packrat form 9

8/10/2019 Packrat Form 9

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ACKNOWLEDGEMENT

The time and effort provided by the following individuals who served as members of thiscommittee are greatly appreciated:

James VanRhee, MS, PA-C. Project Director

Linda Allison, MPH, MDMark Archambault, MHS, RPA-C

Petar Breitinger, MPAS, PA-CChristine Bruce, MHSA, PA-C

Ralph Rice, MPAS, PA-CEric Vangsnes, MSA, PA-CDonna Yeisley, Med, PA-C

DEDICATION

This examination would not have been possible without the years of commitment of the MR. TIBDevelopment Committee. Numerous PA educators from across the nation provided theirexperience and insight as questions for MR. TIB. It has been this data bank that served as thebuilding blocks for PACKRAT.

APAP is proud to be able to continue in the tradition of quality fostered by the forerunners of theself-assessment examination for physical assistants. It is our honor to dedicate PACKRAT to:

Jesse C. Edwards, MSClaire S. Parker, PhD

University of Nebraska, Physician Assistant Program


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ASSOCIATION OF PHYSICIAN ASSISTANT PROGRAMS

Physician Assistant Clinical Knowledge Rating and Assessment Tool(PACKRAT)

Form 9

Directions and Explanations

TABLE OF CONTENTS

I. Introduc tion 1

II. Explanation of the Score Report 2

Page 1: Scores Your total Score and Group Comparisons 2Page 2: Your strengths, Weaknesses, and Quality of Responses 2Page 3: Your Individual and Correct Responses 2Page 4: Your Responses by Task and Category 2Page 5-6: Your Profile Comparison: Demographic Profile 2

III. Recommendations for Using the Feedback Package 3

IV. Study Resources 5

V. Answer Key 7

VI. Examination Explanations 8

VII. Comment Form 101

Copyright 2004. Association of Physician Assistant Programs. All rights reserved. No part of this publication may bereproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy or recording, orany information and retrieval system, without permission in writing from the Association of Physician Assistant Programs.


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PHYSICIAN ASSISTANT CLINICAL KNOWLEDGE RATINGAND ASSESSMENT TOOL (PACKRAT)

I. Introduction

The Physician Assistant Clinical Knowledge Rating and Assessment Tool (PACKRAT) wasdeveloped by a volunteer committee of experts and is based on the content outline of a nationallyrecognized competency examination. The following is a description of the content of PACKRAT:

PACKRAT EXAMINATION MATRIX

CONTENT AREA NUMBER OF ITEMS

1. History & Physical 262. Diagnostic Studies 363. Diagnosis 454. Health Maintenance 225. Clinical Intervention 326. Clinical Therapeutics 487. Scientific Concepts 16

TOTALS 225

Additionally, questions also apply to the following clinical specialties:

A. Cardiology I. Neurology

B. Dermatology J. Obstetrics/GynecologyC. Endocrinology K. Orthopedics/RheumatologyD. ENT L. PediatricsE. Ophthalmology M. Psychiatry/Behavioral MedicineF. Gastrointestinal/Nutritional N. PulmonologyG. Geriatrics O. SurgeryH. Hematology P. Urology/Renal

The task and specialty categories for each item are listed in the answer key on page 5; yourfeedback package contains a breakdown of responses by the task and clinical specialty category.Pay particular attention to the questions you answered incorrectly and determine the specialty for

that question and use this information to identify weaknesses.

The PACKRAT provides a detailed feedback report of performance and it is available to anyoneat any time. Explanations were developed for all the questions to provide a rationale for correct,as well as incorrect, answers. This information will help determine strengths and weaknesses withrespect to the PACKRAT content outline. If you have weaknesses in specific areas, you mayneed to obtain additional clinical experience in those areas.

This booklet is designed to explain and interpret the information contained in the accompanyingcomputerized score report. You can use the report package to learn more about your abilities.

PACKRAT EXAMINATION MATRIX

CONTENT AREA NUMBER OF ITEMS

1. History & Physical 362. Diagnostic Studies 323. Diagnosis 414. Health Maintenance 225. Clinical Intervention 316. Clinical Therapeutics 417. Scientific Concepts 22

TOTALS 225

Additionally, questions also apply to the following clinical specialties:

A. Cardiology I. NeurologyB. Dermatology J. Obstetrics/Gynecology

C. Endocrinology K. Orthopedics/RheumatologyD. ENT/Ophthalmology M. Psychiatry/Behavioral MedicineF. Gastrointestinal/Nutritional N. PulmonologyH. Hermatology P. Urology/Renal

Q. Infectious Diseases


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II. Explanation o f the Score Report

This section provides an interpretation of eachpage of the computerized score report youreceived. You should have your computerscore report in front of you. Begin on page 1of the report and read the followinginformation.

Page 1: Scores Your Total Score andGroup Comparisons

Page 1 is an overview of the PACKRATfeedback report. Toward the bottom of thepage is your examination score. This scoreshows the number of questions you answeredcorrectly out of a possible 225. The averagescore for all first-year and second-yearcandidates who have taken the PACKRAT to

date is also given.

Page 2: Your Strengths, Weaknesses, andQuality of Responses

Page 2 of the score report gives an overviewof the content area in which your performanceis categorized as Strong, Satisfactory, orNeeding Improvement. These areas arebased on the examination matrix on page 1.

In each content area, your answers havebeen classified as correct, acceptable,

unsatisfactory, or harmful. A definition ofthese classifications is also provided on thispage. Pay particular attention to the areasunder Needing Improvement, as these areasshould be noted for further study. Also checkthe answer key for the specialty area of theseitems. If you selected a harmful answer in anycontent area, it will be automatically placed inthe Needing Improvement category,regardless of the number of correct answersselected. Carefully review these questionsand their explanations and specialtyclassifications in Section VI to help you

understand why your answers were correct.

Page 3: Your Individual and CorrectResponses

Page 3 lists your answers to all questions.When your answer differs from the correctone, the proper response appears inparentheses. Use Section VI with this page toreview the rationale for each option that is

provided in the explanations, which arereferenced to the study resources. Theexplanations may help you understand whyone answer is more appropriate than another,or not the best answer, and why some of youranswers may have been incorrect. If theoption you chose was judged potentiallyharmful to the patient or others, an asterisk (*)appears before your answer. Optionsclassified as potentially harmful may identifyserious weaknesses. Go over these questionscarefully and read the explanations for thecorrect answers. You may be able to identifyareas where you need further study.

Page 4: Your Responses by Task andSpecialty Category

Page 4 lists your responses by both specialtyand task category. You will be bale to identify

the areas of the content outline where youmay have difficulty. The numbers reflect howmany items you answered correctly out of thetotal possible correct within each task andspecialty area. Categories 1 through 7 identifythe task areas and A-P the clinically specialtyareas. If you missed a significant number ofitems in an area, check the key and go overthe explanations for the items in these areas.

Page 5-6: Your Profile Comparison:Demographic Profile

Page 5 is the beginning of the individualDemographic Profile Comparison. This profileshows your reported demographic informationand compares your information to the entiregroup of individuals who have taken thePACKRAT to date. The demographic data arebased on the information you provided byanswering the questions in the test booklet.The summary demographic informationshown reflects all the data compiled for eitherfirst or second-year students who taken thePACKRAT. For example, if you are a second-year physician assistant student, your profile

is compared to all other second year students.The example shown later indicated thisindividual is a second-year student who has 3-6 months of clinical experience. The profilealso explains that 15% of those who took thePACKRAT also had 3-6 months experience,compared to 45% with 10 to 12 monthsexperience.


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RESPONDENT DEMPGRAPHICINFORMATION

C. Number of months of clinical rotationscompleted at the time of this exam?

Your response: All Second-yearRespondents:

( ) 1. None ( 0% )( ) 2. Less than 3 months ( 5% )( ) 3. 3 to 6 months ( 15%)( ) 4. 7 to 9 months ( 20%)( ) 5. 10 to 12 months (45%)( ) 6. Greater than 12 months (15%)

You can use the profile to compare your

characteristics to all those second yearstudents who have taken the PACKRAT. Ifyou are a first year student, your profile will becompared to all first-year students.

III. Recommendations for using TheFeedback Package

As a current physician assistant student,PACKRAT can be a useful self-evaluationtool. Through careful review of questionexplanations, noting specific tasks andcontent areas, you will be able to assess your

current strengths and weaknesses. You willbe able to identify particular areas in which toconcentrate more effort as you continue yourstudies. By concentrating your effort on theareas in which you did not do well, you mayimprove your performance, and you may havea better chance of passing the proctoredexamination. However, APAP cannotguarantee that this will occur, since theconditions under which you attempted thePACKRAT may have been different fromthose in a standardized administration of aproctored examination.

Use the explanations in Section VI to analyzewhy you chose various options. Again, payparticular attention to the options that were

judged potentially harmful or unsatisfactory.Look at the question and the four optionsagain to see why the answer you chose wasincorrect. If there appears to be a deficit inyour exposure to a particular clinical specialty,

perhaps further study would make you morefamiliar with these situations.Once you have completely reviewed yourscore report and this booklet, APAP hopesyou will use this information to improve youroverall performance, either on the job or onfuture certification examinations. Should youwish to provide suggestions about PACKRATto APAP, you will find a comment form on thelast page of this booklet.

IV. Study Resources

A variety of textbooks are currently availableto assist candidates in preparing for thecertification examination. For additionalinformation, you may contact a facultymember at an educational program or anexperienced colleague if you need helpdetermining which references to review in a

specific content area. A short list of generaltextbooks is below. All examination questionsare related to material found in theseresources.

Please note that the books on this list are notavailable from APAP. This is not intended asan all-inclusive list, and the materials listedbelow are suggested study materials only.

1. Ahya SN, Flood K, and Paranjothi S(eds). The Washington Manual ofMedical Therapeutics. 30th ed.

Philadelphia, PA: Williams &Wilkins, 2001.

2. Andreoli TE, et al (eds). CecilsEssentials of Medicine. 5th ed.Philadelphia, PA: WB SaundersCo., 2001.

3. Ballweg R et al. Physician Assistant:A Guide to Clinical Practice. 3

rded.,

Saunders, 2003.4. Bates B. Guide to Physical

Examination and History Taking.8th ed.Philadelphia, PA: JBLippincott Co., 2000.

