mental status examination you notice that the patient tends to repeat words and phrases out of context to your questions. This type of thought disorder is defined as which of the following? A. Flight of ideas B. Perseveration C. Circumstantiality D. Derailment Explanations (u) A. With flight of ideas, thoughts move from one topic to another with rapid speech. (c) B. Definition of perseveration is the persistent repetition of words or concepts in the process of speaking. This is often seen in cognitive disorders, schizophrenia, and other mental illness. (u) C. Circumstantiality includes much detail, but information is not relevant. (u) D. Derailment is speech with loose associations and sentences that do not make sense. Ref: (14)
179. Clinical Intervention/ENT/Ophthalmology An elderly patient with a history of hypertension presents with epistaxis. On examination you note blood from both nares and down the posterior oropharynx. Examination of the nasal cavity with an ENT headlamp does not show an area of bleeding. Which of the following is the treatment of choice in this patient? A. Electrical cautery B. Direct pressure on the nose C. Petroleum jelly application D. Posterior nasal packing Explanations (u) A. Cautery and direct pressure are effective in anterior, not posterior epistaxis. (u) B. See A for explanation. (u) C. Petroleum jelly application is not indicated in posterior epistaxis. (c) D. Posterior epistaxis is more common in elderly patients, especially with hypertension. Posterior nasal packing is the treatment of choice. Ref: (29)
69 180. Clinical Therapeutics/Neurology A 50 year-old female with a history of coronary artery disease presents to the office requesting medication for an exacerbation of her migraine headaches. She complains of migraines approximately once a month. What medication is contraindicated in this patient? A. Sumatriptan (Imitrex) B. Propranolol (Inderal) C. Droperidol (Inapsine) D. Naproxen sodium (Anaprox) Explanations (c) A. The triptans are contraindicated in patients with coronary artery disease or peripheral vascular disease and should be avoided in patients with an increased risk for stroke. All other drugs listed are not contraindicated. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (28)
181. Scientific Concepts/Orthopedics/Rheumatology Which of the following is the underlying pathogen for the development of Lyme disease? A. Borrelia burgdorferi B. Bartonella henselae C. Rickettsia rickettsii D. Coxiella brunetti Explanations (c) A. Lyme disease is a tick-borne illness caused by the spirochete B. burgdorferi. (u) B. Bartonella henselae is the spirochete that causes cat scratch fever. (u) C. Rickettsia Rickettsii is the spirochete that causes Rocky Mountain Spotted Fever. (u) D. Coxiella brunetti is the spirochete that causes Q fever. Ref: (32)
182. History & Physical/Cardiology Which of the following is a systemic manifestation of infective endocarditis? A. Hemarthrosis B. Petechiae C. Cafe au lait spots D. Bronzing of the skin Explanations (u) A. Hemarthrosis is most commonly a consequence of a clotting disorder such as hemophilia. (c) B. Petechiae, splinter hemorrhages, J aneway lesions, and Osler's nodes are systemic manifestations of patients who have infective endocarditis. (u) C. Cafe au lait spots are seen in Neurofibromatosis (von Recklinghausen's syndrome). (u) D. Bronzing of the skin is most commonly associated with hemochromatosis or Addison's disease. Ref: (3)
70 183. Diagnostic Studies/Gastrointestinal/Nutritional Which of the following is the most appropriate study for diagnosing Hirschsprung disease? A. Rectal biopsy B. Stool leukocyte test C. CT of the abdomen and pelvis D. Fecal occult blood test Explanations (c) A. A rectal biopsy showing the absence of ganglion cells in both the submucosal and muscular layers of the involved bowel is the most appropriate diagnostic study for Hirschsprung disease. (u) B. Stool leukocyte testing can indicate an infectious etiology of diarrhea and is not indicated in the diagnosis of Hirschsprung disease. (u) C. Radiographic examination may show dilated proximal colon and absence of gas in the pelvic colon, but is not diagnostic for Hirschsprung disease. (u) D. Fecal occult blood testing is not indicated in the diagnosis of Hirschsprung disease. Ref: (13)
184. Clinical Intervention/Urology/Renal A patient has been followed for 3 years with a continual decline in glomerular filtration rate (GFR). Currently the GFR is 10 ml/min and examination of the patient reveals a pericardial friction rub. Which of the following is the most appropriate intervention at this time? A. Hemodialysis B. Continue to observe C. Administration of high dose steroids D. Bilateral nephrectomy Explanations (c) A. The patient has end stage renal disease and with the pericardial friction rub is in need of immediate hemodialysis. (u) B. The patient already has significant renal compromise, further observation will continue to lead to further complications. (u) C. High dose steroids have no benefit in end stage renal disease. (u) D. Surgical removal of the kidneys will not change the progression of the disease. Ref: (28)
