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Question 1 of 67
1. Question
A 71-year-old heavy smoker has weight loss and hemoptysis. A chest radiograph reveals a mass lesion in the left lung and biopsy confirms a squamous carcinoma. Which of the following would be regarded as a contraindication to surgery?
Correct
Malignant pleural effusion
Incorrect
Explanation:
Inoperable non-small cell carcinomas are Stages IIIb or IV (distant metastasis). Stage IIInb is either N3 (metastasis to contralateral mediastinal lymph nodes, contralateral hilar lymph nodes, ipsilateral supraclavicular lymph nodes) or T4 (tumour of any size invading mediastinum or involving heart great vessels, trachea, esophagus, vertebral body, carina, or presence of malignant pleural effusion ).
Hypercalcemia may be a non-metastatic manifesting (ectopic PTH-like hormone).Further lung function tests are needed (e.g. transfer factor, exercise testing) if post-bronchodilator FEV1<1.5 litres for lobectomy, and FEV1<2 limited chest wall invasion and no evidence of distant metastases are considered potentially curable (stage IIIA). -
Question 2 of 67
2. Question
A 41 year old man had a routine chest x-ray which revealed a solid nodule (“coin lesion”) measuring 3.0 x 3.2 cm in the right upper lobe. Tomograms showed no evidence of a cavity or calcification. Tuberculin test was positive. Skin and serologic tests for coccidioidomycosis and histoplasmosis were negative. This patient should
Correct
Enter hospital for biopsy and possible resection of the lesion
Incorrect
Explanation:
A solitary pulmonary nodule is defined as a discrete lesion < 3 cm in diameter that is completely surrounded by lung parenchyma, does not touch the hilum or mediastinum, and is without associated atelectasis or pleural effusion.
Calcification suggests benign disease, particularly if it is central (tuberculoma, histoplasmoma), concentric (healed histoplasmosis), or in popcorn configuration (hamartoma). CT scanning is often necessary to – detect these patterns. Margin patterns are also suggestive. Spiculated or irregular (scalloped) margins are more indicative of malignancy. Diameter < 1.5 cm strongly suggests a benign etiology; diameter > 5.3 cm strongly suggests malignancy.
When historical information or radiographic appearance is not diagnostic, biopsy and culture may be useful, but usually only when history supports TB or coccidioidomycosis as possible diagnoses. Although cancers can be diagnosed by biopsy, definitive treatment is resection, and so invasive testing should be reserved for patients in whom nonmalignant causes are a possibility. -
Question 3 of 67
3. Question
A 66 year old man is going for an elective surgery. He has a history of exertional chest pain for 4 month and develops similar episode of chest pain the night before the surgery that relieves with rest. ECG is normal and cardiac enzymes are not elevated. What action is appropriate to take?
Correct
Postpone the operation and do a stress test
Incorrect
Explanation:
Before an elective surgery most patients will have labs and tests done to determine if the patient is suitable and safe candidate for the surgery. Typical tests include CBC, CRP, EKG, Chest x-rays and urinalysis. Chest pain in an elderly individual warrants further pre-op testing, most appropriately with a cardiac stress test. A cardiac stress test is a medical test performed to evaluate arterial blood flow to (and indirectly the amount of oxygen that will reach) the myocardium (heart muscle) during physical exercise, compared to blood flow while at rest.
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Question 4 of 67
4. Question
A 42 year old woman presents to the ER with fever and left flank pain radiating to the groin. No nausea or vomiting is present. Body CT reveals 8 mm stone in the left proximal ureter. You should
Correct
Admit, hydration, analgesics and IV antibiotics. (e. g. Amp and Gent), and consider stenting if the symptom persists
Incorrect
Explanation:
As stones increase in size beyond 4 mm, the need for urologic intervention increases exponentially. Referral to a urologist is indicated for patients with a stone greater than 5 mm in size for possible surgical intervention (stent placement). Referral is also indicated for patients with a ureteral stone that has not passed after two to four weeks of observation. The complication rate for ureteral calculi has been reported to almost triple (to 20 percent) when symptomatic stones are left untreated beyond four weeks.
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Question 5 of 67
5. Question
A 22 years young adult is brought to the hospital 8 hours after a motor vehicle accident. He is in shock and severe respiratory distress. His upper airway is clear. Trachea is deviated to the right. Breath sounds are absent over the left chest with a dull percussion note. Breath sounds are normal on the right side. The patient has
Correct
Massive hemothorax
Incorrect
Explanation:
In a hemothorax blood from damaged intercostal, pleural, mediastinal, and sometimes lung parenchymal vessels enters the pleural cavity.
Depending on the amount of bleeding and the underlying cause, hemothorax may be associated with varying degrees of lung collapse and mediastinal shift. It usually results from blunt or penetrating chest trauma. Hemothorax may result from thoracic surgery, pulmonary infarction, neoplasm, dissecting thoracic aneurysm, or anticoagulant therapy.
Lung percussion reveals dullness, and auscultation reveals decreased to absent breath sounds over the affected side. Symptoms include chest pain, tachypnea, mild to severe dyspnea (difficulty breathing) may be present. If respiratory failure results, the patient may appear anxious, restless, possibly stuporous, and cyanotic. Marked blood loss produces hypotension and shock.
The affected side of the chest expands and stiffens, while the unaffected side rises and falls with the patient´s gasping respirations. -
Question 6 of 67
6. Question
A 77 year old male presents to the emergency room with a history of pain in the abdomen and back. He is hypotensive, and has a tender, pulsatile abdominal mass. Which is the appropriate immediate management?
Correct
Transfer to the operating room
Incorrect
Explanation:
Abdominal aortic aneurysms (AAA) are aneurysms that occur in the part of the aorta that passes through the abdomen (abdominal aorta). Abdominal aortic aneurysms may occur at any age but are most common among men aged 50 to 80 years. Abdominal aortic aneurysms tend to run in families and to occur in people who have high blood pressure, especially those who also smoke. About 20% of abdominal aneurysms eventually rupture. People who have an abdominal aortic aneurysm often become aware of a pulsing sensation in their abdomen. The aneurysm may cause pain, typically a deep, penetrating pain mainly in the back. The pain can be severe and is usually unrelenting if the aneurysm is leaking. When an aneurysm ruptures, the first symptom is usually excruciating pain in the lower abdomen and back and tenderness in the area over the aneurysm. If the resulting internal bleeding is severe, a person may rapidly go into shock. A ruptured abdominal aneurysm is often fatal. This patient should initially be managed with IV fluids. He will then require a CT scan to demonstrate the aneurysm, and surgery if indicated by the results of the imaging. Abdominal aortic aneurysms > 5 cm in diameter that have ruptured should be surgically repaired immediately.
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Question 7 of 67
7. Question
A 77 year old man has a history of dyspnea on exertion which has worsened over the last several months. No history of chest pain and syncope is present, and was fairly active until the shortness of breath slowed him down recently. On auscultation a grade 3/6 systolic ejection murmur at the right upper sternal border is heard which radiates into the neck. Echocardiography reveals aortic stenosis with a mean transvalvular gradient of 55 mm Hg and a calculated valve area of 9.6 gm2. Left ventricular function is normal. The appropriate management for this patient is which one of the following?
Correct
Aortic valve replacement
Incorrect
Explanation:
Since this patient´s mean aortic-valve gradient exceeds 50 mm Hg and the aortic-valve area is not larger than 1 cm2, it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a dismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptom and does not prolong survival. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis.
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Question 8 of 67
8. Question
A 63 year old man experienced a ten-minute attack of right sided weakness with associated difficulty speaking one week ago. Bilateral carotid atheroma was revealed on carotid ultrasound testing with a 20% carotid stenosis on the left, and an 80% carotid stenosis on the right. Past illness include mild hypertension under treatment. Systemic examination reveals no symptoms suggestive of coronary artery disease. His neurological examination is normal. Appropriate management of this patient would be
Correct
Right carotid endarterectomy
Incorrect
Explanation:
Carotid stenosis refers to the blockage and narrowing of the carotid artery in the neck. The carotid artery supplies blood to the brain. This blockage is causes by fatty build up called plaque and is also referred to as atherosclerosis. This fatty material accumulates in the inner lining of blood vessels and results in narrowing, stenosis and irregularity of the artery. This may result in the formation of blood ´ clots which dislodge and flow up to the brain.
For a patient with <50% occluded artery medication may be prescribed to try and prevent a thromboembolic event (a blood clot to the brain). Medication such as aspirin, and Plavix interfere with platelet function that is involved in blood clotting. Other medication are anticoagulants and these interfere with the formation of a blood clot. Heparin arid coumadin are examples.
Carotid endarterectomy may be recommended for patients with severe symptomatic stenosis of >70% of the vessel. Under a general anesthetic the surgeon exposes and opens the carotid artery. Meticulous removal of the plaque and precise closure of the vessel with a microsurgical technique. -
Question 9 of 67
9. Question
A 79 year old male comes to see you after attending a health fair. He is concerned because he had a prostate-specific antigen (PSA) level of 5.0ng/mL (N 0.0-4.0). He has never had his PSA checked before. His medical history is significant for class IV heart failure. His treatment includes furosemide (Lasix), Enalapril (Vasotec), carvedilol (Coreg), digoxin, and Spironolactone (Aldactone). Systemic review is positive for longstanding nocturia and gradually worsening weakness of the urinary stream. Bibasilar rales, an S3 gallop, and moderate lower extremity edema are present on physical examination. His prostate is diffusely large and smooth. His urinalysis is unremarkable. The most appropriate management for his elevated PSA is
Correct
No intervention
Incorrect
Explanation:
The patient described has a life expectancy that makes the risk-benefit ratio for the detection of asymptomatic prostate cancer extremely unfavorable. In addition, a mildly elevated PSA in a 79 year old with a large prostrate is most likely due to benign prostatic hypertrophy.
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Question 10 of 67
10. Question
Which one of the following cardiomyopathies is due to impairment in contractility?
Correct
Dilated cardiomyopathy
Incorrect
Explanation:
The term dilated cardiomyopathy (DCM) is applied to a form of cardiomyopathy characterized by progressive cardiac dilation and contractile (systolic) dysfunction, usually with concomitant hypertrophy. It is sometimes called congestive cardiomyopathy.
