PANCE Practice Questions

2022/2023 60 PANCE Practice Questions 2022/2023 60 PANCE Practice Questions A 52 year-old male presents complaining of urinary frequency, with hesitancy, and nocturia for the past few months. During his physical examination, you note a nontender, non-enlarged prostate with an isolated right posterior lobe nodule. Which of the following options is most appropriate? *A.* order a serum acid phosphatase level *B.* initiate prazosin and schedule a follow-up appointment in 6 weeks *C.* refer the patient for an ultrasound of the prostate and order a PSA level *D.* reassure the patient and schedule a follow-up appointment in six months *E.* initiate norfloxacin therapy for 7 days and schedule follow-up in two weeks Correct Answer: *Answer: C* This patient has an isolated nodule of the prostate gland — cancer until proven otherwise. You should order an ultrasound and a PSA. BPH will present as diffuse enlargement, and not a discrete nodule. You are educating a patient that has just been advised that he has "polyps" in his colon. Which of the following statements is FALSE? A. The larger the colonic polyp, the greater the risk of malignant transformation B. Villous adenomas have a 30-70% risk of malignant transformation. C. The greater the number of concomitant colonic polyps, the greater the risk of malignant transformatio D. The majority of colonic polyps are hyperplastic in origin E. The majority of colonic polyps are 3 cm in size. Correct Answer: Answer: E, The majority of colonic polyps are 3 cm in size. Most polyps are, in fact, quite small. All the rest of these statements are true Which term is used to describe the characteristic concave or "spoon-shaped" nails of iron deficiency anemia? A. leukonychia B. koilonychias C. clubbing D. onycholysis E. paronychia Correct Answer: *Answer: B. Koilonychia* Koilonychia is a spoon-shaping of the nail itself. It is usually a result of iron deficiency anemia. Leukonychia is often associated with hypoalbuminaemia that causes partial or complete white discoloration of the nails. Leukonychia may also appear as a rare side effect of systemic chemotherapy in some oncological patients but may also be present with arsenic poisoning, renal failure pneumonia, or heart disease. Clubbing of the nails is an actual thickening or elevation of the nail bed - it is a sign of release of TNF associated with pulmonary disorders (tissue necrosis factor) typically found in bronchiectasis, lung cancers and cystic fibrosis (the nails are NOT necessarily cyanotic.) Onycholysis is a painless separation of the nail from the nail bed. Several or all nails are usually affected - there are many causes. Paronychia is an infection of the nail bed and nail margin, usually from trauma or more commonly, nail-biting. Which of the following is NOT a characteristic feature of the nephrotic syndrome? A. proteinuria B. hematuria C. hypoalbuminemia D. hyperlipidemia E. generalized edema Correct Answer: *Answer: B. Hematuria* Hematuria is present in NEPHRITIC syndrome. Nephrotic syndrome characteristically includes proteinuria (3.5 gm/day), with resulting low serum albumin, hyperlipidemia, hypertension, hypercoagulability, and generalized edema (from oncotic third-spacing) A patient describes a history of recurrent bouts of uveitis. Her chemistry panel reveals elevated serum calcium and uric acid levels. Her anergy screen is negative. Her chest x-ray demonstrates bilateral hilar adenopathy. Which diagnosis is most likely? A. Silicosis B. Sarcoidosis C. Alpha-1 antitrypsin deficiency D. Histoplasmosis E. Tuberculosis Correct Answer: *Answer: B. Sarcoidosis* Sarcoid typically presents with hilar lvmphadenopathy and noncaseating granulomas of the lungs (and other organs). In addition, patients may get eye involvement (uveitis). Elevations of ACE, Calcium and uric acid are frequently seen. A 34-old female presents complaining of symmetrical redness and swelling of the small joints of her hands (PIPs and MCPs). She has noted that the symptoms are worst in the morning. Her erythrocyte sedimentation rate is elevated and her rheumatoid factor is negative. Which of the following diagnosis is most likely? A. progressive systemic sclerosis B. CREST syndrome C. osteoarthritis D. rheumatoid arthritis E. ankylosing spondylitis Correct Answer: *Answer: D Rheumatoid Arthritis* In spite of the negative RF, Rheumatoid arthritis is the most likely diagnosis. RA characteristically includes small joint symmetrical arthritis, with an elevated ESR (therefore inflammatory, and not OA). 