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A 65 year-old patient with steroid-dependent chronic obstructive lung disease presents with a headache that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever, but has had photophobia and a stiff neck. Which of the following is the most likely diagnosis? A. Transient ischemic attack B. Bacterial meningitis C. Migraine headache D. Cryptococcosis

(a) B. Bacterial meningitis is typically acute in onset and causes fever, but immunocompromised patients may have a slower onset and no fever.

Scientific Concepts/Hematology A defect in which of the following physiologic processes can lead to the development of a microcytic, hypochromic anemia? A. Hemoglobin production B. IgG antibody formation C. Red blood cell nuclear maturation D. Red blood cell membrane defects

(c) A. A deficiency in substances required for hemoglobin synthesis result in RBCs with a deficient mean corpuscular hemoglobin concentration and usually microcytosis. (u) B. IgG antibody formation would led to the development of a hemolytic anemia. (u) C. Alterations in red blood cell nuclear maturation led to the development of macrocytic red blood cells. (u) D. Red blood cell membrane defects led to the development of hemolytic anemia

Clinical Therapeutics/Endocrinology While awaiting operative removal of pheochromocytoma, which of the following classes of medications are used for control of hypertension? A. alpha-adrenergic blocker B. beta-adrenergic blocker C. ACE inhibitor D. diuretic

(c) A. Alpha-adrenergic blockers are used preoperatively to control hypertension in a patient with pheochromocytoma that occurs from unopposed alpha stimulation when the tumor is manipulated.

Scientific Concepts/Psychiatry/Behavioral Medicine Which of the following medications used in the management of anxiety has a delayed onset of action? A. buspirone (BuSpar) B. diphenhydramine (Benadryl) C. lorazepam (Ativan) D. butalbital (Fiorinal)

(c) A. Buspirone takes several days to weeks for it to have clinical activity. (u) B. Diphenhydramine works as a histamine blocker and will cause sedation immediately because of its anticholinergic effects.

Clinical Therapeutics/Orthopedics/Rheumatology An 80 year-old female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with osteoporotic compression fracture. Which of the following treatment modalities has the potential to cause analgesia of the fracture site with its use? A. Calcitonin (Miacalcin) nasal spray B. Alendronate (Fosamax) C. Raloxifene (Evista) D. Combined estrogen and progesterone (Prempro) therapy

Which of the following medication classes is the treatment of choice in a patient with variant or Prinzmetal's angina? A. Calcium channel blockers B. ACE inhibitors C. Beta blockers D. Angiotensin II receptor blockers

(c) A. Calcium channel blockers are effective prophylactically to treat coronary vasospasm associated with variant or Prinzmetal's angina.

Clinical Therapeutics/Cardiology Which of the following antihypertensive agents is considered to have both alpha- and beta-blocker activities? A. carvedilol (Coreg) B. hydralazine (Apresoline) C. minoxidil (Loniten) D. spironolactone (Aldactone)

(c) A. Carvedilol has both alpha- and beta-blocker activities. (u) B. Hydralazine and minoxidil are considered vasodilators.

Diagnostic Studies/Pulmonology Which of the following is the most common radiographic presentation of lung abscess? A. cavitation B. pleural thickening C. hilar mass D. hyperinflation

(c) A. Cavitation is seen with lung abscess or progressive primary tuberculosis. (u) B. Pleural thickening is noted in mesothelioma. (u) C. Hilar and mediastinal abnormalities are common on chest radiography in patients with lung cancer. (u) D. Hyperinflation is the main clinical feature in emphysema.

Clinical Intervention/Gastrointestinal/Nutritional A 24 year-old female presents with complaints of abdominal pain, bloating, and chronic diarrhea. She says she felt worse last month while on vacation in Italy. Despite eating well she lost weight. What would be the most appropriate treatment for this patient? A. Gluten-free diet B. Small bowel resection C. Ciprofloxacin (Cipro) therapy D. Pancreatic enzymes

(c) A. Celiac disease is a diffuse disease of the small bowel that is caused by immunologic malfunction. This disease is active only in the presence of gluten, a constituent of wheat. Avoidance of gluten-containing foods is the treatment of choice.

History & Physical/Dermatology Erythema nodosum is characterized by A. subcutaneous red tender nodules. B. brown pigmentation on the lower extremities. C. tender lymph nodes in the groin. D. scaling red macules.

(c) A. Erythema nodosum produces erythematous red tender nodules, especially on the shins. (u) B. Brown pigmentation on the lower extremities is a feature of chronic venous insufficiency. (u)C. Lymphovenereum granuloma is likely to produce tender lymph nodes in the groin as can acute infection in the lower extremities. (u) D. Scaling red macules are a feature of tinea corporis.

Diagnostic Studies/Neurology A 2 month-old infant has had a single, generalized tonic-clonic convulsion lasting 4 to 5 minutes. There is no history of trauma and the infant had been well previously. Physical findings include a temperature of 39.6 degrees C (103.2 degrees F), a bulging tympanic membrane on the right, and an inflamed pharynx. The next most appropriate step is to A. perform a lumbar puncture. B. order x-ray studies of the skull. C. obtain an electroencephalogram. D. send home with antibiotics and an anticonvulsant.

(c) A. Febrile convulsions are uncommon under the age of 3 months. The physical findings suggest the possibility of meningitis, so lumbar puncture with CSF analysis is indicated.

Clinical Intervention/Endocrinology Which of the following is the most accurate method to differentiate benign from malignant thyroid nodules? A. Fine needle aspiration biopsy B. Ultrasound of the thyroid gland C. Measurement of thyroid antibodies D. Radionuclide iodine uptake

(c) A. Fine needle aspiration biopsy is the best method used in the evaluation of thyroid cancer. Fine needle aspiration biopsy can be done on an outpatient basis and can be done under ultrasound guidance for patients who have small thyroid nodules. (u) B. Ultrasound of the thyroid gland is performed in order to help to guide the practitioner in performing a fine needle aspiration biopsy. It can also be used to differentiate solid from cystic masses but it cannot predict which nodules are cancer and which are benign. (u) C. Measurement of thyroid antibodies is most helpful in patients who have subclinical hypothyroidism or overt hyperthyroidism. There is a lot of controversy regarding whether treatment should be given to patients with subclinical disease and most providers will use thyroid antibodies to determine whether treatment should be given or delayed. (u) D. Radionuclide iodine uptake is performed to assess the activity of the thyroid gland. This test is most helpful to determine whether the gland is metabolically active (as seen with Graves' disease) or whether the gland is just releasing preformed thyroid hormone (subacute thyroiditis). The test provides a percentage of activity rather than a picture (thyroid scan) provides a picture of whether a nodule is "hot" or cold."

Diagnosis/Urology/Renal 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 Copyright © 2010. Physician Assistant Education Association 11 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.

Clinical Intervention/Endocrinology Radioactive iodine is most successful in treating hyperthyroidism that results from A. Grave's disease. B. subacute thyroiditis. C. Hashimoto's thyroiditis. D. papillary thyroid carcinoma.

Which of the following is an indication for vaccination against hepatitis A? A. Illicit drug users B. Health care workers C. Renal dialysis patients D. Routine vaccination starting at birth

(c) A. Hepatitis A vaccine is recommended for illicit drug users, anyone living or traveling to endemic areas, sewage workers, food handlers, homosexual and bisexual men, animal handlers, patients with a history of chronic liver disease or a clotting factor disease as well as children and workers in day care settings and institutions. (u) B. Health care workers, renal dialysis patients and routine vaccination starting at birth are some of the recommendations for vaccination against hepatitis B, not hepatitis A

A patient presents with eye pain and blurred vision. Snellen testing reveals vision of 20/200 in the affected eye and 20/20 in the unaffected eye. Fluorescein staining reveals the presence of a dendritic ulcer. Which of the following is the most likely diagnosis? A. Viral keratitis B. Fungal corneal ulcer C. Acanthamoeba keratitis D. Bacterial corneal ulcer

23 year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis? A. Hypertrophic cardiomyopathy B. Aortic stenosis C. Mitral regurgitation D. Pulmonic stenosis

(c) A. Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining

Clinical Therapeutics/Dermatology A 45 year-old female presents to the emergency department with generalized, hot, erythema of the skin. Physical exam reveals an oral temperature of 102 degrees Fahrenheit, purulent conjunctivitis, and mucosal erosions. Her skin is painful and separates from the dermis with touch. Which of the following is the most likely cause for this condition? A. Ampicillin B. Prednisolone C. Aspirin D. Hydrochlorothiazide (HCTZ)

(c) A. Medications are most frequently implicated in toxic epidermal necrolysis. These usually include, analgesics (NSAIDs), antibiotics (Ampicillin) and anticonvulsants (Carbamazepine).

Scientific Concepts/Gastrointestinal/Nutritional Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct or A. cystic duct. B. pancreatic duct. C. duodenal ampulla. D. common hepatic duct

(c) A. Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed the gallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis.

A 52 year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study? A. Stool for occult blood B. Stool cultures C. Sigmoidoscopy D. Abdominal CT scan

(c) A. Occult bleeding, as evidenced by the patient's history of black stools, is initially verified by a positive fecal occult blood test.

Diagnosis/Urology/Renal Lab results for a post-operative oliguric patient reveals an increased BUN to creatinine ratio. The patient has a low fractional excretion of sodium (less than 1%). Which of the following is the most likely diagnosis? A. prerenal azotemia B. acute tubular necrosis C. acute glomerulonephritis D. obstructive uropathy

(c) A. Patients who have prerenal azotemia with otherwise normal kidneys will have severe sodium retention in order to help to save fluid. The amount of sodium in the urine is therefore very low. (u) B. Acute tubular necrosis may occur in the post-operative setting but these kidneys are damaged and unable to save sodium. (u) C. Acute glomerulonephritis is a complication of a streptococcal infection wherein the immune complexes damage the glomeruli and lead to hematuria, red blood cell casts, and proteinuria. (u) D. Although patients who undergo abdominal surgery are at risk for damage to the genital urinary system, these patients will not have sodium retention because it is a post renal, not a prerenal injury.

