PACKRAT Exam Questions with 100% Correct Answers | Verified | Updated 2024, Exams of Advanced Education

Download PACKRAT Exam Questions with 100% Correct Answers | Verified | Updated 2024 and more Exams Advanced Education in PDF only on Docsity! PACKRAT Exam Questions with 100% Correct Answers | Verified | Updated 2024 1. Health Maintenance/Obstetrics/Gynecology Which of the following portends the greatest risk for the development of breast cancer? A. Nulliparity B. Early menarche C. BRCA 1 positivity D. Maternal family history of breast cancer - Correct Answer- (u) A. See C for explanation. (u) B. See C for explanation. (c) C. BRCA1 positivity is associated with half of the early onset breast cancers and 90% of the hereditary ovarian cancers. (u) D. See C for explanation. 2. Clinical Therapeutics/Urology/Renal In order to help delay the progression to kidney disease in a diabetic patient with proteinuria, which of the following pg. 1 professoraxe l would you consider using to treat the patient's concomitant hypertension? A. Atenolol (Tenormin) B. Amlodipine (Norvasc) C. Accupril (Quinapril) D. Amiloride (Midamor) - Correct Answer-(u) A. Atenolol is a beta blocker. Beta blockers are not first line therapy for hypertensive diabetics. (u) B. Amlodipine is a calcium channel blocker. Calcium channel blockers are not first line therapy for hypertensive diabetics. (c) C. Accupril is an ACE inhibitor. Because of their beneficial effects in diabetic neuropathy, ACE inhibitors (and ARBs) should be part of the initial treatment regimen for hypertension in diabetics. (u) D. Amiloride is a potassium-sparing diuretic. An ACE inhibitor is the standard first line therapy for hypertensive diabetics. : 3. Diagnosis/Pulmonology pg. 2 professoraxe l 5. Diagnostic Studies/ENT/Ophthalmology Which of the following imaging modalities is most appropriate in the evaluation of chronic sinusitis? A. Coronal CT B. Sinus MRI C. Panorex D. Sinus radiographs - Correct Answer-(c) A. Coronal CT is the most effective imaging to determine the anatomy of the sinuses as well as the presence and extent of sinusitis. (u) B. MRI is of limited value due to less than optimal visualization of bony structures. (u) C. Panorex imaging provides limited viusalization of the sinus structures. (u) D. Sinus radiographs are rarely used due to limited visualization of soft tissues. : (8) 6. Clinical Therapeutics/Orthopedics/Rheumatology pg. 5 professoraxe l Which of the following is indicated as the first-line treatment of an initial case of acute gouty arthritis? A. Indomethacin (Indocin) B. Colchicine (Probenicid) C. Methylprednisolone (Medrol) D. Allopurinol (Zyloprim) - Correct Answer-(c) A. A nonsteroidal antiinflammatory agent is indicated as the first- line treatment for an initial case of acute gout. (u) B. Colchicine is a useful adjunct to NSAIDs, corticosteroids, or synthetic ACTH for the treatment of severe gout, refractory acute gouty attacks, or as prevention. (u) C. An intra-articular injection of glucocorticoid or a tapered regimen of oral prednisone can be used as an alternative treatment to the first-line treatment of an NSAID. (u) D. Allopurinol is a xanthine oxidase inhibitor used for patients with more than three occurrences per year, gout that is difficult to manage safely (polyarticular gout in a transplant patient or one with renal insufficiency), tophaceous gout, and hyperuricemia. Allopurinol can trigger an episode of gout, especially in the first few months of treatment. pg. 6 professoraxe l : (8) 7. Diagnostic Studies/Infectious Diseases Which of the following is the most sensitive laboratory test to diagnose herpes simplex virus? A. Polymerase chain reaction (PCR) B. Enzyme-linked immunosorbent assay (ELISA) C. Tzanck smear D. HSV antibody titer - Correct Answer-(c) A. Diagnosis is usually made clinically however, PCR is more sensitive than culture. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. : (8) 8. Health Maintenance/Psychiatry/Behavioral Medicine Which of the following is the drug of choice for the prevention of Wernicke's encephalopathy? A. Folic acid pg. 7 professoraxe l D. Focal torsion dystonia - Correct Answer-(u) A. Parkinsonism is characterized by combination of tremor, rigidity, bradykinesia, and postural instability. (c) B. Essential tremor can be familial and cause action related hand tremor, head tremor, or voice tremor. The lower extremities are spared and generally no further neurologic findings are present. (u) C. Huntington disease is characterized by gradual onset of chorea and restlessness, progressing to choreiform movements. (u) D. Focal torsion dystonia causes involuntary spasmodic movements including torsion of neck, oromandibular dystonia, or uncontrolled eye blinking. : (11) 11. Health Maintenance/Pulmonology Which of the following is most likely to cause a false negative PPD? A. Aspirin allergy B. Diagnosis of AIDS C. BCG immunization pg. 10 professoraxe l D. Pregnancy - Correct Answer-(u) A. See B for explanation. (c) B. Any process that results in reduced immune response can cause a false negative PPD. Past immunization with BCG would typically result in a false positive while aspirin allergy and pregnancy generally have no effect in and of themselves on PPD results. (u) C. See B for explanation. (u) D. See B for explanation. : (8) 11 12. Diagnostic Studies/Orthopedics/Rheumatology An afebrile 50 year-old male presents with an acute onset of an exquisitely painful first metatarsophalangeal joint. Examination reveals a red and swollen joint with tenderness on palpation. Which of the following test results will most likely be found in this patient? A. Hyperuricemia B. Negative birefringent crystals C. Evidence of a septic joint with needle aspiration pg. 11 professoraxe l D. Calcium pyrophosphate dehydrate crystals - Correct Answer-(u) A. Although 75% of patients with gout have hyperuricemia, few patients with hyperuricemia develop gout. (c) B. Negative birefringence of the needle-shaped crystals associated with gout are seen by a yellow colorization on polarized light microscopy. (u) C. A coexisting septic joint is possible, but not typical of gout. (u) D. Calcium pyrophosphate dehydrate crystal deposition is a gout-like syndrome that typically affects the knee and is also known as pseudogout. : (8) 13. History & Physical/Gastrointestinal/Nutritional An elderly man who recently emigrated from a war-torn area of Africa is brought to the clinic by his daughter. She explains that her father's diet was very limited in calories and protein and