80% of patients with RA will have a positive RF, but 20% will be negative. PSS involves squamous cell thickening and sclerosis causing taut skin of the face and hands and difficulty with esophageal motility. CREST syndrome is a subset of PSS; Ankylosing spondylitis would have an elevated ESR and negative RF, but mainly involves the SI joint and lumbar/thoracic spine fusion (bamboo spine) A 14 year-old is experiencing a severe asthma attack. Although he is using accessory muscles to breath, auscultation of his chest reveals no audible wheezing. His heart rate is 160 and his respiratory rate is 52. Which of the following arterial blood gases represents the worst prognosis? A. pH = 7.52; pC02 = 28; p02 = 80 B. pH = 7.44; pC02 = 38; p02 = 70 C. pH = 7.60; pC02 = 18; p02 = 60 D. pH= 7.40; pC02 = 40; p02 = 60 E. pH = 7.27; pC02 - 62; p02 = 64 Correct Answer: Answer: E. pH = 7.27; pC02 - 62; p02 = 64 This patient has a RR of 52. If she is ventilating, she is blowing of C02 (an acid) and would be alkalotic and should have a low C02. A pH which is acidic with a pC02 which is elevated means that she is no longer ventilating at all (she needs mechanical ventilation or she will die). A 27 year-old nulliparous female presents because she's been trying to get pregnant for two years, but has failed. She relates a history of a misdiagnosis of appendicitis that lead to abscess formation when she was 14 years old. Which of the following diagnostic studies would be most helpful at this point in her evaluation? A. TSH level B. hysterosalpingogram C. laparoscopy D. PAP smear E. pelvic ultrasound Correct Answer: *Answer: B hysterosalpingogram* While I would disagree that an invasive procedures like HSG should be done first-line, the thing to remember in this question is that the patient has reason to have tubal scarring from adhesions (and there is no better answer listed to choose), so, for a board exam I would choose this answer. The TSH level would not be indicated (she has not had a pg loss), lap could diagnose the tubal scarring but would be done after an abnormal HSG. Pap smear is screening for cervical cancer and not indicated in this case of infertility; and pelvic US would yield nothing diagnostically about the tubes. 48 year-old nurse, with a body mass index of 31, presents for an evaluation for back pain. She relates that historically, she had a positive PPD test a year ago and did not follow-up as directed. She has recently been experiencing night sweats and coughing. An x-ray of her lumbar spine reveals osteopenia and cortical breakdown of vertebral bodies L4 and L5. Which of the following diagnosis is most suspect? A compression fractures secondary to obesity B degenerative joint disease C Potts disease D compression fractures secondary to osteoporosis E spondylolisthesis Correct Answer: *Answer: C Potts Disease* Pott's disease is TB of the spine. She could have any of the other diseases; but the question states that she had a positive PPD and did not take meds...that is the clue that she has active TB in the spine. While suturing a wound, you opt to use lidocaine with epinephrine. The rationale for your choice is: A an increase in the absorption of the lidocaine. B an increase in the diffusion of the lidocaine into the nerve's myelin sheath. C an increase in the blood flow to the area of injection. D an increase in the duration of anesthesia. E a decrease in the risk of infection at the site of injection. Correct Answer: *Answer: D* Lidocaine with epinephrine both increases duration of anesthesia and decreases blood flow to the area of injection-i.e. penis, nose, fingers, toes An EKG demonstrates a PR interval of 0.16 seconds, a P to QRS relationship of 1:1, a variable heart rate and an R to R interval that is noted to accelerate ad decelerate during the respiratory cycle. What is the diagnosis? A Wenckebach B third degree heart block C atrial fibrillation D sinus arrhythmia E atrial flutter Correct Answer: *Answer: D Sinus Arrhythmia* This is sinus arrhythmia. Wenckebach & third degree AVB would have a non-conducted P wave. A fib would have no P waves and an irregularly irregular rhythm. A flutter would have "flutter waves" or a regular rhythm of 150. Combinations of antimicrobial agents are commonly employed in the treatment of meningitis in infants less than three months old. Ampicillin is commonly an agent included in this regimen. Ampicillin is used empirically for the possible presence of: A Escherichia coli. B Listeria monocytogenes. C Cytomegalovirus. D Herpesvirus. E Hemophilus influenzae. Correct Answer: *Answer: B Listeria monocytogenes* While E. Coli can infect an infant delivered vaginally, AMPICILLIN is given to eliminate Listeria. CMV & HSV are viruses. E. Coli & H. Flu are also typically resistant to amp, and more likely a broader spectrum antibiotic would