APEA PRACTICE QUESTIONS AND ANSWERS TEST BANK
l APEA practice1.
Answer: he should be referred to the emergency department
Two differential diagnosis that must be included with a complaint of sudden, severe scrotal pain are
testicular torsion and epididymitis. Historical findings suggestive of testicular torsion are pain following
groin trauma, age (adolescence), and sudden onset of symptoms. If testicular torsion is the cause of his
pain, immediate referral to the ER/hospital is paramount. Testicular torsion produces ischemia in the
affected testis. The viability of the testicle will become compromised if this persists beyond 4−6 hours.
Obtaining an ultrasound will delay treatment. A common assessment finding is a high riding testicle on
the affect side occurring secondary to shortening of the spermatic cord.
2. Answer: this can expose you to STDs
Sexual activity during pregnancy could cause exposure to an STD or precipitate preterm labor because
the lower uterine segment may be physically stimulated. Additionally, oxytocin is released, which may
precipitate preterm labor. However, in the absence of complications associated with the pregnancy,
sexual activity is not contraindicated. If vaginal discharge or bleeding occurs; or rupture of membranes
occurs, sexual intercourse should be avoided until assessed by the patient’s provider. STDs should be
screened for and treated.
3. Answer: temporal arteritis
Polymyalgia rheumatica (PMR) is chronic inflammatory condition that produces morning stiffness in the
neck, shoulders, and hips. Its peak incidence is 70−80 years old. PMR is commonly associated with
temporal arteritis, also known as giant cell arteritis. Temporal arteritis is a chronic vasculitis of the
medium and large vessels. Temporal arteritis is characterized by new onset of unilateral temporal
headache, abrupt onset of visual disturbances, elevated sedimentation rate, jaw claudication, and
unexplained fever. this is best diagnosed by temporal artery biopsy. She should be referred to neurology
for evaluation today.
4. Answer: distant vision
The snellen eye chart was named after Dr. Hermann Snellen. The Snellen fractions, 20/20, 20/30, etc.
Are measures of sharpness of distant vision. Acutally, 20/20 is not normal vision; it is a reference
standard. Average acuity in a population is 20/15 or 20/10 (hence the reason there are two lines
beneath the 20/20 vision line). When visual acuity is assessed, each eye is covered and assessed
independently, this is termed monocular.
5. Answer: improves urine flow
Saw palmetto is an extract of fruit of the American dwarf tree. It is commonly used to treat benign
prostatic hypertrophy (BPH) but there is no objective data supporting its use. It is available over the
counter and is purchased by men for BPH. It has an unknown mechanism of action, but men with BPH
report a subjective increase in urine flow rate when taking saw palmetto
6. Answer: pantoprazole
If a patient has been diagnosed with GERD and he is symptomatic on an H2 blocker like ranitidine, a PPI
should be considerd. AN example of PPI is pantoprazole. Relief of symptoms after using a PPI does not
,indicate a benign condition. This patient could have esophageal erosions, Barrett’s esophagitis, or
esophageal cancer. He should be screened for risk factors for these conditions and then a decision to
refer this patient to gastroenterology can be made.
7. Answer: stoke or TIA
A new onset headache in an 80 yo is not likely to be due to an adverse drug event. Stroke risk increases
as age increases. TIA is defined as an episode of transient neurologic dysfunction without acute
infarction. Bell’s palsy is accompanied by facial numbness and sometimes slurred speech occurs if the
upper lip is affected, but headache and an ataxic gait do not accompany Bell’s palsy. Alcohol intoxication
might be considered, but stroke must be ruled out. When headache accompanies stroke, it is often
hemorrhagic stroke, but ischemic stroke can cause headache too.
8. Answer: anxiety disorders
Affective disorders, anxiety disorders, and substance abuse issues are common in patients who have
eating disorders. Obsessive−compulsive disorder is also commonly observed. Patients with eating
disorders are more likely to have a first or second degree relative with an eating disorder, affective
disorder, or alcohol abuse. There is no evidence that patients with eating disorders exhibit a higher
incidence of sleep disorders or liver disease. Thyroid disease should always be assessed in patients with
eating disorders, but this does not represent the reason for weight loss when eating disorder is present.
9. Answer: screen at each visit
Depression is common in all adults, especially older adults. Screening can be accomplished easily and
quickly in a primary care setting. Untreated depression leads to higher rates of mortality when other
comorbid conditions exist, especially heart disease.
