"A Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants"

A 20 y/o presents for removal of sutures that were placed following a knife wound he received in a street brawl. The pt has a hx of alcohol and cocaine abuse and multiple arrests for driving under the influence, assault and burglary. He has a long hx of disruptive behavior and dropped out of highschool. He has not been able to hold a job. When you question the patient about his life, he tells you that he sees no reason to change his lifestyle because he likes things the way they are. This patient most likely has what personality disorder? a. antisocial b. borderline c. paranoid d. schizoid

A. A antisocial personality disorder is characterized by a pervasive pattern of disregard for and violation of lawful behavior, aggressiveness, consistent irresponsibility, and lack of remorse.

A 38 y/o patient has an older brother who was diagnosed with colon cancer at age 43 years. What is the recommended schedule for colorectal screening for this patient? a. screening colonoscopy at 40 y/o b. screening colonoscopy at 50 y/o c. screening flexible sigmoidoscopy at 40 y/o d. screening flexible sigmoidoscopy at 50 y/o

A. A family history of adenomatous polyps or colorectal cancer is one of the most important risk factors for colorectal cancer. If a cancer was diagnosed at less than 45 years of age, the relative risk is 3.8 times greater than that without such a family history. The positive family history puts this 38-year-old at risk comparable to that of an average 50-year-old. Screening typically is done beginning at age 50, but in this patient it should begin by 40 years of age. It is suggested that the best screening is colonoscopy every 5 years in patients with this family history.

A pregnant 22 y/o female presents with vaginal discharge that has been present for 2 days. Speculum exam reveals an inflamed edematous cervix with a mucopurulent discharge. Wet prep is negative for clue cells, motile flagellae, and hyphae. What is the most appropriate treatment? a. ceftriaxone b. clindamycin c. ciprofloxacin d. metronidazole

A. Acute cervicitis caused by Neisseria gonorrhoae can be asymptomatic or associated with a purulent vaginal discharge. The cervix is commonly edematous and inflamed. Ceftriaxone 125 mg is the treatment of choice. Alternative regimens include cefpodoxime or spectinomycin. Doxycycline is given at the same time due to the high prevelance of concomitant Chlamydia infections.

3. Which of the following is an indication to begin early screening for prostate cancer? a. African American race b. cigarette smoking c. history of cryptorchidism d. low sperm count

A. African American race is associated with an increased risk of prostate cancer.

A patient has a blind right eye. If sympathetic and parasympathetic innervation is intact, which of the following responses would occur? a. a light directed at the left eye will cause both pupils to constrict. b. a light directed at the right eye will cause both pupils to dilate c. a light directed at the left eye will cause only the left pupil to constrict d. a light directed at the right eye will cause only the left pupil to dilate

A. As long as sympathetic and parasympathetic innervation is intact, unilateral blindness does not cause anisocoria. A light directed into the seeing eye causes both pupils to constrict; a light directed into the blind eye does not causes any response in either eye.

Over the past year, a 21 y/o female has developed amenorrhea and has had milky discharge from her left nipple. She is not taking any medications. She is sexually active but does not wish to become pregnant. Serum HCG is negative. Serum prolactin is 300 mg/dL.; MRI reveals a 3-mm mass in the pituitary. Which of the following is the most appropriate therapy at this time? a. bromocriptine (Parlodel) b. monthly injections of medroxyprogesterone c. sequential birth control pill d. transphenoidal resection of the tumor

A. Bromocriptine (Parlodel) is a dopamine agonist which is the initial treatment of choice for prolactinomas. This will lead to a drop in serum prolactin and shrinkage of the microadenoma.

Which of the following factors carries the highest risk for promoting development of microvascular disease of the feet in a patient with diabetes? a. cigarette smoking b. high-fat diet c. hot water soaks d. ill-fitting shoes

A. Cigarette smoking represents the strongest risk for the development of microvascular disease regardless of the presence of diabetes. Tobacco use causes vasoconstriction, which compounds the risk of microvascular disease and ischemia.

25. A 45 y/o male presents with erythematous, swollen elbow. Exam reveals tenderness, limited range of motion, warmth of the overlying skin, and mild excoriations. He is febrile; WBC is 23,000 with increased bands. Radiography is negative for fracture or foreign body. What is the best initial course of action? a. dicloxacillin 500 mg four times a day for 10 days b. injection of intra-articular glucocorticoids c. penicillin 500 mg four times a day for 10 days d. warm soaks, rest, and NSAIDs prn

A. Dicloxacillin is effective against septic arthritis.

A 23 y/o presents with a recent development of longer and heavier than normal menses and a rash on her lower extremities. The only thing she can recall of any significance regarding her recent medical history is that she had a sore throat several weeks ago. Exam reveals red to purple hemorrhage that are pinhead sized overlying her shins and ankles; the lesions do not blanch and pressure. Platelet count is 40,000/mm3; the remainder of the CBC and differential is normal. An antistreptolysin O is negative as is a pregnancy test. Which of the following treatments would be most appropriate in this case? a. dexamethasone b. intravenous immunoglobulin (IVIG) c. penicillin VK d. ticlopidine (Ticlid)

A. Either dexamathasone or prednisone would be appropriate to treat this mild case of immune thrombocytopenia purpura (ITP). Most cases of ITP occur in young females following mild to moderate viral infection frequently involving the upper respiratory tract.

