PACKRAT 1

A patient with hypovolemic shock would most likely exhibit which of the following signs?

A. increased CVP; decreased BP; increased pulse rate

B. decreased CVP; decreased BP; increased pulse rate

C. increased CVP; increased BP; decreased pulse rate

D. decreased CVP; increased BP; decreased pulse rate

B. Hypovolemic shock is a condition with a decrease in the amount of circulating blood volume in the intravascular system. A decrease in the amount of circulating volume will result in a decrease in the CVP pressure which is an indirect measurement of the amount of blood in the right ventricle. Less blood in the

vascular system means decreased blood pressure. Since there is less blood in the circulation, the body

will attempt to compensate for this by increasing the number of contractions (pulse rate) and the force of those contractions due to increased sympathetic stimulation.

Examination of the heart in chronic heart failure frequently reveals

A. S3.

B. splitting of S2.

C. paradoxical splitting of S2.

D. holosystolic murmur.

A. S3 occurs as a result of the left ventricle becoming stiff and interfering with blood entering the left ventricle during filling. As the left ventricle loses its compliance, there is impaired filling which results in less blood entering the left ventricle, increased left ventricle filling pressures, and left ventricular failure. Contraction of the left ventricle is not initially affected, but becomes affected with time.

Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm?

A. abdominal mass

B. hypertension

C. chest pain

D. syncope

A. Symptomatic abdominal aortic aneurysm presents with pulsating upper abdominal mass.

Post-infarction syndrome (Dressler's syndrome) occurs after acute myocardial infarction presenting as

A. ventricular aneurysm.

B. pericarditis and pleuritis.

C. cardiac tamponade.

D. pleural effusion and rash.

B. Dressler's syndrome is the occurrence of pericarditis and pleuritis several days to weeks following an MI.

The typical physical examination finding of scarlet fever is which of the following?

A. slapped cheek appearance

B. strawberry tongue

C. Koplik's spots

D. honey-crusted lesions

B. Scarlet fever presents with fever, chills, sore throat, and a generalized fine papular rash with a sandpaper texture which begins on the chest. "Strawberry tongue" is also noted.

In myxedema, the patient commonly complains of which of the following?

A. tremors

B. palpitation

C. cold intolerance

D. eructation

C. Myxedema is the result of hypothyroidism. Cold intolerance is associated with hyopthyroidism

along with constipation and fatigue.

Which of the following signs or symptoms differentiates acute sinusitis from viral rhinitis?

A. fever

B. rhinorrhea

C. facial pain

D. swollen nasal mucous membranes

C. Frontal headache, swollen nasal mucous membranes, rhinorrhea and fever may all be signs of viral rhinitis, along with sneezing and a scratchy throat. Sinusitis usually follows a viral rhinitis, but in addition to the above symptoms, it will include pain and tenderness over the involved sinus.

Which of the following is most commonly seen in viral croup?

A. drooling

B. wheezing

C. sputum production

D. inspiratory stridor

D. Viral croup typically presents with barking cough and stridor.

A patient has double vision when he turns his eyes to the right. Examination shows that he cannot move his right eye laterally. Which of the following cranial nerves is involved?

A. optic

B. oculomotor

C. trochlear

D. abducens

D. The abducens nerve affects lateral eye movement, and if paralyzed will cause double vision with lateral gaze.

When palpating a patient's abdomen at the level of the left costal margin, the physician assistant feels the edge of the spleen. To confirm findings, which of the following is appropriate?

A. Roll the patient onto the right side and palpate for the spleen edge.

B. Roll the patient onto the left side and palpate for the spleen edge.

C. Have the patient get into the knee-chest position.

D. Have the patient sit upright and palpate in the left costal vertebral angle.

A. By rolling the patient onto the right side, gravity may bring the spleen forward and medial so that it is in a palpable location.

Which of the following is a finding in vitamin A deficiency?

A. decreased proprioception

B. night blindness

C. hair loss

D. bleeding

B. Night blindness is the earliest symptom of vitamin A deficiency.

The physician assistant would suspect food poisoning from Staphylococcus aureus in a patient who

presents with

A. ingestion of mayonnaise-based salads 48 hours earlier.

B. bloody diarrhea with mucus for one week.

C. abdominal cramps and vomiting.

D. high fever.

C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with

Staphylococcal food poisoning.

The most common location of bleeding seen in patients with von Willebrand's disease is the

A. mucosal surfaces.

B. spleen.

C. joint spaces.

D. muscle groups.

A. Von Willenbrand's disease most commonly presents with mucosal bleeding such as epistaxis, gingival bleeding, and menorrhagia.

Which of the following physical findings suggest pernicious anemia?

A. splenomegaly and hepatomegaly

B. petechiae and ecchymosis

C. loss of position and vibratory sensation

D. cheilosis and koilonychia

C. Loss of position and vibratory sensation are common neurologic findings in pernicious anemia.

Which of the following is the most common early presenting sign in patients with Alzheimer's disease?

A. change in personality

B. loss of memory

C. multiple physical complaints

D. depressed mood

B. The presence of memory impairment is the most common sign of Alzheimer's disease. Changes occur first with short-term memory.

The most frequent finding in a person presenting with a brain abscess is

A. nuchal rigidity.

B. headache.

C. seizures.

D. vomiting.

B. Headache occurs in over 70% of patients with a brain abscess.

A 28-year-old female presents on examination with enlarged ovaries bilaterally. The possible diagnosis of polycystic ovarian syndrome is enhanced by finding which of the following?

