1. (2)Youarereadinganevidencebasedarticlepublishedinarefereedjournal and note a confidence interval (CI) related to the following statement: “Terminally ill bone cancer patient in the final stages of illness have several episodes of illness have several episodes of nausea every 24 hours.” Which of the following is true?
- ThesmallertheCI,lessvaluedeviatefromthemean
- ThelargertheCI,themoreprecisetherangeofvalues
- The smaller the CI, the more deviates from the mean
- ThesmallertheCI,themoreprecisetherangeofvalues.
*A smaller CI indicates more precise the information. The CI is a specified probability that includes the parameter being estimated.
2. (5)Brenda,57,isamotherofthreeandwasdiagnosedwithPrinzmetal’s angina. Which medication classification is most indicated for this patient’s treatment and control?
- GlycoproteinIIb/IIainhibitors
- AngiotensinIIconvertingenzymeinhibitors
- Beta blockers
- Calciumchannelblockers
*Prinzmetal’s angina is the result of coronary vasospasm, rather than atherosclerosis. Prinzmetal’s (variant) occurs at various times, including rest. Levine’s sign—“clenched fist sign” 90% diagnostic for angina. ST elevation on MI and Prinzmetal’s (p. 315)
3. (20)AcaretakeristakinganAlzheimer’spatientforawalkandhandshimhis jacket. However, the patient merely looks back at the caretaker and stares, as though he is confused. What should the caretaker do?
- Putthejacketonthepatient
- Assumethatthepatientdoesn’tneedthatcoatandcontinuethewalk
- Cancel the walk and reschedule for another time.
- Remindthepatientbytellinghimtoputhisjacketonagain.
*Patient seemingly confused state describes a classic example of apraxia, the inability to perform a previously learned task. Apraxia is a common finding of AD.
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A reminder would not lead the patient to put on the jacket as he has forgotten how to complete the task at hand.
4. (25)Youareexamininganinfantwithred-brownvesiculopapularlesionsand curved burrows on the head, neck, palms and soles. The infant appears to have sensations of intense itching. Which of the following dermatologic conditions is the most likely cause of the infant’s findings?
- Scabies
- Molluscumcontagiosum
- Atopic dermatitis
- Varicellazoster
*Unlike scabies in adults, infants patient do not present with lesions on the skin folds. The presence of curved burrows help to distinguish scabies from varicella zoster virus. (p. 102) Scabies is highly contagious skin infestation caused by parasitic mite that burrows into stratum corneum. Spread through the direct or indirect contact with personal item. S/S: intense itching, irritability in infants, linear curved burrows.
Infants—red-brown vesiculopapular lesions on head, neck, palms, or soles. Older children—red papules on skin folds, umbilicus, or abdomen (hand between fingers).
5. (28)YouhavebeenassistingapatientwithAIDSoverthepastyear.What medication does an AIDS patient usually take daily for Pneumocystis jirovecii pneumonia prophylaxis?
a. PenicillinG
b. Trimethropin-sulfamethoxazole c. Valacyclovir
d. Azithromycin
*Bactrim for Pneumocystis jirovecii pneumonia prophylaxis (p. 238).
6. (29)Susan,a47-year-oldfemale,presentswithbluesclera,atriangularface, and complaints of a loss of hearing. Based on these manifestations, which of the following genetic disorders would you attribute to Susan?
a. Osteogenesisimperfect b. Valgumsyndrome
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c. Rhett syndrome
d. Femoralretroversionbilaterally
*Osteogenesis imperfect type I characteristic include: bone that fracture easily, predisposing family history; near normal or slightly shorter stature, blue sclera, dental problems, triangular face, tendency toward spinal curvatures, hearing loss beginning in early 20-30s; most fractures occur before puberty.
Rhett syndrome characterized by reversals in expressive language and hand movement and the patient would have experienced symptoms very early in childhood.
7. (30)Youspecializeincaringfortheelderlyandareconcernedaboutarecent spike of suicide in the elderly community. What are the two major reasons that the elderly commit suicide?
- Dementiaandovermedication
- Medicaldisabilityandloneliness
- Poor support system and future uncertain
- Financialinstabilityandlacktoaccesscare.
*Statistic show that in the elderly loneliness and medical disability are the two major reasons for suicide.
