PACKRAT 1 Exam Questions and Answers with Complete Solutions 100% Correct 2024, Exams of Advanced Education

Download PACKRAT 1 Exam Questions and Answers with Complete Solutions 100% Correct 2024 and more Exams Advanced Education in PDF only on Docsity! PACKRAT 1 Exam Questions and Answers with Complete Solutions 100% Correct 2024 A patient presents with eye pain and blurred vision. Snellen testing reveals vision of 20/200 in the affected eye and 20/20 in the unaffected eye. Fluorescein staining reveals the presence of a dendritic ulcer. Which of the following is the most likely diagnosis? A. Viral keratitis B. Fungal corneal ulcer C. Acanthamoeba keratitis D. Bacterial corneal ulcer - Correct Answer-(c) A. Herpes Simplex virus is a common cause of dendritic ulceration noted on fluorescein staining. (u) B. Fungal corneal ulcers have an indolent course with intraocular infection being common but fluorescein staining is negative for a dendritic pattern. (u) C. Acanthamoeba keratitis has a waxing and waning course over several months and has no fluorescein staining in a dendritic pattern. (u) D. Bacterial corneal ulcers can progress aggressively resulting in corneal perforation. Fluorescein staining does pg. 1 professoraxe l not occur in a dendritic pattern. A 6 year-old male presents with hemarthrosis of the left knee. Coagulation studies reveal the following results: PT 12.5 seconds (normal range 12-14 seconds), INR 1.0, aPTT 58 seconds (normal range 18-28 seconds), platelet count 430,000/microliter (normal range 150,000-450,000/microliter), and bleeding time 4 minutes (normal range 2-12 minutes). Which of the following is the best treatment option for this patient? A. Desmopressin acetate B. Corticosteroids C. Vitamin K D. Cryoprecipitate - Correct Answer-(u) A. Desmopressin acetate is indicated in von Willebrand's disease, which presents with a prolonged bleeding time. (u) B. Corticosteroids are indicated in immune-mediated thrombocytopenia. (u) C. Vitamin K deficiency will prolong the PT greater than the aPTT. Vitamin K supplement is not indicated in this patient. (c) D.Hemophilia A presents with a prolonged aPTT and normal platelet count and function. Hemophilia A is treated pg. 2 professoraxe l D. Abdominal CT scan - Correct Answer-(c) A. Occult bleeding, as evidenced by the patient's history of black stools, is initially verified by a positive fecal occult blood test. (u) B. Stool cultures are indicated in the evaluation of acute diarrhea and not for the evaluation of acute GI bleeding. (u) C. Melena suggests a source of bleeding that is proximal to the ligament of Treitz, not a lower GI bleed. Sigmoidoscopy is used to evaluate only lower GI bleeding sources. (u) D. Abdominal CT scan is indicated for evaluation of obscure bleeding in order to exclude a pancreatic or hepatic source of bleeding if endoscopy fails to identify the source. Which of the following is considered a risk factor for the development of malignant melanoma? A. male gender B. inability to tan C. Japanese ethnicity D. brown-haired individuals - Correct Answer-(u) A. Incidence of malignant melanoma is equal in males and females. (c) B. Inability to tan and propensity to burn are risk factors for developing malignant melanoma. pg. 5 professoraxe l (u) C. Malignant melanomas are most common in Caucasians and are rarely seen in the Japanese population. (u) D. Red hair and freckling is one of the major risk factors for malignant melanoma, not brown hair. A 43 year-old data entry clerk presents with a one-month history of pain and tingling in the right thumb, index finger, and middle finger. Tinel's sign and Phalen's maneuver are positive. The most appropriate intervention at this time is A. methylprednisolone (Medrol) dose pack. B. splint in neutral position. C. observation. D. surgery. - Correct Answer-(u) A. A Medrol dose pack will have no affect on carpal tunnel syndrome. (c) B. Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal tunnel. (u) C. Observation will not improve symptoms. (u) D. Surgical intervention is reserved for cases unresponsive to conservative therapy. Which of the following is a cause of prerenal azotemia? pg. 6 professoraxe l A. Infection B. Renal toxins C. Poor renal perfusion D. Urinary tract obstruction - Correct Answer-(u) A. Infection is associated with interstitial nephritis, which is considered a cause of intrinsic renal azotemia. (u) B. This is one of the causes of intrinsic renal azotemia. (c) C. Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored. (u) D. Urinary tract obstruction is the cause of postrenal azotemia. Which of the following is the most common cause of secondary hypertension? A. Renal parenchymal disease B. Primary aldosteronism C. Oral contraceptive use D. Cushing's syndrome - Correct Answer-(c) A. Renal parenchymal disease is the most common cause of secondary hypertension. pg. 7 professoraxe l (u) C. Chalazion is a granulomatous inflammation of the meibomian gland. (u) D. Dacryocystitis is an infection of the lacrimal sac due to obstruction of the nasolacrimal system. Progesterone influence on the breast tissue prior to menstruation causes A. proliferation of the mammary ducts. B. growth of the lobules and alveoli. C. proliferation of Cooper's ligaments. D. increase in the number of glands of Montgomery. - Correct Answer-(u) A. Proliferation of the mammary ducts is under the influence of estrogen. (c) B. Growth of the lobules and alveoli is under the influence of progesterone. Prior to menses, the breast swelling that women notice is a result of the progesterone which is secreted from the corpus luteum. During menses, the swelling subsides. (u) C. See B for explanation. (u) D. See B for explanation. A 36 year-old man has a 30 pack-year history of smoking cigarettes and wants to quit. He is otherwise healthy at this pg. 10 professoraxe l time. Which of the following drugs would be appropriate for him? A. Amitriptyline (Elavil) B. Bupropion (Wellbutrin) C. Fluoxetine (Prozac) D. Venlafaxine (Effexor) - Correct Answer-(u) A. See B for explanation. (c) B. The only two approved drugs for aiding smoking cessation are nicotine and bupropion. (u) C. See B for explanation. (u) D. See B for explanation. A patient presents with chronic back pain. On physical examination testing, the patient is found to have abnormalities of proprioception and vibration discrimination. Which of the following portions of the spinal column are most likely affected? A. Lateral spinothalamic tract B. Ventral spinothalamic tract C. Posterior column D. Transection of the cord - Correct Answer-(u) A. The lateral spinothalamic tract affects pain and temperature sensation. pg. 11 professoraxe l (u) B. The ventral spinothalamic tract affects pressures and touch sensations. (c) C. The posterior column affects proprioception (position sense) and vibration sense. (u) D. Patients with transection of the cord will have loss of sensation distal to the area of injury along with paralysis and hyperactive reflexes in the area distal to the transection. A 44 year-old female presents for follow-up results of her lipid profile. She is asymptomatic and has a past medical history of hypothyroidism treated with levothyroxine and hypertension controlled with atenolol (Tenormin). She drinks an average of 6 alcoholic beverages a day and smokes 1 pack per day for the last 32 years. Her family history is unremarkable for premature coronary artery disease. Her fasting blood glucose is 98 mg/dL, total cholesterol is 198 mg/dL, LDL cholesterol is 132 mg/dL, HDL cholesterol is 56 mg/dL and triglycerides of 90 mg/dL. Excluding LDL cholesterol levels, how many major risk factors for coronary artery disease does this female possess? A. 2 B. 3 C. 4 D. 5 - Correct Answer-(c) A. This patient's major cardiac risk factors are smoking and hypertension in addition to the elevated LDL cholesterol. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. pg. 12 professoraxe l On examination of a pregnant patient the physician assistant notes the fundal height is at the level of the umbilicus. This corresponds to what gestational age? A. 16 weeks B. 20 weeks C. 24 weeks D. 28 weeks - Correct Answer-(u) A. See B for explanation. (c) B. At 20-22 weeks, the fundal height is typically at the level of the umbilicus. (u) C. See B for explanation. (u) D. See B for explanation. Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)? A. Drooling B. High fever C. "Hot potato" voice D. Barking cough - Correct Answer-(u) A. Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup. (u) B. Fever is usually absent or low-grade in patients with viral croup. (u) C. See A for explanation. (c) D. Viral croup is characterized by a history of upper respiratory tract symptoms followed by onset of a barking cough and stridor. pg. 15 professoraxe l A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30 minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A. Chest x-ray B. Sputum gram stain C. Peak flow D. Ventilation-perfusion scan - Correct Answer-(u) A. A chest x-ray should be ordered in an asthmatic patient only if you are concerned about the presence of pneumonia or pneumothorax, neither of which is supported by the H&P findings noted above. (u) B. A sputum gram stain is performed in patients who you suspect have an infectious process, such as pneumonia. (c) C. A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring pg. 16 professoraxe l the effectiveness of any treatment interventions. (u) D. A ventilation-perfusion scan (V/Q scan) is indicated in cases of suspected pulmonary embolism. The patient above does not have any risk factors that would lead you to suspect such a diagnosis. A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future? A. Asthma B. Tinea pedis C. Squamous carcinoma D. Systemic lupus erythematosus (SLE) - Correct Answer-(c) A. Up to 50% of patients with atopic dermatitis develop asthma and/or allergic rhinitis in the future. (u) B. Patients with atopic dermatitis are more likely to get superimposed viral or bacterial infections such as herpes simplex or staphylococcal, but they are not more at risk for fungal infections. (u) C. Patients with atopic dermatitis are at no greater risk for any skin cancer. (u) D. Lupus is a connective tissue disorder of the immune system, but unrelated to atopic dermatitis. pg. 17 professoraxe l D. Glucagon - Correct Answer-(h) A. Oral hypoglycemic agents have no role in the treatment of gestational diabetes as these drugs may cross the placenta and harm the fetus. (c) B. Regular insulin is the drug of choice as this will maintain the mother's blood sugar but not cross the placenta. (h) C. Oral corticosteroids have no role in the treatment of gestational diabetes. Corticosteroids will cause the blood glucose to increase. (u) D. Glucagon is given to patients when their blood glucose is abnormally low. Glucagon stimulates gluconeogenesis. Which of the following is an indication for vaccination against hepatitis A? A. Illicit drug users B. Health care workers C. Renal dialysis patients D. Routine vaccination starting at birth - Correct Answer-(c) A. Hepatitis A vaccine is recommended for illicit drug users, anyone living or traveling to endemic areas, sewage workers, food handlers, homosexual and bisexual men, animal handlers, patients with a history of chronic liver disease or a pg. 20 professoraxe l clotting factor disease as well as children and workers in day care settings and institutions. (u) B. Health care workers, renal dialysis patients and routine vaccination starting at birth are some of the recommendations for vaccination against hepatitis B, not hepatitis A. (u) C. See B for explanation. (u) D. See B for explanation. The DSM-IV classifies mental disorders by using five axes in completing the process. Axis III is used to identify which of the following? A. Clinical disorders and other conditions that may be the focus of clinical attention B. Any physical disorder or general medical condition that is present in addition to the mental disorder C. The psychosocial and environmental problems that have had a significant contribution to the development or exacerbation of the disorder D. Personality disorders and/or mental retardation - Correct Answer-(u) A. Axis I identifies clinical disorders and other conditions that may be the focus of clinical attention. pg. 21 professoraxe l (c) B. Axis III identifies any physical disorder or general medical condition that is present in addition to the mental disorder. (u) C. Axis IV identifies the psychosocial and environmental problems having a significant contribution to the disorder. (u) D. Axis II identifies personality disorders and mental retardation. A 2 month-old infant presents for a routine health maintenance visit. The mother has been concerned about the infant's hearing since birth. Physical examination reveals no apparent response to a sudden loud sound. Which of the following is the most appropriate diagnostic evaluation? A. audiometry B. tympanometry C. acoustic reflectometry D. auditory-evoked potentials - Correct Answer-(u) A. Pure tone audiometry can be used to screen for hearing deficits in children over the age of 3 years. (u) B. Tympanometry is used to identify an effusion as the cause of hearing loss, but in infants over the age of months. pg. 22 professoraxe l D. Chronic obstructive lung disease - Correct Answer-(u) A. There has not been any evidence of association between cigarette smoking and the development of mesothelioma. (c) B. Studies confirm the association of asbestos exposure to the development of mesothelioma. (u) C. After cigarette smoking, radon gas is the second most common risk factor for development of bronchogenic lung cancer, not mesothelioma. 