An otherwise healthy 22 y/o presents with mild jaundice. Which of the following additional historical factors best supports a diagnosis of Gilbert's disease? a. family history of recurrent jaundice b. family history of sickle cell trait c. history of fatty food intolerance d. recent fever, malaise, and myalgias

A. Gilbert's syndrome is the most common hereditary hyperbilirubinemia. Bilirubin levels typically do not reach levels higher than 3 mg/dL until the patient develops and intercurrent illness or undergoes a prolonged fast.

When instructing a patient on good lifting mechanics and back care, which of the following should be included? a. always use legs for lifting any object b. do not stretch after heavy lifting c. when lifting objects less than 50lb, always bend at the waist d. when working out at the gym, use heavy weights for low back workout

A. Good back mechanics include lifting with legs, warming up before participating in sports or lifting heavy objects, and getting help if the object is too heavy. It is also recommended to work out regularly with moderate weights and balance lumber workout exercises with an abdominal workout.

35. A 68 y/o female presents with rapid onset of significant eye pain and visual loss. She notes that lights appear to have "halos". Exam reveals a red eye, steamy cornea, and dilated nonreactive pupil What is the initial treatment option? a. IV acetazolamide b. IV mannitol c. topical pilocarpine d. topical latanoprost

A. Initial treatment of primary acute-closure glaucoma is control of intraocular pressure. IV acetazolamide followed by oral dosing is usually adequate. Osmotic diuretics, such as mannitol, may also be required, especially in patients with severely elevated intraocular pressure.

A lactating female presents complaining of redness, swelling and tenderness of the upper outer quadrant of the left breast. Temperature is 101.0 F. The left breast nipple appears fissured with surrounding erythema and induration. The area is warm and tender to the touch. What is the most appropriate treatment? a. dicloxacillin b. metronidazole c. penicillin d. vancomycin

A. Mastitis most commonly presents 2 to 4 weeks after the start of breast feeding. Symptoms include fever and chills followed by redness, induration, and tenderness to an area of the breast. Staphylococcus aureus from the infant's oral pharynx is the most common etiologic agent. A penicillinase-resistant antibiotic such as dicloxacillin is considered first line.

A 6 y/o presents with intermittent episodes of wheezing. Exam reveals expiratory wheezing but no rales or rhonchi. She is developing well and is cooperative with the exam. She responds well to an albuterol treatment. What is the most effective method to monitor symptoms at home? a. peak expiratory flow rate b. respiratory rate c. pulse oximetry d. blood pressure

A. Peak expiratory flow rate can be monitored at home using an inexpensive handheld device.

A 40 y/o tennis player complains of 3 weeks of right elbow pain, in the absence of any trauma. He denies any other joint pain or systemic symptoms. He is afebrile. Exam reveals edema. Active wrist extension produces pain. Which of the following is the best initial treatment? a. ice and rest b. forearm splint c. oral corticosteroids d. surgical management

A. Rest and ice are the best advice for early treatment of lateral epicondylitis. Application of ice three times daily in conjunction with rest usually provides relief in 1 to 2 weeks.

A 43 y/o male presents with a few weeks of shoulder pain with activity. He also states it wakes him up at night when he rolls on that side. On exam, the patient has painful range of motion, especially on abduction, but does not appear to have any weakness of the shoulder. What is the first step in managing this patient? a. activity modification b. corticosteroid injection c. immobilization for 2-4 weeks d. surgical rotator cuff repair

A. Rotator cuff disorders, which include rotator cuff tendinitis, impingement syndrome, subacromial bursitis or partial or full rotator cuff tears, are initially treated conservatively. They are treated first with activity modification, NSAIDs, and physical therapy, and finally with surgical intervention.

