Test Bank For Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses 4th E

Test Bank For Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses 4e by Mary Jo Goolsby EdD MSN NP-C FAANP (Author), Laurie Grubbs PhD ARNP-C (Author) Chapter 1-22

Chapter 1. Assessment and Clinical Decision Making: An Overview

MULTIPLE CHOICE

1. Which type of clinical decision making is most reliable?

A. Analytical I B. Augenblink C. Experiential D. Intuitive ANS: A Croskerry (2009) describes two major types of clinical diagnostic decision making: intuitive and analytical. Intuitive decision making (similar to Augenblink decision making) is based on the experience and intuition of the clinician and is less reliable and paired with fairly common errors. In contrast, analytical decision making is based on careful consideration and has greater reliability with rare errors.

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2. You are using the PQRST approach while completing the history of present illness for a patient complaining of pain. Which of the following questions is relevant to the ―P‖ portion of this approach?

A. How would you describe your pain?

B. Can you point to the area of most severe pain?

C. How has your pain changed since you first noticed it?

D. What makes the pain worse or better?

ANS: D In the PQRST model, ―P‖ refers to exploring precipitating and palliative factors. Identify factors that make the symptom worse and/or better, any previous self-treatment or prescribed treatment, and response.

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3. Essential parts of a health history include all of the following except: A. Chief complaint B. Current vital signs C. History of the present illness D. Review of systems ANS: B Vital signs are part of the physical examination portion of patient assessment, not part of the health history.

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4. While reading an article on hypothyroidism, you find a helpful graphic depiction of the decision-making process recommended by the authors to find a definitive diagnosis. This graphic is an example of: A. A clinical prediction tool B. Clinical guidelines C. A decision tree D. A diagnostic finding guide ANS: C Clinical decision trees provide a graphic depiction of the decision-making process, showing the pathway based on findings at various steps in the process.

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5. Which of the following is the least reliable source of information for diagnostic statistics?

A. Evidence-based investigations B. Primary reports of research C. Estimation based on a provider’s experience D. Published meta-analyses ANS: C Sources for diagnostic statistics include textbooks, primary reports of research, and published meta-analyses. Another source of statistics, the one that has been most widely used and available for application to the reasoning process, is the estimation based on a provider’s experience, although these are rarely accurate. Over the past decade, the availability of evidence on which to base clinical reasoning is improving, and there is an increasing expectation that clinical reasoning be based on scientific evidence.

Evidence-based statistics are also increasingly being used to develop resources to facilitate clinical decision making.

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6. Which of the following can be used to assist in sound clinical decision making?

A. An algorithm published in a peer-reviewed journal article B. Clinical practice guidelines C. Evidence-based research D. All of the above ANS: D To assist in clinical decision making, a number of evidence-based resources have been developed to assist the clinician. Resources, such as algorithms and clinical practice guidelines, assist in clinical reasoning when properly applied.

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7. If a diagnostic study has high sensitivity, this indicates: A. A high percentage of persons with the given condition will have an abnormal result B. A high percentage of persons without the condition will have inconclusive results C. A low likelihood of normal result in persons without a given condition D. A low percentage of persons with the given condition will have an abnormal result ANS: A The sensitivity of a diagnostic study is the percentage of individuals with the target condition who show an abnormal, or positive, result. A high sensitivity indicates that a greater percentage of persons with the given condition will have an abnormal result.

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8. If a diagnostic study has high specificity, this indicates: A. A low percentage of healthy individuals will show a normal result B. A high percentage of healthy individuals will show a normal result C. A high percentage of individuals with a disorder will show a normal result D. A low percentage of individuals with a disorder will show an abnormal result ANS: B The specificity of a diagnostic study is the percentage of normal, healthy individuals who have a normal result. The greater the specificity, the greater the percentage of individuals who will have negative, or normal, results if they do not have the target condition.

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9. A likelihood ratio above 1 indicates that a diagnostic test showing a: A. Positive result is strongly associated with the disease B. Negative result is strongly associated with absence of the disease C. Positive result is weakly associated with the disease D. Negative result is weakly associated with absence of the disease

ANS: A The likelihood ratio is the probability that a positive test result will be associated with a person who has the target condition and a negative result will be associated with a healthy person. A likelihood ratio above 1 indicates that a positive result is associated with the disease; a likelihood ratio less than 1 indicates that a negative result is associated with an absence of the disease.

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10. Which of the following clinical reasoning tools is defined as an evidence-based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients?

A. Clinical practice guideline B. Clinical decision rule C. Clinical algorithm D. Clinical recommendation ANS: B Clinical decision (or prediction) rules provide another support for clinical reasoning.

Clinical decision rules are evidence-based resources that provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met with regard to the prognosis of patients with specific findings. Decision rules use mathematical models and are specific to certain situations, settings, and/or patient characteristics.

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Chapter 2. Genomic Assessment: Interpreting Findings and Formulating Differential Diagnosis

MULTIPLE CHOICE

1. The first step in the genomic assessment of a patient is obtaining information regarding: A. Family history B. Environmental exposures C. Lifestyle and behaviors D. Current medications ANS: A A critical first step in any health assessment is collecting and interpreting the family health history (FHH). FHH is key because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury, 2003).

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2. An affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained is called a(n): A. Consultand B. Consulband C. Index patient D. Proband ANS: D A proband is a family member who manifests symptoms of a particular condition and/or brings the family to medical attention (Bennett, 2010).

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3. An autosomal dominant (AD) disorder involves the: A. X chromosome B. Y chromosome C. Mitochondrial DNA D. Non-sex chromosomes ANS: D AD inheritance is a result of a gene mutation in one of the 22 autosomes.

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4. To illustrate a union between two second cousin family members in a pedigree: A. Arrows are drawn pointing to the male and female B. Brackets are drawn around the male and female C. Double horizontal lines are drawn between the male and female D. Circles are drawn around the male and female ANS: C A consanguineous family is related by descent from a common ancestry and is defined as a ―union between two individuals who are related as second cousins or closer‖ (Hamamy, 2012). Consanguinity, if present in the family history, is portrayed using two horizontal lines to establish the relationship between the male and female partners.

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5. To illustrate two family members in an adoptive relationship in a pedigree: A. Arrows are drawn pointing to the male and female B. Brackets are drawn around the male and female C. Double horizontal lines are drawn between the male and female D. Circles are drawn around the male and female ANS: B For adopted members of the family, use brackets as the appropriate standardized pedigree symbol.

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6. When analyzing the pedigree for autosomal dominant (AD) disorders, it is common to see: A. Several generations of affected members B. Many consanguineous relationships C. More members of the maternal lineage affected than the paternal D. More members of the paternal lineage affected than the maternal ANS: A Pedigrees associated with AD disorders typically reveal multiple affected family members with the disease or syndrome. When analyzing the pedigree for AD disorders or syndromes, it is common to see a vertical pattern denoting several generations of affected members.

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7. In autosomal recessive (AR) disorders, individuals need: A. Only one mutated gene on the sex chromosomes to acquire the disease

B. Only one mutated gene to acquire the disease C. Two mutated genes to acquire the disease D. Two mutated genes to become carriers ANS: C In AR disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents. AR disorders must be inherited through both parents (Nussbaum et al., 2016). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease.

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8. In autosomal recessive (AR) disorders, carriers have: A. Two mutated genes: one from each parent that causes disease B. A mutation on a sex chromosome that causes a disease C. A single gene mutation that causes the disease D. One copy of a gene mutation but not the disease ANS: D Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome.

Carriers typically are not affected by the disease. In pedigrees with an AR inheritance pattern, males and females will be equally affected because the gene mutation is on an autosome.

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9. With an autosomal recessive (AR) disorder, it is important that parents understand that if they both carry a mutation, the following are the risks to each of their offspring (each pregnancy): A. 50% chance that offspring will carry the disease B. 10% chance that offspring will be affected by the disease C. 25% chance that offspring will carry the disease D. 10% chance that offspring will be disease free ANS: A It is important that parents understand that if they both carry a mutation, the risk to each of their offspring (each pregnancy) is an independent event: 25% disease free, 25% affected, and 50% carrier.

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10. A woman with an X-linked dominant disorder will: A. Not be affected by the disorder herself B. Transmit the disorder to 50% of her offspring (male or female) C. Not transmit the disorder to her daughters D. Transmit the disorder to only her daughters ANS: B Everyone born with an X-linked dominant disorder will be affected by the disease.

Transmission of the disorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female).

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11. In creating your female patient’s pedigree, you note that she and both of her sisters were affected by the same genetic disorder. Although neither of her parents had indications of the disorder, her paternal grandmother and her paternal grandmother’s two sisters were affected by the same condition. This pattern suggests: A. Autosomal dominant disorder B. Chromosomal disorder C. Mitochondrial DNA disorder D. X-linked dominant disorder ANS: D A man with an X-linked dominant disorder will transmit the mutation to 100% of his daughters (they receive his X chromosome) and none of his sons (they receive his Y chromosome). The pedigree of a family with an X-linked dominant disorder would reveal all the daughters and none of the sons affected by the disorder if the father has an X-linked disorder.

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12. A woman affected with an X-linked recessive disorder: A. Has one X chromosome affected by the mutation B. Will transmit the disorder to all of her children C. Will transmit the disorder to all of her sons D. Will not transmit the mutation to any of her daughters ANS: C An X-linked recessive disorder means that in a woman, both X chromosomes must have the mutation if she is to be affected. Because males have only one copy of the X chromosome, they will be affected if their X chromosome carries the mutation.

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13. Which of the following are found in an individual with aneuploidy?

A. An abnormal number of chromosomes B. An X-linked disorder C. Select cells containing abnormal-appearing chromosomes D. An autosomal recessive disorder ANS: A An individual with an abnormal number of chromosomes has a condition called aneuploidy, which is frequently associated with mental problems or physical problems or both (Jorde et al., 2015; Nussbaum et al., 2016).

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14. The pedigree of a family with a mitochondrial DNA disorder is unique in that: A. None of the female offspring will have the disease B. All offspring from an affected female will have the disease C. None of the offspring of an affected female will have the disease D. All offspring from an affected male will have the disease ANS: B Mitochondrial DNA is inherited from the ovum and, therefore, from the mother. The pedigree of a family with a mitochondrial DNA disorder is unique in that all offspring (regardless of gender) of an affected female will have the disease, and none of the offspring from an affected male will have the disease.

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15. Which population is at highest risk for the occurrence of aneuploidy in offspring?

A. Mothers younger than age 18 B. Fathers younger than age 18 C. Mothers older than age 35 D. Fathers older than age 35 ANS: C Some individuals or couples have unique identifiable risks that should be discussed prior to conception whenever possible. For example, women who will be 35 years of age or older at delivery (advanced maternal age) are at increased risk for aneuploidy.

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16. Approximately what percentage of cancers are due to a single-gene mutation?

A. 50% to 70% B. 30% to 40%

C. 20% to 25% D. 5% to 10% ANS: D The majority of cancers are sporadic or multifactorial due to a combination of genetic and environmental factors; however, approximately 5% to 10% of all cancers are due to a single-gene mutation (Garber & Offit, 2005).

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17. According to the Genetic Information Nondiscrimination Act (GINA): A. Nurse practitioners (NPs) should keep all genetic information of patients confidential.

B. NPs must obtain informed consent prior to genetic testing of all patients.

C. Employers cannot inquire about an employee’s genetic information.

D. All of the above ANS: D On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based on their genetic information when it comes to health insurance and employment, paving the way for patient-personalized genetic medicine without fear of discrimination (National Human Genome Research Institute, 2012).

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18. The leading causes of death in the United States are due to: A. Multifactorial inheritance B. Single gene mutations C. X-linked disorders D. Aneuploidy ANS: A Most disease-causing conditions are not due to a single-gene disorder, but to multifactorial inheritance, a result of genomics and environmental or behavioral influences. In fact, the leading causes of mortality in the United States—heart disease, cerebrovascular disease, diabetes, and cancer—are all multifactorial. Most congenital malformation, hypertension, arthritis, asthma, obesity, epilepsy, Alzheimer’s disease, and mental health disorders are also multifactorial.

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19. Which of the following would be considered a red flag that requires more investigation in a patient assessment?

A. Colon cancer in family member at age 70 B. Breast cancer in family member at age 75 C. Myocardial infarction in family member at age 35 D. All of the above ANS: C Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders.

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20. When patients express variable forms of the same hereditary disorder this is due to: A. Penetrance B. Aneuploidy C. De novo mutation D. Sporadic inheritance ANS: A Some disorders have a range of expression from mild to severe. This variability is referred to as the penetrance of genetic disease. For example, patients with neurofibromatosis (NF1), an AD disorder of the nervous system, may manifest with many forms of the disease. For instance, some patients with NF1 may have mild symptoms, like café au lait spots or freckling on the axillary or skin, while others may have life-threatening spinal cord tumors or malignancy (Jorde et al., 2015; Nussbaum et al., 2016).

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Chapter 3. Skin

MULTIPLE CHOICE

1. When a patient presents with a skin-related complaint, it is important to first: A. Fully inspect all skin lesions before asking the patient how the lesion in question developed B. Obtain a full history about the development of the skin lesion prior to the physical examination C. Complete a full physical examination of the body prior to inspecting the skin lesion D. Examine the skin lesion without hearing a health history in order to not prejudice the diagnosis ANS: B

When a patient presents with a skin-related complaint, there is an inclination to immediately examine the skin, as the lesion or change is often readily observable. However, it is crucial to obtain a history before proceeding to the examination in order to understand the background of the problem. A thorough symptom analysis is essential.

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2. Jaundice is a state of high bilirubin in the bloodstream. It is most commonly seen first in the: A. Sclera B. Nail beds C. Palms of the hands D. Unexposed skin areas ANS: A Jaundice indicates an elevation in bilirubin and often is evident in the sclera and mucous membranes before it is obvious in the skin.

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3. Skin turgor is best assessed by pinching skin over the: A. Forehead B. Forearm C. Knees D. Dorsum of the hand ANS: B The skin overlying the forehead or dorsal hand is more likely to provide a false impression of tenting or decreased elasticity; therefore, turgor should be tested by gently pinching a fold of skin over the abdomen, forearm, or sternum.

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4. What kind of lesions are caused by the herpes simplex virus?

A. Scales B. Vesicles C. Plaques D. Urticaria ANS: B The skin lesions of herpes consist of multiple vesicles that cluster and are usually preceded by an area of tender erythema. The vesicles erode, forming ulcerations.

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5. A patient presents with vesicles on a reddened base in a symmetrical pattern on the lower neck and upper back, stating that he had noticed discomfort prior to the onset of the rash.

Which of the following should be considered in your differential diagnosis?

A. Dermatitis herpetiformis B. Herpes zoster C. Dyshidrosis D. Contact dermatitis ANS: A Pruritus, burning, or stinging at the site often precedes the development of skin lesions. The lesions consist of clustered vesicles on a reddened base. The lesions have a herpetiform configuration, and the distribution is symmetrical. The extensor surfaces of the knees and elbows are often affected, as are the posterior scalp, neck, back, and thighs.

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6. Herpetic whitlow is commonly located on: A. The eyelid B. The scalp C. A finger D. The lip ANS: C Herpetic whitlow, a herpetic lesion on the finger, is usually a result of self-contamination of an infected patient to a skin break on the finger.

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7. Which type of lesion is referred to as resembling a dewdrop on a rose petal?

A. Varicella zoster B. Measles C. Rubella D. Tinea ANS: A Similar to other herpes lesions, varicella lesions progress from an area of redness to form a vesicle, then become pustular, and finally ulcerate. The vesicles look like a dewdrop on a rose petal.

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8. Which lesions are typically located along the distribution of dermatome?

A. Scabies B. Herpes zoster C. Tinea D. Dyshidrosis ANS: B The distribution of herpes zoster lesions lies along a dermatome and is typically unilateral.

There are many variations of the condition, depending on the affected dermatome. The healing of the lesions is frequently followed by development of postherpetic neuralgia.

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9. Folliculitis is most commonly due to: A. Contact dermatitis B. Varicella zoster C. Dermatophytes D. Staphylococcal infection ANS: D Folliculitis is an inflammation of the hair follicles and is typically associated with staphylococci. Other microorganisms and causes include pseudomonas (associated with hot tubs), Candida, tinea barbae, and herpes.

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10. A patient presents with polymorphous lesions consisting of small red papules and vesicles, with a few eroded and crusted lesions. Your differential diagnosis should include all of the following except: A. Herpes simplex B. Varicella C. Bacterial folliculitis D. Contact dermatitis ANS: C While all of the conditions listed may progress from papules to erosive crusted lesions, folliculitis is associated with pustules, rather than vesicles.

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11. Which of the following has been associated with cervical and anal cancer?

A. Secondary syphilis B. Human papilloma virus C. Herpes simplex

D. Epstein-Barr virus ANS: B Human papilloma virus (HPV) is a viral cause of wart formation. In the perineal area, these are known as genital warts and can lead to cancer of the cervix or anus.

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12. During a routine examination, you notice a 5 mm lesion on the right medial cheek. The border is raised and pearlescent in color, and the area is crusted. The patient admits that it has been present for several months and has only recently become tender with the development of the crusting. This is most likely: A. Squamous cell carcinoma B. Epidermoid cyst C. Basal cell carcinoma D. Actinic keratosis ANS: C Basal cell carcinoma is the most common form of human malignancy and involves sun-exposed skin. This malignancy is generally very slow growing. However, it can become quite destructive and invasive if not diagnosed and treated in a timely manner. The typical complaint is of a nonhealing sore located on the face, ear, or other sun-exposed area.

Although the lesions can vary, the typical lesion has a waxy/pearly appearance with a central indentation.

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13. A patient has a tender, firm, nodular cystic lesion on his scalp that produces cheesy discharge with foul odor. This is most likely: A. Bacterial folliculitis B. Basal cell carcinoma C. Bullous impetigo D. An epidermoid cyst ANS: D With an epidermoid cyst, the patient complains of a cystic lesion that produces cheesy discharge with foul odor. The lesion is sometimes tender or painful. The lesion is nodular, round and firm, and subcutaneous; thus, it is flesh colored. The most common sites include the face, scalp, neck, upper trunk, and extremities.

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14. Which of the following is not associated with development of erythema multiforme?

A. Herpes virus

B. Mycoplasma infections C. Medications D. Trauma ANS: D Erythema multiforme major usually occurs in association with herpes or mycoplasma infection, or in response to medications, although a range of infections is implicated.

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15. Your patient complains of a progressive loss of pigment in various patches on the body.

Affected skin surfaces are otherwise normal (i.e., no scaling, vesicles, elevation, or other changes). The most likely cause is: A. Vitiligo B. Acanthosis nigricans C. Psoriasis D. Pityriasis alba ANS: A With vitiligo, the patient often describes a history of the progressive development of small, multiple areas of depigmentation that, over time, become larger and confluent. There is no overlying scale or vesicle development. Any area of skin can be involved. The hair in the affected area may also lose pigmentation. There is a higher incidence of vitiligo in patients with autoimmune disorders, particularly those affecting the endocrine system, including hypothyroidism, diabetes mellitus, and Addison’s disease.

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16. A patient has an irregularly shaped, brown to black lesion on the upper arm that has changed color recently. The widest diameter is 6 mm. You should: A. Measure and record the dimensions and schedule follow-up to repeat measurement in 2 weeks B. Biopsy the lesion C. Obtain skin scraping for dermatophytes D. All of the above ANS: B In malignant melanoma there is usually a history of a changing mole or other area of hyperpigmentation. The lesion is usually greater than 0.5 cm in diameter and has notched or irregular edges, irregular pigmentation, and asymmetry of shape. Like other skin disorders, there are variations in appearance, and there should be a high suspicion for melanoma in any changing pigmented skin lesion. Biopsy is diagnostic.

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17. Which of the following skin disorders is associated with diabetes?

A. Acanthosis nigricans B. Vitiligo C. Impetigo D. Folliculitis ANS: A Acanthosis nigricans is associated with insulin resistance. It is most prevalent in individuals who are obese and in African Americans and Hispanics. Onset is usually in youth. It is an area of darkly pigmented skin, often within the skinfolds.

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18. Which of the following disorders often presents in patients with café au lait spots?

A. Diabetes B. Malignancy C. Neurofibromatosis D. Autoimmune disease ANS: C Café au lait spots are caused by increased melanin content and are associated with neurofibromatosis. The lesions vary in appearance and size, with color ranging from tan to brown. Frequently, there is a history of a variety of developmental and congenital conditions. The lesions are asymptomatic. They range in size from millimeters to over 10 cm and are usually flat macules or patches. Although the color varies, most are coffee colored.

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19. The patient presents with the complaint of a swollen node under his arm. The area is tender and the node has progressed in size over the past few days. Which of the following should be included in your differential diagnosis?

A. Hidradenitis suppurativa B. Epidermoid cyst C. Furuncle D. Both A and C ANS: D Hidradenitis suppurativa involves occlusions of hair follicles, which causes a red, fluctuant tender lesion. The site is commonly under the breast or in the axillae or groin. The clinician must differentiate this skin condition from an enlarged lymph node, which can appear similar. An enlarged lymph node is usually painless, whereas hidradenitis suppurativa is usually tender. Furuncles are staphylococcal infections of hair follicles or sebaceous glands.

Patients complain of pain, redness, and swelling at the affected site, commonly the axillae and groin.

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20. Which of the following skin conditions frequently heralds an anaphylactic reaction?

A. Contact dermatitis B. Eczema C. Urticaria D. Erythema multiforme ANS: C Urticaria, also commonly called hives, involves a histamine-mediated response that can be either acute or chronic. A wide range of situations are associated with hives, including a variety of infections, allergies to foods and medications, or underlying systemic disease.

Urticaria are pink or red wheals that are very pruritic. Frequently, they are associated with anaphylaxis and/or angioedema.

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21. A patient with sarcoidosis has firm, tender, reddened nodules along the anterior aspect of the leg. These lesions are called: A. Erythema multiforme B. Erythema nodosum C. Discoid rash D. Lichen planus ANS: B Patients with autoimmune disease frequently experience isolated multiple skin lesions that emerge as firm, tender, reddened nodules, usually along the anterior aspect of the leg, although other sites can be involved. Over a period of up to 2 weeks, the lesions fade in color and the degree of firmness decreases.

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22. A patient suffered a laceration of the shin 3 days ago and today presents with a painful, warm, red swollen region around the area. The laceration has a purulent exudate. The clinician should recognize that the infected region is called: A. Contact dermatitis B. Folliculitis C. Hidradenitis suppurativa D. Cellulitis ANS: D

In cellulitis, a patient often describes a history of a break in the skin from an injury, insect bite or sting, or previous procedure preceding the onset of redness, swelling, and pain at the site. The affected area is tender, swollen, reddened, and warm. Streptococcus or staphylococcal commonly causes the infection. The lower leg is a common site, usually unilateral.

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23. A woman complains of malaise and arthralgias. You note a butterfly-shaped, macular, erythematous rash across her cheeks and nose. These conditions are common in: A. Psoriasis B. Lichen planus C. Systemic lupus erythematosus D. Erythema nodosum ANS: C In systemic lupus erythematosus the patient will have a range of symptoms relevant to the diagnosis, depending on the affected organs. There is often coexisting arthralgia and malaise. The rash is macular and erythematous. It is described as a butterfly rash because the distribution resembles a butterfly’s wings overlying the forehead and cheeks.

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24. Which of the following characteristics is not helpful in differentiating between psoriasis and atopic dermatitis?

A. Distribution B. Family history C. Lesion morphology D. Chronicity ANS: D While patients with psoriasis or atopic dermatitis are often able to provide related family history and the distribution and appearance of the lesions are different, both conditions tend to be chronic in nature.

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25. A patient complains of recent onset of aching and malaise followed by the development of a generalized rash. He denies previous rash, although he does admit that about a month ago he had an open sore on his right hand that was nonpainful. The examination reveals a maculopapular rash and lymphadenopathy. This presentation is most consistent with: A. Pityriasis rosea B. Secondary syphilis C. Herpetic whitlow

D. Pyogenic granuloma ANS: B The patient may provide the history of a more generalized rash developing 2 or more weeks following the primary lesion, which may still be evident. The primary lesion is usually an isolated, single red lesion, which ultimately ulcerates, forming a nontender chancre. There may be a period of malaise preceding the eruption of secondary lesions. These lesions vary in appearance and distribution, but the typical finding is of red maculopapular lesions smaller than 1 cm in diameter. Any portion of skin can be involved, including the scalp, mucous membranes, perineum, and the soles and palms. There is generalized lymphadenopathy.

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Chapter 4. Head, Face, and Neck

MULTIPLE CHOICE

1. When obtaining a health history focusing on the patient’s head, face, and neck, which of the following is particularly important with regard to risk of disease?

A. Past dental work B. Use of alcohol and tobacco C. History of tension headaches D. Use of aspirin ANS: B Tobacco and/or alcohol use or abuse are the biggest risk factors for malignancies of the head and neck.

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2. Which of the cranial nerves should be tested if the patient complains of numbness of the cheek?

A. Cranial nerve III B. Cranial nerve V C. Cranial nerve VII D. Cranial nerve X ANS: B Cranial nerve V, the trigeminal nerve, controls the sensation of the face and function of the masseter muscle. Cranial nerve VII, the facial nerve, controls facial expressions or motor function of the facial muscles. Cranial nerve III, the oculomotor nerve, controls the pupil and movement of eyes. Cranial nerve X is the vagus nerve, which is demonstrated by testing the gag reflex.

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3. Which of the cranial nerves should be tested when a patient presents with right-sided facial droop and inability to close the right eye?

A. Cranial nerve III B. Cranial nerve V C. Cranial nerve VII D. Cranial nerve X ANS: C Cranial nerve VII, the facial nerve, controls facial expressions or motor function of the facial muscles. The disorder that causes unilateral facial muscle dysfunction and inability to close the eye is Bell’s palsy. Cranial nerve V, the trigeminal nerve, controls the sensation of the face and function of the masseter muscle. Cranial nerve III, the oculomotor nerve, controls the pupil and movement of eyes. Cranial nerve X is the vagus nerve, which is demonstrated by testing the gag reflex.

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4. A patient complains of pain with chewing, earache, and grinding her teeth when asleep.

These are symptoms of: A. Temporomandibular joint syndrome B. Trigeminal neuralgia C. Facial nerve palsy D. Angina ANS: A The signs and symptoms of temporomandibular joint (TMJ) syndrome range from mild aching to severe, sharp pain in and around the TMJs. Typically, there is pain with movement of the joint, particularly with chewing. There is tenderness of the masticatory muscles. The pain is often referred to the ear, causing pain, tinnitus, and hearing difficulties. Stress can cause jaw clenching or bruxism, resulting in fatigue or spasm of the masticatory muscles and, in turn, TMJ pain.

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5. With the influx of immigrants to the United States and/or parent refusal of immunizations for their children, paramyxovirus (mumps) can still be seen in the clinical setting. Mumps can cause which of the following conditions?

A. Trigeminal neuralgia B. Bruxism C. Parotitis D. Temporomandibular joint syndrome

ANS: C Parotid gland inflammation can occur with paramyxovirus infection, also called mumps.

There is swelling of the preauricular regions of the face.

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6. Calcium phosphate stones can develop within the salivary gland ducts. This can occur in the disorder called: A. Temporomandibular joint syndrome B. Mumps C. Trigeminal neuralgia D. Sialadenitis ANS: D The submandibular glands can become inflamed and develop stones in a condition called sialolithiasis. Often these patients have a history of recurrent sialadenitis, and the stones are composed of calcium phosphate as a result of the pH of the saliva.

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7. Your patient presents to the emergency room due to a bee sting on the cheek. As you are examining the patient, you note increasing facial swelling and redness, as well as swelling of the lips and eyes. This condition is due to: A. Angioedema B. Parotitis C. Sinusitis D. Sialadenitis ANS: A Angioedema is basically anaphylaxis that is restricted to the skin and is generally benign and self-limiting. The causes are numerous and include insect stings; atopic conditions; food allergies (typically nuts, eggs, shellfish, fruit, and sulfites); drug allergies; allergy desensitization injections; a reaction to blood products; a response to exercise, cold, or pressure; heredity; and vasculitis.

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8. Your patient accidentally cut his cheek while shaving 3 days ago. Today, the region is warm, erythematous, swollen, and has the appearance of an orange peel. There is a serous exudate coming from the wound. This is most likely due to: A. Folliculitis B. Cellulitis C. Suppurative parotitis D. Sialadenitis

ANS: B Streptococcus and Staphylococcus are the most common organisms responsible for superficial cellulitis. It can occur from a wound or bite, or as a complication of infections of the eyes, ears, mouth, or nose. The symptoms include redness, warmth, edema, leukocyte infiltration, tenderness, and regional lymphadenopathy. The skin may have a thick, orange peel appearance, and the borders are usually indistinct.

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9. A patient with systemic lupus erythematosus has been taking a prolonged course of steroids.

She complains that her face appears swollen and she has experienced a 10-pound weight gain. This is often referred to as: A. Angioedema B. Parotitis C. Cushingoid effect D. Myxedema ANS: C A cushingoid look can occur in patients who take long-term steroids for chronic diseases, including respiratory, hematologic, and autoimmune. The typical symptoms are those of Cushing’s disease, with a rounded moon face appearance and truncal obesity.

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10. A patient with a positive Lyme titer presents with left-sided unilateral facial droop and inability to close the left eye. This is most likely due to: A. Temporal arteritis B. Temporomandibular joint syndrome C. Multiple sclerosis D. Bell’s palsy ANS: D Bell’s palsy is a unilateral paralysis of the face. The etiology is uncertain, but the paralysis is thought to be due to an inflammation of cranial nerve VII. Lyme disease is a common cause.

The onset of Bell’s palsy is sudden, and the symptoms are unilateral. The affected side of the face droops with asymmetrical facial movement; there is pain in or around the ear, excessive lacrimation and salivation, and inability to close the eye.

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11. A solitary cold nodule on radioactive iodine (RAI) uptake on a thyroid scan is suspicious for: A. Hyperthyroidism

B. Myxedema C. Trigeminal neuralgia D. Thyroid cancer ANS: D Hyperthyroidism does not necessarily coincide with a thyroid nodule. Myxedema is a tissue swelling of the face and body due to hypothyroidism. Trigeminal neuralgia causes paroxysms of pain on one side of the face. Thyroid cancer presents as a solitary cold nodule on a thyroid ultrasound. Predisposing factors include female gender, positive family history, and history of radiation exposure to the head, face, or neck.

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12. A 6-year-old patient complains of a constantly itchy scalp that developed after returning home from school today. The most common cause for this condition in a child is: A. Seborrheic dermatitis B. Pediculosis C. Psoriasis D. Basal cell carcinoma ANS: B It would be unusual for pruritus in the head and neck to indicate anything except a skin condition/disease or infestation. If the patient is a school-age child, pediculosis (head lice) is an obvious choice, and the child’s friends and school administrators should be questioned about recent outbreaks. Nits are lice eggs that are fixed to the hair shaft and are grayish-white in appearance. Unlike the flakiness of seborrhea or psoriasis, nits cannot be easily dislodged. Basal cell carcinoma is a slow-growing, invasive type of skin cancer that occurs on sun-exposed regions of the head, such as the nose.

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13. One of the most common signs of Epstein-Barr viral infection (infectious mononucleosis) is: A. Swelling of the face B. Parotitis C. Cervical lymphadenopathy D. Thyroid enlargement ANS: C Sore throat, fever, and prominent cervical lymphadenopathy are key signs of Epstein-Barr virus, also called infectious mononucleosis. Parotitis is swelling of the parotid glands that occur in mumps. Swelling of the deep tissues of the face often occurs with myxedema, which occurs due to thyroid disease.

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14. A goiter is most commonly associated with: A. Hypothyroidism B. Hyperthyroidism C. Euthyroid function D. All of the above ANS: D A goiter, an enlargement of the thyroid gland, may be associated with hypothyroidism or hyperthyroidism, but patients with goiters may also be euthyroid, a condition termed nontoxic goiter.

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15. On physical examination, your 55-year-old female patient has an enlarged thyroid gland.

She complains of feeling hot all the time, nervousness, palpitations, tremor, and recent weight loss of 10 pounds over the past 3 weeks. These signs and symptoms are commonly due to: A. Hypothyroidism B. Hyperthyroidism C. Thyroid cancer D. All of the above ANS: B Clinical manifestations of Grave’s disease (hyperthyroidism) include diffuse goiter, nervousness, irritability, tremor, heat intolerance, weakness, tachycardia, palpitations, widened pulse pressure, increased sweating, weight loss, insomnia, frequent bowel movements, menstrual irregularities, exophthalmos, and infiltrative dermopathy. Patients older than 50 years often present with cardiac symptoms, such as hypertension, atrial fibrillation, or heart failure.

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16. A patient complains of burning, epigastric pain, and regurgitation of food when lying flat. It is important to recognize that these symptoms are common in: A. Gastroesophageal reflux disease B. Neuromuscular disorders C. Esophageal cancer D. Achalasia ANS: A The patient with gastroesophageal reflux disease describes burning and pain in the esophagus with or without dysphagia. The symptoms may occur more with eating or drinking, and at night when the patient is recumbent. Persons with neuromuscular disorders, achalasia, or esophageal cancer describe difficulty swallowing or feeling of a lump in the throat.

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17. A 40-year-old female patient presents with extremely tight, shiny skin over the hands and face. There is also a lack of nasolabial folds and blank facial expression. This is a common sign of: A. Bell’s palsy B. Trigeminal neuralgia C. Scleroderma D. Hypothyroid myxedema ANS: C Scleroderma is an autoimmune disease that causes infiltration of the skin with autoantibodies and immune complexes. Signs include extremely shiny and taut skin over the face, hands, and feet. Onset is between 30 and 55 years, and occurs mostly in women.

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18. Chronic abuse of alcohol and tobacco are associated with __________________, which can present with lymphadenopathy of the head and neck.

A. Lymphoma B. Squamous cell carcinoma C. Leukemia D. Thyroid cancer ANS: B The most common malignancies of the head and neck are squamous cell carcinomas of the larynx, palatine tonsil, and hypopharynx. More than 80% of patients with these cancers have a history of tobacco and/or alcohol use or abuse.

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19. Weight loss, fever, fatigue, and cervical and mediastinal lymphadenopathy are often the presenting signs of: A. Hypothyroidism B. Scleroderma C. Esophageal cancer D. Lymphoma ANS: D Cervical and mediastinal lymphadenopathy are often the presenting complaints of lymphoma and generally precede systemic symptoms, which include fever, night sweats, weight loss, and fatigue.

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20. Which of the following is a sexually transmitted infection that can cause pharyngitis and cervical lymphadenopathy with oral sex?

A. Hemolytic streptococcus B. Chlamydia trachomatis C. Epstein-Barr virus D. Cytomegalovirus ANS: B Gonococcus or Chlamydia trachomatis are sexually transmitted infections that can cause pharyngitis and lymphadenopathy. Epstein-Barr virus causes infectious mononucleosis, which is not regarded as a sexually transmitted infection. Strep throat is pharyngitis caused by group A beta Hemolytic streptococcus. Streptococcal pharyngitis is not a sexually transmitted infection.

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Chapter 5. The Eye

MULTIPLE CHOICE

1. The most common type of eye disorder is: A. Refractive errors B. Macular conditions C. Neurological conditions D. Astigmatisms ANS: A The most common forms of visual impairment are refractive errors. In fact, over 150 million Americans are reported to use corrective lenses for refractive errors.

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2. Which of the following findings should trigger an urgent referral to a cardiologist or neurologist?

A. History of bright flash of light followed by significantly blurred vision B. History of transient and painless monocular loss of vision C. History of monocular severe eye pain, blurred vision, and ciliary flush D. All of the above ANS: B

Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist.

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3. The first assessment to complete related to the eyes is: A. Eye lids B. Visual acuity C. Extraocular movements D. Peripheral vision ANS: B The eye examination begins with determination of the patient’s visual acuity. Next, the examiner typically inspects the external and accessory structures before concentrating inward to include the eye.

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4. It is important to not dilate the eye if _________________ is suspected.

A. Cataract B. Macular degeneration C. Acute closed-angle glaucoma D. Chronic open-angle glaucoma ANS: C If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute closed-angle glaucoma is present because dilating the eye may increase the intraocular pressure.

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5. Which of the following is true concerning adjustment of diopters during funduscopic examination?

A. Moving toward more positive diopters shifts examiner’s focus posteriorly B. Moving toward more negative diopters shifts examiner’s focus posteriorly C. Moving toward more positive diopters broadens the examiner’s field of view D. Moving toward more negative diopters broadens the examiner’s field of view ANS: B

As the dial on the ophthalmoscope is moved counterclockwise, the diopters shift from positive to negative. Because the more negative diopters direct the focus posteriorly, by moving from the positive to negative diopters, your focus will shift from the anterior eye to the posterior eye, retina, and optic disk.

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6. A clinician can assess the alignment of the eyes by all of the following except: A. Checking for a symmetric light reflex B. Observing eye movements C. Performing cover/uncover examination D. Measuring the palpebral gap ANS: D Alignment is evaluated by observing eye motion, performing the cover/uncover test, and assessing the light reflex.

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7. The fundoscopic examination allows the clinician to directly observe: A. Cranial nerve I B. Cranial nerve II C. Cranial nerve III D. Cranial nerve IV ANS: B The optic nerve (cranial nerve II) is directly observed during the fundoscopic examination.

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8. Shining a light directly on one pupil should make the other pupil constrict. This is called the: A. Accommodation response B. Red reflex C. Corneal light reflex D. Consensual pupil response ANS: D The pupillary reflex is elicited by holding the light source in front of the patient so that it is directed toward one eye. At this point, observe both pupils, noting the direct response of the eye receiving the direct light and the consensual response in the opposite eye.

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9. Your patient describes blurry vision, as well as halos and glares, in response to bright lights or when driving in the dark. There is no pain. These are symptoms of: A. Glaucoma B. Macular degeneration C. Cataracts D. Diabetic retinopathy ANS: C Patients with cataracts generally describe progressive and painless decreased visual acuity.

The altered vision includes general blurring, dimming, and haziness of vision, as well as the development of halos and glares in response to bright lights or when driving in the dark. The opacities may be visible as gray or whitening areas over the pupil.

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10. While assessing visual acuity, you notice that the patient is turning his head side to side for an oblique, or peripheral, view of the Snellen chart, raising your suspicion that the patient may suffer from: A. Glaucoma B. Cataract C. Macular degeneration D. Amaurosis fugax ANS: C Visual loss associated with macular degeneration can be progressive, unilateral, or bilateral, and starts centrally.

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11. When examining the six cardinal fields of gaze, the clinician is assessing function of all the following except: A. Cranial nerve II B. Cranial nerve III C. Cranial nerve IV D. Cranial nerve VI ANS: A The six cardinal fields of gaze are testing the extraocular muscles, which are innervated by the oculomotor nerve (cranial nerve III), trochlear nerve (cranial nerve IV), and abducens nerve (cranial nerve VI).

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12. Your patient has been treated for glaucoma for 5 years. Which of the following will provide indication of the level of progression during the funduscopic examination for this patient?

A. Checking the macula B. Estimating cup-to-disk ratio C. Verifying a red reflex D. Observing extraocular movements ANS: B In glaucoma, inspection may identify cup-to-disk ratio change; late afferent effect is possible.

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13. A patient describes a brief episode of visual impairment as if a dark shade was gradually coming down over one eye. The vision returned a moment later. This is most commonly described in which condition?

A. Glaucoma B. Cataracts C. Amaurosis fugax D. Macular degeneration ANS: C In amaurosis fugax, the patient often describes an episode as if a shade had been pulled over one eye in a descending fashion and then, a short time later, the shade was raised and vision restored.

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14. A Marcus-Gunn effect involves: A. Abnormal pupillary responses B. Abnormal visual acuity C. Abnormal funduscopic findings D. Abnormal visual field ANS: A Note whether the pupil response is a slight constriction, slightly more pronounced with direct light, which is normal, or the pupil slightly relaxes so that the response is slightly less pronounced with direct light, which is an abnormal Marcus-Gunn effect.

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15. In which of the following conditions do patients often describe a sudden, large flash of light with gradual loss of vision in one eye?

A. Amaurosis fugax B. Acute glaucoma C. Temporal arteritis D. Retinal detachment ANS: D With retinal detachment, the patient usually provides a history of a contributing condition or trauma, followed by a sudden visual disturbance, such as flashing light, floaters, or scotoma.

The visual defect may advance or progress as the retinal detachment enlarges, but central vision will be retained unless the macula is involved.

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16. Macular degeneration is a visual disturbance most commonly due to: A. Sudden head trauma B. Ischemia of the central retinal artery C. Elevated intraocular pressure D. Physiological aging ANS: D Most commonly, macular degeneration is associated with aging and results either from atrophy of the macula or exudation and hemorrhage of the vessels in the macular region.

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17. An Amsler grid is used to evaluate which of the following conditions?

A. Optic neuritis B. Macular degeneration C. Amaurosis fugax D. Retinal detachment ANS: B With macular degeneration, a commonly used test, the Amsler grid, assesses the patient’s ability to accurately see a set of grids.

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18. The most common cause of eye redness is: A. Conjunctivitis B. Acute glaucoma C. Head trauma D. Corneal abrasion ANS: A

The most common cause of eye redness is conjunctivitis, which involves an inflammation of one or more areas of the conjunctiva. It is important to discriminate between allergic, viral, bacterial, and other causes of conjunctivitis in order to provide definitive treatment.

Infectious conjunctivitis is usually caused by viral organisms, although bacterial infections are also common and can be secondary to viral infections. Allergies are the most frequent cause of noninfectious conjunctivitis. Other causes include chemical reactions.

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19. A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely present with: A. Allergic conjunctivitis B. Bacterial conjunctivitis C. Chemical conjunctivitis D. Viral conjunctivitis ANS: D Preauricular nodes are nonpalpable and nontender in allergic conjunctivitis, usually nonpalpable in bacterial conjunctivitis, and palpable in viral conjunctivitis.

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20. Your patient with Crohn’s disease complains of eye pain and photophobia. This is likely related to: A. Symptoms of temporal arteritis B. Altered pupil response due to uveitis C. Blurry vision due to bilateral cataracts D. Subconjunctival hemorrhage ANS: B Uveitis involves inflammation of the uveal tract, including the iris. The inflammation may be caused either by infection or as part of a reaction associated with a systemic disorder. For instance, an increased incidence of uveitis is associated with autoimmune disorders, such as Crohn’s disease, ankylosing spondylitis, and HIV infection. The vision changes associated with uveitis stem from altered responsiveness of the pupil and lens. Patients commonly experience both photophobia and eye pain. There is a ciliary flush and, usually, a constricted pupil.

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21. Your patient is suffering from herpes zoster along the trigeminal nerve distribution of the face. You should carefully assess for the presence of: A. Keratitis B. Uveitis

C. Scleritis D. Conjunctivitis ANS: A Keratitis is inflammation of the cornea that can lead to blindness in the affected eye.

Keratitis is commonly caused by herpetic and other infections, ischemia, chemical exposures, foreign bodies, or corneal abrasions. Keratitis is noteworthy because it can lead to ulcerations, opacities, and blindness of the affected eye; thus, patients suspected of this disorder should be immediately referred to an ophthalmologist.

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22. A 4-day-old newborn presents with redness and tearing of one eye. Slight pressure over the lacrimal sac produces white discharge. The clinician should be aware that the following condition is common in newborns: A. Conjunctivitis B. Sinus infection C. Dacryocystitis D. Herpes infection ANS: C Dacryocystitis is an infection of the lacrimal sac and is most common in infants, secondary to congenital stenosis of the lacrimal duct. If the duct is occluded, constant tearing may occur. The lacrimal sac may be edematous, red, and tender. Pressure over the sac produces purulent discharge.

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23. Ptosis is commonly the first sign of: A. Stevens-Johnson syndrome B. Hyperthyroidism C. Temporal arteritis D. Myasthenia gravis ANS: D Ptosis, or drooping of an eyelid, can be related to simple aging, with natural loss of elasticity and lid drooping, or it can result from a variety of other causes. The causes of ptosis are often categorized as congenital and acquired. Causes occurring after birth include trauma, conditions adding mass to the eyelid, and conditions that affect the nerves or muscles controlling the lid’s position. In 75% of the cases, the first manifestation of myasthenia gravis is ptosis.

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24. A 9-month-old patient presents with fever and large areas of redness and bullae over the trunk, palms, legs, and soles of the feet. There is redness and swelling of the conjunctiva and lips. The clinician should recognize this condition as: A. Giant cell arteritis B. Stevens-Johnson syndrome C. Botulism D. Myasthenia gravis ANS: B Stevens-Johnson syndrome, also called erythema multiforme, involves inflammation of the mucous membranes and skin. It is often related to an infection or can be due to almost any medication. Often, no specific cause is identified. The condition can be fatal. It is important to immediately recognize and treat. The patient appears acutely ill and has systemic symptoms, including malaise, fever, and arthralgias, so that the eye findings are not isolated.

Conjunctival bullae and ulcerations may develop. Patients develop erythematous lesions and bullae over the skin and hemorrhagic lesions of the mucous membranes. In addition to the eye tissue, the palms, soles, anus, vagina, nose, and mouth are commonly affected.

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25. In assessing the eyes, which of the following is considered a red flag finding when associated with eye redness?

A. History of prior red-eye episodes B. Grossly visible corneal defect C. Exophthalmos D. Photophobia ANS: B Red flag warnings for eye redness include pain (not discomfort or irritation), decreased vision, profuse discharge, and corneal defect grossly visible.

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Chapter 6. Ear, Nose, Mouth, and Throat

MULTIPLE CHOICE

1. On physical examination of a 1-year-old patient, you note abnormal placement of the ears, hypertelorism, and strabismus. These are often signs of: A. Genetic conditions B. Deafness C. Birth injury D. Physical abuse ANS: A

Facial dysmorphism often indicates a genetic disorder. These features include microcephaly, brachycephaly, hypertelorism, upslanting palpebral fissures, strabismus, broad nasal bridge, wide anterior fontanalle, anteverted nares, high arched palate, microretrognathia, low-set dysmorphic ears, and short neck.

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2. An 86-year-old patient who wears a hearing aid complains of poor hearing in the affected ear. In addition to possible hearing aid malfunction, this condition is often due to: A. Acoustic neuroma B. Cerumen impaction C. Otitis media D. Ménière’s disease ANS: B Elderly clients frequently present with complaints of hardened cerumen and decreased hearing resulting from cerumen impaction aggravated by hearing aid wear.

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3. A patient presents to the emergency department due to head trauma related to a motorcycle accident. On physical examination, you note clear, serous discharge from the ear. This is commonly a sign of: A. Basilar skull fracture B. Injury of the auricle C. Otitis discharge D. Tympanic membrane perforation ANS: A In cases of head trauma, there are signs of skull fracture. These signs include cerebrospinal fluid otorrhea, rhinorrhea, and raccoon eyes.

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4. A pneumatic otoscopic examination is used to assess: A. Inner ear conditions B. Otitis externa C. Cerumen impaction D. Tympanic membrane mobility ANS: D Pneumatic otoscopy is an examination that allows determination of the mobility of a patient’s tympanic membrane (TM). The normal TM moves in response to a puff of air pressure from the otoscope. Immobility may be due to fluid in the middle ear, a perforation, or

tympanosclerosis, among other reasons. The detection of middle ear effusion by pneumatic otoscopy is key in establishing the diagnosis of otitis media with effusion. The inner ear is not visible with an otoscope. Cerumen impaction will impede function of the pneumatic otoscope. Otitis externa is an external ear infection that is diagnosed without the use of an otoscope.