17 (u) D. Chronic obstructive lung disease is associated with an increased risk of bronchogenic lung cancer, not mesothelioma. A 34 year-old female with a history of asthma presents with complaints of increasing asthma attacks. The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. Which of the following is the most appropriate intervention at this time? A. Oral prednisone B. Oral theophylline (Theo-Dur) pg. 25 professoraxe l C. Salmeterol (Serevent) inhaler D. Beclomethasone (Qvar)inhaler - Correct Answer-(u) A. Oral corticosteroids, such as prednisone, are added to therapy in severe persistent asthma. While a course of oral corticosteroids may be needed for mild exacerbations of asthma, they are not added until inhaled corticosteroids have failed to control the symptoms. (u) B. Due to its safety profile, oral theophylline is now considered a third or fourth line treatment option for asthma. (u) C. Long acting inhaled beta2-agonists, such as salmeterol, are not added to the treatment regimen until the symptoms indicate a moderate persistent asthma. Long acting inhaled beta2-agonists should also not be used in place of inhaled steroids. (c) D. This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control. Which of the following mechanisms leads to a primary pneumothorax? A. Penetrating or blunt trauma forces pg. 26 professoraxe l B. Underlying lung cancer C. Pressure of air in the pleural space exceeds room air pressure D. Rupture of subpleural apical blebs due to high negative intrapleural pressures - Correct Answer-(u) A. Penetrating or blunt trauma force is responsible for a traumatic pneumothorax. (u) B. A pneumothorax that results from an underlying lung disease is classified as a secondary pneumothorax. (u) C. When pressure of air in the pleural space exceeds room air pressure, it leads to a tension pneumothorax. (c) D. A primary spontaneous pneumothorax is thought to result from a rupture of subpleural apical blebs secondary to high negative intrapleural pressures. What is the initial treatment of choice for hyperthyroidism in a 10-week pregnant patient? A. No treatment is necessary. B. Propylthiouracil (PTU) C. Radioiodine treatment D. Subtotal thyroidectomy - Correct Answer-(h) A. Although thyroid function tests are altered in pregnancy true hyperthyroidism can occur and should be treated. pg. 27 professoraxe l (u) D. ST segment elevation is a sign of acute myocardial infarction not hypertension. *Poorly worded question! Annual blood pressure determinations should be obtained beginning at the age of A. 3 years. B. 5 years. C. 12 years. D. 18 years. - Correct Answer-(c) A. Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis? A. Femur B. Humerus C. Vertebral spine D. Tibia - Correct Answer-(u) A. Long bones are most commonly affected with osteomyelitis in children. pg. 30 professoraxe l (u) B. See A for explanation. (c) C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection (u) D. See A for explanation. Treatment of the patient with Pediculosis pubis consists of which of the following? A. Permethrin (Nix) cream B. Clotrimazole (Gyne-Lotrimin) C. Podofilox (Condylox) solution D. Selenium sulfide (Selsun) suspension - Correct Answer-(c) A. Permethrin 1% cream/shampoo is used to kill the louse and remove the eggs from the hair shafts. (u) B. Clotrimazole is an antifungal agent and is not used to treat parasitic infestation. (u) C. Podofilox 0.5% solution is used to treat Condyloma accuminata. pg. 31 professoraxe l (u) D. Selenium sulfide suspension is used to treat Tinea versicolor fungal infection. A 43 year-old asymptomatic diabetic female is found to have an elevated total calcium level of 12.4 mg/dL. Which of the following tests must be assessed in order to evaluate this laboratory abnormality? A. Intact parathyroid hormone B. Serum albumin C. 24 hour urine calcium level D. Complete blood count - Correct Answer-(u) A. Intact parathyroid hormone levels are only obtained for patients with true hypercalcemia with an unknown etiology. (c) B. Since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels. (u) C. Demonstration of excessive calcium in the urine does not provide any additional information regarding the increased serum calcium. (u) D. Complete blood count has no relationship to the serum calcium levels. pg. 32 professoraxe l B. Prolapse of orbital soft tissue C. Hematoma of the orbit D. Orbital emphysema - Correct Answer-(u) A. Fracture of the medial orbital wall is associated with diplopia from medial rectus impingement, orbital emphysema and epistaxis. (u) B. Prolapse of orbital soft tissue, including inferior rectus muscle, inferior oblique muscle, orbital fat, and connective tissue results in enophthalmos, ptosis, diplopia, anesthesia of the ipsilateral cheek and upper lip, and limitation of upward gaze and is seen with fractures of the orbital floor. (c) C. Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma. (u) D. Orbital emphysema is seen with fractures of the medial orbital wall or floor of the orbit into the maxillary and ethmoid sinuses respectively. It will not lead to proptosis. Which of the following physical findings is suggestive of atrial septal defect? A. Fixed split S2 B. Increased pulse pressure pg. 35 professoraxe l C. Continuous mechanical murmur D. Difference in blood pressure between the left and right arm - Correct Answer-(c) A. An atrial septal defect will cause a shunt of blood from the left to the right atrium. This will result in an equalization in the amount of blood entering both the left and right ventricles which effectively eliminates the normally wide splitting that inspiration typically causes in hearts without an atrial septal defect. (u) B. Pulse pressures reflect the difference in aortic and left ventricular volumes that occur during ventricular systole Increased pulse pressures are seen in aortic regurgitation which is a different entity than atrial septal defect. (u) C. Continuous mechanical murmurs are noted in patients with patent ductus arteriosus. (u) D. Differences in blood pressure between the left and right arms are seen in conditions such as coarctation of the aorta. Which of the following is essential to make a diagnosis of cystic fibrosis? A. Positive family history B. Elevated sweat chloride C. Recurrent respiratory infections pg. 36 professoraxe l D. Elevated trypsinogen levels - Correct Answer-(u) A. Cystic fibrosis is a genetic disease, but a positive family history in and of itself is not enough to diagnose the condition. (c) B. The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test or demonstration of a genotype consistent with cystic fibrosis. (u) C. While recurrent respiratory infections is a classic presentation of cystic fibrosis, the diagnosis relies on confirmation, as noted in explanation B. (u) D. Trypsinogen levels are used as a neonatal screening test and if elevated should be followed by more definitive testing to confirm the diagnosis. In infants, the eyes should move in parallel without deviation by the age of A. 2 weeks. B. 3 months. C. 6 months. D. 1 year. - Correct Answer-(u) A. See C for explanation. (u) B. See C for explanation. (c) C. Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months. (u) D. See C for explanation. pg. 37 professoraxe l ST segment elevation. What is the treatment of choice in this patient? A. Pericardiocentesis B. Nitroglycerin C. Percutaneous coronary intervention D. Indomethacin (Indocin) - Correct Answer-(u) A. Pericardiocentesis is the treatment of choice in a patient with a pericardial effusion and cardiac tamponade, there is no evidence of either of these in this patient. (u) B. Nitroglycerin is indicated in the treatment of chest pain related to angina. (u) C. Percutaneous coronory intervention is the treatment of choice in a patient with an acute myocardial infarction. (c) D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment of choice in a patient with acute pericarditis. As a general rule, sutures in the face should be removed in A. 3 days. B. 5 days. C. 7 days. D. 10 days. - Correct Answer-(u) A. See B for explanation. (c) B. Sutures of the face should be removed in 5 days in order to allow for adequate healing and to limit the amount of scarring. pg. 40 professoraxe l (u) C. See B for explanation. (u) D. See B for explanation. Patient education for a 23 year-old using oral contraceptives should include which of the following? A. Rifampin may decrease the effectiveness of the oral contraceptives. B. Acetaminophen may decrease the effectiveness of the oral contraceptives. C. Oral contraceptives may provide some protection from coronary artery disease. D. Changing to the "minipill" (progestin only) will inhibit ovulation more consistently than combination oral contraceptives. - Correct Answer-(c) A. Rifampin may interfere with the efficacy of the oral contraceptives. (u) B. Acetaminophen levels or effects may be decreased by oral contraceptives. (u) C. Coronary artery disease is a contraindication to the use of oral contraceptives. (u) D. Progestin only oral contraceptives are less effective at inhibiting ovulation than the combination oral contraceptive. pg. 41 professoraxe l When performing a rectal examination, prostatic massage is contraindicated in A. acute bacterial prostatitis. B. chronic bacterial prostatitis. C. nonbacterial prostatitis. D. prostatodynia. - Correct Answer-(c) A. Vigorous manipulation of the prostate during rectal examination may result in septicemia. This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain. (u) B. Prostate massage can be performed in the absence of fever. Expressed prostatic secretions are cultured to help identify the organism. (u) C. Nonbacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are cultured, and the cause may be unknown. (u) D. Prostatodynia is a noninflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement. A patient with prostate cancer has a nonpalpable, focal lesion, and the patient is reluctant to have surgery at this time. pg. 42 professoraxe l D. Patent ductus arteriosus - Correct Answer-(u) A. Patients with hypertrophic obstructive cardiomyopathy do not present with hypertension or weak femoral pulses. (u) B. The murmur associated with patent foramen ovale is a systolic ejection murmur heard in the second and third intercostal spaces and patients do not present with hypertension. (c) C. Coarctation of the aorta commonly presents with higher systolic pressures in the upper extremities than the lower extremities and absent or weak femoral pulses. (u) D. Patent ductus arteriosus is rare in adults and patients are noted to have a continuous rough, machinery murmur. A mother brings a 3 month-old infant to the office because she is concerned about a red, vascular, nodular growth on the child's back. It appears to be enlarging slightly and the vessels are slightly dilated. It seems to cause the child no discomfort. The most likely diagnosis is A. a hemangioma. B. a pigmented nevus. C. a salmon patch (stork bite). D. a malignant melanoma. - Correct Answer-(c) A. A hemangioma is a bright red to deep purple vascular nodule or pg. 45 professoraxe l plaque that often develops at birth, may enlarge, and may regress and disappear with aging. (u) B. A pigmented nevus is not a vascular lesion. (u) C. A salmon patch is a light red macule over the nape of the neck or the glabella. (u) D. A malignant melanoma presents as a hyperpigmented, asymmetric lesion with irregular borders and is typically seen in the adult population. A 45 year-old male with Type 1 diabetes presents with the following lipid panel: Total cholesterol 321 mg/dL; Triglycerides 225 mg/dL; HDL 30 mg/dL; LDL 155 mg/dL. The treatment of choice for this patient is A. Nicotinic acid (Niacin). B. Cholestyramine (Questran). C. Gemfibrozil (Lopid). D. Simvastatin (Zocor). - Correct Answer-(u) A. Niacin is not indicated in patients with diabetes as it may worsen blood sugar control. (u) B. Cholestyramine is not indicated as it may worsen the triglyceride level in this patient. (u) C. Gemfibrozil should be avoided as it may worsen the LDL level. pg. 46 professoraxe l (c) D. Simvastatin is the drug of choice as it will decreases triglyceride level, decrease LDL, and increase HDL. A 45 year-old male presents with abdominal pain and one episode of mild hematemesis, which happened days ago. On physical examination, vital signs are stable and he is in no acute distress. Hemoglobin and hematocrit are unremarkable; endoscopy reveals non-bleeding small superficial ulceration of the duodenal bulb. Rapid urease test is positive. Which of the following is the most appropriate treatment at this time? A. Schedule for a selective vagotomy and antrectomy B. Start an antacid along with omeprazole (Prilosec) C. Schedule elective ulcer excision and start sucralfate (Carafate) D. Start omeprazole (Prilosec) and antibiotic therapy against H. pylori - Correct Answer-(u) A. Medical therapy should be initiated prior to any consideration of surgery, which is rarely performed secondary to satisfactory ulcer healing with medical therapy. (u) B. While proton pump inhibitors, such as omeprazole, have excellent results in healing duodenal ulcers, this regimen will not treat the H. pylori infection that is documented by the positive rapid urease test. pg. 47 professoraxe l A 17 year-old patient presents to the emergency department with agitation and hallucinations, and has one seizure. He admits to using "some drugs" but does not know what they were. On physical examination, temperature is 103 degrees F, BP 140/90, pulse 120, respirations 20. Remainder of the examination is unremarkable. Which of the following diagnostic studies will be of most help in managing this patient? A. Drug screen B. Urine dipstick C. Complete blood count D. Serum creatinine kinase - Correct Answer-(a) A. Although a drug screen may identify specific drugs, the results will not alter the care of this patient. (u) B. Urine dipstick is not sensitive for myoglobinuria. (u) C. This patient is at risk for myoglobinuria, and a complete blood count will not alter the treatment. (c) D. Serum creatinine