5. Beckmann CR, et al. Obstetrics &Gynecology. 4th ed. Philadelphia,PA: Lippincott Co., 2002.

6. Behrman RE, et al. NelsonsTextbook of Pediatrics. 16th ed.Philadelphia, PA: WB Saunders Co.,2000.

7. Berkowitz, C. Pediatrics: A PrimaryCare Approach, 2nd ed.


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Philadelphia, PA: WB Saunders,2000.

8. Braunwald E, et al (eds). HarrisonsPrinciples of Internal Medicine. 15thed. New York, NY: McGraw-Hill,Inc., 2001.

9. DeCherney AH & Pernoll ML (eds.)Current Obstetric & GynecologicalDiagnosis & Treatment, 9

thed.,

Norwalk, CT: Appleton & Lange,2003

10. Ellsworth AJ, et al. (eds). MosbysMedical Drug Reference. St. Louis,MO: Mosby Yearbook, Inc., 2003.

11. Fitzpatrick TB, Palano MK, andSurmond, D. Color Atlas andSynopsis of Clinical Dermatology.5th ed. New York, NY: McGraw-Hill,Inc., 2001.

12. Goldman J and Bennet JC. Cecil

Textbook of Medicine. 21st.Philadelphia, PA: WB SaundersCo., 2000.

13. Hacker NF and Moore GJ.Essentials of Obstetrics andGynecology. 3rd ed.Philadelphia,PA: WB Saunders Co., 1998.

14. Hay WW, et al. Current PediatricDiagnosis and Treatment. 16th ed.Norwalk, CT: Appleton & Lange,2003.

15. Kaplan HI and Sadock BJ (eds).Concise Textbook of Clinical

Psychiatry. Philadelphia, PA:Williams & Wilkins, 1998.

16. Katzung BG. Basic and ClinicalPharmacology. 8th ed. Stamford,CT: Appleton & Lange, 2001.

17. Mandel GL, Bennett JE, and DolinR. Principlesand Practice ofInfectious Disease. 5th ed.,Churchill Livingston, 2000.

18. McPhee SJ, et al. PathophysiologyofDisease. 3rded., Mcgraw Hill,2000.

19. Mercier LR, et al. Practical

Orthopedics. 5th ed. St. Louis, MO:Mosby Yearbook, Inc., 2000.20. Mettler FA, et al. Primary Care

Radiology. Philadelphia, PA: WBSaunders, Co., 2000.

21. Mycek MJ, Harvey RA, and ChampePC. Lippincotts Illustrated Reviews:Pharmacology. 2nd ed. Baltimore,MD: Williams & Wilkins, 2000.

22. Noble J, et al. Textbook of PrimaryCare Medicine. 2nd ed. St. Louis,MO: Mosby Yearbook, Inc., 1996.

23. Sacher RA and McPherson RA.Widmann's Clinical Interpretation ofLaboratory Tests. 11th ed. FADavis Co., 2000.

24. Schwartz SI, et al. Principles ofSurgery. 7th ed. New York, NY:McGraw-Hill, Inc., 1998.

25. Skinner HB (ed.) Current Diagnosis& Treatment in Orthopedics. 2

nded.,

Norwalk,CT:Appleton & Lange,2000.

26. Steinberg GG. Orthopedics inPrimary Care. 3

rded. Philadelphia,

PA: Lippincott Williams & Wilkins,3

rded, 1999.

27. Tierney LM, et al. Current MedicalDiagnosis and Treatment. 42nd ed.

Stamford, CT: Appleton & Lange,2003.

28. Tintinalli JE, Krome RL, and Ruiz E.Emergency Medicine: AComprehensive Guide. 5th ed.New York, NY: McGraw-Hill, Inc.,2000.

29. Townsend CM. SabistonsTextbook of Surgery. The BiologicalBasis of Modern Surgical Practice.16th ed. Philadelphia, PA: WBSaunders, Co., 2002.

30. Vaughn D. et al. General

Ophthalmology. 15th

ed., McGrawHill, 1998

31. Way LW, et al. Current SurgicalDiagnosis and Treatment. 11

thed.,

McGraw Hill, 2002.32. Wilson WR. Current Diagnosis and

Treatment in Infectious Disease.Norwalk, CT: Appleton & Lange,2001.


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THIS PAGE INTENTIONALLY LEFT BLANKFOR ANSWER KEY


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ASSOCIATION OF PHYSICIAN ASSISTANT PROGRAMS

Physician Assistant Clinical Knowledge Rating and Assessment Tool(PACKRAT) Form 9

EXPLANATIONS

1. History & Physical/CardiologyWhich of the following conditions would cause a positive Kussmaul's sign on physicalexamination?

AnswersA. Left ventricular failureB. Pulmonary edemaC. Coarctation of the aortaD. Constrictive pericarditis

Explanations(u) A. Left ventricular failure results in the back-up of blood into the left atrium and then thepulmonary system so it would not be associated with Kussmaul's sign.

(u) B. Pulmonary edema primarily results in increased pulmonary pressures rather than havingeffects on the venous inflow into the heart.(u) C. Coarctation of the aorta primarily affects outflow from the heart due to the stenosis resultingin delayed and decreased femoral pulses; it has no effect on causing Kussmaul's sign.(c) D. Kussmaul's sign is an increase rather than the normal decrease in the CVP duringinspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding inpatients with constrictive pericarditis or right ventricular infarction.

Ref: (8)

2. History & Physical/CardiologyAnginal chest pain is most commonly desc ribed as which of the fo llow ing?

AnswersA. Pain changing with position or respirationB. A sensation of discomfortC. Tearing pain radiating to the backD. Pain lasting for several hours

Explanations(u) A. Pain changing with position or respiration is suggestive of pericarditis.

(c) B. Myocardial ischemia is often experienced as a sensation of discomfort lasting 5-15 minutes,described as dull, aching or pressure.(u) C. Tearing pain with radiation to the back represents aortic dissection.(u) D. Chest pain lasting for several hours is more suggestive for myocardial infarction.

Ref: (27)


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3. History & Physical/CardiologyEliciting a history from a patient presenting w ith dyspnea due to early heart failure, theseverity of the dyspnea should be quantified by

AnswersA. amount of activity that precipitates it.B. how many pillows they sleep on at night.C. how long it takes the dyspnea to resolve.D. any associated comorbidities.

Explanations(c) A. The amount of activity that precipitates dyspnea should be quantified in the history.(u) B. Orthopnea or paroxysmal nocturnal dyspnea can be quantified by how many pillows apatient needs to sleep on to be comfortable.(u) C. How long dyspnea takes to resolve or associated comorbidities has no bearing onquantifying the severity of dyspnea.(u) D. See answer C above.

Ref: (8)

4. History & Physical/CardiologyA 25 year-o ld female p resents w ith a three-day hi story of chest pain aggravated bycoughing and relieved by sitting. She is febrile and a CBC with dif ferential revealsleukocytosis. Which of the following physical exam signs is characteristic of her problem?

AnswersA. Pulsus paradoxusB. Localized cracklesC. Pericardial friction rubD. Wheezing

Explanations(u) A. Pulsus paradoxus is a classic finding for cardiac tamponade.(u) B. Localized crackles are associated with pneumonia and consolidation, not pericarditis.(c) C. Pericardial friction rub is characteristic of an inflammatory pericarditis.(u) D. Wheezing is characteristic for pulmonary disorders, such as asthma.

Ref: (27)

5. History & Physical/CardiologyA 65 year-o ld wh ite female p resents w ith d ilated, tor tuous veins on the medial aspect o fher lower extremities. Which of the following would be the most common initi alcomplaint?

AnswersA. Pain in the calf with ambulationB. Dull, aching heaviness brought on by periods of standingC. Brownish pigmentation above the ankleD. Edema in the lower extremities

Explanations(u) A. Patients with deep venous thrombosis (DVT) may present with complaints of pain in thecalf with ambulation. Secondary varicosities may result from DVT's.


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(c) B. Dull, aching heaviness or a feeling of fatigue brought on by periods of standing is the mostcommon complaint of patients presenting initially with varicosities.(u) C. Stasis Dermatitis and edema are most suggestive of chronic venous insufficiency.(u) D. See C for explanation.

Ref: (27)

6. History & Physical/CardiologyA 22 year-o ld male received a s tab wound in the chest an hour ago. The d iagnosis o fpericardial tamponade is strongl y supported by the presence of

AnswersA. pulmonary edema.B. wide pulse pressure.C. distended neck veins.D. an early diastolic murmur.

Explanations(u) A. Pulmonary edema may result with low output states as seen with myocardial contusions,

but it is not strongly suggestive of tamponade.

(u) B. Wide pulse pressure is seen in conditions of high stroke volume such as aortic insufficiencyor hyperthyroidism. Narrow pulse pressure is seen with cardiac tamponade.(c) C. Cardiac compression will manifest with distended neck veins and cold clammy skin.(u) D. The onset of diastolic murmur is suggestive of valvular disease, not tamponade.

Ref: (28)

7. History & Physical/DermatologyA patient presents with a rash, character ized by red macules and edematous papules witha clearing center. This best describes which of the following?

AnswersA. erythema marginatumB. erythema multiformeC. varicellaD. impetigo

Explanations(u) A. Erythema marginatum is associated with rheumatic fever and is characterized by macularto maculopapular lesions. A clearing center is not found in the rash.(c) B. Target lesions, also termed iris lesions, are characteristic of erythema multiforme. The rashmay be recurrent but typically resolves over 3-6 weeks.(u) C. The rash of varicella typically has maculopapules, vesicles, and scabs in various stages of

development. A clearing center is not found in the rash.(u) D. The lesions of impetigo are pustules that form a honey-colored crust after rupturing.

Ref: (8)

8. History & Physical/DermatologyIn a patient suspected of having seborrheic dermatitis, the most common site ofinvolvement would be the


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AnswersA. upper extremities.B. thighs.C. scalp.D. feet.

Explanations(u) A. See C for explanation.(u) B. See C for explanation.(c) C. The most common site of involvement of seborrheic dermatitis is the scalp. Other commonsites include the eyebrows, eyelids, nasolabial fold, and ears.(u) D. See C for explanation.