A 36 y/o schoolteacher presents with acute onset of fever, chills, malaise, headache, and congestion. She is coughing and sneezing. Conjuctivae are injected; pharyngeal mucosa is edematous and injected. What is expected on examination of the lungs? a. clear lung fields with good air exchange b. diffuse expiratory wheezes c. dullness and rhonchi at the bases d. scattered crackles and inspiratory wheezes

A. The lung exam in influenza is generally normal.

A 26 y/o is brought to the emergency department by colleagues who state she is acting intoxicated. She denies any use of alcohol or drugs but states that her legs have become weak and tingling, causing progressively worsening difficulty walking for 2 days. She thought she had slept on them wrong as she has also been severely fatigued. Exam reveals tachycardia, an irregular rhythm, and hypotension. As she is waiting for medical consult, she becomes more fatigued and experiences incontinence of urine. What is the next step in management? a. admit to intensive care unit b. admit to reverse isolation unit c. amiodarone d. prednisone

A. This patient likely has Guillain-Barre syndrome (acute idiopathic polyneuropathy), which causes progressive weakness and possibly widespread autonomic dysfunction. Incontinence indicates that her course of disease will probably be severe. She should be admitted to the intensive care unit and provided supportive care including intubation if forced vital capacity begins to become compromised.

Where is thyroid-stimulating hormone produced? a. anterior pituitary b. zona fasciculata c. posterior pituitary d. zona glomerulosa

A. Thyroid-stimulating hormone is produced by the anterior pituitary.

A woman with history of cervical conization and a second trimester miscarriage due to cervical dilation presents after a positive pregnancy test. Last menstrual period was 8 weeks ago and she desires pregnancy. What is the current treatment of choice? a. bed rest b. cerclage c. pessary d. tocolytic medications

B. A cerclage is a purse string-type stitch around the cervix to stop passive dilation during pregnancy. If not labor occurs, it will stay in place until approximately 36 weeks gestation.

An 18 y/o water skier presents with left ear pain with pruritus and discharge. Exam reveals pain on auricular manipulation as well as redness and swelling of the ear canal with purulent debris. The tympanic membrane is intact. What is the most appropriate management? a. oral fluoroquinolone b. otic antibiotic/anti-inflammatory drops c. surgical intervention d. use of an ear wick with otic drops

B. An antibiotic/anti-inflammatory otic drop is the most appropriate treatment in uncomplicated otitis externa.

A basketball player presents after being struck above the eye with an opponent's elbow. Exam is significant for bruising around the eye as well as bleeding into the anterior chamber. Computed tomography is negative for fracture. What is the most appropriate treatment? a. NSAIDs to reduce pain and swelling b. rest and close ophthalmologic follow-up c. surgical intervention d. vitamin K to induce clotting

B. An injury that causes hyphema has the risk of secondary hemorrhage, which can lead to problematic glaucoma and permanent visual loss. The patient should rest until complete resolution; daily ophthalmologic assessment is recommended.

A patient diagnosed with Parkinson's disease displays signs of bradykinesia. Which of following drugs would be least helpful? a. amatantadine b. anticholinergics c. levodopa d. selective monoamine oxidase inhibitors

B. Anticholinergics are helpful in treating the tremor and rigidity but less helpful with bradykinesia. Side effects abound, especially in elderly, and include

A 7 y/o presents with his parents who are complaining that for the last 9 months the child has been having increasing difficulty with school. He has consistently been inattentive, has difficulty following directions, cannot stay on task, is easily distracted, and is often forgetful about what he is assigned to do. At home he does not listen to his parents. What is the most likely diagnosis? a. Asperger's syndrome b. attention-deficit disorder c. disruptive behavior disorder d. hyperkinetic conduct disorder

B. Attention-deficit disorder is characterized by inattentive behavior in school and at home.

An elderly male presents with unilateral hearing loss for 1 day. He denies URI symptoms, fever, or ear pain or discharge. He further denies any dizziness or headaches. Physical exam reveals normal balance, negative Romberg, but evidence of conductive hearing loss in the affected ear. What is the most likely diagnosis? a. barotrauma b. cerumen impaction c. eustachian tube dysfunction d. otitis medida

B. Cerumen impaction is more common in elderly due to age-related changes, such as the production of a drier wax and coarse hair in the ear canal. In many cases, it is self-induced due to incorrect ear cleaning methods. It is the most common cause of acute unilateral hearing loss.

A 75 y/o with a history of Parkinson's disease presents with minimally pruritic facial lesions present for 1 week. Exam reveals scattered discrete macules approximately 1 cm in size with an orange-red greasy scale on the cheeks and nasolabial folds. What is the most appropriate treatment? a. benzoyl peroxide gel b. hydrocoritsone cream c. metronidazole gel d. mupirocin ointment

B. Hydrocortisone cream is a topical corticosteroid that is appropriate for first-line treatment of facial seborrhea.

Which of the following is only intervention documented to improve survival in a patients suffering from chronic obstructive pulmonary disorder (COPD)? a. long-acting anticholinergics b. oxygen on a continuous basis c. patient-initiated COPD action plans d. smoking cessation

B. Continuous oxygen therapy and in some cases continuous positive airway pressure (CPAP) have been found to favorably impact survival rates in COPD, especially in those patients hypoxic at rest.