that he mostly ate corn and very little fresh foods. He has chronic diarrhea and examination reveals pigmented regions on hands, arms, and face and mild dementia. His tongue is smooth and shiny. This patient most likely has a deficiency of which of following vitamins? pg. 12 professoraxe l A 5 year-old male is brought to the office by his father who reports a 2 day history of low grade fever and coryza. The child awoke this morning with bright red cheeks. Physical examination reveals edematous, confluent plaques over the malar region of the face and reticular rash over the child's extensor surfaces. Which of the following is the most likely diagnosis? A. Rubeola B. Parvovirus B19 C. Respiratory syncytial virus D. Epstein-Barr virus - Correct Answer-(u) A. Rubeola (measles) is a highly contagious viral infection characterized by cough, conjunctivitis and coryza. There is an associated rash which is an erythematous maculopapular that spreads centrally and inferiorly. (c) B. This is a classic presentation of Fifth Disease, a childhood exantham associated with human parvovirus B19. (u) C. RSV is a viral infection of the airway that causes annual outbreaks causing pneumonia, bronchiolitis and tracheobronchitis. (u) D. EBV is a common human virus that is present in >90% of the adult population and persists in the host for pg. 15 professoraxe l his/her lifetime. THe most common presentation is a 10-35 year-old with mononucleosis. : (8) 16. Diagnostic Studies/Pulmonology In a patient with a low probability of pulmonary embolism (PE) based on the Wells criteria, which of the following lab studies is most helpful in ruling out a PE? A. D dimer assay B. PT with INR C. Factor V assay D. Clotting time - Correct Answer-(c) A. Even though useful in ruling in a pulmonary embolism, the D dimer is negative in over 95% of patients who do not have a pulmonary embolism. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. : (8) 17. Health Maintenance/Cardiology pg. 16 professoraxe l Which subset of the asymptomatic general population should undergo one-time screening for abdominal aortic aneurysm? A. 65 year-old female with chronic kidney disease B. 65 year-old healthy male who has smoked since age 20 C. 74 year-old male who has diabetes mellitus D. 74 year-old female who has smoked since age 15 - Correct Answer-(u) A. See B for explanation. (c) B. Data support the use of abdominal ultrasound to screen 65- to 74-year old men, but not women, who have a history of smoking. Repeated screening does not appear to be needed if the aorta shows no enlargement. (u) C. See B for explanation. (u) D. See B for explanation. : (8) 18. Clinical Therapeutics/Endocrinology Which of the following is the pharmacologic therapy of choice in male patients suffering from mild-moderate gynecomastia? A. Selective serum reuptake inhibitor (SSRIs) pg. 17 professoraxe l floaters followed by curtain-like vision loss sparing the central vision in the right eye. Which of the following is the most likely diagnosis? A. Classic migraine B. Retinal detachment C. Optic neuritis D. Transient ischemic attack - Correct Answer-(u) A. Classic migraine may present with the above symptoms; however, the symptoms are typically bilateral. Additionally, given the advanced age of the patient migraine would be considered less likely. (c) B. Non-traumatic retinal detachment usually presents in an older individual. The classic symptoms include abrupt onset of painless flashing lights and floaters followed by progressive vision loss. (u) C. Optic neuritis may present with the above symptoms; however, the mean age of onset is 32 years of age and the presentation typically involves ocular pain. (u) D. Vertebrobasilar insufficiency may result in dysfunction of the visual cortex with subsequent vision disturbance similar to the above presentation. In contrast the patient may present with additional findings of sensorimotor pg. 20 professoraxe l dysfunction. : (8) 21. History & Physical/Obstetrics/Gynecology A patient presents to the office with a last menstrual period of May 4th. What is the estimated date of confinement? A. January 4 B. January 11 C. February 11 D. February 12 - Correct Answer-(u) A. See C for explanation. (u) B. See C for explanation. (c) C. Calculation is based on Naegele's rule by adding 7 days to the first day of the last menstrual period and then subtracting 3 months. (u) D. See C for explanation. : (8) 22. Scientific Concepts/Cardiology Empiric treatment for infective endocarditis should target which organism? A. Haemophilus influenzae pg. 21 professoraxe l B. Moraxella catarrhalis C. Mycoplasma pneumoniae D. Staphylococcos aureus - Correct Answer-(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Empiric regimens for endocarditis while culture results are pending should include agents active against staphylococci, streptococci, and enterococci. : (8) 23. History & Physical/Gastrointestinal/Nutritional A 68 year-old woman presents with intermittent crampy abdominal pain and vomiting of 6 hours' duration. She feels bloated but denies rectal bleeding. Examination of the abdomen reveals no palpable mass and you note an upper midline scar from previous abdominal surgery. An abdominal radiograph demonstrates dilated loops of small bowel with air-fluid levels. Which of the following is the most likely cause of this patient's symptoms? A. Adhesions B. Sigmoid volvulus pg. 22 professoraxe l (u) D. Application of topical antifungal may be helpful to prevent recurrences, but not for preventative use. : (28) 25. Scientific Concepts/Pulmonology A 21 year-old college student presents with a 3 week history of slowly worsening dry cough, generalized fatigue and most recently low-grade fevers. He denies nasal congestion, sore throat and nausea and has no past history of pulmonary disease or tobacco use. He does note that many other dorm residents have had similar symptoms over the past two months. Examination reveals mild inspiratory crackles but is otherwise normal. Chest radiograph is clear and CBC is normal. Which of the following is the most likely causative organism? A. Staphylococcus B. Pseudomonas C. Mycoplasma D. Klebsiella - Correct Answer-(u) A. See C for explanation. (u) B. See C for explanation. (c) C. The subacute onset in this demographic of patient along with the lack of more advanced findings on exam and chest pg. 25 professoraxe l radiograph points most strongly to Mycoplasma. The other organisms listed have a generally more acute and severe onset and are associated with patients who have complications