NUR634 Midterm Exam: NUR634/ NUR 634 (Latest 2023/ 2024 Update) Advanced Health Assessment and Diagnostic Reasoning Exam | Questions and Verified Answers| 100% Correct| Grade A- GCU

NUR634 Midterm Exam: NUR634/ NUR 634 (Latest 2023/ 2024 Update) Advanced Health Assessment and Diagnostic Reasoning Exam | Questions and Verified Answers| 100% Correct| Grade A- GCU

Midterm Exam: NUR634/ NUR 634 (Latest
2023/ 2024 Update) Advanced Health
Assessment and Diagnostic Reasoning Exam |
Questions and Verified Answers| 100%
Correct| Grade A- GCU
Q: A 60-year-old baker presents to your clinic, complaining of increasing shortness of breath
and nonproductive cough over the last month. She feels like she can’t do as much activity as she
used to do without becoming tired. She even has to sleep upright in her recliner at night to be
able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical
history is significant for high blood pressure and coronary artery disease. She had a hysterectomy
in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon.
She denies any tobacco, alcohol, or drug use. Her mother died of a stroke and her father died
from prostate cancer. She denies any recent upper respiratory illness, and she has had no other
symptoms. On examination she is in no acute distress. Her blood pressure is
160/100 and her pulse is 100.She is afebrile and her respiratory rate is 16.With auscultation she
has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac
examination the S1 and S2 are distant and
an S3 is heard over the apex. What disorder of the chest best describes her symptoms?
A. Pneumonia
B. Chronic obstructive pulmonary disease (COPD)
C. Pleural pain
D. Left-sided heart failure
Answer:
D
Q: When a patient is suspected of having medial epicondylitis (pitcher’s, golfer’s, or Little
League elbow) where would they experience pain?
Answer:
Wrist flexion against resistance increases the pain.
Q: A differential to consider if a patient is having fever, shortness of breath, productive cough,
and hemoptysis?

A. COPD
B. Raynaud Syndrome
C. Pneumonia
D. Spontaneous Pneumothorax
Answer:
C
With a “fever” think infection
Q: Exam findings of a patient with pneumonia (Select all that Apply)
A. Dullness with percussion
B. Dull, diminished lung sounds
C. Coarse crackles on auscultation
D. Decreased fremitus during palpation
Answer:
A, B, C
Q: You are speaking to an 8th grade class about health prevention and are preparing to discuss
the ABCDEs of melanoma. Which of the following de- scriptions correctly defines the
ABCDEs?
A. A = actinic; B = basal cell; C = color changes, especially blue; D = diameter

6 mm; E = evolution
B. A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6
mm; E = evolution
C. A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E =
evolution
D. A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter >6
mm; E = evolution
Answer:
B
Feedback: This is the correct description for the mnemonic
Q: If a patient has splenomegaly, what sound would be heard when per- cussing the left side of
the abdomen?
A. Dullness
B. Tympany
C. Fremitus
D. Hyperactive bowel sounds

Answer:
A
Q: Which of the following percussion notes would you obtain over the gastric bubble?
A. Resonance
B. Tympany
C. Hyperresonance
D. Flatness
Answer:
B
Feedback: The gastric bubble produces one of the longest percussion notes. A patient with COPD
may have hyperresonance over his chest, while a normal person would have resonance. Dullness
is heard over a normal liver, and flatness is heard if one percusses a large muscle
Q: Where is the point of maximal impulse (PMI) normally located?
A. In the left 5th intercostal space, 7 to 9 cm lateral to the sternum
B. In the left 5th intercostal space, 10 to 12 cm lateral to the sternum
C. In the left 5th intercostal space, in the anterior axillary line
D. In the left 5th intercostal space, in the midaxillary line
Answer:
A
Feedback: The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral
to the sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its
size should not be greater than the size of a US quarter, or about an inch. Left ventricular
enlargement should be suspected if it is larger. The PMI is often the best place to listen for mitral
valve murmurs as well as S3 and S4.The PMI is often difficult to feel in normal patients.
Q: A 62-year-old smoker complains of “coughing up small amounts of blood,” so you consider
hemoptysis. Which of the following should you also consid- er?
A. Intestinal bleeding
B. Hematoma of the nasal septum
C. Epistaxis
D. Bruising of the tongue
Answer:
C

Q: A patient complaining of hemoptysis what may warrant consideration?
A. Upper GI Beed
B. Oral Bruising
C. Hematoma of nasal septum
D. Periungual infection
Answer:
A
Exam HENT, GI, and lungs
Q: A 46-year-old executive who is obese and otherwise healthy presents to a family medicine
clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own
after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she
has had to leave
or miss work on three separate occasions. She would like a diagnosis and the problem fixed.
Which symptoms or signs would be most suggestive of a diagnosis of biliary colic?
A. Vomiting of bile
B. Poorly localized periumbilical pain
C. Associated right shoulder pain
D. Positive McBurney point tenderness
E. Exacerbating factor includes alcohol intake
Answer:
C
Pain with biliary colic can produce referred pain to the right shoulder or scapula due to irritation
of the right hemidiaphragm. Alcohol is not an exacerbating factor for bil- iary colic. Positive
McBurney point tenderness is associated with acute appendicitis. The Murphy sign is associated
with acute cholecystitis. Vomiting bile is associated with small bowel obstruction
Q: A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain.
The pain is associated with nausea and vomiting and occurs
1 to 2 hours after eating greasy foods. Which one of the following physical examination
descriptions would be most consistent with the diagnosis of cholecystitis?
A. Abdomen is soft, nontender, and nondistended, without he- patosplenomegaly or masses.
B. Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or
guarding.
C. Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the
point of stopping inspiration, and there is no rebound or guarding.
D. Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or
guarding.
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For which of the following patients would a comprehensive health history be appropriate?

A. A new patient with the chief complaint of “I sprained my ankle”
B. An established patient with the chief complaint of “I have an upper respiratory infection”
C. A new patient with the chief complaint of “I am here to establish care”
D. A new patient with the chief complaint of “I cut my hand”
ANS: C

Feedback: This patient is here to establish care, and because she is new to you, a comprehensive health history is appropriate.

The following information is recorded in the health history: “The patient completed 8th grade. He currently lives with his wife and two children. He works on old cars on the weekend. He works in a glass factory during the week.” Which category does it belong to?

A. Chief complaint
B. Present illness
C. Personal and social history
D. Review of systems
ANS: C

Feedback: Personal and social history information includes educational level, family of origin, current household status, personal interests, employment, religious beliefs, military history, and lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and sexual preferences and history). All of this information is documented in this example

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

A. It is likely to be related to her lupus.
B. It is likely to be related to an exposure to a chemical.
C. It is likely to be related to an allergic reaction.
D. It should not cause any problems.
ANS: A

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

Two weeks ago, Mary started a job which requires carrying 40-pound buckets. She presents with elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor. What condition does she have?

A. Medial epicondylitis (golfer’s elbow)
B. Olecranon bursitis
C. Lateral epicondylitis (tennis elbow)
D. Supracondylar fracture
ANS: C

Feedback: Mary’s injury probably occurred by lifting heavy buckets with her palms down (toward the bucket). This caused her chronic overuse injury at the lateral epicondyle. Medial epicondylitis has reproducible pain when palmar flexion against resistance is performed and also features tenderness over the involved epicondyle. Olecranon bursitis produces erythema and swelling over the olecranon process. A supracondylar fracture of the humerus is a major injury and would present more acutely.

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

A. Allow the patient to speak uninterrupted for the duration of the appointment.
B. Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you.
C. Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview.
D. Allow your impatience to show so that the patient picks up on your nonverbal cue that the appointment needs to end.
ANS: B

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

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

A. Cancer
B. Lymph node
C. Deep scar
D. Muscle
ANS: B

Feedback: A useful maneuver for discerning lymph nodes from other masses in the neck is to check for their mobility in all directions. Many other masses are mobile in only two directions. Cancerous masses may also be “fixed,” or immobile

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

A. Smooth, large, nontender liver
B. Irregular, large liver
C. Smooth, large, tender liver
D. Irregular, small, nontender
ANS: B

Feedback: With his past history of colon cancer and with recent weight loss and fatigue, a relapse of his colon cancer would be expected. Colon cancer usually metastasizes to the liver, creating hard, irregular nodules, which can sometimes be palpated on examination. A smooth, large liver which is tender is often seen in hepatitis.

A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently started a job as a bartender in town. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe?

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

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

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

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

Feedback: In left-sided heart failure, fluid starts “backing up” into the lungs because the heart is unable to handle the volume. The excess fluid collects in the dependent areas, causing crackles in the bases of the lower lobes. Sitting up allows patients to breathe easier. The two main causes are chronic high blood pressure and coronary artery disease, which lead to myocardial ischemia and decreased contractility of the heart.

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

A. Pneumonia
B. Chronic obstructive pulmonary disease (COPD)
C. Pleural pain
D. Left-sided heart failure
ANS: D

When a patient is suspected of having medial epicondylitis (pitcher’s, golfer’s, or Little League elbow) where would they experience pain?
Wrist flexion against resistance increases the pain.

A differential to consider if a patient is having fever, shortness of breath, productive cough, and hemoptysis?

A. COPD
B. Raynaud Syndrome
C. Pneumonia
D. Spontaneous Pneumothorax
ANS: C

With a “fever” think infection

Exam findings of a patient with pneumonia (Select all that Apply)
A. Dullness with percussion
B. Dull, diminished lung sounds
C. Coarse crackles on auscultation
D. Decreased fremitus during palpation
ANS: A, B, C

You are speaking to an 8th grade class about health prevention and are preparing to discuss the ABCDEs of melanoma. Which of the following descriptions correctly defines the ABCDEs?