Health Maintenance/Orthopedics/Rheumatology Endotracheal intubation should be performed with caution in patients with which of the following underlying conditions due to the propensity to cause subluxation of C1 on C2? A. Rheumatoid arthritis B. Osteoarthritis C. Gout D. Pseudogout

(c) A. Patients with advanced rheumatoid arthritis will have synovitis of the atlantoaxial joint (C1-C2) which may damage the transverse ligament of the atlas, producing forward displacement of the atlas on the axis (atlantoaxial subluxation).

Scientific Concepts/Orthopedics/Rheumatology Which of the following leads to retropatellar pain? A. increased Q angle B. increased quadriceps tone and strength C. Osgood-Schlatter Disease D. hamstring stretching

(c) A. Patients with an increased Q angle have more force directed laterally during knee flexion and are at greater risk of patellofemoral pain syndrome.

Diagnosis/Urology/Renal A 52 year-old patient presents with fatigue, complaints of paleness, anorexia, nausea, and weight loss. The patient also complains of numbness in his hands and feet and a recent occurrence of foot drop. He has a past history of diabetes and hypertension. Based on his clinical presentation, which of the following disorders is most likely to be responsible for this clinical picture? A. chronic renal failure B. middle cerebral artery occlusion C. Guillain-Barre syndrome D. Raynaud's phenomena

(c) A. Patients with chronic renal failure will have accelerated atherosclerosis, hypertension, anemia due to lack of erythropoietin production, a tendency toward GI symptoms of anorexia, nausea, and weight loss, and neurological symptoms of peripheral neuropathy that occurs in a stocking and glove distribution along with peripheral motor impairment such as foot drop and restless legs syndrome. Diabetes and hypertension are risk factors for the development of chronic renal disease. (u) B. Middle cerebral artery occlusion would consist of contralateral neurologic impairment rather than bilateral stocking glove neurological impairment

Clinical Therapeutics/Urology/Renal Which of the following treatments of constipation should be used with extreme caution in patients who have chronic renal insufficiency? A. milk of magnesium B. psyllium (Metamucil) C. docusate sodium (Colace) D. lactulose (Chronulac)

(c) A. Patients with chronic renal insufficiency have difficulty excreting magnesium and hypermagnesemia almost always occurs in a patient with chronic renal insufficiency

Which of the following is the most common cause of secondary hypertension? A. Renal parenchymal disease B. Primary aldosteronism C. Oral contraceptive use D. Cushing's syndrome

(c) A. Renal parenchymal disease is the most common cause of secondary hypertension. (u) B. Primary aldosteronism can cause secondary hypertension, but it is not the most common cause.

. Health Maintenance/Obstetrics/Gynecology Patient education for a 23 year-old using oral contraceptives should include which of the following? A. Rifampin may decrease the effectiveness of the oral contraceptives. B. Acetaminophen may decrease the effectiveness of the oral contraceptives. C. Oral contraceptives may provide some protection from coronary artery disease. D. Changing to the "minipill" (progestin only) will inhibit ovulation more consistently than combination oral contraceptives

(c) A. Rifampin may interfere with the efficacy of the oral contraceptives. (u) B. Acetaminophen levels or effects may be decreased by oral contraceptive

Diagnosis/Orthopedics/Rheumatology 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.

Diagnostic Studies/Gastrointestinal/Nutritional Which of the following is the laboratory test that marks recovery from Hepatitis B infection and non-infectivity? A. Hepatitis B surface antibody(anti-HBs) B. Hepatitis B surface antigen (HBsAg) C. Hepatitis B core antigen (HBcAg) D. Hepatitis A antibody (anti-HAV)

(c) A. Specific antibody to HBsAg appears in most individuals after clearance of HBsAg which indicates recovery from hepatitis B infection, non-infectivity, and immunity. (u) B. This test establishes infection with HBV and implies infectivity. (u) C. Presence of the hepatitis B core antigen reflects active infection.

Scientific Concepts/ENT/Ophthalmology Dental caries are caused by which of the following organisms? A. Streptococcus mutans B. Streptococcus pyogenes C. Staphylococcus epidermidis D. Staphylococcus aureus

Clinical Intervention/Infectious Diseases A 25 year-old male presents to the emergency department for evaluation of a wound on his hand. He cut his hand while tearing down a chicken coop. On examination of his right hand you note a dirty 3cm jagged laceration. The patient is unaware of his tetanus immunization status. Besides cleaning and debriding the wound, what is the recommended clinical intervention in this patient? A. Administer tetanus-diptheria toxoid (Td) and tetanus immune globulin (TIG) B. Administer diphtheria, tetanus, and pertussis vaccine (DTP) C. Administer tetanus toxoid vaccine (TT) and tetanus immune globulin (TIG) D. No tetanus immunization or tetanus immune globulin is necessary in this patient

(c) A. Td or Tdap with TIG is recommended as tetanus prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status.

Diagnosis/Cardiology An elderly female presents for evaluation of exertional syncope, dyspnea, and angina. She admits that previous to these symptoms she had insidious progression of fatigue that caused her to curtail her activities. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral valve prolapse

(c) A. The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina. Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area. (u) B. Patients with aortic regurgitation are likely to complain of an uncomfortable awareness of their heart, especially when lying down. These patients develop sinus tachycardia with exertion and complain of palpitations and head pounding with activity. (u) C. The symptoms related to mitral stenosis are related to increased pulmonary pressure after the left atrium can no longer overcome the outflow obstruction. (u) D. Patients with mitral valve prolapse are typically asymptomatic throughout their lives, although a wide range of symptoms is possible. When symptoms do occur, palpitations from arrhythmias are most common along with lightheadedness. Syncope is not part of this disease process.

History & Physical/Orthopedics/Rheumatology A 75 year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be encountered? A. Inability to extend the wrist against resistance B. Numbness over the deltoid muscle in the shoulder C. Winging of the scapula D. Weakness of the rotator cuff

(c) A. The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance. (u) B. Axillary nerve injury results in numbness over the deltoid muscle; this nerve is more commonly injured in proximal humeral fractures and anterior shoulder dislocations. (u) C. Injury to the long thoracic nerve causes winging of the scapula due to its innervation of the serratus anterior muscle. (u) D. Injury to the subscapular nerve results in weakness and pain of the infraspinatus muscle; this injury is commonly seen in volleyball players from repetitive stress.

Which of the following is the chief adverse effect of thiazide diuretics? A. Hypokalemia B. Hypernatremia C. Hypocalcemia D. Hypermagnesemia

(c) A. Thiazide diuretics can induce electrolyte changes. Principle among those is hypokalemia. (u) B. Hyponatremia, not hypernatremia may be a complication of thiazide diuretics

Health Maintenance/Obstetrics/Gynecology What is the recommended method for screening pregnant women for gestational diabetes? A. Fasting blood sugar and 2 hour post prandial B. 50 gram glucose load followed by a blood sugar in 1 hour C. 75 gram glucose load followed by a blood sugar in 2 hours D. 100 gram glucose load followed by a blood sugar at 1 hour, 2 hours, and 3 hours

(c) B. One hour Glucola is the screening test for gestational diabetes. It is a 50 gram glucose load, with a serum glucose obtained 1 hour after the dose. Normal value is less than 140 mg/dL.

History & Physical/Cardiology An 18 year-old male high school basketball player comes to clinic for a routine physical exam. His height is 193 cm (76 in.); arm span is 201 cm (79 in.). He has long fingers and toes. Blood pressure is 146/62 mmHg and pulse is 64/min. Which of the following exam findings is most consistent with the diagnosis? A. Grade 2/6 high-frequency diastolic murmur at the third right intercostal space B. Grade 2/6 systolic ejection murmur at the second left intercostal space with a fixed widely split S2 C. Grade 2/6 continuous murmur heard best at the high left sternal border D. Grade 2/6 systolic murmur at the fourth left intercostal space that decreases with squatting

(c) A. This murmur is most consistent with aortic regurgitation which can be present in patients with Marfans syndrome and a dilated aortic root

. Clinical Intervention/Orthopedics/Rheumatology Which of the following is the treatment of choice for a torus (buckle) fracture involving the distal radius? A. Open reduction and internal fixation B. Ace wrap or anterior splinting C. Closed reduction and casting D. Corticosteroid injection followed by splinting

(c) B. A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as painful as unstable fractures. They heal uneventfully in 3-4 weeks

Scientific Concepts/Cardiology Which of the following is the most common cause for acute myocardial infarction? A. Occlusion caused by coronary microemboli B. Thrombus development at a site of vascular injury C. Congenital abnormalities D. Severe coronary artery spasm

(c) B. Acute myocardial infarction occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion

Clinical Therapeutics/Orthopedics/Rheumatology Which of the following medications is the treatment of choice for patients with chronic gout to prevent recurrence of symptoms during its quiescent phase? A. Probenecid (Benemid) B. Allopurinol (Zyloprim) C. Colchicine D. Indomethacin (Indocin

(c) B. Allopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It is a xanthine oxidase inhibitor that is used to prevent the formation of uric acid.

Diagnosis/Pulmonology A patient who appears very anxious enters the office complaining of dizziness with perioral and extremity paresthesias. She vaguely describes some chest discomfort. Physical examination is unremarkable, except for moderate tachypnea with obvious sighing respiration. This clinical picture is most consistent with A. bronchial asthma. B. hyperventilation syndrome. C. spontaneous pneumothorax. D. emphysema.

(c) B. Anxiety may result in hyperventilation that can result in perioral numbness and paresthesias of the extremities. These paresthesias are due to decreased CO2 in the blood stream that results from the hyperventilation. Anxious patients also will have nondescript chest pain as part of this condition and may also complain of dizziness.

