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Question 1

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

A) Add a fourth medicine
B) Refer to nephrology
C) Get a CT scan
D) Listen closely to her abdomen

Answer 1

D

Question 2

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

A) Check an ultrasound of the liver
B) Obtain a hepatitis panel
C) Determine liver span by percussion
D) Adopt a “watchful waiting” approach

Answer 2

C

Question 3

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

A) His spleen is definitely enlarged and further workup is warranted.
B) His spleen is possibly enlarged and close attention should be paid to further examination.
C) His spleen is possibly enlarged and further workup is warranted.
D) His spleen is definitely normal.

Answer 3

B

Question 4

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

A) Ultrasound
B) Examination with the abdominal muscles tensed
C) Surgery referral
D) Determine size by percussion

Answer 4

B

Question 5

Mr. Kruger is an 84-year-old man 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

Answer 5

D

Question 6

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

Answer 6

A

Question 7

Which of the following is consistent with obturator sign?

A) Pain distant from the site used to check rebound tenderness
B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated
C) Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion
D) Pain that stops inhalation in the right upper quadrant

Answer 7

B

Question 8

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

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

Answer 8

D

Question 9

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

A) Malingering
B) Neuropathy
C) Ischemia
D) Physical abuse

Answer 9

C

Question 10

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

Answer 10

A

Question 11

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

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

Answer 11

D

Question 12

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

A) Size, symmetry, and skin color
B) Muscle bulk and tone
C) Nodules in joints
D) Lower extremity strength

Answer 12

A

Question 13

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

A) Checked for patency of the radial artery
B) Checked for patency of the brachial artery
C) Checked for patency of the ulnar artery
D) Checked for patency of the femoral artery

Answer 13

C

Question 14

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

A) Resistance varies linearly with the diameter.
B) Resistance varies proportionally to the second power of the diameter.
C) Resistance varies proportionally to the third power of the diameter.
D) Resistance varies proportionally to the fourth power of the diameter.

Answer 14

D (indirectly)

Question 15

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

A) Coldness and pallor of the legs
B) Relief of the pain with bending at the waist
C) Color changes of the skin
D) Swelling with tenderness of the skin

Answer 15

B

Question 16

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

A) Lower calf/superficial femoral
B) Erectile dysfunction/iliac or pudendal
C) Buttock/common femoral
D) Upper calf/tibial or peroneal

Answer 16

B

Question 17

Asymmetric BPs are seen in which of the following conditions?

A) Coronary artery disease
B) Congenital narrowing of the aorta
C) Diffuse atherosclerosis
D) Vasculitis, as seen in systemic lupus erythematosus

Answer 17

B

Question 18

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

A) Fingertips
B) Palms
C) Backs of fingers
D) Ulnar aspect of the hand

Answer 18

C

Question 19

A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a set of boxes that were heavier than usual. He also states that he has numbness and tingling in the left leg. He wants to know if he needs to be off of work. What test should you perform to assess for a herniated disc?

A) Leg-length test
B) Straight-leg raise
C) Tinel’s test
D) Phalen’s test

Answer 19

B

Question 20

A 50-year-old realtor comes to your office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she didn’t think that she needed to go to the emergency room at that time. Now, she has severe pain and stiffness in her neck. On physical examination, you note pain and spasm over the paraspinous muscles on the left side of the neck, and pain when you make the patient do active range of motion of the cervical spine. What is the most likely cause of this neck pain?

A) Simple stiff neck
B) Aching neck
C) Cervical sprain
D) Cervical herniated disc

Answer 20

C

Question 21

A 28-year-old graduate student comes to your clinic for evaluation of pain “all over.” With further questioning, she is able to relate that the pain is worse in the neck, shoulders, hands, low back, and knees. She denies swelling in her joints; she states that the pain is worse in the morning; there is no limitation in her range of motion. On physical examination, she has several points on the muscles of the neck, shoulders, and back that are tender to palpation; muscle strength and range of motion are normal. Which of the following is likely the cause of her pain?

A) Rheumatoid arthritis
B) Osteoarthritis
C) Fibromyalgia
D) Polymyalgia rheumatica

Answer 21

C

Question 22

A 68-year-old retired banker comes to your clinic for evaluation of left shoulder pain. He swims for 30 minutes daily, early in the morning. He notes a sharp, catching pain and a sensation of something grating when he tries overhead movements of his arm. On physical examination, you note tenderness just below the tip of the acromion in the area of the tendon insertions. The drop arm test is negative, and there is no limitation with shoulder shrug. The patient is not holding his arm close to his side, and there is no tenderness to palpation in the bicipital groove when the arm is at the patient’s side, flexed to 90 degrees, and then supinated against resistance. Based on this description, what is the most likely cause of his shoulder pain?