A 52 y/o female presents with 2 months of pain and stiffness in her hands and fingers, along with malaise and a 5-lb weight loss. On examination, she has swelling and tenderness of her MCP and PIP joints. Lab work reveals the presence of anti-CCC antibodies. What is the most effective treatment to prevent bone erosion? a. calcium channel blockers b. disease-modifying antirheumatic drugs (DMARDs) c. high-dose corticosteroids d. nonsteroidal anti-inflammatory drugs (NSAIDs)

B. DMARDs should be started when rheumatoid arthritis (RA) is first diagnosed to reduce inflammation and pain, preserve function, and prevent deformity.

A child who resides with someone who has been newly diagnosed with active tuberculosis has a negative initial skin test. Which of the following is the most appropriate next step in the management of this child? a. Repeat the skin test in 6 months b. Start the child on isoniazid therapy c. obtain a chest x-ray d. obtain sputum cultures

B. Even though the child initially has a negative skin test, it is recommended to begin prophylaxis with isonizid for 3 months. At that time repeat the skin test, and if it is positive, the preventative therapy should be continued for at least 9 months total duration. If the repeat tuberculin skin test is negative, treatment may be discontinued.

An elderly patient with diabetes mellitus type 2 presents with mouth irritation. Exam reveals creamy white, curd-like patches which are easily scraped off revealing erythematous buccal mucosa. What is the most appropriate treatment? a. acyclovir b. fluconazole c. penicillin d. prednisone

B. Fluconazole is one the effective antifungal therapies for candidiasis. Others include ketoconazole, clotrimazole troches, and nystatin mouth rinses.

A 29 y/o male presents with numerous tender, follicular pustules across his buttocks and upper thighs. He reports hot tubbing with friends 3 days prior at a resort hotel. What organism is the most likely cause of his symptoms? a. human papillomavirus b. Pseudomonas aeruginosa c. Staphylococcus aureus d. varicella-zoster virus

B. Hot tub folliculitis is caused by Pseudomonas aeruginosa, erupting between 1 and 4 days after exposure.

A 45 y/o obese female presents for routine gynecologic exam. She complains of heavy, prolonged menstrual periods for the past year. Pelvic exam and TSH are normal. What is the most appropriate next step? a. colposcopy b. endometrial biopsy c. hysterosalpingography d. hysteroscopy

B. In a patient with prolonged heavy menses, endometrial hyperplasia and endometrial cancer must be ruled out. Out of the choices here, endometrial biopsy is the only one that can evaluate the endometrium for both.

A 35 y/o male who is HIV positive with a CD4 count less than 200 cell/uL has had a headache, low-grade fever, lethargy, and confusion for the past 3 weeks. Microscopic examination of the CSF prepared with India ink reveals budding yeasts with prominent capsules. What is the most likely diagnosis? a. candidiasis b. cryptococcosis c. histoplasmosis d. pneumocystis

B. Infections caused by Cryptococcus neoformans have predominant CNS manifestations. The spectrum of disease consists predominantly of meningoencehalitis and pneumonia. A diagnosis of cryptococcosis requires demonstration of C. neoformans in normally sterile tissues. Visualization of the capsule in CSF mixed with India ink is a useful rapid diagnostic technique.

A 73 y/o male with a history of uncontrolled hypertension presents with hemiparesis, hemisensory loss, and aphasia. Presence of which of the following best supports a diagnosis of middle cerebral artery occlusion? a. alexia b. homonymous hemianopia c. Horner's syndrome d. vertigo

B. Middle cerebral artery occlusions often result in homonymous hemianopia.

A 24 y/o male presents after a day of snowboarding with wrist pain and swelling. An initial x-ray of the wrist appears negative; a scaphoid fracture is considered. What exam finding will help confirm this diagnosis? a. dorsal angulation of the wrist b. pain over the anatomic snuffbox c. pain with ulnar deviation of the wrist d. volar angulation of the wrist

B. Pain over the anatomic snuffbox is often seen in a scaphoid fracture.

A 78 y/o female presents with low back pain that radiates to both legs. She states her legs get weak when she walks at the mall. What is expected on physical exam? a. a positive straight leg raise b. normal neurologic exam c. paraspinal muscle spasms d. point tenderness over L5-S1 spinous processes

B. Patients with spinal stenosis often have an unimpressive physical exam; less than 25% have diminished reflexes and about 60% have slight proximal muscle weakness.

A 42 y/o complains of steady, severe right upper quadrant pain that radiates to the right scapula. The type of pain is associated with disorders of which of the following? a. spleen b. gallbladder c. esophagus d. ascending colon

B. Right upper quadrant pain radiating to the right scapula or shoulder is commonly seen in acute cholescystitis.

A 62 y/o male who has not had medical care for many years was seen 2 days ago at the emergency room for chest pain that was diagnosed as angina pectoris. At f/u today, he admits to multiple poor health habits: cigarette smoking since age 12, consumption of 3-4 beers daily, a diet of fast food three times a day, five to seven cups of regular coffee per day, and virtually no exercise. What is the single most important lifestyle modification that he should make? a. abstinence from alcohol b. cessation of smoking c. dietary modifications d. increasing exercise

B. Smoking is the most important cause of preventable morbidity and mortality and is the leading cause of cardiovascular death.