kinase is the most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse. pg. 50 professoraxe l Which of the following medications is the treatment of choice for patients with chronic gout to prevent recurrence of symptoms during its quiescent phase? A. Probenecid (Benemid) B. Allopurinol (Zyloprim) C. Colchicine D. Indomethacin (Indocin) - Correct Answer-(u) A. Probenecid is a uricosuric medication that helps to increase the excretion of uric acid but it does not prevent the formation of uric acid making it less beneficial in chronic gout therapy. It is also not effective in patients with chronic renal disease. (c) B. Allopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It is a xanthine oxidase inhibitor that is used to prevent the formation of uric acid. (u) C. Colchicine treatment is recommended only in patients who have tophaceous deposits in the skin and is used in the acute rather than the chronic setting of gout. (u) D. Indomethacin is used in the acute management of gout but is not effective in decreasing monosodium urate deposition in the joints. A 64 year-old male presents complaining of new onset of fatigue, weight gain, constipation, erectile dysfunction, and pg. 51 professoraxe l loss of body hair. Laboratory investigation demonstrates: TSH less than 0.5 microunits/mL (normal range 0.5-5.0 microU/mL); Thyroxine (T4) 2 mcg/dL (normal range 5-12 mcg/dL); Prolactin 10 nanograms/ml (normal A. Primary hypothyroidism B. Excessive dosing of levothyroxine (Synthroid) C. Hypopituitarism D. Subacute thyroiditis - Correct Answer-(u) A. Primary hypothyroidism is usually associated with an elevated TSH. (u) B. Excessive replacement of levothyroxine would result in symptoms of hyperthyroidism, not hypopituitarism. 28 (c) C. The low trophic and target hormone levels combined with symptoms of hypogonadism indicate this patient has hypopituitarism. (u) D. The T4 level would be elevated in subacute thyroiditis due to excessive release of thyroid hormone. A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar pg. 52 professoraxe l elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction. (u) C. Acute pericarditis presents with atypical chest pain and diffuse ST segment elevation. (u) D. Pulmonary embolism often presents with either no EKG changes or sinus tachycardia. Classically described, rarely seen findings include a large S wave in lead I, a Q wave with T wave inversion in lead III, ST segment depression in lead II, T wave inversion in leads V1-V4 and a transient right bundle branch block. An 18 year-old woman presents to the clinic complaining of fatigue. She reports a past history of lifelong frequent nosebleeds and bleeding gums. She also has menorrhagia. Her mother and maternal grandfather have a similar bleeding history. Initial lab results are as follows: WBC 9,500/mm3, Hgb 10.9 g/dL, HCT 33%, MCV 69 fL, MCHC 26 pg and platelets 284,000/mm3. Which of the following tests should be ordered to evaluate this patient's diagnosis? A. Hemoglobin electrophoresis B. Bleeding time and platelet aggregometry C. Bone marrow aspiration pg. 55 professoraxe l D. PT and aPTT - Correct Answer-(u) A. Hemoglobin electrophoresis would be utilized to evaluate microcytic, hypochromic anemias. (c) B. The patient's presentation is consistent with a congential qualitative platelet disorder, most likely von Willebrand's Disease, necessitating a bleeding time and evaluation of platelet function. (u) C. Bone marrow aspiration is not utilized in the evaluation of qualitative platelet disorders. (u) D. A PT and aPTT would be utilized to evaluate for bleeding consistent with abnormalities with the coagulation cascade. A 35 year-old patient has recurrent seasonal rhinitis and a history of mild asthma. Which of the following should be included for first-line management? A. Immunotherapy B. Decongestants C. Corticosteroid inhalers D. Cromolyn sodium (Intal) - Correct Answer-(u) A. Immunotherapy (desensitization) is indicated as a last resort in patients who fail to either respond to pharmaceutical management or face prolonged exposure to known allergens. pg. 56 professoraxe l (u) B. Decongestants have a limited role in helping to decrease edema, and are generally ineffective in relieving allergic symptoms. (c) C. Regular use of corticosteroid nasal spray and oral inhalers prior to the allergy season is among the best means of preventing allergies. (u) D. Cromolyn sodium has been found to be moderately effective for some patients with allergic symptoms, but it is not usually first-line management. A 35 year-old female presents with multiple ulcerative lesions on her labia and perineum. A Tzanck preparation of one of the lesions reveals multinucleated giant cells. Which of the following is the most likely diagnosis? A. Herpes Simplex Virus (HSV) B. Molluscum Contagiosum Virus (MCV) C. Human Papilloma Virus (HPV) D. Syphilis - Correct Answer-(c) A. The presentation seen on the Tzanck preparation is characteristic of HSV. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. pg. 57 professoraxe l A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical features? A. Chest pain B. Cyanosis C. Convulsions D. Palpitations - Correct Answer-(u) A. Chest pain is not a feature of tetralogy of Fallot. (c) B. Cyanosis is very common in tetralogy of Fallot. (u) C. Convulsions are occasionally seen as part of severe hypoxic spells in infancy rather than a feature of tetralogy of Fallot. (u) D. Palpitations are uncommon in tetralogy of Fallot. Intraarticular injection of hyaluronic acid has been approved for treatment of patients with which of the following conditions? A. Rheumatoid arthritis of the knee B. Osteoarthritis of the knee C. Olecranon bursitis D. Gouty arthritis - Correct Answer-(u) A. See B for explanation. pg. 60 professoraxe l (c) B. Intraarticular injection of hyaluronic acid has been approved recently for treatment of patients with osteoarthritis of the knee that have failed other therapies. Although the onset of action of this medication is slower than injected glucocorticoids, it has a sustained length of activity outlasting the injected glucocorticoids. (u) C. Treatment of olecranon bursitis may include incision and drainage but not hyaluronic acid injections. (u) D. Gout is treated with anti-inflammatory medications. Which of the following drugs is first-line therapy for schizophrenia? A. Chlorpromazine (Thorazine) B. Clozapine (Clozaril) C. Haloperidol (Haldol) D. Olanzapine (Zyprexa) - Correct Answer-(u) A. The older, traditional antipsychotic agents, such as haloperidol and chlorpromazine have higher risk of side effects, including acute motor system side effects a long-term risk of tardive dyskinesias, and should not be considered as first-line drugs. (u) B. Clozapine should not be considered a first-line therapy because of its hematopoietic and hepatic side effects. pg. 61 professoraxe l (u) C. See A for explanation. (c) D. Initial pharmacologic therapy of