A) Rotator cuff tendinitis
B) Rotator cuff tear
C) Calcific tendinitis
D) Bicipital tendinitis

Answer 22

A

Question 23

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

Answer 23

B

Question 24

Mark is a contractor who recently injured his back. He was told he had a “bulging disc” to account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the spine involve which type of joint?

A) Synovial
B) Cartilaginous
C) Fibrous
D) Synostosis

Answer 24

B

Question 25

A 58-year-old man comes to your office complaining of bilateral back pain that now awakens him at night. This has been steadily increasing for the past 2 months. Which one of the following is the most reassuring in this patient with back pain?

A) Age over 50
B) Pain at night
C) Pain lasting more than 1 month or not responding to therapy
D) Pain that is bilateral

Answer 25

D

Question 26

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

Answer 26

B

Question 27

Phil comes to your office with left “shoulder pain.” You find that the pain is markedly worse when his left arm is drawn across his chest (adduction). Which of the following would you suspect?

A) Rotator cuff tear
B) Subacromial bursitis
C) Acromioclavicular joint involvement
D) Adhesive capsulitis

Answer 27

C

Question 28

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

Answer 28

C

Question 29

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

Answer 29

B

Question 30

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) Brachial nerve

Answer 30

A

Question 31

A 50-year-old woman presents with “left hip pain” of several weeks duration. There is marked tenderness when you press over her proximal lateral thigh. What do you think she has?

A) Osteoarthritis
B) Rheumatoid arthritis
C) Sciatica
D) Trochanteric bursitis

Answer 31

D

Question 32

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) Movement tremor

Answer 32

A

Question 33

A 48-year-old grocery store manager comes to your clinic, complaining of her head being “stuck” to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot get it moved back to normal. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is on oral medication for each. She is married and has three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. On examination you see a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left but otherwise her examination is normal.

What form of involuntary movement does she have?

A) Chorea
B) Asbestosis
C) Tic
D) Dystonia

Answer 33

D

Question 34

A 41-year-old real estate agent comes to your office, complaining that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy and as the day progressed he was unable to close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. His past medical history is unremarkable. He is divorced and has one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination you ask him to close his eyes. He is unable to close his left eye. You ask him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. You then ask him to give you a big smile. The right corner of his mouth raises but the left side of his mouth remains the same.

What type of facial paralysis does he have?

A) Peripheral CN V paralysis
B) Central CN V paralysis
C) Peripheral CN VII paralysis
D) Central CN VII paralysis

Answer 34

C

Question 35

A 17-year-old high school student is brought in to your emergency room in a comatose state. His friends have accompanied him and tell you that they have been shooting up heroin tonight and they think their friend may have had too much. The patient is unconscious and cannot protect his airway, so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. Preparing to finish the neurologic examination, you get a penlight.

What size pupils do you expect to see in this comatose patient?

A) Pinpoint pupils
B) Large pupils
C) Asymmetric pupils
D) Irregularly shaped pupils

Answer 35

A

Question 36

Steve has had a stroke and comes to you for follow-up today. On examination you find that he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the following?

A) The corticospinal tract
B) The cerebellum
C) The cerebrum
D) The basal ganglia

Answer 36

D

Question 37

A patient with a history of seizure disorder and on several seizure medications says a friend noted “jumping eye movements.” The patient describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago. On examination you note that the eyes both slowly move to the right and then quickly jump to the left. Which of the following is true?

A) This is called nystagmus to the left
B) This is called saccadic eye movement
C) This represents a subclinical seizure
D) This most likely has an ominous cause

Answer 37

A

Question 38

You are testing the biceps strength in a young man following a spinal trauma from a motor vehicle accident. He cannot lift his hand upward, but if the arm is abducted to 90 degrees, he can then move his forearm side to side. This would represent which muscle strength grading?

A) I
B) II
C) III
D) IV

Answer 38

B

Question 39

You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward. This is most likely a problem with which part of the nervous system?

A) Corticospinal tract
B) Spinothalamic tract
C) Thalamus
D) Dorsal root ganglion

Answer 39

A

Question 40

You are examining a child with severe cerebral palsy. When you suddenly move his foot dorsally, a sustained “beating” of the foot against your hand ensues. What does this represent?

