Packrat 8

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  1. 49 year old male with Peyronie's disease...physical finding?
    fibrotic areas under the penile skin along with a history of penile curvature during erection
  2. What is balanitis?
    inflammation of the glans of the penis
  3. State in which the foreskin of the penis cannot be retracted?
  4. A chancre on the shaft of the penis is noted in what infection?
    Primary syphilis
  5. Renal cell carcinoma most commonly presents with which S/S?
    The most common presenting symptom/sign of renal cell carcinoma is hematuria (approximately60%). Flank pain or abdominal mass is present in about 30% of new cases
  6. Diagnostic test of choice for the evaluation of a patient suspected of secondary HTN due to primary aldosteronism (Conn's syndrome)?
    Serum electrolytes

    Patients having primary aldosteronism as a cause of their secondary hypertension are identified forthis condition by finding unprovoked hypokalemia on the electrolyte testing
  7. In evaluation of secondary HTN using a CXR - what are you suspecting?
    Chest x-ray may be used to evaluate a patient suspected of having coarctation of the aorta as acause of secondary hypertension
  8. In evaluation of secondary HTN using a Renal scan - what are you suspecting?
    A renal scan is indicated in the evaluation of a patient suspected of having secondaryhypertension due to renal artery stenosis or fibromuscular dysplasia of the renal arteries
  9. In evaluation of secondary HTN using UA for metanephrines - what are you suspecting?
    Patients having secondary hypertension due to pheochromocytoma will have an increase in theirurinary metanephrines on testing due to increased catecholamine production by this tumor
  10. What EKG finding is hallmark for pericarditis?
    The hallmark of pericarditis is ST segment elevation throughout the precordium along with PR segment depression

    • Hypocalcemia - prolonged QT
    • Hyperkalemia - tall peaked T waves
  11. What study should be used in diagnosing combined systolic/diastolic failure?
    Echocardiogram - 

    An echocardiogram is especially useful for assessing the dimensions of each cardiac chamber.Heart failure is usually associated with cardiac enlargement and the diagnosis should be questioned (but,not excluded) when all chambers are normal in size. Echocardiogram assesses the function of thevarious chambers along with the ejection fractions of the heart, which is important with systolic dysfunction
  12. What is radionuclide scanning used for?
    Primarily used in the evaluation of CAD as it is able to assess areas of perfusion for the heart
  13. What is exercise stress testing used for?
    Primarily used to assess a patient's cardiovascular status in response to exercise and is primarily a strategy involved in assessing pateints for CAD, not congestive or chronic heart failure
  14. When is cardiac catheterization used?
    Used to assess the amount of CAD in a patient for whom revascularization surgery is being contemplated
  15. The most accurate method of diagnosing thrombophlebitis of the lower leg is?
    While impedance plethysmography, physical exam findings, and Doppler ultrasound are useful indiagnosing thrombophlebitis, venography is the most accurate method for diagnosis in the lower leg
  16. CK-MB rises to a PEAK after an AMI after how many hours?
    CPK-MB is found mainly in cardiac muscle. It begins to rise in 4 to 6 hours, peaks at 18 hours, andreturns to normal in 48 hours
  17. Enzyme most specific for injury or death of the heart muscle?
    Troponin-I is a regulatory protein in the troponin cardiac muscle complex. It is specific formyocardium and is elevated in injury or death of the heart muscle.
  18. When might you see elevated serum aldolase?
    skeletal muscle disorders - like muscular dystrophies
  19. What is alanine aminotransferase elevated?
    disorders causing liver cell injury
  20. A 24-year-old male presents with a generalized erythematous maculopapular rash, including the palmsand soles of the feet. He also shows generalized lymphadenopathy and flat, moist lesions in the genital area. The patient admits to having had a lesion on his penis a month or so before, but it did not bother him. Which of the following is the most appropriate to confirm the diagnosis?