Scientific Concepts/Pulmonology Which of the following pathophysiological processes is associated with chronic bronchitis? A. Destruction of the lung parenchyma B. Mucous gland enlargement and goblet cell hyperplasia C. Smooth muscle hypertrophy in the large airways D. Increased mucus adhesion secondary to reduction in the salt and water content of the mucus

(c) B. Chronic bronchitis results from the enlargement of mucous glands and goblet cell hypertrophy in the large airways.

Clinical Therapeutics/Gastrointestinal/Nutritional A patient presents with a concern about an upcoming trip. He states he is traveling to Mexico and has a question about how to treat diarrhea should it develop. In addition to promoting fluid intake which of the following is recommended? A. kaolin-pectin B. ciprofloxacin C. simethicone D. doxycycline

History & Physical/Neurology The most frequent finding in a person presenting with a brain abscess is A. nuchal rigidity. B. headache. C. seizures. D. vomiting.

Diagnostic Studies/Pulmonology A post-op patient has signs and symptoms highly suggestive of a pulmonary embolism. The results of the CT scan of the lung is nondiagnostic. What is the most appropriate next step in the evaluation? A. Ventilation perfusion (V/Q) scan B. Ultrasound of the legs C. Echocardiography D. D-dimer

(c) B. In a patient with a high likelihood of pulmonary embolism or an inpatient, as in this case, ultrasound of the legs would be the next diagnostic step after a nondiagnostic CT.

Diagnosis/Obstetrics/Gynecology A 30 year-old female presents to the emergency department with a syncopal episode. She has a history of irregular menstrual cycles and infertility. She has scanty, persistent vaginal bleeding and sharp pelvic pain. A left adnexal mass is palpated. The most likely diagnosis is A. placenta abruptio. B. ectopic pregnancy. C. pelvic inflammatory disease. D. ruptured ovarian cyst.

(c) B. Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis. (u) C. Pelvic inflammatory disease typically presents with fever, abdominal pain, purulent vaginal discharge, and cervical motion tenderness. (u) D. Acute pelvic pain may occur secondary to bleeding from the rupture of a hemorrhagic ovarian cyst, but no adnexal mass would be palpable on pelvic examination.

What is the EKG manifestation of cardiac end-organ damage due to hypertension? A. Right bundle branch block B. Left ventricular hypertrophy C. Right ventricular hypertrophy D. ST segment elevation in lateral precordial leads

Scientific Concepts/Cardiology The most common arrhythmia encountered in patients with mitral stenosis is A. atrial flutter. B. atrial fibrillation. C. paroxysmal atrial tachycardia. D. atrio-ventricular dissociation.

(c) B. Mitral stenosis leads to enlargement of the left atrium, which is the major predisposing risk factor for the development of atrial fibrillation.

Health Maintenance/ENT/Ophthalmology A patient with type 2 diabetes mellitus presents for a yearly eye exam. Ophthalmoscopic exam reveals neovascularization. Which of the following is the most likely complication related to this finding?

(c) C. Proliferative retinopathy, as evidenced by neovascularization, is associated with an increased risk of vitreous hemorrhage.

Clinical Therapeutics/Endocrinology Which of the following is the first-line treatment for a patient with mild syndrome of inappropriate secretion of ADH (SIADH)? A. Sodium supplementation to correct the hyponatremia B. Restriction of free water C. High volume hypertonic saline infusion D. Pituitary ablation via transsphenoidal approach

(c) B. Restriction of free water intake is the first-line therapy for patients with euvolemic hyponatremia that is caused by SIADH. Water intake should be restricted to 0.5 to 1 liter per day. A gradual increase in serum sodium will occur over days with this treatment.

Clinical Therapeutics/Pulmonology An immunocompromised patient presents with signs and symptoms consistent with Legionella pneumophila who has not responded to initial antibiotic therapy with a macrolide. Which of the following should be added? A. Clarithromycin (Biaxin) B. Rifampin (Rifadin) C. Levofloxacin (Levaquin) D. Amoxicillin-clavulanate (Augmentin

(c) B. Rifampin should be used as an adjunct in patients with either a macrolide or quinolone antibiotic, who have failed therapy, are immunocompromised or have severe illness.

A 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear lymphocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis?

(c) B. Septic arthritis presents with a large number of WBCs, predominantly polymorphonuclear, and with glucose levels much lower than serum levels.

Diagnostic Studies/Endocrinology A 43 year-old asymptomatic diabetic female is found to have an elevated total calcium level of 12.4 mg/dL. Which of the following tests must be assessed in order to evaluate this laboratory abnormality? A. Intact parathyroid hormone B. Serum albumin C. 24 hour urine calcium level D. Complete blood count

(c) B. Since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels.

A 43 year-old data entry clerk presents with a one-month history of pain and tingling in the right thumb, index finger, and middle finger. Tinel's sign and Phalen's maneuver are positive. The most appropriate intervention at this time is A. methylprednisolone (Medrol) dose pack. B. splint in neutral position. C. observation. D. surgery

Health Maintenance/Cardiology Who is most likely to require subacute bacterial endocarditis (SBE) prophylaxis prior to a dental procedure? A. 22 year-old female with mitral valve prolapse B. 36 year-old male with a bio-prosthesic mitral valve C. 45 year-old female with an ASD closure 8 months ago with no residual defect D. 15 year-old male with a bicuspid aortic valve

(c) B. The AHA recommends that patients with prosthetic heart valves receive antibiotic prophylaxis. As should cardiac transplant recipients with valve disease, unrepaired cyanotic CHD, repaired CHD with prosthetic material or device during the first six months of the procedure and repaired CHD with residual defects at site of patch or prosthetic device

Health Maintenance/ENT/Ophthalmology At what age does the first tooth usually erupt in an infant? A. 2-4 months B. 6-8 months C. 10-12 months D. 14-16 months

Diagnostic Studies/Hematology An 18 year-old woman presents to the clinic complaining of fatigue. She reports a past history of lifelong frequent nosebleeds and bleeding gums. She also has menorrhagia. Her mother and maternal grandfather have a similar bleeding history. Initial lab results are as follows: WBC 9,500/mm3, Hgb 10.9 g/dL, HCT 33%, MCV 69 fL, MCHC 26 pg and platelets 284,000/mm3. Which of the following tests should be ordered to evaluate this patient's diagnosis? A. Hemoglobin electrophoresis B. Bleeding time and platelet aggregometry C. Bone marrow aspiration D. PT and aPTT

(c) B. The patient's presentation is consistent with a congential qualitative platelet disorder, most likely von Willebrand's Disease, necessitating a bleeding time and evaluation of platelet function.

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30 minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A. Chest x-ray B. Sputum gram stain C. Peak flow D. Ventilation-perfusion scan

(c) C. A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.

Health Maintenance/Pulmonology A 65 year-old with COPD receiving their first pneumococcal conjugate vaccination should be revaccinated in A. 1 year. B. 3 years. C. 5 years. D. 10 years

(c) C. A single revaccination for a person over the age of 65 is recommended if it has been more than 5 years since they received their first vaccination.

Clinical Therapeutics/Cardiology A 63 year-old female with history of diabetes mellitus presents for blood pressure follow-up. At her last two visits her blood pressure was 150/92 and 152/96. Today in the office her blood pressure is 146/92. Recent blood work shows a Sodium 140 mEq/L, Potassium 4.2 mEq/L, BUN of 23 mg/dL, and Creatinine of 1.1 mg/dL. Which of the following is the most appropriate initial medication in this patient? A. Terazosin (Hytrin) B. Atenolol (Tenormin) C. Lisinopril (Zestril) D. Hydrochlorothiazide (HCTZ

(c) C. ACE inhibitors should be part of the initial treatment of hypertension in diabetics because of beneficial effects in diabetic nephropathy and is the most appropriate initial medication

Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus aureus? A. Ingestion of mayonnaise-based salads 48 hours earlier B. Bloody diarrhea with mucus for one week C. Abdominal cramps and vomiting for 48 hours D. High fever for 1 week

(c) C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with staphylococcal food poisoning

Clinical Intervention/Neurology A 30 year-old male has a history of weakness without pain on the left side of his face for the past 4 days. Physical examination of the face reveals unilateral weakness to the left side, but not complete paralysis. The left eye does not close completely. The most appropriate initial treatment is to A. begin physical therapy. B. refer for surgical ablation. C. reassure patient and provide patient education. D. initiate high dose steroids and recheck in 24 hours.

(c) C. Bell's palsy is usually a self-limited condition and typically resolves within a few weeks. (u) D. Corticosteroids may be used if paralysis is complete or there is significant pain, but are not first-line.

Clinical Therapeutics/Neurology Which of the following drugs is the first choice for insomnia in an elderly patient? A. Barbiturates B. Cholinesterase inhibitors C. Benzodiazepines D. Beta-blockers

Diagnostic Studies/ENT/Ophthalmology A 26 year-old male presents with headache, sinus pressure, and sinus congestion for over a month. He has a thick nasal discharge in the mornings, but this improves as the day goes on. He is afebrile. On exam, there is tenderness over the face. TMs have normal light reflex. Nasal mucosa reveals thick yellowish discharge. Neck is supple, without lymphadenopathy. Which of the following is the diagnostic study of choice? A. transillumination of sinuses B. routine sinus films C. CT scan of sinuses D. nasal culture

(c) C. CT scan is more sensitive than plain films for the diagnosis and management of chronic sinusitis, and is considered the gold standard for sinus imaging.

Diagnosis/Hematology A 60 year-old male presents with a normochromic, normocytic anemia and splenomegaly. His past history reveals several episodes of bacterial pneumonia in the past year. The WBC count is 43,000 mm3 with 25% segmented neutrophils, 3% blasts, 70% mature lymphocytes, 1% basophils, and 1% eosinophils. This most likely represents A. myelodysplastic syndrome. B. acute lymphocytic leukemia. C. chronic lymphocytic leukemia. D. chronic myelogenous leukemia.

