PACKRAT Exam Study Guide | 100% Correct Answers | Verified | Latest 2024 Version

1. Health Maintenance/Obstetrics/Gynecology Which of the following portends the greatest risk for the development of breast cancer? A. Nulliparity B. Early menarche C. BRCA 1 positivity D. Maternal family history of breast cancer - (u) A. See C for explanation. (u) B. See C for explanation. (c) C. BRCA1 positivity is associated with half of the early onset breast cancers and 90% of the hereditary ovarian cancers. (u) D. See C for explanation. 2. Clinical Therapeutics/Urology/Renal In order to help delay the progression to kidney disease in a diabetic patient with proteinuria, which of the following would you consider using to treat the patient's concomitant hypertension? A. Atenolol (Tenormin) B. Amlodipine (Norvasc) C. Accupril (Quinapril) D. Amiloride (Midamor) - (u) A. Atenolol is a beta blocker. Beta blockers are not first line therapy for hypertensive diabetics. (u) B. Amlodipine is a calcium channel blocker. Calcium channel blockers are not first line therapy for hypertensive diabetics. (c) C. Accupril is an ACE inhibitor. Because of their beneficial effects in diabetic neuropathy, ACE inhibitors (and ARBs) should be part of the initial treatment regimen for hypertension in diabetics. (u) D. Amiloride is a potassium-sparing diuretic. An ACE inhibitor is the standard first line therapy for hypertensive diabetics. :3. Diagnosis/Pulmonology A 58 year-old with a 20 pack-year history of tobacco use presents to the emergency department with sudden onset of severe, progressive right-sided chest pain and shortness of breath. She denies fever, nausea and productive cough but reports returning from a mission trip to South Africa yesterday. Her exam reveals tachycardia, tachypnea, clear lung fields and 3+ edema and erythema of the left leg. Her chest radiograph is normal. Which of the following is the most likely diagnosis? A. Pulmonary embolism B. Pneumothorax C. Pneumonia D. Pleurisy - (c) A. The patient's risk factors, acutely progressive presentation and normal chest radiograph make a pulmonary embolism the most likely and most worrisome diagnosis. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. : (8) 4. History & Physical/Dermatology A 46 year-old male is brought to the emergency department after sustaining burns to his entire right arm and leg in a house fire. Which of the following percentages best classifies the extent of his burns? A. 12 B. 18 C. 27 D. 36 - (u) A. See C for explanation.(u) B. See C for explanation. (c) C. According to the "rule of nines" the percentages can be calculated as follows: entire arm = 9% of body surface area (BSA). Anterior surface of each leg = 9% BSA, posterior surface of each leg = 9% BSA. The patient has a total of 27% BSA with burns. (u) D. See C for explanation. : (8) 5. Diagnostic Studies/ENT/Ophthalmology Which of the following imaging modalities is most appropriate in the evaluation of chronic sinusitis? A. Coronal CT B. Sinus MRI C. Panorex D. Sinus radiographs - (c) A. Coronal CT is the most effective imaging to determine the anatomy of the sinuses as well as the presence and extent of sinusitis. (u) B. MRI is of limited value due to less than optimal visualization of bony structures. (u) C. Panorex imaging provides limited viusalization of the sinus structures. (u) D. Sinus radiographs are rarely used due to limited visualization of soft tissues. : (8) 6. Clinical Therapeutics/Orthopedics/Rheumatology Which of the following is indicated as the first-line treatment of an initial case of acute gouty arthritis? A. Indomethacin (Indocin) B. Colchicine (Probenicid) C. Methylprednisolone (Medrol)D. Allopurinol (Zyloprim) - (c) A. A nonsteroidal antiinflammatory agent is indicated as the first-line treatment for an initial case of acute gout. (u) B. Colchicine is a useful adjunct to NSAIDs, corticosteroids, or synthetic ACTH for the treatment of severe gout, refractory acute gouty attacks, or as prevention. (u) C. An intra-articular injection of glucocorticoid or a tapered regimen of oral prednisone can be used as an alternative treatment to the first-line treatment of an NSAID. (u) D. Allopurinol is a xanthine oxidase inhibitor used for patients with more than three occurrences per year, gout that is difficult to manage safely (polyarticular gout in a transplant patient or one with renal insufficiency), tophaceous gout, and hyperuricemia. Allopurinol can trigger an episode of gout, especially in the first few months of treatment. : (8) 7. Diagnostic Studies/Infectious Diseases Which of the following is the most sensitive laboratory test to diagnose herpes simplex virus? A. Polymerase chain reaction (PCR) B. Enzyme-linked immunosorbent assay (ELISA) C. Tzanck smear D. HSV antibody titer - (c) A. Diagnosis is usually made clinically however, PCR is more sensitive than culture. