TEST BANK for Bates guide to physical examination and history taking 12th Edition by Lynn

downloaded from

Scholarfriends

https://scholarfriends.com Downloaded by: edukinuthia@gmail.com | https://scholarfriends.com/singlePaper/122195/test-bank-for-bates-guide-to-physical-examinationand-history-taking-12th-edition-all-20-chapte Distribution of this document is illegal.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 1: Overview: Physical Examination and History Taking

Multiple Choice

1. For which of the following patients would a comprehensive health history be appropriate?

A) A new patient with the chief complaint of “I sprained my ankle” B) An established patient with the chief complaint of “I have an upper respiratory infection” C) A new patient with the chief complaint of “I am here to establish care” D) A new patient with the chief complaint of “I cut my hand” Ans: C Chapter: 01 Page and Header: 4, Patient Assessment: Comprehensive or Focused Feedback: This patient is here to establish care, and because she is new to you, a comprehensive health history is appropriate.

2. The components of the health history include all of the following except which one?

A) Review of systems B) Thorax and lungs C) Present illness D) Personal and social items Ans: B Chapter: 01 Page and Header: 4, Patient Assessment: Comprehensive or Focused Feedback: The thorax and lungs are part of the physical examination, not part of the health history. The others answers are all part of a complete health history.

3. Is the following information subjective or objective?

Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity and relieved by rest.

A) Subjective B) Objective Ans: A Chapter: 01 Page and Header: 6, Differences Between Subjective and Objective Data Feedback: This is information given by the patient about the circumstances of his chief complaint. It does not represent an objective observation by the examiner.

4. Is the following information subjective or objective?

Mr. M. has a respiratory rate of 32 and a pulse rate of 120.

A) Subjective B) Objective Ans: B Chapter: 01 Page and Header: 6, Differences Between Subjective and Objective Data Feedback: This is a measurement obtained by the examiner, so it is considered objective data.

The patient is unlikely to be able to give this information to the examiner.

5. The following information is recorded in the health history: “The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the midepigastric area.”

Which of these categories does it belong to?

A) Chief complaint B) Present illness C) Personal and social history D) Review of systems Ans: B Chapter: 01 Page and Header: 6, The Comprehensive Adult Health History Feedback: This information describes the problem of abdominal pain, which is the present illness. The interviewer has obtained the location, timing, severity, and associated manifestations of the pain. The interviewer will still need to obtain information concerning the quality of the pain, the setting in which it occurred, and the factors that aggravate and alleviate the pain. You will notice that it does include portions of the pertinent review of systems, but because it relates directly to the complaint, it is included in the history of present illness.

6. The following information is recorded in the health history: “The patient completed 8th grade.

He currently lives with his wife and two children. He works on old cars on the weekend. He works in a glass factory during the week.”

Which category does it belong to?

A) Chief complaint B) Present illness C) Personal and social history D) Review of systems Ans: C Chapter: 01 Page and Header: 6, The Comprehensive Adult Health History Feedback: Personal and social history information includes educational level, family of origin, current household status, personal interests, employment, religious beliefs, military history, and lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and sexual preferences and history). All of this information is documented in this example.

7. The following information is recorded in the health history: “I feel really tired.”

Which category does it belong to?

A) Chief complaint B) Present illness C) Personal and social history D) Review of systems Ans: A Chapter: 01 Page and Header: 6, The Comprehensive Adult Health History Feedback: The chief complaint is an attempt to quote the patient's own words, as long as they are suitable to print. It is brief, like a headline, and further details should be sought in the present illness section. The above information is a chief complaint.

8. The following information is recorded in the health history: “Patient denies chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea.”

Which category does it belong to?

A) Chief complaint B) Present illness C) Personal and social history

D) Review of systems Ans: D Chapter: 01 Page and Header: 6, The Comprehensive Adult Health History Feedback: Review of systems documents the presence or absence of common symptoms related to each major body system. The absence of cardiac symptoms is listed in the above example.

9. The following information is best placed in which category?

“The patient has had three cesarean sections.”

A) Adult illnesses B) Surgeries C) Obstetrics/gynecology D) Psychiatric Ans: B Chapter: 01 Page and Header: 9, Past History Feedback: A cesarean section is a surgical procedure. Approximate dates or the age of the patient at the time of the surgery should also be recorded.

10. The following information is best placed in which category?

“The patient had a stent placed in the left anterior descending artery (LAD) in 1999.”

A) Adult illnesses B) Surgeries C) Obstetrics/gynecology D) Psychiatric Ans: A Chapter: 01 Page and Header: 9, Past History Feedback: The adult illnesses category is reserved for chronic illnesses, significant hospitalizations, significant injuries, and significant procedures. A stent is a major procedure but does not involve a surgeon.

11. The following information is best placed in which category?

“The patient was treated for an asthma exacerbation in the hospital last year; the patient has

never been intubated.”

A) Adult illnesses B) Surgeries C) Obstetrics/gynecology D) Psychiatric Ans: A Chapter: 01 Page and Header: 9, Past History Feedback: This is information about a significant hospitalization and should be placed in the adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider placing this information in the present illness section, because it relates to the chief complaint at that visit.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 2: Clinical Reasoning, Assessment, and Recording Your Findings

Multiple Choice

1. A patient presents for evaluation of a sharp, aching chest pain which increases with breathing.

Which anatomic area would you localize the symptom to?

A) Musculoskeletal B) Reproductive C) Urinary D) Endocrine Ans: A Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: Chest pain may be due to a musculoskeletal condition, such as costochondritis or intercostal muscle cramp. This would be worsened by motion of the chest wall. Pleuritic chest pain is also a sharp chest pain which increases with a deep breath. This type of pain can occur with inflammation of the pleura from pneumonia or other conditions and pulmonary embolus.

2. A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom?

A) Reproductive B) Urinary C) Cardiac D) Hematologic Ans: C Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: Cardiac disorders such as congestive heart failure are the most likely on this list to result in shortness of breath. There are cases within the other categories which may also result in shortness of breath, such as anemia in the hematologic category, pregnancy in the reproductive category, or sepsis with UTI in the urinary category. This demonstrates the “tension” in clinical reasoning between making sure all possibilities are covered, while still being able to pick the most likely cause.

3. A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough?

A) Ophthalmologic B) Auditory C) Cardiac D) Endocrine Ans: C Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: The cardiac system can cause a cough if the patient has congestive heart failure. This results in fluid buildup in the lungs, which in turn can cause a cough that produces pink, frothy sputum. A foreign body in the ear may also cause a cough by stimulating Arnold's branch of the vagus nerve, but this is less likely to be seen clinically than heart failure.

4. A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new, located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash; she also denies recent travel or camping activities. She has a family history significant for rheumatoid arthritis. Based on this information, which of the following pathologic processes would be the most correct?

A) Infectious

B) Inflammatory C) Hematologic D) Traumatic Ans: B Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: The description is most consistent with an inflammatory process, although all the other etiologies should be considered. Lyme disease is an infection which commonly causes arthritis, hemophilia is a hematologic condition which can cause bleeding in the joints, and trauma can obviously cause joint pain. Your clinical reasoning skills are important for sorting through all of the data to arrive at the most likely conclusion.

5. A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for several years. He normally takes over-the-counter medications to ease the pain, but this time they haven't worked as well, and he still has discomfort. He recently wallpapered the entire second floor in his house, which caused him great discomfort. The pain resolved with rest. He denies fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this description, what is the most likely pathologic process?

A) Infectious B) Neoplastic C) Degenerative D) Traumatic Ans: C Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: The description is most consistent with degenerative arthritis in the neck. The patient has had intermittent symptoms and the questions asked to elicit pertinent negative and positive findings are negative for infectious, traumatic, or neoplastic disease.

6. A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which is the most likely pathologic process?

A) Infection B) Inflammation C) Allergic D) Vascular Ans: C

Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: This description is most consistent with allergic rhinitis.

7. A 19-year-old-college student presents to the emergency room with fever, headache, and neck pain/stiffness. She is concerned about the possibility of meningococcal meningitis. Several of her dorm mates have been vaccinated, but she hasn't been. Which of the following physical examination descriptions is most consistent with meningitis?

A) Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range of motion B) Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle spasm and limited range of motion to the right C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion D) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full range of motion Ans: C Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: Blurred disc margins are consistent with papilledema, and neck tenderness and lack of range of motion are consistent with neck stiffness, which in this scenario is likely to be caused by meningeal inflammation. Later, you will learn about Kernig's and Brudzinski's signs, which are helpful in testing for meningeal irritation on examination.

8. A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods.

Which one of the following physical examination descriptions would be most consistent with the diagnosis of cholecystitis?

A) Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses.

B) Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or guarding.

C) Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the point of stopping inspiration, and there is no rebound or guarding.

D) Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or guarding.

Ans: C Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning

Feedback: In cholecystitis, the pain, which originates from the gallbladder, is located in the right upper quadrant. Severity of pain with inspiration that is sufficient to stop further inhalation is also known as Murphy's sign, which, if present, is further indicative of inflammation of the gallbladder.

9. A 55-year-old data entry operator comes to the clinic to establish care. She has the following symptoms: headache, neck pain, sinus congestion, sore throat, ringing in ears, sharp brief chest pains at rest, burning abdominal pain with spicy foods, constipation, urinary frequency that is worse with coughing and sneezing, and swelling in legs. This cluster of symptoms is explained by: A) One disease process B) More than one disease process Ans: B Chapter: 02 Page and Header: 38, The Challenges of Clinical Data Feedback: The patient appears to have several possible conditions: allergic rhinitis, arthritis, conductive hearing loss, pleuritic chest pains, heartburn, stress urinary incontinence, and venous stasis, among other conditions. Although we always try, it is very difficult to assign all of these symptoms to one cohesive diagnosis.

10. A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever, headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of symptoms is best explained by: A) One disease process B) More than one disease process Ans: A Chapter: 02 Page and Header: 38, The Challenges of Clinical Data Feedback: This cluster of symptoms is most consistent with sinusitis. The chance that all of these symptoms are caused by multiple synchronous conditions in the same patient is much less than the possibility of having one problem which accounts for all of them.

11. Steve has just seen a 5-year-old girl who wheezes when exposed to cats. The patient's family history is positive for asthma. You think the child most likely has asthma. What have you just accomplished?

A) You have tested your hypothesis.

B) You have developed a plan.

C) You have established a working diagnosis.

D) You have created a hypothesis.

Ans: D Chapter: 02 Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning Feedback: As you go through a history and examination, you will start to generate ideas to explain the patient's symptoms. It is best to keep an open mind and make as many hypotheses as you can, to avoid missing a possibility. A common mistake is to latch onto one idea too early.

Once you have committed your mind to a diagnosis, it is difficult to change to another. To think about looking for wheezes on examination would be an example of testing your new hypothesis.

Starting a patient on an inhaled medicine would be a plan. It is too early to commit to a working diagnosis, given the amount of information you have gathered.

12. Ms. Washington is a 67-year-old who had a heart attack last month. Now she complains of shortness of breath and not being able to sleep in a flat position (orthopnea). On examination you note increased jugular venous pressure, an S3 gallop, crackles low in the lung fields, and swollen ankles (edema). This is an example of a: A) Pathophysiologic problem B) Psychopathologic problem Ans: A Chapter: 02 Page and Header: 38, The Challenges of Clinical Data Feedback: This is an example of a pathophysiologic problem because Ms. Washington's symptoms are consistent with a pathophysiologic process. The heart attack reduced the ability of her heart to handle her volume status and subsequently produced the many features of congestive heart failure.

13. On the way to see your next patient, you glance at the calendar and make a mental note to buy a Mother's Day card. Your patient is Ms. Hernandez, a 76-year-old widow who lost her husband in May, two years ago. She comes in today with a headaches, abdominal pain, and general malaise. This happened once before, about a year ago, according to your detailed office notes. You have done a thorough evaluation but are unable to arrive at a consistent picture to tie these symptoms together. This is an example of a: A) Pathophysiologic problem B) Psychopathologic problem

Ans: B Chapter: 02 Page and Header: 38, The Challenges of Clinical Data Feedback: It is not uncommon for patients to experience psychopathologic symptoms around the anniversary of a traumatic event. The time of year and the lack of an obvious connection between Ms. Hernandez's symptoms would make you consider this as a possibility. You will note that although this might have been an early consideration in your hypothesis generation, it is key to convince yourself that there is not a physiologic explanation for these symptoms, by performing a careful history and examination.

14. Mr. Larson is a 42-year-old widowed father of two children, ages 4 and 11. He works in a sales office to support his family. Recently he has injured his back and you are thinking he would benefit from physical therapy, three times a week, for an hour per session. What would be your next step?

A) Write the physical therapy prescription.

B) Have your office staff explain directions to the physical therapy center.

C) Discuss the plan with Mr. Larson.

D) Tell Mr. Larson that he will be going to physical therapy three times a week.

Ans: C Chapter: 02 Page and Header: 30, Develop a Plan Agreeable to the Patient Feedback: You should discuss your proposed plan with the patient before implementing it. In this case, you and Mr. Larson will need to weigh the benefit of physical therapy against the ability to provide for his family. You may need to consider other ways of helping the patient, perhaps through prescribed back exercises he can do at home. It is a common mistake to implement a plan without coming to an agreement with the patient first.

15. You are seeing an elderly man with multiple complaints. He has chronic arthritis, pain from an old war injury, and headaches. Today he complains of these pains, as well as dull chest pain under his sternum. What would the order of priority be for your problem list?

A) Arthritis, war injury pain, headaches, chest pain B) War injury pain, arthritis, headaches, chest pain C) Headaches, arthritis, war injury pain, chest pain D) Chest pain, headaches, arthritis, war injury pain Ans: D Chapter: 02 Page and Header: 37, Generating the Problem List Feedback: The problem list should have the most active and serious problem first. This new

complaint of chest pain is almost certainly a higher priority than his other, more chronic problems.

16. You are excited about a positive test finding you have just noticed on physical examination of your patient. You go on to do more examination, laboratory work, and diagnostic tests, only to find that there is no sign of the disease you thought would correlate with the finding. This same experience happens several times. What should you conclude?

A) Consider not doing this test routinely.

B) Use this test when you have a higher suspicion for a certain correlating condition.

C) Continue using the test, perhaps doing less laboratory work and diagnostics.

D) Omit this test from future examinations.

Ans: C Chapter: 02 Page and Header: 38, The Challenges of Clinical Data Feedback: This is an example of a sensitive physical finding that lacks specificity. This does not make this a useless test, because the purpose of a screening physical is to find disease. This finding made you consider the associated condition as one of your hypotheses, and this in itself has value. Other possibilities are that you may be doing the maneuver incorrectly or using it on the wrong population. It is important to ask for hands-on help from your instructor when you have a question about a maneuver. Make sure that your information about the maneuver comes from a reliable source as well. All of this information also applies to history questions.

17. You are growing fatigued of performing a maneuver on examination because you have never found a positive and are usually pressed for time. How should you next approach this maneuver?

A) Use this test when you have a higher suspicion for a certain correlating condition.

B) Omit this test from future examinations.

C) Continue doing the test, but rely more heavily on laboratory work and diagnostics.

D) Continue performing it on all future examinations.

Ans: A Chapter: 02 Page and Header: 38, The Challenges of Clinical Data Feedback: This is an example of a specific test that lacks sensitivity. With this scenario, when you finally find a positive, you might be very certain that a given condition is present. We generally develop our examinations to fit our clinical experiences. Sensitive tests are performed routinely on the screening examination, while specific tests are usually saved for the detailed or “branched” examinations. Branched examinations are further maneuvers we can perform to investigate positive findings on our screening examinations. Save this type of maneuver to

confirm your hypothesis. All of this information also applies to history questions.

18. You have recently returned from a medical missions trip to sub-Saharan Africa, where you learned a great deal about malaria. You decide to use some of the same questions and maneuvers in your “routine” when examining patients in the midwestern United States. You are disappointed to find that despite getting some positive answers and findings, on further workup, none of your patients has malaria except one, who recently emigrated from Ghana. How should you next approach these questions and maneuvers?

A) Continue asking these questions in a more selective way.

B) Stop asking these questions, because they are low yield.

C) Question the validity of the questions.

D) Ask these questions of all your patients.

Ans: A Chapter: 02 Page and Header: 38, The Challenges of Clinical Data Feedback: The predictive value of a positive finding depends upon the prevalence of a given disease in a population. The prevalence of malaria in the Midwest is almost zero, except in people immigrating from areas of high prevalence. You will waste time and resources applying these questions and maneuvers to all patients. It would be wise to continue applying what you learned to those who are from areas of high prevalence of a given disease. Likewise, physicians from Ghana should not ask about signs or symptoms of multiple sclerosis, as it is found almost exclusively in northern latitudes. You will learn to tailor your examination to the population you are serving.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 3: Interviewing and the Health History

Multiple Choice

1. You are running late after your quarterly quality improvement meeting at the hospital and have just gotten paged from the nurses' station because a family member of one of your patients

wants to talk with you about that patient's care. You have clinic this afternoon and are doublebooked for the first appointment time; three other patients also have arrived and are sitting in the waiting room. Which of the following demeanors is a behavior consistent with skilled interviewing when you walk into the examination room to speak with your first clinic patient?

A) Irritability B) Impatience C) Boredom D) Calm Ans: D Chapter: 03 Page and Header: 58, Getting Ready: The Approach to the Interview Feedback: The appearance of calmness and patience, even when time is limited, is the hallmark of a skilled interviewer.

2. Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient–provider interview?

A) Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story.

B) Invite the patient's story, negotiate a plan, establish the agenda, and establish rapport.

C) Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan.

D) Negotiate a plan, establish an agenda, invite the patient's story, and establish rapport.

Ans: C Chapter: 03 Page and Header: 60, Learning About the Patient: The Sequence of the Interview Feedback: This is the most productive sequence for the interview. Greeting patients and establishing rapport allows them to feel more comfortable before “inviting” them to relate their story. After hearing the patient's story, together you establish the agenda regarding the most important items to expand upon. At the end, together you negotiate the plan of diagnosis and treatment.

3. Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The pain is a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and it seems to be worse a couple of hours after eating. She has noticed that it starts after eating greasy foods, so she has cut down on these as much as she can. Initially it occurred once a week, but now it is occurring every other day. Nothing makes it better. From this description, which of the seven attributes of a symptom has been omitted?

A) Setting in which the symptom occurs B) Associated manifestations C) Quality D) Timing Ans: B Chapter: 03 Page and Header: 65, The Seven Attributes of a Symptom Feedback: The interviewer has not recorded whether or not the pain has been accompanied by nausea, vomiting, fever, chills, weight loss, and so on. Associated manifestations are additional symptoms that may accompany the initial chief complaint and that help the examiner to start refining his or her differential diagnosis.

4. Jason is a 41-year-old electrician who presents to the clinic for evaluation of shortness of breath. The shortness of breath occurs with exertion and improves with rest. It has been going on for several months and initially occurred only a couple of times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than a dozen times per day. The shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea.

Which of the following symptom attributes was not addressed in this description?

A) Severity B) Setting in which the symptom occurs C) Timing D) Associated manifestations Ans: A Chapter: 03 Page and Header: 65, The Seven Attributes of a Symptom Feedback: The severity of the symptom was not recorded by the interviewer, so we have no understanding as to how bad the symptom is for this patient. The patient could have been asked to rate his pain on a 0 to 10 scale or used one of the other standardized pain scales available.

This allows the comparison of pain intensity before and after an intervention.

5. You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning?

A) Directed questioning: starting with the general and proceeding to the specific in a manner that does not make the patient give a yes/no answer B) Reassuring the patient that the urinary symptoms are benign and that she doesn't need to

worry about it being a sign of cancer C) Offering the patient multiple choices in order to clarify the character of the urinary symptoms that she is experiencing D) Asking her to tell you exactly what she means when she states that she has a urinary tract infection Ans: B Chapter: 03 Page and Header: 68, Building a Therapeutic Relationship: The Techniques of Skilled Interviewing Feedback: Reassurance is not part of clarifying the patient's story; it is part of establishing rapport and empathizing with the patient.

6. Mr. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to be checked out for the symptom of chest pain. As you listen to him describe his symptom in more detail, you say “Go on,” and later, “Mm-hmmm.” This is an example of which of the following skilled interviewing techniques?

A) Echoing B) Nonverbal communication C) Facilitation D) Empathic response Ans: C Chapter: 03 Page and Header: 68, Building a Therapeutic Relationship: The Techniques of Skilled Interviewing Feedback: This is an example of facilitation. Facilitation can be posture, actions, or words that encourage the patient to say more.

7. Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and doesn't say anything in response to your question. This is an example of which type of challenging patient?

A) Talkative patient B) Angry patient C) Silent patient D) Hearing-impaired patient Ans: C Chapter: 03

Page and Header: 75, Adapting Your Interview to Specific Situations Feedback: This is one example of a silent patient. There are many possibilities for this patient's silence: depression, dementia, the manner in which you asked the question, and so on.

8. Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular provider is on vacation and she wanted to be seen. You have heard about her many times from your colleague and are aware that she is a very talkative person. Which of the following is a helpful technique to improve the quality of the interview for both the provider and the patient?

A) Allow the patient to speak uninterrupted for the duration of the appointment.

B) Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you.

C) Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview.

D) Allow your impatience to show so that the patient picks up on your nonverbal cue that the appointment needs to end.

Ans: B Chapter: 03 Page and Header: 75, Adapting Your Interview to Specific Situations Feedback: You can also say, “I want to make sure I take good care of this problem because it is very important. We may need to talk about the others at the next appointment. Is that okay with you?” This is a technique that can help you to change the subject but, at the same time, validate the patient's concerns; it also can provide more structure to the interview.

9. Mrs. H. comes to your clinic, wanting antibiotics for a sinus infection. When you enter the room, she appears to be very angry. She has a raised tone of voice and states that she has been waiting for the past hour and has to get back to work. She states that she is unimpressed by the reception staff, the nurse, and the clinic in general and wants to know why the office wouldn't call in an antibiotic for her. Which of the following techniques is not useful in helping to calm this patient?

A) Avoiding admission that you had a part in provoking her anger because you were late B) Accepting angry feelings from the patient and trying not to get angry in return C) Staying calm D) Keeping your posture relaxed Ans: A Chapter: 03 Page and Header: 75, Adapting Your Interview to Specific Situations Feedback: In this scenario, the provider was 1 hour late in seeing the patient. The provider should acknowledge that he was late and apologize for this, no matter the reason for being late.

It often helps to acknowledge that a patient's anger with you is understandable and that you might be angry in a similar situation.

10. A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge.

As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information?

A) Are you sexually active?

B) When was the last time you had intimate physical contact with someone, and did that contact include sexual intercourse?

C) Do you have sex with men, women, or both?

D) How many sexual partners have you had in the last 6 months?

Ans: A Chapter: 03 Page and Header: 81, Sensitive Topics That Call For Specific Approaches Feedback: This is inappropriate because it is too vague. Given the complaint, you should probably assume that he is sexually active. Sometimes patients may respond to this question with the phrase “No, I just lie there.” A specific sexual history will help you to assess this patient's risk for other sexually transmitted infections.

11. Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has come to the office many times in the past with a variety of injuries, and you suspect that he has a problem with alcohol. Which one of the following questions will be most helpful in diagnosing this problem?

A) You are an alcoholic, aren't you?

B) When was your last drink?

C) Do you drink 2 to 3 beers every weekend?

D) Do you drink alcohol when you are supposed to be working?

Ans: B Chapter: 03 Page and Header: 81, Sensitive Topics That Call for Specific Approaches Feedback: This is a good opening question that is general and neutral in tone; depending on the timing, you will be able to ask for more specific information related to the patient's last drink.

The others will tend to stifle the conversation because they are closed-ended questions. Answer D implies negative behavior and may also keep the person from sharing freely with you.

12. On a very busy day in the office, Mrs. Donelan, who is 81 years old, comes for her usual visit for her blood pressure. She is on a low-dose diuretic chronically and denies any side effects. Her blood pressure is 118/78 today, which is well-controlled. As you are writing her script, she mentions that it is hard not having her husband Bill around anymore. What would you do next?

A) Hand her the script and make sure she has a 3-month follow-up appointment.

B) Make sure she understands the script.

C) Ask why Bill is not there.

D) Explain that you will have more time at the next visit to discuss this.

Ans: C Chapter: 03 Page and Header: 81, Sensitive Topics That Call for Specific Approaches Feedback: Sometimes, the patient's greatest need is for support and empathy. It would be inappropriate to ignore this comment today. She may have relied heavily upon Bill for care and may be in danger. She may be depressed and even suicidal, but you will not know unless you discuss this with her. Most importantly, you should empathize with her by saying something like “It must be very difficult not to have him at home” and allow a pause for her to answer. You may also ask “What did you rely on him to do for you?” Only a life-threatening crisis with another patient should take you out of her room at this point, and you may need to adjust your office schedule to allow adequate time for her today.

13. A patient is describing a very personal part of her history very quickly and in great detail.

How should you react to this?

A) Write down as much as you can, as quickly as possible.

B) Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every word.

C) Tell her that she can go over the notes later to make sure they are accurate.

D) Push away from the keyboard or put down your pen and listen.

Ans: D Chapter: 03 Page and Header: 58, Getting Ready: The Approach to the Interview Feedback: This is a common event in clinical practice. It is much more important to listen actively with good eye contact at this time than to document the story verbatim. You want to minimize interruption (e.g., answer B). It is usually not appropriate to ask a patient to go over the written notes, but it would be a good idea to repeat the main ideas back to her. You should be certain she has completed her story before doing this. By putting down your pen or pushing away from the keyboard, you let the patient know that her story is the most important thing to you at this moment.

14. You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire right side. She cannot speak (aphasia). You are supposed to examine her. You notice that the last examiner left her socks at the bottom of the bed, and although sensitive areas are covered by a sheet, the blanket is heaped by her feet at the bottom of the bed. What would you do next?

A) Carry out your examination, focusing on the neurologic portion, and then cover her properly.

B) Carry out your examination and let the nurse assigned to her “put her back together.”

C) Put her socks back on and cover her completely before beginning the evaluation.

D) Apologize for the last examiner but let the next examiner dress and cover her.

Ans: C Chapter: 03 Page and Header: 58, Getting Ready: The Approach to the Interview Feedback: It is crucial to make an effort to make a patient comfortable. In this scenario, the patient can neither speak nor move well. Take a moment to imagine yourself in her situation. As a matter of respect as well as comfort, you should cover the patient appropriately and consider returning a little later to do your examination if you feel she is cold. While it is her nurse's job to keep her comfortable, it is also your responsibility, and you should do what you can. It is unacceptable to leave the patient in the same state in which you found her.

15. When you enter your patient's examination room, his wife is waiting there with him. Which of the following is most appropriate?

A) Ask if it's okay to carry out the visit with both people in the room.

B) Carry on as you would ordinarily. The permission is implied because his wife is in the room with him.

C) Ask his wife to leave the room for reasons of confidentiality.

D) First ask his wife what she thinks is going on.

Ans: A Chapter: 03 Page and Header: 60, Learning About the Patient: The Sequence of the Interview Feedback: Even in situations involving people very familiar with each other, it is important to respect individual privacy. There is no implicit consent merely because he has allowed his wife to be in the room with him. On the other hand, it is inappropriate to assume that his wife should leave the room. Remember, the patient is the focus of the visit, so it would be appropriate to allow him to control who is in the room with him and inappropriate to address his wife first.

Although your duty is to the patient, you may get optimal information by offering to speak to both people confidentially. This situation is analogous to an adolescent's visit.

16. A patient complains of knee pain on your arrival in the room. What should your first

sentence be after greeting the patient?

A) How much pain are you having?

B) Have you injured this knee in the past?

C) When did this first occur?

D) Could you please describe what happened?

Ans: D Chapter: 03 Page and Header: 60, Learning About the Patient: The Sequence of the Interview Feedback: When looking into a complaint, it is best to start with an invitation for the patient to tell you in his or her own words. More specific questions should be used later in the interview to fill in any gaps.

17. You have just asked a patient how he feels about his emphysema. He becomes silent, folds his arms across his chest and leans back in his chair, and then replies, “It is what it is.” How should you respond?

A) “You seem bothered by this question.”

B) “Next, I would like to talk with you about your smoking habit.”

C) “Okay, let's move on to your other problems.”

D) “You have adopted a practical attitude toward your problem.”

Ans: A Chapter: 03 Page and Header: 60, Learning About the Patient: The Sequence of the Interview Feedback: You have astutely noted that the patient's body language changed at the time you asked this question, and despite the patient's response, you suspect there is more beneath the surface. Maybe he is afraid of being browbeaten about his smoking, maybe a relative has recently died from this disorder, or maybe a friend told him 20 years ago that he would eventually get emphysema. Regardless, by sharing your observation and leaving a pause, he may begin to talk about some issues which are very important to him.

18. A patient tells you about her experience with prolonged therapy for her breast cancer. You comment, “That must have been a very trying time for you.” What is this an example of?

A) Reassurance B) Empathy C) Summarization D) Validation Ans: D Chapter: 03

Page and Header: 68, Building a Therapeutic Relationship: The Techniques of Skilled Interviewing Feedback: This is an example of validation to legitimize her emotional experience. “Now that you have had your treatment, you should not have any further troubles” is an example of reassurance. “I understand what you went through because I am a cancer survivor myself” is an example of empathy. “So, you have had a lumpectomy and multiple radiation treatments” is an example of summarization as applied to this vignette.

19. You are performing a young woman's first pelvic examination. You make sure to tell her verbally what is coming next and what to expect. Then you carry out each maneuver of the examination. You let her know at the outset that if she needs a break or wants to stop, this is possible. You ask several times during the examination, “How are you doing, Brittney?” What are you accomplishing with these techniques?

A) Increasing the patient's sense of control B) Increasing the patient's trust in you as a caregiver C) Decreasing her sense of vulnerability D) All of the above Ans: D Chapter: 03 Page and Header: 68, Building a Therapeutic Relationship: The Techniques of Skilled Interviewing Feedback: These techniques minimize the effects of transitions during an examination and empower the patient. Especially during a sensitive examination, it is important to give the patient as much control as possible.

20. When using an interpreter to facilitate an interview, where should the interpreter be positioned?

A) Behind you, the examiner, so that the lips of the patient and the patient's nonverbal cues can be seen B) Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of the patient C) Between you and the patient so all parties can make the necessary observations D) In a corner of the room so as to provide minimal distraction to the interview Ans: B Chapter: 03 Page and Header: 75, Adapting Your Interview to Specific Situations Feedback: Interpreters are invaluable in encounters where the examiner and patient do not speak the same language, including encounters with the deaf. It should be noted that deaf people from

different regions of the world use different sign languages. The priority is for you to have a good view of the patient. Remember to use short, simple phrases while speaking directly to the patient and ask the patient to repeat back what he or she understands.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 4: Beginning the Physical Examination: General Survey, Vital Signs, and Pain

Multiple Choice

1. A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter's weight. You measure her daughter's height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?

A) Refer the patient to a nutritionist and a psychologist because the patient is anorexic.

B) Reassure the mother that this is a normal body weight.

C) Give the patient information about exercise because the patient is obese.

D) Give the patient information concerning reduction of fat and cholesterol in her diet because she is obese.

Ans: B Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: The patient has a normal BMI; the range for a normal BMI is 18.5 to 24.9 kg/m2.

You may be able to give the patient and her mother the lower limit of normal in pounds for her daughter's height, or instruct her in how to use a BMI table.

2. A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit?

A) Refer the patient to a nutritionist because he is anorexic.

B) Reassure the patient that he has a normal body weight.

C) Give the patient information about reduction of fat, cholesterol, and calories because he is overweight.

D) Give the patient information about reduction of fat and cholesterol because he is obese.

Ans: C Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: The patient has a BMI in the overweight range, which is 25.0 to 29.9 kg/m2. It is prudent to give him information about reducing calories, fat, and cholesterol in his diet to help prevent further weight gain.

3. A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30.0 kg/m2.

What is the most appropriate amount for a weekly weight reduction goal?

A) .5 to 1 pound per week B) 1 to 2.5 pounds per week C) 2.5 to 3.5 pounds per week D) 3.5 to 4.5 pounds per week Ans: A Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: Based on the NIH Obesity Guidelines, this is the weekly weight loss goal to strive for to maintain long-term control of weight. More rapid weight loss than this does not result in a better outcome at one year.

4. A 67-year-old retired janitor comes to the clinic with his wife. She brought him in because she is concerned about his weight loss. He has a history of smoking 3 packs of cigarettes a day for 30 years, for a total of 90 pack-years. He has noticed a daily cough for the past several years, which he states is productive of sputum. He came into the clinic approximately 1 year ago, and at that time his weight was 140 pounds. Today, his weight is 110 pounds.

Which one of the following questions would be the most important to ask if you suspect that he has lung cancer?

A) Have you tried to force yourself to vomit after eating a meal?

B) Do you have heartburn/indigestion and diarrhea?

C) Do you have enough food to eat?

D) Have you tried to lose weight?

Ans: D Chapter: 04 Page and Header: 102, The Health History Feedback: This is important: If the patient hasn't tried to lose weight, then this weight loss is inadvertent and poses concern for a neoplastic process, especially given his smoking history.

5. Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except: A) Changes in weight B) Fatigue and weakness C) Cough D) Fever and chills Ans: C Chapter: 04 Page and Header: 102, The Health History Feedback: This symptom is more appropriate to the respiratory review of systems.

6. You are beginning the examination of a patient. All of the following areas are important to observe as part of the General Survey except: A) Level of consciousness B) Signs of distress C) Dress, grooming, and personal hygiene D) Blood pressure Ans: D Chapter: 04 Page and Header: 109, The General Survey Feedback: Blood pressure is a vital sign, not part of the General Survey.

7. A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior elevated readings and her family history is negative for hypertension. You measure her blood pressure in your office today. Which of the following factors can result in a false high reading?

A) Blood pressure cuff is tightly fitted.

B) Patient is seated quietly for 10 minutes prior to measurement.

C) Blood pressure is measured on a bare arm.

D) Patient's arm is resting, supported by your arm at her mid-chest level as you stand to measure the blood pressure.

Ans: A Chapter: 04 Page and Header: 114, The Vital Signs

Feedback: A blood pressure cuff that is too tightly fitted can result in a false high reading. The other answers are important to observe to obtain an accurate blood pressure reading. JNC-7 also mentions the importance of having the back supported when obtaining blood pressure in the sitting position.

8. A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient's complete history and physical examination. When you palpate the pulse, what do you expect to feel?

A) Large amplitude, forceful B) Small amplitude, weak C) Normal D) Bigeminal Ans: B Chapter: 04 Page and Header: 114, The Vital Signs Feedback: Congestive heart failure is characterized by decreased stroke volume or increased peripheral vascular resistance, which would result in a small-amplitude, weak pulse. Subtle differences in amplitude are usually best detected in large arteries close to the heart, like the carotid pulse. You may not be able to notice these in other locations.

9. An 18-year-old college freshman presents to the clinic for evaluation of gastroenteritis. You measure the patient's temperature and it is 104 degrees Fahrenheit. What type of pulse would you expect to feel during his initial examination?

A) Large amplitude, forceful B) Small amplitude, weak C) Normal D) Bigeminal Ans: A Chapter: 04 Page and Header: 114, The Vital Signs Feedback: Fever results in an increased stroke volume, which results in a large-amplitude, forceful pulse. Later in the course of the illness, if dehydration and shock result, you may expect small amplitude and weak pulses.

10. A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath and states that his blood sugar was 605 at home. You diagnose the patient with diabetic ketoacidosis. What is the expected pattern of breathing?

A) Normal B) Rapid and shallow C) Rapid and deep D) Slow Ans: C Chapter: 04 Page and Header: 114, The Vital Signs Feedback: This is the expected rate and depth in diabetic ketoacidosis. The body is trying to rid itself of carbon dioxide to compensate for the acidosis. This is known as Kussmaul's breathing and is seen in other causes of acidosis as well.

11. Mrs. Lenzo weighs herself every day with a very accurate balance-type scale. She has noticed that over the past 2 days she has gained 4 pounds. How would you best explain this?

A) Attribute this to some overeating at the holidays.

B) Attribute this to wearing different clothing.

C) Attribute this to body fluid.

D) Attribute this to instrument inaccuracy.

