PACKRAT 2

Which of the following complications of Crohn's disease most frequently requires surgery? A. Hemorrhage B. Intra-abdominal abscess C. Malabsorption D. Perforation

(u) A. Hemorrhage and perforation are uncommon in Crohn's disease. (c) B. Surgery is the treatment of choice for an abscess, which is a common complication of Crohn's disease. (u) C. Malabsorption is often a complication of the surgery itself. (u) D. See A for explanation.

For patients undergoing highly emetogenic chemotherapy regimens, which of the following would be the first-line antiemetic medication? A. Ondansetron (Zofran) B. Lorazepam (Ativan) C. Dronabinol (Marinol) D. Prochlorperazine (Compazine)

(c) A. A 5HT3 receptor blocker such as ondansetron is the agent of choice, given its high efficacy and low risk of side effects (headache being the major, and usually easily manageable, one). (u) B. Benzodiazepines (lorazepam) are associated with significant psychologic side effects including sedation and amnesia, although its anxiolytic properties make it a good choice for patients suffering from anticipatory nausea. (u) C. Cannabinoids (dronabinol) likewise have significant psychogenic side effects. (u) D. The side effect profile of phenothiazides (prochlorperazine) includes hypotension, restlessness, sedation, and extrapyramidal symptoms.

A 70 year-old female with history of hypertension, diabetes, and hypothyroidism presents with complaint of sudden onset of left lower extremity pain. Examination reveals a cool left lower extremity with a mottled appearance. Dorsalis pedis and posterior tibialis pulses are absent. Which of the following is the most likely diagnosis? A. Acute arterial occlusion B. Thromboangiitis obliterans C. Deep vein thrombosis D. Peripheral neuropathy

(c) A. Acute arterial occlusion presents with sudden onset of extremity pain, with absent or diminished pulses. The extremity will be cool to the touch and have a mottled appearance. (u) B. Thromboangitis obliterans occurs in younger patients and primarily effects the distal extremities, especially the toes. It is typically secondary to smoking. (u) C. Deep vein thrombosis presents with lower extremity pain and edema. Pulses would be intact. (u) D. Patients with peripheral neuropathy would have diminished sensation. They would not have a mottled appearance and pulses would be intact.

A 33 year-old presents with sinusitis unresponsive to three various antibiotics over the past four months. Sinus puncture is performed with culture positive for Aspergillus fumigatus. What is the most appropriate treatment for this patient? A. Amphotericin (Amphotericin B) B. Amoxicillin/Clavulanate (Augmentin) C. Ofloxacin (Floxin) D. Cefuroximine (Ceftin)

(c) A. Aspergillus fumigatus is a fungal organism therefore this patient would be most appropriately treated with Amphotericin B which is an anti-fungal medication. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Which of the following neurotransmitters is decreased in early Parkinson's disease? A. Dopamine B. Serotonin C. Norepinephrine D. Acetylcholine

(c) A. Decreased dopamine levels are typical of Parkinson's disease even early in the course of the disease. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation

A 45 year-old female presents complaining of the worst headache of her life. Which of the following is the most appropriate initial diagnostic study? A. Magnetic resonance imaging (MRI) B. Computed tomography (CT) C. Electroencephalogram (EEG) D. Lumbar puncture (LP)

(u) A. An MRI is not as sensitive in detecting an acute cerebral bleed as a CT scan. (c) B. A CT scan is more sensitive in detecting cerebral hemorrhage in the first 24 to 48 hours. (u) C. Electroencephalogram (EEG) is used in the evaluation of seizures and will not assess the presence of cerebral hemorrhage. (u) D. A lumbar puncture is indicated in evaluation of suspected subarachnoid hemorrhage only if the CT scan does not establish the diagnosis.

A 22 year-old woman comes to the office because her urine is cola-colored and she has not urinated since yesterday morning. Her past medical history is significant for pharyngitis two weeks ago. Her mother and grandmother have type 2 diabetes. Her blood pressure is 146/92mmHG. On physical examination, she has edema of her face and hands. Which of the following is the most likely diagnosis? A. Glomerulonephritis B. Acute tubular necrosis C. Nephrolithiasis D. Diabetic nephropathy

(c) A. Glomerulonephritis presents with hematuria, cola-colored urine, oliguria, and edema of the face and eyes in the morning. Urinalysis reveals red blood cells, mild proteinuria and red blood cell casts. Glomerulonephritis can occur 1-3 weeks after a strep infection. (u) B. Acute tubular necrosis is caused by acute kidney injury, such as a nephrotoxin, and is associated with uremic symptoms which include nausea, vomiting, malaise, and altered mental status. Granular casts are nonspecific and may be seen in acute tubular necrosis. (u) C. Nephrolithiasis usually presents as a sudden onset of colicky flank pain with associated nausea and vomiting. Urinalysis often reveals gross or microscopic hematuria. (u) D. Diabetic nephropathy is the most common cause of end stage renal disease in the United States. Urine examination reveals albuminuria.

A 40 year-old G3P3003 female presents complaining of dull aching discomfort of her lower extremities, which is worse in the evening. The patient currently works as a waitress. Examination reveals dilated, tortuous veins beneath the skin in the thigh and leg bilaterally. Which of the following is the best initial approach to prevent progression of disease and complications in this patient? A. Compression stockings B. Warfarin (Coumadin) therapy C. Sclerotherapy D. Clopidogrel (Plavix)

(c) A. Graduated compression stockings can be used in patients with early varicosities to prevent progression of the disease and when used with leg elevation complications from varicose veins can be avoided. (u) B. There is no indication for warfarin or clopidogrel therapy in patients with varicose veins. (u) C. Sclerotherapy is not the best initial choice to prevent disease progression and complications. (u) D. See B for explanation.

A 26 year-old female comes to the office for evaluation of a painful lump on her right buttock for the past week. Initially, it was a firm, tender nodule that has increased in size and tenderness in the past two days. On physical examination of the right buttock, there is a 3-cm fluctuant tender red nodule. Which of the following is the most appropriate initial intervention? A. Incision and drainage B. Mupirocin ointment C. Systemic antibiotics D. Moist compresses

(c) A. Incision and drainage is the mainstay of therapy for abscesses. (u) B. Individuals may be chronic carriers of S. aureus. Mupirocin ointment is effective in eliminating nasal carriage of S. aureus. (u) C. In healthy individuals, incision and drainage is generally adequate therapy for abscesses. Systemic antibiotics may speed the healing of the tissue, and is instituted after incision and drainage of the abscess. (u) D. Application of moist heat can localize or consolidate the abscess when the furuncle is firm and non-fluctuant aiding in the development and drainage of the abscess.

A mean corpuscular volume (MCV) of less than 80 cubic microns is a manifestation of which of the following diagnoses? A. Iron deficiency B. Vitamin B12 deficiency C. Folate deficiency D. G6PD deficiency

(c) A. Iron deficiency is associated with microcytic anemia. (u) B. Vitamin B12 deficiency is associated with macrocytic anemia. (u) C. Folate deficiency is associated with macrocytic anemia. (u) D. G6PD deficiency is not associated with a low MCV.