Ref: (8)

9. History & Physical/EndocrinologyA 26-year-o ld obese female complains of a 3-4 month h is to ry of discrete erythematousplaques on the pretibial areas of her legs. The lesions have increased in size, become

darker, and are painful. She is concerned because the centers of the lesions have becomeulcerated. This patient should be screened for which of the following?

AnswersA. HypothyroidismB. Diabetes mellitusC. MelanomaD. Scleroderma

Explanations(u) A. In hypothyroidism the skin of the pretibial area may thicken leading to edema. This is adiffuse finding, involving the face and eyelids, without discrete lesions.(c) B. The description of the skin lesions is characteristic of necrobiosis lipoidica diabeticorum,

one of the dermatologic manifestations of diabetes mellitus.(u) C. The lesions of melanoma are typically not painful and do not ulcerate.(u) D. Scleroderma is marked by thickening of the skin, with swelling of the fingers and hands.The swelling may involve the forearms and face; the lower extremities are relatively spared.

Ref: (8)

10. History & Physical/EndocrinologyA 40 year-o ld male presen ts to your cl in ic complaining of nontender, yel low patches onboth eyelids. He states his brother and uncle have similar growths. He denies any visualchanges or other complaints. Your primary suspicion is

AnswersA. gout.B. lipoma.C. hyperlipidemia.D. seborrheic dermatitis.

Explanations(u) A. Tophaceous gout may appear as yellow skin lesions but they usually occur around the

joints and helix of the ear.(u) B. Lipomas tend to be flesh-colored and are not usually bilateral.


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(c) C. Xanthelasmas, along with xanthomas, are common findings in familialhypercholesterolemia.(u) D. Eyelids are a common location for seborrheic dermatitis but the lesions are not yellow incolor.

Ref: (8)

11. History & Physical/ENT/OphthalmologyA 4 year-o ld ch ild presents w ith a rapid onset o f h igh fever and extremely sore th roat.Which of the following findings are suggestive of the diagnosis of epiglottitis?

AnswersA. Croupy cough and droolingB. Thick gray, adherent exudateC. Beefy red uvula, palatal petechiae, white exudateD. Inflammation and medial protrusion of one tonsil

Explanations(c) A. A croupy cough with drooling in a patient who appears very il l is consistent with epiglottitis.

Examining the throat is contraindicated, unless the airway can be maintained.(u) B. Thick gray adherent exudate is suggestive of diphtheria.(u) C. Beefy red uvula, palatal petechiae, and white exudate are findings suggestive ofstreptococcal pharyngitis.(u) D. Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.

Ref: (4)

12. History & Physical/ENT/OphthalmologyWhich of the following are normal findings in a Weber test?

Answers

A. The tympanic membrane is movable with pneumatic otoscopy.B. The tympanic membrane is pearly gray with a sharp cone of light with apex at the umbo.C. Sound is heard equally in both ears when a vibrating tuning fork is placed on the mid forehead.D. Air conduction is greater than bone conduction when a vibrating tuning fork is moved from themastoid bone to close to the ear canal.

Explanations(u) A. A movable tympanic membrane indicates there is no effusion, and is not the Weber test.(u) B. The tympanic membrane is evaluated by direct observation with an otoscope, and is notthe Weber test.(c) C. A normal Weber test means there is no lateralization of sound perception when a vibratingtuning fork is placed on the mid forehead.(u) D. A normal Rinne test means that tuning fork vibration is heard longer through the air than

the bone.

Ref: (4)

13. History & Physical/ENT/OphthalmologyWhich of the foll owing is diagnosed by use of the cover/uncover test?

AnswersA. Adies pupil


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B. StrabismusC. GlaucomaD. Myopia

Explanations(u) A. Adies pupil is a sluggish pupil reaction to light and accommodation, evaluated by papillaryreaction to light.(c) B. The cover/uncover test is used to diagnose strabismus.(u) C. Tonometry is used to measure intraocular pressure to evaluate for glaucoma.(u) D. Myopia is evaluated by using a Snellen chart.

Ref: (4)

14. History & Physical/Gastrointestinal/NutritionalA patient is known to have end s tage li ver disease due to ci rrhosis. Wh ich of the fo llow ingphysical examination findings would commonly be seen in this patient?

AnswersA. Testicular hypertrophy

B. Muscular pseudohypertrophyC. GynecomastiaD. Hepatomegaly

Explanations(u) A. Testicular atrophy, wasting of the muscles of the lower extremity, spider angiomas, caputmedusa and gynecomastia are physical examination findings associated with end stage liverdisease associated due to cirrhosis.(u) B. Muscular pseudohypertrophy is seen in muscular dystrophy.(c) C. See A for explanation.(u) D. Patients with end stage liver failure who have cirrhosis have a small shrunken liver from theongoing cellular destruction and fibrosis.

Ref: (8)

15. History & Physical/Gastrointestinal/NutritionalWhich of the following is the most consistent physical examination finding in a patientwith duodenal ul cer?

AnswersA. Flank tendernessB. Right upper quadrant tendernessC. Epigastric tendernessD. Rebound tenderness

Explanations(u) A. Flank tenderness is caused by urologic disorders such as pyelonephritis and renal lithiasis.(u) B. Right upper quadrant tenderness on palpation is a typical feature for cholecystitis.(c) C. Epigastric tenderness is a key feature of duodenal ulcer.(u) D. Rebound tenderness is a feature of peritonitis from rupture of a hollow viscus and is notseen with just the presence of duodenal ulcer.

Ref: (8)


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16. History & Physical/Gastrointestinal/NutritionalThe initial sign or symptom of iron poisoning in a 3 year-old child is usually

AnswersA. vomiting and bloody diarrhea.B. convulsions and tetany.C. somnolence and coma.D. ataxia and colicky abdominal pain.

Explanations(c) A. Iron causes localized necrosis and hemorrhage at the point of contact in the GI systemresulting in abdominal pain, vomiting, bloody diarrhea, and hematemesis.(u) B. Convulsions and tetany are symptoms of hypocalcemia.(u) C. Somnolence and coma are not initial findings in iron ingestion.(u) D. Ataxia and colicky abdominal pain are consistent with lead poisoning.

Ref: (28)

17. History & Physical/Gastrointestinal/Nutritional

A c lassic skin f inding seen in pat ients wi th in flammatory bowel d isease would be

AnswersA. erythematous plaques on the extremities.B. poorly healing, indolent ulcers on the lower extremities.C. pretibial myxedema.D. purple striae.

Explanations(u) A. Granuloma annulare is seen with diabetes mellitus. It consists of erythematous plaques onthe extremities or trunk.(c) B. Pyoderma gangrenosum is classically seen with inflammatory bowel disease and is rarelyseen in the absence of inflammatory bowel disease.

(u) C. Pretibial myxedema is the skin manifestation of hyperthyroidism.(u) D. The dermatologic manifestations of Cushing's disease are purple striae and asupraclavicular fat pad.

Ref: (8)

18. History & Physical/HematologyA 55-year-o ld non-smoking male presents with a hemoglob in of 18.5 g/d l and a hematocr itof 56%. Which of the following physical examination findings is the most l ikely to benoted with thi s patient?

Answers

A. SplenomegalyB. CheilosisC. PurpuraD. Decreased vibratory sense

Explanations(c) A. Patients with polycythemia vera present with elevated hemoglobin and hematocrit. Onphysical examination plethora, engorged retinal veins, and splenomegaly are common.(u) B. Cheilosis is noted in iron deficiency anemia.(u) C. Purpura is typically noted in bleeding disorders.


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(u) D. Decreased vibratory sense is noted in vitamin B12 deficiency.

Ref: (8)

19. History & Physical/NeurologyA 73 year-o ld male presen ts to the cl in ic wi th his w ife. His wi fe has not iced that he hasdeveloped a resting tremor in his right hand and a shuff ling gait over the last year. Whatfinding on physical examination wou ld support your suspected diagnosis?

AnswersA. ChoreaB. DystoniaC. Masked faciesD. Hyperreflexia

Explanations(u) A. See C for explanation.(u) B. See C for explanation.(c) C. The patient symptoms are consistent with Parkinsonism. Physical exam findings include

masked facies, micrographia, decreased arm swing, and monotonous speech.(u) D. See C for explanation.

Ref: (27)

20. History & Physical/NeurologyA patient with an upper moto r neuron les ion would exhib it which of the fo llow ingfindings?

AnswersA. FasciculationsB. Areflexia

C. Muscular atrophyD. Spasticity

Explanations(u) A. Fasciculations, areflexia and muscle atrophy are consistent with lower motor neuronlesions.(u) B. See A for explanations.(u) C. See A for explanation.(c) D. Spasticity is an upper motor neuron lesion finding.

Ref: (4)

21. History & Physical/Obstetrics/GynecologyOn examination of a pregnant patient the physician assistant notes a bluish or purplishdiscoloration of the vagina and cervix. This is called

AnswersA. Hegar's sign.B. McDonald's sign.C. Cullen's signD. Chadwick's sign


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Explanations(u) A. Hegar's sign is the softening of the cervix that often occurs with pregnancy.(u) B. McDonald's sign is when the uterus becomes flexible at the uterocervical junction at 7-8weeks.(u) C. Cullens sign is a purplish discoloration periumbilical and noted in pancreatitis.(c) D. Chadwicks sign is a bluish or purplish discoloration of the vagina and cervix.

Ref: (9)

22. History & Physical/Obstetrics/GynecologyOn examination o f a pregnant patient the physician assistant notes the fundal height is atthe level of the umbil icus. This corresponds to what gestational age?

AnswersA. 16 weeksB. 20 weeksC. 24 weeksD. 28 weeks

Explanations(u) A. See B for explanation.(c) B. At 20-22 weeks the fundal height is typically at the level of the umbilicus.(u) C. See B for explanation.(u) D. See B for explanation.

Ref: (9)

23. History & Physical/Obstetrics/GynecologyWhich of the following is the most common manifestation of polycystic ovariansyndrome?