Ans: C Chapter: 04 Page and Header: 102, The Health History Feedback: This amount of weight over a short period should make one think of body fluid changes. You may consider a kidney problem or heart failure in your differential. The other reasons should be considered as well, but this amount of weight gain over a short period usually indicates causes other than excessive caloric intake. A rule of thumb for dieters is that an energy excess of 3500 calories will cause a 1-pound weight gain, if the increase is to be attributed to food intake.

12. Mr. Curtiss has a history of obesity, diabetes, osteoarthritis of the knees, HTN, and obstructive sleep apnea. His BMI is 43 and he has been discouraged by his difficulty in losing weight. He is also discouraged that his goal weight is 158 pounds away. What would you tell him?

A) “When you get down to your goal weight, you will feel so much better.”

B) “Some people seem to be able to lose weight and others just can't, no matter how hard they try.”

C) “We are coming up with new medicines and methods to treat your conditions every day.”

D) “Even a weight loss of 10% can make a noticeable improvement in the problems you mention.”

Ans: D Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: Many patients trying to change a habit are overwhelmed by how far they are from their goal. As the proverb says: “A journey of a thousand miles begins with one step.” Many patients find it empowering to know that they can achieve a small goal, such as a loss of 1 pound per week. They must be reminded that this process will take time and that slow weight loss is more successful long-term. Research has shown that significant benefits often come with even a 10% weight loss.

13. Jenny is one of your favorite patients who usually shares a joke with you and is nattily dressed. Today she is dressed in old jeans, lacks makeup, and avoids eye contact. To what do you attribute these changes?

A) She is lacking sleep.

B) She is fatigued from work.

C) She is running into financial difficulty.

D) She is depressed.

Ans: D Chapter: 04 Page and Header: 109, The General Survey Feedback: It is important to use all of your skills and memory of an individual patient to guide your thought process. She is not described as sleepy. Work fatigue would most likely not cause avoidance of eye contact. Financial difficulties would not necessarily deplete a nice wardrobe.

It is most likely that she is depressed or in another type of difficulty.

14. You are seeing an older patient who has not had medical care for many years. Her vital signs taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain.

You notice that she has some hypertensive changes in her retinas and you find mild proteinuria on a urine test in your office. You expected the BP to be higher. She is not on any medications.

What do you think is causing this BP reading, which doesn't correlate with the other findings?

A) It is caused by an “auscultatory gap.”

B) It is caused by a cuff size error.

C) It is caused by the patient's emotional state.

D) It is caused by resolution of the process which caused her retinopathy and kidney problems.

Ans: A

Chapter: 04 Page and Header: 114, The Vital Signs Feedback: The blood pressure is unusual in this case in that the systolic pressure is normal while the diastolic pressure is elevated. Especially with the retinal and urinary findings, you should consider that the BP may be much higher and that an auscultatory gap was missed. This can be avoided by checking for obliteration of the radial pulse while the cuff is inflated. Although a large cuff can cause a slightly lower BP on a patient with a small arm, this does not account for the elevated DBP. Emotional upset usually causes elevation of the BP. Although a process which caused the retinopathy and kidney problems may have resolved, leaving these findings, it is a dangerous assumption that this is the sole cause of the problems seen in this patient.

15. Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. How do you respond?

A) You diagnose “white coat hypertension.”

B) You assume he is quite nervous when he comes to your office.

C) You question the accuracy of his measurements.

D) You question the accuracy of your measurements.

Ans: C Chapter: 04 Page and Header: 114, The Vital Signs Feedback: It is not uncommon to see differences in a patient's home measurements and your own in the office. Presuming that this is “white coat hypertension” can be dangerous because this condition is not usually treated. This allows for the effects of a missed diagnosis of hypertension to go unchecked. It is also very difficult to judge if a patient is outwardly nervous.

You should always consider that your measurements are not accurate as well, but the fact that you and your staff are well-trained and perform this procedure on hundreds of patients a week makes this less likely. Ideally, you would ask the patient to bring in his BP equipment and take a simultaneous reading with you to make sure that he is getting an accurate reading.

16. You are observing a patient with heart failure and notice that there are pauses in his breathing. On closer examination, you notice that after the pauses the patient takes progressively deeper breaths and then progressively shallower breaths, which are followed by another apneic spell. The patient is not in any distress. You make the diagnosis of: A) Ataxic (Biot's) breathing B) Cheyne-Stokes respiration C) Kussmaul's respiration D) COPD with prolonged expiration

Ans: B Chapter: 04 Page and Header: 119, Respiratory Rate and Rhythm Feedback: Cheyne-Stokes respiration can be seen in patients with heart failure and is usually not a sign of an immediate problem. Ataxic breathing is very irregular in rhythm and depth and is seen with brain injury. Kussmaul's respiration is seen in patients with a metabolic acidosis, as they are trying to rid their bodies of carbon dioxide to compensate. Respirations in COPD are usually regular and are not usually associated with apneic episodes.

17. Mr. Garcia comes to your office for a rash on his chest associated with a burning pain. Even a light touch causes this burning sensation to worsen. On examination, you note a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. What type of pain is this?

A) Idiopathic pain B) Neuropathic pain C) Nociceptive or somatic pain D) Psychogenic pain Ans: B Chapter: 04 Page and Header: 121, Acute and Chronic Pain Feedback: This vignette is consistent with a diagnosis of herpes zoster, or shingles. This is caused by reemergence of dormant varicella (chickenpox) viruses from Mr. Garcia's nerve root.

The characteristic burning quality without a history of an actual burn makes one think of neuropathic pain. It will most likely remain for months after the rash has resolved. There is no evidence of physical injury and this is a peculiar distribution, making nociceptive pain less likely.

There is no evidence of a psychogenic etiology for this, and the presence of a rash makes this possibility less likely as well. Because of your astute diagnostic abilities, the pain is not idiopathic.

18. A 50-year-old body builder is upset by a letter of denial from his life insurance company. He is very lean but has gained 2 pounds over the past 6 months. You personally performed his health assessment and found no problems whatsoever. He says he is classified as “high risk” because of obesity. What should you do next?

A) Explain that even small amounts of weight gain can classify you as obese.

B) Place him on a high-protein, low-fat diet.

C) Advise him to increase his aerobic exercise for calorie burning.

D) Measure his waist.

Ans: D

Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: The patient most likely had a high BMI because of increased muscle mass. In this situation, it is important to measure his waist. It is most likely under 40 inches, which makes obesity unlikely (even to an insurance company). It is important that you personally contact the company and explain your reasoning. Be prepared to back your argument with data. A special diet is unlikely to be of much use, and more aerobic exercise, while probably a good idea for most, is redundant for this individual.

19. Ms. Wright comes to your office, complaining of palpitations. While checking her pulse you notice an irregular rhythm. When you listen to her heart, every fourth beat sounds different. It sounds like a triplet rather than the usual “lub dup.” How would you document your examination?

A) Regular rate and rhythm B) Irregularly irregular rhythm C) Regularly irregular rhythm D) Bradycardia Ans: C Chapter: 04 Page and Header: 119, Heart Rate and Rhythm Feedback: Because this unusual beat occurs every fourth set of heart sounds, it is regularly irregular. This is most consistent with ventricular premature contractions (or VPCs). This is generally a common and benign rhythm. An irregularly irregular rhythm is a classic finding in atrial fibrillation. The rhythm is very random in character. Bradycardia refers to the rate, not the rhythm.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 5: Behavior and Mental Status

Multiple Choice

1. A 19-year-old college student, Todd, is brought to your clinic by his mother. She is concerned that there is something seriously wrong with him. She states for the past 6 months his behavior has become peculiar and he has flunked out of college. Todd denies any recent illness or injuries.

His past medical history is remarkable only for a broken foot. His parents are both healthy. He has a paternal uncle who had similar symptoms in college. The patient admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but none in the last week. He denies using any other substances. He denies any feelings of depression or anxiety. While speaking with Todd and his mother you do a complete physical examination, which is essentially normal. When you question him on how he is feeling, he says that he is very worried that Microsoft has stolen his software for creating a better browser. He tells you he has seen a black van in his neighborhood at night and he is sure that it is full of computer tech workers stealing his work through special gamma waves. You ask him why he believes they are trying to steal his programs. He replies that the technicians have been telepathing their intents directly into his head. He says he hears these conversations at night so he knows this is happening. Todd's mother then tells you, “See, I told you . . . he's crazy. What do I do about it?”

While arranging for a psychiatry consult, what psychotic disorder do you think Todd has?

A) Schizoaffective disorder B) Psychotic disorder due to a medical illness C) Substance-induced psychotic disorder D) Schizophrenia Ans: D Chapter: 05 Page and Header: 162, Table 5–4 Feedback: Schizophrenia generally occurs in the late teens to early 20s. It often is seen in other family members, as in this case. Symptoms must be present for at least 6 months and must have at least two features of (1) delusions (e.g., Microsoft is after his programs), (2) hallucinations (e.g., technicians sending telepathic signals), (3) disorganized speech, (4) disorganized behavior, and (5) negative symptoms such as a flat affect.

2. A 24-year-old secretary comes to your clinic, complaining of difficulty sleeping, severe nightmares, and irritability. She states it all began 6 months ago when she went to a fast food restaurant at midnight. While she was waiting in her car a man entered through the passenger door and put a gun to her head. He had her drive to a remote area, where he took her money and threatened to kill her. When the gun jammed he panicked and ran off. Ever since this occurred the patient has been having these symptoms. She states she jumps at every noise and refuses to drive at night. She states her anxiety has had such a marked influence on her job performance she is afraid she will be fired. She denies any recent illnesses or injuries. Her past medical history is unremarkable. On examination you find a nervous woman appearing her stated age. Her physical examination is unremarkable. You recommend medication and counseling.

What anxiety disorder to you think this young woman has?

A) Specific phobia

B) Acute stress disorder C) Post-traumatic stress disorder D) Generalized anxiety disorder Ans: C Chapter: 05 Page and Header: 161, Table 5–3 Feedback: Post-traumatic stress disorder is the fearful response (nightmares, avoidance of areas, irritability) to an event that occurred at least 1 month prior to presentation. The patient's fears and reactions cause marked distress and impair social and occupational functions.

3. A 75-year-old homemaker brings her 76-year-old husband to your clinic. She states that 4 months ago he had a stroke and ever since she has been frustrated with his problems with communication. They were at a restaurant after church one Sunday when he suddenly became quiet. When she realized something was wrong he was taken to the hospital by EMS. He spent 2 weeks in the hospital with right-sided weakness and difficulty speaking. After hospitalization he was in a rehab center, where he regained the ability to walk and most of the use of his right hand.

He also began to speak more, but she says that much of the time “he doesn't make any sense.”

She gives an example that when she reminded him the car needed to be serviced he told her “I will change the Kool-Aid out of the sink myself with the ludrip.” She says that these sayings are becoming frustrating. She wants you to tell her what is wrong and what you can do about it.

While you write up a consult to neurology, you describe the syndrome to her.

What type of aphasia does he have?

A) Wernicke's aphasia B) Broca's aphasia C) Dysarthria Ans: A Chapter: 05 Page and Header: 145, Techniques of Examination Feedback: With Wernicke's aphasia the patient can speak effortlessly and fluently, but his words often make no sense. Words can be malformed or completely invented. Wernicke's area is found on the temporal lobes.

4. A 32-year-old white female comes to your clinic, complaining of overwhelming sadness. She says for the past 2 months she has had crying episodes, difficulty sleeping, and problems with overeating. She says she used to go out with her friends from work but now she just wants to go home and be by herself. She also thinks that her work productivity has been dropping because she just is too tired to care or concentrate. She denies any feelings of guilt or any suicidal ideation. She states that she has never felt this way in the past. She denies any recent illness or

injuries. Her past medical history consists of an appendectomy when she was a teenager; otherwise, she has been healthy. She is single and works as a clerk in a medical office. She denies tobacco, alcohol, or illegal drug use. Her mother has high blood pressure and her father has had a history of mental illness. On examination you see a woman appearing her stated age who seems quite sad. Her facial expression does not change while you talk to her and she makes little eye contact. She speaks so softly you cannot always understand her. Her thought processes and content seem unremarkable.

What type of mood disorder do you think she has?

A) Dysthymic disorder B) Manic (bipolar) disorder C) Major depressive episode Ans: C Chapter: 05 Page and Header: 160, Table 5–2 Feedback: Major depression occurs in a person with a previously normal state of mood. The symptoms often consist of a combination of sadness, decreased interest, sleeping problems (insomnia or hypersomnia), eating problems (decreased or increased appetite), feelings of guilt, decreased energy, decreased concentration, psychomotor changes (retardation or agitation), and a preoccupation with thoughts of death or suicide. There must be at least five symptoms for a diagnosis of major depression. This patient has six: (1) sadness, (2) trouble sleeping, (3) overeating, (4) fatigue, (5) difficulty with concentration, and (6) no interest in doing things.

5. A 27-year-old woman is brought to your office by her mother. The mother tells you that her daughter has been schizophrenic for the last 8 years and is starting to decompensate despite medication. The patient states that she has been taking her antipsychotic and she is doing just fine. Her mother retorts that her daughter has become quite paranoid. When asked why, the mother gives an example about the mailman. She says that her daughter goes and gets the mail every day and then microwaves the letters. The patient agrees that she does this but only because she sees the mailman flipping through the envelopes and she knows he's putting anthrax on the letters. Her mother turns to her and says, “He's only sorting the mail!”

Which best describes the patient's abnormality of perception?

A) Illusion B) Hallucination C) Fugue state Ans: A Chapter: 05 Page and Header: 145, Techniques of Examination Feedback: An illusion is merely a misinterpretation of real external stimuli. In this case, the mailman is looking through the letters before he puts them in the box. The mother correctly assumes he is sorting the mail but her schizophrenic daughter attributes his actions to being part of a nefarious bioterrorism plot.

6. A 22-year-old man is brought to your office by his father to discuss his son's mental health disorder. The patient was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and you need to raise it.

He states that his son has been hearing things that don't exist. You ask the young man what is going on and he tells you that his father is just jealous because his sister talks only to him. His father turns to him and says, “Son, you know your sister died 2 years ago!” His son replies “Well, she still talks to me in my head all the time!”

Which best describes this patient's abnormality of perception?

A) Illusion B) Hallucination C) Fugue state Ans: B Chapter: 05 Page and Header: 145, Techniques of Examination Feedback: A hallucination is a subjective sensory perception in the absence of real external stimuli. The patient can hear, see, smell, taste, or feel something that does not exist in reality. In this case, his sister has passed away and cannot be speaking to him, although in his mind he can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.

7. A 26-year-old violinist comes to your clinic, complaining of anxiety. He is a first chair violinist in the local symphony orchestra and has started having symptoms during performances, such as sweating, shaking, and hyperventilating. It has gotten so bad that he has thought about giving up his first chair status so he does not have to play the solo during one of the movements.

He says that he never has these symptoms during rehearsals or when he is practicing. He denies having any of these symptoms at any other time. His past medical history is unremarkable. He denies any tobacco use, drug use, or alcohol abuse. His parents are both healthy. On examination you see a young man who appears worried. His vital signs and physical examination are unremarkable.

What type of anxiety disorder best describes his situation?

A) Panic disorder B) Specific phobia C) Social phobia D) Generalized anxiety disorder Ans: C Chapter: 05 Page and Header: 161, Table 5–3

Feedback: Social phobia is a marked, persistent fear of social or performance situations.

8. A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. He says that she hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up over $1,000 on their credit cards. While he is talking, the patient interrupts him frequently and declares this is all untrue and she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview you find out she has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy but the husband has heard rumors about an aunt with similar symptoms. She and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain-smoking in the last 2 weeks), drinks four to six drinks a week, and smokes marijuana occasionally. On examination she is very loud and outspoken. Her physical examination is unremarkable.

Which mood disorder does she most likely have?

A) Major depressive episode B) Manic episode C) Dysthymic disorder Ans: B Chapter: 05 Page and Header: 160, Table 5–2 Feedback: Mania consists of a persistently elevated mood for at least 1 week with symptoms such as inflated self-esteem, decreased need for sleep, pressured speech, racing thoughts, and involvement in high-risk activities (such as drug use, spending sprees, and indiscriminate sexual activity). In this case, the patient has racing thoughts and pressured speech, has a decreased need for sleep, and is engaging in high-risk activities (spending sprees).

9. A 72-year-old African-American male is brought to your clinic by his daughter for a followup visit after his recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke.

The patient was in rehab for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with the patient. You ask the patient how he thinks he is doing.

Although it is hard for you to make out his words you believe his answer is “well . . . fine . . . doing . . . okay.” His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. His blood pressure is 150/90 and his other vital signs are normal. Other than his weak right arm and leg his

physical examination is unremarkable.

What disorder of speech does he have?

A) Wernicke's aphasia B) Broca's aphasia C) Dysarthria Ans: B Chapter: 05 Page and Header: 145, Techniques of Examination Feedback: In Broca's aphasia patients articulate very slowly and with a great deal of effort.

Nouns, verbs, and important adjectives are usually present and only small grammatical words are dropped from speech. Broca's area is on the lateral portion of the frontal lobes.

10. A 35-year-old stockbroker comes to your office, complaining of feeling tired and irritable.

She also says she feels like nothing ever goes her way and that nothing good ever happens. When you ask her how long she has felt this way she laughs and says, “Since when have I not?” She relates that she has felt pessimistic about life in general since she was in high school. She denies any problems with sleep, appetite, or concentration, and states she hasn't thought about killing herself. She reports no recent illnesses or injuries. She is single. She smokes one pack of cigarettes a day, drinks occasionally, and hasn't taken any illegal drugs since college. Her mother suffers from depression and her father has high blood pressure. On examination her vital signs and physical examination are unremarkable.

What mental health disorder best describes her symptoms?

A) Major depressive episode B) Dysthymic disorder C) Cyclothymic disorder Ans: B Chapter: 05 Page and Header: 160, Table 5–2 Feedback: Someone with dysthymia has a depressed mood and symptoms for most of the day, more days than not, for at least 2 years. The disorder generally begins in adolescence and is fairly stable throughout life. Although the symptoms are similar to those of major depression (in this case, fatigue and irritability), they are milder and fewer.

11. Susanne is a 27-year-old who has had headaches, muscle aches, and fatigue for the last 2 months. You have completed a thorough history, examination, and laboratory workup but have not found a cause. What would your next action be?

A) A referral to a neurologist B) A referral to a rheumatologist

C) To tell the patient you can't find anything D) To screen for depression Ans: D Chapter: 05 Page and Header: 136, Symptoms and Behavior Feedback: Although you may consider referrals to help with the diagnosis and treatment for this patient, screening is a time-efficient way to recognize depression. This will allow her to be treated more expediently. You may tell the patient you have not found an answer yet, but you must also tell her that you will not stop looking until you have helped her.

12. You ask a patient to draw a clock. He fills in all the numbers on the right half of the circle.

What do you suspect?

A) Hemianopsia B) Fatigue C) Oppositional defiant disorder D) Depression Ans: A Chapter: 05 Page and Header: 145, Techniques of Examination Feedback: You should suspect a visual problem because there is no writing on one half of the circle. This is consistent with a hemianopsia, sometimes seen in stroke. These patients may also eat food on only one half of their plate. The other conditions would not account for this pattern.

13. A young woman comes to you with a cut on her finger caused by the lid of a can she was opening. She is pacing about the room, crying loudly, and through her sobs she says, “My career as a pianist is finished!” Which personality type exhibits these features?

A) Narcissistic B) Paranoid C) Histrionic D) Avoidant Ans: C Chapter: 05 Page and Header: 136, Symptoms and Behavior Feedback: The theatrical nature of her behavior as well as her overreaction leads to a diagnosis of histrionic character disorder.

14. Adam is a very successful 15-year-old student and athlete. His mother brings him in today because he no longer studies, works out, or sees his friends. This has gone on for a month and a half. When you speak with him alone in the room, he states it “would be better if he were not here.” What would you do next?

A) Tell him that he has a very promising career in anything he chooses and soon he will feel better.

B) Tell him that he needs an antidepressant and it will take about 4 weeks to work.

C) Speak with his mother about getting him together more with his friends.

D) Assess his suicide risk.

Ans: D Chapter: 05 Page and Header: 142, Health Promotion and Counseling Feedback: His lack of interest in usual activities and duration of symptoms should make you suspicious for depression. Despite his very successful academic and athletic performance, you should recognize this last phrase indicating suicide risk. You could ask if he has had thoughts about hurting himself and, if so, how he would carry this out. Ask about firearms and other weapons at home. Adam needs immediate psychiatric referral if these risks are found, or admission to the hospital for observation if referral is not available in a timely fashion.

15. A 29-year-old woman comes to your office. As you take the history, you notice that she is speaking very quickly, and jumping from topic to topic so rapidly that you have trouble following her. You are able to find some connections between ideas, but it is difficult. Which word describes this thought process?

A) Derailment B) Flight of ideas C) Circumstantiality D) Incoherence Ans: B Chapter: 05 Page and Header: 145, Techniques of Examination Feedback: This represents flight of ideas because the ideas are connected in some logical way.

Derailment, or loosening of associations, has more disconnection within clauses.

Circumstantiality is characterized by the patient speaking “around” the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use. Although severe flight of ideas can produce this condition, evidence is not present in this vignette.

16. In obtaining a history, you note that a patient uses the word “largely” repeatedly, to the point of being a distraction to your task. Which word best describes this speech pattern?

A) Clanging B) Echolalia C) Confabulation D) Perseveration Ans: D Chapter: 05 Page and Header: 145, Techniques of Examination Feedback: Perseveration is the repetition of words or ideas. Echolalia differs in that the patient repeats what is said to him. Clanging is the repetition of the same sounds in different words.

Confabulation is making up a story in response to a question. This is sometimes seen in chronic alcohol use with Korsakoff's syndrome.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 6: The Skin, Hair, and Nails

Multiple Choice

1. A 35-year-old archaeologist comes to your office (located in Phoenix, Arizona) for a regular skin check-up. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this patient?

A) Age B) Hair color C) Actinic lentigines D) Heavy sun exposure Ans: A Chapter: 06 Page and Header: 165, Health Promotion and Counseling Feedback: The risk for melanoma is increased in people over the age of 50; our patient is 35

years old. The other answers represent known risk factors for melanoma. Especially with a family history of melanoma, she should be instructed to keep her skin covered when in the sun and use strong sunscreen on exposed areas.

2. You are speaking to an 8th grade class about health prevention and are preparing to discuss the ABCDEs of melanoma. Which of the following descriptions correctly defines the ABCDEs? A) A = actinic; B = basal cell; C = color changes, especially blue; D = diameter >6 mm; E = evolution B) A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6 mm; E = evolution C) A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E = evolution D) A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter >6 mm; E = evolution Ans: B Chapter: 06 Page and Header: 165, Health Promotion and Counseling Feedback: This is the correct description for the mnemonic.

3. You are beginning the examination of the skin on a 25-year-old teacher. You have previously elicited that she came to the office for evaluation of fatigue, weight gain, and hair loss. You strongly suspect that she has hypothyroidism. What is the expected moisture and texture of the skin of a patient with hypothyroidism?

A) Moist and smooth B) Moist and rough C) Dry and smooth D) Dry and rough Ans: D Chapter: 06 Page and Header: 168, Techniques of Examination Feedback: A patient with hypothyroidism is expected to have skin that is dry as well as rough.

This is a good example of how the skin can give clues to systemic diseases.

4. A 28-year-old patient comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical examination, you note that the pattern of eruption is like a Christmas tree and that there

are a variety of erythematous papules and macules on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?

A) Pityriasis rosea B) Tinea versicolor C) Psoriasis D) Atopic eczema Ans: A Chapter: 06 Page and Header: 176, Table 6–2 Feedback: This is a classic description of pityriasis rosea. The description of a large single or “herald” patch preceding the eruption is a good way to distinguish this rash from other conditions.

5. A 19-year-old construction worker presents for evaluation of a rash. He notes that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He does sweat more than before because being outdoors is part of his job. On physical examination, you note dark tan patches with a reddish cast that has sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is your most likely diagnosis?

A) Pityriasis rosea B) Tinea versicolor C) Psoriasis D) Atopic eczema Ans: B Chapter: 06 Page and Header: 176, Table 6–2 Feedback: This is a typical description of tinea versicolor. The information that the patient is sweating more also helps support this diagnosis, because tinea is a fungal infection and is promoted by moisture.

6. A 68-year-old retired farmer comes to your office for evaluation of a skin lesion. On the right temporal area of the forehead, you see a flattened papule the same color as his skin, covered by a dry scale that is round and feels hard. He has several more of these scattered on the forehead, arms, and legs. Based on this description, what is your most likely diagnosis?

A) Actinic keratosis B) Seborrheic keratosis C) Basal cell carcinoma D) Squamous cell carcinoma

Ans: A Chapter: 06 Page and Header: 185, Table 6–9 Feedback: This is a typical description of actinic keratosis. Actinic keratosis may be easier to feel than to see. If left untreated, approximately 1% of cases can develop into squamous cell carcinoma.

7. A 58-year-old gardener comes to your office for evaluation of a new lesion on her upper chest. The lesion appears to be “stuck on” and is oval, brown, and slightly elevated with a flat surface. It has a rough, wartlike texture on palpation. Based on this description, what is your most likely diagnosis?

A) Actinic keratosis B) Seborrheic keratosis C) Basal cell carcinoma D) Squamous cell carcinoma Ans: B Chapter: 06 Page and Header: 185, Table 6–9 Feedback: This is a typical description for seborrheic keratosis. The “stuck on” appearance and the rough, wartlike texture are key features for the diagnosis. They often produce a greasy scale when scratched with a fingernail, which further helps to distinguish them from other lesions.

Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important to distinguish these lesions to prevent unnecessary biopsy. It is important to consider biopsy whenever there is any doubt, though.

8. A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on the ventilator for 3 weeks. You are completing your initial assessment and are evaluating her skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter, with damage to the subcutaneous tissue. The underlying muscle is not affected. You diagnose this as a pressure ulcer. What is the stage of this ulcer?

A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4 Ans: C Chapter: 06

Page and Header: 191, Table 6–13 Feedback: A stage 3 ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

9. An 8-year-old girl comes with her mother for evaluation of hair loss. She denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her hair in braids. On physical examination, you note a clearly demarcated, round patch of hair loss without visible scaling or inflammation. There are no hair shafts visible. Based on this description, what is your most likely diagnosis?

A) Alopecia areata B) Trichotillomania C) Tinea capitis D) Traction alopecia Ans: A Chapter: 06 Page and Header: 192, Table 6–14 Feedback: This is a typical description for alopecia areata. There are no risk factors for trichotillomania or for traction alopecia. The physical examination is not consistent with tinea capitis because the skin is intact.

10. A mother brings her 11 month old to you because her mother-in-law and others have told her that her baby is jaundiced. She is eating and growing well and performing the developmental milestones she should for her age. On examination you indeed notice a yellow tone to her skin from head to toe. Her sclerae are white. To which area should your next questions be related?

A) Diet B) Family history of liver diseases C) Family history of blood diseases D) Ethnicity of the child Ans: A Chapter: 06 Page and Header: 163, Anatomy and Physiology Feedback: The lack of jaundice in the sclerae is an important clue. Typically, this is the first place where one sees jaundice. This examination should also be carried out in natural light (sunlight) as opposed to fluorescent lighting, which can alter perceived colors. Many infants this age have a large proportion of carrots, tomatoes, and yellow squash, which are rich in carotene.

Liver and blood diseases can cause jaundice, but this should involve the sclerae. The ethnicity of the child should not cause a perceived change from her usual skin tone.

11. A new mother is concerned that her child occasionally “turns blue.” On further questioning, she mentions that this is at her hands and feet. She does not remember the child's lips turning blue. She is otherwise eating and growing well. What would you do now?

A) Reassure her that this is normal B) Obtain an echocardiogram to check for structural heart disease and consult cardiology C) Admit the child to the hospital for further observation D) Question the validity of her story Ans: A Chapter: 06 Page and Header: 163, Anatomy and Physiology Feedback: This is an example of peripheral cyanosis. This is a very common and benign condition which typically occurs when the child is slightly cold and his peripheral circulation is adjusting to keep his core warm. Without other problems, there is no need for further workup. If the lips or other central locations are involved, you must consider other etiologies.

12. You are examining an unconscious patient from another region and notice Beau's lines, a transverse groove across all of her nails, about 1 cm from the proximal nail fold. What would you do next?

A) Conclude this is caused by a cultural practice.

B) Conclude this finding is most likely secondary to trauma.

C) Look for information from family and records regarding any problems which occurred 3 months ago.

D) Ask about dietary intake.

Ans: C Chapter: 06 Page and Header: 163, Anatomy and Physiology Feedback: These lines can provide valuable information about previous significant illnesses, some of which are forgotten or are not able to be reported by the patient. Because the fingernails grow at about 0.1 mm per day, you would ask about an illness 100 days ago. This patient may have been hospitalized for endocarditis or may have had another significant illness which should be sought. Trauma to all 10 nails in the same location is unlikely. Dietary intake at this time would not be related to this finding. Do not assume a finding is necessarily related to a patient's culture unless you have good knowledge of that culture.

13. Dakota is a 14-year-old boy who just noticed a rash at his ankles. There is no history of

exposure to ill people or other agents in the environment. He has a slight fever in the office. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should you do?

A) Prescribe a steroid cream to decrease inflammation.

B) Consider admitting the patient to the hospital.

C) Reassure the parents and the patient that this should resolve within a week.

D) Tell him not to scratch them, and follow up in 3 days.

Ans: B Chapter: 06 Page and Header: 184, Table 6–8 Feedback: Although this may not be an impressive rash, the fact that they do not “blanch” with pressure is very concerning. This generally means that there is pinpoint bleeding under the skin, and while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia. You should always report this feature of a rash immediately to a supervisor or teacher.

14. Mrs. Hill is a 28-year-old African-American with a history of SLE (systemic lupus erythematosus). She has noticed a raised, dark red rash on her legs. When you press on the rash, it doesn't blanch. What would you tell her regarding her rash?

A) It is likely to be related to her lupus.

B) It is likely to be related to an exposure to a chemical.

C) It is likely to be related to an allergic reaction.

D) It should not cause any problems.

Ans: A Chapter: 06 Page and Header: 184, Table 6–8 Feedback: A “palpable purpura” is usually associated with a vasculitis. This is an inflammatory condition of the blood vessels often associated with systemic rheumatic disease. It can cut off circulation to any portion of the body and can mimic many other diseases in this manner. While allergic and chemical exposures may be a possible cause of the rash, this patient's SLE should make you consider vasculitis.

15. Jacob, a 33-year-old construction worker, complains of a “lump on his back” over his scapula. It has been there for about a year and is getting larger. He says his wife has been able to squeeze out a cheesy-textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?

A) An enlarged lymph node B) A sebaceous cyst C) An actinic keratosis D) A malignant lesion Ans: B Chapter: 06 Page and Header: 178, Table 6–4 Feedback: This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland. The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely. This would be an unusual location for a lymph node, and these do not usually drain to the skin.

16. A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small “pits” in his nails. What would account for these findings?

A) Eczema B) Pityriasis rosea C) Psoriasis D) Tinea infection Ans: C Chapter: 06 Page and Header: 178, Table 6–4 Feedback: This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and moist areas.

17. Mrs. Anderson presents with an itchy rash which is raised and appears and disappears in various locations. Each lesion lasts for many minutes. What most likely accounts for this rash?

A) Insect bites B) Urticaria, or hives C) Psoriasis D) Purpura Ans: B Chapter: 06

Page and Header: 178, Table 6–4 Feedback: This is a typical case of urticaria. The most unusual aspect of this condition is that the lesions “move” from place to place. This would be distinctly unusual for the other causes listed.

18. Ms. Whiting is a 68-year-old who comes in for her usual follow-up visit. You notice a few flat red and purple lesions, about 6 centimeters in diameter, on the ulnar aspect of her forearms but nowhere else. She doesn't mention them. They are tender when you examine them. What should you do?

A) Conclude that these are lesions she has had for a long time.

B) Wait for her to mention them before asking further questions.

C) Ask how she acquired them.

D) Conduct the visit as usual for the patient.

Ans: C Chapter: 06 Page and Header: 184, Table 6–8 Feedback: These are consistent with ecchymoses, or bruises. It is important to ask about antiplatelet medications such as aspirin, trauma history, and history of blood disorders in the patient and her family. Because of the different ages of the bruises and the isolation of them to the ulnar forearms, these may be a result of abuse or other violence. It is your duty to investigate the cause of these lesions.

19. A middle-aged man comes in because he has noticed multiple small, blood-red, raised lesions over his anterior chest and abdomen for the past several months. They are not painful and he has not noted any bleeding or bruising. He is concerned this may be consistent with a dangerous condition. What should you do?

A) Reassure him that there is nothing to worry about.

B) Do laboratory work to check for platelet problems.

C) Obtain an extensive history regarding blood problems and bleeding disorders.

D) Do a skin biopsy in the office.

Ans: A Chapter: 06 Page and Header: 184, Table 6–8 Feedback: These represent cherry angiomas, which are very common, benign lesions. Further workup such as laboratory work, skin biopsy, or even further questions are not necessary at this time. It would be wise to ask the patient to report any changes in any of his skin lesions and tell him that you would need to see him at that time.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 7: The Head and Neck

Multiple Choice

1. A 38-year-old accountant comes to your clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region and is an 8 on a scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an overthe-counter analgesic, and this results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

A) Tension B) Migraine C) Cluster D) Analgesic rebound Ans: B Chapter: 07 Page and Header: 196, The Health History Feedback: This is a description of a common migraine (no aura). Distinctive features of a migraine include phonophobia and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.

2. A 29-year-old computer programmer comes to your office for evaluation of a headache. The tightening sensation is located all over the head and is of moderate intensity. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours each day at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain but not taken it away. Based on this description, what is your most likely diagnosis?

A) Tension B) Migraine

C) Cluster D) Analgesic rebound Ans: A Chapter: 07 Page and Header: 196, The Health History Feedback: This is a description of a typical tension headache.

3. Which of the following is a symptom involving the eye?

A) Scotomas B) Tinnitus C) Dysphagia D) Rhinorrhea Ans: A Chapter: 07 Page and Header: 196, The Health History Feedback: Scotomas are specks in the vision or areas where the patient cannot see; therefore, this is a common/concerning symptom of the eye.

4. A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You elicit the information that the dizziness is a spinning sensation of sudden onset, worse with head position changes. The episodes last a few seconds and then go away, and they are accompanied by intense nausea. She has vomited one time. She denies tinnitus. You perform a physical examination of the head and neck and note that the patient's hearing is intact to Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description, what is the most likely diagnosis?

A) Benign positional vertigo B) Vestibular neuronitis C) Ménière's disease D) Acoustic neuroma Ans: A Chapter: 07 Page and Header: 252, Table 7–3 Feedback: This is a classic description of benign positional vertigo. The vertigo is episodic, lasting a few seconds to minutes, instead of continuous as in vestibular neuronitis. Also, there is no tinnitus or sensorineural hearing loss as occurs in Ménière's disease and acoustic neuroma.

You may choose to learn about Hallpike maneuvers, which are also helpful in the evaluation of vertigo.

5. A 55-year-old bank teller comes to your office for persistent episodes of dizziness. The first episode started suddenly and lasted 3 to 4 hours. He experienced a lot of nausea with vomiting; the episode resolved spontaneously. He has had five episodes in the past 1½ weeks. He does note some tinnitus that comes and goes. Upon physical examination, you note that he has a normal gait. The Weber localizes to the right side and the air conduction is equal to the bone conduction in the right ear. Nystagmus is present. Based on this description, what is the most likely diagnosis?

A) Benign positional vertigo B) Vestibular neuronitis C) Ménière's disease D) Acoustic neuroma Ans: C Chapter: 07 Page and Header: 252, Table 7–3 Feedback: Ménière's disease is characterized by sudden onset of vertiginous episodes that last several hours to a day or more, then spontaneously resolve; the episodes then recur. On physical examination, sensorineural hearing loss is present. The patient does complain of tinnitus.

6. A 73-year-old nurse comes to your office for evaluation of new onset of tremors. She is not on any medications and does not take herbs or supplements. She has no chronic medical conditions.

She does not smoke or drink alcohol. She walks into the examination room with slow movements and shuffling steps. She has decreased facial mobility and a blunt expression, without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the patient's symptoms?