A. A = actinic; B = basal cell; C = color changes, especially blue; D = diameter >6 mm; E = evolution
B. A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6 mm; E = evolution
C. A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E = evolution
D. A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter >6 mm; E = evolution
ANS: B

Feedback: This is the correct description for the mnemonic

If a patient has splenomegaly, what sound would be heard when percussing the left side of the abdomen?
A. Dullness
B. Tympany
C. Fremitus
D. Hyperactive bowel sounds
ANS: A

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

A. Resonance
B. Tympany
C. Hyperresonance
D. Flatness
ANS: B

Feedback: The gastric bubble produces one of the longest percussion notes. A patient with COPD may have hyperresonance over his chest, while a normal person would have resonance. Dullness is heard over a normal liver, and flatness is heard if one percusses a large muscle

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

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

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

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

A. Intestinal bleeding
B. Hematoma of the nasal septum
C. Epistaxis
D. Bruising of the tongue
ANS: C

A patient complaining of hemoptysis what may warrant consideration?
A. Upper GI Beed
B. Oral Bruising
C. Hematoma of nasal septum
D. Periungual infection
ANS: A

Exam HENT, GI, and lungs

A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic?

A. Vomiting of bile
B. Poorly localized periumbilical pain
C. Associated right shoulder pain
D. Positive McBurney point tenderness
E. Exacerbating factor includes alcohol intake
ANS: C

Pain with biliary colic can produce referred pain to the right shoulder or scapula due to irritation of the right hemidiaphragm. Alcohol is not an exacerbating factor for biliary colic. Positive McBurney point tenderness is associated with acute appendicitis. The Murphy sign is associated with acute cholecystitis. Vomiting bile is associated with small bowel obstruction

A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods. Which one of the following physical examination descriptions would be most consistent with the diagnosis of cholecystitis?

A. Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses.
B. Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or guarding.
C. Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the point of stopping inspiration, and there is no rebound or guarding.
D. Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or guarding.
ANS: C

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

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

A. Dacryocystitis
B. Chalazion
C. Hordeolum
D. Xanthelasma
ANS: C

Feedback: A hordeolum, or sty, is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

A 55-year-old woman with a headache explains to the clinician that she has had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation?

A. The headache comes and goes
B. The patient had a car accident and minor head trauma about 3 months ago
C. The patient lost her glasses
D. The patient also has developed fever and night sweats and thinks she lost some weight.
E. The headache is similar in nature to prior ones she has had for decades but more severe.
ANS: D

Concomitant fever, night sweats, and weight loss are concerning systemic symptoms and suggest a serious underlying cause of the headaches.

A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lbs. over 4 months. What is the mechanism of his most likely diagnosis?

A. Helicobacter pylori infection
B. Reduced blood supply to the bowel
C. Inflammation of the gallbladder
D. Fibrosis of the pancreas
E. Inflammation of colonic diverticulum
ANS: D

Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzymes insufficiency and diabetes mellitus. H.Pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually associated with diarrhea

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

A. Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range of motion
B. Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle spasm and limited range of motion to the right
C. Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion
D. Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full range of motion
ANS: C

Feedback: Blurred disc margins are consistent with papilledema, and neck tenderness and lack of range of motion are consistent with neck stiffness, which in this scenario is likely to be caused by meningeal inflammation. Later, you will learn about Kernig’s and Brudzinski’s signs, which are helpful in testing for meningeal irritation on examination

During an evaluation of an athletic 30-year-old patient, the clinician conducts an active ROM evaluation at the neck. Which muscle is being assessed when the patient is asked to flex the neck?

A. Sacrospinalis
B. Trapezius
C. Splenius Capitis
D. Sternocleidomastoid (SCM)
E. Splenius cervicis
ANS: D

The SCM muscle flexes and rotates the neck. The splenius capitis and trapezius extends the neck.

Ray works a physical job and notes pain when he attempts to lift his arm over his head. When you move the shoulder passively, he has full range of motion without pain and there is no gross swelling or tenderness. What type of joint disease does this most likely represent?

A. Articular
B. Extra-articular
C. Neither
D. Both
ANS: B

Feedback: This description fits extra-articular disease. Articular disease typically involves swelling and tenderness of the entire joint and limits both active and passive range of motion. This is most likely extra-articular because it affects a certain portion of the range of motion, is not painful with passive range of motion, and is not associated with gross swelling or tenderness

Pain, swelling, loss of both active and passive motion, locking, and deformity would be consistent with which of the following?

A. Articular joint pain
B. Bursitis
C. Muscular injury
D. Nerve damage
ANS: A

Feedback: These features are consistent with articular joint pain, whereas the other problems are associated with extra-articular structures

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

A. An enlarged lymph node
B. A sebaceous cyst
C. An actinic keratosis
D. A malignant lesion
ANS: B

Feedback: This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland. The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely. This would be an unusual location for a lymph node, and these do not usually drain to the skin.

A high school football player injured his wrist in a game. He is tender between the two tendons at the base of the thumb. Which of the following should be considered?

A. DeQuervain’s tenosynovitis
B. Scaphoid fracture
C. Wrist sprain
D. Rheumatoid arthritis
ANS: B

Feedback: The “anatomic snuffbox” is found between the extensor and abductor tendons at the base of the thumb. Tenderness should make one think of a scaphoid fracture. Not only is this the most common carpal bone injury, but the poor blood supply puts the bone at risk for avascular necrosis when injured. This fracture is commonly missed on x-ray, so this is an important physical finding to support further or repeated studies.

18. During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group?

A. Extension of the spine
B. Flexion of the spine
C. Rotation of the spine
D. Lateral bending of the spine
ANS: A

The erector spinae muscle group is one of the deep intrinsic muscle groups of the back that extends the spine.

A 13-year-old girl is brought by her mother to the clinic one day before the start of eighth grade because of a 3-day history of episodes of shortness of breath. When she gets the shortness of breath, she also notices tingling around her lips. She has no fever, cough, sputum production, or chest pain. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Cardiac, lung, and extremity examinations show no abnormalities. Which of the following is the most likely diagnosis?

a. Aspiration of a foreign body
b. Anxiety
c. Asthma
d. Left-sided heart failure
e. Pneumonia
ANS: B

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

A. Unilateral headache
B. Pain over the sinuses
C. Age over 50
D. Phonophobia and photophobia
ANS: C

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

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

A. Tell him that he has a very promising career in anything he chooses and soon he will feel better.
B. Tell him that he needs an antidepressant and it will take about 4 weeks to work.
C. Speak with his mother about getting him together more with his friends.
D. Assess his suicide risk.
ANS: D

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

A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventative health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventative Service Task Force (USPSTF) screening recommendations for this patient?

A. Continue annual FOBT screening until age 80 years
B. Repeat colonoscopy this year
C. Continue annual FOBT screening until age 85 years
D. Do not screen routinely
E. Sigmoidoscopy every 5 years with FOBT every 3 years
ANS: D

The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain in life years is small compared to colonoscopy risks. It is advised to discuss individualized risk and benefits with the patient. Annual FOBT screening may continue until age 80-85 if benefits to doing so outweigh risks for the individual patient; however, screening should not be routinely continued. In general, a life expectancy >7 years in necessary for screening to be potentially beneficial

Cholecystitis may have associated symptoms of (Select all that apply)
A. Positive Murphy’s sign
B. Positive McBurney’s sign
C. right shoulder pain
D. left lower quadrant pain
ANS: A, C

A 25-year-old construction worker is complaining of a swishing noise in both ears that never goes away and has occurred for about 6 months. He is otherwise healthy, is able to work on his job (operating large, vibrating machinery) without problems, and is not taking any medications. A complete examination reveals an abnormality. Which of the following abnormality is most often associated with tinnitis?

A. Bilateral earache
B. Wax in both ears
C. Headache
D. Vertigo
E. Mild Tremor
ANS: D

Vertigo and tinnitus together comprise a syndrome called Meniere’s disease which may affect young adults.

A 74-year-old bus driver is delivered to the hospital via emergency transport after an astute passenger noted that the patient exhibited drooping facial features and slurred speech. The patient was diagnosed rapidly with ischemic (nonhemorrhagic) stroke, and urgent intervention lead to a near complete recovery from his symptoms. The astute passenger was thanked and congratulated for recognizing the signs of acute stroke; this individual credited this recognition to a public safety awareness campaign that outlined the critical public health need to recognize strokes early. Which of the following statements is true for risks and rapid recognition of suspected strokes?

a. Atrial fibrillation is not a risk factor for ischemic stroke in individuals age ≥75 years.

b. Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke.

c. Obesity with normal glucose tolerance is not a risk factor for stroke.

d. Transient ischemic attacks (TIAs) that resolve within in 1 hour confer a 5% risk of death from stroke within the next 12 months.

e. Due to increasing public awareness, the median time for arrival to care for suspected stroke is <3 hours.
ANS: B

A 62-year-old manual laborer presents to an annual physical examination with concerns about skin cancer screening. He does not have any lesions of concern but was recently told by a friend that he should have his skin checked by a doctor yearly. What is the best advice for this patient according to the U.S. Preventive Services Task Force (USPSTF) recommendations on skin cancer screening from 2015?

a. The USPSTF recommends that all individual age >50 years be screened yearly for skin cancer regardless of risk factors.

b. The USPSTF recommendations mirror those of the American Cancer Society (ACS) and American Academy of Dermatologists (AAD) in recommending and annual skin cancer screening for patients age >50 years.

c. The USPSTF recommends skin cancer screening only in sun-exposed areas of fair-skinned individuals every 6 months.

d. The USPSTF recommends focused screening of individuals with a history of dysplastic nevus syndrome.

e. The USPSTF recommends against routine screening for skin cancer due to lack of evidence for this intervention across the general population.
ANS: E

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

A. Illusion
B. Hallucination
C. Fugue state
ANS: A

Feedback: An illusion is merely a misinterpretation of real external stimuli. In this case, the mailman is looking through the letters before he puts them in the box. The mother correctly assumes he is sorting the mail but her schizophrenic daughter attributes his actions to being part of a nefarious bioterrorism plot.