185. Diagnosis/Endocrinology An adult male is noted to have a hard nodule in the helix of his left ear that discharges a small amount of chalky, white crystals. He denies any history of trauma. Which of the following is the most likely diagnosis? A. Rheumatoid nodule B. Keloid C. Cutaneous cyst D. Tophus Explanations (u) A. A rheumatoid nodule does not discharge any material unless subjected to repetitive trauma and tend to be wide spread over the body as well. (u) B. The lack of trauma history and the discharge make keloid unlikely. (u) C. A cutaneous cyst will generally be smooth and may have a comedone associated with it. Any discharge tends to be a foul smelling sebaceous material. (c) D. The discharge of crystalline material is typical for a tophus lesion which represent underlying gout. Ref: (3)
71 186. Diagnosis/Pulmonology Which histologic type of lung cancer is typically centrally located? A. Adenocarcinoma B. Bronchoalveolar C. Large cell D. Squamous cell Explanations (u) A. Adenocarcinoma of the lung typically presents as a peripheral lesion. (u) B. Bronchoalveolar carcinoma, actually a subset of adenocarcinoma of the lung, typically presents as a peripheral lesion. (u) C. Large cell lung cancers usually develop as peripheral lesions. (c) D. Most squamous cell lung cancers are centrally located. Ref: (28)
187. Clinical Therapeutics/Obstetrics/Gynecology A 25 year-old G2P2 married female presents to the clinic for birth control counseling. Her past history includes deep vein thrombosis with her last pregnancy. She does not want another pregnancy for at least 4 years. The birth control method that would be best for this patient is which of the following? A. Vaginal ring B. Transdermal patch C. Combined oral contraceptive pill D. Levonorgestrel releasing IUD Explanations (u) A. The risk of venous thromboembolism with combined hormone in ring is similar to the oral contraceptive pill (OCP). (u) B. The risk of venous thromboembolism with combined hormone in patch is similar to OCP. (u) C. The use of oral OCPs triples a user's risk of venous thromboembolism. (c) D. IUD releases potent progestin only; is not a combination contraceptive. Ref: (8)
188. History & Physical/Orthopedics/Rheumatology Which of the following is an extra-articular manifestation of rheumatoid arthritis? A. Vasculitis B. Malar rash C. Coronary artery aneurysms D. Periorbital xanthelasma Explanations (c) A. Vasculitis affecting any organ system is seen in patients with severe rheumatoid arthritis. (u) B. A malar rash is frequently seen in systemic or discoid lupus. (u) C. Coronary artery aneurysms are frequently a manifestation of Kawasaki's disease. (u) D. Xanthelasma is a skin finding that occurs in hyperlipidemia. Ref: (26)
72 189. Clinical Intervention/Hematology A patient receiving heparin therapy for 6 days for deep vein thrombosis develops thrombosis at the IV site. The INR is 1.1. The aPTT is 66 seconds and the platelet count is 47,000 down from 148,000 on admission. Which of the following is the most appropriate treatment? A. Protamine sulfate administration B. Platelet administration C. Discontinue the heparin D. Schedule the patient for plasmapheresis Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Once the diagnosis of heparin induced thrombocytopenia is suspected treatment should include immediate discontinuation of all forms of heparin and treatment with a direct thrombin inhibitor should begin. Platelet administration is generally not indicated. Protamine sulfate is used for heparin overdosage and plasmapheresis would not be indicated as the platelet count will resume when the heparin is discontinued. (u) D. See C for explanation. Ref: (28)
190. Diagnostic Studies/Cardiology A 76 year-old male presents after returning from a Safari in Africa. Seven days ago he experienced chest pressure lasting one hour that did not respond to three sublingual nitroglycerin tablets. There was no ability to have lab work or an EKG. The pain has not returned. If the patient had a non-STEMI myocardial infarction, which of the following studies will still be positive? A. Electrocardiogram B. Myoglobulin C. CK-MB index D. Troponin I Explanations (u) A. Patients suffering from a non-STEMI myocardial infarction will not develop Q waves and most likely will have a normal EKG five days after an acute event. (u) B. Myoglobulin is a nonspecific enzyme that is released into the circulation after any skeletal muscle damage, including a myocardial infarction. It is the first enzyme that becomes positive in the setting of acute myocardial infarction but its non-specific measurement makes it less useful in the setting of acute myocardial infarction. It returns to baseline within 24 hours after infarction. (u) C. CK-MB index has improved sensitivity for myocardial muscle damage that occurs with acute myocardial infarction but it returns to baseline within 2-3 days after injury. (c) D. Troponin I levels will stay positive for at least one week following myocardial infarction and is the preferred enzyme to measure in this setting. Ref: (28)
