BUTTARO EXAMS WITH VERIFIED QUESTIONS
AND CORRECT ANSWERS
A 25-year-old patient has a tuberculosis (TB) skin test which reveals an area of induration of 12
mm. The patient is a recent immigrant from Mexico and lives in a homeless shelter. What is the
recommended treatment for this patient?
a. Administer the bacillus Calmette-Guérin (BCG) vaccine
b. Begin isoniazid (INH) preventive therapy
c. Order isoniazid (INH) and Rifampin d. Perform regular TB skin testing every few months
- ANSWERS-B -Patients younger than 35 who have any risk factors for TB and with an area of
induration 10 mm should be considered for INH preventive therapy. This patient is an immigrant
from Mexico and lives in a homeless shelter, so TB preventive therapy is acceptable. BCG vaccine
is not helpful. INH and Rifampin are used if patients develop symptoms or if there is antibiotic
resistance.
A 3-year-old child has marked pain in one leg localized to the upper tibia with refusal to bear
weight. The child has a high fever and a toxic appearance. Which type of osteomyelitis is most
likely?
a. Chronic osteomyelitis
b. Hematogenous osteomyelitis
c. Osteomyelitis from a contiguous focus
d. Peripheral vascular disease osteomyelitis
- ANSWERS-ANS: B
Young children are more likely to have hematogenous osteomyelitis, especially with acute
symptoms. Chronic osteomyelitis is more common with underlying diseases such as diabetes.
Contiguous focus osteomyelitis occurs when organisms are introduced from a puncture wound,
foreign body, or adjoining soft tissue infection. Peripheral vascular causes are more common in
chronically ill patients.
A 30-year-old male patient is diagnosed with Hodgkin lymphoma. Initial lab work reveals a
WBC of 20, hemoglobin of 10.1 gm/dL, a serum albumin of 3 g/dL, and lymphopenia of 0.5.
Staging studies identify stage III disease. What is this patient's prognostic score?
a. 2
b. 3
c. 4
d. 5
- ANSWERS-C -Risk factors for lymphoma include age >45 years, male gender, serum albumin
<4, Hb <10.5, stage IV disease, WBC >15, and lymphopenia <0.6. This patient has 4 risk
factors.
,A 40-year-old woman reports pain at the thumb base in one hand radiating to the distal radius.
The provider learns that the woman knits for a hobby and is able to elicit the pain by asking the
patient to pour water from a pitcher. Which condition is suspected in this patient?
a. Carpal tunnel syndrome
b. Palmar fibrosis
c. De Quervain's Tenosynovitis
d. Trigger finger
- ANSWERS-C -De Quervain's tenosynovitis causes pain as described and occurs more in women
between 30 and 59 years who engage in activities requiring excessive repetitive motions, such as
knitting. Carpal tunnel syndrome presents with intermittent wrist pain, numbness, and tingling
radiating from the palm to the thumb, index finger, middle finger, and medial aspect of the ring
finger. Palmar fibrosis causes contractures, usually of the ring finger. Trigger finger causes
nodules in tendons that catch on the finger pulley and impede movement.
A 45-year-old patient has mild osteoarthritis in both knees and asks about nonpharmacologic
therapies. What will the provider recommend?
a. Aerobic exercise
b. Glucosamine with chondroitin
c. Therapeutic magnets or copper bracelets
d. Using a cane or walker
- ANSWERS-A-Aerobic exercise helps with cardiovascular conditioning and weight reduction as
well as improved range of motion, decreased pain, and strengthening of supporting structures.
Randomized controlled studies have failed to demonstrate significant pain relief with glucosamine.
Therapeutic magnets and copper have not been proven to be effective. A young patient with mild
symptoms will not need assistive devices and should focus on conditioning.
A 45-year-old patient reports a recent onset of unilateral shoulder pain which is described as
diffuse and is associated with weakness of the shoulder but no loss of passive range of motion.