A 22-year-old man is brought to your office by his father to discuss his son’s mental health disorder. The patient was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son’s dose isn’t high enough and you need to raise it. He states that his son has been hearing things that don’t exist. You ask the young man what is going on and he tells you that his father is just jealous because his sister talks only to him. His father turns to him and says, “Son, you know your sister died 2 years ago!” His son replies “Well, she still talks to me in my head all the time!” Which best describes this patient’s abnormality of perception?

A. Illusion
B. Hallucination
C. Fugue state
ANS: B

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

Concerning hallucinations, an abnormal perception experienced by a patient, which of the following statements is true about this abnormality?

A. Objective testing can be performed by a trained neuropsychologist to ascertain the correct diagnosis associated with this complaint.
B. It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia.
C. They include false perceptions associated with dreaming and occurring with falling asleep and awakening.
D. By definition, hallucinations are confined to those abnormal perceptions that are either auditory or visual in nature.
E. Although alcoholism may be associated with abnormalities of perception, it is not considered a cause of hallucinations as this finding is due to its direct toxic effects.
ANS: B

Hallucinations may be associated with a number of different primary diagnoses. Hallucinations are subjective and patient self-reported complaints. Abnormal perceptions may include ones of a gustatory, olfactory, and tactile nature as well as auditory and visual

A 24-year-old veteran returns from his second tour of duty in the Middle East. He was witness to a number of violent military encounters and experienced the death of several of his closest friends. He describes a number of problems including nightmares, poor sleep pattern, and mild panic attacks. In persons with trauma- and stress- related disorders as well as other disorders that may be associated with hallucination and illusions, which of the following statements is true that distinguishes the two entities from each other?

A. Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli.
B. Illusions occur only when awake, whereas hallucinations can occur both while awake and while sleeping.
C. Hallucinations by definition never include somatic perceptions, whereas illusions always involve at least some component of a somatic complaint.
D. Illusions involve an irrational fear or perceptions, whereas hallucinations are a misinterpretation of real external stimuli.
E. Hallucinations may be visual or auditory, causing an alteration of the real external world, whereas illusions are entirely imaginary.
ANS: A

Illusions are a misinterpretation of REAL STIMULI, whereas HALLUCINATIONS are subjective perceptions in the absence of real stimuli.

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

A. Seborrheic keratosis
B. Basal cell carcinoma
C. Squamous cell carcinoma
D. Actinic keratosis
ANS: D

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

A. Actinic keratosis
B. Seborrheic keratosis
C. Basal cell carcinoma
D. Squamous cell carcinoma
ANS: B

Which is more likely to metastasize?
A. Actinic keratosis
B. Seborrheic keratosis
C. Acne Vulgaris
D. Eczema
ANS: A

Actinic keratosis is a precursor to squamous cell carcinoma

The clinician is palpating pulses in the foot of a diabetic patient while in the clinic. A strong pulse is felt located on the dorsum of the foot, just lateral to the extensor tendon of the big toe. Which artery is being assessed?

A. Dorsalis pedis
B. Posterior tibial
C. Arterial arch of the foot
D. Femoral
E. Popliteal
ANS: A

The dorsalis pedis artery is usually palpable on the dorsum of the foot just lateral to the extensor tendon of the big toe. The arterial arch of the foot is more distal and runs transversely and is not usually palpable. The posterior tibial artery is found behind the medial malleolus of the ankle. The popliteal and femoral pulses are found more proximally at the knee and near the groin, respectively

A 77-year-old man is experiencing progressive SOB and dizziness. The patient undergoes cardiac catheterization, and the systolic blood pressure measured in the left ventricle is 180 mm Hg, while the systolic blood pressure measured in the aorta is 140 mm Hg. The patient is most likely experiencing symptoms related to what valvular condition?

A. Mitral stenosis
B. Pulmonic stenosis
C. Mitral regurgitation
D. Aortic stenosis
ANS: D

Patients with aortic stenosis often experience dyspnea with exertion, chest pain, or dizziness. The calcification of the aortic valve and narrowing of the valve area effectively decreases the blood flow from the left ventricle to the aorta. Given the obstruction created from the narrowing of the aortic valve, the pressure within the left ventricle is often higher than that seen in the aorta

A slowly progression of loss of vision often seen in elderly patients, who will initially complain of central vision loss

A. Presbyopia
B. Optic Neuritis
C.. Presbycusis
D. Macular Degeneration
ANS: D

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

A. Retinal detachment
B. Corneal ulcer
C. Acute glaucoma
D. Uveitis
ANS: A

Feedback: Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain. Retinal detachment is generally painless, as is chronic glaucoma.

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

A. Vitreous hemorrhage
B. Central retinal artery occlusion
C. Macular degeneration
D. Optic neuritis
ANS: D

Feedback: In multiple sclerosis, sudden painful loss of vision may accompany optic neuritis. The other conditions are usually painless

Which of the following changes are expected in vision as part of the normal aging process?

A. Cataracts
B. Glaucoma
C. Macular degeneration
D. Blurring of near vision
ANS: D

Feedback: The lens loses its elasticity over time as part of the normal aging process, and the eye is less able to accommodate and focus on near objects; therefore, the patient will be expected to have blurring of near vision.

Presbyopia

A 72-year-old retired truck driver comes to the clinic with his wife for evaluation of hearing loss. He has noticed some decreased ability to hear what his wife and grandchildren are saying to him. He admits to lip-reading more. He has a history of noise exposure in his young adult years: He worked as a sound engineer at a local arena and had to attend a lot of concerts. Based on this information, what is the most likely finding regarding his hearing acuity?

A. Loss of acuity for middle-range sounds
B. Increase of acuity for low-range sounds
C. Loss of acuity for high-range sounds
D. Increase of acuity for high-range sounds
ANS: A

Feedback: Human speech is considered to be a middle-range sound. During the aging process there is a loss of acuity, starting with high-pitched sounds but extending to the middle range and then into the low range

A 59-year old unemployed man complains of almost always feeling tired and hungry, despite getting sufficient rest and having a good appetite and access to sufficient food. The patient is obese and despite the warm weather outside, wearing thermal socks with his sandals. He says this is because his feet are always cold and “feel funny.” With which body system should the clinician begin the examination?

A. Posterior thorax
B. Lower extremities
C. Nervous system
D. Head and Neck
ANS: D

The physical examination should proceed “head to toe” to optimize patient comfort; minimize the number of changes in patient position; and, because it is always done in the same way, to ensure that nothing is missed.

A 55-year-old truck driver with obstructive sleep apnea has diastolic heart failure. An echocardiogram demonstrates significant bi-atrial enlargement. What portion of his electrocardiogram would likely be abnormal?

A. QRS complex
B. T wave
C. S wave
D. P wave
ANS: D

The P wave is the result of atrial depolarization and would therefore have changes associated with atrial enlargement.

A 20-year-old college student is experiencing dyspnea on exertion and palpitations. On cardiac auscultation, the second heart sound is split and fixed on both inspiration and expiration. What is the most likely cardiac condition associated with this finding?

A. Pulmonic stenosis
B. Left Bundle branch block
C. Right Bundle branch block
D. Atrial septal defect
E. Tricuspid stenosis
ANS: D

Patients with an atrial septal defect often experience dyspnea as well as atrial arrhythmias. Fixed splitting of the second heart sound occurs in atrial septal defects and right heart failure and does not vary with respiration.

How do you obtain the most accurate blood pressures for a patient with atrial fibrillation?
A. Checking both arms twice in five minutes; take the average
B. Ambulatory monitoring over time is best
C. Automated equipment is more accurate than manual readings
D. Standard procedure; no different than other cardiac rhythms
ANS: B

What are the elements of the FIFE model for interviewing a patient?
A. Feelings, idea, function, and expectation
B. Open ended questioning, re-direction
C. Focus, intensity, function, and evaluation
D. Focus, intensity, function, and emotion
ANS: A

Unilateral blurred and eye pain may be symptoms of (Select all that apply)
A. Corneal ulcer
B. Acute glaucoma
C. Uveitis
D. Macular degeneration
E. Retinal detachment
ANS: A, B, C

Feedback: Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain. Retinal detachment is generally painless, as is chronic glaucoma.

A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?

A. Conjunctivitis
B. Acute iritis
C. Corneal abrasion
D. Subconjunctival hemorrhage
ANS: D

Feedback: A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turning yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rarely caused by a serious condition, so reassurance is usually the only treatment necessary

What can make symptoms of GERD worse?
A. Coffee and carbonated drinks
B. Sleeping with HOB elevated
C. Taking an antacid
D. Not eating 2 hours prior to bed
ANS: A

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

A. Increased cup-to-disc ratio
B. AV nicking
C. Cotton wool spots
D. Microaneurysms
ANS: A

Feedback: It is important to screen for glaucoma on funduscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.

On routine screening you notice that the cup-to-disc ratio of the patient’s right eye is 1:2. What ocular condition should you suspect?

A. Macular degeneration
B. Diabetic retinopathy
C. Hypertensive retinopathy
D. Glaucoma
ANS: D

Feedback: This cup-to-disc ratio means that the cup takes up 50% of the disc, which is abnormally large. This is usually an indication of glaucoma, which is a common cause of visual loss in the elderly. The cup-to-disc changes are not seen in diabetes, hypertension, or macular degeneration. Many elderly do not have regular eye examinations and are not screened for glaucoma.