A. hirsutism

B. gynecomastia

C. anorexia

D. dyspareunia

A. The most common findings in polycystic ovarian syndrome are infertility, menstrual irregularities,

obesity, and hirsutism.

Which of the following signs and symptoms is common in candidal vulvovaginitis?

A. extreme vulvar irritation

B. firm, painless ulcer

C. tender lymphadenopathy

D. purulent discharge

A. Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that is malodorous.

Subacromial bursitis is associated with

A. positive Yergason's sign.

B. pain along the proximal humeral groove.

C. positive Kanavel's sign.

D. pain with abduction of the arm from 70-100 degrees.

D. Subacromial bursitis is believed to be part of the continuum of inflammatory conditions affecting

the shoulder; initial overuse or trauma involves the rotator cuff, supraspinatus, and bicipital tendons. The inflammation then leads to secondary involvement of the subacromial bursae. Pain and tenderness are localized to the lateral aspect of the shoulder, with signs of impingement on active motion noted on exam

between 70-100° abduction.

Which of the following physical examination findings is consistent with a herniated disk at L5-S1?

A. hypesthesia of the medial thigh

B. upgoing Babinski reflex

C. absent Achilles' reflex

D. decreased sensation in the groin region

C. Depression of the Achilles' reflex is common with L5-S1disk disease, and may also be present in a significant number of L4-L5 disk diseases.

A 65-year-old patient has a long history of schizophrenia that is treated with phenothiazines. On an unrelated clinic visit, the patient has difficulty sticking out her tongue, facial tics, increased blink frequency, and lip-smacking behavior. These involuntary movements are most suggestive of

A. tardive dyskinesia.

B. Parkinson's disease.

C. Huntington's disease.

D. Gilles de la Tourette's syndrome.

A. Tardive dyskinesia is characterized by abnormal involuntary movements of the face, mouth, tongue, trunk, and limbs and may develop after months or years of treatment with neuroleptic drugs.

Typical symptoms of depression include which of the following?

A. auditory hallucinations

B. panic attacks

C. multiple somatic complaints

D. narcissism

C. Depressed patients often focus on their bodies and tend to have multiple complaints.

A 47-year-old patient with Type 1 diabetes presents in a coma due to diabetic ketoacidosis. He is noted to have rapid deep breathing. Which of the following best describes this patient's breathing pattern?

A. ataxic breathing

B. Cheyne-Stokes breathing

C. Kussmaul breathing

D. obstructive breathing

C. Kussmaul breathing is deep breathing, and in this case, is a compensatory mechanism for

metabolic acidosis.

Paradoxical motion of the chest wall occurs in which of the following?

A. barrel chest

B. flail chest

C. funnel chest

D. pigeon chest

B. If multiple ribs are fractured in multiple places, paradoxical movements of the thorax may be seen. As descent of the diaphragm decreases intrathoracic pressure on inspiration, the injured area caves

inward. On expiration, it moves outward.

A 49-year-old male presents with complaints consistent with Peyronie's disease. Which of the following is the most likely physical examination finding in this patient?

A. inflammation of the glands of the penis

B. foreskin that cannot be retracted

C. chancre on the shaft of the penis

D. fibrous band on lateral portion of the penis

D. Peyronie disease typically presents with fibrotic areas under the penile skin along with a history of

penile curvature during erection.

Renal cell carcinoma most commonly presents with which of the following symptoms or signs?

A. hypocalcemia

B. inguinal pain

C. anemia

D. hematuria

D. The most common presenting symptom/sign of renal cell carcinoma is hematuria (approximately

60%). Flank pain or abdominal mass is present in about 30% of new cases.

Which of the following is the diagnostic test of choice for the evaluation of a patient suspected of secondary hypertension due to primary aldosteronism (Conn's syndrome)?

A. chest x-ray

B. renal scan

C. serum electrolytes

D. urinalysis for metanephrines

C. Patients having primary aldosteronism as a cause of their secondary hypertension are identified for

this condition by finding unprovoked hypokalemia on the electrolyte testing.

Which of the following electrocardiographic findings is the hallmark of pericarditis?

A. ST elevation

B. prolonged Q-T interval

C. atrial fibrillation

D. tall peaked T waves

A. The hallmark of pericarditis is ST segment elevation throughout the precordium along with PR

segment depression.

Patients with heart failure may have a combination of systolic and diastolic failure. Which of the following

studies should be used in diagnosing this condition?

A. radionuclide scanning

B. echocardiogram

C. exercise stress testing

D. cardiac catheterization

B. An echocardiogram is especially useful for assessing the dimensions of each cardiac chamber. Heart failure is usually associated with cardiac enlargement and the diagnosis should be questioned (but,

not excluded) when all chambers are normal in size. Echocardiogram assesses the function of the various chambers along with the ejection fractions of the heart, which is important with systolic dysfunction.

The most accurate method of diagnosing thrombophlebitis of the lower leg is

A. impedance plethysmography.

B. physical exam findings.

C. Doppler ultrasound.

D. venography.

D. While impedance plethysmography, physical exam findings, and Doppler ultrasound are useful in diagnosing thrombophlebitis, venography is the most accurate method for diagnosis in the lower leg.

The serum creatine phosphokinase-mB (CPK-MB) rises to a peak after an acute myocardial infarction

after how many hours?

A. 4 - 6

B. 8 - 12

C. 18 - 20

D. 48 - 72

C. CPK-MB is found mainly in cardiac muscle. It begins to rise in 4 to 6 hours, peaks at 18 hours, and returns to normal in 48 hours.

