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ACKNOWLEDGEMENT

The time and effort provided by the following individuals who served as members of this committee are

greatly appreciated:

James VanRhee, MS, PA-C, Project DirectorLaura Amon, MS, PA-CLinda Allison, MD, MPH

Christine Bruce, MHSA, PA-CRalph Rice, MPAS, PA-CEric Vangsnes, MS, PA-C

Donna Yeisley, MEd, PA-C

DEDICATION

This examination would not have been possible without the years of commitment of the MR. TIBDevelopment Committee. Numerous PA educators from across the nation provided their experience and

insight as questions for MR. TIB. It has been this data bank that served as the building blocks forPACKRAT.

APAP is proud to be able to continue in the tradition of quality fostered by the forerunners of the self-assessment examination for physical assistants. It is our honor to dedicate PACKRAT to:

Jesse C. Edwards, MSClaire S. Parker, PhDUniversity of Nebraska, Physician Assistant Program

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ASSOCIATION OF PHYSICIAN ASSISTANT PROGRAMS

Physician Assistant Clinical Knowledge Rating and Assessment Tool (PACKRAT)

Form 8

Directions and Explanations

TABLE OF CONTENTS

I. Introduction ………………………………………………………………………...………….. 1

II. Explanation of the Score Report ………………………………………………………….. 2

Your total Score and Group Comparisons ………………………………………………….. 2Your strengths, Weaknesses, and Quality of Responses ………………………………… 2

Your Individual and Correct Responses ……………………………………………………. 2Your Responses by Task and Category ……………………………………………………. 2

III. Recommendations for Using the Feedback Package …………………………………. 2

IV. Study Resources ………………………………………………………………………..…... 3

V. Examination Explanations ……………………………………………………………..….. 5

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Copyright © 2003. Association of Physician Assistant Programs. All rights reserved. No part of this publication may be reproducedor transmitted in any form or by any means, electronic or mechanical, including photocopy or recording, or any information andretrieval system, without permission in writing from the Association of Physician Assistant Programs.

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Copyright © 2003. Association of Physician Assistant Programs . - 1 -

PHYSICIAN ASSISTANT CLINICAL KNOWLEDGE RATING

AND ASSESSMENT TOOL (PACKRAT)

I. Introduction

The Physician Assistant Clinical Knowledge Rating and Assessment Tool (PACKRAT) was developed by

a volunteer committee of experts and is based on the content outline of a nationally recognizedcompetency examination. The following is a description of the content of PACKRAT:

PACKRAT EXAMINATION MATRIX

CONTENT AREA NUMBER OF ITEMS

1. History & Physical 262. Diagnostic Studies 36

3. Diagnosis 454. Health Maintenance 225. Clinical Intervention 32

6. Clinical Therapeutics 487. Scientific Concepts 16

TOTALS 225

Additionally, questions also apply to the following clinical specialties:

A. Cardiology I. Neurology

B. Dermatology J. Obstetrics/Gynecology

C. Endocrinology K. Orthopedics/RheumatologyD. ENT L. Pediatrics

E. Ophthalmology M. Psychiatry/Behavioral MedicineF. Gastrointestinal/Nutritional N. PulmonologyG. Geriatrics O. Surgery

H. Hematology P. Urology/Renal

The task and specialty categories for each item are listed in the answer key on page 5; your feedbackpackage contains a breakdown of responses by the task and clinical specialty category. Pay particular

attention to the questions you answered incorrectly and determine the specialty for that question and usethis information to identify weaknesses.

The PACKRAT provides a detailed feedback report of performance and it is available to anyone at anytime. Explanations were developed for all the questions to provide a rationale for correct, as well asincorrect, answers. This information will help determine strengths and weaknesses with respect to the

PACKRAT content outline. If you have weaknesses in specific areas, you may need to obtain additionalclinical experience in those areas.

This booklet is designed to explain and interpret the information contained in the accompanyingcomputerized score report. You can use the report package to learn more about your abilities.

PACKRAT EXAMINATION MATRIX

CONTENT AREA NUMBER OF ITEMS

1. History & Physical 262. Diagnostic Studies 363. Diagnosis 45

4. Health Maintenance 225. Clinical Intervention 326. Clinical Therapeutics 487. Scientific Concepts 16

TOTALS 225

Additionally, questions also apply to the following clinical specialties:

A. Cardiology I. Neurology

B. Dermatology J. Obstetrics/GynecologyC. Endocrinology K. Orthopedics/RheumatologyD. ENT L. Pediatrics

E. Ophthalmology M. Psychiatry/Behavioral MedicineF. Gastrointestinal/Nutritional N. PulmonologyG. Geriatrics O. Surgery

H. Hematology P. Urology/Renal

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II. Explanation of the Score Report

This section provides an interpretation of eachreport. You should have your score report in frontof you as you read the following information.

Your Total Score and Group Comparisons

This report provides an overview of the PACKRATfeedback report. This score shows the number ofquestions you answered correctly out of a possible

225. The average score for all first-year andsecond-year candidates who have taken thePACKRAT to-date is also provided (when

available.)

Your Strengths, Weaknesses, and Quality of

Responses

This report gives an overview of the content area

in which your performance is categorized as“Strong”, “Satisfactory”, or “NeedingImprovement”. These areas are based on the

examination matrix listed above.

In each content area, your answers have been

classified as correct, acceptable, unsatisfactory, orharmful. A definition of these classifications is alsoprovided on this page. Pay particular attention to

the areas under “Needing Improvement”, as theseareas should be noted for further study. Alsocheck the answer key for the specialty area of

these items. If you selected two (2) or more

harmful answers in any content area, it will beautomatically placed in the “Needing

Improvement” category, regardless of the numberof correct answers selected. Carefully reviewthese questions and their explanations and

specialty classifications in the ExplanationsSection to help you understand why your answerswere correct.

Your Individual and Correct Responses

This report lists your answers to all questions.When your answer differs from the correct one,

the proper response appears in parentheses. Usethe Explanations Section to review the rationalefor each option that is provided in theexplanations, which are referenced to the study

resources. The explanations may help youunderstand why one answer is more appropriatethan another, or not the best answer, and why

some of your answers may have been incorrect. Ifthe option you chose was judged potentiallyharmful to the patient or others, an asterisk (*)

appears before your answer. Options classified aspotentially harmful may identify serious

weaknesses. Go over these questions carefullyand read the explanations for the correct answers.You may be able to identify areas where you need

further study.

Your Responses by Task and Specialty Category

This report lists your responses by both specialtyand task category. You will be able to identify the

areas of the content outline where you may havedifficulty. The numbers reflect how many items youanswered correctly out of the total possible correct

within each task and specialty area. Categories 1through 7 identify the task areas and A-P theclinically specialty areas. If you missed a

significant number of items in an area, check thekey and go over the explanations for the items inthese areas.

III. Recommendations for using The Results

Reports

As a current physician assistant student,

PACKRAT can be a useful self-evaluation tool.Through careful review of question explanations,noting specific tasks and content areas, you will be

able to assess your current strengths andweaknesses. You will be able to identify particularareas in which to concentrate more effort as you

continue your studies. By concentrating your effort

on the areas in which you did not do well, you mayimprove your performance, and you may have a

better chance of passing the proctoredexamination. However, APAP cannot guaranteethat this will occur, since the conditions under

which you attempted the PACKRAT may havebeen different from those in a standardizedadministration of a proctored examination.

Use the Explanations Section to analyze why youchose various options. Again, pay particularattention to the options that were judged

potentially harmful or unsatisfactory. Look at thequestion and the four options again to see why the

answer you chose was incorrect. If there appearsto be a deficit in your exposure to a particularclinical specialty, perhaps further study wouldmake you more familiar with these situations.

