Diagnosis and Treatment in Internal Medicine, Exams of Nursing

Download Diagnosis and Treatment in Internal Medicine and more Exams Nursing in PDF only on Docsity! NCCPA Physician Assistant National Recertifying Exam PANRE Summer 2024 Review Multiple Choice Questions and Answers 100% Pass A 42-year-old female presents after finding a firm, painless bump in her right eyelid. On examination, you note a 6 mm mass within the tarsus of the right eye. The skin is freely movable over the mass. The remainder of the ophthalmoscopic examination is unremarkable. Which of the following is the most likely diagnosis? A. Pterygium B. Chalazion C. Ectropion D. External hordeolum E. Internal hordeolum - Answer>>Chalazion A chalazion is a painless chronic mass in the eyelid. Hordeolum are acute and red and painful. Pterygium involves the sclera. Ectropion is when the eyelid sags outwardly and the lid doesn't close well. Combinations of antimicrobial agents are commonly employed in the treatment of meningitis in infants less than three months old. Ampicillin is commonly an agent included in this regimen. Ampicillin is used empirically for the possible presence of: A. Escherichia coli B. Listeria monocytogenes C. Cytomegalovirus D. Herpesvirus E. Hemophilus influenzae - Answer>>Listeria monocytogenes While E. Coli can infect an infant delivered vaginally, Ampicillin is given to eliminate Listeria. CMV & HSV are viruses. E. Coli & H. Flu are also typically resistant to ampicillin, and more likely a broader spectrum antibiotic would be used An EKG demonstrates a PR interval of 0.16 seconds, a P to QRS relationship of 1:1, a variable heart rate and an R to R interval that is noted to accelerate ad decelerate during the respiratory cycle. What is the diagnosis? A. Wenckebach B. third degree heart block C. atrial fibrillation D. sinus arrhythmia E. atrial flutter - Answer>>Sinus arrhythmia This is sinus arrhythmia. Wenckebach & third-degree AVB would have a nonconducted P wave. A-fib would have no P waves and an irregularly irregular rhythm. A flutter would have "flutter waves" or a regular rhythm of 150. While suturing a wound, you opt to use lidocaine with epinephrine. The rationale for your choice is: A. an increase in the absorption of the lidocaine. B. an increase in the diffusion of the lidocaine into the nerve's myelin sheath. C. an increase in the blood flow to the area of injection. D. an increase in the duration of anesthesia. E. a decrease in the risk of infection at the site of injection. - Answer>>An increase in the duration of anesthesia erythrocyte sedimentation rate is elevated and her rheumatoid factor is negative. Which of the following diagnosis is most likely? A. progressive systemic sclerosis B. CREST syndrome C. osteoarthritis D. rheumatoid arthritis E. ankylosing spondylitis - Answer>>Rheumatoid Arthritis In spite of the negative RF, Rheumatoid arthritis is the most likely diagnosis. RA characteristically includes small joint symmetrical arthritis, with an elevated ESR (therefore inflammatory, and not OA). 80% of patients with RA will have a positive RF, but 20% will be negative. PSS involves squamous cell thickening and sclerosis causing taut skin of the face and hands and difficulty with esophageal motility. CREST syndrome is a subset of PSS; Ankylosing spondylitis would have an elevated ESR and negative RF, but mainly involves the SI joint and lumbar/thoracic spine fusion (bamboo spine) A patient describes a history of recurrent bouts of uveitis. Her chemistry panel reveals elevated serum calcium and uric acid levels. Her anergy screen is negative. Her chest x-ray demonstrates bilateral hilar adenopathy. Which diagnosis is most likely? A. Silicosis B. Sarcoidosis C. Alpha-1 antitrypsin deficiency D. Histoplasmosis E. Tuberculosis - Answer>>Sarcoidosis Sarcoidosis typically presents with hilar lymphadenopathy and noncaseating granulomas of the lungs (and other organs). In addition, patients may have eye involvement (uveitis). Elevations of ACE, Calcium and uric acid are frequently seen. Which of the following is NOT a characteristic feature of nephrotic syndrome? A. proteinuria B. hematuria C. hypoalbuminemia D. hyperlipidemia E. generalized edema - Answer>>Hematuria Hematuria is present in NEPHRITIC syndrome. Nephrotic syndrome characteristically includes proteinuria (>3.5 gm/day), with resulting low serum albumin, hyperlipidemia, hypertension, hypercoagulability, and generalized edema (from oncotic third- spacing) Which term is used to describe the characteristic concave or "spoon-shaped" nails of iron deficiency anemia? A. leukonychia B. koilonychias C. clubbing D. onycholysis E. paronychia - Answer>>Koilonychia Koilonychia is a spoon-shaping of the nail itself. It is usually a result of iron deficiency anemia. Leukonychia is often associated with hypoalbuminemia that causes partial or complete white discoloration of the nails. Leukonychia may also appear as a rare side effect of systemic chemotherapy in some oncological patients but may also be present with arsenic poisoning, renal failure pneumonia, or heart disease. Clubbing of the nails is an actual thickening or elevation of the nail bed - it is a sign of a release of TNF associated with pulmonary disorders (tissue necrosis factor) typically found in bronchiectasis, lung cancers and cystic fibrosis (the nails are NOT necessarily cyanotic.) Onycholysis is a painless separation of the nail from the nail bed. Several or all nails are usually affected - there are many causes. Paronychia is an infection of the nail bed and nail margin, usually from trauma or more commonly, nail-biting. A 52-year-old male presents complaining of urinary frequency, with hesitancy, and nocturia for the past few months. During his physical examination, you note a nontender, non-enlarged prostate with an isolated right posterior lobe nodule. Which of the following options is most appropriate? A. Order a serum acid phosphatase level B. Initiate prazosin and schedule a follow-up