191. Diagnosis/ENT/Ophthalmology A 75 year-old patient with history of macular degeneration and hypertension presents with complaint of sudden onset of visual loss in the left eye. The patient denies pain. On examination you note a dome-shaped retina and subretinal fluid that shifts with position changes. Which of the following is the most likely diagnosis in this patient? A. Central retinal vein occlusion B. Acute angle-closure glaucoma C. Acute nongranulomatous anterior uveitis D. Serous retinal detachment Explanations (u) A. Central retinal vein occlusion is characterized by sudden monocular visual loss on examination there would be disc swelling, venous engorgement, cotton-wool spots, and diffuse retinal hemorrhages. (u) B. Acute angle-closure glaucoma is characterized by pain and blurred vision. On examination the eye is red, the cornea is steamy, and the pupil is moderately dilated and nonreactive to light. 73 (u) C. Acute nongranulomatous anterior uveitis presents with acute unilateral eye pain, redness, photophobia, and vision loss. (c) D. Serous retinal detachment is characterized by a dome shaped retina and subretinal fluid that shifts position with posture changes. Serous retinal detachment results from subretinal fluid accumulation which can occur in exudative age-related macular degeneration. Ref: (28)
192. Scientific Concepts/Psychiatry/Behavioral Medicine A patient with known drug dependence mentions that he commonly sees sounds and hears colors. What is his drug of choice? A. Lysergic acid diethylamide B. Cannabis sativa C. Cocaine D. Heroin Explanations (c) A. Lysergic acid diethylamide is LSD, the phenomenon that this patient is experiencing is called synesthesia, which is common in patients who abuse hallucinogens. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (14)
193. Clinical Therapeutics/Infectious Diseases A disulfiram-like reaction may occur when alcohol is consumed with which of the following antibiotics? A. Ampicillin B. Levofloxacin (Levaquin) C. Metronidazole (Flagyl) D. Erythromycin Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Agents that may elicit a disulfiram-like reaction include calcium carbamide, hypoglycemic sulfonylureas, chloramphenicol, furazolidone, metronidazole, quinacrine, and certain cephalosporins. (u) D. See C for explanation. Ref: (15)
194. History & Physical/Pulmonology Which of the following is the most likely presentation of an acute pulmonary embolism (PE) in a patient without preexisting cardiac or pulmonary disease? A. Anginal chest pain B. Cough C. Tachypnea D. Palpitations Explanations (u) A. While it is quite common for PE to present with pleuritic chest pain, angina-like pain is only rarely reported. (u) B. Cough is reported in roughly one-third of patients with PE. But is not the most common presentation. (c) C. Tachypnea is the most common symptom in acute PE. (u) D. Palpitations are uncommonly reported in acute PE. Ref: (7) 74 195. Diagnostic Studies/Obstetrics/Gynecology A 24 year-old sexually active woman presents to the clinic complaining of dysmenorrhea, dyspareunia and backache that occurs premenstrually. Pelvic examination shows pain upon uterine motion and uterosacral nodularity in the posterior vaginal fornix. The definitive diagnosis for this patient requires which of the following? A. Pelvic ultrasound B. CT of the abdomen C. Laparoscopy with biopsy D. CA-125 test Explanations (u) A. Pelvic ultrasound has little value in diagnosing endometriosis. (u) B. CT of the abdomen has little value in diagnosing endometriosis. (c) C. Diagnosis of endometriosis must be made by direct visualization. Laparoscopy with biopsy is the most appropriate diagnostic study in this patient. (u) D. CA-125 may be elevated in endometriosis, but it is not diagnostic. Ref: (8)
196. Clinical Intervention/Neurology A 45 year-old male patient presents to the office with a complaint of dizziness and vertigo that occurs suddenly when he rolls out of bed in the morning. He denies previous illness or any medical problems. On physical exam you note the presence of lateral nystagmus after a few second latency period. What is your recommendation for this patient? A. Low dose diazepam B. Repositioning maneuvers C. Diuretics and a low salt diet D. MRI of the brain Explanations (u) A. Low dose diazepam is used to treat acute vertigo. (c) B. This patient has benign paroxysmal positional vertigo (BPPV) and repositioning maneuvers are recommended to move endolymphatic debris out of the posterior semicircular canal. (u) C. Diuretics and a low salt diet are used to treat Meniere's disease. (u) D. An MRI of the brain should be ordered in a patient in whom a central etiology of vertigo is suspected. Ref: (1)