AnswersA. DesquamationB. HirsutismC. GalactorrheaD. Rebound tenderness

Explanations(u) A. Desquamation is noted in toxic shock syndrome.(c) B. The patient with polycystic ovarian syndrome typically presents with hirsutism or infertility.(u) C. Galactorrhea is noted in hyperprolactinemia.(u) D. Rebound tenderness is noted in conditions causing peritonitis.

Ref: (9)

24. History & Physical/Orthopedics/RheumatologyAbduct ion o f the shoulder against resistance helps local ize pain in which of the fo llow ingmuscles of the shoulder girdle?

AnswersA. SupraspinatusB. InfraspinatusC. Teres minor


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D. Subscapularis

Explanations(c) A. Abduction against resistance tests the supraspinatus.(u) B. Lateral rotation against resistance tests the infraspinatus and teres minor.(u) C. See B for explanation.(u) D. Medial rotation against resistance tests the subscapularis.

Ref: (4)

25. History & Physical/Orthopedics/RheumatologyA 22 year-o ld male presen ts to the ED after sustaining a blow to the knee during footbal lpractice. The knee exam demonstrates signif icant forw ard translation of the tibia whenthe knee is in 15 degrees of flexion and external rotation at the hip. Which of the followingknee maneuvers does this represent?

AnswersA. Abduction stress testB. Anterior drawer sign

C. Lachman testD. McMurray test

Explanations(u) A. The abduction stress test is performed to evaluate medial collateral ligament tears whileapplying valgus stress.(u) B. The anterior drawer sign is performed to evaluate the anterior cruciate ligament; howeverthe patient is supine, hips and knees flexed, and feet are flat on the table.(c) C. The Lachman test is performed to evaluate the anterior cruciate ligament. The knee isplaced in 15 degrees of flexion and external rotation of the hip.(u) D. The McMurray test is performed to evaluate medial and lateral meniscal tears while rotatingthe lower leg internally and externally.

Ref: (4)

26. History & Physical/Orthopedics/RheumatologyA 12 year-o ld female p resents for a routine sport s physical . The physical exam revealsasymmetry of the posterior chest wall on forward bending. This is the most striking andconsistent abnormality of which of the following?

AnswersA. SpondylolysisB. SpondolisthesisC. ScoliosisD. Herniated disc

Explanations(u) A. Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles.(u) B. Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis.(c) C. Asymmetry of the posterior chest wall on forward bending is the most striking andconsistent abnormality in patients with idiopathic scoliosis.(u) D. Herniated disc presents with lumbar muscle spasm and a positive straight leg test.

Ref: (6)


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27. History & Physical/Orthopedics/RheumatologyPhysical exam findings in a 4 year-old child that include blue sclerae and recurrentfractures indicates which of the follow ing?

AnswersA. Ehlers-Danlos syndromeB. Marfan syndromeC. AchondroplasiaD. Osteogenesis imperfecta

Explanations(u) A. Physical exam findings in Ehlers-Danlos include laxity and hypermobility of joints, mitralvalve prolapse, and associated degenerative arthritis.(u) B. Children with Marfan syndrome have hypotonia, arachnodactyly, joint laxity anddislocations.(u) C. Children with achondroplasia are below normal standards on growth charts. They havedifficulty balancing their large heads when beginning to walk.(c) D. Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures andpresenile deafness.

Ref: (6)

28. History & Physical/Psychiatry/Behavioral MedicineWhich of the fol lowing historical factors differentiates post-traumatic stress disorder fromacute stress disorder?

AnswersA. The inability of the person to recall an important aspect of the event.B. Avoidance of stimuli that invokes recollections of the event.C. A belief that their future has been foreshortened because of the event.D. The presence of sleep disorder.

Explanations(u) A. See C for explanation.(u) B. See C for explanation.(c) C. Post-traumatic stress disorder and acute stress disorder have many of the samecharacteristics. A sense of a foreshortened future, such as not expecting a normal life span or acareer due to the trauma, distinguishes post-traumatic stress disorder from an acute stressdisorder. The other answers are common to both disorders.(u) D. See C for explanation.

Ref: (15)

29. History & Physical/Psychiatry/Behavioral Medicine

A patient with obsessive-compulsive d isorder would most l ikely have which of thefollowing findings?

AnswersA. Raw, red handsB. PriapismC. Memory impairmentD. Abdominal pain

Explanations


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(c) A. Common manifestations of obsessive-compulsive disorder include phobias of germ andcontaminants, which results in frequent hand washing leading to chafe and reddened hands. Theother answers are inconsistent with obsessive-compulsive disorder.(u) B. See A for explanation.(u) C. See A for explanation.(u) D. See A for explanation.

Ref: (8)

30. History & Physical/PulmonologyA 45 year-o ld male presents with sudden onset of pleur it ic chest pain, p roduct iv e coughand fever for 1 day. He relates having symptoms of a co ld for the past week thatsuddenly became worse yesterday. Which of the following findings w ill most likely beseen on physical examination o f this patient?

AnswersA. spoken ee heard as ayB. hyperresonant percussion noteC. wheezes over the involved area

D. vesicular breath sounds over involved area

Explanations(c) A. This patient most likely has a bacterial pneumonia with consolidation, which would produceegophony, where a spoken ee is heard as ay.(u) B. Consolidation from bacterial pneumonia causes findings of dullness to percussion, lateinspiratory crackles and bronchial breath sounds over the involved area.(u) C. See explanation B.(u) D. See explanation B.

Ref: (4)

31. History & Physical/PulmonologyWhich of the following is a common symptom associated with laryngotracheobronchitis(viral croup)?

AnswersA. droolingB. high feverC. "hot potato" voiceD. barking cough

Explanations(u) A. Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup.(u) B. Fever is usually absent or low grade in patients with viral croup.

(u) C. See A for explanation.(c) D. Viral croup is characterized by history of an upper respiratory tract symptoms followed byonset of a barking cough and stridor.

Ref: (14)

32. History & Physical/PulmonologyA foreign body lodged in the trachea that i s causing part ial obst ruct ion w il l most l ikelyproduce what physical examination finding?


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AnswersA. stridorB. aphoniaC. inability to coughD. progressive cyanosis

Explanations(c) A. An inspiratory wheeze is called stridor, which indicates a partial obstruction of the tracheaor larynx.(u) B. Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction ofthe trachea, not partial obstruction.(u) C. See B for explanation.(u) D. See B for explanation.

Ref: (14)

33. History & Physical/PulmonologyOn physical examination you note diminished breath sounds over the right lower lobe with

decreased tactile fremitus and dullness to percussion. Which of the following is the mostlikely cause?

AnswersA. asthmaB. consolidationC. pneumothoraxD. pleural effusion

Explanations(u) A. Asthma is characterized by decreased tactile fremitus, but would have resonant tohyperresonant percussion, not dullness.(u) B. Consolidation from pneumonia is characterized by dullness to percussion, but would have

an increased, not decreased, tactile fremitus.(u) C. A pneumothorax is characterized by decreased to absent tactile fremitus, but would have ahyperresonant percussion note, not dullness.(c) D. A decreased tactile fremitus and dullness to percussion would be found in a pleuraleffusion.

Ref: (4)

34. History & Physical/Urology/RenalA patient wi th a 15-year history of t ype 2 diabet ic mel li tus presents fo r f ol low-up. Labsreveal a BUN 100 mg/dl, serum creatinine 9.2 mg/dl, and serum glucose 164 mg/dl. Whichof the following would you expect to find on physical examination?

AnswersA. PruritusB. HypotensionC. MacroglossiaD. Suprapubic tenderness

Explanations(c) A. Hypertension, pruritus and xerosis are common findings in the uremic patient.(u) B. See A for explanation.


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(u) C. See A for explanation.(u) D. Suprapubic tenderness is associated with urinary tract infection or acute obstructiveuropathy.

Ref: (27)

35. History & Physical/Urology/RenalWhen performing a rectal examination, prostatic massage is cont raindicated in

AnswersA. prostatodynia.B. non-bacterial prostatitis.C. chronic bacterial prostatitis.D. acute bacterial prostatitis.

Explanations(u) A. Prostatodynia is an inflammatory disorder involving voiding dysfunction and pelvic floormusculature dysfunction. There is no bacterial involvement.(u) B. Non-bacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are

cultured, and the cause is unknown.(u) C. Prostate massage can be performed in the absence of fever. Expressed prostaticsecretions are cultured to help identify the organism.(c) D. Vigorous manipulation of the prostate during rectal examination may result in septicemia.This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacralpain.

Ref: (12)

36. History & Physical/Infectious DiseasesWhich of the following is typically noted on physical examination in a patient withdiphtheria?

AnswersA. Papular rash on trunkB. Supraclavicular adenopathyC. Pharyngeal pseudomembranesD. Splenomegaly

Explanations(u) A. See C for explanation.(u) B. See C for explanation.(c) C. The classic exam finding noted in diphtheria is a gray pharyngeal pseudomembrane.Rash, splenomegaly, and supraclavicular adenopathy are not noted in diphtheria.(u) D. See C for explanation.

Ref: (8)

37. Diagnostic Studies/CardiologyCardiac nuclear scanning i s done to detect

AnswersA. electrical conduction abnormalities.B. valvular abnormalities.


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C. ventricular wall dysfunction.D. coronary artery patency/occlusion.

Explanations(u) A. An EKG is used to determine electrical conduction abnormalities.(u) B. An echocardiogram is a non-invasive test used to determine valvular abnormalities and wallmotion.(c) C. Visualization of the cardiac wall can be done with cardiac nuclear scanning. This is done todetermine hypokinetic areas from akinetic areas.(u) D. Patency or occlusion is assessed with cardiac catheterization (invasive).

Ref: (12)

38. Diagnostic Studies/CardiologyA 72 year-o ld male with a new diagnosis of congest ive heart failure and atr ial fibr il lat ion,develops episodes of hemodynamic compromise secondary to inc reased ventricular rate.A decision to perform elec tive card ioversion is made and the pat ien t i s anticoagulatedwith heparin. Which test should be ordered to assess for atrial or ventricu lar muralthrombi?

AnswersA. ElectrocardiogramB. Chest x-rayC. Transesophageal EchocardiogramD. C-reactive protein

Explanations(u) A. Electrical conduction will not assess for mural thrombi.(u) B. A chest x-ray will not visualize the left atria and ventricles to assess for mural thrombi.(c) C. Transesophageal echocardiography allows for determination of mural thrombi that mayhave resulted from atrial fibrillation.