Cranial nerve III (oculomotor) can be tested using all of the following tests EXCEPT:

A. Cover/uncover test
B. Extraocular movement
C. Lid lag test
D. Snellen Chart
ANS: D

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

A. Bronchitis
B. Costochondritis
C. Pericarditis
D. Angina pectoris
ANS: D

Feedback: The clenched fist of Levine’s sign, while not completely specific for ischemic pain, should definitely cause you to consider this etiology. Bronchitis is usually painless, and pericarditis can produce a sharp pain which worsens with inspiration. This is called pleuritic pain and can be associated with pneumonia and other chest diseases. Costochondritis is a parasternal pain, usually well localized. It is exquisitely tender

Retinal detachment may be associated with all of the following EXCEPT:

A. painless, unilateral loss in vision
B. Spontaneous recovery
C. Flashes of light
D. Context of trauma
ANS: B

Optic neuritis may be associated with all the following conditions EXCEPT:

A. Sudden, painful loss in unilateral vision
B. Associated with autoimmune disease
C. Early sign of multiple sclerosis
D. Common incidental finding on fundoscopic exam
ANS: D

Mrs. Fletcher comes to your office with unilateral pain during chewing, which is chronic. She does not have facial tenderness or tenderness of the scalp. Which of the following is the most likely cause of her pain?

A. Trigeminal neuralgia
B. Temporomandibular joint syndrome
C. Temporal arteritis
D. Tumor of the mandible
ANS: B

Feedback: Temporomandibular joint syndrome is a very common cause of pain with chewing. Ischemic pain with chewing, or jaw claudication, can occur with temporal arteritis, but the lack of tenderness of the scalp overlying the artery makes this less likely. Trigeminal neuralgia can be associated with extreme tenderness over the branches of the trigeminal nerve. While a tumor of the mandible is possible, is it much less likely than the other choices.

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

A. Alopecia areata
B. Trichotillomania
C. Tinea capitis
D. Traction alopecia
ANS: A

Feedback: This is a typical description for alopecia areata. There are no risk factors for trichotillomania or for traction alopecia. The physical examination is not consistent with tinea capitis because the skin is intact.

A 46-year-old former salesman presents to the ER, complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. On examination you find a man appearing older than his stated age. His skin has a yellowish tint and he is thin, with a prominent abdomen. You note multiple “spider angiomas” at the base of his neck. Otherwise, his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs?

A. Infectious diarrhea
B. Mallory-Weiss tear
C. Esophageal varices
D. Ulcerative colitis
ANS: C

Varices are often found in alcoholic patients, but only when they have a diagnosis of significant cirrhosis. This patient has symptoms of cirrhosis, including jaundice, ascites, spider hemangiomas, and dilated veins on his abdomen (caput medusa).

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

A. Moist and smooth
B. Moist and rough
C. Dry and smooth
D. Dry and rough
ANS: D

42-year-old florist comes to your office, complaining of chronic constipation for the last 6 months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies any recent illnesses or injuries. She denies any changes to her diet or exercise program. She is on no new medications. During the review of systems you note that she has felt fatigued, had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one vaginal delivery and two cesarean sections. She is married, has three children, and owns a flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has coronary artery disease. There is no family history of cancers. On examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the Achilles tendons. What is the best choice for the cause of her constipation?

A. Large bowel obstruction
B. Irritable bowel syndrome
C. Rectal cancer
D. Hypothyroidism
ANS: D

COPD is associated with what on physical exam?
increase in A/P diameter

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

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
ANS: A

Feedback: The lack of contact with blood and body fluids makes hepatitis B, C, and D unlikely. She regularly changes the diapers of her clients and is at risk for hepatitis A. Vaccine against hepatitis A is recommended for daycare workers

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

A. Eczema
B. Pityriasis rosea
C. Psoriasis
D. Tinea infection
ANS: C

Feedback: This is a classic presentation of plaque psoriasis. Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces. Pityriasis usually is limited to the trunk and proximal extremities. Tinea has a much finer scale associated with it, almost like powder, and is found in dark and moist areas

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

A. Obtain abdominal ultrasound
B. Reassess by examination in 6 months
C. Reassess by examination in 3 months
D. Refer to a vascular surgeon
ANS: A

Feedback: A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 centimeters. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature.

Aortic Aneurysm

A 8-year-old patient presents to the office for evaluation of a rash. At first, there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical examination, you note that the pattern of eruption is like a Christmas tree and that there are a variety of erythematous papules and macules on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?

A. Pityriasis rosea
B. Tinea versicolor
C. Psoriasis
D. Atopic eczema
ANS: A

A 28-year-old patient comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical examination, you note that the pattern of eruption is like a Christmas tree and that there are a variety of erythematous papules and macules on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?

A. Pityriasis rosea
B. Tinea versicolor
C. Psoriasis
D. Atopic eczema
ANS: A

Feedback: This is a classic description of pityriasis rosea. The description of a large single or “herald” patch preceding the eruption is a good way to distinguish this rash from other conditions.

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

A. Direct reaction
B. Consensual reaction
C. Near reaction
D. Accommodation
ANS: B

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

A light is pointed at a patient’s pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. This is considered a __ reaction. Lack of this response may indicate head trauma.

A. Direct reaction
B. Consensual reaction
C. Near reaction
D. Accommodation
ANS: B

Left sided chest pain that is sharp and knife like that is worse with inspiration is most likely
A. Unstable angina
B. Pericarditis
C. Acute cholecystitis
D. Dissecting aortic aneurysm
ANS: B

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

A. Pallor of the foot when raised to 60 degrees for one minute
B. Return of color to the skin within 5 seconds of allowing legs to dangle
C. Filling of the veins of the ankles within 10 seconds of allowing the legs to dangle
D. Hyperpigmentation of the skin
ANS: A

Feedback: Pallor of the soles after one minute of elevation is a reliable sign of arterial insufficiency. Return of the color to the skin should occur within 10 seconds of dangling, and the filling of veins should occur within 15 seconds. Hyperpigmentation of the skin is usually seen in venous insufficiency.

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

A. Corneal arcus
B. Cataracts
C. Corneal scar
D. Pterygium
ANS: D

A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere with vision as it encroaches on the pupil. Otherwise, treatment is unnecessary

Urge incontinence can be secondary to which condition

A. GERD
B. Renal insufficiency
C. Stool impaction
D. Renal stones
ANS: C

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

A. Otitis media
B. External otitis
C. Perforation of the tympanum
D. Cholesteatoma
ANS: B

Feedback: These are classic history and examination findings for a patient suffering from external otitis. Otitis media would not usually have pain with movement of the external ear, nor drainage unless the eardrum was perforated. In this case the examination of the eardrum is recorded as normal. Cholesteatoma is a growth behind the eardrum and would not account for these symptoms. Otitis media would classically be accompanied by a bulging, erythematous eardrum

Mrs. Buckley is a 75-year-old widow who wants you to look at her teeth because over the past 2 weeks she has had right-sided jaw pain when eating. It does not occur otherwise. She also has had a headache with blurred vision. Which of the following should be considered?

A. Palpation of her temples
B. Dental referral
C. Ultrasound of the gallbladder
D. Inquiry about anosmia
ANS: A

Feedback: This story can be consistent with temporal arteritis, which can cause blindness in 15% of those affected. Early recognition is crucial. Most of these patients will have tenderness over one or both of the temporal arteries, and some have diminished temporal pulses as well. Early treatment with corticosteroids is indicated. It can also be associated with polymyalgia rheumatic, a condition which causes pain in the shoulder girdles and pelvis

patients can also have headaches and blurred vision

Diminished radial pulses may be seen in patients with which of the following?
A. Aortic insufficiency
B. Hyperthyroidism
C. Arterial emboli
D. Early “warm” septic shock
ANS: C

A grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you that it has been that way for quite a while. He states he has no symptoms from it and he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was deployed to the Middle East. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. On examination you see a teenage boy appearing his stated age. On visual examination of his chest, you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are unremarkable. What disorder of the thorax best describes your findings?

A. Barrel chest
B. Funnel chest (pectus excavatum)
C. Pigeon chest (pectus carinatum)
D. Thoracic kyphoscoliosis
ANS: B

Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.

A 29-year-old waiter comes to the clinic for a 2-month history of a cough. When he lowers his gown so the clinician can listen to his lungs, the clinician notices a depression of the lower part of his sternum. Which of the following best describes the appearance of his chest?

A. Thoracic kyphoscoliosis
B. Pectus excavatum
C. Barrel Chest
D. Flail Chest
E. Pigeon Chest
ANS: B

Pectus excavatum is a congenital abnormality in which the inferior part of the sternum is displaced inward. In a barrel chest there is an increased anteroposterior diameter (seen in pt with COPD).

A high-pitched non-radiating murmur at the 2nd right intracoastal space during systole
A. Aortic stenosis
B. Pulmonic stenosis
C. Mitral valve stenosis
D. Tricuspid vale stenosis
ANS: A

Patient is more at risk for left-sided heart failure

You notice a patient has a strong pulse and then a weak pulse. This pattern continues. Which of the following is likely?

A. Emphysema
B. Asthma exacerbation
C. Severe left heart failure
D. Cardiac tamponade
ANS: C

Feedback: This finding is consistent with pulsus alternans, which is associated with severe left heart failure. Occasionally, a monitor will read only half of the beats because half are too weak to detect. There may also be electrical alternans on EKG. This can be detected by using a blood pressure cuff and lowering the pressure slowly. At one point the rate of Korotkoff sounds will double, because the weaker beats can then “make it through.” The other findings are associated with paradoxical pulse.

What does pain at the anatomical “snuffbox” with wrist and ulnar deviation suggest?
“Snuffbox” tenderness with the wrist in ulnar deviation and pain at the scaphoid tubercle are suspicious for occult scaphoid fracture. Poor blood supply increases risk of scaphoid bone avascular necrosis, making this a diagnosis that should not be missed

Which is the proper sequence of examination for the abdomen?

