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71 Cards in this Set

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

A. abdominal mass
B. hypertension
C. chest pain
D. syncope
(c) A. Symptomatic abdominal aortic aneurysm presents with pulsating upper abdominal mass.
(u) B. Hypertension is not suggestive of symptomatic abdominal aortic aneurysm.
(u) C. Abdominal aortic aneurysm presents with midabdominal or lower back pain.
(u) D. Syncope is not common in abdominal aortic aneurysm, unless it ruptures.
4. 1. HISTORY/PHYSICAL
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.
(u) A. See B for explanation.
(c) B. Dressler's syndrome is the occurrence of pericarditis and pleuritis several days to weeks following an MI.
(u) C. Pericardial tamponade may result from severe pericardial effusion or hemorrhage into the
pericardium, but it is not typically associated with Dressler's syndrome.
(u) D. Dressler's syndrome is post-MI pericardial inflammation, not pleural effusion or rash.
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
(u) A. Erythema infectiosum presents with a "slapped cheek" appearance.
(c) 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.
(u) C. Koplik's spots are noted in rubeola.
(u) D. Honey-crusted lesions are noted in impetigo.
In myxedema, the patient commonly complains of which of the following?

A. tremors
B. palpitation
C. cold intolerance
D. eructation
(u) A. Tremors and palpations are associated with hyperthyroidism.
(u) B. See A for explanation.
(c) C. Myxedema is the result of hypothyroidism. Cold intolerance is associated with hyopthyroidism
along with constipation and fatigue.
(u) D. Eructation is associated with indigestion and not hypothyroidism.
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
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) 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.
(u) D. See C for explanation.
Which of the following is most commonly seen in viral croup?

A. drooling
B. wheezing
C. sputum production
D. inspiratory stridor
(u) A. Drooling is common in epiglottitis not viral croup.
(u) B Wheezing is noted in asthma.
(u) C. Sputum production is not a feature of viral croup.
(c) 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
(u) A. The optic nerve affects vision, but has no control over eye movement.
(u) B. The oculomotor nerve affects pupillary constriction and movement of eye medial, upward, and
downward lateral.
(u) C. The trochlear nerve affects downward, inward movement of the eye.
(c) 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.
(c) 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.
(u) B. See A for explanation.
(u) C. By having the patient get into a knee-chest position, fluid would pool into the abdomen by gravity.
This is the Puddle's sign.
(u) D. Having the patient sit upright and palpating the left costal vertebral angle would assess for kidney
tenderness.
Which of the following is a finding in vitamin A deficiency?

A. decreased proprioception
B. night blindness
C. hair loss
D. bleeding
(u) A. Decreased proprioception is noted in vitamin E deficiency.
(c) B. Night blindness is the earliest symptom of vitamin A deficiency.
(u) C. Hair loss is noted in vitamin A toxicity.
(u) D. Bleeding is noted in vitamin K 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.
(u) A. Staphylococcal food poisoning has a short incubation period of 1-8 hours.
(u) B. See C for explanation.
(c) C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with
Staphylococcal food poisoning.
(u) D. Staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature.
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.
(c) A. Von Willenbrand's disease most commonly presents with mucosal bleeding such as epistaxis,
gingival bleeding, and menorrhagia.
(a) B. Splenic bleeding is typically associated with trauma.
(u) C. Hemophilia is associated with bleeding into joint spaces, especially knees, ankles, and elbows,
and into muscle groups.
(u) D. See C for explanation.
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
(u) A. Splenomegaly and hepatomegaly are typically seen in hemolytic anemias.
(u) B. Petechiae and ecchymosis are seen in thrombocytopenia.
(c) C. Loss of position and vibratory sensation are common neurologic findings in pernicious anemia.
(u) D. Cheilosis and koilonychia are seen in iron deficiency 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
(u) A. A change in personality is a late finding of Alzheimer's disease.
(c) B. The presence of memory impairment is the most common sign of Alzheimer's disease. Changes
occur first with short-term memory.
(u) C. The history of multiple physical complaints is seen most commonly in somatization disorders.
(u) D. A depressed mood is the most common presenting feature in depression or dysthymic disorders.
The most frequent finding in a person presenting with a brain abscess is