10. Answer: chronic prostatitis
Chronic prostatitis can produce these symptoms. Sometimes this is accompanied by perineal pain, but
the patient may have a normal prostate exam. Acute bacterial prostatitis patients will present with
fever, chills. Examination of the prostate gland reveals a tender, boggy prostate gland. Epididymitis can
produce scrotal pain, not dysuria or irritation with voiding. Asymptomatic bacteriuria is asymptomatic.
These patients don’t know they have this because they have no symptoms.
11. Answer: increased potassium level
Lisinopril is an ACE inhibitor. This medication causes retention of potassium. A potassium level should be
measured about 1 month after initiating therapy and after each dose change. THe other laboratory
values are not specific to changes that can take place when a patient is on on ACE inhibitor.
12. Answer: metoprolol
Beta blockers like metoprolol are indicated to alleviate atrial or ventricular arrhythmias associated with
mitral valve prolapse. However, long−term effectiveness of beta blockers is uncertain. Most patients
with MVP who do not have symptoms of arrhythmias or ectopy at rest usually do not require further
evaluation. However, they should be monitored at least annually for a change in their condition.
13. Answer: in the calf muscle
,This patient’s symptoms are typical of arteriosclerosis. the term used to describe this patient’s symptom
is intermittent claudication. When there is compromised arterial blood flow in the lower legs, a common
complaint is reproducible pain in a specific group of muscles. the pain occurs because there is an
incongruence between blood supply and demand. This produces pain that causes a patient to stop
exercising in order to obtain pain relief.
14. Answer: osteoporosis
Atheltic amenorrhea is a secondary cause of amenorrhea that is observed in females who engage in
excessive amounts of exercise. Excessive exercise can produce significant loss of body fat. Since estrogen
is produced by the body’s fat tissue, there is a subsequent loss in the ability to produce adequate
amounts of estrogen. when this occurs, infertility, vaginal and breast atrophy, and osteopenia are very
likely.
15. Answer: acute lymphocytic leukemia
This child’s platelet count is decreased. The term used to describe this is thrombocytopenia. Acute
lymphocytic leukemia (ALL) is often characterized by low platelet count and other red or white cell
abnormalities. the peak incidence occurs between 2−5 years of age. the most common presenting signs
of ALL are bleeding, fever, and lymphadenopathy. Idiopathic thrombocytopenia (ITP) is the most
common type found in children between the ages of 2−4 years and is preceded by a recent (less than 4
weeks) upper respiratory infection. The Non blanchable rash over the joints probably represents
petechiae, a common manifestation of thrombocytopenia and can be seen with both ITP and ALL.
Nosebleeds and bleeding gums, especially with brushing of teeth, are also common with
thrombocytopenia; however if the thrombocytopenia is mild, there may not be presenting symptoms.
The CBC is otherwise normal in ITP, unlike ALL. The underlying cause is unknown, hence the name
idiopathic. Septic arthritis would be characterized by an elevated white count. Von Willebrand’s disease
(VWD) is a common autosomal dominant bleeding disorder that may include easy bruising or prolonged
bleeding, but is characterized by a normal platelet count.
16. Answer:furosemide
Gout is characterized by hyperuricemia. Uric acid levels are increased when a patient consumes any
medication that results in less circulating fluid volume, specifically fluid volume, any diuretic. Diuretics
such as furosemide will produce hyperuricemia and thus increase the risk of gout in susceptible patients.
Diuretics should be avoided when possible in patients who have a history of gout.
17. Answer: gallbladder disease
One of the major components of gallstones is estrogen. A patient with underlying gallbladder disease
should not take oracl contraceptives (OC) since they will increase estrogen exposure and theoretically,
formation of gallstones. Depression, hypothyroidism and varicose veins are not increased by use of oral
contraceptives.
18. Answer: urinary albumin to creatinine ration and eGFR
2017 American Diabetes Association (ADA) recommends urinary albumin−to−creatinine ration and an
estimated GFR (eGFR) at least once a year in all patients who have Type 2 diabetes. It is an appropriate
screen for undiagnosed diabetic nephropathy. Previously, microalbuminuria was the standard of care.
, 19. Answer: 80−130 mg/dL
Considering this patient’s age and risk of hypoglycemia, a reasonable goal is 80−130mg/dL preprandial. A
value less than 130mg/dL is desirable, but not less than 80 mg/dL. The goal peak postprandial capillary
plasma glucose should be less than 180 mg/dL. Hypoglycemia during sleep can result in stroke or
seizures in this age group.
