Packrat 11 Flashcards

Question

25. Health Maintenance/Gastrointestinal/Nutritional Which of the following is an indication for vaccination against hepatitis A? A. Illicit drug users B. Health care workers C. Renal dialysis patients D. Routine vaccination starting at birth

Answer 1

\*\*\*A. Hepatitis A vaccine is recommended for illicit drug users, anyone living or traveling to endemic areas, sewage workers, food handlers, homosexual and bisexual men, animal handlers, patients with a history of chronic liver disease or a clotting factor disease as well as children and workers in day care settings and institutions. B. Health care workers, renal dialysis patients and routine vaccination starting at birth are some of the recommendations for vaccination against hepatitis B, not hepatitis A. C. See B for explanation. D. See B for explanation.

Answer 2

A. Axis I identifies clinical disorders and other conditions that may be the focus of clinical attention. \*\*\*B. Axis III identifies any physical disorder or general medical condition that is present in addition to the mental disorder. C. Axis IV identifies the psychosocial and environmental problems having a significant contribution to the disorder. D. Axis II identifies personality disorders and mental retardation.

Answer 3

A. Pure tone audiometry can be used to screen for hearing deficits in children over the age of 3 years. B. Tympanometry is used to identify an effusion as the cause of hearing loss, but in infants over the age of months. C. Acoustic reflectometry measures the spectral gradient of the tympanic membrane, but is not used clinically due to concerns about its reliability. \*\*\*D. Brainstem auditory-evoked potentials evaluate the sensory pathway and identify the site of any anatomical disruption. The test does not require any active response from the patient and is useful in the evaluation of suspected hearing loss in an infant.

Answer 4

A. Small atelectasis is commonly asymptomatic, while large atelectasis may produce signs of dyspnea and cough. Exam reveals absence of breath sounds in the area involved and dullness to percussion. A chest x-ray would reveal various findings dependent on the location of the atelectasis, but would not be normal. B. While a pneumothorax commonly presents with pleuritic chest pain and dyspnea, exam would reveal the presence of diminished breath sounds and hyperresonance on the involved side. A chest x-ray would reveal presence of a pleural line on the expiratory chest x-ray. \*\*\*C. This patient's risk factors for pulmonary embolism include advanced age, surgery, and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult to make due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal. D. While a myocardial infarction usually presents with dyspnea, the chest pain is not usually pleuritic in nature. An EKG would commonly reveal ST segment changes which would be consistent with ischemia or infarct.

Answer 5

A. There has not been any evidence of association between cigarette smoking and the development of mesothelioma. \*\*\*B. Studies confirm the association of asbestos exposure to the development of mesothelioma. C. After cigarette smoking, radon gas is the second most common risk factor for development of bronchogenic lung cancer, not mesothelioma. D. Chronic obstructive lung disease is associated with an increased risk of bronchogenic lung cancer, not mesothelioma.

Answer 6

A. Oral corticosteroids, such as prednisone, are added to therapy in severe persistent asthma. While a course of oral corticosteroids may be needed for mild exacerbations of asthma, they are not added until inhaled corticosteroids have failed to control the symptoms. B. Due to its safety profile, oral theophylline is now considered a third or fourth line treatment option for asthma. C. Long acting inhaled beta2-agonists, such as salmeterol, are not added to the treatment regimen until the symptoms indicate a moderate persistent asthma. Long acting inhaled beta2-agonists should also not be used in place of inhaled steroids. \*\*\*D. This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control.

Answer 7

A. Penetrating or blunt trauma force is responsible for a traumatic pneumothorax. B. A pneumothorax that results from an underlying lung disease is classified as a secondary pneumothorax. C. When pressure of air in the pleural space exceeds room air pressure, it leads to a tension pneumothorax. \*\*\*D. A primary spontaneous pneumothorax is thought to result from a rupture of subpleural apical blebs secondary to high negative intrapleural pressures.

Answer 8

A. Although thyroid function tests are altered in pregnancy true hyperthyroidism can occur and should be treated. \*\*\*B. This is the initial treatment of choice. C. Radioiodine treatment is contraindicated in pregnancy. D. Subtotal thyroidectomy is an option for pregnant patients during the second or third trimesters. Surgery is not indicated for first-trimester pregnancies.

Answer 9

\*\*\*A. Herpes Simplex virus is a common cause of dendritic ulceration noted on fluorescein staining. B. Fungal corneal ulcers have an indolent course with intraocular infection being common but fluorescein staining is negative for a dendritic pattern. C. Acanthamoeba keratitis has a waxing and waning course over several months and has no fluorescein staining in a dendritic pattern. D. Bacterial corneal ulcers can progress aggressively resulting in corneal perforation. Fluorescein staining does not occur in a dendritic pattern.

Answer 10

A. Alpha blockers are not the treatment of choice in a diabetic with hypertension. B. Patients with hypertension and diabetes may require a Beta blocker, but it should be added to an ACE inhibitor if the ACE inhibitor is ineffective on its own. \*\*\*C. ACE inhibitors should be part of the initial treatment of hypertension in diabetics because of beneficial effects in diabetic nephropathy and is the most appropriate initial medication. D. Patients with hypertension and diabetes mellitus may require a diuretic, but it should be added to an ACE inhibitor if the ACE inhibitor is ineffective on its own.

Answer 11

A. Right bundle branch block is caused by a delay in the conduction system in the right ventricle. It may be caused by right ventricular hypertrophy or conditions with higher pulmonic resistance such as cor pulmonale. Hypertension, however, is likely to cause changes in the left ventricle rather than the right ventricle. \*\*\*B. Long-standing hypertension can lead to left ventricular hypertrophy with characteristic changes noted on EKG. C. See A for explanation. D. ST segment elevation is a sign of acute myocardial infarction not hypertension.

Answer 12

\*\*\*A. Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 13

A. Long bones are most commonly affected with osteomyelitis in children. B. See A for explanation. \*\*\*C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection D. See A for explanation.

Answer 14

\*\*\*A. Permethrin 1% cream/shampoo is used to kill the louse and remove the eggs from the hair shafts. B. Clotrimazole is an antifungal agent and is not used to treat parasitic infestation. C. Podofilox 0.5% solution is used to treat Condyloma accuminata. D. Selenium sulfide suspension is used to treat Tinea versicolor fungal infection.

Answer 15

A. Intact parathyroid hormone levels are only obtained for patients with true hypercalcemia with an unknown etiology. \*\*\*B. Since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels. C. Demonstration of excessive calcium in the urine does not provide any additional information regarding the increased serum calcium. D. Complete blood count has no relationship to the serum calcium levels.

Answer 16

A. Left ventricular failure results in the back-up of blood into the left atrium and then the pulmonary system so it would not be associated with Kussmaul's sign. B. Pulmonary edema primarily results in increased pulmonary pressures rather than having effects on the venous inflow into the heart. C. Coarctation of the aorta primarily affects outflow from the heart due to the stenosis resulting in delayed and decreased femoral pulses; it has no effect on causing Kussmaul's sign. \*\*\*D. Kussmaul's sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.

Answer 17

A. See B for explanation. \*\*\*B. Bell's palsy is a peripheral neuropathy of cranial nerve VII. Although it has been suggested it may be related to an activation of herpes simplex virus, there is little empiric evidence for this. Approximately 60% of cases of Bell's palsy recover without treatment and patient reassurance of this is advised. Electromyography may provide aid in the prognosis, but not as a treatment option. A neurosurgeon has no role in the management of Bell's palsy. C. See B for explanation. D. See B for explanation.

Answer 18

A. Fracture of the medial orbital wall is associated with diplopia from medial rectus impingement, orbital emphysema and epistaxis. B. Prolapse of orbital soft tissue, including inferior rectus muscle, inferior oblique muscle, orbital fat, and connective tissue results in enophthalmos, ptosis, diplopia, anesthesia of the ipsilateral cheek and upper lip, and limitation of upward gaze and is seen with fractures of the orbital floor. \*\*\*C. Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma. D. Orbital emphysema is seen with fractures of the medial orbital wall or floor of the orbit into the maxillary and ethmoid sinuses respectively. It will not lead to proptosis.

Answer 19

\*\*\*A. An atrial septal defect will cause a shunt of blood from the left to the right atrium. This will result in an equalization in the amount of blood entering both the left and right ventricles which effectively eliminates the normally wide splitting that inspiration typically causes in hearts without an atrial septal defect. B. Pulse pressures reflect the difference in aortic and left ventricular volumes that occur during ventricular systole Increased pulse pressures are seen in aortic regurgitation which is a different entity than atrial septal defect. C. Continuous mechanical murmurs are noted in patients with patent ductus arteriosus. D. Differences in blood pressure between the left and right arms are seen in conditions such as coarctation of the aorta.

Answer 20

A. Cystic fibrosis is a genetic disease, but a positive family history in and of itself is not enough to diagnose the condition. \*\*\*B. The diagnosis of cystic fibrosis is made only after an elevated sweat chloride test or demonstration of a genotype consistent with cystic fibrosis. C. While recurrent respiratory infections is a classic presentation of cystic fibrosis, the diagnosis relies on confirmation, as noted in explanationB. D. Trypsinogen levels are used as a neonatal screening test and if elevated should be followed by more definitive testing to confirm the diagnosis.

Answer 21

A. See C for explanation. B. See C for explanation. \*\*\*C. Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months. D. See C for explanation.

Answer 22

A. Physical examination findings in emphysema include a midline trachea, diffuse hyperresonant to percussion, and decreased tactile fremitus. B. See A for explanation. \*\*\*C. Distant heart sounds are common in emphysema patients due to hyperinflation of the lungs. D. See A for explanation.

Answer 23

A. While weight loss is common with chronic pancreatitis, it is not an indication for surgical intervention. \*\*\*B. Indications for surgical treatment of chronic pancreatitis include severe pain that limits the patient's functioning or intractable pain despite the use of non-narcotic analgesics and absence of alcohol intake. C. While the majority of patients go on to develop diabetes mellitus 25 years after the clinical onset of chronic pancreatitis, this is not an indication for surgical intervention as it would lead to more severe exocrine deficiency. D. While the possible presence of pancreatic cancer is an indication for surgery, there is no indication for prophylactic surgery to decrease the risk of cancer.