    The fluorescent treponemal antibody absorption test is positive in secondary syphilis
  21. What does Weil-Felix test for?
    If positive - Rickettsial diseases
  22. A 55-year-old female presents with a mole that has changed appearance over the past few months. Shesays it has enlarged. Also noted is an asymmetric lesion with an irregular border and variation in colorfrom light brown to dark blue/black. Which of the following is the most appropriate?
    An excisional biopsy is indicated for suspected cases of melanoma

    (Curettage and shave biopsy are contraindicated for suspected melanoma because they leave behind potentially cancerous cells)
  23. Which of the following is the most helpful in establishing the diagnosis of gout?
    Analysis of synovial fluid with polarized light

    Although sedimentation rate, C-reactive protein, and uric acid levels may be elevated, the most specific diagnostic test for gout is the presence of negatively birefringent, needlelike crystals in leukocytes from synovial fluid
  24. A 24-year-old male is initially found to have a single nodule in the right lobe of his thyroid gland. He is clinically and chemically euthyroid. The next step is to...
    The combination of fine needle aspiration and radioisotope scanning of a solitary thyroid noduleprovides the best diagnostic yield. Because cold nodules may be cancerous, they are generally referredfor surgical removal. It is not reasonable to delay the diagnosis.

    Ultrasound is preferred over MRI or CT scan of the thyroid
  25. In differentiating a viral pharyngitis from a streptococcal pharyngitis, which of the following must be included?
    The throat culture is the definitive test to identify beta-hemolytic Group A streptococci

    • CBC - nonspecific
    • ASO titer - identify past infection - not current
    • Cold agglutinins - nonspecific and positive in mycoplasma pna, influenza, mononucleosis, Rheumatoid arthritis
  26. A 2-year-old presents with sudden onset of cough and stridor. On examination the child is afebrile and appears well with a respiratory rate of 42 per minute. What is the next best step in the evaluation and treatment of this patient?
    • Indirect laryngoscopy
    • - Indicated not only for diagnosis, but also for removal of the foreign body

    • Barium swallow - used to evaluate possible esophageal foreign body aspiration - wheezing and stridor are not common
    • Lateral x-ray of neck - only 7% of all foreign bodies are radiopaque - typically done for epiglottitis and retropharyngeal abscess.
  27. A 24-year-old male presents with complaints of increasing drainage from both eyes associated with milddiscomfort for the past day. He denies severe or deep eye pain and any blurring of his vision. On examination, his visual activity is 20/20 OU. There is moderate erythema and edema of the eyelids,diffuse conjunctival injection, and profuse thick mucopurulent discharge on the conjunctiva and lids.Which of the following is the most appropriate diagnostic evaluation?
    This is the typical presentation of a bacterial conjunctivitis. Due to the severity of the presentation and possibility of infection caused by Neisseria gonorrheae , initial evaluation by Gram stain and culture should be performed

    Giemsa and Fluorescent antibody testing - Chlamydia trachomatis; Tzanck smear - HSV
  28. A 4-year-old patient presents with increasing redness and swelling involving her right eye for the past 2days. The mother states that the child has become increasingly irritable, less active, and appears tohave an increased temperature. The child had a recent "cold" and nasal congestion prior to onset ofthese symptoms. Examination reveals an ill-appearing 4-year-old child lying quietly on the exam table.Temperature is 102°F. Visual activity is 20/40 in the right eye and 20/30 in the left eye. The right eyereveals mild proptosis and severe erythema, increased warmth, and swelling involving the eye andsurrounding tissues. Which of the following is the most appropriate diagnostic evaluation?
    This is the typical presentation of orbital cellulitis. A CT scan of the orbit and sinuses is indicatedto check for the presence of a subperiosteal abscess and underlying sinusitis, which is often the cause oforbital cellulitis
  29. What is applanation tonometry?
    Utilized in the measurement of intraocular pressure with suspected glaucoma
  30. What is electronystagmography?
    an objective recording of induced nystagmus utilized for the evaluation of vertigo
  31. A 65-year-old patient with a known history of alcohol and tobacco abuse presents with solid-food dysphagia. The patient also had a 24 lb weight loss over the past 6 months. To establish a diagnosis,which of the following studies should be performed?
    • Endoscopy with biopsy establishes the diagnosis of esophageal carcinoma with a high degree of reliability when biopsy is included as part of the procedure
    • (Barium esophagram is obtained as the first study to evaluate the dysphagia)