or other comorbid conditions. (u) D. See C for explanation. : (29) 26. History & Physical/Urology/Renal A 22 year-old male presents for a physical. On examination you palpate a painless mass that cannot be separated from the right testicle. Which of the following is the most likely diagnosis? A. Spermatocele B. Varicocele C. Testicular cancer D. Epididymitis - Correct Answer-(u) A. A spermatocele is a painless, sperm-filled mass on the epididymis. (u) B. A varicocele is a painless collection of varicosed veins in the spermatic cord. (c) C. Testicular cancer is the most common neoplasm in men 20-35 years of age. It commonly presents as a pg. 26 professoraxe l painless mass which cannot be separated away from the testicle. Any nodule within the testes warrants evaluation for malignancy. (u) D. Epididymitis is an acute infection of the epididymis. The patient most commonly appears acutely ill with a fever and an exquisitely tender epipididymis. : (8) 27. Diagnosis/Cardiology A 9 year-old presents with increasing shortness of breath while playing basketball recently. On examination, radial pulses are exaggerated while femoral pulsations are weak. Chest radiograph shows rib notching and a mildly enlarged heart. Which of the following is the most likely diagnosis for this patient? A. Atrial septal defect B. Coarctation of the aorta C. Patent ductus arteriosus D. Tetralogy of Fallot - Correct Answer-(u) A. See B for explanation. (c) B. In older children, the ECG and chest x-ray usually show left ventricular hypertrophy and a mildly enlarged pg. 27 professoraxe l (u) B. Hidradenitis is a severe, chronic disabling skin infection of the apocrine sweat glands that can occur in the axilla and groin or perineum area and usually presents with multiple abscesses or sinus tracts. (u) C. Cryptoglandular abscess typically presents with continuous throbbing pain, which is worse with walking. Examination will reveal a tender perianal or rectal mass. Signs of sepsis are possible. (c) D. Pilonidal cyst presents with a tender draining abscess or chronic sinus over the sacrococcygeal or perianal region. It is thought to be due to distended and obstructed hair follicles and rupture into subcutaneous tissues with inspissated hair. On exam the patient will have midline pits near the coccyx or sacrum. : (7) 30. Clinical Therapeutics/Obstetrics/Gynecology Which of the following tocolytic agents works by inhibition of calcium influx? A. Nifedipine (Procardia) B. Terbutaline sulfate (Terbutaline) C. Indomethacin (Indocin) pg. 30 professoraxe l D. Ritodrine (Yutopar) - Correct Answer-(c) A. Nifedipine, a calcium channel blocker, prevents calcium entry into muscle cells. It is commonly used for the treatment of preterm labor. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. : (28) 31. Clinical Intervention/Orthopedics/Rheumatology A 20 year-old male is brought to the ED by ambulance for evaluation of a neck injury after diving into shallow water. A radiograph reveals a moderately displaced C1 atlas fracture. Which of the following is the indicated management of this fracture? A. Surgical fusion of C1-C2 B. Halo vest C. Cervical traction D. Cervical collar - Correct Answer-(u) A. C1-C2 fusion is indicated for patients with remaining instability, nonunion, or posterior arch disruption after 3-4 months of halo vest treatment. pg. 31 professoraxe l (c) B. Halo vest application is indicated in cases involving a moderately displaced fracture. (u) C. Cervical traction is not indicated for a C1-C2 fracture. Cervical immobilization is indicated. (u) D. Cervical collar immobilization is indicated for a minimally displaced C1 fracture. : (8) 32. Clinical Therapeutics/Pulmonology Which of the following is the most effective outpatient treatment for Mycoplasma pneumonia? A. Doxycycline (Doryx) B. Amoxicillin (Amoxil) C. Trimethoprim (Septra) D. Cephalexin (Keflex) - Correct Answer-(c) A. Mycoplasma is an intracellular parasite which would require an antibiotic, like doxycyline, to penetrate the cell membrane and eradicate the infection. The other antibiotic selections do not achieve this action. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. pg. 32 professoraxe l : (7) 35. Clinical Intervention/Hematology A 4 year-old female presents with a headache and new onset confusion. She was diagnosed with a viral illness 2 weeks ago. Examination reveals petechiae and mild scant purpura on her legs bilaterally. The CBC demonstrates a platelet count of 8,000/uL. Which of the following is the most appropriate next step in the assessment of this patient? A. Lumbar puncture B. D-dimer C. PT and PTT D. CT scan of the head - Correct Answer-(h) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. The concern for this patient is low platelets and internal bleeding. In this scenario, the patient complaining of a headache would warrant a CT scan to evaluate for an intracranial bleed. : (8) pg. 35 professoraxe l 36. History & Physical/Cardiology A 59 year-old male with longstanding uncontrolled hypertension presents with nausea and a 5 pound weight gain in the last 2 days. He states "my belly is getting bigger and I can't fasten my pants." Which of the following physical examination findings would be most likely in this patient? A. Ankle edema and elevated jugular venous pressure B. Dry cough and mitral regurgitation murmur C. Hypotension and cyanotic extremities D. S3 heart sound heard along the left sternal border and bilateral wheezing - Correct Answer-(c) A. This patient's symptoms indicate right heart failure with bloating. (u) B. Dry cough and mitral regurgitation murmur are symptoms of left-sided failure. (u) C. Hypotension and cyanotic extremities are symptoms of left-sided failure. (u) D. An S3 heart sound heard along the left sternal border and bilateral wheezing are symptoms of left sided failure. : (7) pg. 36 professoraxe l 37. Diagnostic Studies/Psychiatry/Behavioral Medicine Which of the following laboratory tests would differentiate seizure from pseudoseizure? A. Urine cortisol B. Serum prolactin C. Dexamethasone suppression D. Fasting blood sugar - Correct Answer-(u) A. See B for explanation. (c) B. The serum prolactin level can rise briefly after a seizure and therefore may assist in the determination between true seizure activity and pseudoseizure activity. (u) C. See B for explanation. (u) D. See B for explanation. : (8) 38. Clinical Intervention/Gastrointestinal/Nutritional A 34 year-old female 3 days status-post appendectomy complains of mild diffuse abdominal pain with associated nausea