A. nuchal rigidity.
B. headache.
C. seizures.
D. vomiting.
(u) A. Nuchal rigidity occurs in approximately 35% of patients with a brain abscess.
(c) B. Headache occurs in over 70% of patients with a brain abscess.
(u) C. Seizures occur in approximately 35% of patients with a brain abscess.
(u) D. Vomiting occurs in approximately 35% 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
(c) A. The most common findings in polycystic ovarian syndrome are infertility, menstrual irregularities,
obesity, and hirsutism.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
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
(c) A. Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd)
discharge that is malodorous.
(u) B. A firm painless ulcer is seen in syphilis.
(u) C. Tender lymphadenopathy is associated with bacterial infections and is not a feature of candidal
vulvovaginitis.
(u) D. Purulent discharge is noted in gonorrhea.
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.
(u) A. Bicipital tendinitis is associated with pain along the proximal humeral groove and a positive
Yergason's sign.
(u) B. See A for explanation.
(u) C. Kanavel's sign is associated with flexor tenosynovitis.
(c) 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
(u) A. Hypesthesia of the medial thigh is consistent with a herniated disk at L3-L4.
(u) B. Upgoing Babinski reflex would indicate upper motor neuron disease.
(c) 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.
(u) D. Decreased sensation in the groin region is consistent with a herniated disk at L2-L3.
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.
(c) 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.
(u) B. Infrequent blinking, tremor, rigidity, and bradykinesia are characteristic of Parkinsonism.
(u) C. Although part of the differential for involuntary movements, this disease has a positive family
history and usually appears by age 50.
(u) D. Facial motor tics are the most common manifestation of this disorder, but symptoms begin before
age 21.
Typical symptoms of depression include which of the following?

A. auditory hallucinations
B. panic attacks
C. multiple somatic complaints
D. narcissism
(u) A. Auditory hallucinations are commonly seen in schizophrenia disorders.
(u) B. Panic attacks are noted in anxiety disorders.
(c) C. Depressed patients often focus on their bodies and tend to have multiple complaints.
(u) D. Narcissism is associated with personality disorders not depression.
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
(u) A. Biot's breathing, also known as ataxic breathing, is characterized by unpredictable irregularity.
(u) B. Cheyne-Stokes breathing is characterized by periods of deep breathing alternating with periods of
apnea. This is caused by heart failure, uremia, drug-induced respiratory depression, and brain damage.
(c) C. Kussmaul breathing is deep breathing, and in this case, is a compensatory mechanism for
metabolic acidosis.
(u) D. Obstructive breathing is seen in patients with COPD.
Paradoxical motion of the chest wall occurs in which of the following?

A. barrel chest
B. flail chest
C. funnel chest
D. pigeon chest
(u) A. A barrel chest has an increased anteroposterior diameter.
(c) 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.
(u) C. A funnel chest is characterized by a depression in the lower portion of the sternum. Compression
of the heart and great vessels may cause murmurs.
(u) D. In a pigeon chest, the sternum is displaced anteriorly, increasing the anteroposterior diameter.
The costal cartilages adjacent to the protruding sternum are depressed.
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
(u) A. Inflammation of the glands of the penis is noted in balanitis.
(u) B. A foreskin that cannot be retracted is seen in phimosis.
(u) C. A chancre on the shaft of the penis is noted in primary syphilis.
(c) 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
(u) A. Renal cell cancer may present with hypercalcemia.
(u) B. See D for explanation.
(u) C. Renal cell cancer may present with polycythemia, not anemia.
(c) 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 conditions would cause a positive Kussmaul's sign on physical examination?

A. Left ventricular failure
B. Pulmonary edema
C. Coarctation of the aorta
D. Constrictive pericarditis
(u) 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.
(u) B. Pulmonary edema primarily results in increased pulmonary pressures rather than having effects on the venous inflow into the heart.
(u) 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.
(c) 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.
Anginal chest pain is most commonly described as which of the following?

A. Pain changing with position or respiration
B. A sensation of discomfort
C. Tearing pain radiating to the back
D. Pain lasting for several hours
(u) A. Pain changing with position or respiration is suggestive of pericarditis.
(c) B. Myocardial ischemia is often experienced as a sensation of discomfort lasting 5-15 minutes,
described as dull, aching or pressure.
(u) C. Tearing pain with radiation to the back represents aortic dissection.
(u) D. Chest pain lasting for several hours is more suggestive for myocardial infarction.
Eliciting a history from a patient presenting with dyspnea due to early heart failure, the severity of the dyspnea should be quantified by

A. amount of activity that precipitates it.
B. how many pillows they sleep on at night.
C. how long it takes the dyspnea to resolve.
D. any associated comorbidities.
(c) A. The amount of activity that precipitates dyspnea should be quantified in the history.
(u) B. Orthopnea or paroxysmal nocturnal dyspnea can be quantified by how many pillows a
patient needs to sleep on to be comfortable.
(u) C. How long dyspnea takes to resolve or associated comorbidities has no bearing on
quantifying the severity of dyspnea.
(u) D. See answer C above.
A 25 year-old female presents with a three-day history of chest pain aggravated by
coughing and relieved by sitting. She is febrile and a CBC with differential reveals
leukocytosis. Which of the following physical exam signs is characteristic of her problem?