    • CT - once diagnosis of carcinoma is obtained - use CT for pulmonary or hepatic mets, LAD and local tumor extension
    • CXR - shows adenopathy, widened mediastinum, pulmonary or bony mets, or sign of tracheoesophageal fistula such as pneumonia
  32. A 35-year-old male presents to the emergency department with a 4-hour history of abdominal pain,nausea, and vomiting. He denies diarrhea. Examination reveals the following:
    Temperature 101°F (38.3°C)
    Pulse 100 beats/min
    Respiratory rate 20/min
    Blood pressure 110/65 mm Hg

    The patient is in moderate distress and slightly diaphoretic. He has poor oral hygiene and the odor ofalcohol is noted. Examination of the heart and lungs are unremarkable except for tachycardia.Abdominal examination reveals hypoactive bowel sounds, diffuse tenderness with more markedtenderness in the epigastric area, without guarding, rebound, masses, or organomegaly. Along with CBC, what diagnostic studies would be most appropriate?
    The clinical presentation suggests acute pancreatitis, which is best evaluated by liver function tests, amylase, and abdominal films
  33. Which of the following is the most helpful serological test in primary biliary cirrhosis?
    Anti-mitochondrial antibodies are seen in over 90% of cases of primary biliary cirrhosis and are rare in other forms of liver disease.
  34. Anti-smooth muscle antibodies...
    autoimmune hepatitis
  35. Anti-hepatitis B antibodies
    Viral Hepatitis B
  36. Anti-nuclear antibodies
    RA, lupus, scleroderma and Sjogren syndrome
  37. A 26-year-old male patient presents with complaints of diarrhea with marked flatulence and weight loss for the past 6-8 months. In addition, he states that his stools are loose and soft with an oily appearance and foul smelling. The patient has not traveled out of the country. What laboratory tests would be most helpful based upon this history?
    Steatorrhea is usually present, but may be absent in mild disease of celiac sprue. A quantitative72-hour stool collection taken while patients are consuming a 100 gm fat diet is a more sensitive meansof detecting fat malabsorption
  38. The physician assistant is evaluating a patient suspected of having an irondeficiency anemia. When examining the patient's peripheral blood smear, thediagnosis is reinforced by noting
    Hypochromic, microcytic red blood cells are common in patients with iron deficiency anemia

    • Shistocytes - hemolytic anemia
    • Howell-jolly bodies - non-functioning spleen or splenectomy
    • Macrocytosis - megaloblastic anemia
  39. An 18-year-old patient presents with fever, pharyngitis, and cervical lymphadenopathy. The CBC shows a leukocytosis with 25% atypical lymphocytes. Which of the following is the diagnostic test of choice for this patient?
    A heterophile test is the test of choice for the diagnosis of infectious mononucleosis
  40. Which of the following would aid in the diagnosis of Reye’s syndrome?
    Elevated Serum ammonia levels

    Reye’s syndrome results in fatty liver with encephalopathy. It is a complication of influenza and other viral illnesses, particularly in the young and with the use of aspirin. Laboratory characteristics include elevated ammonia levels, elevation of liver enzymes, hypoglycemia, and a prolonged prothrombin time.
  41. Which of the following laboratory studies may be used in the prenatal diagnosis of spina bifida?
    • Alpha-fetoprotein, measured at 16-18 weeks of pregnancy, if elevated, would indicate a neuraltube defect, such as spina bifida.
    • Folic acid has been shown to decrease the incidence of neural tube defects, not as an aid indiagnosis of the defect.
  42. In suspected subarachnoid hemorrhage with a negative head CT, which of the following studies should be used to help establish the diagnosis of subarachnoid hemorrhage?
    Although 95% of subarachnoid hemorrhages show blood on head CT, the remaining do not showevidence of hemorrhaging. A lumbar puncture should then be performed and the fluid examined for redblood cells or xanthochromia

    (EKG may show diffuse T wave inversions in precordial leads, but not always present)
  43. Which of the following is the best test to confirm the presence of gonorrhea in a female?
    The standard for diagnosis of gonorrhea is the isolation of the organism by culture from theendocervix in women
  44. Which of the following is the primary technique for evaluation of an abnormal cervical cytology smear?
    Colposcopy is the primary method for evaluation of abnormal cervical cytology smear

    Dilation and curettage - evaluated abnormal uterine bleeding
  45. Which of the following is a common x-ray finding seen in osteoarthritis?
    Osteophyte formation and joint space narrowing are common in osteoarthritis
  46. Some abnormal findings of bone on xray...
    Chondrocalcinosis is seen in pseudogout.