A. Auscultation, inspection, palpation, percussion
B. Inspection, percussion, palpation, auscultation
C. Inspection, auscultation, percussion, palpation
D. Auscultation, percussion, inspection, palpation
ANS: C

Feedback: The abdominal examination is conducted in a sequence different from other systems, for which the usual order is inspection, percussion, palpation, and auscultation. Because palpation may actually cause some bowel noise when the bowels are not moving, auscultation is performed before percussion and palpation in an abdominal examination.

If a patient has unexplained weight loss, what in their history may explain this finding (Select All that apply)
A. Chewing or swallowing problems
B. Malignancy
C. An eating disorder
D. Thyroid disorder
E. Bariatric surgery
ANS: A, B, C, D

How is chronic pain defined?
pain not caused by cancer or a recognized medical condition that persists for longer than 3-6 months

A 76-year-old retired farmer comes to your office complaining of abdominal pain, constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or diarrhea. The only unusual thing he remembers eating is two bags of popcorn at the movies with his grandson, 3 days before his symptoms began. He denies any other recent illnesses. His past medical history is significant for coronary artery disease and high blood pressure. He has been married for over 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon cancer and his father had a stroke. On examination he appears his stated age and is in no acute distress. His temperature is 100.9 degrees and his other vital signs are unremarkable. His head, cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable and his fecal occult blood test is negative. His prostate is slightly enlarged but his testicular, penile, and inguinal examinations are all normal. Blood work is pending.
What diagnosis for abdominal pain best describes his symptoms and signs?

A. Acute diverticulitis
B. Acute cholecystitis
C. Acute appendicitis
D. Mesenteric ischemia
ANS: A

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

A 70-year-old man complains of double vision. Which of the following associated symptoms or signs would be worrying about an underlying neurological problem (as opposed to pathology in the eye)?

a. Abnormality in extraocular movements on examination
b. Diplopia persisting in the right eye when the left eye is closed
c. An associated conjunctivitis
d. Worsening vision bilaterally on examination
e. Symptoms of flashing lights
ANS: A

Your patient has been diagnosed with GERD what patient education would be provided to them?
Avoid Spicy, fatty, caffeine, sweets, and Acidic foods
Elevate HOB, including entire chest
Avoid recumbence until 2 hours after meals
Reduce meal size
Smoking cessation reduce alcohol consumption
weight loss if indicate
avoid bending, stooping, bending after meals
avoid tight clothing after meals

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

A. Submandibular
B. Tonsillar
C. Occipital
D. Posterior cervical
ANS: D

Feedback: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.

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

A. Weakness of CN III
B. Weakness of CN IV
C. A lesion of the brainstem
D. An irregularity in the cornea or lens
ANS: D

Feedback: Double vision in one eye alone points to a problem in “processing” the light rays of an incoming image. The other causes of diplopia result in a misalignment of the two eyes

What is the normal disc to cup ratio?
1:3

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

A. Talkative patient
B. Angry patient
C. Silent patient
D. Happy Patient
ANS: C

A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent left- sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthy- appearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. Which disorder of the chest best describes these symptoms?

A. Angina pectoris
B. Pericarditis
C. Dissecting aortic aneurysm
D. Pleural pain
ANS: A

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

A. CN IX lesion on the left
B. CN IX lesion on the right
C. CN X lesion on the left
D. CN X lesion on the right
ANS: D

Feedback: The failure of the right side of the palate to rise denotes a problem with the right 10th cranial nerve. The uvula deviates toward the properly functioning side.

A 73-year-old retired accountant comes to your office for her annual examination. She has incontinence of urine when she coughs or sneezes. She takes several medications for control of hypertension and diabetes. You use the DIAPERS mnemonic to assess the cause of her incontinence. All of the following are items represented by the mnemonic except for:

A. Atrophic vaginitis
B. Depression
C. Pharmaceuticals
D. Restricted mobility
ANS: B

Feedback: Depression is not a risk factor for incontinence. The D in the mnemonic stands for delirium.

DIAPERS is the mnemonic used for new-onset of incontinence

What are the clinical findings of a patient with cirrhosis?
Enlarged liver with irregular borders, cliff is present upon palpation
ascites
jaundice
N/V
Anorexia
Elevated LFT’s

Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the symphysis pubis. What does this most likely represent?

A. Sigmoid mass
B. Tumor in the abdominal wall
C. Hernia
D. Enlarged bladder
ANS: D

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

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

A. Clanging
B. Echolalia
C. Confabulation
D. Perseveration
ANS: D

Feedback: Perseveration is the repetition of words or ideas. Echolalia differs in that the patient repeats what is said to him. Clanging is the repetition of the same sounds in different words. Confabulation is making up a story in response to a question. This is sometimes seen in chronic alcohol use with Korsakoff’s syndrome.

Mrs. Fletcher complains of numbness of her right hand. On examination, sensation of the volar aspect of the web of the thumb and index finger and the pulp of the middle finger are normal. The pulp of the index finger has decreased sensation. Which of the following is affected?

A. Median nerve
B. Ulnar nerve
C. Radial nerve
D. Iliac nerve
ANS: A

Feedback: The pulp of the index finger is innervated by the median nerve. A decrease in sensation at this area would support a diagnosis of carpal tunnel syndrome. The pulp of the fifth finger is supplied by the ulnar nerve, and the dorsal web space of the thumb and index finger is supplied by the radial nerve.

this type of pain is also seen with carpal tunnel

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

A. Intermittent claudication
B. Chest pressure with exertion
C. Shortness of breath
D. Knee pain
ANS: A

Feedback: Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of patients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle brachial index can help detect this problem.

additional symptoms of intermittent claudication are abnormal pedal pulses, femoral artery bruit, delayed venous filling time, cool skin, and abnormal skin color

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

A. Arterial insufficiency
B. Neuropathic ulcer
C. Venous insufficiency
D. Trauma
ANS: C

Feedback: These features are most consistent with venous insufficiency. You may also see scaling, redness, varicosities, and other findings. Arterial insufficiency usually affects distal or traumatized areas. Other clues of arterial insufficiency would most likely be present. Neuropathic ulcers occur because of decreased sensation and are common in patients with neuropathy. They are often over bony prominences with surrounding calluses.

A 7-year-old child is brought to your clinic by her mother. The mother states that her daughter is doing poorly in school because she has some kind of “ADD” (attention deficit disorder). You ask the mother what makes her think the child has ADD. The mother tells you that both at home and at school her daughter will just zone out for several seconds and lick her lips. She states it happens at least four to six times an hour. She says this has been happening for about a year. After several seconds of lip-licking her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The patient’s parents are both healthy and no other family members have had these symptoms. What type of seizure disorder is she most likely to have?

A. Generalized tonic-clonic seizure
B. Generalized absence seizure
C. Simple partial seizure (Jacksonian)
D. Complex partial seizure
ANS: B

Feedback: In an absence seizure there is no tonic–clonic activity. There is a sudden, brief lapse of consciousness with blinking, staring, lip-smacking, or hand movements that resolve quickly to full consciousness. It is easily mistaken for daydreaming or ADD. Some will try to induce these episodes with hyperventilation.

A 37-year-old insurance agent comes to your office, complaining of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn’t feel particularly nervous when this occurs but she worries that other people will think she has an anxiety disorder or that she’s a drinker. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married and has three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form she has obvious tremors in her dominant hand. What type of tremor is she most likely to have?

A. Resting tremor
B. Postural tremor
C. Intention tremor
D. Excited tremor
ANS: C

Feedback: Intention tremors are absent at rest or in a postural position and occur only with intentional movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) or in multiple sclerosis. This patient’s tremor, fatigue, bladder problems, and visual problems are suggestive of multiple sclerosis.

A 77-year-old retired school superintendent comes to your office, complaining of unsteady hands. He says that for the past 6 months, when his hands are resting in his lap they shake uncontrollably. He says when he holds them out in front of his body the shaking diminishes, and when he uses his hands the shaking is also better. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for over 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister who has arthritis problems. His children are all essentially healthy. On examination you see a fine, pill-rolling tremor of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back toward you. He has almost no “arm swing” with his gait. What type of tremor is he most likely to have?

A. Resting tremor
B. Postural tremor
C. Intention tremor
D. Excited tremor
ANS: A

Feedback: Resting tremors occur when the hands are literally at rest, such as sitting in the lap. These are slow, fine tremors, such as the pill-rolling seen in Parkinson’s disease, which this patient most likely has. Decreased arm swing with ambulation is one of the earliest objective findings of Parkinson’s disease.

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

A. Closure of the tricuspid valve
B. Opening of the pulmonic valve
C. Closure of the aortic valve
D. Production of the first heart sound (S1)
ANS: C

Feedback: At the beginning of diastole, the valves which allow blood to exit the heart close. It is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the mitral valve is thought to produce the first heart sound (S1).

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

A. Malabsorption syndrome
B. Osmotic diarrhea
C. Secretory diarrhea
D. Irritable Bowel Syndrome
ANS: B

Feedback: Usually related to lactose intolerance, watery diarrhea often follows meal ingestion. Crampy abdominal pain, distension, and gas often accompany symptoms. Diarrhea is often provoked by pizza, milkshakes, yogurt, and other lactose-containing foods. This condition is more common in African-Americans, Latinos, Native Americans, and Asians

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

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
ANS: C

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

A. Benign positional vertigo
B. Vestibular neuronitis
C. Ménière’s disease
D. Acoustic neuroma
ANS: A

Feedback: This is a classic description of benign positional vertigo. The vertigo is episodic, lasting a few seconds to minutes, instead of continuous as in vestibular neuronitis. Also, there is no tinnitus or sensorineural hearing loss as occurs in Ménière’s disease and acoustic neuroma. You may choose to learn about Hallpike maneuvers, which are also helpful in the evaluation of vertigo.