be used. A 42 year-old female presents after finding a firm, painless bump in her right eyelid. On examination, you note a 6 mm mass within the tarsus of the right eye. The skin is freely movable over the mass. The remainder of the ophthalmoscopic examination is unremarkable. Which of the following is the most likely diagnosis? A pterygium B chalazion C ectropion D external hordeolum E internal hordeolum Correct Answer: *Answer: B Chalazion* A chalazion is a painless chronic mass in the eyelid. Hordeolum are acute and red and painful. Pterygium involves the sclera. Ectropion is when the eyelid sags outwardly and the lid doesn't close well. Which white blood cell disorder is characterized by the presence of the Philadelphia chromosome in 90% of cases? A chronic lymphocytic leukemia (CLL) B acute lymphocytic leukemia (ALL) C chronic myelogenous leukemia (CML) D acute myelogenous leukemia (AML) E multiple myeloma Correct Answer: Answer: C Philadelphia Chromosome occurs in CML. ALL occurs in children. AML is associated with Auer rods. Multiple myeloma has Bence-Jones protein. CLL has no clear distinguishing feature except increased lymphocytes. A 22 year-old patient was involved in an automobile accident and is comatose. Which of the following diagnostic modalities would be least useful in this patient's evaluation? A CT scan B skull radiographs C MRI scan D EEG E PET scan Correct Answer: Answer: B Skull radiograph Of these choices, the skull film is LEAST useful. Whether or not the skull is fractured, any LOC in a head trauma requires imaging for bleeding. CT would be the imaging test of choice. MRI should be done for a more chronic bleed. EEG would help to establish brain activity. PET scan (while not done often) would establish physiologic function (uptake of glucose). A positive or negative plain film of the skull would supply NO FURTHER INFORMATION. A patient presents complaining of generalized swelling. Her urine is positive for protein. Her serum testing reveals hyperlipidemia and hypoalbuminemia. Which of the following is the most likely diagnosis? A. cirrhosis B. nephrotic syndrome C. congestive heart failure D. cystitits E. pyelonephritis Correct Answer: Answer: B, nephrotic syndrome This is a classic presentation of nephrotic syndrome. Question 21 of 60 This papulosquamous eruption is most common in young adults. A single oval patch is generally noted several days before a more generalized, fawn-colored rash erupts. This rash is most prevalent on the trunk, and the proximal upper and lower extremities. The rash spontaneously disappears over 5 to 6 weeks. The diagnosis is: A. pityriasis rosea. B. tinea corporis C. psoriasis. D. atopic dermatitis. E. sporotrichosis Correct Answer: Answer: A This is the classic presentation of pityriasis rosea. Remember that the differential diagnosis includes secondary syphilis, so if a positive sexual history - consider ordering a VDRL/RPR. The "herald" patch which is described is pathognomonic for pityriasis. A female in her third trimester of pregnancy developed hypertension, diffuse edema, proteinuria and hyperreflexia. She was treated with intravenous magnesium sulfate and is now hyporeflexic and drowsy. What do you prescribe now? A. calcium B.diazepam C. an amphetamine D. additional magnesium E. oxygen Correct Answer: Answer: A, calcium Pre-eclampsia causes hyper-reflexia. Magnesium is the treatment. The sign of Mg toxicity is loss of reflexes...this is treated with Calcium A 55 year-old male presents complaining of "difficulty wrting" using his dominant hand and some "slurred" speech. He has a h/o hypertension, DM type II, and hypertriglyceridemia. Which of the following would you anticipate to find on a CT scan of his head, as the explanation for his chief complaint? A. hemorrhage in the distribution of his posterior cerebral artery B. hemorrhage in the distribution of the middle cerebral artery C. hypodensity measuring 12 mm by 21 mm in the distribution of the posterior cerebral artery D. hypodensity measuring 4 mm by 4 mm in the internal capsule E. calcifications bilaterally, in the third ventricles Correct Answer: Answer D, hypodensity measuring 4 mm by 4 mm in the internal capsule The main clue in this question is that most strokes are ischemic - especially with THIS patient's history (ruling out hemorrhagic infarct - A & B). Calcifications (E) are not indicative of stroke at all. When trying to decide between C & D - the size of the area needs to correlate with the patient's sxs. If the patient had a HUGE infarct (12 x 21) he would have significantly more sxs than just some slurred speech and difficulty writing. (In addition, as it turns out, the internal capsule is