PACKRAT 2|Questions With Correct Answers|Verified
A 23 year-old male with recent upper respiratory symptoms presents complaining of
chest pain. His pain is worse lying down and better sitting up and leaning forward.
Electrocardiogram shows widespread ST segment elevation. Which of the following is
the most likely physical examination finding in this patient?
A. Elevated blood pressure
B. Subungual hematoma
C. Diastolic murmur
D. Pericardial friction rub - ✅(u) A. Acute pericarditis is usually not associated with
elevated blood pressure. One would expect to see hypertensive pressures in the setting
of an aortic dissection.
(u) B. Subungual hematomas are usually seen in endocarditis not pericarditis.
(u) C. A diastolic murmur in a patient with chest pain would likely be associated with
acute aortic regurgitation in the setting of an aortic dissection.
(c) D. This patient has symptoms consistent with acute pericarditis and would most
likely have a pericardial friction rub on examination.
A 75 year-old woman presents to the office with complaint of vision loss. Examination
reveals a palpable cord in the temporal region. Which of the following is the most helpful
initial test to order on this patient?
A. Carotid ultrasound
B. Chest x-ray
C. Complete blood count
D. Erythrocyte sedimentation rate - ✅(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. The patient is suspected of having temporal arteritis. This disease is most
commonly noted in patients over age 50 and should be suspected in patients with
sudden vision loss and a palpable cord in the temporal region. Erythrocyte
sedimentation rate is almost always increased in this disease.
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 - ✅(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(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.
Which of the following best describes the purpose of intravenous magnesium sulfate in
patients with preeclampsia?
,A. Prevention of convulsions
B. Prevention of HELLP syndrome
C. Lowering of blood pressure
D. Reversal of proteinuria - ✅(c) A. Magnesium sulfate is used to prevent and treat
eclamptic seizures. Magnesium sulfate is not sufficient to treat hypertension, therefore
antihypertensives must be added. Magnesium sulfate is excreted solely from the
kidneys and urine output must be preserved to prevent accumulation of the drug.
Magnesium sulfate does nothing to prevent HELLP syndrome.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 53 year-old male with history of hypertension presents complaining of recent 4/10 left-
sided chest pain with exertion that is relieved with rest. He states the pain usually lasts
approximately 4 minutes and is relieved with rest. Heart examination reveals regular
rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally.
Electrocardiogram reveals no acute changes. Which of the following is the most
appropriate initial step in the evaluation of this patient?
A. Cardiac catheterization
B. CT Angiogram of the chest
C. Echocardiogram
D. Nuclear stress test - ✅(u) A. This patient has signs and symptoms consistent with
stable angina. Noninvasive diagnostic testing is preferred in this patient.
(u) B. CT angiogram may be useful for the evaluation of chest pain, however its role in
routine practice has not been established.
(u) C. This patient has signs and symptoms of stable angina. There are no signs of
valvular heart disease on examination. While an echocardiogram may be performed at
some point, it is not the best initial diagnostic step to determine the etiology of the
patient's angina.
(c) D. Nuclear stress testing is the most appropriate initial diagnostic study in the
evaluation of a patient with signs and symptoms consistent with stable angina.
A 36 year-old African American female comes to the clinic for an insurance physical
which requires a chest x-ray. She denies any respiratory symptoms. Examination of her
chest is negative. X-ray results show marked lymphadenopathy in the right paratracheal
region. Angiotensin-converting enzyme (ACE) levels are elevated. Which of the
following is the most likely diagnosis?
A. Sarcoidosis
B. Tuberculosis
C. Pulmonary fibrosis
D. Lymphoma - ✅(c) A. Sarcoidosis is characterized by paratracheal lymphadenopathy
and elevated ACE levels. It is more common in African American patients and may be
asymptomatic.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
,A 33 year-old male presents to your office with a complaint of right knee injury
associated with pain and swelling. He states he was running after his loose dog and
suddenly stopped, hyperextended his knee, heard a pop and noticed immediate
swelling. On physical examination, the Lachman test and anterior drawer test
demonstrates joint laxity. Which of the following ligaments is most likely injured?
A. Medial collateral
B. Lateral collateral
C. Posterior cruciate
D. Anterior cruciate - ✅(u) A. Medial collateral ligament injuries often occur with
rotational injuries or direct impact to the lateral knee. Tenderness medially with laxity
with valgus (medial) stress is noted.