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Question 11 of 67
11. Question
A 38-year-old female is being considered for a renal transplant. Which one of the following is the second criterion for allograft matching in renal transplantation?
Correct
MHC class II matching (HLA-DR, DQ, and DR)
Incorrect
Explanation:
ABO compatibility is the first immunologic consideration in the matching of renal transplants. After ABO compatibility is made, MHC class II matching is most important, followed by MHC class I matching, then minor histocompatibility antigen matching. Matching of sexes between transplant recipients and donors is relatively unimportant.
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Question 12 of 67
12. Question
The most likely disease process to produce transudative pleural effusion is which one of the following?
Correct
Congestive heart failure
Incorrect
Explanation:
Congestive heart failure has a 60-70% prevalence of an associated pleural effusion.
Other processes that commonly produce a pleural effusion include constrictive pericarditis, pulmonary embolus, and malignancy. Cirrhosis, nephrotic syndrome, and pneumonia are less apt to produce a pleural effusion. -
Question 13 of 67
13. Question
A 34-year-old white female presents with progressive exertional dyspnea. Her past medical history is significant for a prior syncopal episode and Raynaud´s phenomenon. On further testing, she was found to have severe cor pulmonale (right ventricular enlargement secondary to malfunction of lungs producing pulmonary hypertension). Cardiac catheterization reveals pulmonary artery narrowing. All of the following could be used to treat this condition EXCEPT.
Correct
Steroids.
Incorrect
Explanation:
Steroids are not used in primary pulmonary hypertension. This is a rare disorder with a poor prognosis. It is more common in young females in a 5:1 ratio. Ventilation-perfusion scanning, pulmonary function tests, echocardiogram, and cardiac catheterization are some of the tests used to rule out other causes of pulmonary hypertension. Heart lung transplantation is the only known cure for this disorder. Prostacyclin is a very potent vasodilator which can vasodilate the pulmonary artery. Prostacyclin can be given in aerosolized form. Nifedipine is a calcium channel blocker which can cause vasodilation of the pulmonary artery but this effect is temporary Hydralazine is also a vasodilator.
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Question 14 of 67
14. Question
What pleural fluid lab value is elevated in patients with pleural effusion caused by tuberculous pleurisy?
Correct
Adenosine deaminase levels.
Incorrect
Explanation:
An adenosine deaminase level of > 70 U/L is virtually diagnostic of tuberculous pleuritis. Levels < 40 U/L usually rule out this diagnosis. Glucose and pH should be reduced in a tuberculous pleural effusion. Amylase and triglycerides are not usually elevated.
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Question 15 of 67
15. Question
Which of the following manifestations of Marfan´s syndrome is a relative contraindication to pregnancy?
Correct
Aortic root dilatation
Incorrect
Explanation:
A woman, with Marfan´s syndrome who has significant aortic root dilatation is at much greater risk for aortic rupture or dissection during pregnancy. The other symptoms are all associated with Marfan´s, but do not have any known adverse effects on pregnancy.
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Question 16 of 67
16. Question
A 16-year-old male presents to the emergency room following a laceration to his wrist. Bright red blood is spurting out of the wound in a brisk and pulsatile manner. His heart rate is 80 beats per minute and blood pressure is 120/80. The most appropriate initial intervention would be to
Correct
Apply direct pressure over the bleeding site.
Incorrect
Explanation:
All bleeding can be temporarily controlled with direct pressure and in most cases this will be the only intervention that is necessary. While it is controversial whether an isolated radial artery should be repaired, this should only be attempted after the bleeding is controlled. The patient may lose a critical amount of blood on the way to the operating room. Applying a tourniquet will decrease blood loss but does nothing to encourage clotting and clamping of vessels in the wrist and hand in the emergency room should be avoided secondary to the close proximity of nerves. While the patient may need a blood transfusion, control of bleeding should be the first intervention. Elevation alone will not control the bleeding.
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Question 17 of 67
17. Question
An old man is transferred from a nursing home to the emergency department because of generalized edema and oliguria. The patient is afebrile, and his blood pressure is within normal limits. Blood samples yield a serum creatinine of 2.0 mg/dL and serum urea nitrogen of 65mg/dL. The most likely diagnosis is
Correct
Prostatic hyperplasia
Incorrect
Explanation:
This elderly patient with oliguria and edema has high serum creatinine (normal 0.6-1 .2 mg/dL) and high serum urea nitrogen (normal 7-18 mg/dL). The serum urea nitrogen/serum creatinine ratio is 32, greater than the normal 12 to 20 for individuals on a normal diet. High ratios with elevated creatinine levels can occur in postrenal obstruction (probably benign prostatic hyperplasia in this elderly man) and in prerenal azotemia that is superimposed on renal disease (but not pure prerenal azotemia, as would occur in simple congestive heart failure). The reason for the high ratio is that urine flow obstruction causes back pressure on the renal tubules favoring back-diffusion of urea into the blood from the tubules. Acute tubular necrosis is typically characterized by a low urea nitrogen/creatinine ratio. Congestive heart failure generally causes prerenal azotemia. This is associated with a high urea nitrogen/creatinine ratio, mainly because of increased plasma urea nitrogen, with the creatinine level usually near normal. Low protein intake and severe liver disease can cause a low urea nitrogen/creatinine ratio.
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Question 18 of 67
18. Question
A male infant is referred to urologist for bilateral hydronephrosis. Neither bacteria nor neutrophils are seen in the urine. The most likely cause of the obstruction is:
Correct
Ureteropelvic junction obstruction
Incorrect
Explanation:
Ureteropelvic junction obstruction is a relatively common condition that occurs principally in male infants and may be due to several processes occurring at the ureteropelvic junction, including compression by aberrant renal vessels, disorganized smooth muscle, and intramuscular collagen deposition. Both primary and metastatic tumors of the ureter are rare, and would not be expected in an infant. Calculi are also rare in infants, and it would be very unusual for both ureters to be obstructed by stones. Chronic ureteritis is usually a complication of either a lower or upper urinary tract infection.
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Question 19 of 67
19. Question
A 66 year old man presents with complains of increased frequency of urination, nocturia, dysuria, and difficulty starting and stopping the flow of urine. Serum prostate-specific antigen (PSA) is within normal limits, and prostate biopsy demonstrates benign tissue. The patient´s lesion is most likely located on which of the following site?
Correct
Periurethral prostate
Incorrect
Explanation:
This man most likely has benign prostatic hyperplasia, which is thought to be related to the growth promoting effects of dihydrotestosterone (DHT). This is possibly coupled with an age related increase in estradiol, which may potentiate the action of DHT on the prostate. The growth characteristically involves the periurethral prostate. In contrast, prostatic carcinoma (which, if extensive, would elevate the PSA) characteristically involves the posterior lobe of the prostate. Stones and tumors can also involve the bladder neck, causing difficulty in urination, but these are less common than benign prostatic hypertrophy. Lesions of the penile urethra can cause dysuria but do not usually cause difficulty in stopping and starting the urine flow. Lesions of the ureters can cause renal failure but would not cause difficulties with urination.
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Question 20 of 67
20. Question
A 43 year old man has history of perineal pain and increased frequency of urination for the past several months. A mildly enlarged and tender prostate is observed on rectal examination. No bacteria are isolated in cultures of expressed prostatic secretions after prostatic massage. Histologic examination of expressed prostatic secretions reveals the presence of 20 leukocytes per high power field. Prostatic specific antigen (PSA) levels are mildly increased. The patient is most likely suffering from
Correct
Chronic abacterial prostatitis
Incorrect
Explanation:
Prostatitis can be acute, chronic bacterial or chronic abacterial. Laboratory investigations, which are essential in differentiating among these forms, rely on demonstration of leukocytes and/or bacteria in the expressed prostatic secretions. A diagnosis of chronic abacterial prostatitis is made when (1) more than 10 leukocytes per high power field are present on microscopic examination of prostatic secretions, and (2) no bacteria are isolated from cultures of prostatic secretions. This is the most common form of chronic prostatitis. Its pathogenesis is obscure, although microorganisms such as Mycoplasma hominis, Chlamydia trachomatis, and Ureaplasma urealyticum have been implicated, but never proven, as etiologic agents. PSA levels may be elevated in prostatitis. Acute bacterial prostatitis manifests with systemic signs and symptoms of acute infection (fever, chills, and malaise), perineal pain, and extreme tenderness of the prostate on rectal examination. Numerous leukocytes are seen on microscopic examination of expressed prostatic secretions. Cultures lead to isolation of the offending agent, usually Escherichia coli, providing; a target for antibiotic therapy. Clinical history alone excludes acute prostatitis as the cause of this patient´s complaints. Chronic bacterial prostatitis is clinically indistinguishable from chronic abacterial prostatitis, except for a history of recurrent urinary tract infections in the former. Cultures of prostatic secretions are positive in chronic bacterial prostatitis, allowing identification of infectious agents, usually the same as the ones causing prior urinary tract infections (most often E. coil). Prostatic & adenocarcinoma is a very common malignant tumor in elderly men. It tends to develop from the peripheral zone of the prostate manifesting with firm nodules appreciable on rectal examination and osteoblastic metastases to the vertebral column. Perineal pain and increased frequency of urination are rare manifestations. Prostatic hyperplasia manifests with increased frequency and other urinary symptoms, but pain is generally absent. Leukocytes are not demonstrated in expressed prostatic secretions (unless there is concomitant prostatitis).
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Question 21 of 67
21. Question
Correct statement with regard to angioplasty for the treatment of coronary artery disease is which one of the following?
Correct
Usefor for proximal discrete stenosis
Incorrect
Explanation:
Angioplasty is useful for proximal, discrete stenosis. It is not without risk. Risks include coronary artery dissection and emergent bypass surgery. It is less useful for multiple, more distal, heavily calcified lesions, and coronary artery bypass should not be undertaken in patients with significant left main stenosis. While angioplasty relieves symptoms, unlike coronary artery bypass, it has not been shown to improve life expectancy.
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Question 22 of 67
22. Question
Medical therapy aimed at decreasing hypertension and force of cardiac contraction may be appropriate in the management of a dissecting aortic aneurysm in which one of the following conditions?