Once you have completely reviewed your scorereport and this booklet, APAP hopes you will usethis information to improve your overall

performance, either on the job or on futurecertification examinations.

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IV. Study Resources

A variety of textbooks are currently available toassist candidates in preparing for the certificationexamination. For additional information, you may

contact a faculty member at an educationalprogram or an experienced colleague if you needhelp determining which references to review in a

specific content area. A short list of generaltextbooks is below. All examination questions arerelated to material found in these resources.

Please note that the books on this list are notavailable from APAP. This is not intended as an

all-inclusive list, and the materials listed below aresuggested study materials only.

1. Ahya SN, Flood K, and Paranjothi S (eds).TheWashington Manual of Medical Therapeutics.

30th ed. Philadelphia, PA: Williams & Wilkins,2001.

2. Andreoli TE, et al (eds). Cecil’s Essentials ofMedicine. 5th ed. Philadelphia, PA: WBSaunders Co., 2001.

3. Bates B. Guide to Physical Examination andHistory Taking. 8th ed. Philadelphia, PA: JB

Lippincott Co., 2000.

4. Beckmann CR, et al . Obstetrics &

Gynecology . 4th ed. Philadelphia, PA:

Lippincott Co., 2002.

5. Behrman RE, et al. Nelson’s Textbook ofPediatrics. 16th ed. Philadelphia, PA: WBSaunders Co., 2000.

6. Berkowitz, C. Pediatrics: A Primary Care Approach, 2nd ed. Philadelphia, PA: WB

Saunders, 2000.

7. Goldman J and Bennet JC. Cecil Textbook of

Medicine. 21st. Philadelphia, PA: WBSaunders Co., 2000.

8. Ellsworth AJ, et al. (eds). Mosby’s MedicalDrug Reference. St. Louis, MO: MosbyYearbook, Inc., 2003.

9. Braunwald E, et al (eds). Harrison’s Principlesof Internal Medicine. 15th ed. New York, NY:

McGraw-Hill, Inc., 2001.

10. Fitzpatrick TB, Palano MK, and Surmond, D.Color Atlas and Synopsis of ClinicalDermatology . 5th ed. New York, NY:

McGraw-Hill, Inc., 2001.

11. Hacker NF and Moore GJ. Essentials of

Obstetrics and Gynecology. 3rd ed.Philadelphia, PA: WB Saunders Co., 1998.

12. Hay WW, et al. Current Pediatric Diagnosisand Treatment . 16th ed. Norwalk, CT: Appleton & Lange, 2003.

13. Kaplan HI and Sadock BJ (eds). ConciseTextbook of Clinical Psychiatry. Philadelphia,

PA: Williams & Wilkins, 1998.

14. Katzung BG. Basic and Clinical

Pharmacology . 8th ed. Stamford, CT: Appleton & Lange, 2001.

15. Mandel GL, Bennett JE, and Dolin R.Principles and Practice of Infectious Disease. 5th ed., Churchill Livingston, 2000.

16. Tierney LM, et al. Current Medical Diagnosisand Treatment. 42nd ed. Stamford, CT:

Appleton & Lange, 2003.

17. Mercier LR, et al. Practical Orthopedics. 5th

ed. St. Louis, MO: Mosby Yearbook, Inc.,

2000.

18. Mettler FA, et al. Primary Care Radiology. Philadelphia, PA: WB Saunders, Co., 2000.

19. Mycek MJ, Harvey RA, and Champe PC.Lippincott’s Illustrated Reviews:Pharmacology. 2nd ed. Baltimore, MD:

Williams & Wilkins, 2000.

20. Noble J, et al. Textbook of Primary Care

Medicine. 2nd ed. St. Louis, MO: MosbyYearbook, Inc., 1996.

21. Sacher RA and McPherson RA. Widmann'sClinical Interpretation of Laboratory Tests.11th ed. FA Davis Co., 2000.

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22. Schwartz SI, et al. Principles of Surgery . 7th

ed. New York, NY: McGraw-Hill, Inc., 1998.

23. Steinberg GG. Orthopedics in Primary Care.

3rd ed. Philadelphia, PA: Lippincott Williams& Wilkins, 3rd ed, 1999.

24. Tintinalli JE, Krome RL, and Ruiz E.Emergency Medicine: A ComprehensiveGuide. 5th ed. New York, NY: McGraw-Hill,

Inc., 2000.

25. Townsend CM. Sabiston’s Textbook of

Surgery. The Biological Basis of ModernSurgical Practice. 16th ed. Philadelphia, PA:WB Saunders, Co., 2002.

26. Wilson WR. Current Diagnosis and Treatmentin Infectious Disease. Norwalk, CT: Appleton

& Lange, 2001.

27. DeCherney AH & Pernoll ML (eds.) Current

Obstetric & Gynecological Diagnosis &Treatment, 9th ed., Norwalk, CT: Appleton &Lange, 2003

28. Skinner HB (ed.) Current Diagnosis &

Treatment in Orthropedics. 2nd ed.,Norwalk,CT:Appleton & Lange, 2000.

29. Ballweg R et al. Physician Assistant: A Guideto Clinical Practice. 3rd ed., Saunders, 2003.

30. Vaughn D. et al. General Ophthalmology. 15thed., McGraw Hill, 1998

31. Way LW, et al. Current Surgical Diagnosis andTreatment . 11th ed., McGraw Hill, 2002.

32. McPhee SJ, et al. Pathophysiology ofDisease. 3rd ed., Mcgraw Hill, 2000.

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Copyright © 2003. Association of Physician Assistant Programs . 5

c = Correct u = Unsatisfactorya = Acceptable h = Potentially harmful

V. Examination Explanations

1. 1. HISTORY/PHYSICAL

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

A. increased CVP; decreased BP; increased pulse rate

B. decreased CVP; decreased BP; increased pulse rate

C. increased CVP; increased BP; decreased pulse rateD. decreased CVP; increased BP; decreased pulse rate

EXPLANATIONS:

A. See B for explanation.B. Hypovolemic shock is a condition with a decrease in the amount of circulating blood volume in the

intravascular system. A decrease in the amount of circulating volume will result in a decrease in the CVPpressure which is an indirect measurement of the amount of blood in the right ventricle. Less blood in thevascular system means decreased blood pressure. Since there is less blood in the circulation, the body

will attempt to compensate for this by increasing the number of contractions (pulse rate) and the force ofthose contractions due to increased sympathetic stimulation.(u) C. See B for explanation.

(u) D. See B for explanation.

REF: (9)

2. 1. HISTORY/PHYSICALExamination of the heart in chronic heart failure frequently reveals

A. S3.

B. splitting of S2.

C. paradoxical splitting of S2.

D. holosystolic murmur.

EXPLANATIONS:

(c) A. S3 occurs as a result of the left ventricle becoming stiff and interfering with blood entering the left

ventricle during filling. As the left ventricle loses its compliance, there is impaired filling which results in

less blood entering the left ventricle, increased left ventricle filling pressures, and left ventricular failure.Contraction of the left ventricle is not initially affected, but becomes affected with time.(u) B. Splitting of S2 usually results from inspiration lengthening the time difference between closure of

the aortic valve and closure of the pulmonic valve.(u) C. Paradoxical splitting of S2 usually results from conditions that either delay the closure of the aortic

valve, such as aortic stenosis, or left bundle branch block, or in conditions that cause premature closure

of the pulmonic valve.(u) D. Holosystolic murmur occurs as a result of mitral regurgitation or ventricular septal defect.

REF: (9)

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

A. abdominal mass

B. hypertensionC. chest painD. syncope

EXPLANATIONS:(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.

REF: (16)

4. 1. HISTORY/PHYSICALPost-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.

EXPLANATIONS:

(u) A. See B for explanation.(c) B. Dressler's syndrome is the occurrence of pericarditis and pleuritis several days to weeks followingan MI.