A 55 year-old female presents to the emergency department with complaints of dyspnea, chest pain and coughing with hemoptysis. Past medical history includes breast cancer 5 years ago, currently in remission. Vital signs are Temp. 98.6 degrees F, BP 150/90 mmHg, P 110 bpm, RR 20. Physical examination shows her right leg swollen with pain on palpation of deep veins. Which of the patient's history or examination findings is most suggestive of a pulmonary embolus (PE)? A. Leg swelling and pain with palpation of deep veins B. Heart rate > 100 C. Hemoptysis D. Past history of cancer

(c) A. Leg swelling and pain with palpation of the deep veins are consistent with a DVT and increase the likelihood of a PE. (u) B. While a tachycardic rate may be present in a patient with a PE, it is not specific for a PE. (u) C. While hemoptysis may be present in a PE, it is not a specific finding. (u) D. History of cancer may place a patient at increased risk for PE, however is not the most suggestive finding in this patient.

Which of the following is a cause of acute kidney failure due to prerenal azotemia? A. Excessive diuresis B. Urinary tract obstruction C. Radiologic contract media D. Aminoglycosides

(c) A. Prerenal azotemia is due to renal hypoperfusion which can occur with intravascular volume depletion such as excessive diuresis, hemorrhage, and gastrointestinal losses. (u) B. Postrenal azotemia is due to obstruction of urinary flow from both of the kidneys. (u) C. Radiologic contrast media can be directly nephrotoxic causing acute tubular necrosis, which is an intrinsic renal disease. (u) D. Exogenous nephrotoxins, such as aminoglycosides, cause acute tubular necrosis, which is an intrinsic renal disease.

What is the most effective prophylaxis against respiratory syncytial virus (RSV) infection in the general pediatric population? A. Proper hand-washing techniques B. A monoclonal antibody C. H. Influenzae B vaccine D. Oseltamivir (Tamiflu)

(c) A. Proper hand washing and reduction in exposure is most effective in general population to prevent RSV. (u) B. Prophylaxis with a monoclonal antibody has proven effective in high risk infants but is not indicated in the general pediatric population. (u) C. Prophylaxis with H. Influenzae B vaccine has reduced incidence of epiglottis, not RSV. (u) D. Oseltamivir is not indicated in the prophylaxis of RSV.

A 60 year-old right hand dominant male presents to your office complaining of right shoulder pain and progressively worsening arm weakness. His symptoms are aggravated when working above the shoulder level. On physical examination, there is no evidence of muscle atrophy. He has strong (5/5) adduction of his right shoulder but considerable weakness (1/5) with abduction when raising his arm above his head. Passive range of motion is intact. Which of the following is the most likely diagnosis? A. Rotator cuff tear B. Subacromial bursitis C. Adhesive capsulitis D. Supraspinatus tendonitis

(c) A. Rotator cuff tears are associated with full passive range of motion but have pain and weakness during active abduction. (u) B. Subacromial bursitis causes pain with raising hand above head and has mild degree of weakness. (u) C. Adhesive capsulitis (frozen shoulder) causes significant reduction in both active and passive range of motion. (u) D. Of the four rotator cuff muscles, supraspinatus is most likely to strain causing tendonitis. The symptoms cause limited range of motion due to pain but minimal weakness.

A 69 year-old male with a history of chronic lymphocytic leukemia presents to the clinic complaining of cough, dyspnea and production of copious amounts of foul smelling sputum. Physical examination reveals crackles at the lung bases. Chest x-ray shows dilated and thickened bronchi that appear as ring-like markings. Which of the following is the most likely diagnosis? A. Bronchiectasis B. Tuberculosis C. Adenocarcinoma D. Pulmonary fibrosis

(c) A. This patient has signs and symptoms consistent with bronchiectasis including CXR findings of dilated and thickened bronchi that may appear as tram-tracks or as ring-like markings. (u) B. TB would present with CXR findings in the apical or posterior segments of the upper lobes. (u) C. Radiographic findings of adenocarcinoma include enlarged nodule or mass; persistent opacity, atelectasis or pleural effusion. The sputum would not likely be foul smelling. (u) D. Pulmonary fibrosis does not present with dilated bronchi or ring-like markings on CXR.

A 45 year-old male presents to the Emergency Department complaining of sudden onset of tearing chest pain radiating to his back. On examination the patient is hypertensive and his peripheral pulses are diminished. Electrocardiogram shows no acute ST-T wave changes. Which of the following is the diagnostic study of choice in this patient? A. Computed tomography (CT) scan B. Transthoracic echocardiogram C. Magnetic resonance imaging (MRI) D. Cardiac catheterization

(c) A. This patient has signs and symptoms of acute aortic dissection for which CT scan is the diagnostic study of choice. (u) B. CT scan is better than transthoracic echocardiogram for the diagnosis of acute aortic dissection. Transesophageal echocardiogram (TEE) is a good diagnostic modality, however it is not always available in the acute setting. (u) C. MRI is good in the diagnosis of a chronic aortic dissection, but the longer imaging time and the difficulty in monitoring the patient during the test makes it not the first choice in the setting of an acute dissection. (u) D. Cardiac catheterization is not indicated in the diagnosis of an acute aortic dissection.

A 55 year-old male presents with a three month history of progressive weakness in the extremities without associated sensory changes or deficits. Examination reveals widespread muscle atrophy, fasciculations and bilateral hyperactive reflexes with Babinski sign. Which of the following is the most likely diagnosis? A. Amyotrophic lateral sclerosis B. Polymyalgia rheumatica C. Myasthenia gravis D. Multiple sclerosis

(c) A. Though some variability in presentation does occur the characteristic progressive weakness without sensory changes and upper and lower motor nerve dysfunction is a hallmark of amyotrophic lateral sclerosis (ALS). (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

A 5 year-old presents with perianal pruritus that is worse at night. Scotch tape is positive for Enterobius vermicularis. The treatment of choice is A. mebendazole (Vermox). B. metronidazole (Flagyl). C. clindamycin (Cleocin). D. thiabendazole (Mintezol).

(c) A. Treatment of choice for pinworms is mebendazole. (u) B. Metronidazole is used in the treatment of amebic dysentery and trichomoniasis. (u) C. Clindamycin is used in the treatment of anaerobic bacterial infections. (u) D. Thiabendazole is used in the treatment of helminth infections.

A 26 year-old woman comes to the office for her first prenatal visit at 9 weeks gestation. During evaluation, her urinalysis reveals asymptomatic bacteriuria. Which of the following antibiotics is the preferred treatment in this patient? A. Doxycycline (Vibromycin) B. Trimethoprim (Monotrim) C. Nitrofurantoin (Macrobid) D. Erythromycin (Ery-tab)

(h) A. Doxycycline is contraindicated during pregnancy because of dental staining in the exposed child. (u) B. Trimethoprim is a folic acid antagonist, and should be avoided during organogenesis in the first trimester. (c) C. Nitrofurantoin is an effective treatment of asymptomatic bacturia in the pregnant woman. (u) D. Erythromycin is an ineffective treatment for asymptomatic bacteriuria.