(c) C. Chronic lymphocytic leukemia usually occurs after the age of 50 presenting with lymphocytosis > 20,000 mm3 and lymphocytes that appear mature.

Clinical Therapeutics/Cardiology Acute rebound hypertensive episodes have been reported to occur with the sudden withdrawal of A. verapamil (Calan). B. lisinopril (Prinivil). C. clonidine (Catapres). D. hydrochlorothiazide (HCTZ)

Scientific Concepts/ENT/Ophthalmology Small grayish vesicles and punched-out ulcers in the posterior pharynx in a child with pharyngitis is representative of which organism

Clinical Therapeutics/ENT/Ophthalmology Use of systemic corticosteroids can cause which of the following adverse effects in the eye? A. Cortical blindness B. Optic atrophy C. Glaucoma D. Papilledema

(c) C. Glaucoma can be caused by the long-term use of steroids (u) A. Cortical blindness is a rare adverse effect when prescribing salicylates. (u) B. Optic atrophy can occur as an adverse effect with lead compounds, amebicides, and MAO inhibitors.

Clinical Intervention/Neurology A 67 year-old female with history of hypertension, diabetes mellitus, and smoking presents to the emergency department with mild expressive aphasia, right facial weakness and mild right arm weakness. She had awakened 60 minutes ago and was speaking to her husband when her speech suddenly became difficult to understand and weakness was noted. Physical examination reveals a blood pressure of 165/85 mm Hg. A CT of the head shows no intracranial hemorrhage. Which of the following is the most appropriate intervention? A. Aspirin B. Warfarin (Coumadin) C. Tissue plasminogen activator (rt-PA) D. Clopidogrel (Plavix

(c) C. IV thrombolytic therapy with recombinant tissue plasminogen activator is effective in reducing the neurological deficit in selected patient without CT evidence of intracranial hemorrhage and when administered within 3 hours after onset of ischemic stroke.

Diagnostic Studies/Obstetrics/Gynecology A 25 year-old female presents for a routine gynecological examination. You palpate a 2 cm breast mass in her right breast. Her menstrual period was last week. She has no family history of breast cancer. What is the modality of choice to further evaluate her breast mass? A. Magnetic resonance imaging (MRI) B. Excisional biopsy C. Ultrasound D. Mammography

History & Physical/ENT/Ophthalmology Otitis externa can be differentiated from uncomplicated otitis media by which of the following physical examination findings? A. Erythematous tympanic membrane B. Mastoid tenderness C. Normal pneumatic otoscopy D. Posterior auricular adenopathy

(c) C. In contrast to acute otitis media, the tympanic membrane moves normally with pneumatic otoscopy in a patient with otitis externa. (u) A. In otitis externa, the erythema is because the lateral surface of the tympanic membrane is ear canal skin, and therefore is often erythematous.

Clinical Therapeutics/Cardiology A 16 year-old male with a history of tetralogy of Fallot presents to clinic for a follow-up visit status post replacement of his right ventricle to pulmonary artery conduit. He has complaints of chest pain with inspiration, fever and general malaise. Cardiac examination reveals a rub with muffled heart sounds. Labs show an elevated erythrocyte sedimentation rate (ESR) and leukocytosis. Which of the following is the most effective treatment? A. Acetaminophen/oxycodone B. Azithromycin C. Indomethacin D. Furosemid

(c) C. Indomethacin is suitable for controlling pain in Dressler's syndrome. ASA is preferred. Narcotics, diuretics or antibiotics are not recommended.

. Clinical Therapeutics/Neurology Which of the following side effects is associated with long-term administration of phenytoin (Dilantin)? A. Ataxia B. Hypotension C. Osteomalacia D. Cardiac dysrhythmia

(c) C. Osteomalacia, or demineralization of bone, is a side effect of phenytoin that may occur after chronic administration.

Clinical Therapeutics/Cardiology Long term use of which of the following drugs may cause a drug-induced lupus-type eruption? A. prednisone B. tetracycline C. procainamide D. oral contraceptives

Health Maintenance/Neurology A 53 year-old female has a diagnosis of migraine headaches. She had been using sumatriptan (Imitrex) to abort her headaches, but she is now having one or two headaches per week. The most appropriate preventive therapy is A. zolmitriptan (Zomig). B. promethazine (Phenergan). C. propranolol (Inderal). D. fluoxetine (Prozac).

Clinical Therapeutics/ENT/Ophthalmology A 35 year-old patient has recurrent seasonal rhinitis and a history of mild asthma. Which of the following should be included for first-line management? A. Immunotherapy B. Decongestants C. Corticosteroid inhalers D. Cromolyn sodium (Intal

(c) C. Regular use of corticosteroid nasal spray and oral inhalers prior to the allergy season is among the best means of preventing allergies.

7. Which of the following is a cause of prerenal azotemia? A. Infection B. Renal toxins C. Poor renal perfusion D. Urinary tract obstruction

(c) C. Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored.

iagnosis/Neurology During an influenza epidemic, a 6 year-old child is seen with fever and a severe sore throat. A throat swab is taken for culture and the child is sent home. The next day, he is reported to have persistent vomiting and increased lethargy. On examination, he is delirious and disoriented. No rash is noted. His reflexes are hyperactive. The liver edge is 3 cm below the right costal margin in the midclavicular line. Which of the following is the most likely diagnosis? A. acute bacterial meningitis B. Guillain Barré syndrome C. Reye syndrome D. measles encephalitis

(c) C. Reye syndrome is typically post-influenza or URI. The patient develops lethargy, drowsiness, and vomiting. Babinski reflex is positive and hyperreflexia is noted. The liver is normal or enlarged.

Diagnosis/Neurology Seizures that first manifest in early to middle adult life should be considered suspicious of which of the following causes? A. Cerebrovascular disease B. Encephalitis C. Tumor D. Idiopathic epilepsy

(c) C. Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.

History & Physical/Orthopedics/Rheumatology A 65 year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected? A. L3-L4 B. L4-L5 C. L5-S1 77 D. S1-S2

(c) C. The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soleus muscles, and the abductor hallucis and gluteus maximus muscles.

Scientific Concepts/Orthopedics/Rheumatology In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis? A. Femur B. Humerus C. Vertebral spine D. Tibia

Diagnostic Studies/Orthopedics/Rheumatology Which of the following views on plain films is preferred to identify spondylolysis? A. Anterior B. Posterior C. Oblique D. Lateral

(c) C. The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films

History & Physical/ENT/Ophthalmology Hairy leukoplakia has the greatest prevalence of distribution on the 52 A. palate. B. floor of the mouth. C. lateral tongue. D. gingiva

Diagnosis/Endocrinology A 64 year-old male presents complaining of new onset of fatigue, weight gain, constipation, erectile dysfunction, and loss of body hair. Laboratory investigation demonstrates: TSH less than 0.5 microunits/mL (normal range 0.5-5.0 microU/mL); Thyroxine (T4) 2 mcg/dL (normal range 5-12 mcg/dL); Prolactin 10 nanograms/ml A. Primary hypothyroidism B. Excessive dosing of levothyroxine (Synthroid) C. Hypopituitarism D. Subacute thyroiditi

(c) C. The low trophic and target hormone levels combined with symptoms of hypogonadism indicate this patient has hypopituitarism

Clinical Intervention/Orthopedics/Rheumatology A 60 year-old female injured her right wrist when she slipped and fell onto her outstretched hand. Radiographs show a fracture through the metaphysis of the distal radius with dorsal displacement and angulation. Which of the following splints is the best method of temporary immobilization? 26 A. Dorsal forearm B. Ulnar gutter C. Volar forearm D. Volar with thumb spica

(c) C. The volar forearm splint is best for temporary immobilization of forearm, wrist and hand fractures and is the splint of choice for Colles' fracture. (u) D. A volar splint with thumb spica is used to immobilize the first metacarpophalangeal joint and is useful for scaphoid fractures.

A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals sinus tachycardia. Which of the following is the most likely diagnosis? A. Atelectasis B. Pneumothorax C. Pulmonary embolism D. Myocardial infarction

(c) C. This patient's risk factors for pulmonary embolism include advanced age, surgery, and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult to make due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal.

Diagnosis/Endocrinology A 7-year-old child with a history of type 1 diabetes mellitus for 3 years presents for routine follow-up. The mother states that the child has been having nightmares and night sweats. Additionally, his average morning glucose readings have risen from an average of 100 mg/dL to 145 mg/dL over the past week. This child is most likely experiencing A. a growth spurt. B. emotional problems. C. the Somogyi effect. D. the dawn phenomenon.

(c) C. This refers to nocturnal hypoglycemia, which stimulates counter-regulatory hormone release resulting in rebound hyperglycemia. (u) D. This refers to an early morning rise in plasma glucose due to reduced tissue sensitivity to insulin between 5 AM and 8 AM. It is not associated with nightmares and night sweats.

Clinical Therapeutics/Obstetrics/Gynecology What is the treatment of magnesium sulfate toxicity? A. Nifedipine B. Terbutaline C. Potassium carbonate D. Calcium gluconate

Diagnostic Studies/Infectious Diseases A 23 year-old female complains of fever and genital pain. Examination reveals the presence of lymphadenopathy in the groin and the presence of vulvar vesicles surrounded by erythematous skin. The diagnosis may be confirmed by A. A culture of a vesicle using blood agar medium. B. The presence of similar lesions on the fingers and hands. C. A Gram stain of a scraping from the base of the lesion. D. The presence of giant multinucleated cells on Tzanck smear.

(c) D. A Tzanck smear is the standard laboratory test to confirm the herpes virus as an etiologic agent of a vesicular lesion on an erythematous base.

Diagnostic Studies/Psychiatry/Behavioral Medicine A patient with advanced AIDS complicated by toxoplasmosis presents with altered mental status, recent onset of seizures, and focal neurologic deficits. Which of the following diagnostic studies is most helpful? A. Toxoplasma gondii antibody titers B. CT scan of the brain C. Lumbar puncture D. MRI of brain

(c) D. An MRI showing multiple isodense or hypodense ring-enhancing mass lesions is the most useful test for such a patient.