and vomiting. On examination you note diminished bowel sounds. There is generalized abdominal distension with mild tenderness on palpation. There are no signs of peritoneal inflammation. Abdominal radiographs show pg. 37 professoraxe l bleeding or dysuria. Which of the following is the most appropriate next step in the management of this patient? A. Induction of labor with oxytocin (Pitocin) B. Digital examination for the presence of cervical dilation C. Urinalysis for urinary tract infection D. Sterile speculum examination for vaginal pooling and ferning - Correct Answer-(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Fluid passing through the vagina is presumed to be amniotic fluid until proven otherwise. Urinary leakage is common during pregnancy, especially near term and can be difficult for the patient to decifer between urinary incontinence and premature rupture of membranes. : (8) 41. Diagnosis/ENT/Ophthalmology An afebrile 2 year-old female presents with a three-day history of foul smelling, blood-tinged, mucoid drainage from the left nostril. Which of the following is the most likely diagnosis in this patient? A. Acute bacterial sinusitis pg. 40 professoraxe l B. Nasal foreign body C. Acute viral rhinitis D. Allergic rhinitis - Correct Answer-(u) A. Bacterial sinusitis typically follows a viral upper respiratory infection with symptoms of cough, nasal drainage and fever. The symptom duration is typically 10-14 days without improvement. (c) B. Nasal foreign body typically presents in children under 3 years of age. The symptoms include mucopurulent drainage, epistaxis, foul odor and nasal obstruction. (u) C. The patient with acute viral rhinitis typically presents with sudden onset of mucoid rhinorrhea, sore throat, fever and cough. (u) D. Allergic rhinitis is associated with recurrent nasal congestion, frequent sneezing and clear rhinorrhea. : (9) 42. Clinical Intervention/Cardiology You are evaluating a patient who was brought in secondary to an acute onset of repeated syncopal episodes. His electrocardiogram (ECG) shows wide QRS complexes with a fixed R-R interval at a rate of 40 bpm. The P waves pg. 41 professoraxe l occur with a fixed P-P interval at a rate of 70 bpm. The PR interval is variable. Which of the following is the most appropriate initial treatment for this condition? A. Balloon angioplasty B. Endarterectomy C. Transthoracic pacemaker D. Unsynchronized cardioversion - Correct Answer-(u) A. The patient with a 3rd degree heart block would gain no benefit from balloon angioplasty. (u) B. The patient with a 3rd degree heart block would gain no benefit from endarterectomy. (c) C. The ECG this patient's symptoms are consistent with a third degree heart block. Patients with episodic or chronic infranodal complete heart block require permanent pacing, and temporary pacing is indicated if implantation of a permanent pacemaker is delayed. (h) D. Unsynchronized cardioversion in a patient with third degree heart block can result in a fatal ventricular fibrillation conversion. : (9) 43. Scientific Concepts/Pulmonology pg. 42 professoraxe l marked social and occupational impairment. They have acute psychotic episodes with delusions, hallucinations, disorganized speech, bizarre behavior, and flattened affect. (c) B. Schizophreniform disorder is characterized by the same features as schizophrenia except for the total duration of illness being from 1-6 months. Additionally, with schizophreniform, there is no impairment in social or occupation functioning. (u) C. Schizoaffective disorder is a disease condition that combines features of schizophrenia with a mood disorder. Patients are manic, depressed, or have a mixed episode that includes psychotic symptoms. (u) D. Brief psychotic disorder has the sudden onset of delusions, hallucinations, disorganized speech, or bizarre behavior. It lasts at least 1 day but less than 1 month. : (9) 46. Scientific Concepts/ENT/Ophthalmology A 65 year-old female presents with new onset of right eyelid droop. On examination ptosis, ipsilateral anhydrosis and pg. 45 professoraxe l miosis are noted. What is the underlying mechanism associated with this presentation? A. Autoimmune dysfunction of neuromuscular transmission B. Dysfunction of the 7th cranial nerve C. Disturbance of the cranial sympathetic innervation D. Dysfunction of the 5th cranial nerve - Correct Answer-(u) A. Autoimmune dysfunction of the neuromuscular junction typically results in myasthenic syndromes such as, myasthenia gravis or Lambert-Eaton myasthenic syndrome. (u) B. Dysfunction of the 7th cranial nerve results in facial muscle paralysis. (c) C. Horner's Syndrome (ptosis, miosis, anhydrosis) is the result of cranial sympathetic dysfunction that occurs due to nerve injury below the level of entry into the skull. (u) D. Dysfunction of the 5th cranial nerve may result in facial sensory loss and altered motor function of the temporalis and masseter muscles. : (9) 47. Clinical Intervention/Urology/Renal A 28 year-old female is seen for her fourth documented case of uncomplicated cystitis this year. You recommend pg. 46 professoraxe l prophylaxis with nitrofurantoin (Macrodantin) 100 mg at bedtime, however, she would prefer not to take a daily medication. What alternative single-dose schedule can you recommend? A. Day 1 of menstrual cycle B. Following intercourse C. After each bowel movement D. Weekly every Sunday - Correct Answer-(u) A. See B for explanation. (c) B. Women who have more than three episodes of cystitis per year are considered candidates for prophylactic antibiotics to prevent recurrence after treatment for UTI. Single dosing at bedtime or at the time of intercourse is the recommended schedule. (u) C. See B for explanation. (u) D. See B for explanation. : (9) 48. History & Physical/Orthopedics/Rheumatology An obese 12 year-old male presents with a 1 month history of right thigh pain worsened with weight bearing. pg. 47 professoraxe l (u) D. See B for explanation. : (9) 50. Diagnosis/Obstetrics/Gynecology A 35 year-old primigravida presents to your office at 16 weeks gestation. BP measurements in the first trimester were within normal limits. On physical examination her blood pressure after 5 minutes of rest is 160/100 mmHg. A repeat measurement 1 week later is 154/98 mmHg. Fundoscopic exam is normal, and no other abnormalities are noted. Which of the following is the most likely diagnosis in this patient? A. Preeclampsia B. Chronic hypertension C. Gestational hypertension D. Molar pregnancy - Correct Answer-(u) A. See B for