A. Pulsus paradoxus
B. Localized crackles
C. Pericardial friction rub
D. Wheezing
(u) A. Pulsus paradoxus is a classic finding for cardiac tamponade.
(u) B. Localized crackles are associated with pneumonia and consolidation, not pericarditis.
(c) C. Pericardial friction rub is characteristic of an inflammatory pericarditis.
(u) D. Wheezing is characteristic for pulmonary disorders, such as asthma.
A 65 year-old white female presents with dilated, tortuous veins on the medial aspect of
her lower extremities. Which of the following would be the most common initial
complaint?

A. Pain in the calf with ambulation
B. Dull, aching heaviness brought on by periods of standing
C. Brownish pigmentation above the ankle
D. Edema in the lower extremities
(u) A. Patients with deep venous thrombosis (DVT) may present with complaints of pain in the
calf with ambulation. Secondary varicosities may result from DVT's.
10
(c) B. Dull, aching heaviness or a feeling of fatigue brought on by periods of standing is the most
common complaint of patients presenting initially with varicosities.
(u) C. Stasis Dermatitis and edema are most suggestive of chronic venous insufficiency.
(u) D. See C for explanation.
A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of
pericardial tamponade is strongly supported by the presence of

A. pulmonary edema.
B. wide pulse pressure.
C. distended neck veins.
D. an early diastolic murmur.
(u) A. Pulmonary edema may result with low output states as seen with myocardial contusions, but it is not strongly suggestive of tamponade.
(u) B. Wide pulse pressure is seen in conditions of high stroke volume such as aortic insufficiency or hyperthyroidism. Narrow pulse pressure is seen with cardiac tamponade.
(c) C. Cardiac compression will manifest with distended neck veins and cold clammy skin.
(u) D. The onset of diastolic murmur is suggestive of valvular disease, not tamponade.
A patient presents with a rash, characterized by red macules and edematous papules with
a clearing center. This best describes which of the following?

A. erythema marginatum
B. erythema multiforme
C. varicella
D. impetigo
(u) A. Erythema marginatum is associated with rheumatic fever and is characterized by macular to maculopapular lesions. A clearing center is not found in the rash.
(c) B. Target lesions, also termed iris lesions, are characteristic of erythema multiforme. The rash
may be recurrent but typically resolves over 3-6 weeks.
(u) C. The rash of varicella typically has maculopapules, vesicles, and scabs in various stages of development. A clearing center is not found in the rash.
(u) D. The lesions of impetigo are pustules that form a honey-colored crust after rupturing.
In a patient suspected of having seborrheic dermatitis, the most common site of
involvement would be the

A. upper extremities.
B. thighs.
C. scalp.
D. feet.
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The most common site of involvement of seborrheic dermatitis is the scalp. Other common
sites include the eyebrows, eyelids, nasolabial fold, and ears.
(u) D. See C for explanation.
A 26-year-old obese female complains of a 3-4 month history of discrete erythematous plaques on the pretibial areas of her legs. The lesions have increased in size, become darker, and are painful. She is concerned because the centers of the lesions have become ulcerated. This patient should be screened for which of the following?

A. Hypothyroidism
B. Diabetes mellitus
C. Melanoma
D. Scleroderma
(u) A. In hypothyroidism the skin of the pretibial area may thicken leading to edema. This is a diffuse finding, involving the face and eyelids, without discrete lesions.
(c) B. The description of the skin lesions is characteristic of necrobiosis lipoidica diabeticorum, one of the dermatologic manifestations of diabetes mellitus.
(u) C. The lesions of melanoma are typically not painful and do not ulcerate.
(u) D. Scleroderma is marked by thickening of the skin, with swelling of the fingers and hands.
The swelling may involve the forearms and face; the lower extremities are relatively spared.
A 40 year-old male presents to your clinic complaining of nontender, yellow patches on
both eyelids. He states his brother and uncle have similar growths. He denies any visual
changes or other complaints. Your primary suspicion is

A. gout.
B. lipoma.
C. hyperlipidemia.
D. seborrheic dermatitis.
(u) A. Tophaceous gout may appear as yellow skin lesions but they usually occur around the joints and helix of the ear.
(u) B. Lipomas tend to be flesh-colored and are not usually bilateral.
(c) C. Xanthelasmas, along with xanthomas, are common findings in familial
hypercholesterolemia.
(u) D. Eyelids are a common location for seborrheic dermatitis but the lesions are not yellow in color.
A 4 year-old child presents with a rapid onset of high fever and extremely sore throat. Which of the following findings are suggestive of the diagnosis of epiglottitis?