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. : (8) 8. Health Maintenance/Psychiatry/Behavioral Medicine Which of the following is the drug of choice for the prevention of Wernicke's encephalopathy?A. Folic acid B. Calcium gluconate C. Vitamin B 12 D. Thiamine - (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Wernicke's encephalopathy, also called alcoholic encephalopathy, is an acute neurological disorder of thiamine deficiency. Patients are given 100mg po BID to TID for 1 to 2 weeks or parenterally 100mg in each liter of glucose. : (8) 9. History & Physical/Cardiology S3 and S4 gallops are both signs of which type of cardiac abnormality? A. Atrial non-compliance B. Ventricular septal defect C. Valvular insufficiency D. Ventricular dysfunction - (u) A. S3 and S4 are not indicative of atrial abnormalities. (u) B. Ventricular septal defect is not associated with an S3 and S4 gallop. (u) C. S3 and S4 are not directly correlated to valvular insufficiency. (c) D. S3 may be louder if filling pressure is increased or if ventricular compliance is reduced. S4 is most commonly heard when there is increased resistance to filling because of loss of compliance of the ventricular walls or the increased stroke volume of high-output states. : (11) 10. Diagnosis/NeurologyA 48 year-old male presents with a mild tremor that seems to increase with stressful situations and subsides when he has a glass of wine with dinner. The patient does not demonstrate the tremor at rest but it reappears when he reaches for a pen. Which of the following is most likely the cause of this patient's symptoms? A. Parkinson disease B. Essential tremor C. Huntington disease D. Focal torsion dystonia - (u) A. Parkinsonism is characterized by combination of tremor, rigidity, bradykinesia, and postural instability. (c) B. Essential tremor can be familial and cause action related hand tremor, head tremor, or voice tremor. The lower extremities are spared and generally no further neurologic findings are present. (u) C. Huntington disease is characterized by gradual onset of chorea and restlessness, progressing to choreiform movements. (u) D. Focal torsion dystonia causes involuntary spasmodic movements including torsion of neck, oromandibular dystonia, or uncontrolled eye blinking. : (11) 11. Health Maintenance/Pulmonology Which of the following is most likely to cause a false negative PPD? A. Aspirin allergy B. Diagnosis of AIDS C. BCG immunization D. Pregnancy - (u) A. See B for explanation. (c) B. Any process that results in reduced immune response can cause a false negative PPD. Past immunization with BCG would typically result in a false positive while aspirin allergy and pregnancy generally have no effect in and of themselves on PPD results.(u) C. See B for explanation. (u) D. See B for explanation. : (8) 11 12. Diagnostic Studies/Orthopedics/Rheumatology An afebrile 50 year-old male presents with an acute onset of an exquisitely painful first metatarsophalangeal joint. Examination reveals a red and swollen joint with tenderness on palpation. Which of the following test results will most likely be found in this patient? A. Hyperuricemia B. Negative birefringent crystals C. Evidence of a septic joint with needle aspiration D. Calcium pyrophosphate dehydrate crystals - (u) A. Although 75% of patients with gout have hyperuricemia, few patients with hyperuricemia develop gout. (c) B. Negative birefringence of the needle-shaped crystals associated with gout are seen by a yellow colorization on polarized light microscopy. (u) C. A coexisting septic joint is possible, but not typical of gout. (u) D. Calcium pyrophosphate dehydrate crystal deposition is a gout-like syndrome that typically affects the knee and is also known as pseudogout. : (8) 13. History & Physical/Gastrointestinal/Nutritional An elderly man who recently emigrated from a war-torn area of Africa is brought to the clinic by his daughter. She explains that her father's diet was very limited in calories and protein and that he mostly ate corn and very little fresh foods. He has chronic diarrhea and examination reveals pigmented regions on hands, arms, and face and milddementia. His tongue is smooth and shiny. This patient most likely has a deficiency of which of following vitamins? A. Folate B. Niacin C. Thiamine D. Vitamin K - (u) A. See B for explanation. (c) B. This patient's syndrome known as pellagra is due to niacin (vitamin B3) deficiency. It is often seen in people where corn is the major source of energy and is still endemic in parts of Africa. The syndrome includes glossitis, pigmented dermatitis, dementia, and diarrhea. (u) C. See B for explanation. (u) D. See B for explanation. : (8) 14. Diagnosis/Cardiology A 51 year-old patient presents for follow-up after a recent stroke. Cardiac examination reveals a moderately loud systolic ejection murmur in the 2nd and 3rd interspaces parasternally. The second heart sound is fixed and widely split. Which of the following is the most likely diagnosis in this patient? A. Aortic stenosis B. Mitral valve regurgitation C. Patent foramen ovale D. Ventricular septal defect - (u) A. Aortic stenosis will usually manifest as heart failure or if acute, as angina. In severe aortic stenosis a weak to absent aortic second sound or reversed splitting of the second sound is present. (u) B. Heart sounds associated with mitral regurgitation include normal S1 and a prominent 3rd heart sound. (c) C. A patent foramen ovale is present in 25% of the population and can lead to paradoxic emboli and cerebrovascular events. Suspicion should be highest in patients who have cryptogenic stroke before age 55 years.