appointment in 6 weeks C. Refer the patient for an ultrasound of the prostate and order a PSA level D. Reassure the patient and schedule a follow-up appointment in six months E. Initiate norfloxacin therapy for 7 days and schedule follow-up in two weeks - Answer>>Refer the patient for an ultrasound of the prostate and order a PSA level This patient has an isolated nodule of the prostate gland — cancer until proven otherwise. You should order an ultrasound and a PSA. BPH will present as a diffuse enlargement, and not a discrete nodule. A 16-year-old boy is in clinic because of a rash. He noticed an itchy rash on his abdomen that is close to his umbilicus. He is a previously healthy boy and is not on any medications. On physical examination vital signs are normal. On skin examination there is a well-demarcated and pruritic area at the subumbilical region with A 24-year-old pregnant woman presents with a rash on her hands with itching that is worse at night. Physical exam shows excoriations over the web spaces of the hands with tiny burrows noted. Several members in her household have similar symptoms. Which of the following is the most appropriate treatment? Ivermectin Lindane 1% cream Permethrin 5% cream Sulfur in petroleum 5% - Answer>>Permethrin 5% cream is a safe treatment for scabies during pregnancy. Less than 2% of an applied dose is absorbed systemically although residual effects of the drug remain for up to ten days after application. Scabies is caused by a mite infestation with Sarcoptes scabiei. These mites burrow under the skin of infested individuals leaving behind eggs and feces in the small epidermal tunnels that they create. These burrows are usually found in the web spaces between digits, intertriginous areas, and flexor creases. Symptoms include itching that is worse at night and a rash or itching that is worse in web spaces or intertriginous areas. History will often reveal others in the household with similar symptoms. Diagnosis of scabies is usually clinical, however, skin scrapings can reveal microscopic confirmation of adult mites or their eggs. Treatment includes permethrin 5% cream, lindane 1% cream (not available in the USA due to side effects), ivermectin, or crotamiton 10% cream. Permethrin 5% cream is safe during pregnancy and is applied over the entire body from the neck down and left on for eight hours. Afterwards, it is washed off entirely. Patients should also be instructed to launder all clothing and bed linen in hot water to prevent reinfestation. How is scabies transmitted? - Answer>>Skin-to-skin contact A 4-week-old boy presents with a 2-week history of increasing dyspnea, cough, and poor feeding. On examination you note conjunctivitis, and a chest examination reveals tachypnea and rales. A chest X-ray shows hyperinflation and diffuse interstitial infiltrates. Which of the following is the most likely etiologic agent? Chlamydia trachomatis Parainfluenza virus Respiratory syncytial virus Staphylococcus species - Answer>>Chlamydia trachomatis infections in newborns can manifest as pneumonia and conjunctivitis. Chlamydial pneumonia is usually seen in infants 3- 16 weeks of age, and they frequently have been sick for several weeks. Fewer than 10% of neonates born to women with active chlamydia infection during labor develop pneumonia. The infant appears nontoxic and is afebrile, but is tachypneic with a prominent staccato cough. Physical examination reveals diffuse rales with few wheezes. The chest film shows hyperinflation and diffuse interstitial or patchy infiltrates and blood work frequently reveals eosinophilia. In addition to chest radiographs and blood work, specimens should be collected from the nasopharynx. Azithromycin, 10 mg/kg on day 1 and 5 mg/kg on days 2-5, is the treatment of choice. Conjunctivitis is present in about 50% of cases. Symptoms include conjunctival injection, various degrees of ocular discharge, and swollen eyelids. This infection is transmitted vaginally from an infected mother, and can present within the first 15 days of life. The diagnostic standard is to culture a conjunctival swab from an everted eyelid. Treatment for conjunctivitis is the same as for pneumonia. Prophylaxis with silver nitrate solution or antibiotic ointments does not prevent vertical perinatal transmission of C. trachomatis, but it will prevent ocular gonococcal infection and should therefore be administered Which medical treatment is known to be beneficial in patients with croup by decreasing edema in the laryngeal mucosa? - Answer>>Corticosteroids Which of the following patients is at highest risk for developing cholelithiasis? 21-year-old woman of European descent 35-year-old thin man with gastric ulcers 41 year-old obese, pregnant woman 55-year-old man on a statin medication - Answer>>41 years-old obese, pregnant women Gallstones, or cholelithiasis, occur in >10% of American adults. They are made up of cholesterol, bile and phospholipids. The two main types are cholesterol stones (90%) and pigmented stone (10%). Cholesterol stones can exist as a single stone or multiple stones. Black pigmented stones can arise in patients with hepatitis and cirrhosis, while brown stones occur during bile duct infection and stasis. Risk factors include age over 40 years old, female sex, pregnancy and obesity. Biliary colic is the main symptom, and is described as an acute onset, episodic right upper quadrant or epigastric pain and nausea, which lasts for 30 minutes to three hours. Diagnosis is made via ultrasound. Treatment includes cholecystectomy and ursodeoxycholic acid. Name another common risk factor for gallstones, especially in a patient post abdominal surgery. - Answer>>Total parenteral nutrition (TPN). and are preceded by influenza-like symptoms. The incidence of erysipelas is rising, especially in young children, the elderly, persons with diabetes, alcoholic persons, and patients with compromised immune systems or lymphedema. Antibiotics should be started as soon as possible in patients with