Practice exam 1 Flashcards
(98 cards)
1
Q
7 year-old nocturnal enuresis medication? -Imipramine (Tofranil) -Phenytoin (Dilantin) -Pramipexole (Mirapex) -Hyoscyamine (Urised)
A
Imipramine = anti-cholinergic - Tx 7-12yo nocturnal enuresis - 1 hr b4 bed (PO) x 3mo (including gradual withdrawal). - can increase after 1-2 wks - most relapse after discontinuing tx
2
Q
2 yo h/o 4d fever + general malaise. 102 F, rubor & maculopapular rash c/defervescence on trunk started 1d ago. the most appropriate management at this time? Ibuprofen (Motrin) Aspirinc Amoxicillin Valacyclovir
A
Motrin is indicated for management of the fever in Roseola infantum caused by the herpesvirus.
3
Q
Suture removal time - 3-5d - 7-`10d - 10-14d - 14-21d
A
- 3-5d = face - 7-`10d = scalp, UE - 10-14d = trunk, LE, hand & feet - 14-21d = palms & soles
4
Q
Rotator cuff muscles
A
Supraspinatus Subscapularis Infraspinatus Teres minor
5
Q
Rotator cuff inflammation symptoms - list 2 tests
A
Rotator cuff tendiopathy/tear => shoulder pain c/overhead activity or at night lying on arm => weak & immobility after acute injury => MRI
6
Q
Supraspinatus tear or inflammation: Empty can test: 90 degree abduct, 30 degree flex, rotate internal. Apply downward pressure = weakness/pain Full can test: 90 degree abduct, 30 degree flex, rotate external. Apply downward pressure = weakness/pain Arm drop: Arm passively abducted and actively adducted slowly = arm drops at 30 degrees
A
Supraspinatus tear or inflammation: Empty can test: 90 degree abduct, 30 degree flex, rotate internal. Apply downward pressure = weakness/pain Full can test: 90 degree abduct, 30 degree flex, rotate external. Apply downward pressure = weakness/pain Arm drop: Arm passively abducted and actively adducted slowly = arm drops at 30 degrees
7
Q
Supraspinatus impingement
A
- Neer’s test: Forward arm flexion, press greater tuberosity and supraspinatus muscle = pain - Hawkins test: Abduct shoulder 90 degree, flex elbow 90, rotate arm to limit = pain
8
Q
Subscapularis tear or inflammation:
A
Lift off test: Elbow 90 degree, rotate medially against resistance = pain/ weakness
9
Q
Teres minor/ infraspinatus tear or inflammation:
A
Elbow 90 degree, rotate laterally against resistance “resisted external rotation” = pain/ weakness
10
Q
What is the recommended method for screening pregnant women for gestational diabetes?
- Fasting blood sugar and 2 hour post prandial
- 50 gram glucose load followed by a blood sugar in 1 hour
- 75 gram glucose load followed by a blood sugar in 2 hours
- 100 gram glucose load followed by a blood sugar at 1 hour, 2 hours, and 3 hours
A
- Screen: 50 gram glucose load followed by a blood sugar in 1 hour => Normal < 140 mg/dL.
-
Diagnosis: if screen +
- 100 gram glucose load followed by a blood sugar at 1 hour, 2 hours, and 3 hour
11
Q
Which immunoglobulin is the first to respond during the primary immune response for a gram positive bacterial infection? -IgG -IgA -IgM -IgE
A
-IgG: Gatekeeper, records, memory (responds to secondary exposure) -IgA: found in colostrums & GI secretions. -IgM: Mage Killer (respond to acute exposure => opsonization & phagocytosis. -IgE: Eosinophils (responds to allergies & parasites)
12
Q
As a rule, solid foods such as cereal and fruits are best introduced into an infant’s diet at approximately 1 to 3 weeks. 4 to 8 weeks. 4 to 6 months 10 to 14 months.
A
inclusion of solid foods ~4-6 months. Prior increases risk of allergies and atopy - 6 month 1st tooth -12 months brush teeth
13
Q
During an influenza epidemic, a 6 year-old male is seen with fever and a severe sore throat. The parents report that his symptoms have not improved despite administration of aspirin. The next day, the parent calls to report that the child has persistent vomiting and increased lethargy. On examination, he is found to be delirious and disoriented with hyperactive reflexes. The liver edge is 3 cm below the right costal margin in the midclavicular line. Which of the following is the most likely diagnosis? Reye’s syndrome Measles encephalitis Guillain-Barre syndrome Acute bacterial meningitis
A
The suspected influenza + aspirin associated with development of vomiting, progressive mental status changes, hyperreflexia, and hepatomegaly are consistent with a diagnosis of Reye’s syndrome.
14
Q
A 26 year-old male who is an avid swimmer has been experiencing right shoulder pain for the past month. On examination, pain is elicited with palpation below the anterior acromion. Anterior shoulder pain is also reported when the patient flexes and extends his arm. Which of the following diagnostic tests is most appropriate at this time? -Shoulder x-ray -Shoulder arthroscopy -Shoulder MRI -Subacromial lidocaine injection
A
Subacromial injection of lidocaine leading to a transient but dramatic improvement in pain with shoulder extension makes the diagnosis of impingement highly likely.
15
Q
Rinne vs Weber test
A
Rinne = bone vs air (rhino = bones vs air) -Nl = AC>BC Weber = middle of head -Nl = midline
16
Q
Conductive hearing loss in affected ear => Rinne? Weber?
A
Rinne = BC>AC Weber = localize @ affected
17
Q
Sensory hearing loss loss in affected ear => Rinne? Weber?