(u) C. Pericardial tamponade may result from severe pericardial effusion or hemorrhage into thepericardium, 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.

REF: (9)


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

A. slapped cheek appearance

B. strawberry tongueC. Koplik's spotsD. honey-crusted lesions

EXPLANATIONS:

(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.

REF: (10)

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6. 1. HISTORY/PHYSICALIn myxedema, the patient commonly complains of which of the following?

A. tremorsB. palpitationC. cold intolerance

D. eructation

EXPLANATIONS:

(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 hyopthyroidismalong with constipation and fatigue.

(u) D. Eructation is associated with indigestion and not hypothyroidism.

REF: (9)

7. 1. HISTORY/PHYSICALWhich of the following signs or symptoms differentiates acute sinusitis from viral rhinitis?

A. feverB. rhinorrheaC. facial pain

D. swollen nasal mucous membranes

EXPLANATIONS:

(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 ofviral 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.

REF: 16

8. 1. HISTORY/PHYSICALWhich of the following is most commonly seen in viral croup?

A. droolingB. wheezing

C. sputum productionD. inspiratory stridor

EXPLANATIONS:

(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.

REF: (5)

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

A. opticB. oculomotor

C. trochlear

D. abducens

EXPLANATIONS:

(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.

REF: (9)


When palpating a patient's abdomen at the level of the left costal margin, the physician assistant feelsthe 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.

EXPLANATIONS:

(c) A. By rolling the patient onto the right side, gravity may bring the spleen forward and medial so that itis 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.

REF: (3)

11. 1. HISTORY/PHYSICALWhich of the following is a finding in vitamin A deficiency?

A. decreased proprioceptionB. night blindnessC. hair loss

D. bleeding

EXPLANATIONS:

(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.

REF: (16)

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

EXPLANATIONS:

(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 withStaphylococcal food poisoning.

(u) D. Staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature.

REF: (9)

13. 1. HISTORY/PHYSICALThe 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.

EXPLANATIONS:

(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.

REF: (9)

14. 1. HISTORY/PHYSICALWhich of the following physical findings suggest pernicious anemia?

A. splenomegaly and hepatomegalyB. petechiae and ecchymosisC. loss of position and vibratory sensation

D. cheilosis and koilonychia

EXPLANATIONS:

(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.

REF: (16)

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15. 1. HISTORY/PHYSICALWhich of the following is the most common early presenting sign in patients with Alzheimer's disease?

A. change in personalityB. loss of memoryC. multiple physical complaints

D. depressed mood

EXPLANATIONS:

(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. Changesoccur 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.

REF: (9)

16. 1. HISTORY/PHYSICALThe most frequent finding in a person presenting with a brain abscess is

A. nuchal rigidity.B. headache.C. seizures.

D. vomiting.

EXPLANATIONS:

(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.

REF: (9)


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

A. hirsutismB. gynecomastiaC. anorexia

D. dyspareunia

EXPLANATIONS:

(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.

REF: (16)

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18. 1. HISTORY/PHYSICALWhich of the following signs and symptoms is common in candidal vulvovaginitis?

A. extreme vulvar irritationB. firm, painless ulcerC. tender lymphadenopathy

D. purulent discharge

EXPLANATIONS:

(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.

REF: (27)


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.

EXPLANATIONS:

(u) A. Bicipital tendinitis is associated with pain along the proximal humeral groove and a positiveYergason'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. Theinflammation then leads to secondary involvement of the subacromial bursae. Pain and tenderness arelocalized to the lateral aspect of the shoulder, with signs of impingement on active motion noted on exambetween 70-100° abduction.

REF: (24)

20. 1. HISTORY/PHYSICALWhich of the following physical examination findings is consistent with a herniated disk at L5-S1?

A. hypesthesia of the medial thighB. upgoing Babinski reflex

C. absent Achilles' reflexD. decreased sensation in the groin region

EXPLANATIONS:

(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.

REF: (9)

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21. 1. HISTORY/PHYSICAL A 65-year-old patient has a long history of schizophrenia that is treated with phenothiazines. On anunrelated 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.

EXPLANATIONS:

(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 familyhistory and usually appears by age 50.

(u) D. Facial motor tics are the most common manifestation of this disorder, but symptoms begin beforeage 21.

REF: (13)


Typical symptoms of depression include which of the following?

A. auditory hallucinations

B. panic attacksC. multiple somatic complaintsD. narcissism

EXPLANATIONS:

(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.

REF: (16)

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

A. ataxic breathingB. Cheyne-Stokes breathing

C. Kussmaul breathingD. obstructive breathing

EXPLANATIONS:

(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 formetabolic acidosis.

(u) D. Obstructive breathing is seen in patients with COPD.

REF: (3)

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24. 1. HISTORY/PHYSICALParadoxical motion of the chest wall occurs in which of the following?

A. barrel chestB. flail chest

C. funnel chest

D. pigeon chest

EXPLANATIONS:

(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. Compressionof 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.

REF: (3)

25. 1. HISTORY/PHYSICAL A 49-year-old male presents with complaints consistent with Peyronie's disease. Which of the followingis the most likely physical examination finding in this patient?

A. inflammation of the glands of the penisB. foreskin that cannot be retracted

C. chancre on the shaft of the penisD. fibrous band on lateral portion of the penis

EXPLANATIONS:

(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 ofpenile curvature during erection.

REF: (3)

26. 1. HISTORY/PHYSICALRenal cell carcinoma most commonly presents with which of the following symptoms or signs?

A. hypocalcemiaB. inguinal painC. anemia

D. hematuria

EXPLANATIONS:

(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.

REF: (16)

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27. 2. DIAG STUDIESWhich of the following is the diagnostic test of choice for the evaluation of a patient suspected ofsecondary hypertension due to primary aldosteronism (Conn's syndrome)?

A. chest x-rayB. renal scan

C. serum electrolytes

D. urinalysis for metanephrines

EXPLANATIONS:

(u) A. Chest x-ray may be used to evaluate a patient suspected of having coarctation of the aorta as acause of secondary hypertension.(u) B. A renal scan is indicated in the evaluation of a patient suspected of having secondary

hypertension due to renal artery stenosis or fibromuscular dysplasia of the renal arteries.(c) C. Patients having primary aldosteronism as a cause of their secondary hypertension are identified forthis condition by finding unprovoked hypokalemia on the electrolyte testing.

(u) D. Patients having secondary hypertension due to pheochromocytoma will have an increase in theirurinary metanephrines on testing due to increased catecholamine production by this tumor.

REF: (9)

28. 2. DIAG STUDIESWhich of the following electrocardiographic findings is the hallmark of pericarditis?

A. ST elevationB. prolonged Q-T intervalC. atrial fibrillation

D. tall peaked T waves

EXPLANATIONS:

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

segment depression.(u) B. Prolonged Q-T interval is typically the result of hypocalcemia or due to the use of medications.

(u) C. Pericarditis is not related to the production of atrial fibrillation.(u) D. Tall peaked T waves are classically associated with hyperkalemia.

REF: (9)

29. 2. DIAG STUDIES

Patients with heart failure may have a combination of systolic and diastolic failure. Which of the followingstudies should be used in diagnosing this condition?

A. radionuclide scanningB. echocardiogramC. exercise stress testing

D. cardiac catheterization

EXPLANATIONS:

(u) A. Radionuclide scanning is primarily used for the evaluation of coronary artery disease as it is able to

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

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

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dysfunction.

(u) C. Exercise stress testing is primarily used to assess a patient's cardiovascular status in response toexercise and is primarily a strategy involved in assessing patients for coronary artery disease, notcongestive or chronic heart failure.

(u) D. Cardiac catheterization has no role in the evaluation of a patient with CHF. It is used to assess theamount of coronary artery disease in a patient for whom revascularization surgery is being contemplated.