erysipelas. As previously stated, streptococci cause most cases of the disease; thus, penicillin has remained a first-line therapy What is the treatment for erysipelas for patients whom are allergic to penicillin? - Answer>>A first-generation cephalosporin or macrolide, such as erythromycin or azithromycin, may be used if the patient has an allergy Do girls or boys develop SCFE at a younger age? - Answer>>Girls typically present at a younger age (10 to 14 years) as compared to boys (12 to 16 years). Slipped Capital Femoral Epiphysis (SCFE) Patient will be an obese man 12 - 16-years-old Complaining of a progressive limp and knee pain PE will show loss of hip internal rotation Xray will show "scoop of ice cream slipping off an ice cream cone" Diagnosis is made by AP and frog-lateral X-rays Treatment is non-weight bearing and urgent orthopedic consultation A 14-year-old girl presents with right thigh pain that has been going on for the last month. She recalls being kicked in the leg during soccer practice before her symptoms started. She was last seen in the ED two weeks ago and was diagnosed with a muscle contusion. On exam there is a mass palpable over the anterior distal thigh. X-ray of the femur shows a distal femoral diaphyseal lesion with cortical destruction and periosteal reaction with high suspicion for osteosarcoma. Which of the following is true regarding this disease? Blunt trauma is associated with the pathogenesis of osteosarcoma Ionizing radiation for childhood cancer is a risk factor for osteosarcoma Osteosarcoma most often involves the axial skeleton followed by the long bones Pathologic fracture is a common presenting sign - Answer>>Ionizing radiation for childhood cancer is a risk factor for osteosarcoma Osteosarcoma is the most common primary malignancy of the bone. It presents in a bimodal age distribution with peaks in early adolescence and in adults over the age of 65. The most common presenting symptoms are pain and swelling in the affected area. Plain radiographs typically show a mixed radiodense and lytic lesion arising from the metaphyseal bone. "Codman's triangle" or elevation of the periosteum of the bone at the periphery of the tumor is a classic but non-specific feature. The use of ionizing radiation for treatment of childhood solid cancers is well implicated in the development of secondary cancers, with osteosarcoma most often presenting within two decades following treatment. Other risk factors including Paget disease in the adult population and genetic diseases predisposing to a variety of malignancies, for example retinoblastoma. What lab abnormalities are associated with osteosarcoma? - Answer>>Laboratory studies are generally not useful in diagnosis of osteosarcoma, but the most common lab abnormalities include elevated alkaline phosphatase, lactate dehydrogenase (LDH), and erythrocyte sedimentation rate (ESR). Which of the following findings best distinguishes cholangitis from acute cholecystitis? Elevated alkaline phosphatase Fever Jaundice Leukocytosis - Answer>>Jaundice Acute cholecystitis and cholangitis have many similarities in both presentation and laboratory findings. Both can present with right upper quadrant pain, nausea, vomiting, and fever. Patients with cholangitis tend to be more toxic in appearance with possible hypotension and altered sensorium. Laboratory studies for both can also include leukocytosis, elevated alkaline phosphatase, and moderately elevated aminotransferases. An elevated serum bilirubin level (and associated jaundice) is characteristic of cholangitis and infrequently seen in cholecystitis. This may serve to distinguish the two processes. What is Reynold's pentad? - Answer>>Found in patients with cholangitis, it includes right upper quadrant pain, fever, jaundice, hypotension, and altered mental status. A patient presents with weight loss, nervousness, and palpitations. During physical examination, which of the following signs suggests hyperthyroidism? Anterior neck bruit Coarse, dry, scaling skin Distal muscle weakness Superficial spreading melanoma - Answer>>Superficial spreading melanoma This woman most likely has superficial spreading melanoma, the most common subtype of melanoma. Melanoma is a malignant tumor formed by melanocyte transformation. Melanoma is the sixth most common cancer in the United States. Cutaneous melanoma is divided into four major subtypes: superficial spreading, nodular melanoma, lentigo melanoma, and acral lentiginous. Risk factors for melanoma include ultraviolet radiation, history of sunburns, tanning beds, psoralen and ultraviolet A radiation (PUVA) therapy, increased number of nevi, history of melanoma, immunosuppression, increasing age, and fair skin. Key features of melanoma that should prompt referral to a dermatologist are lesion asymmetry, irregular borders, color variations, diameter > 6 mm, and elevated surface. Lesion growth or change, crusting or bleeding, or inflammation should also raise suspicion for melanoma. When performing a skin exam, it is important to not only examine the entire body surface, but to also examine the scalp, palms, soles, digits, and nails. High risk patients should be instructed to perform skin self-examinations. Patients with suspicious lesions should be referred to a dermatologist for biopsy. Depth of invasion is the single most important determinant of prognosis. As tumor thickness increases, survival rate decreases What is Hutchinson sign? - Answer>>Periungual pigmentation. A 73-year-old man presents to his primary care provider complaining of rough bumps on his head. The man is a retired farmer. On physical exam, there are three rough, erythematous papules on his forehead. The lesions are nontender to palpation. Which of the following is the most appropriate management? Bacitracin Topical 0.1% triamcinolone Topical 5% 5-fluorouracil Topical clotrimazole - Answer>>Topical 5% 5-fluorouracil is the most appropriate management for actinic keratosis. Actinic keratosis (AK) are