(u) B. Lateral collateral ligament injury causes pain mostly on the lateral aspect of the
knee and patients can experience knee buckling with normal gait. Tenderness laterally
with laxity with varus (lateral) stress is noted.
(u) C. Posterior cruciate ligament injuries occur with an outside directed force, often a
posterior directed force such as a knee striking a dashboard. The patients often do not
hear a pop. A posterior drawer test or posterior sag test can be useful in the diagnosis.
(c) D. Anterior cruciate ligament injuries occur with sudden deceleration injuries.
Patients often hear a pop and the diagnosis is aided by assessing the anterior drawer
test and Lachman test. The immediate swelling as well as laxity with anterior drawer
test and Lachman test should raise suspicion of anterior cruciate ligamental injury.
A 22 year-old woman comes to the office because her urine is cola-colored and she has
not urinated since yesterday morning. Her past medical history is significant for
pharyngitis two weeks ago. Her mother and grandmother have type 2 diabetes. Her
blood pressure is 146/92mmHG. On physical examination, she has edema of her face
and hands. Which of the following is the most likely diagnosis?
A. Glomerulonephritis
B. Acute tubular necrosis
C. Nephrolithiasis
D. Diabetic nephropathy - ✅(c) A. Glomerulonephritis presents with hematuria, cola-
colored urine, oliguria, and edema of the face and eyes in the morning. Urinalysis
reveals red blood cells, mild proteinuria and red blood cell casts. Glomerulonephritis can
occur 1-3 weeks after a strep infection.
(u) B. Acute tubular necrosis is caused by acute kidney injury, such as a nephrotoxin,
and is associated with uremic symptoms which include nausea, vomiting, malaise, and
altered mental status. Granular casts are nonspecific and may be seen in acute tubular
necrosis.
(u) C. Nephrolithiasis usually presents as a sudden onset of colicky flank pain with
associated nausea and vomiting. Urinalysis often reveals gross or microscopic
hematuria.
(u) D. Diabetic nephropathy is the most common cause of end stage renal disease in
the United States. Urine examination reveals albuminuria.
, A 15 year-old girl is hit in the right eye by a golf ball. There is swelling and ecchymosis
of the orbit. She complains of double vision. The right eye does not move with
downward gaze or right lateral gaze. Which of the following diagnostic tests will provide
the most accurate information regarding this injury?
A. Facial x-ray
B. Schiotz tonometry
C. Fluorescein angiography
D. Slit lamp biomicroscopy - ✅(c) A. X-ray films may show a blow-out fracture of the
orbital floor. Such fractures may lead to oculomotor nerve entrapment or may lead to
swelling that impinges on the nerve, causing decreased eye movements.
(u) B. Schiotz tonometry is used to evaluate intraocular pressures; elevated pressure
indicates glaucoma.
(u) C. Fluorescein angiography is used to evaluate retinopathies.
(u) D. Slit lamp biomicroscopy is used to evaluate lid contour, lesions, lashes,
conjunctiva, sclera, cornea, anterior chamber, and lens.
A 68 year-old male with a history of atrial fibrillation treated with warfarin (Coumadin)
presents to the emergency department after vomiting large amounts of bright red blood.
INR is 3. Which of the following is most appropriate to rapidly lower the patient's INR?
A. Discontinue warfarin
B. Administer fresh frozen plasma
C. Administer protamine sulfate
D. Administer heparin sulphate - ✅(u) A. This will not immediately reverse the effects of
warfarin.
(c) B. Fresh frozen plasma is the most rapid way to lower the patient's INR.
(u) C. Protamine sulfate is used to neutralize heparin sulphate not warfarin.
(h) D. Heparin administration would increase the bleeding and be harmful.
A 48 year-old male with diabetes mellitus presents for routine physical examination. Of
note his blood pressure each of his last two follow-up visits was 150/90 mmHg. Today
the patient's BP is 148/88 mmHg. The patient denies complaints of chest pain, change
in vision, or headache. Which of the following is the most appropriate management for
this patient?
A. Atenolol (Tenormin)
B. Nifedipine (Procardia)
C. Hydralazine (Apresoline)
D. Lisinopril (Zestril) - ✅(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. ACE inhibitors are the first line treatment of choice in a patient with hypertension
and diabetes.