REF: (9)

30. 2. DIAG STUDIESThe most accurate method of diagnosing thrombophlebitis of the lower leg is

A. impedance plethysmography.B. physical exam findings.C. Doppler ultrasound.

D. venography.

EXPLANATION:

(u) A. See D for explanation.

(u) B. See D for explanation.(u) C. See D for explanation.

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

REF: (9)

31. 2. DIAG STUDIESThe serum creatine phosphokinase-mB (CPK-MB) rises to a peak after an acute myocardial infarctionafter how many hours?

A. 4 - 6B. 8 - 12

C. 18 - 20D. 48 - 72

EXPLANATIONS:

(u) A. See C for explanation.(u) B. See C for explanation.(c) C. CPK-MB is found mainly in cardiac muscle. It begins to rise in 4 to 6 hours, peaks at 18 hours, and

returns to normal in 48 hours.(u) D. See C for explanation.

REF: (9)

32. 2. DIAG STUDIESWhich of the following enzymes is most specific for injury or death of the heart muscle?

A. troponin-IB. serum aldolaseC. myoglobin

D. alanine aminotransferase

EXPLANATIONS:

(c) A. Troponin-I is a regulatory protein in the troponin cardiac muscle complex. It is specific formyocardium and is elevated in injury or death of the heart muscle.(u) B. Serum aldolase is elevated in skeletal muscle disorders, such as muscular dystrophies.

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(u) C. While myoglobin is elevated in heart muscle injury or death it is not specific.

(u) D. Alanine aminotransferase is predominantly found in the liver and is elevated in disorders causingliver cell injury.

REF: (9)

33. 2. DIAG STUDIES A 24-year-old male presents with a generalized erythematous maculopapular rash, including the palms

and soles of the feet. He also shows generalized lymphadenopathy and flat, moist lesions in the genitalarea. The patient admits to having had a lesion on his penis a month or so before, but it did not botherhim. Which of the following is the most appropriate to confirm the diagnosis?

A. C-reactive proteinB. Lyme titer

C. FTA-ABSD. Weil-Felix test

EXPLANATIONS:

(u) A. C-reactive protein is nonspecific for inflammatory processes.(u) B. Lyme titer is elevated in Lyme's disease.

(c) C. The fluorescent treponemal antibody absorption test is positive in secondary syphilis.(u) D. The Weil-Felix test is positive in cases of rickettsial diseases.

REF: (9)

34. 2. DIAG STUDIES A 55-year-old female presents with a mole that has changed appearance over the past few months. Shesays it has enlarged. Also noted is an asymmetric lesion with an irregular border and variation in color

from light brown to dark blue/black. Which of the following is the most appropriate?

A. curettage

B. shave biopsyC. excisional biopsy

D. aspiration for cytology

EXPLANATIONS:

(h) A. Curettage and shave biopsy are contraindicated for suspected melanoma because they leavebehind potentially cancerous cells.

(h) B. See A for explanation.(c) C. An excisional biopsy is indicated for suspected cases of melanoma.(u) D. See C for explanation.

REF: (9)

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35. 2. DIAG STUDIES

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

A. analysis of synovial fluid with polarized light

B. C-reactive proteinC. erythrocyte sedimentation rateD. serum and urine uric acid

EXPLANATIONS:(c) A. Although sedimentation rate, C-reactive protein, and uric acid levels may be elevated, the mostspecific diagnostic test for gout is the presence of negatively birefringent, needlelike crystals in leukocytes

from synovial fluid.(u) B. See A for explanation.(u) C. See A for explanation.


REF: (7)

36. 2. DIAG STUDIES

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

A. reassure the patient and reassess yearly.B. recheck in 1-3 months.C. do a fine needle aspiration.

D. obtain a CT scan of the neck.

EXPLANATIONS:

(h) A. See C for explanation.

(h) B. See C for explanation.(c) C. The combination of fine needle aspiration and radioisotope scanning of a solitary thyroid noduleprovides the best diagnostic yield. Because cold nodules may be cancerous, they are generally referred

for surgical removal. It is not reasonable to delay the diagnosis.(u) D. Ultrasound is preferred over MRI or CT scan of the thyroid.

REF: (7)

37. 2. DIAG STUDIESIn differentiating a viral pharyngitis from a streptococcal pharyngitis, which of the following must beincluded?

A. complete blood count with differentialB. ASO titer

C. cold agglutinin antibody testD. throat culture

EXPLANATIONS:

(u) A. CBC is too nonspecific to differentiate between the conditions.(u) B. ASO titers are used to identify past infections with strep, not current infections, as the titerincreases in the convalescent phase.

(u) C. Cold agglutinins are nonspecific and are positive in mycoplasma pneumonia, influenza,mononucleosis, and rheumatoid arthritis.(c) D. The throat culture is the definitive test to identify beta-hemolytic Group A streptococci.

REF: (9)

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38. 2. DIAG STUDIES A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile andappears well with a respiratory rate of 42 per minute. What is the next best step in the evaluation and

treatment of this patient?

A. lateral soft tissue x-ray of the neck

B. indirect laryngoscopy

C. thoracocentesisD. barium swallow

EXPLANATIONS:

(u) A. While lateral x-ray of the soft tissues of the neck may be done only 7% of all aspirated foreignbodies are radiopaque. Lateral x-ray is typically done for epiglottitis and retropharyngeal abscess.

(c) B. Laryngoscopy is indicated not only for diagnosis, but also removal of the foreign body.(u) C. Thoracocentesis is not indicated in patients with airway foreign body aspiration.(u) D. Barium swallow is used to evaluate for possible esophageal foreign body aspiration. Wheezing

and stridor are not common.

REF: (24)

39. 2. DIAG STUDIES A 24-year-old male presents with complaints of increasing drainage from both eyes associated with milddiscomfort for the past day. He denies severe or deep eye pain and any blurring of his vision. On

examination, his visual activity is 20/20 OU. There is moderate erythema and edema of the eyelids,diffuse conjunctival injection, and profuse thick mucopurulent discharge on the conjunctiva and lids.Which of the following is the most appropriate diagnostic evaluation?

A. cultureB. Giemsa stain

C. Tzanck smearD. direct fluorescent antibody testing

EXPLANATIONS:

(c) A. This is the typical presentation of a bacterial conjunctivitis. Due to the severity of the presentationand possibility of infection caused by Neisseria gonorrheae, initial evaluation by Gram stain and cultureshould be performed.

(u) B. Giemsa stain and direct fluorescent antibody testing are both indicated for evaluation of possibleinfection caused by Chlamydia trachomatis.(u) C. Tzanck smear is indicated for evaluation of possible infection caused by herpes simplex viruses.


REF: (16)

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40. 2. DIAG STUDIES

A 4-year-old patient presents with increasing redness and swelling involving her right eye for the past 2days. The mother states that the child has become increasingly irritable, less active, and appears tohave an increased temperature. The child had a recent "cold" and nasal congestion prior to onset of

these symptoms. Examination reveals an ill-appearing 4-year-old child lying quietly on the exam table.Temperature is 102° F. Visual activity is 20/40 in the right eye and 20/30 in the left eye. The right eyereveals mild proptosis and severe erythema, increased warmth, and swelling involving the eye and

surrounding tissues. Which of the following is the most appropriate diagnostic evaluation?

A. applanation tonometry

B. electronystagmographyC. orbital and sinus CT scanD. ultrasonography of sinuses

EXPLANATIONS:

(u) A. Applanation tonometry is utilized in the measurement of intraocular pressure with suspectedglaucoma and is, therefore, not indicated in this patient.

(u) B. Electronystagmography is an objective recording of induced nystagmus utilized for the evaluationof vertigo and is not indicated in this patient.(c) C. This is the typical presentation of orbital cellulitis. A CT scan of the orbit and sinuses is indicated

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

orbital cellulitis.(u) D. Ultrasonography of the sinuses is not clinically utilized to evaluate for the presence of sinusitis or

orbital cellulitis.