A
Rinne = AC>BC Weber = localize @ non affected
18
Q
A 16 year-old male with a history of tetralogy of Fallot presents to clinic for a follow-up visit status post replacement of his right ventricle to pulmonary artery conduit. He has complaints of chest pain with inspiration, fever and general malaise. Cardiac examination reveals a rub with muffled heart sounds. Labs show an elevated erythrocyte sedimentation rate (ESR) and leukocytosis. Which of the following is the most effective treatment?
Acetaminophen/oxycodone
Azithromycin
Indomethacin
Furosemide
A
Indomethacin is suitable for controlling pain in Dressler’s syndrome (trauma à AI à endocarditis). ASA is preferred. Narcotics, diuretics or antibiotics are not recommended.
19
Q
- Antineutrophil cytoplasmic antibodies (ANCA)
- Antiendomysial antibodies (AEA)
- Antinuclear antibodies (ANA)
- Anti-Saccharomyces cerevisiae antibodies (ASCA)
A
- pANCA: UC (ANus), polyangitis
- AEA, anti-gliadin: CEliAc sprue
- ANA, anti-smith, anti-dsDNA: SLE
- ASCA: Crohns
20
Q
What examination finding would be expected in a patient with von Willebrand disease?
- Gingival bleeding
- Splenomegaly
- Muscle weakness
- Hemarthrosis
A
mucosal bleeding = epistaxis, gingival, menorrhagia.
21
Q
Established risk factor for osteoporosis? l
A
- Low body weight
- female
- advanced age
- Caucasian
- b/l oophorectomy before menopause c/o estrogen replacement
22
Q
52 year-old obese c/persistent heavy menses => endometrial bx shows atypical adenomatous hyperplasia. Whats next step in management?
- Total abdominal hysterectomy
- Observation & ut bx in 3 months
- Ut curettage followed by progesterone daily
- Oral progesterone days 16-25 of the month for 6 months and repeat bx
A
Atypical adenomatous hyperplasia = cellular atypia + mitotic figures in addition to glandular crowding and complexity. This has a 20-30% risk of progression to endometrial cancer and the recommendation is hysterectomy
23
Q
Who is most likely to require subacute bacterial endocarditis (SBE) prophylaxis prior to a dental procedure?
- 22 year-old female with mitral valve prolapse
- 36 year-old male with a bio-prosthesic mitral valve
- 45 year-old female with an ASD closure 8 months ago with no residual defect
- 15 year-old male with a bicuspid aortic valve
A
AHA recommends that patients with prosthetic heart valves receive antibiotic prophylaxis. As should cardiac transplant recipients with valve disease, unrepaired cyanotic CHD, repaired CHD with prosthetic material or device during the first six months of the procedure and repaired CHD with residual defects at site of patch or prosthetic device.
24
Q
A 72 year-old male presents to tED c/ crushing chest pain, dyspnea and palpitations for 2 hours. Enzymes are pending and he has been given aspirin and sublingual nitroglycerin. He is rushed to the catheterization lab where they find a totally occluded distal right coronary artery. Which of the following electrocardiogram (ECG) findings supports the diagnosis?
- Q waves in leads I, aVL, V5-V6
- ST segment elevation in leads II, III, aVF
- Hyperacute T waves in leads I, aVL
- Flipped T waves with repolarization changes in leads V1-V4
A
ST segment elevation in leads II, III, aVF, represents an acute process in the right coronary artery.
25
h/o occasional wheezing + chest tightness approximately 1/week and at night only 1/mo Peak expiratory flow is 85% of predicted. Which of the following is the most appropriate initial treatment?
* Albuterol (Proventil) inhaler
* Montelukast (Singular)
* Salmeterol (Serevent) inhaler
* Sustained release theophylline
Mild intermittent asthma = initially treated with inhaled beta 2-agonists as needed. No long-term control medications are indicated.
26
Which of the following medications decreases the exchange of hydrogen for potassium by inhibiting hydrogen, potassium-ATPase?
* Ranitidine (Zantac)
* Misoprostol (Cytotec)
* Sucralfate (Carafate)
* Omeprazole (Prilosec)
Omeprazole, a proton pump inhibitor, works by inhibiting hydrogen, potassium-ATPase
27
3 mo h/o 2 day worsening hoarse cough c/ thick purulent rhinorrhea associated with increasing trouble breathing-feeding.
PE = 100.2F, RR 80/minute, nasal flaring &retractions. Lung examination reveals a prolonged expiratory phase with inspiratory rales. He is tachycardic. Pulse oximetry reveals oxygen saturation of 89%. Chest x-ray reveals hyperinflation with diffuse interstitial infiltrates. Which of the following is the most appropriate intervention?
* Antibiotics
* Hospitalization
* Inhaled corticosteroids
* Racemic epinephrine
most likely bronchiolitis, most cases are mild and can be treated at home
* hospitalization is recommended for infants with hypoxia on room air, moderate tachypnea with feeding difficulties and marked respiratory distress with retractions.
* Additionally hospitalization is recommended for infants less than 2-3 months of age, a history of apnea or an underlying chronic cardiopulmonary disease.
28
preterm labor may be given corticosteroids to ___________ for\_\_\_\_ wks
enhance pulmonary maturity...given from 24-34 wks
29
Which indicate an optic nerve lesion?
* Excessive conjunctival edema
* Ptosis
* Inability to gaze laterally
* Afferent pupillary defect
Pupil size, controlled centrally by the Edinger-Westphal nucleus in the midbrain, is primarily based on the afferent light stimulus transmitted via the optic nerve
30
18 year-old female c/inc. vaginal d/c + odor & urinary frequency. PE = thin, gray, frothy vaginal d/c, red cervix, pH 6. Which of the following is the most likely diagnosis?