    Fat pad displacement is a soft tissue change noted in fractures of the wrist and elbow. 

    Moth-eaten bone destruction is noted in osteomyelitis and certain bone cancers
  47. A break in the cortex of one side of the bony shaft without a separation or break of the opposite cortex is called what type of fracture?
    A greenstick fracture is a break in the cortex of one side of bone shaft without a break in theopposite cortex
  48. A complete fracture of both cortices of a bony shaft is called?
    A transverse fracture

    • (Torus fracture - bowing, bending or buckling without a break in the cortex)
    • (Epiphyseal fracture occurs at the growth plate)
  49. Which of the following abnormalities is most commonly noted in bulimia nervosa?
    Episodes of binge eating are followed by purging in the bulimic patient. Vomiting and laxative abuse are the most common methods of purging, leading to hypokalemia

    (Metabolic alkalosis is K loss is great; serum albumin is normal or decreased)
  50. Which of the following laboratory tests is most appropriate to perform on a patient taking clozapine (Clozaril)?
    Agranulocytosis is a known complication of clozapine and weekly complete blood counts are mandatory when this medication is given
  51. Which of the following is the most common radiographic presentation of pulmonary tuberculosis?
    Cavitation is seen with progressive primary tuberculosis or lung abscess
  52. CXR - pleural thickening should indicate?
    Think Mesothelioma
  53. Main clinical feature of emphysema on a CXR?
  54. Hilar or mediastinal abnormalities on CXR is common in what patients?
    Lung cancer
  55. A 72-year-old patient with a long standing history of COPD will have a reduction in which of the following on spirometry?

    In severe COPD, the forced vital capacity is markedly reduced. Lung volume measurementsreveal an increase in total lung capacity, a marked increase in residual volume, and an elevation of theRV/TLC ratio,is indicative of air trapping, particularly in emphysema.
  56. A 68-year-old patient with chronic obstructive pulmonary disease will typically demonstrate a decreased
    COPD causes a state of respiratory acidosis, which would account for the decreased blood pH.

    • - serum bicarb = normal or increased
    • - elevated Hb = heavy smokers/emphysema
    • - COPD causes CO2 retention - which increases pCO2
  57. The diagnostic gold standard to rule out pulmonary embolism is
    Pulmonary angiography

    Although chest x-ray, arterial blood gases, and ventilation-perfusion scans may be obtained in thework-up of suspected pulmonary embolism, the arteriogram remains the "gold standard" for diagnosis
  58. A urinalysis performed during a routine physical examination on a 43-year-old male reveals 1-2 hyalinecasts/HPF. The remainder of the UA is normal. Based upon these results, the physician assistant should
    do nothing, since these casts are considered normal

    Hyaline casts are not indicative of renal disease. They can be found following strenuous exerciseand with concentrated urine or during a febrile illness
  59. Which of the following urine findings is pathognomonic for acute pyelonephritis?
    White blood cell casts are pathognomonic for acute pyelonephritis
  60. In renal insufficiency, which of the following is used to assess glomerular filtration rate (GFR)?
    Creatinine clearance