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5. In examination of the nose, the clinician observes gray, pale mucous membranes with clear, serous discharge. This is most likely indicative of: A. Bacterial sinusitis B. Allergic rhinitis C. Drug abuse D. Skull fracture ANS: B When examining the nose, assess the mucosa for integrity, color, moistness, and edema/lesions, and the nasal septum for patency. The turbinates should be assessed for color and size. Pale, boggy turbinates suggest allergies; erythematous, swollen turbinates are often seen with infection. Any discharge should be noted. Clear, profuse discharge is often associated with allergies.

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6. With inspection of the mouth and buccal mucosa, Stensen’s duct can be seen on the: A. Underside of the tongue B. Buccal mucosa opposite the lower molars C. Buccal mucosa opposite the upper molars D. Soft palate ANS: C In examination of the mouth, use a tongue depressor to displace the lips and cheeks. Inspect areas of the buccal mucosa that are not otherwise visible, including the sites of the Stensen’s and Wharton’s ducts. Stensen’s duct of the parotid gland, which releases saliva, is located on the upper buccal mucosa opposite the molars.

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7. To examine if there is an intact gag reflex, ask the patient to say ―ah‖ as you observe the: A. Movement of the uvula to the left B. Movement of the uvula to the right C. Tongue extension in the midline D. Upward movement of the uvula in the midline

ANS: D Within the oropharynx, upward movement of the uvula within the midline when the patient says ―ah‖ is indicative of an intact gag reflex.

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8. Malignant oral cancerous lesions are most frequently located on the: A. Tongue B. Tonsils C. Gums D. Hard palate ANS: A There are several types of oral cancers, but approximately 90% are squamous cell carcinomas, originating in the tissues that line the mouth and lips. Oral or mouth cancer most commonly involves the tongue.

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9. Ear pain related to tenderness over the auricle and ear canal is most commonly related to: A. Excessive exposure to noise B. Cerumen impaction C. Otitis externa D. Ménière’s disease ANS: C Ear pain is most often seen in children and is usually associated with bacterial or viral upper respiratory infection. Complaints of ear pain in the summer are often associated with otitis externa, owing to swimmer’s ear. Complaints of primary ear pain decline with age and, in adults, are more likely associated with secondary conditions, such as sinus infection; dental disease; malignancy; other disorders of the head, face, and neck; and nervous and vascular symptoms.

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10. A 6-year-old child presents with complaints of unilateral ear pain, fever, and sore throat.

The clinician should recognize that this is most commonly due to: A. Otitis externa B. Inner ear infection C. Sinusitis D. Otitis media ANS: D Acute otitis media (AOM) involves infection of the fluid in the middle ear space. The three

bacterial organisms most often associated with AOM include Streptococcal pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The patient often complains of unilateral ear pain, which may radiate to the neck or jaw. There is commonly a current or recent history of symptoms consistent with an upper respiratory infection.

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11. Which of the following symptoms is common with acute otitis media?

A. Bulging tympanic membrane B. Bright light reflex of tympanic membrane C. Increased tympanic membrane mobility D. All of the above ANS: A In otitis media (middle ear infection), the tympanic membrane (TM) is typically dull, may be inflamed, and bulges so that the posterior landmarks are obscured. The light reflex is distorted or obscured. If myringitis (inflammation of the TM) is present, the TM is reddened. Purulent or yellow fluid may be evident posterior to the TM, with diminished TM mobility.

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12. Which of the following microorganisms commonly causes otitis externa?

A. Streptococcus pneumoniae B. Pseudomonas C. Moraxella catarrhalis D. Haemophilus influenzae ANS: B Otitis externa is inflammation of the ear canal and outer ear. Frequent causes include Pseudomonas and fungal organisms. It is frequently associated with swimming as well as trauma. Acute otitis media (AOM) involves infection of the fluid in the middle ear space. The three bacterial organisms most often associated with AOM include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Frequently, viral organisms coexist with one of the preceding bacterial causes.

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13. A 5-year-old patient with a history of chronic otitis media complains of severe unilateral ear pain that worsens at night. The pain has progressively worsened over the past 3 days. Your examination reveals tenderness, erythema, and swelling below the right ear, and diminished hearing on the right. Which of the following is a likely diagnosis?

A. Sinus infection B. Skull fracture

C. Mastoiditis D. Foreign body ANS: C Mastoiditis refers to infection of the mastoid bone, which is almost always a complication of acute otitis media. The patient complains of radiating ear pain and fever. The pain is persistent (for days to weeks), severe, deep, and often worst at night. The hearing on the affected side is usually significantly diminished. As the condition progresses, there is swelling, erythema, and tenderness over the mastoid bone.

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14. Presbycusis is the hearing impairment that is associated with: A. Physiological aging B. Ménière’s disease C. Cerumen impaction D. Herpes zoster ANS: A Presbycusis is an age-related cause of gradual sensorineural hearing loss and involves diminished hairy cell function within the cochlea, as well as decreased elasticity of the tympanic membrane. Although the changes associated with presbycusis often start in early adulthood, the decreased hearing acuity is usually not noticed until the individual is older than 65.

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15. A nonmalignant cancerous tumor affecting cranial nerve VIII that causes unilateral hearing loss, tinnitus, and vertigo is: A. Otosclerosis B. Acoustic neuroma C. Cholesteatoma D. Squamous cell carcinoma ANS: B With an acoustic neuroma, the onset of symptoms usually occurs after age 30. Early complaints include unilateral hearing loss, tinnitus, and vertigo. As the tumor advances, symptoms may include headache, facial pain, ataxia, nausea/vomiting, and lethargy. The ear structures appear normal. Cholesteatoma is not a cancer; it is a destructive and expanding growth consisting of keratinizing in the middle ear and/or mastoid process. The growth erodes the ossicles and can spread through the base of the skull into the brain. Otosclerosis involves degenerative changes to the bony structures of the middle ear and results in gradual onset of hearing deficit as the bones lose their vibratory ability. The patient typically complains of painless, progressive changes in hearing. Symptoms are usually bilateral, and tinnitus may be present. The physical examination is usually normal, with the exception of the hearing acuity test.

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16. Epistaxis can be a symptom of: A. Over-anticoagulation B. Hematological malignancy C. Cocaine abuse D. All of the above ANS: D Cocaine abuse, which is more common than might be expected, frequently causes epistaxis.

Hematological disorders likely to cause bleeding include thrombocytopenia, leukemia, aplastic anemia, and hereditary coagulopathies. High doses of anticoagulants can cause epistaxis and bleeding from the gums.

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17. Nasal discharge of green-yellow mucus, pharyngitis, and otitis media commonly indicate: A. Allergic rhinitis B. Viral infection C. Bacterial infection D. Nasal polyps ANS: C Nasal discharge should be assessed for its amount and color, as well as any associated symptoms. Clear, profuse discharge is allergic in nature; yellow-green purulent discharge indicates bacterial infection.

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18. Which disorder commonly presents with vesicular or ulcerated painful lesions with an erythema and a yellow base typically on the oral mucosa?

A. Aphthous ulcer B. Herpes simplex 1 C. Coxsackie viral infection D. All of the above ANS: A Aphthous ulcers are painful and usually small (less than 1 cm). The ulcer is shallow, surrounded by erythema and mild edema. The base of the ulcer is pale yellow or gray. Orolabial ulcers are often caused by herpes simplex type 1 virus. The ulcers are typically preceded by a prodromal phase of tenderness, followed by edema at the site where an individual or cluster of vesicles forms, and progresses to ulceration. The prodromal phase may also include fever. Hand, foot, and mouth disease is caused by a coxsackie virus. Painful skin and

oral lesions are often preceded by a period of malaise and fever. The patient often presents once the lesions appear on the lips and/or oral mucosa. The lesions erupt as vesicles, which later ulcerate.

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19. Hand, foot, and mouth disease often causes vesicular lesions on the palms, soles of the feet, and oral mucosa. The microorganism that causes this disease is: A. Herpes zoster B. Herpes simplex 1 C. Coxsackie virus D. Candida ANS: C Hand, foot, and mouth disease is caused by a coxsackie virus. Outbreaks are most common in the summer and fall months. The condition is occasionally associated with meningitis.

Painful skin and oral lesions are often preceded by a period of malaise and fever. The patient often presents once the lesions appear on the lips and/or oral mucosa. The lesions erupt as vesicles, which later ulcerate. Multiple lesions are located on the lips and oral mucosa. As the condition’s name implies, the lesions often appear on the hands and feet, as well as in the mouth.

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20. Thrush occurs as white patches surrounded by erythematous tissue in oral mucosa. The microorganism that causes this is: A. Candida B. Herpes simplex 1 C. Coxsackie virus D. Herpes zoster ANS: A Candidal infections of the oral mucosa take several forms. Thrush, or pseudomembranous candida, results in white patches, or plaques, overlying a very red base. Erythematous candida results in erythematous lesions and, on occasion, ulcerative lesions. Angular stomatitis results in lesions at the corners or angles of the mouth. The amount of associated pain is variable.

PTS: 1

21. A condition that presents as painless, raised white patches on the oral mucosa that predisposes the patient to squamous cell carcinoma is: A. Candida B. Lichen planus

C. Coxsackie virus D. Leukoplakia ANS: D The cause of most episodes of leukoplakia is not determined. However, this condition, which results in the development of painless, raised white patches on the oral mucosa, is associated with an increased risk of oral squamous cell cancer. Risk factors for the development of leukoplakia include chronic/recurrent trauma to the affected site and the use of smokeless and smoked tobacco and alcohol.

PTS: 1

22. Your patient has been using chewing tobacco for 10 years. On physical examination, you observe a white ulceration surrounded by an erythematous base on the side of his tongue.

The clinician should recognize that very often this is: A. Malignant melanoma B. Squamous cell carcinoma C. Aphthous ulceration D. Behcet’s syndrome ANS: B Most oral malignancies are painless until quite advanced, so patients are often unaware of the lesion unless the lip or anterior portion of the tongue is involved. The patient may become aware of the lesion if it bleeds. Squamous cell cancer lesions vary in appearance, from the reddened patches of erythroplakia, to areas of induration/thickening, ulceration, or necrotic lesions. Lesions of malignant melanoma have varied pigmentation, including brown, blue, and black. Even lesions that appear flat and smooth may be nodular, indurated, or fixed to adjacent tissue on palpation. Even though patients with squamous cell malignancies often have a history of heavy alcohol and/or tobacco use or poor dentition, these are not risk factors for malignant melanoma. In Behcet’s syndrome, the patient complains of recurrent episodes of oral lesions that are consistent with aphthous ulcers. The number of lesions ranges from one to several; the size of the ulcers varies from less than to greater than 1 cm.

Like aphthous ulcers, the lesions are well defined, with a pale yellow or gray base surrounded by erythema. The majority of patients also develop lesions on the genitals and eyes.

PTS: 1

23. A patient complains of fever, fatigue, and pharyngitis. On physical examination there is pronounced cervical lymphadenopathy. Which of the following diagnostic tests should be considered?

A. Mono spot B. Strep test C. Throat culture D. All of the above ANS: D

The physical examination for sore throat should include a comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes.

Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. A complete blood count with differential is helpful in determining the cause of sore throat.

PTS: 1

24. Rheumatic heart disease is a complication that can arise from which type of infection?

A. Epstein-Barr virus B. Diptheria C. Group A beta Hemolytic streptococcus D. Streptococcus pneumoniae ANS: C Group A beta hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly called strep throat. Complications of GABHS pharyngitis, although rare, include rheumatic heart disease and glomerulonephritis, and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths. Other bacterial causes of pharyngitis include mycoplasmal pneumonia, gonorrhea, and diphtheria.

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25. Which microorganism is the most common cause of tonsillitis in adolescents?

A. Epstein-Barr virus B. Streptococcus pneumoniae C. Mycoplasma D. Group A beta Hemolytic streptococcus ANS: A Most cases of tonsillitis are diagnosed in school-aged children and adolescents. Tonsillitis involves infection of the tonsils, usually by GABHS, in very young children. However, viral tonsillitis (often associated with Epstein-Barr virus) is more common in adolescents. Patients can develop chronic tonsillitis and/or have frequent recurrences of the condition.

PTS: 1

26. Which microorganism is the most common cause of peritonsillar abscess?

A. Epstein-Barr virus B. Streptococcus pneumoniae C. Mycoplasma D. Group A beta Hemolytic streptococcus

ANS: D Peritonsillar abscesses may occur at any age, although most cases involve adults. Many cases evolve as a complication of tonsillitis, but others develop as peritonsillar abscess without a history of tonsillitis. The condition involves infection of the peritonsillar space. A number of pathogens cause peritonsillar abscesses, although the most common cause is Group A beta Hemolytic streptococcus.

PTS: 1

27. Which of the following conditions can cause upper airway obstruction?

A. Behcet’s syndrome B. Influenza C. Epiglottitis D. Thrush ANS: C Epiglottitis is rare, but it can cause significant respiratory obstruction and death. The condition can occur at any age. The patient presents with rapidly developing sore throat, fever, cough, and difficulty swallowing. The patient’s voice is muffled, and there is drooling.

Stridor and/or varying signs of respiratory distress may be evident. The patient often leans forward while sitting to maximize the airway opening. The patient has a very ill appearance, and gentle palpation over the larynx causes significant pain.

PTS: 1

28. Your patient is a 78-year-old female with a smoking history of 120-pack years. She complains of hoarseness that has developed over the last few months. It is important to exclude the possibility of: A. Thrush B. Laryngeal cancer C. Carotidynia D. Thyroiditis ANS: B Hoarseness may result from squamous cell cancer of the larynx, as well as from malignancies within the pulmonary tree, neck, and throat. The risk of malignancy as a cause for hoarseness is greatest in patients with a history of cigarette smoking and/or alcohol abuse.

The history usually reveals a progressive onset of hoarseness that has persisted for weeks.

The physical examination specific to a complaint of hoarseness should include the ears, nose, throat, neck, lungs, and cranial nerves (particularly cranial nerves IX and X). When hoarseness is persistent or laryngeal structural disorders are considered, laryngoscopy should be performed to view any redness, edema, motion, and masses or polyps.

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29. A 26-year-old female who gave birth 1 month ago presents with sudden development of fever, neck pain, sore throat with dysphagia, and radiation of pain to the ear. Which of the following conditions is most important to consider?

A. Diptheria B. Epiglottitis C. Thyroiditis D. Otitis media ANS: C Painful subacute thyroiditis involves inflammation of the thyroid gland. A variant, postpartum thyroiditis, occurs within 6 months of giving birth and is generally painless. Although the etiology of painful subacute thyroiditis is not clear, it may have a viral trigger. Patients commonly complain of pain in the throat and/or neck, with radiation to an ear. Onset is described as relatively sudden, and associated symptoms include fever, malaise, and achiness.

The throat pain may be associated with dysphagia.

PTS: 1

Chapter 7. Cardiac and Peripheral Vascular Systems

MULTIPLE CHOICE

1. The first heart sound (S1) occurs because of the closure of the: A. Aortic and mitral valves B. Mitral and tricuspid valves C. Pulmonic valve D. Aortic valve ANS: B S1 is the closing of the mitral and tricuspid (T1) valves; together they are known as the atrioventricular (AV) valves. S2 is the closing of the aortic (A2) and pulmonic (P2) valves; together they are known as the semilunar valves.

PTS: 1

2. The second heart sound (S2) occurs because of the closure of the: A. Aortic valve B. Tricuspid valve C. Aortic and pulmonic valves D. A and B ANS: C S1 is the closing of the mitral and tricuspid (T1) valves; together they are known as the atri-

oventricular (AV) valves. S2 is the closing of the aortic (A2) and pulmonic (P2) valves; together they are known as the semilunar valves.

PTS: 1

3. To distinguish a physiological split S2 heart sound, it is best to listen with the stethoscope at the: A. Left fifth intercostal space midclavicular line B. Fourth intercostal space left sternal border with patient holding his or her breath C. Second intercostal space left sternal border with inspiration D. Fourth intercostal space right sternal border with expiration ANS: C Normally, S1 and S2 occur as single sounds. In some conditions, these sounds may be split and occur as two sounds. In healthy young adults, a physiological split of S2 may be detected in the second and third left interspaces during inspiration as a result of changes in the amount of blood returned to the right and left sides of the heart. During inspiration, there is an increased filling time and, therefore, increased stroke volume of the right ventricle, which can delay closure of the pulmonic valve, causing the second heart sound to be split. This physiological split differs from other splits that are pathological in origin in that it occurs with inspiration and disappears with expiration.

PTS: 1

4. An S3 gallop is commonly heard in: A. Children with fever B. Adults with heart failure C. Children with aortic stenosis D. Adults with hypertension ANS: B Pathological S3, also called a ventricular gallop, is heard in adults and is associated with decreased myocardial contractility, heart failure, and volume overload conditions, as can occur with mitral or tricuspid regurgitation. The sound is the same as a physiological S3 and is heard just after S2 with the patient supine or in the left lateral recumbent position. The sound is very soft and can be difficult to hear.

PTS: 1

5. An S4 sound is commonly heard in: A. Children with fever B. Adults with atrial fibrillation C. Adults with hypertension D. Children with pulmonic stenosis

ANS: C S4, also called an atrial gallop, occasionally occurs in a normal adult or well-trained athlete, but is usually due to increased resistance to filling of the ventricle. Possible causes of a left-sided S4 include hypertension, cardiovascular disease, cardiomyopathy, and aortic stenosis. Possible causes of a right-sided S4 include pulmonic stenosis and pulmonary hypertension. S4 is heard just before S1 with the patient supine or in the left lateral recumbent position. The sound can be as loud as S1 and S2. S4 is not heard in patients with chronic atrial fibrillation due to no distinct atrial kick.

PTS: 1

6. Which of the following heart sounds is commonly heard after myocardial infarction?

A. Friction rub B. S4 C. S3 D. Opening snap ANS: A Opening snap is caused by the opening of a stenotic mitral or tricuspid valve and is heard early in diastole along the lower left sternal border. It is high pitched and heard best with the diaphragm of the stethoscope. Friction rubs occur frequently after a myocardial infarction or with pericarditis. The sound is a high-pitched grating, scratching sound—resulting from inflammation of the pericardial sac—that issues from the parietal and visceral surfaces of the inflamed pericardium as they rub together.

PTS: 1

7. Which of the following is the most important question to ask during a cardiovascular health history?

A. Number of offspring B. Last physical examination C. Sudden death of a family member D. Use of caffeine ANS: C The sudden death of a family member is an important question to ask in the health history because it reveals the cardiovascular disease risk of the patient. Sudden death is usually due to an acute cardiovascular event, such as myocardial infarction, cardiac dysrhythmia, or stroke.

PTS: 1

8. Cardiovascular disease risk increases in women after age:

A. B. C. D.

30 40 45 55

ANS: D In men, cardiovascular risk increases after age 45; however, in women, the risk of cardiovascular disease increases after age 55. Estrogen is cardioprotective, so women are at highest risk for cardiovascular disease after menopause. The average age of natural menopause for women is age 55.

PTS: 1

9. According to the 2017 American College of Cardiology/American Heart Association guidelines, which of the following blood pressure measurements is categorized as prehypertension?

A. 110/78 mm Hg B. 128/79 mm Hg C. 142/80 mm Hg D. 145/92 mm Hg ANS: B Ideal blood pressure is less than 120/80 mm Hg, prehypertension is regarded as 120 to 139 systolic/80 to 89, and hypertension is greater than or equal to 140/90 mm Hg. PTS: 1

10. Xanthelasma is a skin condition that should alert the clinician to _________________ in a patient.

A. Familial hyperlipidemia B. Type 2 diabetes C. Congenital heart disease D. Peripheral arterial disease ANS: A When conducting the inspection part of a physical examination, inspect the skin around the eyes for xanthelasma. Xanthelasma is a skin condition that occurs in familial hyperlipidemia that causes high cholesterol levels and early cardiovascular disease in patients. Small, yellow fatty deposits are located around the eyes.

PTS: 1

11. When palpating the chest, you find the point of maximal impulse (PMI) in the left midaxillary region. This can be indicative of:

A. B. C. D.

Normal PMI Congenital heart disease Ventricular hypertrophy Hypertension

ANS: C The examiner should palpate the PMI and the precordium for heaves or lifts, seen in ventricular hypertrophy. The apical impulse is easily observed in the pediatric client but not always visible in the adult. An accentuated or displaced apical impulse may indicate ventricular hypertrophy.

PTS: 1

12. On inspecting the patient, you find jugular venous distension. This is a sign of: A. Left ventricular hypertrophy B. Right ventricular failure C. Hypertension D. Valve disease ANS: B In right ventricular failure, hydrostatic pressure builds up back into the right atrium and superior as well as inferior vena cava. Venous congestion occurs throughout the body. A sign of venous congestion of the superior vena cava is jugular vein distension. Signs of right ventricular failure include jugular venous distension, ascites, hepatomegaly, splenomegaly, and ankle edema.

PTS: 1

13. On an electrocardiogram, you see a deepened Q wave that is greater than one-third the height of the QRS complex. This is indicative of: A. Acute myocardial infarction B. Acute myocardial ischemia C. Left ventricular hypertrophy D. Past myocardial infarction ANS: D A pathological Q wave, indicative of a past myocardial infarction, measures greater than 0.04 seconds and is greater than one-third the height of the QRS complex.

PTS: 1

14. Your 35-year-old female patient complains of feeling palpitations on occasion. The clinician should recognize that palpitations are often a sign of: A. Anemia

B. Anxiety C. Hyperthyroidism D. All of the above ANS: D Palpitations sensed by the patient are commonly indicative of atrial fibrillation, tachycardia, or premature ventricular contractions. Anemia, anxiety, and hyperthyroidism are all possible etiologies of these cardiac rhythm disturbances.

PTS: 1

15. A pulse rate of 56 beats per minute can be normal in: A. Elderly patients B. Newborns C. Athletic individuals D. Hypertensive patients ANS: C Athletic individuals commonly have a low pulse rate because their heart is well-conditioned and physiologically more efficient. A strong heart has physiologically enlarged muscle chambers that contract slowly and efficiently deliver an adequate blood volume to the body with each contraction. In an elderly or untrained individual, bradycardia is more concerning.

Although normal aging includes a decrease in SA node and AV node conduction, thus increasing the likelihood of bradycardia, sinus node pathology and heart blocks should be suspected in the elderly. Newborns have a normal pulse rate of 120 beats per minute. If the patient has hypertension, this does not decrease the heart rate.

PTS: 1

16. Your patient has a dysrhythmia and has been on a diuretic for 2 months. Which of the following should be suspected?

A. Potassium imbalance B. Sodium deficit C. Calcium imbalance D. Insufficient diuretic ANS: A The most common electrolyte disturbance in patients on diuretics is hypokalemia. Hypokalemia is a common cause of cardiac rhythm disturbance.

PTS: 1

17. Your patient has suffered an inferior wall myocardial infarction. This is most commonly due to an obstruction in the:

A. B. C. D.

Posterior branch of the right coronary artery Circumflex branch of the left coronary artery Right main coronary artery Left main coronary artery

ANS: A Blockage in the right coronary artery (RCA) results in damage to the posterior/inferior area of the heart. The left main coronary artery (LCA) branches off to the left anterior descending artery (LAD) and the left circumflex artery (LCX). A highly stenotic LCA or proximal LAD can cause significant heart damage and is often termed the ―widow maker.‖ Blockage in the LAD results in damage to the anterior portion of the heart. Blockage in the circumflex branch artery (CFX) results in damage to the posterior and lateral areas.

PTS: 1

18. Cardiac chest pain is most often described as: A. Stabbing, piercing pain B. Pain with inhalation C. Crushing, squeezing pain D. Burning, gnawing pain ANS: C Typical characteristics that indicate acute coronary syndrome include crushing, squeezing substernal chest pain with radiation to the neck or left arm, a score of greater than 7 on the pain scale, an association with exertion or stress with relief on rest, a duration of minutes, and associated symptoms of nausea, diaphoresis, weakness, or shortness of breath.

PTS: 1

19. On an electrocardiogram (EKG), an anterior wall myocardial infarction is demonstrated on leads: A. II, III, AVR B. II, III, AVF C. V1, V2, V3, V4 D. I, AVL, V5, V6 ANS: C With angina and myocardial infarction, acute ischemic changes may be seen on the 12-lead EKG. Each lead reflects an area of the heart, and an EKG can determine the location of the ischemia. The lateral wall of the heart is reflected in leads I, aVL, V5, and V6. The inferior wall is reflected in leads II, III, and a VF. The anterior wall is reflected in leads V1, V2, V3, and V4. The posterior wall is reflected in leads V1, V2, and V3. With ischemia, EKG changes need to occur in two contiguous leads. Reciprocal EKG changes can be seen in the area of the heart opposite the injured area.

PTS: 1

20. Which is the most specific and sensitive test for validating a myocardial infarction?

A. 12-lead electrocardiogram B. Troponin C. CK-MB D. Computed tomography scan ANS: B Diagnostic studies of myocardial infarction (MI) include: • CK-MB: The serum level of CK-MB is elevated above normal in the first few hours after MI and returns to normal within 72 hours. The levels can also be elevated following trauma or with progressive muscular dystrophy.

• Troponin: An inhibitory protein found in muscle fibers, troponin is elevated within 4 hours of an MI and stays elevated for 7 to 10 days. It is more sensitive and specific than creatine kinase for cardiac muscle but may be falsely elevated in patients with kidney dysfunction.

• 12-lead electrocardiogram (EKG): The practitioner should look for signs of acute ischemia, such as ST-segment elevation or depression, arrhythmias, and conduction delays. An EKG is minimally helpful in diagnosing pericarditis, except in the case of cardiac tamponade or constrictive pericarditis where decreased amplitude may be seen.

• Imaging: Studies such as computed tomography scan, electron beam computed tomography (EBCT) scan, positron emission tomography (PET) scan, magnetic resonance imaging (MRI), and single photon emission computed tomography (SPECT) scan can assist in diagnosing coronary artery disease, aortic aneurysms, cardiac masses, myocardial disease, and pericardial disease.

PTS: 1

21. It is important for clinicians to recognize that individuals with _______________ often sustain silent myocardial infarction.

A. Diabetes mellitus B. Hypertension C. Valvular disorders D. Congenital heart defects ANS: A Pain sensitivity may be blunted in persons with diabetes. Peripheral and autonomic neuropathy is common in long-term diabetes. Individuals with diabetes often suffer infection or other disorders without sensing the pain, and sustain complications without warning.

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22. The pain associated with pericarditis is _________________________.

A. Crushing and squeezing

B. Constant C. Worse with inspiration D. Only present with fever ANS: C Unlike the symptoms associated with acute coronary syndrome, the pain associated with pericarditis is sharp and stabbing; it may worsen with inspiration or when lying flat or leaning forward. Associated symptoms may include shortness of breath, fever, chills, and malaise.

PTS: 1

23. Pain associated with a dissecting thoracic aortic aneurysm is commonly described as: A. Retrosternal crushing and squeezing B. Chest stabbing and sharp C. Ripping and tearing in the chest or thoracic back D. Worse with inspiration ANS: C Aortic aneurysms are often asymptomatic. However, in a dissecting aortic aneurysm, symptoms are often described as tearing or ripping in the chest, back, or abdomen.

PTS: 1

24. The pain of ___________________ can frequently be mistaken for cardiac chest pain.

A. Gastroesophageal reflux disease B. Peptic ulcer disease C. Cholecystitis D. All of the above ANS: D It is often difficult to differentiate the symptoms of gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD) from cardiac symptoms. A thorough history and diagnostic tests are necessary. Patients with a history of GERD or PUD should still be worked up for a cardiac etiology, particularly if the characteristics of the symptoms or the history have changed to raise the index of suspicion for cardiac disease. The pain of cholecystitis, also sometimes mistaken for cardiac pain, typically presents with right upper quadrant pain with radiation to the thoracic region of the back.

PTS: 1

25. The pain of pancreatitis is described as: A. Abdominal sharp and piercing pain in the left upper quadrant B. Dull and cramping pain in the right upper quadrant

C. Severe, epigastric pain radiating straight into the back D. Sharp pain radiating to the shoulder ANS: C The pain of pancreatitis is severe, steady, and ―boring‖—radiating from the epigastric region through to the back. It is often accompanied by nausea and vomiting, tachycardia, hypotension, and diaphoresis. These symptoms are also seen in myocardial infarction; however, the exquisite abdominal tenderness present in pancreatitis assists in differentiating it from cardiac pain.

PTS: 1

26. The pain of costochondritis typically: A. Mimics cardiac crushing and squeezing pain B. Worsens with movement and full inspiration C. Radiates from the epigastrium into the back D. Is a tearing and ripping pain ANS: B Costochondritis, which is inflammatory pain of the chest wall, can often be differentiated from cardiac pain through history. A history of injury, heavy lifting, contact sports, excessive coughing, or late-stage pregnancy (which stretches the intercostal muscles) leads the examiner to consider chest wall pain. This often occurs in a younger population with no cardiac risk factors. One of the most helpful differentiating symptoms is that the pain increases with movement, cough, or, in some cases, respiration.

PTS: 1

27. The medical record of your patient lists a grade III systolic murmur. This indicates the patient has a heart murmur that is: A. Soft and after S2 B. Loud and crescendo in quality C. Moderately loud and after S1 D. Loud and after S2 ANS: C A grade III murmur is moderately loud and a systolic murmur immediately follows S1.

PTS: 1

28. The radiation of a mitral valve murmur is commonly heard in the: A. Carotid arteries B. Left midaxillary line C. Base of the heart

D. Left midclavicular line ANS: B A thorough cardiac examination is performed with the patient sitting, leaning forward, lying, and in the left lateral recumbent position. Some murmurs are heard better in different positions. Listen over the carotids for radiation of an aortic or pulmonic murmur, in the left midaxillary line for radiation of a mitral murmur, and in the epigastric area for a bruit, indicating an aneurysm.

PTS: 1

29. The murmur of aortic stenosis is best heard in the: A. Left second intercostal space left sternal border B. Left fifth intercostal space midclavicular line C. Right fourth intercostal space right sternal border D. Right second intercostal space right sternal border ANS: D Aortic stenosis is heard best in the second right intercostal space with the client leaning forward. The murmur is harsh, loud, and often associated with a thrill. It may radiate to the neck, left sternal border, and, in some cases, to the apex.

PTS: 1

30. The pulmonary valve is best heard over the: A. Left second intercostal space left sternal border B. Left fifth intercostal space midclavicular line C. Right fourth intercostal space right sternal border D. Right second intercostal space right sternal border ANS: A The valves are best heard over the chest at specific areas. The aortic valve is best heard over the second intercostal space right sternal border and the pulmonic valve is best heard over the second intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space midclavicular line.

PTS: 1

31. The key sign(s) of aortic stenosis are: A. Syncope B. Dyspnea C. Angina D. All of the above ANS: D

Syncope, angina, and dyspnea (remembered with the acronym SAD) on exertion are the classic symptoms of aortic stenosis. If syncope occurs with exertion, the aortic stenosis is typically severe. Angina may be present because of decreased perfusion of the left ventricle due to left ventricular hypertrophy rather than coronary artery disease, but both exist in many cases.

PTS: 1

32. Classically in mitral valve prolapse, the clinician can hear a(n): A. Midsystolic click followed by a grade I murmur that crescendos up to S2 B. Opening snap followed by a grade III holosystolic murmur C. Crescendo-decrescendo grade I diastolic murmur after S2 D. Rough grade III holosystolic murmur that obscures S1 and S2 ANS: A In mitral valve prolapse, a portion of the mitral valve flops open up into the left atrium, giving rise to a classic midsystolic click followed by a soft grade I murmur that crescendos up to S2. It is high pitched and is heard best at the apex or left sternal border.

PTS: 1

33. The best diagnostic test that allows analysis of a heart murmur is: A. Computed tomography scan B. Echocardiogram C. Magnetic resonance imaging D. Electrocardiogram ANS: B Echocardiography is the best diagnostic test for assessing a heart murmur. In addition to visualizing the diseased valve, echocardiography can assist in determining the size of the heart chambers involved in the heart murmur in real time.

PTS: 1

34. The most common cause of tricuspid regurgitation is: A. Left ventricular hypertrophy B. Left atrial enlargement C. Aortic stenosis D. Pulmonary hypertension ANS: D The murmur of tricuspid regurgitation is heard best at the left sternal border and may radiate to the right of the sternum. It is pansystolic, high pitched, and blowing, and increases with respiration. Tricuspid regurgitation may be associated with right ventricular hypertrophy,

resulting in a right parasternal lift. When right ventricular failure occurs, jugular venous distention occurs with a prominent v wave, and liver enlargement may be present. There may be secondary right atrial enlargement owing to backflow into the right atrium. The most common initiator is pulmonary hypertension.

PTS: 1

35. The tricuspid valve is best heard over the: A. Third intercostal space left sternal border B. Fifth intercostal space right sternal border C. Fourth intercostal space left sternal border D. Third intercostal space right sternal border ANS: C The tricuspid valve is best heard over the fourth intercostal space left sternal border. Erb’s point is located over the third intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space in the midclavicular line. The aortic valve is best heard over the second intercostal space right sternal border. The pulmonic valve is best heard over the second intercostal space left sternal border.

PTS: 1

36. From Erb’s point, all the heart valves can be heard equally. Erb’s point is located over the: A. Third intercostal space left sternal border B. Fifth intercostal space right sternal border C. Fourth intercostal space left sternal border D. Third intercostal space right sternal border ANS: A The tricuspid valve is best heard over the fourth intercostal space left sternal border. Erb’s point is where all valves can be heard equally well. Erb’s point is located over the third intercostal space left sternal border. The mitral valve is best heard over the fifth intercostal space in the midclavicular line. The aortic valve is best heard over the second intercostal space right sternal border. The pulmonic valve is best heard over the second intercostal space left sternal border.

PTS: 1

37. On examination of a child, an innocent systolic murmur is heard at the second intercostal space left sternal border. This is usually due to: A. Atrial septal defect B. Patent foramen ovale C. Low flow velocity D. High flow turbulence

ANS: D An innocent murmur is a type of systolic murmur that results from turbulent blood flow and is not associated with heart disease. Innocent murmurs occur commonly in children and young adults, and reflect the contractile force of the heart, resulting in greater velocity of flow during early systole. They are heard best in the second and third left interspaces along the left sternal border or at the apex.

PTS: 1

38. In mitral stenosis, the murmur occurs: A. From S1 through S2 as a holosystolic murmur B. After an opening snap that is heard after S2 during diastole C. As a soft midsystolic click D. As a loud crescendo-decrescendo systolic murmur ANS: B Mitral stenosis results from thickening and stiffening of the mitral valve, usually secondary to rheumatic fever. The murmur is generally grade I to IV and low pitched; therefore, it is heard better with the bell at the apex in the left lateral recumbent position. The first heart sound (S1) is loud, followed by S2 and a loud opening snap that precedes the murmur.

PTS: 1

39. In mitral stenosis, the murmur can be best heard with the patient in the: A. Squatting position B. Seated position C. Left lateral recumbent position D. Supine position ANS: C Mitral stenosis results from thickening and stiffening of the mitral valve, usually secondary to rheumatic fever. The murmur is generally grade I to IV and low pitched; therefore, it is heard better with the bell at the apex in the left lateral recumbent position. The first heart sound (S1) is loud, followed by S2 and a loud opening snap that precedes the murmur.

PTS: 1

40. Due to increased left atrial pressure, a patient with mitral stenosis often suffers from: A. Pulmonary congestion B. Hepatomegaly C. Jugular venous distension D. Ventricular tachycardia ANS: A

In mitral stenosis, the most common presenting symptoms are dyspnea on exertion and hemoptysis due to pulmonary congestion. The pulmonary congestion is caused by increased left atrial pressure related to the decrease in left atrial emptying. Crackles may be heard at the lung bases but are not present in all patients with pulmonary congestion. Orthopnea may be present because the lungs become more congested in the recumbent position. In addition, atrial fibrillation often develops in patients with mitral stenosis, which, in turn, worsens the pulmonary congestion.

PTS: 1

41. A patient with significant aortic stenosis often suffers from: A. Pulmonary hypertension B. Jugular venous distention C. Peripheral vascular disease D. Left-sided heart failure ANS: D In aortic stenosis, the left ventricle has to work against high resistance and, eventually, left ventricular hypertrophy (LVH) develops. The LVH causes an enlarged left ventricle, and eventually left heart failure. Other symptoms may include shortness of breath, angina, and syncope. The point of maximal impulse located at the fifth intercostal space moves leftward toward the midaxillary line.

PTS: 1

42. Aortic regurgitation occurs after S2 during ___________________ because there is turbulent flow that refluxes into the left ventricle after the aortic valve closes.

A. Early diastole B. Late diastole C. Early systole D. Mid-systole ANS: A The aortic valve closes, creating S2. After the aortic valve closes, in aortic regurgitation, some blood flows back into the left ventricle. S1 through S2 is the systolic time frame. S2 through S1 is the diastolic time frame. The sound of a leaky aortic valve would be heard after the aortic valve closes (S2) during early diastole.

PTS: 1

43. The murmur of a ventricular septal defect occurs when the ventricle contracts and blood flows from the left ventricle into the right ventricle. This creates a ____________ heart murmur.

A. Holodiastolic

B. Early diastolic C. Holosystolic D. Late systolic ANS: C Ventricular septal defect (VSD) is a congenital heart defect in which oxygenated blood is shunted from a higher-pressured left ventricle to a lower-pressured right ventricle through an abnormal opening in the ventricular septum. This left-to-right shunt causes an increased blood flow across the pulmonic valve. The signs and symptoms depend on the size of the defect and the age of the patient. A VSD murmur occurs after the mitral valve closes (S1).

Characteristic of a VSD is a loud, harsh, pansystolic murmur at the lower left sternal border, usually accompanied by a thrill.

PTS: 1

44. An atrial septal defect (ASD) causes a left to right shunt, which enlarges the right atrium.

Because of this effect, which of the following conditions often occur with ASD? A. Asthma B. Jugular venous distension C. Atrial fibrillation D. B and C ANS: D ASD is a congenital abnormality in which oxygenated blood is shunted from a higher-pressured left atrium to a lower-pressured right atrium through an abnormal opening in the atrial septum. Atrial arrhythmias, especially atrial fibrillation, are common in the adult population with ASD. ASDs are often accompanied by other congenital heart defects, but in an uncomplicated lesion, patients are often asymptomatic until early adulthood, when they present with dyspnea on exertion or palpitations resulting from atrial arrhythmia. Because patients may be asymptomatic for many years, right heart failure can be the first sign, and patients may present with jugular venous distension, edema, and ascites.

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45. A patient with hypertension who has hyperlipidemia should aim for an LDL measurement of: A. 130 mg/dL or less B. 40 mg/dL or less C. 100 mg/dL or less D. 60 mg/dL or less ANS: C The aim for primary prevention is to keep LDL levels below 130 mg/dL and HDL levels above 40 mg/dL. Although primary prevention lowers a person’s risk of heart disease and myocardial infarction, it has shown only small, if any, effect on all-cause mortality. In patients with known cardiovascular disease or diabetes, the target cholesterol levels are more

stringent, aiming for an LDL level below 100 mg/dL and an HDL level above 60 mg/dL. PTS: 1

46. Your 47-year-old female patient has a waist to hip ratio of 0.1. In terms of cardiovascular disease risk, this is considered: A. Ideal B. Greater than acceptable limits C. Less than acceptable limits D. Within acceptable limits ANS: B The physical examination includes measurement of height and weight to calculate body mass index (BMI). The formula for calculating BMI is wt(kg)/ht(m2). A waist/hip ratio is also an indicator for risk of heart disease. A ratio greater than 0.85 for women and greater than 0.95 for men is considered to place individuals at increased risk, especially if accompanied by hyperinsulinemia or diabetes. These are part of a constellation of symptoms termed metabolic syndrome that indicate the greatest risk for the development of heart disease.

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47. Which of the following conditions is/are part of metabolic syndrome?

A. Hypertension B. Hyperlipidemia C. Insulin resistance D. All of the above ANS: D Characteristics of metabolic syndrome • Hypertension • Dyslipidemia • Central obesity • Glucose intolerance with hyperinsulinemia (insulin resistance) PTS: 1

48. The target body mass index for women is: A. 27 kg/m2 B. 25 kg/m2 C. 22 kg/m2 D. 16 kg/m2 ANS: C

Weight loss through diet and exercise has been found to be the most important factor in the prevention of the progression of metabolic syndrome. Insulin sensitivity increases with weight loss and is thought to be due to the loss of visceral fat. The target body mass index (BMI) is less than 22 kg/m2 for women and less than 27 kg/m2 for men. BMI of 16 kg/m2 is considered too low.

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49. Dyspnea, cough, and pulmonary crackles are symptoms that can occur in left ventricular failure and respiratory disorders, such as pneumonia. Which of the blood tests below can be used to differentiate cardiovascular from pulmonary disease?

A. Brain atriuretic peptide B. Pulse oximetry C. Arterial blood gases D. High sensitivity C reactive protein (hs-CRP) ANS: A Brain natriuretic peptide (BNP): For patients with cardiovascular disease and comorbid respiratory disease, BNP can help differentiate a cardiac from a respiratory etiology of dyspnea. High levels of BNP in the blood, greater than 400 mg/dL, occur if heart failure is present.

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50. When an examiner presses on the liver and elicits hepato-jugular reflux, which of the following conditions is likely?

A. Left ventricular failure B. Right ventricular failure C. Hepatomegaly D. Pulmonary edema ANS: B In right ventricular failure the abdomen should be examined, particularly for right upper quadrant discomfort related to hepatic congestion and enlargement. The examiner can also check for hepatic jugular reflux by placing sustained pressure on the liver while observing for jugular venous distention. In right ventricular failure, ascites may also be present. Examine the extremities for edema seen in right ventricular failure.

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51. Your patient has had hypertension for 10 years, a myocardial infarction 5 years ago, and now complains of dyspnea on exertion, cough, and three-pillow orthopnea. Which of the following conditions is likely?

A. Right ventricular failure

B. Pulmonary embolism C. Cor pulmonale D. Left ventricular failure ANS: D Left ventricular failure is most commonly characterized by dyspnea on exertion, cough, fatigue, orthopnea, paroxysmal nocturnal dyspnea, cardiac enlargement, crackles, gallop rhythm, and pulmonary congestion. Right ventricular failure is commonly characterized by dependent edema, elevated venous pressure, hepatomegaly, and possibly ascites. Pulmonary embolism presents with shortness of breath and tachycardia. Cor pulmonale is a heart disorder that occurs because of lung disease. The lungs are dysfunctional, which causes hypoxia and reflex pulmonary artery vasoconstriction. The right ventricle has to eject blood into the pulmonary artery, however, there is high afterload to deal with because of pulmonary vasoconstriction. The high workload against the right ventricle eventually causes the right ventricle to fail. This right ventricular failure because of lung disease is called cor pulmonale.

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52. Your patient complains of worsening ankle edema and weight gain over the last week. On physical examination, you note jugular venous distension, ascites, hepatomegaly, and splenomegaly. These conditions are indicative of: A. Left ventricular failure B. Pulmonary embolism C. Right ventricular failure D. Myocardial infarction ANS: C Right ventricular failure is characterized by dependent edema, elevated venous pressure, hepatomegaly, and possibly ascites. Pulmonary embolism presents with sudden shortness of breath and tachycardia. Left ventricular failure is characterized by dyspnea on exertion, cough, fatigue, orthopnea, paroxysmal nocturnal dyspnea, cardiac enlargement, crackles, gallop rhythm, and pulmonary congestion. Myocardial infarction presents with crushing retrosternal chest pain, pallor, dyspnea, and diaphoresis.

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53. A 23-year-old patient presents to the emergency department with high fever, chills, extreme fatigue, and arthralgias. Your physical examination reveals grade II heart murmur heard loudest over the fourth intercostal space left sternal border. The arms of the patient reveal past IV drug abuse. The clinician should recognize these are signs and symptoms of: A. Pulmonary embolism B. Right ventricular failure C. Functional heart murmur D. Bacterial endocarditis

ANS: D Bacterial endocarditis is a microbial infection of the endocardium. The most common causative organisms are Staphylococcus aureus, group A Streptococcus, Pneumococcus, and Gonococcus. Risk factors include valvular disease, IV drug use, dental disease, and invasive diagnostic procedures. Initially, the signs and symptoms are similar to those of other systemic illnesses, including fever, chills, arthralgias, malaise, and fatigue. Petechiae, anemia, weight loss, new or worsening heart murmur, and emboli alert the examiner to a more serious disease process.

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54. A 75-year-old patient complains of pain and paresthesias in the right foot that worsens with exercise and is relieved by rest. On physical examination, you note pallor of the right foot, capillary refill of 4 seconds in the right foot, +1 dorsalis pedis pulse in the right foot, and +2 pulse in left foot. Which of the following is a likely cause of the signs and symptoms?

A. Arterial insufficiency B. Femoral vein thrombus C. Venous insufficiency D. Peripheral neuropathy ANS: A Intermittent claudication is pain in the leg or foot that becomes worse with exercise and is relieved by rest. The classic signs of peripheral arterial disease include pain, pallor, weak pulse, paresthesias, and palpable coolness. The signs of venous thrombosis are erythema and ropiness, as well as warmth and tenderness along the course of the vein. Edema of the leg and Homan’s sign of the foot are also common.

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55. Which of the following ankle-brachial index measurements require a referral to a vascular consultant?

A. ABI 1.2 B. ABI 1 C. ABI 0.9 D. ABI 0.5 ANS: D The ankle-brachial index (ABI) is currently the easiest, least expensive noninvasive method for diagnosing paroxysmal nocturnal dyspnea and is particularly helpful in the office and home settings. The ABI is obtained by the following steps: 1. Obtain brachial systolic pressure in both arms. Select the higher of these two values.

2. Use Doppler stethoscope to obtain systolic pressure in the dorsalis pedis or posterior tibialis vessel.

3. Divide ankle pressure by the higher brachial pressure.

The index should be 1 or higher. If it is less than 0.5, impairment to blood flow is significant. An abnormal ABI indicates the need for a vascular consultation.

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56. Your patient complains of a feeling of heaviness in the lower legs daily. You note varicosities, edema, and dusky color of both ankles and feet. Which of the following is the most likely cause for these symptoms?

A. Femoral vein thrombosis B. Femoral artery thrombus C. Venous insufficiency D. Musculoskeletal injury ANS: C Chronic venous insufficiency can be a long-term complication of venous thrombosis, owing to the destruction of valves in the deep veins. The calf muscle pump that returns blood from the lower legs is damaged, increasing ambulatory pressure in the calf veins. A constellation of symptoms is set up: aching or pain in the lower legs, edema, thinning and hyperpigmentation of the skin, superficial varicosities, venous stasis, and ulceration. Ankle edema is often the earliest sign.

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57. After multiple pregnancies, the following vascular disorder is common: A. Deep venous thrombosis B. Varicose veins C. Peripheral arterial disease D. Aortic aneurysm ANS: B Often a precursor to chronic venous insufficiency, varicose veins are usually caused by occupations that involve prolonged standing or sitting in one place, overweight, pregnancy, or a familial tendency. They may increase the patient’s risk for deep venous thrombosis (DVT) or they may occur secondary to a DVT. Blockage to lymphatic flow can cause varicosities, as seen with pelvic neoplasm. They appear as long, dilated, tortuous veins in the lower extremities.

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Chapter 8. Respiratory System

MULTIPLE CHOICE

1. A 66-year-old patient presents to the clinic complaining of dyspnea and wheezing. The patient reports a smoking history of two packs of cigarettes per day since age 16. This would be recorded in the chart as: A. 50 x 2-pack years B. 100-pack years C. 50-year, 2-pack history D. 100 pack history ANS: B When recording the smoking history, the measure is calculated by the number of packs per day multiplied by the number of years the patient smoked. In this scenario, the patient smoked two packs per day for 66 – 16 years = 50 years. This is 100-pack years.