Answer 24

A. Pericardiocentesis is the treatment of choice in a patient with a pericardial effusion and cardiac tamponade, there is no evidence of either of these in this patient. B. Nitroglycerin is indicated in the treatment of chest pain related to angina. C. Percutaneous coronary intervention is the treatment of choice in a patient with an acute myocardial infarction. \*\*\*D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment of choice in a patient with acute pericarditis.

Answer 25

A. See B for explanation. \*\*\*B. Sutures of the face should be removed in 5 days in order to allow for adequate healing and to limit the amount of scarring. C. See B for explanation. D. See B for explanation.

Answer 26

\*\*\*A. Rifampin may interfere with the efficacy of the oral contraceptives. B. Acetaminophen levels or effects may be decreased by oral contraceptives. C. Coronary artery disease is a contraindication to the use of oral contraceptives. D. Progestin only oral contraceptives are less effective at inhibiting ovulation than the combination oral contraceptive.

Answer 27

\*\*\*A. 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/sacral pain. B. Prostate massage can be performed in the absence of fever. Expressed prostatic secretions are cultured to help identify the organism. C. Nonbacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are cultured, and the cause may be unknown. D. Prostatodynia is a noninflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement.

Answer 28

A. Many prostate carcinomas are contained within the gland, making it difficult to assess progression with a digital examination alone. B. Ultrasonography is used largely for staging disease, not monitoring disease progression. C. Serum acid phosphatase is more predictive of metastatic disease than PSA measurement, but its use has largely been replaced by PSA. \*\*\*D. PSA measurement correlates well with volume and stage of disease and is the recommended examination for monitoring disease progression.

Answer 29

A. See B for explanation. \*\*\*B. The endometrial changes seen in the latter half of the cycle are under the influence of both estrogen and progesterone from the corpus luteum. During this phase, the endometrium becomes more vascularized and slightly edematous. C. See B for explanation. D. See B for explanation.

Answer 30

A. Patients with hypertrophic obstructive cardiomyopathy do not present with hypertension or weak femoral pulses. B. The murmur associated with patent foramen ovale is a systolic ejection murmur heard in the second and third intercostal spaces and patients do not present with hypertension. \*\*\*C. Coarctation of the aorta commonly presents with higher systolic pressures in the upper extremities than the lower extremities and absent or weak femoral pulses. D. Patent ductus arteriosus is rare in adults and patients are noted to have a continuous rough, machinery murmur.

Answer 31

\*\*\*A. A hemangioma is a bright red to deep purple vascular nodule or plaque that often develops at birth, may enlarge, and may regress and disappear with aging. B. A pigmented nevus is not a vascular lesion. C. A salmon patch is a light red macule over the nape of the neck or the glabella. D. A malignant melanoma presents as a hyperpigmented, asymmetric lesion with irregular borders and is typically seen in the adult population.

Answer 32

A. Niacin is not indicated in patients with diabetes as it may worsen blood sugar control. B. Cholestyramine is not indicated as it may worsen the triglyceride level in this patient. C. Gemfibrozil should be avoided as it may worsen the LDL level. \*\*\*D. Simvastatin is the drug of choice as it will decreases triglyceride level, decrease LDL, and increase HDL.

Answer 33

A. Medical therapy should be initiated prior to any consideration of surgery, which is rarely performed secondary to satisfactory ulcer healing with medical therapy. B. While proton pump inhibitors, such as omeprazole, have excellent results in healing duodenal ulcers, this regimen will not treat the H. pylori infection that is documented by the positive rapid urease test. C. While sucralfate can be utilized as a cytoprotectant agent in treatment of active ulcer disease or in maintenance of healed ulcers, surgery to remove the ulcer is not warranted as initial therapy. \*\*\*D. Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing.

Answer 34

\*\*\*A. The hallmark of infectious mononucleosis is the presence of lymphocytosis with atypical large lymphocytes seen in the blood smear. These are larger than normal mature lymphocytes, stain more darkly, and frequently show vacuolated, foamy cytoplasm, and dark chromatin in the nucleus. B. Hypersegmented neutrophils are seen in vitamin B12 deficiency. C. Anemia, if seen in mononucleosis, is normocytic and normochromic. D. Schistocytes are noted in hemolytic anemias.

Answer 35

A. High socioeconomic status, not low, is a risk factor. \*\*\*B. The major predisposing risk factor is cryptorchidism unrepaired until after age two. C. Multiple episodes of epididymitis are unrelated to the development of testicular cancer. D. The incidence of testicular cancer is much lower in African-American men than in Caucasian men.

Answer 36

(a)A. Although a drug screen may identify specific drugs, the results will not alter the care of this patient. B. Urine dipstick is not sensitive for myoglobinuria. C. This patient is at risk for myoglobinuria, and a complete blood count will not alter the treatment. \*\*\*D. Serum creatinine kinase is the most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse.

Answer 37

A. Probenecid is a uricosuric medication that helps to increase the excretion of uric acid but it does not prevent the formation of uric acid making it less beneficial in chronic gout therapy. It is also not effective in patients with chronic renal disease. \*\*\*B. Allopurinol is the best drug to lower serum urate in overproducers, stone formers, and patients with advanced renal failure. It is a xanthine oxidase inhibitor that is used to prevent the formation of uric acid. C. Colchicine treatment is recommended only in patients who have tophaceous deposits in the skin and is used in the acute rather than the chronic setting of gout. D. Indomethacin is used in the acute management of gout but is not effective in decreasing monosodium urate deposition in the joints.

Answer 38

A. Primary hypothyroidism is usually associated with an elevated TSH. B. Excessive replacement of levothyroxine would result in symptoms of hyperthyroidism, not hypopituitarism. \*\*\*C. The low trophic and target hormone levels combined with symptoms of hypogonadism indicate this patient has hypopituitarism. D. The T4 level would be elevated in subacute thyroiditis due to excessive release of thyroid hormone.

Answer 39

A. Most children with pulmonary tuberculosis are asymptomatic with few physical examination findings. The results of the diagnostic studies do not support tuberculosis as the most likely diagnosis. \*\*\*B. The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely. C. The clinical presentation of bacterial pneumonias in children is variable, but usually involves fever of acute onset. The WBC count is also usually elevated, making this a less likely diagnosis. D. See C for explanation.

Answer 40

\*\*\*A. Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that may be malodorous. B. A firm painless ulcer is seen in syphilis. C. Tender lymphadenopathy is associated with bacterial infections and is not a feature of candidal vulvovaginitis. D. Purulent discharge is noted in gonorrhea.

Answer 41

A. A patient with aortic dissection will complain of tearing, ripping pain. EKG is often normal, but may reveal left ventricular strain pattern. \*\*\*B. Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST segment elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction. C. Acute pericarditis presents with atypical chest pain and diffuse ST segment elevation. D. Pulmonary embolism often presents with either no EKG changes or sinus tachycardia. Classically described, rarely seen findings include a large S wave in lead I, a Q wave with T wave inversion in lead III, ST segment depression in lead II, T wave inversion in leads V1-V4 and a transient right bundle branch block.

Answer 42

A. Hemoglobin electrophoresis would be utilized to evaluate microcytic, hypochromic anemias. \*\*\*B. The patient's presentation is consistent with a congenital qualitative platelet disorder, most likely von Willebrand's Disease, necessitating a bleeding time and evaluation of platelet function. C. Bone marrow aspiration is not utilized in the evaluation of qualitative platelet disorders. D. A PT and aPTT would be utilized to evaluate for bleeding consistent with abnormalities with the coagulation cascade.

Answer 43

A. Immunotherapy (desensitization) is indicated as a last resort in patients who fail to either respond to pharmaceutical management or face prolonged exposure to known allergens. B. Decongestants have a limited role in helping to decrease edema, and are generally ineffective in relieving allergic symptoms. \*\*\*C. Regular use of corticosteroid nasal spray and oral inhalers prior to the allergy season is among the best means of preventing allergies. D. Cromolyn sodium has been found to be moderately effective for some patients with allergic symptoms, but it is not usually first-line management.

Answer 44

\*\*\*A. The presentation seen on the Tzanck preparation is characteristic of HSV. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 45

A. Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate. B. Group C Streptococcus presents with a red pharynx and enlarged tonsils with a yellow, blood tinged exudates \*\*\*C. Coxsackievirus presents with small grayish vesicles and punched-out ulcers in the posterior pharynx. D. Neisseria gonorrhea of the pharynx may be asymptomatic

Answer 46

A. Zolmitriptan, another 5-HT receptor agonist, is used acutely to abort migraine headaches. B. Promethazine is an antiemetic that may be used to alleviate nausea and vomiting from an acute migraine. \*\*\*C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely. D. Fluoxetine is an SSRI that is used in the treatment of anxiety and obsessive-compulsive disorders.

Answer 47

A. The Moro reflex starts to disappear at about 5-6 months of age. \*\*\*B. The grasp reflex starts to disappear at about 2-3 months of age. C. The tonic neck reflex starts to disappear at about 6-7 months of age. D. The parachute reflex remains throughout life.

Answer 48

A. Chest pain is not a feature of tetralogy of Fallot. \*\*\*B. Cyanosis is very common in tetralogy of Fallot. C. Convulsions are occasionally seen as part of severe hypoxic spells in infancy rather than a feature of tetralogy of Fallot. D. Palpitations are uncommon in tetralogy of Fallot.

Answer 49

A. See B for explanation. \*\*\*B. Intraarticular injection of hyaluronic acid has been approved recently for treatment of patients with osteoarthritis of the knee that have failed other therapies. Although the onset of action of this medication is slower than injected glucocorticoids, it has a sustained length of activity outlasting the injected glucocorticoids. C. Treatment of olecranon bursitis may include incision and drainage but not hyaluronic acid injections. D. Gout is treated with anti-inflammatory medications.