    The GFR provides an overall index of renal function. Creatinine is normally cleared by renalexcretion; as renal GFR declines, serum creatinine will increase
  61. A 59-year-old male complains of pain in his right leg for the last few months. He is normally able to walktwo miles a day, but has noted pain when he climbs hills, which is relieved with rest or resuming walkingon flat ground. He also complains of foot pain at rest. He does not smoke and denies injury to his back.He has been generally healthy with obesity and mildly elevated triglycerides. The most likely cause of the pain in this patient is
    Symptoms of intermittent claudication and arterial occlusive disease include pain with exercise thatis relieved by rest; pain in the feet at rest indicates severe circulatory compromise. The history of obesityand elevated triglycerides is consistent with peripheral vascular disease. Although this patient could alsobe at risk for diabetes, the most likely immediate problem is vascular in nature
  62. A 46-year-old female is being evaluated for a new-onset hypertension that was discovered on screeningat her workplace. The patient had several readings revealing systolic and diastolic hypertension.Physical examination is normal. A complete laboratory evaluation was performed with unexplained hypokalemia as the only abnormality found. Which of the following is the most likely diagnosis for this patient?
    Primary aldosteronism has an increased aldosterone secretion, which causes the retention of sodium and the loss of potassium. This should be the primary consideration for this patient.
  63. Pheochromocytoma will result in
    an increase in the production and release of catecholamines,which results in an increase in urinary metanephrines on testing
  64. Renal artery stenosis is identified by
    an abnormal radionuclide uptake on the affected kidney
  65. Coarctation of the aorta is identified by
    delayed and weakened femoral pulses along with a bloodpressure in the lower extremities significantly lower than in the upper extremities
  66. An 8-year-old boy is brought to a physician because of palpitation, fatigue, and dyspnea. Onexamination, a continuous machinery murmur is heard best in the second left intercostal space and iswidely transmitted over the precordium. The most likely diagnosis is
    Patent ductus arteriosus is classically described in children as a continuous machinery-type murmur that is widely transmitted across the precordium.
  67. A holosystolic murmur rather than a continuous machinery-like murmur
  68. A fixed split S2 rather than a continuous systolic heart murmur
  69. Murmur of congenital aortic stenosis?
    causes a crescendo-decrescendo systolic murmur heard best in thesecond intercostal space
  70. A patient who appears very anxious enters the office complaining of dizziness with perioral and extremityparesthesias. She vaguely describes some chest discomfort. Physical examination is unremarkable,except for moderate tachypnea with obvious sighing respiration. This clinical picture is most consistent with
    Anxiety may result in hyperventilation that can result in perioral numbness and paresthesias of theextremities. These paresthesias are due to decreased CO2in the blood stream that results from thehyperventilation. Anxious patients also will have nondescript chest pain as part of this condition and mayalso complain of dizziness
  71. Patient presents with increased dyspnea and prolonged expiration. Patients may use accessory muscles of respiration as part of this acute condition
    Bronchial asthma attacks
  72. Patients will primarily complain of significant chest pain along with their dyspnea. These patients will not have perioral or extremity called?
    Spontaneous pneumothorax
  73. A 12-year-old boy presents to the office with pain in his legs with activity gradually becoming worse overthe past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination ofthe heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated.Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis?
    Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the "3"
  74. Pheochromocytoma classically causes
    paroxysms of hypertension due to catecholamine releasefrom the adrenal medulla, but does not cause variations in blood pressure in the upper and lowerextremities
  75. Thoracic outlet syndrome occurs when
    the brachial plexus, subclavian artery, or subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterial occlusion in the upper extremity of adults under 40 years old.
  76. A 55-year-old morbidly obese male is seen in the office for routine examination. He has a history of pulmonary hypertension and cor pulmonale. Examination reveals a palpable jugular venous pulse along with a systolic flow murmur on the right side of the sternum. Which of the following is the most likely diagnosis?
    Tricuspid insufficiency will result in blood being put back into the right side of the body with increased jugular pulsation in the neck, along with a palpable venous pulse in the liver.
  77. Thoracic aorta aneurysm results in
    a widened mediastinum that is fairly asymptomatic until itresults in rupture or dissection. These are typically found as incidental findings unless they aresymptomatic from dissection or rupture, which causes severe chest pain or a severe tearing sensation inthe chest
  78. Hepatic vein thrombosis or Budd-Chiari syndrome is associated with
    cirrhosis and liver clotting abnormalities and is not due to right-sided heart failure
  79. On a routine neonate examination, a grade IV/VI holosystolic murmur is heard in the 3rd-4th leftintercostal space in the parasternal line. The murmur is most likely that of
    Ventricular septal defect does cause a holosystolic murmur with blood flowing primarily from theleft to the right side during systole
  80. A patient presents complaining of dyspnea with exercise that worsen at night. He has to use three pillows to sleep comfortably. The most likely diagnosis is which of the following?
    Congestive or chronic heart failure is associated with orthopnea and even paroxysmal nocturnal dyspnea because of increased venous return of blood to the heart when the patient assumes a supine  position
  81. Atelectasis results from
    a portion of the lung collapsing, usually due to patients not taking a deepbreath. This condition is primarily seen in post-operative patients who have pain that makes deepbreathing difficult
  82. A 65-year-old male presents to the emergency department with chest pain since yesterday. The patientdescribes the pain as severe with tingling, but denies dyspnea. On examination, there is a tender band of erythema with superimposed vesicles and bullae on the left anterior chest wall, extending from the left side of the sternum laterally. Which of the following is the most likely diagnosis?
    Herpes zoster presents with painful vesicular rash in dermatomal distribution
  83. Pityriasis rosea usually occurs in children and young adults and is characterized by
    multiple pinkoval lesions that are scattered symmetrically, with a Christmas tree like distribution over the trunk
  84. A 6-year-old girl is brought in by her mother, who is concerned about sores located on the girl's face.Initially, the lesion was described as a "cold sore," but recently it has spread and developed a crustyappearance. On examination, small erosions covered by moist, honey-colored crusts are noted. Themost likely diagnosis is
    The vesiculopustular form of impetigo is characterized by golden-crusted lesions