A 23 year-old male with recent upper respiratory symptoms presents complaining of chest pain. His pain is worse lying down and better sitting up and leaning forward. Electrocardiogram shows widespread ST segment elevation. Which of the following is the most likely physical examination finding in this patient? A. Elevated blood pressure B. Subungual hematoma C. Diastolic murmur D. Pericardial friction rub

(u) A. Acute pericarditis is usually not associated with elevated blood pressure. One would expect to see hypertensive pressures in the setting of an aortic dissection. (u) B. Subungual hematomas are usually seen in endocarditis not pericarditis. (u) C. A diastolic murmur in a patient with chest pain would likely be associated with acute aortic regurgitation in the setting of an aortic dissection. (c) D. This patient has symptoms consistent with acute pericarditis and would most likely have a pericardial friction rub on examination.

A 30 year-old female presents with amenorrhea, proximal muscle weakness, weight gain, and increased emotional lability. Her physical examination consists of central obesity, full face, and protuberant abdomen with thin extremities. Her blood pressure is 150/96 mmHg. Which of the following is the most likely diagnosis? A. Addison disease B. Hypothyroidism C. Cushing syndrome D. Pituitary insufficiency

(u) A. Addison disease symptoms may include weakness but will show weight loss, anorexia, nausea, anxiety, hyperpigmentation over the knuckles, elbows, knees and sometimes vitiligo. (u) B. Hypothyroidism does not present with central obesity, thin extremities or moon face. (c) C. A classic presentation of cushing syndrome is moon facies, buffalo hump, protuberant abdomen, thin extremities, weakness, back and head ache, hypertension, acne and superficial skin infections. There are typically purple striae and easy bruisability. (u) D. Patients with pituitary insufficiency present with short stature and growth failure. Typically the presentation is at an earlier age.

A 19 year-old man comes to the office because he has had a fever, frequent urination, urgency, dysuria and scrotal pain for the past 2 days. On physical examination, he has a temperature of 101 degrees F, scrotal swelling, and purulent urethral discharge is visible on penile examination. Gram stain of the discharge shows gram negative intracellular diplococci. Which of the following is the most appropriate antibiotic therapy? A. Ampicillin (Principen) B. Ciprofloxacin (Cipro) C. Ceftriaxone (Rocephin) D. Nitrofurantoin (Macrobid)

(u) A. Ampicillin can be prescribed in conjunction with gentamicin to treat acute pyelonephritis. (u) B. Ciprofloxacin can be prescribed to treat acute cystitis or chronic bacterial prostatitis. (c) C. Ceftriaxone is an effective treatment for acute epididymitis caused by Neisseria gonorrhoeae. (u) D. Nitrofurantoin can be prescribed to treat acute cystitis.

Which of the following medications is the initial treatment of choice for suppressing the progression of rheumatoid arthritis (RA)? A. Naproxen sodium (Naprosyn) B. Prednisone C. Methotrexate (Rheumatrex) D. Gold salts

(u) A. Antiinflammatory medication may help with the symptoms but does not aid in suppression of RA. (u) B. Corticosteroids are useful in the treatment of symptoms but does not aid in the suppression of disease. (c) C. Methotrexate is the initial treatment choice for RA and aids in suppression of disease. (u) D. Gold salts can be used for an acute RA flare, but do not suppress of the progression of the disease.

A 45 year-old male presents to the clinic complaining of morning sluggishness, daytime fatigue, headaches. He admits to drinking two cocktails each evening. His bed partner reports his loud cyclical snoring, breath cessation and thrashing movements of his extremities during sleep. BMI is 40. Heart examination reveals regular rate and rhythm without S3, S4, or murmur and lungs are clear to auscultation. Polysomnography shows apneic episodes lasting as long as 60 seconds. Which of the following clinical interventions would most likely provide for the acute cessation of apneic episodes? A. Avoidance of alcohol B. Weight loss C. Nasal continuous positive airway pressure D. Supplemental oxygen

(u) A. Avoidance of alcohol is also a necessary step in managing sleep apnea however does not provide immediate relief of apneic episodes. (u) B. Weight loss is also a necessary step in managing sleep apnea however does not provide immediate relief of apneic episodes. (c) C. Nasal CPAP is curative in many patients with sleep apnea. (u) D. Oxygen lessens the severity of nocturnal desaturation but may lengthen the apnea episodes.

A 28 year-old man comes to the office for his yearly follow up of testicular cancer. He was successfully treated with an orchiectomy two years ago. Which of the following tumor markers can be used to identify early relapse in testicular cancer? A. Carcinoembryonic antigen (CEA) B. Prostate specific antigen (PSA) C. CA 125 glycoprotein D. Alpha fetoprotein (AFP)

(u) A. Carcinoembryonic antigen can be elevated in multiple conditions including colon cancer, gastritis, peptic ulcer disease, diverticulitis, liver disease, chronic obstructive pulmonary disease, and diabetes. (u) B. Prostate specific antigen is a sensitive marker for prostate cancer. (u) C. CA 125 glycoprotein is a marker in epithelial ovarian cancer and can be used for post-treatment surveillance. (c) D. Periodic surveillance of alpha fetoprotein is a sensitive method for detecting early relapse of testicular cancer.

In which of the following conditions would human chorionic gonadotropin (hCG) level be lower than expected for gestational age? A. Choriocarcinoma B. Hydatidiform mole C. Ectopic pregnancy D. Twin gestation

(u) A. Choriocarcinoma is a persistent form of gestational trophoblastic neoplasia and will have an elevated hCG level. (u) B. Quantitative hCG levels are excessively elevated for the gestational age of the pregnancy. (c) C. An ectopic pregnancy will have an abnormally low hCG level because the hCG will not double every 48 hours as a normal pregnancy would. (u) D. A twin gestation will have a higher hCG level because of the presence of two fetuses.

A 60 year-old male complains of progressive fatigue and dyspnea. On examination his lungs are clear to auscultation bilaterally, heart exam reveals regular rate and rhythm without S3, S4 or murmur, and extremities show 1+ edema bilaterally. Chest x-ray reveals cardiomegaly. electrocardiogram shows low voltage, and echocardiogram shows an ejection fraction of 55% with a small, thickened left ventricle that has rapid early filling with diastolic dysfunction. Which of the following is the most likely underlying etiology of this patient's cardiomyopathy? A. Alcoholism B. Myocarditis C. Amyloidosis D. Chronic hypertension Explanations (u) A. Chronic alcohol use is commonly associated with a dilated left ventricle with left ventricular dysfunction. (u) B. Myocarditis is associated with a dilated, not small, left ventricle. (c) C. Amyloidosis is the most common cause of restrictive cardiomyopathy and is associated with a small thickened left ventricle that has rapid early filling with diastolic dysfunction. (u) D. Chronic hypertension is associated with a hypertrophic, hypercontractile left ventricle.