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2. Which of the following is characteristic of chronic obstructive pulmonary disease (COPD)?

A. Asymmetric chest expansion B. Increased lateral diameter C. Increased anterior-posterior diameter D. Pectus excavatum ANS: C In COPD, patients commonly develop a barrel-shaped chest due to emphysematous changes in the lungs. A barrel shape is due to an increased anterior-posterior (AP) diameter. In emphysema, there is a 1:1 ratio of AP to lateral diameter; AP diameter equals the lateral diameter. Normally, the AP diameter is twice the lateral diameter.

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3. When palpating the posterior chest, the clinician notes increased tactile fremitus over the left lower lobe. This can be indicative of: A. Pneumonia B. Emphysema C. Pneumothorax D. Asthma ANS: A Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. Conversely, areas of decreased fremitus raise the suspicion of abnormal fluid- or air-filled spaces, such as occurs with pleural effusion, pneumothorax, or emphysema. In the instance of an extensive bronchial obstruction, no palpable vibration is felt in the related field.

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4. During physical examination of a patient, you note resonance on percussion in the upper lung fields. This is consistent with: A. Chronic obstructive pulmonary disease B. Pneumothorax C. A normal finding D. Pleural effusion ANS: C The lung fields should be percussed posteriorly, starting from the superior-most areas and then proceeding inferiorly to the level of the diaphragm. Resonance is the normal sound on percussion. Hyperresonance suggests air trapping, which occurs with chronic obstructive pulmonary disease or tension pneumothorax. Dullness to percussion is detected over the actual site of consolidated lung or pleural fluid. Dullness is also found with pneumonia, severe atelectasis, or pleural effusion.

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5. Which of the following imaging studies should be considered if a pulmonary malignancy is suspected?

A. Computed tomography (CT) scan B. Chest x-ray with posteroanterior, lateral, and lordotic views C. Ultrasound D. Positron emission tomography (PET) scan ANS: A For pulmonary malignancy, chest films are often nondiagnostic, although they may reveal a nodule, mass, or other abnormality. A CT scan of the chest is typically diagnostic.

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6. Alpha-1 antitrypsin deficiency should be considered in patients diagnosed with: A. Exercise-induced cough B. Bronchiectasis C. Chronic obstructive pulmonary disease D. Pericarditis ANS: C When younger patients or nonsmokers develop findings consistent with chronic obstructive pulmonary disease (COPD), alpha-1 antitrypsin deficiency should be suspected. Currently, the American Thoracic Society (2003) recommends that all individuals with COPD or asthma with chronic obstructive changes be tested for alpha-1 antitrypsin deficiency. If alpha-1 antitrypsin deficit is suspected, a qualitative serum should be performed as a screen, followed by quantitative study, as indicated.

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7. On assessment of respiratory excursion, the clinician notes asymmetric expansion of the chest. One side expands greater than the other. This could be due to: A. Pneumothorax B. Pleural effusion C. Pneumonia D. Pulmonary embolism ANS: A The respiratory excursion, or expansion, is determined by placing hands around the patient’s posterior rib cage with the thumbs approximately at the level of the 10th rib between the thumbs, and then asking the patient to take a deep breath and observing the movement of the hands. The motion should be symmetrical. Less than anticipated movement occurs with advanced chronic obstructive pulmonary disease and many restrictive processes, such as interstitial lung disease. Asymmetry of movement occurs with atelectasis, lobar collapse, pneumothorax, and several other conditions.

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8. During auscultation of the chest, your examination reveals a loud grating sound at the lower anterolateral lung fields, at full inspiration and early expiration. This finding is consistent with: A. Pneumonia B. Pleuritis C. Pneumothorax D. A and B ANS: D An adventitious sound, called a pleural friction rub, is a typically loud, grating sound produced when the two inflamed and roughened surfaces of the visceral and parietal pleurae rub together. A friction rub is usually noted in the late inspiratory and early expiratory phases, and in the lower anterolateral lung fields. Examples of conditions that result in a pleural rub include pneumonia, pleuritis, and malignancy.

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9. While assessing auscultated spoken sounds, the auscultated sound is heard as ―a-a-a‖ when the patient is asked to repeat ―e-e-e.‖ This is indicative of: A. Asthma B. Tumor C. Pneumonia D. Pleural effusion

ANS: C Depending on the findings associated with the examination, the examiner can decide whether to proceed with auscultated spoken sounds: bronchophony, egophony, and/or whispered pectoriloquy. If the detected sound is heard as ―a-a-a‖ with a nasal quality over a particular area, indicating egophony, this is an indication of pneumonia.

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10. A cough is described as chronic if it has been present for: A. 2 weeks or more B. 8 weeks or more C. 3 months or more D. 6 months or more ANS: B Cough is classified as acute (less than 3 weeks in duration), subacute (lasting 3 to 8 weeks), and chronic (8 or more weeks in duration), and these distinctions help to narrow the potential differential diagnoses.

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11. Which of the following medications are commonly associated with the side effect of cough?

A. Beta blocker B. Diuretic C. ACE inhibitor D. Calcium antagonist ANS: C The medical history of a patient who complains of cough should be comprehensive, with a particular focus on the potential for asthma, chronic obstructive pulmonary disease, chronic or acute bronchitis, heart failure, gastroesophageal reflux disease, or recent upper or lower respiratory infections. The medication history should be elicited, particularly if the patient is taking an ACE inhibitor that has the potential to induce cough. The patient’s prior self-treatment or prescribed treatment of cough should be explored, including the response and tolerance of the treatment.

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12. Which of the following details are not considered while staging asthma?

A. Nighttime awakenings B. Long-acting beta agonist usage C. Frequency of symptoms D. Spirometry findings

ANS: B The history is an important aspect of asthma because the frequency of various symptoms, nighttime awakenings, use of a short-acting beta agonist, and interference with activities are used, along with spirometry, in staging asthma.

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13. When asthma is suspected, which of the following is not useful in making a diagnosis?

A. Decreased FEV1/FVC ratio B. Decreased FEV1 C. Some reversibility with administration of bronchodilator D. Peak flow meter reading ANS: D Pulmonary function tests, or spirometry, provide diagnosis of asthma; diminished forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio with diminished FEV1. If they are the same, please choose one and use throughout to indicate obstructed outflow. Some degree of reversibility occurs with administration of bronchodilators. Chest films are generally within normal limits unless there is significant air trapping. Peak flow meters should not be used as diagnostic tools. They are appropriate for monitoring ongoing symptoms and determining the response to therapy, particularly once a patient’s ―personal best‖ is determined.

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14. The following criterion is considered a positive finding when determining whether a patient with pneumonia can be safely monitored and treated at home: A. Age over 40 B. Fever greater than 101°F C. Tachypnea greater than 30 breaths per minute D. Productive cough ANS: C Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: • Confusion of new onset • Blood urea nitrogen greater than 20 mg/dL • Respiratory rate of 30 breaths per minute or more • Blood pressure less than 90 mm Hg systolic or diastolic 60 mm Hg or less • Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive.

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15. The most common etiological organism for community-acquired pneumonia is: A. Streptococcus pneumoniae B. Beta hemolytic streptococcus C. Mycoplasma D. Methicillin resistant staphylococcus ANS: A Pneumonia involves inflammation and consolidation of lung tissue. Pneumonia is broadly categorized by whether it occurs outside of the hospital (community-acquired pneumonia) or within the hospital (nosocomial, or hospital-acquired, pneumonia). The cause is most often Streptococcus pneumoniae, Haemophilus influenzae, or Staphylococcus aureus.

Atypical pneumonia involves infection of mycoplasma, legionella, or chlamydia.

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16. A 75-year-old patient with community-acquired pneumonia presents with a temperature of 102.1°F, chills, productive cough, blood pressure 90/62, respiratory rate 28, white blood count 12,000, and blood urea nitrogen 20 mg/dl. He has a history of mild dementia and his mental status is unchanged from his last visit. These findings indicate that the patient: A. Can be treated as an outpatient B. Requires hospitalization for treatment C. Requires a high dose of parenteral antibiotic D. Can be treated with oral antibiotics ANS: A Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: • Confusion of new onset • Blood urea nitrogen greater than 20 mg/dl • Respiratory rate 30 breaths or more per minute • Blood pressure less than 90 mm Hg systolic or diastolic 60 mm Hg or less • Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive.

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17. Your patient with community-acquired pneumonia shows a pleural effusion on chest x-ray, indicating the need for: A. Immediate endotracheal intubation B. Broad spectrum IV antibiotics

C. Thoracentesis to rule out empyema D. Gram stain and culture of sputum ANS: C In pneumonia, chest film typically reveals an area of infiltrate. It is a red flag if a pleural effusion is also visualized, in which case adequate follow-up to exclude development of an empyema is mandatory. This often involves prompt referral to a pulmonologist for possible thoracentesis. Cultures and Gram stains of sputum are usually not ordered for outpatients.

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18. If on physical examination the clinician auscultates rhonchi, the clinician should ask the patient to take a deep breath and cough in order to: A. Mobilize secretions B. Diagnose pleural effusion C. Accurately distinguish lung sounds D. A and C ANS: D Cough is the most common symptom of bronchitis and may persist for several weeks after the initial infection is resolved. During the acute phase, the cough may be productive. There may be associated symptoms, including fever, malaise, chest discomfort, chills, and headache. The chills and chest discomfort are mild in comparison to the symptoms of pneumonia. There may be wheezes and/or rhonchi on auscultation, which disappear or alter with cough effort.

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19. Which of the following is considered a red flag when diagnosing a patient with pneumonia?

A. Fever of 102°F B. Infiltrates on chest x-ray C. Pleural effusion on chest x-ray D. Elevated white blood cell count ANS: C With pneumonia, the chest film typically reveals an area of infiltrate. It is a red flag if a pleural effusion is also visualized, in which case adequate follow-up to exclude development of an empyema is mandatory. This often involves prompt referral to a pulmonologist for possible thoracentesis. Cultures and Gram stains of sputum are usually not ordered for outpatients. The white blood cell count is often elevated.

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20. A 23-year-old patient who has had bronchiectasis since childhood is likely to have which of the following?

A. Barrel-shaped chest B. Clubbing C. Pectus excavatum D. Prolonged capillary refill ANS: B In bronchiectasis there is usually a history of chronic, productive cough. Sputum is typically mucopurulent and produced in increased amounts. Other common findings include shortness of breath, wheezing, fatigue, and possibly hemoptysis. Physical examination reveals rhonchi and/or wheezing. In advanced disease, clubbing and cyanosis may be present.

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21. Your patient has just returned from a 6-month missionary trip to Southeast Asia. He reports unremitting cough, hemoptysis, and an unintentional weight loss of 10 pounds over the last month. These symptoms should prompt the clinician to suspect: A. Legionnaires’ disease B. Malaria C. Tuberculosis D. Pneumonia ANS: C Many times, patients with active tuberculosis (TB) are essentially symptom free. Some complain of malaise and/or fevers but have no significantly disruptive complaints. When respiratory symptoms occur with TB, cough is common; the cough is nonproductive at first and is later associated with sputum production. Additionally, patients with tuberculosis may experience progressive dyspnea, night sweats, weight loss, and hemoptysis. It is important to suspect TB when the patient has travelled to a country where TB is endemic, such as Asia.

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22. A 76-year-old patient with a 200-pack year smoking history presents with complaints of chronic cough, dyspnea, fatigue, hemoptysis, and weight loss over the past 2 months. The physical examination reveals decreased breath sounds and dullness to percussion over the left lower lung field. The chest x-ray demonstrates shift of the mediastinum and trachea to the left. These are classic signs of: A. Lung cancer B. Tuberculosis C. Pneumonia D. Chronic obstructive pulmonary disease ANS: A

Dyspnea is the most common symptom associated with pleural effusion, but effusion may be accompanied by cough, pain, and systemic symptoms, such as malaise and fever.

Abnormal physical findings become evident as the effusion increases in volume. These include decreased lung sounds, dullness over the effusion, decreased fremitus, egophony, and whispered pectoriloquy. With extremely large effusions, the mediastinum and trachea may shift to the opposite side. The exception involves effusion related to malignancy, in which case the mediastinum and trachea may be pulled toward the malignancy.

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23. Causes of pleural effusions include all of the following except: A. Malignancy B. Pneumonia C. Cardiomegaly D. Chronic obstructive pulmonary disease ANS: D Effusions are usually secondary to another condition, such as malignancy, heart failure, cirrhosis, trauma, and infections.

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24. Patients with pulmonary fibrosis show decreased lung tissue compliance and diminished forced vital capacity. Pulmonary fibrosis is a type of: A. Obstructive disease B. Restrictive disease C. Hyperreactive airway disease D. None of the above ANS: B Restrictive lung diseases include pulmonary disorders, such as pneumonitis, pulmonary fibrosis, and sarcoidosis, as well as extrinsic causes, such as kyphosis, scoliosis, or obesity.

In all these disorders there is diminished lung capacity and decreased compliance of lung tissue.

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25. A 24-year-old patient presents to the emergency department after sustaining multiple traumatic injuries after a motorcycle accident. On examination you note tachypnea, use of intercostal muscles to breathe, asymmetric chest expansion, and no breath sounds over the left lower lobe. It is most important to suspect: A. Pulmonary embolism B. Pleural effusion C. Pneumothorax

D. Fracture of ribs ANS: C Pneumothorax involves air in the pleural cavity. A pneumothorax can occur spontaneously in otherwise healthy individuals or be secondary to trauma or intrinsic lung disease. There is history of sudden onset of shortness of breath associated with chest pain. The patient usually presents in great distress, with tachycardia and tachypnea, and is often splinting the chest.

There is decreased fremitus and increased hyperresonance on the affected side. Lung sounds are diminished or absent. The trachea may shift away from the affected side if a large pneumothorax is present.

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Chapter 9. Breasts

MULTIPLE CHOICE

1. When examining the breasts of a 45-year-old female patient, you note nodularity throughout both breasts. There is no dominant mass, tenderness, nipple change, or skin change. Which of the following conditions is most likely?

A. Multiple fibroadenomas B. Fibrocystic breasts C. Mastalgia D. Mastitis ANS: A Breast tissue is normally glandular and may have a rather nodular consistency. The degree of nodularity tends to fluctuate through the menstrual cycle in premenopausal women. A dominant breast mass is a mass that persists throughout a woman’s hormonal cycles, is larger and firmer than any other irregularities, and differs from the rest of the breast tissue.

A fibroadenoma is a soft, discrete breast mass that is moveable, nontender, and benign.

Mastalgia is a condition of pain in the breast. Mastitis is an infection that causes erythema, swelling, and discharge from the breast.

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2. Your 50-year-old patient has a rubbery, firm, mobile breast mass. In order to completely exclude the possibility of cancer, the triple test is necessary, which includes: A. Computed tomography scan B. Magnetic resonance imaging C. Biopsy D. Ultrasound ANS: C

Palpation and mammography, alone or together, are inadequate to definitively identify the cause of a breast mass and to rule out malignancy. The triple test recommended for evaluation of a breast mass involves clinical examination, either ultrasound (<40) or mammogram (>40), and aspiration and/or biopsy. The determination of whether an ultrasound or mammography is recommended is based on age and other situations.

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3. A 23-year-old woman is concerned about a mass she found on palpation. On examination of the patient, the mass feels cystic, round, and mobile with discrete borders. The diagnostic study that is recommended is: A. Computed tomography scan B. Mammogram C. Biopsy D. Ultrasound ANS: D The American College of Radiology (2012) recommends that women under 40 years of age should be assessed through ultrasound, and women older than 40 years should be assessed with a mammogram. Younger women have denser breasts, and ultrasound is, therefore, often more useful than a mammogram. Ultrasounds are helpful in determining whether a mass that feels potentially cystic is fluid filled or solid. It is crucial that the woman understands that the imaging procedure is a screening tool and is never diagnostic regarding the existence or absence of a malignancy.

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4. Which of the following variables is not a component of the Gail model?

A. Age at menarche B. Number of breast biopsies C. Age at first live birth D. Number of live births ANS: D The Gail model is a clinical prediction rule used to estimate a patient’s risk for breast cancer. The model identifies the relative risk associated with three factors obtained through history: age at menarche, number of previous breast biopsies, and age at first live birth.

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5. A 62-year-old female presents with a singular, hard, 1 cm, nontender, nonmobile mass in the right breast. There are no nipple or skin changes, however, you palpate an enlarged right-sided supraclavicular lymph node. The clinician should recognize these are signs of: A. Fibroadenoma

B. Breast cyst C. Malignancy D. Paget’s disease ANS: C The typical malignant breast mass is solitary, nontender, hard, immobile or fixed, and poorly defined. It may be accompanied by nipple erosion or other inflammatory skin changes, as seen in Paget’s disease; nipple discharge; skin thickening or dimpling; retraction; and palpable axillary nodes. Although most malignant masses are painless, associated discomfort does not exclude the potential for breast cancer.

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6. A 45-year-old female patient presents in the emergency department due to multiple chest injuries resulting from a motor vehicle accident. There is a palpable, tender, irregular 3 cm soft mass located in the left breast, with erythema and swelling of the breast. Which of the following is indicated?

A. Compression wrap for chest and breast trauma B. Mammogram C. Reevaluation following complete resolution of obvious injuries D. Ultrasound ANS: B Trauma to the anterior chest area may result in a palpable breast mass. An automobile accident with injury from contact with the seat belt, air bag, steering wheel, or dashboard is a common source of breast trauma. When a palpable mass results from chest trauma, it typically represents either a hematoma or area of secondary fat necrosis. Even when a mass is identified subsequent to direct trauma, the provider must remain suspicious for the possibility of malignancy that preexisted but was undetected before the accident.

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7. A 23-year-old female presents with episodic bilateral breast tenderness. On palpation, there are multiple areas of nodularity with no dominant breast mass and no tenderness. There are no nipple or skin changes. It is best to recommend: A. Ultrasound of the breasts B. Mammogram of the breasts C. Fine needle aspiration of one nodule within a breast D. Diary of menstrual cycle and breast symptoms ANS: D

Women who experience cyclic mastalgia usually have onset as a teen or young adult. It is important to determine menstrual and reproductive history, and to identify all pharmacological agents taken. A complete breast examination should be performed. The pain associated with hormonal fluctuation most commonly occurs during the second half of the woman’s cycle. The variability of the signs and symptoms is identified with a symptom diary and record of the menstrual cycle. The pain is typically poorly localized, bilateral, and nonspecific. It may be accompanied by a sense of breast fullness. The examination may identify the multiple, bilateral nodularities associated with fibroadenomas or fibrocystic changes.

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8. A 34-year-old female who gave birth 2 weeks ago developed fever and pain in the right breast while nursing her baby. The patient has tenderness, erythema, and swelling of the nipple on the right breast. Which of the following diagnostic studies is indicated?

A. White blood cell (WBC) count B. Breast milk culture C. Ultrasound D. Fine needle biopsy ANS: A For mastitis, WBC count should be obtained and is usually elevated. Even though the breast milk can be cultured, this is not generally recommended. If the presentation is atypical; that is, the patient is not lactating and there are no associated systemic signs or symptoms, a consultation should be obtained and mammography ordered to determine the definitive diagnosis and rule out malignancy.

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9. Your patient, a 46-year-old woman suffering from psychosis, complains of milky discharge from both breasts. On examination, there are no significant findings and the patient is not pregnant, breastfeeding, or in the postpartum period. You should: A. Order computed tomography scan of head to rule out pituitary tumor B. Obtain a complete list of the patient’s medications C. Have the patient keep a menstrual cycle diary D. Refer the patient for mammogram ANS: B Galactorrhea is characterized by bilateral and milky discharge from multiple ducts in a woman who is neither pregnant nor lactating. Causes of galactorrhea include a variety of drugs, as well as an elevated prolactin level associated with pituitary tumor or hyperthyroidism. The drugs associated with galactorrhea include antidepressants (amitriptyline, imipramine), psychoactives (haloperidol, thioridazine), hormones (estrogens, progestogens), antiepileptics (valproic acid), and antihypertensives (verapamil). This list is not exhaustive.

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10. Your patient is a 36-year-old woman who complains of milky discharge from both breasts, episodes of headache, and menstrual irregularity. The patient is on no medications. On examination, there are no significant findings, and the patient is not pregnant, breastfeeding, or in the postpartum period. It is important to: A. Order prolactin level B. Obtain magnetic resonance imaging of the head C. Have the patient keep a menstrual cycle diary D. Refer the patient for mammogram ANS: A Galactorrhea can be a symptom of endocrine disorder, particularly pituitary dysfunction. In prolactinoma of the pituitary, a patient complains of galactorrhea, headaches, vision change, relative infertility, and amenorrhea. Laboratory studies should include a pregnancy test, prolactin level, and thyroid functions.

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11. Bloody breast discharge is associated with which of the following?

A. Bleeding disorder, such as von Willebrand disease B. Malignancy C. Excessive nonsteroidal anti-inflammatories D. A and C ANS: B Bloody discharge is often associated with malignancy but can stem from other conditions. If blood is not evident, the discharge should be tested for blood, using guaiac process.

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12. Your patient is a 64-year-old female who presents with complaints of a red, scaly rash on the nipple and areola of one breast. It has been present for a few months. There is no mass or nipple discharge. You should be suspicious of: A. Contact dermatitis B. Mastitis C. Paget’s disease D. Eczema ANS: C

In Paget’s disease of the breast the patient may describe the persistence of skin changes for several months. The typical presentation involves skin changes of the nipple and/or areola, with the nipple being involved first. The condition does not always involve a palpable mass or nodule. The skin changes of the nipple and areola range from scaling redness to various degrees of ulceration.

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13. A 12-year-old boy is brought into the clinic by his mother. The teen boy is embarrassed because he has developed breast tissue and would like to know if there is any treatment. The physical examination reveals early stages of puberty, otherwise it is normal. This presentation is: A. Associated with a high rate of malignancy B. Most often due to altered hormonal levels in puberty C. Commonly indicative of pituitary tumor triggered by puberty D. Too dense for a mammogram and requires biopsy ANS: B Gynecomastia most often occurs during infancy, puberty, and senescence. It is caused by an altered balance between estradiol and testosterone levels. Although it can be an indication of primary hypogonadism, hyperthyroidism, cirrhosis, or renal disease, the majority of cases are specific to hormonal changes of puberty, drug induced, or idiopathic. With the presentation of breast enlargement in a male, malignancy must always be considered.

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14. A condition that increases risk of breast cancer in a male is: A. Pseudogynecomastia B. BRCA1 and 2 C. Klinefelter’s syndrome D. B and C ANS: D It is anticipated that over 2,000 new cases of male breast cancer will be diagnosed in 2013, with over 400 related deaths (ACS, 2013). Men develop the same types of breast cancer as women; therefore, it is important to include malignancy in the differential diagnosis when a man complains of breast enlargement. Factors that increase the risk of breast cancer in men include a previous history of breast or testicular disease and Klinefelter’s syndrome. A history of gynecomastia is not associated with an increased risk for breast cancer.

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15. A 52-year-old female complains of discharge from one breast. There is no pain, no mass, and no skin changes. The physical examination is normal. When putting pressure on the affected breast, the nipple expresses a small amount of thick, white discharge. These findings are consistent with: A. Duct ectasia B. Mastitis C. Fibroadenoma D. Fibrocystic breasts ANS: A Discharge from one breast is commonly benign and frequently caused by duct ectasia or an intraductal papilloma. Duct ectasia results in dilation of one major breast duct and causes approximately one-third of the cases of pathological discharge. Papillomas are responsible for 44% of pathological discharge. Because the discharge associated with ductal ectasia is often stagnant, the discharge is cheesy in appearance. It is often associated with noncyclic breast discomfort and a subareolar lump at the site of the dilated duct. Because one major duct is involved, the discharge comes from one duct or nipple area.

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Chapter 10. Abdomen

MULTIPLE CHOICE

1. When performing abdominal assessment, the clinician should perform examination techniques in the following order: A. Inspection, palpation, percussion, and auscultation B. Inspection, percussion, palpation, and auscultation C. Inspection, auscultation, percussion, and palpation D. Auscultation, palpation, percussion, and inspection ANS: C The abdominal examination begins with inspection, followed by auscultation, percussion, and palpation. Light palpation should precede deep palpation. Auscultating before percussion or palpation allows the examiner to listen to the abdominal sounds undisturbed. Moreover, if pain is present, it is best to leave palpation until last and to gather other data before possibly causing the patient discomfort.

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2. The clinician should auscultate the abdomen to listen for possible bruits of the: A. Aorta B. Renal artery C. Iliac artery

D. All of the above ANS: D Perform auscultation before palpation in order to hear unaltered bowel sounds. Listen for bruits over the aorta and the iliac, renal, and femoral arteries.

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3. On abdominal examination, which of the following is assessed using percussion?

A. Liver B. Kidneys C. Pancreas D. Esophagus ANS: A The purpose of liver percussion is to measure the liver size. The technique used to percuss the liver is as follows: 1. Starting in the midclavicular line at about the third intercostal space, lightly percuss and move down.

2. Percuss inferiorly until dullness denotes the liver’s upper border (usually at fifth intercostal space in midclavicular line).

3. Resume percussion from below the umbilicus on the midclavicular line in an area of tympany.

4. Percuss superiorly until dullness indicates the liver’s inferior border.

5. Measure span in centimeters. Normal liver span: clinically estimated at midclavicular line: 6 to 12 cm and midsternal line: 4 to 8 cm.

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4. In abdominal assessment, a digital rectal exam is performed to assess for all of the following except: A. Hemorrhoids B. Prostate size C. Blood in stool D. Ureteral stenosis ANS: D A digital rectal exam is included in the abdominal examination. Note skin changes or lesions in the perianal region or the presence of external hemorrhoids. Insert the gloved index finger into the anus with the patient either leaning over or side-lying on the examination table, and note any internal hemorrhoids or fissures. Check the stool for occult blood. For males, the rectal exam is necessary for direct examination of the prostate. Ureteral stenosis is detected by angiography.

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5. Rebound tenderness of the abdomen is a sign of: A. Constipation B. Peritoneal inflammation C. Elevated venous pressure D. Peritoneal edema ANS: B Rebound tenderness is tested by slowly pressing over the abdomen with your fingertips, holding the position until pain subsides or the patient adjusts to the discomfort, and then quickly removing the pressure. Rebound pain, a sign of peritoneal inflammation, is present if the patient experiences a sharp discomfort over the inflamed site when pressure is released.

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6. While assessing the abdomen, the clinician deeply palpates the left lower quadrant and this causes pain in the patient’s right lower abdomen. This is most commonly indicative of: A. Constipation B. Diverticulitis C. Appendicitis D. Hepatitis ANS: C Appendicitis is suggested by a positive Rovsing’s sign. This sign is positive when there is referred rebound pain in the right lower quadrant when the examiner presses deeply in the left lower quadrant and then quickly releases the pressure.

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7. Your patient complains of severe right lower quadrant abdominal pain. To assess the patient for peritoneal inflammation, the examiner should: A. Percuss the right lower quadrant of the abdomen B. Deeply palpate the right lower quadrant of the abdomen C. Auscultate the right lower quadrant for hyperactive bowel sounds D. Perform the heel strike test ANS: D Ask the patient to stand with straight legs and raise up on the toes. Then ask the patient to relax, allowing the heel to strike the floor, thus jarring the body. A positive heel strike is indicative of appendicitis and peritoneal irritation. Alternatively, strike the plantar surface of the heel with your fist while the patient rests supine on the examination table.

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8. Your patient is lying supine and you ask him to raise his leg while you place resistance against the thigh. You are testing the patient for: A. Psoas sign B. Obturator sign C. Rovsing’s sign D. Murphy’s sign ANS: A To examine the patient for appendicitis, the clinician can test the patient for psoas sign. This is done in the following manner: Place a hand on the patient’s thigh just above the knee and ask the patient to raise the thigh against your hand. This contracts the psoas muscle and produces pain in patients with an inflamed appendix.

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9. The patient complains of right upper quadrant pain. With the patient lying supine on the examination table, the clinician deeply palpates the right upper quadrant of the abdomen while the patient inhales. The examiner is testing the patient for: A. Psoas sign B. Obturator sign C. Rovsing’s sign D. Murphy’s sign ANS: D Murphy’s sign is elicited by deeply palpating the right upper quadrant of the abdomen. Pain is present on deep inspiration when an inflamed gallbladder is palpated by pressing the fingers under the rib cage. Murphy’s sign is positive in cholecystitis.

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10. The patient has abdominal pain and it is worsened when the examiner rotates the patient’s right hip inward with the knee bent and the obturator internus muscle stretched. This is a sign of: A. Diverticulitis B. Cholecystitis C. Appendicitis D. Mesenteric adenitis ANS: C A positive obturator sign indicates appendicitis. Pain is elicited by inward rotation of the right hip with the knee bent so that the obturator internus muscle is stretched.

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11. On abdominal examination, as the clinician presses on the right upper quadrant to assess liver size, jugular vein distension becomes obvious. Hepatojugular reflux is indicative of: A. Acute hepatitis B. Right ventricular failure C. Cholecystitis D. Left ventricular failure ANS: B Hepatojugular reflux is elicited by applying firm, sustained hand pressure to the abdomen in the midepigastric region while the patient breathes regularly. Observe the neck for elevation of the jugular venous pressure (JVP) with pressure of the hand and a sudden drop of the JVP when the hand pressure is released. Hepatojugular reflux is exaggerated in right ventricular failure.

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12. Your patient demonstrates positive shifting dullness on percussion of the abdomen. This is indicative of: A. Cholecystitis B. Appendicitis C. Ascites D. Hepatitis ANS: C To assess the patient for ascites, test for shifting of the peritoneal fluid to the dependent side by rolling the patient side to side and percussing for dullness on the dependent side of the abdomen.

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13. Your 44-year-old female patient complains of right upper quadrant pain. Her skin and sclera are yellow, and she has hyperbilirubinemia and elevated liver enzymes. The clinician should suspect: A. Acute pancreatitis B. Biliary duct obstruction C. Acute hepatitis D. Atypical appendicitis ANS: B In cholecystitis, acute colicky pain is localized in the right upper quadrant and is often accompanied by nausea and vomiting. Murphy’s sign is frequently present. Fever is low grade, and the increase in neutrophilic leukocytes in the blood is slight. Acute cholecystitis improves in 2 to 3 days and resolves within a week; however, recurrences are common. If acute cholecystitis is accompanied by jaundice and cholestasis (arrest of bile excretion),

suspect common duct obstruction.

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14. The most common cause of acute pancreatitis is: A. Trauma B. Hepatitis virus A C. Hyperlipidemia D. Alcohol abuse ANS: D Biliary tract disease and alcoholism account for 80% or more of pancreatitis admissions.

Other causes include hyperlipidemia, drugs, toxins, infection, structural abnormalities, surgery, vascular disease, trauma, hyperparathyroidism and hypercalcemia, renal transplantation, and hereditary pancreatitis. The most common cause of pancreatitis is alcohol abuse.

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15. Your patient with pancreatitis has a Ranson rule score of 8. The clinician should recognize that this is a risk of: A. Pleural involvement B. Alcoholism C. High mortality from pancreatitis D. Bile duct obstruction ANS: C The Ranson rule uses a score determined by magnetic resonance imaging results, with an index possible range of 0 to 10. A categorization of patients indicates the risk of both mortality and complication from pancreatitis. Patients at the low end of the index (1 to 3) are predicted to have a low risk of mortality (3%) and complications (8%), whereas patients scoring at the high end (7 to 10) of the index are predicted to have a higher incidence of mortality (17%) and/or complications (92%).

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16. Your patient complains of left upper quadrant pain, fever, extreme fatigue, and spontaneous bruising. The clinician should recognize that these symptoms are often related to: A. Hematopoietic disorders B. Hepatomegaly C. Esophageal varices D. Pleural effusion ANS: A Left upper quadrant pain can be associated with stomach or spleen disorders; however, it is

often associated with causes that are outside the abdomen. Hematopoietic malignancies, such as lymphomas and leukemias, and other hematological disorders, such as thrombocytopenia, polycythemia, myelofibrosis, and hemolytic anemia, often cause enlargement of the spleen, leading to left upper quadrant pain. In addition to questions about the specific characteristics of the pain, it is important to ask the patient about fever, unusual bleeding or bruising, recent diagnosis of mononucleosis, fatigue, malaise, lymphadenopathy, cough, arthralgias, anorexia, weight loss, jaundice, high blood pressure, and headache.

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17. A 16-year-old patient presents with sore throat, cervical lymphadenopathy, fever, extreme fatigue, and left upper quadrant pain. The physical examination reveals splenomegaly. The clinician should recognize the probability of: A. Bacterial endocarditis B. Infectious mononucleosis C. Pneumonia with pleural effusion D. Pancreatic cancer ANS: B Hypersplenism is secondary to other primary disorders, most commonly cytopenic hematological disorders, such as lymphoma, leukemia, thrombocytopenia, polycythemia, myelofibrosis, and haemolytic anemias. With the sore throat and cervical lymphadenopathy, infection due to Epstein-Barr virus is common in adolescents. Infectious mononucleosis is an important disorder to consider. Splenomegaly often occurs in infectious mononucleosis.

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18. Your patient complains of lower abdominal pain, anorexia, extreme fatigue, and unintentional weight loss of 10 pounds in the last 3 weeks. You find a positive hemoccult on digital rectal exam. Laboratory tests show iron-deficiency anemia. The clinician needs to consider: A. Diverticulitis B. Appendicitis C. Colon cancer D. Peptic ulcer disease ANS: C A positive hemoccult on rectal examination may indicate an upper gastrointestinal bleed or malignancy. Malignancy should also be suspected if there is weight loss and/or a palpable abdominal mass.

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19. Which of the following is the most common cause of heartburn-type epigastric pain?

A. B. C. D.

Decreased lower esophageal sphincter tone Helicobacteria pylori infection of stomach Esophageal spasm Excess use of NSAIDs

ANS: A Gastroesophageal reflux disease (GERD) is the most common organic cause of heartburn.

GERD is caused by decreased lower esophageal sphincter (LES) tone. LES control can be decreased by several medications (e.g., theophylline, dopamine, diazepam, calcium-channel blockers), foods and/or beverages (caffeine, alcohol, chocolate, fatty foods), and tobacco use. When LES tone is lower than normal, secretions are allowed to reflux into the esophagus, causing discomfort.

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20. A 22-year-old female enters the emergency room with complaints of right lower quadrant abdominal pain, which has been worsening over the last 24 hours. On examination of the abdomen there is a palpable mass and rebound tenderness over the right lower quadrant. The clinician should recognize the importance of: A. Digital rectal exam B. Endoscopy C. Ultrasound D. Pelvic examination ANS: D A female with abdominal pain can have a gastrointestinal or genitourinary disorder, or gynecological problem. It is imperative to ask about the last menstrual period (LMP) and birth control methods in order to rule out ectopic pregnancy. A history of miscarriages and/or sexually transmitted diseases can give more clues for the risk of ectopic pregnancy. Safe sex practices and the number of sexual partners can alert the practitioner to the risk for pelvic inflammatory disease. No complaint of lower abdominal pain in a female should be evaluated without performing a pelvic examination.

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21. The major sign of ectopic pregnancy is: A. Sudden onset of severe epigastric pain B. Amenorrhea with unilateral lower quadrant pain C. Lower back and rectal pain D. Palpable abdominal mass ANS: B The most obvious sign of ectopic pregnancy is amenorrhea followed by spotting and sudden onset of severe lower quadrant pain. A stat pregnancy test should be performed. There is tenderness on pelvic examination, and a pelvic mass may be palpated. Blood is present in the cul-de-sac. Shock and hemorrhage occur if the pregnancy ruptures. Abdominal disten-

tion with peritoneal signs will ensue. Immediate laparoscopy or laparotomy is indicated because this condition is life threatening.

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22. When ruptured ectopic pregnancy is suspected, the following procedure is most important: A. Culdocentesis B. Computed tomography scan C. Abdominal x-ray D. Digital rectal exam ANS: A The most obvious sign of ectopic pregnancy is amenorrhea, followed by spotting and sudden onset of severe lower quadrant pain. A stat pregnancy test should be performed. The diagnosis of ectopic pregnancy can be made with urine human chorionic gonadotropin (hCG) or stat serum hCG, pelvic ultrasound, and, if necessary, culdocentesis to detect blood in the cul-de-sac. There is tenderness on pelvic examination and a pelvic mass may be palpated. Blood is present in the cul-de-sac. Shock and hemorrhage occur if the pregnancy ruptures. Abdominal distension with peritoneal signs will ensue. Immediate laparoscopy or laparotomy is indicated because this condition is life threatening.

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23. The majority of colon cancers are located in the: A. Transverse colon B. Cecum C. Rectosigmoid region D. Ascending colon ANS: C Colorectal cancer is the second leading cause of death from malignancies in the United States. Over half are located in the rectosigmoid region and are typically adenocarcinomas.

Risk factors include a history of polyps, positive family history of colon cancer or familial polyposis, ulcerative colitis, granulomatous colitis, and a diet low in fiber and high in animal protein, fat, and refined carbohydrates.

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24. The following symptom(s) in the patient’s history should raise the clinician’s suspicion of colon cancer: A. Alternating constipation and diarrhea B. Narrowed caliber of stool C. Hematochezia D. All of the above

ANS: D Colon cancer may be present for several years before symptoms appear. Complaints include fatigue, weakness, weight loss, alternating constipation and diarrhea, a change in the caliber of stool, tenesmus, urgency, and hematochezia. Physical examination is usually normal, except in advanced disease, when the tumor can be palpated or hepatomegaly is present, owing to metastatic disease.

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25. A patient presents to the emergency department with nausea and severe, colicky back pain that radiates into the groin. When asked to locate the pain, he points to the right costovertebral angle region. His physical examination is unremarkable. Which of the following laboratory tests is most important for the diagnosis?

A. Urinalysis B. Serum electrolyte levels C. Digital rectal exam D. Lumbar x-ray ANS: A Urinary calculi can occur anywhere in the urinary tract; therefore, pain can originate in the flank or kidney area and radiate into the right or left lower quadrant and then to the suprapubic area as the stone attempts to move down the tract. The pain is severe, acute, and colicky, and may be accompanied by nausea and vomiting. If the stone becomes lodged at the ureterovesical junction, the patient will complain of urgency and frequency. Blood will be present in the urine.

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26. Your 34-year-old female patient complains of a feeling of heaviness in the right lower quadrant, achiness, and bloating. On pelvic examination, there is a palpable mass in the right lower quadrant. Urine and serum pregnancy tests are negative. The diagnostic tool that would be most helpful is: A. Digital rectal exam B. Transvaginal ultrasound C. Pap smear D. Urinalysis ANS: B Ovarian masses are often asymptomatic, but symptoms may include pressure-type pain, heaviness, aching, and bloating. Masses are typically detected on pelvic examination. In advanced malignancies, ascites is often present. An elevated cancer antigen 125 (CA-125) result indicates the likelihood that the mass is malignant. A transvaginal pelvic ultrasound has a higher diagnostic sensitivity than transabdominal ultrasound. If diagnosis is unclear, computed tomography scan, magnetic resonance imaging, or positron emission tomography scan can be performed. A laparoscopy or exploratory laparotomy is necessary for staging,

tumor debulking, and resection.

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27. Your 54-year-old male patient complains of a painless lump in his lower left abdomen that comes and goes for the past couple of weeks. When examining the abdomen, you should have the patient: A. Lie flat and take a deep breath B. Stand and bear down against your hand C. Prepare for a digital rectal exam D. Lie in a left lateral recumbent position ANS: B In the majority of hernia cases, a history of heavy physical labor or heavy lifting can be elicited. Right or left lower quadrant pain that may radiate into the groin or testicle is typical.

The pain is usually dull or aching unless strangulated, in which case the pain is more severe.

The pain increases with straining, lifting, or movement of the lower extremities. Physical examination includes palpating the femoral area and inguinal ring for bulging or tenderness.

Ask the patient to bear down against your hand.

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28. A nurse practitioner reports that your patient’s abdominal x-ray demonstrates multiple air-fluid levels in the bowel. This is a diagnostic finding found in: A. Appendicitis B. Cholecystitis C. Bowel obstruction D. Diverticulitis ANS: C The most common causes of mechanical obstruction are adhesions, almost exclusively in patients with previous abdominal surgery, hernias, tumors, volvulus, inflammatory bowel disease (Crohn’s disease, colitis), Hirschsprung’s disease, fecal impaction, and radiation enteritis. Initially, the patient complains of a cramping periumbilical pain that eventually becomes constant. Physical examination reveals mild, diffuse tenderness without peritoneal signs, and possibly visible peristaltic waves. In early obstruction, tinkles, rushes, and borborygmi can be heard. In late obstruction, bowel sounds may be absent. The diagnosis can be made with flat and upright abdominal films looking for bowel distension and the presence of multiple air-fluid levels. Computed tomography scan or magnetic resonance imaging may be necessary for confirmation.

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29. A 76-year-old patient presents to the emergency department with severe left lower quadrant

abdominal pain, diarrhea, and fever. On physical examination, you note the patient has a positive heel strike and left lower abdominal rebound tenderness. These are typical signs and symptoms of which of the following conditions?

A. Diverticulitis B. Salpingitis C. Inflammatory bowel disease D. Irritable bowel syndrome ANS: A Diverticular disease is prevalent in patients over 60 years of age. Because the sigmoid colon has the smallest diameter of any portion of the colon, it is the most common site for the development of diverticula. Although the pain can be generalized, it is typically localized to the left lower abdomen and accompanied by tenderness, fever, and leukocytosis. Other symptoms can include constipation or loose stools, nausea, vomiting, and positive stool occult blood. With diverticulitis there is an increased risk of perforation, which presents with a more dramatic clinical picture as a result of peritonitis. Look for signs of peritonitis, such as a positive heel strike test and/or rebound tenderness.

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30. Which of the following conditions is the most common cause of nausea, vomiting, and diarrhea?

A. Viral gastroenteritis B. Staphylococcal food poisoning C. Acute hepatitis A D. E. coli gastroenteritis ANS: A Viral gastroenteritis is the most common cause of nausea, vomiting, and diarrhea. At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and astrovirus.

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31. A patient presents to the emergency department with complaints of vomiting and abdominal pain. You note that the emesis contains bile. On physical examination, there is diffuse tenderness, abdominal distension, and rushing, high-pitched bowel sounds. Which of the following diagnoses would be most likely?

A. Gastric outlet obstruction B. Small bowel obstruction C. Distal intestinal blockage D. Colonic obstruction ANS: B The contents of the vomitus commonly vary according to the level of obstruction. Gastric

outlet obstruction is associated with emesis containing undigested food. Proximal small intestinal blockage is likely to be bile-stained. Distal intestinal blockage is more likely to contain fecal matter. The degree of cramping and pain is often related to the proximity of the obstruction, so that obstructions of the lower intestines may have less severe cramping, vomiting, and/or pain. Bowel sounds often are high pitched and metallic sounding, but may later become absent. Tenderness may be localized or diffuse. Distention as well as a succussion splash may be present.

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32. A 5-year-old female patient presents to the emergency department with sore throat, vomiting, ear ache, 103°F degree fever, photophobia, and nuchal rigidity. She has an episode of projectile vomiting while you are examining her. The clinician should recognize that the following should be done: A. Abdominal x-ray B. Fundoscopic examination C. Lumbar puncture D. Analysis of vomitus ANS: C The range of neurological disorders that result in nausea and/or vomiting is broad. Included are meningitis, increased intracranial pressure (ICP), migraines, a space-occupying lesion, and Ménière’s disorder. Central nervous system-related vomiting is often projectile and may not be preceded by nausea. Papilledema may accompany increased ICP. Neurological deficits may be evident with increased ICP, space-occupying lesions, and meningitis. Nuchal rigidity is a classic finding for meningitis.

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33. A 9-year-old boy accompanied by his mother reports that since he came home from summer camp he has had fever, nausea, vomiting, severe abdominal cramps, and watery stools that contain blood and mucus. The clinician should recognize the importance of: A. Stool for ova and parasites B. Abdominal x-ray C. Stool for clostridium D. Fecal occult blood test ANS: A Parasites causing diarrhea usually enter the body through the mouth. They are swallowed and can remain in the intestine or burrow through the intestinal wall and invade other organs. Certain parasites, most commonly Giardia lamblia, transmitted by fecally contaminated water or food, can cause diarrhea, bloating, flatulence, cramps, nausea, anorexia, weight loss, greasy stools (because of its interference with fat absorption), and occasionally fever. Symptoms usually occur about 2 weeks after exposure and can last 2 to 3 months.

Often, the symptoms are vague and intermittent, which makes diagnosis more difficult. Serial stool samples for ova and parasites (O&P) should be ordered because a single sample

may not reveal the offending parasite.

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34. A 56-year-old male complains of anorexia, changes in bowel habits, extreme fatigue, and unintentional weight loss. At times he is constipated and other times he has episodes of diarrhea. His physical examination is unremarkable. It is important for the clinician to recognize the importance of: A. Complete blood count with differential B. Stool culture and sensitivity C. Abdominal x-ray D. Colonoscopy ANS: D The symptoms and severity of the diarrhea vary according to the underlying cause. The symptoms of carcinomas are generally insidious. The diarrhea is mild and intermittent. Often malignancies are found on routine hemoccults, sigmoidoscopy, or colonoscopy. There should be a high index of suspicion with unexplained weight loss or new-onset iron-deficiency anemia in a patient over 40 years old.

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35. A 20-year-old engineering student complains of episodes of abdominal discomfort, bloating, and diarrhea. The symptoms usually occur after eating, and pain is frequently relieved with bowel movement. She is on a celiac diet and the episodic symptoms persist. Physical examination and diagnostic tests are negative. Colonoscopy is negative for any abnormalities.

This is a history and physical consistent with: A. Inflammatory bowel disease B. Irritable bowel syndrome C. Laxative abuse D. Norovirus gastroenteritis ANS: B Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by mild to severe abdominal pain, discomfort, bloating, and alteration of bowel habits. The exact cause is unknown. In some cases, the symptoms are relieved by bowel movements. Diarrhea or constipation may predominate, or they may be mixed (classified as IBS-D, IBS-C, or IBS-M, respectively). IBS may begin after an infection (postinfectious, IBS-PI) or a stressful life event. IBS is a motility disorder involving the upper and lower gastrointestinal (GI) tracts that causes intermittent nausea, abdominal pain and distention, flatulence, pain relieved by defecation, diarrhea, and/or constipation. Symptoms usually occur in the waking hours and may be worsened or triggered by meals. It is three times more prevalent in women, accounts for more than half of all GI referrals, and is highly correlated with emotional factors, particularly anxiety and stress.

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36. A 78-year-old female patient is suffering from heart failure, gastroesophageal reflux disease, diabetes, and depression. She presents with complaints of frequent episodes of constipation.

Her last bowel movement was 1 week ago. On examination, you palpate a hard mass in the left lower quadrant of the abdomen. You review her list of medications. Which of the following of her medications causes constipation?

A. Digitalis (Lanoxin) B. Amlodipine (Norvasc) C. Sertraline (Zoloft) D. Metformin (Glucophage) ANS: B Medications that frequently cause constipation include: - Analgesics/narcotics - Antacids containing aluminum - Anticonvulsants - Antidepressants - Antihypertensives (calcium-channel blockers, beta blockers) - Antiparkinsonism agents - Antispasmodics - Calcium supplements - Diuretics - Iron supplements - Sedatives/tranquilizers PTS: 1

37. You are examining a 55-year-old female patient with a history of alcohol abuse. She complains of anorexia, nausea, pruritus, and weight loss over the last month. On physical examination, you note yellow hue of the skin and sclera. Which of the following physical examination techniques is most important?