    While allergic contact dermatitis presents with vesicular lesions and may go on to form crusts,honey-colored crusts are classically a finding of impetigo
  85. silvery scales on bright red, well-demarcated plaques
  86. pruritic, exudative, or lichenified eruptions
    atopic dermatitis
  87. A 72-year-old male presents to the clinic for evaluation of a bump on his nose. The patient is a lifelong resident of Florida and an avid golfer. On examination, a 1 cm round, firm, pearly nodule with fine telangiectasias is noted. Which of the following is the most likely diagnosis?
    The lesion of basal cell carcinoma is typically firm, round, and pearly or waxy. It is the mostcommon cutaneous neoplasm in humans, with 85% of them occurring on the head or neck. Margin telangiectasis are classically associated with basal cell carcinomas. Risk factors include fair skin,excessive sun exposure, and male gender

    Lesions of squamous cell carcinoma vary in appearance, but do not have overlyingtelangiectasias
  88. seborrheic keratosis demonstrate
    a well-circumscribed border, have a stuck-onappearance, and are a variable tan-brown-black color
  89. Lesions of actinic keratosis are
    3-6 mm in size, have a rough texture, with eventual formation of ayellow adherent crust. These lesions are found in sun-exposed areas and may be considered premalignant
  90. A patient presents with fatigue, weakness and weight loss. On examination, his blood pressure is 90/60mm Hg, and there is hyperpigmentation of skin creases, pressure areas, and nipples. Plasma ACTHlevel is elevated. The most likely diagnosis is which of the following
    This is a classic presentation of Addison's disease, lack of inhibitation of MSH leads tohyperpigmentation
  91. A 58-year-old chemotherapy patient presents with fever, chills, productive cough, and disorientation.The patient appears very ill. 

    Vital signs include:
    T 102°FP 138/min
    R 24/min
    BP 70/40 mm Hg
    Laboratory results include:
    WBC 2.1 x 103 /mm3 
    Na 140 mEq/L
    CI 90 mEq/L
    HCO3-15 mEq/L
    Glucose 140 mg/dL
    Besides sepsis, the most likely diagnosis is
    Lactic acidosis is the most common cause of anion gap acidosis. In a patient with inadequate tissue perfusion, lactic acid builds up due to anaerobic metabolism, leading to accumulation of an"unmeasured ion.
  92. A 72-year-old patient with Type 2 diabetes treated with glyburide is brought into the clinic by herdaughter, who provides the patient's history. The patient has had a mild fever, sore throat, andexcessive diuresis for the past 2 days. She has been reluctant to eat or drink because of the sore throat.At the clinic, she becomes increasingly stuporous and lethargic. Based on this information, the patient ismost likely experiencing
    Correct Answer: A nonketotic hyperglycemic hyperosmolar coma is most common in an elderly patient with mild diabetes. Lethargy and confusion develop as osmolality rises to 300 mosm/kg or higher

    Acceptable Answer: Although hypoglycemia induced by oral glucose lowering agents is less common, it tends to occur in elderly patients with impaired renal function and is generally associated with longer acting sulfonylureas.
  93. Kmahase
Card Set:
Packrat 8
2013-07-04 21:57:08

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