schizophrenia should begin with one of the newer, "atypical" antipsychoticdrugs, such as olanzapine, risperidone, quetiapine, ziprasidone, and clozapine because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms. A 25 year-old presents with pain in the proximal ulna after falling directly on the forearm. X-ray shows fracture of the proximal 1/3rd of the ulna. There is an associated anterior radial head dislocation. What is the proper name for this condition? A. Galeazzi fracture B. Monteggia fracture C. Colles' fracture D. Smith fracture - Correct Answer-(u)A. A Galeazzi fracture is a fracture along the length of the radius with injury to the distal radioulnar joint. (c) B. A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head. (u) C. A Colles' fracture is a fracture of the distal radius with dorsal displacement of the radial head. pg. 62 professoraxe l C. Pioglitazone (Actos) D. Acarbose (Precose) - Correct Answer-(c) A. Sulfonylureas increase insulin levels and predispose patients to hypoglycemia. (u) B. (u) C. (u) D. Acarbose is an alpha glucosidase inhibitor that delays the absorption of carbohydrates in the diet. It does not cause hypoglycemia since it does not drive insulin into the cells. A 75 year-old female presents with medial knee pain that worsens with stair climbing. Physical examination reveals swelling and point tenderness inferior and medial to the patella and tenderness overlying the medial tibial plateau. Which of the following is the most likely diagnosis? A. Pes anserine bursitis B. Prepatellar bursitis C. Infrapatellar bursitis D. Trochanteric bursitis - Correct Answer-(c) A. The pes anserine bursa underlies the semimembranosus tendon and may become inflamed or painful owing to trauma, overuse, or inflammation. It is a common cause of knee pain and it is often misdiagnosed in adults. pg. 65 professoraxe l (u) B. Prepatellar bursitis causes swelling in the prepatellar area and is worse with kneeling. The prepatellar bursa is superficial and is located over the inferior portion of the patella. (u) C. The infrapatellar bursa is deeper and lies beneath the patellar ligament before its insertion on the tibial tubercle. It has a midline location rather than the medial surface as described in the question. (u) D. Trochanteric bursitis causes hip pain rather than knee pain. A 23 year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis? A. Hypertrophic cardiomyopathy B. Aortic stenosis C. Mitral regurgitation D. Pulmonic stenosis - Correct Answer-(c) A. Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid- systolic murmur that decreases with squatting and increases with straining. pg. 66 professoraxe l (u) B. Straining decreases the intensity of the murmur associated with aortic stenosis and squatting increases the intensity. (u) C. Mitral regurgitation is characterized by a blowing systolic murmur that radiates to the axilla, it is not often associated with syncope. (u) D. Pulmonic stenosis is a harsh systolic murmur with a widely split S2, and no change with maneuvers. Which of the following can be a very serious consequence of using antidiarrheals in a patient with inflammatory bowel disease? A. Lymphoma B. Toxic megacolon C. Bone marrow suppression D. Delayed serum sickness-like reaction - Correct Answer-(u) A. There is suggestion that lymphoma may result from the use of infliximab, an anti-TNF agent, utilized in refractory cases of Crohn's disease; however a clear link between the development of lymphoma and the use of infliximab has not been established. (c) B. Antidiarrheals may cause the development of toxic megacolon when used by patients with active severe inflammatory bowel disease. pg. 67 professoraxe l Erythema nodosum is characterized by A. subcutaneous red tender nodules. B. brown pigmentation on the lower extremities. C. tender lymph nodes in the groin. D. scaling red macules. - Correct Answer-(c) A. Erythema nodosum produces erythematous red tender nodules, especially on the shins. (u) B. Brown pigmentation on the lower extremities is a feature of chronic venous insufficiency. (u)C. Lymphovenereum granuloma is likely to produce tender lymph nodes in the groin as can acute infection in the lower extremities. (u) D. Scaling red macules are a feature of tinea corporis. Use of systemic corticosteroids can cause which of the following adverse effects in the eye? A. Cortical blindness B. Optic atrophy C. Glaucoma D. Papilledema - Correct Answer-(u) A. Cortical blindness is a rare adverse effect when prescribing salicylates. pg. 70 professoraxe l (u) B. Optic atrophy can occur as an adverse effect with lead compounds, amebicides, and MAO inhibitors. (c) C. Glaucoma can be caused by the long-term use of steroids. (u) D. Papilledema can be a side effect to many systemic medications. It is determined that a woman has a nonexistent rubella titer level during her first trimester of pregnancy. When should she receive the rubella vaccine? A. During the first trimester of pregnancy B. During the second trimester of pregnancy C. During the third trimester of pregnancy D. After delivery of the infant - Correct Answer-(h) A. See D for explanation. (h) B. See D for explanation. (h) C. See D for explanation. (c) D. The patient should not receive the rubella vaccine during the course of her pregnancy as the possibility of transmission of the rubella virus does exist. During the time that the patient is without protective titer she should avoid anyone with active rubella infection. The proper time to receive the vaccine is after delivery of the infant. pg. 71 professoraxe l A patient with which of the following is at highest risk for coronary artery disease? A. Congenital heart disease B. Polycystic ovary syndrome C. Acute renal failure D. Diabetes mellitus - Correct Answer-(u) A. Congenital heart disease is not an established risk factor for coronary artery disease. (u) B. While patients with polycystic ovary syndrome have hyperinsulimemia, they do not have the same poor prognosis for coronary artery disease as patients with diabetes mellitus. (u) C. Patients with acute renal failure are not at risk for coronary artery disease, although patients with diabetes and chronic renal disease do have this risk. (c) D. Patients with diabetes mellitus are in the same risk category for coronary artery disease as those patients with established atherosclerotic disease. A 44 year-old female presents with ongoing arthralgias and myalgias with intermittent flares of arthritis. She is found to pg. 72 professoraxe l A. Low-carbohydrate, high protein diet B. Routine aerobic exercise C. Metformin (Glucophage) D. Acupuncture - Correct Answer-(u) A. There is no evidence that a low-carbohydrate, high protein diet is effective in improving carbohydrate metabolism. (c) B. Routine exercise improves carbohydrate metabolism and insulin sensitivity. (u) C. Metformin is a biguanide that primarily works to decrease gluconeogenesis rather than affecting carbohydrate