Which of the following enzymes is most specific for injury or death of the heart muscle?

A. troponin-I

B. serum aldolase

C. myoglobin

D. alanine aminotransferase

A. Troponin-I is a regulatory protein in the troponin cardiac muscle complex. It is specific for

myocardium and is elevated in injury or death of the heart muscle.

A 24-year-old male presents with a generalized erythematous maculopapular rash, including the palms and soles of the feet. He also shows generalized lymphadenopathy and flat, moist lesions in the genital area. The patient admits to having had a lesion on his penis a month or so before, but it did not bother him. Which of the following is the most appropriate to confirm the diagnosis?

A. C-reactive protein

B. Lyme titer

C. FTA-ABS

D. Weil-Felix test

C. The fluorescent treponemal antibody absorption test is positive in secondary syphilis.

A 55-year-old female presents with a mole that has changed appearance over the past few months. She says it has enlarged. Also noted is an asymmetric lesion with an irregular border and variation in color from light brown to dark blue/black. Which of the following is the most appropriate?

A. curettage

B. shave biopsy

C. excisional biopsy

D. aspiration for cytology

C. An excisional biopsy is indicated for suspected cases of melanoma.

Which of the following is the most helpful in establishing the diagnosis of gout?

A. analysis of synovial fluid with polarized light

B. C-reactive protein

C. erythrocyte sedimentation rate

D. serum and urine uric acid

A. Although sedimentation rate, C-reactive protein, and uric acid levels may be elevated, the most

specific diagnostic test for gout is the presence of negatively birefringent, needlelike crystals in leukocytes from synovial fluid.

A 24-year-old male is initially found to have a single nodule in the right lobe of his thyroid gland. He is clinically and chemically euthyroid. The next step is to

A. reassure the patient and reassess yearly.

B. recheck in 1-3 months.

C. do a fine needle aspiration.

D. obtain a CT scan of the neck.

C. The combination of fine needle aspiration and radioisotope scanning of a solitary thyroid nodule provides the best diagnostic yield. Because cold nodules may be cancerous, they are generally referred for surgical removal. It is not reasonable to delay the diagnosis.

In differentiating a viral pharyngitis from a streptococcal pharyngitis, which of the following must be included?

A. complete blood count with differential

B. ASO titer

C. cold agglutinin antibody test

D. throat culture

D. The throat culture is the definitive test to identify beta-hemolytic Group A streptococci.

A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and

appears well with a respiratory rate of 42 per minute. What is the next best step in the evaluation and

treatment of this patient?

A. lateral soft tissue x-ray of the neck

B. indirect laryngoscopy

C. thoracocentesis

D. barium swallow

B. Laryngoscopy is indicated not only for diagnosis, but also removal of the foreign body.

A 24-year-old male presents with complaints of increasing drainage from both eyes associated with mild discomfort for the past day. He denies severe or deep eye pain and any blurring of his vision. On examination, his visual activity is 20/20 OU. There is moderate erythema and edema of the eyelids, diffuse conjunctival injection, and profuse thick mucopurulent discharge on the conjunctiva and lids. Which of the following is the most appropriate diagnostic evaluation?

A. culture

B. Giemsa stain

C. Tzanck smear

D. direct fluorescent antibody testing

A. This is the typical presentation of a bacterial conjunctivitis. Due to the severity of the presentation

and possibility of infection caused by Neisseria gonorrheae, initial evaluation by Gram stain and culture should be performed.

A 4-year-old patient presents with increasing redness and swelling involving her right eye for the past 2 days. The mother states that the child has become increasingly irritable, less active, and appears to have an increased temperature. The child had a recent "cold" and nasal congestion prior to onset of these symptoms. Examination reveals an ill-appearing 4-year-old child lying quietly on the exam table.

Temperature is 102° F. Visual activity is 20/40 in the right eye and 20/30 in the left eye. The right eye reveals mild proptosis and severe erythema, increased warmth, and swelling involving the eye and surrounding tissues. Which of the following is the most appropriate diagnostic evaluation?

A. applanation tonometry

B. electronystagmography

C. orbital and sinus CT scan

D. ultrasonography of sinuses

C. This is the typical presentation of orbital cellulitis. A CT scan of the orbit and sinuses is indicated

to check for the presence of a subperiosteal abscess and underlying sinusitis, which is often the cause of orbital cellulitis.

A 65-year-old patient with a known history of alcohol and tobacco abuse presents with solid-food dysphagia. The patient also had a 24 lb weight loss over the past 6 months. To establish a diagnosis, which of the following studies should be performed?

A. CT scan

B. chest x-ray

C. barium esophagram

D. endoscopy

D. Endoscopy with biopsy establishes the diagnosis of esophageal carcinoma with a high degree of

reliability when biopsy is included as part of the procedure.

A 35-year-old male presents to the emergency department with a 4-hour history of abdominal pain, nausea, and vomiting. He denies diarrhea. Examination reveals the following:

Temperature 101° F (38.3° C)

Pulse 100 beats/min

Respiratory rate 20/min

Blood pressure 110/65 mm Hg

The patient is in moderate distress and slightly diaphoretic. He has poor oral hygiene and the odor of alcohol is noted. Examination of the heart and lungs are unremarkable except for tachycardia. Abdominal examination reveals hypoactive bowel sounds, diffuse tenderness with more marked tenderness in the epigastric area, without guarding, rebound, masses, or organomegaly. Along with CBC, which of the following diagnostic studies would be most appropriate?