A) Cushing's syndrome B) Nephrotic syndrome C) Myxedema D) Parkinson's disease Ans: D Chapter: 07 Page and Header: 253, Table 7–4 Feedback: This is a typical description for a patient with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression—a “masked” appearance. The patient also has decreased blinking and a characteristic stare with an upward gaze. In combination with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is almost clinched.

7. A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?

A) Ptosis B) Exophthalmos C) Ectropion D) Epicanthus Ans: B Chapter: 07 Page and Header: 255, Table 7–6 Feedback: Exophthalmos is the condition when the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease. If it is unilateral, it could still be caused by Graves' disease. Alternatively, it could be caused by a tumor or inflammation in the orbit.

8. A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?

A) Dacryocystitis B) Chalazion C) Hordeolum D) Xanthelasma Ans: C Chapter: 07 Page and Header: 256, Table 7–7 Feedback: A hordeolum, or sty, is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

9. A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye.

On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?

A) Conjunctivitis B) Acute iritis C) Corneal abrasion D) Subconjunctival hemorrhage Ans: D Chapter: 07 Page and Header: 257, Table 7–8 Feedback: A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turning yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rarely caused by a serious condition, so reassurance is usually the only treatment necessary.

10. A 67-year-old lawyer comes to your clinic for an annual examination. He denies any history of eye trauma. He denies any visual changes. You inspect his eyes and find a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis?

A) Corneal arcus B) Cataracts C) Corneal scar D) Pterygium Ans: D Chapter: 07 Page and Header: 258, Table 7-9 Feedback: A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere with vision as it encroaches on the pupil. Otherwise, treatment is unnecessary.

11. Which of the following is a “red flag” regarding patients presenting with headache?

A) Unilateral headache B) Pain over the sinuses C) Age over 50 D) Phonophobia and photophobia Ans: C Chapter: 07

Page and Header: 196, The Health History Feedback: A unilateral headache is often seen with migraines and may commonly be accompanied by phonophobia and photophobia. Pain over the sinuses from sinus congestion may also be unilateral and produce pain. Migraine and sinus headaches are common and generally benign. A new severe headache in someone over 50 can be associated with more serious etiologies for headache. Other red flags include acute onset, “the worst headache of my life”; very high blood pressure; rash or signs of infection; known presence of cancer, HIV, or pregnancy; vomiting; recent head trauma; and persistent neurologic problems.

12. A sudden, painless unilateral vision loss may be caused by which of the following?

A) Retinal detachment B) Corneal ulcer C) Acute glaucoma D) Uveitis Ans: A Chapter: 07 Page and Header: 196, The Health History Feedback: Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain.

Retinal detachment is generally painless, as is chronic glaucoma.

13. Sudden, painful unilateral loss of vision may be caused by which of the following conditions?

A) Vitreous hemorrhage B) Central retinal artery occlusion C) Macular degeneration D) Optic neuritis Ans: D Chapter: 07 Page and Header: 196, The Health History Feedback: In multiple sclerosis, sudden painful loss of vision may accompany optic neuritis.

The other conditions are usually painless.

14. Diplopia, which is present with one eye covered, can be caused by which of the following problems?

A) Weakness of CN III

B) Weakness of CN IV C) A lesion of the brainstem D) An irregularity in the cornea or lens Ans: D Chapter: 07 Page and Header: 196, The Health History Feedback: Double vision in one eye alone points to a problem in “processing” the light rays of an incoming image. The other causes of diplopia result in a misalignment of the two eyes.

15. A patient complains of epistaxis. Which other cause should be considered?

A) Intracranial hemorrhage B) Hematemesis C) Intestinal hemorrhage D) Hematoma of the nasal septum Ans: B Chapter: 07 Page and Header: 196, The Health History Feedback: Although the source of epistaxis may seem obvious, other bleeding locations should be on the differential. Hematemesis can mimic this and cause delay in life-saving therapies if not considered. Intracranial hemorrhage and septal hematoma are instances of contained bleeding.

Intestinal hemorrhage may cause hematemesis if there is obstruction distal to the bleeding, but this is unlikely.

16. Glaucoma is the leading cause of blindness in African Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination?

A) Increased cup-to-disc ratio B) AV nicking C) Cotton wool spots D) Microaneurysms Ans: A Chapter: 07 Page and Header: 201, Health Promotion and Counseling Feedback: It is important to screen for glaucoma on funduscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.

17. Very sensitive methods for detecting hearing loss include which of the following?

A) The whisper test B) The finger rub test C) The tuning fork test D) Audiometric testing Ans: D Chapter: 07 Page and Header: 201, Health Promotion and Counseling Feedback: While it is important to screen for hearing complaints with methods available to you, it should be realized that some physical examination techniques are limited. Nonetheless, you should be comfortable performing these tests, as audiometric testing is not always available.

18. Which area of the fundus is the central focal point for incoming images?

A) The fovea B) The macula C) The optic disk D) The physiologic cup Ans: A Chapter: 07 Page and Header: 205, The Eyes Feedback: The fovea is the area of the retina which is responsible for central vision. It is surrounded by the macula, which is responsible for more peripheral vision. The optic disc and physiologic cup are where the optic nerve enters the eye.

19. A light is pointed at a patient's pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?

A) Direct reaction B) Consensual reaction C) Near reaction D) Accommodation Ans: B Chapter: 07 Page and Header: 205, The Eyes Feedback: The constriction of the contralateral pupil is called the consensual reaction. The

response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.

20. A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?

A) She obtains a 20% correct score at 100 feet.

B) She can accurately name 20% of the letters at 20 feet.

C) She can see at 20 feet what a normal person could see at 100 feet.

D) She can see at 100 feet what a normal person could see at 20 feet.

Ans: C Chapter: 07 Page and Header: 205, The Eyes Feedback: The denominator of an acuity score represents the line on the chart the patient can read. In the example above, the patient could read the larger letters corresponding with what a normal person could see at 100 feet.

21. On visual confrontation testing, a stroke patient is unable to see your fingers on his entire right side with either eye covered. Which of the following terms would describe this finding?

A) Bitemporal hemianopsia B) Right temporal hemianopsia C) Right homonymous hemianopsia D) Binasal hemianopsia Ans: C Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Because the right visual field in both eyes is affected, this is a right homonymous hemianopsia. A bitemporal hemianopsia refers to loss of both lateral visual fields. A right temporal hemianopsia is unilateral and binasal hemianopsia is the loss of the nasal visual fields bilaterally.

22. You note that a patient has anisocoria on examination. Pathologic causes of this include which of the following?

A) Horner's syndrome B) Benign anisocoria

C) Differing light intensities for each eye D) Eye prosthesis Ans: A Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Anisocoria can be associated with serious pathology. Remember to exclude benign causes before embarking on an intensive workup. Testing the near reaction in this case may help you to find an Argyll Robertson or tonic (Adie's) pupil.

23. A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally.

Which of the following have you essentially excluded from your differential?

A) Retinoblastoma B) Cataract C) Artificial eye D) Hypertensive retinopathy Ans: D Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Hypertensive retinopathy requires a careful examination of the optic fundus. It cannot be diagnosed or excluded merely from the red reflex. Typically, the red reflex would be normal in this case. The other conditions are all associated with an abnormal red reflex.

24. A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient?

A) Otitis media B) External otitis C) Perforation of the tympanum D) Cholesteatoma Ans: B Chapter: 07 Page and Header: 225, Techniques of Examination Feedback: These are classic history and examination findings for a patient suffering from external otitis. Otitis media would not usually have pain with movement of the external ear, nor drainage unless the eardrum was perforated. In this case the examination of the eardrum is recorded as normal. Cholesteatoma is a growth behind the eardrum and would not account for

these symptoms. Otitis media would classically be accompanied by a bulging, erythematous eardrum.

25. A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely?

A) Otosclerosis of the left ear B) Exposure to chronic loud noise of the right ear C) Otitis media of the right ear D) Perforation of the right eardrum Ans: A Chapter: 07 Page and Header: 271, Table 7–21 Feedback: The above pattern is consistent with a conductive loss on the left side. Causes would include: foreign body, otitis media, perforation, and otosclerosis of the involved side.

26. A young man is concerned about a hard mass he has just noticed in the midline of his palate.

On examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis?

A) Leukoplakia B) Torus palatinus C) Thrush (candidiasis) D) Kaposi's sarcoma Ans: B Chapter: 07 Page and Header: 274, Table 7–23 Feedback: Torus palatinus is relatively common and benign but can go unnoticed by the patient for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and is seen in immunosuppressed patients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive individuals and is classically a deep purple.

27. A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left. Which of the following is likely?

A) CN IX lesion on the left B) CN IX lesion on the right C) CN X lesion on the left D) CN X lesion on the right Ans: D Chapter: 07 Page and Header: 231, Mouth and Pharynx Feedback: The failure of the right side of the palate to rise denotes a problem with the right 10th cranial nerve. The uvula deviates toward the properly functioning side.

28. A college student presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally.

What group of nodes is this?

A) Submandibular B) Tonsillar C) Occipital D) Posterior cervical Ans: D Chapter: 07 Page and Header: 236, The Neck Feedback: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.

29. You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and side-to-side directions. Which of the following is most likely?

A) Cancer B) Lymph node C) Deep scar D) Muscle Ans: B Chapter: 07 Page and Header: 236, The Neck Feedback: A useful maneuver for discerning lymph nodes from other masses in the neck is to check for their mobility in all directions. Many other masses are mobile in only two directions.

Cancerous masses may also be “fixed,” or immobile.

30. You are conducting a pupillary examination on a 34-year-old man. You note that both pupils dilate slightly. Both are noted to constrict briskly when the light is placed on the right eye. What is the most likely problem?

A) Optic nerve damage on the right B) Optic nerve damage on the left C) Efferent nerve damage on the right D) Efferent nerve damage on the left Ans: B Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Because both pupils can constrict, efferent nerve damage is unlikely. When the light is placed on the left eye, neither a direct nor a consensual response is seen. This indicates that the left eye is not perceiving incoming light.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 8: The Thorax and Lungs

Multiple Choice

1. A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently started a job as a bartender in town. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her

respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal.

Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes.

Percussion reveals resonant lungs.

Which disorder of the thorax or lung does this best describe?

A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia Ans: C Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be made worse by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). Realize that in severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these patients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this.

2. A 47-year-old receptionist comes to your office, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middleaged woman appearing her stated age. She looks ill and her temperature is elevated, at 101. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement, and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation.

What disorder of the thorax or lung best describes her symptoms?

A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia Ans: D

Chapter: 08 Page and Header: 318, Table 8–5 Feedback: Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased transmission of high-pitched components of sounds. These higher frequencies are usually filtered out by the multiple air-filled chambers of the alveoli.

3. A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe.

What disorder of the thorax or lung best describes his symptoms?

A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia Ans: A Chapter: 08 Page and Header: 314, Table 8–2 Feedback: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds and on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan's syndrome. Read more about this condition.

4. A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but

denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88.

He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus.

What thorax or lung disorder is most likely causing his symptoms?

A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia Ans: B Chapter: 08 Page and Header: 314, Table 8–2 Feedback: This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance, and during auscultation there are often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this patient's exercise capacity because it may affect his employment and also allows you to follow for progression of his disease. You must offer smoking cessation as an option.

5. A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles.

Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall.

What disorder of the chest best describes this disorder?

A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain Ans: B Chapter: 08

Page and Header: 312, Table 8–1 Feedback: The pain from pericarditis is usually sharp and knifelike and is located over the left side of the chest. Change of position, breathing, and coughing often make the pain worse, whereas leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases such as systemic lupus and in patients with chronic kidney disease. Patients also experience this after a myocardial infarction. You can read more about Dressler's syndrome.

6. A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent leftsided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood.

He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthyappearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending.

Which disorder of the chest best describes these symptoms?

A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain Ans: A Chapter: 08 Page and Header: 312, Table 8–1 Feedback: Angina causes dull chest pain felt in the retrosternal area or anterior chest. It often radiates to the shoulders, arms, neck, and jaw. It is associated with shortness of breath, nausea, and sweating. The pain is generally relieved by rest or medication after several minutes. This patient needs to be admitted to the hospital for further workup for his accelerating symptoms.

7. A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior chest pain radiating to her back. She describes it as if someone is “ripping out her heart.”

It began less than an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain better or worse. Her medical history consists of difficult-to-control

hypertension and coronary artery disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger brother who has had bypass surgery. On examination you see an elderly female in a great deal of distress. She is lying on the table, curled up, holding her left and right arms against her chest and is restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and 130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital's ER for further evaluation.

What disorder of the chest best describes her symptoms?

A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain Ans: C Chapter: 08 Page and Header: 312, Table 8–1 Feedback: A dissecting aortic aneurysm is associated with a ripping or tearing sensation that radiates to the neck, back, or abdomen. Because blood supply to the brain and extremities is disrupted, syncope and paraplegia or hemiplegia can occur. Blood pressure will usually be different between the two arms, and the carotid pulses often show an asymmetry. This is because the aneurysm decreases flow distally and causes inequality of flow between sides.

8. A 25-year-old accountant presents to your clinic, complaining of intermittent lower rightsided chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds, taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring. The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a deep breath. He has taken some Tylenol and put a heating pad on his side but neither has helped. He remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in good health. He has recently married, and his wife has a baby due in 2 months. He denies any smoking or illegal drug use. He drinks two to three beers once a month. He states that he eats a healthy diet and runs regularly, but not since his recent illness. He denies any cardiac, gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable. His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During palpation the ribs are nontender.

What disorder of the chest best describes his symptoms?

A) Pericarditis B) Chest wall pain C) Pleural pain

D) Angina pectoralis Ans: C Chapter: 08 Page and Header: 312, Table 8–1 Feedback: This pain is sharp and knifelike and occurs over the affected area of pleura. Breathing deeply usually makes the pain worse, whereas lying quietly on the affected side makes the pain better. Pleurisy often occurs from inflammation due to an infection, neoplasm, or autoimmune disease.

9. A 60-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can't do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination she is in no acute distress. Her blood pressure is 160/100 and her pulse is 100. She is afebrile and her respiratory rate is 16. With auscultation she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination the S1 and S2 are distant and an S3 is heard over the apex.

What disorder of the chest best describes her symptoms?

A) Pneumonia B) Chronic obstructive pulmonary disease (COPD) C) Pleural pain D) Left-sided heart failure Ans: D Chapter: 08 Page and Header: 314, Table 8–2 Feedback: In left-sided heart failure, fluid starts “backing up” into the lungs because the heart is unable to handle the volume. The excess fluid collects in the dependent areas, causing crackles in the bases of the lower lobes. Sitting up allows patients to breathe easier. The two main causes are chronic high blood pressure and coronary artery disease, which lead to myocardial ischemia and decreased contractility of the heart.

10. A grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you that it has been that way for quite a while. He states he has no symptoms from it and he just

tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was deployed to the Middle East. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. On examination you see a teenage boy appearing his stated age. On visual examination of his chest, you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are unremarkable.

What disorder of the thorax best describes your findings?

A) Barrel chest B) Funnel chest (pectus excavatum) C) Pigeon chest (pectus carinatum) D) Thoracic kyphoscoliosis Ans: B Chapter: 08 Page and Header: 317, Table 8–4 Feedback: Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.

11. Which of the following anatomic landmark associations is correct?

A) 2nd intercostal space for needle insertion in tension pneumothorax B) T6 for lower margin of endotracheal tube C) Sternal angle marks the 4th rib D) 5th intercostal space for chest tube insertion Ans: A Chapter: 08 Page and Header: 283, Anatomy and Physiology Feedback: The 2nd intercostal space is indeed the correct location for insertion of a needle in tension pneumothorax. The other answers are incorrect. T4 marks the approximate bifurcation of the trachea and therefore marks the inferior limit for an endotracheal tube on chest X-ray. The sternal angle marks the 2nd rib, which helps establish the 2nd interspace for needle insertion as above or locations for cardiac auscultation (aortic and pulmonary areas). Finally, the 4th intercostal space is normally used for chest tube insertion.

12. A 55–year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses should you consider because of her gesture?

A) Bronchitis B) Costochondritis C) Pericarditis D) Angina pectoris Ans: D Chapter: 08 Page and Header: 290, The Health History Feedback: The clenched fist of Levine's sign, while not completely specific for ischemic pain, should definitely cause you to consider this etiology. Bronchitis is usually painless, and pericarditis can produce a sharp pain which worsens with inspiration. This is called pleuritic pain and can be associated with pneumonia and other chest diseases. Costochondritis is a parasternal pain, usually well localized. It is exquisitely tender.

13. A 62-year-old smoker complains of “coughing up small amounts of blood,” so you consider hemoptysis. Which of the following should you also consider?

A) Intestinal bleeding B) Hematoma of the nasal septum C) Epistaxis D) Bruising of the tongue Ans: C Chapter: 08 Page and Header: 290, The Health History Feedback: When you suspect hemoptysis, you must consider other etiologies for bleeding.

Commonly, epistaxis can mimic this as well as bleeding from the gastrointestinal tract. The other answers, although they involve bleeding, are contained or distant from the pharynx.

14. Which of the following occurs in respiratory distress?

A) Speaking in sentences of 10–20 words B) Skin between the ribs moves inward with inspiration C) Neck muscles are relaxed D) Patient torso leans posteriorly Ans: B Chapter: 08 Page and Header: 297, Examination of the Posterior Chest Feedback: This description is consistent with retractions that occur with respiratory distress.

Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing, in which the patient

exhales against his lips, which are pressed together.

15. Which of the following is consistent with good percussion technique?

A) Allow all of the fingers to touch the chest while performing percussion.

B) Maintain a stiff wrist and hand.

C) Leave the plexor finger on the pleximeter after each strike.

D) Strike the pleximeter over the distal interphalangeal joint.

Ans: D Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Percussion takes practice to master. Most struggle initially with keeping the wrist and hand relaxed. Other challenges include removing the plexor quickly and keeping the other fingers off the chest wall. These can dampen the sound you are trying to obtain. The ideal target for the plexor is the distal interphalangeal joint.

16. Which of the following percussion notes would you obtain over the gastric bubble?

A) Resonance B) Tympany C) Hyperresonance D) Flatness Ans: B Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: The gastric bubble produces one of the longest percussion notes. A patient with COPD may have hyperresonance over his chest, while a normal person would have resonance.

Dullness is heard over a normal liver, and flatness is heard if one percusses a large muscle.

17. Which of the following conditions would produce a hyperresonant percussion note?

A) Large pneumothorax B) Lobar pneumonia C) Pleural effusion D) Empyema Ans: A Chapter: 08

Page and Header: 296, Techniques of Examination Feedback: There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. The other three conditions produce dullness by dampening the percussion note with fluid.

18. Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration?

A) Bronchovesicular B) Vesicular C) Bronchial D) Tracheal Ans: C Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: These sounds are consistent with bronchial breath sounds. Be alert for these, as they may occur elsewhere and indicate a pneumonia or other pathology. The current explanation for this phenomenon is that the sound from the trachea is carried very well to the chest wall by fluid.

This same explanation explains “ee” to “aa” changes, whispered pectoriloquy, bronchophony, and other circumstances in which high-frequency sounds, normally blocked by the air-filled alveoli, could be transmitted to the chest wall.

19. A patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most likely explanation for these?

A) Asthma B) COPD C) Bronchiectasis D) Heart failure Ans: D Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: The timing of crackles within inspiration provides important clues. These late inspiratory crackles that appeared suddenly would be most consistent with heart failure. COPD and asthma usually produce early inspiratory crackles. Bronchiectasis, as seen in cystic fibrosis, classically produces mid-inspiratory crackles, but this is not always reliable. Interestingly, endexpiratory crackles can be heard in asthma on occasion.

20. When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?

A) Bronchitis B) Simple asthma C) Cystic fibrosis D) Heart failure Ans: A Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis. The other conditions would not be associated with findings that cleared with a cough.

21. A patient with longstanding COPD was told by another practitioner that his liver was enlarged and this needed to be assessed. Which of the following would be reasonable to do next?

A) Percuss the lower border of the liver B) Measure the span of the liver C) Order a hepatitis panel D) Obtain an ultrasound of the liver Ans: B Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: In this patient, measuring the span of the liver saved the patient an involved workup, because it was normal. His history of COPD is consistent with flattening of the diaphragms, which pushed the liver edge down while the actual size of the liver remained the same.

Percussing the lower border of the liver alone caused this referral, because it was assumed that the liver was enlarged.

22. You are at your family reunion playing football when your uncle takes a hit to his right lateral thorax and is in pain. He asks you if you think he has a rib fracture. You are in a very remote area. What would your next step be?

A) Call a medevac helicopter B) Drive him to the city (4 hours away) C) Press on his sternum and spine simultaneously

D) Examine him for tenderness over the injured area Ans: C Chapter: 08 Page and Header: 309, Special Techniques Feedback: The area involved in the injury will of course be tender. If you press in an area remote to the injury, but over the same bone which may be involved, you can produce tenderness at the site of injury. This would indicate that there may be a fracture at the lateral ribs.

Fortunately, this maneuver did not reproduce pain remotely, and your uncle simply sat on the sidelines for the rest of the game.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 9: The Cardiovascular System

Multiple Choice

1. You are performing a thorough cardiac examination. Which of the following chambers of the heart can you assess by palpation?

A) Left atrium B) Right atrium C) Right ventricle D) Sinus node Ans: C Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: The right ventricle occupies most of the anterior cardiac surface and is easily accessible to palpation. The other structures are less likely to have findings on palpation and the sinus node is an intracardiac structure. You may be able to diagnose abnormal rhythms caused by the sinus node indirectly by palpation, but this is less obvious.

2. What is responsible for the inspiratory splitting of S2?

A) Closure of aortic, then pulmonic valves B) Closure of mitral, then tricuspid valves C) Closure of aortic, then tricuspid valves D) Closure of mitral, then pulmonic valves Ans: A Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: During inspiration, the closure of the aortic valve and the closure of the pulmonic valve separate slightly, and this may be heard as two audible components, instead of a single sound. Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, you may not hear it away from the left second intercostal space. Because it is a low-pitched sound, you may not hear it unless you use the bell of your stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting.

3. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur?

A) Mitral B) Tricuspid C) Aortic D) Pulmonic Ans: A Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: Mitral valve sounds are usually heard best at and around the cardiac apex.

4. A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity.

The patient has no chronic conditions and does not take any medications, herbs, or supplements.

Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?

A) Abdominal pain B) Orthopnea C) Hematochezia D) Tenesmus

Ans: B Chapter: 09 Page and Header: 337, The Health History Feedback: Orthopnea, which is dyspnea that occurs when the patient is lying down and improves when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.

5. You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this?

A) Normal B) Prehypertension C) Stage 1 hypertension D) Stage 2 hypertension Ans: B Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Prehypertension is considered to be a systolic blood pressure from 120 to 139 and a diastolic BP from 80 to 89. Previously, this was considered normal. JNC 7 recommends taking action at this point to prevent worsening hypertension. Research shows that this population is likely to progress to more serious stages of hypertension.

6. You are participating in a health fair and performing cholesterol screens. One person has a cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease?

A) Ethnicity B) Alcohol intake C) Gender D) Asthma Ans: C Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Gender is used in the calculation of the 10-year risk for developing coronary heart disease, because men have a higher risk than women.

7. You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is well-controlled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. Which of the following conditions is considered to be a coronary heart disease risk equivalent?

A) Hypertension B) Peripheral arterial disease C) Systemic lupus erythematosus D) Chronic obstructive pulmonary disease (COPD) Ans: B Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Peripheral arterial disease is considered to be a coronary heart disease risk equivalent, as are abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.

8. You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid pulse?

A) Palpable B) Soft, rapid, undulating quality C) Pulsation eliminated by light pressure on the vessel D) Level of pulsation changes with changes in position Ans: A Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.

9. A 68-year-old mechanic presents to the emergency room for shortness of breath. You are concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated.

Which one of the following conditions is a potential cause of elevated JVP? A) Left-sided heart failure B) Mitral stenosis C) Constrictive pericarditis D) Aortic aneurysm

Ans: C Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: One cause of increased jugular venous pressure is constrictive pericarditis. Others include right-sided heart failure, tricuspid stenosis, and superior vena cava syndrome. You may wish to read about these conditions.

10. You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse?

A) Hypothyroidism B) Aortic stenosis, with pressure overload of the left ventricle C) Mitral stenosis, with volume overload of the left atrium D) Cardiomyopathy Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the apical impulse or not be palpable at all.

11. You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position.

Which of the following valvular defects is best heard in this position?

A) Aortic B) Pulmonic C) Mitral D) Tricuspid Ans: C Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If you do not listen to the heart in this position with both the diaphragm and bell in a quiet room, it is possible to miss significant murmurs such as mitral stenosis.

12. You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur?

A) Upright B) Upright, but leaning forward C) Supine D) Left lateral decubitus Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). You can further your ability to hear this soft murmur by having the patient hold his breath in exhalation.

13. A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a cardiac examination and find that his pulse rate is less than 60. Which of the following conditions could be responsible for this heart rate?

A) Second-degree A-V block B) Atrial flutter C) Sinus arrhythmia D) Atrial fibrillation Ans: A Chapter: 09 Page and Header: 375, Table 9–1 Feedback: A second-degree A-V block can result in a pulse rate less than 60. Atrial flutter and atrial fibrillation do not cause bradycardia unless there is a significant accompanying block.

Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart rate.

14. Where is the point of maximal impulse (PMI) normally located?

A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum B) In the left 5th intercostal space, 10 to 12 cm lateral to the sternum C) In the left 5th intercostal space, in the anterior axillary line D) In the left 5th intercostal space, in the midaxillary line Ans: A

Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral to the sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its size should not be greater than the size of a US quarter, or about an inch. Left ventricular enlargement should be suspected if it is larger. The PMI is often the best place to listen for mitral valve murmurs as well as S3 and S4. The PMI is often difficult to feel in normal patients.

15. Which of the following events occurs at the start of diastole?

A) Closure of the tricuspid valve B) Opening of the pulmonic valve C) Closure of the aortic valve D) Production of the first heart sound (S1) Ans: C Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: At the beginning of diastole, the valves which allow blood to exit the heart close. It is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the mitral valve is thought to produce the first heart sound (S1).

16. Which is true of a third heart sound (S3)?

A) It marks atrial contraction.

B) It reflects normal compliance of the left ventricle.

C) It is caused by rapid deceleration of blood against the ventricular wall.

D) It is not heard in atrial fibrillation.

Ans: C Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.

17. Which is true of splitting of the second heart sound?

A) It is best heard over the pulmonic area with the bell of the stethoscope.

B) It normally increases with exhalation.

C) It is best heard over the apex.

D) It does not vary with respiration.

Ans: A Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: S2 splitting is best heard over the pulmonic area because this is the only place where both of its components can be heard well. The closure of the pulmonic valve is normally not loud because the right heart is a low-pressure system. The bell is best used because it is a lowpitched sound. S2 splitting normally increases with inhalation.

18. Which of the following is true of jugular venous pressure (JVP) measurement?

A) It is measured with the patient at a 45-degree angle.

B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP. C) A JVP below 9 cm is abnormal.

D) It is measured above the sternal notch.

Ans: B Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: Measurement of the JVP is important to assess a patient's fluid status. Although it may be measured at 45°, it is important to adjust the level of the patient's torso so that the blood column is visible. This may be with the patient completely supine or sitting completely upright, depending on the patient. Any measurement greater than 4 cm above the sternal angle is abnormal. This would correspond to a JVP of 9 cm because we add a constant of 5 cm, which is an estimate of the height of the sternal notch above the right atrium.

19. Which of the following regarding jugular venous pulsations is a systolic phenomenon?

A) The “y” descent B) The “x” descent C) The upstroke of the “a” wave D) The downstroke of the “v” wave Ans: B Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: The most prominent upstrokes of jugular venous pulsations are diastolic phenomena.

These can be timed using the carotid pulse. The only event listed above which is a systolic phenomenon is the “x” descent.

20. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure?

A) 25% B) 50% C) 75% D) 100% Ans: D Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Each increase of BP by 20 systolic and 10 diastolic doubles the risk of cardiovascular disease. Being “low risk” by JNC 7 criteria confers a 72%–85% reduction in CVD mortality and 40%–58% reduction in overall mortality.

21. In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines?

A) Every 6 months B) Every year C) Every 2 years D) Every 5 years Ans: C Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse.

22. Which of the following is a clinical identifier of metabolic syndrome?

A) Waist circumference of 38 inches for a male B) Waist circumference of 34 inches for a female C) BP of 134/88 for a male D) BP of 128/84 for a female Ans: C Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: The physical examination criteria for identifying metabolic syndrome include a waist

of 40 inches or greater for a male, a waist of 35 inches or greater for a female, and a blood pressure of 130/85 or greater. Other criteria include triglycerides greater than or equal to 150 mg/dL, fasting glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less than 50 for women.

23. Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52. What heart rate should she achieve?

A) 80 B) 100 C) 120 D) 140 Ans: B Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Maximum heart rate is calculated by subtracting the patient's age from 220. For Mrs. Adams, 60% of this number is about 100. She must also be instructed in how to measure her own pulse or have a device to do so. Most people are able to carry on a conversation at this level of exertion.

24. In measuring the jugular venous pressure (JVP), which of the following is important?

A) Keep the patient's torso at a 45-degree angle.

B) Measure the highest visible pressure, usually at end expiration.

C) Add the vertical height over the sternal notch to a 5-cm constant.

D) Realize that a total value of over 12 cm is abnormal.

Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: In measuring JVP, the angle of the patient's torso must be varied until the highest oscillation point, or meniscus is visible. This varies. The landmark used is actually the sternal angle, not the sternal notch. We assign a constant height of 5 cm above the right atrium to this landmark. A value of over 8 cm total (more than 3 cm vertical distance above the sternal angle, plus the 5 cm constant) is considered abnormal.

25. You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you

search out?

A) Mitral valve prolapse B) Pulmonic stenosis C) Tricuspid insufficiency D) Aortic insufficiency Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Bounding carotid pulses would be found in aortic insufficiency. This should be sought by listening over the third left intercostal space, with the patient leaning forward in held exhalation. This is a very soft diastolic murmur usually. A bounding pulse may also be seen in any condition which increases cardiac output, including stimulant use, anxiety, hyperthyroidism, fever, etc.

26. To hear a soft murmur or bruit, which of the following may be necessary?

A) Asking the patient to hold her breath B) Asking the patient in the next bed to turn down the TV C) Checking your stethoscope for air leaks D) All of the above Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: All examiners should carefully search for soft murmurs and bruits. These can have great clinical significance. A quiet patient and room, as well as an intact stethoscope, will greatly increase your ability to hear soft sounds.

27. Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell?

A) Mitral stenosis murmur B) Opening snap of the mitral valve C) S3 and S4 gallops D) All of the above Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Placing the patient in the left lateral decubitus position and auscultating with the bell will enable you to hear these sounds, which would otherwise be missed.

28. How should you determine whether a murmur is systolic or diastolic?

A) Palpate the carotid pulse.

B) Palpate the radial pulse.

C) Judge the relative length of systole and diastole by auscultation.

D) Correlate the murmur with a bedside heart monitor.

Ans: A Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Timing of a murmur is crucial for identification. The carotid pulse should be used because there is a delay in the radial pulse relative to cardiac events, which can lead to error.

Some clinicians can estimate timing by the relative length of systole and diastole, but this method is not reliable at faster heart rates. A bedside monitor is not always available, nor are all designed to correlate in time with the actual pulse.

29. Which of the following correlates with a sustained, high-amplitude PMI? A) Hyperthyroidism B) Anemia C) Fever D) Hypertension Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: While hyperthyroidism, anemia, and fever can cause a high-amplitude PMI, pressure work by the heart, as seen in hypertension, causes the PMI to be sustained.

30. You are examining a patient with emphysema in exacerbation and are having difficulty hearing his heart sounds. What should you do to obtain a good examination?

A) Listen in the epigastrium.

B) Listen to the patient in the left lateral decubitus position.

C) Ask the patient to hold his breath for 30 seconds.

D) Listen posteriorly.

Ans: A Chapter: 09

Page and Header: 348, Techniques of Examination Feedback: It is often difficult to hear the heart well in a patient with emphysema. The shape of the chest as well as the interfering lung noise make examination challenging. By listening in the epigastrium, these barriers can be overcome. It is impractical to ask a patient who is short of breath to hold his breath for a prolonged period. Listening posteriorly would make the heart sounds even softer. It is always a good idea to listen to a patient in the left lateral decubitus position, but in this case it would not make auscultation easier.

31. You are listening carefully for S2 splitting. Which of the following will help?

A) Using the diaphragm with light pressure over the 2nd right intercostal space B) Using the bell with light pressure over the 2nd left intercostal space C) Using the diaphragm with firm pressure over the apex D) Using the bell with firm pressure over the lower left sternal border Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: S2 splitting is composed of an aortic and pulmonic component. Because the pulmonic component is softer, it can usually be heard only over the 2nd left intercostal space. It is a low-pitched sound and thus should be sought using the bell with light pressure. Conversely, the diaphragm is best used with firm pressure.

32. Which of the following is true of a grade 4-intensity murmur?

A) It is moderately loud.

B) It can be heard with the stethoscope off the chest.

C) It can be heard with the stethoscope partially off the chest.

D) It is associated with a “thrill.”

Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: The grade 4 murmur is differentiated from those below it by the presence of a palpable thrill. A murmur cannot be graded as a 4 unless this is present. The thrill is a “buzzing” feeling over the area where the murmur is loudest. For practice, you may often feel a thrill over a dialysis fistula.

33. Which valve lesion typically produces a murmur of equal intensity throughout systole?

A) Aortic stenosis B) Mitral insufficiency C) Pulmonic stenosis D) Aortic insufficiency Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: This description fits a holosystolic murmur. Because aortic and pulmonic stenosis murmurs vary with the flow of blood during systole, they typically produce a crescendo– decrescendo murmur. The murmur of aortic insufficiency represents backleak across the valve in diastole. It is a decrescendo pattern murmur, which gets softer as the pressure gradient decreases.

34. You notice a patient has a strong pulse and then a weak pulse. This pattern continues.

Which of the following is likely?

A) Emphysema B) Asthma exacerbation C) Severe left heart failure D) Cardiac tamponade Ans: C Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: This finding is consistent with pulsus alternans, which is associated with severe left heart failure. Occasionally, a monitor will read only half of the beats because half are too weak to detect. There may also be electrical alternans on EKG. This can be detected by using a blood pressure cuff and lowering the pressure slowly. At one point the rate of Korotkoff sounds will double, because the weaker beats can then “make it through.” The other findings are associated with paradoxical pulse.

35. Suzanne is a 20-year-old college student who complains of chest pain. This is intermittent and is located to the left of her sternum. There are no associated symptoms. On examination, you hear a short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2. This is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. Which of the following is the most likely diagnosis?

A) Mitral stenosis B) Mitral insufficiency C) Mitral valve prolapse D) Mitral valve papillary muscle ischemia

Ans: C Chapter: 09 Page and Header: 382, Table 9–8 Feedback: The description above is classic for mitral valve prolapse. The extra sound is a midsystolic click, which is typically a short, high-pitched sound. Mitral stenosis is a soft, lowpitched rumbling murmur which is difficult to hear unless the bell is used in the left lateral decubitus position. Mitral insufficiency is a holosystolic murmur heard best over the apex, and papillary muscle ischemia often creates a mitral insufficiency with its accompanying murmur.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 10: The Breasts and Axillae

Multiple Choice

1. A 72-year-old retired saleswoman comes to your office, complaining of a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The patient denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetric, with no skin changes. You are able to express bloody discharge from her left nipple. You feel no discrete masses, but her left axilla has a hard, 1-cm fixed node. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable.

What cause of nipple discharge is the most likely in her circumstance?

A) Benign breast abnormality B) Breast cancer C) Galactorrhea Ans: B Chapter: 10 Page and Header: 392, The Health History Feedback: Nipple discharge in breast cancer is usually unilateral and can be clear or bloody.

Although a breast mass is not palpated, in this case a fixed lymph node is palpated. Other forms

of breast cancer can present as a chronic rash on the breast.

2. A 44-year-old female comes to your clinic, complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a selfexamination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism.

She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use.

On examination you find a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath you palpate a nontender 2-cm mass. The axilla contains only soft, moveable nodes. The left breast and axilla examination findings are unremarkable.