Answer 50

A. The older, traditional antipsychotic agents, such as haloperidol and chlorpromazine have higher risk of side effects, including acute motor system side effects a long-term risk of tardive dyskinesias, and should not be considered as first-line drugs. B. Clozapine should not be considered a first-line therapy because of its hematopoietic and hepatic side effects. C. See A for explanation. \*\*\*D. Initial pharmacologic therapy of schizophrenia should begin with one of the newer, "atypical" antipsychotic drugs, such as olanzapine, risperidone, quetiapine, ziprasidone, and clozapine because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms.

Answer 51

A. A Galeazzi fracture is a fracture along the length of the radius with injury to the distal radioulnar joint. \*\*\*B. A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head. C. A Colles' fracture is a fracture of the distal radius with dorsal displacement of the radial head. D. A Smith fracture is a fracture of the distal radius with ventral displacement of the radial head.

Answer 52

\*\*\*A. An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum. B. A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. It is the result of a weakness in the inguinal 3external ring. Hernial contents may radiate anteriorly rather than into the scrotum. C. Obturator hernia's are more commonly seen in elderly women and are rarely palpable in the groin. D. Femoral hernias are rare in males and do not typically reduce with lying down.

Answer 53

A. Glaucoma occurs in about 6% of diabetics. Neovascularization of the iris can cause closed angle glaucoma. B. Cataracts can occur secondary to diabetes, but are not caused by proliferative retinopathy. \*\*\*C. Proliferative retinopathy, as evidenced by neovascularization, is associated with an increased risk of vitreous hemorrhage. D. Optic neuritis is strongly associated with demyelinating disease, like multiple sclerosis.

Answer 54

\*\*\*A. Sulfonylureas increase insulin levels and predispose patients to hypoglycemia. B. C. D. Acarbose is an alpha glucosidase inhibitor that delays the absorption of carbohydrates in the diet. It does not cause hypoglycemia since it does not drive insulin into the cells.

Answer 55

\*\*\*A. The pes anserine bursa underlies the semimembranosus tendon and may become inflamed or painful owing to trauma, overuse, or inflammation. It is a common cause of knee pain and it is often misdiagnosed in adults. B. Prepatellar bursitis causes swelling in the prepatellar area and is worse with kneeling. The prepatellar bursa is superficial and is located over the inferior portion of the patella. C. The infrapatellar bursa is deeper and lies beneath the patellar ligament before its insertion on the tibial tubercle. It has a midline location rather than the medial surface as described in the question. D. Trochanteric bursitis causes hip pain rather than knee pain.

Answer 56

\*\*\*A. Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining. B. Straining decreases the intensity of the murmur associated with aortic stenosis and squatting increases the intensity. C. Mitral regurgitation is characterized by a blowing systolic murmur that radiates to the axilla, it is not often associated with syncope. D. Pulmonic stenosis is a harsh systolic murmur with a widely split S2, and no change with maneuvers.

Answer 57

A. There is suggestion that lymphoma may result from the use of infliximab, an anti-TNF agent, utilized in refractory cases of Crohn's disease; however a clear link between the development of lymphoma and the use of infliximab has not been established. \*\*\*B. Antidiarrheals may cause the development of toxic megacolon when used by patients with active severe inflammatory bowel disease. C. Bone marrow suppression is a side effect of methotrexate, which is being increasingly used in the treatment of Crohn's disease. D. Delayed serum sickness-like reaction is another potential side effect of infliximab.

Answer 58

A. Rheumatoid arthritis usually involves more than one joint, primarily affecting metacarpophalangeal and wrist joints initially. Synovial fluid analysis would show moderate leukocytosis (

Answer 59

\*\*\*A. Ceftriaxone is recommended therapy for gonococcal urethritis. B. Effective single-dose regimens for uncomplicated gonococcal urethritis include cefixime or one of the fluoroquinolones, but NOT amoxicillin due to penicillin-resistant strains of gonorrhea. C. Penicillin G benzathine is the treatment of choice for primary syphilis. D. Doxycycline is the treatment of choice for Chlamydia urethritis, not gonococcal urethritis.

Answer 60

\*\*\*A. Erythema nodosum produces erythematous red tender nodules, especially on the shins. B. Brown pigmentation on the lower extremities is a feature of chronic venous insufficiency. C. Lymphovenereum granuloma is likely to produce tender lymph nodes in the groin as can acute infection in the lower extremities. D. Scaling red macules are a feature of tinea corporis.

Answer 61

A. Cortical blindness is a rare adverse effect when prescribing salicylates. B. Optic atrophy can occur as an adverse effect with lead compounds, amebicides, and MAO inhibitors. \*\*\*C. Glaucoma can be caused by the long-term use of steroids. D. Papilledema can be a side effect to many systemic medications.

Answer 62

A. See D for explanation. B. See D for explanation. C. See D for explanation. \*\*\*D. The patient should not receive the rubella vaccine during the course of her pregnancy as the possibility of transmission of the rubella virus does exist. During the time that the patient is without protective titer she should avoid anyone with active rubella infection. The proper time to receive the vaccine is after delivery of the infant.

Answer 63

A. Congenital heart disease is not an established risk factor for coronary artery disease. B. While patients with polycystic ovary syndrome have hyperinsulimemia, they do not have the same poor prognosis for coronary artery disease as patients with diabetes mellitus. C. Patients with acute renal failure are not at risk for coronary artery disease, although patients with diabetes and chronic renal disease do have this risk. \*\*\*D. Patients with diabetes mellitus are in the same risk category for coronary artery disease as those patients with established atherosclerotic disease.

Answer 64

A. Rheumatoid factor is most commonly performed in the assessment of rheumatoid arthritis and not suspected systemic lupus erythematosus. B. Antihistone antibodies are seen in drug-induced SLE rather than in spontaneously occurring SLE. C. Anti-Smith antibodies and antibodies to the double stranded DNA are fairly specific to SLE but their role is for confirmation rather than screening for SLE. \*\*\*D. ANA's are the best screening test used in the evaluation for SLE.

Answer 65

A. Kernig's sign is positive when pain is noted on straightening the knee after flexing both the hip and knee. B. Brudzinski's sign occurs with neck flexion resulting in resultant flexion of the hips. It is a sign of meningeal irritation. \*\*\*C. A Babinski test is performed by stroking the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan in a positive test. D. A positive Gower's sign is noted in certain types of muscular dystrophy and is described as children rising to stand by rolling over prone and pushing off the floor with arms while the legs remain extended.

Answer 66

A. There is no evidence that a low-carbohydrate, high protein diet is effective in improving carbohydrate metabolism. \*\*\*B. Routine exercise improves carbohydrate metabolism and insulin sensitivity. C. Metformin is a biguanide that primarily works to decrease gluconeogenesis rather than affecting carbohydrate metabolism. D. There is no evidence that acupuncture improves carbohydrate metabolism.

Answer 67

A. Verapamil is a calcium channel blocker and there is no associated rebound hypertension after withdrawal. B. Lisinopril is an ACE inhibitor, which is not associated with rebound hypertension. \*\*\*C. Clonidine (Catapres) is a central alpha agonist and abrupt withdrawal may produce a rebound hypertensive crisis. D. Hydrochlorothiazide is a thiazide diuretic, which is not associated with rebound hypertension.

Answer 68

\*\*\*A. Vulvular squamous cell hyperplasia causes thickening and hyperkeratosis of the vulva. The lesions are red and moist and cause intense pruritus over time the area becomes thickened and a white plaque may develop. Biopsy must be done to evaluate for intraepithelial neoplasm or invasive tumor. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 69

A. This is primarily a third trimester cause of vaginal bleeding. \*\*\*B. Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis. C. Pelvic inflammatory disease typically presents with fever, abdominal pain, purulent vaginal discharge, and cervical motion tenderness. D. Acute pelvic pain may occur secondary to bleeding from the rupture of a hemorrhagic ovarian cyst, but no adnexal mass would be palpable on pelvic examination.

Answer 70

A. Pain from the bladder, uterus, or colon causes hypogastric pain. B. Pain from the stomach, duodenum, or pancreas causes epigastric pain. C. See B for explanation. \*\*\*D. Pain from the small intestine, appendix, or proximal colon causes periumbilical pain.

Answer 71

A. Rheumatoid arthritis typically involves the MCP and PIP joints of the digits for the second through fifth fingers. The thumb is classically spared. \*\*\*B. The base of the thumb is typically involved with osteoarthritis as are the DIP joints of the other fingers. C. Hemochromatosis classically involves the MCP joints of the second through fifth fingers. D. Pseudogout joint involvement is typically the MCP joints of the second through fifth fingers.

Answer 72

A. Acute MI presents with complaint of chest pain, SOB, not with fever and myalgias. \*\*\*B. Bacterial endocarditis presents as febrile illness lasting several days to weeks, commonly with nonspecific symptoms, echocardiogram often reveals vegetations on affected valves. C. Pericarditis does not present with systolic or diastolic murmur or vegetation, more commonly pericardial friction rub would be noted. D. Restrictive cardiomyopathy will show impaired diastolic filling on echocardiogram and is not associated with fever.

Answer 73

A. Medical therapy should be initiated prior to any consideration of surgery, which is rarely performed secondary to satisfactory ulcer healing with medical therapy. B. While proton pump inhibitors, such as omeprazole, have excellent results in healing duodenal ulcers, this regimen will not treat the H. pylori infection that is documented by the positive rapid urease test. C. While sucralfate can be utilized as a cytoprotectant agent in treatment of active ulcer disease or in maintenance of healed ulcers, surgery to remove the ulcer is not warranted as initial therapy. \*\*\*D. Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing.

Answer 74

A. Patients with Addison's disease tend to have anorexia and weight loss. B. Patients with Addison's disease tend to have hypotension. \*\*\*C. Patients with Addison's disease have diffuse tanning over nonexposed and exposed skin due to increased melanocytic factor that is released with adrenocorticotropic hormone. D. Patients with Addison's disease tend to have low plasma cortisol levels.