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 23 year-old male with recent upper respiratory symptoms presents complaining of
chest pain. His pain is worse lying down and better sitting up and leaning forward.
Electrocardiogram shows widespread ST segment elevation. Which of the following is
the most likely physical examination finding in this patient?
A. Elevated blood pressure
B. Subungual hematoma
C. Diastolic murmur
D. Pericardial friction rub - ✅(u) A. Acute pericarditis is usually not associated with
elevated blood pressure. One would expect to see hypertensive pressures in the setting
of an aortic dissection.
(u) B. Subungual hematomas are usually seen in endocarditis not pericarditis.
(u) C. A diastolic murmur in a patient with chest pain would likely be associated with
acute aortic regurgitation in the setting of an aortic dissection.
(c) D. This patient has symptoms consistent with acute pericarditis and would most
likely have a pericardial friction rub on examination.
A 75 year-old woman presents to the office with complaint of vision loss. Examination
reveals a palpable cord in the temporal region. Which of the following is the most helpful
initial test to order on this patient?
A. Carotid ultrasound
B. Chest x-ray
C. Complete blood count
D. Erythrocyte sedimentation rate - ✅(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. The patient is suspected of having temporal arteritis. This disease is most
commonly noted in patients over age 50 and should be suspected in patients with
sudden vision loss and a palpable cord in the temporal region. Erythrocyte
sedimentation rate is almost always increased in this disease.
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 - ✅(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(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.
Which of the following best describes the purpose of intravenous magnesium sulfate in
patients with preeclampsia?
,A. Prevention of convulsions
B. Prevention of HELLP syndrome
C. Lowering of blood pressure
D. Reversal of proteinuria - ✅(c) A. Magnesium sulfate is used to prevent and treat
eclamptic seizures. Magnesium sulfate is not sufficient to treat hypertension, therefore
antihypertensives must be added. Magnesium sulfate is excreted solely from the
kidneys and urine output must be preserved to prevent accumulation of the drug.
Magnesium sulfate does nothing to prevent HELLP syndrome.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 53 year-old male with history of hypertension presents complaining of recent 4/10 left-
sided chest pain with exertion that is relieved with rest. He states the pain usually lasts
approximately 4 minutes and is relieved with rest. Heart examination reveals regular
rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally.
Electrocardiogram reveals no acute changes. Which of the following is the most
appropriate initial step in the evaluation of this patient?
A. Cardiac catheterization
B. CT Angiogram of the chest
C. Echocardiogram
D. Nuclear stress test - ✅(u) A. This patient has signs and symptoms consistent with
stable angina. Noninvasive diagnostic testing is preferred in this patient.
(u) B. CT angiogram may be useful for the evaluation of chest pain, however its role in
routine practice has not been established.
(u) C. This patient has signs and symptoms of stable angina. There are no signs of
valvular heart disease on examination. While an echocardiogram may be performed at
some point, it is not the best initial diagnostic step to determine the etiology of the
patient's angina.
(c) D. Nuclear stress testing is the most appropriate initial diagnostic study in the
evaluation of a patient with signs and symptoms consistent with stable angina.
A 36 year-old African American female comes to the clinic for an insurance physical
which requires a chest x-ray. She denies any respiratory symptoms. Examination of her
chest is negative. X-ray results show marked lymphadenopathy in the right paratracheal
region. Angiotensin-converting enzyme (ACE) levels are elevated. Which of the
following is the most likely diagnosis?
A. Sarcoidosis
B. Tuberculosis
C. Pulmonary fibrosis
D. Lymphoma - ✅(c) A. Sarcoidosis is characterized by paratracheal lymphadenopathy
and elevated ACE levels. It is more common in African American patients and may be
asymptomatic.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
,A 33 year-old male presents to your office with a complaint of right knee injury
associated with pain and swelling. He states he was running after his loose dog and
suddenly stopped, hyperextended his knee, heard a pop and noticed immediate
swelling. On physical examination, the Lachman test and anterior drawer test
demonstrates joint laxity. Which of the following ligaments is most likely injured?
A. Medial collateral
B. Lateral collateral
C. Posterior cruciate
D. Anterior cruciate - ✅(u) A. Medial collateral ligament injuries often occur with
rotational injuries or direct impact to the lateral knee. Tenderness medially with laxity
with valgus (medial) stress is noted.