What visible skin change of the breast does she have?

A) Nipple retraction B) Paget's disease C) Peau d'orange sign Ans: B Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: This uncommon form of breast cancer starts as an eczema-like, scaly skin change around the areola. The lesion may weep, crust, or erode. It can be associated with an underlying mass, but the skin change can also be found alone. Any eczema-like area around the nipple that does not respond to topical treatment needs to be evaluated for breast cancer.

3. A 56-year-old female comes to your clinic, complaining of her left breast looking unusual.

She says that for 2 months the angle of the nipple has changed direction. She does not do selfexaminations, so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On examination you find a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels thickened. Lateral to the areola you palpate a nontender 4-cm mass.

The axilla contains several fixed nodes. The right breast and axilla examinations are unremarkable.

What visible skin change of the breast does she have?

A) Nipple retraction B) Paget's disease C) Peau d'orange sign

Ans: A Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: A retracted nipple is flattened or pulled inward or toward the medial, lateral, anterior, or posterior side of the breast. The surrounding skin can be thickened. This is a relatively late finding in breast cancer.

4. A 19-year-old female comes to your office, complaining of a clear discharge from her right breast for 2 months. She states that she noticed it when she and her boyfriend were “messing around” and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies using tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetric with no skin changes. You are able to express clear discharge from her right nipple. You feel no discrete masses and her axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative.

What cause of nipple discharge is the most likely in her circumstance?

A) Benign breast abnormality B) Breast cancer C) Nonpuerperal galactorrhea Ans: A Chapter: 10 Page and Header: 392, The Health History Feedback: Nipple discharge in benign breast abnormalities tends to be clear and unilateral. The discharge is usually not spontaneous. This patient needs to be told to stop compressing her nipple. If the problem still persists after the patient has stopped compressing the nipple, further workup is warranted.

5. A 23-year-old computer programmer comes to your office for an annual examination. She has recently become sexually active and wants to be placed on birth control. Her only complaint is that the skin in her armpits has become darker. She states it looks like dirt, and she scrubs her skin nightly with soap and water but the color stays. Her past medical symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high blood pressure. The patient denies using tobacco but has four to five drinks on Friday and Saturday nights. She denies any illegal drug use. On examination you see a mildly obese female who is breathing comfortably. Her vital signs are unremarkable. Looking under her axilla, you see dark, velvet-like skin. Her annual examination is otherwise unremarkable.

What disorder of the breast or axilla is she most likely to have?

A) Peau d'orange B) Acanthosis nigricans C) Hidradenitis suppurativa Ans: B Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: Acanthosis nigricans can be associated with an internal malignancy, but in most cases it is a benign dermatologic condition associated with polycystic ovarian syndrome, consisting of acne, hirsutism, obesity, irregular periods, infertility, ovarian cysts, and early onset type 2 diabetes. It is also known to correlate with insulin resistance.

6. A 43-year-old store clerk comes to your office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago), and until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The patient does not smoke, drink, or use illegal drugs. Her father is in good health. On examination you see a tense female appearing her stated age. On visual inspection of her left axilla you see a tense red area. There is no scarring around the axilla. Palpating this area, you feel a 2-cm tender, movable lymph node underlying hot skin. Other shotty nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examining her left arm, you see a scabbed-over superficial laceration over her left hand. Upon your questioning, she remembers she cut her hand gardening last week.

What disorder of the axilla is most likely responsible for her symptoms?

A) Breast cancer B) Lymphadenopathy of infectious origin C) Hidradenitis suppurativa Ans: B Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: A lymph node enlarged because of infection is generally hot, tender, and red. Close examination of the skin that drains to that lymph node region is advised. Often there will be a cut or scratch over the involved arm that has an infectious agent. An example is cat scratch disease.

7. A 63-year-old nurse comes to your office, upset because she has found an enlarged lymph node under her right arm. She states she found it last week while taking a shower. She isn't sure if she has any breast lumps because she doesn't know how to do self-exams. She states her last mammogram was 5 years ago and it was normal. Her past medical history is significant for high

blood pressure and chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-packs/year history. She denies using any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and her father died of a stroke. She has no children. On examination you see an older female appearing her stated age. On visual inspection of her right axilla you see nothing unusual. Palpating this area, you feel a 2-cm hard, fixed lymph node. She denies any tenderness. Visualization of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On palpation of her right breast you feel a nontender 1-cm lump in the tail of Spence.

What disorder of the axilla is most likely responsible for her symptoms?

A) Breast cancer B) Lymphadenopathy of infectious origin C) Hidradenitis suppurativa Ans: A Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: Metastatic lymph nodes tend to be hard, nontender, and fixed, often to the rib cage.

Although the patient has no family history of breast cancer, she is at a slightly increased risk due to her never having had children.

8. A 40-year-old mother of two presents to your office for consultation. She is interested in knowing what her relative risks are for developing breast cancer. She is concerned because her sister had unilateral breast cancer 6 years ago at age 38. The patient reports on her history that she began having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco, alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable.

Which risk factor of her personal and family history most puts her in danger of getting breast cancer?

A) First-degree relative with premenopausal breast cancer B) Age at menarche of less than 12 C) First live birth between the ages of 25 and 29 D) First-degree relative with postmenopausal breast cancer Ans: A Chapter: 10 Page and Header: 393, Health Promotion and Counseling Feedback: Having a first-degree relative with cancer before menopause gives a relative risk of 3.1.

9. A 51-year-old cook comes to your office for consultation. She recently found out that her 44year-old sister with premenopausal breast cancer is positive for the BRCA1 gene. Your patient has been doing research on the Internet and saw that her chance of having also inherited the BRCA1 gene is 50%. She is interested in knowing what her risk of developing breast cancer would be if she were positive for the gene. She denies any lumps in her breasts and has had normal mammograms. She has had no weight loss, fever, or night sweats. Her mother is healthy and her father has prostate cancer. Two of her paternal aunts died of breast cancer. She is married. She denies using tobacco or illegal drugs and rarely drinks alcohol. Her breast and axilla examinations are unremarkable.

At her age, what is her risk of getting breast cancer if she has the BRCA1 gene?

A) 10% B) 50% C) 80% Ans: B Chapter: 10 Page and Header: 393, Health Promotion and Counseling Feedback: At the age of 50, the risk of breast cancer for someone with the BRCA1 gene is 50%.

10. A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. On examination you see a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test.

What is the most likely cause of his gynecomastia?

A) Breast cancer B) Imbalance of hormones of puberty C) Drug use Ans: B Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: Approximately one third of teenage boys develop gynecomastia during puberty. It is not surprising that the two older brothers did not have this.

11. A patient is concerned about a dark skin lesion on her anterolateral abdomen. It has not

changed, and there is no discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion?

A) Melanoma B) Dysplastic nevus C) Supernumerary nipple D) Dermatofibroma Ans: C Chapter: 10 Page and Header: 389, Anatomy and Physiology Feedback: This represents a supernumerary nipple. These occur along the “milk line” and do not exhibit features of more concerning lesions.

12. A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no diagnosis of breast cancer in his first-degree relatives. What is the most likely diagnosis?

A) Breast tissue B) Fibrocystic disease C) Breast cancer D) Lymph node Ans: A Chapter: 10 Page and Header: 389, Anatomy and Physiology Feedback: Approximately one third of adult men will have palpable breast tissue under the areola. While males can have breast cancer, this is much less common. There are no lymph nodes in this area.

13. Which of the following lymph node groups is most commonly involved in breast cancer?

A) Lateral B) Subscapular C) Pectoral D) Central Ans: D Chapter: 10 Page and Header: 389, Anatomy and Physiology Feedback: The central nodes at the apex of the axilla are most commonly involved in breast cancer. The axilla can be viewed roughly as a four-sided pyramid. An examination covering all sides and the apex is unlikely to miss a significant node.

14. When should a woman conduct breast self-examination with respect to her menses?

A) Five to seven days following her menses B) Midcycle C) Immediately prior to menses D) During her menses Ans: A Chapter: 10 Page and Header: 392, The Health History Feedback: The breast examination should be conducted during the time with the least estrogen stimulation of the breast tissue. This corresponds to five to seven days following menses.

15. Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass.

Without any other information, what is the risk of this mass being cancerous?

A) About 10% B) About 20% C) About 30% D) About 40% Ans: A Chapter: 10 Page and Header: 393, Health Promotion and Counseling Feedback: Eleven percent of women presenting with a breast mass will have breast cancer. This statistic can be reassuring to a patient, but the importance of further studies must be emphasized.

16. How often, according to American Cancer Society recommendations, should a woman undergo a screening breast examination by a skilled clinician?

A) Every year B) Every 2 years C) Every 3 years D) Every 4 years Ans: C Chapter: 10 Page and Header: 393, Health Promotion and Counseling Feedback: The current recommendation for screening by breast examination is every 3 years.

17. Which of the following is most likely benign on breast examination?

A) Dimpling of the skin resembling that of an orange B) One breast larger than the other C) One nipple inverted D) One breast with dimple when the patient leans forward Ans: B Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: Asymmetry in size of the breasts is a common benign finding. The others are concerning for underlying malignancy.

18. Which is the most effective pattern of palpation for breast cancer?

A) Beginning at the nipple, make an ever-enlarging spiral.

B) Divide the breast into quadrants and inspect each systematically.

C) Examine in lines resembling the back and forth pattern of mowing a lawn.

D) Beginning at the nipple, palpate outward in a stripe pattern.

Ans: C Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: The vertical strip pattern has been shown to be the most effective pattern for palpation of the breast. The most important aspect, however, is to be systematic. The tail of Spence, located on the upper anterior chest, is an area commonly missed on examination.

19. Which is true of women who have had a unilateral mastectomy?

A) They no longer require breast examination.

B) They should be examined carefully along the surgical scar for masses.

C) Lymphedema of the ipsilateral arm usually suggests recurrence of breast cancer.

D) Women with breast reconstruction over their mastectomy site no longer require examination.

Ans: B Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: A woman who has had breast cancer remains at high risk for recurrence, especially in the contralateral breast. The mastectomy site should be carefully examined for local recurrence

as well. Lymphedema or swelling of the ipsilateral arm following mastectomy is common and does not usually indicate recurrence. Women with breast reconstruction must also undergo careful examination.

20. Which of the following is true regarding breast self-examination?

A) It has been shown to reduce mortality from breast cancer.

B) It is recommended unanimously by organizations making screening recommendations.

C) A high proportion of breast masses are detected by breast self-examination.

D) The undue fear caused by finding a mass justifies omitting instruction in breast selfexamination.

Ans: C Chapter: 10 Page and Header: 402, Techniques of Examination Feedback: Although self-examination has not been shown to reduce mortality and is not recommended by all groups making screening recommendations, many choose to teach women a systematic method in which to examine their breasts. A high proportion of breast masses are detected by breast self-examination.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 11: The Abdomen

Multiple Choice

1. A 52-year-old secretary comes to your office, complaining about accidentally leaking urine when she coughs or sneezes. She says this has been going on for about a year now. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past

medical history is significant for four spontaneous vaginal deliveries. She is married and has four children. She denies alcohol, tobacco, or drug use. During her pelvic examination you note some atrophic vaginal tissue, but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable.

Which type of urinary incontinence does she have?

A) Stress incontinence B) Urge incontinence C) Overflow incontinence Ans: A Chapter: 11 Page and Header: 418, The Health History Feedback: Stress incontinence usually occurs when the intra-abdominal pressure goes up during coughing, sneezing, or laughing. This is usually due to a weakness of the pelvic floor, with inadequate muscle support of the bladder. Vaginal deliveries and pelvic surgery are often associated with these symptoms. Usually, female patients are postmenopausal when stress incontinence begins. Kegel exercises are usually recommended to strengthen the pelvic floor muscles.

2. A 46-year-old former salesman presents to the ER, complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. On examination you find a man appearing older than his stated age. His skin has a yellowish tint and he is thin, with a prominent abdomen. You note multiple “spider angiomas” at the base of his neck. Otherwise, his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation.

Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination.

What cause of black stools most likely describes his symptoms and signs?

A) Infectious diarrhea B) Mallory-Weiss tear C) Esophageal varices Ans: C Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: Varices are often found in alcoholic patients, but only when they have a diagnosis of significant cirrhosis. This patient has symptoms of cirrhosis, including jaundice, ascites, spider hemangiomas, and dilated veins on his abdomen (caput medusa).

3. A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool.

Occasionally she has periods of constipation, but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a junior in college majoring in accounting. She smokes when she drinks alcohol but denies using any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable.

What is most likely the etiology of her diarrhea?

A) Secretory infections B) Inflammatory infections C) Irritable bowel syndrome D) Malabsorption syndrome Ans: C Chapter: 11 Page and Header: 418, The Health History Feedback: Irritable bowel syndrome will cause loose bowel movements with cramps but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse, as do certain foods.

4. A 42-year-old florist comes to your office, complaining of chronic constipation for the last 6 months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies any recent illnesses or injuries. She denies any changes to her diet or exercise program.

She is on no new medications. During the review of systems you note that she has felt fatigued, had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one vaginal delivery and two cesarean sections. She is married, has three children, and owns a flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has coronary artery disease. There is no family history of cancers. On examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the Achilles tendons.

What is the best choice for the cause of her constipation?

A) Large bowel obstruction B) Irritable bowel syndrome C) Rectal cancer D) Hypothyroidism Ans: D

Chapter: 11 Page and Header: 418, The Health History Feedback: Many metabolic conditions can interfere with bowel motility. In this case the patient has many symptoms of hypothyroidism, including cold intolerance, weight gain, fatigue, constipation, and irregular menstrual cycles. On examination, thyromegaly and delayed reflexes can help to make the diagnosis. Medication will usually correct these symptoms.

5. A 22-year-old law student comes to your office, complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank something like 14 drinks. On examination you find a young male appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending.

What etiology of abdominal pain is most likely causing his symptoms?

A) Peptic ulcer disease B) Biliary colic C) Acute cholecystitis D) Acute pancreatitis Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates into the back. There is often a history of long-standing gallbladder disease or recent alcohol ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump inhibitors can also cause pancreatitis in people without these other risk factors. Treatment includes hydration, pain management, and bowel rest.

6. A 76-year-old retired farmer comes to your office complaining of abdominal pain, constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or diarrhea. The only unusual thing he remembers eating is two bags of popcorn at the movies with his grandson, 3 days before his symptoms began. He denies any other recent illnesses. His past

medical history is significant for coronary artery disease and high blood pressure. He has been married for over 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon cancer and his father had a stroke. On examination he appears his stated age and is in no acute distress. His temperature is 100.9 degrees and his other vital signs are unremarkable. His head, cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable and his fecal occult blood test is negative. His prostate is slightly enlarged but his testicular, penile, and inguinal examinations are all normal. Blood work is pending.

What diagnosis for abdominal pain best describes his symptoms and signs?

A) Acute diverticulitis B) Acute cholecystitis C) Acute appendicitis D) Mesenteric ischemia Ans: A Chapter: 11 Page and Header: 418, The Health History Feedback: Diverticulitis is caused by localized infections within the colonic diverticula.

Constipation, fever, and abdominal pain are common. Mesenteric ischemia classically presents in older people with a history of vascular disease elsewhere. The typical pain is unusual in that it is not made worse by examination despite being severe. Some mistake this feature to indicate malingering, with bad results.

7. A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife's request. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for over 40 years. He denies any tobacco or drug use and has not drunk alcohol in over 40 years. His parents both died of cancer in their 60s. On examination his vital signs are normal. His head, cardiac, and pulmonary examinations are unremarkable. On abdominal examination you hear normal bowel sounds, but when you palpate his liver it is abnormal. His rectal examination is positive for occult blood.

What further abnormality of the liver was likely found on examination?

A) Smooth, large, nontender liver B) Irregular, large liver C) Smooth, large, tender liver Ans: B Chapter: 11 Page and Header: 469, Table 11–12 Feedback: With his past history of colon cancer and with recent weight loss and fatigue, a relapse of his colon cancer would be expected. Colon cancer usually metastasizes to the liver, creating hard, irregular nodules, which can sometimes be palpated on examination. A smooth, large liver which is tender is often seen in hepatitis.

8. A 26-year-old sports store manager comes to your clinic, complaining of severe right-sided abdominal pain for 12 hours. He began having a stomachache yesterday, with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 100.4 and his heart rate is 110. His bowel sounds are decreased and he has rebound and involuntary guarding, one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal.

What is the most likely cause of his pain?

A) Acute appendicitis B) Acute mechanical intestinal obstruction C) Acute cholecystitis D) Mesenteric ischemia Ans: A Chapter: 11 Page and Header: 418, The Health History Feedback: Appendicitis is common in the young and usually presents with periumbilical pain that localizes to the right lower quadrant in an area known as McBurney's Point, described above as one third of the way between the anterior superior iliac spine and the umbilicus on the right.

Rebound and guarding are common. Remote rebound or Rovsing's sign is also seen commonly when the course of appendicitis is advanced. Bowel movements are usually unaffected.

9. A 15-year-old high school freshman is brought to the clinic by his mother because of chronic diarrhea. The mother states that for the past couple of years her son has had diarrhea after many meals. The patient states that the diarrhea seems the absolute worst after his school lunches. He describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or fatigue. He has had no recent illness, injuries, or foreign travel. His past medical history is unremarkable. He denies tobacco, alcohol, or drug use. His parents are both healthy. On examination you see a relaxed young man breathing comfortably. His vital signs are normal and his head, eyes, ears, throat, neck, cardiac, and pulmonary examinations are normal. His abdomen is soft and nondistended. His bowel sounds are active, and he has no tenderness, no enlarged organs, and no rebound or guarding. His rectal examination is nontender with no blood on the glove. You collect a stool sample for further study.

What is the most likely explanation for this patient's chronic diarrhea?

A) Malabsorption syndrome B) Osmotic diarrhea C) Secretory diarrhea Ans: B Chapter: 11 Page and Header: 458, Table 11–4 Feedback: Usually related to lactose intolerance, watery diarrhea often follows meal ingestion.

Crampy abdominal pain, distension, and gas often accompany symptoms. Diarrhea is often provoked by pizza, milkshakes, yogurt, and other lactose-containing foods. This condition is more common in African-Americans, Latinos, Native Americans, and Asians.

10. A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency or urgency with urination but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood cells.

What type of urinary tract pain is she most likely to have?

A) Kidney pain (from pyelonephritis) B) Ureteral pain (from a kidney stone) C) Musculoskeletal pain D) Ischemic bowel pain Ans: B Chapter: 11 Page and Header: 418, The Health History Feedback: The pain from a kidney stone causes dramatic, severe, colicky pain at the costovertebral angle that radiates across the flank and down into the groin.

11. Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?

A) Peptic ulcer B) Cholecystitis C) Pancreatitis D) Appendicitis Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.

12. Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or more at a time and has started recently. Which of the following should be considered?

A) Peptic ulcer B) Pancreatitis C) Myocardial ischemia D) All of the above Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: Epigastric pain can have many causes. History and physical will help discern which causes are most likely, but it is important to realize that any of the above, including myocardial ischemia, is always a possibility. Pneumonia and gallbladder pain can also cause pain in this location.

13. Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely?

A) Colon cancer B) Cholecystitis C) Inflammatory bowel disease D) Irritable bowel syndrome Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: Although colon cancer should be a consideration, these symptoms are intermittent

and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely. This is a very common condition which can be triggered by certain foods and stress.

14. Jim is a 60-year-old man who presents with vomiting. He denies seeing any blood with emesis, which has been occurring for 2 days. He does note a dark, granular substance resembling the coffee left in the filter after brewing. What do you suspect?

A) Bleeding from a diverticulum B) Bleeding from a peptic ulcer C) Bleeding from a colon cancer D) Bleeding from cholecystitis Ans: B Chapter: 11 Page and Header: 418, The Health History Feedback: When blood is exposed to the environment of the stomach, it often resembles “coffee grounds.” This is not always recognized by patients as blood, so it is important to inquire about this. This symptom is not common in cholecystitis, and the other possibilities occur lower in the intestine. It should be noted that conversely, rapid bleeding from the stomach or other upper gastrointestinal source can produce bright red blood in the stool. Do not rule out proximal bleeding on the basis of the absence of “coffee grounds.” Likewise, bright red blood seen with emesis may originate from the stomach. Black, sticky stools also can accompany upper GI bleeding.

15. A daycare worker presents to your office with jaundice. She denies IV drug use, blood transfusion, and travel and has not been sexually active for the past 10 months. Which type of hepatitis is most likely?

A) Hepatitis A B) Hepatitis B C) Hepatitis C D) Hepatitis D Ans: A Chapter: 11 Page and Header: 418, The Health History Feedback: The lack of contact with blood and body fluids makes hepatitis B, C, and D unlikely.

She regularly changes the diapers of her clients and is at risk for hepatitis A. Vaccine against hepatitis A is recommended for daycare workers.

16. Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely, given this presentation?

A) Appendicitis B) Dysmenorrhea C) Ureteral stone D) Ovarian cyst Ans: C Chapter: 11 Page and Header: 418, The Health History Feedback: The presentation of right flank pain spiraling down to the groin is typical of a ureteral stone. There would most likely be microscopic hematuria as well. The migration pattern of this condition makes the others less likely.

17. Mrs. LaFarge is a 60-year-old who presents with urinary incontinence. She is unable to get to the bathroom quickly enough when she senses the need to urinate. She has normal mobility.

Which of the following is most likely?

A) Stress incontinence B) Urge incontinence C) Overflow incontinence D) Functional incontinence Ans: B Chapter: 11 Page and Header: 418, The Health History Feedback: Stress incontinence occurs with increased intra-abdominal pressure such as with coughing, sneezing, or laughing. This history is most consistent with urge incontinence secondary to detrusor overactivity. Overflow incontinence occurs with anatomic obstruction such as prostatic hypertrophy (obviously not in this case, as the patient is a woman), urethral stricture, or neurogenic bladder. Functional incontinence results from lack of mobility severe enough to impair getting to the bathroom quickly enough.

18. Which is the proper sequence of examination for the abdomen?

A) Auscultation, inspection, palpation, percussion B) Inspection, percussion, palpation, auscultation

C) Inspection, auscultation, percussion, palpation D) Auscultation, percussion, inspection, palpation Ans: C Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: The abdominal examination is conducted in a sequence different from other systems, for which the usual order is inspection, percussion, palpation, and auscultation. Because palpation may actually cause some bowel noise when the bowels are not moving, auscultation is performed before percussion and palpation in an abdominal examination.

19. A 62-year-old woman has been followed by you for 3 years and has had recent onset of hypertension. She is still not at goal despite three antihypertensive medicines, and you strongly doubt nonadherence. Her father died of a heart attack at age 58. Today her pressure is 168/94 and pressure on the other arm is similar. What would you do next?

A) Add a fourth medicine B) Refer to nephrology C) Get a CT scan D) Listen closely to her abdomen Ans: D Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: At this point, it is important to consider secondary causes for this woman's hypertension because of its severity, rapidity of progression, and lack of response to therapy.

While you will most likely add a fourth medicine, it is important to carefully examine the abdomen for the presence of renal artery bruits. These are usually heard best in the upper quadrants. It may be necessary to have the patient hold her breath, to have a very quiet room, and to listen with the diaphragm for a very soft, high-pitched sound with systole. It may also help to simultaneously feel the patient's pulse (a bruit with both a systolic and diastolic component is very specific for a significant blockage, while a lone systolic bruit may not be abnormal).

Obtaining a CT scan is not likely to be useful, and you may save the delay, expense, and inconvenience of a nephrology referral if you can hear a bruit.

20. Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which of the following would you do next?

A) Check an ultrasound of the liver B) Obtain a hepatitis panel

C) Determine liver span by percussion D) Adopt a “watchful waiting” approach Ans: C Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A liver edge palpable this far below the costal arch should not be ignored. Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has developed emphysema with flattening of the diaphragms. This pushes a normal-sized liver below the costal arch so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall until dullness is heard. A measurement is then made between this point and the lower border of the liver to determine its span; 6–12 centimeters in the mid-clavicular line is normal. Percussion is the only way to assess liver size on examination, and in this case it saved the patient much inconvenience and expense.

21. Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?

A) It is a splenic rub.

B) It is a variant of bowel noise.

C) It represents borborygmi.

D) It is a vascular noise.

Ans: A Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A rough, grating noise over this area represents a splenic rub, which can accompany splenic infarction. Rubs also occur over the liver and pleura and pericardium.

22. You are palpating the abdomen and feel a small mass. Which of the following would you do next?

A) Ultrasound B) Examination with the abdominal muscles tensed C) Surgery referral D) Determine size by percussion Ans: B Chapter: 11 Page and Header: 451, Recording Your Findings Feedback: It is easy to determine whether the mass is actually in the abdominal wall versus in

the abdomen by palpating with the abdominal wall tensed. This can be accomplished by having the patient lift her head off the bed while supine. Usually, abdominal wall masses can be observed, whereas intra-abdominal masses are more concerning.

23. Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice dullness in the last intercostal space in the anterior axillary line on his left side with a deep breath. What does this indicate?

A) His spleen is definitely enlarged and further workup is warranted.

B) His spleen is possibly enlarged and close attention should be paid to further examination.

C) His spleen is possibly enlarged and further workup is warranted.

D) His spleen is definitely normal.

Ans: B Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: This scenario is not uncommon in infectious mononucleosis. The presence of dullness with inspiration should definitely increase your attention to further examination of the spleen, although dullness can occur in normal patients too.

24. A young patient presents with a left-sided mass in her abdomen. You confirm that it is present in the left upper quadrant. Which of the following would support that this represents an enlarged kidney rather than her spleen?

A) A palpable “notch” along its edge B) The inability to push your fingers between the mass and the costal margin C) The presence of normal tympany over this area D) The ability to push your fingers medial and deep to the mass Ans: C Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A left upper quadrant mass is more likely to be a kidney if there is no palpable “notch,” you can push your fingers between the mass and the costal margin, there is normal tympany over this area, and you cannot push your fingers medial and deep to the mass. These findings are very difficult to appreciate in an obese patient.

25. Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the

symphysis pubis. What does this most likely represent?

A) Sigmoid mass B) Tumor in the abdominal wall C) Hernia D) Enlarged bladder Ans: D Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: It is possible that this represents a sigmoid colon mass, but this is less likely than an enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently cause partial urinary obstruction with bladder enlargement. If the mass resolves with catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A hernia would most likely not be dull to percussion. Midline abdominal wall tumors of this size would be unusual but could be discerned by having the patient tense his abdominal muscles.

26. Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What should you do next?

A) Obtain abdominal ultrasound B) Reassess by examination in 6 months C) Reassess by examination in 3 months D) Refer to a vascular surgeon Ans: A Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 centimeters. It would be inappropriate to recheck him at a later time without taking action.

Likewise, referral to a vascular surgeon before ultrasound may be premature.

27. Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?

A) Bilateral flank tympany B) Dullness which remains despite change in position C) Dullness centrally when the patient is supine D) Tympany which changes location with patient position

Ans: D Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float so that dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany which changes location with patient position (“shifting dullness”) would support the presence of ascites. A fluid wave and edema would support this diagnosis as well.

28. Which of the following is consistent with obturator sign?

A) Pain distant from the site used to check rebound tenderness B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated C) Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion D) Pain that stops inhalation in the right upper quadrant Ans: B Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: Obturator sign is seen in appendicitis. It is pain with the stretching of the internal obturator muscle because of inflammation. Pain distant from the site used to check rebound tenderness is Rovsing's sign and is a reliable sign of peritonitis. Answer “C” describes psoas sign, which is also seen in appendicitis. Palpation in the right upper quadrant that causes pain severe enough to stop inhalation is consistent with inflammation of the gallbladder and is called Murphy's sign.

29. An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect?

A) Malingering B) Neuropathy C) Ischemia D) Physical abuse Ans: C Chapter: 11 Page and Header: 454, Table 11–1 Feedback: Ischemic pain can be severe but is not made worse with palpation. The history of bypass could be a clue that there is vascular narrowing elsewhere. Malingering is less likely, and

neuropathic pain, as seen in herpes zoster, would worsen with touch. You are to be commended if you considered elder abuse, because this is frequently missed. Ordinarily, this pain would be worse with examination because of the preceding trauma.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 12: The Peripheral Vascular System

Multiple Choice

1. A 57-year-old maintenance worker comes to your office for evaluation of pain in his legs. He has smoked two packs per day since the age of 16, but he is otherwise healthy. You are concerned that he may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?

A) Intermittent claudication B) Chest pressure with exertion C) Shortness of breath D) Knee pain Ans: A Chapter: 12 Page and Header: 477, The Health History Feedback: Intermittent claudication is leg pain that occurs with walking and is relieved by rest.

It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of patients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle brachial index can help detect this problem.

2. A 72-year-old teacher comes to your clinic for an annual examination. She is concerned about her risk for peripheral vascular disease and states that there is a place in town that does tests to let her know her if she has this or not. Which of the following disease processes is a risk factor for peripheral vascular disease?

A) Gastroesophageal reflux disease B) Coronary artery disease C) Migraine headaches D) Osteoarthritis Ans: B Chapter: 12 Page and Header: 478, Health Promotion and Counseling Feedback: Evidence of coronary artery disease implies that there is most likely disease in other vessels; therefore, this is a risk factor for peripheral vascular disease. Conversely, the presence of peripheral vascular disease is also a risk factor for coronary artery disease, and if present, it should be considered in reduction of cardiac risk factors.

3. A 68-year-old retired truck driver comes to your office for evaluation of swelling in his legs.

He is a smoker and has been taking medications to control his hypertension for the past 25 years.

You are concerned about his risk for peripheral vascular disease. Which of the following tests are appropriate to order to initially evaluate for this condition?

A) Venogram B) CT scan of the lower legs C) Ankle–brachial index (ABI) D) PET scan Ans: C Chapter: 12 Page and Header: 478, Health Promotion and Counseling Feedback: The ankle–brachial index is a good test for obtaining information about significant stenosis in the vessels of the lower extremities. Sixteen percent of patients with known peripheral vascular disease also have coronary artery disease.

4. A 55-year-old secretary with a recent history of breast cancer, for which she underwent surgery and radiation therapy, and a history of hypertension comes to your office for a routine checkup. Which of the following aspects of the physical are important to note when assessing the patient for peripheral vascular disease in the arms?

A) Femoral pulse, popliteal pulse B) Dorsalis pedis pulse, posterior tibial pulse C) Carotid pulse D) Radial pulse, brachial pulse Ans: D Chapter: 12

Page and Header: 481, Techniques of Examination Feedback: This is an important aspect of physical examination to assess for peripheral vascular disease. This patient is at risk for disease in this distribution because of her recent radiation therapy.

5. You are a student in the vascular surgery clinic. You are asked to perform a physical examination on a patient with known peripheral vascular disease in the legs. Which of the following aspects is important to note when you perform your examination?

A) Size, symmetry, and skin color B) Muscle bulk and tone C) Nodules in joints D) Lower extremity strength Ans: A Chapter: 12 Page and Header: 481, Techniques of Examination Feedback: This is an important aspect to note in physical examination. Swelling in the legs, cyanosis, and lack of appropriate hair growth are all signs of peripheral vascular disease.

6. You are assessing a patient for peripheral vascular disease in the arms, secondary to a complaint of increased weakness and a history of coronary artery disease and diabetes. You assess the brachial and radial pulses and note that they are bounding. What does that translate to on a scale of 0 to 3?

A) 0 B) 3+ C) 2+ D) 1+ Ans: B Chapter: 12 Page and Header: 481, Techniques of Examination Feedback: A pulse of 3+ is considered to be bounding.

7. You are obtaining an arterial blood gas in the radial artery on a retired cab driver who has been hospitalized in the intensive care unit for a stroke. You are concerned about the possibility of arterial insufficiency. You perform the Allen test. This means that you: A) Checked for patency of the radial artery

B) Checked for patency of the brachial artery C) Checked for patency of the ulnar artery D) Checked for patency of the femoral artery Ans: C Chapter: 12 Page and Header: 488, Special Techniques Feedback: The Allen test is for determining patency of the ulnar artery before puncturing the radial artery. In the event of an occlusion in the radial artery system, the ulnar artery can provide adequate blood flow.

8. You are assessing a 59-year-old gas station owner for atherosclerosis in the lower extremities.

In which of the following locations would the patient's pain make you concerned for this disease process?

A) Thigh B) Knee C) Calf D) Ankle Ans: C Chapter: 12 Page and Header: 477, The Health History Feedback: Pain in the calf is the most common site for claudication; however, there could be pain in the buttock, hip, thigh, or foot, depending on the level of the obstruction. The absence of this pain does not rule out significant vascular disease, and actually the minority of these patients are symptomatic.

9. You are performing a routine check-up on an 81-year-old retired cotton farmer in the vascular surgery clinic. You note that he has a history of chronic arterial insufficiency. Which of the following physical examination findings in the lower extremities would be expected with this disease?

A) Normal pulsation B) Normal temperature C) Marked edema D) Thin, shiny, atrophic skin Ans: D Chapter: 12 Page and Header: 494, Table 12–1 Feedback: Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in

chronic venous insufficiency the skin often has a brown pigmentation and may be thickened.

10. A 77-year-old retired nurse has an ulcer on a lower extremity that you are asked to evaluate when you do your weekly rounds at a local long-term care facility. All of the following are responsible for causing ulcers in the lower extremities except for which condition?

A) Arterial insufficiency B) Venous insufficiency C) Diminished sensation in pressure points D) Hypertension Ans: D Chapter: 12 Page and Header: 498, Table 12–4 Feedback: Hypertension is not directly associated with the formation of ulcers. It is an indirect risk factor if it is uncontrolled for a long time and associated with atherosclerosis, because it can lead to arterial insufficiency or neuropathy.

11. As the internal diameter of a blood vessel changes, the resistance changes as well. Which of the following descriptions depicts this relationship?

A) Resistance varies linearly with the diameter.

B) Resistance varies proportionally to the second power of the diameter.

C) Resistance varies proportionally to the third power of the diameter.

D) Resistance varies proportionally to the fourth power of the diameter.

Ans: D Chapter: 12 Page and Header: 471, Anatomy and Physiology Feedback: The body is able to make significant changes in blood vessel resistance with very small changes to diameter. LaPlace's law tells us that the resistance varies proportionally to the fourth power of the diameter.

12. Which area of the arm drains to the epitrochlear nodes?

A) Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger B) Radial surface of the forearm and hand, thumb and index fingers, and radial middle finger C) Ulnar surface of the forearm and hand; second, third, and fourth fingers D) Radial surface of the forearm and hand; second, third, and fourth fingers

Ans: A Chapter: 12 Page and Header: 471, Anatomy and Physiology Feedback: The epitrochlear node receives lymphatic drainage from the ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger. More importantly, it is generally a sign of generalized lymphadenopathy as seen in syphilis and HIV infection.

13. Mr. Edwards complains of cramps and difficulties with walking. The cramps occur in his calves consistently after walking about 100 yards. After a period of rest, he can start to walk again, but after 100 yards these same symptoms recur. Which of the following would suggest spinal stenosis as a cause of this pain?

A) Coldness and pallor of the legs B) Relief of the pain with bending at the waist C) Color changes of the skin D) Swelling with tenderness of the skin Ans: B Chapter: 12 Page and Header: 477, The Health History Feedback: While these symptoms are classic for claudication, they may also be accounted for by spinal stenosis. Relief with bending at the waist would be consistent with this etiology. Some will state that they must lean over the shopping cart while shopping to avoid these symptoms.

Bending stretches the spinal cord and presumably decreases compression. The other symptoms would lead one to suspect a vascular etiology.

14. Which of the following pairs of ischemic symptoms versus vascular supply is correct?

A) Lower calf/superficial femoral B) Erectile dysfunction/iliac or pudendal C) Buttock/common femoral D) Upper calf/tibial or peroneal Ans: B Chapter: 12 Page and Header: 477, The Health History Feedback: The ischemia from the iliac or pudendal arteries results in erectile dysfunction. The lower calf is supplied by the popliteal artery, the buttock is supplied by the common femoral artery, and the upper calf is supplied by the superficial femoral artery.

15. The ankle–brachial index (ABI) is calculated by dividing the systolic BP at the dorsalis pedis by the systolic BP at the brachial artery. Which of the following values would be consistent with mild peripheral arterial disease?