20. What organism is responsible for the vast majority of cases of acute infective endocarditis in patients with native valves? a. Streptococcus viridans b. Staphylococcus aureus c. enterococci d. Pseudomonoas aeruginosa

B. Staphylococcus aureus tends to cause a rapidly progressive picture of endocarditis. It commonly results in a destructive infection in which patients present with acute febrile illnesses, acute valvular insufficiency, early embolization, and myocardial abscess formation. It is more common in injection drug users.

A 12 y/o male woke suddenly this morning with severe scrotal pain ad edema and the scrotal sac that has continued for 2 hours. He has had similar pain before, but it subsided without intervention. Physical examination reveals a tender, swollen, retracted testis. A routine urine exam is normal. Which of the following is the most appropriate next step? a. scrotal support and ice packs b. immediate surgical intervention c. initiation of antibiotic therapy d. Tc99 pertechnetate scan

B. Testicular torsion is the most common in adolescent boys. It is a surgical emergency. If torsion is complete, a testis can be infarcted in 4 to 6 hours.

A 34 y/o female presents with pain along the radial aspect of her wrist. On exam, there is tenderness over the abductor policis longus and the extensor pollicis brevis tendons. Which of the following describes the special provocative maneuver that should be done to diagnose the most likely cause for this pain? a. arm extended and externally rotated with the patient opening and closing hands for 3 minutes b. enclose the thumb in the palm and deviate the wrist in an ulnar direction c. passively flex both wrist and hold for 60 seconds d. percuss over the ulnar nerve at the elbow

B. The Finkelstein's test is used to diagnose de Quervain tenosynovitis which is described in this scenario.

A 15 y/o girl reports that she has never had menses. She is short in stature and has a webbed neck and wide-spaced nipples. Initial lab work shows high levels of FSH. Which of the following is best to confirm diagnosis? a. estrogen levels b. karyotype c. LH levels d. ultrasonography

B. This is the classic picture of Turner's syndrome (gonadal dysgenesis), which is a frequent cause of primary amenorrhea. Karyotyping will show a 45XO pattern.

1. Physical exam of a 60 y/o male reveals perioral cyanosis with a normal respiratory rate and no use of accessory muscles. Chest percussion is resonant; auscultation demonstrates wheezes and coarse rhonchi that change in location and intensity after a cough. What is the most likely diagnosis? a. chronic asthma b. chronic bronchitis c. community-acquired pneumonia d. emphysema

B. This is the typical picture of bronchitis- predominant COPD

A 30 y/o female is scheduled to undergo a breast biopsy in the next few days. She gives a history of a mild bleeding disorder that runs in her family. Platelet count, PT, and PTT are normal. Which of the following medications should be administered prior to undergoing this procedure? a. cryoprecipitate b. desmopressin acetate c. factor VII concentrate d. fibrin sealent (Tissel)

B. This patient likely has type 1 von Willebrand disease. Intranasal desmopressin on the day of the procedure will likely control blood loss experienced as a result of the breast biopsy.

A 68 y/o female presents for health maintenance. She experienced natural menopause 15 years ago. She is healthy and does not have a significant past medical history. She takes 1,000 mg of calcium per day. Her 74 y/o sister has osteoporosis. The patient's bone mineral density T score is found to be -2.6 SD. She is placed on weekly medication. What is the mechanism of action of this medication? a. activation of bone remodeling b. impairment of osteoclast function by action of the calcitonin receptor c. inhibition of bone resorption by impairment of osteoclast function d. regulation of calcium absorption from the gastrointestinal tract

C. Biphosphonates impair osteoclast function and reduce their numbers by induction of apoptosis.

A 37 y/o complains of diplopia and difficulty swallowing. Exam reveals ptosis and weakness of the extraocular muscles but no nystagmus. Rapid improvement after administration of what medication will confirm the suspected diagnosis? a. aminoglycoside b. corticosteroids c. edrophonium d. guanidine

C. Edrophonium is a short-acting anticholinesterase. Patients with myasthenia gravis will have a prompt improvement that lasts for 5 to 10 minutes. This is diagnostic.