(u) A. Chronic alcohol use is commonly associated with a dilated left ventricle with left ventricular dysfunction. (u) B. Myocarditis is associated with a dilated, not small, left ventricle. (c) C. Amyloidosis is the most common cause of restrictive cardiomyopathy and is associated with a small thickened left ventricle that has rapid early filling with diastolic dysfunction. (u) D. Chronic hypertension is associated with a hypertrophic, hypercontractile left ventricle

Which of the following is the diagnostic study of choice in the evaluation of Zollinger-Ellison syndrome? A. D-xylose absorption test B. Gastrin level C. 5-hydroxyindoleacetic acid assay (5-HIAA) D. Urea breath test

(u) A. D-xylose absorption test is used in the evaluation of possible gluten-induced enteropathy. (c) B. Zollinger-Ellison Syndrome (ZES) is characterized by elevated levels of serum gastrin resulting from gastrin-secreting tumors usually located in the duodenum or pancreas. (u) C. 5-HIAA levels are elevated in metastatic carcinoid tumors. (u) D. The urea breath test is used to evaluate ulcers caused by H. pylori infection

A 14-year old male active in sports, has been complaining of intermittent anterior right knee pain for several months.He denies any specific injuries. On examination, there is no erythema, swelling, deformities, joint laxity, or crepitus. Palpation reveals tenderness over the tibial tubercle and bursa of the right knee. This finding is characteristic of which of the following disorders? A. Discoid meniscus B. Osgood-Schlatter disease C. Chondromalacia patella D. Osteochondritis dissecans

(u) A. Discoid meniscus causes clicking over the lateral meniscus during flexion. This disorder is mostly painless and occasionally may cause mild aching or effusion. (c) B. Osgood-Schlatter disease causes pain at the tibial tubercle and it is caused by fragmentation of the tip of the proximal tibial physis. (u) C. Chondromalacia patella may demonstrate exaggerated knee valgus and subluxation. (u) D. Osteochondritis dissecans in older children may have effusions, pain, and locking of the joint caused by a portion of the joint surface softening and a shearing leading to a loose fragment.

Bony and cartilaginous enlargement of distal interphalangeal joints is commonly seen in which of the following medical conditions? A. Rheumatoid arthritis B. Osteoarthritis C. Psoriatic arthritis D. Gouty arthritis

(u) A. Findings in Rheumatoid arthritis include skin nodules, pannus formations and symmetric joint involvement sparing the distal interphalangeal joints. (c) B. Heberden's nodes are commonly seen in primary osteoarthritis. (u) C. Psoriatic arthritis manifests commonly as sacroiliitis. Asymmetrical arthritis occurs in psoriatic arthritis and causes a sausage like appearance to the fingers. It can also mimic the presentation of rheumatoid arthritis. (u) D. Gout commonly affects the great toe, midfoot, ankle, and knee. Tophi may be present which are subcutaneal deposits of monosodium urate crystals.

A 30 year-old male presents with sudden onset of chills, fever, chest pain and a cough productive of greenish-brown sputum. On examination his temperature is 102 degrees F. He appears acutely ill and his respirations are shallow. Chest x-ray demonstrates left lower lobe consolidation. Which of the following findings would most likely be present on examination of his left lower lung? A. Hyperresonance B. Vesicular breath sounds C. Increased tactile fremitus D. Wheezing

(u) A. Hyperresonance is an abnormal sound as a result of air trapping as in COPD. (u) B. Vesicular breath sounds are the description of normal lung sounds. (c) C. Increased tactile fremitus occurs in the presence of fluid or a lung consolidation such as lobar pneumonia. (u) D. Wheezing is a musical noise sounding like a squeak caused by high velocity air flow through a narrow or obstructed airway.

A 73 year-old male with chronic renal failure due to longstanding hypertension and diabetes is being discharged from the hospital today. Which dietary recommendation should be made to prevent further complications and progression of his renal disease? A. Increase salt intake B. Restrict dietary protein C. Add a daily potassium supplement D. Decrease gluten consumption

(u) A. Increased salt intake can lead to volume overload in patients with chronic renal disease. (c) B. Restricting protein in the diet may slow the progression of chronic kidney disease. (u) C. Hyperkalemia can develop in patients with chronic renal failure who are taking supplements or have a high potassium diet. (u) D. Decreasing gluten consumption has no effect on renal failure.

Which of the following is the best radiologic study to image the pituitary gland? A. Lateral skull films B. Ultrasound C. Magnetic resonance imaging (MRI) D. Computed tomography (CT) scan

(u) A. Lateral skull films will not show the pituitary gland due to location. (u) B. It is not possible to visualize the pituitary gland by ultrasound due to physical location. (c) C. The pituitary gland and specifically pituitary tumors are best visualized by an MRI. (u) D. CT scan is not the preferred test for imaging the pituitary gland.

A 56 year-old female with a 35 pack year smoking history presents to the clinic with shortness of breath and cough. On examination, she is thin with no recent weight loss. She appears uncomfortable, breath sounds are diminished without adventitious sounds. Pulmonary function tests show a marked increase in total lung capacity (TLC) and a decreased FEV1. What is the most likely diagnosis for this patient? A. Persistent asthma B. Chronic obstructive pulmonary disease C. Idiopathic fibrosing interstitial pneumonia D. Sarcoidosis

(u) A. Lung function in asthma is evaluated by FEV1/FVC ratio with reduction noted with airflow obstruction. (c) B. Lung volume measurements in COPD reveal a marked increase in residual volume indicative of air trapping. (u) C. Pulmonary function testing in idiopathic fibrosing interstitial pneumonia shows a loss of lung volume with normal to increased airflow rates in interstitial lung disease. (u) D. Restrictive changes with decreased lung volumes and diffusing capacity are common in sarcoidosis.

A 60 year-old male with history of hypertension presents for routine physical examination. He has no current complaints. Vital signs are BP of 136/70 mmHg, HR 60 bpm, regular, RR 14, unlabored. Heart shows regular rate and rhythm with no S3, S4 or murmur, Lungs are clear to auscultation bilaterally, and the abdomen is soft, nontender. There is a 5cm palpable pulsatile abdominal mass noted. Which of the following is the best initial diagnostic study in this patient? A. Magnetic resonance imaging (MRI) B. Arteriography C. Ultrasound (US) D. Plain film

(u) A. MRI, arteriography, and abdominal flat plate are not indicated in the initial diagnostic evaluation of a patient with a suspected abdominal aortic aneurysm. (u) B. See A for explanation. (c) C. Abdominal ultrasound is the diagnostic study of choice for the initial diagnosis of an abdominal aortic aneurysm. (u) D. See A for explanation.