metabolism. (u) D. There is no evidence that acupuncture improves carbohydrate metabolism. Acute rebound hypertensive episodes have been reported to occur with the sudden withdrawal of A. verapamil (Calan). B. lisinopril (Prinivil). C. clonidine (Catapres). D. hydrochlorothiazide (HCTZ) - Correct Answer-(u) A. Verapamil is a calcium channel blocker and there is no pg. 75 professoraxe l associated rebound hypertension after withdrawal. (u) B. Lisinopril is an ACE inhibitor, which is not associated with rebound hypertension. (c) C. Clonidine (Catapres) is a central alpha agonist and abrupt withdrawal may produce a rebound hypertensive crisis. (u) D. Hydrochlorothiazide is a thiazide diuretic, which is not associated with rebound hypertension. A 72 year-old female presents with vulvular pruritus for the last nine months, which has progressively worsened over the last two months. She states that she went through menopause at age 54 and has been on estrogen and progesterone therapy since that time. Physical examination reveals red lesions with white plaques on the vulva. What should the next course of management include? A. Refer to a gynecologist for biopsy. B. Refer to a dermatologist for antifungal therapy. C. Treat with a topical steroid. D. Treat with estrogen cream. - Correct Answer-(c) A. Vulvular squamous cell hyperplasia causes thickening and hyperkeratosis of the vulva. The lesions are red and moist and cause intense pruritus over time the area becomes thickened pg. 76 professoraxe l and a white plaque may develop. Biopsy must be done to evaluate for intraepithelial neoplasm or invasive tumor. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. A 30 year-old female presents to the emergency department with a syncopal episode. She has a history of irregular menstrual cycles and infertility. She has scanty, persistent vaginal bleeding and sharp pelvic pain. A left adnexal mass is palpated. The most likely diagnosis is A. placenta abruptio. B. ectopic pregnancy. C. pelvic inflammatory disease. D. ruptured ovarian cyst. - Correct Answer-(u) A. This is primarily a third trimester cause of vaginal bleeding. (c) B. Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis. (u) C. Pelvic inflammatory disease typically presents with fever, abdominal pain, purulent vaginal discharge, and pg. 77 professoraxe l grade III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border. What is the most likely diagnosis? A. Acute myocardial infarction B. Bacterial endocarditis C. Acute pericarditis D. Restrictive cardiomyopathy - Correct Answer-(u) A. Acute MI presents with complaint of chest pain, SOB, not with fever and myalgias. (c) B. Bacterial endocarditis presents as febrile illness lasting several days to weeks, commonly with nonspecific symptoms, echocardiogram often reveals vegetations on affected valves. (u) C. Pericarditis does not present with systolic or diastolic murmur or vegetation, more commonly pericardial friction rub would be noted. (u) D. Restrictive cardiomyopathy will show impaired diastolic filling on echocardiogram and is not associated with fever. A 45 year-old male presents with abdominal pain and one episode of mild hematemesis, which happened days ago. On physical examination, vital signs are stable and he is in no pg. 80 professoraxe l acute distress. Hemoglobin and hematocrit are unremarkable; endoscopy reveals non-bleeding small superficial ulceration of the duodenal bulb. Rapid urease test is positive. Which of the following is the most appropriate treatment at this time? A. Schedule for a selective vagotomy and antrectomy B. Start an antacid along with omeprazole (Prilosec) C. Schedule elective ulcer excision and start sucralfate (Carafate) D. Start omeprazole (Prilosec) and antibiotic therapy against H. pylori - Correct Answer-(u) A. Medical therapy should be initiated prior to any consideration of surgery, which is rarely performed secondary to satisfactory ulcer healing with medical therapy. (u) B. While proton pump inhibitors, such as omeprazole, have excellent results in healing duodenal ulcers, this regimen will not treat the H. pylori infection that is documented by the positive rapid urease test. (u) C. While sucralfate can be utilized as a cytoprotectant agent in treatment of active ulcer disease or in maintenance of healed ulcers, surgery to remove the ulcer is not warranted as initial therapy. (c) D. Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing. pg. 81 professoraxe l Which of the following findings is usually associated with Addison's disease? A. Weight gain B. Hypertension C. Increased pigmentation D. High plasma cortisol levels - Correct Answer-(u) A. Patients with Addison's disease tend to have anorexia and weight loss. (u) B. Patients with Addison's disease tend to have hypotension. (c) C. Patients with Addison's disease have diffuse tanning over nonexposed and exposed skin due to increased melanocytic factor that is released with adrenocorticotropic hormone. (u) D. Patients with Addison's disease tend to have low plasma cortisol levels. A 60 year-old patient with COPD characteristic of emphysema presents with a cough and increased sputum production. The following information is noted: Temperature 100°F (37.8°C); Respiratory rate 20/min; Heart rate 88 beats/min; pH 7.44; PaO2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable for increased AP diameter, pg. 82 professoraxe l C. chronic lymphocytic leukemia. D. chronic myelogenous leukemia. - Correct Answer-(u) A. Myelodysplastic syndrome may present with this clinical picture, but a CBC would indicate a normal or reduced white cell count. (u) B. A hallmark of acute leukemia is pancytopenia with numerous circulating blasts. (c) C. Chronic lymphocytic leukemia usually occurs after the age of 50 presenting with lymphocytosis > 20,000 mm3 and lymphocytes that appear mature. (u) D. Chronic myelogenous leukemia presents with markedly elevated WBC count (mean 150,000/mm3) with left shifted myeloid series. Which of the following conditions will not produce a transudative pleural effusion? A. Kaposi's sarcoma B. Pneumonia C. Cirrhosis D. Mesothelioma - Correct Answer-(u) A. Kaposi's sarcoma, pneumonia, or mesothelioma will produce a transudative pleural effusion. (u) B. See A for explanation. pg. 85 professoraxe l (c) C. Transudative pleural effusions result from alteration in the formation of pleural fluid, the absorption of pleural fluid, or both, by systemic factors. Local factors affecting pleural fluid absorption and/or formation produce exudative pleural effusions. (u) D. See A for explanation. Which of the following pathophysiological processes is believed to initiate acute appendicitis? A. Obstruction B. Perforation C. Hemorrhage D. Vascular compromise - Correct Answer-(c) A. Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body initiates most cases of appendicitis. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. A 23 year-old female with history of palpitations presents for evaluation. She admits to acute onset of rapid heart beating lasting seconds to minutes with associated shortness of pg. 86 professoraxe l breath and chest pain. The patient states she can relieve her symptoms with valsalva. Which of the following is the most appropriate diagnostic study to establish a definitive diagnosis in this patient? A. Cardiac catheterization B. Cardiac MRI C. Chest CT scan D. Electrophysiology study - Correct Answer-(u) A. Cardiac catheterization evaluates coronary arteries but has no role in the diagnosis of supraventricular tachycardia. (u) B. Cardiac MRI cannot diagnose and define pathway of supraventricular tachycardia. (u) C. Chest CT scan will not establish definitive diagnosis of supraventricular tachycardia. (c) D. Electrophysiology study is useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardia. A known alcoholic presents to the emergency department with altered level of consciousness and a blood glucose level of 35 mg/dL. Which of the following best explains this glucose result? A. Excess pancreatic insulin release pg. 87 professoraxe l D. lobar pneumonia. - Correct Answer-(u) A. Emphysema presents with diminished or absent breath sounds and hyperresonance to percussion without egophony. (u) B. Atelectasis most commonly has decreased breath sounds and dullness to percussion without egophony. (u) C. Pneumothorax presents with absent breath sounds, tactile fremitus, and resonance to percussion without egophony. (c) D. Egophony occurs with consolidation caused by lobar pneumonia. A patient presents with edema, which is most noticeable in the hands and face. Laboratory findings include proteinuria, hypoalbuminemia, and hyperlipidemia. The most likely diagnosis is A. congestive heart failure. B. end-stage liver disease. C. nephrotic syndrome. D. malnutrition. - Correct Answer-(u) A. Dependent edema is the most typical finding with CHF. Laboratory findings do not generally include proteinuria or hypoalbuminemia. (u) B. Symptoms of end-stage liver disease usually include increased abdominal girth indicating ascites. pg. 90 professoraxe l Hypoalbuminemia can occur as a result of malnutrition or concurrently with nephrotic syndrome. (c) C. Proteinuria, hyperlipidemia, and hypoalbuminemia are consistent with nephrotic syndrome. (u) D. Malnutrition is marked by physical wasting, not edema. Hypoalbuminemia may be seen, but hyperlipidemia is not typical. The best course of action for a patient with a bothersome inflamed pingueculae (pingueculitis) is A. antibiotic drops. B. excision. C. Visine drops. D. no treatment. - Correct Answer-(u) A. Antibiotic drops have no benefit with pingueculitis. (h) B. Excision is indicated for a pterygium that is threatening vision. (u) C. Visine drops will not do anything, but artificial tears may be beneficial. (c) D. With pingueculitis, no treatment is necessary; a short course of NSAID drops or steroids may help. pg. 91 professoraxe l An immunocompromised patient presents with signs and symptoms consistent with Legionella pneumophila who has not responded to initial antibiotic therapy with a macrolide. Which of the following should be added? A. Clarithromycin (Biaxin) B. Rifampin (Rifadin) C. Levofloxacin (Levaquin) D. Amoxicillin-clavulanate (Augmentin) - Correct Answer-(u) A. The macrolides (Clarithromycin) and fluoroquinolones (Levofloxacin) should be used for initial treatment, but not for adding to failed treatments when a macrolide was already used. (c) B. Rifampin should be used as an adjunct in patients with either a macrolide or quinolone antibiotic, who have failed therapy, are immunocompromised or have severe illness. (u) C. See A for explanation. (u) D. Legionella pneumophila does not respond to Beta- lactam antibiotics. A mother brings her 6 year-old boy for evaluation of school behavior problems. She says the teacher told her that the boy does not pay attention in class, that he gets up and runs around the room when the rest of the children are listening to a story, and that he seems to be easily distracted by events pg. 92 professoraxe l D. Levofloxacin (Levaquin) - Correct Answer-(u) A. See D for explanation. (u) B. See D for explanation. (u)\C. See D for explanation. (c) D. Chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate. A 25 year-old male with history of syncope presents for evaluation. The patient admits to intermittent episodes of rapid heart beating that resolve spontaneously. 12 Lead EKG shows delta waves and a short PR interval. Which of the following is the treatment of choice in this patient? A. Radiofrequency catheter ablation B. Verapamil (Calan) C. Percutaneous coronary intervention D. Digoxin (Lanoxin) - Correct Answer-(c) A. Radiofrequency catheter ablation is the treatment of choice on patients with accessory pathways, such as Wolff-Parkinson-White Syndrome. (h) B. Calcium channel blockers such as verapamil decrease refractoriness of the accessory pathway or increase that of the pg. 95 professoraxe l AV node leading to faster ventricular rates, therefore calcium channel blockers should be avoided in patients with WPW. (u) C. Percutaneous coronary intervention is indicated in the treatment of coronary artery disease, not preexcitation syndromes. (h) D. Digoxin decreases refractoriness of the accessory pathway and increases that of the AV node leading to faster ventricular rates. It should therefore be avoided in patients with WPW. Which of the following pathophysiological processes is associated with chronic bronchitis? A. Destruction of the lung parenchyma B. Mucous gland enlargement and goblet cell hyperplasia C. Smooth muscle hypertrophy in the large airways D. Increased mucus adhesion secondary to reduction in the salt and water content of the mucus - Correct Answer-(u) A. Destruction of the gas-exchanging structures in the lung is characteristic of emphysema. (c) B. Chronic bronchitis results from the enlargement of mucous glands and goblet cell hypertrophy in the large airways. pg. 96 professoraxe l (u) C. There may be smooth muscle hypertrophy in chronic bronchitis but it is not to the extent as found in asthma and is not an underlying factor in the pathology of chronic bronchitis. (u) D. Abnormal absorption of sodium and a reduced rate of chloride secretion in cystic fibrosis leads to thickening of the mucus and increase in adhesion of the mucus. Which of the following dietary substances interact with monoamine oxidase-inhibitor antidepressant drugs? A. Lysine B. Glycine C. Tyramine D. Phenylalanine - Correct Answer-(u) A. Lysine, glycine, and phenylalanine are not known to interact with MAO inhibitors. (u) B. See A for explanation. (c) C. Monoamine oxidase inhibitors are associated with serious food/drug and drug/drug interactions. Patient must restrict intake of foods having a high tyramine content to avoid serious reactions. Tyramine is a precursor to norepinephrine. (u) D. See A for explanation. pg. 97 professoraxe l