PACKRAT 5 QUESTIONS AND ANSWERS
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 - Answers - 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 - Answers - 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 - Answers - 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 - Answers - 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.
,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 - Answers - 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 - Answers - A. Sarcoidosis is characterized by paratracheal
lymphadenopathy and elevated ACE levels. It is more common in African American
patients and may be asymptomatic.
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 - Answers - 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 - Answers - 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.
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 - Answers - 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.
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 - Answers - B. Fresh frozen plasma is the most rapid
way to lower the patient's INR.
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) - Answers - 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. Cherry angioma
B. Telangiectasia
C. Spider angioma
D. Pyogenic granuloma - Answers - B. Telangiectatic vessels are often visible skin
findings with basal cell carcinoma.
, 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 - Answers - 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.
Hypoglycemia in an elderly patient with diabetes is most likely to manifest as which of
the following symptoms?
A. Tachycardia
B. Diaphoresis
C. Intense hunger
D. Mental confusion - Answers - D. Manifestations of hypoglycemia in the elderly are
mainly from impaired central nervous system function.
Manifestations include mental confusion, bizarre behavior, and ultimately coma.
An 85 year-old nursing home resident presents with abrupt onset of cough, sore throat,
headache, myalgias, and malaise. On examination the patient's temperature is 102
degrees F; the rest of the exam is unremarkable. Nasal smear is positive for Influenza
B. Which of the following is the treatment of choice in this patient?
A. Amantadine (Symmetrel)
B. Oseltamivir (Tamiflu)
C. Acyclovir (Zovirax)
D. Nevirapine (Viramune) - Answers - B. Oseltamivir is used to treat both influenza A
and B.
A 36 year-old female presents for a routine physical. She has no current complaints and
her only medication is oral contraceptives. The patient is preparing for a trip to Australia
and is worried about the long flight as her mom has a
history of deep vein thrombosis after a long trip several years ago. Physical examination
reveals BP 110/60 mmHg, HR 66 bpm, regular. Heart is regular rate and rhythm without
murmur, lungs are clear to auscultation bilaterally and
extremities are without edema. Which of the following is the most appropriate
recommendation for your patient?
A. Discontinue oral contraceptives
B. Recommend walking frequently during the flight
C. Begin daily aspirin therapy
D. Increase fluid intake 2-3 days prior to the flight - Answers - B. The risk of deep vein
thrombosis after air travel increases with flight duration. Preventive measures for
patients include using support hose and performing in-flight exercises and walking.
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 - Answers - 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 - Answers - 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 - Answers - 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 - Answers - 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.
,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 - Answers - 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 - Answers - A. Sarcoidosis is characterized by paratracheal
lymphadenopathy and elevated ACE levels. It is more common in African American
patients and may be asymptomatic.
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 - Answers - 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 - Answers - 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.
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 - Answers - 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.
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 - Answers - B. Fresh frozen plasma is the most rapid
way to lower the patient's INR.
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) - Answers - 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. Cherry angioma
B. Telangiectasia
C. Spider angioma
D. Pyogenic granuloma - Answers - B. Telangiectatic vessels are often visible skin
findings with basal cell carcinoma.
, 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 - Answers - 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.
Hypoglycemia in an elderly patient with diabetes is most likely to manifest as which of
the following symptoms?
A. Tachycardia
B. Diaphoresis
C. Intense hunger
D. Mental confusion - Answers - D. Manifestations of hypoglycemia in the elderly are
mainly from impaired central nervous system function.
Manifestations include mental confusion, bizarre behavior, and ultimately coma.
An 85 year-old nursing home resident presents with abrupt onset of cough, sore throat,
headache, myalgias, and malaise. On examination the patient's temperature is 102
degrees F; the rest of the exam is unremarkable. Nasal smear is positive for Influenza
B. Which of the following is the treatment of choice in this patient?
A. Amantadine (Symmetrel)
B. Oseltamivir (Tamiflu)
C. Acyclovir (Zovirax)
D. Nevirapine (Viramune) - Answers - B. Oseltamivir is used to treat both influenza A
and B.
A 36 year-old female presents for a routine physical. She has no current complaints and
her only medication is oral contraceptives. The patient is preparing for a trip to Australia
and is worried about the long flight as her mom has a
history of deep vein thrombosis after a long trip several years ago. Physical examination
reveals BP 110/60 mmHg, HR 66 bpm, regular. Heart is regular rate and rhythm without
murmur, lungs are clear to auscultation bilaterally and
extremities are without edema. Which of the following is the most appropriate
recommendation for your patient?
A. Discontinue oral contraceptives
B. Recommend walking frequently during the flight
C. Begin daily aspirin therapy
D. Increase fluid intake 2-3 days prior to the flight - Answers - B. The risk of deep vein
thrombosis after air travel increases with flight duration. Preventive measures for
patients include using support hose and performing in-flight exercises and walking.