(u) D. Clinical features depend on the size of the defect and the presence or absence of right ventricular outflow obstruction or increased peripheral vascular resistance. Stroke and fixed S2 split are not representative of a VSD. : (8) 15. Diagnosis/Dermatology A 5 year-old male is brought to the office by his father who reports a 2 day history of low grade fever and coryza. The child awoke this morning with bright red cheeks. Physical examination reveals edematous, confluent plaques over the malar region of the face and reticular rash over the child's extensor surfaces. Which of the following is the most likely diagnosis? A. Rubeola B. Parvovirus B19 C. Respiratory syncytial virus D. Epstein-Barr virus - (u) A. Rubeola (measles) is a highly contagious viral infection characterized by cough, conjunctivitis and coryza. There is an associated rash which is an erythematous maculopapular that spreads centrally and inferiorly. (c) B. This is a classic presentation of Fifth Disease, a childhood exantham associated with human parvovirus B19. (u) C. RSV is a viral infection of the airway that causes annual outbreaks causing pneumonia, bronchiolitis and tracheobronchitis. (u) D. EBV is a common human virus that is present in 90% of the adult population and persists in the host for his/her lifetime. THe most common presentation is a 10-35 year-old with mononucleosis. : (8) 16. Diagnostic Studies/PulmonologyIn a patient with a low probability of pulmonary embolism (PE) based on the Wells criteria, which of the following lab studies is most helpful in ruling out a PE? A. D dimer assay B. PT with INR C. Factor V assay D. Clotting time - (c) A. Even though useful in ruling in a pulmonary embolism, the D dimer is negative in over 95% of patients who do not have a pulmonary embolism. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation. : (8) 17. Health Maintenance/Cardiology Which subset of the asymptomatic general population should undergo one-time screening for abdominal aortic aneurysm? A. 65 year-old female with chronic kidney disease B. 65 year-old healthy male who has smoked since age 20 C. 74 year-old male who has diabetes mellitus D. 74 year-old female who has smoked since age 15 - (u) A. See B for explanation. (c) B. Data support the use of abdominal ultrasound to screen 65- to 74-year old men, but not women, who have a history of smoking. Repeated screening does not appear to be needed if the aorta shows no enlargement. (u) C. See B for explanation. (u) D. See B for explanation. : (8) 18. Clinical Therapeutics/EndocrinologyWhich of the following is the pharmacologic therapy of choice in male patients suffering from mildmoderate gynecomastia? A. Selective serum reuptake inhibitor (SSRIs) B. Selective estrogen receptor modulator (SERMs) C. Testosterone D. Progesterone - (u) A. SSRIs are useful in the treatment of depression and are not indicated in the treatment of gynecomastia. (c) B. SERM therapy is particularly effective in glandular ("lumpy") gynecomastia. Examples of SERMS are tamoxifen and raloxifene. (u) C. Neither testosterone nor progesterone is indicated in the treatment of gynecomastia. (u) D. See C for explanation. : (8) 19. History & Physical/Orthopedics/Rheumatology A 4 week-old female is seen for a well child visit. Birth history is significant for breech presentation and weighing 9 pounds 8 ounces at delivery. Which of the following is indicated to rule out developmental dysplasia of the hip? A. Ultrasound B. Physical examination C. Anterior/posterior radiograph D. Computed tomography - (u) A. Ultrasound is useful for the diagnosis of developmental dysplasia of the hip (DDH). False positive readings prior to 8-10 weeks of age, expense, and comprehensive training needed for interpretation exclude this as a standard evaluation tool. (c) B. A careful physical examination at birth and repeated evaluation at each well visit until the child walks is indicated to identify DDH. A high degree of suspicion is necessary in children with risk factors for DDH, such as positive family history, ligamentous laxity, breech presentation, female gender, large fetal size, and firstbornstatus. (u) C. Radiographs are not helpful because the femoral head is composed of radiolucent cartilage in the newborn. (u) D. Computed tomography is not indicated in a newborn. : (8) 20. Diagnosis/ENT/Ophthalmology A 72 year-old female with a history of diabetes mellitus presents with sudden onset of painless flashing lights and floaters followed by curtain-like vision loss sparing the central vision in the right eye. Which of the following is the most likely diagnosis? A. Classic migraine B. Retinal detachment C. Optic neuritis D. Transient ischemic attack - (u) A. Classic migraine may present with the above symptoms; however, the symptoms are typically bilateral. Additionally, given the advanced age of the patient migraine would be considered less likely. (c) B. Non-traumatic retinal detachment usually presents in an older individual. The classic symptoms include abrupt onset of painless flashing lights and floaters followed by progressive vision loss. (u) C. Optic neuritis