supplied by the MCA - which is the most common vessel involved in an ischemic stroke) A 6 year-old child falls onto his right arm. An x-ray demonstrates a buckle in the cortices of the distal radius, proximal to the growth plate, without angulation. What is the term used to describe this fracture? A. Salter-Harris Type III B. Salter Harris Type IV C. Salter Harris Type V D. torus E. greenstick Correct Answer: Answer: D, torus Torus or buckle fracture is most common in a child. This is proximal to the epiphyseal plate and so is not a Salter-Harris issue. Greenstick fracture is also common in children in long bones and is a fracture which "bends" the bone without fracturing it. A patient warrants antihypertensive medication use for the duration of her pregnancy. Which of the following is the antihypertensive recommended for such patients? A alpha-methyldopa B captopril C nifedipine D propranolol E clonidine Correct Answer: Answer: A Methyl Dopa (Aldomet) is indicated in pregnancy. ACEI's (captopril) are contraindicated in pg. B-Blockers can be used but may cause growth restriction. Diuretics are not used in pg. CCB's and centrally acting agents (while not contraindicated) should be avoided. All of the following are factors that predispose a patient to the development of gastroesophageal reflux EXCEPT: A hiatal hernia. B pregnancy C scleroderma. D an incompetent esophageal sphincter E pernicious anemia. Correct Answer: Answer: E Pernicious anemia has no correlation with GERD. It is an autoimmune destruction of the gastric parietal cells that make intrinsic factor. Signs & symptoms are not present until B12 levels are very low (and include peripheral neuropathies & ataxia) Which of the following thyroid profiles is most compatible with a diagnosis of primary hypothyroidism? A a low TSH (thyroid stimulating hormone) level and a high T4 B a low TSH level and a normal T4 C a low TSH level and a low T4 D a high TSH level and a low T4 E a high TSH and a high T4 Correct Answer: Answer: D Low T4 is diagnostic for low thyroid function. If the pituitary is normal (as in primary thyroid disease) the TSH should be high as the pituitary tries to stimulate the failing thyroid gland. A patient is experiencing an acute exacerbation of asthma. Which of the following drugs would be the least useful in the management of this asthma attack? A. albuterol B. cromolyn sodium C. prednisone D. theophyline E. epinephrine Correct Answer: Answer: B, cromolyn sodium Cromolyn is a mast cell stabilizer and must be present in the system PRIOR to the symptoms. It would be useless in a patient already having symptoms. 34 year-old female patient presents to the ER with sharp pleuritic-type chest pain. An x-ray reveals pericarditis. On more careful questioning, the patient admits to a polyarticular arthritis involving the small joints of her hands. Her obstetrical history is positive for two third trimester spontaneous abortions. At this point, you would suspect which autoimmune process as the cause of her symptoms: A. Rheumatoid arthritis B. Systemic Lupus Erythematosis C. Wegener's granulomatosis D. Sjogren's Syndrome E. Scleroderma Correct Answer: Answer: B 40-60% of patients with SLE have serositis (pleuritis and pericarditis). That, combined with joint pains, habitual AB - should cause you to order an ANA. A patient with AIDS develops severe headaches. A CT scan demonstrates multiple ring-enhancing lesions of the brain. What diagnosis is most likely? A. Toxoplasmosis B. Histoplasmosis C. lymphoma D. Cytomegalovirus E. Herpes encephalitis Correct Answer: Answer: A Toxo occurs commonly in HTV, and is a parasitic infection causing ring-enhancing lesions (but lots of things can cause ring-enhancing lesions). CMV is common as well and typically causes retinitis. Herpes encephalitis can happen frequently too, but causes a diffuse encephalitis. A Caucasian male has a history of a meconium ileus as a newborn, steatorrhea and a positive sweat test. What is the most likely diagnosis? A. Von Gierke's disease B. Hurler's syndrome C. Cystic fibrosis D. Hunter's syndrome E. Cri du chat syndrome Correct Answer: Answer: C, Cystic fibrosis This is the classic presentation of Cystic fibrosis A 32 year-old male presents with dyspnea and a nonproductive cough. His is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia and his LDH is elevated. What is the most likely diagnosis? A. Streptococcal pneumoniae pneumonia B. Mycoplasma pneumoniae pneumonia C. Pneumocystis carinii pneumonia D. Bowen's disease E. Steven-Johnson syndrome Correct Answer: Answer: C, Pneumocystis carinii pneumonia Many AIDS patients present initially with PCP. These are the classic sns & sxs of PCP