ultraviolet light-induced skin lesions that arise from proliferation of atypical epidermal keratinocytes. AKs have the potential to progress to squamous cell carcinoma. It is estimated that AKs have a transformation rate of 0.03 to 20% per year. Risk factors for the development of AK include fair skin, outdoor occupations, history of sunburn, male sex, increased age, and immunosuppression. AKs most commonly present as solitary or multiple, rough, scaly, erythematous papules on sun-exposed areas. The scalp and forehead are the most common site in men. AKs are commonly seen on the lower extremities in women. The diagnosis of AK is made through physical exam. A punch or shave biopsy is indicated if squamous cell carcinoma is suspected. There are multiple treatment options for AK include surgery, cryotherapy, topical medications (e.g. 5-fluorouracil, imiquimod, diclofenac), chemical peels, and photodynamic therapy. Topical medications are commonly used to treat multiple AKs. What role does epidermal melanin play in the protection against actinic keratosis? - Answer>>Absorbs ultraviolet radiation and shields keratinocytes. Which of the following is the greatest risk factor for an ectopic pregnancy? Multiple sexual partners Previous abdominal surgery Previous ectopic pregnancy Previous pelvic inflammatory disease - Answer>>Previous ectopic pregnancy An ectopic pregnancy is when implantation of the gestational sac occurs outside of the uterus. The most common location for an ectopic pregnancy is the fallopian tubes. It can also occur in the interstitial or cornual portion of the uterus (2%), intraabdominally (1.5%), on the ovary (0.1%) and or within the cervix (0.1%). A history of a previous ectopic pregnancy is regarded as the greatest risk factor for an ectopic pregnancy with an odds ratio of 8.3. Other high-risk features include previous tubal surgery and in utero diethylstilbestrol (DES) exposure. How many days after implantation is beta-hCG detectable? - Answer>>Beta-hCG is secreted from the time of implantation and is detectable about 7-8 days after fertilization A 26-year-old woman reports a history of amenorrhea for the past year. She also had an increased amount of milky discharge from her nipples over the past several months and has lost all interest in sex for the past 6 months. She denies any drug or medication use other than occasional over-the-counter analgesics for frequent headaches. A physical examination confirms the presence of an easily expressed milky discharge, as well as vaginal dryness. A pregnancy test is negative. Which one of the following tests would be most appropriate at this point? Dexamethasone suppression test MRI of the sella turcica Serum prolactin level menstruation is the most widely accepted cause; however its pathogenesis is not clearly understood. The "3 Ds," dysmenorrhea, dyspareunia, and dyschezia, as well as abnormal uterine bleeding are among the well-recognized manifestations. With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or "chocolate cyst." Imaging is of limited value and is only useful in the presence of pelvic or adnexal mass. Ultimately, a definitive diagnosis of endometriosis is made only by histology of lesions removed at surgery. Where is the most common location to find ectopic endometrial tissue in endometriosis? - Answer>>Ovaries What is the most serious complication of impetigo? - Answer>>Acute glomerulonephritis. Impetigo Patient will be a child < 6 y/o Complaining of NON painful, pruritic lesions on face PE will show "honey colored," weeping Most commonly caused by S. aureus Treatment is topical mupirocin Complications: poststreptococcal glomerulonephritis A 72-year-old man with a history of hypertension and coronary artery disease presents with acute onset, painless loss of vision in his right eye. His visual acuity is 20/200 OD and 20/25 OS. His fundoscopic examination is shown above. What is his likely diagnosis? Acute angle closure glaucoma Central retinal artery occlusion Central retinal vein occlusion Retinal detachment - Answer>>Central retinal artery occlusion Central retinal artery occlusion is an ischemic stroke of the retina. It occurs most commonly in patients 50-70 years of age and those with risk factors including hypertension, cardiac and carotid artery disease, vasculitis, and collagen vascular disease. Patients present with an acute onset of unilateral, painless loss of vision that occurs over seconds to minutes. Visual acuity is markedly reduced and there will be an afferent pupillary defect. Fundoscopic examination will reveal an edematous, pale retina with a cherry-red spot. Emergent ophthalmologic consultation is indicated. Potential therapies include digital globe massage, anterior globe paracentesis, intraocular pressure lowering agents such as acetazolamide, and intraarterial thrombolytic therapy. Unfortunately, none of these therapies have been conclusively shown to be beneficial and the prognosis for recovery of vision is poor. What is a normal intraocular pressure? - Answer>>12-22 mm Hg Which white blood cell disorder is characterized by the presence of the Philadelphia chromosome in 90% of cases? A. chronic lymphocytic leukemia (CLL) B. acute lymphocytic leukemia (ALL) C. chronic myelogenous leukemia (CML) D. acute myelogenous leukemia (AML) E. multiple myeloma - Answer>>Chronic Myeloid Leukemia (CML) - (Philadelphia CreaM cheese) Philadelphia Chromosome occurs in CML. ALL occurs in children. AML is associated with Auer rods. Multiple myeloma has Bence- Jones protein. CLL has no clear distinguishing feature except increased lymphocytes. All of the following are factors that predispose a patient to the development of gastroesophageal reflux EXCEPT: A. hiatal hernia B. pregnancy C. scleroderma D. an incompetent esophageal sphincter E. pernicious anemia - Answer>>Pernicious anemia has no correlation with GERD. It is an autoimmune destruction of the gastric parietal cells that make intrinsic factor. Signs & symptoms are not present