REF: (24)

41. 2. DIAG STUDIES A 65-year-old patient with a known history of alcohol and tobacco abuse presents with solid-fooddysphagia. The patient also had a 24 lb weight loss over the past 6 months. To establish a diagnosis,

which of the following studies should be performed?

A. CT scan

B. chest x-rayC. barium esophagramD. endoscopy

EXPLANATIONS:

(u) A. CT scan should be obtained once the diagnosis of carcinoma has been made to evaluate forpulmonary or hepatic metastases, lymphadenopathy, and local tumor extension.

(u) B. Chest x-ray may show adenopathy, a widened mediastinum, pulmonary or bony metastases, orsign of tracheoesophageal fistula such as pneumonia.(u) C. Barium esophagram is obtained as the first study to evaluate the dysphagia.

(c) D. Endoscopy with biopsy establishes the diagnosis of esophageal carcinoma with a high degree ofreliability when biopsy is included as part of the procedure.

REF: (16)

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42. 2. DIAG STUDIES

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

Temperature 101° F (38.3° C)Pulse 100 beats/minRespiratory rate 20/min

Blood pressure 110/65 mm Hg

The patient is in moderate distress and slightly diaphoretic. He has poor oral hygiene and the odor of

alcohol is noted. Examination of the heart and lungs are unremarkable except for tachycardia. Abdominal examination reveals hypoactive bowel sounds, diffuse tenderness with more markedtenderness in the epigastric area, without guarding, rebound, masses, or organomegaly. Along with

CBC, which of the following diagnostic studies would be most appropriate?

A. liver function tests, amylase, and abdominal films

B. ESR, urinalysis, and electrolytesC. electrolytes, ECG, and upper GID. ECG, barium enema, and sonogram

EXPLANATIONS:

(c) A. The clinical presentation suggests acute pancreatitis, which is best evaluated by liver functiontests, amylase, and abdominal films.

(u) B. ESR is for nonspecific indication of inflammation. Urinalysis may be useful for evaluating fluidstatus (specific gravity) or urinary system involvement only. Electrolytes may be useful in prolongedvomiting. These tests do not help in the diagnosis of any specific entities that may cause epigastric pain.

While an ECG may be indicated in patients with epigastric pain, an upper GI is not a first-line diagnostictest.(u) C. See B for explanation.

(u) D. Given the clinical presentation, a sonogram and barium enema are not indicated.

REF: (9)

43. 2. DIAG STUDIESWhich of the following is the most helpful serological test in primary biliary cirrhosis?

A. anti-smooth muscle antibodiesB. anti-mitochondrial antibodiesC. anti-hepatitis B antibodies

D. anti-nuclear antibodies

EXPLANATIONS:

(u) A. Anti-smooth muscle antibodies are commonly seen in autoimmune hepatitis.

(c) B. Anti-mitochondrial antibodies are seen in over 90% of cases of primary biliary cirrhosis and arerare in other forms of liver disease.(u) C. Anti-hepatitis B antibodies are commonly seen in viral hepatitis B.

(u) D. Anti-nuclear antibodies are commonly seen in rheumatoid arthritis, lupus, scleroderma, andSjogren syndrome.

REF: (9)

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44. 2. DIAG STUDIES

A 26-year-old male patient presents with complaints of diarrhea with marked flatulence and weight lossfor the past 6-8 months. In addition, he states that his stools are loose and soft with an oily appearanceand foul smelling. The patient has not traveled out of the country. Which of the following laboratory tests

would be most helpful based upon this history?

A. stool for leukocytes

B. stool for ova and parasites

C. stool for 72-hour fecal fatD. stool for culture and sensitivity

EXPLANATIONS:

(u) A. See B for explanation.(u) B. Laboratory tests stool for culture and sensitivity, leukocytes and ova and parasites would be

warranted if the patient had evidence of bacterial or parasitic infection.(c) C. Steatorrhea is usually present, but may be absent in mild disease of celiac sprue. A quantitative72-hour stool collection taken while patients are consuming a 100 gm fat diet is a more sensitive means

of detecting fat malabsorption.(u) D. See B for explanation.

REF: (16)

45. 2. DIAG STUDIESThe physician assistant is evaluating a patient suspected of having an iron

deficiency anemia. When examining the patient's peripheral blood smear, thediagnosis is reinforced by noting

A. shistocytes.B. Howell-Jolly bodies.C. macrocytic red blood cells.

D. hypochromic, microcytic red blood cells.

EXPLANATIONS:

(u) A. Shistocytes are typically noted in hemolytic anemias.(u) B. Howell-Jolly bodies are noted in patients who have had the spleen removed or have a non-functioning spleen.(u) C. Macrocytic red blood cells are noted in megaloblastic anemias, not iron deficiency anemia.

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

REF: (9)

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46. 2. DIAG STUDIES An 18-year-old patient presents with fever, pharyngitis, and cervical lymphadenopathy. The CBC showsa leukocytosis with 25% atypical lymphocytes. Which of the following is the diagnostic test of choice for

this patient?

A. heterophile test

B. throat culture

C. blood cultureD. lymph node biopsy

EXPLANATIONS:

(c) A. A heterophile test is the test of choice for the diagnosis of infectious mononucleosis.(u) B. Throat culture is used in the diagnosis of strep pharyngitis. Strep pharyngitis does not present withatypical lymphocytes.

(u) C. Blood cultures are of no value in the diagnosis of infectious mononucleosis.(u) D. A lymph node biopsy is used in the diagnosis of lymphoma. Lymphoma typically does not presentwith pharyngitis or atypical lymphocytes.

REF: (9)

47. 2. DIAG STUDIESWhich of the following would aid in the diagnosis of Reye’s syndrome?

A. hyperglycemiaB. elevated serum ammonia levelC. proteinuria

D. elevated cholesterol

EXPLANATIONS:

(u) A. Hypoglycemia is more likely to be seen in Reye’s syndrome.(c) B. Reye’s syndrome results in fatty liver with encephalopathy. It is a complication of influenza and

other viral illnesses, particularly in the young and with the use of aspirin. Laboratory characteristicsinclude elevated ammonia levels, elevation of liver enzymes, hypoglycemia, and a prolonged prothrombintime.(u) C. Reye’s syndrome does not affect the kidneys and should not result in proteinuria.

(u) D. Cholesterol should not be affected by Reye’s syndrome.

REF: (16)

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48. 2. DIAG STUDIES

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

A. hCG

B. alpha-fetoproteinC. folic acid levelsD. prolactin

EXPLANATIONS:(u) A. HCG is used to assess Down's Syndrome as part of the maternal triple screen.(c) B. Alpha-fetoprotein, measured at 16-18 weeks of pregnancy, if elevated, would indicate a neural

tube defect, such as spina bifida.(u) C. Folic acid has been shown to decrease the incidence of neural tube defects, not as an aid indiagnosis of the defect.

(u) D. Prolactin is a hormone with the main purpose of inducing lactation. It would have no value in thediagnosis of spina bifida.

REF: (27)

49. 2. DIAG STUDIES

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

A. complete blood count

B. lipid profileC. lumbar punctureD. electrocardiogram

EXPLANATIONS:

(u) A. A complete blood count has no diagnostic value in the evaluation of a subarachnoid hemorrhage.(u) B. A lipid profile may reveal elevated cholesterol and triglycerides, and risk factors for intracerebral

hemorrhages, but it is of no diagnostic value.(c). C. Although 95% of subarachnoid hemorrhages show blood on head CT, the remaining do not show

evidence of hemorrhaging. A lumbar puncture should then be performed and the fluid examined for redblood cells or xanthochromia.(u) D. An electrocardiogram may show diffuse T wave inversion in the precordial leads in a subarachnoidhemorrhage, but these are not always present.