(u) B. Lateral collateral ligament injury causes pain mostly on the lateral aspect of the
knee and patients can experience knee buckling with normal gait. Tenderness laterally
with laxity with varus (lateral) stress is noted.
(u) C. Posterior cruciate ligament injuries occur with an outside directed force, often a
posterior directed force such as a knee striking a dashboard. The patients often do not
hear a pop. A posterior drawer test or posterior sag test can be useful in the diagnosis.
(c) D. Anterior cruciate ligament injuries occur with sudden deceleration injuries.
Patients often hear a pop and the diagnosis is aided by assessing the anterior drawer
test and Lachman test. The immediate swelling as well as laxity with anterior drawer
test and Lachman test should raise suspicion of anterior cruciate ligamental injury.
A 22 year-old woman comes to the office because her urine is cola-colored and she has
not urinated since yesterday morning. Her past medical history is significant for
pharyngitis two weeks ago. Her mother and grandmother have type 2 diabetes. Her
blood pressure is 146/92mmHG. On physical examination, she has edema of her face
and hands. Which of the following is the most likely diagnosis?
A. Glomerulonephritis
B. Acute tubular necrosis
C. Nephrolithiasis
D. Diabetic nephropathy - ✅(c) A. Glomerulonephritis presents with hematuria, cola-
colored urine, oliguria, and edema of the face and eyes in the morning. Urinalysis
reveals red blood cells, mild proteinuria and red blood cell casts. Glomerulonephritis can
occur 1-3 weeks after a strep infection.
(u) B. Acute tubular necrosis is caused by acute kidney injury, such as a nephrotoxin,
and is associated with uremic symptoms which include nausea, vomiting, malaise, and
altered mental status. Granular casts are nonspecific and may be seen in acute tubular
necrosis.
(u) C. Nephrolithiasis usually presents as a sudden onset of colicky flank pain with
associated nausea and vomiting. Urinalysis often reveals gross or microscopic
hematuria.
(u) D. Diabetic nephropathy is the most common cause of end stage renal disease in
the United States. Urine examination reveals albuminuria.
, A 15 year-old girl is hit in the right eye by a golf ball. There is swelling and ecchymosis
of the orbit. She complains of double vision. The right eye does not move with
downward gaze or right lateral gaze. Which of the following diagnostic tests will provide
the most accurate information regarding this injury?
A. Facial x-ray
B. Schiotz tonometry
C. Fluorescein angiography
D. Slit lamp biomicroscopy - ✅(c) A. X-ray films may show a blow-out fracture of the
orbital floor. Such fractures may lead to oculomotor nerve entrapment or may lead to
swelling that impinges on the nerve, causing decreased eye movements.
(u) B. Schiotz tonometry is used to evaluate intraocular pressures; elevated pressure
indicates glaucoma.
(u) C. Fluorescein angiography is used to evaluate retinopathies.
(u) D. Slit lamp biomicroscopy is used to evaluate lid contour, lesions, lashes,
conjunctiva, sclera, cornea, anterior chamber, and lens.
A 68 year-old male with a history of atrial fibrillation treated with warfarin (Coumadin)
presents to the emergency department after vomiting large amounts of bright red blood.
INR is 3. Which of the following is most appropriate to rapidly lower the patient's INR?
A. Discontinue warfarin
B. Administer fresh frozen plasma
C. Administer protamine sulfate
D. Administer heparin sulphate - ✅(u) A. This will not immediately reverse the effects of
warfarin.
(c) B. Fresh frozen plasma is the most rapid way to lower the patient's INR.
(u) C. Protamine sulfate is used to neutralize heparin sulphate not warfarin.
(h) D. Heparin administration would increase the bleeding and be harmful.
A 48 year-old male with diabetes mellitus presents for routine physical examination. Of
note his blood pressure each of his last two follow-up visits was 150/90 mmHg. Today
the patient's BP is 148/88 mmHg. The patient denies complaints of chest pain, change
in vision, or headache. Which of the following is the most appropriate management for
this patient?
A. Atenolol (Tenormin)
B. Nifedipine (Procardia)
C. Hydralazine (Apresoline)
D. Lisinopril (Zestril) - ✅(u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. ACE inhibitors are the first line treatment of choice in a patient with hypertension
and diabetes.
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?