until B12 levels are very low (and include peripheral neuropathies & ataxia) Which of the following thyroid profiles is most compatible with a diagnosis of primary hypothyroidism? A. a low TSH (thyroid stimulating hormone) level and a high T4 B. a low TSH level and a normal T4 C. a low TSH level and a low T4 D. a high TSH level and a low T4 E. a high TSH and a high T4 - Answer>>High TSH level and a low T4 Low T4 is diagnostic for low thyroid function. If the pituitary is normal (as in primary thyroid disease) the TSH should be high as the pituitary tries to stimulate the failing thyroid gland. A patient warrants antihypertensive medication use for the duration of her pregnancy. Which of the following is the antihypertensive recommended for such patients? A. alpha-methyldopa B. captopril C. nifedipine D. propranolol E. clonidine - Answer>>Alpha-methyldopa Methyldopa (Aldomet) is indicated in pregnancy. ACEI's (captopril) are contraindicated in pregnancy. ß Blockers can be C. Toradol (Ketorlac) D. Hydrotherapy - Answer>>A. IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for rhabdomyolysis. A 42 year-old male presents complaining of a sudden onset of a severe intermittent pain originating in the flank and radiating into the right testicle. He also complains of nausea and vomiting. On examination the patient is afebrile, but restless. Examination of the abdomen reveals tenderness to palpation along the right flank with no rebound or direct testicular tenderness. Urinalysis reveals a pH of 5.4 and microscopic hematuria, but is otherwise unremarkable. Which of the following is the most likely diagnosis? A. Bladder cancer B. Nephrolithiasis C. Acute appendicitis D. Acute epididymitis - Answer>>B. A sudden onset of severe colicky flank pain associated with nausea and vomiting as well as the absence of rebound or direct testicular tenderness makes nephrolithiasis the most likely diagnosis. This is further supported by the presence of hematuria on the urinalysis. Which of the following pathophysiological processes is believed to initiate acute appendicitis? A. Obstruction B. Perforation C. Hemorrhage D. Vascular compromise - Answer>>A. Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body initiates most cases of appendicitis. What is the term for blue discoloration about the umbilicus? A. Cullen's sign B. Murphy's sign C. Rovsing's sign D. Turner sign - Answer>>A. Cullen's sign is a blue discoloration about the umbilicus and can occur in hemorrhagic pancreatitis and results from hemoperitoneum. A patient presents with abdominal pain in the right lower quadrant, examination reveals increased pain in the right lower quadrant on deep palpation of the left lower quadrant. This commonly known as which of the following? A. Psoas sign B. Murphy's sign C. Rovsing's sign D. Obturator sign - Answer>>C. A positive Rovsing's sign can be elicited in a patient with appendicitis when increased pain occurs in the right lower quadrant upon palpation of the left lower quadrant. A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022. Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The most likely diagnosis is A. acute salpingitis. B. nephrolithiasis. C. acute pyelonephritis. D. appendicitis. - Answer>>C. Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness. Urinalysis shows pyuria with leukocyte casts 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 - Answer>>A. High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain. 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. - Answer>>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. Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm? A. abdominal mass B. hypertension C. chest pain A 28 year-old female with diabetes mellitus type 2 sustains a partial thickness burn to her left upper arm and her chest when hot grease spilled on her at home. The burn to her arm is circumferential and the estimated total body surface burned is 18%. She has no allergies. The most appropriate treatment of this patient would include A. outpatient application of silver sulfadiazine. B. debridement of all intact blisters. C. IV cefazolin (Ancef, Kefzol). D. transfer to a burn center. - Answer>>D. Reasons for transfer to a burn center include a partial thickness burn covering greater than 10% of total body surface area. In addition, burns in patients with pre-existing medical conditions, such as diabetes, that could complicate their management, prolong recovery, or affect their outcome, is also a reason for transfer to a burn center. A 72 year-old female is being evaluated for recurrent kidney stones. PE reveals no abnormal findings. Laboratory findings show elevated calcium and decreased phosphate levels. Which of the following is the most likely diagnosis? A. Pheochromocytoma B. Adrenal insufficiency C. Hyperparathyroidism D. Breast cancer - Answer>>C. The majority of patients with hyperparathyroidism are asymptomatic. Recurrent nephrolithiasis may be one of the presentations of primary hyperparathyroidism. Measurement of parathyroid levels would be the initial laboratory test for the evaluation of hypercalcemia. A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention? A. Intra-aortic balloon counterpulsation B. Mitral valve replacement C. Coronary artery bypass surgery D. Immediate fluid bolus - Answer>>B. MVR is the definitive intervention to correct MR caused by papillary muscle rupture. 