A. liver function tests, amylase, and abdominal films

B. ESR, urinalysis, and electrolytes

C. electrolytes, ECG, and upper GI

D. ECG, barium enema, and sonogram

A. The clinical presentation suggests acute pancreatitis, which is best evaluated by liver function

tests, amylase, and abdominal films.

Which of the following is the most helpful serological test in primary biliary cirrhosis?

A. anti-smooth muscle antibodies

B. anti-mitochondrial antibodies

C. anti-hepatitis B antibodies

D. anti-nuclear antibodies

B. Anti-mitochondrial antibodies are seen in over 90% of cases of primary biliary cirrhosis and are

rare in other forms of liver disease.

A 26-year-old male patient presents with complaints of diarrhea with marked flatulence and weight loss for the past 6-8 months. In addition, he states that his stools are loose and soft with an oily appearance and foul smelling. The patient has not traveled out of the country. Which of the following laboratory tests would be most helpful based upon this history?

A. stool for leukocytes

B. stool for ova and parasites

C. stool for 72-hour fecal fat

D. stool for culture and sensitivity

C. Steatorrhea is usually present, but may be absent in mild disease of celiac sprue. A quantitative

72-hour stool collection taken while patients are consuming a 100 gm fat diet is a more sensitive means of detecting fat malabsorption.

The physician assistant is evaluating a patient suspected of having an iron

deficiency anemia. When examining the patient's peripheral blood smear, the

diagnosis is reinforced by noting

A. shistocytes.

B. Howell-Jolly bodies.

C. macrocytic red blood cells.

D. hypochromic, microcytic red blood cells.

D. Hypochromic, microcytic red blood cells are common in patients with iron deficiency anemia.

An 18-year-old patient presents with fever, pharyngitis, and cervical lymphadenopathy. The CBC shows a leukocytosis with 25% atypical lymphocytes. Which of the following is the diagnostic test of choice for this patient?

A. heterophile test

B. throat culture

C. blood culture

D. lymph node biopsy

A. A heterophile test is the test of choice for the diagnosis of infectious mononucleosis.

Which of the following would aid in the diagnosis of Reye's syndrome?

A. hyperglycemia

B. elevated serum ammonia level

C. proteinuria

D. elevated cholesterol

B. Reye's syndrome results in fatty liver with encephalopathy. It is a complication of influenza and

other viral illnesses, particularly in the young and with the use of aspirin. Laboratory characteristics

include elevated ammonia levels, elevation of liver enzymes, hypoglycemia, and a prolonged prothrombin time.

Which of the following laboratory studies may be used in the prenatal diagnosis of spina bifida?

A. hCG

B. alpha-fetoprotein

C. folic acid levels

D. prolactin

B. Alpha-fetoprotein, measured at 16-18 weeks of pregnancy, if elevated, would indicate a neural

tube defect, such as spina bifida.

In suspected subarachnoid hemorrhage with a negative head CT, which of the following studies should be used to help establish the diagnosis of subarachnoid hemorrhage?

A. complete blood count

B. lipid profile

C. lumbar puncture

D. electrocardiogram

C. Although 95% of subarachnoid hemorrhages show blood on head CT, the remaining do not show evidence of hemorrhaging. A lumbar puncture should then be performed and the fluid examined for red blood cells or xanthochromia.

Which of the following is the best test to confirm the presence of gonorrhea in a female?

A. culture of the endocervix

B. culture of vaginal discharge

C. Gram stain of cervical discharge

D. presence of yellow discharge

A. The standard for diagnosis of gonorrhea is the isolation of the organism by culture from the

endocervix in women.

Which of the following is the primary technique for evaluation of an abnormal cervical cytology smear?

A. laparoscopy

B. colposcopy

C. abdominal CT scan

D. dilation and curettage

B. Colposcopy is the primary method for evaluation of abnormal cervical cytology smear.

Which of the following is a common x-ray finding seen in osteoarthritis?

A. osteophyte formation

B. chondrocalcinosis

C. fat pad displacement

D. moth-eaten bone destruction

A. Osteophyte formation and joint space narrowing are common in osteoarthritis.

A break in the cortex of one side of the bony shaft without a separation or break of the opposite cortex is

called what type of fracture?

A. greenstick

B. transverse

C. torus

D. epiphyseal

A. A greenstick fracture is a break in the cortex of one side of bone shaft without a break in the

opposite cortex.

Which of the following abnormalities is most commonly noted in bulimia nervosa?

A. metabolic acidosis

B. hypokalemia

C. hyperalbuminemia

D. amenorrhea

B. Episodes of binge eating are followed by purging in the bulimic patient. Vomiting and laxative abuse are the most common methods of purging, leading to hypokalemia.

Which of the following laboratory tests is most appropriate to perform on a patient taking clozapine

(Clozaril)?

A. BUN and creatinine

B. white blood cell count

C. liver function tests

D. brain EEG

B. Agranulocytosis is a known complication of clozapine and weekly complete blood counts are mandatory when this medication is given.

Which of the following is the most common radiographic presentation of pulmonary tuberculosis?

A. cavitation

B. pleural thickening

C. hilar mass

D. hyperinflation

A. Cavitation is seen with progressive primary tuberculosis or lung abscess.

A 72-year-old patient with a long standing history of COPD will have a reduction in which of the following

on spirometry?