Correct
Distal hypertensive dissection
Incorrect
Explanation:
In an older patient with distal hypertensive dissection, medical therapy, consisting of nitroprusside and a beta-blocker, may be tried. In all the other answer choices, surgery is the best treatment.
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Question 23 of 67
23. Question
A 72 year old man complains of increasing urinary frequency and dribbling. A digital rectal exam reveals a normal sized prostate. The prostate specific antigen level is elevated at 14ng/mL. Ultrasonography reveals a small hypoechoic area on the prostate measuring 5 x 9 mm. The most appropriate next step is
Correct
Biopsy of prostate
Incorrect
Explanation:
Measurement of serum levels of prostate specific antigen (PSA) can be used to screen for prostate cancer. However, this substance can also be elevated in prostate hypertrophy. A transrectal ultrasound can identify lesions not palpable on rectal examination, and the area can be biopsied under ultrasound guidance.
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Question 24 of 67
24. Question
A 77 year old man presents with complaints of nocturia, urinary urgency, and a feeling that he could not completely empty his bladder. Digital rectal examination reveals a firm, enlarged prostate. A bone scan is performed and shows positivity in multiple vertebral bodies. Elevation of which of the following substances would be most strongly associated with the development of bone lesions?
Correct
Serum alkaline phosphatase
Incorrect
Explanation:
The patient has prostate cancer causing osteoblastic bone lesions. Osteoblastic cells respond to metastatic prostate carcinoma by forming bone (osteoid) and secreting alkaline phosphatase, which is thought to either initiate or facilitate mineralization. Prostatic acid phosphatase and prostate specific antigen are not correct because they do not answer the question being asked. The question asks for bone metabolites related to the patient´s skeletal metastasis. These two markers are synthesized by the tumor and would most likely be elevated in this case; however, they are elevated due to the prostatic cancer, independent from the bony metastasis. Tartrate resistant acid phosphatase and urinary hydroxyproline are metabolic markers of osteoclastic (not osteoblastic) cell activity. Lytic tumor metastasis (lung kidney, gastrointestinal tract, melanoma) would he associated with increased levels of these markers. Tartrate resistant acid phosphatase is secreted by the osteoclast during bone resorption. Hydroxyproline is associated with collagen breakdown and increased levels are excreted in the urine.
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Question 25 of 67
25. Question
The recommendation for patients with prosthetic heart valves who plan to undergo dental procedures is
Correct
Oral amoxicillin prior to and after the procedure
Incorrect
Explanation:
The American Heart Association currently recommends antibiotic prophylaxis with amoxicillin, 3 grams prior to the dental procedure and 1.5 grams after the procedure, for all patients with prosthetic valves. IV antibiotics are not indicated and vancomycin is only used in patients allergic to the penicillin, cephalosporin, and erythromycin classes of antibiotics.
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Question 26 of 67
26. Question
Which of the following statement does NOT characterize infection of the urinary tract?
Correct
Bacteria placed in the bladder proliferate rapidly.
Incorrect
Explanation:
Under normal circumstances, bacteria placed in the urine are rapidly cleared. This occurs because of flushing and dilutional effects of voiding, as well as from the high urea concentration and high osmolarity of bladder urine, which inhibit bacterial growth. Several factors predispose to periurethral colonization. Urethral massage during sexual intercourse introduces bacteria into the bladder; Diaphragm and spermicide use after the normal introital bacterial flora, resulting in a marked increase in vaginal colonization with E. coli. Predisposition to upper tract infections in pregnancy results from decreased ureteral tone, decreased ureteral peristalsis and temporary incompetence of the vesicoureteral valves.
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Question 27 of 67
27. Question
Clinical finding NOT associated with BPH is which of the following?
Correct
Renal calculi result from hydronephrosis.
Incorrect
Explanation:
Renal calculi results from hydronephrosis. As the hyperplastic prostate enlarges, it may compress the posterior portion of the urethra, resulting in urinary retention. This leads to urinary stasis, which sets the stage for urinary tract infections. Hypertrophy of the detrusor muscle may lead to hydronephrosis and bladder diverticuli.
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Question 28 of 67
28. Question
A 54 year old man received a heart transplant for severe atherosclerotic disease. He died suddenly after five years of transplantation with no premonitory symptoms. He had been maintained on cyclosporine since his transplant. What complication would most likely be found at autopsy?
Correct
Graft vascular disease
Incorrect
Explanation:
Patients receiving heart transplants are prone to develop a number of complications, the most serious of which is graft vascular disease i.e., graft arteriosclerosis. This complication develops years after transplantation and is due to intimal thickening of coronary arteries without associated atheroma formation or significant inflammation. Thickening of the arterial intima is due to proliferation of fibroblasts and myocytes and leads to progressive stenosis of the lumen. Since transplanted hearts are denervated, chest pain does not accompany the ischemic injury. Graft vascular disease is of unknown etiology and cannot be prevented with current immunosuppressant therapy. Allograft rejection is certainly a major postoperative problem. However thanks to early diagnosis based on periodic endomyocardial biopsy and the availability of immunosuppressant therapy, this complication can be prevented or successfully treated. Atherosclerosis of coronary arteries is by far the most frequent cause of ischemic heart disease. Although recurrence of atherosclerosis may be observed in the transplanted heart of patients predisposed to this condition, it rarely results in sudden death 5 years after transplantation. Hyaline arteriolosclerosis and hyperplastic arteriolosclerosis are pathologic changes that result from chronic damage to arteriolar walls due to hypertension. Hyaline arteriolosclerosis is associated with benign hypertension and consists of thickening of the media caused by deposition of altered proteins. This change is actually not at all benign, since it leads to chronic ischemic injury to important organs, such as brain and kidneys, resulting in tissue damage (e.g., nephrosclerosis in the kidney and white matter damage in the brain). Hyperplastic arteriolosclerosis follows untreated malignant hypertension. It leads to thickening of arteriolar wall media from hyperplasia of myocytes arranged in concentric layers (onion skinning). Hyperplastic arteriosclerosis leads to more severe and more rapid ischemic damage to kidneys, heart, and brain. Neither type of arteriolosclerosis is observed in transplanted hearts.
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Question 29 of 67
29. Question
A 56 year old female becomes lightheaded and loses consciousness while shopping. In emergency department she is pulseless and medical technicians are unable to resuscitate her. Autopsy indicates that the woman experienced sudden cardiac death (SCD). The most likely underlying cause of SCD in this patient is
Correct
Ischemic heart disease
Incorrect
Explanation:
About 300,000 to 400,000 individuals succumb to sudden cardiac death (SCD) each year in the United States. SCD is defined as any unexpected death of proven cardiac origin, occurring either within 1 hour after the onset of symptoms or without the onset of symptoms. By far the most common cause of SCD is ischemic heart disease (IHD), which is most frequently related to atherosclerosis of the coronary arteries. In younger populations, the non-atherosclerotic causes listed above are proportionately more frequent. Aortic valve stenosis is most commonly due to senile calcification of the valve leaflets or a congenitally bicuspid valve.
Congenital anomalies of the heart, whether involving the cardiac chambers and valves or the conduction systems, should be strongly suspected in cases of SCD of a young person. Dilated cardiomyopathy has numerous etiologies, whereas hypertrophic cardiomyopathy is more often familial. Hypertrophy of the heart (increased cardiac mass) is an independent risk factor for SCD and may be associated with hypertension or increased physical activity (athletes). Mitral valve prolapse is a frequent anomaly in the general population and, although usually asymptomatic, has been found in young victims of SCD. Myocarditis is usually caused by viral infections and may be asymptomatic, may manifest with slowly progressive heart failure, or may lead to SCD. Patients with pulmonary hypertension (whether primary or secondary) are at increased risk for SCD. Although IHD is the underlying cause in the majority of SCD cases, nonatherosclerotic causes should be suspected in young victims or patients without evidence of siqnificant coronary artery disease. -
Question 30 of 67
30. Question
This bladder specimen displays marked thickening of the smooth muscle, resulting in trabeculation of the bladder wall. The condition that is most likely to result in this change is
Correct
Prostatic hyperplasia
Incorrect
Explanation:
Compensatory hypertrophy of the smooth muscle in the urinary bladder wall develops whenever there is a chronic impediment to the outflow of urine. The most common cause is prostatic hyperplasia, which results in narrowing of the proximal urethra. Trabeculation refers to the prominence of smooth muscle underneath the bladder mucosa, which creates a characteristic meshwork of intersecting bundles.
Chronic cystitis may result from a number of causes, such as repeated bacterial infections in predisposed patients or treatment with toxic drugs (cyclophosphamide). It manifests with erythema and, in more severe cases, with ulceration of the urinary bladder mucosa. Neoplasms involving the cauda equina will result in compression or infiltration of the lumbar spinal roots. The resulting cauda equina syndrome includes sensory and motor deficits in a specific dermatomeric distribution impotence and urinary incontinence. Atony of the bladder due to loss of innovation causes dilatation and thinning of the bladder wall.
Prostatic carcinoma rarely manifests with obstructive symptoms. Even so, stenosis of the urethra develops rapidly, and there is insufficient time for a compensatory hypertrophy of the bladder smooth muscle to take place. Transitional cell carcinoma of the bladder is usually discovered because of hematuria. Cystoscopy examination reveals a papillary neoplasm usually located in the trigone. The wall may be muscular hypertrophy. -
Question 31 of 67
31. Question
A homeless man is found dead in an alley. Autopsy shows a large saddle embolus at the bifurcation of the pulmonary trunk. The autopsy finding was most likely associated with which of the following?