(u) D. C-reactive protein is not going to give you any information regarding thrombi. This test isused to identify the presence of inflammation.

Ref: (12)

39. Diagnostic Studies/CardiologyA 64 year-o ld pat ien t w ith known history of t ype 1 diabetes mell itus fo r 50 years hasdeveloped pain radiating from the right buttock to the calf. Patient states that the pain ismade worse with walking and climbing stairs. Based upon this hi story which of thefollowing w ould be the most appropriate test to order?

Answers

A. VenogramB. Arterial duplex scanningC. X-ray of the right hip and L/S spineD. Venous Doppler ultrasound

Explanations(u) A. See B for explanation.(c) B. Given the patient's long history of type 1 diabetes mellitus the patient most likely hasvascular occlusive disease. Evaluation of arterial blood flow is assessed using the duplex


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scanner. X-ray of the L/S spine and right hip while not harmful may give information regardingbony structures. Venous Doppler ultrasound will not give information of arterial perfusion.(u) C. See B for explanation.(u) D. See B for explanation.

Ref: (12)

40. Diagnostic Studies/CardiologyA 36 year-o ld male complains of occasional ep isodes of " heart f lu ttering" . The patientdescribes these episodes as frequent, short -lived and episodic. He denies any associatedchest pain. Based on this i nformation, which one of the following tests would be the mostappropriate to order?

AnswersA. Holter monitorB. Cardiac catheterizationC. Stress testingD. Cardiac nuclear scanning

Explanations(c) A. Holter monitoring is a non-invasive test done to obtain a continuous monitoring of theelectrical activity of the heart. This can help to detect cardiac rhythm disturbances that cancorrelate with the patient symptoms. Cardiac catheterization is an invasive procedure done toassess coronary artery disease. Stress testing and cardiac nuclear scanning are non-invasivetesting maneuvers done to assess coronary artery disease.(u) B. See A for explanation.(u) C. See A for explanation.(u) D. See A for explanation.

Ref: (12)

41. Diagnostic Studies/CardiologyA patient with a mit ral valve replacement was placed post-operat ively on warfarin(Coumadin) for anticoagulation prophylaxis. To monitor this drug for its effectiveness,what test would be used?

AnswersA. PTTB. PT-INRC. Platelet aggregationD. Bleeding time

Explanations(u) A. PTT is a reflection of the intrinsic clotting system and is used to monitor heparin

administration.(c) B. PT-INR is a reflection of the extrinsic and common pathway clotting system. Coumadininterferes with Vitamin K synthesis which is needed in the manufacture of factors II, VII, IX, Xwhich are part of the extrinsic clotting pathway.(u) C. Platelet aggregation tests are utilized to assess platelet dysfunction.(u) D. Bleeding time is used to assess platelet function.

Ref: (12)


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42. Diagnostic Studies/DermatologyA 26 year-o ld male complains of in tense i tching, espec ial ly at night and af ter hot showers,for the past 4 days. On physical examination he has a few red papules and areas ofexcoriation on his volar wrist s, between his fingers, and around his waist. Properdiagnosis should include which of the following tests?

AnswersA. KOH prepB. Gram stainC. Skin scraping microscopyD. Tzanck prep

Explanations(u) A. A KOH prep would be used to examine for evidence of a fungal infection.(u) B. A Gram stain would be used for a bacterial infection and would be inappropriate in thissituation.(c) C. The history and exam is consistent with a scabies infection. Scrapings from the burrowsshould be examined for the presence of mites, eggs, and feces.

(u) D. A Tzanck prep would be used to examine for giant multinucleated cells characteristic of a

herpes infection.

Ref: (8)

43. Diagnostic Studies/DermatologyA 35 year-o ld female who recent ly returned from a backpack ing t rip complains of f atigue,malaise, fever, chill s, and arthralgias. Physical examination reveals a 6 cm annular lesionwith a red border and a clear center on her mid-back. Which of the fol lowing laboratorytests would support your diagnosis?

AnswersA. KOH prep of skin scrapings

B. Blood culturesC. RAST testingD. Serologic antibody testing

Explanations(u) A. Although the skin lesion may resemble a fungal infection, a fungal dermatophyte would notpresent with systemic symptoms.(u) B. Culturing of Borrelia burgdorferi from clinical specimens, with the exception of skinbiopsies at the site of the lesion, have resulted in low yields.(u) C. RAST testing is utilized in evaluation of allergies and is not indicated in this situation.(c) D. Most people with Lyme Disease will have a positive serologic test after the first few weeksof infection and this would support the diagnosis.

Ref: (8)

44. Diagnostic Studies/EndocrinologyA patient complains of fat igue, t remors, palp itations, and heat in to lerance. The thyroid isdiffusely enlarged and firm on palpation. Which of the following laboratory findings is themost consistent with this presentation?

AnswersA. Low T4


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B. Low TSHC. Decreased bilirubinD. Normal radionuclide scan

Explanations(u) A. See B for explanation.(c) B. The presentation is consistent with hyperthyroidism. Laboratory findings include low TSH,elevated free and total thyroid hormone levels, and an increased uptake on radionuclide scan.There may also be elevated bilirubin, liver enzymes, and ferritin levels, along with anemia andthrombocytopenia.(u) C. See B for explanation(u) D. See B for explanation

Ref: (8)

45. Diagnostic Studies/EndocrinologyA sol itary thyroid nodule is noted on physical examination. The TSH level is normal. Thenext step in the evaluation is

AnswersA. measurement of T4 and free T3 levels.B. a radionuclide thyroid scan.C. a fine needle biopsy.D. a surgical excision.

Explanations(u) A. Measurement of T4 and T3 levels would not be of benefit in the evaluation of a solitarythyroid nodule with a normal TSH level.(u) B. A thyroid scan would be the next step if there were a low TSH level.(c) C. Fine needle aspiration (FNA) is the first step in the evaluation of a solitary nodule with anormal TSH level. FNA has a high level of accuracy in diagnosing benign versus malignantnodules in this setting.

(u) D. Surgical excision would be the final step after determination of malignancy or suspicion ofmalignancy by FNA.

Ref: (8)

46. Diagnostic Studies/ENT/OphthalmologyA 32 year-o ld carpenter comp lains of right eye i rr it ation all day after d riving a metal stakeinto the ground with his hammer. He states that something flew into my eye. Visualacuity is 20/20. Pupils are equal, round, reactive to light and accommodation. Extraocularmovements are intact. There is minimal righ t corneal injection. No foreign body is notedwith l id eversion. Fluorescein stain reveals a tiny pinpo int uptake in the area of thecorneal injection. Which of the following is the most appropriate diagnostic test at this

stage?

AnswersA. MRIB. X-ray orbitsC. Applanation tonometryD. Fluorescein angiography

Explanations


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(h) A. MRI should never be used when there is suspicion of an iron-containing intraocular foreignbody.(c) B. Orbital x-rays or CT scan will be most helpful in identifying an intraocular metallic foreignbody.(u) C. Tonometry is used to evaluate intraocular pressure, but not the presence of intraocularforeign bodies.(u) D. Fluorescein angiography is used to evaluate vessels of the eye, not intraocular foreignbodies.

Ref: (30)

47. Diagnostic Studies/ENT/OphthalmologyA 45 year-o ld male complains of loss o f hearing in his left ear. He also complains ofringing in the ear, and has had occasional dizziness. On exam, there is uni lateral left-sided sensorineural hearing loss and a dimin ished corneal reflex. Neuro exam isotherwise normal. TMs are normal, and canals are clear. Neck is supple, withoutadenopathy. Oropharynx is normal. Of the following, the best diagnost ic study to identif ythe cause of this patients complaints is

AnswersA. auditory brainstem evoked response.B. gadolinium-enhanced MRI.C. acoustic reflex testing.D. vestibular testing.

Explanations(u) A. See B for explanation.(c) B. MRI has replaced auditory brainstem evoked response and acoustic reflex testing in theevaluation of patients for acoustic neuromas.(u) C. See B for explanation.(u) D. Vestibular testing is not a useful screening test for acoustic neuromas.

Ref: (12)

48. Diagnostic Studies/Gastrointestinal/NutritionalWhich of the following laboratory abnormalities is most commonly seen acutely in apatient who has a massive GI bleed?

AnswersA. Increased BUN levelB. HypercalcemiaC. HyponatremiaD. Increased AST

Explanations(c) A. Blood in the gut will cause a considerable increase in the BUN that is independent ofdecreased renal perfusion or intrinsic renal dysfunction. BUN rises as a result of catabolism andabsorption of blood protein with a resultant increase in nitrogenous waste.(u) B. Acute blood loss does not result in a change in the calcium level unless multipletransfusions are given.(u) C. Massive GI blood loss acutely results in blood volume contraction without acutely changingthe sodium concentration until intravenous therapy is given(u) D. Increases in the serum AST is the result of hepatocyte injury or inflammation and does notoccur as a result of GI bleeding.


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Ref: (8)

49. Diagnostic Studies/Gastrointestinal/NutritionalPrimary biliary cir rhosis will have which of the following laboratory results?

AnswersA. Decreased haptoglobinB. Anticholinesterase antibodiesC. Antimitochondrial antibodiesD. Elevated ceruloplasmin

Explanations(u) A. Haptoglobin is a glycoprotein that is made in the liver that acts as a scavenger molecule torecapture iron after hemolysis occurs. Its levels decrease with active bleeding or cell destructionas seen in hemolytic anemia.(u) B. Anticholinesterase antibodies are evaluated in patients suspected of having myastheniagravis.(c) C. Antimitochondrial antibodies are seen in patients with primary biliary cirrhosis, a chronic,

progressive cholestatic disease of the liver that is characterized by destruction of the extrahepaticbile ducts.(u) D. Ceruloplasmin elevations are seen with Wilsons disease, a disease that is due to adisordered copper metabolism.

Ref: (8)

50. Diagnostic Studies/Gastrointestinal/NutritionalWhich of the following diagnostic tests is considered to be the best initial test to order in apatient with suspected gallbladder disease?