* Candida vaginitis
* Bacterial vaginosis
* Trichomonas vaginitis
* Chlamydia Trachomatis
* Gonorrhea
* Tric = thin frothy or bubbly, pale yellow-green to gray adherent vaginal d/c, red vulva/vagina, petechiae on the cervix, amine odor, dysuria/dyspareunia, pH 5 to 6.5 (basic).
* Candida = hypha (KOH), cottage cheese
* BV = clue cells, Sniff test, Fishy odor
* Tric = Protozoa, strawberry cervix, thin frothy/bubbly, yellow-green-gray
* Chlamydia = clear
* Gonorrhea = yellow purulent d/c
31
h/o severe peptic ulcer dz is 5 weeks status post Billroth I surgery. One week ago restarted normal diet =\> onset of severe nausea, abdominal cramping, and light-headedness occur approximately thirty minutes after eating. The abdominal exam reveals a healing surgical scar without areas of unusual tenderness or any palpable masses. Which of the following is the most likely diagnosis?
* Anxiety disorder
* Celiac sprue
* Dumping syndrome
* Irritable bowel syndrome
Dumping syndrome typically occurs after Billroth type I surgeries as well as gastric bypass surgeries when the patient attempts to eat a large amount of simple sugars.
32
41 year-old female h/o 3 weeks of gradually worsening pain at the base of the thumb and radial aspect of the wrist. She has been renovating home for past 2 months and it has become increasingly difficult for her to hold a hammer. She denies numbness or tingling. She no h/o previous trauma to wrist. On examination, tenderness over distal radial styloid and pain reproduced with ulnar deviation of a fist clenched over the abducted thumb. Which of the following is the most likely diagnosis?
* Carpal tunnel syndrome
* deQuervain's tenosynovitis
* Ganglion cyst
* Volar flexor tenosynovitis
deQuervain's tenosynovitis typically results from repetitive activity involving pinching the thumb while moving the wrist. There is often pain and tenderness over the radial styloid and Finkelstein's is positive in this patient.
33
40 year-old female presents with a Pap smear abnormality revealing atypical glandular cells (AGUS). What is the most appropriate intervention?
* HPV DNA testing
* Colposcopy with endometrial curretage(ECC)
* Repeat Pap smear in 3 months
* Colposcopy and endometrial sampling
Colposcopy and endometrial sampling are important to perform in patients with AGUS Pap results because glandular cells are associated with squamous and glandular precursor lesions and carcinoma.
34
Pap Guidelines
35
Which of the following is most common presentation for primary hyperparathyroidism in elderly female?
* Abdominal pain
* Renal lithiasis
* Acute pancreatitis
* Asymptomatic
primary hyperparathyroidism
mc in F \>50 yo
incidental finding on routine labs = hypercalcemia
36
male patient presents for routine physical examination. He denies chronic health problems, regular medication use or previous surgeries.
He exercises 4-5 times weekly, does not use tobacco products, and consumes alcohol in moderation. His last intake of alcohol was two weeks ago while on a trip to Mexico. His review of systems and physical examination are both negative.
Routine labs were drawn which were significant for the following:
* Total serum bilirubin 3.5 mg/dL (0.3-1.0 mg/dL)
* direct bilirubin 0.2 mg/dL (0.1-0.3 mg/dL)
* AST 35 U/L (0-35 U/L), ALT 30 U/L (0-35 U/L),
* Alkaline Phosphatase 48 U/L (30-120 U/L), GGT 12 U/L (1-94 U/L)
What is the most likely diagnosis in this patient?
* Alcoholic hepatitis
* Crigler-Najjar syndrome
* Gilbert's syndrome
* Wilson's disease
* Gilbert's syndrome = cause mild isolated elevations in indirect serum bilirubin. incidental finding, inherited condition. Can causes cosmetic sxs (jaundice), does not req tx
* ETOHIC hep = ALT 3x
* Crigler -Najjar syndrome
* Wilsons = Cu overload ïƒ vital organs & brain
37
Long history of dyspepsia refractory to maximum appropriate therapy. A recent upper GI series revealed multiple gastric and duodenal ulcerations with prominent mucosal folds. What diagnostic study would be confirmatory of this patient's suspected diagnosis?
* EGD with duodenal biopsy
* Serum gastrin level
* Helicobacter pylori serology
* Abdominal CT scan
Serum gastrin levels can be elevated for many reasons; however significant elevations in a fasting state as well as with the secretin stimulation test are confirmatory for Zollinger-Ellison syndrome which is highly suspect in this case.
38
Which of the following Rh genotypes in a mother and father would represent a risk for hemolytic disease of the newborn?
* mom Rh +, dad Rh -
* mom Rh +, dad Rh +
* mom Rh -, dad Rh -
* mom Rh -, dad Rh +
Mom Rh - & Dad Rh + =\> can have Rh + fetus
## Footnote
Rh-negative woman carries an Rh-positive fetus, she may develop antibodies against Rh when fetal blood cells enter her circulation.
39
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?
* Carotid U/S
* CXR
* CBC
* ESR
Temporal arteritis.
mc \> 50 yo 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.
40
60 year-old female recently d/c after an 8 day hospital stay for PNA presents c/ pain and redness in her right arm in area where IV was placed. No fever or chills
Examination of the area reveals localized induration, erythema and tenderness. There is no edema or streaking noted. Which of the following is the most likely diagnosis?
* Acute thromboembolism
* Thrombophlebitis
* Cellulitis
* Lymphangitis
Thrombophlebitis = dull pain, induration, redness and tenderness along the course of vein thrombophlebitis. Common cause is Short-term venous catheterization of a superficial arm vein
41
Bony and cartilaginous enlargement of distal interphalangeal joints is commonly seen in which of the following medical conditions?