A. forced vital capacity (FVC)

B. total lung capacity (TLC)

C. residual volume (RV)

D. RV/TLC ratio

A. In severe COPD, the forced vital capacity is markedly reduced. Lung volume measurements reveal an increase in total lung capacity, a marked increase in residual volume, and an elevation of the RV/TLC ratio,is indicative of air trapping, particularly in emphysema.

A 68-year-old patient with chronic obstructive pulmonary disease will typically demonstrate a decreased

A. serum bicarbonate content.

B. blood hemoglobin.

C. blood pCO2.

D. blood pH.

D. COPD causes a state of respiratory acidosis, which would account for the decreased blood pH.

The diagnostic gold standard to rule out pulmonary embolism is

A. chest x-ray.

B. spiral CT scan.

C. ventilation/perfusion scan.

D. pulmonary angiography.

D. Although chest x-ray, arterial blood gases, and ventilation-perfusion scans may be obtained in the work-up of suspected pulmonary embolism, the arteriogram remains the "gold standard" for diagnosis.

A urinalysis performed during a routine physical examination on a 43-year-old male reveals 1-2 hyaline casts/HPF. The remainder of the UA is normal. Based upon these results, the physician assistant should

A. collect a urine for culture and sensitivity.

B. do nothing, since these casts are considered normal.

C. refer the patient to a nephrologist.

D. schedule the patient for a CT scan.

B. Hyaline casts are not indicative of renal disease. They can be found following strenuous exercise and with concentrated urine or during a febrile illness.

Which of the following urine findings is pathognomonic for acute pyelonephritis?

A. red blood cell casts

B. hyaline casts

C. leukocyte casts

D. renal tubular epithelial casts

C. White blood cell casts are pathognomonic for acute pyelonephritis.

In renal insufficiency, which of the following is used to assess glomerular filtration rate (GFR)?

A. urinalysis

B. blood urea nitrogen

C. renal plasma flow measure

D. creatinine clearance

D. The GFR provides an overall index of renal function. Creatinine is normally cleared by renal

excretion; as renal GFR declines, serum creatinine will increase.

A 59-year-old male complains of pain in his right leg for the last few months. He is normally able to walk two miles a day, but has noted pain when he climbs hills, which is relieved with rest or resuming walking on flat ground. He also complains of foot pain at rest. He does not smoke and denies injury to his back. He has been generally healthy with obesity and mildly elevated triglycerides. The most likely cause of

the pain in this patient is

A. sciatica.

B. diabetic neuropathy.

C. deep vein thrombosis.

D. intermittent claudication.

D. Symptoms of intermittent claudication and arterial occlusive disease include pain with exercise that

is relieved by rest; pain in the feet at rest indicates severe circulatory compromise. The history of obesity

and elevated triglycerides is consistent with peripheral vascular disease. Although this patient could also

be at risk for diabetes, the most likely immediate problem is vascular in nature.

A 46-year-old female is being evaluated for a new-onset hypertension that was discovered on screening at her workplace. The patient had several readings revealing systolic and diastolic hypertension. Physical examination is normal. A complete laboratory evaluation was performed with unexplained hypokalemia as the only abnormality found. Which of the following is the most likely diagnosis for this

patient?

A. pheochromocytoma

B. renal artery stenosis

C. coarctation of the aorta

D. primary aldosteronism

D. Primary aldosteronism has an increased aldosterone secretion, which causes the retention of

sodium and the loss of potassium. This should be the primary consideration for this patient.

An 8-year-old boy is brought to a physician because of palpitation, fatigue, and dyspnea. On

examination, a continuous machinery murmur is heard best in the second left intercostal space and is widely transmitted over the precordium. The most likely diagnosis is

A. ventricular septal defect.

B. atrial septal defect.

C. congenital aortic stenosis.

D. patent ductus arteriosus.

D. Patent ductus arteriosus is classically described in children as a continuous machinery-type

murmur that is widely transmitted across the precordium.

A patient who appears very anxious enters the office complaining of dizziness with perioral and extremity paresthesias. She vaguely describes some chest discomfort. Physical examination is unremarkable, except for moderate tachypnea with obvious sighing respiration. This clinical picture is most consistent with

A. bronchial asthma.

B. hyperventilation syndrome.

C. spontaneous pneumothorax.

D. anaerobial emphysema.

B. Anxiety may result in hyperventilation that can result in perioral numbness and paresthesias of the

extremities. These paresthesias are due to decreased CO2 in the blood stream that results from the

hyperventilation. Anxious patients also will have nondescript chest pain as part of this condition and may

also complain of dizziness.

A 12-year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated.

Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?

A. abdominal aortic aneurysm

B. pheochromocytoma

C. coarctation of the aorta

D. thoracic outlet syndrome

C. Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile

intercostal arteries and the "3"

is due to the coarctation site with proximal and distal dilations.

A 55-year-old morbidly obese male is seen in the office for routine examination. He has a history of pulmonary hypertension and cor pulmonale. Examination reveals a palpable jugular venous pulse along with a systolic flow murmur on the right side of the sternum. Which of the following is the most likely

diagnosis?

A. mitral insufficiency

B. tricuspid insufficiency

C. hepatic vein thrombosis

D. aneurysm of the thoracic aorta

B. Tricuspid insufficiency will result in blood being put back into the right side of the body with increased jugular pulsation in the neck, along with a palpable venous pulse in the liver.