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 - Answer>>A. Tetanus prophylaxis should be initially considered in all burn patients. Which of the following hyperthyroid patients would be the best candidate for radioiodine therapy? A. A 30-year-old patient with toxic adenoma. B. A 50-year-old man with subacute thyroiditis. C. A patient over age 65 with Grave's disease. D. A pregnant woman with Hashimoto's thyroiditis. - Answer>>C. Radioactive iodine is the recommended treatment for overactive thyroid tissue in patients without risk for subsequent thyroid cancer, leukemia, or other malignancies. A 40-year-old male is hit in the face with a baseball. There is nasal deformity with bleeding. The most appropriate initial management is to A. treat the hematoma with I&D and antibiotics. B. consult with an ENT for immediate reconstructive nasal surgery. C. reduce septal defect using open technique. D. maintain nasal patency and nasal cosmesis. - Answer>>D. Maintain nasal patency until closed reduction can be attempted in 1 week. Which of the following is the selected method for the prevention of venous thromboembolism in a 38-year-old male undergoing an inguinal hernia repair? A. early ambulation B. elastic stockings C. intermittent pneumatic compression D. low-molecular weight heparin - Answer>>A. Early ambulation is recommended for prophylaxis of venous thromboembolism in low-risk, minor procedures when the patient is under 40 years of age and there are no clinical risk factors. A 16-year-old male presents with increasing pain and swelling of his right scrotum. The right testicle is extremely tender to palpation on examination. A Doppler ultrasound demonstrates decreased blood flow. Which of the following is the most appropriate intervention? A. oral doxycycline B. emergent surgery C. incision and drainage D. scrotal elevation and ice packs - Answer>>B. Once a diagnosis of testicular torsion is suspected, emergent surgery is indicated to have the bestpossible chance of salvaging the testicle (85-97% chance if less than 6 hours). Any other treatment measures delay the definitive treatment and increase the risk of testicular ischemia and infarction. Which of the following is the most appropriate intervention for a stage I testicular seminoma? Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis? A.Weight loss B. Intractable pain C. Exocrine deficiency D. To decrease risk of cancer - Answer>>B. Indications for surgical treatment of chronic pancreatitis include severe pain that limits the patient's functioning or intractable pain despite the use of non-narcotic analgesics and absence of alcohol intake. A patient with prostate cancer has a nonpalpable, focal lesion, and the patient is reluctant to have surgery at this time. Which of the following would best monitor disease progression? A. Periodic rectal exams B. Transrectal ultrasonography C. Measurements of serum acid phosphatase D. Measurements of prostate-specific antigen - Answer>>D. PSA measurement correlates well with volume and stage of disease and is the recommended examination formonitoring disease progression. 52 year-old male with history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient? A. Coronary artery bypass grafting (CABG) B. Streptokinase C. Percutaneous coronary intervention (PCI) D. Warfarin (Coumadin) - Answer>>C. Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis 78 year-old male with history of coronary artery disease status post CABG and ischemic cardiomyopathy presents with complaint of progressive dyspnea and orthopnea. He also complains of lower extremity edema. The patient denies fever, chest pain, or cough. On physical examination, vital signs are BP 120/68, HR 75 and regular, RR 22, afebrile. You note the patient to have an S3 heart sound, jugular venous distention, and 2+ lower extremity edema. The patient is admitted and treated. Upon discharge from the hospital, the patient should be educated to monitor which of the following at home? A. Daily weights B. Daily spirometry C. Daily blood glucose D. Daily fat intake - Answer>>A. Home monitoring of daily weights can alert the health care provider to the early recognition of worsening heart failure. A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient? A. Anticoagulation B. Embolectomy C. Thrombolysis D. Inferior vena cava filter - Answer>>A. Anticoagulation is the treatment of choice in patients with pulmonary embolism with normal ventricular function and no absolute contraindications. Lab results for a post-operative oliguric patient reveals an increased BUN to creatinine ratio. The patient has a low fractional excretion of sodium (less than 1%). Which of the following is the most likely diagnosis? A. prerenal azotemia B. acute tubular necrosis C. acute glomerulonephritis D. obstructive uropathy - Answer>>A. Patients who have prerenal azotemia with otherwise normal kidneys will have severe sodium retention in order to help to save fluid. The amount of sodium in the urine is therefore very low. A 60 year-old patient returned from the recovery room to the floor following a subtotal gastrectomy. At 3 AM the next morning, the patient's temperature is 102° F (39° C) and pulse is 112/min. Which of the following is the most likely cause? A. wound infection B. atelectasis C. phlebitis D. shock - Answer>>B. Atelectasis is the most common pulmonary complication, affecting 25% of patients with abdominal surgery. It is more common in elderly and overweight patients and occurs within the first 12 to 24 hours postoperatively. A 54 year-old female who has diabetes presents with rubor, absence of hair, and brittle nails of her left foot. She complains of leg pain that awakens her at night. Examination reveals a femoral bruit with diminished popliteal and pedal pulses on the left side. The most appropriate therapy would be A. vasodilator therapy. B. bypass surgery. C. exercise program. D. embolectomy. - Answer>>B. Bypass surgery is indicated in the presence of rest pain and provides relief of symptoms in 80 to 90% of patients. The first step in the treatment of a patient with an intestinal obstruction and no comorbid diseases is A. nasogastric decompression. B. invasive hemodynamic monitoring. A. Administration of IM penicillin B. No treatment is warranted C. Place tooth in saline and refer to plastic surgery for reimplantation D. Immediately reimplant the tooth and refer to an oral surgeon - Answer>>D. Avulsed permanent teeth should be cleansed, transported in Hanks solution or saline and reimplanted by an oral surgeon within one hour. A 62 year-old male presents with a right hilar mass. Needle- biopsy of the mass reveals the presence of small-cell carcinoma and a bone scan reveals the presence of scattered hot spots throughout the skeleton. Which of the following is the most appropriate treatment? A. Lobectomy B. Pneumonectomy C. Thoracic radiation therapy D. Combination chemotherapy - Answer>>D. Combination chemotherapy is the treatment of choice for a patient with small- cell carcinoma of the lung. 