Correct
Sudden death
Incorrect
Explanation:
A large saddle embolus is at the bifurcation of the pulmonary trunk and entirely blocks the pulmonary circulation. This is one of the few non cardiac causes of sudden death. The majority of such thromboemboli originate from the deep veins of the legs and indeed you can appreciate the valvular markings on the surface of this embolus. If cardiopulmonary resuscitation is being performed, electromechanical dissociation is often noted, depolarization of the heart continues to produce an ECG recording, but the patient does not: have a pulse due to the complete block of circulation by this massive embolus. Chronic cor pulmonale refers to any condition of increased resistance to the right ventricular outflow, leading to right ventricular hypertrophy and dilatation. This eventually results in right sided heart failure. Numerous small pulmonary thromboemboli may cause chronic cor pulmonale by reducing the cross sectional area of the pulmonary circulation and increasing resistance to pulmonary blood flow. Chronic right sided heart failure results in chronic passive congestion of the liver, which is associated with a characteristic nutmeg appearance on cut surface. Pulmonary thromboemboli may mimic myocardial infarction giving rise to acute chest pain, dyspnea, and shock. However, this would occur for thromboemboli smaller than the one described here. A saddle embolus is associated with instantaneous death. Pulmonary infarction is due to smaller emboli that block pulmonary branches.
Development of pulmonary infarcts depends on a number of factors including size and number of emboli and the state of circulation prior to embolism. Possible manifestations of pulmonary infarction are chest pain dyspnea, tachycardia, fever, hemoptysis, and elevation of blood levels of lactic acid. -
Question 32 of 67
32. Question
A low pitched diastolic rumble, opening snap, and pre accentuated S1 are classic auscultatory findings in which of the following?
Correct
Mitral stenosis.
Incorrect
Explanation:
The murmur of mitral stenosis consists of an opening snap followed by a low pitched rumbling diastolic murmur, best heard with the bell of the stethoscope at the LV apex. Pre accentuation of the S1 (first heart sound) follows. Both the opening snap and pre accentuation of S1 indicate that the mitral valve is not totally rigid. Mitral regurgitation, aortic stenosis, and ventricular septal defect produce systolic murmurs. The diastolic murmur of aortic regurgitation is high pitched and does not produce an opening snap or accentuation of S1.
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Question 33 of 67
33. Question
What type of crystal is produced by tumor lysis syndrome on urinalysis?
Correct
Uric acid
Incorrect
Explanation:
Hexagonal crystals are diagnostic of cystinuria. After chemotherapy of certain tumors (e.g., lymphomas, leukemias), tumor lysis syndrome may be produced. One manifestation is an increase in the uric acid level, which can cause uric acid crystals (yellow brown, seen only in acid urine). Ethylene glycol ingestion can produce calcium oxalate (“envelope”) crystals. In alkaline urine (pH > 7.0), ammonium magnesium phosphate (“triple phosphate”) crystals may be seen (“coffin lid” shape). Serratia, a urease producing organism, has the ability to alkalinize the urine. Calcium phosphate crystals may also be found in alkaline urine.
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Question 34 of 67
34. Question
Endocarditis prophylaxis would NOT be indicated for which of the following patients?
Correct
Patient with cardiac pacemaker
Incorrect
Explanation:
Endocarditis prophylaxis is recommended, as a general rule, for those patients with underlying cardiac diseases. Most congenital cardiac normalities, hypertrophic cardiomyopathy, prosthetic cardiac valves, previous history of bacterial endocarditis, and any states of valvular dysfunction indicate the use of endocarditis prophylaxis. However, patients with cardiac pacemakers or implanted defibrillators do not mandate endocarditis prophylaxis.
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Question 35 of 67
35. Question
A patient with rheumatoid arthritis presents with a urinary tract infection and is started on oral sulfimethisoxazole/trimethoprim (Bactrim). He is noted to be confused on the next day. He is afebrile with a blood pressure of 90/50 mmHg and has been on IV fluids to maintain her blood pressure. WBC count normal. Blood cultures are pending, but a Gram stain of the cultures show Gram negative rods. What should be the most appropriate management at this time?
Correct
Starting IV broad spectrum antibiotics for presumed sepsis.
Incorrect
Explanation:
This patient is most likely septic, although she has a normal white count and is afebrile because of her chronic steroid use. Oral antibiotics are not effective for the treatment of sepsis, and there is no indication of an allergic reaction that would necessitate a switch to another oral agent. Acute discontinuation of steroids can lead to an Addisonian crisis.
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Question 36 of 67
36. Question
A 52 year old male is being followed conservatively for an abdominal aortic aneurysm. Surgery is definitely indicated when the aneurysm exceeds which of the following size?
Correct
5 cm.
Incorrect
Explanation:
The risk of rupture and sudden death from an abdominal aortic aneurysm increases greatly once the aneurysm exceeds 5 cm. Surgery is indicated, unless contraindicated for other reasons. Aneurysms less than 5 cm have a lower risk of rupture and observation is indicated. Aneurysms should be resected prior to reaching 10 cm.
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Question 37 of 67
37. Question
Initial evaluation of the multiply injured trauma patient shows blood at the urethral meatus. On X-rays a pelvic fracture is revealed. The patient´s blood pressure is 70/40 mmHg and heart rate is 120beats/min. In order to monitor urine output you should
Correct
Consult urology to place a suprapubic tube.
Incorrect
Explanation:
When blood appears at the meatus in association with a pelvic fracture, a urethral injury should be assumed until proven otherwise. Placement of a Foley catheter risks further injury to the urethra. Only after a dye study through suprapubic entry establishes the patency of the urethra should a Foley be inserted.
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Question 38 of 67
38. Question
A 66 year old man with prostatic hypertrophy notices urine escaping from his umbilicus. The most likely diagnosis is which one of the following?
Correct
Patent urachus
Incorrect
Explanation:
A patent urachus occurs through the allantois not being destroyed; it may cause diversion of urine through the umbilicus in males with prostatic hypertrophy Failure of development of kidneys, either unilateral or bilateral, is known as renal agenesis. Double ureter occurs through growth of two ureteric buds or early splitting of one ureteric bud. A renal cyst occurs as a blind tubule that is fluid filled; it is thought to occur through communication between collecting and distal convoluted tubules in the kidney. Extrophy of the bladder usually occurs through protrusion of the posterior urinary bladder into the abdomen; it is caused by migration of mesenchymal tissue to the bladder.
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Question 39 of 67
39. Question
Surgical mortality following coronary artery bypass grafting is NOT affected by which one of the following?
Correct
Age greater than 50.
Incorrect
Explanation:
Surgical mortality following coronary artery bypass grafting is increased in persons older than 70, in females, and in persons with poor left ventricular function. Mortality varies with the acuity of the clinical syndrome ranging from 2-25%, depending on whether the indication is post infarction angina with good left ventricular function or acute infarction with cardiogenic shock. Mortality is less than 1% in good risk patients if operated on by an experienced surgical team.
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Question 40 of 67
40. Question
Which of the following is NOT a characteristic of an intra aortic balloon pump (IABP)?
Correct
Coronary filling during systole is augmented.
Incorrect
Explanation:
Coronary filling is augmented during diastole when the IABP inflates, backfilling the coronary arteries. An IABP cannot be placed indefinitely, heparinization is required to avoid clot formation, afterload is reduced, and admission to an ICU is often necessary.
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Question 41 of 67
41. Question
What is the recommended treatment for mild benign prostatic hyperplasia (BPH) without middle lobe involvement?
Correct
Pharmacologic therapy.
Incorrect
Explanation:
Mild BPH can be effectively managed with pharmacologic therapy such as Proscar or Hydrin. No treatment will often lead to an increase in symptoms. TURP is indicated for high middle lobe disease or moderate to severe disease. Radical prostatectomy and cystectomy are usually reserved for malignant disease
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Question 42 of 67
42. Question
The best treatment for metastatic prostate cancer is which one of the following?
Correct
Orchiectomy and Eulexin.
Incorrect
Explanation:
The treatment of choice for metastatic prostate carcinoma is either orchiectomy and Eulexin or Lupron and Eulexin. Lupron alone is insufficient. Pain medication for palliation is incorrect for a cancer that is very treatable. Transurethral prostatectomy is inadequate A treatment and radical prostatectomy is more appropriate for non-metastatic disease
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Question 43 of 67
43. Question
What is the initial management of a patient presenting with a painful urolithiasis without obstruction?
Correct
Brisk diuresis.
Incorrect
Explanation:
Many stones will pass with simple diuresis, and this should be the first intervention, especially if no obstruction is present. A salt restricted diet may help prevent recurrence of stone formation, but is of no use once a stone has formed. Allopurinol is useful for prevention in patients with hyperuricosuria. Lithotripsy and lithotomy would be indicated if diuresis failed in a patient with obstruction.
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Question 44 of 67
44. Question
A male aged 62 years with a known history of prostate cancer presents with a new complaint of low back pain. Neurologic exam is normal. What is the first test that should be ordered in the work up of suspected metastasis?
Correct
Lumbar spine X-rays.
Incorrect
Explanation:
Prostate metastasis to bone are blastic mets that will often be detected on X-ray. In the presence of a normal X-ray and normal neurological exam, an MRI is not indicated. A chest X-ray, CT, and bone scan should all be obtained once a diagnosis of metastatic disease is established, but the first diagnostic test should be plain radiographs.
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Question 45 of 67
45. Question
Which one of the following is NOT a screening test for evaluating coronary artery disease?
Correct
Coronary catheterization.
Incorrect
Explanation:
Coronary catheterization is an invasive procedure which is not a screening test for ischemic heart disease, but a vascular procedure used to determine the severity of the plaques and the number of vessels involved. Exercise echocardiography can be used to detect improved contractility in ventricular walls in a normal response and worsening in regional wall motion in an ischemic response. The major noninvasive test in coronary artery disease is the exercise electrocardiogram, which can be used to detect the ST segment depression characteristic of ischemia on exercise testing. Dobutamine increases heart rate and can be used in conjunction with echocardiography to assess heart wall function. Dipyridamole is a potent vasodilator that can be used in place of exercise to evaluate the degree of myocardial ischemia in patients who cannot exercise. It is given intravenously and an ECG with thallium 201 is used to detect the ischemia.
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Question 46 of 67
46. Question
A 42 year old man presents because of lesion on his penis. Exam shows an 8 mm opaque, gray white, relatively flat penile plaque. Biopsy shows the presence of clearly dysplastic squamous epithelium. The most likely diagnosis is
Correct
Bowen disease
Incorrect
Explanation:
The lesion described is the form of in situ penile carcinoma known as Bowen disease. If left untreated, Bowen disease is thought to carry a 10% risk of progressing to invasive squamous cell carcinoma. Bowenoid papulosis is a form of in-situ penile carcinoma that is characterized clinically by multiple reddish brown papular lesions. Condyloma acuminatum is a benign lesion that resembles the common wart. Condylomata are associated with papillomavirus infection. Erythroplasia of Queyrat is a form of in-situ penile carcinoma that produces a soft red plaque. Giant condyloma is an uncommon variant of condyloma acuminatum that is locally aggressive but does not usually metastasize.
