CME RESOURCES EXAM 2 UPDATED
ACTUAL QUESTIONS AND CORRECT
ANSWERS
1. A 3 year old boy presents to the ER with persistent fever over more than 5 days with temp as high as
103 F. He was seen in clinic 2 days after onset of fever, no etiology was found, and this was thought to be
viral. Today, however, he woke with bilateral "pink eye" and cracked bleeding lips with desquamation of
the palms and soles of his feet. On PE you note a strawberry tongue, bilateral cervical adenopathy,
bilateral injected conjunctiva without discharge and dry fissured lips.
Which of the following is the most likely complication of this condition?
a. sydenham's chorea
b. cardiomyopathy
c. coronary artery aneurysm
d. mesenteric arteritis
e. mitral valve insufficiency - CORRECT ANSWERS c. coronary artery aneurysm
Classic features of Kawasaki's syndrome include fever, age less than 5 years, conjunctivitis, mucous
membrane abnormalities, desquamation of superficial epidermis of palms and soles, or marked erythema,
morbilliform rash and cervical lymphadenopathy.
- Coronary artery aneurysm occurs in about 25% of untreated or undiagnosed patients and is a major
complication of Kawasaki's syndrome, which is a vasculitic - type autoimmune disease.
-(A) Sydenham's chorea is a complication of untreated strep group A and causes abnormal involuntary
movements of the limbs and body.
-(B) Cardiomyopathy is incorrect, although it can occur as a result of many viruses in the young; it's onset
is more insidious occurring months after the initial attack on the myocardium.
-(D) Mesenteric arteritis can also result from vasculitic- type autoimmune disorder, but Kawasaki's
syndrome favors the coronary circulation.
-(E) Mitral valve insufficiency is incorrect because this patient does not have characteristics of this
disease, which include past evidence of infection with group A beta hemolytic streptococcus resulting in
rheumatic heart disease.
,2. A 47 year old Male construction worker was lifting a 75 pound bag of cement when he twisted and
injured his back. He presents complaining of lumbar back pain with radiating pain in his right lower
extremity. He denies any other trauma, did not fall, has no loss of bladder/ bowel function. He had never
injured his back before.
On PE, he has normal sensation to light touch throughout the lower extremity with the exception of
decreased sensation over the heel and lateral border of his foot. Lower extremity strength is measured as
follows:
Quads 5/5
Guteals 5/5
Peroneals 3/5
EHL 5/5
EDL 5/5
Gastrocnemius / soleus 4/5
Based upon this assessment, the most likely nerve root injured would be:
a. L3
b. L4
c. L5
d. S1
e. S2 - CORRECT ANSWERS d.
3. A 20 year old presents with a hard mass on his right testicle. There has been no previous infection or
trauma to the scrotum. However, the patient has a past medical history of an undescended testicle. You
suspect that this is testicular cancer. Select the answer below that pairs the most common histology with
its corresponding hormone marker.
a. Seminoma, no increase in AFP
b. Nonseminoma, decrease in HCG
c. Nonseminoma, no increase in LDH
d. Seminoma, decrease in CA-19-9.
e. Adenomatous, increase in CA-125 - CORRECT ANSWERS a.
,- AFP is never elevated in pure seminomas.
- Cryptorchidism predisposes a Male to a 5% lifetime risk of testicular cancer, with seminoma being the
most common form in this case - the right testicle is the key here.
-(B) HCG can occasionally be elevated with non-seminomas, as well as be slightly higher than a level for
a seminoma.
-(C) LDH can be elevated in either seminomas or nonseminomas.
-(D) and (E) Neither CA-19-9 nor CA-125 are genetic markers for testicular cancer.
4. A 22 year old college athlete injured his back while doing dead lifts in the weight room. For the last
two weeks, he has pain localized to his lumbar region that is aggravated with exercise, specifically any
type of back extension. He has noticed the slow progression of numbness down the buttocks and
hamstring i'if his right leg. It was annoying at first, but now is starting to be concerning as it is present all
the time. You order xrays which demonstrate a 30% anterior vertebral slippage of L5 on S1. This is
classic presentation of what condition?
a. Spondylolysis
b. Spondylolisthesis
c. Cauda equine syndrome
d. Spinal stenosis
e. Herniated nucleus pulposus - CORRECT ANSWERS b.