* RA
* OA
* Psoriatic arthritis
* Gout
Heberden's nodes are commonly seen in primary osteoarthritis.
42
Define
1. Menorrhea
2. Dysmenorrhea
3. Polymenorrhea
4. Menorrhagia
5. Metorrhagia
6. Menometorrhagia
1. Menorrhea = menses "bleeding"
2. Dysmenorrhea = painful menses (cramps)
3. Polymenorrhea = freq menses (cycle \<21d)
4. Menorrhagia = heavy menses (\>7d or \>80mL)
5. Metorrhagia = frequent/irregular menses
6. Menometorrhagia = heavy frequent/irregular menses
43
Dysmenorrhea would most likely occur in which of the following patients?
1. young teen just starting menses
2. woman on OCPs
3. Marathon runner c/1 menses/yr
4. 35 woman c/regular menses
Women with regular menstrual cycles are most likely to have dysmenorrhea. Dysmenorrhea is caused by a excess of prostaglandin F 2 alpha. Prostaglandin production increases under the influence of progesterone, reaching a peak at, or soon after, the start of menstruation
44
Lesion of optic chiasm will produce which of the following conditions?
* Amaurosis fugax
* Bitemporal hemianopia
* R blindness
* R Homonymous hemianopia
* R nasal hemianopia
* R homonymous hemianopia
* R superior quadrantanopia
* R inferior quadrantopia
* Right hemianopia c/macular sparing
* Amaurosis fugax = temporary loss of vision in one or both eyes that appears as a black "curtain coming down vertically into the field of vision in one eye
* causes: embolic, hemodynamic, ocular, neurologic, idiopathic
45
75 year-old female with a history of long-standing hypertension presents with shortness of breath. On examination you note a diastolic murmur at the left upper sternal border. Which of the following maneuvers would accentuate this murmur?
* sitting up and leaning forward
* lying on left side
* performing valsalva
* standing upright
patient has history findings consistent with aortic insufficiency which is characterized by a diastolic murmur that is accentuated when the patient sits up and leans forward
46
47
32 year-old male presents with a one-month history of weakness, anorexia, and weight loss. On physical examination, he is hypotensive and his skin has diffuse hyperpigmentation. Plasma cortisol levels drawn at 8 am are low. Which of the following is the most likely diagnosis?
* Pituitary insufficiency
* Addisons
* Cushings syndrome
* Primary aldosteronism
classic presentation of Addison's disease (chronic adrenocortical insufficiency).
48
75 year-old female with history of coronary artery disease and dyslipidemia presents for routine follow-up. Physical examination reveals loss of hair on the lower extremities bilaterally with thinning of the skin. Femoral pulses are +2/4 bilaterally, pedal pulses are diminished bilaterally. Ankle brachial index is reduced. Which of the following signs or symptoms is this patient most likely to have?
* LE edema
* Calf pain c/walking
* LE numbness
* LE itching
Calf pain c/walking = arterial insufficiency and would most likely complain of intermittent claudication.
49
23 month-old male presents to the office with his father who reports the patient has had an acute onset of severe pharyngitis, fever of 103.5 degrees F and what sounds like harsh, high-pitched breath sounds. His dad states the child has started drooling and seems to be worsening. The child is not presently crying but has muffled voice sounds. The child has not been immunized due to religious reasons. What is the most appropriate next step?
* Administer Ceftriaxone (rocephin)
* Emergent transfer
* Administer racemic epinephrine
* Obtain IV access
Emergent transfer, Epiglottitis (HIb flu) requires endotracheal intubation to maintain airway & should be performed in OR or ER
50
physical examination of a pregnant patient, which can be considered a normal finding?
* inc. S2 split c/inspiration
* diastolic murmur
* facial edema
* hyperreflexia
Increased second heart sound split with inspiration is common in pregnancy due to the increased blood flow across the aortic and pulmonic valves.
51
55 year-old male with history of hypertension and diabetes mellitus presents to the emergency department. The patient's wife states that the patient developed progressive irritability and confusion today after complaining of a headache. Physical examination reveals a BP of 230/130 mmHg and papilledema. Which of the following is the most accurate diagnosis in this patient?
* HTN urgency
* HTN emergency
* Malignant HTN
* Resistant HTN
Malignant hypertension is significantly elevated BP with progressive retinopathy, including papilledema, encephalopathy, and headache.
* HTN urgency = \>220/\>125; asx, =\> outpt tx c/+2 meds
* HTN emergency = \>220/130; organ damage sxs (encephalopathy/ICH, neuropathy, aortic dissection, PE, unstable angina, protinuria/hematuria) =\> inpt tx bring down to 160/100 over 6hrs
* Malignant HTN = \>200/130; organ damage sxs (encephalopathy/neuropathy + **papilledema**) =\> inpt tx bring down to 160/100 over 6hrs
* Resistant HTN = does not decrease BP c/ diuretic + 2 BP meds
52
22 year-old female presents with onset of right eye vision loss 24 hours ago which has partially improved. She has experienced various widespread paresthesias, regional weakness and fatigue over the past six months. Episodes vary in location, severity and duration but invariably lead to recovery. Her exam is completely normal but MRI reveals numerous areas of periventricular gadolinium uptake. For this condition, what treatment has shown the greatest benefit with long term use?
* Interferon beta 1a (avonex)
* Ethosuixmide (zarontin)
* Methylprednisolone (solumedrol)
* Pyridostigmine (meslinon)
interferon agents have been the longest used and best studied medications that provide the best long term benefits in multiple sclerosis. Steroids do play a role in acute exacerbations but not as long term agents.