Answer 75

\*\*\*A. Sputum production is extremely variable from patient to patient, but any increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly. B. Admission is only warranted if the patient's respiratory status requires ventilatory assistance. This patient's blood gases are unremarkable for a patient with COPD and the patient is not in respiratory distress. C. Oxygen therapy should only be used for severe hypoxemia and should only be given at a low concentration, such as 2 L/min. Higher dose oxygen may stop the hypoxemic ventilatory drive. D. Oral theophylline is considered a secondary bronchodilator. The use of a metered-dose inhaler would be a preferable first-line treatment if this method of treatment were chosen.

Answer 76

A. Splenomegaly and hepatomegaly are typically seen in hemolytic anemias. B. Petechiae and ecchymosis are seen in thrombocytopenia. \*\*\*C. Loss of position and vibratory sensation are common neurologic findings in pernicious anemia. D. Cheilosis and koilonychia are seen in iron deficiency anemia.

Answer 77

A. Myelodysplastic syndrome may present with this clinical picture, but a CBC would indicate a normal or reduced white cell count. B. A hallmark of acute leukemia is pancytopenia with numerous circulating blasts. \*\*\*C. Chronic lymphocytic leukemia usually occurs after the age of 50 presenting with lymphocytosis \> 20,000 mm3 and lymphocytes that appear mature. D. Chronic myelogenous leukemia presents with markedly elevated WBC count (mean 150,000/mm3) with left shifted myeloid series.

Answer 78

A. Kaposi's sarcoma, pneumonia, or mesothelioma will produce a transudative pleural effusion. B. See A for explanation. \*\*\*C. Transudative pleural effusions result from alteration in the formation of pleural fluid, the absorption of pleural fluid, or both, by systemic factors. Local factors affecting pleural fluid absorption and/or formation produce exudative pleural effusions. D. See A for explanation.

Answer 79

\*\*\*A. Obstruction of the appendiceal lumen by lymphoid hyperplasia, a fecalith or foreign body initiates most cases of appendicitis. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 80

A. Cardiac catheterization evaluates coronary arteries but has no role in the diagnosis of supraventricular tachycardia. B. Cardiac MRI cannot diagnose and define pathway of supraventricular tachycardia. C. Chest CT scan will not establish definitive diagnosis of supraventricular tachycardia. \*\*\*D. Electrophysiology study is useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardia.

Answer 81

A. See D for explanation. B. See D for explanation. C. See D for explanation. \*\*\*D. Alcohol-related hypoglycemia results from hepatic glycogen depletion and impaired gluconeogenesis and not due to antibody formation, excessive insulin release from the pancreas, or rapid release of carbohydrate into the small bowel.

Answer 82

\*\*\*A. Thiazide diuretics can induce electrolyte changes. Principle among those is hypokalemia. B. Hyponatremia, not hypernatremia may be a complication of thiazide diuretics. C. Thiazide diuretics cause the retention of calcium and would not cause hypocalcemia. D. Thiazide diuretics cause the retention of calcium and do not readily affect magnesium levels.

Answer 83

A. Stridor without cough suggests foreign body aspiration. B. A productive cough and rales suggest pneumonia. C. Coarse rhonchi and a loose cough suggest bronchitis. \*\*\*D. A paroxysmal cough with a loud inspiration (the whoop) is noted in pertussis.

Answer 84

A. Stridor without cough suggests foreign body aspiration. B. A productive cough and rales suggest pneumonia. C. Coarse rhonchi and a loose cough suggest bronchitis. \*\*\*D. A paroxysmal cough with a loud inspiration (the whoop) is noted in pertussis.

Answer 85

A. Emphysema presents with diminished or absent breath sounds and hyperresonance to percussion without egophony. B. Atelectasis most commonly has decreased breath sounds and dullness to percussion without egophony. C. Pneumothorax presents with absent breath sounds, tactile fremitus, and resonance to percussion without egophony. \*\*\*D. Egophony occurs with consolidation caused by lobar pneumonia.

Answer 86

A. Dependent edema is the most typical finding with CHF. Laboratory findings do not generally include proteinuria or hypoalbuminemia. B. Symptoms of end-stage liver disease usually include increased abdominal girth indicating ascites. Hypoalbuminemia can occur as a result of malnutrition or concurrently with nephrotic syndrome. \*\*\*C. Proteinuria, hyperlipidemia, and hypoalbuminemia are consistent with nephrotic syndrome. D. Malnutrition is marked by physical wasting, not edema. Hypoalbuminemia may be seen, but hyperlipidemia is not typical.

Answer 87

A. Antibiotic drops have no benefit with pingueculitis. (h)B. Excision is indicated for a pterygium that is threatening vision. C. Visine drops will not do anything, but artificial tears may be beneficial. \*\*\*D. With pingueculitis, no treatment is necessary; a short course of NSAID drops or steroids may help.

Answer 88

A. The macrolides (Clarithromycin) and fluoroquinolones (Levofloxacin) should be used for initial treatment, but not for adding to failed treatments when a macrolide was already used. \*\*\*B. Rifampin should be used as an adjunct in patients with either a macrolide or quinolone antibiotic, who have failed therapy, are immunocompromised or have severe illness. C. See A for explanation. D. Legionella pneumophila does not respond to Beta-lactam antibiotics.

Answer 89

A. Antisocial behavior disorder is characterized by disregard for rights of others; a defect in the experience of compunction or remorse for harming others. B. Dysthymic mood disorder is characterized by chronic, sad mood occurring for at least 2 years in an adult (one year in a child). Behavioral problems are not part of this disorder. C. Obsessive-compulsive disorder is characterized by recurrent obsessions and compulsions that result in anxiety and disruptive behaviors related to those compulsions. \*\*\*D. Attention deficit hyperactivity disorder is characterized by inattention, including increased distractibility and difficulty sustaining attention; poor impulse control and decreased self-inhibitory capacity; and motor overactivity and motor restlessness, which are pervasive and interfere with the individual's ability to function under normal circumstances.

Answer 90

A. See B for explanation. \*\*\*B. A torus or buckle fracture occurs after a minor fall on the hand. These fractures are very stable and are not as painful as unstable fractures. They heal uneventfully in 3-4 weeks. C. See B for explanation. D. See B for explanation.

Answer 91

A. See D for explanation. B. See D for explanation. \C. See D for explanation. \*\*\*D. Chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate.

Answer 92

\*\*\*A. Radiofrequency catheter ablation is the treatment of choice on patients with accessory pathways, such as Wolff-Parkinson-White Syndrome. (h)B. Calcium channel blockers such as verapamil decrease refractoriness of the accessory pathway or increase that of the AV node leading to faster ventricular rates, therefore calcium channel blockers should be avoided in patients with WPW. C. Percutaneous coronary intervention is indicated in the treatment of coronary artery disease, not preexcitation syndromes. (h)D. Digoxin decreases refractoriness of the accessory pathway and increases that of the AV node leading to faster ventricular rates. It should therefore be avoided in patients with WPW.

Answer 93

A. Destruction of the gas-exchanging structures in the lung is characteristic of emphysema. \*\*\*B. Chronic bronchitis results from the enlargement of mucous glands and goblet cell hypertrophy in the large airways. C. There may be smooth muscle hypertrophy in chronic bronchitis but it is not to the extent as found in asthma and is not an underlying factor in the pathology of chronic bronchitis. D. Abnormal absorption of sodium and a reduced rate of chloride secretion in cystic fibrosis leads to thickening of the mucus and increase in adhesion of the mucus.

Answer 94

A. Lysine, glycine, and phenylalanine are not known to interact with MAO inhibitors. B. See A for explanation. \*\*\*C. Monoamine oxidase inhibitors are associated with serious food/drug and drug/drug interactions. Patient must restrict intake of foods having a high tyramine content to avoid serious reactions. Tyramine is a precursor to norepinephrine. D. See A for explanation.

Answer 95

\*\*\*A. Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed the gallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis. B. Obstruction of the pancreatic duct leads to development of acute pancreatitis. C. The duodenal ampulla is the area where the pancreatic duct and the common bile duct empty into the duodenum. Gallstones do not cause obstruction at this distal site. D. The common hepatic duct from the liver joins the cystic duct from the gallbladder to form the common bile duct. Stone migration occurs along the pathway of the cystic duct to the common bile duct, not along the common hepatic duct.

Answer 96

A. Inhaled corticosteroids are not utilized in the management of community-acquired pneumonia. \*\*\*B. Community acquired pneumonia is the most deadly infectious disease in the U.S. Important risk factors for increased morbidity and mortality include advanced age, alcoholism, comorbid medical conditions, altered mental status, respiratory rate greater than 30 breaths/min, hypotension, and a BUN greater than 30. C. Due to the age of the patient, comorbid diseases, and current signs of respiratory distress, intravenous not oral antimicrobial therapy is indicated. D. Endotracheal intubation is indicated for respiratory failure unresponsive to conservative management.

Answer 97

\*\*\*A. The current symptoms, along with the past treatment of hyperthyroidism with radioactive iodine, would indicate hypothyroidism. B. This is a possible later complication of subtotal thyroidectomy, not radioactive iodine therapy. C. This is an immediate complication of subtotal thyroidectomy or injury and does not occur with radioactive iodine therapy. D. Radiation thyroiditis may occur following radiation therapy but there is no history of the patient having previous external beam radiation therapy.

Answer 98

\*\*\*A. Significant persistent hematuria \>3 RBC/HPF on three urinalyses, a single urinalysis with \>100 RBC, or gross hematuria, identifies significant renal or urologic lesions. Bladder cancer usually presents with painless hematuria. B. Dysuria, urgency, and frequency are associated with irritative voiding symptoms associated with cystitis. C. See B for explanation. D. See B for explanation.