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Question 47 of 67
47. Question
A baby boy is taken at child visit at scheduled for 2 weeks of age. His prior visits were normal. At this time, a grade IV murmur starting after the first heart sound and extending into diastole exists. It is heard best in the left second intercostal space and radiated to the clavicle. There is also prominent apical impulse, bounding pulses, and wide pulse pressure. Which of the following is the definitive corrective procedure for this anomaly?
Correct
Ligation
Incorrect
Explanation:
This patient has a congenital heart lesion that is not producing cyanosis. Thus, the lesion is a left-to-right shunt an obstructive lesion, or a regurgitant lesion. The most common are volume overload lesions produced by some left-to-right shunting of blood into the pulmonary circulation. It is important to understand the basic physiology of these lesions. With this patient, the lesion is not apparent until the 2-week visit. Over the First days to weeks of life, as the pulmonary vascular resistance and hence pressures decrease normally in the extrauterine environment, the effect of a left-to-right shunt should become evident whereas it may not be evident at first. The physical findings lead us to the correct diagnosis. With a patent ductus arteriosus (PDA), the murmur is often loud and associated with a thrill (i.e., grade IV), is heard best in the left intercostal space, and radiates to the clavicle. It is a systolic murmur that spills well into diastole and is therefore referred to as a machinery murmur. In patients with a large shunt, a low-pitched mitral mid-diastolic murmur may be heard at the apex (as is the case with a VSD). This is due to increased volume of blood across the mitral valve during diastolic filling of the left ventricle. Findings attributable to a wide pulse pressure, including bounding pulses, are also seen. The apical impulse is prominent and there is a heave with cardiac enlargement. With a small PDA, at first the heart is small; but overtime with a large PDA, the heart enlarges and failure may ensue. The question, however, asks for the definitive surgical correction of the lesion, and that would be a ductal ligation.
The arterial switch procedure is done for transposition of the great arteries because in this condition, the aorta and pulmonary arteries arise from the opposite physiologic ventricles.
An atrial balloon septostomy is required as an emergent procedure for any situation where better mixing is needed at the atrial level. This would be a first procedure for transposition, prior to the atrial switch. It is also necessary for tricuspid atresia because the blood needs to have a good channel for flow out of the right atrium. Heart transplantation is not necessary as a ductal ligation will correct the problem.
Patch placement would be done for a septal defect (ASD, VSD or AV canal). -
Question 48 of 67
48. Question
A 57 year old female is placed on anticoagulants and prophylactic antibiotics after her mitral valve replacement surgery. Five days later she develops a sharply demarcated, erythematous rash on her left thigh. Two days after the rash appears large hemorrhage bullae begin to form in the area of the rash. Which drug most likely caused the patient´s rash?
Correct
Warfarin
Incorrect
Explanation:
warfarin is a coumarin anticoagulant used for the prophylaxis and treatment of thromboembolic complications associated with cardiac valve replacement, well as the prophylaxis and treatment of venous thrombosis and pulmonary embolism. It is also used for atrial fibrillation. Warfarin may cause necrosis of the skin (typically on the breasts, thighs, and buttocks) generally between the third and tenth days of therapy. The lesions are initially sharply demarcated, erythematous, and purpuric. They may resolve, or progress to large, irregular, hemorrhagic bullae that can eventually become necrotic. This reaction is related to warfarin´s ability to deplete protein C, which can lead to a state of hypercoagulability and thrombosis in the cutaneous microvasculature. Aspirin is commonly used for its antiplatelet effect however; it would not be indicated for anticoagulation of a patient with a recent cardiac valve replacement. Furthermore, aspirin is not associated with the development of this type of skin necrosis. Cefazolin is a first generation cephalosporin antibiotic commonly used as a perioperative prophylactic agent. If the patient were allergic to this antibiotic, an erythematous rash might have appeared. However the rash would not include hemorrhagic bullae. Heparin is an intravenous anticoagulant indicated for the prophylaxis and treatment of thromboembolic complications associated with cardiac valve replacement and for atrial fibrillation. It is also indicated for the prophylaxis and treatment of venous thrombosis, pulmonary embolism, and for treatment of some coagulopathies. Although heparin is associated with the development of thrombocytopenia, it is not associated with skin necrosis vancomycin is an antibiotic typically reserved for treatment of life threatening infections caused by gram positive organisms. If vancomycin is administered too rapidly via the intravenous route, a maculopapular rash may appear on the chest and on the extremities. However, once the administration is complete, the rash usually disappears in a few hours.
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Question 49 of 67
49. Question
A 20-year-old man sustained multiple injuries in a high-speed automobile collision. There is a pneumothorax on the left side, for which he has a chest tube placed. Over the next several days, a large amount of air drains continuously through the tube, and daily chest x-rays show that his collapsed left lung is not expanding. The patient is not on a respirator. All of his other injuries have been treated appropriately. Which of the following is the most likely cause of these findings?
Correct
Injury to a major bronchus
Incorrect
Explanation:
This patient most likely has an injury to a major bronchus. In addition to the wrenching effect of a sudden deceleration, these can happen when a major blow to the chest occurs at a time when the glottis is closed. If not recognized right away by the presence of subcutaneous emphysema, they become evident once the air leak persists and the lung does not re-expand.
Air embolism is manifested by sudden death shortly after a patient with unrecognized injuries to the tracheobronchial tree in proximity to major intrathoracic vessels is placed on a respirator. Injured lung parenchyma can indeed leak air and produce a pneumothorax, but it typically heals rapidly. It is the delayed resolution of the pneumothorax that suggests that a major bronchus, rather than lung parenchyma, has been damaged.
Suction applied to a chest tube is used to accelerate the rate of resolution of a pneumothorax, but the large amount of air draining due to the bronchial tear in this case indicates that the pleural space is tilling in as quickly as it is being drained out. Suction via a chest tube will not be able to keep pace with the air drainage occurring as a result of the bronchial tear.
Tension pneumothorax occurs when air cannot leave the pleural space and pressure builds up within. The manifestations are respiratory distress and extrinsic cardiogenic shock. -
Question 50 of 67
50. Question
A patient presents to the urologist to discuss an “embarrassing issue.” Patient asks that the medical student leave the room. Later the patient admits to sexual problems. A thorough evaluation is performed. Later, while discussing the case, the physician says that this patient´s type of sexual dysfunction is the most difficult to treat. The most likely cause of this patient´s sexual dysfunction is
Correct
Primary ejaculatory incompetence in a male
Incorrect
Explanation:
Primary ejaculatory incompetence means that the adult male has never developed the ability to ejaculate while engaged in sexual activity with another person. It is extremely difficult to treat. Dyspareunia is painful intercourse and is easily treated by addressing the underlying medical causes that exist in the vast majority of cases. Premature ejaculation is readily addressed by the “squeeze technique.” Secondary orgasmic dysfunction means there had been function but it has been lost. Any secondary sexual dysfunction is easier to treat than a primary problem. Vaginismus is often related to fear and apprehension regarding the act of penetration and is quite easily treated by behavior modification.
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Question 51 of 67
51. Question
A 63 year old has erectile dysfunction. Over the last year he lost interest in sex, although he still loves his wife and does wish to have sex with her. He has not had any recent nocturnal erections. There is no history of sexual problems or depression. Past history is significant for osteoporosis and 10 year history of hypertension, which has been treated with metoprolol. Systemic review and examination is unremarkable. The appropriate next step in management is
Correct
Determine the bioavailable testosterone level
Incorrect
Explanation:
Erectile dysfunction is classified as organic and functional (psychological); the latter has normal nocturnal and morning erections and can have normal erections with masturbation. This patient´s lack of nocturnal erections points to an organic cause of the erectile dysfunction. He has signs and symptoms of hypogonadism, as evidenced by diminished libido and osteoporosis (testosterone is converted to estradiol by aromatase; low estrogen levels alter bone turnover and consequently leads to osteoporosis and osteopenia). This patient may benefit from testosterone replacement. The most appropriate next step is to determine his baseline testosterone level and then titrate testosterone to a high normal level. If the man´s desire returns and he has difficultly maintaining an erection, then adding a phosphodiesterase-5 inhibitor (E) is appropriate. These medications, however, are unlikely to restore libido, which is this patient´s concern. Metoprolol (B) and other beta-blockers have been associated with erectile dysfunction. It is likely, however, that only 1-3% of patients on these medications actually suffer from erectile dysfunction. Because this man has been on beta blockers for 10 years, it is unlikely that his recent loss of libido is related to his medications. Furthermore, the osteoporosis hints at hypogonadism, a condition that results in reduced bone mineral density. Psychosocial evaluation (C) and meeting the patient´s wife (D) may be appropriate for certain causes of sexual dysfunction. This man´s problem is likely organic, however, and his erectile dysfunction is likely a representation of testosterone deficiency, which should be tested and treated.