REF: (9)

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50. 2. DIAG STUDIES

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

A. culture of the endocervix

B. culture of vaginal dischargeC. Gram stain of cervical dischargeD. presence of yellow discharge

EXPLANATIONS:(c) A. The standard for diagnosis of gonorrhea is the isolation of the organism by culture from theendocervix in women.

(u) B. See A for explanation.(u) C. Gram stain can be done on urethral and endocervical exudates to warrant a presumptivediagnosis.


REF: (9)

51. 2. DIAG STUDIESWhich of the following is the primary technique for evaluation of an abnormal cervical cytology smear?

A. laparoscopyB. colposcopyC. abdominal CT scan

D. dilation and curettageEXPLANATIONS:

(u) A. Laparoscopy is used to evaluate pelvic structure, not for evaluation of abnormal cervical cytologysmear.

(c) B. Colposcopy is the primary method for evaluation of abnormal cervical cytology smear.(u) C. Abdominal CT scan is used to evaluate pelvic structures.(u) D. Dilation and curettage is used to evaluate abnormal uterine bleeding.

REF: (27)

52. 2. DIAG STUDIES

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

A. osteophyte formation

B. chondrocalcinosisC. fat pad displacementD. moth-eaten bone destruction

EXPLANATIONS:

(c) A. Osteophyte formation and joint space narrowing are common in osteoarthritis.(u) B. Chondrocalcinosis is seen in pseudogout.

(u) C. Fat pad displacement is a soft tissue change noted in fractures of the wrist and elbow.(u) D. Moth-eaten bone destruction is noted in osteomyelitis and certain bone cancers.

REF: (9)

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53. 2. DIAG STUDIES

A break in the cortex of one side of the bony shaft without a separation or break of the opposite cortex iscalled what type of fracture?

A. greenstickB. transverseC. torus

D. epiphyseal

EXPLANATIONS:

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

opposite cortex.(u) B. A transverse fracture is a complete fracture of both cortices.(u) C. A torus fracture is a bowing, bending, or buckling without a break in the cortex.

(u) D. Epiphyseal fracture occurs at the growth plate.

REF: (24)

54. 2. DIAG STUDIES

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

A. metabolic acidosisB. hypokalemiaC. hyperalbuminemiaD. amenorrhea

EXPLANATIONS:

(u) A. A metabolic alkalosis may be noted if potassium losses from purging are great enough.

(c) B. Episodes of binge eating are followed by purging in the bulimic patient. Vomiting and laxativeabuse are the most common methods of purging, leading to hypokalemia.(u) C. Serum albumin levels may be normal or decreased.

(u) D. Unlike anorexia nervosa, a patient who is bulimic may maintain a normal body weight and normalmenstruation.

REF: (13)

55. 2. DIAG STUDIESWhich of the following laboratory tests is most appropriate to perform on a patient taking clozapine(Clozaril)?

A. BUN and creatinineB. white blood cell count

C. liver function testsD. brain EEG

EXPLANATIONS:

(u) A. See B for explanation.(c) B. Agranulocytosis is a known complication of clozapine and weekly complete blood counts aremandatory when this medication is

given.(u) C. See B for explanation.(u) D. See B for explanation.

REF: (14)

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56. 2. DIAG STUDIESWhich of the following is the most common radiographic presentation of pulmonary tuberculosis?

A. cavitationB. pleural thickeningC. hilar mass

D. hyperinflation

EXPLANATIONS:

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

(u) B. Pleural thickening is noted in mesothelioma.(u) C. Hilar and mediastinal abnormalities are common on chest radiography in patients with lung cancer.(u) D. Hyperinflation is the main clinical feature in emphysema.

REF: (9)

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

on spirometry?

A. forced vital capacity (FVC)B. total lung capacity (TLC)C. residual volume (RV)D. RV/TLC ratio

EXPLANATIONS:

(c) A. In severe COPD, the forced vital capacity is markedly reduced. Lung volume measurementsreveal an increase in total lung capacity, a marked increase in residual volume, and an elevation of the

RV/TLC ratio,is indicative of air trapping, particularly in emphysema.(u) B. See A for explanation.(u) C. See A for explanation.


REF: (16)

58. 2. DIAG STUDIES A 68-year-old patient with chronic obstructive pulmonary disease will typically demonstrate a decreased

A. serum bicarbonate content.B. blood hemoglobin.C. blood pCO2.

D. blood pH.

EXPLANATIONS:

(u) A. The serum bicarbonate content is sometimes normal, but is usually increased in respiratoryacidosis.(u) B. An elevated, not decreased, hemoglobin can be seen in heavy smokers, which is the primarycause of emphysema.

(u) C. COPD causes CO2 retention, which would result in an increased, not decreased, pCO2.

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

REF: (16)

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59. 2. DIAG STUDIES

The diagnostic gold standard to rule out pulmonary embolism is

A. chest x-ray.

B. spiral CT scan.C. ventilation/perfusion scan.D. pulmonary angiography.

EXPLANATIONS:

(u) A. See D for explanation.(u) B. See D for explanation.(u) C. See D for explanation.

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

REF: (9)

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

should

A. collect a urine for culture and sensitivity.

B. do nothing, since these casts are considered normal.C. refer the patient to a nephrologist.D. schedule the patient for a CT scan.

EXPLANATIONS:

(u) A. See B for explanation.

(c) B. Hyaline casts are not indicative of renal disease. They can be found following strenuous exerciseand with concentrated urine or during a febrile illness.(u) C. See B for explanation.


REF: (16)

61. 2. DIAG STUDIES

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

A. red blood cell casts

B. hyaline castsC. leukocyte castsD. renal tubular epithelial casts

EXPLANATIONS:

(u) A. Red blood cell casts are seen in glomerular disease.(u) B. Hyaline casts may be seen in normal urine.(c) C. White blood cell casts are pathognomonic for acute pyelonephritis.

(u) D. Renal tubular epithelial cell casts are associated with ischemic and nephrotoxic acute renal failure.

REF: (9)

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62. 2. DIAG STUDIESIn renal insufficiency, which of the following is used to assess glomerular filtration rate (GFR)?

A. urinalysisB. blood urea nitrogenC. renal plasma flow measure

D. creatinine clearance

EXPLANATIONS:

(u) A. See D for explanation.(u) B. See D for explanation.

(u) C. See D for explanation.(c) D. The GFR provides an overall index of renal function. Creatinine is normally cleared by renalexcretion; as renal GFR declines, serum creatinine will increase.

REF: (16)

63. 3. DIAGNOSIS A 59-year-old male complains of pain in his right leg for the last few months. He is normally able to walk

two miles a day, but has noted pain when he climbs hills, which is relieved with rest or resuming walkingon flat ground. He also complains of foot pain at rest. He does not smoke and denies injury to his back.He has been generally healthy with obesity and mildly elevated triglycerides. The most likely cause of

the pain in this patient is

A. sciatica.B. diabetic neuropathy.

C. deep vein thrombosis.D. intermittent claudication.

EXPLANATIONS:

(u) A. See D for explanation.

(u) B. See D for explanation.(u) C. Deep vein thrombosis does not cause intermittent pain, but rather continuous aching pain notrelieved by rest.

(c) D. Symptoms of intermittent claudication and arterial occlusive disease include pain with exercise thatis relieved by rest; pain in the feet at rest indicates severe circulatory compromise. The history of obesityand elevated triglycerides is consistent with peripheral vascular disease. Although this patient could also

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

REF: (9)

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64. 3. DIAGNOSIS

A 46-year-old female is being evaluated for a new-onset hypertension that was discovered on screeningat her workplace. The patient had several readings revealing systolic and diastolic hypertension.Physical examination is normal. A complete laboratory evaluation was performed with unexplained

hypokalemia as the only abnormality found. Which of the following is the most likely diagnosis for thispatient?