8. (32)Youaremonitoringatoddlerwhohasserousotitismedia.Theparents want to understand the treatment their child will receive. Which of the following would be the most appropriate way to manage this condition?
a. Antihistamines
b. Monitorandre-evaluateinthreemonths
c. Decongestants
d. Oralantibiotics
*Oral antibiotics are not typically used to treat serous otitis media since this condition does not have a bacterial pathology a majority of the time. (p. 113) Management: watchful monitoring for three months; antibiotic therapy no long- term efficacy, antihistamines/decongestants ineffective. Re-evaluate in three to six months.
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9. (33)A24-year-oldpatientpresentstoyourofficewithcomplaintsoffatigue, headaches, and a recent onset of a very pale complexion. Upon examination, you note her tongue appears very smooth and has absence of papillae. When you question the patient about her diet, she tells you that she frequently skips meals and tends to eat fast food on the times when she does eat. What is the most likely diagnosis?
- Perniciousanemia
- Sicklecellanemia
- Folic acid deficiency
- Anemiaofchronicdisease
*Folic acid deficiency is caused by an inadequate intake/malabsorption of folic acid. Patient seemingly anorexic eating habits and symptoms most indicate this condition. Pernicious anemia also causes glossitis, however, the patients dietary habits indicate folic acid deficiency. (p.270)
10. (35) A 45-year-old goat farmer presents with an unusual lesion on his left arm. He explains that the lesion started out as a harmless, painless, itchy blister, but has since turned into a large, black scab surrounded by lots of swelling. An exam also reveals purulent discharge. You order a skin culture. Of the following, what is the most likely diagnosis?
a. Seborrheickeratosis b. Malignantmelanoma c. Cutaneous anthrax d. Smallpox
*Farmer are especially at risk of exposure to infection since farm animals, such as goats, can be infected with anthrax. (p. 218) S/S: Cutaneous (most common, 95% of cases); occurs on exposed areas on the arms and hands, followed by face and neck, pruritic papule leading to ulcer surround by vesicles, develops into black necrotic central eschar with edema, after 1-2 weeks, eschar dries, loosens, separates, leaving a permanent scar, regional lymphadenopathy. Lab: gram stain of specimen. Tx. Vaccine for those at risk. Antibiotics: penicillin, Ciprofloxacin, Doxycycline. Report to health department.
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11. (37) A nurse practitioner in a family practice clinic is examining a 40-year-old patient who has recently gained 15 pounds. The patient is concerned that her diaphragm, otherwise known as a cervical cap will not be as effective because of her weight gain. Which of the following indicates the minimum weight gain thresh hold for when women would most likely need to see their healthcare provider about refitting their diaphragm?
- Onetofivepounds
- Thentotwentypounds
- Twenty to thirty pounds
- Fivetotenpounds.
*Diaphragm users should see their healthcare provider when they have gained 10-20 lbs. Also regularly check their device for holes and refrain from using oil- based lubricants.
12. (38) You are performing a quad screen on a pregnant patient. Which component of the screen is most telling in detecting Down syndrome?
a. Alpha-fetoprotein
b. Humanchononicgonadotropin c. Estriol
d. Amnioticfluid
*Lower than normal AFP levels usually indicate a higher chance of Down syndrome.
13.(39) Scientist do not yet fully understand what causes Alzheimer’s disease, but it is clear that this disease develops because of a complex series of events in the brain over a long period of time. The likely causes of Alzheimer’s includes genetic, environmental, and lifestyle factors. One theoretical cause is an improper balance and function of neurotransmitters in the brain. Which of the following conditions is considered a causal factor of this aspect?
- Acetylcholinedeficiency
- Serotoingexcess
- Dopamine deficiency
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d. Excessivenorepinephrine
*Acetylcholine deficiency is a leading theory, important for memory and thinking. (p. 281)
14. (40) The parents of a 1-year-old patient presents to you with concerns regarding their daughter’s health. At birth, they were told that their daughter had abnormal facial features and decreased muscle tone. They hoped their daughter would “grow out” of some of these defects but, to their disappointment, she has not. They report that their daughter is having trouble walking and sitting up by herself. Furthermore, they state that no matter how much they feed their baby, she is always crying out for more food and, as a result, has been rapidly gaining weight. You suspect a chromosomal condition which of the following would be most likely?