A) 1.1 B) 0.85 C) 0.65 D) 0.35 Ans: B Chapter: 12 Page and Header: 478, Health Promotion and Counseling Feedback: The mild disease is represented by an ABI of 0.71 to 0.9. Any value above 0.9 is normal. Moderate disease is defined as between 0.7 and 0.41, and severe disease is defined as 0.4 or less. Patients in the “severe” category have a 20% to 25% annual risk of death.

16. Asymmetric BPs are seen in which of the following conditions?

A) Coronary artery disease B) Congenital narrowing of the aorta C) Diffuse atherosclerosis D) Vasculitis, as seen in systemic lupus erythematosus Ans: B Chapter: 12 Page and Header: 481, Techniques of Examination Feedback: A difference of as little as 10 mm Hg in the systolic blood pressure may be significant. Coarctation and dissecting aortic aneurysm are causes of asymmetric blood pressures. Coarctation represents a congenital narrowing of the aorta. While some forms of vasculitis can affect large vessels where we measure the blood pressure, lupus is generally a small-vessel vasculitis. Usually, neither diffuse atherosclerosis nor coronary artery disease is responsible for a focal difference in blood pressure.

17. Diminished radial pulses may be seen in patients with which of the following?

A) Aortic insufficiency B) Hyperthyroidism C) Arterial emboli D) Early “warm” septic shock Ans: C Chapter: 12

Page and Header: 481, Techniques of Examination Feedback: Arterial emboli would decrease flow to a region, and therefore pulses would decrease as well. The other conditions actually cause bounding pulses. Aortic insufficiency can cause significant leakage of blood back to the heart, so the heart compensates by increasing forward flow. Stroke volume can increase dramatically with hyperthyroidism, especially in “thyroid storm.” This also results in bounding pulses. Although shock generally causes decreased blood pressure and pulses, early septic shock can produce increased peripheral circulation and increase pulses.

18. When assessing temperature of the skin, which portion of your hand should be used?

A) Fingertips B) Palms C) Backs of fingers D) Ulnar aspect of the hand Ans: C Chapter: 12 Page and Header: 481, Techniques of Examination Feedback: The backs of the fingers are thought to be the most temperature sensitive, perhaps because the skin is thinnest there. You may have difficulty detecting subtle differences if you do not use the backs of the fingers.

19. A patient presents with claudication symptoms and diminished pulses. Which of the following is consistent with chronic arterial insufficiency?

A) Pallor of the foot when raised to 60 degrees for one minute B) Return of color to the skin within 5 seconds of allowing legs to dangle C) Filling of the veins of the ankles within 10 seconds of allowing the legs to dangle D) Hyperpigmentation of the skin Ans: A Chapter: 12 Page and Header: 481, Techniques of Examination Feedback: Pallor of the soles after one minute of elevation is a reliable sign of arterial insufficiency. Return of the color to the skin should occur within 10 seconds of dangling, and the filling of veins should occur within 15 seconds. Hyperpigmentation of the skin is usually seen in venous insufficiency.

20. You note a painful ulcerative lesion near the medial malleolus, with accompanying hyperpigmentation. Which of the following etiologies is most likely?

A) Arterial insufficiency B) Neuropathic ulcer C) Venous insufficiency D) Trauma Ans: C Chapter: 12 Page and Header: 498, Table 12–4 Feedback: These features are most consistent with venous insufficiency. You may also see scaling, redness, varicosities, and other findings. Arterial insufficiency usually affects distal or traumatized areas. Other clues of arterial insufficiency would most likely be present.

Neuropathic ulcers occur because of decreased sensation and are common in patients with neuropathy. They are often over bony prominences with surrounding calluses.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 13: Male Genitalia and Hernias

Multiple Choice

1. A 28-year-old musician comes to your clinic, complaining of a “spot” on his penis. He states his partner noticed it 2 days ago and it hasn't gone away. He says it doesn't hurt. He has had no burning with urination and no pain during intercourse. He has had several partners in the last year and uses condoms occasionally. His past medical history consists of nongonococcal urethritis from Chlamydia and prostatitis. He denies any surgeries. He smokes two packs of cigarettes a day, drinks a case of beer a week, and smokes marijuana and occasionally crack. He has injected IV drugs before but not in the last few years. He is single and currently unemployed.

His mother has rheumatoid arthritis and he doesn't know anything about his father. On examination you see a young man appearing deconditioned but pleasant. His vital signs are unremarkable. On visualization of his penis there is a 6-mm red, oval ulcer with an indurated base just proximal to the corona. There is no prepuce because of neonatal circumcision. On palpation the ulcer is nontender. In the inguinal region there is nontender lymphadenopathy.

What disorder of the penis is most likely the diagnosis?

A) Condylomata acuminata

B) Genital herpes C) Syphilitic chancre D) Penile carcinoma Ans: C Chapter: 13 Page and Header: 516, Table 13–2 Feedback: Primary syphilis causes a larger ulcer that is firm and painless. Syphilis is fairly uncommon but does occur in the highly promiscuous population, especially when coupled with illegal drug use. You should consider further questions and workup regarding HIV status.

2. A 20-year-old part-time college student comes to your clinic, complaining of growths on his penile shaft. They have been there for about 6 weeks and haven't gone away. In fact, he thinks there may be more now. He denies any pain with intercourse or urination. He has had three former partners and has been with his current girlfriend for 6 months. He says that because she is on the pill they don't use condoms. He denies any fever, weight loss, or night sweats. His past medical history is unremarkable. In addition to college, he works part-time for his father in construction. He is engaged to be married and has no children. His father is healthy, and his mother has hypothyroidism. On examination the young man appears healthy. His vital signs are unremarkable. On visualization of his penis you see several moist papules along all sides of his penile shaft and even two on the corona. He has been circumcised. On palpation of his inguinal region there is no inguinal lymphadenopathy.

Which abnormality of the penis does this patient most likely have?

A) Condylomata acuminata B) Genital herpes C) Syphilitic chancre D) Penile carcinoma Ans: A Chapter: 13 Page and Header: 516, Table 13–2 Feedback: Warts are generally painless papules along the shaft and corona. They are likely to spread and are caused by the human papilloma virus, transmitted through sexual contact. You should discuss prevention of STIs with him. Although his girlfriend's contraceptive pill protects her from pregnancy, he and she are unprotected from sharing STIs. She should receive regular Pap examinations and consider the HPV vaccine.

3. A 29-year-old married computer programmer comes to your clinic, complaining of “something strange” going on in his scrotum. Last month while he was doing his testicular selfexamination he felt a lump in his left testis. He waited a month and felt the area again, but the

lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable.

What disorder of the testes is most likely the diagnosis?

A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele Ans: B Chapter: 13 Page and Header: 519, Table 13–5 Feedback: Scrotal hernias occur when the small intestine passes through a weak spot of the inguinal ring. The examiner cannot get a finger above the hernia into the ring. Hernias are often caused by increased abdominal pressure, such as in weight lifting. Patients who have a hernia on one side often have another hernia on the opposite side. In this patient's case, a right-sided hernia was repaired as an infant.

4. A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn't change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He is a married hospital administrator with two children. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On examination you see a young man appearing his stated age with unremarkable vital signs. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down, you feel no bulges. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate examination is unremarkable.

What abnormality of the scrotum does he most likely have?

A) Hydrocele

B) Scrotal hernia C) Scrotal edema D) Varicocele Ans: D Chapter: 13 Page and Header: 518, Table 13–4 Feedback: Varicoceles are varicose veins surrounding the spermatic cord, coming through the inguinal ring. These veins feel like spaghetti and are often referred to as a “bag of worms.” The increased number of veins affects the temperature of the testes, often causing infertility problems. Like most varicose veins in any area, varicoceles can cause a nonspecific aching.

Although usually benign, a unilateral varicocele on the right or a varicocele which does not resolve in the supine position deserves further workup.

5. A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn't know if intercourse would hurt. He states he has become more tired lately and has also gained 10 pounds in the last month. He denies any fever or weight loss. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is married and has five children. He is currently on disability because of his health problems. Both of his parents died of complications of diabetes. On examination you see a pleasant male appearing chronically ill. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges. The prostate is smooth and nontender.

What abnormality of the scrotum is most likely the diagnosis?

A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele Ans: C Chapter: 13 Page and Header: 515, Table 13–1 Feedback: Scrotal edema is a generalized swelling of the scrotum due to a systemic illness. No discrete masses are palpated. In this case, with the history of diabetes, hypertension, and coronary artery disease, the symptom of weight gain, and the signs of crackles in the lungs and an extra heart sound, the patient is probably suffering from congestive heart failure. This is also

seen in patients with edema from hypoalbuminemia.

6. A 36-year-old security officer comes to your clinic, complaining of a painless mass in his scrotum. He found it 3 days ago during a testicular self-examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. His past medical history is notable for high blood pressure. He is married and has three healthy children. He denies using illegal drugs, smokes two to three cigars a week, and drinks six to eight alcoholic beverages per week. His mother is in good health and his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis, he is circumcised and has no lesions. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft cystic-like lesion measuring 2 cm over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight bearing there are no bulges. His prostate examination is unremarkable.

What disorder of the scrotum does he most likely have?

A) Hydrocele B) Scrotal hernia C) Testicular tumor D) Varicocele Ans: A Chapter: 13 Page and Header: 515, Table 13–1 Feedback: The hydrocele is a fluid-filled cyst originating within the tunica vaginalis. An examining finger can be placed over the mass into the inguinal ring. An outside light source can be placed beneath the scrotum. Hydroceles often transilluminate light, whereas solid tumors do not.

7. A 22-year-old unemployed roofer presents to your clinic, complaining of pain in his testicle and penis. He states the pain began last night and has steadily become worse. He states it hurts when he urinates and he has not attempted intercourse since the pain began. He has tried Tylenol and ibuprofen without improvement. He denies any fever or night sweats. His past medical history is unremarkable. He has had four previous sexual partners and has had a new partner for the last month. She is on oral contraceptives so he has not used condoms. His parents are both in good health. On examination you see a young man lying on his side. He appears mildly ill. His temperature is 100.2 and his blood pressure, respirations, and pulse are normal. On visualization of the penis he is circumcised, with no lesions or discharge from the meatus. Visualization of the scrotal skin appears unremarkable. Palpation of the testes shows severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An

examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells and bacteria.

What diagnosis of the male genitalia is most likely in this case?

A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis Ans: B Chapter: 13 Page and Header: 518, Table 13–4 Feedback: Epididymitis is an infection of the epididymis superior to the testicle. It can often be caused by sexually transmitted disease and can cause burning with urination and scrotal pain.

Palpate the spermatic cord through the scrotum by pinching medially and sliding your pinched fingers laterally. The spermatic cord, including the epididymis, will pass between your fingers and be tender if involved.

8. A 15-year-old high school football player is brought to your office by his mother. He is complaining of severe testicular pain since exactly 8:00 this morning. He denies any sexual activity and states that he hurts so bad he can't even urinate. He is nauseated and is throwing up.

He denies any recent illness or fever. His past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. On examination you see a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. His blood pressure is 150/100, his pulse is 110, and his respirations are 24.

On visualization of the penis he is circumcised and there are no lesions and no discharge from the meatus. His scrotal skin is tense and red. Palpation of the left testicle causes severe pain and the patient begins to cry. His prostate examination is unremarkable. His cremasteric reflex is absent on the left but is normal on the right. By catheter you get a urine sample and the analysis is unremarkable. You send the boy with his mother to the emergency room for further workup.

What is the most likely diagnosis for this young man's symptoms?

A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis Ans: C Chapter: 13 Page and Header: 518, Table 13–4 Feedback: Torsion is caused by the twisting of the testicle on its spermatic cord and blood vessels, leading to severe pain. The scrotum becomes red and tense. Torsion is usually seen in adolescents and is a true surgical emergency. If not quickly surgically repaired, the testicle's function is lost and it has to be removed. The presence of a cremasteric reflex is reassuring, but

in this case a thorough evaluation must take place as soon as possible.

9. A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged and tender. He isn't sure if he has had burning with urination and he says he has never had sexual intercourse. He has had a sore throat, cough, and runny nose for the last 3 days. His past medical history is significant for a tonsillectomy as a small child. His father has high blood pressure and his mother is healthy. On examination you see a teenager in no acute distress. His temperature is 100.8 and his blood pressure and pulse are unremarkable.

On visualization of his penis, he is uncircumcised and has no lesions or discharge. His scrotum is red and tense on the left and normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. The right testicle is unremarkable. An examining finger is put through both inguinal rings, and there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is also unremarkable.

What abnormality of the testes does this teenager most likely have?

A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis Ans: A Chapter: 13 Page and Header: 517, Table 13–3 Feedback: Acute orchitis causes an inflamed, tender testicle. The scrotum will be red and tense.

Orchitis is usually unilateral and often associated with viral infections such as mumps.

10. A 45-year-old electrical engineer presents to your clinic, complaining of spots on his scrotum. He first noticed the spots several months ago, and they have gotten bigger. He denies any pain with urination or with sexual intercourse. He has had no fever, night sweats, weight gain, or weight loss. His past medical history consists of a vasectomy 10 years ago and mild obesity. He is on medication for hyperlipidemia. He denies any tobacco or illegal drug use and drinks alcohol socially. His mother has Alzheimer's disease and his father died of leukemia. On examination he appears relaxed and has unremarkable vital signs. On visualization of his penis, he is circumcised and has no lesions on his penis. Visualization of his scrotum shows three yellow nodules 2–3 millimeters in diameter. During palpation they are firm and nontender.

What abnormality of the male genitalia is this most likely to be?

A) Condylomata acuminata B) Syphilitic chancre C) Peyronie's disease D) Epidermoid cysts

Ans: D Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: Epidermoid cysts are firm, yellowish, painless cysts on the scrotal skin. They are very common and are benign.

11. Jim is a 47-year-old man who is having difficulties with sexual function. He is recently separated from his wife of 20 years. He notes that he has early morning erections but otherwise cannot function. Which of the following is a likely cause for his problem?

A) Decreased testosterone levels B) Psychological issues C) Abnormal hypogastric arterial circulation D) Impaired neural innervation Ans: B Chapter: 13 Page and Header: 504, The Health History Feedback: The fact that he has an early morning erection is indicative of normal physiologic function. You may consider looking further into psychological issues, perhaps related to his marital difficulties. If the patient is unsure of whether early morning erections are occurring, some recommend the postage stamp test in which a ring of postage stamps or other perforated stickers is placed around the penis while in the flaccid state. If the perforations are broken, it is likely an erection has occurred. Do not perform this test without perforations in the stickers, or the ring may function as a tourniquet.

12. Which of the following conditions involves a tight prepuce which, once retracted, cannot be returned?

A) Phimosis B) Paraphimosis C) Balanitis D) Balanoposthitis Ans: B Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: This describes paraphimosis. Phimosis describes a foreskin which cannot be retracted. Balanitis involves an inflammation of the glans, whereas balanoposthitis involves inflammation of both the glans and the prepuce.

13. Induration along the ventral surface of the penis suggests which of the following?

A) Urethral stricture B) Testicular carcinoma C) Peyronie's disease D) Epidermoid cysts Ans: A Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: Urethral stricture may cause induration of the ventral surface of the penis. It more rarely represents a local carcinoma. A testicular carcinoma would be much more likely to occur in the scrotum. Peyronie's disease often causes induration on the dorsal proximal penis, and epidermoid cysts are benign findings on the scrotum.

14. A tender, painful swelling of the scrotum should suggest which of the following?

A) Acute epididymitis B) Strangulated inguinal hernia C) Torsion of the spermatic cord D) All of the above Ans: D Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: A tender, painful swelling of the scrotum can be a medical emergency. All of these conditions should be considered, as well as acute orchitis.

15. A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a “bag of worms” in the left scrotum, superior to the testicles. Which of the following is most likely?

A) Hydrocele of the spermatic cord B) Varicocele C) Testicular carcinoma D) A normal vas deferens Ans: B Chapter: 13 Page and Header: 508, Techniques of Examination

Feedback: Varicoceles are common in normal men. They are often found in the left scrotum or bilaterally and should normally resolve in the supine position. This is because they represent varicosities within the scrotum. These require further investigation if they occur only on the right side or do not resolve in the supine position. They can contribute to infertility because the testicles are unable to achieve a cool enough temperature for sperm production, due to increased blood flow from the varicocele. A hydrocele would be a painless mass on the spermatic cord and the vas deferens is palpated as part of the spermatic cord. You should lightly pinch the scrotum medially and move laterally until you feel the spermatic cord pass between your fingers.

16. Which of the following would lead you to suspect a hydrocele versus other causes of scrotal swelling?

A) The presence of bowel sounds in the scrotum B) Being unable to palpate superior to the mass C) A positive transillumination test D) Normal thickness of the skin of the scrotum Ans: C Chapter: 13 Page and Header: 515, Table 13–1 Feedback: A cystic structure will often transilluminate well. While a transilluminator head for your battery handle is ideal, it is possible to use an otoscope to transilluminate the scrotum. You should be able to get above the mass on palpation and bowel sounds should not be present. If they are, it should lead you to consider an inguinal hernia. Scrotal edema involves thickened skin which can be measured by gently pinching a section of the scrotum itself.

17. You are examining a newborn and note that the right testicle is not in the scrotum. What should you do next?

A) Refer to urology B) Recheck in 6 months C) Tell the parent the testicle is absent but that this should not affect fertility D) Attempt to bring down the testis from the inguinal canal Ans: D Chapter: 13 Page and Header: 517, Table 13–3 Feedback: This is not an uncommon finding, and the testis must often be “milked” into the scrotum from the inguinal canal. Six months is too long to wait, but urology referral is unnecessary unless the testicle cannot be brought into the scrotum. An intra-abdominal testis is at much higher risk for testicular cancer.

18. Francis is a middle-aged man who noted right-sided lower abdominal pain after straining with yard work. Which of the following would make a hernia more likely?

A) Absence of pain with straining B) Absence of bowel sounds in the scrotum C) Absence of a varicocele D) Absence of symmetry of the inguinal areas with straining Ans: D Chapter: 13 Page and Header: 519, Table 13–5 Feedback: Even in the presence of a hernia, absolute symmetry to inspection may be preserved.

The action of straining and increasing intra-abdominal pressure causes the hernia to protrude.

Hernias will not necessarily be present on CT scans either unless this maneuver is undertaken.

Pain with straining and bowel sounds heard in the scrotum further support the diagnosis of indirect hernia.

19. Frank is a 24-year-old man who presents with multiple burning erosions on the shaft of his penis and some tender inguinal adenopathy. Which of the following is most likely?

A) Primary syphilis B) Herpes simplex C) Chancroid D) Gonorrhea Ans: B Chapter: 13 Page and Header: 516, Table 13–2 Feedback: The multiplicity of lesions as well as the burning quality of the pain would lead one to suspect herpes simplex. Syphilis usually presents with a single chancre which is generally painless. Chancroid forms a single, jagged, deep ulcer and gonorrhea usually results in a burning discharge without skin lesions.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 14: Female Genitalia

Multiple Choice

1. A 22-year-old architecture major comes to your office, complaining of severe burning with urination, a fever of 101 degrees, and aching all over. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of severe acne. She is currently on an oral contraceptive. She has had no pregnancies or surgeries. She reports one new partner within the last month. She does not smoke but does drink occasionally.

Her parents are both in good health. On examination you see a young woman appearing slightly ill. Her temperature is 100.3 and her pulse and blood pressure are unremarkable. Her head, ears, eyes, nose, throat, cardiac, pulmonary, and abdominal examinations are unremarkable. Palpation of the inguinal nodes shows lymphadenopathy bilaterally. On visualization of the perineum there are more than 10 shallow ulcers along each side of the vulva. Speculum and bimanual examination are unremarkable for findings, although she is very tender at the introitus. Urine analysis has some white blood cells but no red blood cells or bacteria. Her urine pregnancy test is negative.

Which disorder of the vulva is most likely in this case?

A) Genital herpes B) Condylomata acuminata C) Syphilitic chancre D) Epidermoid cyst Ans: A Chapter: 14 Page and Header: 546, Table 14-1 Feedback: Genital herpes consists of small, shallow, painful ulcers. Primary infections are often associated with fever, malaise, and regional lymphadenopathy. The outbreak occurs generally between 1 and 3 weeks after exposure. Herpes is contagious and the majority of transmission occurs without the presence of obvious lesions. Transmission during passage through the birth canal can cause serious illness in affected newborns.

2. A 42-year-old realtor comes to your clinic, complaining of “growths” in her vulvar area. She is currently undergoing a divorce and is convinced she has a sexually transmitted disease. She denies any vaginal discharge or pain with urination. She has had no fever, malaise, or night sweats. Her past medical history consists of depression and hypothyroidism. She has had two spontaneous vaginal deliveries and one cesarean section. She has had no other surgeries. She denies smoking or drug use. She has two to three drinks weekly. Her mother also has hypothyroidism and her father has high blood pressure and hypercholesterolemia. On examination you see a woman who is anxious but appears otherwise healthy. Her blood pressure,

pulse, and temperature are unremarkable. On visualization of the perineum you see two 2- to 3mm, round, yellow nodules on the left labia. On palpation they are nontender and quite firm.

What diagnosis best fits this description of her examination?

A) Genital herpes B) Condylomata acuminata C) Syphilitic chancre D) Epidermoid cyst Ans: D Chapter: 14 Page and Header: 546, Table 14-1 Feedback: These cysts are small, firm, round cystic nodules in the labia that are nonpainful.

These do not represent a sexually transmitted infection, but rather a blocked sebaceous gland.

3. A 30-year-old paralegal analyst comes to your clinic, complaining of a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. She tried douching but it did not help. She has had no pain with urination or with sexual intercourse. She has noticed the smell increased after intercourse and during her period last week. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of one spontaneous vaginal delivery. She is married and has one child. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died from a heart disease. On examination she appears healthy and has unremarkable vital signs. On examination of the perineum there are no lesions noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5 and there is a fishy odor when potassium hydroxide (KOH) is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells).

What type of vaginitis best describes her findings?

A) Trichomonas vaginitis B) Candida vaginitis C) Bacterial vaginosis D) Atrophic vaginitis Ans: C Chapter: 14 Page and Header: 550, Table 14-6 Feedback: Bacterial vaginosis generally has a homogenous, grayish-white, thin discharge. The pH will be over 4.5 and the KOH wet prep releases a strong fishy odor, known as a “positive whiff test.” Any basic pH fluid (semen or blood) will cause the fish-like odor to occur, often after intercourse, as with this patient. The wet prep will show clue cells, which are epithelial cells with borders stippled by bacteria.

4. A 48-year-old high school librarian comes to your clinic, complaining of 1 week of heavy discharge causing severe itching. She is not presently sexually active and has had no burning with urination. The symptoms started several days after her last period. She just finished a course of antibiotics for a sinus infection. Her past medical history consists of type 2 diabetes and high blood pressure. She is widowed and has three children. She denies tobacco, alcohol, or drug use.

Her mother has high blood pressure and her father died of diabetes complications. On examination you see a healthy-appearing woman. Her blood pressure is 130/80 and her pulse is 70. Her head, eyes, ears, nose, throat, cardiac, lung, and abdominal examinations are unremarkable. Palpation of the inguinal lymph nodes is unremarkable. On visualization of the vulva, a thick, white, curdy discharge is seen at the introitus. On speculum examination there is a copious amount of this discharge. The pH of the discharge is 4.1 and the KOH whiff test is negative, with no unusual smell. Wet prep shows budding hyphae.

What vaginitis does this patient most likely have?

A) Trichomonas vaginitis B) Candida vaginitis C) Bacterial vaginosis D) Atrophic vaginitis Ans: B Chapter: 14 Page and Header: 550, Table 14-6 Feedback: Candida is associated with a thick, white, curd-like discharge that causes severe pruritus. The pH will be normal (£4.5) and the KOH whiff test will be normal. The wet prep often shows yeast spores and budding hyphae. Candida is very common in diabetics and after recent use of antibiotics. It is not thought to be sexually transmitted.

5. A 55-year-old married homemaker comes to your clinic, complaining of 6 months of vaginal itching and discomfort with intercourse. She has not had a discharge and has had no pain with urination. She has not had a period in over 2 years. She has no other symptoms. Her past medical history consists of removal of her gallbladder. She denies use of tobacco, alcohol, and illegal drugs. Her mother has breast cancer, and her father has coronary artery disease, high blood pressure, and Alzheimer's disease. On examination she appears healthy and has unremarkable vital signs. There is no lymphadenopathy with palpation of the inguinal nodes. Visualization of the vulva shows dry skin but no lesions or masses. The labia are somewhat smaller than usual.

Speculum examination reveals scant discharge, and the vaginal walls are red, dry, and bleed easily. Bimanual examination is unremarkable. The KOH whiff test produces no unusual odor and there are no clue cells on the wet prep.

What form of vaginitis is this patient most likely to have?

A) Trichomonas vaginitis B) Candida vaginitis C) Bacterial vaginosis

D) Atrophic vaginitis Ans: D Chapter: 14 Page and Header: 524, The Health History Feedback: The itching and pain with intercourse in atrophic vaginitis are due to the decreased amount of estrogen after menopause. There is generally scant discharge and the wet prep and KOH whiff test are unremarkable. Use of vaginal lubricants or hormonal replacement in selected patients often corrects the problem.

6. A 28-year-old married clothing sales clerk comes to your clinic for her annual examination.

She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal deliveries. Her past six Pap smears have all been normal. She is married and has two children. Her mother is in good health and her father has high blood pressure. On examination you see a young woman appearing healthy and relaxed. Her vital signs are unremarkable and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness and both ovaries are palpated and nontender.

What is the most likely diagnosis for the abnormality of her cervix?

A) Carcinoma of the cervix B) Mucopurulent cervicitis C) Cervical polyp D) Retention cyst Ans: C Chapter: 14 Page and Header: 548, Table 14-3 Feedback: Cervical polyps are polyps of endometrial cells arising from either the uterus or the cervix. They are benign and usually painless but can bleed during intercourse.

7. An 18-year-old college freshman comes to your clinic, complaining of severe left-sided lower abdominal pain and a foul yellow discharge. The pain began last night while she was having intercourse with her boyfriend. Afterward the pain became more severe and the discharge started.

By this morning she had a fever of 101 degrees and walking was making the pain worse. Only lying very still makes the pain better. She has tried ibuprofen and acetaminophen without any improvement. She denies any nausea, vomiting, diarrhea, or constipation. Her past medical history is unremarkable. She has had two past sexual partners. She uses the birth control patch instead of condoms. She smokes a half pack of cigarettes a day and drinks four to five beers per

weekend night. She denies any illegal drug use. Her parents are both healthy. On examination you find a young woman who appears ill. Her temperature is 102 degrees and her pulse is elevated at 110. She is tender in the left lower quadrant but has no guarding or rebound.

Speculum examination reveals yellow purulent drainage from the os. On palpation there is cervical motion tenderness and the left adnexa is swollen and tender. A urine analysis is unremarkable and the urine pregnancy test is pending.

What is the best choice of diagnosis for this adnexal swelling?

A) Ovarian cyst B) Tubal pregnancy C) Pelvic inflammatory disease Ans: C Chapter: 14 Page and Header: 533, Techniques of Examination Feedback: PID is common in young sexually active woman and is usually caused by bacteria that have been sexually transmitted. It is often associated with fever, pelvic pain, and a purulent cervical discharge. On examination there is often cervical motion tenderness and adnexal swelling and pain. A purulent discharge is often seen in the cervical os. Causes of cervical infection are gonorrhea, Chlamydia, and sometimes herpes. This woman should be made aware that barrier methods of contraception may prevent transmission of these diseases, whereas the contraceptive patch or pill will not. It would be prudent to consider further history and screening for HIV in this patient.

8. A 34-year-old married daycare worker comes to your office, complaining of severe pelvic pain for the last 6 hours. She states that the pain was at first cramp-like but is now sharp. Nothing makes the pain better or worse. She has had no vaginal bleeding or discharge. She has had no pain with urination. She has had some nausea for the last few days but denies vomiting, constipation, or diarrhea. She states she feels so bad that when she stands up she has fainted. Her past medical history consists of two prior cesarean sections and an appendectomy. She is married and has two children. She denies any tobacco, alcohol, or drug use. Her parents are both healthy.

On examination you find a pale young woman who is obviously in a great deal of pain. She is lying on her right side with her eyes closed. Her blood pressure is 90/60 and her pulse is 110. She is afebrile. She has bowel sounds and her abdomen is soft. The speculum examination reveals a bluish cervix but no blood or purulent discharge at the os. There is a mild amount of tenderness with palpation of the cervix. The uterus is nongravid but the right adnexal area is swollen and very tender. Urine analysis is normal and the urine pregnancy test is pending.

What type of adnexal disorder is causing her pain?

A) Ovarian cysts B) Tubal pregnancy C) Pelvic inflammatory disease Ans: B Chapter: 14

Page and Header: 553, Table 14-9 Feedback: Tubal pregnancies start to cause pain as the fetus grows too large to be contained in the tube. Eventually the tube begins to rupture and bleeding ensues, leading to hypotension, tachycardia, and syncope. On visualization of the cervix, the purple to bluish color of pregnancy may be seen.

9. A 23-year-old waitress comes to your clinic complaining of severe pelvic pain radiating to her right side. The pain began yesterday and is getting much worse. She has had no burning with urination and denies any recent sexual activity. She has no nausea, vomiting, constipation, diarrhea, fever, or vaginal discharge. Her last period was 3 to 4 weeks ago. Her past medical history consists of severe acne, depression, and mild obesity. She has had no surgeries. She broke up with her boyfriend 6 months ago and denies dating anyone else. She smokes one pack of cigarettes a day, drinks three to four beers two to three times a week, and denies any illegal drug use. Her mother is diabetic and her father has coronary artery disease. On examination you see a mildly obese female in moderate distress. Her blood pressure is 130/80 and her pulse is 90. She is afebrile. On auscultation she has active bowel sounds. She has no rebound or guarding in any abdominal quadrant. Speculum examination shows no lesions on the cervix and no discharge or bleeding from the os. During the bimanual examination she has no cervical motion tenderness, but her right adnexal area is swollen and tender. A urine analysis is normal and the urine pregnancy test is pending.

What disorder of the adnexa is most likely the diagnosis?

A) Ovarian cyst B) Tubal pregnancy C) Pelvic inflammatory disease Ans: A Chapter: 14 Page and Header: 553, Table 14-9 Feedback: Ovarian cysts often occur just before the onset of menses. They are also common in a disease known as polycystic ovarian syndrome. Other symptoms of this disorder are acne, hirsutism (increased hair growth), irregular periods, obesity. This disorder runs in families and later manifestations include diabetes, high blood pressure, and coronary artery disease. Single cysts on the right side can mimic the symptoms of appendicitis.

10. A 24-year-old travel agent comes to your clinic, complaining of pain and swelling in her vulvar area. She states that 2 days earlier she could feel a small tender spot on the left side of her vagina but now it is larger and extremely tender. Her last period was 1 year ago, and she is sexually active. She uses the Depo-Provera shot for contraception. She denies any nausea, vomiting, constipation, diarrhea, pain with urination, or fever. Her past medical history is significant for ankle surgery. Her mother is healthy, and her father has type 2 diabetes. On

examination she appears her stated age and is standing up. She states she cannot sit down without excruciating pain. Her blood pressure, temperature, and pulse are unremarkable. On visualization of her perineum, a large, red, tense swelling is seen to the left of her introitus.

Palpation of the mass causes a great deal of pain.

What disorder of the vulva is most likely causing her problems?

A) Bartholin's gland infection B) Vulvar carcinoma C) Secondary syphilis D) Condylomata acuminata Ans: A Chapter: 14 Page and Header: 547, Table 14-2 Feedback: Bartholin's gland infections cause a red-hot tender abscess at the duct opening to the Bartholin's glands. Gonococci, Chlamydia, and other organisms often cause them. Size is variable; if chronic, the infection can present as a nontender cyst.

11. Which of the following represents metrorrhagia?

A) Fewer than 21 days between menses B) Excessive flow C) Infrequent bleeding D) Bleeding between periods Ans: D Chapter: 14 Page and Header: 524, The Health History Feedback: Metrorrhagia is bleeding between periods. Menorrhagia is excessive bleeding with menses, while oligomenorrhea is infrequent menses. Polymenorrhea is menstruation with fewer than 21 days between periods.

12. Jean has just given birth 6 months ago and is breast-feeding her child. She has not had a period since giving birth. What does this most likely represent?

A) Primary amenorrhea B) Secondary amenorrhea C) Oligomenorrhea D) Dysmenorrhea Ans: B Chapter: 14 Page and Header: 524, The Health History

Feedback: Periods will normally stop after menarche for several reasons, including pregnancy, lactation, and menopause. Failure to start periods usually indicates an endocrine problem and is referred to as primary amenorrhea. Oligomenorrhea represents infrequent menses and dysmenorrhea is pain with menstruation.

13. Mrs. Jaeger is a 67–year-old who went through menopause at age 55. She has now had some vaginal bleeding. Which of the following should be considered?

A) Endometrial cancer B) Hormone replacement therapy C) Uterine or cervical polyps D) All of the above Ans: D Chapter: 14 Page and Header: 524, The Health History Feedback: Bleeding after menopause can have serious as well as benign causes. It is important to consider endometrial cancer as a cause of postmenopausal bleeding.

14. Abby is a newly married woman who is unable to have intercourse because of vaginismus.

Which of the following is true?

A) This is most likely due to lack of lubrication.

B) This is most likely due to atrophic vaginitis.

C) This is most likely due to pressure on an ovary.

D) Psychosocial reasons may cause this condition.

Ans: D Chapter: 14 Page and Header: 524, The Health History Feedback: Vaginismus is an involuntary contraction of the muscles around the vaginal opening.

While all of the above may contribute to vaginismus, the psychosocial history must be obtained and frequently is helpful in finding the underlying cause.

15. Which of the following is true of human papilloma virus (HPV) infection?

A) Pap smear is a relatively ineffective screening method.

B) It commonly resolves spontaneously in 1–2 years.

C) It is the second most common STI in the United States.

D) HPV infections cause a small but important number of cervical cancers.

Ans: B Chapter: 14 Page and Header: 528, Health Promotion and Counseling Feedback: HPV is the most common STI in the United States and is by far the most common cause of cervical cancers. The sensitivity of the liquid-based cytology is between 61% and 95% and specificity is from 78% to 82%. While HPV affects almost 50% of the population at some point, many of these infections resolve spontaneously.

16. Which of the following is true of the HPV vaccine?

A) Ideally it should be administered within 3 years of first intercourse.

B) It covers against almost every HPV type.

C) It can be used as adjuvant therapy in cervical cancer.

D) It can protect against anogenital lesions.

Ans: D Chapter: 14 Page and Header: 528, Health Promotion and Counseling Feedback: The HPV vaccine confers the greatest protection if given before exposure to the HPV. Currently, HPV types 6, 11, 16, and 18 are targeted because these are among the most common types causing cervical cancer. There are many other types, some of which are associated with cervical cancer. It is not recommended for treatment of preexisting cervical cancer but is protective against anogenital lesions.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 15: The Anus, Rectum, and Prostate

Multiple Choice

1. A 36-year-old married bank teller comes to your office, complaining of pain with defecation and occasional blood on the toilet paper. She states that last week she had food poisoning with nausea, vomiting, and diarrhea. She had runny stools but no black or bloody stools. Ever since

her illness, she has continued to have severe pain with bowel movements. She now tries to put off defecation as long as possible. Although she is having constipation, she denies any further diarrhea or leakage of stool. She has a past medical history of hypothyroidism and two spontaneous vaginal deliveries. She has had no other chronic illnesses or surgeries. She does not smoke and rarely drinks. She has two children. There is no family history of breast or colon cancer. She has had no weight gain, weight loss, fever, or night sweats. On examination she is afebrile, with a blood pressure of 115/70 and a pulse of 80. On abdominal examination she has active bowel sounds, is nontender in all quadrants, and has no hepatosplenomegaly. Inspection of the anus reveals inflammation on the posterior side with erythema. Digital rectal examination is painful for the patient, but no abnormalities are palpated. Anoscopic examination reveals no inflammation or bleeding. What is the anal disorder that best describes her symptoms?