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 - Answer>>C. CABG is indicated in patients with stenosis of the left main coronary artery and those with three-vessel CAD 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 - Answer>>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. 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 - Answer>>B. Cholangitis is characterized by a history of biliary pain, fever, chills, and jaundice associated with episodes of abdominal pain. A 52-year-old female presents with diffuse abdominal pain accompanied by distention and visible peristalsis. Ausculation reveals hyperactive bowel sounds. Percussion is tympanic throughout. Palpation reveals mild diffuse tenderness without masses. The most likely diagnosis is A. intra-abdominal abscess. B. intestinal obstruction. C. paralytic ileus. D. cholecystitis. - Answer>>B. Intestinal obstruction without complications is suggested by crampy pain, abdominal distention, hyperactive bowel sounds, visible peristalsis, and minimal tenderness. A female in her third trimester of pregnancy developed hypertension, diffuse edema, proteinuria and hyperreflexia. She was treated with intravenous magnesium sulfate and is now hyporeflexic and drowsy. What do you prescribe now? A. calcium B. diazepam C. an amphetamine D. additional magnesium E. oxygen - Answer>>Calcium Pre-eclampsia causes hyperreflexia. Magnesium is the treatment. The sign of magnesium toxicity is a loss of reflexes... this is treated with calcium A 55-year-old male presents complaining of "difficulty wrtiing" using his dominant hand and some "slurred" speech. He has a h/o hypertension, DM type II, and hypertriglyceridemia. Which of the following would you anticipate to find on a CT scan of his head, as the explanation for his chief complaint? A. hemorrhage in the distribution of his posterior cerebral artery B. hemorrhage in the distribution of the middle cerebral artery C. hypodensity measuring 12 mm by 21 mm in the distribution of the posterior cerebral artery D. hypodensity measuring 4 mm by 4 mm in the internal capsule E. calcifications bilaterally, in the third ventricles - Answer>>Hypodensity measuring 4 mm by 4 mm in the internal capsule The main clue in this question is that most strokes are ischemic - especially with this patient's history (ruling out hemorrhagic infarct - A & B). Calcifications (E) are not indicative of stroke at all. When trying to decide between C & D - the size of the area needs to correlate with the patient's symptoms. If the patient had a HUGE infarct (12 x 21) he would have significantly more signs and symptoms than just some slurred speech and difficulty writing. (In addition, as it turns out, the internal capsule is supplied by the factor-1 (IGF-1). Both GH and IGF-1 were extremely elevated, up to five times the upper limit of normal. An MRI of her pituitary revealed - Answer>>Acromegaly is a rare, chronic syndrome that is often diagnosed by the general internist. Most commonly, it is caused by excessive secretion of GH by the somatotroph adenoma of the anterior pituitary. However, very rarely, ectopic tumors may secrete GH and present in an indolent fashion. Diagnosis is usually delayed for many years resulting in significant morbidity and mortality. In the era of healthcare reform, the emphasis is on a problem focused clinical encounter. This case illustrates that a rare, debilitating disease can be diagnosed by simply shifting the focus back to the patient. A firm handshake or first impression can still be a valuable clinical tool. A 38-year-old man has had upper abdominal pain for 3 months. For the past week he has had nausea. On physical examination a stool sample tested for occult blood is positive. An upper GI endoscopy reveals no esophageal lesions, but there is a solitary 2 cm diameter shallow, sharply demarcated ulceration of the stomach. Which of the following statements regarding this lesion is most appropriate? A. It is probably located in the antrum B. It is probably malignant C. It is probably associated with increased gastric acid production. D. Because of its small size, a biopsy is not necessary E. A gastrinoma of the pancreas is probably present - Answer>>A Which of the following is NOT a complication of a gastric ulcer: A. Hemorrhage B. Peritonitis C. Barrett's esophagus D. Pyloric stenosis E. Penetration into the omentum - Answer>>Barrett's esophagus A 54-year-old man has complained for 5 months of upper abdominal pain accompanied by nausea. He does not have hematemesis. On physical examination the only finding is a stool sample positive for occult blood. Upper GI endoscopy is performed and gastric biopsies are taken. On microscopic examination the biopsies reveal acute and chronic mucosal inflammation along with the presence of Helicobacter pylori organisms. The presence of these organisms is most likely to be associated with which of the following? A. Mucosal invasion with septicemia B. Duodenal peptic ulceration C. Development of pernicious anemia D. Hypochlorhydria with atrophic gastritis - Answer>>Duodenal peptic ulceration Which of the following statements regarding treatment of H. pylori infection are true: A. Proton pump inhibitors are administered twice daily. B. Two or three different antimicrobial agents are administered 2 to 4 times daily C. Bismuth-containing compounds provide some antimicrobial activity. D. Fourteen days of treatment is superior to 10 days of treatment for eradication of H pylori. E. All of the above - Answer>>ALL of the above Marker of severe acute pancreatitis: A. Elevated serum Amylase B. Elevated serum Lipase C. Intravascular volume depletion and metabolic acidosis D. Pancreatic edema on CT scan - Answer>>Intravascular volume depletion and metabolic acidosis A 78-year-old woman with a previous history of a peptic ulcer that bled comes to see you because she has developed dyspepsia while taking ibuprofen. All of the following are reasonable choices EXCEPT: A. Test for H. pylori and eradicate if present B. Consider switching to a COX-2 selective non-steroidal anti- inflammatory drug C. Co-prescribe a proton pump inhibitor D. Perform endoscopy E. Screen her family members for peptic ulcer disease - Answer>>E Both famotidine and cimetidine are likely to: A. Cause constipation. B. Inhibit both basal (fasting) acid secretion and acid secretion stimulated by food. C. Inhibit the cytochrome p450-mediated metabolism of some drugs. D. Irreversibly inactivate the H+ K+ ATPase of the parietal cell E. Enhance gastrointestinal motility. - Answer>>B. Inhibit both basal (fasting) acid secretion and acid secretion stimulated by food. Which of the following statements about intrinsic factor is correct? A. It is hydrolyzed by pepsin B. Intrinsic factor-vitamin B12 binding is inhibited by an alkaline pH C. It is secreted by the chief cells of the gastric mucosa D. It is hydrolyzed by pepsin E. It has a lower binding affinity for vitamin B12 than the salivary R protein (Haptocorrin) - Answer>>E. It has a lower binding affinity for vitamin B12 than the salivary R protein (Haptocorrin) Hepatic encephalopathy can be improved by which of the following?: A. Colonic acidification B. Gastrointestinal bleeding crypts. Which of the following therapies is most likely to be useful for this man? A. Antibiotics B. Gluten-free diet C. Selective vagotomy D. Corticosteroids E. Segmental duodenal resection - Answer>>B. Gluten free diet Stimulant laxatives such as senna are effective in the treatment of constipation because: A. They rapidly increase osmotic pressure of the small and large intestinal contents and thereby inhibit water absorption. B. They increase the bulk contents of the colon because they are indigestible. C. They inhibit sodium absorption and promote chloride excretion by the colonic mucosa, and increase colonic motility. D. They have an atropine-like effect on the colonic musculature. E. They antagonize the effect of PGE2 on chloride flux in the colonic mucosa. - Answer>>C. They inhibit sodium absorption and promote chloride excretion by the colonic mucosa, and increase colonic motility. A primary mechanism by which castor oil induces laxation is: A. It stimulates sodium absorption, inhibits chloride excretion by the colonic mucosa, and decreases colonic motility. B. It acts as an osmotic agent to increase luminal retention of water, as does magnesium hydroxide. C. After hydrolysis to ricinoleic acid, it decreases the net absorption of water and electrolytes by intestinal mucosal cells and stimulates colonic motility. D. It increases the bulk content of the small intestine. E. It decreases the synthesis of PGE2 in the intestinal mucosa. - Answer>>C. After hydrolysis to ricinoleic acid, it decreases the net absorption of water and electrolytes by intestinal mucosal cells and stimulates colonic motility. Motor function of the lower esophageal sphincter (LES) is characterized by?: A. Tonic contraction mediated by the release of ACh from cholinergic nerves B. Contraction in response to a swallow or to gastric distension C. Relaxation mediated by release of nitric oxide from nonadrenergic, noncholinergic neurons. D. All of the above - Answer>>C. Relaxation mediated by release of nitric oxide from nonadrenergic, noncholinergic neurons. Which of the following defects is responsible for the acid reflux in patients with gastro-esophageal reflux disease A. Hiatus hernia B. Gastric acid C. Lower esophageal sphincter weakness D. Transient lower esophageal sphincter relaxation E. All of the above - Answer>>E. All of the above What is the preferred location for a transnasal enteric feeding tube in a patient with delayed gastric emptying? A. Stomach B. Duodenum C. Jejunum D. Ileum - Answer>>C. Jejunum A 70-year old otherwise very healthy male is admitted to the Oncology service for treatment of carcinoma of the body of the pancreas. He develops acute upper gastrointestinal bleeding, and is found to have gastric varices on upper endoscopy. CT scan shows the pancreatic tumor, and adjacent splenic vein thrombosis. Which of the following is correct? A. His wedged hepatic venous pressure (WHVP) gradient is > 12 mm Hg B. Placement of a TIPSS will reduce his risk of recurrent variceal bleeding C. Diuretics and beta-blockers will reduce his risk of recurrent hemorrhage D. Splenectomy may be required to prevent recurrent bleeding - Answer>>D. Splenectomy may be required to prevent recurrent bleeding Which of the following statements regarding the use of the 5aminosalicylates for the treatment of Inflammatory Bowel Disease is true?: A. Therapeutic effects of the 5-aminosalicylates are not seen until 3, 4 or more months of therapy. B. They decrease production of proinflammatory cytokines possibly by decreasing the nuclear translocation of NF-kB. C. They are effective for use in mild to moderate disease and as maintenance therapy. D. The side effects of the sulfa -containing sulfasalazine are not dose-related and are due to a hypersensitivity reaction - Answer>>C. They are effective for use in mild to moderate disease and as maintenance therapy. The patient is admitted to the hospital and becomes confused and agitated 3 days later. Hepatic encephalopathy is diagnosed after a blood ammonia level of 163 mg/dL is found. All of the following statements regarding hepatic encephalopathy in this patient are correct EXCEPT? A. Placement of TIPS would likely make it worse B. Constipation would likely make it worse C. Oral lactulose is the treatment of choice D. Oral neomycin may be harmful if reabsorbed from the colon