Diagnostic Studies/Urology/Renal A 60 year-old patient presents with elevated blood pressure and peripheral edema. Laboratory testing reveals a BUN of 58 mg/dl and a creatinine of 4.5 mg/dl, these results are unchanged from six months ago. Urinalysis today is negative except for the following, specific gravity of 1.002, 2+ protein, and trace glucose. Which of the following laboratory findings would be most consistent for this patient? A. Hypercalcemia B. Metabolic alkalosis C. Hypokalemia D. Anemia

Clinical Therapeutics/Urology/Renal Which of the following can be used to treat chronic bacterial prostatitis? A. Penicillin B. Cephalexin (Keflex) C. Nitrofurantoin (Macrobid) D. Levofloxacin (Levaquin)

(c) D. Chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate.

Health Maintenance/Orthopedics/Rheumatology Which of the following is an established risk factor for osteoporosis? A. Parity status B. Carbohydrate intake C. Lactation history D. Low body weight

(c) D. Established risk factors for osteoporosis include low body weight, female sex, advanced age, Caucasian race, and bilateral oophorectomy before menopause without estrogen replacement.

Clinical Therapeutics/Gastrointestinal/Nutritional In a patient with metabolic acidosis due to ingestion of methanol, which substance below is considered therapeutic? A. Salicylates B. Paraldehyde C. Ethylene glycol D. Ethanol

(c) D. Ethanol, along with hemodialysis and supportive measures, is indicated for metabolic acidosis caused by methanol ingestion.

Scientific Concepts/Cardiology Which of the following is a cause of high output heart failure? A. myocardial ischemia B. complete heart block C. aortic stenosis D. thyrotoxicosis

(c) D. High output heart failure occurs in patients with reduced systemic vascular resistance. Examples include: thyrotoxicosis, anemia, pregnancy, beriberi and Paget's disease. Patients with high output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands.

Which of the following drugs is first-line therapy for schizophrenia? A. Chlorpromazine (Thorazine) B. Clozapine (Clozaril) C. Haloperidol (Haldol) D. Olanzapine (Zyprexa

(c) D. Initial pharmacologic therapy of schizophrenia should begin with one of the newer, "atypical" antipsychotic drugs, such as olanzapine, risperidone, quetiapine, ziprasidone, and clozapine because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms.

. History & Physical/Cardiology Which of the following conditions would cause a positive Kussmaul's sign on physical examination? A. Left ventricular failure B. Pulmonary edema C. Coarctation of the aorta D. Constrictive pericarditis

(c) D. Kussmaul's sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.

Diagnostic Studies/Obstetrics/Gynecology A 23 year-old female is in active labor and has progressed from 3 cm to 6 cm in the last six hours. Fetal monitoring demonstrates mild repetitive late decelerations. Which of the following is the most likely cause of this finding? A. Fetal hypoxia B. Head compression C. Cord compression D. Uteroplacental insufficiency

(c) D. Late decelerations are from uteroplacental insufficiency. The decelerations have a smooth, gradual symmetrical decrease in FHR beginning at or after the peak of the contraction

Clinical Therapeutics/Gastrointestinal/Nutritional A 62 year-old patient with arthritis is on daily naproxen therapy. Which of following medications is used to protect against GI complications? A. diphenoxylate (Lomotil) B. sulfasalazine (Azulfidine) C. metoclopramide (Reglan) D. misoprostol (Cytotec)

Diagnosis/ENT/Ophthalmology A 52 year-old female presents with complaints of intermittent episodes of dizziness, tinnitus, and hearing loss in the right ear for 6 months. She describes the dizziness as the "room spinning around her," with the episodes typically lasting for 2 to 4 hours. Physical examination reveals horizontal nystagmus and right ear hearing loss, but the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis? A. Acute labyrinthitis B. Positional vertigo C. Acoustic neuroma D. Ménière's syndrome

(c) D. Ménière's syndrome usually presents with episodes of vertigo that last from 1 to 8 hours, sensorineural hearing loss and tinnitus.

Diagnosis/Endocrinology A patient presents to the office with worsening fatigue, weight loss, and weakness. She notes that she is having recurrent bouts of abdominal pain and has been losing her pubic hair. Patient is found to have orthostatic hypotension. Which of the following conditions is most likely? A. Cushing's syndrome B. Pheochromocytoma C. Primary hyperparathyroidism D. Addison's disease

(c) D. Patients with Addison's disease have primary adrenal failure from an autoimmune problem in the adrenal gland or due to hemorrhage into the adrenal gland. These patients are not able to make glucocorticoids, mineralocorticoids, or sex hormones which result in hypotension, hyperpigmentation (from an increase in the ACTH and MSH hormones) and are hyponatremic. (u) A. Cushing's syndrome is caused by an increase in the cortisol levels in the body. These patients will have hypertension, buffalo hump, striae, and proximal muscle weakness.

Clinical Therapeutics/Pulmonology A 42 year-old male with unremarkable past medical history is admitted to the general medical ward with communityacquired pneumonia. He has a 20 pack-year history of cigarette smoking. He is empirically started on ceftriaxone (Rocephin). Which of the following antibiotics would be most appropriate to add to his empiric treatment regimen? A. piperacillin (Pipracil) B. vancomycin (Vancocin) C. clindamycin (Cleocin) D. azithromycin (Zithromax)

(c) D. Patients with community-acquired pneumonia who require hospitalization on the general medical ward are treated with an extended-spectrum beta-lactam antibiotic, such as ceftriaxone, with a macrolide, such as azithromycin. Addition of a macrolide is also recommended due to the patient's smoking history and possible involvement of Hemophilus influenzae.

Health Maintenance/Dermatology Which of the following patients is at highest risk for the development of the skin disorder known as erythrasma? A. Lactating women B. Postmenopausal women C. Seniors living in cold northern climate D. People living in tropical climate

(c) D. People living in warm, tropical climate, people wearing occlusive clothing or shoes, obese patients, and those with hyperhidrosis are at increased risk for erythrasma. The diagnosis of this condition is made by demonstration of a coral red fluorescence.

Clinical Intervention/Hematology A 29 year-old patient with idiopathic thrombocytopenia purpura (ITP) is treated with prednisone therapy. Despite therapy, platelet counts remain consistently below 20,000/microliter over the course of 6 weeks. Which of the following is the most appropriate intervention for this patient? A. Aspirin B. Intravenous immunoglobulin C. Danazol (Danocrine) D. Splenectomy

(c) D. Persistently low platelet counts (< 20,000) require effective long-term treatment, and splenectomy is the treatment of choice.

A male patient complains of chronic dysuria, frequency, and urgency with associated perineal pain. The most likely diagnosis is A. cystitis. B. gonococcal urethritis. C. epididymitis. D. prostatitis.

(c) D. Some patients are asymptomatic, but low back or perineal pain, fever, chills, and irritative urinary symptoms are common in prostatitis

. Diagnostic Studies/Orthopedics/Rheumatology A 26 year-old male who is an avid swimmer has been experiencing right shoulder pain for the past month. On examination, pain is elicited with palpation below the anterior acromion. Anterior shoulder pain is also reported when the patient flexes and extends his arm. Which of the following diagnostic tests is most appropriate at this time? A. Shoulder x-ray B. Shoulder arthroscopy C. Shoulder MRI D. Subacromial lidocaine injection

(c) D. Subacromial injection of lidocaine leading to a transient but dramatic improvement in pain with shoulder extension makes the diagnosis of impingement highly likely.

Clinical Intervention/Dermatology A patient sustained a 6 cm laceration on his anterior tibia that was primarily closed in the emergency department. What is the most appropriate time frame for removal of these sutures? A. 1-2 days B. 3-5 days C. 6-8 days D. 7-14 days

(c) D. Suture removal is based upon the area of the body that was sutured. Facial sutures are placed for 3-4 days, scalp sutures for 5-7 days, trunk sutures are placed for 6-8 days, and sutures on the extremity are placed for 7-14 days. Sutures on the extremities can stay for longer periods of time if the area is under maximal tension.

Clinical Intervention/Gastrointestinal/Nutritional A 32 year-old presents with a 3-day history of diarrhea. The patient denies blood, mucus, or night awakening with diarrhea. He recently returned from a business trip to Canada. On physical examination, the patient is afebrile and vital signs reveal BP 115/80, pulse is 76, and respirations are 14. The abdominal examination reveals hyperactive bowel sounds, but is otherwise unremarkable. Which of the following is the most appropriate initial intervention? A. Stool for culture, ova, and parasites B. Proctosigmoidoscopy C. Metronidazole (Flagyl) D. Supportive treatment

(c) D. Symptomatic treatment, including dietary management and over-the-counter antidiarrheals, is indicated for afebrile patients with watery diarrhea of less than 5 days duration.

Scientific Concepts/Endocrinology What is the recommended target LDL to reduce the risk of coronary artery disease in a diabetic patient? A. 200 mg/dL B. 160 mg/dL C. 130 mg/dL D. 100 mg/dL

(c) D. The National Cholesterol Education Program clinical practice guidelines have designated diabetes as a coronary risk equivalent and have recommended that patients with diabetes should have an LDL cholesterol goal of 100 mg/dL.

Clinical Intervention/Gastrointestinal/Nutritional A patient presents to the emergency department with right upper quadrant pain over eight hours, nausea, and vomiting. On exam there is a fever of 101.2 degrees F. Ultrasound shows a distended gallbladder. What is the most appropriate management of this patient? A. Oral analgesics B. Diagnostic peritoneal lavage C. Proton pump inhibitors D. Laparoscopic cholecystectomy

(c) D. The proper treatment for acute cholecystitis is IV fluids, antibiotics, pain control, and surgery. Cholecystectomy is the definitive treatment for acute cholecystitis and laparoscopic cholecystectomy is the procedure of choice.