A) Anorectal fistula B) External hemorrhoids C) Anal fissure D) Anorectal cancer Ans: C Chapter: 15 Page and Header: 561, Techniques of Examination Feedback: Anal fissures often occur after severe diarrhea or constipation. They cause bright blood on the toilet paper and are extremely painful during defecation. A small ulceration or fissure is observed proximal to the anus.

2. A 42-year-old house painter comes to your clinic, complaining of pain with defecation and profuse bleeding in the toilet after a bowel movement. He was in his usual state of health until 2 weeks ago, when he was injured in a car accident. After the accident he began taking prescription narcotics for the pain in his shoulder. Since then he has had very few bowel movements. His stool is hard and pebble-like. He states he has always been “regular” in the past, with easy bowel movements. His diet has not changed but he states that he is exercising less since the accident.

His past medical history includes hypertension and he is on a low-dose diuretic. He has had no other chronic illnesses or surgeries. He has a family history of hypertension, coronary heart disease, and diabetes but no cancer. He is divorced and has three children. He smokes two packs of cigarettes per day and quit drinking more than 10 years ago. He has had no recent weight loss, weight gain, fever, or night sweats. On examination he appears muscular and healthy; he is afebrile. His blood pressure is 135/90 with a pulse of 80. His cardiac, lung, and abdominal examinations are normal. He is wearing a sling on his left arm. On observation of his anus you find a swollen bluish ovoid mass that appears to contain a blood clot. Digital rectal examination is extremely painful for the patient. No other mass is palpated within the anus or rectum.

What disorder of the anus is this patient likely to have?

A) Anal fissure B) External hemorrhoid C) Anorectal cancer D) Internal hemorrhoid

Ans: B Chapter: 15 Page and Header: 568, Table 15–2 Feedback: A swollen, bluish ovoid mass is most likely a thrombosed external hemorrhoid. These can cause brisk bleeding with defecation. Hemorrhoids are often caused by low-fiber diets, dehydration, lack of exercise, and anything that causes constipation leading to increased straining with defecation. Narcotics can cause severe constipation, leading to this disorder.

3. A 75-year-old retired construction worker comes to your clinic, complaining of bright red blood in the toilet for the last several months. He has no pain with defecation but has occasional constipation. He states he eats a healthy diet with fruits and vegetables and walks 2 miles a day.

He has had a 10-pound weight loss over the last 3 months. He denies fever or night sweats. His medical history includes high blood pressure, coronary artery disease, and arthritis. He has also had an appendectomy. He smoked for 40 years, two packs a day, but quit 15 years ago. He used to drink alcohol but doesn't now. His father died in his 60s of a heart attack and his mother had breast cancer in her 70s. On examination he appears his stated age and sits comfortably on the examining table. His blood pressure is 150/85 and his pulse is 88. He is afebrile. His cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no erythema, masses, or inflammation. Digital rectal examination elicits an irregular, firm mass on the posterior side of the rectum. After you remove your finger you notice frank blood on your glove.

What anal or rectal disorder is this patient most likely to have?

A) Anal fissure B) Internal hemorrhoid C) Prostate cancer D) Anorectal cancer Ans: D Chapter: 15 Page and Header: 568, Table 15-2 Feedback: This patient has the common symptom of bright red blood in the toilet over time. He also has had weight loss and has an irregular hard mass in the rectum. It is not uncommon for these masses to be friable (bleed easily), even with gentle manipulation.

4. A 60-year-old coach comes to your clinic, complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats.

His medical history includes type 2 diabetes and high blood pressure treated with medications.

He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s and his father is currently in his 80s with high blood pressure and arthritis. On examination you see a mildly obese male who is alert and cooperative. His blood pressure is 130/70 with a heart rate of 80. He is afebrile and his cardiac, lung, and abdominal examinations are normal. On visualization of the anus you see no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate.

No discrete masses are felt. There is no blood on the glove or on guaiac testing. An analysis of the urine shows no red blood cells, white blood cells, or bacteria.

What disorder of the anus, rectum, or prostate is this most likely to be?

A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Anorectal cancer Ans: A Chapter: 15 Page and Header: 570, Table 15–3 Feedback: BPH becomes more prevalent during the fifth decade and is often associated with the urinary symptoms of hesitancy in starting a stream, decreased strength of stream, nocturia, and leaking of urine. On examination an enlarged, symmetric, firm prostate is palpated. The anterior lobe cannot be felt. These patients may also develop UTIs secondary to the obstruction.

5. A 24-year-old graduate student comes to your clinic, complaining of burning during urination and increased urinary frequency. He has had a low-grade fever (100.5 degrees) and does not feel very well. He is very worried about sexually transmitted diseases because he had a drunken encounter 2 weeks ago and did not use a condom. He has had no recent weight loss, weight gain, or night sweats. His past medical history includes knee surgery in high school and genital warts in college. He does not smoke but drinks six beers every Friday and Saturday night. He denies using any IV drugs but has tried marijuana in the past. His father has high cholesterol but his mother is healthy. On examination he appears tired. His temperature is 99.5 degrees and his blood pressure is 110/70. His abdominal examination is normal. Visualization of the anus shows no masses, inflammation, or fissures. Digital rectal examination reveals a warm, boggy, tender prostate. No discrete masses are felt and there is no blood on the glove. The scrotum and penis appear normal. Urinalysis shows moderate amounts of white blood cells and bacteria.

What disorder of the anus, prostate, or rectum best describes this situation?

A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Epididymitis Ans: B Chapter: 15 Page and Header: 570, Table 15–3

Feedback: Prostatitis generally causes increased frequency of urination, pain with urination, and lower back pain. On digital rectal examination a warm, tender, boggy prostate will be palpated.

In young men the etiology is often a sexually transmitted disease such as chlamydia or gonorrhea. This man's substance abuse problem should also be discussed with him, and you should consider further questions and screening for HIV.

6. A 45-year-old African-American minister comes to your clinic for a general physical examination. He has not been feeling very well for about 3 months, including night sweats and a chronic low-grade fever of 100 to 101 degrees. He denies any upper respiratory symptoms, chest pain, nausea, constipation, diarrhea, blood in his stool, or urinary tract symptoms. He has had some lower back pain. He has a past history of difficult-to-control high blood pressure and high cholesterol. He has had no surgeries in the past. His mother has diabetes and high blood pressure.

He knows very little about his father because his parents divorced when he was young. He knows his father died in his 50s, but he is unsure of the exact cause. The patient denies smoking, drinking, or drug use. He is married and has three children. On examination he appears his stated age and is generally fit. His temperature is 99.9 degrees and his blood pressure is 160/90. His head, ears, nose, throat, and neck examinations are normal. His cardiac, lung, and abdominal examinations are also normal. On visualization of the anus there is no inflammation, masses, or fissures. Digital rectal examination elicits an irregular, asymmetric, hard nodule on the otherwise normal posterior surface of the prostate. Examination of the scrotum and penis are normal.

Laboratory results are pending.

What disorder of the anus, rectum, or prostate is mostly likely in this case?

A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Anorectal cancer Ans: C Chapter: 15 Page and Header: 570, Table 15–3 Feedback: Prostate cancer often presents with few symptoms and can sometimes be found on routine digital rectal examination. It is more common at a younger age in African-American men, and PSA screening, if indicated, begins at age 40, ten years earlier than in other races. Palpation on digital rectal examination can reveal a hard, irregular, asymmetric nodule, but can also reveal an asymmetry in texture between the two lobes.

7. A 26-year-old woman comes to your clinic, complaining of leakage of stool despite generally normal, pain-free bowel movements. She denies any blood in her stool or on the toilet paper. She has had no recent episodes of diarrhea. Her past medical history includes a spontaneous vaginal delivery 3 months ago. She had a fourth-degree tear of the perineal area (from the vagina through

the rectum) that was surgically repaired after delivery. A few days later the patient developed an abscess in the anal area that had to be incised and drained. She denies using any tobacco, alcohol, or illegal drugs. Her mother and father are both in good health. She denies any weight gain, weight loss, fever, or night sweats. She is still breast-feeding without any problems. On examination you visualize a small opening anterior to the anus with some surrounding erythema.

There is not a mass or other inflammation on inspection. Digital rectal examination reveals smooth rectal walls with no blood. She has no pain during the rectal examination. Bimanual vaginal examination is also normal.

What anal or rectal disorder is the most likely cause of her symptom?

A) Anal fissure B) External hemorrhoids C) Internal hemorrhoids D) Anorectal fistula Ans: D Chapter: 15 Page and Header: 568, Table 15–2 Feedback: Anorectal fistula can commonly cause a leakage of stool, even when the patient is not having a bowel movement. They are common after infections, especially after trauma to the anal musculature (such as in a fourth-degree perineal tear). With more chronic gastrointestinal symptoms, this finding may lead you to suspect Crohn's disease.

8. A 22-year-old nurse comes to your clinic, complaining of severe constipation and pain during defecation. She has also seen blood on the toilet paper. She states that she eats a healthy diet and does some light exercising. She is currently at the beginning of her third trimester of an unremarkable pregnancy. Her past medical history is unremarkable. Her mother has high cholesterol but her father is in good health. She does not smoke, drink alcohol, or use illegal drugs. She is married and expecting her first child. On examination she appears healthy and is afebrile, with a blood pressure of 110/60. Her abdominal examination reveals a gravid uterus but is otherwise unremarkable. On visualization of the anus there is a slight red, moist-appearing protrusion from the anus. As you have her bear down, the protrusion grows larger. On digital rectal examination you can feel an enlarged tender area on the posterior side. There is some blood on the glove after the examination.

What disorder of the anus or rectum best fits this presentation?

A) Anal fissure B) External hemorrhoids C) Internal hemorrhoids D) Anorectal fistula Ans: C Chapter: 15 Page and Header: 568, Table 15–2 Feedback: Internal hemorrhoids are common during pregnancy. A red, swollen, moist mass is

seen prolapsing through the anus, which worsens with bearing down. These are not usually palpable on rectal examination if not prolapsed.

9. A 55-year-old retired property manager comes to your clinic, concerned that she may have a tumor in her rectum. When asked why, she states that after straining at a bowel movement she felt a mass around her rectum. She denies any blood in her stool, black stools, or pain with defecation. She admits to having had chronic constipation for 30 years. She often uses laxatives to be able to have a bowel movement. She denies any recent weight gain, weight loss, fever, or night sweats. Her past medical history consists of hypothyroidism, and she has had two spontaneous vaginal deliveries. Her mother died recently of colon cancer and her father has high blood pressure but is otherwise healthy. She denies any smoking and only occasionally drinks alcohol. On examination she seems nervous. Her blood pressure is 140/90 and her pulse is 100.

Her cardiac, lung, and abdominal examinations are normal. On visualization of her anus, no inflammation, masses, or fissures are noted. When she is asked to bear down, you see a rosette of red mucosa prolapsing from the anus. On digital rectal examination there are no masses and no blood is found on the glove.

What disorder of the anus or rectum is this likely to be?

A) Prolapse of the rectum B) Internal hemorrhoids C) Anorectal cancer D) Prostate cancer Ans: A Chapter: 15 Page and Header: 568, Table 15–2 Feedback: Unless someone is bearing down, such as during a bowel movement, the red mucosa is not seen. This is common when there is heavy straining during a bowel movement. This finding in a young child or infant may lead you to suspect cystic fibrosis.

10. A 50-year-old truck driver comes to your clinic for a work physical. He has had no upper respiratory, cardiac, pulmonary, gastrointestinal, urinary, or musculoskeletal system complaints.

His past medical history is significant for mild arthritis and prior knee surgery in college. He is married and just changed jobs, working for a different trucking company. He smokes one pack of cigarettes a day, drinks less than six beers a week, and denies using any illegal drugs. His mother has high blood pressure and arthritis and his father died of lung cancer in his 60s. On examination, his blood pressure is 130/80 and his pulse is 80. His cardiac, lung, and abdominal examinations are normal. He has no inguinal hernia, but on his digital rectal examination you palpate a soft, smooth, nontender pedunculated mass on the posterior wall of the rectum.

What anal, rectal, or prostate disorder best fits his presentation?

A) Internal hemorrhoid

B) Prostate cancer C) Anorectal cancer D) Rectal polyp Ans: D Chapter: 15 Page and Header: 568, Table 15–2 Feedback: Polyps are generally symptom-free and can be found on routine rectal examinations.

Proctoscopy with biopsy is necessary to see if the polyp has any potential to become cancerous.

Anyone with a rectal polyp needs a colonoscopy.

11. Which is true of the pectinate or dentate line?

A) It is a palpable landmark.

B) It demarcates the areas supplied by the central nervous system from the peripheral nervous system.

C) It is the border between the anal canal and the rectum.

D) It is not visible on proctoscopic examination.

Ans: C Chapter: 15 Page and Header: 555, Anatomy and Physiology Feedback: The pectinate or dentate line marks the division between the anal canal and rectum.

It is not palpable but is visible on proctoscopy. It also marks the areas supplied by the visceral and peripheral nervous systems.

12. Which is a sign of benign prostatic hyperplasia?

A) Weight loss B) Bone pain C) Fever D) Nocturia Ans: D Chapter: 15 Page and Header: 557, The Health History Feedback: Benign prostatic hyperplasia (BPH) is usually not associated with systemic symptoms such as weight loss or fever. Bone pain is associated with prostate cancer, which often metastasizes to the lower axial skeleton. Nocturia, sensation of incomplete voiding, weak stream, and difficulty initiating urination are also common symptoms of prostate cancer.

13. Which is true of prostate cancer?

A) It is commonly lethal.

B) It is one of the less common forms of cancer.

C) Family history does not appear to be a risk factor.

D) Ethnicity is a risk factor.

Ans: D Chapter: 15 Page and Header: 558, Health Promotion and Counseling Feedback: Although prostate cancer is the most commonly diagnosed cancer in men, biologic risk and mortality are only 3%. Lung and colon cancers are more common causes of mortality.

Genetics appear to account for 42% of cases in one study. The rate of prostate cancer is almost double in African American men, which is one of the reasons to begin screening at 40 years of age rather than the standard recommendation of 50.

14. Important techniques in performing the rectal examination include which of the following?

A) Lubrication B) Waiting for the sphincter to relax C) Explaining what the patient should expect with each step before it occurs D) All of the above Ans: D Chapter: 15 Page and Header: 561, Techniques of Examination Feedback: Lubricating the entire finger (yet removing excess lubricant), being patient while the anal sphincter relaxes, and preparing the patient for each step are key parts of a good rectal examination. The examination itself, while it may be awkward for a patient, should never cause pain in a normal person.

15. Dawn is a 55-year-old woman who comes in today for her yearly wellness examination.

You carefully perform the rectal examination in the lithotomy position and feel a mass against the bowel wall which is firm and immobile. Which of the following is most likely?

A) Colon cancer B) Hemorrhoid C) Anal fissure D) Valve of Houston Ans: A

Chapter: 15 Page and Header: 561, Techniques of Examination Feedback: This examination should make you think of colon cancer because the mass is firm, nonmobile, and nontender. Hemorrhoids are not firm and are frequently visible externally, although some may be internal as well. An anal fissure would be a palpable linear lesion in the anal canal that may be tender. Valves of Houston are sometimes palpable but are not firm.

16. Mr. Jackson is a 50-year-old African-American who has had discomfort between his scrotum and anus. He also has had some fevers and dysuria. Your rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is your most likely diagnosis?

A) Prostate cancer B) Colon cancer C) Prostatitis D) Colonic polyp Ans: C Chapter: 15 Page and Header: 570, Table 15–3 Feedback: The above examination, associated with a history of dysuria, frequency, and incomplete voiding, should lead you to suspect acute prostatitis. Prostate cancer, colon cancer, and polyps should not ordinarily cause systemic symptoms such as fever.

17. An elderly woman with dementia is brought in by her daughter for a “rectal mass.” On examination you notice a moist pink mass protruding from the anus, which is nontender. It is soft and does not have any associated bleeding. Which of the following is most likely?

A) Rectal prolapse B) External hemorrhoid C) Perianal fistula D) Prolapsed internal hemorrhoid Ans: A Chapter: 15 Page and Header: 568, Table 15–2 Feedback: Rectal prolapse is occasionally seen in chronic constipation. It represents actual rectal tissue which has protruded through the anus. In young children it is associated with cystic fibrosis as well as other conditions. An external hemorrhoid or a prolapsed internal hemorrhoid is not moist and does not have the same mucosa. A perianal fistula represents a connection from the bowel to the exterior apart from the anus and can be associated with inflammatory bowel disease, especially Crohn's disease.

18. A 56-year-old homosexual man presents with itching, anorectal pain, and tenesmus of 1 week's duration. Rectal examination reveals generalized tenderness without frank prostate abnormalities. Which of the following is most likely?

A) Acute prostatitis B) External hemorrhoid C) Proctitis D) Colon cancer Ans: C Chapter: 15 Page and Header: 557, The Health History Feedback: The combination of itching, anorectal pain, and tenesmus in a homosexual man should make one consider proctitis. This may be caused by a sexually transmitted infection such as gonorrhea, chlamydia, or lymphogranuloma venereum. A careful history should be taken, and counseling regarding protection from these diseases should be offered. While pain and itching are associated with hemorrhoids, the internal tenderness on examination makes this less likely than proctitis in this patient. Acute prostatitis does not usually cause itching and is usually associated with examination findings. Most colon cancers do not cause any symptoms, which is why screening for asymptomatic disease is so important.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 16: The Musculoskeletal System

Multiple Choice

1. You are assessing a patient with joint pain and are trying to decide whether it is inflammatory or noninflammatory in nature. Which one of the following symptoms is consistent with an inflammatory process?

A) Tenderness B) Cool temperature C) Ecchymosis D) Nodules

Ans: A Chapter: 16 Page and Header: 575, The Health History Feedback: Tenderness implies an inflammatory process along with increased temperature and tenderness.

2. You are assessing a patient with diffuse joint pains and want to make sure that only the joints are the problem, and that the pain is not related to other diseases. Which of the following is a systemic cause of joint pain?

A) Gout B) Osteoarthritis C) Lupus D) Spondylosis Ans: C Chapter: 16 Page and Header: 578, Joint Pain and Systemic Disorders Feedback: Lupus is a systemic disease, one symptom of which may be joint pain. It is important to consider the presence of a systemic illness when a patient presents with arthritis.

3. A 19-year-old college sophomore comes to the clinic for evaluation of joint pains. The student has been back from spring break for 2 weeks; during her holiday, she went camping. She notes that she had a red spot, shaped like a target, but then it started spreading, and then the joint pains started. She used insect repellant but was in an area known to have ticks. She has never been sick and takes no medications routinely; she has never been sexually active. What is the most likely cause of her joint pain?

A) Trauma B) Gonococcal arthritis C) Psoriatic arthritis D) Lyme disease Ans: D Chapter: 16 Page and Header: 578, Joint Pain and Systemic Disorders Feedback: Lyme disease is characterized by a target-shaped red spot at the site of the bite, which disappears, then reappears and starts spreading (erythema migrans). Lyme disease can also result in joint pain as well as cardiac and neurologic manifestations.

4. An 85-year-old retired housewife comes with her daughter to establish care. Her daughter is concerned because her mother has started to fall more. As part of her physical examination, you ask her to walk across the examination room. Which of the following is not part of the stance phase of gait?

A) Foot arched B) Heel strike C) Mid-stance D) Push-off Ans: A Chapter: 16 Page and Header: 587, Techniques of Examination Feedback: The foot when it is flat is part of the stance phase of gait, not the foot when it is arched.

5. A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a set of boxes that were heavier than usual. He also states that he has numbness and tingling in the left leg. He wants to know if he needs to be off of work. What test should you perform to assess for a herniated disc?

A) Leg-length test B) Straight-leg raise C) Tinel's test D) Phalen's test Ans: B Chapter: 16 Page and Header: 642, Table 16-1 Feedback: The straight-leg raise involves having the patient lie supine with the examiner raising the leg. If the patient experiences a sharp pain radiating from the back down the leg in an L5 or S1 distribution, that suggests the presence of a herniated disc.

6. A 33-year-old construction worker comes for evaluation and treatment of acute onset of low back pain. He notes that the pain is an aching located in the lumbosacral area. It has been present intermittently for several years; there is no known trauma or injury. He points to the left lower back. The pain does not radiate and there is no numbness or tingling in the legs or incontinence.

He was moving furniture for a friend over the weekend. On physical examination, you note muscle spasm, with normal deep tendon reflexes and muscle strength. What is the most likely cause of this patient's low back pain?

A) Herniated disc

B) Compression fracture C) Mechanical low back pain D) Ankylosing spondylitis Ans: C Chapter: 16 Page and Header: 642, Table 16-1, Low Back Pain Feedback: The case is an example of mechanical low back pain; in a large percentage of cases there is no known underlying cause. The pain is often precipitated by moving, lifting, or twisting motions and relieved by rest.

7. A 50-year-old realtor comes to your office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she didn't think that she needed to go to the emergency room at that time. Now, she has severe pain and stiffness in her neck. On physical examination, you note pain and spasm over the paraspinous muscles on the left side of the neck, and pain when you make the patient do active range of motion of the cervical spine. What is the most likely cause of this neck pain?

A) Simple stiff neck B) Aching neck C) Cervical sprain D) Cervical herniated disc Ans: C Chapter: 16 Page and Header: 643, Table 16-2 Feedback: The patient most likely has an acute whiplash injury secondary to the collision. The features of the physical examination, local tenderness and pain on movement, are consistent with cervical sprain.

8. A 28-year-old graduate student comes to your clinic for evaluation of pain “all over.” With further questioning, she is able to relate that the pain is worse in the neck, shoulders, hands, low back, and knees. She denies swelling in her joints; she states that the pain is worse in the morning; there is no limitation in her range of motion. On physical examination, she has several points on the muscles of the neck, shoulders, and back that are tender to palpation; muscle strength and range of motion are normal. Which of the following is likely the cause of her pain?

A) Rheumatoid arthritis B) Osteoarthritis C) Fibromyalgia D) Polymyalgia rheumatica

Ans: C Chapter: 16 Page and Header: 644, Table 16-3 Feedback: The patient has pain in specific trigger point areas on the muscles, with normal strength and range of motion. This is an indication for fibromyalgia.

9. A 68-year-old retired banker comes to your clinic for evaluation of left shoulder pain. He swims for 30 minutes daily, early in the morning. He notes a sharp, catching pain and a sensation of something grating when he tries overhead movements of his arm. On physical examination, you note tenderness just below the tip of the acromion in the area of the tendon insertions. The drop arm test is negative, and there is no limitation with shoulder shrug. The patient is not holding his arm close to his side, and there is no tenderness to palpation in the bicipital groove when the arm is at the patient's side, flexed to 90 degrees, and then supinated against resistance.

Based on this description, what is the most likely cause of his shoulder pain?

A) Rotator cuff tendinitis B) Rotator cuff tear C) Calcific tendinitis D) Bicipital tendinitis Ans: A Chapter: 16 Page and Header: 646, Table 16-4 Feedback: Rotator cuff tendinitis is typically precipitated by repetitive motions, such as occurs with throwing or swimming. Crepitus/grating is noted in the shoulder with range of motion.

10. A high school soccer player “blew out his knee” when the opposing goalie's head and shoulder struck his flexed knee while the goalie was diving for the ball. All of the following structures were involved in some way in his injury, but which of the following is actually an extra-articular structure?

A) Synovium B) Joint capsule C) Juxta-articular bone D) Tendons Ans: D Chapter: 16 Page and Header: 572, Assessing the Musculoskeletal System Feedback: Extra-articular structures include the periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin. The articular structures include the joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments, and juxta-articular

bone.

11. Ray works a physical job and notes pain when he attempts to lift his arm over his head.

When you move the shoulder passively, he has full range of motion without pain and there is no gross swelling or tenderness. What type of joint disease does this most likely represent?

A) Articular B) Extra-articular C) Neither D) Both Ans: B Chapter: 16 Page and Header: 572, Assessing the Musculoskeletal System Feedback: This description fits extra-articular disease. Articular disease typically involves swelling and tenderness of the entire joint and limits both active and passive range of motion.

This is most likely extra-articular because it affects a certain portion of the range of motion, is not painful with passive range of motion, and is not associated with gross swelling or tenderness

12. Mark is a contractor who recently injured his back. He was told he had a “bulging disc” to account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the spine involve which type of joint?

A) Synovial B) Cartilaginous C) Fibrous D) Synostosis Ans: B Chapter: 16 Page and Header: 573, Assessing the Musculoskeletal System Feedback: The vertebral bodies of the spine are connected by cartilaginous joints involving the discs. The elbow would be an example of a synovial joint, and the sutures of the skull are an example of a fibrous joint.

13. Which of the following synovial joints would be an example of a condylar joint?

A) Hip B) Interphalangeal joints of the hand C) Temporomandibular joint

D) Intervertebral joint Ans: C Chapter: 16 Page and Header: 574, Structure of Synovial Joints Feedback: The TMJ is an example of a condylar joint because it involves the movement of two surfaces which are not dissociable. The hip would be an example of a spheroidal joint and the interphalangeal joints of the hand are hinge joints. The intervertebral joints are not synovial joints at all, but rather cartilaginous joints.

14. A 58-year-old man comes to your office complaining of bilateral back pain that now awakens him at night. This has been steadily increasing for the past 2 months. Which one of the following is the most reassuring in this patient with back pain?

A) Age over 50 B) Pain at night C) Pain lasting more than 1 month or not responding to therapy D) Pain that is bilateral Ans: D Chapter: 16 Page and Header: 575, The Health History Feedback: While bilateral pain can be associated with serious illness, it is not one of the “red flags” of back pain. Red flags should make one suspicious for serious underlying systemic disease such as cancer, infection, or others. This list includes: age over 50, history of cancer, unexplained weight loss, pain lasting more than 1 month or not responding to treatment, pain at night or increased by rest, history of intravenous drug use, or presence of infection. The presence of one of these with low back pain indicates a 10% probability of a serious systemic disease.

15. Marion presents to your office with back pain associated with constipation and urinary retention. Which of the following is most likely?

A) Sciatica B) Epidural abscess C) Cauda equina D) Idiopathic low back pain Ans: C Chapter: 16 Page and Header: 575, The Health History Feedback: The presence of bowel and bladder symptoms associated with back pain is worrisome

and should suggest impingement of nerve roots S2–S4. For this reason idiopathic low back pain is unlikely. Epidural abscess may present with midline pain which can be increased with percussion over the spinous processes. Sciatica is associated with pain which radiates into the buttocks and/or down the posterior leg in the S1 distribution.

16. Louise, a 60-year-old, complains of left knee pain associated with tenderness throughout, redness, and warmth over the joint. Which of the following is least helpful in determining if a joint problem is inflammatory?

A) Tenderness B) Pain C) Warmth D) Redness Ans: B Chapter: 16 Page and Header: 576, The Health History Feedback: Pain is present in both inflammatory and noninflammatory conditions. Warmth, redness, and tenderness to palpation should lead one to consider an inflammatory etiology for the pain.

17. Pain, swelling, loss of both active and passive motion, locking, and deformity would be consistent with which of the following?

A) Articular joint pain B) Bursitis C) Muscular injury D) Nerve damage Ans: A Chapter: 16 Page and Header: 576, The Health History Feedback: These features are consistent with articular joint pain, whereas the other problems are associated with extra-articular structures.

18. You are working in a college health clinic and seeing a young woman with a red, painful, swollen DIP joint on the left index finger. There are also a few papules, pustules, and vesicles on reddened bases, located on the distal extremities. This would be consistent with which of the following?

A) Lyme disease B) Systemic lupus erythematosus C) Hives (urticaria) D) Gonococcal arthritis Ans: D Chapter: 16 Page and Header: 578, The Health History Feedback: The presentation of a monoarthritis in this age group should lead one to think of gonococcal disease. Skin findings are often seen in conjunction with arthritis. Lyme disease is associated with an expanding erythematous patch. Lupus is associated with a “butterfly” rash on the cheeks, while serum sickness and drug reactions can be associated with hives.

19. An obese 55-year-old woman went through menarche at age 16 and menopause 2 years ago.

She is concerned because an aunt had severe osteoporosis. Which of the following is a risk factor for osteoporosis?

A) Obesity B) Late menopause C) Having an aunt with osteoporosis D) Delayed menarche Ans: D Chapter: 16 Page and Header: 581, Risk Factors for Osteoporosis Feedback: Obesity and late menopause are not associated with osteoporosis. Having a firstdegree relative with osteoporosis is a risk factor, but an aunt is a second-degree relative. Delayed menarche is the only choice which is a known risk factor for osteoporosis.

20. A 38-year-old woman comes to you and has multiple small joints involved with pain, swelling, and stiffness. Which of the following is the most likely explanation?

A) Rheumatoid arthritis B) Septic arthritis C) Gout D) Trauma Ans: A Chapter: 16 Page and Header: 583, Examination of Specific Joints Feedback: Rheumatoid arthritis is a systemic disease and accounts for multiple symmetrically involved joints. Septic arthritis is usually monoarticular, as are gout and trauma-related joint

pain.

21. Mrs. Fletcher comes to your office with unilateral pain during chewing, which is chronic.

She does not have facial tenderness or tenderness of the scalp. Which of the following is the most likely cause of her pain?

A) Trigeminal neuralgia B) Temporomandibular joint syndrome C) Temporal arteritis D) Tumor of the mandible Ans: B Chapter: 16 Page and Header: 587, Techniques of Examination Feedback: Temporomandibular joint syndrome is a very common cause of pain with chewing.

Ischemic pain with chewing, or jaw claudication, can occur with temporal arteritis, but the lack of tenderness of the scalp overlying the artery makes this less likely. Trigeminal neuralgia can be associated with extreme tenderness over the branches of the trigeminal nerve. While a tumor of the mandible is possible, is it much less likely than the other choices.

22. A man's wife is upset because when she hugs him with her hands on his left shoulder blade, “it feels creepy.” This came on gradually after a recent severe left-sided rotator cuff tear. How long does it usually take to develop muscular atrophy with increased prominence of the scapular spine following a rotator cuff tear?

A) 1 week B) 2–3 weeks C) 1 month D) 2–3 months Ans: B Chapter: 16 Page and Header: 591, Techniques of Examination Feedback: Prominence of the scapular spine occurs with generalized muscle wasting as well as with specific injuries such as a rotator cuff tear. It is easily palpable, even through indoor clothing, although the back should be exposed to make other important observations. Atrophy usually occurs several weeks following a rotator cuff tear.

23. Phil comes to your office with left “shoulder pain.” You find that the pain is markedly worse

when his left arm is drawn across his chest (adduction). Which of the following would you suspect?

A) Rotator cuff tear B) Subacromial bursitis C) Acromioclavicular joint involvement D) Adhesive capsulitis Ans: C Chapter: 16 Page and Header: 596, Maneuvers for Examining the Shoulder Feedback: Adduction of the patient's arm across his chest can cause pain if the acromioclavicular joint is involved. In adhesive capsulitis, this maneuver may not be possible due to limited range of motion. Subacromial bursitis would present with tenderness inferior to the acromion. Rotator cuff injury would ordinarily not be associated with pain during this maneuver.

24. Two weeks ago, Mary started a job which requires carrying 40-pound buckets. She presents with elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor. What condition does she have?

A) Medial epicondylitis (golfer's elbow) B) Olecranon bursitis C) Lateral epicondylitis (tennis elbow) D) Supracondylar fracture Ans: C Chapter: 16 Page and Header: 600, Techniques of Examination Feedback: Mary's injury probably occurred by lifting heavy buckets with her palms down (toward the bucket). This caused her chronic overuse injury at the lateral epicondyle. Medial epicondylitis has reproducible pain when palmar flexion against resistance is performed and also features tenderness over the involved epicondyle. Olecranon bursitis produces erythema and swelling over the olecranon process. A supracondylar fracture of the humerus is a major injury and would present more acutely.

25. A high school football player injured his wrist in a game. He is tender between the two tendons at the base of the thumb. Which of the following should be considered?

A) DeQuervain's tenosynovitis B) Scaphoid fracture C) Wrist sprain D) Rheumatoid arthritis

Ans: B Chapter: 16 Page and Header: 604, Techniques of Examination Feedback: The “anatomic snuffbox” is found between the extensor and abductor tendons at the base of the thumb. Tenderness should make one think of a scaphoid fracture. Not only is this the most common carpal bone injury, but the poor blood supply puts the bone at risk for avascular necrosis when injured. This fracture is commonly missed on x-ray, so this is an important physical finding to support further or repeated studies.

26. Mrs. Fletcher complains of numbness of her right hand. On examination, sensation of the volar aspect of the web of the thumb and index finger and the pulp of the middle finger are normal. The pulp of the index finger has decreased sensation. Which of the following is affected?

A) Median nerve B) Ulnar nerve C) Radial nerve Ans: A Chapter: 16 Page and Header: 607, Examination of Specific Joints Feedback: The pulp of the index finger is innervated by the median nerve. A decrease in sensation at this area would support a diagnosis of carpal tunnel syndrome. The pulp of the fifth finger is supplied by the ulnar nerve, and the dorsal web space of the thumb and index finger is supplied by the radial nerve.

27. A 50-year-old woman presents with “left hip pain” of several weeks duration. There is marked tenderness when you press over her proximal lateral thigh. What do you think she has?

A) Osteoarthritis B) Rheumatoid arthritis C) Sciatica D) Trochanteric bursitis Ans: D Chapter: 16 Page and Header: 617, Examination of Specific Joints Feedback: Bursitis is usually accompanied by tenderness on examination. This location is consistent with trochanteric bursitis. Osteoarthritis would generally not be tender and would more likely have decreased range of motion. Rheumatoid arthritis and sciatica would not likely be tender over this area.

28. Sarah presents with left lateral knee pain and has some locking in full extension. There is tenderness over the medial joint line. When the knee is extended with the foot externally rotated and some valgus stress is applied, a click is noted. What is the most likely diagnosis?

A) Torn anterior cruciate ligament B) Torn posterior cruciate ligament C) Torn medial meniscus D) Torn lateral meniscus Ans: C Chapter: 16 Page and Header: 632, Maneuvers for Examining the Knee Feedback: This maneuver is called the McMurray test. Along with the medial joint line tenderness, you should suspect a medial meniscus injury. Cruciate ligament tears should cause an anterior or posterior “drawer sign.” Although we can't rule out a lateral meniscus tear, the tenderness along the medial joint line makes this the more likely site of injury.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 17: The Nervous System

Multiple Choice

1. A 28-year-old book editor comes to your clinic, complaining of strange episodes. He states that about once a week for the last 3 months his left hand and arm will stiffen and then start jerking. He says that after a few seconds his whole left arm and then his left leg will also start to jerk. He denies any loss of consciousness or loss of bowel or bladder control. When the symptoms resolve, his arm and leg feel tired but otherwise he feels fine. His past medical history is significant for a cyst in his brain that was removed 6 months ago. He is married and has two children. His parents are both healthy. On examination you see a scar over the right side of his head but otherwise his neurologic examination is unremarkable.

What type of seizure disorder is he most likely to have?

A) Generalized tonic–clonic seizure B) Generalized absence seizure C) Simple partial seizure (Jacksonian) D) Complex partial seizure Ans: C Chapter: 17 Page and Header: 718, Table 17-3 Feedback: Simple partial seizures start with a unilateral symptom, involve no loss of consciousness, and have a normal postictal state. In a Jacksonian seizure the symptoms start with one body part and “march” along the same side of the body.

2. A 7-year-old child is brought to your clinic by her mother. The mother states that her daughter is doing poorly in school because she has some kind of “ADD” (attention deficit disorder). You ask the mother what makes her think the child has ADD. The mother tells you that both at home and at school her daughter will just zone out for several seconds and lick her lips. She states it happens at least four to six times an hour. She says this has been happening for about a year.

After several seconds of lip-licking her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The patient's parents are both healthy and no other family members have had these symptoms.

What type of seizure disorder is she most likely to have?

A) Generalized tonic–clonic seizure B) Generalized absence seizure C) Simple partial seizure (Jacksonian) D) Complex partial seizure Ans: B Chapter: 17 Page and Header: 718, Table 17-3 Feedback: In an absence seizure there is no tonic–clonic activity. There is a sudden, brief lapse of consciousness with blinking, staring, lip-smacking, or hand movements that resolve quickly to full consciousness. It is easily mistaken for daydreaming or ADD. Some will try to induce these episodes with hyperventilation.