What does the provider suspect as the cause of these symptoms?
a. Acromioclavicular joint disease
b. Cervical radicular pain
c. Glenohumeral arthritis
d. Rotator cuff injury
- ANSWERS-: D --Rotator cuff injury is usually characterized by diffuse pain, weakness of the
joint, but no change in range of motion. Acromioclavicular joint disease is associated with anterior-
superior shoulder pain. Glenohumeral arthritis has similar symptoms, but with loss of range of
motion. Cervical radicular pain is characterized by pain distal to the elbow
A 50-year-old patient presents with supraclavicular lymphadenopathy. Which action is correct?
a. Consult with an oncologist for evaluation.
b. Perform testing for sexually transmitted infections.
c. Reassure the patient that this will resolve.
d. Treat empirically with an antibiotic
- ANSWERS-A- In patients over 40 years old, supraclavicular lymphadenopathy is likely to be
cancerous in 90% of cases, so an oncologist should be consulted. STI causes are not associated
with supraclavicular lymphadenopathy. Because this is likely to be cancer, reassuring the patient is
not appropriate. Empirical antibiotic therapy is not indicated.
,A 50-year-old patient with diabetes mellitus has a low-grade fever and pain on one foot. The
provider notes erythema and swelling at the site along with several superficial skin ulcers without
necrosis and suspects osteomyelitis. Which type of diagnostic study will the provider order?
a. Biopsy of bone or debridement cultures
b. Blood cultures and serologic markers of inflammation
c. Magnetic resonance imaging of the foot
d. Plain radiograph of the foot
- ANSWERS-D --A patient with diabetic foot infection suspected of having osteomyelitis should
have a plain radiograph to identify bony abnormality or soft tissue changes. MRI may be
performed if more specific evaluation is needed or if abscess is suspected. Blood cultures are not
diagnostic of osteomyelitis. Biopsy and debridement cultures increase the risk of further infection if
poor healing at the site occurs.
A 50-year-old woman reports pain in one knee upon awakening each morning that goes away
later in the morning. A knee radiograph is negative for pathology and serum inflammatory
markers are normal. What will the provider tell this patient?
a. A magnetic resonance imaging study is necessary for diagnosis
b. That the lack of findings indicates no disease process
c. To take acetaminophen 1 gram three times daily for pain
d. To use a cyclooxygenase 2-selective NSAIDs to reduce inflammation
- ANSWERS-C- Acetaminophen is the mainstay for initial treatment of osteoarthritis. Radiologic
findings are often negative in the early stages of the disease. There are no serologic markers for
OA. A COX-2-selective inhibitor has cardiovascular side effects and should not be used unless
necessary. These agents are used more for pain than for inflammation.
A 6-month-old infant is suspected of having an immune deficiency disorder. Which diagnostic tests
may be included to evaluate this patient? (Select all that apply.) a. Blood, urine, sputum, and
wound cultures b. Delayed-type hypersensitivity skin testing c. Erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) levels d. Metabolic profiles e. Serum electrolytes
- ANSWERS-A, C, D-Cultures are obtained to determine causative organisms in patients with
frequent infections. ESR and CRP are performed to assess whether an inflammatory response is
present. Metabolic profiles are useful to identify underlying metabolic disease that may cause
immunodeficiency. Delayed-type hypersensitivity skin testing is not useful in children under 1 year
of age because even unaffected children this age have not developed an exposure history
adequate to have a positive result. Serum electrolytes are not indicated.
A 60-year-old female patient has recently lost weight and a physical examination reveals a
beefy-red, sore tongue, with no neurological findings. Based on these clinical findings, what will
the provider anticipate finding in the laboratory data?
a. Decreased homocysteine levels
b. Leukopenia and thrombocytopenia c. Low hemoglobin and elevated MCV
d. Normal methylmalonic acid level
- ANSWERS-: C-- Macrocytic anemia caused by vitamin B12 deficiency will have symptoms
described above. Although folate acid deficiency causes macrocytic anemia, there are rarely any
symptoms. Hemoglobin will be decreased and MCV will increase. Homocysteine levels will be
increased. The patient with B12 deficiency will have leukopenia and thrombocytopenia with
, severe deficiency, characterized by neurologic findings, which this patient does not have.
Methylmalonic acid level will decrease.
A 60-year-old patient reports new onset of bilateral shoulder pain with morning stiffness lasting
approximately 1 hour. Which will be included in initial diagnostic testing for this patient? (Select
all that apply.) a. Antinuclear antibodies
b. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
c. Liver function tests (LFTs)
d. Protein electrophoresis
e. Serum calcitonin
- ANSWERS-B, C, D-- ESR, CRP, and protein electrophoresis are included in the initial diagnostic
workup when polymyalgia rheumatica is suspected. ANA testing is not specific for this disorder.
Serum calcitonin is not indicated.