Spondylolisthesis - a "slipping" of the anterior vertebral body, not to be confused with a "slipped disc",
the old colloquialism for a herniated nucleus pulposis which should show disc space narrowing.
- Spondylolysis is the "scotty dog" on xray without the slippage - these are worth looking on the ortho site
at plain films if you are not an ortho PA.
5. A 43 year old black female presents with complaint of fever, fatigue and increasing dyspnea. She
denies smoking history or history of emphysema. Lungs are clear to auscultation bilaterally. Chest xray
findings include bilateral hilar adenopathy and diffuse reticular infiltrates. Labs reveal elevated
sedimentation rate and hypercalcemia. What is the most likely diagnosis?
a. Pulmonary tuberculosis
, b. Sarcoidosis
c. Chlamydial pneumonia
d. Pneumoconiosis
e. Pneumocystis jiroveci - CORRECT ANSWERS b.
Sarcoidosis is common in the third and fourth decades of life. There are often no lung findings noted on
exam and hepatosplenomegaly is a common finding.
- Hypercalcemia is found in about 5% of patients with sarcoidosis and indicates need for therapy.
- TB is commonly associated with cough, chills and night sweats. Chest xray typically shows apical
cavitation
- Chlamydial pneumonia is commonly associated with cough. It is not usually associated with hilar
adenopathy and reticular infiltrates.
- Pneumoconiosis is typically asymptomatic with no associated fever.
6. A patient with progressing symptoms of aortic insufficiency has an echocardiogram done which shows
ventricle to be markedly dilated and significant regurgitant flow is noted. Which of the following PE
findings would NOT be expected?
a. A displaced PMI
b. A wide pulse pressure
c. A water hammer pulse
d. Delayed and diminished carotids pulses
e. Peripheral edema - CORRECT ANSWERS d.
A delayed pulse would be seen in aortic stenosis; where there is obstruction to flow through the valve and
decreased aortic upstroke.
- In regurg, there is TOO much blood (from backward flow) and all pulses are increased.
- This is causing him to develop a dilated myopathy and systolic failure.
7. A 64 year old man presents to the clinic with a history of dyspnea, headache and malaise. He has no
other specific complaints. He is a nonsmoker.
ACTUAL QUESTIONS AND CORRECT
ANSWERS
1. A 3 year old boy presents to the ER with persistent fever over more than 5 days with temp as high as
103 F. He was seen in clinic 2 days after onset of fever, no etiology was found, and this was thought to be
viral. Today, however, he woke with bilateral "pink eye" and cracked bleeding lips with desquamation of
the palms and soles of his feet. On PE you note a strawberry tongue, bilateral cervical adenopathy,
bilateral injected conjunctiva without discharge and dry fissured lips.
Which of the following is the most likely complication of this condition?
a. sydenham's chorea
b. cardiomyopathy
c. coronary artery aneurysm
d. mesenteric arteritis
e. mitral valve insufficiency - CORRECT ANSWERS c. coronary artery aneurysm
Classic features of Kawasaki's syndrome include fever, age less than 5 years, conjunctivitis, mucous
membrane abnormalities, desquamation of superficial epidermis of palms and soles, or marked erythema,
morbilliform rash and cervical lymphadenopathy.
- Coronary artery aneurysm occurs in about 25% of untreated or undiagnosed patients and is a major
complication of Kawasaki's syndrome, which is a vasculitic - type autoimmune disease.
-(A) Sydenham's chorea is a complication of untreated strep group A and causes abnormal involuntary
movements of the limbs and body.
-(B) Cardiomyopathy is incorrect, although it can occur as a result of many viruses in the young; it's onset
is more insidious occurring months after the initial attack on the myocardium.
-(D) Mesenteric arteritis can also result from vasculitic- type autoimmune disorder, but Kawasaki's
syndrome favors the coronary circulation.
-(E) Mitral valve insufficiency is incorrect because this patient does not have characteristics of this
disease, which include past evidence of infection with group A beta hemolytic streptococcus resulting in
rheumatic heart disease.
,2. A 47 year old Male construction worker was lifting a 75 pound bag of cement when he twisted and
injured his back. He presents complaining of lumbar back pain with radiating pain in his right lower
extremity. He denies any other trauma, did not fall, has no loss of bladder/ bowel function. He had never
injured his back before.