20. Answer: 36 months of age
A child’s head is usually measured at each periodic well child visit until he has attained the age of 36
months. During the first 3 years of life, these measurements are recorded on a grwoth chart so that
changes in head circumference can be followed and percentile for age and rate of growth can be
determined. Measure head circumference over the largest circumference of the head occipital frontal
circumference (OFC), namely the most prominent part on the back of the head (occiput) and just above
the eyebrows (supraorbital ridges). this can be translated to mean the largest circumference of the
head. Head circumference should correlat4e with teh child’s length (eg if length is in the 40th percentile,
head circumference should also be in the 40th percentile).
21. Answer: postprandial glucose elevation
The earliest glycemic abnormality is postprandial glucose elevation. Early in the pathogenesis of
diabetes, glucose levels increase to abnormal levels after eating. Over the next few hours, if the patient
does not eat, the glucose levels will fall to a normal range again, via many different physiologic
mechanisms. This may occur for months or years before glucose levels become consistently elevated
and are not able to return to normal despite long periods of fasting. Once glucose levels are elevated
and remain elevated, patients usually experience symptoms such as fatigue, thirst, frequent urination,
and hunger.
22. Answer: Elevated AST, ALT, & GGT
Liver enzymes rise in response to acute injury to the liver. AST and ALT are frequently elevated when
alcohol abuse occurs. Specifically, the AST is usually the higher of the two enzymes and can signify
alcohol abuse when it is more than two times greater than the ALT. In patients who abuse alcohol daily,
the ALT and AST may be normal. GGT, gamma−glutamyl transferase, is often elevated even when AST
and ALT are normal. It can help identify damage to the liver as a result of alcohol abuse.
23. Answer: he may have a GI bleed
This microcytic, hypochromic anemia is most likely due to iron deficiency anemia. The most likely cause
of iron deficiency anemia in an older male is a GI bleed. Malignancy is possible, but workup at this point
is premature. Excessive consumption of alcohol may produce macrocytic anemia secondary to
malabsorption of vitamin B12 and/or folate deficiency.
24. Answer: amenorrhea, vaginal bleeding, abdominal pain
A majority of patients with ectopic pregnancy report these common symptoms: abdominal pain: 99%,
amenorrhea 74%, and vaginal bleeding 56%. Classic symptoms of an ectopic pregnancy usually appear 6−
8 weeks after last menstrual period. the usual symptoms of pregnancy are also present. Shoulder pain
can be present after the tube has ruptured because blood irritates the diaphragm, producing referred
l APEA practice1.
Answer: he should be referred to the emergency department
Two differential diagnosis that must be included with a complaint of sudden, severe scrotal pain are
testicular torsion and epididymitis. Historical findings suggestive of testicular torsion are pain following
groin trauma, age (adolescence), and sudden onset of symptoms. If testicular torsion is the cause of his
pain, immediate referral to the ER/hospital is paramount. Testicular torsion produces ischemia in the
affected testis. The viability of the testicle will become compromised if this persists beyond 4−6 hours.
Obtaining an ultrasound will delay treatment. A common assessment finding is a high riding testicle on
the affect side occurring secondary to shortening of the spermatic cord.
2. Answer: this can expose you to STDs
Sexual activity during pregnancy could cause exposure to an STD or precipitate preterm labor because
the lower uterine segment may be physically stimulated. Additionally, oxytocin is released, which may
precipitate preterm labor. However, in the absence of complications associated with the pregnancy,
sexual activity is not contraindicated. If vaginal discharge or bleeding occurs; or rupture of membranes
occurs, sexual intercourse should be avoided until assessed by the patient’s provider. STDs should be
screened for and treated.
3. Answer: temporal arteritis
Polymyalgia rheumatica (PMR) is chronic inflammatory condition that produces morning stiffness in the
neck, shoulders, and hips. Its peak incidence is 70−80 years old. PMR is commonly associated with
temporal arteritis, also known as giant cell arteritis. Temporal arteritis is a chronic vasculitis of the
medium and large vessels. Temporal arteritis is characterized by new onset of unilateral temporal
headache, abrupt onset of visual disturbances, elevated sedimentation rate, jaw claudication, and
unexplained fever. this is best diagnosed by temporal artery biopsy. She should be referred to neurology
for evaluation today.
4. Answer: distant vision
The snellen eye chart was named after Dr. Hermann Snellen. The Snellen fractions, 20/20, 20/30, etc.
Are measures of sharpness of distant vision. Acutally, 20/20 is not normal vision; it is a reference
standard. Average acuity in a population is 20/15 or 20/10 (hence the reason there are two lines
beneath the 20/20 vision line). When visual acuity is assessed, each eye is covered and assessed
independently, this is termed monocular.