A 65-year-old patient who has not had an influenza vaccine is exposed to influenza and comes to
the clinic the following day with fever and watery, red eyes. What will the provider do initially?
a. Administer LAIV influenza vaccine b. Begin treatment with an antiviral medication
c. Observe for improvement or worsening for 24 hours
d. Perform a nasal swab for RT-PCR assay
- ANSWERS-D-Samples to isolate the virus should be collected within 12 to 36 hours of onset of
illness and this should be performed to confirm the disease. Administration of the LAIV influenza
vaccine will not prevent symptoms in this patient, is not recommended in persons over 59 years of
age, and is contraindicated when also giving antiviral medications. Antiviral drugs should be
started within 48 hours of onset of illness and may be started empirically while waiting on cultures
because this patient is higher risk than younger patients. Because identification of the virus and
effectiveness of treatment are time-limited, it is not correct to watch and wait for symptoms to
worsen.
A 70-year-old patient reports frequent infections, shortness of breath, fatigue, and palpitations.
An exam reveals pallor and petechiae. The provider orders a peripheral blood smear and bone
marrow biopsy. Which findings are consistent with a diagnosis of myelodysplasia? (Select all that
apply.)
a. Anisocytosis and poikilocytosis of erythrocytes on peripheral smear
b. Defects in cellular maturation in all cell lines in bone marrow aspirate
c. Hypercellular bone marrow with peripheral cytopenia
d. Larger than normal megakaryocytes in bone marrow
e.Smaller than normal granulocytes in the peripheral blood smear
- ANSWERS-A,b,C,D-- The key finding in MDS is packed, hypercellular bone marrow with
peripheral cytopenia. Erythrocytes in peripheral blood will show anisocytosis, poikilocytosis, or
basophilic stippling. The bone marrow will have defects in all cellular maturation.
Megakaryocytes in bone marrow will be smaller than normal. Granulocytes in peripheral blood
will be larger than normal.
A child developed cervical lymphadenopathy after a scabies infestation. One node remains
enlarged 6 months after the infestation but has not increased in size. The physical examination
reveals a non-tender, non-erythematous node. What will the provider tell the child's parents?
a. The child may need surgical intervention.
b. The child should see a pediatric oncologist.
AND CORRECT ANSWERS
A 25-year-old patient has a tuberculosis (TB) skin test which reveals an area of induration of 12
mm. The patient is a recent immigrant from Mexico and lives in a homeless shelter. What is the
recommended treatment for this patient?
a. Administer the bacillus Calmette-Guérin (BCG) vaccine
b. Begin isoniazid (INH) preventive therapy
c. Order isoniazid (INH) and Rifampin d. Perform regular TB skin testing every few months
- ANSWERS-B -Patients younger than 35 who have any risk factors for TB and with an area of
induration 10 mm should be considered for INH preventive therapy. This patient is an immigrant
from Mexico and lives in a homeless shelter, so TB preventive therapy is acceptable. BCG vaccine
is not helpful. INH and Rifampin are used if patients develop symptoms or if there is antibiotic
resistance.
A 3-year-old child has marked pain in one leg localized to the upper tibia with refusal to bear
weight. The child has a high fever and a toxic appearance. Which type of osteomyelitis is most
likely?
a. Chronic osteomyelitis
b. Hematogenous osteomyelitis
c. Osteomyelitis from a contiguous focus
d. Peripheral vascular disease osteomyelitis
- ANSWERS-ANS: B
Young children are more likely to have hematogenous osteomyelitis, especially with acute
symptoms. Chronic osteomyelitis is more common with underlying diseases such as diabetes.
Contiguous focus osteomyelitis occurs when organisms are introduced from a puncture wound,
foreign body, or adjoining soft tissue infection. Peripheral vascular causes are more common in
chronically ill patients.
A 30-year-old male patient is diagnosed with Hodgkin lymphoma. Initial lab work reveals a
WBC of 20, hemoglobin of 10.1 gm/dL, a serum albumin of 3 g/dL, and lymphopenia of 0.5.
Staging studies identify stage III disease. What is this patient's prognostic score?
a. 2
b. 3
c. 4
d. 5
- ANSWERS-C -Risk factors for lymphoma include age >45 years, male gender, serum albumin
<4, Hb <10.5, stage IV disease, WBC >15, and lymphopenia <0.6. This patient has 4 risk
factors.