A 25 year-old female with irritable bowel syndrome presents with complaint of upper and lower extremity discomfort. The patient has pinpoint muscle tenderness over the shoulder girdle, low back and hips. Which of the following medications is the most appropriate treatment in this patient? A. Hydrocodone (Vicodin) B. Amitriptyline (Elavil) C. Methotrexate (Rheumatrex) D. Naproxen sodium (Naprosyn)

(u) A. Opioid medication is not effective in the treatment of fibromyalgia. (c) B. Amitriptyline is the treatment of choice for fibromyalgia and is typically administered at bedtime. (u) C. Methotrexate is not effective in treating fibromyalgia. (u) D. NSAIDs are generally ineffective in treating fibromyalgia.

A 69 year-old male presents with complaint of increasing dyspnea over the past 6-8 months. The patient denies cough, chest pain or smoking history. Physical examination reveals inspiratory crackles at the bases and clubbing of the nails. Chest x-ray reveals interstitial fibrosis of the lower lungs, thickened pleura and calcified pleural plaques of the lateral chest wall. Pulmonary function testing shows a restrictive pattern with a decreased diffusing capacity. What information is most likely noted in this patient's history? A. Coal mining B. Silica exposure C. Textile work D. Asbestos exposure

(u) A. Patients with coal miners pneumoconiosis are typically asymptomatic with unremarkable pulmonary function tests. CXR shows small opacities in the upper lungs. (u) B. Patients with a history of silica exposure are also asymptomatic and have unaffected pulmonary function tests. CXR shows small rounded opacities throughout the lung and calcified hilar lymph nodes. (u) C. Textile workers present with an asthma-like disorder with chest tightness, cough and dyspnea that is worse on the first day back to work and improves as the week goes on. (c) D. Asbestos exposure often presents years later with increasing dyspnea and interstitial fibrosis of the lower lungs, thickened pleura and calcified pleura plaques. They will have a restrictive pattern on PFT.

A 23 year-old male comes to the office with an intensely itchy rash, especially at night for the past week. His roommates have similar symptoms but have not been evaluated. On physical examination, the wrists, web spaces of the hands, and axillae have thin linear markings, tiny vesicles, and excoriations. Which of the following is the most likely diagnosis? A. Pediculosis B. Folliculitis C. Impetigo D. Scabies

(u) A. Pediculosis is a lice infection of the scalp, trunk or pubic region. Body louse occurs in persons living in overcrowded residences, and is characterized by intense pruritis with resultant deep excoriation of the neck, shoulders, and upper back. Nits are identifiable on hair shafts. (u) B. Folliculitis is an infection of the upper hair follicles characterized by itching, burning and pustules in the hairy regions of the body. (u) C. Impetigo is a contagious infection of the skin caused by staphylococci or streptococci characterized by honey-crusted erythematous erosions of the face or other exposed areas of the body. (c) D. Scabies is an infestation of the mite Sarcoptes scabiei. It is usually spread by skin-to-skin contact. Scabies is characterized by intense pruritic burrows, vesicles and excoriations of the finger webs, wrist creases and axillae.

A 32 year-old male presents with a one-month history of weakness, anorexia, and weight loss. On physical examination, he is hypotensive and his skin has diffuse hyperpigmentation. Plasma cortisol levels drawn at 8 am are low. Which of the following is the most likely diagnosis? A. Pituitary insufficiency B. Addison disease C. Cushing syndrome D. Primary aldosteronism

(u) A. Pituitary insufficiency presents with hypopigmentation, not hyperpigmentation. (c) B. This is the classic presentation of Addison's disease (chronic adrenocortical insufficiency). (u) C. Hypercortisolism (Cushing syndrome) would present with central obesity, hypertension, and elevated cortisol levels. (u) D. Weakness is a symptom of primary aldosteronism, but the patient would be hypertensive and aldosterone levels would be elevated.

A 13 year-old female presents to the office with right knee and thigh pain and the inability to bear weight since waking yesterday morning. The mother states the child had a fever of 100.9 degrees F this morning and continues to be non-weight bearing. Examination reveals a warm, erythematous, swollen knee. Which of the following tests would be most beneficial in the diagnosis and treatment of this patient? A. Plain x-ray of the femur B. Antistreptolysin O titer C. Magnetic resonance imaging (MRI) of the femur D. Culture of joint aspirate

(u) A. Plain x-rays may aid in diagnostic suspicion, usually after a week or two, but do not aid in treatment choice. (u) B. ASO titer is not indicated in a patient with osteomyelitis. (u) C. MRI will detect the early inflammation of osteomyelitis but does not aid in the treatment choice. (c) D. A culture of the joint fluid will confirm the diagnosis and offer information regarding infectious agent.

A 60 year-old female with history of radiation therapy for the treatment of cancer presents with progressive dyspnea and fatigue. On examination the patient has lower extremity edema, significant ascites, and an elevated jugular venous pressure that does not fall with inspiration. Heart examination reveals a pericardial knock. Echocardiogram shows rapid early filling and reduced mitral inflow velocities with inspiration. Which of the following is the most likely diagnosis in this patient? A. Pulmonary hypertension B. Atrial myxoma C. Constrictive pericarditis D. Tako-Tsubo cardiomyopathy

(u) A. Pulmonary hypertension is usually associated with chest pain, dyspnea, fatigue and syncope. Examination would reveal a narrow splitting of S2 with a loud pulmonic component. Echocardiogram would show increased pulmonary artery pressures, right ventricular enlargement and possibly paradoxical motion of the intraventricular septum. (u) B. Atrial myxoma is characterized by fever, weight loss, malaise, embolization, and a diastolic sound or murmur (tumor plop) on examination. Atrial myxoma would be seen on echocardiogram. (c) C. Constrictive pericarditis is associated with TB, radiation therapy, cardiac surgery, or following viral pericarditis. There is evidence of right-sided heart failure, a positive Kussmaul sign, and a septal bounce and reduced mitral inflow velocities with inspiration on echocardiogram. (u) D. Tako-Tsubo cardiomyopathy (broken heart syndrome) is commonly seen in postmenopausal women who experience signs and symptoms of acute coronary syndrome. Echocardiogram shows left ventricular apical dyskinesia.

A 54 year-old woman with history of lupus comes to the office with increasing significant peripheral edema over the past four days. Laboratory findings include marked proteinuria, hypoalbuminemia and hyperlipidemia. Which of the following diagnostic studies is the best for determining the cause of the proteinuria? A. Renal ultrasound B. Renal biopsy C. Cystoscopy D. Computed tomography scan

(u) A. Renal ultrasound may identify hydronephrosis from a stone or other source of obstruction. (c) B. Renal biopsy is performed in adults with new onset of nephrotic syndrome to determine the cause of the proteinuria and to guide management decisions. (u) C. Cystoscopy can be used in the evaluation of hematuria to assess for bladder or urethral neoplasm, benign prostatic hyperplasia, and radiation or chemical cystitis. (u) D. CT scanning may identify neoplasms of the kidney or ureter as well as benign conditions such as urolithiasis.