2. A patient admitted to the ICU after a MVA has become oliguric. BUN and creatinine are rising. The prescence of which of the following indicates a need for urgent dialysis? a. blood pH 7.30 b. pigmented granular casts c. seizures d. hyperphosphatemia

C. Uremic conditions, such as encephalopathy and seizures are indications for urgent dialysis.

A 7 y/o male presents with a history of frequent respiratory infections with recurrent pulmonary infiltrates and failure to thrive. His cough is persistent and productive of thick, green sputum. A recent sputum culture was positive for Haemophilus influenzae and Staphylococcus aureus. Which of the following laboratory results is pathognomonic for his condition? a. abdominal flat plate showing small intestinal air-fluid levels and small colon b. chest radiography revealing hyperinflation and small airway obstruction c. elevated sweat chloride levels d. irreversible changes in FVC and FEV1

C. Elevated sweat chloride values are the key to diagnosis of cystic fibrosis. The values for the chloride (and sodium) concentrations in sweat vary with age, but typically a chloride concentration of greater than 70 mEq/L discriminates between patients with cystic fibrosis and those with other lung diseases.

A 26 y/o female is being placed on hydroxychloroquine (Plaquenil) for systemic lupus erythematosus. Which of the following needs to be completed at least annually as part of regular monitoring for medical side effects? a. kidney function tests b. liver function tests c. retinal exams d. upper GI endoscopy

C. Hydroxychloroquine is effective against the fevers, arthritis, and mucocutaneous manifestations of systemic lupus erythematosus. Although retinal toxicity is not common, it is dose dependent. Opthalmologic exam, including visual acuity, slit-lamp, fundoscopic, and visual field exam, is recommended at baseline and regularly, dependent on the medication dose.

A 32 y/o male presents for a routine physical. He takes no medications, exercises one to two times a week, and eats a fairly healthy diet. He does not smoke and has three to four alcohol drinks on the weekends. His family history is significant or a parent with myocardial infarction at the age of 72 years. His review of systems is essentially negative and physical exam is unremarkable. Fasting lipid panel: total cholesterol 154 mg/dL; triglycerides 78 mg/dL; HDL 24 mg/dL; LDL 109 mg/dL. When should the next fasting lipid profile be obtained on this patient? a. 1 year b. 3 years c. 5 years d. 7 years

C. In adults with no significant risk factors, fasting lipid profiles should be obtained every 5 years.

A 49 y/o female reports that when she tried recently to donate blood on behalf of a friend, she was refused because of a low hemoglobin level. Today her hemoglobin level is 11 g/dL. She has had mild fatigue for the past several months, but otherwise feels well. She takes no medications on a regular basis. She is most likely to have a history of which of the following? a. alcohol abuse b. familial anemia c. heavy menses d. poor diet

C. Iron deficiency anemia is the most common anemia worldwide. In adults in the United States, the most common cause is chronic blood loss.

Radiculopathy due to herniation of the intervertebral disc at L5-S1 would lead to motor deficit of which area? a. dorsiflexors b. multiple areas c. plantar flexors d. quadriceps

C. L5-S1, L5 nerve root, affects plantar flexion

A 14 y/o male presents with anterior knee pain and swelling that gets worse after soccer games. The patient reports no trauma to the knee. On exam, knee range of motion ins normal but the patient is tender to palpitation over the tibial tubercle. What is the most likely diagnosis? a. chrondromalacia patella b. medial collateral ligament tear c. Osgood-Schlatter disease d. prepatellar bursitis

C. Osgood-Schlatter disease presents with anterior knee pain and swelling over the tibial tubercle that is associated with activity. It is caused by fragmentation of the tibial tubercle apophysis from chronic tensile stress.

Which of the following is an important concern with the continued administration of proton pump inhibitors (PPIs) or H2 receptor blockers? a. antacids should not be used within 30 minutes of administration of PPI or H2 receptor blockers b. poor compliance occurs because they need to be taken four times a day with food c. they alter absorption of pH-dependent drugs d. they potentiate CNS depression with alcohol use

C. PPIs are H2 receptor blockers lessen the acidity, thereby affecting the absorption of drugs dependent upon an acidic pH. PPIs are typically dosed once per day and H2 blockers one to two times per day.

A 3-week old male is brought to the clinic due to nonbilious vomiting that has continued for 1 week. Emesis has become more frequent and is now projectile. The infant is observed being bottle fed during the interview and appears hungry with a good suck. What physical finding will most likely be found in this patient? a. abdominal distention b. abdominal wall muscle rigidity c. olive-shaped abdominal mass d. sausage-shaped abdominal mass

C. Pyloric stenosis most commonly manifests in the first 2 to 4 weeks of life. The typical clinical manifestation is nonbilious vomiting that becomes projectile. An olive shaped mass may be palpated during or immediately after feeding.

