PA Easy questions well solved

Your patient is asked to see you in followup for his fasting labs. His total cholesterol = 230 mg/dl, triglycerides = 1200 mg/dl, unable to calculate LDL. Your patient should be advised that due to these findings he is at risk for which of the following? A: diabetes mellitus B: pancreatitis C: gout D: diabetes insipidus E: hypertension B The correct answer is (B). Very elevated triglycerides, especially over 1000 mg/dl, increase the patient's risk of acute pancreatitis. This patient requires prompt treatment. Hypertriglyceridemia may be a component of metabolic syndrome but does not directly cause diabetes mellitus or hypertension. Hypertriglyceridemia does not increase the risk of gout and diabetes insipidus. Patients diagnosed with an auricular hematoma are at increased risk of developing which condition? A: Cartilage necrosis B: Cholesteatoma C: Coagulopathy D: Exostosis E: Otomycosis The Correct Answer is: A Auricular hematomas occupy the subperichondral space, leading to decreased or absent diffusion from the perichondrium to the cartilage and resulting in increased risk of necrosis (A). Coagulopathy (C) may predispose a patient to experiencing a hematoma. Cholesteatoma (B) may result from TM trauma, but not blunt trauma to the outer ear. 00:18 00:46 A 78-year-old Caucasian female has a 3-year history of stiffness and achiness of bilateral shoulders and hips. She has been tested for rheumatoid arthritis in the past and has been found negative. Multiple radiographs of her hips and shoulders are unremarkable. She admits that she was placed on prednisone for an allergic reaction and noted a temporary resolution of her symptoms. For the past two weeks she complains of increasing symptoms now involving her neck and pain in her jaw with chewing. Today she noticed that her scalp is sore when she brushed her hair on the right side. What is the most feared complication of this condition that may be prevented with prompt diagnosis and treatment? A blindness B costovertebral angle (CVA) C aneurysm D arm claudication E polymyalgia rheumatica (PMR) A The correct answer is (A). This patient has long standing symptoms of PMR with current symptoms suggestive of giant cell (temporal) arteritis. Visual loss is the most feared complication of temporal arteritis, but it can be prevented by prompt initiation of high-dose prednisone. PMR often occurs with or prior to development of temporal arteritis and is not considered a complication. Large vessel involvement--which may result in choices (B), (C), and (D)--is less common than temporal artery involvement in GCA. The patient does not have symptoms of large vessel involvement. A 4-month-old male presents for a well child check. He is healthy, and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely diagnosis? A Atrial septal defect B Coarctation of the aorta C Patent ductus arteriosus D Tetralogy of fallot E Ventricular septal defect The Correct Answer is: E The patient in this scenario is exhibiting the classic signs of a ventricular septal defect. An atrial septal defect has a fixed, widely split S2, with a right ventricular heave as well as a systolic ejection murmur, which is best heard at the left sternal border second intercostal space. Coarctation of the aorta has absent or diminished femoral pulses and a blowing systolic murmur. A patent ductus arteriosus murmur is classically described as a rough machinery systolic murmur, and there are bounding pulses with a widened pulse pressure. Tetralogy of fallot can have associated cyanosis, with hypoxemic spells during infancy, easy fatigability, and dyspnea on exertion. Tetralogy of fallot has the presence of a right ventricular lift and a rough, systolic ejection murmur that is present along the left sternal border in the third intercostal space that radiates to the back. Aortic stenosis has a harsh systolic ejection murmur present at the right sternal border, and associated thrill in the carotid arteries. A 24-month-old infant presents for his routine physical examination. The parents state that he has been following all of his developmental milestones. On examination, the clinician hears a grade II/VI murmur along the left sternal border, which radiates into the left axilla and the left side of the back. The child also has decreased femoral pulses bilaterally. The clinician orders a chest X-ray. Which of the following is the expected finding on X-ray based on the presentation? A notching or scalloping of the ribs B boot-shaped heart—right ventricular hypertrophy C "egg on string"—narrowed mediastinum D absence of the main pulmonary artery The Correct Answer is: A The patient's presentation is consistent with findings of coarctation of the aorta. The pathognomonic finding in coarctation is decreased or absent femoral pulses. However, the majority of children show no signs of coarctation in infancy and develop signs and symptoms during childhood, most notably unequal pulses and blood pressure between arms and legs (arms greater than legs). In addition, a grade II/VI ejection murmur is heard at the aortic area and left sternal border that radiates into the left axilla and left back. Chest X-ray shows a normal-sized heart, a prominent aorta, indents at the level of the coarctation, and a dilated poststenotic segment resulting in the "figure 3" sign. Scalloping or notching of the ribs is due to enlargement of the intercostal arteries. Echocardiography is used to directly visualize the coarctation and estimate the obstruction. Asymptomatic infants and children are encouraged to have corrective surgery prior to age 5, after which they are at increased risk for myocardial dysfunction and hypertension, and require exercise testing prior to participation in aerobic activities. The boot-shaped heart is seen in patients with tetralogy of Fallot secondary to right ventricular hypertrophy; the narrowed mediastinum finding with "egg on a string" is typically seen in patients with transposition of the great vessels. A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Serial troponin elevations above the 99 th percentile of normal are noted. Which of the following would be the most appropriate next step in the management of this patient? A Clopidogrel, heparin, and aspirin, followed by cardiac catheterization B Nuclear stress