Answer 99

A. Gastric obstruction, such as that seen with pyloric stenosis, causes vomiting that is not bilious. B. Blood-streaked vomitus, but not hemoccult positive stools, may be seen in pyloric stenosis. \*\*\*C. An olive-sized mass may be palpated in the right upper abdomen in pyloric stenosis and if found, is pathognomonic for pyloric stenosis. D. A sausage-shaped mass may be noted in intussusception, not pyloric stenosis.

Answer 100

A. This behavior is not normal for a child this age. B. Social phobia is an excessive and persistent fear of social situations in which the person may be scrutinized by others. \*\*\*C. Children with autism do not tend to make eye contact, and even avoid it. They do not accept comfort when hurt and stiffen up when hugged. They do not tend to play with others, and do not tend to imitate grown-ups in play. They approach play in a more mechanical way, using others as props rather than interacting with them. D. Avoidant personality disorder is characterized by timidity, social awkwardness, and a pervasive sense of inadequacy and fear of criticism.

Answer 101

A. See C for explanation. B. See C for explanation. \*\*\*C. A single revaccination for a person over the age of 65 is recommended if it has been more than 5 years since they received their first vaccination. D. See C for explanation.

Answer 102

\*\*\*A. Calcitonin has the ability to cause analgesia when used for acute compression fracture of the vertebral body. B. Alendronate is effective in building new bone for a patient with osteoporosis but has no associated analgesic effect. C. Raloxifene is a selective estrogen receptor modulator and has positive effects on bone density when used to treat osteoporosis. Raloxifene, however, has no analgesic properties. D. Combined hormonal therapy may have positive effects on bone density but it has no analgesic properties.

Answer 103

A. Increased levels of Cyclic AMP inhibit the histamine response. B. Prostaglandins inhibit the release of histamine. C. Prednisone is used to treat urticaria. \*\*\*D. IgE triggers the release of histamine from mast cells that leads to urticaria.

Answer 104

\*\*\*A. Patients with sickle cell disease should receive prophylactic penicillin V starting at 2 months of age and folic acid starting at 1 year of age. Ferrous sulfate is not globally recommended for patients with sickle cell disease. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 105

(h)A. Decreasing the oxygen flow rate would be harmful as it would decrease the amount of oxygen delivered to the patient. B. Administration of steroids is an important treatment modality but this patient is in respiratory failure and needs more immediate therapy. \*\*\*C. This person has increasing respiratory failure as indicated by the raising PaCO2 levels. Intubation is required at this time. (h)D. Long-acting beta agonist therapy such as salmeterol is not utilized for rescue therapy.

Answer 106

\*\*\*A. Etanercept is an anti-cytokine agent used in the treatment of rheumatoid arthritis and has as a side effect the potential for serious infections. One of these side effects includes reactivation of dormant tuberculosis. B. Cyclosporine, methotrexate, and prednisone do not have the requirement to check for tuberculosis prior to initiating treatment. C. See B for explanation. D. See B for explanation.

Answer 107

A. Ataxia is associated most often with acute oral overdosage of phenytoin. B. Cardiac dysrhythmia, with or without hypotension, is an expected side effect of rapid IV phenytoin administration. \*\*\*C. Osteomalacia, or demineralization of bone, is a side effect of phenytoin that may occur after chronic administration. D. See B for explanation.

Answer 108

A. See C for explanation. B. See C for explanation. \*\*\*C. The lateral border of the tongue is where hairy leukoplakia is commonly seen. D. See C for explanation.

Answer 109

A. While a seizure may present with fine or gross uncontrolled motor movements, the tremor described is classic pill-rolling tremor noted in Parkinson's disease. B. Peripheral neuropathy presents with loss of sensation not tremor. C. Shy-Drager syndrome is due to autonomic degeneration and typically presents with orthostatic hypotension. \*\*\*D. Parkinson's disease presents with tremor at rest (pill-rolling), bradykinesia, rigidity, and postural instability.

Answer 110

\*\*\*A. Medications are most frequently implicated in toxic epidermal necrolysis. These usually include, analgesics (NSAIDs), antibiotics (Ampicillin) and anticonvulsants (Carbamazepine). B. Systemic glucocorticoids may be used early in the treatment of this condition and are not a cause. C. Aspirin is not linked to toxic epidermal necrolysis. D. Hydrochlorothiazide diuretics are not associated with the production of toxic epidermal necrolysis.

Answer 111

A. Limitation of fluid is not indicated and may be harmful. \*\*\*B. Dependent edema is a common and rarely serious complication of pregnancy due to impedance of venous return. Leg elevation improves circulation. C. Thiazide diuretics are contraindicated and could be harmful. D. Edema due to impedance of venous return will not respond to sodium restriction.

Answer 112

\*\*\*A. In ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while tympany shifts to the top as the gas-filled organs float to the top of the ascitic fluid. B. See A for explanation. C. Pain with movement is associated with peritonitis and not ascites. D. Caput medusa is the dilation of the superficial abdominal veins due to increased intraabdominal fluid accumulation. It is visible with the patient standing and does not need a special maneuver for identification.

Answer 113

A. Nightmares and night sweats are not associated with growth spurts. B. With this limited history, it is impossible to label the child as emotionally unstable. \*\*\*C. This refers to nocturnal hypoglycemia, which stimulates counter-regulatory hormone release resulting in rebound hyperglycemia. D. This refers to an early morning rise in plasma glucose due to reduced tissue sensitivity to insulin between 5 AM and 8 AM. It is not associated with nightmares and night sweats.

Answer 114

A. See C for explanation. B. See C for explanation. \*\*\*C. The dermatome T10 is at the level of the umbilicus. D. See C for explanation.

Answer 115

A. See C for explanation. B. See C for explanation. \*\*\*C. Cigarette smoking will increase the hepatic clearance of theophylline, resulting in decreased levels in the system. The use of cimetidine or ciprofloxacin or the presence of congestive heart failure will reduce hepatic clearance and causing an increase in theophylline serum levels. D. See C for explanation.

Answer 116

A. Conversion disorder is characterized by onset of symptoms or deficits mimicking neurologic or medical illness, but the etiology is psychological. \*\*\*B. Hypochondriasis is the chronic preoccupation with the idea of having a serious disease, which is usually not amenable to reassurance C. Malingering is the intentional production or feigning of physical or psychological signs and symptoms for some gain. D. Somatization disorder is characterized by complaints of pain, often related to gastrointestinal and sexual dysfunction, and pseudoneurological symptoms.

Answer 117

\*\*\*A. Fever, chills, and sweats coincide with the release of merozoites from red blood cells that have been infected with Plasmodium species. Each merozoite may infect a new red blood cell, leading to a cycle of invasion growth, and release. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 118

A. Aspirin inhibits platelet function and could lead to significant bleeding and death of this patient. B. Intravenous immunoglobulin can be utilized for short-term treatment, but the platelet count is likely to return to baseline within a month. C. Danazol is typically reserved for ITP that fails to respond to splenectomy. \*\*\*D. Persistently low platelet counts (

Answer 119

\*\*\*A. Multiple sclerosis typically presents with relapsing weakness of the limbs, sensory loss, paresthesias, and visual changes. Diagnosis is based on history and either abnormal brain or spinal cord MRI, or visual, auditory, or somatosensory evoked electrical response. B. See A for explanation. C. Glucose tolerance test is used in the evaluation of diabetes mellitus. D. Electroencephalograph is used to evaluate patients for possible seizure disorder.

Answer 120

A. Optic neuritis is a potential side effect of ethambutol, used in the treatment of tuberculosis. B. Hyperuricemia or encephalopathy are not known side effects of bleomycin. C. See B for explanation. \*\*\*D. Pulmonary fibrosis and pulmonary infiltrates are known side effects of bleomycin.

Answer 121

A. Cherry-red fovea and boxcar segmentation of the retinal veins are findings seen in central retinal artery occlusion. B. See letter A for explanation. C. Papilledema is noted in conditions causing increased intracranial pressure. \*\*\*D. Arteriovenous nicking is common in chronic hypertension.

Answer 122

A. A preformed toxin causes staphylococcal food poisoning; it has a short incubation period of 1-8 hours. B. Because Staphylococcus aureus does not invade the mucus, blood and mucus are not seen with this noninflammatory cause of food poisoning. \*\*\*C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with staphylococcal food poisoning. D. Staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature.

Answer 123

A. Venogram has been replaced by noninvasive tests due to discomfort, cost, technical difficulties, and complications, such as phlebitis. B. Thrombophlebitis is a venous problem, not an arterial one. Any unnecessary invasive procedure is potentially harmful. \*\*\*C. Ultrasound is the technique of choice to detect deep venous thrombosis in the leg. D. Impedance plethysmography is equivalent to ultrasound in detecting thrombi of the femoral and popliteal veins, but it may miss early, nonocclusive thrombi.

Answer 124

A. See C for explanation. B. See C for explanation. \*\*\*C. Transsphenoidal resection of the tumor cures about 80% of patients. The remainder can be given a combination of pituitary radiation and medical adrenalectomy with one or more drugs. If these procedures fail, the last option is bilateral adrenalectomy. D. See C for explanation.

Answer 125

A. Systemic (anaphylactic) reactions can rapidly become life-threatening. Delay in treatment may cause death. B. This is only supportive local therapy and does not address the need to treat the systemic reaction present. \*\*\*C. Epinephrine hydrochloride 1:1000, 0.2 to 0.5 mL subcutaneously is indicated for the initial treatment of this systemic reaction. Additional injections may be given every 20 to 30 minutes if needed. D. Albuterol is indicated in the presence of bronchospasm (suggested by the presence of chest tightness), but would be delivered by an aerosol, not an oral, route.

Answer 126

A. This presentation suggests a complication of an incompletely treated streptococcal pharyngitis rather than recurrent disease. B. Infectious mononucleosis may present with severe sore throat, fever, and cervical adenopathy in this age group, but would not cause deviation of the soft palate or the muffled voice. C. Gonococcal pharyngitis usually follows a more indolent course than this patient's presentation. \*\*\*D. The soft palate deviation and a muffled voice are classic signs of peritonsillar abscess.