3. A 37-year-old insurance agent comes to your office, complaining of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn't feel particularly nervous when this occurs but she worries that other people will think she has an anxiety disorder or that she's a drinker. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has

an older brother with type 1 diabetes. She is married and has three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form she has obvious tremors in her dominant hand.

What type of tremor is she most likely to have?

A) Resting tremor B) Postural tremor C) Intention tremor Ans: C Chapter: 17 Page and Header: 720, Table 17-4 Feedback: Intention tremors are absent at rest or in a postural position and occur only with intentional movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) or in multiple sclerosis. This patient's tremor, fatigue, bladder problems, and visual problems are suggestive of multiple sclerosis.

4. A 77-year-old retired school superintendent comes to your office, complaining of unsteady hands. He says that for the past 6 months, when his hands are resting in his lap they shake uncontrollably. He says when he holds them out in front of his body the shaking diminishes, and when he uses his hands the shaking is also better. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for over 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister who has arthritis problems. His children are all essentially healthy. On examination you see a fine, pill-rolling tremor of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back toward you. He has almost no “arm swing” with his gait.

What type of tremor is he most likely to have?

A) Resting tremor B) Postural tremor C) Intention tremor Ans: A Chapter: 17 Page and Header: 720, Table 17-4 Feedback: Resting tremors occur when the hands are literally at rest, such as sitting in the lap.

These are slow, fine tremors, such as the pill-rolling seen in Parkinson's disease, which this patient most likely has. Decreased arm swing with ambulation is one of the earliest objective findings of Parkinson's disease.

5. A 48-year-old grocery store manager comes to your clinic, complaining of her head being “stuck” to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot get it moved back to normal. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is on oral medication for each. She is married and has three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. On examination you see a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left but otherwise her examination is normal.

What form of involuntary movement does she have?

A) Chorea B) Asbestosis C) Tic D) Dystonia Ans: D Chapter: 17 Page and Header: 720, Table 17-4 Feedback: Dystonia involves large movements of the body, such as with the head or trunk, leading to grotesque twisted postures. Some medications (such as one commonly used for gastroparesis) often cause dystonia.

6. A 41-year-old real estate agent comes to your office, complaining that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy and as the day progressed he was unable to close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. His past medical history is unremarkable. He is divorced and has one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination you ask him to close his eyes. He is unable to close his left eye. You ask him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. You then ask him to give you a big smile. The right corner of his mouth raises but the left side of his mouth remains the same.

What type of facial paralysis does he have?

A) Peripheral CN VII paralysis B) Central CN VII paralysis Ans: A Chapter: 17 Page and Header: 676, Techniques of Examination Feedback: In a peripheral lesion the entire side of the face will be involved. This causes the

inability to close the eye, raise the eyebrow, wrinkle the forehead, and smile on the affected side.

Bell's palsy is an example of this type of paralysis and is probably what is affecting this patient.

7. A 60-year-old retired seamstress comes to your office, complaining of decreased sensation in her hands and feet. She states that she began to have the problems in her feet a year ago but now it has started in her hands also. She also complains of some weakness in her grip. She has had no recent illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children. Her mother has Alzheimer's disease and coronary artery disease. Her father died of a stroke and also had diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration on both feet. She has decreased two-point discrimination on her hands. Her grip strength is decreased and her plantar and dorsiflexion strength is decreased.

Where is the disorder of the peripheral nervous system in this patient?

A) Anterior horn cell B) Spinal root and nerve C) Peripheral polyneuropathy D) Neuromuscular junction Ans: C Chapter: 17 Page and Header: 727, Table 17-9 Feedback: With peripheral polyneuropathy there will be distal extremity symptoms before proximal symptoms. There will be weakness and atrophy and decreased sensory sensations.

There is often the classic glove-stocking distribution pattern of the lower legs and hands. Causes include diabetic neuropathy, as in this case, alcoholism, and vitamin deficiencies.

8. A 21-year-old engineering student comes to your office, complaining of leg and back pain and of tripping when he walks. He states this started 3 months ago with back and buttock pain but has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms.

He can think of no specific traumatic incidences but he was a defensive lineman in high school and junior college. His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy. On examination he is tender over the lumbar spine and he has a positive straight-leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching his gait you notice he has to pick his left foot up high in order not to trip.

What abnormality of gait does he most likely have?

A) Sensory ataxia B) Parkinsonian gait C) Steppage gait

D) Spastic hemiparesis Ans: C Chapter: 17 Page and Header: 730, Table 17-10 Feedback: This gait is associated with foot drop, usually secondary to a lower motor neuron disease. This is often seen with a herniated disc, such as in this patient.

9. A 17-year-old high school student is brought in to your emergency room in a comatose state.

His friends have accompanied him and tell you that they have been shooting up heroin tonight and they think their friend may have had too much. The patient is unconscious and cannot protect his airway, so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. Preparing to finish the neurologic examination, you get a penlight.

What size pupils do you expect to see in this comatose patient?

A) Pinpoint pupils B) Large pupils C) Asymmetric pupils D) Irregularly shaped pupils Ans: A Chapter: 17 Page and Header: 731, Table 17-11 Feedback: Narcotics and cholinergics cause very small (1 mm) pupils. Reactions to light can be appreciated with a magnifying glass.

10. A 37-year-old woman is brought into your emergency room comatose. The paramedics say her husband found her unconscious in her home. Her past medical history consists of type 1 diabetes and she is on insulin. In the ambulance the paramedics obtained a glucose check and her sugar was 15 (normal is 70 to 105). They began a dextrose saline infusion and intubated her to protect her airway. Despite their efforts, she is posturing in the emergency room with her arms straight at her side and her jaw clenched. Her legs are also straight and her feet are plantar flexed.

What type of posturing is she showing?

A) Decorticate rigidity B) Decerebrate rigidity C) Hemiplegia D) Chorea Ans: B Chapter: 17

Page and Header: 733, Table 17-13 Feedback: In this type of rigidity the jaws are clenched and the neck is extended. The arms are adducted and stiffly extended at the elbows with forearms pronated and wrists and fingers flexed.

The legs are stiffly extended at the knees with the feet plantar flexed. This posture occurs with lesions in the diencephalon, midbrain, or pons. It can also be seen with severe metabolic disorder such as hypoxia or hypoglycemia, as in this case.

11. A patient presents with a left-sided facial droop. On further testing, you note that he is unable to wrinkle his forehead on the left and has decreased taste. Which of the following is true?

A) This represents a central lesion.

B) This represents a CN IV lesion.

C) This may be related to travel.

D) This most likely represents a stroke.

Ans: C Chapter: 17 Page and Header: 725, Table 17-7 Feedback: Because the forehead is also involved, this represents a peripheral nerve lesion of CN VII and does not represent a classic middle cerebral artery stroke. The latter would spare the upper face but include speech difficulties as well as upper extremity weakness on the ipsilateral side. One cause of this type of lesion is Lyme disease and relates to travel to endemic areas, so a careful travel history should be sought.

12. Which is true of examination of the olfactory nerve?

A) It is not tested for laterality.

B) The smell must be identified to declare a normal response.

C) Abnormal responses may be seen in otherwise normal elderly.

D) Allergies are unrelated to testing of this nerve.

Ans: C Chapter: 17 Page and Header: 658, Anatomy and Physiology Feedback: Abnormal olfactory nerve examination findings may be seen in otherwise normal elderly but may also be associated with other conditions such as Parkinson's disease. You should try to determine if only one side is abnormal by occluding the contralateral nostril. The smell must only be detected, not identified by name, to indicate a normal examination. If nasal occlusion occurs for other reasons, such a allergic rhinitis or anatomic abnormalities, the nerve cannot be tested and may seem to be abnormal for unrelated reasons.

13. Steve has had a stroke and comes to you for follow-up today. On examination you find that he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the following?

A) The corticospinal tract B) The cerebellum C) The cerebrum D) The basal ganglia Ans: D Chapter: 17 Page and Header: 656, Anatomy and Physiology Feedback: These findings are typical of disease in the basal ganglia.

14. You are conducting a mental status examination and note impairment of speech and judgement, but the rest of your examination is intact. Where is the most likely location of the problem?

A) Cerebrum B) Cerebellum C) Brainstem D) Basal ganglia Ans: A Chapter: 17 Page and Header: 656, Anatomy and Physiology Feedback: The cerebrum is responsible for higher cognitive functions such as speech and judgement.

15. A patient presents with a daily headache which has worsened over the past several months.

On funduscopic examination, you notice that the disk edge is indistinct and the veins do not pulsate. Which is most likely?

A) Migraine B) Glaucoma C) Visual acuity problem D) Increased intracranial pressure Ans: D Chapter: 17

Page and Header: 673, Techniques of Examination Feedback: This is a description of papilledema, which should make you think of increased intracranial pressure. This can be a critical finding. This patient may have a brain tumor or benign intracranial hypertension. These findings cannot be ignored and should be acted upon quickly.

16. A young woman comes in today, complaining of fatigue, irregular menses, and polyuria which have gradually increased over the past few months. Which eye findings would be consistent with her condition?

A) An upper quadrantanopsia B) A lower quadrantanopsia C) A bitemporal hemianopsia D) An increased cup-to-disc ratio Ans: C Chapter: 17 Page and Header: 673, Techniques of Examination Feedback: These symptoms are consistent with a pituitary lesion. Enlargement of a tumor in this area would compress the fibers responsible for the lateral visual fields. A quadrantanopsia would usually be caused by a lesion in the optic radiations in the parietal lobe of the cerebrum.

Glaucoma would cause a narrowing of the entire visual field, not just the lateral aspects.

17. A patient with a history of seizure disorder and on several seizure medications says a friend noted “jumping eye movements.” The patient describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago. On examination you note that the eyes both slowly move to the right and then quickly jump to the left. Which of the following is true?

A) This is called nystagmus to the left B) This is called saccadic eye movement C) This represents a subclinical seizure D) This most likely has an ominous cause Ans: A Chapter: 17 Page and Header: 674, Techniques of Examination Feedback: Nystagmus is named for the fast component, in this case, toward the left. Nystagmus is common with several seizure medications and in this case is likely due to the recent increase in medications rather than a more ominous cause. Saccadic eye movements are similar to nystagmus but represent fixations on apparently moving objects, like watching roadside trees from a moving vehicle. A subclinical seizure with bilateral findings and no effect on

consciousness would be unusual.

18. You are testing the biceps strength in a young man following a spinal trauma from a motor vehicle accident. He cannot lift his hand upward, but if the arm is abducted to 90 degrees, he can then move his forearm side to side. This would represent which muscle strength grading?

A) I B) II C) III D) IV Ans: B Chapter: 17 Page and Header: 680, Techniques of Examination Feedback: The ability to move an extremity, but not against gravity, represents a strength of 2 out of 5. Zero represents no muscular contraction detected (not even a “flicker”); one represents a contraction but no movement of the extremity; three means that the extremity can move against gravity but not against resistance; four means perceived weakness but the patient can oppose some resistance; and five is normal.

19. You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward. This is most likely a problem with which part of the nervous system?

A) Corticospinal tract B) Spinothalamic tract C) Thalamus D) Dorsal root ganglion Ans: A Chapter: 17 Page and Header: 689, Techniques of Examination Feedback: This describes a pronator drift, which signifies decreased position sense involvement of the corticospinal tract. This tract does not travel through the thalamus. This is commonly tested as an early sign of stroke. This would not occur with a dorsal root ganglion problem.

20. You are examining a child with severe cerebral palsy. When you suddenly move his foot dorsally, a sustained “beating” of the foot against your hand ensues. What does this represent?

A) A focal seizure

B) Clonus C) Extinction D) Reinforcement Ans: B Chapter: 17 Page and Header: 696, Techniques of Examination Feedback: Clonus is a sustained rhythmic “beating” which correlates with CNS disease and hyperreflexia. A focal seizure could be virtually ruled out by stopping the stimulus and watching the phenomenon stop. Extinction is a term applied to sensory testing where one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex. Reinforcement applies to enhancing reflex examination by distracting the patient, for example, by pulling his hands against each other.

21. Jim is an HIV-positive patient who complains about back pain in addition to several other problems. On percussion, there is slight tenderness over the T7 vertebrae, and when you flex his thigh to 90 degrees and extend his lower legs, you meet strong resistance at about 45 degrees of extension. What are likely causes of this constellation of symptoms?

A) Fractured vertebrae B) Malingering C) Infection D) Medication side effect Ans: C Chapter: 17 Page and Header: 703, Techniques of Examination Feedback: This represents Kernig's sign. When present bilaterally it often indicates meningeal irritation. (Kernig was a physician in eastern Europe and treated many children with tuberculous meningitis.) It is useful in cases when there has been chronic inflammation of the meninges, as seen in TB and cryptococcal disease. There was no trauma reported, and these signs are too important to ascribe them to malingering. Such localized physical findings are unlikely to be caused by medication side effects.

22. A patient with alcoholism is brought in with confusion. You ask him to “stop traffic” with his palms and notice that every few seconds his palms suddenly move toward the floor. What does this indicate?

A) Stroke B) Metabolic problems C) Carpal tunnel syndrome D) Severe fatigue and weakness

Ans: B Chapter: 17 Page and Header: 704, Techniques of Examination Feedback: This is asterixis and represents the inability to maintain a sustained contraction of the muscles. It is usually due to various metabolic diseases. A variant of this is called “milkmaid's grip” in which the patient is asked to grasp two fingers. A positive occurs if the patient is unable to sustain the grip and it feels as if the patient is trying to milk a cow. Most would consider checking an ammonia level in this patient. A stroke is less likely to produce bilateral symptoms.

Carpal tunnel represents a sensory loss in the median nerve distribution.

23. You examine a “sleepy” patient. You note that she will open her eyes and look at you but responds slowly and is confused. She does not appear interested in her surroundings. How would you describe her level of consciousness?

A) Lethargic B) Obtunded C) Stuporous D) Comatose Ans: B Chapter: 17 Page and Header: 706, Techniques of Examination Feedback: An obtunded patient is responsive but slow speaking and is less interested in her surroundings. A patient with lethargy opens her eyes to verbal cues and may respond appropriately but promptly falls back to sleep. The stuporous patient responds only to painful stimuli, and when the stimulus is withdrawn lapses into unconsciousness again. Such patients have little awareness of self or the environment. The comatose patient has no obvious response to external stimuli.

24. A woman experiences syncope after hearing that her son was severely injured. She becomes pale and collapses to the ground without injuring herself. On waking, she states that she feels very warm. She denies any other symptoms. There are no findings on examination. What caused her loss of consciousness?

A) Micturition syncope B) Postural hypotension C) Cardiac arrhythmia D) Vasovagal syncope Ans: D Chapter: 17

Page and Header: 715, Table 17-2 Feedback: This is a classic description of vasodepressor or vasovagal syncope with the feeling of warmth, while bystanders note paleness. The lack of injury is also helpful because she has maintained her protective reflexes. Injuring oneself can indicate that a cardiac origin for syncope may be present. Micturition syncope occurs with urination, and there are no postural changes mentioned, making postural hypotension unlikely.

25. A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen “staring off into space” and not paying attention. If this is a seizure, it most likely represents which type?

A) Pseudoseizure B) Tonic–clonic seizure C) Absence D) Myoclonus Ans: C Chapter: 17 Page and Header: 718, Table 17-3 Feedback: This is a common description and scenario for absence seizures. These are generally brief (less than 10 seconds, “petit mal”). These generally occur without warning and generally do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic–clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs.

26. A patient comes to you because she is experiencing a tremor only when she reaches for things. This becomes worse as she nears the “target.” When you ask her to hold out her hands, no tremor is apparent. What type of tremor does this most likely represent?

A) Intention tremor B) Postural tremor C) Resting tremor D) Nervous tremor Ans: A Chapter: 17 Page and Header: 720, Table 17-4 Feedback: Because this tremor worsens as the target is approached, this represents an “intention” tremor. In this patient, one may suspect cerebellar pathway disease, possibly from multiple sclerosis (one could also look for an intranuclear ophthalmoplegia). A postural tremor occurs when a certain position is maintained, and resting tremors can occur in diseases such as Parkinson's. These do not occur during sleep.

27. A young woman comes in with brief, rapid, jerky, irregular movements. They can occur at rest or during other intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements?

A) Tics B) Dystonia C) Athetosis D) Chorea Ans: D Chapter: 17 Page and Header: 720, Table 17-4 Feedback: These represent chorea because they are brief, rapid, unpredictable, and irregular.

Tics are irregular but tend to be stereotyped and can be vocal (throat-clearing), facial expressions, or shoulder shrugging. Athetosis is a slow, squirming motion usually affecting the face and distal extremities. Dystonia is similar to athetosis but the movements are more coarse and can involve twisted postural changes.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 18: Assessing Children: Infancy Through Adolescence

Multiple Choice

1. During the delivery of a male infant, you are there to assess the Apgar score. He was born through an intact pelvis and had no complications during labor or delivery. At 1 minute he is pink all over and grimaces. He is flexing his arms and legs occasionally. He is breathing well and his heart rate is 110. At 5 minutes he is still pink all over but now is crying vigorously, with active movement. His respiratory effort is good and his heart rate is 130.

What is his Apgar score?

A) 8 at 1 minute, 10 at 5 minutes B) 7 at 1 minute, 9 at 5 minutes C) 9 at 1 minute, 10 at 5 minutes

D) 8 at 1 minute, 9 at 5 minutes Ans: A Chapter: 18 Page and Header: 745, Assessing the Newborn Feedback: In checking the Apgar, five things are looked at during the 1-minute and 5-minute marks. The color, reflex irritability, muscle tone, respiratory effort, and heart rate are evaluated.

In this case, at 1 minute he received 2 points for being pink all over, 1 point for grimacing, 1 point for flexion of the arms and legs, 2 points for strong respiratory effort, and 2 points for a heart rate over 100. This gives a 1-minute total of 8. At 5 minutes he was given 2 points for being pink all over, 2 points for vigorous crying, 2 points for active movement, 2 points for strong breathing, and 2 points for a heart rate over 100. This gives a 5-minute total of 10. These are normal, healthy Apgar scores.

2. A 24-year-old mother who is a smoker and cocaine addict gave birth at 39 weeks to a 2,000gram female infant who is in the neonatal intensive care unit. Using the Intrauterine Growth Curve chart, you determine whether the infant's weight is appropriate for her gestational age.

In which category does the infant best fit?

A) Large for gestational age B) Normal for gestational age C) Small for gestational age Ans: C Chapter: 18 Page and Header: 746, Assessing the Newborn Feedback: For a 39-week infant, any weight less than 2,500 grams would be considered small.

Intrauterine growth retardation and low birth weight would be expected in a smoker who also abuses cocaine.

3. A mother brings her 16-month-old son in for an evaluation. She is afraid he is not meeting his developmental milestones and wants to know if he should be sent to therapy. He was the product of an uneventful pregnancy and a spontaneous vaginal delivery. His Apgar scores were 7 and 9.

Until reaching a year old the mother believes he was hitting his milestones appropriately. You decide to administer the Denver Developmental Screening Test. You find that he is using a spoon to eat with and can take off his own shoes and shirt. He can build a tower of two cubes and dump raisins. His vocabulary consists of at least 10 words. He can stand alone and stoop and recover, but he is unable to walk without holding onto someone's hand.

What type of developmental delay does he have?

A) Personal/social B) Fine motor

C) Language D) Gross motor Ans: D Chapter: 18 Page and Header: 751, The Health History Feedback: By 16 months a child should be able to walk unaided and even walk backwards and run. This child was referred to physical therapy and did well.

4. A foster mother brings a 4-year-old child to see you for an evaluation. She has had custody of the girl for 2 weeks. She knows that the child was born in your state and that her maternal grandmother had custody for 6 months. She received good medical care during that time, but after her biologic mother obtained custody the child was abused and has had no further medical care. She says the child has had many behavioral problems and seems to be very behind on her developmental tasks. When you examine the child you notice short palpebral fissures, a wide nasal philtrum, and thin lips. Her cardiac, pulmonary, musculoskeletal, and abdominal examinations are normal. Her Denver Developmental Screening Test shows most of her milestones have occurred only through the 24th month.

What form of congenital retardation is she most likely to have?

A) Fetal alcohol syndrome B) Congenital hypothyroidism C) Down syndrome Ans: A Chapter: 18 Page and Header: 767, Assessing the Infant Feedback: The facial appearance in fetal alcohol syndrome shows short palpebral fissures, a wide and flattened philtrum, and thin lips. These children often have mild retardation even with good care, but with abuse they may have more profound retardation. This condition may occur with only modest alcohol consumption.

5. A young Hispanic mother brings in her 2-month-old son. She is upset because her neighbors have threatened to call the Child Protective Agency because they think his birthmark is a bruise.

Her son was the product of an uneventful pregnancy and spontaneous vaginal delivery. On examination you see a large, smooth-bordered bluish mark on his buttock and lower back.

Otherwise his examination is unremarkable.

What form of birthmark is this likely to be?

A) Café-au-lait spot B) Salmon patch C) Mongolian spot

Ans: C Chapter: 18 Page and Header: 762, Newborn Skin Findings Feedback: Mongolian spots are large, smooth-bordered birthmarks found on the back and/or buttocks. They are found more often in darker-pigmented infants such as in the Hispanic or Asian population. They are commonly mistaken for bruises.

6. A 32-year-old white female presents to labor and delivery fully effaced and delivers a 5.8-lb (2,500-gram) infant female with Apgar scores of 6 and 8. The mother has had no prenatal care and in the nursery you perform the newborn examination. With the Ballard scoring system, the neuromuscular examination score is 15. Looking at physical maturity, you see superficial peeling and few veins on the skin. The lanugo hair has bald areas and the plantar surface of the foot has creases on two thirds of it. The areola is stippled with a 2-mm bud. The pinna is well curved, is firm, and has instant recoil. The labia majora and minora are equally prominent.

Add the score of the neuromuscular components to your score of physical maturity to determine weeks of gestation. How many weeks of gestation has this child had?

A) 34 weeks B) 36 weeks C) 40 weeks Ans: B Chapter: 18 Page and Header: 748, Assessing the Newborn Feedback: Superficial peeling with few veins gives a score of 2 points; lanugo with balding areas gives a score of 3 points; the plantar surface being covered by two thirds gives a score of 3 points; the stippled areola with a 2-mm bud gives a score of 2 points; the well-formed pinna with instant recoil gives a score of 3 points. The equal labia majora and labia minora give a score of 2 points. Adding these numbers up gives a score of 15 points for physical maturity. Adding that to the 15 points for neuromuscular maturity gives a point total of 30, which correlates to a gestational age of 36 weeks. This would be expected with a birth weight of 2,500 grams.

7. A mother brings in her 3-year-old son for a well-child check-up. She is concerned that he seems different in size from all of the other preschool boys. He was the product of an uneventful pregnancy and vaginal delivery. He has hit all of his developmental milestones on time. On examination he is 26 lbs (11.8 kg) and is 35 inches (89 cm) tall. Otherwise his examination is unremarkable. You give the correct education for his age and then discuss his size.

For his age, what are his growth chart percentiles?

A) Tall and heavy for his age (>95%) B) Average height and weight for his age (5 to 95%)

C) Small and light for his age (<5%) Ans: C Chapter: 18 Page and Header: 806, Techniques of Examination (Children) Feedback: According to the growth charts, this child is less than the fifth percentile for both height and weight, indicating that he is small and light for his age. This can be from a growth hormone deficiency but is usually due to genetic factors (such as short, light parents). It is most important to follow the trend of growth. It is more significant if this child was previously at the 50th percentile for height and weight than if he has always been about the same percentile and following a line parallel to expected growth lines.

8. A mother brings her 4-year-old daughter to your office because of fever and decreased eating and drinking. When you ask the little girl what is wrong, she says her mouth and throat hurt. On examination her temperature is 101 degrees. Her ears and nose examinations are unremarkable.

Her mouth has ulcerations on the buccal mucosa and the tongue. She also has cervical lymphadenopathy. Her cardiac and pulmonary examinations are normal. She is up to date on her childhood vaccinations.

What mouth abnormality does she most likely have?

A) Strep throat B) Herpetic stomatitis C) Oral candidiasis (thrush) D) Diphtheria Ans: B Chapter: 18 Page and Header: 862, Table 18-7 Feedback: With herpetic stomatitis there is often a low-grade fever with small ulcers covering the mucosa of the mouth. The pain from the ulcers leads to decreased oral intake and even dehydration.

9. A mother brings her 15-month-old daughter to your office for evaluation of a rash and fever.

She says the rash started one day and the fever developed the next day. Her daughter has had all of her vaccinations up to 10 months. The mother sheepishly admits that she hasn't had time to bring her daughter in since her 10-month check-up. On examination you see a mildly sickappearing toddler with a 102-degree temperature. Looking at her skin you see at least 100 of a variety of papules, vesicles, and ulcers in different stages of development.

What illness prevented by proper vaccination does this toddler have?

A) Varicella (chickenpox) B) Measles

C) Smallpox Ans: A Chapter: 18 Page and Header: 869, Table 18-14 Feedback: Normally the first vaccine for varicella is given at 12 to 15 months. The characteristic rash in waves of lesions is in a pattern of papules, vesicles, ulcers, and scabs. Because of the number of persons who still get shingles (an outbreak of varicella in one dermatome following the original infection by years), there is still enough virus in the United States to easily get chickenpox without vaccination. This child is regarded as contagious to others until all of the lesions are “scabbed over.” Smallpox would appear different in that all of the lesions would be in the same stage of development.

10. An adolescent male comes to your clinic with a note from his mother stating it is okay for him to be seen today without her presence. He has come in for his annual sports physical required to play football. For his age his physical examination is unremarkable and you sign his school's physical examination form. You decide to take this opportunity to do some health education with him. He admits to wondering a lot lately if he is normal. Although he is in football he really enjoys science and computers more. He is worried that all his buddies will think he is a geek. He is convinced he also won't get a date for the Sadie Hawkins dance next week because the girls all think he is boring, too. He denies any experimentation with tobacco or alcohol, and he blushes when you mention sex. After hitting all the pertinent age-appropriate education points you give him his sports physical form and he leaves.

The patient's concerns during the visit most resemble what developmental stage of adolescence?

A) Early adolescence (10 to 14 years old) B) Middle adolescence (15 to 16 years old) C) Late adolescence (17 to 20 years old) Ans: A Chapter: 18 Page and Header: 834, Assessing Adolescent Development Feedback: His concern with whether he is normal or not is often seen in the development of social identity in early adolescence. He is also concerned with the present (Sadie Hawkins dance) and not the distant future, as is seen with late adolescence. He also denies the experimentation often seen in middle adolescence.

11. A 38-week gestation, 2500-gram infant is placed on your service. How would she be described?

A) Term, normal birth weight B) Term, low birth weight

C) Preterm, normal birth weight D) Preterm, low birth weight Ans: A Chapter: 18 Page and Header: 746, Assessing the Newborn Feedback: Preterm is defined as less than 37 weeks; term, 37–42 weeks; and post-term, over 42 weeks of gestation. Birth weights have similar limits: extremely low birth weight, less than 1000 grams; very low birth weight, less than 1500 grams; low birth weight, less than 2500 grams; and normal birth weight, equal to or more than 2500 grams. These have prognostic implications and impact on how closely to watch and how aggressively to treat these infants.

12. You are observing an infant who is able to pull to a stand, uses “mama” and “dada” specifically, and indicates his wants by vocalization and pointing. Where would you place this child's developmental age?

A) 12 months B) 10 months C) 8 months D) 6 months Ans: C Chapter: 18 Page and Header: 750, Development Feedback: Assessing developmental milestones is of major importance during the first year and beyond. These accomplishments in the physical, cognitive/language, and social domains are normal for an 8-month-old infant.

13. Which of the following will help to optimize yield from a pediatric examination?

A) Doing the examination out of order if necessary to take advantage of quiet periods for auscultation, etc.

B) Being very orderly, so as not to miss a portion of the examination C) Using firmness as needed to make it through your examination D) Making sure to place the infant on the table during the examination while mom watches close by Ans: A Chapter: 18 Page and Header: 751, The Health History Feedback: While order and routine are comforting to the examiner, children should be examined in an order which allows maximum yield. Many prefer to listen to the heart and lungs first while

the child is quiet, in a parent's arms. Likewise, you may gain advantage to examining the mouth while the baby is crying. Most view the ENT examination as the most invasive for a child (especially the otoscopic examination), so many leave this for last.

14. A 6-month-old infant is brought in for a well check. It is noted his head circumference is off the chart and at a much higher percentile than was previously measured. What should you do next?

A) Recommend a neurology consult.

B) Order a CT of the head.

C) Remeasure the circumference.

D) Admit the child to the hospital for further workup.

Ans: C Chapter: 18 Page and Header: 756, Techniques of Examination Feedback: It is difficult to obtain accurate measurements of a squirming infant. The first step would be to remeasure. Some recommend starting with three measurements and averaging or picking the middle measurement. Height is technically not measured until a child is standing, so infants' measurements are recorded as length.

15. You are examining an infant in the nursery and notice a soft bump over the posterior right side of the skull. It is not evident on the left. What does this represent?

A) Caput succedaneum B) Plagiocephaly C) Craniosynostosis D) Cephalohematoma Ans: D Chapter: 18 Page and Header: 766, Assessing the Infant Feedback: Cephalohematoma represents bleeding under the periosteum, which is why this lesion does not cross the midline. The blood can contribute to neonatal jaundice as it breaks down.

Caput succedaneum is commonly seen as a spongy mass over the vertex, particularly when vacuum extraction is used. Craniosynostosis describes a premature closure of bony skull sutures, and plagiocephaly is a flattening of the parieto-occipital region on one side of the skull, which is frequently thought to be positional.

16. You are assessing an infant and notice that his nares flare, he has a soft grunt with each breath, and the skin between his ribs is pulled inward with inhalation. What is the significance of these findings?

A) These are indicative of a CNS process.

B) These are indicative of respiratory distress.

C) These are indicative of muscular dystrophy.

D) These are frequently accompanied by stridor.

Ans: B Chapter: 18 Page and Header: 774, Assessing the Infant Feedback: It is critical to notice these findings of respiratory distress. Muscular dystrophy may not allow the appearance of these signs because they are caused by muscular effort. It is hard to find a cause for these signs in the CNS. Stridor is usually inspiratory, so while nasal flaring and retractions may occur, grunting is unusual because exhalation is unimpeded.

17. A mother brings her infant to you because of a “rattle” in his chest with breathing. Which of the following would you hear if there were a problem in the upper airway?

A) Different sounds from the nose and chest B) Asymmetric sounds C) Inspiratory sounds D) Sounds louder in the lower chest Ans: C Chapter: 18 Page and Header: 774, Assessing the Infant Feedback: It is important to distinguish upper airway sounds from lower because many benign conditions cause upper airway noise, such as viral upper respiratory infections. It is reassuring to hear the same noises at the nose as at the chest. Lower respiratory conditions also are generally symmetric, and sounds are louder at the upper chest versus the lower chest. They are usually very harsh and loud, which concerns parents.

18. An infant presents with a heart rate of 180, a respiratory rate of 68, and an enlarged liver.

What diagnosis does this suggest?

A) Pneumonia B) Heart failure C) Sepsis D) Necrotizing enterocolitis Ans: B

Chapter: 18 Page and Header: 776, Assessing the Infant Feedback: Heart failure presents differently in infants than in adults. This triad should suggest this diagnosis. Pneumonia, necrotizing enterocolitis, and sepsis should not necessarily cause hepatomegaly. Observe closely for central cyanosis of the lips and tongue. Peripheral cyanosis alone does not mean much in infants. Perform a careful cardiac examination in as quiet a setting as possible, perhaps while the infant is in the mother's arms, to look for evidence of valvular disease.

19. You have been unable to hear normal S2 splitting in children up to this point. What technique will maximize your chances of hearing this phenomenon?

A) Listen with the diaphragm over the left lower sternal border.

B) Listen with the bell over the 2nd left intercostal space.

C) Listen with the bell over the apex.

D) Listen with the diaphragm in the axilla.

Ans: B Chapter: 18 Page and Header: 778, Assessing the Infant Feedback: S2 is made of aortic and pulmonic components. Of these, the pulmonic component is much softer and heard best over the pulmonic area. Even in the proper location, the pulmonic component may be difficult to hear with the diaphragm because it is a soft, low-pitched sound.

For this reason, the bell should be used to listen for S2 splitting over the pulmonic area during inspiration, when splitting should be maximized. Breathing also changes heart rate more rapidly in children. One may think an arrhythmia is present until she notices that this rate change is related to the respiratory cycle.

20. A mother is upset because she was told by another provider that her child has a worrisome murmur. You listen near the clavicle and notice both a systolic and diastolic sound. You remember that diastolic murmurs are usually indicative of bad pathology. What would you do next?

A) Cardiology referral B) Echocardiogram C) Supine examination D) Reassure the mother Ans: C Chapter: 18 Page and Header: 781, Assessing the Infant Feedback: The next step would be to examine the patient in the supine position. If this is a

venous hum, this murmur will resolve almost completely in the supine position. This is a very common phenomenon in school-aged children, particularly over the clavicle, but can also occur outside this range. Reassurance cannot be given without further examination, especially with a diastolic murmur. Cardiology referral and echocardiography are unnecessary if examination in the supine position reveals no murmur.

21. A toddler is able to jump in place and balance on one foot as well. She can also speak in full sentences and feed herself. What is the approximate developmental age of this child?

A) 2 years B) 3 years C) 4 years D) 5 years Ans: B Chapter: 18 Page and Header: 797, Assessing Young and School-Aged Children Feedback: These milestones are consistent with a physical, cognitive/language, and social and emotional developmental age of 3 years.

22. You are having trouble examining the abdomen of a school-aged child due to ticklishness.

What should you do?

A) Have the child press on your hand.

B) Have the parent insist that the child allow you to examine her.

C) Ask the parent to leave the room.

D) Make the child realize that this is part of the examination and must be done.

Ans: A Chapter: 18 Page and Header: 823, Assessing Young and School-Aged Children Feedback: By having the child participate in the examination and pressing on your hand, it will eliminate the ticklishness. Resistance to examination at this age is normal. The last three options only make the situation worse. The key is to have the child participate in the examination in a fun way.

23. You are examining a 5-year-old before he begins school. You notice a systolic, grade II/VI vibratory murmur over the LLSB and apex with normal S2 splitting. He has normal pulses as well. Which of the following is most likely?

A) Tricuspid stenosis B) Mitral stenosis C) Still's murmur D) Venous hum Ans: C Chapter: 18 Page and Header: 822, Assessing Young and School-Aged Children Feedback: This description is consistent with Still's murmur, a very common and benign murmur of childhood. Tricuspid and mitral stenosis would be diastolic murmurs and the venous hum is usually not heard in this area. Further evaluation is usually not necessary.

24. You are going to obtain a social history on an early adolescent boy. How should you proceed to obtain the best information?

A) Ask his mother to leave the room.

B) Ask if he would prefer his mother to leave the room.

C) Ask your questions with his mother in the room.

D) Ask his mother how she would like to proceed.

Ans: B Chapter: 18 Page and Header: 836, The Health History Feedback: It is best to ask the patient what he or she would prefer. Because the examination should include a genitalia examination, some children in early adolescence are more comfortable with their parents in the room. Some examiners will provide “confidential time” to both the adolescent and the parent, so that parental concerns can also be adequately addressed. Leaving the parent in the room without asking the adolescent is usually not a good idea and can limit optimal history gathering and examination.

25. You are assessing Tanner staging of the breast in a young woman. You notice projection of the areola and nipple to form a secondary mound above the level of the breast. Which Tanner stage would this be?

A) I B) II C) III D) IV Ans: C Chapter: 18 Page and Header: 841, Assessing Adolescents

Feedback: This would be a Tanner stage III because there is elevation of the nipple and areola above the level of the surrounding breast tissue and because the areola has not receded to the general contour of the breast.

26. A quiet 3-year-old is brought in for a routine check-up when you notice a fresh bruise in the axilla and bilateral bruises over the upper back that appear slightly older. There are brown bruises over his shins as well. His mother said this happened when he fell off of a couch. What diagnosis should be considered?