On a routine neonate examination, a grade IV/VI holosystolic murmur is heard in the 3rd-4th left

intercostal space in the parasternal line. The murmur is most likely that of

A. atrial septal defect.

B. ventricular septal defect.

C. patent ductus arteriosus.

D. mitral stenosis.

B. Ventricular septal defect does cause a holosystolic murmur with blood flowing primarily from the

left to the right side during systole.

A patient presents complaining of dyspnea with exercise that worsen at night. He has to use three

pillows to sleep comfortably. The most likely diagnosis is which of the following?

A. pneumonia

B. mitral valve disease

C. chronic heart failure

D. atelectasis

C. Congestive or chronic heart failure is associated with orthopnea and even paroxysmal nocturnal dyspnea because of increased venous return of blood to the heart when the patient assumes a supine position.

A 65-year-old male presents to the emergency department with chest pain since yesterday. The patient describes the pain as severe with tingling, but denies dyspnea. On examination, there is a tender band of erythema with superimposed vesicles and bullae on the left anterior chest wall, extending from the left

side of the sternum laterally. Which of the following is the most likely diagnosis?

A. bullous pemphigoid

B. contact dermatitis

C. pityriasis rosea

D. herpes zoster

D. Herpes zoster presents with painful vesicular rash in dermatomal distribution.

A 6-year-old girl is brought in by her mother, who is concerned about sores located on the girl's face. Initially, the lesion was described as a "cold sore," but recently it has spread and developed a crusty appearance. On examination, small erosions covered by moist, honey-colored crusts are noted. The

most likely diagnosis is

A. impetigo.

B. psoriasis.

C. atopic dermatitis.

D. allergic contact dermatitis.

A. The vesiculopustular form of impetigo is characterized by golden-crusted lesions.

A 72-year-old male presents to the clinic for evaluation of a bump on his nose. The patient is a lifelong resident of Florida and an avid golfer. On examination, a 1 cm round, firm, pearly nodule with fine telangiectasias is noted. Which of the following is the most likely diagnosis?

A. basal cell carcinoma

B. squamous cell carcinoma

C. seborrheic keratosis

D. actinic keratosis

A. The lesion of basal cell carcinoma is typically firm, round, and pearly or waxy. It is the most

common cutaneous neoplasm in humans, with 85% of them occurring on the head or neck. Margin telangiectasis are classically associated with basal cell carcinomas. Risk factors include fair skin, excessive sun exposure, and male gender.

A patient presents with fatigue, weakness and weight loss. On examination, his blood pressure is 90/60 mm Hg, and there is hyperpigmentation of skin creases, pressure areas, and nipples. Plasma ACTH level is elevated. The most likely diagnosis is which of the following?

A. thyrotoxicosis

B. hypothyroidism

C. Cushing's disease

D. Addison's disease

D. This is a classic presentation of Addison's disease, lack of inhibitation of MSH leads to

hyperpigmentation.

A 58-year-old chemotherapy patient presents with fever, chills, productive cough, and disorientation.

The patient appears very ill. Vital signs include:

T 102° F

P 138/min

R 24/min

BP 70/40 mm Hg

Laboratory results include:

WBC 2.1 x 103/mm3

Na 140 mEq/L

CI 90 mEq/L

HCO3- 15 mEq/L

Glucose 140 mg/dL

Besides sepsis, the most likely diagnosis is

A. lactic acidosis.

B. hyperglycemia.

C. hyperchloremia.

D. blast crisis.

A. Lactic acidosis is the most common cause of anion gap acidosis. In a patient with inadequate

tissue perfusion, lactic acid builds up due to anaerobic metabolism, leading to accumulation of an

"unmeasured ion."

A 72-year-old patient with Type 2 diabetes treated with glyburide is brought into the clinic by her daughter, who provides the patient's history. The patient has had a mild fever, sore throat, and excessive diuresis for the past 2 days. She has been reluctant to eat or drink because of the sore throat. At the clinic, she becomes increasingly stuporous and lethargic. Based on this information, the patient is most likely experiencing

A. a diabetic ketoacidosis.

B. a nonketotic hyperglycemic hyperosmolar state.

C. hypoglycemia secondary to her refusal to eat.

D. lactic acidosis secondary to an infectious process.

B. A nonketotic hyperglycemic

hyperosmolar coma is most common in an elderly patient with mild diabetes. Lethargy and confusion

develop as osmolality rises to 300 mosm/kg or higher.

A 2-year-old child presents to the emergency department with increasing respiratory distress. The mother states that the child had a "cold" 2 weeks ago. Last week the cough progressed and is described as barky in nature, associated with stridor. The child appeared to be getting better, but last night, developed a fever and increased respiratory distress. Physical examination reveals a temperature of 102° F. The child is in moderate respiratory distress. A portable lateral neck x-ray film reveals severe subglottic and tracheal narrowing. Which of the following is the most likely diagnosis?

A. acute epiglottitis

B. bacterial tracheitis

C. acute spasmodic croup

D. laryngotracheobronchitis

B. Bacterial tracheitis usually presents following a viral upper respiratory infection, especially

laryngotracheobronchitis (croup). It should be suspected when a patient develops high fever and

respiratory distress after a few days of apparent improvement or if the patient fails to respond to the usual

treatment for croup. The findings of subglottic and tracheal narrowing on the lateral neck x-ray film highly

support this diagnosis.