Which of the following histories is most consistent with rheumatoid arthritis (RA)? A. Acute onset, morning stiffness, monoarticular joint swelling and tenderness B. Insidious onset, morning stiffness, symmetrical joint swelling and tenderness C. Insidious onset, morning stiffness, monoarticular joint swelling and tenderness D. Acute onset, morning stiffness, symmetrical joint swelling and tenderness

(u) A. Rheumatoid arthritis has an insidious onset, morning stiffness is typically longer than 30 minutes, and although early RA may have monoarticular presentation, it is typically symmetrical. (c) B. Rheumatoid arthritis has an insidious onset, morning stiffness is typically longer than 30 minutes, and is typically symmetrical in presentation. (u) C. Rheumatoid arthritis has an insidious onset, morning stiffness is typically longer than 30 minutes, and although early RA may have monoarticular presentation, it is typically symmetrical. (u) D. Rheumatoid arthritis has an insidious onset, morning stiffness is typically longer than 30 minutes, and although early RA may have monoarticular presentation, it is typically symmetrical.

An otherwise healthy college student presents with complaints of cough, malaise, fever, yellow-green nasal discharge and headache for the past 3 weeks. She complains of facial pain over the cheeks and while chewing. On examination, the nasal turbinates are erythematous and edematous nearly obstructing the nares bilaterally. She has not been previously evaluated. What is the most appropriate antibiotic in this patient? A. Amoxicillin/clavulanate (Augmentin) B. Trimethoprim/sulfamethoxazole (Bactrim) C. Levofloxacin (Levaquin) D. Moxifloxacin (Avelox)

(u) A. See B for explanation. (c) B. Acute bacterial rhinosinusitis (sinusitis) is associated with S. pneumoniae, H. Influenzae, and less commonly S. Aureus or Moraxella catarrhalis. First line therapies for bacterial sinusitis include amoxicillin, Bactrim, or doxycycline. Second line therapy includes Augmentin, Moxifloxacin, or Telithromycin. (u) C. See B for explanation. (u) D. See B for explanation.

What are the most effective agents in treating somatoform spectrum pain disorder? A. Analgesics B. Antidepressants C. Antipsychotics D. Anxiolytics

(u) A. See B for explanation. (c) B. Antidepressants, especially SSRIs and TCAs are the main pharmacologic treatments used in somatoform spectrum pain disorder as analgesics and anxiolytics provide little to no relief and generally result in dependency. As there is no associated psychosis, delusions or hallucinations antipsychotics are not helpful. (u) C. See B for explanation. (u) D. See B for explanation.

Which of the following is the rationale for the utilization of beta blocker therapy in a patient with hyperthyroidism? A. Reduce goiter size B. Alleviate symptoms C. Regulate TSH D. Normalize free T4

(u) A. See B for explanation. (c) B. Propranolol is used for symptomatic relief until the hyperthyroidism is resolved. It relieves tachycardia, tremor, diaphoresis and anxiety. (u) C. See B for explanation. (u) D. See B for explanation.

A 22 year-old graduate student presents with a six-month history of abdominal pain relieved with defecation which seems to coincide with her starting PA school. She describes alternating constipation and diarrhea as well as bloating. She denies any recent weight changes. Her only medication is citalopram (Celexa) What is the most likely diagnosis for this patient? A. Crohn's disease B. Irritable bowel syndrome C. Thyroid storm D. Celiac disease

(u) A. See B for explanation. (c) B. The patient's symptoms are consistent with irritable bowel syndrome. More than 50% of patients who seek medical attention for symptoms of IBS also have a diagnosis of depression, anxiety, or somatization. (u) C. See B for explanation. (u) D. See B for explanation.

A 41 year-old male with a history of intravenous drug abuse presents to your office with acute, nontraumatic right knee pain, chills, and sweats starting 2 days ago. On physical examination, his temperature is 102.9 degrees F. The right knee is erythematous, edematous and tender to palpation and range of motion. Plain knee x-ray reveals soft tissue swelling. Which of the following is most likely the diagnosis? A. Gouty arthritis B. Septic arthritis C. Rheumatoid arthritis D. Psoriatic arthritis

(u) A. See B for explanation. (c) B. This patient's signs and symptoms are most consistent with septic arthritis. IV drug abuse places this patient at even greater risk. (u) C. See B for explanation. (u) D. See B for explanation.

A 57 year-old man is being evaluated for shortness of breath. The following spirometric data are obtained: VC 4.90 L (predicted), 5.15 L (observed) 105% predicted FRC 3.99 L (predicted), 4.37 L (observed) 110% predicted RV 2.47 L (predicted), 3.17 L (observed) 128% predicted FEV1 3.50 L (predicted), 2.35 L (observed) 67% predicted These findings are consistent with which of the following? A. No demonstratable abnormality B. Restrictive lung disease C. Obstructive lung disease D. A ventilation/perfusion mismatch

(u) A. See C for explanation. (u) B. Restrictive lung disease would show decreased total lung capacity, vital capacity, and normal to increased FEV1. (c) C. Spirometry findings in obstructive lung disease typically show normal or increased total lung capacity, decreased vital capacity, prolonged FEV1, and increased residual volume. (u) D. A ventilation/perfusion scan would be abnormal with a pulmonary embolism.

What physical examination finding is most specific for acute cholecystitis? A. Psoas sign B. Rovsing's sign C. Murphy's sign D. Cullen's sign

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a postive Murphy's sign and is most specific for cholecystitis. (u) D. See C for explanation.

Which of the following laboratory values would be noted in a patient with primary hyperthyroidism? A. Increased TSH, increased free T4 B. Increased TSH, decreased free T4 C. Decreased TSH, increased free T4 D. Decreased TSH, decreased free T4

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. Serum TSH is depressed and serum T3, T4 and uptake are usually all increased in patients with primary hyperthyroidism. (u) D. See C for explanation

A 30 year-old female presents with left wrist pain after slipping on the ice while walking to her car. On examination, pain is noted on palpation over the anatomical snuff box. X-ray of her wrist shows no identifiable fracture. Which of the following is the most appropriate treatment in this patient? A. No treatment necessary B. ACE wrap application C. Splint application D. Immediate orthopedic referral

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. Tenderness in the snuff box should be treated as a suspected scaphoid fracture. The patient should be treated as if it is fractured and placed in a splint with a referral to an orthopedic specialist for further evaluation and repeat imaging. (u) D. See C for explanation.

A patient describes a history of intermittent and uncontrollable twitching of his right hand that spreads to involve the entire arm after a few minutes. Afterward, the arm is extremely weak. There are no other areas of involvement, sensory deficit or altered consciousness. What is the most likely seizure diagnosis? A. Absence B. Complex-partial C. Simple-partial D. Myoclonic

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. The lack of altered consciousness and focal motor symptoms are strongly indicative of this type of seizure. (u) D. See C for explanation.