Answer 127

A. Electrocardiogram offers no specific information of functional status, but may provide clues about the cause. B. A chest x-ray may show findings of chronic heart failure, such as cardiomegaly or pulmonary congestion, but does not reflect cardiac functional status. C. Serum electrolytes may be abnormal, either as a result of heart failure, or as a contributing factor, but they do not indicate functional status. \*\*\*D. Echocardiogram will estimate ejection fraction, which is an indicator of left ventricular function.

Answer 128

A. A cervical cone biopsy may be indicated in further evaluation of this patient, but it is dependent on the results of the colposcopy. B. An aspiration needle biopsy has no role in the evaluation of cervical dysplasia. C. Dilatation and curettage has no role in either the diagnosis or treatment of isolated cervical dysplasia. \*\*\*D. A colposcopy-directed biopsy is the first diagnostic evaluation indicated for cervical dysplasia.

Answer 129

A. Pelvic dystocia, particularly that due to small bony architecture, is the most common cause of passage abnormalities and is not directly associated with FHR decelerations. B. This refers to the length of labor, not decelerations in FHR. C. The drop in FHR is caused by an interference with uterine blood flow to the intervillous space causing an early, not late, deceleration. \*\*\*D. Placental insufficiency is the probable cause of fetal distress resulting in late decelerations.

Answer 130

\*\*\*A. Given the presence of cardiomyopathy, the patient's heart has decreased functional reserve. The symptoms and chest x-ray findings are typical of congestive heart failure. B. Endocarditis occurs as a result of infection that primarily occurs in the blood stream. Endocarditis would present with signs of infection or seeding rather than signs of heart failure. C. Pulmonary embolus usually presents with an acute onset of chest pain, severe dyspnea, and anxiety. D. Pneumonia is less likely since there is no fever and edema is not usually associated with pneumonia.

Answer 131

\*\*\*A. Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome. B. Radiofrequency ablation is used for the treatment of accessory pathways in the heart. C. See A for explanation. D. See A for explanation.

Answer 132

A. Proctitis is usually caused by anorectal infections that produce symptoms of anorectal discomfort, tenesmus, constipation, and discharge from the rectum. \*\*\*B. Anal fissures are easily diagnosed from history alone with the classic finding of severe pain upon defecation. Constipation is also a common cause of the trauma that leads to development of a fissure. C. Rectal prolapse is commonly seen in elderly females with complaints that include an anal mass, rectal bleeding and a change in bowel habits. D. While internal hemorrhoids may cause rectal bleeding, tearing pain is an uncommon complaint unless there is evidence of thrombosis of irreducible tissue.

Answer 133

A. The use of barbiturates is obsolete and these agents may actually disrupt the sleep cycle. B. Cholinesterase inhibitors are used in the treatment of Alzheimer's, but have no effect on insomnia. \*\*\*C. Benzodiazepines are the drugs of choice for insomnia in the elderly population. D. Beta-blockers have no use in the treatment of insomnia.

Answer 134

A. Squeezing pain is more characteristic of angina or esophageal pain. B. Dull, aching pain is more characteristic of chest wall pain, possibly angina, or anxiety. \*\*\*C. A dissecting aortic aneurysm often presents with a very severe ripping, tearing-like pain. D. Burning pain is more characteristic of esophageal reflux, esophagitis, or tracheobronchitis.

Answer 135

A. See C for explanation. B. See C for explanation. \*\*\*C. The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films. D. See C for explanation.

Answer 136

A. See B for explanation. \*\*\*B. The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via splinting for 6 to 8 weeks. C. See B for explanation. D. Short arm casting is indicated in wrist and metacarpal injuries but not in DIP extensor injuries.

Answer 137

A. Pityriasis alba is caused by dermal inflammation that becomes scaly and hypopigmented. B. Tinea versicolor is a fungal infection of the skin presenting as oval or circular lesions \*\*\*C. Vitiligo is the acquired loss of pigmentation due to the absence of epidermal melanocytes presenting on the back of hands, face, or body folds. D. Melasma is an acquired brown hyperpigmentation involving the face and neck in women during their second or third trimester of pregnancy.

Answer 138

\*\*\*A. Buspirone takes several days to weeks for it to have clinical activity. B. Diphenhydramine works as a histamine blocker and will cause sedation immediately because of its anticholinergic effects. C. Lorazepam is an anxiolytic medication that has an immediate onset of activity. D. Butalbital is a short to intermediate-acting barbiturate that has immediate activity.

Answer 139

A. Ophthalmic antibiotics and copious irrigation are indicated when treating a patient with a suspected corneal ulcer due to an infectious cause. \*\*\*B. Patching of the eye after abrasion associated with organic material contamination is contraindicated due to increased risk of fungal infection. C. Examination for assessment of visual acuity should be performed. D. See A for explanation.

Answer 140

\*\*\*A. The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance. B. Axillary nerve injury results in numbness over the deltoid muscle; this nerve is more commonly injured in proximal humeral fractures and anterior shoulder dislocations. C. Injury to the long thoracic nerve causes winging of the scapula due to its innervation of the serratus anterior muscle. D. Injury to the subscapular nerve results in weakness and pain of the infraspinatus muscle; this injury is commonly seen in volleyball players from repetitive stress.

Answer 141

A. See C for explanation. B. See C for explanation. \*\*\*C. Protect the eye from any pressure with a rigid metal eye shield and refer for immediate ophthalmologic consultation. Avoid unnecessary actions that would delay treatment or cause further injury. D. See C for explanation.

Answer 142

A. Rectal pseudopolyps are associated with ulcerative colitis rather than Crohn's. B. Diffuse ulcerations and bleeding are more characteristic of ulcerative colitis than Crohn's disease. C. Sheets of WBCs or "pseudomembranes" can be detected in patients with pseudomembranous colitis. \*\*\*D. Ulcerations tend to be linear with transverse fissures in Crohn's disease. These skip lesions are common with Crohn's disease.

Answer 143

A. Focal seizures usually cause abnormal motor movement rather than weakness or loss of feeling. B. Patients with migraines commonly have a history of episodes since adolescence. C. Hypoglycemic episodes do not present with focal neurological findings. \*\*\*D. This patient's symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli.

Answer 144

\*\*\*A. A deficiency in substances required for hemoglobin synthesis result in RBCs with a deficient mean corpuscular hemoglobin concentration and usually microcytosis. B. IgG antibody formation would led to the development of a hemolytic anemia. C. Alterations in red blood cell nuclear maturation led to the development of macrocytic red blood cells. D. Red blood cell membrane defects led to the development of hemolytic anemia.

Answer 145

\*\*\*A. Age is a non modifiable risk factor, as is family history of premature coronary heart disease B. High LDL is a modifiable risk factor, as is Hypertension, low HDL, obesity, tobacco abuse, physical inactivity C. See B for explanation. D. See B for explanation.

Answer 146

A. Hyperresonance to percussion would be suggestive of emphysema or pneumothorax. B. Increased tactile fremitus would be consistent with a consolidation. \*\*\*C. A lag on chest expansion may be seen in the presence of a pleural effusion. D. The presence of egophony would be consistent with a consolidation.

Answer 147

\*\*\*A. This patient has polymyalgia rheumatica and treatment with glucocorticoids can relieve discomfort and prevent the associated ischemic temporal arteritis, which threatens vision. B. Cyclophosphamide is an immunosuppressant used in the treatment of acute leukemia. C. Methotrexate is a folate inhibitor used to treat rheumatoid arthritis, not polymyalgia rheumatica. D. Azathioprine is an immunosuppressant that is used to treat rheumtatic disease and inflammatory bowel disease, not polymyalgia rheumatica.

Answer 148

(h)A. See B for explanation. (h)B. The fluoroquinolones and trimethoprim-sulfamethoxazole are contraindicated in pregnancy. C. Gentamicin is not indicated as first line therapy in the treatment of pyelonephritis in a pregnant patient. \*\*\*D. IV cephalosporins are first line treatment of pyelonephritis in a pregnant patient, followed by oral step-down therapy.

Answer 149

\*\*\*A. Treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.). Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 150

A. A retrograde urethrogram should be performed when blood is found at the external urinary meatus prior to insertion of a catheter. \*\*\*B. CT scan of the abdomen and pelvis is indicated in blunt trauma including those resulting in hematuria or when renal injury is suspected. C. A decreased serum haptoglobin is seen in hemolysis and does not provide information on renal status. D. A positive test for blood in the absence of red blood cells on urine examination suggests myoglobinuria, and should be confirmed by electrophoresis.

Answer 151

\*\*\*A. Ranitidine, an H2 receptor blocker, is indicated for the treatment of mild, intermittent symptoms of gastroesophageal reflux disease. B. Sucralfate is used in the treatment of duodenal ulcers. C. Metoclopramide is indicated for the treatment of gastroparesis as a first-line agent and as a second-line agent in the treatment of refractory gastroesophageal reflux. D. Misoprostol is indicated for the prevention of NSAID-induced gastritis.

Answer 152

\*\*\*A. Radioactive iodine (I131) is an excellent method to destroy overactive thyroid tissue of Grave's disease. B. Radioactive iodine is ineffective in subacute thyroiditis due to the thyroid's low uptake of iodine. C. Radioiodine uptake is low in Hashimoto's thyroiditis making radioactive therapy ineffective. D. Papillary thyroid carcinoma is a common thyroid malignancy and should be treated by a thyroidectomy.

Answer 153

A. Ventricular septal defect causes a holosystolic murmur rather than a continuous machinery-like murmur. B. Atrial septal defect causes a fixed split S2 rather than a continuous systolic heart murmur. C. Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in the second intercostal space. \*\*\*D. Patent ductus arteriosus is classically described in children as a continuous machinery-type murmur that is widely transmitted across the precordium.