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

A. Narcissistic
B. Paranoid
C. Histrionic
D. Avoidant
ANS: C

Feedback: The theatrical nature of her behavior as well as her overreaction leads to a diagnosis of histrionic character disorder.

When writing a SOAP note, what part would you put in quotes? Considered to be the patient’s own words
Chief Complaint

A patient states she is feeling just blah, nothing is going her way, nothing good ever happens, she states that her life sucks, what type of disorder would you say this is?
Dysthymic Mood

Dysthymia is a milder, but long-lasting form of depression. Patients can present with the following symptoms poor appetite or overeating; insomnia or excessive sleep; low energy or fatigue; low self-esteem; poor concentration or indecisiveness; and hopelessness

A 38-year-old accountant presents to the office with a series of generalized complaints. He relates that he feels a loss of pleasure in daily activities, has difficulty sleeping, and is experiencing problems making decisions. Which of the following best explains the patient’s presentation?

a. Substance abuse with anhedonia
b. Bipolar disorder in the early pre-excitatory phase
c. Histrionic personality
d. Depression
e. Antisocial personality
ANS: D

You order an EKG on your patient in bay #1, patient is a 25 year old male who appears healthy except his complaint today of a runny nose and cough. The nurse brings the EKG and it shows a HR of 25, what is your next step?
Have the nurse re-do the EKG

A 61-year-old retired librarian was recently diagnosed with ovarian cancer. She was otherwise healthy until her recent cancer diagnosis. She has not been feeling well lately and has had a cough and some mild shortness of breath for the past couple of days. She now presents to the clinic complaining of pain and swelling in her right groin and leg, which she says has been there for about a week but is worsening. On physical examination, 2+ edema of the right leg up to the thigh; 1+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses; and no significant erythema are noted. What is the chief concern with this patient?

A. Acute arterial occlusion
B. Ovarian metastasis
C. Pulmonary embolism (PE)
D. Acute Lymphangitis
ANS: C

Cancer patient are at high risk of deep venous thrombosis (DVT) and, with the presenting symptoms of swelling and pain in her groin, along with recent history of cough and shortness of breath, this patient’s presentation is suspicious for PE. Patients with DVT in the proximal leg veins are at high risk of thromboembolism.

if an ultrasound of the leg does NOT reveal a clot the next place to check is the lungs

When assessing for the femoral pulse, where should the clinician begin deeply palpating?

A. Above the inguinal ligament, just lateral to the symphysis pubis
B. Below the inguinal ligament, just medial to the anterior superior iliac spine
C. Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis.
D. Above the inguinal ligament, just medial to the anterior superior iliac spine.
ANS: C

The clinician would begin deeply palpating below the inguinal ligament, midway between the anterior superior iliac spine in the symphysis pubis.

A 55-year-old actress sustains a heart attack and the follow-up electrocardiogram demonstrates a left bundle branch block. What would be the likely duration of the QRS complex?

A. 125 milliseconds
B. 95 milliseconds
C. 90 milliseconds
D. 75 milliseconds
E. 100 milliseconds
ANS: A

The QRS complex is the duration of ventricular depolarization and is normally less than 100 milliseconds.

A 65-year-old overweight male presents at the clinic with hoarseness which has lasted for around 2 months. He thinks it began along with a cold. He is not feeling badly other than frequent heartburn, and he has continued to work as a bartender (for the past 30 years), but he is having difficulty being heard and understood because of his hoarse voice. A diagnosis that is on the differential list includes which of the following?

a. Voice strain from bartending and talking amidst loud ambient noise
b. Viral infection
c. Acid reflux
d. Inhalation of fumes
e. Environmental allergies
ANS: C

A 32-year-old day care worker presents with a worsening stiff, painful neck. On inspection, the patient’s head is laterally deviated toward the shoulder and rotated. At this point of the examination, what is the most likely diagnosis?

A. Torticollis
B. Osteoarthritis (OA)
C. Thoracic kyphosis
D. Ankylosing spondylitis
ANS: A

The characteristic physical signs of torticollis are head rotation and lateral deviation.

A patient that has a known history of cardiovascular disease including a myocardial infarction and positive ankle-brachial index indicating peripheral arterial disease in his left leg is now having some issues with erectile dysfunction (ED). The clinician suspects it may be due to medications or further vascular disease. He does not complain of any other symptoms. If his symptoms are related to vascular disease, where would the lesion likely be located?

a. Aortorenal
b. Iliac pudendal
c. Common femoral
d. Superficial femoral
e. Popliteal
ANS: B

A 21-year-old college student experiences tachycardia following a night of heavy drinking. She is advised to undergo a stress electrocardiogram (ECG). As she exercises, the recently calibrated pulse oximeter records a heart rate ranging from 25 beats per min at rest to 50 bpm while jogging. The test is stopped and restarted twice, and each time the pulse oximeter yields a resting heart rate of 25 and a jogging heart rate of 50. Which aspect of this instrument does the ECG technician question?

A. Validity
B. Prevalence
C. Predictive Value
D. Sensitivity
E. Specificity
ANS: A

Validity is a measure of “the true state of affairs” or accuracy. Prevalence is a measure of the proportion of a population with a particular condition at a particular moment in time. Sensitivity is defined as the proportion of patients with true disease who are accurately identified as positive by a particular test. (Sensitivity is also known as the true positive rate)

A 55-year-old air traffic control agent reports his home blood pressure log to clinic after he was diagnosed with hypertension at a prior visit. He notes that he consistently measures within the normal range at home, but seems to fall outside the normal range every time he comes to the clinic. Which of the following blood pressure measurements is considered to be most accurate (i.e., reflecting the patient’s “true” blood pressure)?

a. Blood pressure recorded in three positions in the health practitioner’s office
b. Three separate blood pressure measurements recorded by a medical technician within 90 minutes of awakening in the morning in an office setting using an automated device
c. Blood pressure recorded in three positions in the health practitioner’s office after resting for a 10-minute period in a supine position
d. Regular ambulatory monitoring recorded outside of the office setting
e. A total of six blood pressures averaged over three visits to a health practitioner’s office over a 3-month period
ANS: D

Patient mentions he smokes a pack of cigarettes a day for the last 20 years, what is he pack per year history?
20 cigarettes per pack

It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on

what spinal nerve assesses the Achilles Tendon reflex?
The Achilles reflex is a monosynaptic stretch reflex similar to the patellar reflex.

The Achilles reflex originates in the S1 and S2 nerve roots.

A student is practicing the performance of a lung examination on a classmate. Which of the following is the correct order for performing the components of the lung examination?

A. Inspection, Palpation, Percussion, and Auscultation
B. Auscultation, Inspection, Palpation, and Percussion
C. Auscultation, Percussion, Palpation, and Inspection
D. Auscultation, Inspection, Palpation, and Percussion
E. Inspection, Auscultation, Percussion, and Palpation
F. Palpation, Inspection, Auscultation, and Percussion
ANS: A

The orderly fashion in which lung examination is performed is inspection, palpation, percussion, and auscultation

A 16-year-old boy is brought to the ED after a motor vehicle accident for headaches
for 1 hour. A chest x-ray shows a rib fracture and a pneumothorax on the right side. The ED physician decides that a chest tube needs to be placed in the fouth intercostal space. How does he determine where the fourth intercostal space is?

A. He finds the clavicle. The second intercostal space is just below the clavicle. He then walks down to the third rib, third intercostal space, fourth rib, then the fourth intercostal space.
B. He finds the suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
C. He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to the fourth intercostal space.
D. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space
ANS: D

He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib, and then the fourth intercostal space.

Parents bring in their 3-year-old toddler, stating that he has been pulling at this right ear and fussing all day. Examination of the auditory canal shows a small green plastic toy pieces partially obstructing the passage. Which cranial nerve (CN) supplies the sensory innervation to that area and is conducting the boy’s pain sensation?

A. CN IX
B. CN XII
C. CN X
D. CN VII
E. CN XI
ANS: A

The glossopharyngeal nerve (CN IX, 9) is a mixed sensorimotor nerve; it innervates the muscles of the pharynx and provides sensory fibers to the portions of the tympanic membrane, auditory canal, pharynx, and the posterior third of the tongue.

Patient c/o double vision, which cranial nerves are affected?
CN 3(Oculomotor)
CN 4 (Trochlear)
CN 6 (Abducens)
extraocular movements, cardinal gaze

A 74-year-old man is being seen because of a 1-day history of a painful right eye. He also mentions that he has blurred vision in that eye. He thought something had blown into his eye, but after flushing it out, the pain and blurred vision remains. What is the best course of action?

a. Reassure him that pain from a foreign body can remain for a day or two (even after the foreign body is removed).
b. Perform a vision examination.
c. Perform a complete neurological examination.
d. Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma.
e. Check his blood pressure.
ANS: D

A patient with cystic fibrosis (CF) has been complaining of fullness in his left nasal cavity. Examination of his nose using an otoscope and a speculum reveals a normal nasal septum, but a pale, saclike growth of inflamed tissue that is obstructing a large part of the nasal cavity. What is the most likely diagnosis?

A. Ulcer
B. Nasal Polyp
C. Allergic Rhinitis
D. Deviated Nasal Septum
E. Viral Rhinitis
ANS: B

Nasal polyps are more likely in patients with CF.

Upon assessment your patient states ” I can’t keep a relationship, I’m ugly, and I want all the attention in the world” what type of personality disorder is this?
Borderline personality disorder

A patient’s weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?

A. Normal blood pressure
B. Prehypertension
C. Stage 1 hypertension
D. Stage 2 hypertension
ANS: B

According to the Seventh Report of the Joint National Committee (JNC 7) guidelines, prehypertension blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm Hg.