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Question 52 of 67
52. Question
A 66 year old male noticed that he is waking up more often at night to urinate, and when he tries to urinate, he must push harder to start his urinary stream. On rectal examination, his prostate is smooth, symmetric, and weighs approximately 50 grams. No nodules are felt. He is prescribed tamsulosin. 4 weeks later, he reports mild improvement of his symptoms, but he still complains of urinary frequency and dribbling. The next best step in his management is
Correct
Prescribe finasteride
Incorrect
Explanation:
This patient presented with classic signs and symptoms of BPH. He was prescribed an alpha adrenergic blocking agent (tamsulosin), which acts by blocking alpha-1 receptors located on the bladder trigone and urinary sphincter. Tamsulosin acts specifically on the ´a subunit´ of the receptor, which prevents orthostatic hypertension associated with some of the other “-sin” drugs. Follow-up has revealed that the patient has not had much improvement. This is most likely due to the fact that the prostate is very large (50 grams, as compared with normal [20 to 25 grams]). The next step would be to add a drug to reduce the size of the prostate. This can be achieved with the use of a 5a-reductase inhibitor (finasteride). 5a-reductase converts testosterone to dihydrotestosterone in the prostate. Dihydrotestosterone is responsible for hormone dependent enlargement of the prostate. Finasteride inhibits 5a-reductase, reducing dihydrotestosterone and, subsequently, prostatic volume. Studies have shown that finasteride is beneficial in men with prostates that are larger than 40 grams. Performing an abdominal X-ray (A) is not indicated at this time. An abdominal X-ray (KUB) would be a reasonable study if there was suspicion of abdominal or renal pathology (Specifically calcium stones). Prescribing ciprofloxacin (B) is not warranted as there is no infection. Bacteriuria is defined as >100,000 CFU/mL. Prescribing doxazosin (C), an alpha-1 blocker, would not help reduce the size of the prostate. Alpha blockers help relax the trigone and sphincter, facilitating the flow of urine through the prostatic urethra Furthermore, the patient is already using n alpha-1 blocker (tamsulosin), with little improvement. Goserelin (E) is a gonadotropin-releasing hormone agonist (GnRH agonist) indicated for the treatment of androgen receptor positive prostate cancer and advanced breast cancer, and reduction of endometriotic lesions.
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Question 53 of 67
53. Question
A 22 year old man sustains serious trauma following accident. In the emergency department he has injuries to the head, chest, pelvis, and legs. He is tachycardic, with BP of 100/60 mm Hg. Blood is also noticed at the urethral meatus. A pelvic radiograph shows an open book fracture of the pelvis with diastasis of the pubic symphysis. CT shows active extravasation of arterial contrast in the pelvis, and he is taken to the interventional radiology suite, where several embolization coils are placed in branches of the internal iliac artery. He is taken to the ICU. The next step in management of his potential urethral injury is
Correct
Retrograde urethrogram
Incorrect
Explanation:
This-patient has one of the most serious injuries associated with trauma, open-book, diastatic pelvic fracture. In addition to the high risk of pelvic arterial and venous bleeding, the injury is associated with urethral mid bladder disruption. Here, blood was noted at the urethral meatus, thus urethral injury must be suspected and a retrograde urethrogram should be performed to confirm the diagnosis. The procedure is done by placing a catheter in the distal urethra and injecting contrast. Urethral injury is diagnosed by an irregular appearance or extravasation of contrast beyond the urinary tract.
Intravenous pyelography (IVP) (A) would not provide the anatomic detail of the urethra that retrograde urethrogram would. IVP may be performed to detect problem of the kidneys, ureters, and bladder. Most often, it is done to locate suspected obstruction to the flow of urine through the collecting system. The most common cause of blockage is a kidney stone. The IVP test also gives information about the functioning of the kidneys. IVP is no longer the investigation of choice as CT scan is more convenient and accurate.
Urethral injury can cause many complications, if not repaired in a timely manner. It would be unwise to wait for spontaneous healing (B) that is often not the case. A Foley catheter (C) is contraindicated in urethral trauma, as it may worsen the damage. Surgical exploration (E) may very well be necessary; however, it is premature before a diagnostic test. -
Question 54 of 67
54. Question
A male aged 76 years is recovering from an emergency CABG. He is diabetic, hypertensive and has hyperlipidemia and chronic tobacco use. On postop day 7 he complains of abdominal pain and vomits once. He is noted to be febrile to 38.8°C (101.8°F). Labs show a WBC count of 16,000/mm3, hemoglobin of 9.2 mg/dL, and creatinine of 1.8 mg/dL. Abdominal X-ray is unremarkable. Ultrasound of the right upper quadrant reveals normal intra and extrahepatic bile ducts, a dilated gallbladder with no stones but a thickened wall, and a small amount of fluid surrounding the gallbladder. The next step in his management is
Correct
Percutaneous cholecystostomy
Incorrect
Explanation:
This patient has acalculous cholecystitis, as evident from the presence of cholecystitis symptoms-fever, leukocytosis, and a thickened gallbladder wall with pericholecystic fluid, in the absence of gallstones. Acalculous cholecystitis accounts for approximately 5-10% of the incidence of cholecystitis. It is considered a stasis phenomenon, typically presenting in hospitalized patients who are in critical condition. Contributing factors include hypovolemia, absence of alimentary nutrition, multiple blood transfusions, narcotic use, and prolonged ventilator dependence, several of which are present in this patient. Patients are often still ventilated and sedated, and therefore no subjective complaints present this diagnosis must be suspected in fever of unknown origin in this patient population. Ultrasonography and HIDA scan findings are similar to calculous cholecystitis, with the exception of visible cholelithiasis. Management is limited by patient illness, i.e., the ability to tolerate general anesthesia. The next step is determining the appropriate management of cholecystitis in this patient. A recent myocardial infarction (MI) is a contraindication to elective surgery, and even emergency surgery is avoided when possible. This situation serves as an excellent example of avoiding surgery in the immediate post MI period, in which cholecystitis can be temporarily treated with percutaneous drainage via a cholecystostomy tube, with interval cholecystectomy at 6-8 weeks. A CT scan (A) is not necessary to make this diagnosis; further, this diagnosis would be difficult to make on CT scan without intravenous contrast, which is contraindicated in the presence of a serum creatinine of 1.8. A high morbidity and mortality rate would exist with either laparoscopic (C) or open (D) cholecystectomy, especially when an alternative approach exists. ERCP (B) would offer no therapeutic intervention for acalculous cholecystitis.
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Question 55 of 67
55. Question
A 69 year old man has difficulty urinating for the past 2 years. Now he often leaks a small amount of urine, particularly when he coughs, sneezes, or laughs. He has urinary hesitancy with a weak urinary stream and dribbling. Rectal exam shows a firm, smooth, enlarged prostate. A Foley catheter is placed, resulting in the evacuation of 900 cc of straw colored urine. Appropriate initial treatment for his problem is
Correct
Alpha antagonist agent
Incorrect
Explanation:
This patient has overflow incontinence in which outlet obstruction-in this case large prostate-traps a large amount of urine, which overwhelms an otherwise competent bladder. The most appropriate first line pharmacotherapy is an alpha blocker, which will relax urethral tone, following easier voiding. Alpha 1 blockers are the most commonly used agents in this class. Examples include doxazosin, terazosin, and tamsulosin (which is a selective alpha 1 blocker). 5alpha reductase inhibitors (A), such s finasteride, also treat prostatic hyperplasia, but take long time to act (up to a year for full effect). An appropriate first treatment for this patient´s incontinence needs to act quickly and provide immediate relief of symptoms. Alpha agonists (B) are occasionally used to treat pure stress incontinence, where an incompetent valve results in urinary, leakage. Alpha agonists will tighten the urethral sphincter, and likely worsen this patient´s symptoms. Oxybutynin and tolterodine are commonly prescribed antispasmodics (D) that are thought to relax the detrusor muscle. They are appropriate pharmacologic adjuncts in the treatment of urge incontinence, where bladder hyperactivity is the primary problem, but are not appropriate for cases of obstruction. Cholinergic agonists (E), such as bethanechol, are generally not very effective, except in patients who require treatment with an anticholinergic agent.
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Question 56 of 67
56. Question
A 66 year old diabetic and hypertensive male with prostatic cancer has erectile dysfunction for the last 10 years. His medications include glyburide, nifedipine, amlodipine and leuprolide injection each month. He has no allergies. Complete physical exam is normal. All lab values are within normal limits. He asks if he can have a prescription for sildenafil. Which statement is correct?
Correct
There is no contraindication for him to use sildenafil.
Incorrect
Explanation:
Sildenafil is an oral medication used in the treatment of erectile dysfunction. It works by inhibiting the type 5 cGMP phosphodiesterase enzyme that is located primarily in the cavernously smooth muscle. Inhibition of this enzyme leads to the buildup of cGMP in the smooth muscle cell of the cavernously body. Increased cGMP leads to decreased intracellular calcium and relaxation of smooth muscle. Relaxation of the cavernously smooth muscle allows for increased blood flow into the cavernously bodies, thus leading to erection.
Sildenafil is contraindicated in any patient taking nitrates or nitric oxide donors. Sildenafil potentiates the effects of these medications, which may cause life threatening hypotension. Side effects of sildenafil include headache, flushing, dyspepsia, nasal congestion, abnormal vision, diarrhea, dimness, and rash. Calcium channel blockers are not a contraindication to the use of sildenafil (A). As previously stated, it is important to question potential users of sildenafil about nitrate use. Diabetic patients often have problems with erectile function. The use of oral hypoglycemic medications is not a contraindication to the use of sildenafil (B). Prostate cancer (C) is not a contraindication to use of sildenafil. In fact, many men with prostate cancer require treatment for erectile dysfunction. This is because treatment modalities for prostate cancer (i.e., radical prostatectomy, radiation therapy, anti-androgen therapy) can cause erectile dysfunction. Patients with prostate cancer constitute a large percentage of patients taking sildenafil. This patient takes leuprolide, which results in atrophic testes. However, atrophic testes is not a contraindication to sildenafil use (D). Leuprolide acetate is a luteinizing hormone-releasing hormone (LH-RH) agonist that works at the level of the pituitary gland. By constantly stimulating LH-RH receptors, leuprolide destroys the normal palatial input, resulting in suppression of LH and FSH secretion. This leads to a decrease in testosterone levels and testicular atrophy (as seen in this patient). -
Question 57 of 67
57. Question
A 65 year old smoker has blood in his urine. He saw the blood on two separate occasions a month ago. He has not seen the blood since. There was some associated dysuria and frequency. His history is significant for cataracts, migraines, and acid reflux. He takes PPI daily and ibuprofen as needed for headaches. Exam and lab studies are normal. He asks about the cause of hematuria. At this time, which one is the most appropriate response?
Correct
“I would like to do some more tests today.”