Answer 154

A. Helical CT scan aids in the diagnosis of pulmonary embolism, not in the evaluation of angina. B. Chest x-ray is not used as a diagnostic study to evaluate symptoms of angina or coronary heart disease. \*\*\*C. In patients with classic symptoms of angina, nuclear stress testing is the most widely used test for diagnosis of ischemic heart disease. D. Coronary angiography is indicated in patients with classic stable angina who are severely symptomatic despite medical therapy and are being considered for percutaneous intervention (PCI), patients with troublesome symptoms that are difficult to diagnose, angina symptoms in a patient who has survived sudden cardiac death event, patients with ischemia on noninvasive testings.

Answer 155

A. Percutaneous coronary intervention is a better, less invasive alternative to CABG for single vessel coronary artery disease. (h)B. Streptokinase is not commonly used for treatment of acute myocardial infarction because it is ineffective at opening the occluded artery and reducing mortality. Streptokinase would be harmful because it would increase the risk of bleeding. \*\*\*C. Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis. D. Warfarin is used to prevent thrombosis and not for acute treatment.

Answer 156

A. See C for explanation. B. See C for explanation. \*\*\*C. Even with normal initial radiographs, patients with a consistent history and tenderness in the anatomical snuffbox are treated as a stable fracture with immobilization in a thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures. D. See C for explanation.

Answer 157

\*\*\*A. In the absence of old x-rays in a nonsmoking individual less than 35 years old, CT scan of the chest is the next step in the evaluation of a solitary pulmonary nodule. B. A needle biopsy would be indicated for a person greater than 35 years old and/or with a history of smoking to evaluate a solitary pulmonary nodule. C. Positron emission tomography (PET scan) would be indicated if the CT scan was nonconclusive. D. Fiberoptic bronchoscopy would be indicated only in the presence of a history of tobacco use or if the lesion was suggestive of malignancy.

Answer 158

\*\*\*A. Anxiety, decreased cognition, tremulousness, increasing irritability, and hyperactivity are common early clues to impending delirium tremens. B. Mental confusion, tremor, sensory hyperacuity, visual hallucinations, autonomic hyperactivity, diaphoresis, dehydration, electrolyte disturbances, seizures, and cardiovascular abnormalities are common signs and/or symptoms of full-blown delirium tremens. C. See B for explanation. D. See B for explanation.

Answer 159

\*\*\*A. Streptococcus mutans is the principle organism that helps to demineralize the enamel. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 160

A. Oxybutynin chloride is used for bladder spasms. It cannot be used for children under 5 years of age and is not indicated in primary enuresis. B. Imipramine is an older form of treatment that is moderately effective, but many patients relapse when therapy is stopped. This is no longer considered the treatment of choice. C. TMP-SMX is indicated for urinary tract infections that may cause secondary enuresis, but it is not used in primary enuresis. \*\*\*D. Intranasal desmopressin is effective in 50% of patients treated and is the treatment of choice.

Answer 161

\*\*\*A. Abnormal uterine bleeding and irregular enlargement of the uterus are most consistent with leiomyoma. Pain is rarely present unless vascular compromise occurs. B. While adenomyosis may present with hypermenorrhea, dysmenorrhea is often also present. Physical examination would reveal the presence of diffuse globular uterine enlargement, not the irregular enlargement as noted in the case presented. C. Endometriosis presents with dyspareunia, dysmenorrhea, and infertility. If the pelvic exam were abnormal, uterine findings would include tender nodules in the cul de sac, not the uterus. D. While endometrial polyps are compatible with the history of abnormal uterine bleeding, the uterus would be normal size without the irregular enlargement noted in the case presented.

Answer 162

\*\*\*A. Specific antibody to HBsAg appears in most individuals after clearance of HBsAg which indicates recovery from hepatitis B infection, non-infectivity, and immunity. B. This test establishes infection with HBV and implies infectivity. C. Presence of the hepatitis B core antigen reflects active infection. D. Patients who have immunity to hepatitis A do not have immunity to hepatitisB.

Answer 163

A. See B for explanation. \*\*\*B. Women are more likely to be assaulted or murdered when attempting to report the abuse or leave the abusive relationship; up to 75% of domestic assaults occur after separation. C. See B for explanation. D. See B for explanation.

Answer 164

A. Vena cava filters are used in the management of venous thromboembolic disease when anticoagulation cannot be done. \*\*\*B. Embolectomy within 4 to 6 hours is the treatment of choice. (h)C. Amputation is done only when no viable tissue is present. Cutting off a viable limb is never a good idea. D. Aspirin is used in the prevention and treatment of coronary disease and has no role in the treatment of peripheral arterial embolism.

Answer 165

A. See D for explanation. B. See D for explanation. C. Compartment pressures are performed in cases of suspected compartment syndrome, not to determine the patency of the popliteal artery. \*\*\*D. The popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pedal pulses.

Answer 166

\*\*\*A. This person has an obstructive lung disease based on PFTs. Emphysema is the most likely diagnosis, and may be related to alpha-1 antitrypsin deficiency based on family history and lack of smoking history and young age. B. The PFTs from a person with pulmonary fibrosis would be consistent with a restrictive pattern. This patient has an obstructive pattern of lung disease. C. Ventricular septal defect will have a systolic murmur associated with it. D. Congestive heart failure might explain some of the symptoms of this patient (increasing shortness of breath and DOE), he denies other common symptoms, such as orthopnea and peripheral edema. CHF should not result in changes in the PFTs.

Answer 167

A. Cystitis is characterized by dysuria without urethral discharge. B. Initially there is burning on urination and serous or milky discharge in gonococcal urethritis. C. Epididymitis is characterized by dysuria, unilateral scrotal pain and swelling. \*\*\*D. Some patients are asymptomatic, but low back or perineal pain, fever, chills, and irritative urinary symptoms are common in prostatitis.

Answer 168

A. Calcitonin does not have any estrogen effects on the body and serves as an analgesic when used in the management of vertebral fractures. B. Alendronate is a bisphosphonate that does not have any hormonal effects on the body. C. Estrogen/progesterone replacement has the benefit of maintaining bone and decreasing vertebral fractures but it would improve perimenopausal hot flashes. \*\*\*D. Raloxifene has effects on bone turnover and bone mass and has been shown to decease vertebral fractures. It has anti-estrogen effects on the non-skeletal portions of the body and increases hot flashes in perimenopausal females.

Answer 169

A. Acyclovir is used to treat meningitis secondary to herpes. Viral meningitis presents with increase number of lymphocytes and elevated glucose in the CSF . B. Fluconazole is used to treat fungal meningitis. Fungal meningitis, typically noted in immunocompromised hosts, presents with increase number of lymphocytes in the CSF. \*\*\*C. Ampicillin and ceftriaxone is used to treat bacterial meningitis, secondary to Listeria monocytogenes , which is common in the elderly. Ceftriaxone will cover other common etiologic agents such as Streptococcal pneumonia D. Penicillin and chloramphenicol is used to treat bacterial meningitis, secondary to Neisseria meningitidis. Bacterial meningitis due to N

Answer 170

\*\*\*A. Microalbuminuria is most consistent with early diabetic neuropathy. B. Red cell casts are more indicative of acute glomerular nephritis. C. White cell casts are more consistent with acute pyelonephritis. D. A few renal epithelial cells normally may be found in the urine.

Answer 171

A. See B for explanation. \*\*\*B. This patient presents with a history of minor trauma and progressive neurological abnormalities consistent with subdural hematoma. Diagnosis would be confirmed by CT scan, which is less expensive and more sensitive for blood than an MRI. C. Skull x-rays would not be helpful because they evaluate bony, not soft tissue, injury. (h)D. A lumbar puncture is contraindicated because of the potential for brain herniation.

Answer 172

A. Ventilation perfusion scans are performed prior to the CT scan of the chest and would not likely add additional information to this clinical scenario. \*\*\*B. In a patient with a high likelihood of pulmonary embolism or an inpatient, as in this case, ultrasound of the legs would be the next diagnostic step after a nondiagnostic CT. C. Although echocardiography may show right ventricular free wall hypokinesis with normal motion of the apex suggestive of pulmonary embolism, more than 50% of patients with a pulmonary embolism will have normal echocardiography. Echocardiography is not used in the diagnosis on inpatients.; D. In a post-op patient, a d-dimer will be positive regardless of the presence or absence of a pulmonary embolism.

Answer 173

A. See C for explanation. B. See C for explanation. \*\*\*C. Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal. D. See C for explanation.

Answer 174

A. Digoxin is not used for the acute termination of supraventricular tachycardia. \*\*\*B. Adenosine is an endogenous nucleoside that results in profound (although transient) slowing of the AV conduction and sinus node discharge rate. This agent has a very short half-life of 6 seconds. C. Although verapamil may be used for the termination of acute supraventricular tachycardia, it does not lead to sinus arrest in therapeutic doses. D. Quinidine is rarely used today and is not indicated for the termination of supraventricular tachycardia.

Answer 175

A. Stool culture and examination for ova and parasites are indicated when the diarrhea has persisted longer than 3 weeks or is associated with abdominal pain, fever, and/or bloody stools. B. Proctosigmoidoscopy is indicated when inflammatory bowel disease is suspected on the basis of fever, bloody diarrhea, or abdominal pain. C. Metronidazole is indicated with a confirmed diagnosis of Giardia lamblia or amebic disease. \*\*\*D. Symptomatic treatment, including dietary management and over-the-counter antidiarrheals, is indicated for afebrile patients with watery diarrhea of less than 5 days duration.

Answer 176

A. VDRL serology is useful in the diagnosis of syphilis, not contact dermatitis. B. KOH prep is used for diagnosis of fungal infections, not contact dermatitis. \*\*\*C. Patch testing with a suspected agent is usually positive in cases of allergic contact dermatitis. D. Gram's stain is useful in the diagnosis of bacterial infections, not contact dermatitis.