A 34 year-old female with a history of asthma presents with complaints of increasing asthma attacks. The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. Which of the following is the most appropriate intervention at this time? A. Oral prednisone B. Oral theophylline (Theo-Dur) C. Salmeterol (Serevent) inhaler D. Beclomethasone (Qvar)inhaler

(c) D. This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control.

Diagnosis/Neurology A 72 year-old patient with a history of hypertension and atrial fibrillation presents with episodes of weakness, numbness, and paresthesias in the right arm. At the same time, she notes speech difficulty and loss of vision in her left eye. These symptoms come on abruptly and clear within minutes. Physical examination is normal except for the previously known arrhythmia. Which of the following is the most likely diagnosis? A. Focal seizure B. Migraine headache C. Hypoglycemic episodes D. Transient ischemic attack

(c) D. This patient's symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli (u) A. Focal seizures usually cause abnormal motor movement rather than weakness or loss of feeling.

History & Physical/Neurology In addition to tremor, which of the following are cardinal symptoms of Parkinson disease? A. Cognitive decline and rigidity B. Personality change and bradycardia C. Eye movement abnormalities and hyperkinesias D. Rigidity and bradykinesia

(c) D. Tremor, rigidity, bradykinesia and postural instability are the cardinal features of Parkinsonism and may be present in any combination.

Clinical Therapeutics/Urology/Renal A 35 year-old pregnant patient presents with fever, chills, and left-sided flank pain. On physical examination left-sided CVA tenderness is noted. Urinalysis reveals numerous white blood cells and white blood cell casts. Which of the following is the most appropriate treatment? A. Oral ciprofloxacin (Cipro) B. Oral trimethoprim-sulfamethoxazole (Bactrim) C. IV gentamicin (Garamycin) D. IV ceftriaxone (Rocephin

(h) B. The fluoroquinolones and trimethoprim-sulfamethoxazole are contraindicated in pregnancy. (u) C. Gentamicin is not indicated as first line therapy in the treatment of pyelonephritis in a pregnant patient. (c) D. IV cephalosporins are first line treatment of pyelonephritis in a pregnant patient, followed by oral step-down therapy

History & Physical/Dermatology A 72 year-old farmer comes to the office for evaluation of a pearly ulcerated papule on his right nostril. The papule has been bleeding off and on for the past couple weeks. Which of the following findings would be most concerning on the physical examination of this patient? A. Cherry angioma B. Telangiectasia C. Spider angioma D. Pyogenic granuloma

(u) A. A cherry angioma is a common, violaceous vascular lesion usually located on the trunk. (c) B. Telangiectatic vessels are often visible skin findings with basal cell carcinoma. (u) C. A spider angioma is a benign red papule with radiating telangiectasia usually located on the face, forearms and hands. (u) D. A pyogenic granuloma is a solitary vascular nodule that develops rapidly following minor trauma.

Diagnostic Studies/Urology/Renal A 20 year-old male presents with a hard mass on the testicle. There has been no previous infection or trauma to the area. Which of the following is the initial diagnostic evaluation to pursue? A. serum alpha fetoprotein levels B. serum human chorionic gonadotropin hormone C. CT scan of the pelvis D. ultrasound of the testicles

(u) A. Although tumor markers are useful to follow patients with testicular cancer, they are not used as the initial screen. (u) B. See A for explanation. (u) C. CT scanning of the pelvis is most commonly used in the evaluation for metastatic disease and not used in the initial screen for testicular cancer. (c) D. An ultrasound of the testes will enable the clinician to discriminate between testicular tumors and epididymitis, orchitis, hematomas, hydroceles, and infiltrative diseases of the testes.

Diagnosis/Neurology A 37 year-old male presents with headaches for the past 2 months. They occur daily and are worse in the morning. In the past week, he has noticed a tendency to drop things from his right hand. On examination, vital signs are normal, and general examination is unremarkable. Neurologic examination reveals mild weakness of the right upper extremity compared to the left. Which of the following is the most likely diagnosis? A. focal seizure disorder B. intracerebral neoplasm C. transient ischemic attack D. amyotrophic lateral sclerosis

(u) A. Focal seizure disorder is not associated with morning headaches. (c) B. Intracerebral neoplasms may present with headaches that are worse in the morning, with improvement during the day. Focal motor or sensory loss depends upon the tumor's location. (u) C. A TIA is characterized by focal findings that resolve completely and spontaneously within 24 hours. (u) D. Amyotrophic lateral sclerosis is a degenerative disorder characterized by motor weakness, but is not associated with morning headaches.

Diagnostic Studies/Urology/Renal Which of the following diagnostic findings in the urinary sediment is specific for a diagnosis of chronic renal failure? A. Hematuria B. Proteinuria C. Broad waxy casts D. Hyaline casts

(u) A. Hematuria and proteinuria are frequent, but nonspecific, findings in chronic renal failure. (u) B. See A for explanation. (c) C. Broad waxy casts in urinary sediment are a specific finding in chronic renal failure. (u) D. Hyaline casts may be found in normal urine or in states of dehydration.

Diagnosis/Pulmonology Which of the following physical examination findings would be consistent with a pleural effusion? A. Hyperresonance to percussion B. Increased tactile fremitus C. Unilateral lag on chest expansion D. Egophony

(u) A. Hyperresonance to percussion would be suggestive of emphysema or pneumothorax. (u) B. Increased tactile fremitus would be consistent with a consolidation. (c) C. A lag on chest expansion may be seen in the presence of a pleural effusion. (u) D. The presence of egophony would be consistent with a consolidation

Clinical Therapeutics/Neurology A 38 year-old female has a 10 year diagnosis of migraine headaches. She had been using ergotamine to abort her headaches, but is now having one or two headaches per week that are interfering with work. Which of the following is the most appropriate preventive therapy? A. Sumatriptan (Imitrex) B. Promethazine (Phenergan) C. Propranolol (Inderal) D. Ketorolac (Toradol)

(u) A. Imitrex is not approved for preventive therapy but is used as abortive therapy. (u) B. Phenergan is an antiemetic that helps with nausea and vomiting for people who get migraines. It is not a preventive medication. (c) C. Propanolol is one beta blocker that is frequently used as a first-line prophylaxis for migraines. (u) D. Ketorolac is not indicated for scheduled, daily use as a preventive for migraines.

History & Physical/Cardiology Which of the following would you expect on physical examination in a patient with mitral valve stenosis? A. Systolic blowing murmur B. Opening snap C. Mid-systolic click D. Paradoxically split S2

(u) A. Mitral stenosis is a diastolic, not a systolic murmur. (c) B. Mitral stenosis is characterized by a mid-diastolic opening snap. (u) C. Mid-systolic clicks are noted in mitral valve prolapse, not mitral stenosis. (u) D. Paradoxical splitting of S2 occurs in aortic stenosis not mitral stenosis.

Clinical Intervention/Dermatology Which of the following interventions is the treatment of choice for actinic keratosis? A. Mohs surgery B. Cryotherapy C. Acid peels D. Radiation therapy

(u) A. Mohs surgery and radiation therapy are not indicated in the treatment for actinic keratosis. (c) B. Cryotherapy is the treatment of choice for isolated superficial actinic keratosis.

Clinical Intervention/ENT/Ophthalmology A 57 year-old male was working on his farm, when some manure was slung hitting his left eye. He presents several 62 days after with a red, tearing, painful eye. Fluorescein stain reveals uptake over the cornea looking like a shallow crater. Which of the following interventions would be harmful? A. Ophthalmic antibiotics B. Pressure patch C. Examination for visual acuity D. Copious irrigation

(u) A. Ophthalmic antibiotics and copious irrigation are indicated when treating a patient with a suspected corneal ulcer due to an infectious cause. (c) B. Patching of the eye after abrasion associated with organic material contamination is contraindicated due to increased risk of fungal infection. (u) C. Examination for assessment of visual acuity should be performed.

History & Physical/Gastrointestinal/Nutritional A patient presents complaining of periumbilical pain. Which of the following anatomical sites is this finding associated with? A. Bladder B. Stomach C. Pancreas D. Small bowel

(u) A. Pain from the bladder, uterus, or colon causes hypogastric pain. (u) B. Pain from the stomach, duodenum, or pancreas causes epigastric pain. (u) C. See B for explanation. (c) D. Pain from the small intestine, appendix, or proximal colon causes periumbilical pain.

History & Physical/Endocrinology Which of the following findings is usually associated with Addison's disease? A. Weight gain B. Hypertension C. Increased pigmentation D. High plasma cortisol levels

(u) A. Patients with Addison's disease tend to have anorexia and weight loss. (u) B. Patients with Addison's disease tend to have hypotension. (c) C. Patients with Addison's disease have diffuse tanning over nonexposed and exposed skin due to increased melanocytic factor that is released with adrenocorticotropic hormone. (u) D. Patients with Addison's disease tend to have low plasma cortisol levels.

Which of the following physical exam findings is consistent with moderate emphysema? A. Increased tactile fremitus B. Dullness to percussion C. Distant heart sounds D. Deviated trachea

(u) A. Physical examination findings in emphysema include a midline trachea, diffuse hyperresonant to percussion, and decreased tactile fremitus. (u) B. See A for explanation. (c) C. Distant heart sounds are common in emphysema patients due to hyperinflation of the lungs.