,A 40-year-old woman reports pain at the thumb base in one hand radiating to the distal radius.
The provider learns that the woman knits for a hobby and is able to elicit the pain by asking the
patient to pour water from a pitcher. Which condition is suspected in this patient?
a. Carpal tunnel syndrome
b. Palmar fibrosis
c. De Quervain's Tenosynovitis
d. Trigger finger
- ANSWERS-C -De Quervain's tenosynovitis causes pain as described and occurs more in women
between 30 and 59 years who engage in activities requiring excessive repetitive motions, such as
knitting. Carpal tunnel syndrome presents with intermittent wrist pain, numbness, and tingling
radiating from the palm to the thumb, index finger, middle finger, and medial aspect of the ring
finger. Palmar fibrosis causes contractures, usually of the ring finger. Trigger finger causes
nodules in tendons that catch on the finger pulley and impede movement.
A 45-year-old patient has mild osteoarthritis in both knees and asks about nonpharmacologic
therapies. What will the provider recommend?
a. Aerobic exercise
b. Glucosamine with chondroitin
c. Therapeutic magnets or copper bracelets
d. Using a cane or walker
- ANSWERS-A-Aerobic exercise helps with cardiovascular conditioning and weight reduction as
well as improved range of motion, decreased pain, and strengthening of supporting structures.
Randomized controlled studies have failed to demonstrate significant pain relief with glucosamine.
Therapeutic magnets and copper have not been proven to be effective. A young patient with mild
symptoms will not need assistive devices and should focus on conditioning.
A 45-year-old patient reports a recent onset of unilateral shoulder pain which is described as
diffuse and is associated with weakness of the shoulder but no loss of passive range of motion.
What does the provider suspect as the cause of these symptoms?
a. Acromioclavicular joint disease
b. Cervical radicular pain
c. Glenohumeral arthritis
d. Rotator cuff injury
- ANSWERS-: D --Rotator cuff injury is usually characterized by diffuse pain, weakness of the
joint, but no change in range of motion. Acromioclavicular joint disease is associated with anterior-
superior shoulder pain. Glenohumeral arthritis has similar symptoms, but with loss of range of
motion. Cervical radicular pain is characterized by pain distal to the elbow
A 50-year-old patient presents with supraclavicular lymphadenopathy. Which action is correct?
a. Consult with an oncologist for evaluation.
b. Perform testing for sexually transmitted infections.
c. Reassure the patient that this will resolve.
d. Treat empirically with an antibiotic
- ANSWERS-A- In patients over 40 years old, supraclavicular lymphadenopathy is likely to be
cancerous in 90% of cases, so an oncologist should be consulted. STI causes are not associated
with supraclavicular lymphadenopathy. Because this is likely to be cancer, reassuring the patient is
not appropriate. Empirical antibiotic therapy is not indicated.
,A 50-year-old patient with diabetes mellitus has a low-grade fever and pain on one foot. The
provider notes erythema and swelling at the site along with several superficial skin ulcers without
necrosis and suspects osteomyelitis. Which type of diagnostic study will the provider order?
a. Biopsy of bone or debridement cultures
b. Blood cultures and serologic markers of inflammation
c. Magnetic resonance imaging of the foot
d. Plain radiograph of the foot
- ANSWERS-D --A patient with diabetic foot infection suspected of having osteomyelitis should
have a plain radiograph to identify bony abnormality or soft tissue changes. MRI may be
performed if more specific evaluation is needed or if abscess is suspected. Blood cultures are not
diagnostic of osteomyelitis. Biopsy and debridement cultures increase the risk of further infection if
poor healing at the site occurs.
A 50-year-old woman reports pain in one knee upon awakening each morning that goes away
later in the morning. A knee radiograph is negative for pathology and serum inflammatory
markers are normal. What will the provider tell this patient?
a. A magnetic resonance imaging study is necessary for diagnosis
b. That the lack of findings indicates no disease process
c. To take acetaminophen 1 gram three times daily for pain
d. To use a cyclooxygenase 2-selective NSAIDs to reduce inflammation
- ANSWERS-C- Acetaminophen is the mainstay for initial treatment of osteoarthritis. Radiologic
findings are often negative in the early stages of the disease. There are no serologic markers for
OA. A COX-2-selective inhibitor has cardiovascular side effects and should not be used unless
necessary. These agents are used more for pain than for inflammation.