pneumonia. While mycoplasma patients can be acutely ill, they are more likely (especially on the Boards) to present as mildly ill with normal PE and no hypoxia. S. pneumo is the most common CAP, but would present with a focal/lobar consolidation. A patient describes a history of a "curtain being brought down over my right eye it stayed there for a few minutes then was lifted back up." In which of the following arteries is the etiology of this complaint located? A. anterior cerebral B. middle cerebral C. posterior cerebral D. internal carotid E. external carotid Correct Answer: Answer: D, Internal Carotid This is amaurosis fugax....a form of "TIA" of the optic artery — it arises from the internal carotid - most common location for occlusion in TIA. Upon review of an EKG you notice periodic, repetitively absent QRS complexes and "grouped beating." Which of the following is the explanation? A. Third degree heart block B. Mobitz Type II heart block C. Mobitz Type I heart block D. first degree heart block E. sinus tachycardia Correct Answer: Answer: C, Mobitz Type I heart block I don't like the wording of this question, but typically "group beating" suggests Wenckebach. The fact that there are absent QRS complexes means there is a second or third degree AVB. In Mobitz II, the PR intervals are the same - so no "grouped" beating, in Third degree, there is no rhyme or reason to the rhythm. In Wenckebach, the rhythm "repeats", causing a "regularly irregular" rhythm. A 14 month-old female is brought to your office with a 3-day history of a fever of 104 degrees rectally. Suddenly, today, the fever stopped and a rash developed. Examination reveals a diffuse, fine, maculopapular rash. Presently, the child does not appear ill. The most likely diagnosis is: A. Rubella B. Rubeola C. erythema infectiosum (Fifth's disease) D. Roseola E. Chicken pox Correct Answer: Answer: D, Roseola This is typical for Roseola. Rubella has mild illness with a fine macular rash. Rubeola (measles) is an acute illness, the child is toxic, has conjunctivitis and Koplik spots. Fifth's disease has mild illness with a "lacey" rash on the extremities. Chicken pox has vesicles. The most common cause of preventable blindness in the United States is: A. macular degeneration. B. cataracts. C. retinal detachments. D. glaucoma. E. trauma. Correct Answer: Answer: D, glaucoma Again, the wording is difficult in this question. Macular degeneration, retinal detachments and trauma are not preventable. Cataracts are "curable", but the cataract itself is probably not "preventable". Chronic glaucoma can be treated to prevent blindness this is a matter of semantics. Which of the following agents is effective in the treatment of Parkinson's? A. penicillin B. amantadine C. erythromycin D. acyclovir E. cephalexin Correct Answer: Answer: B, amantadine Amantadine (Symmetrel) is effective (somewhat). It is used in treating Influenza A. Another choice is selegiline, and levodopa/carbidopa. The other antibiotics listed here are not useful in Parkinson's Laboratory report: elevated serum free t4; low serum TSH level. Which of the following is the MOST likely diagnosis? A. Primary hypothyroidism B. Secondary hypothyroidism C. T3 thyrotoxicosis D. Graves disease E. Chronic Hashimoto's thyroiditis Correct Answer: Answer: D, Graves disease High T4 (hyperthyroid), with a low TSH indicates that the pituitary is working normally, and the thyroid is hyperactive, i.e. Grave's disease. Primary hypothyroidism (Hashimoto's) is low T4 with a high TSH. Secondary hypothyroidism (from pituitary disease) is a low T4 with a low TSH. The results of a barium esophagram reveal esophageal webbing in a woman with long-standing iron deficiency anemia. Her diagnosis is: A. Barretts esophagus. B. achalasia. C. Plummer-Vinson syndrome. D. Dresslers syndrome. E. Ogilvies syndrome. Correct Answer: Answer: C, Plummer-Vinson syndrome. Plummer-Vinson is something to know for those who want a 100% on the exam. There is no need to memorize this. More importantly, webbing in the distal esophagus with no other symptoms but dysphagia would be a Shatzki's ring (much more common). Barrett's causes GERD symptoms and dysplasia of the esophageal mucosa. Achalasia is a primary neurologic problem of the esophagus causing dysphagia. Which of the following agents has a mechanism of action that does not involve beta-receptors? A. epinephrine B. albuterol C. propranolol D. prazosin E. ritodrine Correct Answer: Answer: D, prazosin. Of these choices, prazosin is an alpha- blocker. Ritodrine and epinephrine cause beta sympathetic stimulation. Albuterol is a beta agonist. Propranolol is a beta blocker. A 6 year-old male is brought into your office