What is the mechanism of action of salmeterol (Serevent) in the treatment of asthma? A. Anti-inflammatory B. Immunotherapy for specific allergens C. Relaxing of bronchial smooth muscle D. Reduction of leukotriene production

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. The mechanism of action for salmeterol is the relaxation of bronchial smooth muscle. (u) D. See C for explanation.

A 70 year-old male with history of ischemic cardiomyopathy presents with a syncopal episode. He denies complaints of chest pain, palpitations, or dyspnea. ECG shows no acute ST-T wave changes. Echocardiogram reveals an ejection fraction of 25% with no valvular abnormalities. Which of the following is the most appropriate management for this patient? A. Dual chamber permanent pacemaker B. Diltiazem (Cardizem) C. Implantable cardio defibrillator D. Midodrine (ProAmatine)

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. This patient has ischemic cardiomyopathy and syncope, which is most likely due to ventricular tachycardia. Instertion of a cardio defibrillator is the management of choice in this patient. (u) D. See C for explanation.

A 54 year-old type 2 diabetic male presents for follow up evaluation of previously diagnosed persistent otitis externa. Early in the disease process, a CT scan was obtained secondary to non-improvement on antibiotics. Results showed osseous erosion of the floor of the ear canal. He has been on ciprofloxacin 1000mg twice daily for two months since the CT scan and currently has no further edema, erythema, or exudate from the external auditory canal or surrounding tissue. Which of the following is an appropriate treatment plan? A. Continue prophylactic antibiotics for an additional 6 weeks B. Immediately discontinue antibiotics C. Obtain gallium scan to ensure reduction of inflammatory process D. Skin swab culture of healthy tissue

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. Treatment of malignant external otitis requires prolonged antipseudomonal antibiotic administration often for several months. To avoid relapse, antibiotics should be continued even in the asymptomatic patient, until gallium scanning indicates a marked reduction in the inflammatory process. (u) D. See C for explanation.

A 17 year-old female is seen who has a history of eating large amounts of food at night 3 to 4 times weekly. These episodes are always followed by extreme guilt and either induced vomiting or hours of strenuous exercise. She excels at work and school and maintains many active relationships. Her physical examination reveals a normal BMI and an otherwise normal exam. What is the best initial intervention for this patient? A. Begin an anxiolytic B. Immediate hospitalization C. Start an antidepressant D. Test for substance abuse

(u) A. See C for explanation. (u) B. See C for explanation. (c) C. Uncomplicated bulimia generally does not require hospitalization as the physical manifestations encountered in bulimia are generally mild if present at all. Some patients with bulimia have concomitant substance abuse issues but her successful relationships and work activities lessen the probability. Antidepressants, not anxiolytics, have been found helpful in lessening the binge/purge cycles and improving overall well-being even outside of comorbid mood disorders. (u) D. See C for explanation.

In what region of the brain are cerebrovascular lesions most likely to cause post-event depressive symptoms? A. Cerebellum B. Occipital C. Pons D. Temporal

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Cerebrovascular lesions in the anterior brain regions are more common than the posterior areas. The temporal lobe and the diencephalon are especially prone to post event depression.

A 57 year-old male presents with episodic diplopia over the past two months. Symptoms progressed over the last two days with the onset of bilateral facial weakness made worse with repetitive use. Weakness improves somewhat with rest. He denies fever, headache or areas of pain. Exam reveals a nasal voice, drooping eyelids and a normal sensory exam. Which of the following is the most likely diagnosis? A. Multiple sclerosis B. Guillain-Barre syndrome C. Lambert-Eaton syndrome D. Myasthenia gravis

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Episodic diplopia progressing to proximal weakness worsened by repetition and lacking sensory deficits is typical of myasthenia gravis. In Lambert-Eaton syndrome muscular responses actually improve with repetition and the weakness in Guillain-Barre syndrome always begins peripherally.

A 62 year-old male chronic smoker is examined for slowly progressive non-painful vision loss. Visual acuity showed 20/150 in both eyes. Extra-ocular muscles are intact. Pupils are responsive to direct and consensual stimuli however appear hazy. During funduscopic exam you are unable to visualize the optic cup, disk or the vessels. What is the most appropriate diagnosis? A. Anterior uveitis B. Narrow angle glaucoma C. Retinal detachment D. Senile cataract

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Patients with cataract have gradually progressive blurred vision without pain or redness. Lens opacification usually develops and can be grossly visible. Cataracts are the leading cause of blindness worldwide. They usually occur bilaterally. Senile cataracts is by far the most common type with most persons over the age of 60 having some degree of lens opacity. Cigarette smoking increases the risk of cataract formation.

A 47 year-old perimenopausal female with vasomotor symptoms complains of vulvar itching and copious vaginal discharge with a rancid odor. Physical examination reveals erythema of the vulva and petechiae on the cervix. The pH of the vaginal discharge is five. Which of the following is the recommended treatment for this patient? A. Topical metronidazole (Metrogel) B. Oral fluconazole (Diflucan) C. Topical estradiol (Estrace) cream D. Oral metronidazole (Flagyl)

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. This is a classic description of trichomonas vulvovaginitis. This condition must be treated with oral metronidazole or tinidazole.

A 16 year-old nulliparous acutely ill female presents with bilateral lower abdominal pain. She has a temperature of 100.4 degrees F and on examination has a tender, enlarged left adnexa. Cervical culture is positive for Chlamydia. Ultrasound reveals a complex tubular structure in the left adnexal area. What is the recommended treatment? A. Outpatient treatment with IM ceftriaxone and oral doxycycline B. Oral doxycycline C. IM procaine penicillin D. Hospitalization with parenteral doxycycline and cefoxitin

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. This patient has pelvic inflammatory disease and most likely a tubo-ovarian abscess. It is recommended that the patient be hospitalized and treated with high-dose IV antibiotic therapy. For patients with tubo-ovarian abscesses, surgical drainage is often necessary.

Prolonged use of a proton pump inhibitor can lead to low levels of which of the following nutrients? A. Folic acid B. Magnesium C. Vitamin B6 D. Vitamin B12

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Vitamin B12 requires gastric acid for absorption in the stomach. Prolonged use of a proton pump inhibitor suppresses gastric acid production.

An O2 saturation of 90% corresponds to what PO2 value? A. 90 mmHg B. 80 mmHg C. 70 mmHg D. 60 mmHg

(u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. Copyright © 2010. Physician Assistant Education Association 84 (c) D. O2 sat values above 90% correspond with a PO2 >70 mmHg and values less than 94% represent hypoxemia. Less than 90% O2 sat warrants measurement of arterial blood gasses.