197. Clinical Therapeutics/Dermatology A patient presents with 3 weeks of worsening pruritic rash located on the upper extremities and interdigital spaces. He is a migrant farm worker with no history of skin disorders. Examination reveals excoriated, erythematous papules with numerous 3-4 mm long, narrow tracts spreading from the papules. What is the best treatment for this patient? A. Permethrin (Nix) B. Prednisone (Deltasone) C. Montelukast (Singulair) D. Pimecrolimus (Elidel) Explanations (c) A. Permethrin is used to kill the scabies mite. (u) B. Corticosteroids have no affect on mites. (u) C. Montelukast would possibly provide symptomatic relief but would not be curative for scabies. (u) D. Pimecrolimus has no affect on destruction of mites. Ref: (28)
75 198. Diagnosis/Gastrointestinal/Nutritional A 32 year-old male with history of tobacco abuse presents with an intermittent burning sensation in his chest for six months, worsening over the past 2 weeks. His wife has noticed episodes of coughing at night. He denies dysphagia, weight loss, hematemesis, or melena. His vital signs are all normal and physical examination is unremarkable. Which of the following is the most likely diagnosis? A. Peptic ulcer disease B. Acute gastritis C. Gastroesophageal reflux disease D. Esophageal stricture Explanations (u) A. Peptic ulcer disease typically presents with midepigastric pain and is not usually associated with cough. (u) B. Acute gastritis would have a duration of less than 2 weeks. (c) C. Gastroesophageal reflux disease presents with at least weekly episodes of heartburn and typically occurs after meals and upon reclining. Patients may complain of regurgitation, chronic cough, laryngitis, or sore throat. (u) D. Esophageal stricture develops from long term gastroesophageal reflux disease. Patients with esophageal stricture usually have dysphagia. Ref: (1)
199. Clinical Intervention/Cardiology A 52 year-old patient with episodes of syncope has an electrocardiogram which shows a consistently prolonged PR interval with a missing QRS every two beats. Which of the following is the most effective management? A. Permanent pacing B. Beta-blocker C. ACE Inhibitor D. Defibrillation Explanations (c) A. This is consistent with ECG findings of a Mobitz type II AV block. Since the patient is symptomatic this type of AV block requires a permanent pacing to prevent total AV disassociation. (u) B. Beta-blockers will slow conduction from the AV node and is not indicated with this type of AV block. (u) C. There is no indication for ACE Inhibitors in Mobitz Type II heart block. (u) D. Defibrillation is not indicated in a person with AV block. Ref: (7)
200. Health Maintenance/Orthopedics/Rheumatology Which of the following groups is most likely to present with Duchenne's muscular dystrophy? A. Adolescent females B. Middle-aged males C. Infant females D. Toddler-aged males Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Duchenne's muscular dystrophy, a genetic defect on the short arm of the X chromosome, affects toddler-aged males. Ref: (28)
76 201. Diagnostic Studies/Pulmonology What is the diagnostic modality of choice to diagnose cystic fibrosis (CF)? A. Chest radiograph B. Clinical features C. Sweat chloride concentration testing D. Genotyping Explanations (u) A. Radiographic findings may suggest the diagnosis but are not specific. (u) B. While clinical features may suggest the need for testing they are not useful in confirming the diagnosis. (c) C. The standard for diagnosis is two positive sweat chloride concentration tests obtained on separate days or identification of CF mutations or an abnormal nasal potential difference measurement. (u) D. Genotyping screens for only a fraction of the known CF mutations. Ref: (28)
202. Scientific Concepts/Obstetrics/Gynecology A pregnant 28 year-old female presents at 30 weeks gestation complaining of fatigue and headache. Her vital signs and physical examination are normal. Routine hemoglobin screening is 10.1 g/dL. Peripheral smear shows microcytic, hypochromic red blood cells. Besides the physiologic dilution of pregnancy, what type of anemia is most likely in this patient? A. Iron deficiency B. Folic acid deficiency C. Thalassemia D. Hereditary spherocytosis Explanations (c) A. Iron deficiency anemia is responsible for 95% of anemias during pregnancy. (u) B. Folic acid deficiency anemia is common where nutrition is inadequate. (u) C. Thalassemia is a rare cause of anemia in pregnancy. (u) D. Hereditary spherocytosis is rare during pregnancy. Ref: (8)