A. pheochromocytoma

B. renal artery stenosisC. coarctation of the aorta

D. primary aldosteronism

EXPLANATIONS:

(u) A. Pheochromocytoma will result in an increase in the production and release of catecholamines,

which results in an increase in urinary metanephrines on testing.(u) B. Renal artery stenosis is identified by an abnormal radionuclide uptake on the affected kidney.(u) C. Coarctation of the aorta is identified by delayed and weakened femoral pulses along with a blood

pressure in the lower extremities significantly lower than in the upper extremities.(c) D. Primary aldosteronism has an increased aldosterone secretion, which causes the retention ofsodium and the loss of potassium. This should be the primary consideration for this patient.

REF: (9)

65. 3. DIAGNOSIS An 8-year-old boy is brought to a physician because of palpitation, fatigue, and dyspnea. Onexamination, a continuous machinery murmur is heard best in the second left intercostal space and is

widely transmitted over the precordium. The most likely diagnosis is

A. ventricular septal defect.

B. atrial septal defect.C. congenital aortic stenosis.D. patent ductus arteriosus.

EXPLANATIONS:

(u) A. VSD causes a holosystolic murmur rather than a continuous machinery-like murmur.(u) B. ASD causes a fixed split S2 rather than a continuous systolic heart murmur.(u) C. Congenital aortic stenosis causes a crescendo-decrescendo systolic murmur heard best in the

second intercostal space.(c) D. Patent ductus arteriosus is classically described in children as a continuous machinery-typemurmur that is widely transmitted across the precordium.

REF: (9)

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66. 3. DIAGNOSIS

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

with

A. bronchial asthma.

B. hyperventilation syndrome.

C. spontaneous pneumothorax.D. anaerobial emphysema.

EXPLANATIONS:

(u) A. Bronchial asthma attacks are associated with increased dyspnea and prolonged expiration.Patients may use accessory muscles of respiration as part of this acute condition.(c) B. Anxiety may result in hyperventilation that can result in perioral numbness and paresthesias of the

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

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

(u) C. Spontaneous pneumothorax patients will primarily complain of significant chest pain along withtheir dyspnea. These patients will not have perioral or extremity paresthesias.

(u) D. Emphysema alone will not result in hyperventilation or the production of perioral or extremityparesthesias and is a chronic progressive rather than an acute onset condition.

REF: (9)

67. 3. DIAGNOSIS A 12-year-old boy presents to the office with pain in his legs with activity gradually becoming worse over

the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination ofthe heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses areweak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated.

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

A. abdominal aortic aneurysm

B. pheochromocytomaC. coarctation of the aortaD. thoracic outlet syndrome

EXPLANATIONS:

(u) A. Abdominal aortic aneurysm is usually asymptomatic until the patient has dissection or rupture. It isuncommon in a child.(u) B. Pheochromocytoma classically causes paroxysms of hypertension due to catecholamine release

from the adrenal medulla, but does not cause variations in blood pressure in the upper and lowerextremities.(c) C. Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a

result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile

intercostal arteries and the "3"is due to the coarctation site with proximal and distal dilations.

(u) D. Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or subclavian veinbecomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterialocclusion in the upper extremity of adults under 40 years old.

REF: (5)

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68. 3. DIAGNOSIS A 55-year-old morbidly obese male is seen in the office for routine examination. He has a history ofpulmonary hypertension and cor pulmonale. Examination reveals a palpable jugular venous pulse along

with a systolic flow murmur on the right side of the sternum. Which of the following is the most likelydiagnosis?

A. mitral insufficiency

B. tricuspid insufficiencyC. hepatic vein thrombosis

D. aneurysm of the thoracic aorta

EXPLANATIONS:

(u) A. Mitral insufficiency results in the accumulation of blood primarily in the pulmonary system and notthe right side of the heart.

(c) B. Tricuspid insufficiency will result in blood being put back into the right side of the body withincreased jugular pulsation in the neck, along with a palpable venous pulse in the liver.(u) C. Hepatic vein thrombosis or Budd-Chiari syndrome is associated with cirrhosis and liver clotting

abnormalities and is not due to right-sided heart failure.(u) D. Thoracic aorta aneurysm results in a widened mediastinum that is fairly asymptomatic until itresults in rupture or dissection. These are typically found as incidental findings unless they are

symptomatic from dissection or rupture, which causes severe chest pain or a severe tearing sensation inthe chest.

REF: (9)

69. 3. DIAGNOSIS

On a routine neonate examination, a grade IV/VI holosystolic murmur is heard in the 3rd-4th leftintercostal space in the parasternal line. The murmur is most likely that of

A. atrial septal defect.B. ventricular septal defect.C. patent ductus arteriosus.

D. mitral stenosis.

EXPLANATIONS:

(u) A. Atrial septal defect will cause fixed splitting of the S2 heart sound as its dramatic auscultatoryfinding.

(c) B. Ventricular septal defect does cause a holosystolic murmur with blood flowing primarily from theleft to the right side during systole.(u) C. Patent ductus arteriosus causes a continuous machinery -like murmur from blood flowing through

this structure that failed to close after birth.(u) D. Mitral stenosis causes an opening snap and is a diastolic, not systolic, heart murmur.

REF: (9)

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70. 3. DIAGNOSIS

A patient presents complaining of dyspnea with exercise that worsen at night. He has to use threepillows to sleep comfortably. The most likely diagnosis is which of the following?

A. pneumoniaB. mitral valve diseaseC. chronic heart failure

D. atelectasis

EXPLANATIONS:

(u) A. Pneumonia may be related to episodic dyspnea related to coughing, but it does not classicallycause orthopnea.

(u) B. Mitral valve disease may cause exertional dyspnea as one of the early symptoms from bloodbacking up into the pulmonary system, but it does not primarily cause orthopnea unless this is related tochronic heart failure.

(c) C. Congestive or chronic heart failure is associated with orthopnea and even paroxysmal nocturnaldyspnea because of increased venous return of blood to the heart when the patient assumes a supineposition.

(u) D. Atelectasis results from a portion of the lung collapsing, usually due to patients not taking a deepbreath. This condition is primarily seen in post-operative patients who have pain that makes deepbreathing difficult.

REF: (16)

71. 3. DIAGNOSIS A 65-year-old male presents to the emergency department with chest pain since yesterday. The patientdescribes the pain as severe with tingling, but denies dyspnea. On examination, there is a tender band

of erythema with superimposed vesicles and bullae on the left anterior chest wall, extending from the leftside of the sternum laterally. Which of the following is the most likely diagnosis?

A. bullous pemphigoidB. contact dermatitisC. pityriasis rosea

D. herpes zoster

EXPLANATIONS:

(u) A. The lesions of bullous pemphigoid may be pruritic, but are not painful.(u) B. The lesions of contact dermatitis are not painful.

(u) C. Pityriasis rosea usually occurs in children and young adults and is characterized by multiple pinkoval lesions that are scattered symmetrically, with a Christmas tree like distribution over the trunk.(c) D. Herpes zoster presents with painful vesicular rash in dermatomal distribution.

REF: (16)

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72. 3. DIAGNOSIS

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

most likely diagnosis is

A. impetigo.

B. psoriasis.

C. atopic dermatitis.D. allergic contact dermatitis.

EXPLANATIONS:

(c) A. The vesiculopustular form of impetigo is characterized by golden-crusted lesions.(u) B. Psoriasis is characterized by silvery scales on bright red, well-demarcated plaques.(u) C. Atopic dermatitis is characterized by pruritic, exudative, or lichenified eruptions.

(u) D. While allergic contact dermatitis presents with vesicular lesions and may go on to form crusts,honey-colored crusts are classically a finding of impetigo.