A 62-year-old male with Type 2 diabetes presents complaining of left ear pain and drainage for the past 2 weeks. He states the pain is deep in the ear and that the drainage is greenish and foul-smelling and has increased over the past 2 weeks. He denies cough, congestion, fever, or placing anything in his ear. On physical examination, the patient is afebrile. Otoscopic examination reveals a markedly edematous left ear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized. Examination of the right ear is unremarkable. Which of the following is the most likely diagnosis?

A. auricular cellulitis

B. acute mastoiditis

C. chronic otitis externa

D. malignant otitis externa

D. Malignant (invasive) otitis externa is seen primarily in patients with diabetes. It usually presents

with ear pain and drainage present for several weeks to months. Physical examination findings include

an edematous ear canal with the presence of granulation tissue in the posterior wall at the mid-portion of

the canal. Fever is rare. Accurate diagnosis is needed for this patient as this is a potentially lifethreatening

infection.

A patient presents with progressive hearing loss, tinnitus, and vertigo. Which of the following is the

probable diagnosis?

A. Ramsay Hunt syndrome

B. presbycusis

C. Meniere's syndrome

D. vestibular neuronitis

C. Meniere's syndrome is associated with the triad of hearing loss, vertigo, and tinnitus. It results

from the distention of the endolymphatic compartment of the inner ear.

A patient presents complaining of "yellow vision". The physician assistant noticed a small, central lens opacity on her last visit that seems to have enlarged. The most likely diagnosis is which of the following?

A. cataract

B. pterygium

C. keratitis

D. glaucoma

A. Nuclear cataract presents with slowly progressive visual loss with a yellow discoloration to vision.

An 89-year-old female presents with a diagnosis of chronic open-angle glaucoma which has been well controlled until recently, when topical beta-adrenergic blocker eye drops were prescribed. She is now complaining of fatigue, generalized weakness, and dizziness. Which of the following is the most likely etiology of these symptoms?

A. depression

B. the eye drops

C. glaucoma

D. advanced age

B. Topical beta-blockers may be absorbed systemically, decreasing the heart rate, resulting in a decrease in cardiac output. This process would cause these symptoms.

A 60-year-old male presents with a recent history of change of bowel habits, weight loss, and blood and

mucus in his stools. The most likely diagnosis is

A. hemorrhoids.

B. colorectal carcinoma.

C. acute diverticulitis.

D. fistula-in-ano.

B. Colorectal cancer presents with weight loss, change of bowel habits, and blood in stool.

A 52-year-old female presents with diffuse abdominal pain accompanied by distention and visible peristalsis. Ausculation reveals hyperactive bowel sounds. Percussion is tympanic throughout. Palpation reveals mild diffuse tenderness without masses. The most likely diagnosis is

A. intra-abdominal abscess.

B. intestinal obstruction.

C. paralytic ileus.

D. cholecystitis.

B. Intestinal obstruction without complications is suggested by crampy pain, abdominal distention, hyperactive bowel sounds, visible peristalsis, and minimal tenderness.

Marked hypersecretion, gastric hyperacidity, and persistent ulcers are associated with which of the following?

A. Zollinger-Ellison syndrome

B. Peutz-Jeghers syndrome

C. hyperthyroidism

D. hypercalcemia

A. Gastrin-producing islet cell tumors stimulate hypersecretion of gastric acid with resultant severe

peptic ulcers as indicated in Zollinger-Ellison syndrome.

Infants who consistently choke and cough or become cyanotic with feeding should be evaluated for the

presence of

A. achalasia.

B. pyloric stenosis.

C. lactose intolerance.

D. tracheoesophageal fistula.

D. These symptoms are consistent with tracheoesophageal fistula due to the connection between the trachea and esophagus.

A 20-year-old male presents with a mass in the groin. On inspection with the patient standing a

symmetric, round swelling is noted at the external ring. When the patient lies down the mass disappears.

The patient denies any trauma. The most likely diagnosis is

A. an indirect inguinal hernia.

B. a direct inguinal hernia.

C. an obturator hernia.

D. a femoral hernia.

B. A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down.

A preterm neonate was doing well initially until 6 days postpartum. At this time, the neonate exhibited increasing lethargy and poor feeding associated with temperature instability, hypotonia, and increasing periods of apnea. Which of the following is the most likely diagnosis?

A. phenylketonuria

B. bacterial sepsis

C. congenital syphilis

D. hepatitis B infection

B. Late-onset bacterial infections presenting after 5 days of age exhibit the subtle signs and

symptoms noted. This diagnosis must be considered and appropriately evaluated.

A 40-year-old patient presents with fever, night sweats, and a 3 cm, nontender lymph node in the neck. Chest x-ray shows mediastinal adenopathy. The most likely diagnosis is

A. chronic lymphocytic leukemia.

B. hairy cell leukemia.

C. multiple myeloma.

D. Hodgkin's disease.

D. Hodgkin's disease typically presents with nontender lymphadenopathy in the neck and axilla and B-symptoms. Mediastinal adenopathy is also common.

An 8-year-old boy is admitted for "seizures" that are described as "20-second lapses of awareness" when he blinks his eyes. After these attacks, he resumes his previous activity. Which of the following seizure types is most likely?

A. tonic-clonic

B. myoclonic

C. absence

D. focal

C. Absence seizures are characterized by lapses of consciousness associated with postictal confusion.

A 32-year-old female presents with a 7-month history of recurrent, brief episodes of weakness and tingling in the extremities, diplopia, and vertigo. The most likely diagnosis is

A. Guillain-Barré syndrome.

B. myasthenia gravis.

C. multiple sclerosis.

D. amyotrophic lateral sclerosis.

C. Multiple sclerosis is most frequently seen in patients in their twenties and presents with episodes of weakness, paresthesias, and diplopia.