203. Diagnosis/Neurology A 70 year-old male is brought to the office by his wife. She is complaining that her husband has been having great difficulty remembering things, however remains alert. She also complains that he is having difficulty getting to the bathroom on time. On physical examination you notice that the patient's gait is wide-based and slow and he walks without lifting his feet off the floor. You also notice a tremor in his right hand. What is the most likely diagnosis? A. Lewy body dementia B. Parkinson's disease C. Normal pressure hydrocephalus D. Frontotemporal dementia Explanations (u) A. Patients with Lewy body dementia have hallucination, Parkinsonism, fluctuating alertness, and falls. (c) B. Patients with Parkinson's disease have clinical features such as bradykinesia, rest tremor, rigidity, postural instability, autonomic dysfunction and behavioral changes. Of the diseases listed, Parkinson's is the most common. (u) C. Patients with normal pressure hydrocephalus have an abnormal gait (apraxic or ataxic), dementia, and urinary incontinence. (u) D. Patients with frontotemporal dementia have predominant behavioral symptoms, dementia, apraxia, Parkinsonism, and motor neuron disease. Ref: (1)
77 204. Clinical Therapeutics/Psychiatry/Behavioral Medicine Higher doses of SSRIs are usually required in which of the following conditions? A. Obsessive-compulsive disorders B. Depression C. Manic depression D. Panic disorder Explanations (c) A. Higher doses of SSRIs are needed in the treatment of OCD for a beneficial effect. (u) B. Although patients with depression may occasionally need to have an increase in the SSRI dosage, higher doses are not needed for beneficial effect. (u) C. Patients who are bipolar will often have worsening of their manic symptoms with the use of SSRIs. (u) D. SSRIs are good drugs to treat patients with panic disorder, however, these patients are particularly sensitive to the activating effects of SSRIs, so they should be started initially at small dosages and titrated up slowly. Ref: (14)
205. Health Maintenance/Cardiology According to the J oint National Commission VII Guidelines, blood pressure targets are lower in patients with diabetes mellitus and what other condition? A. Liver disease B. Renal disease C. Thyroid disease D. Peripheral vascular disease Explanations (u) A. See B for explanation. (c) B. Blood pressure targets for hypertensive patients at the greatest risk for cardiovascular events, particularly those with diabetes and chronic kidney disease, are lower (less than 130/80) than for those individuals with lower cardiovascular risk (goal is less than 140/90). (u) C. See B for explanation. (u) D. See B for explanation. Ref: (28)
206. Clinical Intervention/Pulmonology A 67 year-old man presents complaining of gradually worsening fatigue and shortness of breath. He is a previous smoker with an 80 pack-year smoking history. He denies chest pain, night sweats, or hemoptysis. On physical examination, you note a very thin male who appears older than his stated age. Lung and heart sounds are barely audible to auscultation. Which of the following interventions is likely to alter the disease course? A. Inhaled bronchodilator therapy B. Inhaled steroid therapy C. Home oxygen D. Theophylline Explanations (u) A. Inhaled bronchodilators afford symptomatic relief for some patients with COPD but do not alter the disease course. (u) B. Inhaled steroid therapy may reduce the number and severity of COPD exacerbations but has not been shown to alter the disease course. (c) C. Home oxygen therapy has been shown to prolong life in patients with COPD and alter the natural history of the disease. (u) D. Theophylline is a third-line agent for treating COPD and will not alter the natural history of the disease Ref: (28)
78 207. History & Physical/Gastrointestinal/Nutritional An afebrile 22 year-old female presents with 2 days of a painful rectal mass which worsens with defecation. She denies any blood with bowel movements. She admits to ongoing constipation and generally poor diet of fast food. She is otherwise healthy. On examination there is a tender, swollen, bluish, ovoid mass visible at the anal margin. Which of the following is the most likely diagnosis? A. Rectal prolapse B. Thrombosed hemorrhoid C. Internal Hemorrhoid D. Rectal polyp Explanations (u) A. Rectal prolapse shows radiating folds and is typically painless. (c) B. A thrombosed hemorrhoid causes acute pain increased with defecation and sitting. (u) C. Internal hemorrhoids are an enlargement of the normal vascular cushions located above the pectinate line. They are not usually palpable and might cause bright red bleeding during defecation. (u) D. Polyps are soft and may be difficult or impossible to feel. Proctoscopy is usually required for diagnosis. Ref: (3)
208. Clinical Therapeutics/Urology/Renal A 26 year-old sexually active woman has a 3-day history of dysuria, frequency, and urgency. She has a fever of 102 degrees F orally with shaking chills and right-sided costovertebral angle tenderness. Urinalysis reveals 10-20 RBCs/HPF, 30 WBCs in clumps/HPF, 3-4 WBC casts and 3+bacteria. Which of the following is the treatment of choice for outpatient management? A. Ciprofloxacin B. Erythromycin C. Doxycycline D. Amoxicillin Explanations (c) A. Treatment with a quinolone is first line treatment of pyelonephritis on an outpatient basis. If the patient were admitted then empiric treatment with Ampicillin and an aminoglycoside IV would be initiated until culture and sensitivity results were obtained. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. Ref: (28)