Normal BP is less than 120/80

What is OPQRST used for?
used to obtain HPI

Onset
Palliative/ Proactive
Quality
Radiating
Severity
Timing

What is the normal percussion sound heard when percussing the abdomen
Tympany

What sound is normally heard in the lungs?
Resonance

what is a abnormal percussion sound heard over inflated lungs, ex. emphysema
Hyper Resonance

The normal percussion sound heard over the liver
Dullness

The normal percussion sound heard over the bones and muscles
Flatness

A 39-year-old architect comes to the clinic for a 2-day history of fever, chills, cough productive of green sputum, and dyspnea. He has no history of serious illness. His temperature is 101.2ºF. His other vital signs are within normal limits. Late inspiratory crackles are heard on auscultation over the left lower lung posteriorly. When the clinician listens over that area and instructs the patient to say “ee,” it sounds like “A.” Which of the following would most likely be found on percussion of his lungs?

a. Flatness
b. Hyperresonance
c. Stridor
d. Tympany
e. Dullness
ANS: E

On examination of your patients heart you hear friction rub, what can this be indicative of?
Acute pericarditis

What is a differential diagnosis for a patient having a faint pulse on one side but the other side is regular?
Thrombus/Embolus

What is the test that is used to confirm acute appendicitis?
A positive McBurney’s sign

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

A. Otosclerosis of the left ear
B. Exposure to chronic loud noise of the right ear
C. Otitis media of the right ear
D. Perforation of the right eardrum
ANS: A

Feedback: The above pattern is consistent with a conductive loss on the left side. Causes would include: foreign body, otitis media, perforation, and otosclerosis of the involved side.

Inspect the ear for the above listed causes

As a person ages, what happens to their blood pressure
Systolic blood pressure increases. A systolic BP >150/90 may be normal in a patient over the age of 65

What is para-language?
The nonverbal elements of the voice, it is a primary aspect of speech that can affirm or belie a verbal message.

What does the cerebellar system control?
Coordinates motor Activity
Maintains equilibrium
Helps to control posture.
Helps coordinate eye movement
Speech (Pronunciation of repetitive words ” LALALA”)

If a patient had damage to their cerebellar system what symptoms might you see?
Ataxia
Decrease muscle tone
Nystagmus
Dysarthria

Auspitz sign
removal of scaling causes pinpoint bleeding seen in psoriasis

Herald patch + christmas tree
Pityriasis rosea

Initially when you start a patient interview you started with open-ended questions and progress to what type of questions?
focused

What are the sequence of events for conducting a patient interview?

1. Introduce yourself
2. Greet Patient
3. Establish rapport
4. Ask “what brings you in today?”
5. Listen
6. Establish the agenda (after 5 minutes summarize what you have heard)
7. Ask focused questions
8. Shared decision making in treatment plan

What is a review of systems?
pertinent positive and negatives based on body systems

A 53-year-old caterer comes to the clinic for a routine examination. She has type 2 diabetes mellitus, which is well controlled on medication. Her history from her last visit reveals that she smoked one pack of cigarettes a day at that time. The 5 As Model is a useful approach to take with trying to help patients to quit smoking. What is the 5 As Model?

a. Admonish, action, available, assess, alleviating factors
b. Agitate, assist, alleviating factors, able, action
c. Affable, associated manifestations, ask, admonish, available
d. Ask, advise, assess, assist, arrange
e. Arrange, aggravating factors, action, attitude, able
ANS: D

What is therapeutic communication?
Verbal and nonverbal communication techniques that encourage patients to express their feelings and to achieve a positive relationship.

What are the physical exam findings for otitis media?

1. Bulging, erythematous, and opaque tympanic membrane
2. Fever
3. Ear pain
4. kids will pull on their ear
5. babies will cry, refuse to take bottle

The patient presents with sudden bilateral ear loss what are the next steps?

1. Check to make sure nothing is occluding the canal
2. Perform Whisper, Rhine, and Weber tests
3. Refer them they need further evaluation

A patient has possible strep throat what will you see on physical exam that is indicative of this infection?

1. White patches (exudate) on tonsils
2. Enlarged tonsils, grade them, sit behind tonsillar pillars
3. Fever > 100.5
4. Enlargement of Submandibular and posterior cervical lymph nodes

Pt complains of sore throat but NO cough

If a patient is suspected of having asthma what specific questions should be asked in their family history?
If anyone has atopic dermatitis (eczema), allergies, or asthma

Atopic Triad

Exam findings of a patient with COPD

1. Chronic productive cough in the AM
2. Increased AP diameter
3. NO chest pain
4. clear tactile fremitus (will be louder)
5. Decreased breath sounds
6. Rhonchi on auscultation

Exam findings for PNA

1. Possible fever
2. Cough with sputum production
3. Chest pain
4. Crackles at the bases of the lungs
5. Dullness on percussion
6. Egophony (pt says “EEEE” but you hear “AAAAAA”)F

What is believed to cause IBS
Stress

What signs and symptoms may a person exhibit with IBS
Episodes of diarrhea or constipation

Abdominal cramping

In acute pancreatitis where is the patient going to complain of pain?
Pain starts in the epigastric area and moves to the left and go around to the back

The US Preventatitive Task Force according to Bate’s textbook recommends colonoscopy start when
Start at age 50 and stop at age 75 if there are no risk factors, no polyps on a recent colonoscopy

A 70-year-old male presents to the Emergency Department accompanied by his wife, who is concerned that he has experienced a stroke. She states that he awoke with drooping of the right side of his mouth. He has a history of hypertension and diet-controlled diabetes, but no history of prior transient ischemic attacks (TIAs), strokes, or neurologic deficits. Physical examination reveals a well-nourished, right-handed male, who has an obvious flattening of the right nasolabial fold at rest. He is unable to close his right eye, wrinkle his forehead, or raise his eyebrows. The remainder of the neurologic examination is symmetric with intact strength and normal deep tendon reflexes. Based on this history and physical examination, which of the following statements is true?

a. The patient most likely has a central upper motor neuron lesion involving cranial nerve (CN) VII (the facial nerve).

b. The patient most likely has a central process of unclear location; an acute ischemic event must be ruled out with an emergent computed tomography (CT) scan.

c. The patient most likely has had an embolic affecting an upper motor neuron (UMN).

d. The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve.

e. The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) V, the trigeminal nerve.
ANS: D

A 14-year-old student comes with her family to the urgent care center, having been hit in the right eye with a plastic baseball during a family reunion. She complains of a painful, watery, red right eye and sensitivity to light. She has normal visual acuity in both eyes, no diplopia, and can open and close her eyes normally. The pupils are unequal in size, 3 mm in diameter on the left, 5 mm in diameter on the right. Which cranial nerve (CN) would be implicated as the cause of the photosensitivity complaint and the pupillary asymmetry?

a. CN II
b. CN III
c. CN IV
d. CN V
e. CN VI
ANS: B

A 45-year-old physician is having increasing difficulty with speech for the past 6 months. She is less precise in pronunciation of words (dysarthria), has found it more effortful to speak, and finds that her voice sounds more nasal than usual. On examination, her articulation is less than precise, especially with rapid repetition of single syllables, such as “ta-ta-ta-ta,” “go-go-go-go,” “la-la-la-la,” and “ba-ba-ba.” Her neurological examination is otherwise normal. Which nervous system pathway is responsible for control of the muscles producing this symptom?

a. Corticospinal tract
b. Corticobulbar tract
c. Spinothalamic tract
d. Cerebellar system
e. Posterior column system
ANS: B

A 63-year-old practicing attorney makes an appointment with the office urgently for pain in his right leg for 3 days. Since working in the garden moving heavy bags of mulch for his wife this past weekend, he has had intermittent but excruciating pain shooting down the posterior aspect of his right leg. On examination, sensory loss to light touch in the right leg posteriorly, corresponding to a sacral 1 (S1) dermatome, is noted. Which reflex would be expected to be decreased compared to the other side?

a. Right plantar (Babinski)
b. Right ankle
c. Right knee
d. Left plantar (Babinski)
e. Left ankle
f. Left knee
ANS: B

When would you do PHQ-2 or PHQ-9 to evaluate for possible depression?
Patient complains of vague or somatic symptoms such as fatigue, headache. muscle aches for at least 2 weeks.

Findings for major depressive episode

1. Flat affect
2. Poor eye contact
3. Loss of interest in activities, work, or school
4. Overwhelming sadness/crying
5. Difficulty sleeping
6. Over or under eat

**No illusions, delusions, or hallucinations”

Symptoms for two months

What is flight of ideas?
An almost continuous flow of accelerated speech with abrupt changes from one topic to the next. Changes are based on understandable associations, plays on words, or distracting stimuli, but ideas are not well connected.