Incorrect
Explanation:
Gross painless hematuria in a male should always elicit concern for bladder cancer or another malignancy of the urinary tract. Other causes of hematuria include infection, stones, benign prostatic hyperplasia, or trauma. It is important not to ignore this patient´s history of tobacco use. Cigarette smokers have up to a fourfold higher incidence of bladder cancer than do people who have never smoked. The risk correlates with the number of cigarettes smoked, the duration of smoking, and the degree of inhalation of smoke. The risk decreases by approximately 60% on cessation of smoking; it remains elevated when compared with nonsmokers and may persist after smoking is stopped. Because of this patient´s history and the risk for cancer, it is completely appropriate to express your concerns to the patient and tell him you would like to do more testing. It is not uncommon for hematuria related to malignancy to be intermittent and painless; therefore, one must not wait and at tribute it to local irritation. Even if a repeat urine analysis reveals a decreased amount of red blood cells or no red blood cells, the history of tobacco use and gross hematuria is enough to warrant immediate investigation. Although this patient may have bladder cancer, it is not appropriate to make this diagnosis without an appropriate evaluation. The only way to definitely diagnose bladder cancer is to perform a cystoscopy and obtain tissue for diagnosis. Also, not all bladder cancers require radical cystectomy. This patient does not describe a typical history for urinary tract infection; no dysuria, urinary frequency, or urgency are present. These symptoms probably would be present if a patient had a UTI, and it is unlikely he would have improved without treatment. Although infection can cause hematuria, it would be inappropriate to prescribe antibiotics (ciprofloxacin) before further evaluating the cause of the hematuria.
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Question 58 of 67
58. Question
A 66 year old man has recent onset of passage of “bubbles” with his urine that started 2 weeks ago and has not improved. There is also some burning on urination and he thinks that he may have seen some fecal material when he urinates. He had diverticulitis 1 year ago. Examination is normal, including guaiac-negative stool. Which diagnostic study is likely to confirm the diagnosis?
Correct
CT scan
Incorrect
Explanation:
This patient is complaining of pneumaturia, or the passage of air with urination and fecaluria (the passage of fecal material with urination). This is most likely caused by a Fistula between the bidder and the gastrointestinal tract (i.e., a colovesical fistula). Colovesical fistulas are the most common, but others types may occur (enter colic, colocolonic, vaginal-colonic). The most common site for the vestal is the sigmoid colon and the most common cause is diverticulitis, with sigmoid cancer as the second possibility. Bladder cancer is a very distant third possible source. History will provide clues to the diagnosis, but imaging studies are important. CT scan is the study of choice and the one that is most likely to confirm the diagnosis by revealing an inflammatory diverticular mass. The direct visualization of the fistula from barium enema (A) can be done, but the results tend to be low in sensitively (around 25%). A barium enema might not allow visualization of the fistula, but it does not rule it out because the thick barium contrast may clog up the orifice of a small fistula. However, barium enema studies are valuable in assessing the remainder of the colon. Cystoscopy and sigmoidoscopy (C and D) are necessary evaluations, but usually the site of the fistula cannot be visualized. Sigmoidoscopy is also necessary, to rule out carcinoma of the colon. Even with a negative Cystoscopy and sigmoidoscopy, the diagnosis of Colovesical fistula cannot be ruled out. A retrograde urethrogram evaluates the urethra. The fistula that causes pneumaturia involves the bladder and colon. The urethra is not involved; therefore, the retrograde urethrogram will be normal (E).
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Question 59 of 67
59. Question
A 65 year old man has increasing difficulty with urination for 5 months that is slowly progressive. He notices a weak stream and occasionally a burning sensation. He is sexually monogamous with his wife. No other symptom is present. Physical examination is normal. Rectal examination is also normal. Which study is likely to reveal the diagnosis?
Correct
Retrograde urethrogram with voiding cystourethrogram
Incorrect
Explanation:
The patient described has difficultly with urination. Common things being common, benign prostatic hyperplasia is the most likely diagnosis. This is less likely, however, given the normal-sized prostate. Another source for an obstruction to urine flow must be considered, such as a stricture of the urethra. Other diagnoses that must be kept in mind include calculi and foreign body. The diagnosis of a urethral stricture can be made with a combination of direct visualization and radiography. A retrograde urethrogram is performed by injecting dye through a catheter placed just inside the tip of the penis, such that the urethra is outlined with radiopaque contrast. The voiding cystourethrogram is performed by filling the bladder with contrast by way of a Foley, then removing the Foley and having the patient urinate under fluoroscopy with visualization of the length of the urethra. An intravenous pyelogram (A) is unlikely to yield a diagnosis, as it outlines mainly the renal collecting system, urethras, and urinary bladder. A prostate biopsy (B) would not yield the diagnosis, especially in light of the normal-sized prostate. If prostate cancer were believed to be the etiology of the patient´s dysuria, then measuring the serum prostate specific antigen (PSA) level (D) would be a reasonable choice. A urinalysis (E) would likely be benign, especially given the noninfectious description in the vignette.
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Question 60 of 67
60. Question
A 44 year old man presents because of low back pain that radiates to the scrotum, dysuria, and pain upon defection for the last 4 weeks. He is treated with trimethoprim-sulfamethoxazole, but symptoms recur 1 week after therapy is stopped. Ciprofloxacin is given but symptoms again recur after cessation. Today, rectal examination shows an enlarged prostate with areas of tenderness and fluctuance. Which one is the most likely diagnosis?
Correct
Prostatic abscess
Incorrect
Explanation:
The patient has prostatic abscess. The typical age is 40 to 60 years, some what younger then the chess at which benign prostatic hyperplasia (BPH) and prostate cancer become major problems. Infecting organisms include aerobic gram-negative bacilli and Staphylococcus aureus. Prostatic abscess should be suspected when a man develops repeated urinary tract infections that seem to get better with antibiotic therapy, only to recur later. The most important diagnostic clue, if detectable, is the presence of a fluctuant mass in the prostate on rectal exam. Some patients have only prostatic enlargement or even no positive findings on physical examination. Patients may have normal urine, although it is more usual for an organism to be cultured at some point prostatic ultrasound may be helpful if abscess is suspected. A few cases are even picked up at the time of prostatic resection for benign prostatic hyperplasia or other disease. Treatment is with evacuation of the abscess by a transurethral or perinea route, followed by appropriate antibiotics. Typical signs and symptoms of acute prostatitis (A) include spiking fever, chills, malaise, myalgias, dysuria, pelvic or perinea pain, and cloudy urine. Swelling of the acutely inflamed prostate can cause obstructive symptoms, but will not present with a fluctuant mass. Benign prostatic hyperplasia (B) can cause urinary obstruction predisposing for bladder infection, but the prostate would not be flu count. Chronic nonbacterial prostatitis (C) can cause symptoms resembling urinary tract infection, but would not cause a fluctuant prostate. Urine cultures with antibiotic sensitivity are necessary in order to establish the diagnosis of multidrug resistant UTI (D). UTI presents with urgency, dysuria, and frequency. It does not present with a fluctuant mass on examination of the prostate.
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Question 61 of 67
61. Question
A 48 year old man has pain and burning when he urinates. He has been urinating more often than usual. Now he has developed a fever, lower back pain, and discomfort “under his scrotum.” Last evening he felt very weak, and his joints were also sore. His temperature is 101.3°F. Physician is unable to conduct a thorough rectal examination due to an exquisitely tender prostate and extreme discomfort. The most likely diagnosis is
Correct
Acute prostatitis
Incorrect
Explanation:
Prostatitis is an inflammation of the prostate, which may be acute or chronic. In this case, the patient is presenting with acute prostates manifested by chills, fevers, and low back and perinea pain. There is associated urinary urgency and frequency with dysuria and varying degrees of bladder outlet obstruction. Generalized malaise with arthralgias and myalgias are common. On examination, the prostate is exquisitely tender, warm, and swollen. Common bacteria implicated in prostatitis include Escherichia coli, Klebsiella, Proteus, Pseudomonas, Enterobacter, Enterococcus, Serrate, and Staphylococci aureus Prostatic secretions may be recovered by performing prostatic massage. Secretions are sent for Gram stain and culture to better direct the antibiotic treatment. However, this is not usually done for acute prostatitis because the prostate is extremely vascular and bacterial seeding into the bloodstream is possible. The treatment of choice is usually Fluoroquinolones. Because of the thick prostatic capsule, long-term treatment with antibiotics for 4 to 6 weeks is required to ensure adequate drug levels in the prostatic tissue. Acute cystitis (A) is an infection of the bladder. Patients will complain of frequency, dysuria, urgency, and nocturnal. There may be low back or suprapubic pain also. Fever is unusual and prostate examination should be normal. Acute epididymitis (B) is an infection of the epididymis acquired by retrograde spread of organisms down the vas deferens from the urethra. Patients complain of heaviness and a dull, aching discomfort in the affected hemi-scrotum that can radiate up the ipsilateral flank. The epididymis is markedly swollen and tender to touch. Acute pyelonephritis (D) is an infection of the renal parenchyma and renal pelvis. There are associated fevers, chills, and flank pain. Atypical sign is cost vertebral angle tenderness.
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Question 62 of 67
62. Question
A 65 year old man with history of benign prostatic hyperplasia presents complaining of an inability to void for 16 hours. He has severe suprapubic pain and discomfort. A mass is palpated in the suprapubic region. Foley´s catheter placed per urethra yields 1000 mL of clear urine. He is taking tamsulosin for BPH. Which medication would have treated the prostate enlargement?
Correct
Finasteride
Incorrect
Explanation:
Finasteride and dutasteride are 5alpha reductase inhibitors used to treat BPH and gross hematuria due to prostatic bleeding. Finasteride blocks the intracellular conversion of testosterone to dihydrotestosterone, and as a result shrinks hyperplasic prostate tissue and helps to reduce the progression of BPH. A long term, double blind, randomized, placebo controlled efficacy study demonstrated that finasteride reduced the risk or acute urinary retention by 57%, while reducing the risk of BPH related surgery by 55%. Finasteride, however, is not as effective at controlling BPH related symptoms. The 5alpha reductase inhibitors are indicated in severe BPH (prostatic volume >40 g) or BPH which is unresponsive to monotherapy with alpha-adrenergic antagonists. It is important to note that the patient has an elevated blood pressure even though he is being treated for hypertension. This is most likely due to his severe suprapubic pain. Always remember there is e normal increase in blood pressure during stress.