209. Scientific Concepts/ENT/Ophthalmology Which of the following is the most common etiologic agent associated with acute bacterial sinusitis in the adult population? A. Staphylococcus aureus B. Streptococcus pneumoniae C. Pseudomonas aeruginosa D. Mycoplasma pneumoniae Explanations (u) A. See B for explanation. (c) B. The typical pathogens associated with acute bacterial sinusitis are Streptococcus pneumoniae, other streptococci species, and Haemophilus influenzae. Moraxella catarrhalis and Staphylococcus aureus are less common causes. Pseudomonas is a less common cause and would be associated with nosocomial infection often in a critically ill patient. Mycoplasma is not a typical cause of bacterial sinusitis. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (28) 79 210. Diagnosis/Cardiology A patient presents to the office following a syncopal episode. The patient claims that the syncope occurs when he changes position such as rolling over in bed or when he bends over to tie his shoes. Which of the following is the most likely explanation for this presentation? A. Carotid sinus hypersensitivity B. Vasovagal episode C. Subclavian steal syndrome D. Atrial myxoma Explanations (u) A. Carotid sinus hypersensitivity may present with syncope but is usually related to tight collars or when excessively turning the head. (u) B. Vasovagal episodes may occur with syncope as its manifestation but it is not caused by changes in position. (u) C. Subclavian steal syndrome may present with syncope that is related to exercise of the affected arm which results in a decreased pulse when the Adson maneuver is performed. (c) D. Atrial myxoma most commonly presents with sudden onset of symptoms that are typically positional in nature due to the effect that gravity has on the tumor. Myxomas are the most common type of primary cardiac tumor in all age groups and are most commonly found in the atria. Ref: (28)
211. Diagnostic Studies/Orthopedics/Rheumatology Spina bifida occulta is usually detected by which initial diagnostic evaluation? A. Electroencephalogram B. Alpha-fetoprotein levels C. Folic acid levels D. X-ray of the spine Explanations (u) A. Electroencephalogram (EEG) cannot detect or diagnose spina bifida occulta. (u) B. Alpha-fetoprotein, measured at 16-18 weeks of pregnancy, if elevated, would indicate a neural tube defect, such as spina bifida. (u) C. Folic acid has been shown to decrease the incidence of neural tube defects, not as an aid in diagnosis of the defect. (c) D. X-ray or MRI is the definitive test to diagnose spina bifida occulta, showing the vertebral bony defect. Ref: (5)
212. Scientific Concepts/Hematology Which of the following conditions is caused by a disorder in the red blood cell membrane? A. G6PD deficiency B. Folate deficiency C. Sickle cell anemia D. Hereditary spherocytosis Explanations (u) A. G6PD deficiency results in an increased destruction of red cells that leads to anemia. (u) B. Folate is essential in DNA synthesis, lack of folate leads to ineffective erythropoiesis. (u) C. Sickle cell anemia is a hemoglobinopathy which leads to increased red cell destruction. (c) D. The cell membrane defect of spherocytosis leads to hemolysis due to trapping of the cells by the spleen. Ref: (28)
80 213. Clinical Therapeutics/ENT/Ophthalmology A patient presents complaining of right ear pain and itching. On physical examination you note erythema and edema of the right ear canal with purulent exudate. Palpation of the tragus and manipulation of the auricle is painful. The tympanic membrane is not well visualized. Which of the following is the treatment of choice for this patient? A. Amoxicillin B. Aqueous irrigation C. Tympanocentesis D. Polymyxin B sulfate Explanations (u) A. Amoxicillin is the initial treatment of choice in acute otitis media, not otitis externa. (u) B. Aqueous irrigation is not indicated in the treatment of otitis externa. (u) C. Tympanocentesis is not indicated in the treatment of otitis externa. (c) D. Polymyxin B sulfate is the treatment of choice for otitis externa. Ref: (28)
214. Health Maintenance/Obstetrics/Gynecology A 56 year-old female presents to the clinic wanting testing for ovarian cancer. Her best friend was just diagnosed with Stage 4 primary cancer of the ovary. She denies family history of breast or ovarian cancer. According to screening guidelines, which of the following do you recommend? A. BRCA 1-2 gene testing B. A pelvic ultrasound yearly C. Continue her yearly women's health examinations D. CA-125 testing Explanations (u) A. BRCA 1-2 has been found to be associated with ovarian cancers in approximately 5% of cases. However the expression of this gene in BRACA 1-2 carriers are unpredictable. Therefore, routine testing for this gene has limited value at this time. (u) B. Refined imaging techniques offer promise for the future however much work remains before these tests are considered accurate or cost effective screening tests. (c) C. The patient is advised to have regular pelvic exams. The limited prevalence of ovarian cancer and the lack of sensitivity and specificity of current available tests have so far prevented the implementation of routine ovarian cancer screening of the general population. (u) D. The CA-125 recognizes the antigen CA-125 which is present in serous ovarian tumors but not in mucinous or nonepithelial ovarian tumors however the test is not considered a cost effective screening test. Ref: (8)