A 6-month-old infant is suspected of having an immune deficiency disorder. Which diagnostic tests
may be included to evaluate this patient? (Select all that apply.) a. Blood, urine, sputum, and
wound cultures b. Delayed-type hypersensitivity skin testing c. Erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) levels d. Metabolic profiles e. Serum electrolytes
- ANSWERS-A, C, D-Cultures are obtained to determine causative organisms in patients with
frequent infections. ESR and CRP are performed to assess whether an inflammatory response is
present. Metabolic profiles are useful to identify underlying metabolic disease that may cause
immunodeficiency. Delayed-type hypersensitivity skin testing is not useful in children under 1 year
of age because even unaffected children this age have not developed an exposure history
adequate to have a positive result. Serum electrolytes are not indicated.
A 60-year-old female patient has recently lost weight and a physical examination reveals a
beefy-red, sore tongue, with no neurological findings. Based on these clinical findings, what will
the provider anticipate finding in the laboratory data?
a. Decreased homocysteine levels
b. Leukopenia and thrombocytopenia c. Low hemoglobin and elevated MCV
d. Normal methylmalonic acid level
- ANSWERS-: C-- Macrocytic anemia caused by vitamin B12 deficiency will have symptoms
described above. Although folate acid deficiency causes macrocytic anemia, there are rarely any
symptoms. Hemoglobin will be decreased and MCV will increase. Homocysteine levels will be
increased. The patient with B12 deficiency will have leukopenia and thrombocytopenia with
, severe deficiency, characterized by neurologic findings, which this patient does not have.
Methylmalonic acid level will decrease.
A 60-year-old patient reports new onset of bilateral shoulder pain with morning stiffness lasting
approximately 1 hour. Which will be included in initial diagnostic testing for this patient? (Select
all that apply.) a. Antinuclear antibodies
b. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
c. Liver function tests (LFTs)
d. Protein electrophoresis
e. Serum calcitonin
- ANSWERS-B, C, D-- ESR, CRP, and protein electrophoresis are included in the initial diagnostic
workup when polymyalgia rheumatica is suspected. ANA testing is not specific for this disorder.
Serum calcitonin is not indicated.
A 65-year-old patient who has not had an influenza vaccine is exposed to influenza and comes to
the clinic the following day with fever and watery, red eyes. What will the provider do initially?
a. Administer LAIV influenza vaccine b. Begin treatment with an antiviral medication
c. Observe for improvement or worsening for 24 hours
d. Perform a nasal swab for RT-PCR assay
- ANSWERS-D-Samples to isolate the virus should be collected within 12 to 36 hours of onset of
illness and this should be performed to confirm the disease. Administration of the LAIV influenza
vaccine will not prevent symptoms in this patient, is not recommended in persons over 59 years of
age, and is contraindicated when also giving antiviral medications. Antiviral drugs should be
started within 48 hours of onset of illness and may be started empirically while waiting on cultures
because this patient is higher risk than younger patients. Because identification of the virus and
effectiveness of treatment are time-limited, it is not correct to watch and wait for symptoms to
worsen.
A 70-year-old patient reports frequent infections, shortness of breath, fatigue, and palpitations.
An exam reveals pallor and petechiae. The provider orders a peripheral blood smear and bone
marrow biopsy. Which findings are consistent with a diagnosis of myelodysplasia? (Select all that
apply.)
a. Anisocytosis and poikilocytosis of erythrocytes on peripheral smear
b. Defects in cellular maturation in all cell lines in bone marrow aspirate
c. Hypercellular bone marrow with peripheral cytopenia
d. Larger than normal megakaryocytes in bone marrow
e.Smaller than normal granulocytes in the peripheral blood smear
- ANSWERS-A,b,C,D-- The key finding in MDS is packed, hypercellular bone marrow with
peripheral cytopenia. Erythrocytes in peripheral blood will show anisocytosis, poikilocytosis, or
basophilic stippling. The bone marrow will have defects in all cellular maturation.
Megakaryocytes in bone marrow will be smaller than normal. Granulocytes in peripheral blood
will be larger than normal.
A child developed cervical lymphadenopathy after a scabies infestation. One node remains
enlarged 6 months after the infestation but has not increased in size. The physical examination
reveals a non-tender, non-erythematous node. What will the provider tell the child's parents?
a. The child may need surgical intervention.
b. The child should see a pediatric oncologist.