- Prader-Willisyndrome
- DiGeorgesyndrome
- Hurder syndrome
- Downsyndrome
*Prader-Willi syndrome: constant craving for food and rapid weight gain. A rare inherited condition marked by genetic obesity, mental retardation, inadequate growth hormone secretion, short stature, sexual infantilism, and hypotonia. Abnormal chromosome 15. (p. 58)
DiGeorge syndrome explain developmental delays and poor muscle tone, usually have feeding difficulties and results in weight loss.
15. (41) An 8-year-old girl tells you that she has cancer because God is punishing her for “being bad.” She shares her concern that if she dies, she will go to hell. You should interpret this as a being which of the following?
- Acommonbeliefatherage
- Abeliefthatformsthebasisforherreligion
- Suggestive of a sociopathic tendency
- n/a
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*Many children feel that a serious disease is punishment for their behavior. Attributing their disease to divine punishment is a common coping mechanism.
16. (43) A 47-year-old smoker presents with a low-grade fever and cough. While taking his medical history, you learn he has been smoking one pack per day for the last 20 years. The patient’s completed blood count indicates increased hematocrit and you suspect chronic bronchitis. Which of the following would help to confirm diagnosis?
- Excessivebronchialmucussecretionw/coughforatleastfivemonth or more in at least two consecutive years.
- Excessivebronchialmucussecretionwithcoughforatleast6moths for at least two years.
- Excessive bronchial mucus secretion with cough for at least 3 months in at least two consecutive years.
- Low,flatteneddiaphragmbyCXR.
*Chronic bronchitis is characterized by excessive secretion of bronchial mucus and is manifested by a productive cough for 3 months or more in at least 2 consecutive years. Although a low flattened diaphragm is supportive of the diagnosis, it is not in and of itself diagnostic of this condition. (p.305)
17. (44) After insistence from his girlfriend, 18-year-old Tim is seeing you regarding persistent headaches that have occurred since high school. While interviewing Tim, who is overweight, you learn that his symptoms have a slow onset and sometimes he sees stars when the symptoms are at their worst. He also reports that his headaches, which usually occur during the afternoon, can last for up to several hours. Which of the following is the most likely diagnosis?
- HeadachesduetosevereHTN
- Tensionheadache
- Cluster headache
- Migraineheadache
*Patient descriptions of symptoms, visual disturbance duration, and insidious onset indicate migraine. Cluster headache usually last less than 2 hours.
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Migraine headaches—typically lasts 2-72 hours following the trigeminal nerve pathway; onset usually in adolescence or early adult years.
18. (52) A 6-year-old female comes to the clinic with “cold symptoms,” including a low-grade fever and cough. Her gym teacher sent her home the day before because she was experiencing dyspnea and stridor. Her lungs, however, are clear on auscultation. Which of the following is the most likely diagnosis?
a. Epiglottitis
b. Croup
c. Common cold
d. GroupAbeta-hemolyticstreptococcalinfection
*Clear lungs despite several other respiratory symptoms are indicative of croup. Group A beta-hemolytic streptococcal infections do not present with cough. Epiglottitis symptoms include a high fever and drooling.
(p. 117) S/S: recent symptoms of an upper respiratory infection, bark-like cough, low grade fever, vital signs consistent with infection, dyspnea, stridor if severe, lungs typically clear. X-ray: appearance of a “steeple” –shaped narrowing of the trachea.
19. (53) A young married couple comes to your office inquiring about birth control methods. They have both had bad experiences with past methods and ask you about natural family planning. Which of the following statements should you include in the management guidelines for this contraceptive treatment?
a. Forthecalendarmethodofplanning18daysissubtractedfromthe shortest cycle and 11 days from the longest cycle to determine the abstinence period.
*According to the BBT, a woman’s fertility can be gauged according to her body temperature, which drops 12-24 hours prior to ovulation. The calendar method is a way to determine a woman’s fertility by subtracting 18 days from the shortest cycle and 11 days from the longest cycle. (p. 185)
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20. (56) A 59-year-old male is having a follow-up evaluation two years after the successful conclusion of radiation therapy for leukemia. He tells you that he has been feeling run-down and reports unexplained weight loss and night sweats. Upon examination, you determine that he also has a fever and pain below his ribs on the left side. You know that he is at risk for chronic lymphocytic leukemia. Which of the following results is considered the hallmark of this disease?