A 69 y/o male with a 120 pack-year smoking hx presents with painless hematuria for 2 days. He also describes frequency and dysuria as well as mild flank pain. He is afebrile and denies a history of recent upper respiratory tract infection. Urine dip is positive for blood. Which of the following is the most likely diagnosis? a. benign prostatic hyperplasia b. IgA nephropathy c. renal cell carcinoma d. Wegener's granulomatosis

C. Renal cell carcinoma is linked to cigarette smoking as a risk factor. It is common in the sixth decade and often presents as painless hematuria with mild flank pain or an abdominal mass.

A 12 y/o male has been limping for the past 2 months. Exam reveals a moderately obese young male in no acute distress who complains of pain in his left hip region. There is a limitation of internal rotations of the hip with a 2-cm left limb discrepancy as compared to the right. What is the most appropriate diagnostic treatment? a. AP and lateral radiographs of the left hip b. AP pelvic films c. frog leg view of both hips d. weight-bearing MRI of the left hip

C. Slipped capital femoral epiphysis (SCFE) typically occurs during an adolescent growth spurt; patients are frequently overweight. Typical presentation is with hip pain. The pain may worsen on ambulation or cause a "waddling" gait. Pain may be felt in the hip but may be referred to the thigh or knee. Radiographs of the child in the frog leg position are usually diagnostic and can be utilized to grade SCFE severity.

Patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency should be counseled to avoid which class of antibiotic therapy, as it may provoke a hemolytic crisis? a. cephalosporins b. fluoroquinolones c. sulfonamides d. tetracyclines

C. Sulfa-containing drugs, such as trimethoprim-sulfamethoxazole (Bactrim) and nitrofurantoin (Macrodantin), should be avoided in patients with G6PD deficiency, as they can provoke hemolytic crisis.

A 23 y/o male prostitute presents seeking treatment for recurrence of a nonpainful perianal rash. He gives a history of a similar rash that was treated with multiple "freezing" treatments and a prescription for a gel that he used a couple of times. What is expected on physical exam? a. discrete papules, 2 to 5 mm in diameter, slightly umbilicated, flesh colored, and dome shaped b. discrete, small (<4mm), skin-colored to dark brown pedunculated lesions c. numerous pale pink, discrete lesions with narrow to wide projections on a broad base with a smooth or velvety, moist surface d. small groups of vesicles that erode, crust, and heal in 10-14 days

C. The history of freezing and gels supports the diagnosis of condyloma acuminata. This infection is caused by the human papillomavirus (HPV). Condyloma acuminata may progress to form painless cauliflower-like lesions in the rectal or perineal areas.

A 26 y/o female describe several episodes of weakness and numbness of her extremities. Each episode comes on acutely and resolves without residua in 1 to 3 days. Today she presents with imbalance in her gait. What diagnostic study would be most beneficial at this time? a. cerebrospinal fluid analysis b. computed tomography of the head c. magnetic resonance scan of head d. visual evoked potentials

C. This patient is manifesting symptoms of multiple sclerosis (MS). Magnetic resonance is very helpful in demonstrating multiple demyelinating lesions, which are the diagnostic criteria for MS.

A 3 y/o female presents with rough, erythematous pruritic lesions on her cheeks and antecubital fossae. The family hx is significant for asthma. Which of the following measures would be beneficial in the management of her condition? a. avoid moisturizers b. dehumidifier in bedroom c. frequent bathing d. wear cotton clothing

D. Cotton clothing is preferred for persons with atopic dermatitis. Wools and acrylics should be avoided, as they can exacerbate the condition.

An 8 y/o boy is being evaluated for short stature. His mother reports that he has gained weight over the last year, but he has little or no energy, sleeps more than normal, and complains of being cold all of the time. His growth curve demonstrates that he has fallen from the 50th percentile to the 5th percentile for height, but his weight has increased from the 50th percentile to the 90th percentile for weight. On physical exam, he is obese, has immature facies, thin hair, and slow reflexes. What is the most likely cause of this child's symptoms? a. acromegaly b. Cushing's syndrome c. dwarfism d. hypothyroidism

D. Deceleration of growth is usually the first clinical manifestation of hypothyroidism in children. Myxedmatous changes of the skin, constipation, cold intolerance, decreased energy, and an increased need for sleep develop insidiously. Reflexes may be slowed, especially in the ankles.

An otherwise healthy 70 y/o presents with a painful vesicular eruption spread throughout the left mid lower back. Which of the following would best confirm the suspected diagnosis? a. complete a Tzanck smear b. measure IgG for varicella c. obtain a fungal culture d. perform PCR of skin scraping

D. Herpes zoster is typically a clinical diagnosis. If testing is deemed necessary, a PCR or direct immunofluroscopy is the test of choice.

A 24 y/o male, status post tetralogy of Fallot surgical repair 20 years ago, continues to exhibit signs of mild pulmonary hypertension. Currently not a surgical candidate, which of the following would slow the progression of his pulmonary hypertension? a. corticosteroids b. prostacyclin c. sildenafil d. supplemental oxygen

D. Oxygen should be provided most hours of the day and night, reducing his O2 demand, resulting in improved pulmonary hypertension.