(steroids for acute flares)
53
severe, stabbing pains, lasting only seconds, over the cheek and chin areas. She also experiences intense pain in these areas with chewing, washing her face and even with smiling. Examination reveals no sensory or motor deficits. Head computer tomography (CT) and erythrocyte sedimentation rate (ESR) are normal. She has been unresponsive to maximum doses of carbamazepine. What is the next best option for this patient?
* B/l deep rain stimulation
* Simvastatin-Sertraline combo
* high dose corticosteroids
* Sterotatctic radiosrugery
Trigeminal neuralgia is generally responsive to Carbamazepine however, for those who fail to respond to medicinal therapy surgery is the next valid option. Though there are various procedures, Stereotactic (Gamma knife) radiosurgery has provided the best results.
54
Screening for hypothyroidism is indicated in which of the following patients??
1. newborn
2. young female c/anxiety
3. pt c/new onset of afib
4. heat intolerance
American Academy of Pediatrics recommends screening of hypothyroid disease between 2-4 days of birth
55
Your patient has just delivered her baby vaginally without difficulty. The patient has a laceration of the vaginal mucosa including the perineal body. You repair it without difficulty. On the chart you document this as what type of tear?
* 1st degree
* 2nd degree
* 3rd degree
* 4th degree
* 1st degree = vagina
* 2nd degree = perineum
* 3rd degree = rectal spincter
* 4th degree = rectal mucosa
56
osteoporosis + osteomalacia treatments
* osteoporosis = Weight bearing exercises adjunct to medication. Water aerobics are non-weight bearing.
* osteomalacia = Sun exposure adn vitamin D supplementation are useful in preventing
57
31 year-old female complains of diarrhea. She admits to associated weight loss and steatorrhea, but denies melena or hematochezia. Which of the following is the most likely diagnosis?
* Celiac dz
* lactose intolerance
* short bowel syndrome
* IBS
Greater than 10 grams of fecal fat in 24 hours is most consistent with a malabsorption syndrome such as celiac sprue.
58
A 9 year-old patient presents with conjunctivitis after swimming at the local pool. On examination, there is visible lid edema with redness of the palpebral conjunctiva, copious watery discharge, and scanty exudate. The sanitation system of the public pool is through the use of a salt water system; therefore, the possibility of a chemical induced conjunctivitis is almost non-existent. Which of the following should be instituted to prevent the sequalae of the condition?
* ketorolac tromethamine (acular)
* dexamethasone ophtalmic
* Naphazoline HCL
* Sulfacetamide opthalmic
One of the most common causes of viral conjunctivitis is adenovirus type 3. Contaminated swimming pools can be source of infection. Topical sulfonamides prevent secondary bacterial infection.
59
36 year-old male who is hospitalized because of severe injuries from a motor vehicle accident develops rapid onset of profound dyspnea. Initial chest x-ray shows a normal heart size with diffuse bilateral infiltrates. Follow-up chest xray shows confluent bilateral infiltrates that spare the costophrenic angles. Which of the following is the best clinical intervention for this patient?
* supplemental o2
* chest tube
* tracheal intubation
* corticosteroids
Treatment of hypoxemia in acute respiratory distress syndrome (ARDS) usually requires tracheal intubation.
60
37 year-old right-handed landscaper comes to the office for evaluation of recurrent itching and stinging of the skin on his right hand. Physical examination reveals confluent papules, vesicles, erosions and crusts on the dorsum of his right hand. Which of the following is the most appropriate initial diagnostic study in this patient?
* skin scaping & micro
* patch test
* rast test
* skin bx
patch testing, substances are applied to the skin in shallow cups and left in place for 24-48 hours. Sensitivity to an allergen is confirmed by a papular vesicular reaction that occurs within 48-72 hours of the laboratory testing.
61
A 15 year-old man comes to the office with acute onset of nausea, severe pain and swelling within the right testis. He has no fever or irritative voiding symptoms. Which of the following scrotal physical examination findings would you expect in this patient?
* nodular mass c/in testis
* high lying testis
* transilluminate fluid mass
* palpation of soft bag of worms
Testicular torsion occurs in the 10-20 year age group, and is characterized by acute onset of severe pain and swelling of the testis. Physical examination will reveal a tender high-riding testis.
62
Which of the following is the most appropriate management of acute psychosis in a patient with schizophrenia?
* amitriptyline
* fluphenazine
* Li
* Sertraline
* management of acute psychosis including benzodiazepines and the typical antipsychotics such as fluphenazine, haloperidol, and olanzapine.
* Antidepressants and lithium have no benefit in the treatment of acute psychosis.
63
You are following a patient in labor at term. You evaluate the fetal monitoring tracing and note the presence of variable, repetitive decelerations in the heart rates. The contractions have a sharp deceleration slope. What is the recommended treatment for these decelerations?
* change maternal position
* tocolytics
* vibroacustic stimulation
* c-section
Variable decelerations occur from umbilical cord compression and oligohydramnios. They are treated by changing maternal positioning to relieve pressure on the umbilical cord. Additionally, amnioinfusion may be used to relieve umbilical cord compression in cases of oligohydramnios.
64
An otherwise healthy college student presents with complaints of cough, malaise, fever, yellow-green nasal discharge and headache for the past 3 weeks. She complains of facial pain over the cheeks and while chewing. On examination, the nasal turbinates are erythematous and edematous nearly obstructing the nares bilaterally. She has not been previously evaluated. What is the most appropriate antibiotic in this patient?
* Amoxicillin/clavulanate (Augmentin)
* Trimethoprim/sulfamethoxazole (Bactrim)
* Levofloxacin (Levaquin
* Moxifloxacin
Acute bacterial rhinosinusitis (sinusitis) is associated with S. pneumoniae, H. Influenzae, and less commonly S. Aureus or Moraxella catarrhalis.