Answers

A. UltrasoundB. Hepatic iminodiacetic acid (HIDA) scanC. Flat plate of the abdomenD. Endoscopic retrograde cholangiopancreatography (ERCP)

Explanations(c) A. Ultrasound of the abdomen is the best test for checking the extra-hepatic biliary tree forductal dilatation and choledocholithiasis.(u) B. HIDA scan is usually ordered to assess gallbladder function. It is mostly ordered if initialultrasound is normal and there is still a high index of suspicion for gallbladder disease.(u) C. Flat plate of the abdomen will only identify about 10 to 15% of gallstones.(u) D. ERCP is performed to remove gallstones that have become lodged in the common bileduct. It is not an initial study that is performed.

Ref: (8)

51. Diagnostic Studies/HematologyAn 8-year-old p resents w ith splenomegaly . CBC resu lts reveal the fo llow ing: WBC-6,300/micro lit er, Hgb- 10.5 g/dl, Hct - 31%, MCV- 87 fL, MCHC- 39 g/dl, MCH- 28 pg, andplatelets- 317,000/mL. Examination of the RBC morphology reveals 80% spherocytes.Which of the following would be most helpful in confirming the diagnosis?


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AnswersA. Direct Coombs testB. Osmotic fragilityC. G-6-PD levelD. Serum ferritin

Explanations(u) A. The direct Coombs test would be negative and would not be helpful in diagnosinghereditary spherocytosis.(c) B. Hereditary spherocytosis presents with a normocytic, normochromic anemia and manyspherocytes. Diagnosis is confirmed with a positive osmotic fragility test.(u) C. G-6-PD deficiency presents with minimal or no RBC morphologic abnormalities and isdiagnosed by measuring G-6-PD enzyme activity level.(u) D. Iron deficiency anemia typically presents with microcytic, hypochromic red blood cells andis diagnosed with a serum ferritin.

Ref: (8)

52. Diagnostic Studies/Neurology

What test is the single most useful test in establishing the diagnosis of multipl e sclerosis?

AnswersA. Cerebral spinal fluid cell count and protein levelB. Cerebral spinal fluid immunoglobulin studiesC. Evoked potentialsD. Magnetic Resonance Imaging

Explanations(u) A. While cerebral spinal fluid cell count, protein levels, and immunoglobins may be abnormalthey are not specific for multiple sclerosis.(u) B. See A for explanation.(u) C. Evoked potentials are most useful in the detection of subclinical involvement of

neuropathways in MS, but does not establish the diagnosis.(c) D. The presence of plaques on MRI is a key finding in establishing the diagnosis of MS.

Ref: (27)

53. Diagnostic Studies/NeurologyA 22 year-o ld male presen ts to the cl in ic complaining of excess ive daytime somnolenceand strong desires to sleep at inappropriate times. He came in today because he had anepisode of "f eeling paralyzed" as he was falling asleep yesterday. What is the mostappropriate diagnostic test to confirm this patients diagnosis?

Answers

A. MRI of the brainB. ElectroencephalogramC. Multiple sleep latency testD. Overnight polysomnography

Explanations(u) A. See C for explanation.(u) B. See C for explanation.(c) C. Multiple sleep latency test is required to observe the abrupt transition to REM sleep andestablish the diagnosis of narcolepsy.


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(u) D. See C for explanation.

Ref: (27)

54. Diagnostic Studies/Obstetrics/GynecologyA 25 year-o ld female p resents w ith vulvar prur itus and a th ick, whi te vaginal discharge.Which of the following tests will be most helpful in making the correct diagnosis?

AnswersA. KOH prepB. Gram stainC. Tzanck smearD. FTA-ABS

Explanations(c) A. KOH prep is used to assist in the diagnosis of vaginal candidiasis, which presents withvulvar pruritus and white curd like, cheesy vaginal discharge.(u) B. Gram stain is used in the diagnosis of bacterial infections.(u) C. Tzanck smear is used to diagnose herpes infections.

(u) D. FTA-ABS is used to diagnose syphilis.

Ref: (9)

55. Diagnostic Studies/Obstetrics/GynecologyA 25 year-o ld presen ts with pelv ic pain and uter ine bleeding . Her Beta-HCG was 1200mIU/L six days ago. Her cur rent Beta-HCG is 1600 mIU/L. What is the next best test in theevaluation of this patient?

AnswersA. LaparoscopyB. Culdocentesis

C. Dilation and curettageD. Transvaginal ultrasound

Explanations(u) A. The use of laparoscopy in the diagnosis of an ectopic pregnancy has decreased, but is stilluseful when a definitive diagnosis is difficult.(u) B. Culdocentesis is used in the diagnosis of intraperitoneal bleeding, which may or may not bepresent in an ectopic pregnancy.(u) C. Dilation and curettage may confirm or exclude intrauterine pregnancy but is not the nextbest test in the evaluation of ectopic pregnancy.(c) D. Transvaginal ultrasound is the best test to separate ectopic from intrauterine pregnancy.

Ref: (9)

56. Diagnostic Studies/Obstetrics/GynecologyA couple presents hav ing not been able to conceiv e over the past 12 months . Evaluat ionof the male has been normal. The female has had regular menses. Ovulation can beconfirmed with mid-luteal phase measurement of which of the following?

AnswersA. Thyroid stimulating hormoneB. Luteinizing hormone


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C. ProgesteroneD. Prolactin

Explanations(u) A. TSH is used only if signs of thyroid disease are present.(u) B. LH, FSH, and prolactin are used to confirm ovulation in patients with irregular menstrualcycles.(c) C. Ovulation can best be confirmed by measuring serum progesterone levels in the mid-lutealphase.(u) D. See B for explanation.

Ref: (9)

57. Diagnostic Studies/Orthopedics/RheumatologyA 65 year-o ld female p resents to the off ice wi th a six-month history o f back pain. Thepatient states that she is shrink ing and thinks she is about an inch shorter than she was ayear ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphataseare all normal. Which of the follow ing would you most likely see on the x-ray of her spine?

AnswersA. Radiolucent lesionsB. DemineralizationC. ChondrocalcinosisD. Subperiosteal resorption

Explanations(u) A. Pagets disease of bone presents with bone pain, kyphosis, bowed tibias, large head, anddeafness. The initial lesions are destructive and radiolucent. Pagets disease has a normalserum calcium and phosphate, but the serum alkaline phosphatase is elevated.(c) B. Osteoporosis presents with varying degrees of back pain and loss of height is common.The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. X-ray findings demonstrate demineralization in the spine and pelvis.

(u) C. Chondrocalcinosis is the presence of calcium-containing salts in articular cartilage and iscommonly seen in hyperparathyroidism, diabetes, hypothyroidism, and gout.(u) D. Hyperparathyroidism is frequently asymptomatic. Serum parathyroid hormone and serumcalcium are elevated. X-ray findings include demineralization, subperiosteal resorption of boneespecially in the radial aspects of the fingers.

Ref: (27)

58. Diagnostic Studies/Orthopedics/RheumatologyIn a trauma patient who has a suspected cervical spine injury, the x-ray view that wil lidentify the majority of significant injuries is

AnswersA. lateral.B. oblique.C. anteroposterior.D. odontoid.

Explanations(c) A. The lateral view shows 70-80% of significant injuries. It is important to visualize all sevencervical vertebrae and the upper margin of T1 to avoid missing possible pathology.


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(u) B. The oblique view is usually not included in the initial set of x-rays taken. Bilateral supineoblique is a view that may be ordered if all seven cervical vertebrae are not seen on the lateralview.(u) C. Anteroposterior view shows < 1% of significant injuries.(u) D. The odontoid view reveals 10% of significant injuries.

Ref: (28)

59. Diagnostic Studies/Orthopedics/RheumatologyA 38 year-o ld male sustained a fracture of the left distal t ib ia fol lowing a 25-foot f all and istaken to the operating room for an open reduction in ternal fixation of the distal tibia.Sixteen hours post-op, the patient develops sustained pain, which is not relieved withnarcotics. On passive range of motion of the toes the patient "yells" in agony. The patientalso states that the top of his foot has decreased sensation. On physical examination thephysici an assistant notes that the leg is swollen and the foot is cool to touch. Based uponthis information what diagnostic testing should be done?

AnswersA. X-ray of the lower leg and ankle.

B. Doppler studies.C. Bone scan.D. Compartment pressure

Explanations(u) A. X-rays of the lower leg and ankle will only determine bone placement.(u) B. Doppler studies will confirm the presence of a decreased pulse.(u) C. A bone scan is not indicated in the evaluation of compartment syndrome.(c) D. Compartmental pressures should be obtained as soon as possible. If they are elevated thisis a surgical emergency.

Ref: (31)

60. Diagnostic Studies/Psychiatry/Behavioral MedicineA 19 year-o ld female p res ents w ith complain ts of in termi ttent abdominal pain assoc iatedwith recent, frequent episodes of regurgi tation of food for the past several months andworsening over the past 12 hours . She maintains a normal weight for her height how evershe seems obsessed with losing weight. On examination the physician assistant notesmult iple dental caries, bilateral tenderness of the parotid glands and mild epigastrictenderness. Which of the following findings would you expect to find on laboratory teststo support your suspected diagnosis?

AnswersA. hypokalemiaB. hypocalcemia

C. hyperchloremiaD. hypermagnesemia

Explanations(c) A. This patient most likely has bulimia nervosa - purging type. Self-induced vomiting is themost common method of purging and this is supported by the physical examination findings notedin this patient. Laboratory findings to support this diagnosis include hypochloremia withsubsequent hypokalemia due to renal compensatory mechanisms, hypomagnesemia andmetabolic alkalosis.(u) B. See A for explanation.


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(u) C. See A for explanation.(u) D. See A for explanation.

Ref: (14)

61. Diagnostic Studies/Psychiatry/Behavioral MedicineA d ivorced female pati ent presents fo r an employment phys ical. She s tates she has had a"run of bad luck" with jobs and has not been able to hold any job for longer than 2-3months. She also states she has been arrested several times for getting into fi ghts whenshe is out with the girls. She states she drinks an occasional beer, but denies anysignificant problems with alcohol. Which of the following laboratory findings wouldsupport your suspected diagnosis?