may present with the above symptoms; however, the mean age of onset is 32 years of age and the presentation typically involves ocular pain. (u) D. Vertebrobasilar insufficiency may result in dysfunction of the visual cortex with subsequent vision disturbance similar to the above presentation. In contrast the patient may present with additional findings of sensorimotor dysfunction. : (8) 21. History & Physical/Obstetrics/GynecologyA patient presents to the office with a last menstrual period of May 4th. What is the estimated date of confinement? A. January 4 B. January 11 C. February 11 D. February 12 - (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Calculation is based on Naegele's rule by adding 7 days to the first day of the last menstrual period and then subtracting 3 months. (u) D. See C for explanation. : (8) 22. Scientific Concepts/Cardiology Empiric treatment for infective endocarditis should target which organism? A. Haemophilus influenzae B. Moraxella catarrhalis C. Mycoplasma pneumoniae D. Staphylococcos aureus - (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Empiric regimens for endocarditis while culture results are pending should include agents active against staphylococci, streptococci, and enterococci. : (8) 23. History & Physical/Gastrointestinal/Nutritional A 68 year-old woman presents with intermittent crampy abdominal pain and vomiting of 6 hours' duration. She feels bloated but denies rectal bleeding. Examination of the abdomen reveals no palpable mass and you note an uppermidline scar from previous abdominal surgery. An abdominal radiograph demonstrates dilated loops of small bowel with air-fluid levels. Which of the following is the most likely cause of this patient's symptoms? A. Adhesions B. Sigmoid volvulus C. Incisional hernia D. Intussusception - (c) A. The patient's surgical history, presenting symptoms and abdominal imaging are consistent with small bowel obstruction. Peritoneal adhesions are the most common cause of small bowel obstruction. (u) B. Sigmoid volvulus or twisting of the sigmoid colon on its mesentery leads to colonic obstruction. This patient does not complain of constipation or report laxative use. Abdominal radiographs would show a dilated colon lacking haustral folds. (u) C. Hernias may occur after abdominal surgery but are usually more chronic in nature and a mass would be palpable especially with maneuvers that increase intra-abdominal pressure. (u) D. Intussusception, although rare in adults, may occur due to small bowel neoplasia but this patient does not complain of bleeding and no mass was palpable on exam. Also a CT scan would usually show a target lesion representing the layers of intussuscepted segment. : (8) 24. Health Maintenance/Infectious Diseases An 18 year-old college freshman presents to the student health clinic complaining of an outbreak of "athlete's foot" in his dormitory. He has no current signs or symptoms of infection, but is asking for advice on how to prevent contracting this condition. Which of the following is the best piece of preventative advice? A. Apply topical corticosteroids to any affected area B. Avoid excessive moisture and dry the skin carefully after bathing C. Avoid talc or other drying powders D. Apply a topical antifungal preventatively to area of concern - (u) A. Topical corticosteroids are effective for contact dermatitis but will not treat tinea pedis (a fungal infection) andmay make the condition worse. (c) B. Personal hygiene is essential for prevention. Avoiding extra moisture and drying carefully between the toes after showering is effective prevention.Wear open toe shoes and change absorbent, nonsynthetic socks regularly. (u) C. Talc and drying agents can assist in keeping the affected area dry and prevent the development of this fungal infection. (u) D. Application of topical antifungal may be helpful to prevent recurrences, but not for preventative use. : (28) 25. Scientific Concepts/Pulmonology A 21 year-old college student presents with a 3 week history of slowly worsening dry cough, generalized fatigue and most recently low-grade fevers. He denies nasal congestion, sore throat and nausea and has no past history of pulmonary disease or tobacco use. He does note that many other dorm residents have had similar symptoms over the past two months. Examination reveals mild inspiratory crackles but is otherwise normal. Chest radiograph is clear and CBC is normal. Which of the following is the most likely causative organism? A. Staphylococcus B. Pseudomonas C. Mycoplasma D. Klebsiella - (u) A. See C for explanation. (u) B. See C for explanation. (c) C. The subacute onset in this demographic of patient along with the lack of more advanced findings on exam and chest radiograph points most strongly to Mycoplasma. The other organisms listed have a generally more acute and severe onset and are associated with patients who have complications or other comorbid conditions. (u) D. See C for explanation.: (29) 26. History & Physical/Urology/Renal A 22 year-old male presents for a physical. On examination you palpate a painless mass that cannot be separated from the right testicle. Which of the following is the most likely diagnosis? A. Spermatocele