A. Scratch test B. Heel strike C. Digital rectal exam D. Pelvic examination ANS: A Cirrhosis develops with the replacement of normal liver tissue by regenerative, fibrotic nodules and may occur in the late phase of a variety of disorders that damage the liver, such as alcohol toxicity. A patient may present with jaundice and describe an associated, progressive pattern of pruritus, weakness, anorexia, nausea, and weight loss. Determine the size and consistency of the liver, as well as any tenderness. The scratch test is a method used to ascertain the location and size of a patient’s liver during a physical assessment. The scratch test uses auscultation to detect the differences in sound transmission through the abdominal cavity over solid and hollow organs and spaces. After placing a stethoscope over the approximate location of a patient's liver, the examiner will then scratch the skin of the patient's

abdomen lightly, moving laterally along the liver border. When the liver is encountered, the scratching sound heard in the stethoscope will increase significantly. In this manner, the size and shape of a patient’s liver can be ascertained.

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38. You observe Charcot’s triad of signs and symptoms in a patient under your care. This is commonly seen in which of the following disorders?

A. Cirrhosis B. Pancreatitis C. Cholangitis D. Portal hypertension ANS: C Occlusion of the common bile duct may occur with disorders of the gallbladder and/or bile duct, such as cholecystitis, cholelithiasis, and cholangitis. All three conditions are generally accompanied by right upper quadrant discomfort, anorexia, and nausea. Charcot’s triad, which includes jaundice, right upper quadrant pain, and fever/chills, is common to problems resulting in obstructions of the bile duct.

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39. A 59-year-old patient with a history of alcohol abuse is admitted for hematemesis. On physical examination, you note ascites and caput medusa. A likely cause for the hematemesis is: A. Peptic ulcer disease B. Barrett’s esophagus C. Pancreatitis D. Esophageal varices ANS: D Patients with portal hypertension may develop gastrointestinal bleeding from varices of the esophagus, stomach, intestines, or other sites. Portal hypertension is most commonly associated with cirrhosis, usually caused by alcohol abuse or hepatitis. Check for signs of liver disease, including jaundice, cirrhosis, telangiectasia, hepatomegaly, and right upper quadrant tenderness. Ascites occurs due to venous congestion. Caput medusa is the distension of paraumbilical veins due to portal hypertension.

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40. A 16-year-old female with anorexia and bulimia is admitted for hematemesis. She admits to inducing vomiting often. On physical examination, you note pallor, body mass index less than 15, and hypotension. A likely reason for hematemesis is: A. Mallory-Weiss tear

B. Cirrhosis C. Peptic ulcer disease D. Esophageal varies ANS: A Upper gastrointestinal (GI) hemorrhage may result from a tear at the gastroesophageal junction, known as a Mallory-Weiss tear. A patient may develop more than one tear. These tears are most common in alcoholic or bulimic patients following repeated episodes of vomiting or severe retching. If a laceration/tear of the mucosa causes GI bleeding, the patient may demonstrate alterations in hemodynamic status.

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41. An 82-year-old female presents to the emergency department with epigastric pain and weakness. She admits to having dark, tarry stools for the last few days. She reports a long history of pain due to osteoarthritis. She self-medicates daily with ibuprofen, naprosyn, and aspirin for joint pain. On physical examination, she has orthostatic hypotension and pallor.

Fecal occult blood test is positive. A likely etiology of the patient’s problem is: A. Mallory-Weiss tear B. Esophageal varices C. Gastric ulcer D. Colon cancer ANS: C Bleeding occurs after an area of gastric mucosal injury has ulcerated. Explore symptoms of epigastric and/or periumbilical discomfort. Identify potential causes of gastric mucosal injury—the most common being NSAID use and stress. Many elderly individuals self-medicate with over-the-counter aspirin preparations and various NSAIDs. Commonly, they use too many medications that have side effects of gastric irritation.

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42. A 48-year-old male presents to the clinic with complaints of anorexia, nausea, weakness, and unintentional weight loss over the last few weeks. On physical examination, the patient has jaundice of the skin, as well as sclera and a palpable mass in the epigastric region. In addition to complete blood count and bilirubin levels, all of the following tests would be helpful except: A. Liver enzymes B. Amylase C. Lipase D. Uric acid ANS: D Primary or metastatic cancers of the liver and/or pancreas can cause obstructive hyperbilirubinemia and jaundice. Jaundice may be the initial sign of a malignancy or may follow the development of other symptoms. Ask about associated symptoms, such as right upper quad-

rant discomfort, nausea, fever, back pain, weight loss, fatigue/weakness, and pruritus. None of these symptoms are specific to malignancy; however, other causes of jaundice are less likely to be associated with weight loss. During the abdominal examination, carefully palpate the area of the liver and the remainder of the abdomen, checking for masses or unexpected findings. In addition to a complete blood count, liver functions, amylase, lipase, and bilirubin levels, abdominal computed tomography and/or ultrasound should be ordered promptly.

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43. Your 66-year-old male patient complains of weakness, fatigue, chronic constipation for the last month, and dark stools. On complete blood count, his results show iron-deficiency anemia. Colon cancer is diagnosed. Which of the following laboratory tests is used to follow progress of colon cancer?

A. Alpha fetoprotein (AFP) B. Carcinogenic embryonic antigen (CEA) C. Carcinoma antigen 125 (CA-125) D. Beta-human chorionic gonadotropin (beta HCG) ANS: B AFP can help diagnose and guide the treatment of liver cancer (hepatocellular carcinoma).

CA-125 is the standard tumor marker used to follow women during or after treatment for epithelial ovarian cancer (the most common type of ovarian cancer), as well as fallopian tube cancer and primary peritoneal cancer. Serum beta HCG is a pregnancy marker. CEA is not used to diagnose or screen for colorectal cancer, but it is the preferred tumor marker to help predict outlook in patients with colorectal cancer. The higher the CEA level at the time colorectal cancer is detected, the more likely it is that the cancer is advanced.

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44. Your patient is a 33-year-old female who gave birth last week. She complains of constipation, rectal pain, and itching. She reports bright red blood on the toilet tissue. The clinician should recognize the need for: A. Digital rectal exam B. Carcinogenic embryonic antigen blood test C. Colonoscopy D. Fecal occult blood test ANS: A The most common cause of lower gastrointestinal bleeding is hemorrhoids. The bleeding associated with hemorrhoids is usually evident as red blood on the formed stool, in the toilet bowl, or on the toilet tissue following a bowel movement. Patients with hemorrhoids often complain of rectal discomfort, as well as the contributing factors for hemorrhoid development, including constipation. Inspect the perianal rectal tissue. Anoscopy may be indicated.

Perform a digital rectal exam to assess internal hemorrhoids.

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Chapter 11. Genitourinary System

MULTIPLE CHOICE

1. When performing a dipstick test on a patient’s urine sample, a positive leukocyte esterase and nitrite is indicative of: A. Microscopic hematuria B. Urinary tract infection C. Calculi in the urine D. Possible bladder tumor ANS: B With urinary tract infection, urine dipstick will show positive leukocyte esterase, positive nitrite, and greater than 3 to 5 white blood cells per high-power field.

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2. An IV pyelogram should not be performed if serum creatinine is: A. Less than 1.5 B. Greater than 1.0 C. Greater than 1.6 D. Less than 1.0 ANS: C IV pyelogram (also known as IV urography or excretory urography) is a study for noninvasive evaluation of the renal pelvis and ureter, with moderate cost and ease of administration. It demonstrates a wide variety of upper tract lesions and is well tolerated by most patients with a serum creatinine of 1.6 or less.

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3. Your 55-year-old male patient presents to the emergency department with complaints of sudden development of severe right-sided, colicky lower abdominal pain. He cannot sit still on the examining table. The patient has previously been in good health. On physical examination, there are no signs of peritoneal inflammation. A urine sample reveals hematuria and crystalluria. Which is the next diagnostic test that should be done immediately?

A. Ultrasound of the abdomen B. Abdominal x-ray C. Digital rectal exam

D. Spiral computed tomography scan ANS: D The initial study can be a kidney, ureter, and bladder (KUB) study or IV pyelogram (IVP); however, many facilities can perform a stone protocol spiral computed tomography (CT) scan, a much more definitive test for the evaluation of kidney stones. CT scan can demonstrate filling defects and is a highly specific and sensitive test for urinary tract calculi.

After the initial evaluation with CT scan, pain reliever can be administered. An IVP can be done at another time when the patient can better prepare for the test.

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4. The most common complication of an untreated urinary obstruction due to a ureteral calculus is: A. Hydronephrosis B. Renal artery stenosis C. Ureteral rupture D. Kidney mass ANS: A Hydronephrosis is swelling of the renal pelvis caused by an obstructing stone, ureteral stricture, prostatic hyperplasia, or renal or abdominal tumor that prevents the kidney from draining. The obstruction can be unilateral or bilateral, symptoms can be sudden or gradual in onset, and progressive renal damage will occur with time.

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5. A 43-year-old male patient complains of right-sided abdominal and pain in the back in the right costovertebral angle region, fever, chills, dysuria, and nausea. On physical examination, there is a 102°F fever, tachycardia, and right costovertebral angle tenderness to percussion. The most likely condition is: A. Lower urinary tract infection B. Pyelonephritis C. Nephrolithiasis D. Hydronephrosis ANS: B Pyelonephritis is a bacterial infection of the renal pelvis and parenchyma, typically caused

by Escherichia coli ascending from the lower urinary tract. The patient will have bilateral or unilateral flank pain, fever, chills, nausea, and vomiting, and lower urinary tract symptoms (LUTS), such as dysuria, may also be present. The patient will appear ill on presentation, with fever and tachycardia commonly noted. Palpation and/or percussion over the infected side is painful. There may be accompanying abdominal discomfort or abdominal distension.

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6. On a physical examination for employment, a 45-year-old male shows no significant findings and takes no medications. Past medical history and surgery are unremarkable. On urinalysis, hematuria is present. The urinalysis is repeated on another day and still reveals microscopic hematuria. It is important to recognize that painless hematuria can be diagnostic of: A. Urinary tract infection B. Bladder cancer C. Nephrolithiasis D. Pyelonephritis ANS: B Approximately 80% to 90% of patients with bladder cancer present with painless gross hematuria. All patients with this classic presentation should be considered to have bladder cancer until there is proof to the contrary. Patients should be referred to a urologist. They usually undergo cystoscopy to rule out bladder tumor. The majority of patients with bladder cancer present with no urinary tract symptoms or palpable masses.

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7. On digital rectal exam, you note that a 45-year-old patient has a firm, smooth, nontender but asymmetrically shaped prostate. The patient has no symptoms and a normal urinalysis. The patient’s prostate specific antigen is within normal limits for the patient’s age. The clinician should: A. Refer the patient for transrectal ultrasound-guided prostate biopsy B. Obtain an abdominal x-ray of kidneys, ureter, and bladder C. Recognize this as a normal finding that requires periodic follow-up D. Obtain urine culture and sensitivity for prostatitis ANS: C An asymmetric prostate is typically asymptomatic and not necessarily diagnostic of prostate cancer; asymmetry can be a normal finding on digital rectal exam (DRE) but should be followed periodically to monitor for changes. Age-specific reference ranges for prostate specific antigen (PSA) (see Table 11.4) should be used as a guide when there is no previous PSA for comparison. A prostatic nodule found on DRE necessitates a referral to a urologist or radiologist for transrectal ultrasound-guided prostate biopsy and may well be the first indication of the presence of a cancer.

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8. Your 77-year-old patient complains of frequent urination, hesitation in getting the stream started, and nocturnal frequency of urination that is bothersome. On digital rectal exam there is an enlarged, firm, nontender, smooth prostate. The clinician should recognize these as symptoms of: A. Prostatitis

B. Prostate cancer C. Urethritis D. Benign prostatic hyperplasia ANS: D Benign prostatic hyperplasia (BPH) is an enlargement of the transition zone of the prostate gland that occurs as men age. An enlarged prostate causes symptoms that include urinary urgency, frequency, hesitation in getting the stream started, decreased caliber and force of stream, and nocturnal frequency of urination that is bothersome. This collection of symptoms has also been termed prostatism. A patient with BPH shows symmetric or asymmetric enlargement and a firm, smooth, nontender gland.

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9. Your 66-year-old patient complains of frequency of urination and hesitancy of the urine stream. On digital rectal exam there is a hard, nodular, enlarged, nontender prostate. The clinician should recognize these as symptoms of: A. Prostatitis B. Prostate cancer C. Urethritis D. Benign prostatic hyperplasia ANS: B A prostate suspicious for malignancy will demonstrate nodular areas and/or overall hardness. Definitive diagnosis is made via prostate biopsy. Routine or urgent referral to a urologist is indicated, depending on the degree of prostate specific antigen elevation and/or the degree to which it has risen since the previous value in conjunction with any suspicious findings on the rectal examination. A patient with prostate cancer often has no symptoms.

Alternatively, an enlarged prostate can cause obstructive symptoms that include urinary urgency, frequency, hesitation in getting the stream started, decreased caliber and force of stream, and nocturnal frequency of urination that is bothersome.

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10. A 27-year-old male comes in to the clinic for symptoms of dysuria and urinary frequency, as well as urgency and perineal pain. Transrectal palpation of the prostate reveals a very tender, boggy, swollen prostate. The clinician should recognize these as signs of: A. Prostatitis B. Prostate cancer C. Urethritis D. Benign prostatic hyperplasia ANS: A

Prostatitis is an acute or chronic infection of the prostate gland. Acute bacterial prostatitis is usually the result of infection by aerobic Gram-negative rods (coliform bacteria or Pseudomonas). Enterococcus faecalis, an aerobic Gram-positive bacteria, can also cause prostatitis. Routes of infection are ascent from the urethra, reflux of infected urine into the prostatic ducts, direct extension of bacteria, and migration via the lymphatic and vascular system. Acute symptoms commonly include fever, low back and perineal pain, possible penis pain, urinary urgency and frequency, nocturia, dysuria, and muscle and joint aches.

Transrectal palpation of the prostate reveals a very tender, boggy, swollen prostate.

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11. Your 24-year-old female patient complains of dysuria, as well as frequency and urgency of urination that develops the day after she uses her diaphragm. Urine culture reveals a bacterial count of 100 CFU/mL. These signs and symptoms indicate: A. Upper urinary tract infection B. Lower urinary tract infection C. Normal bacteriuria D. Urethritis ANS: B In women whose symptoms suggest uncomplicated urinary tract infection (UTI), a culture of greater than 102 CFU/mL of a specific bacterium is indicative of cystitis. However, this CFU number is controversial. Infectious disease specialists recommend use of 103 CFU/mL as diagnostic of UTI. In the past, a bacterial count of 105 CFU/mL was regarded as significant for UTI. UTI diagnosis relies on the patient’s subjective report of symptoms of UTI, not only the number of bacteria. Patients with asymptomatic bacteriuria can have bacterial counts as high as 105 CFU/mL. Asymptomatic bacteriuria is not treated. Risk factors for the development of a UTI include increasing age, recent sexual intercourse, a history of UTI, use of a diaphragm or cervical cap, and anatomical abnormalities.

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12. An 18-year-old female patient presents with repeated urinary tract infections. She has no risk factors in her history, and her physical examination is unremarkable. She also has a normal pelvic examination. Which of the following should be obtained if anatomical abnormalities are suspected?

A. IV pyelogram B. Ultrasound of the kidneys C. Cystoscopy D. Transvaginal ultrasound of the bladder ANS: A

Risk factors for the development of a urinary tract infection (UTI) include increasing age, recent sexual intercourse, a history of UTI, use of a diaphragm or cervical cap, and anatomical abnormalities. Urine cultures should be considered in the patient with recurrent UTI or refractory UTI and in the patient who appears toxic. Blood for complete blood count and electrolyte tests should also be drawn based on the overall clinical presentation. If anatomical causes are suspected, diagnostic imaging, such as kidney, ureter, and bladder (KUB) study or IV pyelogram, should be arranged based on the suspected cause and patient’s presentation.

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13. A 33-year-old female patient visits the clinic multiple times over the last year complaining of dysuria, frequency, urgency, suprapubic pain, and dyspareunia. Her physical examination, including a pelvic examination, is normal. Urinalysis and urine culture is repeatedly negative. Her IV pyelogram is also normal. The clinician should recognize that this presentation is consistent with symptoms of: A. Asymptomatic bacteriuria B. Upper urinary tract infection C. Interstitial cystitis D. Polycystic kidneys ANS: C Patients with interstitial cystitis (IC) suffer from chronic symptoms that include a combination of dysuria, suprapubic pain, chronic pelvic pain, dyspareunia, and negative urine cultures. Patients may become debilitated by this disease; they may be making up to 40 trips to the bathroom in 24 hours. IC is also marked by periods of remission and flare-up throughout a patient’s lifetime. Typical age at onset varies from 30 to 70, and most patients visit an average of five physicians and wait 4 years before the correct diagnosis is made.

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14. A 65-year-old male patient complains of frequency, urgency, hesitancy, and weak urine stream. Physical examination is unremarkable, except digital rectal exam reveals an enlarged, firm, nontender prostate gland. Urine culture reveals 100 bacteria CFU/mL. The clinician should suspect: A. Lower urinary tract infection due to benign prostatic hyperplasia B. Bacteriuria due to prostatitis C. Obstructive uropathy due to prostate cancer D. Upper urinary tract infection due to benign prostatic hyperplasia ANS: A

Urinary tract infection (UTI) is uncommon in males and when UTI is diagnosed in the male the etiology should be determined. Benign prostatic hyperplasia presents as an enlarged, firm, nontender prostate on digital rectal exam (DRE). An enlarged prostate is commonly diagnosed when a male presents with a lower UTI. The enlarged prostate causes urine retention in the bladder, and stagnant urine in the bladder is a medium for bacterial growth, causing lower UTI. PTS: 1

15. Calculation of prostate specific antigen (PSA) velocity provides a more specific measure of prostate cancer risk. An increased risk of prostate cancer is indicated when the PSA rises more than: A. 0.125 ng/mL per year B. 0.25 ng/mL per year C. 0.5 ng/ml per year D. 0.75 ng/mL per year ANS: D Recent attempts have been made to make this test more specific to prostate cancer by establishing additional variables, such as PSA velocity: If the PSA rises more than 0.75 ng/mL per year, the risk for prostate cancer is increased.

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16. A 77-year-old male patient with a history of benign prostatic hyperplasia treated with finasteride has routine laboratory revealing a prostate specific antigen (PSA) of 7.5 ng/mL. Which of the following must be considered in interpreting this finding?

A. Finasteride is associated with a 50% decrease in prostate cancer risk B. Finasteride is associated with a 50% increase in prostate cancer risk C. Finasteride is associated with a 50% decrease in PSA D. Finasteride is associated with a 50% increase in PSA ANS: C Pharmacotherapy with finasteride is associated with a 50% decrease in PSA, which must be considered when evaluating results on men so treated.

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17. A 15-year-old female patient presents with complaints of constant thirst, urination up to 20 times a day, and recent unintentional weight loss of 10 pounds over the last month. It is important for the clinician to recognize these symptoms as those of: A. Renal cancer B. Diabetes insipidus C. Diabetes mellitus

D. Interstitial cystitis ANS: C Changes to the fluid and electrolyte balance of the body can directly affect urinary output, such as in the osmotic diuresis seen with poorly controlled or undiagnosed diabetes mellitus.

Other examples include diabetes insipidus, metabolic acidosis and alkalosis, renal insufficiency, and congestive heart failure.

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18. When conducting an initial evaluation of incontinence, which of the following is not indicated?

A. Postvoid residual volume B. IV pyelogram C. Urinalysis D. Blood, urea, nitrogen (BUN) and creatinine ANS: B The initial evaluation should include a urinalysis to rule out reversible causes of incontinence, such as a urinary tract infection. Consider a urine culture based on urinalysis results, BUN and creatinine as history and comorbidities indicate, and measurement of a postvoid residual volume to help distinguish the type of incontinence. If an imaging study is needed, the initial choice is renal ultrasound.

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19. Which of the following disorders can cause urinary incontinence?

A. Cystocele B. Overactive bladder C. Uterine prolapse D. All of the above ANS: D Cystocele and prolapse of the uterus can affect pelvic floor anatomy and cause urinary changes, including incontinence and changes to the quality of the urinary stream. Overactive bladder is a cause of incontinence due to atrophic changes of the pelvic floor muscles.

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20. A major reason for the atrophic changes that occur in the pelvic floor muscles of the elderly woman is: A. Diminished levels of estrogen B. Increased levels of testosterone C. Autonomic neuropathy

D. Decreased glycogen in the vagina ANS: A The most significant age-related changes in women are related to decreased estrogen influence. As estrogen levels decline, the epithelium and supporting tissues of the pelvis atrophy, resulting in friable mucosa and possible prolapse of the pelvic structures. The change in relationship of the pelvic structures results in hypermobility of the bladder base, pelvic muscle weakness, and urethral weakness, resulting in stress urinary incontinence in women. The decreased glycogen content of the vaginal epithelium causes decreased lactic acid metabolism by Döderlein’s bacillus, an increased pH of vaginal secretions and, therefore, an increased risk for urinary tract infection.

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Chapter 12. Male Reproductive System

MULTIPLE CHOICE

1. Examination of the male patient is best done in a warm room in order to avoid: A. Exaggeration of the cremasteric reflex B. Discomfort during digital rectal exam C. Retraction of the testes into the abdomen D. Concealment of an inguinal hernia ANS: A Examination of the male patient is best done in a warm room in order to avoid exaggeration of the cremasteric reflex.

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2. A 12-year-old boy accompanied by his mother reports sudden severe pain in the right lower abdomen and scrotum. There is no history of trauma. On physical examination, the right scrotum is extremely tender to touch. These are signs of: A. Fournier’s disease B. Testicular cancer C. Testicular torsion D. Varicocele of the testes ANS: C

Testicular torsion is a urological emergency and can result in the loss of blood flow to the affected testicle. Compromised blood flow results in swelling and tissue necrosis after 6 to 8 hours. There are no established risk factors, but it is more common during adolescence due to the rapid growth of the testes. Patients experience an acute and sudden onset of pain that localizes in the affected testicle, but it may also radiate to the inguinal areas or abdomen.

This pain is often accompanied by abdominal discomfort, nausea, and vomiting.

Asymmetric scrotal swelling is apparent on physical examination, with the affected testicle being somewhat elevated.

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3. Which of the following is a risk factor for testicular cancer?

A. Fournier’s disease B. Testicular torsion C. Varicocele of the testes D. Cryptorchidism ANS: D Malignant tumors of the testes are uncommon, usually present between the ages of 15 and 35, are slightly more common on the right side, and arise from germ cells. The greatest risk factor for the development of a testicular tumor is cryptorchidism, with an overall incidence of 7% to 10% in the patient with a history of unilateral or bilateral undescended testes.

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4. A 22-year-old male patient recently noticed swelling of the right testicle. He reports a feeling of heaviness and a dull ache in the testicle. There is no history of recent trauma.

Physical examination reveals enlargement of the affected testicle, which is firm. The right scrotum is erythematous, and inguinal lymph nodes are palpable. It is important to recognize these are signs and symptoms of: A. Varicocele of the testes B. Testicular cancer C. Hematocele of the testes D. Torsion of the testes ANS: B Malignant tumors of the testes are uncommon, but usually present between the ages of 15 and 35, are slightly more common on the right side, and arise from germ cells. A patient may have noticed a painless swelling of the testicle or a distinct nodule on self-examination.

Minor trauma may have occurred to the affected side and initiated the onset of pain and/or swelling. The testicle gradually enlarges over time, with some associated heaviness. Patients usually complain of a dull ache or heaviness that localizes to the affected side. Physical examination reveals a distinct mass or diffuse enlargement of the affected testicle; the mass may be firm, smooth, nodular, or fixed; and the scrotum itself may feel warm and be erythematous. Palpation of the inguinal, supraclavicular, and axillary areas may show evidence of enlarged lymph nodes.

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5. A 35-year-old male patient recently noticed a nodular growth on the right testicle. He reports a feeling of pain and heaviness in the testicle. Physical examination reveals a smooth, firm nodule of 5 to 6 cm on the right testicle. The right scrotum is erythematous, and inguinal lymph nodes are palpable. The clinician should order a(n) ____ to evaluate this finding.

A. Ultrasound of the scrotum B. Computed tomography scan of the pelvis C. Pelvic x-ray D. Digital rectal exam ANS: A The ultrasound is considered an extension of the physical examination in the case of a suspected testicular mass; a scrotal ultrasound can quickly and accurately distinguish a tumor from other intrascrotal pathologies.

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6. Which of the following is a biochemical marker for testicular cancer?

A. Carcinogenic antigen 125 (CA-125) B. Alpha-fetoprotein (AFP) C. Carcinoembryonic antigen (CEA) D. Tumor necrosis factor (TNF) ANS: B Lactate dehydrogenase (LDH), -fetoprotein (AFP), and beta human chorionic gonadotropin (-hCG) are the biochemical markers required to diagnose and classify testicular masses.

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7. In homosexual men, the most common cause of epididymitis is/are: A. Shigella B. Neisseria gonorrhoeae C. Chlamydia trachomatis D. Escherichia coli ANS: D

The inflammation of the epididymis is caused by the spread of an infection from the bladder or urethra, owing to an alteration in the urethral closure mechanism. In heterosexual men younger than 35, the causative organisms are likely to be Neisseria gonorrhoeae and Chlamydia trachomatis. In homosexual men, the causative organism is usually Escherichia coli. In cases in which an organism associated with a sexually transmitted disease is suspected, the exposure to the organism can significantly predate the development of epididymitis.

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8. A 26-year-old male complains of pain in the left scrotal region and burning on urination that started 2 days ago. The scrotum is swollen and tender to palpation. A urethral discharge is evident. Pain decreases with elevation of the left scrotum. There is no pain on digital rectal exam. These are signs of: A. Testicular torsion B. Testicular cancer C. Epididymitis D. Prostatitis ANS: C Complaints associated with epididymitis usually involve a sudden onset (over 24 to 48 hours) of painful swelling in the scrotum, which can be unilateral or bilateral. Pain may decrease with elevation of the scrotum (Prehn’s sign), although this is an unreliable indicator. There may be an associated urethral discharge and/or fever, and complaints of urethritis, cystitis, or prostatitis are possible. On physical examination, the pain will localize to the affected epididymis with palpation, which will be swollen and indurated.

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9. A 7-year-old male presents with fever and swollen parotid glands. He is diagnosed with mumps. A complication that can occur with mumps in a male patient is: A. Orchitis B. Prostatitis C. Testicular torsion D. Varicocele ANS: A Orchitis is usually caused by the extension of an infection from the epididymis to the testicle and rarely exists independent of epididymitis. The risks and causative organisms are the same as for epididymitis. Orchitis may also occur as a sequela of mumps and occurs in up to 30% of prepubertal male patients with mumps.

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10. In order for the clinician to diagnose a varicocele, the patient needs to: A. Lie in the left lateral recumbent position B. Stand and bear down C. Lean over for digital rectal exam D. Lie in the supine position ANS: B Most varicoceles are asymptomatic, but the patient may complain of a dull ache, fullness, pain that does not radiate, or pulling to the affected side of the scrotum. If the varicocele is large enough, it typically results in scrotal swelling that is noticeable to the patient, along with a bluish discoloration beneath the scrotal skin. Primary or secondary male infertility may be the presenting symptom. The varicocele can be exaggerated during physical examination by asking the patient to perform the Valsalva maneuver while standing; any distention of the pampiniform plexus should disappear when the patient lies down.

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11. Which of the following male reproductive disorders resembles a bag of worms on inspection?

A. Spermatocele B. Hydrocele C. Varicocele D. None of the above ANS: C Most varicoceles are asymptomatic, but the patient may complain of a dull ache, fullness, pain that does not radiate, or pulling to the affected side of the scrotum. If the varicocele is large enough, it typically results in scrotal swelling that is noticeable to the patient, along with a bluish discoloration beneath the scrotal skin. A longstanding varicocele may cause testicular atrophy. If the varicocele is large, it may be visible during inspection (bag of worms).

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12. Which of the following is considered a risk factor for penile cancer?

A. Chlamydia infection B. Condyloma acuminata C. Epispadias D. Circumcision ANS: B Risk factors for cancer of the penis include not being circumcised and a history of sexually transmitted diseases, particularly condyloma acuminata.

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13. Which of the following most commonly causes balanitis?

A. Tinea B. Syphilis C. Candida D. Gonorrhea ANS: C Generally seen in uncircumcised males or a very obese male with a retracted penis, balanitis is an inflammation of the glans, commonly caused by a Candida albicans infection. Men with poorly controlled diabetes mellitus are at particular risk for balanitis, as are morbidly obese patients who demonstrate a retractile penis as a result of their body habitus.

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14. Balanitis xerotica obliterans (BXO) is a painful condition most common in: A. Adolescent males B. Young adult males C. Middle-aged males D. Males over 65 years old ANS: C BXO is a variation of lichen sclerosus et atrophicus, which is common in middle-aged men and is a painful condition associated with patches of white, thinned skin. Uncircumcised and diabetic males have an increased risk, and the patient with longstanding BXO has a higher risk for squamous cell carcinoma of the penis.

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15. The condition of the penis termed phimosis is: A. Difficulty separating the foreskin from the penis B. Curvature of the penis when erect C. Inability of the penis to attain erection D. Inability of detumescence of the penis ANS: A Phimosis is a condition seen only in males who are uncircumcised. The patient will often present with a history of progressive difficulty at retracting the foreskin and, in some cases, urinary obstruction. This is commonly preceded by poor personal hygiene, chronic balanitis or balanoposthitis, or poor control of diabetes mellitus. Long-standing phimosis will create a risk for chronic inflammation and squamous cell cancer of the penis.

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16. Which of the following conditions is considered a urological emergency?

A. Balanitis B. Paraphimosis C. Phimosis D. Balanoposthitis ANS: B Paraphimosis is a condition in which the foreskin has been retracted and cannot be advanced forward to its normal position over the glans. It results from chronic inflammation under the foreskin and is commonly preceded by poor personal hygiene, chronic balanitis or balanoposthitis, or poor control of diabetes mellitus. Over time, a tight ring of tissue forms when the foreskin is retracted, resulting in additional edema to the glans with retraction of the foreskin. Paraphimosis is a urological emergency; the patient should be referred to a urologist for further evaluation and management because arterial occlusion and necrosis of the glans and distal urethra may result.

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17. The majority of male newborns born with cryptorchidism usually attain testicular descent by: A. 1 week old B. 1 month old C. 6 months old D. 1 year old ANS: B Cryptorchidism is the condition in which one or both testes have failed to descend normally into the scrotum. Descent may have stopped at any point between the renal and scrotal areas, but most commonly, the undescended testes are found in the inguinal canal. In male infants with undescended testes, more than half will descend into the scrotum during the first month after birth.

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18. In Klinefelter’s syndrome, males commonly have all of the following except: A. Gynecomastia B. Undeveloped testes C. Tall height D. Elevated testosterone levels ANS: D

In Klinefelter’s syndrome, patients present with the typical triad of small, firm testes; gynecomastia; and elevated urine gonadotropins. Variants of Klinefelter’s syndrome may also result in increased height, diabetes mellitus, obesity, and decreased intelligence.

Although testicles are not absent, their small size may lead to lack of recognition as the testes. Hormone studies will demonstrate decreased or normal testosterone, decreased free testosterone, elevated estradiol, normal or elevated LH, and elevated FSH. PTS: 1

19. Which of the following is the genetic makeup of a male with Klinefelter’s syndrome?

A. 46 XX B. 47 XXY C. 47 XYY D. 45 XXY ANS: B In males with Klinefelter’s syndrome, physical examination reveals a lack of development of secondary sexual characteristics (small [less than 3 cm] atrophic testes, small phallus, diminished body hair, diminished muscle bulk), and feminine, or truncal, rather than male fat distribution that often includes gynecomastia. Patients will be tall due to a delay in the fusion of the epiphyseal plates in the long bones. Karyotype analysis will show 47 XXY or a mosaic 46 XY/47 XXY. PTS: 1

20. The most common cause of erectile dysfunction is: A. Peripheral neuropathy B. Low testosterone C. Peripheral vascular disease D. Autonomic neuropathy ANS: C Vascular disease is one of the most common causes of organic erectile dysfunction (ED).

Many epidemiological studies have shown not only that ED coexists with hypertension, but also that as the severity of hypertension increases, so do reports of ED severity from patients.

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21. Priapism often occurs in male patients with: A. Sickle cell anemia B. Low testosterone C. Diabetes mellitus D. Autonomic neuropathy

ANS: A Priapism is often a condition of vaso-occlusive crisis in sickle cell anemia. Vascular congestion of the penis can occur secondary to hypoxia, a stressful event, or exertion in males with sickle cell anemia.

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22. Peyronie’s disease in the male causes: A. Balanitis of the penis B. Cryptorchidism C. Curvature of the penis D. Fracture of the penis ANS: C Although the precise cause of Peyronie’s disease is not known, current belief regarding its etiology is that plaque formation results after disordered wound healing, often with calcium deposition in the plaque (Pendleton & Wang, 2013). During regular sexual activity, susceptible patients may suffer nonpainful minor trauma to the penis that leads to a decrease in the elasticity of the tissue and fibroblast formation, eventually resulting in plaque. The plaque is present in the tunica albuginea of the corpora cavernosa, which leads to shortening and curvature of the shaft of the penis. The resulting curvature can be in any direction: lateral, ventral, or dorsal.

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23. Your male patient is 456 pounds and complains of erectile dysfunction. On physical examination, you note gynecomastia; decreased pubic, facial, and axillary hair; as well as atrophic testes. This is due to: A. Vascular disease that affects the testes B. Conversion of testosterone in fatty tissue to estradiol C. Androgen resistance of fatty tissue D. Elevated insulin levels ANS: B Obesity can lead to the aromatization of testosterone in fatty tissue to estradiol, leaving lowered amounts of testosterone available for maintenance and virilization functions. The patient is a clinically obese male, with possible evidence of feminization or regression of secondary male sex characteristics found on physical examination. Testosterone and free testosterone levels, along with estradiol, LH, and FSH levels, should be done. Routine referral to an endocrinologist or urologist, preferably one with expertise in male infertility (if this is an issue) and andrology, is recommended.

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24. A male and female patient complain of problems with conception. The female patient is in generally good health. The male patient reports history of cystic fibrosis (CF). It is important for the clinician to recognize that in male patients with CF, there is often malformation of the: A. Vas deferens B. Epididymis C. Seminal vesicles D. All of the above ANS: D Male patients with CF frequently demonstrate malformation of the epididymis; the vas deferens, seminal vesicles, and ejaculatory ducts are atrophic or absent. However, spermatogenesis is usually normal. It is possible that the patient has a much rarer unilateral absence of the vas deferens. Usually, there are no signs and symptoms other than infertility if the patient has not been previously diagnosed with CF. Physical examination may show complete absence of the vas deferens unilaterally or bilaterally or a palpable gap in the vas deferens. Testes are usually of normal size and consistency, and the patient will demonstrate normal libido and age-appropriate secondary sexual characteristics.

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25. A male and female patient complain of problems with conception. The female patient is in generally good health. The male patient is a bodybuilder who admits to anabolic steroid use.

It is important for the clinician to recognize that in male steroid users there is often: A. Atrophic testes B. Excessive natural testosterone C. Testicular hypertrophy D. Elevated LH levels ANS: A Supplementation with testosterone or with testosterone-like substances can result in decreased endogenous testosterone, as well as LH, hypogonadotropic hypogonadism, and suppressed spermatogenesis. Hypogonadism induced by exogenous steroid use is usually temporary, and endogenous hormone production and spermatogenesis rebound after approximately 4 months. The patient may complain of increased or decreased libido and possible erectile dysfunction. There may be some noticeable testicular atrophy on examination. Semen analysis will show oligospermia or azoospermia, and total testosterone will be above the normal range (or supraphysiological with anabolic use).

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Chapter 13. Female Reproductive System

MULTIPLE CHOICE

1. Your 16-year-old patient reports that she gets her period sometimes every month and sometimes she skips a month. If menstrual periods are irregular, the term for this condition is: A. Menorrhagia B. Metrorrhagia C. Dysmenorrhea D. Amenorrhea ANS: B The menstrual history includes any episodes of amenorrhea, menorrhagia (excessive bleeding at the time of the menstrual cycle), metrorrhagia (bleeding at irregular noncyclic intervals), dysmenorrhea, and postmenopausal bleeding. Amenorrhea has many causes, including pregnancy; anorexia nervosa; excessive exercise; low body fat; and disorders or tumors of the hypothalamus, pituitary gland, ovary, uterus, and thyroid gland. Menorrhagia is most commonly caused by uterine fibroids, but hematological disorders should be considered.

Metrorrhagia can be caused by anovulation, intrauterine devices (IUDs), and ovarian and uterine tumors.

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2. If amenorrhea is reported by the young female patient, the clinician should attribute this to _____________ until proven otherwise.

A. Pregnancy B. Ovarian failure C. Lack of progesterone D. Menopause ANS: A Last menstrual period is one of the most important questions to ask, particularly when prescribing medications, because many are contraindicated in pregnancy. If menstrual cycles are not regular, pregnancy should be ruled out first, and then other diagnoses can be considered. The menstrual history includes any episodes of amenorrhea, menorrhagia (excessive bleeding at the time of the menstrual cycle), metrorrhagia (bleeding at irregular noncyclic intervals), dysmenorrhea, and postmenopausal bleeding. Amenorrhea has many causes, including pregnancy; anorexia nervosa; excessive exercise; low body fat; and disorders or tumors of the hypothalamus, pituitary gland, ovary, uterus, and thyroid gland.

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3. In order to perform interventions or prescribe medication for the female patient, it is most important to obtain a complete health history. Which of the following is the most important question to ask female patients?

A. Age at menarche B. Age at menopause

C. Last menstrual period D. Number of pregnancies ANS: C Last menstrual period is one of the most important questions to ask, particularly when prescribing medications, because many are contraindicated in pregnancy. If menstrual cycles are not regular, pregnancy should be ruled out first, and then other diagnoses can be considered.

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4. Your patient who has a uterine fibroid complains of bleeding through up to 10 tampons per day. Excessive bleeding at the time of the menstrual cycle is termed: A. Menorrhagia B. Metrorrhagia C. Dysmenorrhea D. Premenstrual syndrome ANS: A The menstrual history includes any episodes of amenorrhea, menorrhagia (excessive bleeding at the time of the menstrual cycle), metrorrhagia (bleeding at irregular noncyclic intervals), dysmenorrhea, and postmenopausal bleeding.

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5. Your 35-year-old female patient complains of severe cramping with monthly menstrual flow. Painful menstrual periods are termed: A. Menorrhagia B. Metrorrhagia C. Dysmenorrhea D. Premenstrual syndrome ANS: C Primary dysmenorrhea, which typically presents as severe cramping during menstruation, is common and generally does not indicate pathology, particularly in the young population. It is most severe in the first few days of the menstrual cycle.

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6. In the health history, you ask a young adult female patient about safe sex and the use of contraception. The patient does not understand what you mean by safe sex. This is an indication for: A. Patient teaching and counseling B. Promotion of oral contraceptive use

C. Pregnancy testing and counseling D. Sexually transmitted disease, HIV, and hepatitis testing ANS: A Ask the patient about the type of birth control being used, if any. Ask about condom use. Be sure to inquire as to the consistency with which the patient uses birth control methods. Often patients deny the use of birth control, deny the desire for pregnancy, and yet admit to being sexually active. This definitely indicates the need for health teaching and counseling.

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7. When obtaining the health history of a 60-year-old female, it is important to ask: A. The age of menopause B. About any bleeding since menopause C. About use of any hormone replacement treatment D. All of the above ANS: D Bleeding that occurs after menopause has been established is cause for concern. It may indicate endometrial cancer, and referral for endometrial biopsy or dilation and curettage (D&C) is warranted. If the patient is menopausal, ask about age of menopause, symptoms of menopause, and past or current use of hormone replacement therapy.

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8. Your 24-year-old patient complains of vaginal discharge. When deciding what diagnostics to perform, what is most important to ascertain?

A. Color of the discharge B. Timing of the menstrual cycle C. Consistency of the discharge D. Sexual activity and safe sex practices ANS: D If the patient complains about vaginal discharge it is important to determine if the patient is sexually active, how many partners they have had, and their use of condoms. That will lead you to which diagnostics should be performed. The history should also include amount, color, consistency, odor, itching, burning, inflammation, or lesions, and history of sexually transmitted diseases.

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9. A 32-year-old female reports normal monthly menstrual periods but complains of having trouble with conception. It is important to ask about history of: A. Dysmenorrhea

B. Sexually transmitted disease C. Menorrhagia D. Pap smears ANS: B Infertility may be caused by anovulation, decreased function of the corpus luteum, or blocked or scarred fallopian tubes. Any of these can occur despite the fact that the patient may be having menstrual cycles. A history of menstrual irregularities may suggest anovulation or thyroid disease, either of which can cause infertility. A history of sexually transmitted diseases could lead to scarring of the fallopian tubes, which can cause infertility.

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10. A 38-year-old female complains of having trouble with conception. It is important to ask the patient to: A. Schedule a date for pelvic examination and Pap smear B. Chart at least three menstrual cycles C. Take basal body temperature for three cycles D. B and C ANS: D Infertility may be caused by anovulation, decreased function of the corpus luteum, or blocked or scarred fallopian tubes. Any of these can occur despite the fact that the patient may be having menstrual cycles. A history of menstrual irregularities may suggest anovulation or thyroid disease, either of which can cause infertility. A history of sexually transmitted disease could lead to scarring of the tubes. If the patient has not already done so, ask her to chart her menstrual cycles and basal body temperatures for 3 months to determine if and when ovulation is occurring.

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11. It is important for the clinician to ask the female patient about multiple sexual partners. It is known that multiple sexual partners increases patient risk for: A. Human papilloma virus infection B. Endometriosis C. Uterine cancer D. Ovarian cysts ANS: A The matter of sexual activity and sexual partners is an important area to inquire about, especially with the high risk of HIV and other sexually transmitted diseases (STDs). Multiple sexual partners, even in the absence of STDs, puts women at risk for infection with human papilloma virus (HPV).

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12. During a pelvic examination, a clinician asks the patient to bear down to inspect the vaginal outlet for: A. Cystocele B. Rectocele C. Prolapsed uterus D. All of the above ANS: D During a pelvic examination, the clinician can inspect the external genitalia for lesions, ulcerations, inflammation, warts, swelling, discharge, or nodules. Inspect the perineum and anal areas for fissures, hemorrhoids, inflammation, lesions, ulcers, warts, or nodules. Assess the support of the vaginal outlet by asking the patient to bear down while you look for bulging at the introitus, suggesting a cystocele, rectocele, or prolapsed uterus.

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13. Which of the following findings on the bimanual examination of a female patient requires further investigation?

A. Retroverted uterus B. Varicose veins in vaginal wall C. Cervical motion tenderness D. Anteflexed uterus ANS: C The uterus should be pear-shaped, smooth, mobile, nontender, and firm but not hard. Malignancies may occur, causing the uterus to be hard and fixed. Tenderness with movement of the cervix and uterus occurs in pelvic inflammatory disease and is termed cervical motion tenderness. Variations in the position of the uterus are not considered abnormal, but significant variations may be related to back pain, especially during menses or childbirth, and occasionally to infertility. Common uterine positions are retroverted, retroflexed, anteverted, and anteflexed.

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14. Which of the following findings on the bimanual examination of a female patient in early pregnancy requires further investigation?

A. Unilateral adnexal tenderness B. Bluish colored cervix C. Varicose veins of vaginal walls D. None of the above ANS: A On bimanual examination, significant unilateral adnexal pain or tenderness in an early pregnant female can indicate ectopic pregnancy.

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15. A 65-year-old female complains of frequency and urgency of urination, and episodes of urinary incontinence. On pelvic examination, there is a smooth, soft bulge of the anterior vaginal wall that is more pronounced with straining. These findings are indicative of: A. Rectocele B. Cystocele C. Uterine prolapse D. Anteflexed uterus ANS: B A cystocele can contribute to urinary frequency, urgency, infection, and stress incontinence.

The bimanual examination reveals a smooth, soft bulge of the anterior vaginal wall that is more pronounced with straining. Kegel exercises may be helpful, but surgical repair may be needed.

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16. Your 24-year-old female patient complains of tenderness at the entrance of the vagina on the right side. She cannot sit comfortably because of the soreness in the perineal area. On pelvic examination, there is a tender, inflamed, fluctuant cyst at the introitus on the right side.

These signs and symptoms are indicative of: A. Possible malignancy B. Bartholin cyst C. Nabothian cyst D. Candidiasis ANS: B The two Bartholin’s glands are mucus-secreting glands, one located in each lateral wall of the vagina at the introitus. They can become abscessed in acute or chronic inflammatory processes, usually as a result of sexually transmitted disease infection or from other bacteria that are prevalent in the vaginal and perineal area, but also by thickened mucus or congenital narrowing of the duct. In postmenopausal women, a malignant cause should be considered in the differential diagnosis. Acutely, Bartholin’s abscesses are extremely painful, in part due to their anatomical location, which makes sitting difficult. The area becomes swollen with the presence of a tender, inflamed, fluctuant cyst that is easily visualized.

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17. A 33-year-old female patient complains of white, thick vaginal discharge and severe pruritus of the outer genitalia. On pelvic examination, the vaginal introitus is red and swollen with a thin layer of white exudate. The bimanual examination is normal. A KOH prep is positive for hyphae. These findings are indicative of:

A. B. C. D.

Vaginal candidiasis Trichomonas infection Chlamydia Bacterial vaginosis

ANS: A The discharge associated with yeast vaginitis can be differentiated from other infections by symptomatology and wet prep examination. The discharge is very thick, curdlike, and adheres to the vaginal walls. Intense vulvar itching accompanies the discharge. In most cases, inflammation and swelling around the labia and introitus occur. A high suspicion of yeast can be made on physical examination with a wet prep to confirm the diagnosis of Candida albicans. A 10% KOH prep is most helpful for visualizing budding yeast and hyphae microscopically.

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18. A 23-year-old female complains of a white-yellow vaginal discharge with a fishy odor for the last 2 days. A wet prep shows characteristic clue cells (epithelial cells embedded with bacteria). These findings are indicative of: A. Chlamydia infection B. Bacterial vaginosis C. Vaginal candida D. Gonorrhea ANS: B Gardnerella vaginalis causes bacterial vaginosis, the most prevalent vaginal infection. Of those women who are symptomatic, the overwhelming complaint is of a malodorous discharge. The odor of G. vaginalis is a distinct, fishy odor. The odor is usually noticeable during the pelvic examination, but a few drops of 10% KOH solution on the wet prep slide augments the odor. The discharge is fairly thick and white. Patients do not complain of itching, and generally, there is no inflammation of the vaginal mucosa. Microscopically, the wet prep shows the characteristic clue cells (epithelial cells embedded with bacteria).

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19. A 20-year-old female complains of thin vaginal discharge and pruritus. On pelvic examination, there are ―strawberry spots‖ on the vaginal walls. With this infection, it is important to: A. Treat the patient’s partner B. Perform sexually transmitted disease and HIV testing C. Look for characteristic clue cells D. A and B ANS: D The presenting complaints with trichomoniasis are discharge and itching. It can be differentiated from yeast by the discharge, which is thin and frothy rather than the thick, curdlike

discharge of yeast. It can also be differentiated from Gardnerella vaginalis by the presence of vulvar itching and inflammation with trichomoniasis but no complaint of odor, as there is with G. vaginalis. Inflammation with petechiae of the vaginal walls, known as ―strawberry spots,‖ is diagnostic of Trichomonas vaginalis. Male partners are usually asymptomatic but harbor the organism, and they must be treated along with the patient; intercourse should be avoided or condoms used until treatment is completed.

