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PACKRAT 2: Questions With Detailed Answers (100%)
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PACKRAT 2: Questions With Detailed Answers (100%)**(C) Denotes - Right Ans **
A 23 year-old male with recent upper respiratory symptoms presents
complaining of chest pain. His pain is worse lying down and better sitting up
and leaning forward. Electrocardiogram shows widespread ST segment
elevation. Which of the following is the most likely physical examination
finding in this patient?
A. Elevated blood pressure
B. Subungual hematoma
C. Diastolic murmur
D. Pericardial friction rub (u) A. Acute pericarditis is usually not associated
with elevated blood pressure. One would expect to see hypertensive pressures
in the setting of an aortic dissection.
(u) B. Subungual hematomas are usually seen in endocarditis not pericarditis.
(u) C. A diastolic murmur in a patient with chest pain would likely be
associated with acute aortic regurgitation in the setting of an aortic dissection.
(c) D. This patient has symptoms consistent with acute pericarditis and would
most likely have a pericardial friction rub on examination.
A 75 year-old woman 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 x-ray
C. Complete blood count
D. Erythrocyte sedimentation rate (u) A. See D for explanation.
(u) B. See 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.
What is the recommended target LDL to reduce the risk of coronary artery
disease in a diabetic patient?
,A. 200 mg/dL
B. 160 mg/dL
C. 130 mg/dL
D. 100 mg/dL (u) A. See D for explanation.
(u) B. See D for explanation.
(u) C. See D for explanation.
(c) D. The National Cholesterol Education Program clinical practice guidelines
have designated diabetes as a coronary risk equivalent and have
recommended that patients with diabetes should have an LDL cholesterol goal
of 100 mg/dL.
Which of the following best describes the purpose of intravenous magnesium
sulfate in patients with preeclampsia?
A. Prevention of convulsions
B. Prevention of HELLP syndrome
C. Lowering of blood pressure
D. Reversal of proteinuria (c) A. Magnesium sulfate is used to prevent and
treat eclamptic seizures. Magnesium sulfate is not sufficient to treat
hypertension, therefore antihypertensives must be added. Magnesium sulfate
is excreted solely from the kidneys and urine output must be preserved to
prevent accumulation of the drug. Magnesium sulfate does nothing to prevent
HELLP syndrome.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 53 year-old male with history of hypertension presents complaining of
recent 4/10 left-sided chest pain with exertion that is relieved with rest. He
states the pain usually lasts approximately 4 minutes and is relieved with rest.
Heart examination reveals regular rate and rhythm with no S3, S4, or murmur.
Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute
changes. Which of the following is the most appropriate initial step in the
evaluation of this patient?
A. Cardiac catheterization
B. CT Angiogram of the chest
C. Echocardiogram
D. Nuclear stress test (u) A. This patient has signs and symptoms
consistent with stable angina. Noninvasive diagnostic testing is preferred in
this patient.
,(u) B. CT angiogram may be useful for the evaluation of chest pain, however
its role in routine practice has not been established.
(u) C. This patient has signs and symptoms of stable angina. There are no
signs of valvular heart disease on examination. While an echocardiogram may
be performed at some point, it is not the best initial diagnostic step to
determine the etiology of the patient's angina.
(c) D. Nuclear stress testing is the most appropriate initial diagnostic study in
the evaluation of a patient with signs and symptoms consistent with stable
angina.
A 36 year-old African American female comes to the clinic for an insurance
physical which requires a chest x-ray. She denies any respiratory symptoms.
Examination of her chest is negative. X-ray results show marked
lymphadenopathy in the right paratracheal region. Angiotensin-converting
enzyme (ACE) levels are elevated. Which of the following is the most likely
diagnosis?
A. Sarcoidosis
B. Tuberculosis
C. Pulmonary fibrosis
D. Lymphoma (c) A. Sarcoidosis is characterized by paratracheal
lymphadenopathy and elevated ACE levels. It is more common in African
American patients and may be asymptomatic.
(u) B. See A for explanation.
(u) C. See A for explanation.
(u) D. See A for explanation.
A 33 year-old male presents to your office with a complaint of right knee
injury associated with pain and swelling. He states he was running after his
loose dog and suddenly stopped, hyperextended his knee, heard a pop and
noticed immediate swelling. On physical examination, the Lachman test and
anterior drawer test demonstrates joint laxity. Which of the following
ligaments is most likely injured?
A. Medial collateral
B. Lateral collateral
C. Posterior cruciate
D. Anterior cruciate (u) A. Medial collateral ligament injuries often occur
with rotational injuries or direct impact to the lateral knee. Tenderness
medially with laxity with valgus (medial) stress is noted.
, (u) B. Lateral collateral ligament injury causes pain mostly on the lateral
aspect of the knee and patients can experience knee buckling with normal
gait. Tenderness laterally with laxity with varus (lateral) stress is noted.
(u) C. Posterior cruciate ligament injuries occur with an outside directed force,
often a posterior directed force such as a knee striking a dashboard. The
patients often do not hear a pop. A posterior drawer test or posterior sag test
can be useful in the diagnosis.
(c) D. Anterior cruciate ligament injuries occur with sudden deceleration
injuries. Patients often hear a pop and the diagnosis is aided by assessing the
anterior drawer test and Lachman test. The immediate swelling as well as
laxity with anterior drawer test and Lachman test should raise suspicion of
anterior cruciate ligamental injury.
A 22 year-old woman comes to the office because her urine is cola-colored
and she has not urinated since yesterday morning. Her past medical history is
significant for pharyngitis two weeks ago. Her mother and grandmother have
type 2 diabetes. Her blood pressure is 146/92mmHG. On physical
examination, she has edema of her face and hands. Which of the following is
the most likely diagnosis?
A. Glomerulonephritis
B. Acute tubular necrosis
C. Nephrolithiasis
D. Diabetic nephropathy (c) A. Glomerulonephritis presents with
hematuria, cola-colored urine, oliguria, and edema of the face and eyes in the
morning. Urinalysis reveals red blood cells, mild proteinuria and red blood
cell casts. Glomerulonephritis can occur 1-3 weeks after a strep infection.
(u) B. Acute tubular necrosis is caused by acute kidney injury, such as a
nephrotoxin, and is associated with uremic symptoms which include nausea,
vomiting, malaise, and altered mental status. Granular casts are nonspecific
and may be seen in acute tubular necrosis.
(u) C. Nephrolithiasis usually presents as a sudden onset of colicky flank pain
with associated nausea and vomiting. Urinalysis often reveals gross or
microscopic hematuria.
(u) D. Diabetic nephropathy is the most common cause of end stage renal
disease in the United States. Urine examination reveals albuminuria.
A 15 year-old girl is hit in the right eye by a golf ball. There is swelling and
ecchymosis of the orbit. She complains of double vision. The right eye does not
move with downward gaze or right lateral gaze. Which of the following
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