Answer 177

\*\*\*A. The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina. Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area. B. Patients with aortic regurgitation are likely to complain of an uncomfortable awareness of their heart, especially when lying down. These patients develop sinus tachycardia with exertion and complain of palpitations and head pounding with activity. C. The symptoms related to mitral stenosis are related to increased pulmonary pressure after the left atrium can no longer overcome the outflow obstruction. D. Patients with mitral valve prolapse are typically asymptomatic throughout their lives, although a wide range of symptoms is possible. When symptoms do occur, palpitations from arrhythmias are most common along with lightheadedness. Syncope is not part of this disease process.

Answer 178

A. Conservative therapy for stress incontinence should be attempted prior to any evaluation, such as cystoscopy, that might indicate the need for surgical correction. \*\*\*B. Strengthening the pelvic muscles by Kegel exercises and emptying the bladder frequently may resolve the problem. C. See A for explanation. D. There is no indication in the history for hormone replacement therapy and no vaginal atrophy was noted on pelvic examination.

Answer 179

A. While viral hepatitis may cause jaundice, the liver is enlarged and tender. \*\*\*B. Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer. C. While acute cholecystitis may present with jaundice and an enlarged gallbladder, the pain is classically colicky and located in the right upper quadrant. On physical examination with deep inspiration and palpation of the right subcostal area increased pain and respiratory arrest (Murphy's sign) is usually seen. D. Gilbert's syndrome is the most common of the hereditary hyperbilirubinemias. It is most often diagnosed near puberty or adult life based on results of a comprehensive metabolic panel.

Answer 180

A. Mitral stenosis is a diastolic, not a systolic murmur. \*\*\*B. Mitral stenosis is characterized by a mid-diastolic opening snap. C. Mid-systolic clicks are noted in mitral valve prolapse, not mitral stenosis. D. Paradoxical splitting of S2 occurs in aortic stenosis not mitral stenosis.

Answer 181

A. Lesions of herpes, Treponema, and Pediculus infections do not fluoresce. B. See A for explanation. C. See A for explanation. \*\*\*D. Microsporum causes tinea capitis and fluoresces blue-green under Wood's light.

Answer 182

\*\*\*A. Acanthosis nigricans is associated with patients who have hyperinsulinemia. B. Hairy cell leukemia is associated with an enlarged spleen and pancytopenia. Acanthosis nigricans is not a cutaneous manifestation. C. Erythema chronicum migrans is the characteristic lesion associated with Lyme disease. D. Eruptive xanthelasma is associated with increased triglycerides.

Answer 183

A. See C for explanation. B. See C for explanation. \*\*\*C. The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soleus muscles, and the abductor hallucis and gluteus maximus muscles. D. See C for explanation.

Answer 184

A. Propylthiouracil is used to treat hyperthyroidism, not anorexia nervosa. B. Hormone replacement is not indicated for the amenorrhea of anorexia nervosa, but nutritional support may help. \*\*\*C. Anorexia nervosa requires a comprehensive, multidisciplinary approach to treatment that integrates medical management, individual psychotherapy, and family therapy. Currently, the best results have been shown with weight restoration accompanied by family therapy for patients with adolescent-onset anorexia nervosa and individual therapy for patients with onset after 18 years of age. Inpatient treatment is often required. D. Antidepressant therapy may be useful in bulimia nervosa.

Answer 185

A. Acute labyrinthitis typically presents with an acute onset of continuous vertigo that lasts several days to a week and is associated with nausea and vomiting. It does not have any associated auditory or neurologic symptoms. B. Positional vertigo occurs following changes in head positioning with very brief, less than 1 minute, episodes. Nystagmus occurs following the position change. C. Acoustic neuroma typically presents with hearing loss and tinnitus. The neuroma grows slowly and central compensatory mechanisms can prevent or minimize the vertigo. Vertigo, when present, is continuous and not episodic. \*\*\*D. M‚niŠre's syndrome usually presents with episodes of vertigo that last from 1 to 8 hours, sensorineural hearing loss and tinnitus.

Answer 186

A. Coronary microemboli occlusion is a rare cause of acute myocardial infarction. \*\*\*B. Acute myocardial infarction occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion. C. Congenital abnormalities are rare causes of acute MI. D. Severe coronary artery spasm is more likely to result in Prinzmetal's angina rather than true infarction.

Answer 187

\*\*\*A. Patients with advanced rheumatoid arthritis will have synovitis of the atlantoaxial joint (C1-C2) which may damage the transverse ligament of the atlas, producing forward displacement of the atlas on the axis (atlantoaxial subluxation). B. Although patients with osteoarthritis may have neck pain and stiffness, there is no predilection for the atlantoaxial joints. C. Patients with gout are likely to have involvement of peripheral joints rather than spinal joints. D. Patients with pseudogout are more likely to have involvement of the knees, wrist, shoulder, ankle, elbow, and hands rather than the cervical spine.

Answer 188

A. Mohs surgery and radiation therapy are not indicated in the treatment for actinic keratosis. \*\*\*B. Cryotherapy is the treatment of choice for isolated superficial actinic keratosis. C. Acid peels can be used to treat actinic keratosis but are not the treatment of choice. D. See A for explanation.

Answer 189

A. Hypothenar atrophy may occur with aging and disuse but it is not part of the median nerve involvement that occurs with carpal tunnel syndrome. B. Finger abduction weakness is associated with ulnar nerve injury, which does not occur with carpal tunnel syndrome. C. Radial nerve injury causes weakness of wrist extension and this is not part of carpal tunnel syndrome. \*\*\*D. Median nerve injury causes weakness of thumb abduction (measured by thumb opposition strength) along with thenar atrophy. Tinel's and Phalen's signs will also be positive with carpal tunnel syndrome.

Answer 190

\*\*\*A. Home monitoring of daily weights can alert the health care provider to the early recognition of worsening heart failure. B. Spirometry monitoring is important in a patient with asthma, not heart failure. C. Daily blood glucose monitoring is important in a patient with diabetes, not heart failure. D. Daily fat intake is important, but will not improve his heart failure management.

Answer 191

\*\*\*A. A critical zone exists for the supraspinatus tendon due to its superior insertion site. It is susceptible for injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is most commonly seen with the supraspinatus tendon, the long head of the biceps tendon and/or the subacromial bursa. B. See A for explanation. C. See A for explanation. D. See A for explanation.

Answer 192

A. Hematuria and proteinuria are frequent, but nonspecific, findings in chronic renal failure. B. See A for explanation. \*\*\*C. Broad waxy casts in urinary sediment are a specific finding in chronic renal failure. D. Hyaline casts may be found in normal urine or in states of dehydration.

Answer 193

A. Sun exposure is a risk factor for cancer of the lip, but is not considered a major risk factor for oral cancer. \*\*\*B. Major risk factors for development of oral cancer are use of tobacco products and alcohol abuse. C. While occupational exposures and presence of premalignant lesions, such as leukoplakia, are risk factors for development of oral cancer, they are not considered major risk factors. D. History of oral candidiasis has no correlation to development of oral cancer.

Answer 194

A. Cautery is not used because the edges of the cauterized area may begin to bleed. B. Silver nitrate is not used in children because it increases the risk for nasal septal perforation. C. Posterior nasal packing is indicated for posterior bleeds in the inferior meatus. \*\*\*D. Petrolatum gauze will provide pressure to the bleeding point while the cause of bleeding is corrected.

Answer 195

A. Antihistamines and intranasal corticosteroids have not been adequately studied in children to prove they make a difference in treating recurrent sinusitis. B. Ribavirin is approved for the treatment of RSV infection. C. See A for explanation. \*\*\*D. High dose amoxicillin-clavulanate is the treatment of choice for resistant bacterial sinusitis, especially in children presenting with risk factors (daycare attendance, previous antibiotic treatment 1-3 months prior, age younger than 2 years).

Answer 196

A. See B for explanation. \*\*\*B. Adults over 65, and adults and children who are at high risk for contracting influenza or suffering complications should be immunized. Health care providers, including health care students who come in contact with patients with influenza and who can become carriers and infect others should be immunized. C. See B for explanation. D. See B for explanation.

Answer 197

A. Rheumatic heart disease is a rare cause of embolization B. Myxoma is a rare cause of embolization. \*\*\*C. Atrial fibrillation is present in 60-70% of patients with arterial emboli and is associated with left atrial appendage thrombus. D. Venous thrombosis may be a cause of embolization paradoxically, but is uncommon.

Answer 198

A. Opiate abuse would be suspected with the presence of euphoria, drowsiness, and constricted pupils. More severe cases present with bradycardia, hypotension, coma, or respiratory arrest. B. While acute anxiety disorder may present with tachycardia, agitation, diaphoresis, and hypertension, this diagnosis should be a diagnosis of exclusion. Failure to diagnose cocaine intoxication could lead to severe consequences. \*\*\*C. Cocaine is a stimulant and presenting clinical manifestations of intoxication include agitation, tachycardia, hypertension, diaphoresis, and dilated pupils. D. While the history may suggest the diagnosis of bipolar affective disorder, the physical exam findings do not support this diagnosis.

Answer 199

A. Acyclovir is an antiviral used in the treatment of herpes esophagitis. B. Omeprazole is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease with esophageal ulceration and peptic ulcer disease and is not indicated in the treatment of infectious esophagitis. \*\*\*C. The patient has Candida esophagitis and the treatment of choice is fluconazole. D. Penicillin G is an antibiotic and is not effective against fungal infections.

Answer 200

A. See B for explanation. \*\*\*B. Mitral stenosis leads to enlargement of the left atrium, which is the major predisposing risk factor for the development of atrial fibrillation. C. See B for explanation. D. See B for explanation.

Answer 201

A. While hyperthyroidism can cause tremor and sometimes hunger, it is not associated with a dysphoric mood. It also generally occurs in early adulthood. \*\*\*B. A drug screen would be helpful for many drugs of abuse that might cause these symptoms, but may not be definitive for amphetamines. C. The MMPI is an objective personality assessment instrument. There is no indication for its use here. D. While an EEG might be useful later (assuming the drug screen was negative), there is no history to indicate use of this test early on.

Packrat 11 Flashcards

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