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20. Which of the following infections can cause an eye infection in the newborn during vaginal delivery?

A. Candida vaginitis B. Chlamydia trachomatis C. Trichomonas vaginalis D. vaginalis ANS: B Chlamydia is a sexually transmitted disease caused by the bacteria Chlamydia trachomatis.

It is thought to be the main cause of salpingitis and scarring of the fallopian tubes, thus leading to ectopic pregnancy or infertility. It can also cause conjunctivitis in the neonate if present during delivery. Patients are often asymptomatic with chlamydia infections but may present with mucopurulent discharge, dysuria, abdominal pain, fever, and abnormal vaginal bleeding. Cervicitis and cervical motion tenderness on physical examination indicate pelvic inflammatory disease. It is the causative organism in the majority of nongonococcal urethritis in both women and men.

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21. Which of the following organisms can cause a syndrome that includes arthritis and conjunctivitis?

A. Neisseria gonorrhoeae B. Chlamydia trachomatis C. Trichomonas vaginalis D. Gardnerella vaginalis ANS: B Reiter’s syndrome, a serious systemic complication of chlamydia infection, occurs more commonly in men and is characterized by urethritis, arthritis, and conjunctivitis or uveitis.

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22. Which of the following infections often causes scarring of the fallopian tubes?

A. Chlamydia trachomatis B. Pandida albicans

C. Trichomonas vaginalis D. Gardnerella vaginalis ANS: A Infection with Neisseria gonorrhoeae can persist, leading to salpingitis, abscess, and peritonitis. As with infection caused by Chlamydia trachomatis, long-term complications include scarring of the fallopian tubes, ectopic pregnancy, and infertility.

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23. A 23-year-old female presents to the emergency room with fever, pelvic pain, vomiting, and dysuria. She reports having had an abortion yesterday in an urban birth control clinic. On physical examination, there is a bloody vaginal discharge, tenderness of the left lower quadrant of the abdomen, and cervical tenderness on pelvic examination. The following is a likely diagnosis: A. Neisseria gonorrhoeae infection B. Chlamydia trachomatis infection C. Staphylococcal endometritis D. Fulminant candidiasis ANS: C Pelvic inflammatory disease is defined as an infection of the uterus, fallopian tubes, and adjacent pelvic structures. It is often secondary to a sexually transmitted disease or other infection of the lower reproductive tract that migrates upward into the uterus and tubes. Neisseria gonorrhea and Chlamydia trachomatis are two of the commonly offending organisms. Pelvic infections can also occur postsurgery, postpartum, or postabortion, but are generally caused from other organisms, such as staphylococcus or streptococcus. Abdominal pain, mucopurulent cervical discharge, and often fever are the more common presenting symptoms. Rebound tenderness indicates peritoneal irritation. Dysuria, nausea, and vomiting may also be present. The abdominal pain is midline and often accompanied by right and left lower quadrant pain, particularly when accompanied by salpingitis. During the pelvic examination, there is pain with cervical motion and with palpation of the uterus and ovaries.

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24. Your postmenopausal 60-year-old female patient complains of vaginal irritation and pruritus of the external genitalia. She self-medicated with an over-the-counter anti-candida agent; however, the vaginal symptoms persist. The clinician should recognize that: A. Over-the-counter medications do not treat all species of candida B. Postmenopausal women are susceptible to trichomonas infection C. Decreased estrogen makes vaginal mucosa susceptible to bacterial vaginosis D. Irritation due to atrophic vaginal mucosa can mimic symptoms of candida ANS: D Although atrophic vaginitis is not an infection and does not cause a discharge, its signs and symptoms can mimic the Candida albicans yeast vaginitis. It occurs in postmenopausal

women as a result of a lack of estrogen.

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25. Your 26-year-old female patient reports a history of herpes simplex type 2 infection. On physical examination, you note red blisters over the vulva region. When questioned about sexual activity, she explains that her partner uses a condom whenever her infectious blisters are present. The clinician should recognize: A. The herpes virus can be transmitted during the patient’s asymptomatic periods B. If the lesions are herpes simplex type 1, then the virus is not contagious C. Only herpes simplex type 2 infects the genital region, and it is always contagious D. When the blisters rupture, viral particles are transmitted to a sexual partner ANS: A Herpes 1 or 2 can infect the pelvic region and they cause the same syndrome. Approximately 10% to 15% of persons who carry the herpes virus are asymptomatic, but they can still shed the virus; thus, they are referred to as asymptomatic shedders. This, among other things, contributes to the spread of the herpes virus.

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26. Your 33-year-old female patient reports the development of a cold sore on her lower lip. She asks if this is the kind of sore that is transmitted during sex. The clinician should explain that: A. The sore can be either herpes type 1 or 2, and both can be transmitted during oral sex B. A cold sore in the oral region is caused by herpes type 1, and this is not contagious C. Herpetic lesions on the lips and in the mouth are herpes type 2 and caused by oral sex D. A blood test is done to determine the specific type of virus because treatments for herpes type 1 and 2 differ ANS: A The majority of genital herpes infections are due to herpes simplex virus (HSV) 2, and approximately 10% are due to the HSV1 virus that has been transferred to the genital area either by sexual or oral contact. Although blood tests can be done to determine the presence or absence of antibodies to HSV1 and HSV2, it is mostly academic because the symptoms, transmission, and treatment are the same regardless of type.

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27. A 39-year-old female patient comes to the clinic for a pelvic examination and Pap smear.

She reports that her partner is infected with Condyloma acuminata. In her history, she always has her partner use a condom. The external genitalia, vagina, and cervix appear normal

on pelvic examination, but the Pap smear shows dysplasia. The patient is worried that she could be infected with human papilloma virus (HPV). The clinician should: A. Assure the patient that safe sexual practices protect against HPV infection B. Explain that there is no condyloma present, so HPV infection is improbable C. Explain that HPV infection can be transmitted even in the presence of barrier contraception D. Teach the patient about hysterectomy because she has cervical cancer ANS: C There is an increased incidence of cervical cancer in women infected with HPV, with neoplasias being associated with types 16 and 18. Visible manifestations of HPV occur in less than a dozen genotypes, estimated at only 1% of those infected. Of those who develop condylomas, the presentation is variable. Lesions are often very small, even microscopic, and the rugae of the vaginal mucosa may mask the lesion. If dysplasia is seen on the Pap smear, biopsies should be taken to rule out intraepithelial neoplasia because more than 90% of the cervical neoplasias are caused by HPV. Unfortunately, barrier contraceptives offer only limited protection against the spread of HPV infection.

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28. On pelvic examination, you observe a nontender, ulcerated, red lesion with raised borders on a patient’s labia. Her inguinal lymph nodes are enlarged but nontender. The patient reports that her partner, who is HIV positive, has a similar lesion on his penis. The clinician should have a high suspicion of: A. Herpes simplex 1 B. Herpes simplex 2 C. Condyloma acuminata D. Syphilis ANS: D The incidence of syphilis has risen dramatically in the last 30 years with the increase in HIV and other sexually transmitted diseases. In syphilis, the primary chancre lesion appears as a firm, indurated, painless papule that erodes into an ulcer with raised or reddened borders.

Chancres are usually single lesions and can occur on any mucous membrane or skin area.

Nontender lymphadenopathy is present in the regional nodes. Genital lesions are most commonly seen in women on the external genitalia. Symptoms may be mild enough to go unnoticed, especially when they are in areas other than the genitalia, and they heal without treatment in 4 to 8 weeks.

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29. Your 24-year-old female patient comes to the clinic for a routine pelvic examination and Pap smear. She has no history of abnormal Pap smears. It is recommended that a female of this age obtain a Pap smear: A. Every year B. Every 3 years

C. Every 5 years D. None of the above ANS: B In March 2012, updated screening guidelines were released by the U.S. Preventive Services Task Force, American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology. These guidelines recommend a Pap smear by age 21 and a Pap smear every 3 years for women ages 21 to 29. Women ages 30 to 65 should be screened every 5 years with Pap and human papilloma virus co-testing, or every 3 years with Pap smear alone. Recommendations for women with a history of abnormal Pap smears should be adjusted as needed for follow-up (National Cancer Institute, 2012).

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30. Pap smears assist in early diagnosis of endometrial cancer. The peak incidence of endometrial cancer occurs in: A. Postmenopausal women aged 50 to 70 years old B. Postmenopausal women aged 40 to 50 years old C. Premenopausal women between 30 and 40 years old D. Premenopausal women between 40 and 50 years old ANS: A It is important to perform Pap smears on older women because 25% of cervical cancers occur in women older than 65 years of age, and the peak incidence of endometrial cancer occurs in postmenopausal women between 50 and 70 years. In patients who have had hysterectomies, a smear of the vaginal cuff is still suggested, as well as inspection of the vaginal mucosa and external genitalia for signs of malignancy.

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31. Postmenopausal vaginal bleeding commonly indicates: A. Hormonal imbalance B. Endometrial cancer C. Endometriosis D. Atrophic vaginitis ANS: B Abnormal uterine bleeding is much more common in the younger population, especially during the teen years when menstrual patterns are becoming established. Also, during the early reproductive years, malignancies are much less likely to be the cause. Most cases of dysfunctional uterine bleeding are due to organic causes and to dysfunction of the hypothalamic-pituitary-ovarian axis. Bleeding after menopause has been established is cause for concern, and referral for endometrial biopsy is a must.

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32. Your 45-year-old female patient complains of irregular menstrual cycles, severe pain with menses, and heavy bleeding every month for the last year. On examination, you palpate an enlarged uterus. Pregnancy test is negative. A recommended diagnostic test for this patient is: A. Abdominal computed tomography scan B. Kidney, ureter, bladder x-ray C. Pelvic ultrasound D. Abdominal magnetic resonance imaging ANS: C Uterine leiomyomas, more commonly known as uterine fibroids, are benign growths consisting mostly of smooth muscle. The etiology is unknown, but their growth is hormone dependent; therefore, they are seen in approximately 25% of women during their reproductive years. Heavy menstrual bleeding (menorrhagia) and irregular bleeding (metrorrhagia) are the most common presenting symptoms, although a large percentage of patients are asymptomatic. Other symptoms include heaviness or fullness in the lower abdomen, pelvic pain, backache, dysmenorrhea, and urinary complaints. Most leiomyomas can be palpated on bimanual examination, and some larger fibroids can be palpated through the abdomen. The uterus may feel enlarged, irregular, or nodular. A pregnancy test should be performed to rule out pregnancy as a cause of the symptoms. A complete blood count is needed in cases of heavy bleeding to determine whether anemia or platelet disorder is present. Pelvic ultrasound or magnetic resonance imaging should be performed if symptoms of leiomyoma are present or for any palpable pelvic mass detected on physical examination.

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33. A 17-year-old female patient complains of amenorrhea for the last 8 months, weight gain, excessive hair growth on the arms and chest, and development of acne. Pelvic examination is normal. The clinician should recognize these are signs of: A. Ovarian cancer B. Endometriosis C. Hormonal imbalance D. Stress-induced anovulation ANS: C Anovulation may present with amenorrhea but also may present with dysfunctional uterine bleeding, polymenorrhea, or menorrhagia. The symptoms vary with the cause. Overweight may be seen with several of the causes, including hypothyroidism, polycystic ovarian syndrome, and pituitary and adrenal dysfunction. Underweight is seen in anorexia nervosa, excessive exercise, hyperthyroidism, or stress-induced anovulation. Hirsutism, acne, and other skin changes can be seen with imbalances in LH, FSH, and androgens, as seen in polycystic ovary disease. Delayed puberty or regression of sexual characteristics is seen in hypopituitarism; galactorrhea can be the presenting symptom in pituitary tumors.

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34. A 55-year-old woman complains of amenorrhea and hot flashes for the last 3 months.

Pregnancy test is negative. The clinician should recognize that menopause is defined as the absence of menses for: A. 3 months B. 6 months C. 1 year D. 18 months ANS: B Menopause is the absence of menses for at least 6 months. Age of menopause varies greatly, although age 50 to 55 is the typical range of onset. Although the absence of menses in a woman around the age of 50 years is diagnostic for menopause, measurement of FSH, LH, and estradiol levels are helpful in confirming the diagnosis.

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35. To confirm the diagnosis of amenorrhea due to menopause, blood should be drawn for hormones. Which are the changes that occur with menopause?

A. FSH rises B. LH decreases C. LH rises D. A and C ANS: D In menopause, FSH rises first and then LH rises, both greater than 100 mU/mL. A fall in estradiol is the last hormonal change that occurs with the decline of ovarian function. An estradiol level of less than 30 pg/mL indicates loss of ovarian function.

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36. Primary dysmenorrhea is pain with menses that occurs due to: A. Rise in prostaglandins B. Endometriosis C. Fibroid tumor D. Excessive estrogen ANS: A Dysmenorrhea is the most common gynecological complaint, particularly in the adolescent and young adult population. Primary dysmenorrhea is due to a rise in prostaglandins that occurs at the onset of menses, and it has been found that prostaglandins are higher in women with dysmenorrhea. Recently, increased leukotriene levels have been found to contribute to dysmenorrhea. Other psychosocial variables may contribute, such as response to pain, anxiety, stress, and attitudes about menstruation. Secondary dysmenorrhea is most often caused

by endometriosis. Other causes include chronic pelvic inflammatory disease, adhesions, IUDs, cervical stenosis, and uterine fibroids.

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37. The definitive diagnosis of endometriosis is made with: A. Hysteroscopy B. Pelvic computed tomography scan C. Laparoscopy D. Pelvic magnetic resonance imaging ANS: C The history and physical examination generally lead you to suspect endometriosis, but the definitive diagnosis is made through laparoscopic surgery and biopsy. The lesions seen in endometriosis, termed endometrial implants, appear as dark red to dark brown lesions that give the appearance of a powder burn from a gunshot. They appear on the peritoneal, bladder, uterine, and ovarian surfaces.

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38. Which type of pelvic disorder has the highest rate of mortality in the United States?

A. Uterine cancer B. Cervical cancer C. Ovarian cancer D. Pelvic inflammatory disease ANS: C Ovarian cancer has the highest mortality of the gynecological malignancies because as much as 85% of cases have metastases outside the ovaries at the time of diagnosis, and the cancer is usually widespread before the patient has signs or symptoms. It occurs most often in postmenopausal women, in women with a positive family history, and in women with BRCA1 and BRCA2 gene mutations. Use of oral contraceptives may decrease a woman’s risk of developing ovarian cancer.

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39. To diagnose ovarian disorders, which of the following diagnostic studies is most helpful?

A. Transvaginal ultrasound B. Pelvic computed tomography scan C. Pelvic magnetic resonance imaging scan D. Pap smear ANS: A Pelvic examination has been shown to have a low sensitivity and specificity for ovarian

cancer, with many tumors smaller than 10 cm being missed. Several diagnostic studies are useful for detecting ovarian cancer. The CA-125 blood test by immunoassay is used as a tumor marker for treatment decisions, but can also be used as a diagnostic tool.

False-positive elevations in CA-125 do occur with endometriosis and pelvic surgeries; therefore, tests should be interpreted with caution and followed up with transvaginal ultrasound. Transvaginal ultrasound will show a solid, irregular mass that may be adhered to adjoining structures. A Pap smear may contain malignant cells. X-rays may show metastatic lung or bone lesions. Transvaginal ultrasound will give the best information for differentiating a blood- or fluid-filled ovarian cyst from a solid mass.

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40. Your patient is a 63-year-old postmenopausal female with complaints of bloating, left lower quadrant abdominal pain, and feeling of abdominal fullness. On physical examination, the abdomen is nontender with shifting dullness and there are enlarged left sided inguinal lymph nodes. Pelvic examination reveals slight adnexal tenderness. The clinician should have a high index of suspicion of: A. Endometriosis B. Ovarian cancer C. Uterine cancer D. Ovarian cyst ANS: B In the postmenopausal female, early symptoms of ovarian cancer are vague and include mild lower abdominal discomfort, feelings of fullness, bloating, distension, nausea, dyspepsia, constipation, and urinary frequency if the tumor is large. The CA-125 blood test by immunoassay can be used as a diagnostic tool. The characteristics typical of a malignant ovarian mass include solid, fixed, nodular, nontender, and bilateral. The abdominal examination is essential in looking for distension, changes in percussion, or ascites. As the cancer metastasizes, lymphadenopathy occurs, especially in the inguinal and supraclavicular areas.

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41. A 16-year-old female complains of sudden left-sided lower quadrant abdominal pain. Her last menstrual period was 2 weeks ago. On physical examination, the abdomen is nontender with no masses and no organomegaly. Bowel sounds are normal in four quadrants. Pelvic examination shows mild left lower quadrant tenderness. Pregnancy test is negative. These signs and symptoms are consistent with: A. Ovarian cancer B. Hydatidiform mole C. Endometriosis D. Follicular cyst ANS: D Ovarian cysts are common in the younger population and tend to occur in the latter half of the menstrual cycle. Many spontaneously resolve. Others may need surgical intervention if

they become twisted, owing to the risk of gangrene. Right or left lower quadrant pain is usually the presenting complaint. Pelvic examination reveals significant tenderness in the affected adnexal area. Rebound tenderness may be present. Follicular cysts are most common, and the pain typically occurs in the second half of the menstrual cycle. These cysts usually resolve with menses and require no further treatment.

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42. A 19-year-old female complains of sudden severe left-sided lower quadrant abdominal pain, as well as nausea and vomiting for the last 2 weeks. Last menstrual period was 2 months ago. On physical examination, there is left sided lower quadrant abdominal tenderness and heel strike is positive. Pelvic examination reveals bluish discoloration of the cervix and left-sided adnexal tenderness. These signs and symptoms are consistent with: A. Ovarian cyst B. Ectopic pregnancy C. Pelvic inflammatory disease D. Follicular cyst ANS: B These are key signs of ectopic pregnancy. Amenorrhea in a female of childbearing age should be treated as pregnancy until proven otherwise. Sudden pain is characteristic of tubal ectopic pregnancy, when the embryo outgrows the space within the fallopian tube. The nausea and vomiting are symptoms of early pregnancy. Left-sided lower quadrant pain, bluish discoloration of the cervix, and left-sided adnexal tenderness are all signs of tubal pregnancy. Positive heel strike indicates peritoneal irritation.

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43. Your 61-year-old female patient complains of dyspareunia. On pelvic examination, you note atrophic vaginitis. The clinician should explain that these are most likely: A. Signs of vaginismus B. Postmenopausal symptoms C. Signs of estrogen deficiency D. B and C ANS: B There are no special examinations to be done for sexual dysfunction, although hormonal assessment may be helpful. A thorough gynecological examination is adequate to determine whether there is a physical cause for the problem. Decreases in libido and sexual response are not uncommon with aging, although it is an erroneous stereotype to assume that sexual desire or functioning automatically declines with age. In the aging client, lubricating agents may be helpful to deal with decreased or uncomfortable stimulation due to loss of lubrication. Decreased estrogen can cause atrophic vaginitis and thus decreased lubrication, leading to dyspareunia. Serum for free testosterone can be drawn if loss of libido is a problem in the postmenopausal woman.

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44. A 34-year-old female patient complains of lack of conception after unprotected sexual intercourse for 1 year. The patient has been keeping track of basal body temperature to plot ovulation. Pelvic examination is normal. The clinician should ask the patient if which of the following laboratory test(s) have been done?

A. TSH B. FSH C. LH D. All of the above ANS: D The work-up for infertility is complex and will need to be referred to a gynecologist specializing in infertility. The causes are numerous but generally fall into the categories of anovulation, implantation failure, hormonal failure, chromosomal abnormalities, or low sperm count in the male partner. Preliminary tests that can be initiated by the nurse practitioner include the following: pelvic examination to ensure that the cervix is open and that there are no uterine abnormalities, basal body temperature charts to plot monthly ovulation and menstrual patterns, and laboratory testing that includes TSH, FSH, LH, and estradiol.

PTS: 1 Chapter 14. Musculoskeletal System

MULTIPLE CHOICE

1. To assess muscle tone, the clinician should: A. Palpate the patient’s muscle as the muscle is passively stretched B. Examine how the patient performs active range of motion C. Palpate the muscles, comparing side to side D. A and C ANS: D To assess muscle tone, passively stretch the muscle, ask the patient to relax, and then palpate the muscle, comparing side to side. Alternatively, assessment of muscle tone can be combined with a determination of the patient’s resistance to passive movement. Tense patients, those with increased muscle tone, will have increased resistance to passive movements. Flaccid or hypotonic muscles do not have any palpable tension. A spastic muscle has increased resistance, which may vary as the limb is moved, as in ―cogwheeling,‖ such as that found in patients with parkinsonism. Resistance with both flexion and extension is called lead-pipe rigidity, as is sometimes seen in parkinsonism.

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2. Muscle strength is assessed by: A. Having the patient move their muscle against the clinician’s resistance B. Examining how the patient performs active range of motion C. Passively stretching the patient’s muscle D. Performing passive range of motion on the patient’s muscle ANS: A Muscle strength is determined by asking the patient either to resist the examiner’s attempt to flex or extend a muscle group or to flex or extend the muscles against the examiner’s resistance. Muscle strength is graded 0 (no evidence of strength) to 5 (complete or full resistance). Pain, contracture, and disease can all affect muscle strength.

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3. Which of the following serological diagnostic tests is most specific for rheumatoid arthritis?

A. C-reactive protein (CRP) B. Rheumatoid factor (RF) C. Antinuclear antibodies (ANAs) D. Anti-citrullinated protein autoantibodies (ACPAs) ANS: D A variety of laboratory tests are used to diagnose rheumatoid arthritis (RA), including the RF, which is positive in up to 80% of persons with RA but not specific to this disorder. It is often falsely positive in patients with other diseases, including lupus, sarcoidosis, and syphilis. RA is often associated with normocytic, hypochromic anemia, as well as elevations in sedimentation rate and C-reactive protein. Other laboratory tests that may be positive at diagnosis include ANAs and ACPAs. The ACPAs are more specific to RA than the RF. Radiological images show loss of joint space and erosion.

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4. A 33-year-old female reports general malaise, fatigue, stiffness, and pain in multiple joints of the body. There is no history of systemic disease and no history of trauma. On physical examination, the patient has no swelling or decreased range of motion in any of the joints.

She indicates specific points on the neck and shoulders that are particularly affected. She complains of tenderness on palpation of the neck, both shoulders, hips, and medial regions of the knees. The clinician should include the following disorder in the list of potential diagnoses: A. Osteoarthritis B. Rheumatoid arthritis C. Fibromyalgia D. Polymyalgia rheumatica ANS: C

In fibromyalgia, the most common symptoms are generalized pain, stiffness, and decreased range of motion, with multiple-point tenderness. The diagnostic criteria currently rest on a patient reporting point tenderness in at least 11 of 18 specified sites (Fig. 14.1) in addition to the presence of widespread pain for at least 3 months. The most common tender sites are in the neck, shoulders, spine, and hips. Other common symptoms include morning stiffness, anxiety, depression, sleep disturbances, ―brain fog,‖ and irritable bowel syndrome.

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5. A 46-year-old female complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. On physical examination, you note swelling of the metacarpophalangeal joints bilaterally. These are common signs of: A. Osteoarthritis B. Rheumatoid arthritis C. Scleroderma D. Sarcoidosis ANS: B Rheumatoid arthritis (RA) typically affects the joints symmetrically. Symptoms may wax and wane, but the effects are cumulative and progressive. Although RA can affect any joint, it commonly affects the small joints of the hands and feet, and this is often helpful in diagnosis. There is often history of prolonged morning stiffness and fatigue. Affected joints are often tender, swollen with effusions, warm, and inflamed. The disease most commonly affects metacarpophalangeal and proximal interphalangeal joints.

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6. Your patient is a 55-year-old male who presents with sudden, severely tender, swollen, erythematous elbow. The patient reports that he experienced similar symptoms in the past.

You note the right elbow has a swollen, tender, soft, 3 cm round nodule. The clinician should recognize these are signs and symptoms of: A. Gouty arthritis B. Rheumatoid arthritis C. Epicondylitis D. Reiter’s syndrome ANS: A Gout is a classic cause of monoarthritis, and most cases involve a joint in the lower extremities. Acute pain usually develops in one joint, with swelling, redness, and warmth, and the severity of the pain increases rapidly. Range of motion of the affected joint(s) is limited by pain, and there is significant tenderness to the site. Patients who have had gout for an extended time often have gouty tophi, which are soft tissue nodules containing urate crystals.

The olecranon bursa is a common site for tophi development, and the tophi are often painful.

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7. Sarcoidosis is an autoimmune disease that presents with nonspecific symptoms of fatigue, fever, and arthralgias. Which of the following signs should raise suspicion of this disorder?

A. Facial rash across nose and cheeks B. Bilateral hilar lymphadenopathy on chest x-ray C. Specific tender points on the body D. Swelling of metacarpophalangeal joints ANS: B Sarcoidosis is an inflammatory disorder in which patients develop granulomas and a wide range of symptoms, including arthritis. It is most commonly diagnosed in persons between ages 20 and 40. Arthralgias occur in approximately 3% of patients with sarcoidosis, and the most commonly affected joints include the ankles, feet, and hands. The patient may complain of constitutional symptoms, including fatigue, fever, and altered appetite. Respiratory symptoms, including cough, wheezing, and shortness of breath, are primary symptoms. On chest x-ray, hilar lymphadenopathy and pulmonary granulomas are key diagnostic signs.

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8. Which of the following infectious diseases is often the cause of a reactive arthritis?

A. Gonococcus infection B. Beta-hemolytic streptococcus infection C. Chlamydia infection D. Norovirus infection ANS: A Gonorrhea is a sexually transmitted infection that often involves reactive arthritis. The polyarthritis is often migratory and affects lower extremities as well as the hands. In addition to the arthritis, the syndrome usually includes a nonpruritic dermatitis and tenosynovitis. Generalized muscle aches and fever are also common.

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9. A 34-year-old female presents with fever, general malaise, fatigue, arthralgias, and rash for the last 2 weeks. On physical examination, you note facial erythema across the nose and cheeks. Serum diagnostic tests reveal positive antinuclear antibodies, anti-DNA antibodies, elevated C-reactive protein, and erythrocyte sedimentation rate. The clinician should include the following disorder in the list of potential problems: A. Fibromyalgia B. Sarcoidosis C. Systemic lupus erythematosus D. Rheumatoid arthritis

ANS: C Systemic lupus erythematosus (SLE) has many potential symptoms. The classic findings include a malar rash. Patients often have arthralgias, myalgias, fever, fatigue, Raynaud’s syndrome, and neuropathy. SLE effects depend on the organs involved and diagnosis can be difficult. A positive antinuclear antibodies test occurs at some point in the condition in the majority of patients but is neither consistent nor specific for SLE. Positive anti-DNA and lupus erythematosus prep are also common to SLE. PTS: 1

10. Which of the following microorganisms causes Lyme disease?

A. Clostridia B. Shigella C. Borrelia D. Epstein-Barr virus ANS: C Lyme disease is caused by the bacterium Borrelia burgdorferi and is transmitted by a bite from a deer tick. Whereas the incubation period ranges from 3 to 30 days, the onset of symptoms typically appears in 7 to 14 days. Although the disorder can be asymptomatic, the patient generally develops migratory polyarthralgia, myalgia, and neurological findings, including meningitis and/or neuropathy. An early finding is a solitary target lesion that may be followed by multiple lesions.

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11. A 60-year-old female patient complains of pain in the hands that is worse in the morning.

On physical examination, the thumb metacarpophalangeal joint is swollen on both hands.

There is swelling of the proximal and distal interphalangeal joints bilaterally. These are typical signs of: A. Osteoarthritis B. Rheumatoid arthritis C. Normal aging D. Gouty arthritis ANS: A Compared with rheumatoid arthritis (RA), osteoarthritis (OA) has a higher likelihood of affecting larger joints, such as the hips and knees. Like RA, OA also frequently involves the small joints of the hands, although it tends to occur at the distal interphalangeal joints (Heberden’s nodes) and proximal interphalangeal joints (Bouchard’s nodes). Most frequently, the second and/or third digits and the base of the thumb are involved. The distribution is asymmetrical. The pain and stiffness associated with OA often improve with moderate use and are worse after extended periods of rest. If three or more metacarpophalangeal joints are swollen, the differential should include RA. PTS: 1

12. A 56-year-old male presents with complaints of right-sided neck pain with radiation down the right arm into the right index finger and thumb. He reports a recent fall from a scaffold while painting on the job. On physical examination, you note a 0/4 biceps reflex on the right compared to 2/4 on the left and 1/5 grip strength of the right hand compared to 5/5 of the left hand. Which of the following is a test that can be performed to assist in the diagnosis of cervical disk herniation?

A. Spurling’s sign B. Apley’s sign C. Lhermitte’s sign D. A and C ANS: D In cervical spine trauma, cervical disk herniation can occur. A positive Spurling’s sign is noted if this maneuver reproduces neck and radicular pain, suggesting a herniated disk.

Spurling’s sign is tested for by lightly pressing downward on the top of the patient’s head while tilting back and toward the side of pain. Lhermitte’s sign may support suspicion of a herniated disk. This test is conducted by having the patient flex the neck in a chin-to-chest motion and is positive if an electric shock-like sensation down the spine results.

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13. Your 66-year-old male patient has recently started treatment for metabolic syndrome and is currently taking an ACE inhibitor and beta blocker for treatment of hypertension. He is also taking a statin medication, simvastatin for hyperlipidemia, and a biguanide, metformin, for type 2 diabetes. The patient complains of myalgias of the legs bilaterally, and blood work shows elevated serum creatine kinase. Which of the medications can cause such a side effect?

A. Beta blocker B. ACE inhibitor C. Statin medication D. Metformin ANS: C Myalgias are a side effect of lipid-lowering medications called statins. If the myalgia is related to rhabdomyolysis, the urine is often reddish-brown. When drug-induced myalgia is present, there is often eosinophilia. For rhabdomyolysis myalgia, the serum creatine kinase is significantly elevated.

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14. A 75-year-old female patient complains of fatigue, as well as pain and stiffness of the shoulders and neck. There is no history of trauma or exercised-induced pain. Medications include a beta blocker and ACE inhibitor. Medical history includes giant cell arteritis and

Raynaud’s syndrome. Physical examination is unremarkable. There is no swelling or erythema over the temporal arteries. There is no swelling, erythema, limitation in range of motion, or point tenderness over the shoulder joints. The neck has normal range of motion and no tenderness or swelling. Which of the following disorders should be included in the list of possible diagnoses?

A. Rheumatoid arthritis B. Polymyalgia rheumatic C. Drug-induced myalgia D. Fibromyalgia ANS: B Polymyalgia rheumatica is usually identified in adults aged 60 or older. The actual etiology of this condition is unknown. Giant cell arteritis occurs in about 15% of those with polymyalgia rheumatica, and the two conditions may be different expressions of the same etiology. The patient typically complains of sudden onset of widespread pain. Commonly affected sites include the neck, shoulders, and pelvis. Pain is accompanied by fatigue and stiffness. The stiffness is most profound in the morning. There is no actual muscle weakness. Unlike rheumatoid arthritis, there is no small joint inflammation and effusion.

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15. A 20-year-old male construction worker is experiencing new onset of knee pain. He complains of right knee pain when kneeling, squatting, or walking up and down stairs. On physical examination, there is swelling and crepitus of the right knee and obvious pain with resisted range of motion of the knee. He is unable to squat due to pain. Which of the following disorders should be considered in the differential diagnosis?

A. Joint infection B. Chondromalacia patella C. Prepatellar bursitis D. All of the above ANS: D Prepatellar bursitis is also called housemaid’s knee, which is common to persons whose occupation requires extended periods of kneeling, such as plumbers and carpet layers. This bursitis can also be caused by an infection. The patient complains of pain in the area inferior to and over the patella, and there is swelling and inflammation of the bursa. Chondromalacia patella is seen in young active persons of either gender. The condition is also commonly called patella-femoral syndrome and runner’s knee. The pain involves the anterior knee, often develops gradually, and is moderate in intensity. Pain can be reproduced by pressing the patella against the femoral condyles, and there is tenderness around the patella. Other maneuvers that reproduce the pain include applying pressure against the patella as the patient extends the lower leg, flexing the quadriceps, and moving the patella from side to side.

Crepitus and effusion are often present.

Decision Rule in Chondromalacia Patella: Two or more of the following symptoms (pain reported on muscle contraction, squatting, or kneeling) is associated with 60% sensitivity and 85% specificity for patellofemoral pain syndrome. Of these, the one maneuver with greatest diagnostic strength is pain on resisted contraction (Cook et al., 2010).

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16. A 17-year-old male complains of severe right knee pain. He was playing football when he heard a pop at the moment of being tackled and his knee gave way from under him. On physical examination, there is right knee swelling and decreased range of motion. There is a positive anterior drawer sign. These findings indicate: A. Knee ligament injury B. Osgood-Schlatter disease C. Prepatellar bursitis D. Chondromalacia patella ANS: A The anterior, medial, and lateral knee ligaments are vulnerable to injury in athletic activities.

The mechanism through which the anterior cruciate ligament (ACL) is typically injured involves deceleration combined with sudden turning or pivoting. The medial collateral ligament (MCL) is most prone to injury through motions that place valgus stress on the knee.

Compared with ACL and MCL injury, damage to the lateral collateral ligament (LCL) is much rarer but typically occurs when sudden varus stress is placed on the knee. The patient often relates history of an acute trauma followed by the onset of pain, swelling, and limited mobility. Often patients recall hearing or feeling a pop at the moment of injury and/or give-way sense. ACL injury is identified through a positive drawer (Fig. 14.9) and/or Lachman’s test (Fig. 14.10). Laxity of the LCL is assessed by placing varus stress on the knee with the leg both extended and flexed.

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17. A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday.

He reports weakness of the left leg and paresthesias in the left foot. On physical examination, the patient has diminished ability to dorsiflex the left ankle. Which of the following symptoms should prompt the clinician to make immediate referral to a neurosurgeon?

A. Straight leg raising sign B. Lumbar herniated disc on x-ray C. Loss of left-sided patellar reflex D. Urinary incontinence ANS: D With low back pain in a patient, it is important to obtain a detailed history of the onset and progression of the pain. A thorough pain history should be completed, noting its quality, location, radiation, and intensity, as well as any exacerbating and relieving factors. A thorough review of systems is necessary to identify any associated symptoms that may indicate an urgent problem. These include altered bowel and/or bladder function, fever, weight loss, and/or weakness. The physical examination should begin by noting the patient’s posture and apparent level of comfort. The standing patient should be directed through a series of maneuvers to assess the back motion, including flexion, hyperextension, lateral flexion, and rotation, as the smoothness of motion, range of motion, and any obvious signs of discomfort

are noted. Observe the patient walking on heels and on toes, noting any signs of weakness.

Next, with the patient resting supine on the examination table, the straight leg maneuver should be performed. As the patient rests supine with both legs extended, the examiner should passively elevate one leg at a time. A positive test is indicated if the patient experiences discomfort with the initial elevation rather than once the hip has been hyperflexed beyond 50 degrees. If the results indicate nerve impingement or disk injury, further radiographic testing is then indicated.

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18. Your patient is a 40-year-old baseball player who needs his yearly physical examination. He reports a 5-year history of chronic lower back pain due to spinal stenosis. Which of the following findings indicate spinal stenosis?

A. Lumbar x-ray demonstrates vertebral osteophytes B. Positive straight leg raising sign on physical examination C. Lumbar magnetic resonance imaging shows decreased intervertebral space D. A and C ANS: D Caused by progressive degenerative spine changes, spinal stenosis is most common at middle age or later. Spinal stenosis pain is usually worse during the day. It is aggravated by standing and relieved by rest. The pain varies from severe to mild. Osteoarthritis signs may be present. Radiological findings may indicate extensive vertebral osteophytes and degenerative disk disease. A magnetic resonance imaging or computed tomography scan can be helpful if initial x-rays are inconclusive.

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19. Which of the following disorders has a strong genetic component and causes loss of spinal mobility and progressive erosion of the sacroiliac joint?

A. Syringomyelia B. Spinal stenosis C. Ankylosing spondylitis D. None of the above ANS: C Ankylosing spondylitis is one of the spondyloarthropathies, which have genetic predispositions and are inflammatory disorders. Early symptoms include lower back pain and stiffness, which gradually become persistent and increase in severity. There is loss of spine mobility, and posture gradually changes with flexion of the neck, increased kyphosis of the thoracic region, and loss of the lumbar curve. The gene HLA-B27 is present in most patients. Radiographs show abnormality of the sacroiliac joint with progressive erosion. A computed tomography scan is useful to identify sacroiliitis.

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20. Whenever a patient presents with acute nontraumatic shoulder pain, the clinician should make sure to exclude a: A. Cardiac or respiratory origin of symptoms B. Gastrointestinal condition C. Cervical spine disorder D. All of the above ANS: D Acute shoulder syndromes frequently arise from inflammation. Most frequently, the capsule of the glenohumeral joint, supraspinatus tendon, and the subacromial bursa are involved.

When patients present with shoulder pain, always consider the possibility of cardiac, cervical neck, or gastrointestinal cause. Cardiac pain commonly radiates to the left shoulder.

Cervical spine degeneration and osteoarthritis frequently causes right- or left-sided shoulder pain. Gastrointestinal disorders, such as cholecystitis, frequently cause pain radiation to the right shoulder.

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21. A 34-year-old baseball pitcher complains of pain in the left shoulder, particularly with raising the left arm when attempting to pitch. Which of the following is a test used to diagnose rotator cuff injury?

A. Apley’s test B. Trousseau test C. Hawkin’s test D. A and C ANS: D The rotator cuff consists of the supraspinatus, infraspinatus, subscapularis, and teres minor.

Injury to the rotator cuff is typically due to chronic impingement with degenerative changes over time. The patient typically complains of anterior and lateral shoulder pain that increases with arm elevation and reaching overhead. The pain is usually progressive and may be associated with repetitive activities. Pain at night may cause sleep disturbance. Range of motion is typically preserved. Apley’s (see Fig. 14.2) and Hawkin’s (see Fig. 14.3) tests may reproduce the pain, depending on the component of the rotator cuff involved. There may be point or diffuse tenderness to the shoulder area. Crepitus and/or arm weakness suggest an acute tear.

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22. Which of the following is a sign of glenohumeral instability?

A. Positive Lachman test B. Negative Spurling’s sign C. Positive apprehension test D. Negative Lhermitte’s sign

ANS: C Unlike the other conditions affecting the shoulder, glenohumeral instability is most common in young patients who are physically active. The instability can result in displacement of the humeral head in various directions. The patient will experience sudden onset of pain and be unwilling to move the arm. The displacement may follow an acute injury/trauma or may be associated with specific movements or overuse. A positive apprehension test suggests glenohumeral instability. This can be somewhat validated by performing the relocation test, in which the apprehension test is immediately followed by placing mild anterior pressure on the arm paired with external rotation.

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23. Your patient is a 43-year-old female golfer who complains of arm pain. On physical examination, there is point tenderness on the elbow and pain when the patient is asked to flex the wrist against the clinician’s resistance. These are typical signs of: A. Carpal tunnel syndrome B. Osteoarthritis of the wrist C. Epicondylitis D. Cervical osteoarthritis ANS: C Epicondylitis involves inflammation of the tendon/tendon insertion of the forearms. This tendinitis results in either lateral elbow pain associated with overuse of the wrist extensors (tennis elbow) or in medial elbow pain associated with overuse of involving wrist flexion and rotation (golfer’s elbow). Point tenderness is noted at the medial or lateral epicondyle.

The onset and severity of pain is usually gradual and progressive but may have relatively acute onset following an activity involving significant repetitive use. The pain may be referred to the forearm and is increased by the offending motion (wrist flexion, extension, or rotation). Pain is usually greater when the motion is made against resistance.

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24. A 3-year-old male toddler complains of sudden arm pain. The mother indicated that pain occurred suddenly while his 9-year-old sister was helping him get dressed. The child presents with the arm flexed while protecting his elbow. On physical examination, there is tenderness along the radius with no swelling or evidence of trauma. This is a typical history of: A. Nursemaid’s elbow B. Epicondylitis C. Smith fracture D. Nursery pseudo-fracture ANS: A Also known as pulled elbow or toddler’s elbow, nursemaid’s elbow involves the head of the radius slipping under the annular ligament in children, usually between 1 and 4 years of age.

The condition occurs when traction is applied to the young child’s hand or wrist. There is a

history of sudden onset of pain associated with sudden immobility of the affected arm as the child protects the elbow. The parent may be able to identify a situation in which the child’s hand was held and traction applied. The child may have moved in an opposite direction or injury could occur while pulling the arm through clothing. There is no associated swelling or inflammation. Examination is otherwise normal, with the exception of resistance to attempts to move the arm, elbow, and possibly, wrist. There may be tenderness along the upper margin of the radius.

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25. A 46-year-old administrative assistant complains of pain in the wrist that radiates into the palm and into the fingers. The clinician can test the patient for carpal tunnel syndrome by eliciting which of the following signs?

A. Phalen’s sign B. Apley’s sign C. Finkelstein sign D. Lhermitte’s sign ANS: A Carpal tunnel syndrome causes a range of neurological symptoms, including pain, paresthesia, and weakness. Frequently, nighttime pain is an early symptom. There may be a swelling at the wrist related to inactivity or flexion at night. The pain and/or paresthesia typically involve the anterior aspects of wrist, medial palm, and first three digits on the affected hand.

However, pain may radiate up the forearm to the shoulder with numbness and tingling along the median nerve. Over time, hand weakness often develops. Pain and paresthesia are often relieved by the patient shaking the affected hand in a downward fashion; this is called the flicking sign. Phalen’s maneuver reproduces the pain after 1 minute of wrist flexion against resistance. Although Tinel’s sign has been used as well, it has a low sensitivity for correct diagnosis.

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26. Which of the following describes the pathology of De Quervain’s tenosynovitis?

A. Irritation of a tendon located on the radial side of the wrist, near the thumb B. Impingement of the median nerve, causing pain in the palm and fingers C. Fluid-filled cyst that typically develops adjacent to a tendon sheath in the wrist D. Ulnar nerve compression at the olecranon process ANS: A De Quervain’s tenosynovitis involves irritation of a tendon located on the radial side of the wrist, near the thumb. With overuse, the tissues surrounding the tendon sheath hypertrophy, causing pressure on the tendon and making it difficult to move. The pain is usually limited to the radial aspect of the wrist and area immediately around the base of the thumb. Pain increases with use of the hand, such as with gripping maneuvers. Other symptoms include swelling, decreased sensation, and limited range of motion with a locking sensation with thumb motion. The Finkelstein maneuver (Fig. 14.7) is used to diagnose De Quervain’s dis-

ease. A positive test results in pain, which is often severe. Patients who can repeatedly open and close the fist with smooth thumb motion are unlikely to have De Quervain’s.

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27. What is the most common cause of hip pain in older adults?

A. Osteoporosis B. Osteoarthritis C. Trauma due to fall D. Trochanteric bursitis ANS: B There are many potential causes of hip pain. Among adults, the most common cause is osteoarthritis with degenerative changes. In younger patients, the cause is often strain of the muscles or tendons. In comparison to other joints, the hip is often difficult to assess, in part because much of the joint and its periarticular structures lie deeper than those of other joints.

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28. A 33-year-old male marathon runner presents with knee pain. Which of the following tests is positive if the meniscus of the knee is torn?

A. McMurray’s test B. Straight leg raising sign C. Anterior drawer sign D. Lachman test ANS: A Tears or disruptions of the meniscus sheath of cartilage are associated with osteoarthritis in older persons and with athletic activities in younger persons. There is typically a sudden onset of pain and swelling over the lateral or medial joint line, as well as locking and painful popping. Onset often follows a twisting injury. Point tenderness is present over the joint line, with mild effusion. A positive McMurray’s test is often present.

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29. A 23-year-old female presents with ankle pain due to a fall while walking on ice 1 hour ago.

You watch her limp as she walks into the emergency room. On physical examination, the ankle is erythematous, swollen, and tender to touch. The patient cannot stand on the affected ankle. Range of motion is severely limited on inversion of the ankle. On palpation, there is no pain with pressure on the medial or lateral malleolus. Should this patient be sent for ankle x-rays according to the Ottawa ankle rules?

A. No, the ankle shows no tenderness over the medial or lateral malleolus B. Yes, the patient is unable to bear weight on the ankle C. Yes, ankle range of motion is limited

D. No, range of motion of the ankle is not limited in all planes ANS: B The following Ottawa rules recommend x-ray of the ankle if either one of the following conditions exist: Inability to bear weight for four steps (both immediately and in emergency department) Bone tenderness at posterior edge or tip of either malleolus PTS: 1

30. A 43-year-old female was in a bicycling accident and complains of severe pain of the right foot. The patient limps into the emergency room. On physical examination, there is no point tenderness over the medial or lateral ankle malleolus. There is no foot tenderness except at the base of the fifth metatarsal bone. According to the Ottawa foot rules, should an x-ray of the feet be ordered?

A. Yes, there is tenderness over the fifth metatarsal B. No, there is not tenderness over the navicular bone C. Yes, the patient cannot bear weight on the foot D. A and C ANS: D Foot Rule: Order film if one of the following is met: Inability to bear weight for four steps (both immediately and in emergency department) Bone tenderness at navicular or base of fifth metatarsal Sensitivity = 100% Specificity = 79% PTS: 1

31. A 36-year-old female patient complains of foot pain when she wears high heels. There is no history of trauma or arthritis. On physical examination, there is tenderness at the space between the third and fourth metatarsal bones. Foot x-ray shows no evidence of stress fracture.

This history is typical of: A. Plantar fasciitis B. Morton’s neuroma C. Achilles tendonitis D. None of the above ANS: B Morton’s neuroma, also called interdigital neuroma, is actually not neuroma but rather fibrous tissue thickening along digital nerves, typically in the space between the third and fourth intermetatarsals. They occur most frequently in women and may be associated with footwear, such as heels. Most common is localized pain that is increased with walking and decreased with rest and/or removal of shoes. Palpation often reproduces the sharp pain.

PTS: 1

Chapter 15. Neurological System

MULTIPLE CHOICE

1. When carrying out a mental status examination on a non-English speaking patient, it is important to have a(n): A. Patient’s family member, who is bilingual, interpret for the patient B. Objective interpreter ask the questions for the patient C. Friend of the patient interpret the questions for the patient D. Any of the above is acceptable ANS: B Ask the family or significant other whether the patient’s behavior patterns have changed. If the patient does not speak or write English, have an interpreter available during the examination. It is important to have an objective interpreter ask the patient translated questions.

The patient may not be truthful or forthcoming if he or she knows the interpreter. A friend or relative may slant the mental status examination questions or influence the patient regarding the answers. A good screening tool for use in the outpatient setting is the Mini-Mental Status Examination, described in detail in Chapter 20.

PTS: 1

2. When examining the carotid arteries, the clinician should: A. Ask the patient to hold his or her breath while auscultating the carotid arteries B. Use the bell of the stethoscope to listen over the carotid arteries C. Palpate one carotid artery at a time D. All of the above ANS: D Auscultation of the carotid arteries is an important portion of the neurological examination, particularly for elderly patients. The patient should be asked to hold his or her breath during auscultation. The bell of the stethoscope is used to auscultate for bruits. One carotid artery at a time is palpated. A bruit in the carotid artery may be an indicator of potential stroke or carotid artery stenosis and should be followed by further tests, such as carotid duplex and carotid ultrasound.