* First line therapies for bacterial sinusitis include amoxicillin, Bactrim, or doxycycline.
* Second line therapy includes Augmentin, Moxifloxacin, or Telithromy
65
An O2 saturation of 90% corresponds to what PO2 value?
* 90 mmHg
* 80
* 70
* 60
* O2 sat \> 90% = PO2 \>70 mmHg
* \< 94% = hypoxemia
* \< 90% O2 sat warrants measurement of arterial blood gasses.
66
In order to prevent the progression of diabetic nephropathy which of the following medications should be instituted?
Lisinopril (Prinipril)
Propanolol (Inderal)
Verapamil (Calan)
Hydrochlorothiazide (Diuril)
All patients should be started on an ACE inhibitor to prevent the progression of proteinuria. ACE inhibitors appear to improve glomerular hemodynamics by decreasing glomerular pressure.
67
A 5 year-old male presents with a history of recurrent episodes of acute bronchitis, characterized by fever and productive cough. He has no known significant past medical history. His pulmonary examination reveals crackles in the bilateral lower lobes. The remainder of his physical examination is normal. Chest x-ray demonstrates platelike atelectasis and dilated, thickened airways in the middle and lower lungs. Which of the following is the most likely diagnosis?
Acute bronchitis
Bronchiectasis
Pneumonia
Tuberculosis
Bronchiectasis typically presents as recurrent episodes of acute bronchitis. Platelike atelectasis and dilated and thickened airways, sometimes described as tram lines, are common radiographic findings.
68
Which of the following clinical characteristics is associated with bicipital tendonitis?
Aggravated by resisted supination of the forearm
Bulging appearance to the proximal arm
Weakness of the arm with internal rotation and adduction
Pain that awakens the patient at night
Supraspinatus tendonitis will be aggravated by resisted supination of the forearm.
69
Antedote for which drug?
1. Flumazenil (Romazicon)
2. Naloxone (Narcan)
3. Chlordiazepoxide (Librium)
4. Clonidine (Catapres)
5. Atenolol
6. Carbamazepine
7. Valproate
8. Gabapentin
9. Methadone
10. Buprenorphine
11. Naloxone
12. Naltrexone
13. Varenicline
14. Bupriopion
1. Flumazenil (Romazicon) = Benzodiazepines OD
2. Naloxone (Narcan) = Opioid OD
3. Chlordiazepoxide (Librium) = Benzo txs =\> ETOH/Benzo c/d (stage 1 = anxiety sxs)
4. Clonidine (Catapres) = a-agonist txs =\> ETOH/Benzo c/d (stage 2 = HTN)
5. Atenonol = BB txs =\> ETOH/Benzo c/d (stage 2 = irregular HR)
6. Carbamazepine = anticonv txs =\> ETOH/Benzo c/d (stage 3 = Delerium Tremors)
7. Valproate = anticonv txs =\> ETOH/Benzo c/d (stage 3 = Delerium Tremors)
8. Gabapentin = anticonv txs =\> ETOH/Benzo c/d (stage 3 = Delerium Tremors)
9. Methadone = Opioid agonist txs =\> opioid addiction & c/d
10. Buprenorphine = Opioid partial agonist txs =\> opioid addiction & c/d
11. Naloxone (Narcan) = Opioid partial antagnoist txs =\> opioid OD
12. Naltrexone = Opioid antagnoist txs =\> opioid addiction & c/d
13. Varenicline (Chantix)= cholinometic txs =\> smoking addiction
14. Bupriopion (wellbutrin) = antidepressant txs =\> smoking addiction
70
48 year-old female c/hematuria during insurance physical examination. No dysuria, frequency, abdomen/flank/meatus pain. No h/o nephrolithiasis. UA = yellow & slightly hazy, positive Hgb dipstick. Microscopic = 5-7 RBCs/HPF without WBCs, bacteria, casts, or crystals. What is the next diagnostic study this patient should undergo?
* CT urography
* Intravenous pyelogram
* Abd US
* Cystoscopy
*
* CT urography with and without contrast should be done to evaluate the upper and lower urinary tract for neoplasms, and benign conditions such as urolithiasis. This has replaced IVP for imaging of the upper tracts.
* Abdominal ultrasound will not help in this scenario and the role of renal ultrasound in evaluation of hematuria is unclear.
* Cystoscopy will help to assess the bladder and urethra but will not help with evaluation of the upper urinary tract.
71
56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg to be cool to the touch and the toes to be cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities have 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis?
Venous thrombosis
Arterial thrombosis
Thromboangiitis obliterans
Thrombophlebitis
* Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse.
* FYI: Thrombophlebitis = dull pain, induration, redness and tenderness along the course of vein thrombophlebitis. Common cause is Short-term venous catheterization of a superficial arm vein
72
18 year-old G1P0 female presents for her 35 week prenatal visit with complaints of headache, blurred vision and right upper quadrant discomfort. Vital signs show BP of 170/100 mmHg and brisk patellar reflexes. Urinalysis shows 3+ proteinuria. Fetal heart tones are 150. What is your next step in the care of this patient?
Admit to hospital and prepare for delivery
Admit to hospital with antepartum fetal surveillance and close monitoring of maternal conditions
Order bed rest at home with daily fetal movement counts and twice weekly antepartum care
Order bed rest at home with administration of prophylactic magnesium sulfate
Severe preeclampsia mandates hospitalization. Delivery is indicated if gestational age is 34 weeks or greater.
73
Which of the following medications is most useful in maintaining remission in a patient with ulcerative colitis?