REF: (12)

73. 3. DIAGNOSIS A 72-year-old male presents to the clinic for evaluation of a bump on his nose. The patient is a lifelongresident of Florida and an avid golfer. On examination, a 1 cm round, firm, pearly nodule with fine

telangiectasias is noted. Which of the following is the most likely diagnosis?

A. basal cell carcinomaB. squamous cell carcinoma

C. seborrheic keratosisD. actinic keratosis

EXPLANATIONS:

(c) A. The lesion of basal cell carcinoma is typically firm, round, and pearly or waxy. It is the mostcommon cutaneous neoplasm in humans, with 85% of them occurring on the head or neck. Margintelangiectasis are classically associated with basal cell carcinomas. Risk factors include fair skin,

excessive sun exposure, and male gender.(u) B. Lesions of squamous cell carcinoma vary in appearance, but do not have overlyingtelangiectasias.

(u) C. The lesions of seborrheic keratosis demonstrate a well-circumscribed border, have a stuck-onappearance, and are a variable tan-brown-black color.(u) D. Lesions of actinic keratosis are 3-6 mm in size, have a rough texture, with eventual formation of a

yellow adherent crust. These lesions are found in sun-exposed areas and may be consideredpremalignant.

REF: (16)

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74. 3. DIAGNOSIS

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

A. thyrotoxicosisB. hypothyroidism

C. Cushing's disease

D. Addison's disease

EXPLANATIONS:

(u) A. Thyrotoxicosis, hypothyroidism and Cushing's disease may present with vitiligo, ahypopigmentation disorder, not hyperpigmentation.(u) B. See A for explanation.

(u) C. See A for explanation.(c) D. This is a classic presentation of Addison's disease, lack of inhibitation of MSH leads tohyperpigmentation.

REF: (16)

75. 3. DIAGNOSIS

A 58-year-old chemotherapy patient presents with fever, chills, productive cough, and disorientation.The patient appears very ill. Vital signs include:

T 102° F

P 138/minR 24/minBP 70/40 mm Hg

Laboratory results include:

WBC 2.1 x 103/mm3 Na 140 mEq/LCI 90 mEq/L

HCO3- 15 mEq/L

Glucose 140 mg/dL

Besides sepsis, the most likely diagnosis is

A. lactic acidosis.

B. hyperglycemia.C. hyperchloremia.D. blast crisis.

EXPLANATIONS:

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

tissue perfusion, lactic acid builds up due to anaerobic metabolism, leading to accumulation of an"unmeasured ion."

(u) B. The glucose level is only mildly elevated and would not constitute hyperglycemia.(u) C. The chloride is low, not elevated.(u) D. Severely elevated WBC with blast forms would most likely accompany a blast crisis.

REF: (7)

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76. 3. DIAGNOSIS A 72-year-old patient with Type 2 diabetes treated with glyburide is brought into the clinic by herdaughter, who provides the patient's history. The patient has had a mild fever, sore throat, and

excessive diuresis for the past 2 days. She has been reluctant to eat or drink because of the sore throat. At the clinic, she becomes increasingly stuporous and lethargic. Based on this information, the patient ismost likely experiencing

A. a diabetic ketoacidosis.B. a nonketotic hyperglycemic hyperosmolar state.

C. hypoglycemia secondary to her refusal to eat.D. lactic acidosis secondary to an infectious process.

EXPLANATIONS: Ref 6

(u) A. Diabetic ketoacidosis is usually preceded by a day or more of polyuria and polydipsia in

association with nausea and vomiting in someone receiving insulin. (c) B. A nonketotic hyperglycemichyperosmolar coma is most common in an elderly patient with mild diabetes. Lethargy and confusiondevelop as osmolality rises to 300 mosm/kg or higher.

(a) C. Although hypoglycemia induced by oral glucose lowering agents is less common, it tends tooccur in elderly patients with impaired renal function and is generally associated with longer actingsulfonylureas.

(u) D. Lactic acidosis is a possibility, but is often associated with a severe infectious process, which isnot definite in this patient.

REF: (9)

77. 3. DIAGNOSIS

A 2-year-old child presents to the emergency department with increasing respiratory distress. Themother states that the child had a "cold" 2 weeks ago. Last week the cough progressed and is describedas barky in nature, associated with stridor. The child appeared to be getting better, but last night,

developed a fever and increased respiratory distress. Physical examination reveals a temperature of

102° F. The child is in moderate respiratory distress. A portable lateral neck x-ray film reveals severesubglottic and tracheal narrowing. Which of the following is the most likely diagnosis?

A. acute epiglottitisB. bacterial tracheitis

C. acute spasmodic croupD. laryngotracheobronchitis

EXPLANATIONS: Ref 12

(h) A. While acute epiglottitis usually presents with respiratory distress and high fever, it is also typically

associated with dysphagia and drooling. Findings on a lateral neck x-ray film would be consistent withswelling of the epiglottitis described as a "thumbprint"sign.(c) B. Bacterial tracheitis usually presents following a viral upper respiratory infection, especially

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

respiratory distress after a few days of apparent improvement or if the patient fails to respond to the usualtreatment for croup. The findings of subglottic and tracheal narrowing on the lateral neck x-ray film highly

support this diagnosis.(h) C. Acute spasmodic croup is clinically very similar to acute laryngotracheobronchitis, but the patient isusually afebrile and the lateral neck x-ray film would be unremarkable.

(h) D. See C for explanation.

REF: (12)

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78. 3. DIAGNOSIS A 62-year-old male with Type 2 diabetes presents complaining of left ear pain and drainage for the past 2weeks. He states the pain is deep in the ear and that the drainage is greenish and foul-smelling and has

increased over the past 2 weeks. He denies cough, congestion, fever, or placing anything in his ear. Onphysical examination, the patient is afebrile. Otoscopic examination reveals a markedly edematous leftear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized.

Examination of the right ear is unremarkable. Which of the following is the most likely diagnosis?

A. auricular cellulitis

B. acute mastoiditisC. chronic otitis externaD. malignant otitis externa

EXPLANATIONS:

(h) A. Auricular cellulitis usually presents with swelling, erythema, and tenderness of the ear, primarilyinvolving the lobule of the ear. There would not be any associated otorrhea.(h) B. Acute mastoiditis presents with pain, tenderness, and swelling over the mastoid. This can

accompany an untreated acute otitis media, but is now rare with prompt antibiotic treatment of acute otitismedia.(h) C. Chronic otitis externa presents primarily with pruritus and rarely is associated with ear pain. It is

usually caused by irritation from repeated minor trauma to the ear canal or drainage from a chronicmiddle ear infection.(c) D. Malignant (invasive) otitis externa is seen primarily in patients with diabetes. It usually presents

with ear pain and drainage present for several weeks to months. Physical examination findings includean edematous ear canal with the presence of granulation tissue in the posterior wall at the mid-portion ofthe canal. Fever is rare. Accurate diagnosis is needed for this patient as this is a potentially life-threatening infection.

REF: (9)

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

probable diagnosis?

A. Ramsay Hunt syndrome

B. presbycusisC. Meniere's syndromeD. vestibular neuronitis

EXPLANATIONS:

(u) A. Ramsey-Hunt syndrome is caused by herpes zoster. It presents with facial palsy, lesions of theexternal ear, vertigo, tinnitus, and deafness.(u) B. Presbycusis is sensory hearing loss associated with aging. Tinnitus and vertigo are not associated

with presbycusis.

(c) C. Meniere's syndrome is associated with the triad of hearing loss, vertigo, and tinnitus. It resultsfrom the distention of the endolymphatic compartment of the inner ear.

(u) D. Vestibular neuronitis is characterized by vertigo without any loss of hearing.

REF: (16)

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c = Correct u = Unsatisfa

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