PTS: 1

3. A 44-year-old male presents to the emergency room with the ―worst headache of my life.‖ He is holding his head and appears severely distressed. This is a patient symptom that

should prompt a clinician to look for signs of a: A. Migraine headache B. Subdural hematoma C. Subarachnoid hemorrhage D. Brain tumor ANS: C The pain associated with subarachnoid hemorrhage is generally described as severe and acute in onset. The onset is often described as a thunderbolt or lightning. The severity is described as ―the worst headache of my life.‖ It is generally made worse by lying down. There is often associated nausea and/or vomiting and possible rapid deterioration in neurological function. Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated by movement, light, and noise. The headache associated with subdural hematoma is generally dull and aching in nature and may be transient. The history often includes a blow to the head, fall, or other injury, which preceded the pain. The pain will gradually worsen over days to weeks. Headache due to a brain tumor is difficult to diagnose. A headache that awakens a patient from sleep is often a brain tumor. Headache with neurological deficits should also raise suspicion of brain tumor.

PTS: 1

4. An 8-year-old child presents to the emergency room with a severe unilateral, throbbing headache. She is lying on the gurney with her eyes closed while holding her head. She denies ever having this kind of headache in the past. She complains of sensitivity to light and noise. An appropriate history question to ask the parent would be: A. What do you think triggered the headache?

B. Have you had a fever?

C. Does anyone in your family suffer from migraine headache?

D. B and C ANS: D A migraine is one of the most common types of vascular headache and accounts for a significant percentage of clinic and emergency department visits each year. They occur more frequently in women, and the majority of patients report a family history of migraine. Onset of migraine is uncommon after the age of 40 years. They generally do not occur daily and are often associated with the menstrual cycle. Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated by movement, light, and noise. Accompanying symptoms may include nausea, vomiting, photophobia, phonophobia, osmophobia, dizziness, chills, and/or ataxia.

PTS: 1

5. A 41-year-old male patient presents to the emergency department complaining of severe headache pain. He describes it as a piercing, right-sided head pain that occurred earlier in the day for about 1 hour and now is recurring. You note lacrimation and rhinorrhea on the right side of the face. Which of the following types of headache is the patient describing?

A. Sinusitis B. Cluster headache C. Migraine D. Subdural hematoma ANS: B Cluster headaches have rapid crescendo patterns, peaking in approximately 10 to 15 minutes and often lasting 30 to 60 minutes per episode (rarely lasting over 2 hours each). Attacks occur as frequently as two to three times per day. The pain is generally in the area of the trigeminal nerve and is described as unilateral, penetrating, sharp, excruciating, and unrelenting in nature. There may be associated unilateral lacrimation, nasal congestion or rhinorrhea, pallor, flushing, conjunctival redness, ptosis—all on the same side as the pain.

PTS: 1

6. An 85-year-old female patient arrives by ambulance to the emergency department accompanied by her husband. He reports that his wife had been ill with pneumonia and, 2 days ago, went to the family physician who prescribed azithromycin twice a day. The husband reports that he is making sure she gets the medicine. His wife has been staying in bed and resting. She awoke from sleep last night and was extremely agitated, left the house, and was walking outside. She did not recognize her husband and wanted to call the police.

Which of the following is an appropriate question for the history?

A. Does your wife have dementia or frequent episodes of confusion?

B. Has your wife been running a fever?

C. Is your wife allergic to any medication?

D. Has your wife ever had a mental status examination?

ANS: A Delirium can be observed in both elderly and younger patients and is generally defined as an acute confusional state, affecting all aspects of cognition and mentation. The signs and symptoms of delirium generally have a more acute or rapidly progressive onset as opposed to the slow, gradual decline noted in the organic dementias. The acute mental status change is often associated with other signs or symptoms—such as hallucinations, illusions, incoherent speech, and constant aimless activity—that help to narrow the differential diagnosis.

Electrolyte disturbances, infection, and polypharmacy are frequent causes of delirium in the elderly.

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7. A 60-year-old female complains of several episodes of dizziness and nausea that started this morning. She denies trauma, falling, or loss of consciousness. She has a 5-year history of hypertension and takes a beta blocker daily. On physical examination, there are no neuro-

logical deficits or any abnormal findings, and electrocardiogram is normal. Which of the following tests should be performed?

A. Test the patient for Kernig’s sign B. Test the patient for Brudzinski sign C. Perform the Hallpike maneuver D. Assess for Babinski’s sign ANS: C Characterized by sudden-onset dizziness lasting less than 30 seconds and following a head position change, benign positional vertigo (cupulolithiasis) may be accompanied by nystagmus. It usually subsides but may recur at any time. In addition to the history, a provocative test for positional nystagmus can be performed (Hallpike maneuver), although it is not always positive. The provocative test involves moving the patient quickly from a sitting position to a lying position with the head turned to the side and the head dependent over the side of the examination table. After a few seconds, vertigo and nystagmus occur. This response fatigues with immediate repetition of the test.

PTS: 1

8. Ménière’s disease presents with the following triad of symptoms: A. Vertigo, nystagmus, hearing loss B. Vertigo, tinnitus, hearing loss C. Vertigo, syncope, hearing loss D. None of the above ANS: B The exact cause of Ménière’s disease is unknown; however, the symptoms are associated with increased fluid and pressure in the labyrinth. Ménière’s disease commonly involves a triad of symptoms: severe vertigo, tinnitus, and hearing loss. The vertigo is transient but recurrent. The tinnitus and hearing loss may also be intermittent and/or recurrent but often become worse over time. A sensation of ear fullness may precede an episode. During the episode, vertigo is often debilitating and is associated with nausea and vomiting. The tinnitus and hearing loss are usually unilateral.

PTS: 1

9. A 77-year-old male is brought into the emergency department accompanied by his daughter.

She reports that her father has been complaining of right-handed weakness for 2 to 3 hours and that she has noticed him slurring his speech. On physical examination, the right hand grip strength is 1/5 compared to the left hand grip of 5/5. A facial droop is noted on the right side of the face. Cranial nerve dysfunction is noted in the right-sided cranial nerves VII, V, IX, X, XI, and XII. The clinician should request the following diagnostic test immediately: A. Magnetic resonance imaging of the head B. Computed tomography scan of the head C. Lumbar puncture D. Electrocardiogram

ANS: B Strokes are divided into two main categories: thrombotic and hemorrhagic; however, the two can be difficult to differentiate using clinical signs and symptoms. The onset is usually an abrupt altered level of consciousness accompanied by hemiparesis or hemiplegia. Patients may experience confusion, memory impairment, and aphasia. Signs and symptoms vary with the location and severity of the stroke. Mentation and cognitive changes may be temporary or permanent depending on the extent of injury. Communication alterations stemming from fluent or receptive aphasia may be mistaken as dementia. A computed tomography (CT) scan, without contrast, is the preferred imaging study in early stroke because hemorrhage may be difficult to determine on a magnetic resonance imaging (MRI) in the first 48 hours. In studies of ischemic stroke patients, researchers have shown the reversibility of abnormalities on CT scan or MRI through the use of thrombolytic therapy within a 3-hour window.

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10. A female patient presents to the clinic with complaints of a severe, throbbing, unilateral headache. She complains of seeing flashes of light prior to the headache. She complains of sound and light sensitivity, as well as nausea. The clinician should recognize these as symptoms of: A. Epilepsy with aura B. Cluster headache C. Migraine headache D. Normal pressure hydrocephalus ANS: C Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated by movement, light, and noise. Accompanying symptoms may include nausea, vomiting, photophobia, phonophobia, osmophobia, dizziness, chills, and/or ataxia. There may be tenderness to palpation of the temporal arteries. Auras, if experienced, may include blurred vision and scotoma, and/or other prodromal symptoms, such as anorexia, irritability, restlessness, or paresthesias lasting from 30 minutes to 3 hours before the onset of migraine pain.

PTS: 1

11. On a history and physical examination of a 34-year-old patient, during the review of systems, he reports occasional episodes of headache. He describes the headache pain as a ―band around my head‖ and tightness in the neck and shoulders. The clinician should recognize these symptoms as: A. Tension headache B. Cluster headache C. Sinusitis

D. Migraine headache ANS: A Typical symptoms of tension headache include mild to moderate nonthrobbing pressure, or squeezing pain, that can occur anywhere in the head or neck. The pain often starts slowly as a dull and aching discomfort that progresses to holocranial pain and pressure. The pain can recur intermittently, lasting from minutes to hours, usually remitting with rest or removal of the stressful trigger. There is usually no associated nausea and vomiting. Although patients may report photophobia and phonophobia, it is less severe than those associated with migraines. Tension headaches are not aggravated by movement or activity. The neck muscles are often tight to palpation.

PTS: 1

12. An 81-year-old patient with heart failure comes into the emergency room accompanied by his daughter. The daughter reports that her father banged his head as he was getting out of the car 4 days ago. He did not complain of headache pain, so she did not obtain medical advice. She reports that she noticed a mild facial droop, slurring of speech, and gait disturbance in her father today. She reports that her father takes Coumadin, digoxin, and an ACE inhibitor. On physical examination, there is decreased right hand grip 2/5 strength and decreased right quadriceps strength 2/5 compared to the left side 5/5. Computed tomography scan shows an intracranial bleed. Which of the following is the most probable diagnosis?

A. Subarachnoid hemorrhage B. Epidural hematoma C. Subdural hematoma D. Intracerebral hemorrhage ANS: C Subdural hematomas can be either acute or chronic. Acute subdural hematomas are usually associated with an acute head injury and can cause a range of symptoms, including headache and loss of consciousness. A chronic subdural hematoma in the elderly population may enlarge significantly before the patient begins to notice head pain. The headache associated with subdural hematoma is generally dull and aching in nature and may be transient. The history often includes a blow to the head, fall, or other injury, which preceded the pain. The physical findings vary depending on the severity of the trauma but may include progressive neurological deterioration, which may advance to include coma. The elderly patient with head trauma who is taking anticoagulants should raise suspicion of subdural hematoma.

PTS: 1

13. Which of the following microorganisms is a common cause of meningitis?

A. Enterococcus B. Haemophilus influenzae C. Influenza virus D. Chlamydia

ANS: B Meningitis involves inflammatory central nervous system disease generally caused by either viral or bacterial infection. The etiology of meningitis includes community-acquired, post-traumatic, aseptic, carcinomatous, or transferred from another bodily source. The most common organisms belong to such genera as Streptococcus, Neisseria (meningitides), Haemophilus (influenzae), Listeria, Staphylococcus (aureus), as well as Gram-negative bacilli and Gram-positive cocci. Meningitis can affect persons of all ages, including children.

PTS: 1

14. A 43-year-old male presents to the emergency department in a stupor, accompanied by his wife. She called the ambulance because her husband was difficult to awaken this morning.

She reports that for the last 3 days he has had a fever and an upper respiratory infection.

Yesterday he had a headache. He has had no medical treatment. On physical examination, the patient demonstrates 103°F fever, sluggish pupil response, and nuchal rigidity. Which of the following should the clinician attempt to elicit next?

A. Hallpike maneuver B. Kernig’s sign C. Epley maneuver D. Babinski’s sign ANS: B In meningitis, fever, photophobia, phonophobia, nausea, vomiting, and nuchal rigidity occur. Patients can rapidly decline to delirium, seizures, and, if untreated, coma. On neurological examination, the patient may be lethargic and febrile and have altered mentation along with nuchal rigidity and/or guarding, contracted and sluggish pupils, and a generally ―toxic‖ appearance. Brudzinski’s and Kernig’s signs are helpful in assessing potential meningeal conditions (see Box 15.6). Delirium or acute confusion necessitates immediate transfer to an emergency department for treatment, as the patient can rapidly deteriorate to coma.

PTS: 1

15. Spina bifida is a disorder that is associated with a headache syndrome caused by: A. Chiari malformation B. Normal pressure hydrocephalus C. Meningioma D. Temporal arteritis ANS: A Chiari malformations are brainstem malformations. There are three types of Chiari malformations. Type 1 is most often associated with occipital headaches and generally seen in the adult population, but can be diagnosed at any age. Type 1 symptoms may be very vague and transient, and is often misdiagnosed as another neurological disease. Type 2 is generally diagnosed in infants or children and is associated with myelomeningocele or other open neural tube defects or in adults with undiagnosed spina bifida occulta or tethered cord. Type 3 is rare, diagnosed in infants, associated with cervical myelomeningocele or pseudomeningo-

cele, and carries a very poor prognosis.

PTS: 1

16. Which of the following is a common trigger of migraine headache?

A. Missed meals B. Menses C. Alcohol D. All of the above ANS: D Common Migraine Triggers: • Stress • Caffeine • Altered sleep • Specific foods, missed meals • Menses • Alcohol • Hormone supplements PTS: 1

17. Your patient with a cervical herniated disc presents with a weakened biceps reflex. The biceps reflex is a test of the following spinal nerves: A. C3 to C4 B. C4 to C5 C. C5 to C6 D. C7 to T1 ANS: C Box 15.3 Deep Tendon Reflexes Biceps: C5, C6 Brachioradialis: C5, C6 Triceps: C6, C7 Patellar: L3, L4 Achilles: S1 PTS: 1

18. In order to test abstract thought on the mental status examination, the clinician can ask the patient: A. To count by serial 7’s backward B. To spell the word world backward

C. To draw a clock that shows 2:30 D. How is your brother-in-law related to you?

ANS: D Rationale: Box 15.1 Mental Status Components Orientation: The patient should normally be aware of person, date, and place. Ask the patient his or her full name, current date, and place in which the examination is being done.

Memory: Recent and remote memory should normally be intact. Ask what the patient had for lunch yesterday (recent) and where he or she graduated from elementary school (remote).

Fund of knowledge (take into consideration the patient’s level of education): Ask about any recent news events or significant upcoming or past holiday.

Attention span: Ability to focus on the interviewer without being easily distracted. Ask the patient to repeat a short list of numbers (e.g., 7-8-9-3-0-2). Inability to repeat six or more numbers indicates attention deficit.

Concentration: Ability to concentrate on a question or task. Ask the patient to remember three unrelated words (red, happy, and five) and then to repeat them in 5 minutes, or ask the patient to count backward from 100 by 7.

Language: Use and understanding of language. Ask the patient to write a full sentence or to spell world backward. Distinguish between dysphonias and dysarthrias, as these indicate mechanical disturbances often due to central nervous system dysfunction. Assess fluency of speech by asking the patient to repeat ―no ifs, ands, or buts about it.‖ Dysfluent speech is Broca’s aphasia. Speech that is devoid of content indicates Wernicke’s aphasia.

Abstract thoughts: Ask the patient to interpret a common proverb (e.g., A stitch in time saves nine), or ask the patient to answer an abstract question (e.g., ―Is my sister’s brother a man or a woman?‖).

PTS: 1

19. A 56-year-old woman brings her 78-year-old father to the emergency room. The patient complains that sometimes he can’t think straight. His daughter reports that her father has been tripping over his own feet and has become incontinent of urine in the last few days.

The patient’s medications include an ACE inhibitor and beta blocker. On physical examination, vital signs are within normal limits, heart and lungs show no abnormalities, cranial nerves are intact, and sensation and muscle strength are normal. A mental status examination is normal. Imbalanced gait and a positive Romberg test are apparent. Which of the following are possible disorders?

A. Cerebellar dysfunction B. Normal pressure hydrocephalus C. Early dementia D. A and B ANS: D Normal pressure hydrocephalus is not fully understood. It is seen primarily in persons over 60 years of age and involves enlargement of the ventricles, often without increased cerebrospinal fluid pressure; intraventricular pressures may be high or normal. One of the theorized

causes includes intermittent pressure increases. It is slightly more common in men than in women. The patient often first notices some degree of gait disorder, followed by the onset of a ―clouding‖ of thought processes, which gradually progress. The typical picture is a patient who has a triad of gait disturbance, altered thought processes, and urinary incontinence.

Strength and sensation are usually within normal limits. However, focal neurological findings are present and include increased deep tendon reflexes, the inability to tandem walk, positive Babinski, and/or positive Romberg.

PTS: 1

20. A 65-year-old woman is accompanied by her daughter for a physical examination. She has mild heart failure and takes digitalis and an ACE inhibitor. As you examine the patient, you note flat affect, hand tremor, and slowed movements. The tremor is worsened at rest. There are no neurological deficits. Hand grip, sensation of face and extremities, and lower extremity muscle strength are within normal limits and bilaterally equal. Deep tendon reflexes are equal bilaterally. Cranial nerves II to XII are intact. The mental status examination is normal. These are key signs of: A. Chiari malformation B. Normal pressure hydrocephalus C. Parkinson’s disease D. Drug toxicity ANS: C Parkinson’s disease occurs with approximately equal sex distribution, and usually begins between 45 and 65 years of age. Unilateral pill-rolling tremor at rest is usually the first symptom. The tremor is maximal at rest but absent during sleep and can be differentiated from essential tremor, which is absent at rest and worsens with voluntary movement. There is a flattened affect and blank stare. There is bradykinesia of gross and fine motor movement, speech volume, swallowing, and blinking. There is generally no muscle weakness, and deep tendon reflexes are normal. Although Alzheimer’s disease can manifest with rigidity, bradykinesia, and gait disorders, no resting tremor is seen with Alzheimer’s.

PTS: 1

21. A 65-year-old male complains of a headache that feels ―like a knife is cutting into my head.‖ He also reports feeling right-sided scalp and facial pain, and seeing double at times. He has a history of hypertension and hyperlipidemia. His medications include a beta blocker, statin drug, and ACE inhibitor. On physical examination, you note palpable tenderness over the right side of the forehead. There are no neurological deficits. Vision is 20/20 with lenses. No weakness of extremities. Cranial nerves II to XII are intact. The history corresponds to which of the following disorders?

A. Drug toxicity B. Giant cell arteritis C. Cluster headache D. Migraine headache

ANS: B Temporal arteritis is also referred to as giant cell arteritis or cranial arteritis. It is characterized by chronic inflammation and the presence of giant cells in large arteries, usually the temporal artery, but can occur in the cranial arteries, the aorta, and coronary and peripheral arteries. It affects the arteries containing elastic tissue, resulting in narrowing and eventual occlusion of the lumen. It occurs more among persons over 50 years of age and is slightly more common in females than in males. The cause is unknown, but there seems to be a genetic predisposition. If left untreated, arteritis can rapidly lead to blindness that is often irreversible. The most common chief complaint is head pain that is lancinating, sharp, or ―ice pick‖ in nature. Patients often complain of visual changes, including amaurosis, diplopia, blurred vision, visual field cuts, eye pain, periorbital edema, and intermittent unilateral blindness. Other common presenting symptoms include scalp and/or jaw tenderness, facial pain, and tenderness to palpation over the affected artery. The pain is generally hemicranial but can be bilateral or diffuse. There may be eye pain, which is usually bilateral; periorbital edema may be present. Other potential associated symptoms include an intermittent fever (generally low grade), nausea, and/or weight loss.

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22. In dementia, which of the following cognitive functions is most commonly lost first?

A. Recognizing persons B. Knowing the place C. Estimating the time D. Long-term memory ANS: C When evaluating a patient’s mental status, assess orientation by asking the patient to recite his or her full name, current location/place (clinic, hospital, home, etc.), and the date (day of the week, month, or year). Knowledge of time is generally impaired first, followed by place.

The inability to recite or recognize one’s name implies a significant deficit in mental status.

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23. A 78-year-old female comes to the clinic for a physical examination. She is accompanied by her daughter and looks to her daughter to answer questions during the interview. She was diagnosed with early Alzheimer’s disease 2 years ago, and her daughter would like her current mental status evaluated. You ask the patient her daughter’s name, and she answers correctly. You ask her the date and time, and she answers incorrectly. You hand the patient a pencil and ask her if she knows what it is. She replies with, ―Is it a stick?‖ You ask the patient to put on a patient gown, and she does not know how to perform the task. These are examples of disorientation to time and: A. Agnosia and apraxia B. Anomia and aphasia C. Agnosia and ataxia D. Apathy and ataxia

ANS: B Most organic dementias develop over months to years. There are typically no physical motor or sensory alterations until the condition is advanced. Memory impairment is the predominant symptom. There may be impairment in another area of cognitive functioning, such as with aphasia (difficulty producing language as well as understanding it), anomia (a form of aphasia in which patients are unable to recall the names of everyday objects), agnosia (perceptual impairment of environment), apraxia (inability to perform complex motor acts), and impairment in executive functioning (inability to plan, organize, sequence, and think abstractly). Ataxia is not a symptom of dementia—it is a problem with gait, usually due to cerebellar dysfunction.

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24. You are an emergency room clinician that assisted with CPR on a 20-year-old trauma patient. The CPR was unsuccessful, the patient expired, and you need to explain this to the family in the waiting room. On telling the mother about the death of her son, she becomes dizzy and faints. What is the most likely cause for the woman fainting?

A. Cardiogenic shock B. Vasovagal response C. Syncope due to hypoxia D. Dizziness and vertigo ANS: B Neurocardiogenic syncope, also called vasovagal syncope, is a common cause of dizziness and fainting. It is due to a sudden decrease in blood pressure and heart rate after prolonged standing, with stress, or from dehydration. It is a result of sympathetic sensitivity, causing a reflexive response that suddenly causes bradycardia and venous dilation. Hypotension and dizziness result.

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25. An 88-year-old female is accompanied by her daughter to the emergency department. The daughter explains that her mother was having her hair washed at the beauty salon, then complained of dizziness and fainted. The 88-year-old patient has a history of hypertension for which she takes a beta blocker; otherwise she was in her usual state of health until this incident. On examination, she has no neurological deficits. Which of the following conditions should be considered?

A. Benign positional vertigo B. Vertebrobasilar insufficiency C. Labyrinthitis D. Dehydration ANS: B Vertebrobasilar insufficiency is seen mostly in the elderly and is exacerbated by extension of the neck or changes in head position. There is temporary interruption of circulation in the posterior brain due to vertebral artery occlusion. Benign paroxysmal positional vertigo, or

cupulolithiasis, is the most common vestibular disorder, resulting from otolithic crystals/particles detaching from the utricle membrane and migrating to the semicircular canal. It can occur spontaneously with motion or position change, or as a result of vascular or labyrinth trauma. Characterized by sudden-onset dizziness lasting less than 30 seconds and following a head position change, cupulolithiasis may be accompanied by nystagmus. It usually subsides but may recur at any time. Labyrinthitis is caused by the invasion of the ear by bacteria or a virus. The bacterial version is more serious because it may lead to meningitis.

Prompt treatment with antibiotics is necessary. Labyrinthitis is characterized by severe vertigo, nystagmus, and hearing loss. Suppurative labyrinthitis may be secondary to bacterial otitis media or other bacterial infection. Serous labyrinthitis can be secondary to a variety of viral illnesses, including measles, mumps, chickenpox, influenza, mononucleosis, and adenovirus.

PTS: 1

Chapter 16. Nonspecific Complaints

MULTIPLE CHOICE

1. A 45-year-old female complains of feeling extremely anxious, fatigued, and has a loss of enjoyment of previously engaging activities. She has a difficult time arising from bed in the morning to go to work. She has lost her appetite, cannot sleep, and has trouble ―thinking straight.‖ On physical examination, there are no significant findings. These signs and symptoms are characteristic of: A. The presence of a malignancy B. Clinical depression C. Hypothyroidism D. Adrenal insufficiency ANS: B Individuals with clinical depression often present with feelings of sadness, hopelessness, and worthlessness, with diminished interest in both work and recreation. There may be cognitive complaints, such as difficulty thinking and concentrating, obsessive ruminations, and difficulty making decisions. There may be difficulty sleeping, appetite changes, loss of energy, and decreased libido. Often, depression is accompanied by anxiety or agitation, as well as by various somatic complaints, such as fatigue, headache, nausea, and irritability.

PTS: 1

2. A 22-year-old female patient complains of excessive thirst, feeling shaky when she misses meals, and increased frequency of urination. Family history is positive for cardiovascular disease, cerebrovascular disease, and diabetes. The patient denies use of tobacco, alcohol, or other drugs. She takes no medication. Daily diet is fast food, and the patient does not exercise regularly. On physical examination, there are no significant findings except obesity,

demonstrated by a body mass index of 35 and blood pressure of 145/90. The signs and symptoms are characteristic of: A. Type 2 diabetes mellitus B. Chronic fatigue syndrome C. Cushing’s disease D. Clinical depression ANS: A Patients who are overweight and sedentary, with a positive family history, are at high risk for developing type 2 diabetes. Polydipsia, polyphagia, and polyuria are the hallmark signs of diabetes, but fatigue, weight loss, and blurred vision are often the symptoms that bring patients into the office.

PTS: 1

3. A 44-year-old female comes in for a physical examination. She complains of having trouble losing weight, excessive fatigue, sluggishness, and loss of excessive blood with menses. On physical examination, there are no significant findings, except her body mass index of 28 is in the overweight category. What other question(s) would assist in the diagnosis?

A. Is there a history of thyroid disorders in the family?

B. Do you feel excessively cold or hot when others are not?

C. Have you had a recent upper respiratory infection?

D. A and B ANS: D The incidence of hypothyroidism is greater in women and more common in people over 40 years of age. Because the onset of hypothyroidism can be insidious, patients may not be aware that their thyroid levels have diminished. Common signs and symptoms include fatigue or lack of energy, puffy face, constipation, intolerance to cold, hypotension, bradycardia, dry skin, menorrhagia, modest weight gain, diminished deep tendon reflexes, and dulled cognition.

PTS: 1

4. A 54-year-old male complains of loss of appetite, weakness, fatigue, and unintentional weight loss of 10 pounds over the last month. His wife recommended that he get a physical examination. On physical examination, you do not find significant signs of a specific disorder. The complete blood count with differential shows anemia. A serum metabolic panel has all normal findings. Which diagnostic test(s) would you recommend to obtain more information?

A. Cystoscopy B. Digital rectal exam C. Colonoscopy D. B and C ANS: D

Anemia in a middle-aged male is a key sign to investigate. Iron-deficiency anemia is commonly a sign of colon cancer in a male; therefore, a colonoscopy is necessary. A digital rectal exam can provide a specimen for hemoccult testing and allow the clinician to palpate the prostate gland. A malignancy any place in the body may cause the patient to feel fatigued. It is often an indirect cause of fatigue, stemming from anemia, shortness of breath, decreased appetite, nausea and vomiting, decreased renal function, or a variety of other symptoms caused by the malignancy. The signs and symptoms depend on the system where the malignancy exists. If a patient presents with a primary complaint of fatigue, an index of suspicion for a malignancy should alert you to ask about other signs or symptoms that the patient might have noticed. If malignancy is advanced enough to cause fatigue, there are usually other symptoms present.

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5. A 45-year-old female patient complains of nausea, vomiting, fatigue, and weakness. She admits to a history of heroin abuse for 11 years. She quit using the drug after rehabilitation last year and denies current use of the drug. Habits include use of alcohol (four to five drinks daily) and tobacco use of 60-pack years. On physical examination, she is afebrile, has a blood pressure of 148/98, pulse 78 beat/min, and respirations 16 breaths/min. The patient has periorbital edema. Lungs are clear to auscultation. Abdomen is nontender and distended with mild hepatomegaly. No neurological deficits. Laboratory testing reveals Hgb 10, BUN 60, potassium 6.1, and serum creatinine 2.9 mg/dL. These findings are characteristic of: A. Chronic renal failure B. Dehydration C. Congestive heart failure D. Liver failure ANS: A Patients with mild renal dysfunction are generally asymptomatic, but as the disease progresses, vague symptoms appear. Fatigue and weakness are early signs, as are decreased cognitive functioning and irritability. Patients may complain of nocturia, which is due to the kidney not concentrating the urine at night. Many of these early signs are nonspecific, and patients often pass them off as a normal part of aging. Gastrointestinal complaints, such as nausea, vomiting, and anorexia, are common and contribute to the muscle wasting and fatigue. Patients may complain of a metallic taste in the mouth. Hypertension may develop from fluid overload and can result in congestive heart failure. Pericarditis may develop, producing a friction rub. Neurological symptoms include muscle cramps and twitching, peripheral neuropathy, difficulty concentrating, and sleep disturbances.

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6. A 66-year-old female presents with fatigue, shortness of breath with exertion, cough, and swelling of the ankles. Current medications include lipid-lowering medication for hyperlipidemia and beta blocker for hypertension. On physical examination, vital signs are: temperature 98°F, respirations18 breaths/min, pulse 56 beats/min, and blood pressure 100/60.

Heart demonstrates S3 gallop and S4. Lungs reveal bilateral basilar crackles. Abdomen is distended with shifting dullness and hepatomegaly. Extremities show bilateral ankle edema.

No neurological deficits. These signs and symptoms are characteristic of: A. Chronic renal failure B. Congestive heart failure C. Metabolic syndrome D. Liver failure ANS: B Congestive heart failure, commonly occurring in the elderly or in patients with past myocardial infarctions or cardiomyopathy, can often present with complaints of fatigue, decreased activity tolerance, and/or shortness of breath. A patient with a history of hypertension and hyperlipidemia indicates cardiovascular disease that predisposes to heart failure with age. The signs of heart failure include cough, shortness of breath with exertion, S3 and S4 heart sounds, pulmonary crackles, ascites, hepatomegaly and ankle edema.

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7. A 67-year-old male with a smoking history of 120-pack years complains of fatigue with exertion, shortness of breath, chronic cough, and wheezing. On physical examination, the patient shows barrel-shaped chest, prolonged exhalation, circumoral cyanosis, and wheezing throughout both lung fields. His heart has a regular rate and rhythm of 80 beats/min. The abdomen is obese and nontender. Extremities show no significant findings. No neurological deficits. Arterial blood gases reveal acidosis. These signs and symptoms are characteristic of: A. Congestive heart failure B. Chronic obstructive pulmonary disease C. Asthma D. Lung cancer ANS: B Chronic obstructive pulmonary disease, such as chronic asthma/bronchitis, bronchiolitis, and emphysema, may be associated with fatigue, shortness of breath, cough, and wheezing.

The patient in this scenario shows signs of chronic bronchitis and emphysema. Cough and cyanosis are caused by chronic bronchitis. Barrel-shaped chest and acidosis are caused by emphysema.

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8. A 15-year-old male presents to the clinic with fatigue, weakness, and sore throat for 4 days.

The patient has no significant medical or surgical history. On physical examination, there is fever of 102°F, erythematous pharynx and tonsillar enlargement, and prominent cervical lymphadenopathy. Heart has a regular rate and rhythm. Lungs are clear to auscultation. Abdomen examination demonstrates left upper quadrant tenderness to deep palpation and splenomegaly. Extremities show no significant findings. No neurological deficits. These signs and symptoms are characteristic of:

A. B. C. D.

Beta-hemolytic streptococcal infection Scarlet fever Infectious mononucleosis Human immunodeficiency viral infection

ANS: C Mononucleosis is a viral infection that typically occurs in adolescence and early adulthood and is caused by the Epstein-Barr virus. Fatigue is a common complaint. Fever, sore throat, prominent cervical lymphadenopathy, and splenomegaly are characteristic of infectious mononucleosis.

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9. A 34-year-old male complains of extreme fatigue and weakness, lightheadedness, anorexia, and unintentional weight loss of 20 pounds over the last month. The patient has a history of tuberculosis as a child from age 4. Current tuberculin purified protein derivative is pending.

On physical examination, the patient is afebrile, with heart rate 110 beats/min., respirations 18 breaths/min, and blood pressure 100/50. He has a tanned complexion, is thin and frail looking, and looks younger than his stated age. His heart presents with tachycardia and a regular rhythm. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities show no significant findings. No neurological deficits. Chest x-ray demonstrates an area of scar tissue. These signs and symptoms are characteristic of: A. Congestive heart failure B. Active tuberculosis C. Cushing’s disease D. Addison’s disease ANS: D Weakness and fatigue are early signs of Addison’s disease. The patient may complain of lightheadedness, owing to volume depletion, and orthostatic hypotension is found on examination. In most cases, the skin and mucous membranes are hyperpigmented, especially over creases, bony prominences, and nipples. The patient may complain of anorexia, nausea, vomiting, or diarrhea, and weight loss is evident. Adrenal tuberculosis causes hypoadrenalism.

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10. A 32-year-old morbidly obese male complains of excessive fatigue, snoring, and awakening in the middle of the night, which prevents restorative sleep. He is sluggish during the day due to the lack of sleep and feels like he is going to fall asleep at the wheel when driving to work. Occupation: dishwasher. Medical history includes hypertension and type 2 diabetes.

Current medications include ACE inhibitor and metformin. He denies use of alcohol, tobacco, or drugs. On physical examination, the patient is afebrile, pulse 88 beats/min, respirations 20 breaths/min, blood pressure 178/95. Body mass index is 45. These are signs and symptoms of: A. Obstructive sleep apnea

B. Primary insomnia C. Heart failure D. All of the above ANS: A With the obesity epidemic, the incidence of obstructive sleep apnea (OSA) is also increasing. Besides obesity, other predisposing and risk factors include narrowed upper airways, macroglossia, tonsillar hypertrophy, sleep medicines, alcohol, smoking, nasal obstruction, and hypothyroidism. OSA occurs more in middle-aged men. A thorough medication history, respiratory history, neurological history, and mental health assessment should be performed.

One of the more common symptoms of OSA is snoring, usually reported by the spouse. The patient may complain of frequent nighttime awakening, morning drowsiness, headache (caused by carbon dioxide buildup in the brain), cognitive impairment, as well as impotence and weight gain, which can be both a cause and an effect. Systemic hypertension is a complication of OSA but often resolves when the cause of the apnea is corrected.

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11. A 66-year-old female complains of fatigue and a burning and itching feeling in the legs. The patient reports that the leg problem occurs during sleep and awakens her during the night.

Current medications include: ACE inhibitor, Wellbutrin, and Prilosec. Denies use of tobacco or alcohol. History of hypertension, gastroesophageal reflux disease, and depression. On physical examination, vital signs are: temperature 98°F, respirations 18 breaths/min, pulse 66 beats/min, and blood pressure 110/60. Heart: regular rate and rhythm, no murmurs.

Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities: skin is pink, cool to touch, and intact bilaterally. Positive Hallux valgus bilaterally. Left and right quadriceps muscle strength 5/5. Deep tendon reflexes left and right +3/4. No clonus.

Negative Homan’s and Babinski’s signs. Sensation to pin prick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally. No neurological deficits. These signs and symptoms are characteristic of: A. Peripheral vascular disease B. Restless legs syndrome C. Peripheral neuropathy D. All of the above ANS: B Although the exact cause of restless legs syndrome (RLS) is unknown, it has been associated with obesity, pregnancy, smoking, iron-deficiency anemia, peripheral neuropathy, heavy metal toxicity and other toxins, endocrine disorders, renal failure, caffeine and alcohol use, and certain medications, particularly H2 blockers and some antidepressants. A hereditary basis has also been suggested. RLS is characterized by an uncontrollable need to move the limbs, especially during times of rest and relaxation. Other symptoms attributed to RLS include leg tingling, itching, burning, or aching in the legs (and sometimes arms). Other conditions that may mimic RLS include Parkinson’s disease, neuropathic or circulatory conditions, muscle diseases, or joint conditions. Eliminating tobacco and alcohol and adding exercise to your routine can help alleviate symptoms.

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12. When assessing a patient who complains of muscle weakness, the clinician should assess if there is specifically: A. Bilateral or unilateral muscle weakness B. Proximal versus distal muscle weakness C. Upper extremity and/or lower extremity weakness D. All of the above ANS: D The history should include the type of weakness, whether it is proximal weakness, which might alert you to thyroid disease, malignancy, or adrenal dysfunction, or distal weakness, which would raise an index of suspicion for a neurological cause, especially if it was accompanied by paresthesia. Ask the patient when and with what types of activities the weakness is most prominent, and how much it interferes with activities of daily living. Inquire about changes in speech patterns or slurring that might indicate a neurological cause. Ask whether there are any cognitive or personality changes, which are often seen with adrenal dysfunction. The review of systems should include headache, cold or heat intolerance, change in appetite, weight gain or loss, nausea, vomiting or diarrhea, changes in balance or gait, numbness or paresthesia, diplopia or other vision changes, and difficulty with speech or swallowing.

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13. A 23-year-old female complains of episodes of blurry vision, and numbness and tingling in the left foot. When the foot falls asleep, the patient feels imbalanced and a gait disturbance develops, making the patient fall. The patient has a medical-surgical history of appendectomy at age 10. Otherwise, the patient has no history of illness and takes no medications. She denies use of tobacco or alcohol. On physical examination, vital signs are: temperature 98°F, respirations 18 breaths/min, pulse 66 beats/min, and blood pressure 110/60. Vision: 20/20 os, 20/20 od, and 20/20 ou. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities: skin is pink, cool to touch, and intact bilaterally. Left and right quadriceps muscle strength 5/5.

Deep tendon reflexes left and right are positive 2/4. No clonus. Negative Homan’s and Babinski’s signs. Sensation to pinprick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally. No neurological deficits. The following disorder(s) should be considered in the diagnosis: A. Multiple sclerosis B. Peripheral vascular disease C. Restless legs syndrome D. None of the above ANS: A In multiple sclerosis, visual disturbances may be the initial presenting symptom, indicating a plaque on the optic nerve. Associated visual disturbances include diplopia, blurred vision, tunnel vision, scotoma, or amaurosis. The visual changes are usually monocular. The patient may complain of intermittent weakness, parasthesias, or numbness of the face or extremities

that occurs intermittently and may resolve for weeks to months. Patients may report episodes of falling or stumbling with gait ataxia. Hyperreflexia may be noted, particularly in the lower extremities. Other symptoms include bladder incontinence or retention. Spastic bladder may also occur. In later stages, mental status changes may be noted. Initial symptoms are typically intermittent, and the disease may go undiagnosed for months or years.

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14. A 33-year-old female complains of episodes of weakness of the left side of the face and double vision. Drooping of the left eyelid and weakness of the jaw muscle develops gradually throughout the day, and it is worse at night than the morning. The patient has a medical-surgical history of cholecystectomy at age 30. Otherwise, the patient has no history of illness and takes no medications. She denies use of tobacco or alcohol. On physical examination, vital signs are: temperature 98°F, respirations 18 breaths/min, pulse 66 beats/min, and blood pressure 110/60. Ptosis of the left eyelid is noted. Vision: 20/20 os, 20/20 od, and 20/20 ou. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities: skin is pink, cool to touch, and intact bilaterally. Left and right quadriceps muscle strength 5/5. Deep tendon reflexes left and right +2/4. No clonus. Negative Homan’s and Babinski’s signs. Sensation to pinprick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally.

Eyelids: left-sided ptosis. No facial droop. Left and right cheek sensation to pinprick and cotton ball intact. Masseter muscle: 2/5 on left versus 5/5 on right. Extraocular muscles intact. Gag reflex: uvula midline gag intact. Shrug and sternocleidomastoid muscle strength 5/5 bilaterally. Tongue: midline and strength 5/5 bilaterally. The following disorder(s) should be considered in the diagnosis: A. Bell’s palsy B. Stroke C. Myasthenia gravis D. Multiple sclerosis ANS: C Myasthenia gravis can occur at any age and may be associated with other autoimmune diseases. Limb weakness and fatigability of the affected muscles is a diagnostic sign. Symptoms are due to a variable blocking of neuromuscular transmission by autoantibodies that bind to acetylcholine receptors. Ocular, facial, masticatory, and pharyngeal muscles are most often affected. The eye symptoms of diplopia and ptosis are common early signs. Other symptoms include dysphagia, weakness in the extremities, and respiratory difficulties.

Symptoms fluctuate during the day and often relapse or remit over long periods of time, but ultimately the disease is progressive. Sustained activity of the affected muscles increases the weakness, and symptoms will improve with rest. Patients may require life support if respiratory effort is significantly affected.

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15. To evaluate pain, the following objective scales are used:

A. B. C. D.

Visual analog scale Verbal rating scale McGill questionnaire All of the above

ANS: D There are many ways to measure severity of pain. The most commonly used are: the numerical rating scales (NRS), with which the patient rates the pain on an 11, 21, or 101 point range (0–10, 0–20, 0–100, for instance); the visual analog scale (VAS), with which the patient notes a point corresponding to the degree of pain along a 10-centimeter scale with poles of no pain at all to worst possible pain; and verbal rating scale (VRS), with which patients are asked to use verbal descriptors such as no pain, mild pain, considerable pain, and most severe pain. There are a number of more detailed options, such as the Pain Faces Scale for pediatric patients and the McGill Pain Questionnaire, which includes sensory and emotional aspects of pain, as well as a pain diagram.

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16. There is a high risk of respiratory depression with administration of an opiate medication in patients with: A. Chronic obstructive pulmonary disease B. Congestive heart failure C. Obstructive sleep apnea D. A and C ANS: D According to JAHCO’s Sentinel Event Database (Zhani, 2012), opioid analgesics rank among the drugs most frequently associated with adverse drug events. Opioids, such as morphine, oxycodone, and methadone, can slow breathing to dangerous levels and cause other problems, such as dizziness, nausea, and falls. JAHCO cites reasons for such adverse events, including dosing errors, improper monitoring of patients, and interactions with other drugs. Patients who have obstructive sleep apnea, are obese, or are very ill may be at higher risk for harm from opioids. Patients with severe chronic obstructive pulmonary disease are vulnerable to respiratory failure with opiates.

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17. A patient with Crohn’s disease complains of extreme muscle weakness, fatigue, diarrhea, bruising, 10-pound weight loss over the last few weeks, and dyspnea on exertion. On physical examination, the patient is afebrile, pulse 110 beats/min, respirations 20 breaths/min, and blood pressure 100/50. Body mass index is 15. The patient is pale and frail looking, with bilateral ankle edema and bruises noted on cachectic thighs. Which of the following diagnostic tests is most helpful in the diagnosis of intestinal malabsorption?

A. Liver enzymes B. Vitamin B12 assay C. Stool for fat

D. International normalized ratio ANS: C The signs and symptoms vary according to the underlying problem, but common symptoms include weight loss, flatulence, abdominal bloating, edema in the lower extremities resulting from protein deficiency, muscle weakness, possibly diarrhea or steatorrhea, dehydration, glossitis, and bruising. A variety of abnormal findings can be associated with malabsorption syndromes, including iron, folic acid, or B12 deficiency anemia; calcium deficiency; vitamins A, B, C, and D deficiencies; and niacin deficiency. A combination of weight loss, diarrhea, and anemia should raise the possibility of malabsorption. A variety of abnormal findings can be associated with malabsorption syndromes, including iron, folic acid, or B12 deficiency anemia; calcium deficiency; vitamins A, B, C, and D deficiencies; and niacin deficiency. There are as many diagnostics as there are causes of malabsorption. Measurement of fat in the stool is the most valuable diagnostic for diagnosing malabsorption, and a 3- to 4-day stool collection is advised. Stool specimens for ova, parasites and culture, and sensitivity will help to rule out infectious causes. Absorption tests, flat plate of the abdomen, upper gastrointestinal with small bowel follow-through, endoscopy, and small bowel biopsy may be necessary for definitive diagnosis.

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18. Which of the following disorders is associated with unintentional weight loss?

A. Clinical depression B. Hyperthyroidism C. Diabetes D. All of the above ANS: D Unexplained weight loss is considered significant if it is greater than 5% of the usual body weight over a 6- to 12-month period, and often indicates a serious medical or psychological illness. Malignancy, diabetes, digestive diseases, thyroid disease, and depression should top the list of differential diagnoses for unexplained weight loss. A thorough history and review of systems will alert the practitioner to other complaints that could give clues to the cause, such as cough, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, steatorrhea, hematemesis, melena, fatigue/weakness/lethargy, changing or new moles, persistent pain, enlarged lymph nodes, abnormal menstrual bleeding, breast discharge, and chronic headaches.

A thorough medicine history is critical, especially in the elderly or those with chronic diseases who are on a multitude of medicines. A psychosocial history is critical, especially in the elderly client, who may not be eating due to the inability to shop for groceries because of financial or transportation problems, inability to prepare meals resulting from a functional limitation, poorly fitting dentures or no dentures, or loss of appetite owing to depression or medications. Inquire about smoking and alcohol intake because both of these can increase the risk for both weight loss and malignancies.

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19. A 28-year-old male complains of fever of 101°F to 103°F for the last week. He reports fatigue, no appetite, sore throat, 7-pound weight loss in the last week, and two episodes of nosebleeds. The patient reports no medical problems and no current medications. Surgical history is tonsillectomy at 5 years old. Paternal family history of hypertension and diabetes; father alive at age 50. Maternal history: no significant disorders. Denies use of tobacco; occasional alcohol use on weekends. Denies unsafe sex. No recent travel. On review of systems, night sweats and dyspnea on exertion are noted. Which of the following should be considered in the differential diagnosis?

A. HIV infection B. Hematological malignancy C. Thrombocytopenia D. Tuberculosis ANS: B Many malignancies can cause fever, but lymphoma and leukemia should be at the top of the differential list. Acute leukemia is more common in children, and the chronic leukemias are more common in middle-aged to elderly adults. Hodgkin’s lymphoma is more prevalent in children and young adults, although the peak for incidence is bimodal and can be seen in patients over the age of 60. Non-Hodgkin’s lymphoma is more common in middle-aged to elderly adults. Burkitt’s lymphoma is more common in HIV patients. With leukemia, common symptoms include unexplained fever, easy bruising or bleeding, fatigue, bone or joint pain, and enlarged liver or spleen. With lymphoma, common symptoms include fatigue, fever, night sweats, lymphadenopathy, and weight loss.

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20. A 45-year-old female complains of recent weight gain, amenorrhea for 3 months, and bruising. No current medications. Medical and surgical history positive for cholecystectomy at age 41. On review of systems, the patient reveals hair growth on face, acne, and easy bruisability. Vital signs are: afebrile, pulse 80 beats/min, respirations 12 breaths/min, blood pressure 148/92. Physical examination shows abdominal obesity and striae over abdomen.

Which of the following questions is most helpful toward a differential diagnosis?

A. Have you used corticosteroids in the last month?

B. How much weight have you gained in the last 3 months?

C. Have you had any bleeding episodes, such as nosebleeds or gums bleeding?

D. Is cancer in the family history?

ANS: A Cushing’s disease is caused by excess cortisol and corticosteroid hormones, either endogenous or exogenous. Endogenous causes of cortisol hypersecretion include pituitary adenomas; other malignancies, such as small cell lung cancer; and adrenal tumors. Exogenous causes are related to the administration of steroids for the management of other chronic diseases. A thorough medical history will alert the practitioner to chronic diseases or medications that may be causing or contributing to the Cushingoid signs and symptoms. Although weakness can be profound because of the muscle wasting that occurs, it is generally not the first symptom that will bring the patient to the office. For women, it may be oligomenorrhea or amenorrhea and hirsutism, and for men, impotence. Patients develop a ―moon face‖ and ―buffalo hump‖ with central obesity and thin extremities. Hypertension and osteoporosis

develop over time. Purple striae around the thighs, breasts, and abdomen are characteristic of Cushing’s syndrome; they are prone to easy bruisability, acne, and skin infections with poor wound healing. Patients complain of excessive thirst and polyuria owing to glucose intolerance, and they are prone to renal calculi. Changes in mental health are common and range from mood swings to psychosis.

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21. Which of the following is/are diagnostic criteria for primary insomnia?

A. The sleep disturbance is defined as difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month B. The disturbance does not occur during the course of another mental disorder C. The sleep disturbance or associated daytime fatigue causes clinically significant distress or impairment in social, occupational, or other important areas of functioning D. All of the above ANS: D Insomnia has a multitude of causes, including age, menopause, chronic illness, pain, stress, anxiety, depression, poor sleep habits, endocrine disorders, or medications. The DSM-5 criteria for primary insomnia are as follows (American Psychiatric Association, 2013): 1. The sleep disturbance is defined as difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month.

2. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

3. The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia.

4. The disturbance does not occur exclusively during the course of another mental disorder (e.g., major depressive disorder, generalized anxiety disorder, a delirium).

5. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

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22. A 57-year-old female complains of fatigue, muscle weakness, palpitations, nervousness, and insomnia for the last few weeks. She thought she was just experiencing stress from her husband’s recent stroke 1 month ago. There are no current medications. Past medical history includes cholecystectomy at age 45; D&C at age 50. On physical examination, the patient is afebrile, pulse 102 beats/min, respirations18 breaths/min, blood pressure 156/98. Physical examination reveals tremulousness and quadriceps weakness bilaterally +4/5. Which of the following diagnostic tests is a priority in the work-up?

A. ACTH challenge test B. Thyroid-stimulating hormone C. Atrial fibrillation D. Fasting blood glucose

ANS: B Common signs and symptoms of hyperthyroidism include muscle weakness, nervousness, insomnia, tachycardia, increased sweating, moist skin, intolerance to heat, exophthalmos, weight loss, loose stools, hypertension, and hyperreflexia. In the elderly, the presenting symptom may be atrial fibrillation. Even though the physical examination may increase suspicions, measuring the thyroid hormones T3, free T4 and thyroid-stimulating hormone (TSH) confirms the diagnosis. The T3 and T4 levels are above normal, and the TSH level is below normal, sometimes to the point at which it is barely measurable.

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23. A 77-year-old female patient presents with increasing muscle weakness and numbness in both lower legs over the last week. She presents using crutches and with her daughter for walking assistance. The patient had influenza 3 weeks ago and was treated with amantadine.

The patient denies recent trauma. Current medications include a beta blocker and ACE inhibitor. She denies use of tobacco or alcohol. On physical examination, the patient is alert and oriented x 3, afebrile, pulse 66 beats/min, respirations 16 breaths/min, blood pressure 110/70. Neck: no jugular venous distention, no thyromegaly, no bruits over carotid arteries.

Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities: skin is pink, cool to touch, and intact bilaterally. Hand grip strength: 5/5 bilaterally. Biceps deep tendon reflex +2/4 bilaterally. Left and right quadriceps muscle strength 4/5. Patella reflex 1/4 bilaterally. Achilles reflex 1/4 bilaterally. Ankle strength R +3/5 and L +3/5. Sensation to pinprick and cotton ball intact in face and upper extremities and bilaterally equal. Sensation to pinprick and cotton ball decreased in feet bilaterally. Dorsalis pedis pulses +1/4 bilaterally. Negative Homan’s and Babinski’s signs. The following disorder(s) should be high priority in the differential diagnosis: A. Amyotrophic lateral sclerosis B. Guillain-Barré syndrome C. Polymyositis D. Multiple sclerosis ANS: B Guillain-Barré syndrome is an acute, rapidly progressive polyneuropathy that is often preceded by a virus, surgical procedure, or immunization. It is thought to have an immune etiology. Symmetric weakness and paresthesias are the main symptoms. The weakness usually begins in the legs and then proceeds to the arms. In addition to motor symptoms, patients often complain of distal paresthesias and neuropathic pain. Over 50% develop respiratory involvement, which may require mechanical ventilation. Autonomic dysfunction can occur in severe cases and can be fatal. The maximal degree of weakness usually occurs in the first 2 to 3 weeks. Most patients will recover, but approximately 20% will have persistent disability (Aminoff & Kerchner, 2014). Amyotrophic lateral sclerosis (ALS) actually belongs to a group of motor neuron diseases and is characterized by mixed upper and lower motor neuron deficits. ALS is characterized by muscle weakness and atrophy, usually starting in the hands and then progressing randomly and asymmetrically. Other common symptoms include muscle cramps, fasciculations, spasticity, dysarthria, dysphagia, and increased deep tendon reflexes.

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24. Which of the following assists in the diagnosis of myasthenia gravis?

A. Tensilon test B. Tinel’s sign C. McGill questionnaire D. ACTH challenge test ANS: A A highly sensitive test for the diagnosis of myasthenia gravis is the measurement of serum levels of circulating acetylcholine receptor antibodies. The Tensilon test is definitive and involves blocking acetylcholine by administering edrophonium chloride. If the patient has myasthenia gravis, the symptoms will temporarily worsen after the administration of edrophonium chloride. Because thymomas also can be present in these patients, a computed tomography scan of the chest should be performed.

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25. In which of the following dysrhythmias does the patient commonly complain of feelings of palpitations?

A. Supraventricular tachycardia B. Premature ventricular contraction C. Atrial fibrillation D. A and B ANS: D In atrial fibrillation, the symptoms generally depend on the ventricular response rate. The patient may be very symptomatic, with shortness of breath, decreased exercise tolerance, and fatigue, or may be completely asymptomatic. In supraventricular tachycardia, the rate is usually quite high, up to 200 beats per minute, and the patient is aware of palpitations. There may be accompanying complaints of shortness of breath and fatigue, particularly if the arrhythmia persists for any length of time. With bigeminy and trigeminy, patients are usually aware of palpitations or the sensation of missed beats. They may complain of shortness of breath and probably have more of a complaint of weakness or lightheadedness rather than fatigue.

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Chapter 17. Psychiatric Mental Health

MULTIPLE CHOICE

1. Which of the following statements is true regarding anxiety disorders?

A. Recent studies suggest that chronic anxiety disorders may increase the rate of cardiovascular-related mortality.

B. Women are 60% more likely than men to experience an anxiety disorder over their lifetime.

C. Men are 60% more likely than women to experience an anxiety disorder over their lifetime D. Approximately 50% of patients with anxiety present primarily with somatic complaints in primary care and emergency department settings.

ANS: B Women are 60% more likely than men to experience an anxiety disorder over their lifetime.

Both functional impairment and morbidity has been linked to anxiety disorders, and recent studies suggest that chronic anxiety disorders may increase the rate of cardiovascular-related mortality. Anxiety disorders often go unrecognized and untreated in primary care (Combs & Markman, 2014; Kroenke et al., 2007). Anxiety is an unpleasant feeling of apprehension, often accompanied by perspiration, palpitation, stomach discomfort, restlessness, difficulty sitting still, and even tightness in the chest. More than 90% of patients with anxiety present primarily with somatic complaints in primary care and emergency department settings (Stern, Herman, & Gorrindo, 2012).

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2. Patients with anxiety frequently complain of all of the following except: A. Chest pain B. Dizziness C. Generalized rash D. Chronic fatigue ANS: C More than 90% of patients with anxiety present primarily with somatic complaints in primary care and emergency department settings (Stern, Herman, & Gorrindo, 2012).

Patients may initially complain of only somatic symptoms before they are ultimately diagnosed with a primary anxiety disorder (DeVane et al., 2005). Patients with anxiety often present with the following symptoms: chest pain (with negative angiogram), irritable bowel, unexplained dizziness, migraine headache, and chronic fatigue.

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3. Which of the following statements is not true regarding phobia?

A. The anxiety associated with phobia is out of proportion to the actual danger or threat in the situation.

B. Diagnosis is based on the presence of symptoms for at least a 6-week duration.

C. Persons with phobias have apprehension of a future attack, which is referred to as anticipatory anxiety.

D. Diagnosis is made at any age.

ANS: B The anxiety involved in phobia must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account. Diagnosis is based on the presence of symptoms for at least a 6-month duration, regardless of age, to minimize overdiagnosis of transient fears. Panic attacks are discrete episodes of intense anxiety that peak within 10 minutes and are associated with autonomic arousal. After an initial panic attack, apprehension of a future attack often occurs and is referred to as anticipatory anxiety.

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4. Which of the following is true about separation anxiety?

A. It is a fear mainly expressed by children and adolescents under age 18.

B. It is a fear limited to children under age 8.

C. A duration of 6 weeks is required to minimize overdiagnosis of transient fears.

D. A and C ANS: A While separation anxiety has historically (through DSM-IV) been classified in the section ―Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,‖ it is now classified as an anxiety disorder, recognizing the expression of anxiety symptoms in adulthood. Previously, the diagnostic criteria included onset before age 18; however, a substantial number of adults report onset of separation anxiety after age 18. For example, attachment figures may include the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school. A duration of 6 months is required to minimize overdiagnosis of transient fears (e.g., when a new parent returns to work and places an infant in the care of another).

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5. In obsessive-compulsive disorder, a common obsession: A. Is that of contamination and washing or avoidance of a particular object that is contaminated B. Involves repetitive behaviors in response to preoccupations with perceived flaws in physical appearance C. Is a marked fear of being the center of attention or behaving in a way that will result in embarrassment or humiliation D. None of the above ANS: A

Obsessive-compulsive disorder is defined by obsessions (recurring thoughts) and compulsions (recurrent actions) over which the patient has little or no control. These defining characteristics interfere with functioning and may cause embarrassment. The most common obsession is that of contamination and washing or avoidance of a particular object that is contaminated. Another common obsession is self-doubt, associated with repeatedly checking to see that routine safety chores are done. Body dysmorphic disorder involves repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance. Social anxiety disorder (formerly called social phobia) is characterized by a marked fear of being the center of attention or behaving in a way that will result in embarrassment or humiliation.

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6. Which of the following medications may cause depression in some individuals?

A. Allopurinol B. Statin anti-lipidemia drugs C. Levodopa D. Retin-A ANS: C Drugs That Can Cause Depression • Antihypertensives (reserpine, propranolol, methyldopa, guanethidine monosulfate, and clonidine hydrochloride) • Corticosteroids and hormones (cortisone acetate, estrogen, and progesterone) • Antiparkinsonian drugs (levodopa and carbidopa, amantadine hydrochloride) • Antianxiety drugs (diazepam, chlordiazepoxide) • Accutane • Birth control pills PTS: 1

7. All of the following are true regarding depression except: A. It is associated with a 25% lifetime prevalence B. There is a 50% risk of recurrence after one episode C. There is a 70% risk of recurrence after two episodes D. All of the above are true ANS: A There is a 5% to 11% lifetime prevalence for depression; morbidity is comparable to angina and advanced coronary artery disease. The risk of recurrence of depression is 50% after one episode, 70% after two episodes, and 90% after three episodes.

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8. What percentage of patients who commit suicide have depressive illness?

A. 100% B. 90% C. 70% D. 50% ANS: C Untreated and undertreated depression significantly increases the risk of suicide. One out of seven people with recurrent depressive illness commit suicide. Seventy percent of suicides have depressive illness and 70% of suicides see their primary care provider within 6 weeks of suicide. Suicide is the seventh leading cause of death in the United States (Stahl, 2013).

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9. Depression can cause the following physiological changes: A. Lack of appetite or overeating B. Avolition or agitation C. Insomnia or hypersomnia D. All of the above ANS: D Depression can present in a variety of ways, and the cluster of symptoms can vary markedly from one individual to the next. For example, depression may cause severe sleep disturbance for one individual and hypersomnia in another. Some individuals with depression complain of weight gain, whereas others lose weight because they find it hard to eat. Avolition is a common presenting feature in depression, but some individuals experience restlessness and agitation.

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10. Abuse of alcohol or street drugs is a frequent cause of: A. Mania B. Obsessive-compulsive disorder C. Depression D. Hypomania ANS: C As with other mental health assessments, psychiatric history and history of alcohol and/or drug use should always be elicited; they are commonly associated with depression. What appears to be major depression may actually be a result of alcohol or street drug use (Shea, 1998).

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11. It is widely recognized that bereavement-associated depression can last for up to: A. 6 months B. 1 year C. 2 years D. 5 years ANS: C It is recognized that the duration for bereavement is more commonly 1 to 2 years.

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12. In bereavement-associated depression: A. Antidepressant medications usually do not provide relief B. The same antidepressants used for nonbereavement depression can provide relief C. Only SSRI antidepressants can provide relief for grieving individuals D. Only TCA antidepressants can provide relief for bereaved individuals ANS: B The depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as nonbereavement-related depression.

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13. Clinical depression with mixed features: A. Indicates at least three manic symptoms coexist with a major depressive episode B. Is more prevalent in older adults than adolescents and young adults C. Decreases the likelihood that the illness exists in a bipolar spectrum D. All of the above ANS: A The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier ―with mixed features.‖ The presence of mixed features in an episode of major depressive disorder increases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of major depressive disorder is retained. Mixed episodes are more prevalent in adolescents and young adults than in older adults.

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14. A manic episode is a distinct period of a persistently elevated, expansive, or irritable mood lasting at least: A. 1 week B. 2 weeks

C. 3 months D. 6 months ANS: A Bipolar disorder is a cluster of disorders that reflect a marked flux in mood. A manic episode is a distinct period of a persistently elevated, expansive, or irritable mood lasting at least 1 week. This mood must coexist with at least three of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences.

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15. Hypomania is different from mania in that: A. Hypomania does not cause impaired social or occupational functioning B. Hypomania requires hospitalization C. Mania can endure for a longer period of time than hypomania D. All of the above are true ANS: A Hypomanic episodes differ from manic episodes in the degree of severity. Hypomanic episodes are not usually sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization (APA, 2013). They may, however, evolve into fully manic episodes. The mnemonic DIG FAST is helpful for remembering the critical criteria for mania (see Box 17.11).

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16. High distractibility or leaving projects unfinished is characteristic of: A. Hypomania B. Mania C. Obsession D. Cyclothymic disorder ANS: B A manic episode is a distinct period of a persistently elevated, expansive, or irritable mood lasting at least 1 week. This mood must coexist with at least three of the following symptoms: inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences. Hypomanic episodes differ from manic episodes in the degree of severity. Hypomanic episodes are not usually sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization (APA, 2013).

They may, however, evolve into fully manic episodes. The mnemonic DIG FAST is helpful for remembering the critical criteria for mania (see Box 17.11).

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17. In order to diagnose an individual with bipolar 1 syndrome, the clinician should look for episodes of: A. Irritability and rage B. Grandiosity and high self-esteem C. Rapidly alternating moods D. None of the above ANS: C Bipolar 1 disorder is characterized by the occurrence of one or more manic episodes or mixed episodes. Mixed episodes are characterized by a period of time (lasting at least 1 week) in which the criteria are met both for manic episode and major depressive episode nearly every day. Social and/or occupational functioning are severely impaired as the individual experiences rapidly alternating moods (APA, 2013).

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18. It is a psychiatric emergency if a patient confides in you that: A. There are no reasons for him to keep from dying B. He is having episodes of elation and increased energy C. He is experiencing free floating anxiety and fear D. Death and dying is constantly on his mind ANS: A Completed suicides occur in 10% to 15% of individuals with bipolar 1 disorder. Suicide ideation and attempts are more likely in the depressive or mixed state (APA, 2013).

Therefore, suicide risk should always be assessed in a psychiatric evaluation. Box 17.12 lists several questions for assessing suicide risk. If the responses identify a detailed plan for ending life, a lack of hope that things can be better in the future, or an inability to identify reasons for not dying (such as not wanting to leave loved ones), it is considered a psychiatric emergency, requiring immediate intervention.

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19. In bipolar 2 disorder, individuals: A. Do not experience depression B. Do not experience manic episodes C. Have episodes of elation and high energy D. Do not experience hypomania ANS: B

Bipolar 2 disorder is determined when the clinical course includes one or more major depressive episodes and at least one hypomanic episode. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (APA, 2013). To meet the bipolar 2 criteria, the individual has not experienced a manic or mixed episode.

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20. For premenstrual dysphoric disorder the clinician should: A. Give the patient a trial of an SSRI to see if it relieves symptoms B. Recognize that oral contraceptives can relieve symptoms C. Ask the patient to keep a diary of mood and menses for 2 months D. Diagnose the disorder only if the patient exhibits psychotic symptoms ANS: C Premenstrual dysphoric disorder (PMDD) is characterized by recurrent symptoms that occur during the luteal phase of the menstrual cycle and remit during menstruation. Even though many women express mood changes and other symptoms during the premenstrual phase, 5% to 9% fully meet the criteria for PMDD. Differential diagnosis includes bipolar disorder, thyroid dysfunction, premenstrual syndrome, exacerbation of unipolar depression, anxiety disorder, and cyclothymic disorder. Careful tracking of symptoms for at least 2 months is advised to determine a diagnosis of PMDD (Box 17.13).

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21. Which of the following mental health disorders commonly affects substance abusers?

A. Obsessive-compulsive disorder B. Antisocial personality C. Mania D. None of the above ANS: B Comorbidity with other psychiatric conditions is high in substance abusers. Antisocial personality disorder is present in a high percentage (35% to 60%) of patients presenting for treatment of substance abuse and dependence. Other psychiatric disorders associated with substance-related disorders include mood disorders and anxiety disorders.

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22. Eating disorders are driven by: A. Perfectionism B. Heightened sense of power C. Obsessive-compulsive disorder D. Chronic depression

ANS: A As explained in Schwitzer and colleagues (2001, 158), eating disorders are driven by ―(1) perfectionism regarding body image, romantic and other personal relationships, and grades; (2) a fragile sense of self, feelings of inadequacy, and a need to be bolstered by others; (3) self-doubt expressed as sexual intimacy questions and ambivalence about whether one is thin enough to attract a romantic partner and whether one should want to please a partner at all; and (4) a sense of powerlessness in intimate relationships and the world generally.‖ PTS: 1

23. Individuals with anorexia are below ____ of the normal weight for their height, which is not attributed to a medical condition.

A. 25% B. 50% C. 85% D. 100% ANS: C Individuals with anorexia are below 85% of the normal weight for their height, which is not attributable to a medical condition. Normal weight can also be determined by a body mass index equal to or below 17.5 kg/m2 (APA, 2013).

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24. A significant physical finding in females with anorexia is: A. An irregular menstrual cycle or amenorrhea B. Hair loss C. Ascites D. Esophageal tear ANS: A While the restricting pattern is more common in anorexia, binge-purge behavior may also exist. Although purging may follow a binge episode, purging may also be used even after the consumption of small amounts of food. A significant physical finding in anorexia is an irregular menstrual cycle or amenorrhea.

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25. Which of the following questions is not used to diagnose an individual with anorexia?

A. ―Do you think your current weight is normal or excessive?‖ B. ―Do you think that any part of your body is still too fat?‖ C. ―Do you have concern or fear about gaining weight even though you are underweight?‖ D. "Do you want to gain weight?"

ANS: D Box 17.14 Questions to Screen for Anorexia 1. ―Do you think your current weight is normal or excessive?‖ 2. ―Do you think that any part of your body is still too fat?‖ 3. ―Do you have concern or fear about gaining weight even though you are underweight?‖ PTS: 1

26. Individuals with bulimia are commonly: A. Overweight B. Normal weight C. Underweight D. Obese ANS: B Individuals with bulimia are usually within the normal range for weight. The essential features of bulimia nervosa are binge eating and the use of inappropriate compensatory methods to prevent weight gain, such as vomiting or purging.

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27. Individuals with bulimia commonly have: A. Hypernatremia B. Loss of teeth enamel C. Enlarged cervical lymph nodes D. All of the above ANS: B A feature of bulimia is an inability to control binges. Individuals with bulimia have a high degree of dissatisfaction with appearance and often have low self-esteem. Physical findings may be a noticeable loss of dental enamel on the lingual surfaces of the front teeth as a result of recurrent vomiting. Teeth may become chipped, and there may also be an increase in dental cavities. The parotid glands may also be enlarged. Calluses or scars may be noted on the dorsal surface of the hand from inducing vomiting. If the dominant hand is used, calluses or scars may be evident on only that hand. There may be electrolyte imbalances—frequently hypokalemia, hyponatremia, and hypochloremia.

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28. To diagnose a patient with binge eating, a binge is defined as occurring at least: A. Once a week for 3 months.

B. Twice a week for 6 months C. Three times a week for 3 months

D. At least 12 times in a year ANS: A Binge eating is often done alone, is not associated with hunger, and is done to the point of feeling uncomfortable. The minimum average frequency of binge eating required for diagnosis is once weekly over the past 3 months (compared to at least twice weekly for 6 months in DSM-IV). Patients present as overweight with marked distress associated with the binge episodes.

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29. A schizoaffective disorder is characterized by: A. Mood component coexisting with the schizophrenic symptoms B. Thought disorder that comes and goes C. Psychotic disorder with substance abuse D. Schizophrenia with auditory and visual hallucinations ANS: A In schizophrenia, psychotic features are evident with two or more of the following characteristics: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. The last of these characteristics, negative symptoms, refers to affective flattening, poverty of speech, avolition, anhedonia, and social isolation. Schizophrenia subtypes include paranoid, disorganized, catatonic, undifferentiated, and residual. Differential diagnoses include schizophreniform disorder, characterized by schizophrenic symptoms of 1 to 6 months; schizoaffective disorder, characterized by a prominent mood component coexisting with the schizophrenic symptoms; delusional disorder, characterized by at least 1 month of no bizarre delusions without an active phase of symptoms of schizophrenia; brief psychotic disorder, characterized by symptoms that last more than 1 day but remit by 1 month; and substance-induced psychotic disorder, characterized by symptoms directly related to an abused substance, toxin, or medication.

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30. It is important for the clinician to recognize that elderly patients may present with drug-induced psychosis, particularly with: A. Beta blocker drugs B. Anticholinergic drugs C. Antibiotics D. Antiviral agents ANS: B

In addition to street drugs or commonly abused drugs, anticholinergic agents can precipitate delirium, especially in elderly patients. Anticholinergic medications can cause a patient to present with hyperthermia, blurred vision, dry skin, facial flushing, and delirium. The mnemonic ―hot as a pepper, blind as a bat, dry as a bone, red as a beet, and mad as a hatter‖ can be used to describe this toxic state (Shea, 1998). It is important to note that anticholinergic syndrome may be incomplete or hidden by other medications, such as opiates, and not present as a classic anticholinergic syndrome.

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Chapter 18. Pediatric Patients

MULTIPLE CHOICE

1. When examining an infant, the clinician should recognize that separation anxiety is normal behavior in an infant as early as: A. 2 months B. 4 months C. 6 months D. 12 months ANS: C Infants are in the midst of the developmental stage of trust and mistrust, so they should be approached slowly. Be prepared for stranger anxiety in an infant of 6 to 7 months and for separation anxiety in an infant just slightly older. Owing to these normal fears, it is best to conduct most, or all, of your examination with the infant on the parent’s lap.

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2. In infants and toddlers, it is recommended to perform the physical examination: A. In head-to-toe sequence B. In noninvasive-to-invasive sequence C. On the parent’s lap D. B and C ANS: D Allow toddlers to touch or hold some of your equipment before you begin the physical examination. Demonstrate what you are going to do on a doll, stuffed animal, or parent before doing it on the child. Use distraction as much as possible, and give the child choices when they exist, such as, ―Which ear should I look in first?‖ Be direct but friendly—tell the child what you are going to do instead of asking permission. At this age, continue to conduct as much of the examination as you can with the child on a parent’s lap, working from noninvasive to invasive procedures.

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3. With school-age children, the examiner should: A. Use a head-to-toe sequence B. Explain everything they plan to do in detail C. Allow them to hold and look over the equipment D. A and C ANS: D School-age children generally want to be brave and cooperate, although they still fear pain and the loss of control. They often ask lots of questions and are curious about using your equipment. Allow them to examine the equipment and provide concrete answers to their questions whenever possible because children at this age become very logical. Teach them the proper names for equipment and body parts. Modesty may begin to appear in this age group, so be sensitive to this. A head-to-toe sequence is possible for this age.

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4. When examining adolescents, it is important to recognize: A. They might want the examination to be private from their parents B. Normalcy and fitting in is usually an important subject C. That a physical examination is an opportunity to do some health teaching D. All of the above ANS: D Adolescents are at the height of trying to fit in and be ―normal.‖ They worry about how they stack up alongside their peers and may have concerns about their physical appearance, including their height, weight, or the presence of acne. They are striving to be independent and fear the loss of control and possibly even death. Privacy is very important at this age, so offer to examine the child without the parent unless the child prefers it otherwise. Remember to keep body parts covered when you are not examining them. Explain each step of your examination, and give the child a chance to ask questions or make choices as you progress.

Be very nonjudgmental and talk professionally but casually with them. Teach adolescents about their bodies and stress the normalcy of their features and appearance.

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5. It is important for the clinician to examine head circumference in infants/children up to age: A. 1 year B. 2 years C. 3 years D. 4 years ANS: B

The head circumference should be measured at all well visits up to 2 years of age to assess for macro- or microcephaly. Assess the head symmetry and look for plagiocephaly. For the fontanel to be accurately assessed, the child should be sitting upright and not crying. Some variants that might be noted in newborns include the following: • Caput succedaneum: Seen at birth, usually following a traumatic vaginal delivery or vacuum-assisted delivery; edema of the soft tissue of the scalp that usually crosses the suture lines; no specific treatment; should resolve in a few days • Cephalohematoma: Often appears several hours after birth and may increase for the first 24 hours; subperiosteal collection of blood that does not cross the suture lines; may take weeks to months to resolve; watch for hyperbilirubinemia.

Red Flags for the Head Examination • No growth in head circumference between well visits.

• Enlarged head size or excessive growth between well visits.

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6. It is important to examine the infant’s anterior fontanel when the child is: A. Lying supine B. Relaxed and sitting up C. Lying prone D. Standing with assistance ANS: B When assessing pediatric patients, remember to ask about head trauma, head growth, and the history of headaches. The head circumference should be measured at all well visits up to 2 years of age to assess for macro- or microcephaly. Assess the head symmetry and look for plagiocephaly. For the fontanel to be accurately assessed, the child should be sitting upright and not crying.

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7. In infants, the following is a serious examination finding: A. Lack of red reflex B. Eyelid telangiectasia C. Delayed pupillary reaction D. A and C ANS: D Red Flags for the Eye Examination • Presence of white instead of red reflex may indicate retinoblastoma; an absent red reflex or opacity of the lens may indicate cataracts • Dilated and fixed pupils, which indicate severe brain damage • Strabismus, which requires referral to ophthalmology for further evaluation Some variations that may be noted in newborns include the presence of ―stork bites‖ (telangiectatic nevi) on the eyelids, nasolabial area, or nape of the neck; they appear as a purplish-red color and generally diminish and/or disappear by 12 months of age

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8. How should the clinician examine the ear canal in an infant?

A. Pull the auricle down and out B. Pull the auricle up and back C. First in the sequence of a physical examination D. Child should be lying in prone position ANS: A The otoscopic examination is described in detail in Chapter 6 (Ear, Nose, Mouth, and Throat). The otoscopic examination should be saved for last in infants and young children because of the distress it often causes. To examine the inner ear in an infant or young child, pull the pinna down and out. For examination in an older child, pull up and back as you would with an adult.

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9. What assessment technique should be used to assist in the diagnosis of otitis media in a child?

A. Cotton tip applicator to gather sample for culture B. Curettage removal of cerumen C. Pneumatic otoscopy D. Hearing evaluation ANS: C The otoscopic examination is described in detail in Chapter 6 (Ear, Nose, Mouth, and Throat). The otoscopic examination should be saved for last in infants and young children because of the distress it often causes. To examine the inner ear in an infant or young child, pull the pinna down and out. For examination in an older child, pull up and back as you would with an adult. As with adults, the tympanic membrane (TM) should be mobile and intact and should appear thin, smooth, and pearly gray with bright light reflexes. The mobility of the TM should be assessed by pneumatic otoscopy if a diagnosis of acute otitis media is expected. Although crying will cause erythema of the TMs, the light reflexes and mobility should remain intact. Diagnosis of acute otitis media should not be based solely on a reddened TM. Also observe for bubbles or an obvious fluid level line behind the TM, which indicates middle ear effusion.

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10. It is important for the clinician to recognize that a patent ductus arteriosus, which directs the fetal bloodstream from pulmonary artery to aorta, does not close until: A. Day 4 after birth B. 1 week after birth

C. 2 weeks after birth D. 1 month after birth ANS: A In newborns, innocent murmurs are common and are usually systolic, grade 1 or 2, and are not associated with other symptoms. The transition period from fetal to maternal conditions may take 48 hours. Patent ductus arteriosus is a fetal vascular connection that directs blood from the pulmonary artery to the aorta. It typically closes by day 4 following birth. However, if it remains patent, the direction of blood flow is reversed through the ductus, owing to the higher pressure in the aorta. Clinical findings in a newborn with a still-patent ductus arteriosus include diaphoresis (especially during feedings) and poor feedings with easy tiring that may result in failure to thrive.

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11. To examine the abdomen of a ticklish child, the clinician can: A. Leave the abdomen examination for last B. Use the child’s smaller hand under your own to palpate the belly C. Distract the child by handing them a doll or toy D. B and C ANS: D To aid in the abdominal assessment of a ticklish child, have the child lie with knees bent or use the child’s smaller hand under your own to palpate the belly. It is also helpful to engage the child in conversation to provide distraction from what you are doing.

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12. Which of the following is a serious symptom in a feverish child?

A. Teary eyes B. Projectile vomiting C. Lack of appetite D. Diarrhea ANS: B Projectile vomiting is commonly a sign of increased intracranial pressure in a child.

Increased intracranial pressure is present in meningitis.

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13. Which of the following is an abnormal finding in a male child?

A. Gynecomastia during puberty B. Undescended testicles at 3 months C. Enlarged scrotum during infancy

D. None of the above ANS: D Observe the location of the urethral meatus. Hypospadias is a congenital defect that causes the meatus to be on the ventral surface of the penis, and epispadias results in dorsal placement of the meatus. Palpate the scrotum for the presence of testes; cryptorchidism is the term for an undescended testicle. If the testes are not immediately palpable in the scrotum but can be ―milked‖ down into the scrotum, consider them descended. If one or both testes are undescended at 1 year of age, referral to a specialist is indicated. Male newborns frequently have an enlarged scrotum as a normal finding. Gynecomastia may be normal in males during puberty. It usually occurs during Tanner stages 2 and 3 and may last up to 2 years. Gynecomastia typically presents as a small, tender oval mass directly under the areola that may measure up to 2 to 3 cm.

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14. To assess a newborn for hip dislocation, the following physical assessment technique is used: With the infant supine, place fingers posteriorly over the greater trochanter, flex the hip 90 degrees, and abduct the thigh while pushing up with the fingers. Feel for a clunk and palpable jerk as the femur is relocated. Do the maneuver gently on an infant who is not crying. This is called: A. Barlow’s maneuver B. Ortolani’s maneuver C. Galeazzi’s maneuver D. Hallpike maneuver ANS: B Table 18.2 Special Maneuvers Barlow’s Maneuver (see Fig. 18.1) Dislocates a dislocatable hip posteriorly. With the infant supine, flex the hip, adduct the thigh, and feel for a palpable dislocation. As the thigh is adducted, the femoral head drops (or can be gently pushed) out of the acetabulum. Do the maneuver gently on an infant who is not crying.

Ortolani’s Maneuver (see Fig. 18.2) Reduces a posteriorly dislocated hip. With the infant supine, place fingers posteriorly over the greater trochanter, flex the hip 90 degrees, and abduct the thigh while pushing up with the fingers. Feel for a clunk and palpable jerk as the femur is relocated. Do the maneuver gently on an infant who is not crying.

Galeazzi’s Maneuver (see Fig. 18.3) Assesses knee height for equality. With the infant supine, flex the hips and knees, and place the soles of the child’s feet on the table near the buttocks. Observe the knees for equal height. The sign is considered positive if the knee heights are unequal. A dislocatable hip will fall out of socket in this position and will cause the knee on the affected side to appear lower.

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15. Which of the following stances is normal in a toddler?

A. Genu varum B. Genu valgum C. Lordosis D. A and C ANS: A Observe a child’s gait during well examination. Toddlers commonly walk with a wide-based gait and a bowlegged (genu varum) appearance. A knock-kneed (genu valgum) appearance is common in preschoolers. Assessment for scoliosis (a lateral curvature of the spine) should be performed at each well visit starting at age 10. With the child standing straight and arms at his or her side, observe for equal shoulder height. While the child bends forward, assess for curvature of the spine, as well as rib humps. If abnormal findings are present, radiographs should be obtained for confirmation and to guide possible referral. Both the age of the child and the degree of the curve will guide treatment, if any. Scoliosis is more worrisome in a child who is prepubertal because there is more growth to occur and, therefore, more time for a curve to worsen.

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16. Which of the following is abnormal in a 2-year-old child?

A. Walking on toes B. Bowed leg stance C. Click heard on hip abduction D. All of the above ANS: A Red Flags for the Musculoskeletal Examination • Refusal to bear weight or walk • Refusal to use or bend an arm • Heat, redness, and/or swelling of one or more joints • Hip clunks • Toe walking—can be a normal phase and also can be associated with cerebral palsy, tight heel cords, autism, or muscular dystrophy PTS: 1

17. Which of the following indicates abnormal behavior in a 12-month-old child?

A. No imitating B. No babbling C. Inability to walk independently D. Short attention span ANS: B

Red Flags for Autism • No big smiles or expressions of happiness by 6 months • No back and forth sounds, gestures, or facial expressions by 9 months • No babbling by 12 months • No pointing, waving, or reaching by 12 months • No words by 16 months • No two-word phrases by 24 months (without imitating) • Any language regression or unusual use of language PTS: 1

18. Criteria for diagnosing attention deficit-hyperactivity disorder in a child include attention problems that: A. Have been present before the age of 12 B. Have been present for at least 6 months C. Are present in at least two settings D. All of the above ANS: D Attention deficit-hyperactivity disorder (ADHD) is a neurobehavioral disorder that affects an estimated 5% to 10% of the school-age population. Its main symptoms are inattention with increased distractibility, poor impulse control, and motor restlessness and hyperactivity. There are three subtypes of ADHD: The predominantly inattentive type of ADHD is more common in females, and the predominantly hyperactive-impulsive type and combined type are more frequently diagnosed in males. When assessing a child for ADHD, it is important to ascertain the degree of symptoms, as well as when they were first noticed and in what settings they are present. It is also important to remember that many children with ADHD have comorbid psychiatric diagnoses.

According to the DSM-5, a child with ADHD must exhibit behavior that is developmentally inappropriate and clearly interferes with the quality of social, school, and/or work functions.

The behavior must also meet the following criteria: • Has been present before the age of 12 • Has been present for at least 6 months • Is present in at least two settings • Is not related to another disorder PTS: 1

19. Which of the following is true regarding concussion in a child?

A. A concussion causes loss of consciousness B. The effects of more than one concussion are cumulative C. The child with concussion can return to sports after 24 hours D. None of the above ANS: B

Symptoms of a concussion can vary, and some may be quite subtle, so it is important to conduct a full interview and examination when there is concern for this type of injury. Almost 90% of children with a concussion will complain of headache. There may also be complaints of light or noise sensitivity, nausea, and fatigue. It is not uncommon for these children to be very tired at the end of a school day. They may also be more irritable and have trouble with cognition, memory, and/or sleep.

The most important thing when caring for a patient suspected of having a concussion is to prevent another head injury. This means that the child who plays sports must stay off the field and out of the game until fully recovered. He or she may also need time away from school, and there may be restrictions on using electronics and reading. The trend in concussion management is leading toward a multidisciplinary approach in which primary care providers, neuropsychologists, and school athletic trainers work together to assess the child often and initiate a return-to-play plan. Children who have experienced a concussion need close follow up to ensure they are symptom free, both during exertion and while at rest, before resuming activities and sports. It is not uncommon for full recovery to take many weeks. Any child or adolescent experiencing a repeat concussion within 1 year’s time will take even longer to recover fully. Research has shown that the effects of concussions are cumulative, so rest and recovery are crucial to preventing brain injury and long-term effects on memory and cognition.

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20. When performing dermatological examination, the clinician should recognize that a flat darkened area of skin in the sacral region is called: A. Spina bifida occulta B. Mongolian spot C. Nevus flammeus D. Café au lait spot ANS: B When evaluating the skin of a child, ask about birthmarks, lesions, and skin conditions.

Common birthmarks are: • Stork bites commonly appear on eyelids, nasolabial area, or nape of neck, and usually disappear by 12 months.

• Nevus flammeus (port-wine stain) is pinkish-red in color and grows as the child grows.

• Strawberry nevus (raised hemangioma) may not be present at birth; it usually starts out as a grayish-white area and later becomes red and raised; most resolve spontaneously by age 10.

• Mongolian spots are usually seen in newborns of African American, Latin, or Asian descent; they are generally found in the sacral or gluteal region.

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21. The skin lesion that is infected with Methicillin-resistant staphylococcus resembles a(n):

A. B. C. D.

Insect bite Blister Benign mole Café au lait spot

ANS: A The incidence of community-acquired Methicillin-resistant staphylococcus aureus (MRSA) has been on the rise and is now managed quite frequently in the primary care setting. In children, a common presentation is a small bump that may resemble a bug bite and then quickly enlarges and turns into a pustule. In infants, this is commonly seen in the diaper area, but it can occur anywhere. A culture and sensitivity should be obtained on any questionable lesions or abscesses to confirm diagnosis.

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22. Which of the following is true regarding growth and development of a child?

A. Average head circumference of an infant under 6 months is 13 to 14 inches.

B. The head circumference generally increases by a half inch per month during the first 6 months.

C. A child’s weight typically doubles by 4 to 6 months.

D. All of the above ANS: D The following trends are generalizations that can be used as rules of thumb in assessing pediatric growth and development. An average American newborn weighs around 7 pounds and is 20 to 21 inches long. The average head circumference of an American newborn is 13 to 14 inches, with a chest circumference of 2 cm less than that of the head. The head circumference generally increases by a half inch per month during the first 6 months of life and a quarter inch per month during the second 6 months.

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23. Which of the following statements is true regarding the average child’s growth and development?

A. A child’s weight typically triples at a year.

B. A child’s weight typically quadruples by age 2.

C. During the puberty growth spurt, females gain approximately 38 pounds, males 42 pounds.

D. All of the above ANS: D Up to an initial 10% loss of weight can be expected in the first 3 to 4 days of life. This is typically regained by 2 weeks of age. Thereafter, a child’s weight typically doubles around 4 to 6 months, triples at a year, and quadruples around age 2. During the first 6 months of life, a baby gains 5 to 8 ounces a week. Between 6 and 12 months, this decreases to 3 to 5 ounces a week. During the second year of life, a child gains 8 to 9 ounces a month. Toddlers and

preschoolers gain 4.5 to 6.5 pounds a year. A school-age child gains 5 to 6 pounds a year.

During the pubertal growth spurt, an average American female gains 38 pounds, and an average male gains 42 pounds.

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24. Which of the following statements is true regarding growth and development of an infant?

A. At 2 weeks, an infant should be lifting the head while lying prone.

B. An infant should smile and respond to mother at 1 month.

C. The infant should roll over by 6 months.

D. The infant should sit independently by 3 months.

ANS: C See Table 18.5 for normal behaviors of first year of life.

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25. Which of the following is false regarding newborn reflexes?

A. When startled, a newborn should exhibit the Moro reflex.

B. Stroking the cheek of a newborn should elicit a rooting reflex.

C. A newborn’s dominant hand palmar grasp is stronger than the nondominant hand grasp.

D. A newborn should have a strong suck reflex at birth.

ANS: C See Table 18.3 regarding newborn reflexes.

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26. Which of the following should warrant further investigation?

A. A 9-month-old child does not interact with another person B. The infant does not stand up by 12 months C. The infant does not smile at 2 months D. A and B ANS: D See Table 18.6 regarding red flags in newborn development.

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27. By what age should the normal child put together a sentence when speaking?

A. 1 year

B. 18 months C. 2 years D. None of the above ANS: C See Table 18.7 regarding toddler milestones.

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28. What age is the child who is in the ―do it myself‖ stage?

A. 18 months B. 2 years C. 3 years D. 4 years ANS: B See Table 18.7 regarding toddler milestones.

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29. At what stage does a child develop a sense of self-worth?

A. Toddler B. Preschool C. School age D. Adolescence ANS: C See Table 18.9 regarding school-age milestones.

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30. Assessing hearing ability is important early in the course of child development. The clinician should recognize that if a child does not speak with some recognizable words by age ____________, audiometry testing should be done.

A. 12 months B. 18 months C. 2 years D. 3 years ANS: B See Table 18.4.

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31. It recommended that a child use a car seat until ______________________.

A. 8 years old or 80 lbs B. 7 years old or 70 lbs C. 6 years old or 60 lbs D. 5 years old or 50 lbs ANS: A See Table 18.2.

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32. At what age range should a mother begin feeding the child solid food, such as rice cereal?

A. 3 to 4 months B. 5 to 6 months C. 6 to 7 months D. 7 to 8 months ANS: B See Table 18.2.

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33. By what age is a child usually toilet trained?

A. 1 to 2 years B. 2 to 3 years C. 3 to 4 years D. 4 to 5 years ANS: C See Table 18.2.

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34. At what age do the baby teeth start to erupt in the majority of children?

A. 3 months B. 4 months C. 5 months D. 6 months ANS: D See Table 18.13.

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35. What is the minimum daily calcium requirement for adolescents?

A. 1,200 mg/day B. 1,300 mg/day C. 1,400 mg/day D. 1,500 mg/day ANS: B 12- to 14-year-old males need approximately 60 kcal/kg–1/day–1, whereas females at this age need 45 to 50 kcal/kg–1/day–1. At age 15, daily caloric intake decreases to 40 to 45 kcal/kg–1/day–1 for males and 35 to 40 kcal/kg–1/day–1 for females. Daily calcium intake during adolescence should be a minimum of 1,300 mg per day.

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Chapter 19. Pregnant Patients

MULTIPLE CHOICE

1. Estimated date of delivery is calculated by: A. Adding 7 days to the date of the last menstrual period and subtracting 3 months B. Adding 9 months to the date of the last menstrual period C. Most accurately by ultrasound examination D. A and C ANS: A An estimated date of delivery (EDD) is projected at this time by using the date of the last menstrual period (LMP). This estimation can be made either with a pregnancy wheel or calculator, or by applying Naegele’s rule of adding 7 days to the first day of the LMP and then subtracting 3 months (Cunningham et al., 2010). This method of estimating the EDD depends on the woman having regular menstrual cycles of 28, plus or minus 7 days. If the EDD cannot be accurately estimated by Naegele’s rule, an early ultrasound is recommended because of the linkage of specific prenatal interventions with gestational dating of the pregnancy. The EDD should be updated throughout the pregnancy for confirmation of dates by determining when quickening occurs, when fetal heart tones (FHTs) are first auscultated, when the fundal height is at the umbilicus, and, most accurately, through an ultrasound estimation at 16 to 20 weeks.

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2. An ultrasound should be performed on all pregnant women at: A. 5 to 6 weeks B. 10 to 12 weeks

C. 16 to 20 weeks D. None of the above ANS: C The estimated date of delivery should be updated throughout the pregnancy for confirmation of dates by determining when quickening occurs, when fetal heart tones are first auscultated, when the fundal height is at the umbilicus, and, most accurately, through an ultrasound estimation at 16 to 20 weeks.

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3. A reproductive history is recorded in terms of gravida and para, which indicates: A. Number of times pregnant and number of pregnancies beyond 20 weeks B. Number of times pregnant and number of spontaneous or medically induced abortions C. Number of live births and number of times pregnant D. Number of times pregnant and number of vaginal births ANS: A The reproductive history includes an obstetric history consisting of the number of pregnancies and their outcomes using the gravida–para–TPAL nomenclature (Table 19.1).

This portion of the history also includes the year of each pregnancy, infant birth weight, gestational age at birth, type of delivery (vaginal or cesarean), length of labor, anesthesia received, and any maternal or fetal complications during the pregnancy. Gravida indicates the number of pregnancies. Para indicates the number of pregnancies that surpassed 20 weeks. In TPAL, T indicates term pregnancies, P indicates premature births, A indicates abortions (spontaneous or induced), and L indicates live births.

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4. The fetal heartbeat can be first heard using Doppler equipment at: A. 2 weeks B. 5 weeks C. 10 weeks D. 20 weeks ANS: C Monitoring fetal heart rate (FHR) is a vital component of fetal surveillance, as it provides important information on placental function, fetal hypoxia, and whether the intrauterine environment can support and sustain the fetus. The FHR can usually be auscultated as early as 10 weeks with an electronic Doppler and by 16 to 19 weeks with careful assessment and fetoscope (Cunningham et al., 2010).

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5. The normal fetal heart rate is: A. 70 to 100 beats/minute B. 100 to 110 beats/minute C. 110 to 120 beats/minute D. 120 to 160 beats/minute ANS: D A normal fetal heart rate (FHR) is 120 to 160 beats/minute. A sustained FHR of below 100 beats per minute is indicative of fetal jeopardy. If there is a question of whether the FHR is being adequately evaluated, the maternal pulse should simultaneously be assessed to ensure that the FHR, not the maternal heart rate, is actually being auscultated.

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6. A sustained fetal heart rate below _______________ is indicative of fetal health jeopardy.

A. 160 beats/minute B. 140 beats/minute C. 120 beats/minute D. 100 beats/minute ANS: D A normal fetal heart rate (FHR) is 120 to 160 beats per minute. A sustained FHR of below 100 beats per minute is indicative of fetal jeopardy. If there is a question of whether the FHR is being adequately evaluated, the maternal pulse should simultaneously be assessed to ensure that the FHR, not the maternal heart rate, is actually being auscultated.

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7. A fetal heart rate is auscultated in the upper abdomen above the umbilicus. This commonly indicates the fetus is in the: A. Vertex presentation position B. Transverse lie position C. Breech presentation D. Upper region of the uterus ANS: C Fetal heart tones (FHTs) are best auscultated through the fetal back in vertex and breech presentations, and toward the mother’s flank when the fetus is in a transverse lie. In vertex presentations, FHTs are usually best heard below the mother’s umbilicus, in the lower abdomen, whereas for breech presentations, they are best heard at or slightly above the umbilicus, in the mother’s upper abdomen.

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8. When measuring the fundal height, if you find the fundus at the umbilicus, this usually indicates a pregnancy at: A. 20 weeks B. 16 weeks C. 12 weeks D. 10 weeks ANS: A Assessment of fundal height provides an estimation of gestational age in relationship to uterine size. Fundal height is measured by placing the end of a tape measure at the symphysis pubis and extending it to the fundus (Fig. 19.2). The uterus is usually palpable above the symphysis at 12 weeks gestation, midway between the symphysis pubis and umbilicus at 16 weeks, and at the umbilicus at 20 weeks.

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9. The fundus of a pregnant woman is located just above the symphysis pubis. This indicates a pregnancy of: A. 16 weeks B. 12 weeks C. 10 weeks D. 6 weeks ANS: B Fundal height changes are reflective of fetal growth and correlate closely with the number of weeks of pregnancy from 20 to 24 weeks gestation (Cunningham et al., 2010). Assessment of fundal height provides an estimation of gestational age in relationship to uterine size.

Fundal height is measured by placing the end of a tape measure at the symphysis pubis and extending it to the fundus (Fig. 19.2). The uterus is usually palpable above the symphysis at 12 weeks gestation, midway between the symphysis pubis and umbilicus at 16 weeks, and at the umbilicus at 20 weeks.

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10. In a pregnant woman, a glucose screening test should be done at: A. 24 weeks B. 20 weeks C. 16 weeks D. 10 weeks ANS: A

Laboratory studies during the initial visit are quite extensive. These screening tests are dependent on the disease prevalence within the screened population (Table 19.2).

Laboratory testing throughout the pregnancy is dependent on presenting complaints and the developmental stage of the pregnancy. For example, a glucose screen should be done between 24 and 26 weeks gestation, whereas an anemia screen (hemoglobin and hematocrit) should be done initially and again at 28 to 36 weeks. However, if the woman complains of a vaginal discharge later in the pregnancy, a gonorrhea and Chlamydia culture could be done even if the initial screen was negative.