for evaluation of his gait. You note that when ambulatory, the medial aspects of his knees are far apart and his feet are unusually close together. Which of the following best describes this condition? A. cubitus valgus B. cubitus varus C. genu valgus D. genu varum E. Legg-Calve-Perthes disease Correct Answer: Answer: D, genu varum This is genu varum (bow legs). Valgus deformity forms an "L" in the knock-kneed child, and has an "L" in the middle of it (try it, it works) A female presents complaining of a grayish, watery vaginal discharge. The KOH prep does not reveal any hyphae. Clue cells are identified on the wet mount. A paucity of WBCs are noted. What diagnosis is most likely? A. Gonorrhea B. Chlamydia C. Candidiasis D. bacterial vaginosis E. Trichomoniasis Correct Answer: Answer: D, bacterial vaginosis Clue cells means BV You note polygonal, purple, popular lesions involving the flexor surfaces of a patient's wrists. The patient has no other lesions. The lesions appear to follow a linear pattern of distribution. What is this phenomenon? A. Auspitz sign B. Koebner's phenomenon C. Darier's sign D. Gorlin's sign E. Gottron's papules Correct Answer: Answer: B, Koebner's phenomenon Koebner's phenomenon is described - it suggests psoriasis. Auspitz sign is also present in psoriasis where the scales bleed when removed. Darier's sign is in allergic patients who develop urticaria when the skin is rubbed. Gottron's papules are purple papules on the fingers seen in dermatomyositis. Gorlin's sign is seen in Ehlers-danlos when a patient can touch the tip of the nose with his tongue (I learn something new every day!!) These last two are not important to know. A 6 year-old female presents complaining of right ear pain. The tympanic membrane cannot be well visualized. She complains of pain when the tragus is manipulated. Several periauricular lymph nodes are easily palpable. Which of the following is the most likely diagnosis? A. acute otitis media B. acute otitis externa C. eustachian tube dysfunction D. Ramsey-Hunt syndrome E. perforated tympanic membrane Correct Answer: Answer: B, acute otitis externa OE is described here. OM would not cause periauricular nodes and tragal tenderness. Eustachian tube dysfn would cause middle ear pain (like when you're up in a plane). Ramsey- Hunt is herpes zoster of the ear canal and would be visible. A perforated TM would cause middle ear, not external ear pain (typically). A 51 year-old male with renal artery stenosis and an elevated BUN and creatinine, is newly diagnosed as hypertensive. Which of the following agents should be avoided? A. hydrochlorothiazide-triamterene B. prazosin C. nifedipine D. verapamil E. furosemide Correct Answer: Answer: A, hydrochlorothiazide-triamterene This is a potassium sparing diuretic and should be avoided in anyone with renal disease. ACEI should be avoided as well (but none of these are ACEI's). A patient with known hyperlipidemia, taking clofibrate, presents to your office complaining of severe myalgias and weakness. He has noted a dark color to his urine. The laboratory calls with a panic value CPK of 8500. He was recently started on a new medication, four days earlier. Which of the following is most likely the new medication? A. lovastatin B. hydrochlorothiazide. C. dexamethasone D. phenytoin E. ampicillin Correct Answer: Answer: A, lovastatin Statin + fibrate = suspicion for rhabdomyolysis in a patient with myalgias, ALWAYS order a CPK. (statin alone, or fibrate alone may cause it too, but the combination is most likely) A patient at a Christmas party on a cruise ship develops a terrible headache. His blood pressure is 224/158 mm Hg. Which of the following agents is this patient most likely taking regularly? A. tricyclic antidepressants B. barbiturates C. benzodiazepines D. monoamine oxidase inhibitors E. phenothiazines Correct Answer: Answer: D, monoamine oxidase inhibitors This is a typical scenario for MAOI induced malignant hypertension from eating the "wrong" foods, which are frequently found on a Christmas buffet, (cheese, sausages, red wine, etc). A female patient presents for an evaluation for primary amenorrhea. She is noted to be short of stature and have short fourth metacarpals. What diagnosis do you suspect? A. XO B. XXY C. XXX D. XXXY E. Trisomy 21 Correct Answer: Answer: A, XO This is the genotype for Turner's syndrome. XXY is the genotype for Klinefelter's (which is a tall, mildly retarded male). Trisomy 21 is Down's. The other two are not common genotypes. An 18 year-old female presents after completing her freshman year at college. Two months ago, she developed "bronchitis" which has persisted. She has become increasingly tired and has frequent