explanation. (c) B. Chronic hypertension in a pregnant patient is defined as hypertension present before the 20th week of pregnancy or hypertension present before pregnancy. (u) C. See B for explanation. (u) D. See B for explanation. pg. 50 professoraxe l : (8) 51. Clinical Therapeutics/Cardiology A patient presents with complaints of headaches during strenuous exercise. Twenty-four hour ambulatory blood pressure readings indicate he is hypertensive with exercise. A chest radiograph reveals mild cardiomegaly. An echocardiogram shows an ejection fraction of 75% with interventricular septal hypertrophy. Which of the following is the most appropriate initial choice of medications for this patient? A. Phentolamine (Regitine) B. Metoprolol (Lopressor) C. Disopyramide (Norpace) D. Isoproterenol (Isuprel) - Correct Answer-(u) A. Phentolamine is a nonselective alpha-adrenergic antagonist and is therefore not a first-line drug of choice. (c) B. Beta-blockers should be the initial drug in symptomatic individuals, especially when dynamic outflow obstruction is noted on the echocardiogram. Diuretics may also be required to decrease pre-load. pg. 51 professoraxe l (u) C. Disopyramide is an antiarrhythmic medication that may be used in conjunction with a beta-blocker, however is not first-line drug of choice. (h) D. Isuprel is a sympathomimetic beta adrenergic agonist that is structurally similar to adrenaline and therefore may exacerbate the symptoms. : (9) 52. Health Maintenance/ENT/Ophthalmology What is the recommended frequency of retinal screening in a patient with type 2 diabetes mellitus without evidence of retinopathy? A. Examination if symptoms develop B. Every 3-months examination C. Every 6-months examination D. Annual examination - Correct Answer-(h) A. This strategy is unacceptable given the high likelihood of lost follow-up or delayed follow-up. (u) B. This frequency is typically indicated for individuals with proliferative retinopathy. (u) C. Screening is recommended at 6-12 month intervals in individuals with mild to moderate non-proliferative pg. 52 professoraxe l D. Chronic renal failure - Correct Answer-(c) A. Prerenal azotemia can present as nonspecific symptoms including nausea, vomiting, malaise, and confusion. Prerenal causes are most common and include hypovolemia, which is the likely etiology in this case as her BUN:Creatinine ratio is consistent with dehydration. (u) B. Postrenal azotemia is relatively uncommon and can occur as the result of obstruction of urine flow from both kidneys. Causes include ureteral obstruction and bladder obstruction. Kidney stones (or in men, BPH) are a common cause. (u) C. Intrinsic renal failure occurs as a direct result of insult to the kidney. It should be considered if pre- or postrenal azotemia is not the appropriate diagnosis. (u) D. These are acute changes and we have no reason to suspect that the patient has longstanding kidney insufficiency. 55. History & Physical/Pulmonology While examining a patient's chest you discover an area with absent breath sounds, increased tactile fremitus and egophony. Which of the following conditions do these findings most likely represent? pg. 55 professoraxe l A. Pleural effusion B. Pneumothorax C. Pneumonia D. Pulmonary hypertension - Correct Answer-(u) A. See C for explanation. (u) B. See C for explanation. (c) C. These physical exam findings most often correlate with an increased density of the pulmonary tissues. This would most commonly be caused by a consolidation secondary to pneumonia. (u) D. See C for explanation. : (9) 56. Clinical Therapeutics/Psychiatry/Behavioral Medicine Which of the following laboratory tests should be followed in patients treated with atypical antidepressants? A. CBC B. BUN C. TSH D. FBS - Correct Answer-(u) A. See D for explanation. (u) B. See D for explanation. pg. 56 professoraxe l (u) C. See D for explanation. (c) D. Patients who take atypical antidepressants should be monitored for the development of diabetes on a quarterly or semiannual basis. : (9) 27 57. Scientific Concepts/Infectious Diseases Which of the following clinical pictures best defines acquired immune deficiency syndrome (AIDS)? A. HIV +, CD 4 lymphocyte count of 250 cells/mcL B. Non-Hodgkin lymphoma with or without evidence of HIV infection C. HIV +, community acquired pneumonia (CAP) D. Mycobacterium avium complex with or without evidence of HIV infection - Correct Answer-(u) A. HIV infection with a CD 4 lymphocyte count under 200 cells/mcL is diagnostic of AIDS. (u) B. Non-Hodgkin lymphoma with evidence of HIV infection is a definitive AIDS diagnosis. Non-Hodgkin lymphoma can be present in patients who do not have HIV infection. pg. 57 professoraxe l the MI. Troponins begin to rise within 4-6 hours and remain elevated for 7-10 days. : (27) 59. Clinical Therapeutics/Neurology A 58 year-old male presents with a 4 month history of instability upon ambulation. Examination reveals resistance to passive movements, mild tremor of the lips and a shuffling gait. Which of the following medications is most appropriate for this patient? A. Levadopa/carbidopa (Sinemet) B. Benztropine mesylate (Cogentin) C. Clozapine (Clozaril) D. Risperidone (Risperdal) - Correct Answer-(c) A. Levodopa/carbidopa generally helps reduce many symptoms associated with Parkinsonism, including 28 bradykinesia. (u) B. Benztropine mesylate is useful in the treatment of tremor and rigidity, and less effective on bradykinesia. pg. 60 professoraxe l (u) C. Clozapine is useful in treating the behavioral aspects of Parkinsonism. (u) D. Risperidone is useful in treating the behavioral aspects of Parkinsonism. : (27) 60. Diagnostic Studies/Obstetrics/Gynecology A 24 year-old G2 P1 at 32 weeks of gestation presents to labor and delivery with contractions. Her previous pregnancy resulted in an uncomplicated term delivery at 37 weeks. Which of the following will be most helpful in predicting the likelihood of preterm delivery in this patient? A. Fetal fibronectin B. Screening for candidiasis C. Weekly digital cervical examinations D. Ultrasound of lower uterine segment - Correct Answer-(c) A. An increase in the concentration of fetal fibronectin in cervicovaginal secretions is found with preterm labor. A preterm rise in the concentration may be associated with an increase likelihood of birth between 22 and 34 weeks of gestation and birth within 7-14 days of the test. (u) B. See A for explanation. pg. 61 professoraxe l (h) C. Digital examinations increase the risk for infection and preterm labor and delivery and are therefore