A. Croupy cough and drooling
B. Thick gray, adherent exudate
C. Beefy red uvula, palatal petechiae, white exudate
D. Inflammation and medial protrusion of one tonsil
(c) A. A croupy cough with drooling in a patient who appears very ill is consistent with epiglottitis. Examining the throat is contraindicated, unless the airway can be maintained.
(u) B. Thick gray adherent exudate is suggestive of diphtheria.
(u) C. Beefy red uvula, palatal petechiae, and white exudate are findings suggestive of
streptococcal pharyngitis.
(u) D. Inflammation with medial protrusion of the tonsil is suggestive of a peritonsillar abscess.
Which of the following are normal findings in a Weber test?

A. The tympanic membrane is movable with pneumatic otoscopy.
B. The tympanic membrane is pearly gray with a sharp cone of light with apex at the umbo.
C. Sound is heard equally in both ears when a vibrating tuning fork is placed on the mid forehead.
D. Air conduction is greater than bone conduction when a vibrating tuning fork is moved from the mastoid bone to close to the ear canal.
(u) A. A movable tympanic membrane indicates there is no effusion, and is not the Weber test.
(u) B. The tympanic membrane is evaluated by direct observation with an otoscope, and is not
the Weber test.
(c) C. A normal Weber test means there is no lateralization of sound perception when a vibrating
tuning fork is placed on the mid forehead.
(u) D. A normal Rinne test means that tuning fork vibration is heard longer through the air than
the bone.
Which of the following is diagnosed by use of the cover/uncover test?

A. Adie’s pupil
B. Strabismus
C. Glaucoma
D. Myopia
(u) A. Adie’s pupil is a sluggish pupil reaction to light and accommodation, evaluated by papillary
reaction to light.
(c) B. The cover/uncover test is used to diagnose strabismus.
(u) C. Tonometry is used to measure intraocular pressure to evaluate for glaucoma.
(u) D. Myopia is evaluated by using a Snellen chart.
A patient is known to have end stage liver disease due to cirrhosis. Which of the following physical examination findings would commonly be seen in this patient?

A. Testicular hypertrophy
B. Muscular pseudohypertrophy
C. Gynecomastia
D. Hepatomegaly
(u) A. Testicular atrophy, wasting of the muscles of the lower extremity, spider angiomas, caput
medusa and gynecomastia are physical examination findings associated with end stage liver disease associated due to cirrhosis.
(u) B. Muscular pseudohypertrophy is seen in muscular dystrophy.
(c) C. See A for explanation.
(u) D. Patients with end stage liver failure who have cirrhosis have a small shrunken liver from the ongoing cellular destruction and fibrosis.
Which of the following is the most consistent physical examination finding in a patient with duodenal ulcer?

A. Flank tenderness
B. Right upper quadrant tenderness
C. Epigastric tenderness
D. Rebound tenderness
(u) A. Flank tenderness is caused by urologic disorders such as pyelonephritis and renal lithiasis.
(u) B. Right upper quadrant tenderness on palpation is a typical feature for cholecystitis.
(c) C. Epigastric tenderness is a key feature of duodenal ulcer.
(u) D. Rebound tenderness is a feature of peritonitis from rupture of a hollow viscus and is not seen with just the presence of duodenal ulcer.
The initial sign or symptom of iron poisoning in a 3 year-old child is usually

A. vomiting and bloody diarrhea.
B. convulsions and tetany.
C. somnolence and coma.
D. ataxia and colicky abdominal pain.
(c) A. Iron causes localized necrosis and hemorrhage at the point of contact in the GI system resulting in abdominal pain, vomiting, bloody diarrhea, and hematemesis.
(u) B. Convulsions and tetany are symptoms of hypocalcemia.
(u) C. Somnolence and coma are not initial findings in iron ingestion.
(u) D. Ataxia and colicky abdominal pain are consistent with lead poisoning.
A classic skin finding seen in patients with inflammatory bowel disease would be

A. erythematous plaques on the extremities.
B. poorly healing, indolent ulcers on the lower extremities.
C. pretibial myxedema.
D. purple striae.
(u) A. Granuloma annulare is seen with diabetes mellitus. It consists of erythematous plaques on the extremities or trunk.
(c) B. Pyoderma gangrenosum is classically seen with inflammatory bowel disease and is rarely seen in the absence of inflammatory bowel disease.
(u) C. Pretibial myxedema is the skin manifestation of hyperthyroidism.
(u) D. The dermatologic manifestations of Cushing's disease are purple striae and a supraclavicular fat pad.
A 55-year-old non-smoking male presents with a hemoglobin of 18.5 g/dl and a hematocrit of 56%. Which of the following physical examination findings is the most likely to be noted with this patient?