AnswersA. decreased triglyceridesB. decreased serum uric acidC. increased LDL cholesterolD. increased mean corpuscular volume

Explanations(u) A. See D for explanation.(u) B. See D for explanation.(u) C. The primary lipid abnormalities demonstrated with alcoholism are increased triglyceridesand increased HDL cholesterol, not LDL cholesterol.(c) D. This patient most likely has alcohol abuse as evidence by her social, occupational and legalissues. Laboratory tests will reveal the presence of an elevated mean corpuscular volume,triglycerides, serum uric acid and liver function tests.

Ref: (27)

62. Diagnostic Studies/Pulmonology

Which of the following is essential to make a diagnosis of cystic fibrosis?

AnswersA. Positive family historyB. Elevated sweat chlorideC. Recurrent respiratory infectionsD. Elevated trypsinogen levels

Explanations(u) A. Cystic fibrosis is a genetic disease, but a positive family history in and of itself is notenough to diagnose the condition.(c) B. The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test ordemonstration of a genotype consistent with cystic fibrosis.

(u) C. While recurrent respiratory infections are a classic presentation of cystic fibrosis, thediagnosis relies on confirmation, as noted in explanation B.(u) D. Trypsinogen levels are used as a neonatal screening test and if elevated should befollowed by more definitive testing to confirm the diagnosis.

Ref: (6)


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63. Diagnostic Studies/PulmonologyAn adult pat ient who is HIV posi ti ve receives a PPD. He develops an area of indurat ionthat measures 8 mm after 48 hours. Which of the follow ing is the most appropriateinterpretation of t his test result?

AnswersA. positiveB. negativeC. active infectionD. falsely negative

Explanations(c) A. A reaction size of greater than or equal to 5 mm in a HIV positive patient is considered apositive tuberculin skin test reaction.(u) B. See A for explanation.(u) C. A positive PPD identifies patients that have been infected with Mycobacterium tuberculosis,but does not indicate whether the disease is currently active or inactive.(u) D. See A for explanation.

Ref: (27)

64. Diagnostic Studies/PulmonologyA 23 year-o ld female w ith h is to ry of asthma for t he past 5 years presents w ith complain tsof increasing shor tness of breath for 2 days. Her asthma has been well cont rolled unti l 2days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours.She is normally very active, however yesterday she did not complete her 30 minutesexercise routine due to increasing dyspnea. She denies any cough, fever, recentsurgeries or use of oral contraceptives. On examination, you note the presence ofprolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable.Which of the following is the most appropriate initial diagnostic evaluation pri or toinitiation of treatment?

AnswersA. chest x-rayB. sputum gram stainC. peak flowD. ventilation perfusion scan

Explanations(u) A. A chest x-ray should be ordered in an asthmatic patient only if you are concerned about thepresence of pneumonia or pneumothorax, neither of which is supported by the H&P findingsnoted above.(u) B. A sputum gram stain is performed in patients who you suspect have an infectious process,such as pneumonia.(c) C. A peak flow reading will help you to gauge her current extent of airflow obstruction and is

helpful in monitoring the effectiveness of any treatment interventions.(u) D. A ventilation-perfusion scan (V/Q scan) is indicated in cases of suspected pulmonaryembolism. The patient above does not have any risk factors that would lead you to suspect sucha diagnosis.

Ref: (27)


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65. Diagnostic Studies/PulmonologyA patient presents with a h is to ry of progress ive worsening o f dyspnea over t he pastseveral years. He gives a history of having worked as a ship bui lder for over 50 years. Hedenies any alcohol or tobacco use. On examination you note clubbing and inspiratorycrackles. Which of the following chest x-ray findings support your suspected diagnosis?

AnswersA. hyperinflation and flat diaphragmsB. interstitial fibrosis and pleural thickeningC. cavitary lesions involving the upper lobesD. eggshell calcification of hilar lymph nodes

Explanations(u) A. Chest x-ray findings of hyperinflation and flat diaphragms suggest long-standing chronicobstructive lung disease.(c) B. This patient most likely has asbestosis, which is supported by his occupation as a shipbuilder and clinical presentation as noted above. Chest x-ray findings include interstitial fibrosis,pleural thickening and calcified pleural plaques on the diaphragm or lateral chest wall.(u) C. Chest x-ray findings of cavitary lesions involving the upper lobes suggest pulmonarytuberculosis.

(u) D. Chest x-ray findings of eggshell calcification of hilar lymph nodes strongly supports thediagnosis of silicosis.

Ref: (27)

66. Diagnostic Studies/Urology/RenalA 38 year-o ld female presen ts with r ight flank pain for several days, shak ing chi lls, fever to102F, and general malaise. The flank pain has been intermittently severe, and she has ahistor y of kidney stones. Urinalysis reveals 3+ red blood cells, 3+ leukocyte esterase, traceprotein and negative glucose. Which of the following findings would most likely be seenon a renal ultrasound?

AnswersA. Small echogenic kidneysB. CystsC. HydronephrosisD. Capsular hemorrhage

Explanations(u) A. Small echogenic kidneys bilaterally, less than 10cm, support a diagnosis of chronic renalfailure.(u) B. Cysts and capsular hemorrhage are not causes of obstructive pyelonephritis.(c) C. Hydronephrosis, dilation of the collecting ducts, may be present due to a stone or othersource of obstruction.(u) D. See B for explanation.

Ref: (8)

67. Diagnostic Studies/Urology/RenalA 65 year-o ld pat ient p resents w ith hypertens ion and peripheral edema. Urinalysis revealspale urine, with a specific gravity of 1.002, 2+ protein, trace glucose, and is negative forred blood cells and leukocytes. Serum electrolytes include BUN of 58 mg/dl and creatinineof 4.5 mg/dl. These are unchanged from previous results obtained 3 months and 6 monthsago. Of the follow ing, what other laboratory abnormaliti es would you expect?


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AnswersA. HypercalcemiaB. Metabolic alkalosisC. HypophosphatemiaD. Anemia

Explanations(u) A. Patients with chronic renal failure typically present with hypocalcemia, hyperphosphatemia,and metabolic acidosis.(u) B. See A for explanation.(u) C. See A for explanation.(c) D. Anemia of chronic disease is associated with chronic renal failure.

Ref: (8)

68. Diagnostic Studies/Infectious DiseasesAn 8 year-old pati ent presents wi th fever, nausea, vomit ing, and d iar rhea, 12 hours afterplaying with a turtle. The stools are watery, non-bloody and of moderate volumes. Which

of the following laboratory tests will be most helpful in making the diagnosis?

AnswersA. Stool for ova and parasitesB. Scotch tape testC. Widal testD. Stool culture

Explanations(u) A. The most likely diagnosis is salmonellosis, which is a bacterial infection, and this will not bediagnosed with ova and parasite studies.(u) B. The scotch tape test is used to diagnose pinworm infections, which typically present withperianal itching.

(u) C. The Widal test detects febrile agglutinins seen in typhoid fever, but a large number of false-positives and false-negatives make this test not useful clinically.(c) D. Salmonellosis presents with fever, nausea, vomiting and diarrhea, 6-48 hours afteringestion of the organism. It is commonly transmitted to humans from eggs, poultry, and reptiles.Diagnosis is made by isolation of the organism via stool culture.

Ref: (8)

69. Diagnosis/CardiologyA 64 year-o ld male, wi th a long history of COPD, presents wi th increasing fat igue over thelast three months. The patient has stopped playing golf and also complains of decreasedappetite, chron ic cough and a bloated feeling. Physical examination reveals distant heart

sounds, questionable gallop, lungs with decreased breath sounds at lung bases and theabdomen reveals RUQ tenderness with the liver two finger-breadths below the costalmargin, the extremities show 2+/4+ pitting edema. Labs reveal the serum creatinine level1.6 mg/dl, BUN 42 mg/dl, liver function test's mildl y elevated and the CBC to be normal.Which of the following is the most likely diagnosis?

AnswersA. Right ventricular failureB. PericarditisC. Exacerbation of COPD


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(u) C. Pseudotumor cerebri presents with papilledema, but not hypertension and is more commonin young females.(c) D. Malignant HTN is characterized by diastolic reading greater than 140 mm Hg with evidenceof target organ damage.

Ref: (8)

72. Diagnosis/CardiologyA 55 year-o ld male is seen in fo llow -up fo r a complain t o f chest pain . Patient states that hehas had this chest pain for about one year now. The patient further states that the pain isretrosternal with radiation to the jaw. "It feels as though a tightness, or heaviness is onand around my chest" . This pain seems to come on with exertion however, over the pasttwo weeks he has noticed that he has episodes whi le at rest. If the patient remains non-active the pain usually resolves in 15-20 minutes. Patient has a 60-pack year smokinghisto ry and drinks a martin i daily at lunch. Patient appears overweight on inspection .Based upon this history what is the most likely diagnosis?

AnswersA. Acute myocardial infarction

B. Prinzmetal variant anginaC. Stable anginaD. Unstable angina

Explanations(u) A. Pain does not resolve in an acute MI, it gradually gets worse.

(u) B. Pain typically occurs at rest is one of the hallmarks of Prinzmetal variant angina. Thispatient has just started to develop pain at rest.(u) C. Pain in stable angina is relieved with rest and usually resolves within 10 minutes. Stableangina does not have pain at rest.(c) D. Pain in unstable angina is precipitated by less effort than before or occurs at rest.

Ref: (27)

73. Diagnosis/CardiologyA 60 year-o ld male is brought t o the ED complain ing of severe onset of chest pain andintrascapular pain. The patient states that the pain feels as though " something is rippingand tearing" . The patient appears shocky; the skin is cool and clammy. The patient hasan impaired sensorium. Physical examination reveals a loud diastol ic murmur andvariation in blood pressure between the right and left arm. Based upon this presentationwhat is the most li kely diagnosis?

AnswersA. Aortic dissection

B. Acute myocardial infarctionC. Cardiac tamponadeD. Pulmonary embolism

Explanations(c) A. The scenario presented here is typical of an ascending aortic dissection. In an acutemyocardial infarction the pain builds up gradually. Cardiac tamponade may occur with adissection into the pericardial space; syncope is usually seen with this occurrence. Pulmonaryembolism is usually associated with dyspnea along with chest pain.(u) B. See A for explanation.