* Oral corticosteroids
* corticosteroids enemas
* Sulfasalzine
* Macrodantin
Sulfasalazine, olsalazine, and mesalamine are effective in maintaining remission in patients with ulcerative colitis.
74
adult presents with a three month history of progressive severe muscle cramps, extremity paresthesias and lethargy
* hypo/hyper-parathyroid
* hypot/hyper--thyroid
Hypocalcemia secondary to hypoparathyroidism is commonly seen as a complication of thyroidectomy.
75
Elderly patient is noted to have a painless, brown-colored ulceration in the area of the medial malleolus. Which of the following is the most likely diagnosis?
* Arterial ulcer
* Venous ulcer
* Arterial insufficency
* Diabetic ulcer
* Venous ulceration = develops in the lower extremity secondary to venous incompetence and chronic edema. The medial aspect of the ankle is the most common location
* Arterial ulcer = mc tip of toes, decrease temp, decrease pulse
* Diabetic ulcer = heels/soles, to bone
76
patient with known relapsing-remitting multiple sclerosis (MS) presents to the hospital with an exacerbation of MS symptoms. What is the recommended treatment?
* Baclofen
* Interferon
* Glatiramer acetate
* Methylprednisone
Acute relapses of MS are treated with a short course of IV methylprednisolone followed by oral prednisone. This regimen reduces the severity and shortens the duration of attacks. All other drugs listed are used to reduce the attack rate of relapsing remitting multiple sclerosis.
(chronic = interferon)
77
Acute relapses of MS are treated with a short course of IV methylprednisolone followed by oral prednisone. This regimen reduces the severity and shortens the duration of attacks. All other drugs listed are used to reduce the attack rate of relapsing remitting multiple sclerosis.
* IM steroids
* Antivenin
* Cold bath
* Hospital admission for symptomatic care
Hospital admission for symptomatic care should be considered in children, pregnant women, and patients with preexisting cardiovascular disease.
* Antivenin = snake bites
78
Which of the following is the portion of the nephron responsible for the absorption of 90% of the ultrafiltrate?
* prox convoluted tubule
* loop of henle
* distal convoluted tubule
* Collecting duct
* prox convoluted tubule = ultrafiltrate 90% is reabsorbed
* loop of henle = gradient
* distal convoluted tubule = reabsorb & secrete =\> blood pH & e-lytes
* Collecting duct = reabsorb water & solutes (urea)
79
80
When instituting diuretic therapy for patients with heart failure, which of the following is considered the treatment of choice as first-line therapy in a failing kidney due to its improved sodium clearance?
* HTZ
* Bumetanide
* Spiranolactone
* Acetazolamide
Loop diuretics remain active in severe renal insufficiency and are the most effective type of diuretics used in the management of heart failure symptoms. These agents have a rapid onset and result in natriuresis due to their activity in the ascending limb in the Loop of Henle.
81
A female patient presents with weakness and fatigue for the past three months. A CBC was ordered and revealed the following values: RBC 3.8 X 10(6)mcL (4.7-6.1 x 10(6)mcL) HCT 27% (35-45%) Hgb 9.2 gms/dL (12-15.5 gms/dL) MCV 120 fL (80-100 fL) MCH 35 pg (26-34 pg) On physical examination which of the following would be a consistent finding for this type of anemia?
* Paresthesia of hands & feet
* Hepatomegaly
* Tachycardia
* Jaundice
Neurological manifestation is the earliest type most commonly seen with megaloblastic anemia most commonly from vitamin B12 deficiency.
82
newborn male infant is seen by the PA prior to discharge home. On examination it is noted that the meatal opening is on the dorsal surface of the penile shaft just behind the coronal sulcus. The testicles are descended bilaterally. This physical examination finding is called which of the following?
* penile epispadias
* penile hypospadias
* Glandular epispadias
* Glandular hypospadias
This is a penile epispadias which can develop anywhere along the penile shaft to the pubic bone. It is caused by displacement of urethra/meatal opening on the dorsal surface of the penis. If the opening occurs in the glans penis then it would be a glandular epispadias. If this abnormality occurs on the ventral surface of the penis or glans penis then it is known as a hypospadias.
83
24 year-old male presents to the emergency room via ambulance. He was found by the police walking naked on the highway. His speech is minimal but disorganized and he appears to be responding to auditory hallucinations. With further questioning, he is preoccupied with the delusion of the FBI listening in on his conversations. His mother tells you that he has been acting bizarre for two months now. What is the most likely diagnosis?
* Schizophrenia
* Schizophreniform disorder
* Schizoaffective disorder
* Schizotypal personality disorder
Schizophreniform disorder is characterized by the same features as schizophrenia except the total duration of the illness is at least one month and less than six months.
84
During a routine prenatal visit, the fundal height is found to be at the umbilical level. The number of weeks gestation is estimated to be
* 10 to 12.
* 16 to 18.
* 20 to 22
* 26 to 28.
At 20 weeks, fundal height is at the umbilicus.
85
According to the American College of Cardiology/American Heart Association classification of heart failure, which of the following patients fits the Stage B Classification system?
* Asymptomatic patient with no structural disease or patients who are at high risk for the development of heart failure
* Asymptomatic patient with structural heart disease.
* Symptomatic patient with structural heart disease.
* Patients with refractory symptoms despite intervention.
According to the ACC/AHA 2005 guidelines, patients with structural heart disease who have not yet experienced symptoms are classified as Stage B. This is the initial stage in which medication therapy other than just ACE inhibitors are recommended.
86
A stuporous patient is brought to the emergency room with a five day history of progressive lethargy and confusion along with polyuria and polydipsia. On examination the patient is dehydrated and is without Kussmaul respirations. Serum glucose is 1200 mg/dL (75-110 mg/dL), serum sodium 150 mEq/L (136-146 mEq/L) serum pH is 7.5 and serum osmolality is 320 mosm/kg (280-300 mosm/kg). Urinalysis reveals no ketones. What is the most likely diagnosis?