5. Answer: improves urine flow
Saw palmetto is an extract of fruit of the American dwarf tree. It is commonly used to treat benign
prostatic hypertrophy (BPH) but there is no objective data supporting its use. It is available over the
counter and is purchased by men for BPH. It has an unknown mechanism of action, but men with BPH
report a subjective increase in urine flow rate when taking saw palmetto
6. Answer: pantoprazole
If a patient has been diagnosed with GERD and he is symptomatic on an H2 blocker like ranitidine, a PPI
should be considerd. AN example of PPI is pantoprazole. Relief of symptoms after using a PPI does not
,indicate a benign condition. This patient could have esophageal erosions, Barrett’s esophagitis, or
esophageal cancer. He should be screened for risk factors for these conditions and then a decision to
refer this patient to gastroenterology can be made.
7. Answer: stoke or TIA
A new onset headache in an 80 yo is not likely to be due to an adverse drug event. Stroke risk increases
as age increases. TIA is defined as an episode of transient neurologic dysfunction without acute
infarction. Bell’s palsy is accompanied by facial numbness and sometimes slurred speech occurs if the
upper lip is affected, but headache and an ataxic gait do not accompany Bell’s palsy. Alcohol intoxication
might be considered, but stroke must be ruled out. When headache accompanies stroke, it is often
hemorrhagic stroke, but ischemic stroke can cause headache too.
8. Answer: anxiety disorders
Affective disorders, anxiety disorders, and substance abuse issues are common in patients who have
eating disorders. Obsessive−compulsive disorder is also commonly observed. Patients with eating
disorders are more likely to have a first or second degree relative with an eating disorder, affective
disorder, or alcohol abuse. There is no evidence that patients with eating disorders exhibit a higher
incidence of sleep disorders or liver disease. Thyroid disease should always be assessed in patients with
eating disorders, but this does not represent the reason for weight loss when eating disorder is present.
9. Answer: screen at each visit
Depression is common in all adults, especially older adults. Screening can be accomplished easily and
quickly in a primary care setting. Untreated depression leads to higher rates of mortality when other
comorbid conditions exist, especially heart disease.
10. Answer: chronic prostatitis
Chronic prostatitis can produce these symptoms. Sometimes this is accompanied by perineal pain, but
the patient may have a normal prostate exam. Acute bacterial prostatitis patients will present with
fever, chills. Examination of the prostate gland reveals a tender, boggy prostate gland. Epididymitis can
produce scrotal pain, not dysuria or irritation with voiding. Asymptomatic bacteriuria is asymptomatic.
These patients don’t know they have this because they have no symptoms.
11. Answer: increased potassium level
Lisinopril is an ACE inhibitor. This medication causes retention of potassium. A potassium level should be
measured about 1 month after initiating therapy and after each dose change. THe other laboratory
values are not specific to changes that can take place when a patient is on on ACE inhibitor.
12. Answer: metoprolol
Beta blockers like metoprolol are indicated to alleviate atrial or ventricular arrhythmias associated with
mitral valve prolapse. However, long−term effectiveness of beta blockers is uncertain. Most patients
with MVP who do not have symptoms of arrhythmias or ectopy at rest usually do not require further
evaluation. However, they should be monitored at least annually for a change in their condition.
13. Answer: in the calf muscle
,This patient’s symptoms are typical of arteriosclerosis. the term used to describe this patient’s symptom
is intermittent claudication. When there is compromised arterial blood flow in the lower legs, a common
complaint is reproducible pain in a specific group of muscles. the pain occurs because there is an
incongruence between blood supply and demand. This produces pain that causes a patient to stop
exercising in order to obtain pain relief.
14. Answer: osteoporosis
Atheltic amenorrhea is a secondary cause of amenorrhea that is observed in females who engage in
excessive amounts of exercise. Excessive exercise can produce significant loss of body fat. Since estrogen
is produced by the body’s fat tissue, there is a subsequent loss in the ability to produce adequate
amounts of estrogen. when this occurs, infertility, vaginal and breast atrophy, and osteopenia are very
likely.
15. Answer: acute lymphocytic leukemia
This child’s platelet count is decreased. The term used to describe this is thrombocytopenia. Acute
lymphocytic leukemia (ALL) is often characterized by low platelet count and other red or white cell
abnormalities. the peak incidence occurs between 2−5 years of age. the most common presenting signs
of ALL are bleeding, fever, and lymphadenopathy. Idiopathic thrombocytopenia (ITP) is the most
common type found in children between the ages of 2−4 years and is preceded by a recent (less than 4
weeks) upper respiratory infection. The Non blanchable rash over the joints probably represents
petechiae, a common manifestation of thrombocytopenia and can be seen with both ITP and ALL.