On PE, he has normal sensation to light touch throughout the lower extremity with the exception of
decreased sensation over the heel and lateral border of his foot. Lower extremity strength is measured as
follows:
Quads 5/5
Guteals 5/5
Peroneals 3/5
EHL 5/5
EDL 5/5
Gastrocnemius / soleus 4/5
Based upon this assessment, the most likely nerve root injured would be:
a. L3
b. L4
c. L5
d. S1
e. S2 - CORRECT ANSWERS d.
3. A 20 year old presents with a hard mass on his right testicle. There has been no previous infection or
trauma to the scrotum. However, the patient has a past medical history of an undescended testicle. You
suspect that this is testicular cancer. Select the answer below that pairs the most common histology with
its corresponding hormone marker.
a. Seminoma, no increase in AFP
b. Nonseminoma, decrease in HCG
c. Nonseminoma, no increase in LDH
d. Seminoma, decrease in CA-19-9.
e. Adenomatous, increase in CA-125 - CORRECT ANSWERS a.
,- AFP is never elevated in pure seminomas.
- Cryptorchidism predisposes a Male to a 5% lifetime risk of testicular cancer, with seminoma being the
most common form in this case - the right testicle is the key here.
-(B) HCG can occasionally be elevated with non-seminomas, as well as be slightly higher than a level for
a seminoma.
-(C) LDH can be elevated in either seminomas or nonseminomas.
-(D) and (E) Neither CA-19-9 nor CA-125 are genetic markers for testicular cancer.
4. A 22 year old college athlete injured his back while doing dead lifts in the weight room. For the last
two weeks, he has pain localized to his lumbar region that is aggravated with exercise, specifically any
type of back extension. He has noticed the slow progression of numbness down the buttocks and
hamstring i'if his right leg. It was annoying at first, but now is starting to be concerning as it is present all
the time. You order xrays which demonstrate a 30% anterior vertebral slippage of L5 on S1. This is
classic presentation of what condition?
a. Spondylolysis
b. Spondylolisthesis
c. Cauda equine syndrome
d. Spinal stenosis
e. Herniated nucleus pulposus - CORRECT ANSWERS b.
Spondylolisthesis - a "slipping" of the anterior vertebral body, not to be confused with a "slipped disc",
the old colloquialism for a herniated nucleus pulposis which should show disc space narrowing.
- Spondylolysis is the "scotty dog" on xray without the slippage - these are worth looking on the ortho site
at plain films if you are not an ortho PA.
5. A 43 year old black female presents with complaint of fever, fatigue and increasing dyspnea. She
denies smoking history or history of emphysema. Lungs are clear to auscultation bilaterally. Chest xray
findings include bilateral hilar adenopathy and diffuse reticular infiltrates. Labs reveal elevated
sedimentation rate and hypercalcemia. What is the most likely diagnosis?
a. Pulmonary tuberculosis
, b. Sarcoidosis
c. Chlamydial pneumonia
d. Pneumoconiosis
e. Pneumocystis jiroveci - CORRECT ANSWERS b.
Sarcoidosis is common in the third and fourth decades of life. There are often no lung findings noted on
exam and hepatosplenomegaly is a common finding.
- Hypercalcemia is found in about 5% of patients with sarcoidosis and indicates need for therapy.
- TB is commonly associated with cough, chills and night sweats. Chest xray typically shows apical
cavitation
- Chlamydial pneumonia is commonly associated with cough. It is not usually associated with hilar
adenopathy and reticular infiltrates.
- Pneumoconiosis is typically asymptomatic with no associated fever.
6. A patient with progressing symptoms of aortic insufficiency has an echocardiogram done which shows
ventricle to be markedly dilated and significant regurgitant flow is noted. Which of the following PE
findings would NOT be expected?
a. A displaced PMI
b. A wide pulse pressure
c. A water hammer pulse
d. Delayed and diminished carotids pulses
e. Peripheral edema - CORRECT ANSWERS d.
A delayed pulse would be seen in aortic stenosis; where there is obstruction to flow through the valve and
decreased aortic upstroke.
- In regurg, there is TOO much blood (from backward flow) and all pulses are increased.
- This is causing him to develop a dilated myopathy and systolic failure.
7. A 64 year old man presents to the clinic with a history of dyspnea, headache and malaise. He has no
other specific complaints. He is a nonsmoker.