* Primary hyperaldosteronism
* Diabetic ketoacidosis
* Lactic acidosis
* Hyperglycemic hyperosmolar state
## Footnote
Extreme hyperglycemia with normal pH and negative ketones are hallmark for this clinical picture.
87
A 9 year-old patient presents for follow up of his allergic rhinitis symptoms. He continues to complain of nasal congestion, sneezing, rhinorrhea, and eczema despite avoidance therapy and treatment with oral cetirizine (Zyrtec) and nasal flunisolide (Nasarel). Examination reveals pale, boggy nasal mucosa and eczema of the face and lower extremities. Which of the following is the most appropriate treatment at this time?
* Montelukast
* Immunotherapy
* Ipratropium bromide
* Cromolyn sodium
Immunotherapy is recommended in patients with severe allergic rhinitis who fail to respond to drug therapy and allergen avoidance. This patient has failed avoidance therapy, as well as antihistamines and intranasal corticosteroids.
88
A 23 year-old male presents with symptoms of irritative urethral discharge. History reveals recent unprotected intercourse with a new partner. A Gram stain of the urethral discharge is negative for intracellular diplococci. Assuming no allergies, which of the following is the drug of choice?
* Doxycycline
* Penicillin G
* Ceftriaxone
* Amoxicillin
Doxycycline 100 mg orally for 7 days is indicated for the treatment of non-gonococcal urethritis. (Chlamydia)
89
Elevated levels of LP(a) (Lipoprotein a) are considered to be a risk factor for coronary artery disease through which of the following proposed mechanisms?
* Direct inhibition of HDL
* Increasing the formation of VLDL cholesterol
* Competes for binding to the plasminogen receptor
* Enhancement of naturally circulating triglycerides
Lp(a) lipoproteins are secreted by the liver, constitute 10% or less of the total plasma lipoprotein mass, possess kringle domains homologous to plasminogen, and are associated with vascular disease risk. Having domains homologous to plasminogen, Lp(a) will compete with actual plasminogen for its receptor sites. Plasminogen activates plasmin, which facilitates degradation of fibrin and matrix components. The main component of LP (a) is LDL, a known risk factor for atherosclerosis.
90
Which of the following medication classes is the recommended treatment for patients who have an anterior wall myocardial infarction with poor left ventricular function?
* Beta blockers
* Calcium channel blockers
* Potassium sparing diuretics
* ACE inhibitors
ACE inhibitors have been proven to be effective in the therapy of heart failure, especially in the setting of left ventricular dysfunction. They are considered first-line therapy in patients with symptomatic left ventricular systolic function
91
35 year-old female presents with a long standing complaint of dry, scratchy eyes and dry mouth. She also reports dyspareunia. Labs demonstrate a positive anti-nuclear antibody and Anti-La antibodies. The patient has a prolonged Schirmer test. Which of the following classes of medicines should be avoided in treating this condition?
* Antimalarials
* NSAIDs
* Glucocorticoids
* Anticholinergics
Anticholinergics should be avoided in a patient with Sjogrens syndrome. All the other medications may be used to treat the systemic symptoms of Sjogrens .
92
A 19 year-old college student has a severe sore throat and a temperature of 102° F. On examination, there are vesicles on the soft palate with some erythema. The tonsils are not enlarged. There is mild cervical lymph node enlargement. Which of the following is the most likely diagnosis?
* Epstein-Barr virus
* Coxsackie virus group A
* Streptococcus pyogenes
* Mycoplasma pneumoniae
Coxsackie virus group A is characterized early by petechiae or papules/vesicles on the soft palate that become shallow ulcers in about 3 days.
93
Which of the following is the underlying pathogen for the development of Lyme disease?
* Borrelia burgdorferi
* Bartonella henselae
* Rickettsia rickettsii
* Coxiella brunetti
* Borrelia burgdorferi = Lyme disease is a tick-borne illness caused by the spirochete B. burgdorferi .
* Bartonella henselae = cat scratch
* Rickettsia rickettsii = Rocky Mt Spotted Fever
* Coxiella brunetti = Q fever, found in animals
94
95
Which of the following is the most appropriate study for diagnosing Hirschsprung disease?
Rectal biopsy
Stool leukocyte test
CT of the abdomen and pelvis
**Fecal occult blood test**
A rectal biopsy showing the absence of ganglion cells in both the submucosal and muscular layers of the involved bowel is the most appropriate diagnostic study for Hirschsprung disease.
96
97
* 71-year-old at ED for worsening back pain x4 days. Prostatectomy 7 mo ago for advanced prostate cancer. Has fallen 4 times since yesterday due to imbalance.
* 37C (98F),125/82 mmHg, 84/min, 17/min.
* PE: LE 4/5 bilaterally with mild spasticity
* 3+ DTR. Weak Rectal sphincter tone,
* point tenderness L5 & S1 region
* next step in management of this patient?
A- Leuprolide
B- X-ray of lumbar spine
C- IV glucocorticoids
D- NSAIDs and baclofen
E- Radionuclide bone scan
epidural spinal cord compression (ESCC) from malignancy. Common metastatic malignancies affecting the spine are lung, breast, prostate cancer and multiple myeloma. Rapid recognition of ESCC is vital to avoid permanent neurologic complications. MRI of the spine is recommended for initial evaluation, however treatment with IV glucocorticoids must be initiated while awaiting for imaging studies. Glucocorticoids decrease vasogenic edema caused by obstructed epidural venous plexus & help alleviate pain & restore neurologic function
98