30. A patient with a history of hypertrophic subaortic stenosis present with fever, dyspnea, and joint and back pains. Exam reveals a III/VI systolic murmur, conjuctival petechiae, and exudative lesions in the retina. What is the name of these retinal lesions? a. Auspitz's sign b. Janeway's lesions c. Osler's nodes d. Roth's spots

D. Roth's spots are exudative retinal lesions, seen in endocarditis

A 26 y/o female presents with a history of recent deterioration of her health. A month ago she got fired from her job for making careless errors disorganized. In the last month, she has started to lose weight and talk about family members who are "against" her and poisoning her food. Most recently, she started to perform stereotypical movement of cleaning the countertops, although she was not actually cleaning. Her family is very concerned about her condition. When you examine the patient, she is laughing and does not answer your questions. What is the most likely diagnosis? a. anorexia nervosa b. bipolar disorder c. histrionic personality disorder d. schizophrenia

D. Schizophrenia may present with disorganized behavior, delusions, stereotyped movement, and an inappropriate affect. This patient most likely has disorganized or paranoid subtype based on the history of delusions and the inappropriate affect.

During a wilderness emergency medicine training course, conducted in a remote location, a member of the group begins choking on a piece of food. The patient has lost the ability to cough and seems unable to breath. What is the next best step in management? a. blind sweep of the oral cavity b. emergent cricothyrotomy c. emergent tracheostomy d. initiate Heimlich maneuver

D. The Heimlich maneuver should be tried before invasive procedures are undertaken, especially in the setting where emergency services and sterile conditions are not available.

A 62 y/o male requests sleeping pills. His sleep is often disturbed by drenching sweats requiring him to change his pajamas two to three times per night. He has daytime fatigue, which he attributes to his poor sleep. On physical exam, he is tender over the sternum and his spleen is easily palpable. A complete blood count is is remarkable for a WBC count of 165,000/uL with a left shift. Both basophils and eosinophils are noted on peripheral smear. He has no red cell abnormalities and his platelet count is within normal limits. PCR demonstrates presence of the bcr/abl gene. What is the most likely diganosis? a. acute lymphoblastic leukemia b. acute myeloid leukemia c. chronic lymphocyte leukemia d. chronic myeloid leukemia

D. The clinical picture plus the presence of the bcr/abl gene in the peripheral blood is that of chronic myeloid leukemia.

A neonate is found to have right ventricular hypertrophy, right ventricular outflow obstruction, and an over-riding aorta via cardiac imaging. What additional finding would you expect to see in this child? a. atrial septal defect b. discrepancy in upper and lower extremity blood pressure c. left bundle branch block d. ventricular septal defect

D. The finding of ventricular septal defect completes the diagnostic criteria for tetralogy of Fallot.

15. What is the best method to confirm fetal death? a. measuring HCG level since it drops immediately b. serial pelvic exams to monitor the regression in the size of the uterus c. serial titers of fetal growth hormone d. ultrasonography to assess fetal heart movement

D. The first change noted is the absence of movement followed by the absence of fetal heart tones. Fetal death is best evaluated by ultrasonography. In the case of an equivocal ultrasound,serial HCGs are indicated to evaluate levels over 48 hours.

10. Which of the following in women is most likely to develop breast cancer? a. 30 y/o Japanese woman with a hx of menarche at age 14 b. 40 y/o African American woman currently on birth control pills c. 50 y/o Indian woman who had her first pregnancy at age 17 d. 60 y/o white woman whose mother had breast cancer

D. The strongest risk factors in developing breast cancer are increasing age, white race, and a first-degree relative (mother, sister, daughter) with a history of the disease.

A woman presents complaining of irregular menses and infertility for 1 year. Pelvic ultrasonography reveals multiple smooth, pear-white ovarian cysts characterized as "oyster ovaries". Which of the following lifestyle modifications would be best at preventing further cysts from reocurring? a. decrease alcohol intake b. moderate weight lifting c. smoking cessation d. weight loss

D. This woman likely has PCOS, which is often characterized by infertility, hirsutism, and obesity. Forty percent of patients with PCOS are obese. Weight loss is often effective in decreasing the severity of the disease.

A 55 y/o female presents with sudden onset of dyspnea and chest pain. She is afebrile but is not coughing. She is a smoker with a 30 pack history. She returned to the United States from Australia 5 days ago. She is tachycardic. Exam of the heart and lungs in normal. What is the most likely diagnosis? a. congestive heart failure b. emphysema c. pleurisy d. pulmonary embolus

D. Venous stasis, such as a long plane ride, is an important risk factor for deep venous thrombosis which may progress to pulmonary embolus. Dyspnea and chest pain are the most common symptoms.