Cernilton (B) is an herbal remedy produced from eye grass pollen. Home studies have shown that it improved symptoms of BPH but had no street on urinary flow, residual volume, or prostatic volume. Because or safely concerns, this and other herbal therapies (including saw palmetto) are not recommended for routine use in BPH. Goserelin (D) is an LH-RH agonist used to treat prostate cancer, not BPH. It acts to suppress LH and thus testosterone production, thereby reducing the actively of androgen dependent prostate cancer cells. Effect on LH normally occurs in the first 2 to 3 weeks or therapy, and an anti-androgen agent, such as bicalutamide (A) is often given simultaneously to inhibit this phenomenon. Terazosin (E) is selective alpha1 blocker used to treat the symptoms of BPH, but it does not treat prostate enlargement Instead, the drug works by relaxing the prostatic smooth muscle as well as the bladder neck fibers to relieve bladder outlet obstruction and decrease voiding symptoms. It is important to keep in mind that the “-sin drugs” can be effectively used in patients with hypertension due to their vasodilation effects. However, these drugs must be given with caution because they may cause orthostatic hypotension in normotensive patients. -
Question 63 of 67
63. Question
A 65 year old diabetic and hypertensive man notices a gradual loss of erectile function over several years. Initially his erections do not last long. Later, he notices a decrease in the quality of his erections, and more recently, he becomes, by his own criteria, completely impotent. He has occasional, brief nocturnal erections, but the can never get an erection when he needs one. The most appropriate initial step in management is which one of the following?
Correct
Pharmacologic therapy
Incorrect
Explanation:
This patient has organic impotence, but it is not related to trauma for which surgical reconstruction would be indicated. His remaining function can be augmented with sildenafil. Nerve damage (A) is the source of impotence following pelvic surgery, which is not the case here. As of now, there is no effective way to reams tomes those invisible nerve fibers. Penile prosthesis (B) is always the last option, never the first one. Once a prosthesis is inserted, the normal erectile mechanism is destroyed forever. Psychotherapy (D) would be appropriate for psyohogenic impotence, which has a sudden onset rather than the gradual development described in this case. Had the history been that of a young man becoming impotent after a motorcycle accident a vascular lesion would have been the likely problem, and reconstruction (E) would be the thing to do.
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Question 64 of 67
64. Question
A 64 year old man has complaint of blood in his urine. Bleeding is painless and occurs throughout micturation but there are times when he suffers from painful urination and an overwhelming urgency to urinate. His urination frequency has also increased. He has a 40 pack year smoking history. He is vitally stable and physical exam is normal. Urinalysis reveals 3+ hematuria, but is negative for protein, glucose, leukocyte esterase, and nitrates. The most appropriate next diagnostic step is
Correct
Cystoscopy
Incorrect
Explanation:
This patient is at risk for bladder cancer. The triad of dysuria, frequency, and urgency, combined with painless hematuria, is worrisome for bladder cancer. Painless hematuria, particularly in a man this age with a smoking history demands examination of the urinary, epithelium. Cystoscopy with biopsy provides the best evidence for cancer. Bladder tumor antigen (BTA) (A) is used for the detection of recurrent bladder tumors. It is not approved for widespread screening, initial diagnosis, or risk assessment. This test has not shown sufficient diagnostic reliability to eliminate the need for Cystoscopy for either primary or recurrent bladder tumors. Transvesical needle biopsy (C) is occasionally used in the staging of urothelial tumors. It is not indicated, however, until the diagnosis is made. Ultrasound (D) is not very useful in the diagnosis or staging of urothelial cancer. It provides poor visualization of the bladder. Although it may visualize large masses, particularly of the renal collecting system, more sensitive tests (such as an intravenous pyelogram) may be used if disease is suspected but not seen on Cystoscopy.
Urine flow cytometry (E) and direct urine cytology all have varying sensitively, depending on the location and size of the tumor. These studies may have ancillary value; however, the first test should be Cystoscopy. -
Question 65 of 67
65. Question
A 58 year old black male presents for a routine checkup. On exam he is found to have a discrete, 1.5 cm, hard nodule that is felt in his prostate during a rectal exam. Rectal exam previous year was unremarkable and his PSA done 3 months ago was normal for his age. He denies any family history of prostate cancer. The next best step in management is
Correct
Determination of the Gleason score.
Incorrect
Explanation:
workup for a prostatic nodule includes the use of digital rectal examination PSA levels, and biopsy when necessary. In this case, the patient presents with a prostatic mass, and it is necessary to determine the significance by doing a biopsy. Biopsy is necessary to aid in the diagnosis, when a mass can not be distinguished between a cyst or a benign condition and a cancerous one and for staging. The main purpose of biopsy of the mass is to obtain a histological diagnosis and the Gleason score, which is the most commonly, used classification system for the histological findings in prostate biopsy. Further workup will depend on the staging of the disease. A higher stage of cancer correlates with an increased risk of extra prostatic spread. Clinical follow up (A) is inappropriate at this age, but it would be the thing to do if the man had been 75 years of age or older. To repeat PSA levels (C) would not be the next best step because a prostatic nodule needs to be biopsied and staged regardless of PSA level. A trans-rectal sonogram (D) might be needed to identify, a tumor that is not palpable, but has been discovered by a high PSA level. In this case, the tumor has been felt. It can be biopsied, guided by the finger or by a sonogram. But, the sonogram will not establish the diagnosis, it will only help do the biopsy. In other words, Trans-rectal ultrasound is no better than digital rectal examination for the diagnosis of this disease. It would be inappropriate to resect the prostate (E) before there is a diagnosis. Depending on the results of the complete workup, one might elect a different surgical approach or a different treatment (radiation, for instance). As stated above, any further workup will depend on staging of the disease. Patients with PSA levels less than 10 g/m and low or moderate grade histology (Gleason score 7) with no findings or minimal findings upon physical examination may proceed to surgery or brachytherapy without further studies, although this is not the case for this particular patient.
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Question 66 of 67
66. Question
According to a 70 year old man over the past 2 weeks his normally weak stream has gotten even weaker. Over the last 24 hours he has been unable to urinate at all. He takes tamsulosin for BPH. His abdomen is soft and there is lower abdominal distention with suprapubic discomfort on palpation. On rectal exam his prostate is enlarged, non-tender, and without modularity. Attempts to place a Foley catheter are met with resistance. Blood begins to ooze from the urethral meatus. The next best step in management is
Correct
Perform suprapubic tube placement
Incorrect
Explanation:
Clinically this patient has urinary retention with bladder outlet obstruction. The etiology of his bladder outlet obstruction is most likely because of benign prostatic hyperplasia. The only way to make this patient comfortable is to drain his bladder. Of the options, the least invasive, most expeditious choice is suprapubic tube placement. The fact this patient´s bladder is distended will make the procedure easier. The procedure is preformed 4 cm above the pubic symphysis using local anesthesia. A spinal needle is used to locate the bladder by aspirating urine and then inserting the tube directly in the same location. The suprapubic tube drains the bladder and makes the patient more comfortable. It also prevents the progression of any further renal damage that might be taking place because of the over distended bladder transmitting pressure back to cause hydronephrosis. Percutaneous nephrostomy tubes (A) are used when there is renal failure and bilateral hydronephrosis. There is no guarantee that this patient has hydronephrosis, although the likely hood is moderate. Also, these tubes only drain the kidneys; they do not decompress the bladder and therefore will not help this patient´s discomfort. Retrograde urethrogram (B) is a diagnostic test that places contrast into the urethra to identify urethral anatomy. This test my show the level of this patient´s blockage but it is only diagnostic and not therapeutic. An ilea conduit (D) is done by isolating a segment of ileum and surgically inserting the ureters into this conduit on its proximal end. The distal aspect of the conduit is used to create a stoma on the abdominal wall. It is not performed for urinary retention. Most commonly it is done after radical cystectomy for bladder cancer. Transurethral resection (E) of the prostate is the procedure of choice for patients who develop urinary retention while being treated conservatively with medication for benign prostatic hyperplasia. Although this patient will need this surgery, it should be done when the patient is medically stable.
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Question 67 of 67
67. Question
An 86 year old diabetic male with many co-morbidities is brought for a routine checkup. His temperature is 98.0°F, BP is 147/88 mm Hg, pulse is 76/min, and respirations are 18/min. On rectal exam his sphincter tone is fair and the prostate is moderately enlarged, firm, and with a non tender 0.5 cm nodule over the apex of the right lobe. The patient denies any form of bone pain or any difficultly with urination. Appropriate statement regarding his findings is
Correct
This patient does not need serum PSA level or a prostate biopsy
Incorrect
Explanation:
Digital rectal examination and serum PSA levels are used as screening tools in patients who are at risk for developing and dying from prostate cancer. When determining who should undergo screening for prostate cancer, it is important to locus on the natural history of the disease progression and survivability. Studies have found that disease specific survival for localized disease at 10 years was 83% for those who deferred therapy, 93% for those undergoing radical prostatectomy, and 62% for those who received external beam radiotherapy. In patients over 70 years of age, invasive treatment may be harmful, and associated morbidity related to treatment must be considered. Furthermore, death from untreated localized prostate cancer occurs only after a protracted course. It generally is believed, therefore, that there is no need to treat localized prostate cancer in patients with limited life spans. Only in patients with metastatic prostate cancer, is further evaluation and treatment warranted. This patient provides no evidence that he has anything more then localized prostate cancer because he has no back pain, other bone pain, or significant obstructive voiding symptoms. Because this patient is likely to die from one of his other co-morbidities, and if he has prostate cancer, it is probably localized, it is appropriate to provide no intervention and monitor him. This patient is not a candidate for any intervention; therefore, radiation (A) is not an option. In those patients who are expected to live for some time but are not surgical candidates, radiation therapy is a treatment option. For the reasons stated above, it is unnecessary to draw a PSA or biopsy this patient´s prostate. Because a positive prostate biopsy would not result in aggressive treatment, the expense of the serum PSA test and the morbidity of the biopsy are unnecessary (B and D). In general, prostate cancer has relatively long clinical course. This sick, elderly man is more likely to die of other conditions than he is to die from metastatic prostate cancer (C).