contraindicated. (u) D. See A for explanation. : (27) 61. Health Maintenance/Orthopedics/Rheumatology A 13 year-old patient presents to the orthopedic surgeon's office for a follow-up evaluation for scoliosis. The Cobb angle is measured at 65 degrees. Which of the following is indicated at this time? A. Observation for 4 months B. Physical therapy C. Leg length measurements D. Pulmonary function testing - Correct Answer-(u) A. Patients with a Cobb angle less than 10 degrees can be managed by observation alone while patients with a Cobb angle less than 20 degrees are typically managed conservatively. (u) B. See D for explanation. (u) C. See D for explanation. pg. 62 professoraxe l (u) C. Deep vein thrombosis is not associated with factor VIII deficiency. (u) D. Purpura is not typically found in Factor VIII disorders. : (27) 64. Scientific Concepts/Dermatology Which of the following is the single most important prognostic factor in regard to melanoma? A. Histopathology of the lesion B. Diameter of the lesion C. Thickness of the lesion D. Ulceration of the lesion - Correct Answer-(u) A. See C for explanation. (u) B. See C for explanation. (c) C. The single most significant prognostic factor in melanoma is tumor thickness. Ten year survival rate in years according to thickness : < 1mm, 95%; 1-2mm, 80%; 2-4 mm, 55%; >4mm, 30%. (u) D. See C for explanation. : (28) pg. 65 professoraxe l 65. Diagnosis/Cardiology A 1 month-old infant is brought to your office by his mother for routine evaluation and immunizations. Examination reveals a continuous, rough machinery pansystolic murmur that is best heard in the first and second interspaces of the left sternal border associated with a thrill. Which of the following is the most likely diagnosis in this patient? A. Atrial septal defect B. Coarctation of the aorta C. Patent ductus arteriosus D. Ventricular septal defect 30 - Correct Answer-(u) A. See C for explanation. (u) B. See C for explanation. (c) C. In an infant with patent ductus arteriosus, there are no symptoms unless left ventricular failure or pulmonary hypertension develops. The pulse pressure is wide, and diastolic pressure is low. A continuous, rough, machinery murmur, accentuated in late systole at the time of S2 is heard best in the left first and second interspaces at the left sternal border. Thrills are common. (u) D. See C for explanation. pg. 66 professoraxe l : (27) 66. Clinical Therapeutics/Endocrinology Which of the following disorders responds most readily to treatment with vitamin D alone? A. Osteomalacia B. Osteitis deformans C. Osteoporosis D. Osteogenesis imperfecta - Correct Answer-(c) A. Vitamin D deficiency decreases the intestinal absorption of calcium and is the most common cause of osteomalacia. Treatment is vitamin D in various natural and pharmaceutical forms. The addition of supplemental calcium is usually not necessary when treating osteomalacia. (u) B. Bisphosphonates are the treatment of choice for Paget disease of the bone (osteitis deformans). (u) C. A combination of Vitamin D plus Calcium is needed to treat osteoporosis. Bisphosphonates are another option. (u) D. Osteogenesis imperfecta is caused by a major mutation in the gene encoding for type 1 collagen, the major pg. 67 professoraxe l the following is most appropriate in the emergent management of this patient? A. Perform fluorescein staining B. Measure intraocular pressure C. Place rigid shield over eye D. Palpate the orbital rim - Correct Answer-(u) A. Fluorescein evaluation would be unnecessary given the signs indicating globe rupture. (h) B. Measurement of intraocular pressure is contraindicated with suspected globe rupture. (c) C. The enophthalmos and flattened anterior chamber is highly suggestive of globe rupture. The eye should be shielded and the patient should be referred for an urgent ophthalmology consultation. (h) D. The examination should be limited with emphasis on protection of the globe and contents. : (27) 70. Diagnosis/Urology/Renal Hypertension, hematuria, and dependent edema are the classic symptomatic triad of what type of kidney disease? A. Nephritic syndrome pg. 70 professoraxe l B. Nephrotic syndrome C. Hemolytic uremic syndrome D. Goodpasture syndrome - Correct Answer-(c) A. This is the classic triad for nephritic syndrome. Edema is first seen in areas of low tissue pressure such as the periorbital and scrotal areas; hypertension is due to volume overload. Hematuria may or may not also include red blood cell casts. (u) B. Heavy proteinuria, hypoalbuminemia, hyperlipidemia, and edema are more typical of nephrotic syndrome. (u) C. Hemolytic uremic syndrome is common in children following infection, usually diarrheal illness. (u) D. Goodpasture syndrome is defined by the clinical constellation of glomerulonephritis and pulmonary hemorrhage. : (8) 71. Clinical Therapeutics/Cardiology An ambulance transports a patient to your facility from the nursing home with anuria and diminished level of consciousness. Paramedics report a blood pressure of 225/130mm Hg. Which of the following medications is most pg. 71 professoraxe l appropriate for this patient? A. Esmolol (Brevibloc) B. Nitroprusside sodium (Nipride) C. Nitroglycerine (Nitrostat) D. Nifedipine (Procardia) 32 - Correct Answer-(u) A. Esmolol is approved only for treatment of supraventricular techycardia. When used for hypertension it should be reserved for patients in whom there is particular concern about serious adverse events related to beta blockers. (c) B. Parenteral therapy is indicated in most hypertensive emergencies, especially if encephalopathy is present. Nitroprusside lowers blood pressure in seconds by direct arteriolar and venous dilation. (h) C. Excessive reductions in pressure may precipitate coronary, cerebral, or renal ischemia. As such, the use of sublingual or oral fast-acting nitroglycerine preparations should be avoided. (h) D. Excessive reductions in pressure may precipitate coronary, cerebral, or renal ischemia. As such, the use of pg. 72 professoraxe l 74. Diagnostic Studies/Dermatology At the urging of his wife a 47 year-old construction worker presents to your office with a skin lesion. He reports he has had a slowly growing nodule on the side of his nose for the past year or two. It recently developed a small central area of erosion. He denies pain, fever, chills, pruritus or other similar lesions. On physical exam the lesion is approximately 1 cm as described above, with a few telangiectatasias. Which of the following is the best diagnostic study for this condition? 