A. Splenomegaly
B. Cheilosis
C. Purpura
D. Decreased vibratory sense
(c) A. Patients with polycythemia vera present with elevated hemoglobin and hematocrit. On physical examination plethora, engorged retinal veins, and splenomegaly are common.
(u) B. Cheilosis is noted in iron deficiency anemia.
(u) C. Purpura is typically noted in bleeding disorders.
(u) D. Decreased vibratory sense is noted in vitamin B12 deficiency.
A 73 year-old male presents to the clinic with his wife. His wife has noticed that he has
developed a resting tremor in his right hand and a shuffling gait over the last year. What
finding on physical examination would support your suspected diagnosis?

A. Chorea
B. Dystonia
C. Masked facies
D. Hyperreflexia
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The patient symptoms are consistent with Parkinsonism. Physical exam findings include masked facies, micrographia, decreased arm swing, and monotonous speech.
(u) D. See C for explanation.
A patient with an upper motor neuron lesion would exhibit which of the following
findings?

A. Fasciculations
B. Areflexia
C. Muscular atrophy
D. Spasticity
(u) A. Fasciculations, areflexia and muscle atrophy are consistent with lower motor neuron lesions.
(u) B. See A for explanations.
(u) C. See A for explanation.
(c) D. Spasticity is an upper motor neuron lesion finding.
A 12 year-old female presents for a routine sports physical. The physical exam reveals
asymmetry of the posterior chest wall on forward bending. This is the most striking and
consistent abnormality of which of the following?

A. Spondylolysis
B. Spondolisthesis
C. Scoliosis
D. Herniated disc
(u) A. Spondylolysis presents with limitation of lumbar flexibility and tight hamstring muscles.
(u) B. Spondylolisthesis presents with reduced lumbar lordosis and sacral kyphosis.
(c) C. Asymmetry of the posterior chest wall on forward bending is the most striking and consistent abnormality in patients with idiopathic scoliosis.
(u) D. Herniated disc presents with lumbar muscle spasm and a positive straight leg test.
Physical exam findings in a 4 year-old child that include blue sclerae and recurrent
fractures indicates which of the following?

A. Ehlers-Danlos syndrome
B. Marfan syndrome
C. Achondroplasia
D. Osteogenesis imperfecta
(u) A. Physical exam findings in Ehlers-Danlos include laxity and hypermobility of joints, mitral valve prolapse, and associated degenerative arthritis.
(u) B. Children with Marfan syndrome have hypotonia, arachnodactyly, joint laxity and
dislocations.
(u) C. Children with achondroplasia are below normal standards on growth charts. They have difficulty balancing their large heads when beginning to walk.
(c) D. Mild osteogenesis imperfecta presents with blue sclerae, history of recurrent fractures and presenile deafness.
Which of the following historical factors differentiates post-traumatic stress disorder from acute stress disorder?

A. The inability of the person to recall an important aspect of the event.
B. Avoidance of stimuli that invokes recollections of the event.
C. A belief that their future has been foreshortened because of the event.
D. The presence of sleep disorder.
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. Post-traumatic stress disorder and acute stress disorder have many of the same characteristics. A sense of a foreshortened future, such as not expecting a normal life span or a career due to the trauma, distinguishes post-traumatic stress disorder from an acute stress disorder. The other answers are common to both disorders.
(u) D. See C for explanation.
A patient with obsessive-compulsive disorder would most likely have which of the
following findings?

A. Raw, red hands
B. Priapism
C. Memory impairment
D. Abdominal pain
(c) A. Common manifestations of obsessive-compulsive disorder include phobias of germ and
contaminants, which results in frequent hand washing leading to chafe and reddened hands. The
other answers are inconsistent with obsessive-compulsive disorder.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough
and fever for 1 day. He relates having symptoms of a “cold” for the past week that
suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient?

A. spoken “ee” heard as “ay”
B. hyperresonant percussion note
C. wheezes over the involved area
D. vesicular breath sounds over involved area
(c) A. This patient most likely has a bacterial pneumonia with consolidation, which would produce
egophony, where a spoken “ee” is heard as “ay.”
(u) B. Consolidation from bacterial pneumonia causes findings of dullness to percussion, late
inspiratory crackles and bronchial breath sounds over the involved area.
(u) C. See explanation B.
(u) D. See explanation B.
Which of the following is a common symptom associated with laryngotracheobronchitis
(viral croup)?

A. drooling
B. high fever
C. "hot potato" voice
D. barking cough
(u) A. Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup.
(u) B. Fever is usually absent or low grade in patients with viral croup.
(u) C. See A for explanation.
(c) D. Viral croup is characterized by history of an upper respiratory tract symptoms followed by
onset of a barking cough and stridor.
A foreign body lodged in the trachea that is causing partial obstruction will most likely
produce what physical examination finding?