test C Treadmill stress test D Thiazide diuretics and loop diuretics E Dobutamine stress echocardiogram The Correct Answer is: A In patients with non-ST-segment myocardial infarction, such as this patient with ischemic symptoms and serial troponin elevation above the 99 th percentile of normal, clopidogrel, aspirin, and heparin prior to cardiac catheterization are recommended, with the intention of percutaneous coronary intervention. In addition, morphine, oxygen, nitrates, beta blockade, ACE inhibitors, statin therapy, and glycoprotein IIb/IIa inhibitors should be considered, depending on the patient's blood pressure, heart rate, and hemodynamic stability. Choice D would be useful in the treatment of patients with hypertension and lower extremity edema. Choices B, C, and E, are all forms of stress testing, which should be performed in patients with symptoms of angina pectoris, but not for patients with acute myocardial infarction A 2-month-old female presents for a well child check. The mother has no concerns and feels that the child is doing well. On exam, there is no evidence of cyanosis and the peripheral pulses are normal and equal. However, there is a fixed and widely split S2, a right ventricular heave, and a systolic ejection murmur present. The murmur is heard best at the left sternal border second intercostal space. What is the most common abnormality present on an ECG? A Atrioventricular heart block B Atrial fibrillation C Bifasicular block D Right axis deviation E Supraventricular tachycardia The Correct Answer is: D The most likely diagnosis is an atrial septal defect, which usually shows right axis deviation on ECG. The other ECG abnormalities listed do not commonly occur with an atrial septal defect. A 48-year-old female complains of ear fullness, episodes of tinnitus, and vertigo. She also complains that her hearing is not as good as it used to be. She states that this has occurred sporadically over the past year. What is the most likely diagnosis? A Benign paroxysmal positional vertigo (BPPV) B Labyrinthitis C Vestibular neuronitis D Meniere's syndrome E Presbycusis The Correct Answer is: D BPPV is characterized by sudden vertigo, made worse with head position change, and accompanied by nausea and vomiting. Meniere syndrome is characterized by episodic severe vertigo, fluctuating sensorineural hearing loss, tinnitus, and ear "fullness." Pathologically, there is distention of the endolymphatic system throughout the inner ear, presumably due to dysfunction of the endolymphatic sac. Labyrinthitis is characterized by severe vertigo and hearing loss, and is likely a result of a viral inner ear infection. Vestibular neuronitis is also a result of a viral inner ear infection, with symptoms of severe vertigo, nausea, and vomiting, without hearing loss. Both labyrinthitis and vestibular neuronitis resolve in one to two weeks. Presbycusis is age related hearing loss. A 37-year-old G3P2 female at 39 weeks gestation presents to the labor and delivery unit complaining of abdominal pain. Laboratory evaluation reveals anemia coagulopathy that is felt to be consumptive. What is the most likely diagnosis to have caused this? Placental abruption B Placenta previa C Preeclampsia D Labor E Pre-existing anemia The Correct Answer is: A Reproductive placental abruption is the most common cause of coagulopathy in pregnancy; the hemorrhage may be concealed and is not always evident. In the presence of pain, anemia, and coagulopathy, abruption should be assumed until proved otherwise. A 19 year old female presents for her first pelvic examination and is noted to have a palpable, non-tender right ovary. She is sexually active, and uses condoms for birth control and protection from STDs. Her LMP was 20 days ago. She underwent transvaginal ultrasound and was found to have a 3-cm follicular cyst. What does this right ovarian mass represent? A Retained hemorrhagic products B Intrafollicular fluids C Solid intracellular material D Germ cell layers E Keratinized squamous epithelium The Correct Answer is: B Follicular cysts occur prior to ovulation and cause expansion of the follicular antrum, serious fluid collection, and subsequent follicular cyst formation. Corpus luteum cysts form after ovulation and may accumulate blood products. Germ cell layers and keratinized squamous epithelium are solid components of teratomas. A 56-year-old male patient is diagnosed with prostatitis. Which of the following is the least appropriate antibiotic to prescribe in the family practice setting? A ceftriaxone B doxycycline C levofloxacin D trimethoprim-sulfamethoxazole (TMP-SMX) E All are appropriate antibiotics for this patient in this setting. The Correct Answer is: A The response to antibiotics in acute bacterial prostatis is usually prompt, perhaps because drugs penetrate readily into the acutely inflamed prostate Antibiotic selection should be guided by results of urine cultures and susceptibility results. Appropriate empiric antibiotics include a fluroquinolone (loxacin 500 mg once daily) or TMP/SMX (one double-strength tablet every 12 hours). Patients who are too ill for oral therapy or are septic on presentation should be hospitalized for initial parenteral treatment (intravenous quinolones with or without an aminoglycoside). Ceftriaxone would not be recommended as first-line. A 54-year-old male patient presents to your office complaining of pain to the left eye with nausea, vomiting, and a headache after being brushed in the eye with his grandchild's stuffed animal. On examination the conjunctiva is not injected, and the cornea has a steamy appearance. You cannot visualize the retina. The pupil is fixed and 4 mm. When you stain the eye you are unable to see any lesions or scratches. You suspect: A acute bacterial conjunctivitis B acute narrow angle glaucoma C allergic conjunctivitis D herpes simplex ophthalmicus E traumatic iritis The Correct Answer is: B Patients with acute glaucoma usually seek treatment immediately because of extreme pain and blurred vision, though there are subacute cases. The blurred vision is associated with halos around lights. Nausea and abdominal pain may occur. The eye is red, the cornea steamy, and the pupil moderately dilated and nonreactive to light. Intraocular pressure is usually over 50 mm Hg, producing a hard eye on palpation.