Flight of ideas is most frequently noted in manic episodes

What is a positive predictive value?
The positive predictive value (PPV) is the probability that a person with a positive test has the disease

Example: a physical examination maneuver you can perform in adults with symptoms suspicious of carpal tunnel syndrome is the Phalen test, which has a PPV of 76%. This means that a patient with a positive Phalen test result has about a 76% probability of having carpal tunnel syndrome based on the gold-standard diagnostic test (i.e., an abnormal nerve conduction study)

A 32-year-old cabdriver complains of pain in his left leg. He has a history of type 2 diabetes, is a smoker, and recently was diagnosed with hypertension. He does not remember injuring his leg; however, he notes that there is a small wound on the lateral aspect of his mid-shin. Upon examination, some mild erythema surrounding the wound and flat, nonpalpable red streaks progressing up his leg are noted. What do these streaks likely represent?

a. Thrombus formation in a superficial vein
b. Dilated veins secondary to incompetent valves
c. Occluded arterial vessels
d. Draining lymphatic channels
e. Dilated arterioles
ANS: D

Who do we preform monofilament testing on?
Diabetics on the plantar side of feet to test for peripheral neuropathy

A 17-year-old woman presents with her parents to her primary care provider. She desires to utilize a tanning facility ahead of an upcoming event. Her parents have heard that this is a dangerous practice, although the tanning facility insists it is safe without risk of skin cancer in the future after tanning. Which of the following is true regarding ultraviolet (UV) light exposure and subsequent risk of skin cancer?

a. Chronic sun exposure confers greater risk for skin cancer than intermittent intensive exposure.

b. Tanning beds and sunlamps do not increase risks of skin cancer as they utilize UV wavelengths that are not carcinogenic.

c. Water-resistant sunscreens confer no advantage over water-soluble products.

d. Targeted messaging and practitioner reinforcement in primary care amplify sun-protective behaviors.

e. Sunscreen with a sun protective factor (SPF) of 15 blocks ~50% of UV-B light.
ANS: D

A 72-year-old retired woman presents to a primary care provider for evaluation of a suspicious mole. She noticed this lesion 3 weeks ago on her right flank in an area where she had previously seen no abnormality. She is very concerned about melanoma and asks if this could be a possible diagnosis and also wonders if this should have been noticed at her annual examination 7 months ago. Concerning the initial recognition of melanoma, which of the following is true?

a. The majority of melanomas are recognized during an annual physical examination.

b. Approximately 50% of melanomas are initially noticed by patients then brought to the attention of a practitioner.

c. General screening programs conducted by medical facilities identify ~75% of melanomas.

d. Most melanomas are initially identified in individuals with positive family histories by DNA analysis for causative genes.

e. Asymmetry of a mole is rarely associated with melanoma
ANS: B

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

A. Reassure him that there is nothing to worry about.
B. Do laboratory work to check for platelet problems.
C. Obtain an extensive history regarding blood problems and bleeding disorders.
D. Do a skin biopsy in the office
ANS: A

Cherry Angioma

A 51-year-old moderately overweight college professor visits the clinic with a complaint of chest pain after tennis matches. He jokes that his tennis partner “is in a lot better shape than I am” but says he is trying to keep up. Later in the day, a 28-year-old female student at the same college reports that “my chest often feels hot and tight.” She also feels stressed on the evening before mid-term exams. The clinician recommends an immediate evaluation for coronary artery disease (CAD) for the professor, but not the student. Why?

A. Positive predictive value of an observation is higher in a group with a higher prevalence of disease.
B. Positive predictive value of an observation is lower in a group with a higher prevalence of disease.
C. Negative predictive value of an observation is lower in a group with a higher prevalence of disease.
D. Negative predictive value of an observation is higher in a group with a higher prevalence of disease.
E. Positive predictive value of an observation is greater in older people than in younger people.
ANS: A

The predictive value of a test or observation depends heavily on the prevalence of the condition of the test or observation measures in the population being studied.

A young adult patient presents to the clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the examination continues, which of the following maneuvers would confirm a likely diagnosis?

A. Assess the lateral bending movement of his neck
B. Assess his ability to touch his toes
C. Check for listing of his trunk
D. Assess his ability to extend his back
E. Compare the strength of his trapezia muscles
ANS: E

One cause of winged scapula is the contralateral weakness of the trapezius muscle.

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?

A. Vestibular disease

B. Lesion of CN IX

C. Dysfunction of the cerebellum

D. Inability to understand directions

ANS: C

When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect.

An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation?

a. A large, firm fecal mass in the rectum
b. Decreased fecal bulk
c. Functional change in bowel movement
d. Spasm of the external sphincter
e. Impairment of autonomic innervations
ANS: C

A 72-year-old woman presents with concerns about several ruby-red spots on her chest and abdomen. She reports that these are growing in both size and number over time. On examination, the provider notes a number of cherry angiomas at the locations indicated by the patient. No other abnormalities are noted. Which of the following best describes the clinical characteristics and significance of a cherry angioma?

a. Cherry angiomas never show blanching under pressure.

b. Cherry angiomas are associated with liver disease and B vitamin deficiencies.

c. Cherry angiomas are benign and may increase in size and number with aging.

d. Cherry angiomas rarely occur on the trunk and are most often noted on the legs near veins.

e. Cherry angiomas are a marker for underlying pathology that requires additional evaluation.
ANS: C

A 33-year-old nurse presents with a history of weight gain, decreased energy, and menorrhagia over the past several months. Review of her family history reveals Hashimoto thyroiditis and hypothyroidism in four female first-degree relatives (her mother and three sisters). Which of the following skin findings best supports a diagnosis of clinical hypothyroidism?

a. Discoid rash, alopecia, oral ulcers, and Raynaud phenomenon
b. Warm moist skin, hyperpigmentation, and pretibial myxedema
c. Dry skin, myxedema, alopecia of the eyebrows, and brittle nails
d. Spider angiomas, telangiectasia, palmar erythema, and Terry nails
e. Thickened, taut skin with sclerodactyly and telangiectasia
ANS: C

A 17-year-old male presents to a sexually transmitted disease clinic at the behest of his brother, who convinced the patient to attend the clinic after he disclosed that he prefers homosexual partners but is afraid that his last partner may have given him an infection. The patient expresses to the intake nurse that he is unashamed of his sexual orientation and will not stay through the visit if he feels that he is dismissed or discriminated against because of it. The nurse practitioner receives this communication prior to entering the examination room and decides to employ active listening to best connect with the patient at this critical juncture in his care with the clinic. Which of the following is an example of an active listening technique?

a. Ignoring visual cues to focus on the patient’s exact words
b. Setting aside the patient’s emotional state to focus on his medical needs
c. Paring down the patient’s concerns to concrete medical needs
d. Using nonverbal communication to encourage the patient to expand their narrative
e. Considering a differential diagnosis while the patient is speaking to maximize the patient’s time with the provider
ANS: D

A 62-year-old former tennis pro obtained a home blood pressure cuff after an office measurement revealed that his blood pressure fell in the hypertensive range. At a follow-up visit, he questions the accuracy of the clinician’s blood pressure cuff and the veracity of his diagnosis of hypertension. Which of the following is true regarding blood pressures recorded in a practitioner’s office versus values obtained in the ambulatory setting?

a. The accepted normal values for blood pressure are lower for ambulatory measurements compared with office measurements.

b. Masked hypertension is a phenomenon whereby ambulatory blood pressure is measured in the normal range but measurement in the office is elevated.

c. The accepted normal values for blood pressure are the same for ambulatory measurements compared with office measurements.

d. Both systolic and diastolic measurements must be in the hypertensive range to confer cardiovascular risk on the patient.

e. The American Heart Association (AHA) has issued consensus statements regarding the number and timeframe for blood pressure measurement to guide practitioners in diagnosing hypertension.
ANS: A

A 72-year-old retiree presents to the cardiology clinic with palpitations after several months of symptoms. An electrocardiogram (ECG) shows a tachyarrhythmia, which the cardiologist diagnoses as atrial fibrillation. In measuring the blood pressure of a patient with chronic atrial fibrillation, which of the following statements is true?

a. The precise blood pressure is measured by taking the average of three pressures in both arms over a span of 20 minutes.

b. Single automated measurement in the office setting provides a reliable value for the true blood pressure.

c. Ambulatory monitoring over 2-24 hours is recommended because this rhythm produces variable and inconsistent blood pressures.

d. Measuring blood pressure in patients with atrial fibrillation is no different than measuring blood pressure in patients with normal cardiac rhythms.

e. Because atrial fibrillation is an uncommon arrhythmia, blood pressure management of these patients does not have widespread significance in office or ambulatory practice.
ANS: C

A 42-year-old architect presents with widespread pain complaints, including headaches almost daily, pain at the site of an old motor vehicle accident injury, and generalized achiness and hypersensitivity throughout the body. He recounts that his first episodes of ongoing pain occurred in his early 20s, and he has been to many practitioners over several years seeking a firm diagnosis and adequate treatment of his complaints. Which of the following statements is true regarding chronic pain?

a. Following assessment and evaluation, ~80% of patients with non-cancer-related pain report control of their symptoms.

b. Chronic pain is defined as pain not due to cancer or a recognized medical condition that persists for >3-6 months.

c. Chronic pain is defined as focused pain lasting >8 months following acute injury or illness.

d. In primary care practices, non-cancer-related chronic pain is seen in <10% of patients.

e. Pain that recurs at intervals of months or years is never considered to be “chronic pain.”
ANS: B

Disparities in pain treatment have been well described in numerous studies comparing Caucasian patients to those of African American and Hispanic origin. Which of the following statements is true concerning this issue?

a. Racial and ethnic biases are only relevant in geographic areas that have a history of racial and ethnic discrimination.

b. Racial and ethnic biases never involve two persons of the same race or ethnic group.

c. Language barriers do not contribute to the problem of racial and ethnic biases.

d. Biases of the treating clinician are associated with overtreatment of pain in minority patients and non-English speakers.

e. Biases of the treating clinician are associated with under-treatment of pain in minority patients and non-English speakers.
ANS: E

Concerning a patient that may demonstrate a diagnosis of aphasia, which of the following statements is true?

a. It involves a loss of the voice or a slurring or hoarseness of speech secondary to pathology of the larynx or its nerve supply.
b. It is best characterized by slurred speech with an associated defect in language control.
c. It is best characterized by involuntary, rhythmic, repetitive movements involving the tongue and jaws making speech difficult to comprehend.
d. The ability to write a full correct sentence does not rule out the presence of aphasia in a patient.
e. It is defined as an inability to produce or understand language.
ANS: E

A 14-year-old high school student comes to the clinic for a 3-month history of periodic dyspnea when playing basketball. It resolves shortly after resting. He has not had fever, chills, cough, sputum production, or chest pain. He has no history of serious illness. Based on the boy’s history, asthma is suspected. Which of the following sounds heard on expiration during lung auscultation would be most suggestive of asthma?

a. Mediastinal crunch
b. Pleural rub
c. Rhonchi
d. Wheezes
e. Stridor
ANS: D

sources;

https://www.gcu.edu/

https://yaveni.com/