A. stridor
B. aphonia
C. inability to cough
D. progressive cyanosis
(c) A. An inspiratory wheeze is called stridor, which indicates a partial obstruction of the trachea
or larynx.
(u) B. Aphonia, inability to cough and progressive cyanosis are seen with complete obstruction of
the trachea, not partial obstruction.
(u) C. See B for explanation.
(u) D. See B for explanation.
On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause?

A. asthma
B. consolidation
C. pneumothorax
D. pleural effusion
(u) A. Asthma is characterized by decreased tactile fremitus, but would have resonant to
hyperresonant percussion, not dullness.
(u) B. Consolidation from pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus.
(u) C. A pneumothorax is characterized by decreased to absent tactile fremitus, but would have a hyperresonant percussion note, not dullness.
(c) D. A decreased tactile fremitus and dullness to percussion would be found in a pleural effusion.
A patient with a 15-year history of type 2 diabetic mellitus presents for follow-up. Labs reveal a BUN 100 mg/dl, serum creatinine 9.2 mg/dl, and serum glucose 164 mg/dl. Which of the following would you expect to find on physical examination?

A. Pruritus
B. Hypotension
C. Macroglossia
D. Suprapubic tenderness
(c) A. Hypertension, pruritus and xerosis are common findings in the uremic patient.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. Suprapubic tenderness is associated with urinary tract infection or acute obstructive
uropathy.
When performing a rectal examination, prostatic massage is contraindicated in

A. prostatodynia.
B. non-bacterial prostatitis.
C. chronic bacterial prostatitis.
D. acute bacterial prostatitis.
(u) A. Prostatodynia is an inflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement.
(u) B. Non-bacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are
cultured, and the cause is unknown.
(u) C. Prostate massage can be performed in the absence of fever. Expressed prostatic
secretions are cultured to help identify the organism.
(c) D. Vigorous manipulation of the prostate during rectal examination may result in septicemia.
This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain.
Which of the following is typically noted on physical examination in a patient with
diphtheria?

A. Papular rash on trunk
B. Supraclavicular adenopathy
C. Pharyngeal pseudomembranes
D. Splenomegaly
(u) A. See C for explanation.
(u) B. See C for explanation.
(c) C. The classic exam finding noted in diphtheria is a gray pharyngeal pseudomembrane.
Rash, splenomegaly, and supraclavicular adenopathy are not noted in diphtheria.
(u) D. See C for explanation.
A 28 year-old female presents with lower abdominal pain and vaginal discharge. On examination the patient
is toxic appearing and her temperature is 39°C. Pelvic examination reveals cervical motion tenderness. What
is the next best step in the evaluation of this patient?

A. Abdominal x-ray
B. Endocervical culture
C. Laparoscopy
D. Hysterosalpingogram
(u) A. Abdominal x-rays are not helpful in the diagnosis of pelvic inflammatory disease.
(c) B. Endocervical culture would be helpful in the diagnosis of pelvic infection.
(u) C. Laparoscopy is invasive and would not be the next best step in evaluation of this patient.
(u) D. Hysterosalpingogram is indicated in the evaluation of abnormal uterine bleeding and infertility.
Which of the following is a common physical examination finding in early intestinal obstruction?

A. high fever.
B. profuse flatulence.
C. rebound tenderness
D. hyperactive, high-pitched bowel sounds
(u) A. Fever and rebound tenderness occur only if a perforation has occurred.
(u) B. Profuse flatulence is not noted in early intestinal obstruction.
(u) C. See A for explanation.
(c) D. Abdominal distention and high-pitched, hyperactive bowel sounds are common in early intestinal obstruction.
A 26 year-old man complains of itching, redness, tearing of both eyes, sneezing, and a clear nasal discharge
for over a week. Both eyes are injected and a watery discharge is noted. There is no foreign body with lid
eversion and there is no uptake of fluorescein. Which of the following is the most appropriate topical
treatment at this time?

A. Bacitracin (AK-Tracin)
B. Prednisolone (Pred Forte)
C. Naphazoline (Naphcon).
D. Flurbiprofen (Ocufen)
(u) A. Antibiotics, steroids, and nonsteroidal anti-inflammatory medications are not indicated for allergic conjunctivitis.
(u) B. See A for explanation.
(c) C. Allergic conjunctivitis responds to cool compresses, topical vasoconstrictors, topical antihistamines, and topical
cromolyn sodium.
(u) D. See A for explanation.
Which of the following is the first line agent in the outpatient management of Legionella pneumonia?