215. Clinical Therapeutics/Cardiology Which of the following is the optimal therapy for a 76 year-old patient with no allergies who has chronic atrial fibrillation? A. Aspirin B. Clopidogrel (Plavix) C. Warfarin (Coumadin) D. Low molecular weight heparin Explanations (u) A. Aspirin's role to prevent thromboembolism in atrial fibrillation is limited to patients with no risk factors who are under age 65. (u) B. Clopidogrel is not the optimal therapy for patients with atrial fibrillation. (c) C. Patients older than age 75 who have chronic atrial fibrillation should be anticoagulated with warfarin to maintain an INR between 2.5 and 3.0 for optimum therapy unless a contraindication to therapy exists. (u) D. Due to the increased costs and need for parenteral therapy, daily subcutaneous heparin is not first line therapy unless warfarin therapy is contraindicated. Ref: (7) 81 216. Scientific Concepts/Pulmonology Which of the following causes of pneumonia is most likely to be complicated by diarrhea? A. Legionella B. Chlamydophila C. Mycoplasma D. Pneumococcal Explanations (c) A. Legionella is a water-borne pathogen that can cause diarrhea as a complication of its infection. (u) B. Chlamydophila pneumonia is associated with dry cough, low-grade fever, and hoarseness. (u) C. Mycoplasma pneumonia is most likely complicated by bullous myringitis, hoarseness, rash, and chronic cough. (u) D. Pneumococcal pneumonia presents with a single rigor, rust-colored sputum, and productive cough. There is no diarrhea as part of its infection. Ref: (7)
217. Diagnosis/Psychiatry/Behavioral Medicine A 38 year-old female is brought to the emergency room with a complaint of paralysis of her arms bilaterally. Her history is significant for a sexual assault two days previously. Her physical examination is unremarkable with normal reflexes. There is no apparent physical explanation for her paralysis. What is the most likely diagnosis? A. Body dysmorphic disorder B. Conversion disorder C. Hypochondriasis D. Factitious disorder Explanations (u) A. Body dysmorphic disorder patients have a preoccupation with an imagined defect in appearance that causes significant distress. (c) B. Patients have abrupt loss of motor or sensory function caused by psychological factors that often precede the physical symptoms (u) C. Hypochondriasis is characterized by six months or more of general, non delusional preoccupation with fears of having a serious disease. (u) D. Patients with factitious disorder fake illness. Ref: (14)
218. Health Maintenance/ENT/Ophthalmology At what age should a child's eyes be consistently well-aligned? A. Two months B. Six months C. Twelve months D. Eighteen months Explanations (u) A. See B for explanation. (c) B. A child's eyes should be consistently well-aligned by five to six months of age. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (13)
82 219. Clinical Intervention/Cardiology Patients who undergo percutaneous angioplasty or who have coronary artery revascularization often are treated with glycoprotein IIb/IIIa inhibitors. What is the major side effect associated with these agents? A. Hypotension B. Bleeding C. Coronary vasospasm D. Acute renal failure Explanations (u) A. See B for explanation. (c) B. Glycoprotein IIb/IIa inhibitors have their activity in the final stages of platelet bridging and are associated with bleeding when used in the management of acute myocardial infarction. Since they are effective at treating and preventing new clot formation, bleeding is the main concern and complication with the use of these agents. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (7)
220. Clinical Therapeutics/Gastrointestinal/Nutritional A cirrhotic patient presents with progressive drowsiness and delirium. Physical examination reveals asterixis and tremor. Which of the following medications would you initiate? A. Empiric antibiotic therapy B. Lactulose (Kristalose) C. Bolus fluid challenge with sodium chloride D. Hydrochlorothiazide (Diuril) Explanations (u) A. See B for explanation. (c) B. This patient has hepatic encephalopathy. Increased ammonia levels contribute to the mental status changes associated with hepatic encephalopathy. Lactulose leads to a change in bowel flora so that fewer ammonia forming organisms are present and also helps in the acidification of colon contents which leads to a nonabsorbable ammonium ion creation. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (1)