Nosebleeds and bleeding gums, especially with brushing of teeth, are also common with
thrombocytopenia; however if the thrombocytopenia is mild, there may not be presenting symptoms.
The CBC is otherwise normal in ITP, unlike ALL. The underlying cause is unknown, hence the name
idiopathic. Septic arthritis would be characterized by an elevated white count. Von Willebrand’s disease
(VWD) is a common autosomal dominant bleeding disorder that may include easy bruising or prolonged
bleeding, but is characterized by a normal platelet count.
16. Answer:furosemide
Gout is characterized by hyperuricemia. Uric acid levels are increased when a patient consumes any
medication that results in less circulating fluid volume, specifically fluid volume, any diuretic. Diuretics
such as furosemide will produce hyperuricemia and thus increase the risk of gout in susceptible patients.
Diuretics should be avoided when possible in patients who have a history of gout.
17. Answer: gallbladder disease
One of the major components of gallstones is estrogen. A patient with underlying gallbladder disease
should not take oracl contraceptives (OC) since they will increase estrogen exposure and theoretically,
formation of gallstones. Depression, hypothyroidism and varicose veins are not increased by use of oral
contraceptives.
18. Answer: urinary albumin to creatinine ration and eGFR
2017 American Diabetes Association (ADA) recommends urinary albumin−to−creatinine ration and an
estimated GFR (eGFR) at least once a year in all patients who have Type 2 diabetes. It is an appropriate
screen for undiagnosed diabetic nephropathy. Previously, microalbuminuria was the standard of care.
, 19. Answer: 80−130 mg/dL
Considering this patient’s age and risk of hypoglycemia, a reasonable goal is 80−130mg/dL preprandial. A
value less than 130mg/dL is desirable, but not less than 80 mg/dL. The goal peak postprandial capillary
plasma glucose should be less than 180 mg/dL. Hypoglycemia during sleep can result in stroke or
seizures in this age group.
20. Answer: 36 months of age
A child’s head is usually measured at each periodic well child visit until he has attained the age of 36
months. During the first 3 years of life, these measurements are recorded on a grwoth chart so that
changes in head circumference can be followed and percentile for age and rate of growth can be
determined. Measure head circumference over the largest circumference of the head occipital frontal
circumference (OFC), namely the most prominent part on the back of the head (occiput) and just above
the eyebrows (supraorbital ridges). this can be translated to mean the largest circumference of the
head. Head circumference should correlat4e with teh child’s length (eg if length is in the 40th percentile,
head circumference should also be in the 40th percentile).
21. Answer: postprandial glucose elevation
The earliest glycemic abnormality is postprandial glucose elevation. Early in the pathogenesis of
diabetes, glucose levels increase to abnormal levels after eating. Over the next few hours, if the patient
does not eat, the glucose levels will fall to a normal range again, via many different physiologic
mechanisms. This may occur for months or years before glucose levels become consistently elevated
and are not able to return to normal despite long periods of fasting. Once glucose levels are elevated
and remain elevated, patients usually experience symptoms such as fatigue, thirst, frequent urination,
and hunger.
22. Answer: Elevated AST, ALT, & GGT
Liver enzymes rise in response to acute injury to the liver. AST and ALT are frequently elevated when
alcohol abuse occurs. Specifically, the AST is usually the higher of the two enzymes and can signify
alcohol abuse when it is more than two times greater than the ALT. In patients who abuse alcohol daily,
the ALT and AST may be normal. GGT, gamma−glutamyl transferase, is often elevated even when AST
and ALT are normal. It can help identify damage to the liver as a result of alcohol abuse.
23. Answer: he may have a GI bleed
This microcytic, hypochromic anemia is most likely due to iron deficiency anemia. The most likely cause
of iron deficiency anemia in an older male is a GI bleed. Malignancy is possible, but workup at this point
is premature. Excessive consumption of alcohol may produce macrocytic anemia secondary to
malabsorption of vitamin B12 and/or folate deficiency.
24. Answer: amenorrhea, vaginal bleeding, abdominal pain
A majority of patients with ectopic pregnancy report these common symptoms: abdominal pain: 99%,
amenorrhea 74%, and vaginal bleeding 56%. Classic symptoms of an ectopic pregnancy usually appear 6−
8 weeks after last menstrual period. the usual symptoms of pregnancy are also present. Shoulder pain
can be present after the tube has ruptured because blood irritates the diaphragm, producing referred