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(u) C. See A for explanation.(u) D. See A for explanation.

Ref: (27)

74. Diagnosis/CardiologyA 42 year-o ld male is brought into the ED w ith a complain t o f chest pain . The pain comeson suddenly wi thout exertion and lasts anywhere from 10-20 minutes. The patient hasexperienced this on three previous occasions. Today the patient complains o f light -headedness with the chest pain lasting longer. Vital signs T-99.3F oral, P-106/minute andregular, R-22/minute, BP 146/86 mm Hg. EKG reveals sinus rhythm w ith a rate of 100.Intervals are PR = 0.06 seconds, QRS = 0.12 seconds. A delta wave is noted in manyleads. Based upon this information what is the most likely diagnosis?

AnswersA. Sinus tachycardiaB. Paroxysmal supraventricular tachycardiaC. Wolff-Parkinson-White syndromeD. Ventricular tachycardia

Explanations(u) A. See C for explanation.(u) B. See C for explanation.(c) C. Wolff-Parkinson-White syndrome hallmarks on EKG include a shorten PR interval, widenedQRS, and delta waves. Sinus tachycardia has a normal PR interval and no delta waves. PSVTusually has a retrograde P wave or it may be buried in the QRS complex.(u) D. Ventricular tachycardia has a widened QRS as it originates in the ventricles.

Ref: (8)

75. Diagnosis/Cardiology

A 63 year-o ld male is admit ted to the hospital w ith an exacerbation of COPD. Theelectrocardiogram shows an irregularly, irregular rhythm at a rate of 120/minute with atleast three varying P wave morpho logies. These electrocardiogram findings are mostsuggestive of

AnswersA. atrial fibrillation.B. multifocal atrial tachycardia.C. atrioventricular junctional rhythm.D. third degree heart block.

Explanations(u) A. Atrial fibrillation is an irregularly, irregular rhythm with no definable P waves.

(c) B. Multifocal atrial tachycardia is seen most commonly in patients with COPD.Electrocardiogram findings include an irregularly, irregular rhythm with a varying PR interval andvarious P wave morphologies (Three or more foci).(u) C. Atrioventricular junctional rhythm is an escape rhythm, because of depressed sinus nodefunction, with a ventricular rate between 40-60/minute.(u) D. Third degree heart block presents with a wide QRS at a rate less than 50/minute andblocked atrial impulses.

Ref: (27)


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76. Diagnosis/DermatologyA 56 year-o ld , right hand dominant, carpenter p resents to your c linic complain ing of aprolonged bruise under his l eft thumbnail. He states that he first noticed it one year ago.Physical examination reveals a nontender left thumb with a 6 mm macular lesion locatedunder the distal nail bed. It is mixed dark brown and black in color , with irregular borders.The most likely diagnosis is

AnswersA. lentigo.B. trauma.C. melanoma.D. nevus.

Explanations(u) A. Lentigos are typically uniform in color with well-demarcated borders.(u) B. If the lesion was from trauma, it should have resolved well before one year.

(c) C. Acral lentiginous melanoma may occur on the palm, sole, nail bed, or mucus membrane.This lesion is suspicious for a melanoma due to its irregular borders, being variegated in color,and its size. A biopsy is required and will insure the diagnosis.

(u) D. A nevus usually has regular, well-demarcated borders.

Ref: (8)

77. Diagnosis/DermatologyA mother br ings in her 2 year-old chi ld stating that t he chi ld has had a 3-day h is to ry of anonproductive cough, thick copious rhinorrhea, conjunctiviti s, and a fever to 103 degrees.Physical examination reveals a well-hydrated child, wi th numerous 1-2 mm white papuleson both buccal mucosa, normal heart and breath sounds. This presentation is mostconsistent with early

Answers

A. rubeola.B. rubella.C. varicella.D. streptococcal pharyngitis

Explanations(c) A. Rubeola (measles) is characterized by cough, coryza, and conjunctivitis, along with a feveras a prodrome. Koplik spots appear prior to the onset of the typical erythematous, maculopapularrash and are pathognomonic for rubeola.(u) B. See A for explanation.(u) C. See A for explanation.(u) D. See A for explanation.

Ref: (8)

78. Diagnosis/EndocrinologyA 30 year-o ld female complains o f fatigue, weakness, diminished appet ite, weight loss,and syncope. She denies fever, chest or abdominal pain, palpitations, changes in bowelpatterns or sleep patterns. Physical examination reveals a thin female, BP 90/65 mmHg,and pulse 80 beats per minu te. Pulmonary, cardiovascular, abdominal, and neurologi cexam are without abnormaliti es. Areas of brown and bronze hyperpigmentation are noted


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on her elbows and the creases of her hands. Which of the following is the most likelydiagnosis?

AnswersA. Addison's diseaseB. Cushing's diseaseC. Anorexia nervosaD. Porphyria

Explanations(c) A. Addisons disease (adrenal insufficiency) would account for all her symptoms, thehypotension, and the hyperpigmentation of the skin.(u) B. Cushings disease, the presence of an ACTH-producing adenoma, is characterized bycentral obesity, hypertension, moon facies, purple striae, and glucose intolerance.(u) C. Anorexia nervosa may explain the weakness, weight loss, hypotension, and syncope,however, a normal pulse rate would be an unexpected finding along with the hyperpigmentation.(u) D. Porphyria presents acutely with anxiety, depression, disorientation, and insomnia.

Ref: (8)

79. Diagnosis/EndocrinologyA 72 year-o ld female is being evaluated fo r recur ren t k idney stones. Phys ical examinat ionreveals no abnormal findings. Laboratory find ings show elevated calcium and decreasedphosphate levels. Which of the following is the most likely diagnosis?

AnswersA. PheochromocytomaB. Adrenal insufficiencyC. HyperparathyroidismD. Breast cancer

Explanations

(u) A. Pheochromocytoma may lead to hypercalcemia but the patient does not have any signs orsymptoms suggestive of pheochromocytoma, such as hypertension, headache, profuse sweating,or weight loss.(u) B. Adrenal insufficiency, Addison's disease, would reveal, in addition to the hypercalcemia,anorexia, nausea and vomiting, weight loss, and cutaneous hyperpigmentation, none of which areevident in this patient.(c) C. The majority of patients with hyperparathyroidism are asymptomatic. Recurrentnephrolithiasis may be one of the presentations of primary hyperparathyroidism. Measurement ofparathyroid levels would be the initial laboratory test for the evaluation of hypercalcemia.(a) D. Hypercalcemia may be the earliest manifestation of a malignancy and this must beinvestigated. Most often the signs and symptoms of a malignancy will cause the patient to seekmedical care. Malignancy is the second leading cause of hypercalcemia, behindhyperparathyroidism.

Ref: (8)

80. Diagnosis/EndocrinologyA 38 year-o ld male presents to your cl in ic complain ing of i ncreas ing constant headachesand progressive loss of peripheral vision. His medical and family history is unremarkable.Physical examination reveals bitemporal hemianopsia but is otherwise withou t anyabnormalities. Which of the follow ing is the most li kely diagnosis?


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AnswersA. Aneurysm involving the circle of WillisB. Migraine headacheC. Multiple sclerosisD. Pituitary tumor

Explanations(u) A. An aneurysm involving the circle of Willis would result in CN III palsy. This would be a rarefinding.(u) B. Although a migraine headache may produce visual field defects, these defects would remitupon resolution of the migraine. It would also be unusual to have the scotomas occur bilaterally.(u) C. Optic neuritis associated with multiple sclerosis presents with decreased visual acuity,dimness, or color desaturation in the central visual field. It would not affect the periphery.(c) D. A pituitary tumor would account for the headaches and the loss of the peripheral vision inboth visual fields. As the tumor grows, the optic chiasm will be compressed by the tumor.

Ref: (8)

81. Diagnosis/ENT/Ophthalmology

A 23 year-o ld graduate student presents with sudden onset of severe d izziness, w ithnausea and vomiting fo r the past couple of hours. She denies hearing loss or tinnitus .She has had a recent cold. Which of the following is the most likely diagnosis?

AnswersA. Mnires diseaseB. Vestibular neuronitisC. Benign positional vertigoD. Vertebrobasilar insufficiency

Explanations(u) A. Mnires disease is associated with hearing loss, tinnitus, and vertigo that lasts fromseconds to hours.

(c) B. Vestibular neuronitis or labyrinthitis presents with vertigo, nausea, and vomiting, but nothearing loss or tinnitus. It is related to viral URIs, and develops over several hours, withsymptoms worse in the first day, with gradual recovery over several days.(u) C. Benign positional vertigo occurs with changes in position, especially rapid movements ofthe head. Nausea may occur, but vomiting is not significant.(u) D. Vertebrobasilar insufficiency is usually accompanied by brain stem findings, such asdiplopia, dysarthria, or dysphagia, and is not common in this age group.

Ref: (12)

82. Diagnosis/ENT/OphthalmologyA 4 year-o ld boy presents w ith purulent , foul -smell ing nasal discharge for th ree days. He

has not had any other symptoms of respiratory ill ness, cough, wheeze, or fever. Hisactivity level and appetite has been normal. On exam, he is afebrile. TMs have normallight reflex, canals are clear. Left nare is clear; there is considerable amount of purulentexudate from the right nare, and a brigh t reflection of light is noticed. Oropharynx iswithout inflammation or exudate. Neck is supple, without lymphadenopathy. Lungs areclear, with equal breath sounds and no wheezing. Heart has regular rhythm withou tmurmurs. Which of the following is the most li kely diagnosis?

AnswersA. Viral URI


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B. Acute sinusitisC. Allergic rhinitisD. Nasal foreign body

Explanations(u) A. Viral URI does not present with foul-smelling nasal discharge.(u) B. Acute sinusitis may present with purulent nasal discharge, but the observation of a brightlight reflection suggests a foreign body.(u) C. Allergic rhinitis is seasonal, associated with sneezing and other allergy-related symptoms.(c) D. Nasal foreign body is suggested by unilateral nasal obstruction or discharge .

Ref: (6)

83. Diagnosis/ENT/OphthalmologyA 59 year-o ld male complains of flash ing l ights behind my eye fo ll owed by sudden lossof vision , stating that it was like a curtain a

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