A) Von Willebrand's disease B) Normal childhood bruises from activity C) Abuse D) Seizure disorder Ans: C Chapter: 18 Page and Header: 860, Table 18-6 Feedback: No one wants to think that a child could be abused. In this case the bruises on the shins are very normal for this age group with normal activity. The presence of bruises in other areas which do not correlate with the given history are important to notice and should make you consider this diagnosis. A very thorough examination must be conducted to search for other lesions that might be consistent with the use of implements such as an electrical cord, clothes iron, cigarette, etc. A social services consult and/or formal abuse evaluation should be considered. Unfortunately, emotional and sexual abuse do not frequently leave outward signs. It is important to keep an open mind to the presence of these other types of abuse as well.

27. A 15-month-old is brought to you for a fever of 38.6 degrees Celsius and fussiness. The ear examination is as follows: external ear, normal appearance and no tenderness with manipulation; canal, normal diameter without evidence of inflammation; tympanic membrane, bulging, erythematous, and opaque. Insufflation is deferred due to pain. What is your diagnosis?

A) Otitis externa B) Cholesteatoma C) Ruptured tympanic membrane D) Otitis media Ans: D Chapter: 18 Page and Header: 862, Table 18-7 Feedback: There is no inflammation of the outer ear, including the canal, thus excluding otitis externa. Cholesteatoma is a painless white lesion behind the TM. There is no drainage from the TM; thus, rupture is unlikely. This is a classic description of otitis media. Many examiners will

forego insufflation if the diagnosis is clear, because this can cause discomfort in an already uncomfortable ear.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 19: The Pregnant Woman

Multiple Choice

1. A 29-year-old homemaker who is G4P3 comes to your clinic for her first prenatal check. Her last period was 2 months ago. She has had three previous pregnancies and deliveries with no complications. She has no medical problems and has had no surgeries. Her only current complaint is of severe reflux that occurs in the mornings and evenings. On examination she is in no acute distress. Her vitals are 110/70 with a pulse of 88. Her respirations are 16. Her head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On bimanual examination her cervix is soft and her uterus is 10 weeks in size. Pap smear, cultures, and blood work are pending.

What is the most likely cause of her first-trimester reflux?

A) Increasing prolactin levels B) Increasing ADH (antidiuretic hormone) levels C) Increasing progesterone D) Enlarged gravid uterus Ans: C Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: Progesterone lowers the esophageal sphincter tone, leading to reflux and heartburn. It also relaxes tone and contraction of the ureters and bladder, increasing risk of UTI and subsequent bacteremia.

2. A 26-year-old telephone operator comes to your office for her first prenatal visit. This is her first pregnancy. Her last period was about 2 months ago. She has no current complaints. She is eating healthily, taking vitamins, and exercising. She has a past medical history of an

appendectomy as a teenager. Her mother had three children vaginally with no complications. On examination she appears healthy and her vital signs are unremarkable. Her head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are also unremarkable. By speculum examination, her cervix appears bluish in color and highly vascular. A bimanual examination reveals a soft cervix and a 12-week-sized uterus. No masses are felt in either adnexal area. Results of her Pap, cultures, and blood work are pending.

What clinical sign is responsible for her blue, highly vascular cervix?

A) Chadwick's sign B) Hegar's sign C) Leopold's sign D) Leo's sign Ans: A Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: Chadwick's sign is observed during the speculum examination when the cervix appears more vascular and takes on a bluish hue. It can also occur with ectopic pregnancy.

3. A 22-year-old clerk, primigravida, comes to your office for a prenatal visit. She is in her second trimester and has had prenatal care since she was 8 weeks pregnant. Her only complaint is that she has a new brownish line straight down her abdomen. On examination her vital signs are unremarkable. Her urine has no protein, glucose, or leukocytes. With a Doptone the fetal heart rate is 140, and her uterus is palpated to the umbilicus. Today you are sending her for congenital abnormality screening and setting up an ultrasound.

What physical finding is responsible for her new “brown line”?

A) Corpus luteum B) Linea nigra C) Linea alba D) Diastasis recti Ans: B Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: The linea nigra is a linear hyperpigmented area of skin along the midline of the abdomen. It is caused by the hormonal changes of pregnancy. It is considered normal.

4. A 20-year-old college student comes in with symptoms of fatigue, nausea, and an increase in urination. Her last period was 3 months ago (June 20, 2008). She is sexually active and always uses condoms. Her past medical history is unremarkable. On examination you see a young, anxious-appearing woman. Her vital signs are unremarkable. Her head, eyes, ears, throat, neck,

thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On pelvic examination a soft cervix is palpated and a 14-week-sized uterus is palpated. A urine pregnancy test is positive. You then inform the patient that she is expecting and, using Naegele's rule, give her the estimated date of confinement (EDC, or due date).

What was the due date you gave her?

A) March 27, 2009 B) March 13, 2009 C) September 27, 2009 D) March 20, 2009 Ans: A Chapter: 19 Page and Header: 878, Health Promotion and Counseling Feedback: By Naegele's rule you add 7 days to the last menstrual period and then subtract 3 months. This gives you March 27, 2009.

5. A 19-year-old childcare worker comes to you for her first prenatal visit. She cannot remember when her last period was but thinks it was between 2 and 5 months ago. When she began gaining weight and feeling “something” moving down there, she did a home pregnancy test and it was positive. She states she felt the movement about a week ago. She has had no nausea, vomiting, fatigue, or fevers. Her past medical history is remarkable only for irregular periods. She has been dating the same young man for a year. She says they were not using condoms. On examination you see an overweight young lady appearing her stated age. Her head, eyes, ears, nose, throat, neck, thyroid, cardiac, and pulmonary examinations are unremarkable. Her abdomen is nontender, with normal bowel sounds, and the gravid uterus is palpated to the level of the umbilicus. Fetal tones are easily found with Doptone, and with the fetoscope a faint heart rate of 140 is heard. By speculum examination the cervix is bluish and by bimanual examination the cervix is soft. Results of Pap smear, cultures, and blood work are pending. You give the patient her due date and how far along she is, based on your clinical findings. An OB ultrasound to confirm her dates is ordered.

With only the clinical examination, how many weeks pregnant did you tell this patient she is?

A) 6 to 8 weeks B) 12 to 14 weeks C) 18 to 20 weeks D) 24 to 26 weeks Ans: C Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: Fetal tones can be easily found with Doptone and faintly auscultated with the fetoscope. The uterus is usually at the level of the umbilicus at 20 weeks. First-time mothers usually don't feel fetal movement until 19 to 20 weeks.

6. A 32-year-old attorney comes to your office for her second prenatal visit. She has had two previous pregnancies with uneventful prenatal care and vaginal deliveries. Her only problem was that with each pregnancy she gained 50 lbs (23 kg) and had difficulty losing the weight afterward. She has no complaints today. Looking at her chart, you see she is currently 10 weeks pregnant and that her prenatal weight was 130 lbs (59 kg). Her weight today is 134 lbs (60.9 kg).

Her height is 5'4”, giving her a BMI of 22. Her blood pressure, pulse, and urine tests are unremarkable. The fetal heart tone is difficult to find but is located and is 150. While you give her first trimester education, you tell her how much weight you expect her to gain.

How much weight should this patient gain during pregnancy?

A) Less than 15 pounds (less than 7 kg) B) 15 to 25 pounds (7 to 11.5 kg) C) 25 to 35 pounds (11.5 to 16 kg) D) 30 to 40 pounds (12.5 to 18 kg) Ans: C Chapter: 19 Page and Header: 878, Health Promotion and Counseling Feedback: This is the appropriate amount of weight gain for a person with a normal BMI of 19.8 to 26.0.

7. A 35-year-old bus driver comes to your office for a prenatal visit. She is approximately 28 weeks pregnant and has had no complications. She is complaining only of heartburn and has had no fatigue, headaches, leg swelling, contractions, leakage of fluid, or bleeding. On examination her blood pressure is 142/92 and her urine shows no glucose, protein, or leukocytes. Her weight gain is appropriate, with no large recent increases. Fetal tones are 140 and her uterus measures 32 cm from the pubic bone. Looking back through her chart, you see her prenatal blood pressure was 120/70 and her blood pressures during the first 20 weeks were usually 120 to 130/70 to 80.

What type of blood pressure is this?

A) Normotensive for pregnancy B) Chronic hypertension C) Gestational hypertension D) Preeclampsia Ans: C Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: Gestational hypertension occurs in women who are normotensive before pregnancy and develop systolic pressures over 140 and diastolic pressures over 90 after week 20 of pregnancy. There will be no protein in the urine and no symptoms of preeclampsia such as rapid weight gain, leg edema, or headaches. These patients must be cautioned about symptoms of

preeclampsia and receive aggressive follow-up.

8. A 26-year-old stewardess comes in for a third trimester prenatal visit. She has had prenatal care since her sixth week of pregnancy. She has no complaints today and her prenatal course has been unremarkable. Today her blood pressure and weight gain are appropriate and her urine is unremarkable. You have a first-year medical student shadowing you, so you ask the student to get Doptones and measure the patient's uterus in centimeters. The student promptly reports fetal heart tones of 140, but he is having difficulty obtaining the correct measurement. He knows one end of the tape goes over the uterine fundus.

From what inferior anatomic position should the tape be placed?

A) Vagina B) Clitoris C) Pubic symphysis D) Umbilicus Ans: C Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: In most women, measuring from the symphysis to the uterine fundus is approximately the same and very predictable for dating purposes.

9. A 24-year-old cashier comes to your clinic for her first OB visit. She had her last period 10 weeks before, which would mean she is 12 weeks pregnant. She did a home pregnancy urine test a month ago and it was positive. She has had some fatigue and nausea, but not in the last week.

She has had no cramping or bleeding. Her vital signs, head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are all unremarkable. On speculum examination her os is closed and there is a pinkish hue to the cervix. On bimanual examination the cervix is soft and the uterus is enlarged to the pelvic brim. Despite 20 minutes of trying, you cannot find heart tones. You repeat a urine pregnancy test and it is negative. A serum pregnancy test is ordered and is positive. You send the patient for a vaginal ultrasound.

What is the most likely explanation for her presentation?

A) Earlier than 12 weeks B) Fetal demise (missed abortion) C) False pregnancy Ans: B Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: This patient has lost some of the symptoms of pregnancy, including fatigue and nausea. Also, there are no fetal heart tones despite the 12-week uterus. A negative urine test

indicated decreasing levels of beta HCG of pregnancy, although there is still enough to pick up on the more sensitive serum test.

10. A 26-year-old white female comes to your clinic at 38 weeks, complaining of intermittent contractions. They last for 30 seconds and are coming every 10 minutes. Her prenatal course has so far been uneventful. You send her to labor and delivery for a labor assessment. On vaginal examination she has effaced 4 cm, but you cannot feel a presenting part. You admit her for active labor; however, you wish to assess if she is vertex (baby's head is down), so you do the Leopold's maneuver. Palpating the upper pole with your hands, you feel a firm round mass. Placing your hand along the right side of her abdomen, you feel a smooth firmness. Palpating your other hand along the left side of her abdomen, you feel irregular bumps. Above the pelvic brim you feel a firm irregular mass. While awaiting ultrasound to confirm your diagnosis, you write the pertinent orders.

How is this fetus presenting?

A) Vertex B) Breech C) Transverse Ans: B Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: When a baby is breech you often cannot feel a presenting part with the cervical check. In a breech lie, the irregular firm mass (the buttock) will be at the pelvis, while the firm round mass (the head) will be at the uterine pole.

11. Jeannie is a 24-year-old pregnant woman who asks you today if her frequent urination is normal. Which of the following hormones is most likely responsible for this?

A) TSH B) HCG C) Oxytocin D) Estradiol Ans: B Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: HCG resets the thirst receptors and releases ADH. Estradiol increases prolactin output in the anterior lobe of the pituitary to ready the breasts for lactation. Thyroid output increases in pregnancy, but the free T3 and T4 are kept relatively constant because of the increase in thyroid binding globulin.

12. Which of the following is the major effect of placental hormones?

A) Insulin resistance B) Increased tidal volume C) Relative hypercortisolism, which may trigger labor D) Decreased lower esophageal sphincter tone Ans: A Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: Placental hormones are thought to contribute to insulin resistance. Progesterone increases tidal volume and minute volume. Decreased lower esophageal sphincter tone is due to progesterone and estradiol. Near term, increases in placental CRH and ACTH produce a relative hypercortisolism which may trigger labor.

13. A young woman comes in for a routine wellness examination. You notice that her vaginal walls have deep rugae and are slightly bluish in color. She also has a thicker white discharge.

What should you suspect?

A) Hypoxia B) Varicosities C) Pregnancy D) Sexually transmitted infection Ans: C Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: You should suspect early pregnancy with a bluish discoloration of the vaginal walls and thicker discharge (Chadwick's sign). You may also notice a softening at the isthmus of the uterus on bimanual examination (Hegar's sign). New hypoxia in an otherwise asymptomatic patient would be unusual. While any unusual discharge should make one consider an STI, this is less likely.

14. Mrs. Kelly comes to you for her usual prenatal check-up. You measure the fundal height at 24 cm. What would you estimate the length of her gestation to be?

A) 20 weeks B) 24 weeks C) 28 weeks D) 32 weeks

Ans: B Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: The fundal height is an approximation of the number of weeks of gestation. For a more accurate estimate, see the figure at the top of page 883.

15. A pregnant woman is concerned by the recent onset of a midline swelling. It is soft and nontender. What does this represent?

A) Linea nigra B) Chadwick's sign C) Round ligament pain D) Diastasis recti Ans: D Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: In advanced pregnancy, muscle tone diminishes, which may aid in the separation of the rectus abdominis muscles. This is a benign finding and does not usually cause other symptoms. You may palpate the fetus well through this opening. Linea nigra is a hyperpigmentation along the midline. Chadwick's sign is the bluish tinge to the cervix and vaginal walls seen early in pregnancy, and round ligament pain occurs as the uterus enlarges.

This discomfort is usually found in the right more often than the left.

16. A young mother presents with a pregnancy confirmed by urine HCG. Her LMP was June 20. Using Naegele's rule, you estimate what day of delivery?

A) March 27 B) April 13 C) February 20 D) February 13 Ans: A Chapter: 19 Page and Header: 878, Health Promotion and Counseling Feedback: Naegele's rule calculates the EDD by adding 7 days and subtracting 3 months from the date of the last period.

17. A pregnant woman finally comes in for her prenatal checkup. She complains today of headache and abdominal pain of several months' duration. She appears somewhat hurried or nervous. What question would you ask next?

A) Do you have a family history of thyroid disease?

B) Have you been eating properly and taking a prenatal vitamin?

C) Do you feel safe at home?

D) How much activity have you been able to fit into your schedule?

Ans: C Chapter: 19 Page and Header: 878, Health Promotion and Counseling Feedback: All of these questions are important in interviewing a pregnant woman. This picture may make you think of social problems such as domestic violence and/or substance abuse.

Asking more directed questions in these areas may be fruitful.

18. A woman in her 24th week of pregnancy notices she feels faint when lying down for a period. What would you suspect as a cause for this?

A) Adrenal insufficiency B) Orthostatic hypotension C) Supine hypotensive syndrome D) Hypoglycemia Ans: C Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: It is unusual to become lightheaded in the supine position. The gravid uterus can cause decreased blood return through the inferior vena cava. Orthostatic hypotension as seen in adrenal insufficiency and with moderate dehydration will cause these symptoms in the upright position. Hypoglycemia should not be positional.

19. Lucille is in her 24th week. You notice a new onset of high blood pressure readings.

Today's value is 168/96. Her urine is normal. What do you suspect?

A) Preeclampsia B) Chronic hypertension C) Supine hypotensive syndrome D) Gestational hypertension Ans: D Chapter: 19 Page and Header: 881, Techniques of Examination

Feedback: Because Lucille's BP is greater than 140/90 with onset after the 20th week and no proteinuria, this is gestational hypertension. Chronic hypertension, while the same BP cutoff is used, is present before the 20th week. If this patient had accompanying proteinuria, preeclampsia could be considered. Supine hypotensive syndrome does not cause hypertension.

20. Which of the following is worrisome in Melissa, a woman in her 26th week of pregnancy?

A) Generalized hair loss B) A hyperpigmented rash over the maxillary region bilaterally C) Nosebleeds D) Facial edema Ans: D Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: Generalized hair loss, hyperpigmented maxillary rash (chloasma), and nosebleeds are usually benign and common in pregnancy. Facial edema after the 24th week of gestation may indicate gestational hypertension.

21. A woman in her third trimester complains of shortness of breath on occasion, without other symptoms. She has a normal examination. The most likely cause of this symptom is: A) Hormonal B) Asthma C) Pulmonary embolus D) Infection Ans: A Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: While these other etiologies must be considered in any dyspneic pregnant woman, the lack of other symptoms and findings makes it more likely that this is a hormonal effect of progesterone. Expect a normal respiratory rate and respiratory alkalosis.

22. During cardiac examination you notice a new parasternal systolic murmur of 2/6 intensity.

On palpation, the PMI is slightly higher than usual. What do you suspect?

A) Mammary souffle B) Mitral stenosis C) Mitral regurgitation

D) Aortic insufficiency Ans: A Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: Although a mammary souffle may be diastolic, the murmurs of mitral stenosis and aortic insufficiency cannot be heard in systole. Mitral regurgitation is a possibility, but the upward shift in PMI and lack of other symptoms make this less likely. Any new diastolic murmur should be investigated further.

23. You are examining for fetal heart tones with a fetoscope and are unable to hear any. Using a Doptone, you measure the rate as 164. Which gestational age is most likely?

A) 8 weeks B) 14 weeks C) 20 weeks D) 26 weeks Ans: B Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: With a fetoscope, the fetal heart should be audible starting at about 18 weeks. The Doptone is able to detect this at about 10 weeks. This would put the gestational age at between 10 and 18 weeks.

24. A woman in her 30th week has a cervical length estimated at 1 cm. Should you be concerned?

A) Yes; she may be at risk for preterm labor.

B) Yes; she most likely has a bicornuate uterus.

C) No; this is a normal measurement for this gestational age.

D) Yes; it likely indicates the fetus is in the breech position.

Ans: A Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: A normal cervical length prior to 34 to 36 weeks' gestation is 1.5 to 2 cm. Shorter lengths indicate the patient may be at risk for preterm labor. Cervical lengths do not correlate with the other choices.

25. A woman has a positive pregnancy test and comes to you with left lower quadrant pain. On bimanual examination, you feel a tender mass. Which of the following should you suspect?

A) Threatened abortion B) Appendicitis C) Ovarian cyst D) Tubal pregnancy Ans: D Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: Lower quadrant pain in a young woman could represent any of these possibilities. A positive HCG and left-sided but not right-sided pain make appendicitis less likely. The presence of an extrauterine mass makes threatened abortion less likely.

Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 20: The Older Adult

Multiple Choice

1. Which of the following changes are expected in vision as part of the normal aging process?

A) Cataracts B) Glaucoma C) Macular degeneration D) Blurring of near vision Ans: D Chapter: 20 Page and Header: 918, Techniques of Examination Feedback: The lens loses its elasticity over time as part of the normal aging process, and the eye is less able to accommodate and focus on near objects; therefore, the patient will be expected to have blurring of near vision.

2. A 72-year-old retired truck driver comes to the clinic with his wife for evaluation of hearing loss. He has noticed some decreased ability to hear what his wife and grandchildren are saying to him. He admits to lip-reading more. He has a history of noise exposure in his young adult years: He worked as a sound engineer at a local arena and had to attend a lot of concerts. Based on this information, what is the most likely finding regarding his hearing acuity?

A) Loss of acuity for middle-range sounds B) Increase of acuity for low-range sounds C) Loss of acuity for high-range sounds D) Increase of acuity for high-range sounds Ans: A Chapter: 20 Page and Header: 896, Anatomy and Physiology Feedback: Human speech is considered to be a middle-range sound. During the aging process there is a loss of acuity, starting with high-pitched sounds but extending to the middle range and then into the low range.

3. A 79-year-old retired banker comes to your office for evaluation of difficulty with urination; he gets up five to six times per night to urinate and has to go at least that often in the daytime. He does not feel as if his bladder empties completely; the strength of the urinary stream is diminished. He denies dysuria or hematuria. This problem has been present for several years but has worsened over the last 8 months. You palpate his prostate. What is your expected physical examination finding, based on this description?

A) Normal size, smooth B) Normal size, boggy C) Enlarged size, smooth D) Enlarged size, boggy Ans: C Chapter: 20 Page and Header: 899, Anatomy and Physiology Feedback: This is the expected physical examination finding in benign prostatic hyperplasia (BPH).

4. A 70-year-old retired auto mechanic comes to your office because his neighbor is concerned about his memory. The patient himself admits to misplacing his keys more often and forgets what he is supposed to buy from the grocery store and where he has parked the car. He denies getting lost in familiar places. Upon further questioning, he states that his wife of 40 years died 8 months ago; his three children live in three different states; and he has limited his activities because the

people he interacted with were “his wife's friends, not his.” He drinks a six-pack of beer daily; he does not smoke or use illicit drugs. You perform a mini-mental state examination and obtain a total score of 24 out of 28. Based on this information, what is your most likely diagnosis?

A) Benign forgetfulness B) Dementia C) Meningitis D) Depression Ans: D Chapter: 20 Page and Header: 911, Health Promotion and Counseling Feedback: The patient has symptoms of depression: His wife died, he has no real social support system, and he has isolated himself from his usual activities. He also drinks a considerable amount of alcohol on a daily basis, which can further depress his mood. Depression can masquerade as dementia in the elderly and must be considered in a patient with memory loss.

5. An 85-year-old retired teacher comes to your office for evaluation of weakness. You obtain a complete history, perform a thorough physical examination, and order laboratory tests. You diagnose her with hyperthyroidism. Based on her age, which of the atypical symptoms of hyperthyroidism is more likely to be seen?

A) Fatigue B) Weight loss C) Tachycardia D) Anorexia Ans: D Chapter: 20 Page and Header: 903, The Health History Feedback: This is an atypical symptom of hyperthyroidism that is more likely to be seen in the older patient.

6. A 78-year-old retired seamstress comes to the office for a routine check-up. You obtain an ECG (electrocardiogram) because of her history of hypertension. You diagnose a previous myocardial infarction and ask her if she had any symptoms related to this. Which of the following symptoms would be more common in this patient's age group for an acute myocardial infarction?

A) Chest pain B) Syncope C) Pain radiating into the left arm D) Pain radiating into the jaw

Ans: B Chapter: 20 Page and Header: 903, The Health History Feedback: This is an atypical symptom and more likely to be seen in this patient's age group.

7. An 88-year-old retired piano teacher comes for evaluation of fatigue. You notice that her clothes are hanging loosely off her frame and that she has lost 15 pounds. She is unaware of this.

Her husband of 63 years died a few months ago. You ask the patient to complete a Rapid Screen for Dietary Intake. Which of the following statements is considered to be part of this rapid screen?

A) I eat more than two meals per day.

B) I drink one glass of alcohol every day.

C) Without wanting to, I have lost or gained 10 pounds in the last 6 months.

D) I eat with at least one other person most of the time.

Ans: C Chapter: 20 Page and Header: 906, The Health History Feedback: This is part of the Rapid Screen for Dietary Intake.

8. An 89-year-old retired school principal comes for an annual check-up. She would like to know whether or not she should undergo a screening colonoscopy. She has never done this before. Which of the following factors should not be considered when discussing whether she should go for this screening test?

A) Life expectancy B) Time interval until benefit from screening accrues C) Patient preference D) Current age of patient Ans: D Chapter: 20 Page and Header: 909, Health Promotion and Counseling Feedback: The current age of the patient is not as important as her actual life expectancy and current health status.

9. Which of the following booster immunizations is recommended in the older adult population?

A) Tetanus B) Diphtheria C) Measles D) Mumps Ans: A Chapter: 20 Page and Header: 909, Health Promotion and Counseling Feedback: Older adults who have received the primary series of three tetanus immunizations should receive the single booster dose of tetanus immunization every 10 years.

10. You are asked to perform a home safety assessment for an 87-year-old retired farmer who lives by himself. Which of the following is not considered to be an increased risk for falls?

A) Loose electrical cords B) Slippery or irregular surfaces C) Chairs at awkward angles D) Bright lighting Ans: D Chapter: 20 Page and Header: 911, Health Promotion and Counseling Feedback: Bright lighting is a recommendation to improve an older person's ability to see all possible things that could result in a fall.

11. A 73-year-old retired accountant comes to your office for her annual examination. She has incontinence of urine when she coughs or sneezes. She takes several medications for control of hypertension and diabetes. You use the DIAPERS mnemonic to assess the cause of her incontinence. All of the following are items represented by the mnemonic except for: A) Atrophic vaginitis B) Depression C) Pharmaceuticals D) Restricted mobility Ans: B Chapter: 20 Page and Header: 913, Techniques of Examination Feedback: Depression is not a risk factor for incontinence. The D in the mnemonic stands for delirium.

12. Which of the following brief screening measures is useful in assessing memory?

A) Three-item recall B) Serial 7s C) Spelling “world” backward D) Copying intersecting pentagrams Ans: A Chapter: 20 Page and Header: 913, Techniques of Examination Feedback: If the patient is unable to remember three items after 1 minute has passed, then this is a positive screening test and indicates a need for further testing. This is part of the “10-Minute Geriatric Screener.”

13. Which of the following questions is part of the screening for physical disability?

A) Are you able to go shopping for groceries or clothes?

B) Are you able to walk one block?

C) Are you able to pass the driver's license test?

D) Are you able to perform light dusting and pick up after yourself around the house?

Ans: A Chapter: 20 Page and Header: 914, Techniques of Examination Feedback: This is part of the Physical Disability screening portion of the 10-Minute Geriatric Screener.

14. It is summer and an 82-year-old woman is brought to you from her home after seeing her primary care doctor 2 days ago. She was started on an antibiotic at that time. Today, she comes to the emergency room not knowing where she is or what year it is. What could be a likely cause of this?

A) Alzheimer's dementia B) Stroke C) Delirium D) Meningitis Ans: C Chapter: 20 Page and Header: 931, Table 20-2 Feedback: These are not signs of normal aging and seem to be of acute onset. This makes

Alzheimer's less likely. Stroke and meningitis could cause these symptoms as well, but the combination of the heat and a recent infection make delirium much more likely. Though she was prescribed an antibiotic, she may not have improved because of bacterial resistance or because of noncompliance due to cost, depression, or even an underlying mild dementia. Dementia should not result in an acute mental status change, although illness may cause a worsening of dementia.

15. Blood pressure abnormalities found more commonly in Western elderly include which of the following?

A) Isolated elevation of the diastolic BP B) Narrow pulse pressure C) Elevation of the systolic BP D) Elevation of the BP with standing Ans: C Chapter: 20 Page and Header: 895, Anatomy and Physiology Feedback: Isolated systolic hypertension is common in the elderly because of stiffening of the large arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP changes are often seen with postural changes and can account for falls as well.

16. Which of the following represents age-related changes in the lungs?

A) Decrease in chest wall compliance B) Speed of expiration increases C) Increase in respiratory muscle strength D) Increased elastic recoil of lung tissue Ans: A Chapter: 20 Page and Header: 897, Anatomy and Physiology Feedback: The lungs age along with the rest of the body. These changes include decreased lung and chest wall compliance, increased expiratory time, decreased muscle strength and cough, and decreased elastic recoil.

17. Mrs. Stanton is a 79-year-old widow who presents to your office for a routine BP visit. You note a new pulsatile mass in the right neck at the carotid artery. Which of the following is the most likely cause for this?

A) Anxiety

B) Carotid artery aneurysm C) Kinking of the artery D) Tortuous aorta Ans: C Chapter: 20 Page and Header: 897, Anatomy and Physiology Feedback: While a carotid artery aneurysm is a possibility, it is more likely due to kinking of the carotid artery in this patient with HTN. A tortuous aorta will sometimes cause elevation of the left jugular vein by impairing drainage within the thorax.

18. Mr. Chin is an 82-year-old man who comes to your office for a routine check. On examination, you notice a somewhat high-pitched murmur in the second right intercostal space during systole. It does not radiate and the rest of his examination is normal for his age. Which is true of the most likely cause of this murmur?

A) It often decreases carotid upstroke.

B) It carries with it increased risk for cardiovascular disease.

C) It is usually accompanied by an S3 gallop.

D) It is found in 10% of otherwise normal elderly patients.

Ans: B Chapter: 20 Page and Header: 898, Anatomy and Physiology Feedback: This murmur most likely represents aortic sclerosis, a common murmur affecting about one third of those near 60 years of age. It is caused by calcification of the valve and is associated with cardiovascular risk. Aortic sclerosis does not usually cause obstruction to normal flow, so carotid upstroke should be normal, and it is not associated with an S3 gallop.

19. Mrs. Buckley is a 75-year-old widow who wants you to look at her teeth because over the past 2 weeks she has had right-sided jaw pain when eating. It does not occur otherwise. She also has had a headache. Which of the following should be considered?

A) Palpation of her temples B) Dental referral C) Ultrasound of the gallbladder D) Inquiry about anosmia Ans: A Chapter: 20 Page and Header: 898, Anatomy and Physiology Feedback: This story can be consistent with temporal arteritis, which can cause blindness in

15% of those affected. Early recognition is crucial. Most of these patients will have tenderness over one or both of the temporal arteries, and some have diminished temporal pulses as well.

Early treatment with corticosteroids is indicated. It can also be associated with polymyalgia rheumatic, a condition which causes pain in the shoulder girdles and pelvis.

20. Which of the following is commonly seen in aging men?

A) Erectile dysfunction in 20% of all men B) Testicles ride higher within the scrotum C) Strong response to visual erotic cues D) Persistent sexual interest Ans: D Chapter: 20 Page and Header: 899, Anatomy and Physiology Feedback: Erectile dysfunction affects about half of elderly men but sexual interest generally remains intact. A decrease in sexual interest may indicate other problems such as depression.

Visual cues become less important and tactile stimulation more important. The testicles are positioned lower in the scrotum.

21. Which of the following accompanies decreased ovarian function?

A) Increased sleep B) Diminution of sexual interest C) Enlargement of the clitoris D) Decrease in vaginal secretions Ans: D Chapter: 20 Page and Header: 899, Anatomy and Physiology Feedback: Menopause, or the cessation of menses for 1 year, commonly occurs in the late 40s to early 50s. Many experience hot flashes, sweating, chills, anxiety, decreased sleep, and urge incontinence. Dyspareunia is common secondary to decreased vaginal secretions. Sexual interest does not normally decrease. The clitoris and length of the vaginal vault decrease in response to decreased estrogen.

22. You are examining an elderly man and notice the following: decreased vibration sense in the feet and ankles, diminished gag reflex, right patellar reflex less than the left, and diminished abdominal reflexes. Which of these is abnormal?

A) Decreased vibration sense B) Diminished gag reflex C) Diminished right patellar reflex compared to the left D) Diminished abdominal reflexes Ans: C Chapter: 20 Page and Header: 901, Anatomy and Physiology Feedback: Asymmetry on any examination is usually reason for concern. The other changes are commonly associated with aging. You may consider looking for other neurologic signs on the right, although occasionally you may mistake an abnormally brisk reflex to be normal when compared to the other side. It is usually a good idea to question whether the opposite side is actually the abnormal one when you find asymmetry on examination.

23. Mrs. Glynn is 90 years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living?

A) Bathing B) Dressing C) Preparing food D) Transferring from bed to chair Ans: C Chapter: 20 Page and Header: 906, The Health History Feedback: Instrumental activities of daily living involve higher thought processes such as preparing food, whereas bathing, dressing, and transferring are considered physical activities of daily living.

24. Mr. Kelly comes to you today for a burning pain in his lower abdomen. This has gone on for 2 months. He has received radiation for prostatic cancer for the past quarter. What assumptions could you draw from this?

A) This represents persistent pain.

B) His pain reporting is likely to be unreliable.

C) There are “red flags” present.

D) He is depressed.

Ans: C Chapter: 20

Page and Header: 906, The Health History Feedback: This scenario is consistent with acute pain, although this may become persistent if it lasts beyond 3 months. The burning quality to the pain should be a red flag, along with descriptions of pain as “discomfort” or “soreness.” Depressed affect or changes in posture or gait are also red flags. Studies have found that pain reporting in the elderly is accurate.

Although depression may be present, we have no indications of it in this scenario.

25. Mr. White's son brings him in today because he notes that Mr. White has not been himself lately. He seems forgetful and has not taken care of himself as he normally does. He has reported falling twice at home to his son and has telephoned late at night because of insomnia.

His blood pressure and diabetes have been difficult to control and his warfarin dosing has become more difficult. Which of the following should you suspect?

A) Alzheimer's dementia B) Alcohol use C) Urinary tract infection D) Stroke Ans: B Chapter: 20 Page and Header: 908, The Health History Feedback: All of these answers are common diseases of the elderly and many have atypical presentations in this age group. The fact that his hypertension has become more difficult to control and his warfarin dosing is challenging to manage should lead you to consider that there is alcohol use. Further questioning, quantifying his use of alcohol, and application of the CAGE questionnaire may be useful.

26. Claire's daughter brings her in today after Claire fell at her home. Which assessments are indicated at this time?

A) Orthostatic vital signs B) Review of her medications C) Assessment of gait and balance D) All of the above Ans: D Chapter: 20 Page and Header: 913, Techniques of Examination Feedback: Falls are common in the elderly and can often result in serious injuries. When assessing the cause of falls, gait and balance should be checked first. Medication, particularly use of more than three, is associated with falls. Vision problems, lower-limb joint problems, and cardiovascular problems such as arrhythmias may be reasonable to search for. Orthostatic vital

sign changes should be sought.

27. Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar aspects of her forearms and on her abdomen. She otherwise has no complaints and her diabetes and hypertension are well managed. Her son from out of state accompanies her today and has recently moved in to help her. What should you suspect?

A) Overuse of aspirin B) Frequent falls C) Elder abuse D) Depression Ans: C Chapter: 20 Page and Header: 912, Health Promotion and Counseling Feedback: The different colors of the bruising indicate that they have occurred at different times and are unlikely to have resulted from a single fall. The location of the bruising on the ulnar aspects of the forearms potentially indicates that she was trying to defend herself and are not typical areas to be bruised by a fall. Depression may be evident, but this is more likely to be a result rather than a cause of her situation today. While nothing is proven, it would be wise to interview her without her son in the room. If in doubt, a social worker consult may be helpful to determine if elder abuse is occurring.

28. A patient comes to you for the appearance of red patches on his forearms that have been present for several months. They remain for several weeks. He denies a history of trauma.

Which of the following is likely?

A) Actinic keratoses B) Pseudoscars C) Actinic purpura D) Cherry angiomas Ans: C Chapter: 20 Page and Header: 917, Techniques of Examination Feedback: Actinic purpura is a common benign skin condition of the elderly, frequently involving the forearms. Pseudoscars are white patches and cherry angiomas are bright-red raised lesions usually found on the torso. Actinic keratoses are lesions resembling nevi, often with features which would be concerning if considering melanoma (review the ABCDEs of melanoma), but they produce a slightly greasy scale when scratched with a nail.

29. On routine screening you notice that the cup-to-disc ratio of the patient's right eye is 1:2.

What ocular condition should you suspect?

A) Macular degeneration B) Diabetic retinopathy C) Hypertensive retinopathy D) Glaucoma Ans: D Chapter: 20 Page and Header: 918, Techniques of Examination Feedback: This cup-to-disc ratio means that the cup takes up 50% of the disc, which is abnormally large. This is usually an indication of glaucoma, which is a common cause of visual loss in the elderly. The cup-to-disc changes are not seen in diabetes, hypertension, or macular degeneration. Many elderly do not have regular eye examinations and are not screened for glaucoma.

30. Which of the following is true of assessment of the vascular system in the elderly?

A) Fewer than one third of patients with peripheral vascular disease have symptoms of claudication.

B) An aortic width of 2.5 cm is abnormal.

C) Bruits are commonly benign findings.

D) Orthostatic blood pressure and pulse are not useful in this population.

Ans: A Chapter: 20 Page and Header: 921, Techniques of Examination Feedback: It is the minority of patients with peripheral vascular disease who experience claudication; therefore, ankle–brachial ratios should be performed more frequently. The aorta should be 3 cm or less. Bruits usually indicate pathology, and even when there is not a significant blockage, the risk of vascular disease throughout the body is increased. Orthostatic vital signs are very useful in this population. Remember to observe the pulse as well, as failure of the heart to increase its rate is a common cause of orthostatic hypotension. This can occur as a result of autonomic neuropathy or medications such as beta-blockers, among other causes.