221. Diagnostic Studies/Infectious Diseases A 19 year-old college student presents to the student health center complaining of a sore throat and mild flu-like symptoms for 2 days. A rapid strep screen and culture are negative. Symptomatic therapy is instituted. The patient returns 3 weeks later complaining of continued sore throat with increasing fatigue and onset of fever. Physical examination reveals an exudative pharyngitis, tender enlarged posterior cervical lymphadenopathy, and the spleen is palpable. Which of the following is most appropriate as the next step in diagnosis? A. Mono spot B. Repeat strep screen C. Anti-EBV antibodies D. Lymph node biopsy Explanations (c) A. With the presence of exudative pharyngitis associated with posterior cervical lymphadenopathy and splenomegaly, infectious mononucleosis is the most likely diagnosis. A mono spot would most likely be positive since the patient has had symptoms for more than 3 weeks. (u) B. A strep screen tests for the presence of beta-hemolytic Streptococcus group A, which would not account for the splenomegaly. (u) C. Anti-EBV antibodies measure specific antibody titers and are not a cost effective diagnostic test at this time. (h) D. Lymph node biopsy is not indicated and may lead to complications in the setting of acute mononucleosis. Ref: (28) 83 222. History & Physical/ENT/Ophthalmology A 50 year-old patient presents complaining of headache and left eye pain for 5 hours. The patient admits to decreased vision in the left eye. The patient also complains of associated nausea. Which of the following is most likely on physical examination? A. Neovascularization B. Central vision loss C. Impaired red reflex D. Moderately dilated, nonreactive pupil Explanations (u) A. Neovascularization is seen with diabetic retinopathy not glaucoma. (u) B. Central vision loss is seen with macular degeneration not glaucoma. (u) C. Impaired red reflex is common with cataract not glaucoma. (c) D. The pupil is moderately dilated and nonreactive to light in acute angle closure glaucoma. Ref: (28)
223. Health Maintenance/Cardiology Which of the following is an absolute contraindication for the performance of exercise stress testing for patients who wish to start an exercise program? A. Second degree heart block type 1 B. Severe aortic stenosis C. Atrial fibrillation with controlled ventricular response D. Recent diagnosis of lung cancer Explanations (u) A. See B for explanation. (c) B. Contraindications to stress testing include rest angina within the last 48 hours, unstable cardiac rhythm, hemodynamically unstable patient, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, and active infective endocarditis. (u) C. See B for explanation. (u) D. See B for explanation. Ref: (7)
224. Diagnosis/Orthopedics/Rheumatology A mother brings her 14 month-old son to your clinic. Earlier today she lifted her son by grabbing him by the wrists and pulling him up off the floor. The child is sitting in his mother's lap with his left forearm is extended and in pronation. He is refusing to move the left arm, forearm or wrist. The arm and joints appear normal with no noted deformities, edema or erythema. Distal pulses and capillary refill are normal and he can move his fingers. Which of the following is the most likely diagnosis? A. Nursemaid's elbow B. Fractured left wrist C. Osteochondritis dissecans D. Child abuse Explanations (c) A. This clinical history is classic for radial head dislocation or nursemaid's elbow. (u) B. There is no edema, deformity or erythema to suggest a fractured wrist. (u) C. Osteochondritis dissecans is avascular necrosis of subchondral bone, most commonly seen during adolescence. (a) D. Although child abuse could be suspected the clinical history best describes nursemaid's elbow. Ref: (29)
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225. Clinical Therapeutics/Endocrinology A patient with Type 2 diabetes uses a mixture of NPH and regular insulin twice daily. She consistently has mid- afternoon bouts of hypoglycemia, despite eating her meals as scheduled. Which modification is most appropriate to reduce her mid-afternoon hypoglycemic events? A. Increase carbohydrate content of lunchtime meal B. Increase fat content of breakfast meal C. Reduce morning dose of NPH insulin D. Reduce morning dose of regular insulin Explanations (u) A. Increasing carbohydrate content of lunchtime meal would be inappropriate if the glycemic control is otherwise normal; might promote weight gain. (u) B. Increasing fat content of breakfast meal would not aid in symptoms as it would slow glucose absorption and potentially worsen the hypoglycemia. (c) C. Reducing the morning dose of NPH insulin would be most appropriate as it exerts its greatest effect on the noontime meal. (u) D. Reducing the morning dose of regular insulin would have more effect on noon blood sugar control. Ref: (28)
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