33 A. Skin scraping B. Dermascopy C. Excision D. Punch biopsy - Correct Answer-(u) A. Skin scraping may not provide adequate sample to determine a diagnosis and thus delay treatment leading to additional mobidity, cosmetic deformity. (u) B. Dermascopy does not allow for tissue sampling and can delay diagnosis and treatment which may lead to additional mobidity, cosmetic deformity. pg. 75 professoraxe l (u) C. Excision is reserved for after confirmation of diagnosis by biopsy. (c) D. This patient has a basal cell carcinoma (BCC), which is the most common form of skin cancer and occurs in sun exposed areas of the skin. Any lesion suspected of being a BCC should be biopsied with a punch biospy. : (13) 75. History & Physical/Orthopedics/Rheumatology A 45 year-old female secretary presents with complaints of numbness, tingling, and pain in the thumb, index, and third fingers. On examination the patient experiences numbness and tingling while holding her wrists in a flexed position for 60 seconds. This suggests compression of which of the following nerves? A. Radial B. Ulnar C. Median D. Brachial - Correct Answer-(u) A. Radial neuropathy syndrome commonly occurs with lateral epicondylitis. Patients have pain over the pg. 76 professoraxe l brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis muscles. On examination, patients have pain with resisted forearm supination and when simultaneously extending the wrist and fingers while the long finger is passively flexed. (u) B. Patients with ulnar nerve compression complain of numbness and tingling of the 4th and 5th digits. (c) C. Carpal tunnel syndrome results from compression of the median nerve that innervates the first three digits. It is associated with pregnancy, amyloidosis, flexor tenosynovitis, overuse phenomenon, acute or chronic inflammatory conditions, traumatic disorders of the wrist, diabetes mellitus, hypothyroidism, and tumors within the carpal tunnel. (u) D. Brachial plexus injury usually occurs after a fall on the shoulder. Symptoms include numbness of the affected arm. : (5) 76. Scientific Concepts/Urology/Renal Which of the following types of kidney stones occur secondary to infections due to urease-producing bacteria? pg. 77 professoraxe l A. ST elevation in leads I, avL, V5 and V6 B. ST elevation in leads II, III, and avF C. ST elevation across V2, V3 and V4 D. Tall upright R and T waves in V1 and V2 - Correct Answer- (u) A. Occlusion of the circumflex artery or diagonal branch of the LAD will affect the lateral wall. This manifests as ST elevation in leads V5 and V6. (c) B. The right coronary artery is responsible for inferior wall of the heart. Inferior wall of the heart is best illustrated on EKG in leads II, III, aVF. (u) C. The anterior wall of the heart is supplied by the left anterior descending. On ECG this is manifested on ECG in leads V2-V4. (u) D. The posterior wall generally has a dual blood supply from the RCA and the circumflex artery. Posterior wall MI is usually manifested by ST depression and tall, upright R and T waves in leads V1-V3 : (7) 79. History & Physical/ENT/Ophthalmology Which of the following is a characteristic finding on examination of a patient who presents with herpangina? pg. 80 professoraxe l A. Scattered vesicles of the buccal mucosa and fingers B. Erythema and pustular exudates of the tonsillar crypts C. Vesicular lesions of the tonsillar fauces D. Grouped vesicles about the vermillion border - Correct Answer-(u) A. Coxsackie virus A16 often presents with scattered vesicles about the mouth along with associated hand and foot lesions (u) B. Erythema and pustular exudates of the tonsillar crypts are typical findings associated with group A β-hemolytic strep infection. (c) C. Herpangina, associated with a number of enteroviruses, typically presents with painful vesicles about the tonsillar fauces. (u) D. Grouped vesicles around the vermillion border is most consistent with herpes simplex labialis. : (27) 35 80. Scientific Concepts/Neurology pg. 81 professoraxe l A 58 year-old truck driver is found to have a positive Romberg test and loss of vibratory sensation in his lower extremities. What anatomical structure is the most likely affected? A. Cerebellum B. Posterior column C. Sensory cortex D. Vestibular apparatus - Correct Answer-(u) A. See B for explanation. (c) B. Posterior column is responsible for vibratory sensation and proprioception. The Romberg test is a general test of proprioception with disease of the cerebellum, vestibular apparatus or posterior column being the most likely source. (u) C. The bilateral lower extremity findings make a lesion of the sensory cortex unlikely. (u) D. See B for explanation. : (5) 81. Clinical Intervention/Gastrointestinal/Nutritional A 50 year-old female presents with constipation following an episode of tearing pain associated with bleeding while pg. 82 professoraxe l cough with pain over the precordial region. His vital signs reveal a heart rate 130bpm and respiratory rate 26. Blood pressure is 130/105 mmHg but fluctuates with inspiration resulting in a 20 mmHg decline in the systolic pressure. Which of the following is the most appropriate therapy for this patient? A. Serial echocardiography B. Urgent pericardiocentesis C. Surgery for pericardial window D. Furosemide (Lasix) bolus - Correct Answer-(u) A. Serial echocardiography is indicated if no intervention is immediately contemplated. (c) B. This patient has signs and symptoms consistent with pericardial tamponade. Urgent pericardiocentesis is required. (u) C. Recurrent effusion in neoplastic disease or uremia may require pericardial window. For this patient with acute onset tamponade, pericardiocentesis would be corrective. (u) D. Lasix will not affect the collection of fluid in the pericardium. 