A. Penicillin
B. Cefaclor (Ceclor)
C. Amoxicillin/Clavulanate (Augmentin)
D. Azithromycin (Zithromax)
(u) A. Penicillin is ineffective against atypical causes of pneumonia including Mycoplasma, Chlamydia and
Legionella.
(u) B. Cephalosporins are ineffective against atypical causes of pneumonia including Mycoplasma, Chlamydia and
Legionella.
(u) C. Amoxicillin/clavulanate is ineffective against atypical causes of pneumonia including Mycoplasma, Chlamydia
and Legionella.
(c) D. Macrolides are the preferred treatment in a patient with atypical pneumonia.
A 67 year-old male with COPD is most likely to have which of the following physical exam findings?

A. Barrel chest
B. Egophony
C. Tracheal shift
D. Pectus excavatum
(c) A. An increase in anteroposterior diameter (barrel chest) often accompanies COPD.
(u) B. Egophony is associated with consolidation but not COPD.
(u) C. Tracheal shift is associated with pleural effusion and pneumothorax.
(u) D. Pectus excavatum is not associated with COPD.
A 24 year-old near drowning victim has been hospitalized for 24 hours. The patient has now had a rapid
decline in her respiratory status and has labored breathing, tachypnea and intercostal retractions. Arterial
blood gases reveal a pH 7.28, pO2 60 mm Hg, pCO2 52 mm Hg, and bicarbonate 26 mEq/L. CXR reveals
diffuse bilateral infiltrates, normal heart size and no pleural effusions. Which of the following is the most
appropriate intervention in this patient?

A. Tracheal intubation with positive-pressure mechanical ventilation.
B. Systemic corticosteroid therapy.
C. Oxygen via nasal canula
D. Chest tube placement
(c) A. Treatment of hypoxemia in ARDS requires tracheal intubation and positive-pressure mechanical ventilation.
(u) B. Systemic corticosteroids have variable and inconsistent results in their effectiveness in treating ARDS.
(u) C. See A for explanation.
(u) D. Chest tube placement is therapeutic for pneumothorax, but has no role in the treatment of ARDS.
A 65 year-old male presents with a transudative pleural effusion. This patient most likely has a history of
which of the following?

A. Uremia
B. Pneumonia
C. Connective tissue disorder
D. Congestive heart failure
(u) A. Uremia causes an exudative pleural effusion.
(u) B. Pneumonia causes an exudative pleural effusion.
(u) C. Connective tissue disorders are associated with an exudative pleural effusion.
(c) D. CHF accounts for up to 90% of all transudative pleural effusions.
A 36 year-old female with history of HIV presents with complaint of increasing dyspnea for three weeks. She
admits to fever and nonproductive cough. She denies chest pain, congestion or edema. Physical exam
reveals no wheezes or rales. Chest x-ray shows bilateral diffuse infiltrates. What is the most likely diagnosis?

A. Pulmonary tuberculosis
B. Bronchogenic carcinoma.
C. Pneumocystis pneumonia.
D. Pneumoconiosis
(u) A. TB usually has productive cough and apical cavitation on CXR.
(u) B. Bronchogenic carcinoma is not associated with fever and would be seen as a solitary nodule on chest x-ray,
not a diffuse process.
(c) C. Pneumocystis is a common cause of pneumonia in HIV positive patients. There are often nonspecific lung
findings on exam with diffuse infiltrates on x-ray.
(u) D. Pneumoconiosis is typically asymptomatic with no associated fever.
A 75 year-old women presents to the office with complaint of vision loss. Examination reveals a palpable cord in the temporal region. Which of the following is the most helpful initial test to order on this patient?

A. Carotid ultrasound
B. Chest radiograph
C. Complete blood count
D. Erythrocyte sedimentation rate
(a) A . See D for explanation.
(u) B. Dee D for explanation.
(u) C. See D for explanation.
(c) D. The patient is suspected of having temporal arteritis. This disease is most commonly noted in patients over age 50 and should be suspected in patients with sudden vision loss and a palpable cord in the temporal region. Erythrocyte sedimentation rate is almost always increased in this disease.
A 5 year-old with a severe penicillin allergy is diagnosed with acute otitis media. Which of the following is the
treatment of choice?

A. Trimethoprim-sulfamethoxazole (Bactrim).
B. Ciprofloxacin (Cipro).
C. Azithromycin (Zithromax)
D. Cephalexin (Keflex)
(a) A. Trimethoprim-sulfamethoxazole is not the preferred agent in penicillin allergic patients but it can be used.
(u) B. Topical ciprofloxacin is used in the treatment of otitis externa.
(c) C. A macrolide, such as azithromycin, is the preferred agent in the penicillin allergic patient with acute otitis
media.
(h) D. A cephalosporin, such as cephalexin, is contraindicated in severe penicillin allergic patients.
A patient with streptococcal pharyngitis is treated to prevent which of the following conditions?