- Philadelphiachromosomeinleukemiccell
- Lymphocytosis
- Non-circulating blast cell in bone marrow
- Pancytopeniawithcirculatingblasts
*Lymphocytosis is the hallmark of chronic lymphocytic leukemia, most common chronic leukemia in adults.
21. (62) A 23-year old foreign exchange student enters your emergency facility because she is concerned about her medroxyprogesterone injection (Depo- Provera) status. The student mentions that she has not visited a nurse practitioner since she has come to the U.S. over two months ago and is worried that she might need another injection soon. Which of the following is a proper response?
- Depo-Proverainjectioncontraceptiontreatmentrequiresaninjection every three months with a two-week grace period
- Requiredonceayearwithtwo-weekgraceperiod
- Should get injection every six months
- Requiremonthlywithone-weekgraceperiod.
*Popular due to its relatively long lasting effect and ease to use; Every 3 months with two-week grace period. Disadvantages: include menstrual irregularities and delayed return of fertility (up to 1 year) and injection every three months. (p. 178) Prolonged amenorrhea possible w/ concomitant effects (decrease anemia, cramps, ovulatory pain); useful in reducing pain associated with endometriosis, no estrogen related side effects.
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22. (66) A 19-year-old college student complains of a fluid-filled vesicle on her thigh that appeared shortly after returning from vacation. She also complains of a fever. She believes that it is a spider bite. Upon assessment, you strongly suspect community associated methicillin-resistant Staphylococcus aureus (MRSA). Which of the following would be the best drug to order after incision and drainage?
a. Metronidazole b. Amoxicillin
c. Azithromycin d. Clindamycin
*The major drugs used to treat outpatient MRSA, a beta-lactamase producing bacteria, includes: clindamycin, co-trimaxazole and doxycycline/minocycline. Metronidazole treats CDiff. (p. 211)
(Clinda came with MARSA, give clindamycin )
23.(67) Which of these medication regimens should be prescribed to control symptoms in an asthmatic 6-year-old patient who is awakened not more three times per week?
- High-doseinhaledcorticosteroidandlong-actinginhaledbetaagonist
- Low-mediumdoseinhaledcorticosteroidandlong-actinginhaledbeta agonist
- Low dose inhaled corticosteroid and short-acting bronchodialator.
- Mediumdoseinhaledcorticosteroidandshort-actingbronchodialator
*Treatment for moderate persistent asthma includes low-medium dose inhaled corticosteroids and long-acting beta-2 agonists. (p. 305)
24. (71) You have a 2-year-old patient who has an upper respiratory infection. Findings include a fever of 102F and signs of respiratory distress, including nasal flaring, grunting, and prolonged expiration. A physical exam indicates a palpable liver and spleen. You would most expect to see which of the following if the patient’s signs and symptoms are the result of a condition that could have caused all these?
- Productivecough
- Chestx-raywithhyperinflatedlungs
- Peak flow less than 60L/min
- SlightWBCelevationwitheosinophilia
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*Chest x-ray with hyperinflated lungs would be the most likely findings, as the patient signs and symptoms most indicate bronchiolitis, especially the palpable liver and spleen. (p. 122)
25.(72) Mr. Whitmore, a 74-year-old former professional athlete, is being screened for hypertension, a condition which runs in his family. He wants to know what symptoms he may experience. You tell that although hypertension is frequently asymptomatic, symptoms that are present typically include all of the following except:
- Blurredvision
- Morningsubparietalheadaches
- S4 heart sound
- Epistaxis
*Suboccipital, no subparietal headache is common hypertensive presentation in the morning.
26. (73) Assessing proteinuria in a pregnant patient can help to specifically determine the earliest presentation of which condition?
- HELLP
- Eclampsia
- Pregnancy induced hypertension
- Pre-eclampsia
*Proteinuria is an indicator of pre-eclampsia. Pre-eclampsia is a hypertensive pregnancy disorder that involves pregnancy-induced hypertension, plus proteinuria and generalized edema after 20 weeks gestation. (p. 191)
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27. (79) A mother brings her 3-month-old baby to your clinic to screen for failure to thrive (FTT). Which of the following is not a sign or symptom that would cause you to associate the infant with FTT?