Progesterone influence on the breast tissue prior to menstruation causes A. proliferation of the mammary ducts. B. growth of the lobules and alveoli. C. proliferation of Cooper's ligaments. D. increase in the number of glands of Montgomery

(u) A. Proliferation of the mammary ducts is under the influence of estrogen. (c) B. Growth of the lobules and alveoli is under the influence of progesterone. Prior to menses, the breast swelling that women notice is a result of the progesterone which is secreted from the corpus luteum. During menses, the swelling subsides

Diagnosis/Orthopedics/Rheumatology A 53 year-old patient presents with severe pain at the base of the thumb and no other finger involvement. The pain is worse with activity and lasts a short period of time following rest. There is no specific history of trauma to the thumb but the patient admits working with her hands as a typist. Which of the following is the most likely diagnosis? A. Rheumatoid arthritis B. Osteoarthritis C. Hemochromatosis D. Pseudogou

(u) A. Rheumatoid arthritis typically involves the MCP and PIP joints of the digits for the second through fifth fingers. The thumb is classically spared. (c) B. The base of the thumb is typically involved with osteoarthritis as are the DIP joints of the other fingers. (u) C. Hemochromatosis classically involves the MCP joints of the second through fifth fingers. (u) D. Pseudogout joint involvement is typically the MCP joints of the second through fifth fingers.

Scientific Concepts/Pulmonology 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.

Diagnosis/Obstetrics/Gynecology 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 patient presents with chronic back pain. On physical examination testing, the patient is found to have abnormalities of proprioception and vibration discrimination. Which of the following portions of the spinal column are most likely affected? A. Lateral spinothalamic tract B. Ventral spinothalamic tract C. Posterior column D. Transection of the cord

(u) A. The lateral spinothalamic tract affects pain and temperature sensation. (u) B. The ventral spinothalamic tract affects pressures and touch sensations. (c) C. The posterior column affects proprioception (position sense) and vibration sense.

h of the following is the most likely source of blood? A. renal pelvis B. bladder neck C. anterior urethra D. ureter

(u) A. Total hematuria, blood throughout the urinary stream, suggests a bladder or upper urinary tract source. (c) B. Terminal hematuria, blood at the end of the urinary stream, suggests a bladder neck or prostatic urethral source. (u) C. Presence of blood at the beginning of the urinary stream suggests an anterior (penile) urethral source. (u) D. Hematuria from the kidneys or ureter may be present microscopically or throughout the stream.

A 26 year-old female presents with several pruritic lesions on her dorsal forearms. The lesions are erythematous with vesicles, with a few beginning to weep. She works in a photography laboratory, but denies any other possible exposures. Which of the following is the most useful diagnostic test? A. VDRL serology B. KOH prep C. Patch testing D. Gram's stain

(u) A. VDRL serology is useful in the diagnosis of syphilis, not contact dermatitis. (u) B. KOH prep is used for diagnosis of fungal infections, not contact dermatitis. (c) C. Patch testing with a suspected agent is usually positive in cases of allergic contact dermatitis. (u) D. Gram's stain is useful in the diagnosis of bacterial infections, not contact dermatitis

Health Maintenance/ENT/Ophthalmology Which of the following is considered a risk factor for retinopathy of prematurity? A. maternal rubella infection B. maternal alcohol abuse C. perinatal oxygen therapy D. family history of retinal detachment

(u) A. While maternal rubella infection is a risk factor for ocular disease in the newborn, it is not a specific risk for retinopathy of prematurity. (u) B. Maternal alcohol abuse is associated with the development of fetal alcohol syndrome, which includes craniofacial abnormalities, but does not include increased risk for retinopathy of prematurity. (c) C. Risk factors for retinopathy of prematurity include perinatal oxygen therapy, low birth weight, prematurity, and sepsis. (u) D. If retinopathy of prematurity is not treated, retinal detachment may occur causing blindness. A family history of retinal detachment is not considered a risk factor for the development of retinopathy of prematurity.

A patient presents for a follow-up visit for chronic hypertension. Which of the following findings may be noted on the fundoscopic examination of this patient? A. cherry-red fovea B. boxcar segmentation of retinal veins C. papilledema D. arteriovenous nicking

(u) C. Papilledema is noted in conditions causing increased intracranial pressure. (c) D. Arteriovenous nicking is common in chronic hypertension. (u) A. Cherry-red fovea and boxcar segmentation of the retinal veins are findings seen in central retinal artery occlusion.

Which of the following mechanisms leads to a primary pneumothorax? A. Penetrating or blunt trauma forces B. Underlying lung cancer C. Pressure of air in the pleural space exceeds room air pressure D. Rupture of subpleural apical blebs due to high negative intrapleural pressures

(u) C. When pressure of air in the pleural space exceeds room air pressure, it leads to a tension pneumothorax. (c) D. A primary spontaneous pneumothorax is thought to result from a rupture of subpleural apical blebs secondary to high negative intrapleural pressures

History & Physical/Hematology What examination finding would be expected in a patient with von Willebrand disease? A. Gingival bleeding B. Splenomegaly C. Muscle weakness D. Hemarthrosis

Explanations (c) A. A patient with von Willebrand disease most commonly presents with mucosal bleeding seen in epistaxis, gingival bleeding, and menorrhagia.

History & Physical/Orthopedics/Rheumatology Abduction of the shoulder against resistance helps localize pain in which of the following muscles of the shoulder girdle? A. Supraspinatus B. Infraspinatus C. Teres minor D. Subscapularis

Explanations (c) A. Abduction against resistance tests the supraspinatus. (u) B. Lateral rotation against resistance tests the infraspinatus and teres minor. (u) C. See B for explanation. (u) D. Medial rotation against resistance tests the subscapularis

History & Physical/Cardiology Which of the following conditions is most suggestive of an abdominal aortic aneurysm? A. Abdominal mass B. Hypertension C. Chest pain D. Syncope

Explanations (c) A. An abdominal aortic aneurysm presents with a pulsatile upper abdominal mass.

Clinical Intervention/Obstetrics/Gynecology A 52 year-old obese patient with persistent heavy menses undergoes an endometrial biopsy and is diagnosed with atypical adenomatous hyperplasia. What is the next step in the management of this patient? A. Total abdominal hysterectomy B. Observation and endometrial biopsy in 3 months C. Endometrial curettage followed by progesterone daily D. Oral progesterone days 16-25 of the month for 6 months and repeat biopsy

Explanations (c) A. Atypical adenomatous hyperplasia contains cellular atypia and mitotic figures in addition to glandular crowding and complexity. This has a 20-30% risk of progression to endometrial cancer and the recommendation is hysterectomy

Diagnosis/Gastrointestinal/Nutritional A 30 year-old patient presents with weight loss, diarrhea, and steatorrhea. Labs reveal that the antiendomysial antibody (AEA) is positive. What is the most likely diagnosis? A. Celiac sprue B. Ulcerative colitis C. Whipple's disease D. Zollinger-Ellison syndrome

Explanations (c) A. Celiac sprue is not only characterized by these classic symptoms. The antiendomysial antibody has a 90-95% sensitivity and 90-95% specificity for celiac sprue

Diagnosis/Endocrinology A 54 year-old female presents to the office for radiographic and laboratory results. The radioactive iodine uptake is elevated while the thyroid hormone levels are increased with TSH levels being suppressed. Which of the following is the most likely diagnosis? A. Graves' disease B. Hashimoto's thyroiditis C. Subacute thyroiditis D. Pituitary failure

Explanations (c) A. Graves' disease is associated with an elevated uptake on the radioactive thyroid scan due to an increase in the activity for the thyroid gland. Because the gland is actually making thyroid hormone, the free T4 level will be increased and the TSH will be suppressed as a result of negative feedback to the hypothalamus and pituitary gland.

. Scientific Concepts/Neurology The source of pain experienced during a migraine headache is a result of activation of which nerve? A. Trigeminal B. Vagus C. Optic D. Occulomotor

Explanations (c) A. Headache may result in release of neuropeptides acting as neurotransmitters at trigeminal nerve branches.

Scientific Concepts/Hematology Normal hemoglobin A is made of what combination of heme and globin chains? A. 2-alphas and 2-betas B. 4-gammas C. 2-alphas and 2-gammas D. 4-betas

Explanations (c) A. Hemoglobin A1 is composed of two alpha and two beta chains. (u) B. Barts Hemoglobin-Hydrops Fetalis has 4-gamma chains and is incompatible with life. (u) C. Fetal hemoglobin consists of 2-alpha and 2-gamma chains. (u) D. Hemoglobin H consists of 4-beta chains and is nonfunctional

Scientific Concepts/Infectious Diseases Which immunoglobulin is the first to respond during the primary immune response for a gram positive bacterial infection? A. IgM B. IgG C. IgA D. IgE

Explanations (c) A. IgM is the first immunoglobin to respond during the acute exposure. This immunoglobulin promotes opsonization and phagocytosis. IgG is the immunoglobulin that responds during the secondary exposure. IgE is the immunoglobulin that responds during an allergic response as well as during a parasitic infection. IgA is an antibody found in colostrums and GI secretions

Clinical Therapeutics/Urology/Renal A 7 year-old boy wets the bed on most nights. Which of the following is the preferred pharmacological agent to decrease the incidence of bed wetting episodes? A. Imipramine (Tofranil) B. Phenytoin (Dilantin) C. Pramipexole (Mirapex) D. Hyoscyamine (Urised)

Explanations (c) A. Imipramine is an anti-cholinergic and when given before bedtime has been shown to decrease the incidence of bed wetting.

Clinical Intervention/Infectious Diseases A 2 year-old male presents with a four day history of fever and general malaise. On examination the vitals reveal an oral temperature of 102 degrees F. The child appears to have rubor on the trunk which started one day prior to this visit. Physical examination reveals a maculopapular rash with defervescence. Which of the following is the most appropriate management at this time? A. Ibuprofen (Motrin) B. Aspirin C. Amoxicillin D. Valacyclovir (Valtrex)

Explanations (c) A. Motrin is indicated for management of the fever in Roseola infantum caused by the herpesvirus.