A) A focal seizure
B) Clonus
C) Extinction
D) Reinforcement

Answer 40

B

Question 41

A patient with alcoholism is brought in with confusion. You ask him to “stop traffic” with his palms and notice that every few seconds his palms suddenly move toward the floor. What does this indicate?

A) Stroke
B) Metabolic problems
C) Carpal tunnel syndrome
D) Severe fatigue and weakness

Answer 41

B

Question 42

You examine a “sleepy” patient. You note that she will open her eyes and look at you but responds slowly and is confused. She does not appear interested in her surroundings. How would you describe her level of consciousness?

A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose

Answer 42

B

Question 43

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen “staring off into space” and not paying attention. If this is a seizure, it most likely represents which type?

A) Pseudoseizure
B) Tonic–clonic seizure
C) Absence
D) Myoclonus

Answer 43

C

Question 44

A patient comes to you because she is experiencing a tremor only when she reaches for things. This becomes worse as she nears the “target.” When you ask her to hold out her hands, no tremor is apparent. What type of tremor does this most likely represent?

A) Intention tremor
B) Postural tremor
C) Resting tremor
D) Nervous tremor

Answer 44

A

Question 45

A young woman comes in with brief, rapid, jerky, irregular movements. They can occur at rest or during other intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements?

A) Tics
B) Dystonia
C) Athetosis
D) Chorea

Answer 45

D

Question 46

A mother brings her 15-month-old daughter to your office for evaluation of a rash and fever. She says the rash started one day and the fever developed the next day. Her daughter has had all of her vaccinations up to 10 months. The mother sheepishly admits that she hasn’t had time to bring her daughter in since her 10-month check-up. On examination you see a mildly sick-appearing toddler with a 102-degree temperature. Looking at her skin you see at least 100 of a variety of papules, vesicles, and ulcers in different stages of development.

What illness prevented by proper vaccination does this toddler have?

A) Varicella (chickenpox)
B) Measles
C) Smallpox
D) Hand-foot-mouth disease

Answer 46

A

Question 47

Which of the following will help to optimize yield from a pediatric examination?

A) Doing the examination out of order if necessary to take advantage of quiet periods for auscultation, etc.
B) Being very orderly, so as not to miss a portion of the examination
C) Using firmness as needed to make it through your examination
D) Making sure to place the infant on the table during the examination while mom watches close by

Answer 47

A

Question 48

A 6-month-old infant is brought in for a well check. It is noted his head circumference is off the chart and at a much higher percentile than was previously measured. What should you do next?

A) Recommend a neurology consult.
B) Order a CT of the head.
C) Remeasure the circumference.
D) Admit the child to the hospital for further workup.

Answer 48

C

Question 49

You are assessing an infant and notice that his nares flare, he has a soft grunt with each breath, and the skin between his ribs is pulled inward with inhalation. What is the significance of these findings?

A) These are indicative of a CNS process.
B) These are indicative of respiratory distress.
C) These are indicative of muscular dystrophy.
D) These are frequently accompanied by stridor.

Answer 49

B

Question 50

You have been unable to hear normal S2 splitting in children up to this point. What technique will maximize your chances of hearing this phenomenon?

A) Listen with the diaphragm over the left lower sternal border.
B) Listen with the bell over the 2nd left intercostal space.
C) Listen with the bell over the apex.
D) Listen with the diaphragm in the axilla.

Answer 50

B

Question 51

You are having trouble examining the abdomen of a school-aged child due to ticklishness. What should you do?

A) Have the child press on your hand.
B) Have the parent insist that the child allow you to examine her.
C) Ask the parent to leave the room.
D) Make the child realize that this is part of the examination and must be done.

Answer 51

A

Question 52

You are going to obtain a social history on an early adolescent boy. How should you proceed to obtain the best information?

A) Ask his mother to leave the room.
B) Ask if he would prefer his mother to leave the room.
C) Ask your questions with his mother in the room.
D) Ask his mother how she would like to proceed.

Answer 52

A

Question 53

A quiet 3-year-old is brought in for a routine check-up when you notice a fresh bruise in the axilla and bilateral bruises over the upper back that appear slightly older. There are brown bruises over his shins as well. His mother said this happened when he fell off of a couch. What diagnosis should be considered?

A) Von Willebrand’s disease
B) Normal childhood bruises from activity
C) Abuse
D) Seizure disorder

Answer 53

C