night sweats. A chest x-ray today reveals a left mediastinal mass. What is the next step in her evaluation? A. repeat the chest x-ray in six months B. ultrasound of the left hemithorax C. bone scan D. CT scan of the chest E. proceed directly to bronchoscopy with biopsy Correct Answer: Answer: D, CT scan of the chest Any patient presenting with mediastinal nodes should have a CT. This patient may have sarcoid or Hodgkin's or another type of cancer - CT is indicated. An elderly patient is recovering from a pneumonia caused by Influenza. Suddenly, the patient's condition deteriorates. You order a chest x-ray that demonstrates an air-fluid level, suggestive of an abscess. You empirically begin treatment for: A. Streptococcal pneumoniae. B. Chlamydia. C. Hemophilus influenzae. D. Staphylococcus aureus. E. Legionella pneumophila Correct Answer: Answer: D, Staphylococcus aureus. Empyema (lung abscess) is almost always staph aureus. While strep pneumo is the most common CAP, when a complication like empyema occurs, it is almost always staph. A 17 year-old male is stabbed in the anterior chest with an ice pick. He quickly becomes hypotensive, tachycardic and obtunded. His breath sounds are equal, his neck veins are distended, and his chest x-ray is normal. What condition is most likely? A. Simple pneumothorax B. Tension pneumothorax C. Pericardial Tamponade D. aortic laceration distal to the origin of the left common carotid artery E. inferior vena cava laceration Correct Answer: Answer: C, Pericardial Tamponade This is the typical clinical presentation of tamponade (hypotension, JVD). He was stabbed and probably has a mediastinal bleed (so, I think the mediastinum would be widened on his chest film — but the "normal CXR" is what rules out the pneumothorax - another common problem in a stabbing injury. A 48 year-old male presents with crushing chest pain for 45 minutes. He is diaphoretic, nauseous and short of breath. His EKG demonstrates 4 mm of ST segment depression in leads I, aVL, V5 and V6. What is the most likely diagnosis? A. esophageal spasm B. hiatal hernia C. acute lateral wall subendocardial myocardial ischemia D. acute inferior wall myocardial subendocardial ischemia E. acute anterior wall myocardial transmural ischemia Correct Answer: Answer: C, acute lateral wall subendocardial myocardial ischemia It is obvious this patient is having an AMI. The ECG lead abnormalities suggest occlusion of the high lateral and low lateral walls of the LV - typically supplied by the circumflex - there are no Q waves - so subendocardial. Inferior AMI is leads II, III, avF. Anterior wall AMI is leads +- VI, with V2-V4, and maybe V5& V6. A 14 month-old female is brought to your office with a 1 day history of a fever of 101 degrees rectally. Suddenly, today, the parent noted small red spots that became bumps and are now blisters. The majority of the lesions are on the thorax. Each vesicle resides on its own erythematous base. A. shingles. B. Ramsey-Hunt syndrome. C. erythema infectiosum. D. herpes simplex, E. varicella Correct Answer: Answer: E, varicella This is a typical presentation of varicella (chicken pox) A 35 year-old male complains of acute left eye pain immediately after he struck a nail with a hammer. On examination, you note that the left pupil is elliptical. What diagnostic test/procedure will most likely confirm your diagnostic suspicion? A. flourescein staining of the ey B. pressing on the globe to assess intraocular pressure C. an X-ray of the orbits D. testing the extra-ocular eye muscles E. having the patient finger count Correct Answer: Answer: C, an X-ray of the orbits This patient struck a nail (think metal splinter), pain was immediate (as the splinter entered his eye). His pupil is elliptical, indicating penetration of the globe. He needs X-ray of the globe to look for the metal splinter. Flouroscein staining is for a corneal abrasion - it should not be done if the globe is penetrated This drug causes gingival hyperplasia and hirsutism. At high doses it can cause nystagmus, ataxia and diplopia. Which drug is best described by these statements A. aspirin B. acetaminophen C. acyclovir D. phenytoin E. valproic acid Correct Answer: Answer: D, phenytoin Dilantin (phenytoin) causes these typical symptoms Which of the following choices is associated with meconium staining of the amniotic fluid? A. bowel obstruction B. peeling of the infant's skin C. aspiration pneumonitis and respiratory distress syndrome D. infection with E. coli E. intrauterine cataract formation and sensorineural hearing loss Correct Answer: Answer: C, aspiration pneumonitis and respiratory distress syndrome When the infant has meconium in the amniotic