A 50-year-old male presents with a 3-month history of weakness, cramping, fasciculations, and loss of muscle mass in his left arm. The most likely diagnosis is

A. amyotrophic lateral sclerosis.

B. Guillain-Barré syndrome.

C. Parkinson's disease.

D. myasthenia gravis.

A. The most common acquired motor neuron disease is amyotrophic lateral sclerosis. It is a disorder of both upper and lower motor neurons, leading to a complex clinical syndrome that includes painless, progressive weakness, muscle atrophy, fasciculations, muscle cramps, spasticity, and clonus.

A 15-year-old female is seen for routine prenatal care at 28 weeks' gestation. She denies any

complaints, but has noted some increase in dependent edema and her ring appears tight in the morning. Her PMHx is unremarkable. Physical examination reveals VS: P - 82 reg; R - 20 unlabored; BP - 126/90 mm Hg. She has gained 10 lbs since her last routine visit. Fundal height is consistent with 26.5 weeks with reactive fetal heart tones. +1/4 pedal edema is present bilaterally and DTRs are +3/4 bilaterally.

Dipstick of urine reveals trace protein. The most likely diagnosis is

A. eclampsia.

B. pre-eclampsia.

C. chronic hypertension.

D. transient hypertension.

B. The classic findings of edema, especially involving the hands or face in the morning, hypertension,

and proteinuria are most consistent with pre-eclampsia, which is more common in the first pregnancy and

more frequent in adolescent over adult pregnancies.

A woman who is late in her last trimester presents in the emergency department with bright, red vaginal bleeding with no abdominal pain. Her blood pressure is 120/80 mm Hg. The most likely diagnosis is

A. spontaneous abortion.

B. placenta previa.

C. hydatidiform mole.

D. abruptio placentae.

B. Placenta previa presents sudden painless, profuse bleeding in the third trimester.

A 10-year-old male presents with pain in his left leg that is worse at night. Aspirin relieves the pain and the patient denies injury. On examination, there is point tenderness over the tibia, and the patient has a slight limp that favors the left leg. Radiographs show a 1 cm radiolucent nidus surrounded by

osteosclerosis. The most likely diagnosis is

A. osteosarcoma.

B. bone cyst.

C. osteoblastoma.

D. osteoid osteoma.

D. Osteoid osteoma is a benign tumor in children age 5 to 20, presents with increasing pain, worse at night and relieved by aspirin.

An 18-year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following is the most likely diagnosis?

A. avascular necrosis

B. myositis ossificans

C. compartment syndrome

D. reflex sympathetic dystrophy

C. Compartment syndrome is characterized by a pathological increase of pressure within a closed

space and results from edema or bleeding within the compartment. It may occur as an early local

complication of fracture.

A 14-year-old patient who fell on his outstretched hand, now complains of pain along the entire arm. There is point tenderness just proximal to the wrist and also over the proximal ulna. There is significant pain with movement of the elbow joint. An x-ray will most likely show a

A. Galeazzi's fracture/dislocation.

B. Monteggia's fracture/dislocation.

C. Colles' fracture.

D. Smith's fracture.

A. Galeazzi's fracture/dislocation involves a fracture of the distal radial shaft with proximal radioulnar joint disruption and subluxation of the proximal ulna.

A 26-year-old woman complains of a lack of energy and decreased sleep at night. Her lack of sleep has interfered with her work and social activities. She awakens several times each night and checks her doors and windows to ensure they are closed and locked. This is an example of

A. agoraphobia.

B. alcohol abuse.

C. obsessive-compulsive disorder.

D. panic disorder.

C. This person displays a compulsive behavior by reassuring herself that the doors and windows are locked and secure, thereby her anxiety regarding her safety is reduced. This behavior is resulting in interference with her normal daily routine.

A person who witnessed the World Trade Towers attack complains of sleep disturbances associated with recurrent distressing dreams of the attacks, withdrawal from friends, sensations of foreboding on the anniversary date, and depression. This person is most likely suffering from

A. major depressive disorder.

B. posttraumatic stress disorder.

C. generalized anxiety disorder.

D. dysthymic disorder.

B. This is a classic presentation for post-traumatic stress disorder, when a person has experienced an event that would be traumatic to almost anyone. All of this person's complaints are characteristic of PTSD.

Chest x-ray of a 63-year-old smoker reveals a hilar mass, mediastinal widening, and cavitation. Which of the following is the most likely diagnosis?

A. squamous cell carcinoma

B. adenocarcinoma

C. mesothelioma

D. large cell tumor

A. Squamous cell carcinoma commonly produces a hilar mass, mediastinal widening, and cavitation.

An 82-year-old nursing home patient has a fever of 102° F orally for 48 hours. Preliminary urine culture results reveal more than 100,000 gram negative rods. The patient now develops a rapid onset of profound dyspnea with tachypnea, interstitial retractions, and bilateral crackles. Which of the following is the most likely diagnosis?

A. acute respiratory distress syndrome

B. influenza

C. spontaneous pneumothorax

D. upper airway obstruction

A. Acute respiratory distress syndrome (ARDS) denotes acute hypoxemic respiratory failure following a systemic or pulmonary insult without evidence of heart failure. ARDS is the most severe form of acute

lung injury and is characterized by bilateral, widespread, radiographic, pulmonary infiltrates.