A. Glomerulonephritis
B. Anemia
C. Rheumatoid arthritis
D. Rheumatic fever
(u) A. Glomerulonephritis cannot be prevented with antibiotic treatment of streptococcal pharyngitis; it is an immune
complex disease.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. Inadequately treated streptococcal pharyngitis may lead to rheumatic fever, but not anemia, or rheumatoid
arthritis.
A 16 year-old female G1P0Ab0 is 30 weeks pregnant. Her last two monthly prenatal exams have shown a
trace to 1 plus proteinuria. The patient denies any previous history of hypertension, seizures, headache, visual disturbances or spotting. On examination, blood pressure is 150/98. The fundal height is 32 cm, the uterus is soft and nontender and fetal heart tones are 160 bpm. DTRs are 4 plus out of 4 plus in the upper and lower extremities, and there is moderate pedal edema bilaterally. The skin examination is unremarkable.
Based upon these findings what is the most likely diagnosis?

A. Eclampsia
B. Pre-eclampsia
C. Gestational hypertension
D. HELLP Syndrome
(u) A. Eclampsia is the occurrence of seizures in a pre-eclamptic patient.
(c) B. Pre-eclampsia is the hypertension associated with proteinuria. This occurs in greater frequency in nulliparous,
adolescent and black women.
(u) C. Gestational hypertension is hypertension that continues after pre-eclampsia for 12 weeks post-partum then
returns to normal. If hypertension continues after 12 weeks then the patient is said to have chronic
hypertension and is often predictive of later development of essential hypertension.
(u) D. HELLP syndrome is a subcategory of pre-eclampsia in which the patient develops hemolytic anemia, elevated
liver enzymes and low platelets.
A 34 year-old female G2P1Ab0 at 36 weeks gestation presents to the clinic with a complaint of a sudden gush
of fluid from the vagina 18 hours ago. The patient denies any blood in the discharge but describes the fluid
as watery. Examination reveals that there is a collection of fluid in the posterior fornix, the Nitrazine test is
blue as well as the fluid giving a fern-like crystallization pattern on a slide. Given these findings what is the
appropriate clinical intervention?

A. Observation
B. Induce labor
C. Antibiotics
D. Corticosteroids
(u) A. With premature rupture of the membranes, the patient is at risk for the development of amnionitis.
(c) B. Since the patient is 36 weeks gestation and it has been greater than 12 hours since the leakage of fluid, labor
should be induced to minimize infection.
(u) C. If the patient was less than 33 weeks pregnant and amnionitis had been ruled out, then antibiotics along with
corticosteroids would be advisable. Favorable outcomes utilizing both of these drugs have been demonstrated.
(u) D. See C for explanation.
In the treatment of endometriosis, which of the following medications has a side effect profile that includes
loss of bone mineral density, vasomotor symptoms, vaginal dryness and mood changes?

A. Oral contraceptives
B. Dantrolene (Danazol)
C. Leuprolide (Lupron)
D. Progestational agents
(u) A. Oral contraceptives, dantrolene, and progestational agents do not have this side effect profile.
(u) B. See A for explanation.
(c) C. Leuprolide is a gonadotropin releasing hormone analogue that results in suppression of gonadotropic
secretion. This suppression leads to a hypoestrogenic state which contributes to these side effects.
(u) D. See A for explanation.
Which of the following lesions is often associated with the nodular type of basal cell carcinoma?

A. Spider vein
B. Cherry angioma
C. Spider angioma
D. Telangiectatic vessels
(u) A. A spider vein often accompanies increased pressure in the superficial veins as seen with varicose veins.
(u) B. A cherry angioma is often found on the trunk or extremities and has no clinical significance.
(u) C. Spider angiomas are associated with liver disease, pregnancy and vitamin B deficiency. They may also occur
in some healthy people.
(c) D. Telangiectatic vessels are often visible in the lesions seen with basal cell carcinoma.
Which of the following is the most important factor in determining this patient’s risk of sun reactivity and
therefore higher risk of developing skin cancer?

A. Ethnicity.
B. Geography
C. How old they are.
D. How easily they tan
(u) A. The skin phototypes of various ethnic groups has not yet been established and skin phototypes are not solely
based on ethnicity.
(u) B. Sunburn can occur at any latitude and therefore geography does not play a large role in a patient’s risk.
(u) C. While very young children and the elderly are thought to have an increased risk of sunburn, this has not been
studied and thoroughly documented.
(c) D. Sun reactivity is greatest in individuals who are classified with a “white” skin color and who have a limited
ability to tan after exposure to ultraviolet radiation.