84. Clinical Therapeutics/Obstetrics/Gynecology pg. 85 professoraxe l An 18 year-old G1 P0 patient at 32 weeks gestation is sent to labor and delivery directly from her obstetrician's office. Her blood pressure on presentation is 162/114 mmHg; she is hyperreflexic and has 3+ protein on random urine dipstick. There is good fetal beat to beat variability with an occasional mild contraction on the uterine monitor. Which of the following would be the benefit of magnesium sulfate in this patient? A. Cessation of contractions B. Lowering of blood pressure C. Stabilization of renal function D. Prevention of seizures - Correct Answer-(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. This patient has findings consistent with severe preeclampsia. Magnesium sulfate is given to prevent and treat eclamptic convulsions. If the patient continues to have systolic blood pressure measurements >160 mmHg or if diastolic blood pressures exceeds 105-110 mm Hg an antihypertensive medication will need to be added. pg. 86 professoraxe l Magnesium sulfate can also be used to treat preterm labor, however an occasional mild contraction at this gestational age is not unusual and does not need to be treated. : (13) 85. Diagnostic Studies/Urology/Renal A 25 year-old female presents with acute right knee pain with associated dysuria, urgency, and body aches. She admits to an episode of unprotected sex 2 weeks ago. Which of the following organisms is most likely to be found on joint aspiration? A. Chlamydia trachomatis B. Herpes simplex virus C. Neisseria gonorrhea D. Human immunodeficiency virus - Correct Answer-(u) A. Chlamydia infection is often cotransmitted with gonorrhea and the patient should be treated for chlamydia as well. However, the organism does not seed the joint and present as monoarticular arthritis. (u) B. The patient needs a full workup to evaluate and treat for and sexually transmitted diseases, including herpes pg. 87 professoraxe l newborn. : (28) 87. History & Physical/Gastrointestinal/Nutritional Which of the following symptoms most commonly indicates diarrhea of an inflammatory etiology? A. Bloody stools B. Large volume stools C. Fatty stools D. Watery stools - Correct Answer-(c) A. Bloody diarrhea occurs due to mucosal inflammation and/or erosions/ulcerations and may be caused by infection, inflammation, or ischemic enterocolitis. (u) B. Large volume indicates anatomical orgin (small intestine) but not etiology. (u) C. Fatty stools usually seen in malabsorptive conditions of the small intestine and do not necessarily involve inflammation but the increase in fat remaining in the lumen. (u) D. Watery stools are just an indication of increase amount of water, either osmotic or secretory in nature. : (28) pg. 90 professoraxe l 38 88. Clinical Therapeutics/Orthopedics/Rheumatology A 40 year-old female is starting infliximab (Remicade) for the management of rheumatoid arthritis. This patient should be screened for which of the following disease processes prior to initiating this medication? A. Osteoporosis B. Tuberculosis C. Hypothyroidism D. Renal failure - Correct Answer-(u) A. See B for explanation. (c) B. Patients on TNF inhibitors are at greater risk for developing infections, specifically TB. Screening should be done prior to initiation. (u) C. See B for explanation. (u) D. See B for explanation. : (14) 89. Health Maintenance/Pulmonology Which of the following should be screened for in a 35 year- old, non-smoker diagnosed with emphysema? A. Alpha-1 antitrypsin deficiency pg. 91 professoraxe l B. Cystic fibrosis C. Celiac sprue D. Surfactant deficiency syndrome - Correct Answer-(c) A. Alpha-1 antitrypsin deficiency should be screened for as a potentially causative agent in patients diagnosed with emphysema prior to the age of 40. This is especially true for non-smokers. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. : (27) 90. Clinical Therapeutics/Neurology Which of the following medications is most appropriate for migraine headache prophylaxis? A. Lisinopril (Zestril) B. Ergotamine tartrate (Cafergot) C. Metoclopromide (Reglan) D. Propanolol (Inderal) - Correct Answer-(u) A. See D for explanation. (u) B. See D for explanation. pg. 92 professoraxe l (u) C. F is fetal hemoglobin and is seen in someone who is successfully undergoing treatment for sickle cell anemia. (c) D. SS is the dominant hemoglobin found in sickle cell anemia. : (7) 93. Clinical Therapeutics/Cardiology A 48 year-old male patient presents with a recent onset of anterior chest pain. The pain increases with deep breathing and coughing. He says he slept in the recliner last night as his discomfort worsens when he lies down. He also complains of feeling feverish although did not have a thermometer to check his temperature. An electrocardiogram (ECG) shows ST elevations in the precordial and limb leads. Additionally you note PR depression predominantly over leads I, II and III. Past medical history is significant for pharyngitis diagnosed as mononucleosis about 10 days ago. What is the most appropriate next step in the evaluation of this patient? A. Streptokinase B. Pericardiocentesis C. Indomethacin pg. 95 professoraxe l D. Cardiac catheterization - Correct Answer-(h) A. Pericarditis is not treated with thrombolytic therapy. (h) B. Pericardiocentesis is not indicated for inflammation of the pericardial sac unless evidence of tamponade or constrictive effusion is present. (c) C. Acute inflammatory pericarditis presents with anterior pleuritic chest pain that is worse supine than upright. ECG reveals diffuse ST segment elevation with associated PR depression. Viral infections (including Epstein- Barr) are the most common cause of acute pericarditis. Treatment for viral pericarditis is generally symptomatic. ASA or other NSAIDs are usually effective. (u) D. There is no indication for cardiac catheterization in this patient. 94. Health Maintenance/Dermatology A 67 year-old male presents for worsening lower extremity edema. He denies chest pain, shortness of breath or history of congestive heart failure. On examination the patient's lungs are clear to auscultation bilaterally and his cardiac exam reveals a regular rate and rhythm. His lower extremity physical examination is significant for 1+ pitting pg. 96 professoraxe l edema to the mid shin, multiple varicosities, and hyperpigmentation without skin breakdown. His ankle/brachial index (ABI) is within normal limits. You explain your concern to the patient about the development of stasis ulcers. Which of the following is the most important preventative step for this patient? A. Compression stockings B. Immobilization of the affected leg C. Diuretic therapy D. Referral to vascular surgeon - Correct Answer-(c) A. In the setting of venous insufficiency, compression stockings are the best preventative tool to developing stasis ulcers by reducing edema. (u) B. The patient has venous insufficiency, immobilization of the leg may exacerbate the edema, leading to increased morbidity. The patient should ambulate and use the leg as tolerated. (u) C. The patient has venous insufficiency. Diuretic therapy is not indicated at this time. (u) D. This patient has venous insufficiency, not peripheral artery disease. He has a normal ABI, therefore does not require referral to a vascular surgeon at this time. pg. 97 professoraxe l