Diagnostic Studies/Infectious Diseases A patient states that he has been camping in the mountains of North Carolina for the past two weeks. He presents to the clinic complaining of "flu-like" symptoms for the past 10-14 days however he notes that he started to develop a slight rash on his wrist and ankles about seven days ago. Which of the following tests would provide a confirmatory diagnosis? A. Immunofluorescent assay B. C-reactive protein C. Heterophile agglutination D. Anti-streptolysin O titer

Explanations (c) A. The immunofluorescent assay will confirm antibodies to Rickettsia. (u) B. C-reactive protein is a protein found in patients with inflammation during the acute phase illness. It is nonspecific. (u) C. Heterophile agglutination is used to detect antibodies to the Epstein-Barr virus which is responsible for infectious mononucleosis. (u) D. ASO titer is done to detect antibodies to streptococcal infection.

Clinical Intervention/Gastrointestinal/Nutritional Which of the following is the most important intervention in acute pancreatitis? A. IV fluid administration B. Antibiotic administration C. Calcium replacement D. Antiemetics

Explanations (c) A. The mainstay of management in acute pancreatitis is fluid resuscitation. Isotonic solutions are best to maintain renal perfusion and urine output > 100 ml/hour.

Diagnosis/ENT/Ophthalmology A 45 year-old smoker presents with a sore mouth and increasing difficulty eating for two weeks. Physical examination reveals a 1 cm white lesion on the buccal mucosa that cannot be rubbed off. Which of the following is the most likely diagnosis? A. Oral cancer B. Oral candidiasis C. Aphthous ulcer D. Necrotizing ulcerative gingivitis

Explanations (c) A. The presence of leukoplakia in a smoker over the age of 40 should be biopsied to rule out the presence of oral cancer. (u) B. Oral candidiasis presents with white patches. Unlike leukoplakia, the patches easily rub off. (u) C. While aphthous ulcers are commonly found on the buccal mucosa, they are usually 1 to 2 mm round ulcerative lesions. (u) D. Necrotizing ulcerative gingivitis is common in young adults under stress. Clinically, it presents with painful acute gingival inflammation and necrosis.

. History & Physical/Dermatology Which of the following is the only disease that forms an ulcer at the site of inoculation? A. Tularemia B. Scabies C. Lyme disease D. Rocky Mountain Spotted Fever

Explanations (c) A. Tularemia is an acute infection that is transmitted by handling the flesh of infected animals, by the bites of insect vectors and by inoculation of conjunctiva.

Diagnostic Studies/Gastrointestinal/Nutritional Which of the following laboratory tests, if positive, would be most indicative of Crohn's disease? A. Antineutrophil cytoplasmic antibodies (ANCA) B. Antiendomysial antibodies (AEA) C. Antinuclear antibodies (ANA) D. Anti-Saccharomyces cerevisiae antibodies (ASCA)

Explanations (u) A. Antineutrophil cytoplasmic antibodies is positive in 60-70% of patients with ulcerative colitis while only 5-10% of Crohn's disease patients have positive results. (u) B. The antiendomysial IgA antibodies are directed against tissue transglutaminase and has a 90-95% specificity for celiac sprue. (u) C. Antinuclear antibodies are elevated in a wide variety of autoimmune disorders and therefore are a nonspecific finding. (c) D. About 60-70% of patients with Crohn's disease are positive for these antibodies which are directed at the cell walls of S. cerevisiae while only 10-15% of ulcerative colitis is found to be positive

Diagnosis/Cardiology An electrocardiogram (ECG) shows a sinus rhythm with varying T wave heights, axis changes every other beat and a wandering baseline. Which of the following is most likely the diagnosis? A. Artifact B. Digoxin toxicity C. Pericardial effusion D. Poor lead placement

Explanations (u) A. Artifact could show a wandering baseline, but not the distinct axis changes. (u) B. Digoxin toxicity can cause bidirectional tachycardia, but not electrical alternans. (c) C. This ECG pattern best represents pericardial effusion due to a swinging heart in fluid and is known as electrical alternans. (u) D. Poor lead placement would show different patterns per the leads.

Scientific Concepts/Cardiology Which of the following factors in patients with chronic venous insufficiency predisposes them to development of skin ulcers? A. Increased intravascular oncotic pressure B. Leakage of fibrinogen and growth factors into the interstitial space C. Decreased capillary leakage D. Inherited deficiency of protein C

Explanations (u) A. Decreased intravascular oncotic pressure can cause swelling (c) B. Leakage of fibrinogen and growth factors into the interstitial space, leukocyte aggregation and activation, and obliteration of the cutaneous lymphatic network can predispose a patient to skin ulcers

. History & Physical/ENT/Ophthalmology Which of the following would indicate an optic nerve lesion? A. Excessive conjunctival edema B. Ptosis C. Inability to gaze laterally D. Afferent pupillary defect

Explanations (u) A. Excessive edema of the conjunctiva is a feature of chemosis. (u) B. Ptosis is not indicative of an optic nerve lesion. (u) C. Inability to gaze laterally would be due to paralysis of the lateral rectus muscle controlled by cranial nerve VI. (c) D. Pupil size, controlled centrally by the Edinger-Westphal nucleus in the midbrain, is primarily based on the afferent light stimulus transmitted via the optic nerve.

Diagnosis/Orthopedics/Rheumatology A 32 year-old male presents with an acute onset of pain and swelling to his left ankle. On physical examination the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leukocytosis with a low glucose. Which of the following is the most likely diagnosis? A. Gout B. Pseudogout C. Acute rheumatic fever D. Septic arthritis

Explanations (u) A. Gout and pseudogout are excluded by the failure to find crystals on synovial fluid analysis. (u) B. See A for explanation. (u) C. Acute rheumatic fever commonly involves multiple joints. (c) D. Leukocytosis and a low synovial glucose are indicative of septic arthritis.

Diagnostic Studies/Cardiology A 72 year-old male presents to the emergency department with crushing chest pain, dyspnea and palpitations for 2 hours in duration. Enzymes are pending and he has been given aspirin and sublingual nitroglycerin. He is rushed to the catheterization lab where they find a totally occluded distal right coronary artery. Which of the following electrocardiogram (ECG) findings supports the diagnosis? A. Q waves in leads I, aVL, V5-V6 B. ST segment elevation in leads II, III, aVF C. Hyperacute T waves in leads I, aVL D. Flipped T waves with repolarization changes in leads V1-V4

Explanations (u) A. Q waves in leads I, aVL, V5-V6 represent infarction involving the circumflex artery. (c) B. ST segment elevation in leads II, III, aVF, represents an acute process in the right coronary artery. (u) C. Hyperacute T waves in leads I, aVL can represent the initial changes of an infarction involving the circumflex artery. (u) D. Flipped T waves with repolarization changes in leads V1-V4 can represent early stages of infarction involving the left anterior descending artery.

Clinical Therapeutics/Gastrointestinal/Nutritional Which of the following medications decreases the exchange of hydrogen for potassium by inhibiting hydrogen, potassium-ATPase? A. Ranitidine (Zantac) B. Misoprostol (Cytotec) C. Sucralfate (Carafate) D. Omeprazole (Prilosec)

Explanations (u) A. Ranitidine is an H2 receptor antagonist. (u) B. Misoprostol is a prostaglandin analogue. (u) C. Sucralfate is a coating agent. (c) D. Omeprazole, a proton pump inhibitor, works by inhibiting hydrogen, potassium-ATPase.

Shy-Drager Syndrome

Shy-Drager syndrome is due to autonomic degeneration and typically presents with orthostatic hypotension

History & Physical/ENT/Ophthalmology Whispered voice test on a patient reveals decreased hearing in the left ear. Which of the following would be most consistent with conductive hearing loss in the left ear? A. Sounds best heard in the left ear on Weber test. B. Air conduction longer than bone conduction in the left ear on Rinne test. C. Sound best heard in the right ear on Weber test. D. Bone conduction longer than air conduction in the right ear.

c) A. Sound best heard in the ear with decreased hearing on Weber test (in this case, the left ear) is indicative of conductive hearing loss.

Which of the following is considered a risk factor for the development of malignant melanoma? A. male gender B. inability to tan C. Japanese ethnicity D. brown-haired individuals

c) B. Inability to tan and propensity to burn are risk factors for developing malignant melanoma.

Clinical Intervention/Cardiology A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention? A. Intra-aortic balloon counterpulsation B. Mitral valve replacement C. Coronary artery bypass surgery D. Immediate fluid bolus

c) B. MVR is the definitive intervention to correct MR caused by papillary muscle rupture

Diagnosis/ENT/Ophthalmology A patient is evaluated in the office with a red eye. The patient awoke with redness and a watery discharge from the eye. The eyelids were not matted together. Examination reveals a palpable preauricular node. Which of the following is the most likely diagnosis? A. bacterial conjunctivitis B. viral conjunctivitis C. allergic conjunctivitis D. gonococcal conjunctivitis

c) B. Viral conjunctivitis is associated with copious watery discharge and preauricular adenopathy.

Best screening test for SLE

c) D. ANA's are the best screening test used in the evaluation for SLE.

Clinical Therapeutics/Pulmonology A 25 year-old male with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist prn. He is presently using his short acting beta agonist on a daily basis. Which of the following is the most appropriate addition to this patient's regimen? A. methylxanthine oxidase inhibitor B. long acting beta agonist inhaler C. leukotriene inhibitor D. inhaled corticosteroid

c) D. According to the stepwise approach for managing asthma by the National Asthma Education and Prevention Program, inhaled corticosteroids are indicated for mild to moderate persistent asthma.

Clinical Therapeutics/Cardiology A 25 year-old female presents to the emergency department after an episode of substernal chest pain with radiation to the middle of her back that came on suddenly and lasted for about four minutes this morning while in bed. She denies previous episodes. Examination is unremarkable, but she appears jittery. Toxicology screen is positive for cocaine. Which of the following medications is contraindicated in this patient? A. Lorazepam (Ativan) B. Diltiazem (Cardizem) C. Nitroglycerin (Nitrostat) D. Propanolol (Inderal)

c) D. Pure Beta blockers, such as propranol, can cause a paradoxical hypertension because of unopposed alphaadrenergic effects.

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