A 26 year-old patient is brought to the emergency department after a head on collision. The patient complains of chest pain, dyspnea and cough. Examination reveals the patient to be tachypneic and tachycardic with a narrow pulse pressure. Jugular venous distension is noted. Electrocardiogram reveals nonspecific t wave changes and electrical alternans. Which of the following is the most appropriate management plan for this patient? A. Serial echocardiograms B. Pericardiocentesis C. Cardiac catheterization D. Pericardiectomy

(u) A. Serial echocardiograms would be indicated if a patient had a small pericardial effusion and no intervention was immediately needed. This patient has signs and symptoms of cardiac tamponade and needs immediate intervention. (c) B. Urgent pericardiocentesis is the initial treatment of choice in a patient with cardiac tamponade. (u) C. There is no indication for cardiac catheterization in the management of cardiac tamponade. (u) D. A partial pericardiectomy may be needed in patients with recurrent pericardial effusions that occur secondary to neoplastic disease and uremia, but there is no indication for partial pericardiectomy in the acute management of cardiac tamponade.

A recent Haitian immigrant presents to the clinic for an employment physical examination before starting work at a local hospital. The patient has a history of receiving bacilli Calmette-Guerin (BCG) vaccination. Screening for tuberculosis for this employee should include which of the following tests? A. Sputum induction B. PPD skin test C. Chest x-ray D. No screening needed

(u) A. Sputum induction should not be used as a screening test for tuberculosis. (u) B. False-positive tuberculin skin test reactions can occur in persons previously vaccinated against M. tuberculosis with BCG. PPD should be avoided as a screening test in these patients. (c) C. Chest x-ray is the test of choice in patients where the PPD test is not indicated or in high-risk individuals. (u) D. This patient has recently emigrated from a possible endemic region and should be screened for tuberculosis.

A 62 year-old male smoker presents to the clinic with the complaint of a chronic cough, hemoptysis, and weight loss. Chest CT shows a mass obstructing the bronchus with hilar and mediastinal lymph node abnormalities. Bronchoscopy with biopsy is performed. On reviewing pathology results you explain to the patient that his type of lung cancer is prone to early hematogenous spread, is rarely amenable to surgical resection and has a very aggressive course. What type of lung cancer is most likely in this patient? A. Squamous cell B. Small cell C. Large cell D. Adenocarcinoma

(u) A. Squamous cell carcinoma, large cell carcinoma, and adenocarcinoma spread more slowly and have the possibility of cure in early stages following resection and chemotherapy. (c) B. Small cell lung cancer is very aggressive with a median survival (untreated) of 6-18 weeks. (u) C. See A for explanation. (u) D. See A for explanation.

A 26 year-old woman requests screening after her boyfriend was treated for a sexually transmitted infection recently. On examination you find a painless vulvar ulcer. Which of the following is the most likely diagnosis? A. Herpes B. Syphilis C. Chancroid D. Granuloma inguinale

(u) A. The classic presentation of herpes is a painful vesicle. (c) B. The primary lesion of syphilis presents as a painless ulcer or chancre. Secondary syphilis presents with a skin rash lymphadenopathy and mucocutaneous lesions. (u) C. Chancroid presents with a painful genital ulcer and tender suppurative inguinal adenopathy. (u) D. Granuloma inguinale presents with raised, red lesions that bleed easily.

A person with type 2 diabetes who requires insulin brings in a home monitoring record for review. The current insulin regimen is 15 units of NPH with 5 units of regular in the morning, and 10 units of NPH with 5 units of regular in the evening. A trend of elevated blood sugar readings occurring at noon should prompt an insulin increase of which of the following? A. Morning NPH dose B. Morning regular dose C. Evening NPH dose D. Evening regular dose

(u) A. The effectiveness of the morning NPH dose would be reflected by the 5 PM sugar reading. (c) B. The elevated noon blood sugar reading indicates a need to increase the morning regular dose. (u) C. The morning glucose reading would reflect the effectiveness of the evening NPH. (u) D. The evening (10 PM) reading would reflect the effect of the evening regular dose.

A 75 year-old female with history of coronary artery disease and dyslipidemia presents for routine follow-up. Physical examination reveals loss of hair on the lower extremities bilaterally with thinning of the skin. Femoral pulses are +2/4 bilaterally, pedal pulses are diminished bilaterally. Ankle brachial index is reduced. Which of the following signs or symptoms is this patient most likely to have? A. Lower extremity edema B. Calf pain with walking C. Numbness of the lower extremities D. Itching of the lower extremities

(u) A. This patient has signs and symptoms consistent with arterial insufficiency. Lower extremity edema is seen in patients with venous insufficiency. (c) B. This patient has signs and symptoms consistent with arterial insufficiency and would most likely complain of intermittent claudication. (u) C. Numbness of the lower extremities would be seen with acute arterial occlusion. (u) D. Itching of the lower extremities may be seen in chronic venous insufficiency because of secondary skin changes, but is not common in arterial insufficiency.

A 53 year-old male with history of hypertension presents complaining of recent 4/10 left-sided chest pain with exertion that is relieved with rest. He states the pain usually lasts approximately 4 minutes and is relieved with rest. Heart examination reveals regular rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute changes. Which of the following is the most appropriate initial step in the evaluation of this patient? A. Cardiac catheterization B. CT Angiogram of the chest C. Echocardiogram D. Nuclear stress test

(u) A. This patient has signs and symptoms consistent with stable angina. Noninvasive diagnostic testing is preferred in this patient. (u) B. CT angiogram may be useful for the evaluation of chest pain, however its role in routine practice has not been established. (u) C. This patient has signs and symptoms of stable angina. There are no signs of valvular heart disease on examination. While an echocardiogram may be performed at some point, it is not the best initial diagnostic step to determine the etiology of the patient's angina. (c) D. Nuclear stress testing is the most appropriate initial diagnostic study in the evaluation of a patient with signs and symptoms consistent with stable angina.

An 18 year-old young woman comes to the office with a mildly itchy rash on her chest and back for the past two weeks. She noticed an initial area on her back two weeks ago, and now it has spread across her back and chest. On physical examination, she has several salmon-colored plaques with fine scale that follow the cleavage lines of the trunk. Which of the following is the most likely diagnosis? A. Tinea versicolor B. Seborrheic dermatitis C. Psoriasis D. Pityriasis rosea

(u) A. Tinea versicolor is a mild infection characterized by hypopigmented macules on the trunk. This eruption is often asymptomatic-usually appearing during humid, warmer temperatures. It is most often on the upper trunk of older teenagers or young adults. Patients may complain of mild pruritis. (u) B. Seborrheic dermatitis consists of pruritic greasy scales and underlying erythematous patches or plaques on the scalp, central face, presternal areas, and upper back. (u) C. Psoriasis is characterized by chronic, recurring, erythematous papules and plaques with thick silvery white scale on the elbows, knees, and scalp. (c) D. Pityriasis rosea is an acute eruption of fine scaling fawn-colored papules and plaques that are distributed along the cleavage lines of the trunk, often referred to as a Christmas tree pattern. A single plaque, called a herald patch, precedes the secondary eruption by 1-2 weeks.