- Absolute length/width are between 5th percentile
- Commonlycriesformorefoodormilk
- Avoid eye contact
- Weigh falling greater than 2nd percent below standard
*All of the criteria listed for FTT are accurate except for commonly crying for more food or milk. In fact, a decrease of food intake is a common sign.
28. (81) A 52-year-old woman comes to your office horrified by the lesions on her face. The lesions are smooth, rounded, firm, and flesh-colored, pearly-white papules that are 1 to 5 millimeters in size. She is not experiencing pain and tells you that she has recently been diagnosed with gonorrhea; however, you believe this to be a case of another kind of sexually transmitted disease. Which of the following is most likely?
- Molluscumcontagiousum
- Secondarysyphilis
- Condyloma acuminate
- Lymphogranulomavenerum
*A common, benign viral skin infection; frequently these lesions disappear on their own in a few weeks to a few months and are not easily treated. Diagnostic criteria include: pruritus, the presence of very small, firm, pink to flesh-colored discrete papules, which become umbilicated papules with a cheesy core. (p.97)
29. (83) You have used the Dubowitz tool to estimate the gestational age of a Caucasian newborn at 44 weeks. Which best describes the physical maturity of the newborn?
- Amoderateflexionofhipandknees
- Leathery,crackedandwrinkledskin
- Anterior transverse crease only
- Flatareolawithnobud
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*For a gestational age estimate of 44 weeks an infant would need the maximum possible score in every criterion in the Dubowitz Ballard exam, which includes leathery, cracked and wrinkled skin.
30.(86) Over the course of a month, you have evaluated a number of middle to late-age patients. Of the following visitors, which is most at risk for developing osteoporosis?
- A62-year-oldAfricanAmericanfemalewithhypertension
- A55-year-oldAsianmalewhosmoke2packperday
- A 58-year-old male alcoholic
- A47-year-oldCaucasianfemalewithearlymenopause
*While alcohol and smoking are causes of osteoporosis, early menopause is a leading cause of osteoporosis.
31.(91) In addition to infection by Helicobacter pylori (H. pylori), peptic ulcers may also arise from regular use of certain medications and other conditions. In which of the following populations of patient is prophylactic therapy not indicated for ulcers induced by non-steroidal anti-inflammatory drugs (NSAIDs)?
- Thosewithhistoryofgastrointestinalulcers
- ThosetakingmoderatedNSAIDs
- Those taking potent anti-hypertensive
- Thosetakinganticholinergic
*The use of potent anti-hypertensives has not been linked to non-steroidal anti- inflammatory drugs (NSAIDs)-induced ulcer formation. Among the strategies used to decrease the risk of ulcer developments are: the use of analgesics other than NSAIDs; the use of the lowest possible dosage of NSAID; the use of a COX-2 selective NSAIDs; the use of low doses of corticosteroids instead of NSAIDs; and lastly, avoiding concomitant use of NSAIDs and corticosteroids. Corticosteroids frequently cause gastrointestinal symptoms and may lead to ulcer development.
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32. (96) A young man presents to the emergency room with overall weakness. The patient states that he was riding his bicycle when the weakness occurred and worries that it may be a severe asthma attack. While taking his medical history, you learn he has a history of asthma, but has not had an attack several years prior to today. Which of the following is not an expected ominous finding in this man when having an asthma attack?
- Inabilitytoremainrecumbent
- Dullnesstopercussion
- Chest tightness
- Diaphoresistotouch
*A dull sound to percussion indicated the presence of a non-ominous solid mass under the surface; a more resonant sound indicates hollow, air-containing structures. Diaphoresis, inability to stay lying down, and chest tightness are all ominous signs of asthma.
33.(97) James, 28, presents with what he thinks is an asthma attack and tightness in his chest. While taking his medical history, you learn he has a history of severe asthma attacks. Which arterial blood gas abnormality would you initially expect to see in James during this asthma attack?
- Metabolicacidosis
- Respiratoryacidosis
- Metabolic alkalosis
- Respiratoryalkalosis
*Respiratory alkalosis often occurs during asthma attack; as a result of hyperventilation, which elevates the blood ph.