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11. The American College of Obstetricians and Gynecologists (ACOG, 2013) recommends a total pregnancy weight gain of: A. 10 to 11 kg B. 11.5 to 16 kg C. 18 to 19 kg D. 20 to 21 kg ANS: B The American College of Obstetricians and Gynecologists (ACOG) recommends a total pregnancy weight gain of 11.5 to 16 kg for women of normal weight (Women’s Health Care Physicians, 2013). While weight gain is slower during the first trimester, it is recommended to average 1 pound per week during the second and third trimesters. The recommended weight gain for pregnancy is adjusted according to the patient’s body mass index (Table 19.3).

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12. The schedule of prenatal care should be: A. Every 2 weeks between 28 and 36 weeks B. Every week between 28 and 36 weeks C. Every week between 36 and 40 weeks D. A and C ANS: D For routine pregnancies, prenatal visits are usually scheduled from 4 to 28 weeks gestation.

At that time, visits are scheduled every 2 weeks from 28 to 36 weeks, at which point the patient is then seen weekly until she goes into labor (Cunningham et al., 2014).

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13. A diagnosis of hyperemesis gravidarum is associated with: A. Multiparity B. Low body weight

C. Increased body weight D. Food allergies ANS: C Hyperemesis gravidarum occurs in only approximately 2% of pregnancies but is associated with nulliparity, increased body weight, history of migraines, multiple gestation, and molar pregnancies (Cashion, 2007; Harvey-Banchik, 2007). More than 50% of patients with hyperemesis gravidarum have elevated aminotransferase levels (Harvey-Banchik, 2007).

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14. A pregnant woman with hyperemesis gravidarum should be checked for: A. Multiple pregnancy B. Hyperadrenalism C. Hyperthyroidism D. Fibroid tumor ANS: C Causes of nausea and vomiting associated with pregnancy are unknown but believed to be related to increased levels of estrogen, human chorionic gonadotropin, estradiol, and progesterone (Davidson, 2016). Persistent or severe nausea and vomiting, to the point of affecting the woman’s nutritional status, known as hyperemesis gravidarum, may be an early symptom of hyperthyroidism. Beta-hCG has a thyroid-stimulating hormone–like effect on the maternal thyroid, and hyperthyroidism may be evident only by an increase in free T4 instead of by both the TSH decrease and the free T4 increase that are usually seen in women who are not pregnant (Turok & Schultz, 2008).

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15. If radiological studies are needed to evaluate intra-abdominal conditions during pregnancy, it is important for the clinician to recognize that a(n) _______________ exposes a fetus to ionizing radiation.

A. Ultrasound B. Computed tomography scan C. Magnetic resonance imaging D. Doppler equipment ANS: B If radiology studies are warranted, ultrasound is safe and effective in diagnosing intra-abdominal conditions during pregnancy. Current knowledge indicates that magnetic resonance imaging is safe during pregnancy, but computed tomography imaging exposes the fetus to doses of ionizing radiation and should only be done in cases of extreme nonobstetrical emergencies (Sadro & Dubinsky, 2013).

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16. A pregnant woman under your care complains of indigestion, belching, flatulence, and upper right quadrant cramping pain that comes and goes. Which of the following is not true concerning use of upper endoscopy as a diagnostic procedure during pregnancy?

A. Upper endoscopy is not associated with preterm labor or other complication.

B. Upper endoscopy is associated with an increase in preterm labor and should not be performed during pregnancy.

C. As a general rule, procedures are usually postponed during pregnancy or at least until after the first trimester.

D. Upper endoscopy is associated with fetal demise.

ANS: B Pregnancy also increases the risk of developing gallstones owing to an increased progesterone level that reduces gallbladder emptying and therefore increases biliary stasis. Subsequent pregnancies exponentially increase the risk of cholelithiasis. Gallstones occur in approximately 7% of nulliparous women and 19% of multiparous women (Creasy et al., 2014). Upper endoscopy is a safe diagnostic procedure during pregnancy and does not carry an increased risk of preterm labor or other complications as compared to other diagnostic modalities such as diagnostic radiology studies (Sadro & Dubinsky, 2013). However, as a general rule, any procedures during pregnancy are usually postponed until after delivery or at least until after the first trimester unless the risk of the disease outweighs the risk of the procedure and definitive evaluation is needed.

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17. Your pregnant patient is at 28 weeks gestation and complains of pain that radiates from the wrist into the fingers in the right hand. She is a computer programmer and uses a keyboard daily for 6 hours or more. The clinician should: A. Ask the person to place dorsal surfaces of hands together to check for Phalen’s test B. Teach the patient that carpal tunnel syndrome is common during the last trimester C. Tap the patient’s right wrist to try to elicit tingling in the fingers for Tinel’s sign D. All of the above ANS: D Carpal tunnel syndrome results from compression of the median nerve in the carpal tunnel, which results in paresthesias or weakness of the thumb, index, and middle fingers (Davidson, 2016). Carpal tunnel syndrome occurs in 7% to 43% of pregnant women and often causes these women to awake with burning, numbness, and tingling in the median nerve distribution (Khosrawi & Maghrouri, 2012). However, these symptoms usually tend to occur during the last trimester. Tinel’s sign and Phalen’s test should be performed. Upper extremity, grip, and finger strength should be assessed, along with the ability to oppose the thumb to the fingers. An evaluation for thenar atrophy and dry skin on the thumb and index and middle fingers (median nerve distribution) should be completed.

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18. Your pregnant patient complains of back pain. When inquiring about the pain, the clinician should use the PQRST method. This includes asking the patient about: A. Radiation B. Severity C. Timing D. All of the above ANS: D Back pain is reported as a dull, aching pain in the upper or lower back that worsens as the day progresses. Standing or sitting for long periods may aggravate the back pain. The location of the pain is important, as is the information gathered via a PQRST report. This inquiry usually provides sufficient diagnostic information and comprises the precipitating (P) factors (what aggravates or alleviates the pain; the symptoms associated with the pain); the quality (Q) of the pain (achy, burning, cramping, shooting, etc.); the radiation (R) of the pain; the severity (S) of the pain (typically reported on a 1 to 10 scale and whether it interferes with the usual activities of daily living); and the timing (T) of the pain (sudden or gradual onset, duration). Worrisome symptoms include a history of back injuries, problems, or surgeries; urinary tract infection or vaginal infection symptoms; bowel changes; uterine contractions; pain, numbness, or tingling that radiates either into the abdomen or down into the legs; and any neurological deficits.

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19. The clinician should be aware of the Wells’ Criteria when evaluating a patient for deep vein thrombosis (DVT). Wells’ Criteria are risk factors that are assigned points toward the likelihood of DVT. Wells’ Criteria include: A. Active cancer B. Recent bedridden condition C. Pitting edema D. All of the above ANS: D Wells’ Criteria Possible Score: –2 to 9 1. Active cancer (treatment within last 6 months or palliative): +1 point 2. Calf swelling greater than or equal to 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point 3. Swollen unilateral superficial veins (nonvaricose in symptomatic leg): +1 point 4. Unilateral pitting edema (in symptomatic leg): +1 point 5. Previous documented DVT: +1 point 6. Swelling of entire leg: +1 point 7. Localized tenderness along the deep venous system: +1 point 8. Paralysis, paresis, or recent cast immobilization of lower extremities: +1 point 9. Recently bedridden 3 days or more, or major surgery requiring regional or general anesthetic in the past 12 weeks: +1 point 10. Alternative diagnosis at least as likely: –2 points PTS: 1

20. A pregnant patient complains of nasal stuffiness and rapid breathing. The clinician should recognize that: A. Elevated progesterone directly stimulates the central respiratory center in pregnancy to enhance loss of CO2 B. Elevated estrogen and progesterone levels cause nasal edema C. Elevated estrogen and progesterone cause nasal turbinate enlargement D. All of the above ANS: D As the uterus enlarges, it presses against the abdominal organs and diaphragm, and this prevents the lungs from fully expanding and results in a decreased residual volume and functional residual capacity (Cunningham et al., 2014). Increased progesterone directly stimulates the central respiratory system to increase minute ventilation and tidal volume, and to decrease blood PCO2. Oxygen consumption and basal metabolic rate also increases.

These changes are the basis of an increased awareness of breathing or even dyspnea that is experienced during pregnancy. Nasal congestion or stuffiness may result from increased estrogen and progesterone levels, which increase perivascular edema and enlargement of the nasal turbinates (Davidson, 2016).

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21. A pregnant patient complains of severe fatigue and exercise intolerance. Laboratory tests that should be investigated include: A. Complete blood count B. Thyroid-stimulating hormone C. T4 D. All of the above ANS: D Fatigue usually occurs during the first and third trimesters of pregnancy. First-trimester fatigue is often associated with the physical and psychosocial pregnancy changes. Fatigue may also be indicative of a more serious physical, emotional, or dietary problem. The woman may experience a higher than expected amount of fatigue despite a normal amount of energy expenditure and sleep. Vital signs and physical examination, with attention to the thyroid, cardiac, and pulmonary systems, should be normal. Weight gain during the pregnancy should be noted. A complete blood count and thyroid function tests (TSH and free T4) are reasonable choices for screening.

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22. A pregnant patient complains of urinary frequency. She denies fever, dysuria, back pain, or hematuria. Urine dipstick is negative for leukocytes, protein, or blood. The clinician should: A. Explain to the patient that the uterus places pressure on the bladder during

pregnancy B. Advise the patient she needs urine culture and sensitivity C. Obtain a glucose tolerance test D. Obtain 24-hour urine for protein ANS: A Urinary frequency is often at the top of the list of common pregnancy complaints. The kidneys change in size and shape as early as 10 weeks gestation (Cunningham et al., 2014).

Renal enlargement may originally be caused by increased tone and decreased smooth muscle motility, but after 20 weeks gestation, it is caused by ureter compression caused by a growing uterus. Increases in circulating fluid volume and glomerular filtration rate may contribute to urinary frequency (Cunningham et al., 2014). During the first trimester, the weight of the growing uterus begins to cause pressure on the bladder. Uterine displacement of the bladder by the end of the second trimester can result in urinary frequency and incontinence. Urinary infections and risk of trauma are greater owing to increased bladder tone relaxation, enlarged bladder capacity, increased bladder pressure, and increased edema of the bladder mucosa. Vital signs should be normal. An abdominal examination should rule out any uterine contractions or irritability. There should be no costovertebral angle or suprapubic tenderness. Complete blood count and glucose levels should be within normal limits. Urine dipstick, urinalysis, and culture and sensitivity tests should be normal.

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23. Your pregnant patient complains of hemorrhoids. On physical examination, vital signs are: temperature 98.6°F, pulse 80 beats/min, respirations 14 breaths/min, blood pressure 110/60.

The heart has a regular rate and rhythm, no S3, no murmurs. Lungs are clear to auscultation.

Abdominal examination is negative. Uterus fundus is at the umbilicus. Ankles show +1/4 bilateral ankle nonpitting edema. Dorsalis pedis pulses + 2/4 bilaterally. Rectal exam: + external hemorrhoid. Urine dipstick is negative for protein. The clinician should: A. Explain to the patient to lie in a left lateral recumbent position at night B. Refer the patient to an obstetric physician for a diuretic prescription C. Obtain 24-hour urine for protein D. Obtain HbA1c and fasting serum glucose ANS: A A 30% to 50% increase in cardiac output occurs during pregnancy (Davidson, 2016). This increase begins as early as 10 weeks gestation and peaks at 20 to 24 weeks. A 40% to 50% increase in blood volume results in an increased venous pressure below the level of the uterus. This increased pressure can result in varicosities in the legs and perineum (hemorrhoids), especially when the pregnant woman is in an upright position, such as with prolonged sitting or standing. An enlarging uterus compresses the vena cava or pelvic and lower extremity veins, leading to venous pooling, which can result in edema, hypotension, dizziness, or even syncope. In order to lessen these complications, the pregnant woman should be instructed not to lie in a supine or recumbent position, but rather in a left lateral tilt.

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24. Your pregnant patient at 8 months gestation complains of bilateral ankle swelling and no other symptoms. Which of the following findings require further investigation?

A. Ankle swelling that is noticed at the end of the day after standing for a prolonged time B. Weight gain of approximately 1 pound per week C. A systolic rise of 30 mm Hg or diastolic rise of 15 mm Hg over the patient’s baseline blood pressure D. Uterine fundus above the umbilicus ANS: C Swelling that worsens as the day progresses and gets better after rest and elevation is generally reported by pregnant women. Edema may be worse during warm weather or after prolonged sitting or standing. The woman should be questioned on the use of any type of constrictive clothing, such as pantyhose, girdles, or tight belts; nutrition, especially sodium and sugar intake; and medication use. There should be no numbness, strength or sensation loss, mental status changes, report of headaches, flashing lights, upper abdominal pain, nausea or vomiting, dyspnea, decreased fetal movement, or decreased urine output. Vital signs, especially blood pressure, should be normal for gestational age. Abnormal blood pressure readings that need to be evaluated include (1) 120/75 or higher in midpregnancy, (2) 130/85 in the last trimester, (3) a systolic rise of 30 mm Hg or diastolic rise of 15 mm Hg over baseline, or (4) a variation of 20 or more in postural (orthostatic) blood pressures (Lindheimer & Akbari, 2000). The woman’s weight gain should be noted. An increase of more than 2 pounds per week should be investigated. Cardiac and pulmonary status should be evaluated. Deep tendon reflexes should be normal, and urine dipstick should be negative or no greater than a trace for protein. The location, amount, and extent of the edema should be documented. Worrisome symptoms include edema that does not respond to rest and leg elevation, rapidly progressing or generalized edema, hard or painful veins or legs, and temperature changes to the extremities.

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25. A pregnant patient at 24 weeks gestation complains of shortness of breath on exertion, fatigue, weakness, and constant cravings for ice chips. On physical examination, vital signs are: temperature 98.6°F, pulse 100 beats/min, respirations 18 breaths/min, blood pressure 120/70. On physical examination, the heart has a regular rate and rhythm at 100 beats/min, no S3, no murmurs. Lungs are clear to auscultation. Abdominal examination is negative.

Uterus fundus is above the umbilicus. Ankles: no edema. Dorsalis pedis pulses +2/4 bilaterally. Urine dipstick is negative for protein. Laboratory tests reveal complete blood count: hemoglobin 10 microcytic hypochromic red blood cells. Which of the following conditions should be suspected?

A. Iron-deficiency anemia B. Folic acid deficiency anemia C. Vitamin B12 deficiency anemia D. Pernicious anemia ANS: A

Anemia is not a disease unto itself but a sign of an underlying disorder, which is common among pregnant women. A hemoglobin level less than 11 g/dL in either the first or third trimester or less than 10.5 g/dL in the second trimester is considered anemia (Arnett, Greenspoon, & Roman, 2013). Anemia during pregnancy is associated with high-output heart failure, premature delivery, low birth weight, and fetal demise. The etiology of the anemia can be classified according to the size and color of the red blood cells (Table 19.5).

The anemias most often diagnosed during pregnancy are folic-acid and iron-deficiency anemia (IDA). The principle etiologies for these anemias are inadequate nutrition, especially among women in lower socioeconomic groups, and the increased body requirements of pregnancy. If IDA is suspected on the basis of a complete blood count (CBC) (low hemoglobin and low red blood cell indices), iron studies should be attained. These iron studies will generally reveal a low serum iron level, decreased serum ferritin, increased total iron-binding capacity, and decreased transferrin saturation percentage (Arnett, Greenspoon, & Roman, 2013). Folate is needed for normal DNA production, but the body stores of folate are limited to a 3-month reserve and may be depleted during high rates of cell turnover, such as during pregnancy. A folate and vitamin B12 level should be checked if the CBC suggests that a macrocytic anemia (low hemoglobin level and a mean corpuscular volume of greater than 100) is the cause. An anemic woman may complain of fatigue and dyspnea on exertion.

Common findings include skin pallor, tachycardia, grade II/VI systolic heart murmur, and increased respiratory rate. The CBC will indicate potential causes (see Table 19.5) and guide selection of additional diagnostic studies, such as iron panel, folate level, sickle-cell screen or hemoglobin electrophoresis, and liver function tests. Differential diagnoses include iron deficiency, folate deficiency, vitamin B12 deficiency, sickle cell trait/anemia, and thalassemia.

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26. A pregnant patient at 6 months gestation who is 37 years old complains of urinary frequency, thirst, increased appetite, and candida vaginitis that is refractory to treatment.

The patient has a history of vaginal delivery of a 10-pound neonate 3 years ago. On physical examination, vital signs are: temperature 98.6°F, pulse 88 beats/min, respirations 18 breaths/min, blood pressure 120/70. Heart has a regular rate and rhythm at 88 beats/min, no S3, no murmurs. Lungs are clear to auscultation. Abdominal examination is negative. Uterus fundus is above the umbilicus. Ankles: no edema. Dorsalis pedis pulses +2/4 bilaterally.

Urine dipstick is negative for protein, + for glucose and + for ketones. The clinician should consider all of the following except: A. Obtain a 3-hour glucose tolerance test B. Order an HbA1c blood test C. Obtain a fasting serum glucose D. Review family history of diabetes, including gestational diabetes mellitus ANS: C

Gestational diabetes mellitus (GDM) involves glucose intolerance that develops or is first discovered during pregnancy and, hence, may include women who have undiagnosed pregestational diabetes. A pregnant woman may be asymptomatic throughout the entire pregnancy or may report classic episodes of polyuria, polyphagia, or polydipsia. She may experience episodes of urinary tract infections or vaginitis; therefore, recurrent infections should signal an earlier screening for diabetes or at least a random glucose level. Obstetric history should be investigated for unexplained stillbirths, spontaneous abortions, unexplained preterm birth, low birth weight (with undiagnosed preexisting diabetes), newborn weighing 4,000 g or more, or a previous incident of major congenital abnormality.

Family history should be explored for diabetes, including GDM. A urine dipstick should be evaluated for glycosuria and proteinuria.

Universal screening continues to be widely practiced within the United States between 24 and 28 weeks gestation with a 50-g, 1-hour Glucola test using a venous blood sample.

Although both tests are similar in ruling out GDM, the oral glucose challenge test (OGCT)is superior in identifying women with GDM. Glycated hemoglobin level (HbA1c) changes lag behind changes in serum glucose by months. It is therefore not a good screen for GDM, as glucose elevations do not often start to occur until after 20 weeks gestation (USPSTF, 2013). A fasting blood sugar (FBS) should be checked, and if it is elevated (above 85 to 95 mg/dL), the woman should be considered as having GDM. If the FBS is under 85 mg/dL, a 3-hour OGCT should still be done.

The 3-hour OGCT is usually administered after an overnight fast for at least 8, but not more than 14, hours. An FBS is obtained, and then a 100-g glucose load is given. Venous blood sugar samples are then obtained at 1, 2, and 3 hours after the glucose load. Either an elevated FBS or two elevated values on the 3-hour OGCT is diagnostic of GDM. If only one value on the OGCT is elevated, the test should be repeated between 32 and 34 weeks gestation.

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27. Which of the following statements is true regarding gestational blood pressures?

A. Pre-eclampsia is diagnosed in pregnant women who have a blood pressure greater than 130/80 mm Hg in the third trimester.

B. Pre-eclampsia can occur even if the blood pressure is within the accepted normal range.

C. Gestational hypertension is defined as a rise in systolic blood pressure of 15 mm Hg and a diastolic blood pressure rise of 30 mm Hg. D. Gestational hypertension is diagnosed if the patient has proteinuria and ankle edema, regardless of blood pressure measures.

ANS: B The appropriate clinical response to elevated blood pressure during pregnancy is determined by the underlying pathology rather than the actual elevation in pressure (Cunningham et al., 2014). Determination of the woman’s nonpregnant blood pressure is important in the evaluation of blood pressure during pregnancy. Gestational hypertension is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mmHg or higher

that occurs after 20 weeks gestation in a woman with previously normal blood pressure (Sibai & Minza, 2014). The past 30-15 rule, which followed elevations of systolic blood pressure increases by more than 30 mm Hg or diastolic increases of more than 15 mm Hg over baseline has not been proven to be a good prognostic indicator. However, pre-eclampsia may still occur even if the blood pressure is still within the accepted normal range and women who demonstrate the 30-15 rule still warrant close observation.

Evaluation should include the presence of edema, blood pressure measurement, urine dip or 24-hour urine for proteinuria, complete blood count or platelet count, liver enzymes, reflex testing, retinal changes, hepatomegaly, or right upper quadrant tenderness.

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28. A pregnant patient at 5 weeks gestation reports a slight amount of vaginal bleeding. The clinician should obtain the following laboratory test: A. Serial human chorionic gonadotropin levels over the next several days B. Measurement of estrogen levels C. Cervical mucus analysis D. Pap smear for sexually transmitted infection ANS: A Approximately 20% of early pregnancies are complicated by vaginal bleeding, and about half of these will end in spontaneous abortion (Deutchman, 2008). Single or serial qualitative human chorionic gonadotropin (HCG) levels can be helpful in evaluating vaginal bleeding during early pregnancy because the levels should double every 2 to 3 days during the fourth to eighth weeks of gestation. Other tests that may be useful include a transvaginal ultrasound, HCG level measurement, progesterone level, wet mount, urinalysis, and stool for occult blood. A complete blood count and coagulation studies should be considered.

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29. A pregnant patient at 12 weeks gestation complains of yellow vaginal discharge. Laboratory tests reveal bacterial vaginosis. The clinician should recognize that bacterial vaginosis is: A. A normal finding in pregnancy B. Associated with preterm labor and delivery C. Diagnosed by a nitrazine test D. Often accompanied by vaginal bleeding ANS: B Observational studies have demonstrated an association between bacterial vaginosis and certain adverse pregnancy outcomes, such as preterm labor, preterm delivery, premature rupture of membranes, and spontaneous abortions. Bacterial vaginosis can be treated with antibiotic therapy, but cure rates are erratic and recurrences are common. There is currently conflicting evidence on whether screening and treatment of asymptomatic bacterial vaginosis in high-risk pregnant women actually reduces the incidence of preterm delivery. A nitrazine test (done to evaluate a change in the pH) or fern test should be done to evaluate for a rupture of membranes.

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30. The clinician should recognize that in a pregnant patient the fundus should be at the umbilicus at 20 weeks gestation and rise by _______ per week until 32 weeks.

A. 3 cm B. 2 cm C. 1 cm D. 0.5 cm ANS: C The fundus should be at the level of the umbilicus at 20 weeks gestation, and it rises 1 cm per week until 32 weeks gestation. False small-for-dates presentations may result from inaccurate last menstrual period (LMP) dates, varying menstrual cycle lengths, improper fundal height measurement, or a fetus in a transverse lie. False large-for-dates presentations may likewise be produced by inaccurate LMP dates, improper fundal height measurement, and a large amount of amniotic fluid, as well as maternal obesity or short stature.

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31. As you assess a pregnant patient, you suspect false small-for-dates presentation. You should recognize that a possible cause for this is: A. Error in date of last menstrual period B. Fetus in transverse lie C. Error in calculation of fundal height D. All of the above ANS: D A fetus may be found to be of a size that is not commensurate with normal growth rates (size not equal to dates) when the uterine size is measured and evaluated during routine prenatal visits. First-trimester uterine sizes are usually determined with bimanual examination, and size-date discrepancies are often not clinically relevant. After 20 weeks gestation, fundal height measurements begin to correlate (within 2 cm) with gestational age.

The fundus should be at the level of the umbilicus at 20 weeks gestation, and it rises 1 cm per week until 32 weeks gestation. False small-for-dates presentations may result from inaccurate last menstrual period dates, varying menstrual cycle lengths, improper fundal height measurement, or a fetus in a transverse lie. Differential diagnoses include intrauterine growth restriction (either asymmetric or symmetric), which affects about 5% of the general population and as much as 10% of high-risk populations (Table 19.9); constitutionally small fetus; inaccurate pregnancy dating; improper fundal height measurement; transverse lie of the fetus; and oligohydramnios.

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32. The diagnosis of preterm labor is confirmed by: A. Effacement of the cervix B. Dilation of the cervix C. Sensation of contractions D. None of the above ANS: B Preterm labor is the onset of labor before 37 completed weeks of gestation. The accurate diagnosis of preterm labor is critical but often difficult. Fewer than half of the women who have four or more contractions per hour will deliver in 7 to 14 days of the preterm labor assessment. The diagnosis may be confirmed when there is a cervical dilatation of 3 cm or more in a woman without persistent contractions. Women who are having persistent contractions need a cervical change of at least 1 cm, a dilatation of 2 cm or more, or a positive fetal fibronectin assay for diagnosis (Roman, 2013). If the diagnosis is not confirmed, but the index of suspicion remains high, it is entirely reasonable to repeat the cervical examination at a later time. Transabdominal ultrasounds and home uterine activity monitoring have also been used in an effort to identify preterm labor, but with mixed results.

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Chapter 20. Assessment of the Transgender or Gender Diverse Adult

MULTIPLE CHOICE

1. The term transgender is used to describe all of the following except: A. Individuals whose gender identity varies from the gender assigned at birth B. Individuals who fluidly identify as neither male nor female C. Individuals classified by sexual orientation D. Approximately 1 million individuals in the United States ANS: C Transgender is a term used to describe a diverse group of individuals whose gender identity varies from the gender assigned at birth. This assignation at birth is dependent on the external genitalia visualized. In many cultures, society then often classifies individuals into binary gender patterns based on the birth sex (either male or female). Individuals can also be more fluid in their identification, identifying as nonbinary (i.e., neither male nor female).

The population of transgender individuals in the United States in 2016 was estimated to be 390 per 100,000 adults, or nearly 1 million adults nationally. Sexual orientation is different from gender identity and describes sexual attraction only, is self-defined, and is not related to gender expression.

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,

2. Gender-neutral pronouns are often used to avoid assuming the binary gender classifications denoted by pronouns such as he and she. Which of the following is not a gender-neutral pronoun?

A. Ze B. Hir C. They D. Person ANS: D Gender-neutral pronouns include they or them used as singular pronouns; alternatively, some individuals may use pronouns such as ze (pronounced ―zee,‖ as a substitute for he, she, or they) and hir (pronounced ―here‖ as a substitute for hers, his, or theirs).

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3. While seeing a trans-male patient with an acute complaint, you should not: A. Obtain demographic information, including what the patient chooses to be called B. Complete a focused medical history specific to the complaint C. Document all prior gender reassignment procedures D. Document all current medications ANS: C During the social history obtain, as with every other patient, demographic information, including what the patient chooses to be called. The medical history elicited should be focused and specific and pertain to the chief complaint. Asking nonrelated information out of curiosity or as a personal learning opportunity is disrespectful, invasive, and unprofessional. Another component of the medical record that remains crucial is the maintenance of an accurate medication list.

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4. Which of the following is true of trans men?

A. Contraception is no longer needed.

B. A quarterly lab to monitor hormonal treatment is recommended for life.

C. There is an increased risk of polycystic ovarian syndrome.

D. There is an increased risk of migraine headaches.

ANS: C

Lab monitoring is conducted every 3 months for the first year of hormonal treatment, then once or twice annually. Remember that, as with any other patient, the patient may have sex with partners of any gender, so if birth control is necessary, be certain to address contraception and advise the use of condoms to prevent sexually transmitted diseases. In addition, there is an increased prevalence of polycystic ovarian syndrome in female-to-male individuals, even if the patient does not use testosterone therapy.

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5. Hormonal therapies for trans women carry increased risks for: A. Electrolyte abnormalities B. Weight gain C. Deep vein thrombosis D. All of the above ANS: D Hormonal therapies for trans women carry the risks of increased incidence of electrolyte abnormalities, specifically hyperkalemia (with spironolactone) and hypotension, or if on estrogen therapy, increased risks of deep venous thrombosis (the risk is higher with oral estrogen therapy versus estrogen delivered cutaneously with a patch), weight gain, gallstones, hypertriglyceridemia, reduced fertility, and possibly increased risk of cardiovascular disease and diabetes if other certain risk factors are present.

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6. Your transgender patient has had a gonadectomy and is no longer on hormone replacement.

You should screen for: A. Free testosterone B. Deep venous thrombosis C. Bone density D. All of the above ANS: C If the patient has had a gonadectomy and does not continue hormonal replacement therapy after surgery, they will need to be screened with a bone mineral density test.

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7. Among trans women, the risk for deep venous thrombosis is higher if: A. They use oral estrogen replacement B. They use cutaneous estrogen replacement C. They take spironolactone D. They use goserelin as a GnRH agonist

ANS: A If on estrogen therapy, there is an increased risk of deep venous thrombosis (the risk is higher with oral estrogen therapy versus estrogen delivered cutaneously with a patch).

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8. Contraindications for testosterone therapy in trans men include: A. Anemia B. Pregnancy C. Gallbladder disease D. History of deep venous thrombosis ANS: B Contraindications to testosterone therapy include pregnancy, unstable coronary artery disease, and untreated polycythemia.

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9. Which of the following is true concerning gender-affirming treatments?

A. All transgender patients elect gender-affirming treatments.

B. Trans males are more likely to use pharmacological treatments over nonpharmacological treatments.

C. Gender-affirming treatments are reserved for those preparing for transition surgery.

D. Not all individuals undergo gender-affirming treatments.

ANS: D Gender-affirming treatment may include facial hair removal, behavioral modifications such as binding or tucking, surgery, or hormonal therapy. Hormonal therapy involves the suppression of the person’s sex hormones and maintenance of physiological sex hormone levels for the affirmed gender (Hembree et al., 2017). Not all individuals choose to undergo gender-affirming treatments; some choose nonpharmacological and/or pharmacological treatments, both hormonal and gender-reassignment surgery (GRS).

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10. Every effort should be made to treat other medical conditions prior to beginning gender-affirming treatments. Which of the following would be imperative to address/treat prior to beginning treatments?

A. Cardiovascular disease B. Depression/mood disorders

C. Urological conditions D. Sleep disturbances ANS: B Current recommendations, prior to medication or surgical treatment, include a psychological evaluation and support assessment, living a real-life experience in which the person lives in the desired gender (although during transition patients may at first find ease in transitioning to the desired gender in only certain settings), and discussion by the health-care provider of risks and side effects of treatment before beginning pharmacological treatment or surgery. If the patient has concomitant depression or an underlying mood disorder, every effort should be made to treat the condition before beginning gender-affirming treatments (Hembree et al., 2009).

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11. Which of the following is not a potential side effect/risk with exogenous testosterone therapy?

A. Elevated liver enzymes B. Hyperlipidemia C. Diabetes D. Peptic ulcer disease

ANS: D Hormonal therapy elected by trans males provides masculinization of primary and secondary sexual characteristics. Testosterone therapy, either injections or gel, is often prescribed if hormonal therapy is desired. Exogenous testosterone therapy carries the potential risks of acne, polycythemia, sleep apnea, weight gain, male pattern balding, elevated liver function tests, hyperlipidemia and reduced fertility, and, in the presence of other risk factors, a possible increase in cardiovascular disease, hypertension, diabetes, and exacerbation of underlying mood disorders (WPATH, 2012).

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12. For trans men on hormone therapy, labs to assess treatment response should include a complete blood count (CBC). For what, specifically, is it important to monitor the CBC? A. Anemia B. Thrombocytopenia C. Polycythemia

D. Neutropenia ANS: C Exogenous testosterone therapy carries the potential risks of acne, polycythemia, sleep apnea, weight gain, male pattern balding, elevated liver function tests, hyperlipidemia and reduced fertility, and, in the presence of other risk factors, a possible increase in cardiovascular disease, hypertension, diabetes, and exacerbation of underlying mood disorders (WPATH, 2012). Contraindications to testosterone therapy include pregnancy, unstable coronary artery disease, and untreated polycythemia with a hematocrit of 55% or greater (WPATH, 2012).

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13. For both trans women and trans men receiving gender-affirming treatments, labs should be monitored at regular intervals. The recommendation for follow-up intervals is: A. Every 3 months for the first year, then once or twice annually B. Every month for the first year, then every 3 months after that C. Every 6 months for the first year, then annually D. Regular labs should be checked annually ANS: A Lab monitoring is conducted every 3 months for the first year of hormonal treatment, then once or twice annually (Hembree et al., 2009).

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Chapter 21. Older Patients

MULTIPLE CHOICE

1. Based on the 2014 Census of the United States, the fastest growing segment of the population is: A. Adults aged 65 to 75 B. Adults aged 75 to 85 C. Adults aged 85 to 95 D. Adults aged 100 or more ANS: D According to 2014 U.S. Census data, the number of older adults aged 65 and over increased by 28% from 2004 to a total of 46.2 million (14.9% of the total U.S. population); it is esti-

mated that number will increase to about 82.3 million by 2040 (Administration on Aging, 2017). The fastest-growing group among older adults since the 2000 Census are those over 100 years of age, increasing by 44% to a total of 72,197 in 2014 (CDC, 2014).

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2. The order of the physical examination in the older patient should: A. Begin with gait observation or transfer ability from wheelchair to examination table B. Begin with activities that cause the least expenditure of energy C. Be performed in a head-to-toe sequence D. Be a focused physical examination limited to the patient symptoms ANS: B With older adults who are debilitated, it is important to focus the examination and reduce extraneous activities and distractions. Whenever possible, begin the examination with maneuvers that can be accomplished with the patient in his or her current position. For example, when the patient arrives to the examination seated in a wheelchair, check vital signs, heart rate, extremities, or anything else that can be done in the seated position first. If a patient’s ability to transfer from the wheelchair is in question, observe the transfer before the patient becomes fatigued. The exertion of getting on the examination table could fatigue an individual enough to preclude optimal performance. Likewise, perform all supine or standing examinations together to preserve the patient’s stamina. A reordering of the sequence of the examination should be done in a logical and thoughtful manner.

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3. A functional assessment is the most appropriate type of evaluation of well older patients. A basic component of the functional assessment is: A. Activities of daily living score B. Instrumental activities of daily living score C. 10-Minute Screener for Geriatric Conditions D. All of the above ANS: D For the well elderly, the 10-Minute Screener for Geriatric Conditions is a useful tool for general practice (Bluestein & Rutledge, 2006). This brief screening tool (Table 20.2) addresses vision, hearing, leg mobility, urinary incontinence, nutrition and weight loss, memory, depression, and physical disability. Using a combination of subjective and objective measures, the 10-Minute Screener covers all the basic activities of daily living and instrumental activities of daily living functions in a manner that fits well within the outpatient examination. A positive screen requires further evaluation, in some cases by a specialist or a geriatric specialist.

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4. A preliminary, concise test to screen patients for dementia in primary care is the: A. Mini-Mental Status Examination B. Mini-Cog Clock Drawing Test C. Geriatric Depression Scale D. Physical Self-Maintenance Scale ANS: B One instrument that holds promise for rapid screening in primary care is the Mini-Cog. It takes 2 to 4 minutes to administer, has good sensitivity (76% to 99%) and specificity (89% to 96%), and has been validated in primary care (Harvan & Cotter, 2006). A positive screen on the Mini-Cog requires a more thorough evaluation.

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5. The most sensitive test for assessing cognitive impairment of the older patient is the: A. Montreal Cognitive Assessment B. Mini-Mental Status Examination C. Mini-Cog Clock Drawing Test D. Activities of Daily Living Index ANS: A The Montreal Cognitive Assessment is the most sensitive instrument for detecting mild cognitive impairment and is recommended by the Hartford Institute for Geriatric Nursing.

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6. The most common reason for functional decline in nursing home patients is: A. Heart failure B. Stroke C. Urinary tract infection D. Myocardial infarction ANS: C Clinical practice guidelines suggest that in 77% of episodes of functional decline in long-term care residents, infection is the cause, and the most frequent site of such infection is the urinary tract (55%).

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7. One of the most common causes for cognitive impairment in older patients suffering from infection is: A. Delirium B. Depression

C. Dementia D. Pseudodementia ANS: A Delirium is a reversible condition frequently caused by infection. After treatment of infection, delirium is usually resolved.

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8. Which of the following tests of mobility can be included in a physical examination of older adults?

A. Get Up and Go Test B. Tinetti Evaluation C. Fall Toolkit D. All of the above ANS: D The Get Up and Go Test is a simple screening measure that takes only minutes and can be conducted by trained staff. Instruct the patient to stand up from a seated position without using his or her arms or the chair arms for support, walk a few feet away, turn around, return to the chair, and sit down again without using any support. If the examiner observes any instability or difficulty with this test, further evaluation of gait and balance is required.

Using the example of falls again, a home safety evaluation that includes questions about lighting, clutter on floors, footwear, bathroom configuration, stairways, sidewalks, and the availability of help in the case of a fall can focus attention on areas where safety can be improved to prevent falls. A useful tool that can be completed by patients or their families is available online in the Falls Toolkit (www.gericareonline.net/tools/eng/falls) from the Practicing Physicians Education in Geriatrics (2006). In the case of patients who have fallen frequently, a home visit by a nurse or physical therapist is very helpful to determine what risk factors are modifiable.

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9. Prior to giving clearance for an older adult to take part in an exercise regimen, the _______________________ assessment tool should be used by the clinician.

A. Get Up and Go Test B. Tinetti Evaluation C. MoCa Stress Test D. PAR-Q ANS: D Older adults are increasingly turning to exercise for socialization and fitness, and this trend should be supported. The question always arises: How much screening and assessment should be conducted prior to initiating an exercise program? A screening tool utilized by many health-care professionals is the PAR-Q+, a 4-page document that contains a range of

questions to identify any possible restrictions or limitations on activity levels and exercise participation.

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10. The rapid pace walk is a good screening test for driving ability of the elderly. The patient is timed to walk as swiftly as possible along a 10-foot path. A completion time of greater than ______________ indicates possible need for intervention.

A. 9 seconds B. 8 seconds C. 7 seconds D. 6 seconds ANS: A The rapid pace walk is specifically suggested (AMA, 2010) as a good predictor of driving safety. A completion time of greater than 9 seconds indicates a possible need for intervention.

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11. During examination of the eyes, dilation of the pupil is needed to check for: A. Distance vision B. Macular degeneration C. Cataracts D. Peripheral vision ANS: B An examination of the eyes should always include measuring ocular pressure to rule out glaucoma, which is a serious cause of blindness and is more common with aging; screening for close and distance vision, particularly when there are questions related to driving or medication-taking ability; dilating the pupil to examine the retina for macular degeneration, a common cause of blindness in the elderly; and screening for cataracts, also increasingly common with age.

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12. A Get Up and Go Test involves having the patient rise from a chair, walk 20 feet, turn, and walk back to the examiner. This should be completed within ______ seconds.

A. 10 B. 15 C. 20 D. 25 ANS: B

The timed Get Up and Go Test should be administered to all patients who have experienced a fall or who report difficulty with strenuous activities, such as fast walking, heavy housework, shopping, or climbing stairs. It is easy to perform and takes very little additional time during the examination. Place a chair in an unobstructed location and instruct the patient to rise from the seated position, walk 20 feet, turn, walk back to the chair, and sit down. Time this activity with a stopwatch. In populations that cannot complete the task in 15 seconds or less, research has shown a strong correlation (0.6–0.8) with other measures of gait and balance (Gerety, 2000).

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13. The functional reach test is a good predictor of: A. Susceptibility to fall B. Complete range of motion C. Shoulder abduction D. Shoulder extension against resistance ANS: A The functional reach test is another useful test for upper extremity function that correlates well with an increased risk for falls and dependence (Behrman et al., 2002).

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14. Adults tend to lose 1 inch every ______ years after age 40.

A. 30 B. 25 C. 20 D. 15 ANS: C Most adults overestimate their height and underestimate their weight on self-report; height is a particular problem because adults tend to lose 1 inch of height every 20 years after age 35 to 40. Measurement of standing height is difficult if there is any degree of kyphosis (underestimates the actual height).

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15. A body mass index of less than ______ is an indicator of high risk for malnutrition.

A. 21 B. 22 C. 23 D. 24 ANS: A

A body mass index of less than 21 or a total body weight of less than 100 pounds is an indicator of a high risk for protein-energy malnutrition.

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16. A total weight of less than ______ pounds is an indicator for high risk for malnutrition.

A. 120 B. 115 C. 110 D. 100 ANS: D The formula for calculating body mass index (BMI) is the same for the elderly as for any other population. A BMI of less than 21 or a total body weight of less than 100 pounds is an indicator of a high risk for protein-energy malnutrition.

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17. Useful laboratory measures that indicate protein-energy malnutrition in hospitalized elders include a serum albumin level below ________.

A. 3.4 g/dl B. 4.2 g/dl C. 5.2 g/dl D. 6.4 g/dl ANS: A Useful laboratory measures that indicate protein-energy malnutrition or potentially poor outcomes in hospitalized elders include a serum albumin level below 3.4 g/dL and total cholesterol below 160 mg/dL. PTS: 1

18. A useful laboratory measure that indicates protein-energy malnutrition in hospitalized elders includes a total cholesterol below _______.

A. 190 mg/dl B. 180 mg/dl C. 170 mg/dl D. 160 mg/dl ANS: D Useful laboratory measures that indicate protein-energy malnutrition or potentially poor outcomes in hospitalized elders include a serum albumin level below 3.4 g/dL and total cholesterol below 160 mg/dL.

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19. Obesity defined as a body mass index greater than ______ is an independent risk factor for functional decline in the elderly patient.

A. 20 B. 24 C. 30 D. 35 ANS: C Although a lot of attention is devoted to undernutrition, obesity, defined as a body mass index of greater than 30, or 20% greater than ideal body weight, is also an independent risk factor for functional decline in the elderly.

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20. The best indicator of fluid status in the elderly is _________________.

A. Patient thirst B. Patient weight C. Blood urea nitrogen/creatinine ratio D. Serum creatinine ANS: C The best method for monitoring hydration status is with the blood urea nitrogen/creatinine ratio; anything greater than 20:1 is highly suggestive of dehydration.

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21. Which of the following is regarded as a quality of care indicator?

A. Frequent episodes of dehydration B. Pattern of weight loss C. Chronic constipation D. Repeat urinary tract infections ANS: B Significant weight loss is a quality indicator measure, and a pattern of weight loss in any facility will trigger an investigation by state and federal regulatory agencies.

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22. Which of the following statements is true?

A. Women have a higher prevalence of functional decline than men at the upper end of

body mass index.

B. Men have a higher prevalence of functional decline than women at the upper end of body mass index.

C. To be sure the elderly patient’s fluid needs are met, the clinician should rely on the patient’s thirst.

D. The Get Up and Go Test is a more accurate assessment of gait and balance than the Tinetti Mobility Scale.

ANS: A Women have a higher prevalence of functional decline than men at the upper end of the body mass index (BMI) categories (three times greater risk at a BMI of greater than 35), independent of the usual factors, such as depression and polypharmacy (Jensen & Friedmann 2002). Dehydration is common in the elderly and has serious consequences. The best method for monitoring hydration status is with the blood urea nitrogen/creatinine ratio; anything greater than 20:1 is highly suggestive of dehydration. The Tinetti Performance-Oriented Mobility Assessment (POMA) scale is a more sensitive and specific test of gait, balance, and mobility.

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23. The American Medical Association guidelines for assessing driving ability recommend focused assessment of all of the following except: A. Vision B. Cognition C. Cardiac D. Motor function ANS: D The American Medical Association guidelines provide useful information on appropriate physical examination techniques to validate medical recommendations about driving ability; however, the report cautions that there are currently no tests that predict crash risk. These tests focus on vision, cognition, and motor function and can be integrated into the routine examination.

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24. Before calculating your patient’s body mass index, you must adjust the weight to account for her below-the-knee amputation by: A. Adding 6% to the weight obtained on the scale B. Adding 9% to the weight obtained on the scale C. Using her pre-surgery weight D. Omitting body mass index as inaccurate ANS: A For amputees, add the following percentages of the weight obtained on the scale prior to

calculating the body mass index: below knee 6%, at knee 9%, above knee 15%, arm 6.5%, arm below elbow 3.6%.

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Chapter 22. Persons With Disabilities

MULTIPLE CHOICE

1. Which of the following statements concerning persons with disabilities (PWD) is not true?

A. Over 56 million persons in the United States have at least one disability.

B. PWD are more likely to have a regular source of care, due to their disability.

C. PWD are likely to experience delays in diagnosis.

D. PWD are more likely to have one or more chronic health conditions than those without.

ANS: B Over 56 million persons in the United States have at least one disability; PWD are more likely to have one or more chronic health conditions and to encounter significant health disparities. PWD are less likely to have a regular source of health care and have unmet needs, including cancer screenings and vaccinations. They are more likely to have poor outcomes associated with conditions, such as breast cancer, due to delays in diagnosis.

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2. To allow for easier transfer, a height adjustable examination table should lower to _________ inches.

A. 9 to 12 B. 13 to 16 C. 17 to 20 D. 21 to 25 ANS: C Height-adjustable examination tables should lower to 17 to 20 inches, allowing for an easier transfer from wheelchair to table.

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3. Which of the following statements is true concerning the American Disabilities Act (ADA) requirement that persons with disabilities (PWD) receive care equivalent to others?

A. If unable to accommodate PWD, clinics must post inability to accept PWD on their signage.

B. Clinicians may require PWD to be accompanied by companions knowledgeable of and able to assist with their limitations.

C. Clinicians should omit portions of the examination that cannot be accurately conducted if the patient cannot accomplish the move to the examination table.

D. None of the above ANS: D In spite of the ADA requirement for PWD to receive care equivalent to others, practice sites and clinicians often are ill-prepared to conduct necessary examinations when PWD are present. For the patient’s safety, staff should be available to assist in the transfer, as needed. The examination table should also be equipped with handrails or grips to assist the PWD in transferring and positioning, as well to prevent a fall from the table. As needed, ask a staff person to remain during the examination to assist with any balance or repositioning needs. While PWD may be accompanied by a friend or family member, this individual cannot be required to assist during the examination or to stay in the examination room, unless the patient so requests.

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4. A patient with significant spasticity associated with cerebral palsy presents for a gynecological examination. She has a Foley catheter in place. Which of the following should be accomplished prior to the examination?

A. The catheter should be removed temporarily during the examination.

B. She should be asked to return at a later time without the catheter.

C. The catheter should be secured to avoid dislodgement during the examination.

D. The catheter bag should be emptied prior to the examination.

ANS: C If a Foley catheter or other device is in place, plan to secure it to avoid dislodgement during the transfer and examination.

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5. Your new patient has profound hearing loss. He uses sign language. You were unaware of his limited communication ability and no staff are able to interpret with sign language. His wife has accompanied him to the visit. Which of the following must occur prior to using the wife as the interpreter?

A. The patient must request that his wife interpret.

B. The wife must agree that she is comfortable and able to serve as his interpreter.

C. You should determine that the wife would be able to understand the terminology involved.

D. All of the above ANS: D Even when another person accompanies a patient during the visit, effective communication is the practice’s responsibility. Companions cannot be relied on unless it is at the patient’s request, the interpreter agrees, and you determine that the interpreter will provide reliable communication (i.e., is able to understand the terminology being used and communicate impartially). For example, children should not be used as interpreters. Adults who may be biased or otherwise prejudiced in some way (e.g., a spouse, when concern involves domestic abuse; a companion uncomfortable with the nature of the discussion) should not be used as interpreters.

PTS: 1

6. Alternatives to lithotomy position for gynecological examination include all of the following except: A. Staff members elevating and separating legs while patient is seated in wheelchair B. Positioning the patient on a mat, using staff and pillows to assist with positioning C. Replacing gynecological stirrups with obstetrical stirrups D. ―M‖ position with patient rotating and flexing hips and flexing knees, allowing feet to rest on table.

ANS: A See Figures 22.1, 22.2, 22.3, 22.4, and 22.5.

PTS: 1