fluid, he has been in distress, and the meconium is frequently aspirated prior to delivery and can cause pneumonitis and respiratory distress syndrome in the neonate. A 32 year-old male presents after slipping and falling off the roof of his home and striking his head. He suffered a brief loss of consciousness. Since that time, he has noted increasing urination and thirst. His serum chemistries reveal an elevated sodium level. His urine specific gravity is 1.003. Which of the following is the most likely diagnosis? A. cerebral contusion B. subarachnoid hemorrhage C. epidural hematoma D. diabetes insipidus E. renal contusion Correct Answer: Answer: D, diabetes insipidus Diabetes inspidus (ADH deficiency) can occur after acute head trauma. ADH is secreted by the posterior pituitary gland and causes the body to retain fluid (to increase volume). In a patient who has damaged the posterior pituitary, ADH is not secreted, so the body urinates "water". There is frequent large volume urination with a very low specific gravity, and will cause hypernatremia unless the patient is given large quantities of water to drink Wolf-Parkinson-White (WPW) and Lown-Ganong-Levine (LGL) syndrome are both characterized by: A. left ventricular dysfunction. B. a shortened PR interval. C. the presence of delta waves. D. large pericardial effusions. E. marked left ventricular hypertrophy Correct Answer: Answer: B, a shortened PR interval. WPW & LGL both have short PR intervals. WPW also has a "delta wave" and predisposes the patient to supraventricular tachyarrhythmias. A patient that you are examining for carpal tunnel syndrome reveals that her paresthesias occur in all five digits. Which digit does NOT experience paresthesias with median nerve neuropathy? A. first (thumb) B. second (index) C. third (long) D. fourth (ring) E. fifth (pinky) Correct Answer: Answer: E, fifth (pinky) The fifth finger is ALWAYS innervated by the ulnar nerve, and would not be affected in a true carpal tunnel syndrome. A 22 year-old female complains of vaginal bleeding for 24 hours. Her last menstrual cycle was seven weeks ago She has had an IUD, but currently uses no form of contraception. Her HCG is positive. She denies fever, chills and vaginal discharge, prior to the onset of the vaginal bleeding. You order a pelvic ultrasound to rule out: A. cervicitis. B. pelvic inflammatory disease. C. dysfunctional uterine bleeding. D. an ectopic pregnancy. E. vaginitis. Correct Answer: Answer: D, an ectopic pregnancy. Any patient with an IUD, or with a tubal ligation, or known obstruction of a tube, who has a positive HCG needs an ultrasound to r/o ectopic pregnancy. The examination of a 26 year-old male demonstrates a "bag of worms" consistency within the left hemiscrotum. This finding is suggestive of a(n): A. acute case of balanitis B. varicocele. C. hydrocele. D. spermatocele. E. paraphimosis. Correct Answer: Answer: B, varicocele. This is a description of varicocele (varicose veins of the scrotum). Hydrocele is just a water collection in the scrotum. Spermatocele is just a fluid collection which happens to contain sperm (sperm are not palpable). A patient presents with a recurrent history of swelling on the right side of the jaw that begins while eating and subsides within two hours postprandially. You suspect: A. hypochondriasis B. sialolithiasis C. parotitis. D. an abscessed tooth. E. conjunctivitis manibularis. Correct Answer: Answer: B, sialolithiasis Sialo(salivary gland) lithiasis (stone) is described in this question. Parotitis would be inflammation and infection of the parotid gland (usually due to a stone that is stuck in the duct). A parotitis patient would be acutely ill with redness of the gland and fever. Which of the following is the earliest manifestation of diabetic nephropathy? A. proteinuria B. a progressive decline in the creatinine clearance C. an elevated serum haptoglobin D. renal insufficiency E. microalbuminuria Correct Answer: Answer: E, microalbuminuria Tiny amounts of albumin (microalbumin) show up first - but need a special test ordered to detect it. Intervention at this point with an ACEI prolongs the length of time before the patient progresses to albuminuria (noted on a typical urine "dip") Fluid from a thoracentesis is grossly purulent. The effusion from which this fluid was aspirated is best described as a(n): A. loculated effusion B. chylothorax. C. empyema. D. hydrothorax. E. hemothorax. Correct Answer: Answer: C, empyema. A grossly purulent tap would suggest staph (empyema). Loculated effusion does not describe either a trans or exudative effusion. Chylo and hydro thorax suggest a transudative effusion (not purulent). And hemothorax is blood