APEA ONLY Flashcards

Question

Indicators of oropharyngeal dysphagia include all of the following symptoms except: a. Drooling b. Nasopharyngeal regurgitation c. Cough d. Vomiting

Answer 1

d. Vomiting **APEA Gastroenterology

Answer 2

b. Tenesmus **APEA Gastroenterology

Answer 3

b. Loss of lean body mass and strength with aging **APEA Gastroenterology

Answer 4

b. Intestinal obstruction **APEA Gastroenterology

Answer 5

a. Hemorrhoids **APEA Gastroenterology

Answer 6

a. Tympany **APEA Gastroenterology

Answer 7

b. Anorectal fistula **APEA Gastroenterology When performing a rectal exam, if a tender, purulent, reddened mass is palpated, consider an anal abscess, especially in the presence of fever and chills. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining anorectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Rectal carcinoma may present with pain along with bleeding from the rectum and changes in bowel habits. Genital warts present as tiny growths and may increase in size to that of a pea. They are usually non-tender and are not associated with rectal discharge.

Answer 8

d. Adenomatous polyps **APEA Gastroenterology Blood in the stools, hematochezia, is often the only symptom seen with adenomatous polyps. Although adenomatous polyps are benign, they are the most common cause of colorectal cancer. Lower abdominal pain accompanied by fever or shock in older adults could be consistent with ischemic colitis. Generally, the abdomen is soft on palpation. Hemorrhoids typically present with noticeable blood on the tissue paper, surface of stool, or dripping in the toilet. Colon cancer can cause bloody stool but usually presents with changes in bowel habits and weight loss.

Answer 9

c. Peritonitis **APEA Gastroenterology

Answer 10

Back **APEA Gastroenterology Referred pain of duodenal or pancreatic origin may be perceived in the back. Referred pain from the biliary tree may be perceived in the right shoulder or the right posterior chest. Heartburn may be associated with retrosternal pain.

Answer 11

b. A pilonidal cyst **APEA Gastroenterology Pilonidal cyst is a fairly common, probably congenital, abnormality located in the midline superficial to the coccys or the lower sacrum. The opening may exhibit a small tuft of hair surrounded by a halo of erythema. Although Pilonidal cysts are generally asymptomatic, they may drain, form abscesses, or secondary sinus tracts.

Answer 12

b. Right-sided heart failure **APEA Gastroenterology An enlarged liver with a smooth, tender edge suggests inflammation, as in hepatitis, or venous congestion, as in right-sided heart failure. Cirrhosis, hematochromatosis (increased amount of iron in the blood), and lymphoma produce an enlarged liver with a firm, non-tender edge. An enlarged liver that is firm or hard and has an irregular edge or surface suggests hepatocellular carcinoma

Answer 13

b. Hepatocellular carcinoma **APEA Gastroenterology An enlarged liver that is firm or hard and has an irregular edge or surface suggests hepatocellular carcinoma. There may be one or more nodules. The liver may or may not be tender. With cirrhosis, the liver is enlarged with a firm, non-tender edge.

Answer 14

a. The bite of a blood-sucking insect **APEA Gastroenterology Helminths are worm-like organisms living in and feeding on living hosts, receiving nourishment and protection while disrupting their hosts' nutrient absorption, causing weakness and disease. They are transmitted via fecal-oral ingestion, ingestion of infected pork, via sexual contact, and through skin penetration. Examples of helminths are tapeworms, pinworms, and hookworms. Venom is transmitted by arachnids and insects. Casual contact and body fluids are not modes of transmission for helminths

Answer 15

b. 24 pounds **APEA Gastroenterology Normal infants double their birth weight at 6 months and triple their birth weight at one year of age.

Answer 16

b. Intussusception **APEA Gastroenterology Intussusception generally occurs in children without a history of chronic GI problems. Pain progresses from colicky-like, intermittent discomfort to a more constant, intense pain. Vomiting may occur and the child may pass "currant jelly-like" stools due to the blood/mucus from inflammation secondary to intussusception. These are classic signs of intussusception. The other choices do not present with these symptoms.

Answer 17

a. A prolapsed internal hemorrhoid **APEA Gastroenterology Internal hemorrhoids are enlargements of the normal vascular cushions located above the pectinate line. They are not usually visible but may become visible if prolapse occurs after defecation. They would appear in the anal canal as reddish, moist, protruding masses. External hemorrhoids are dilated hemorrhoidal veins that originate below the pectinate line and are covered with skin. They present as tender, swollen, bluish, ovoid masses at the anal margin. A tender, purulent, reddened mass palpated in the rectum would be consistent with an anal abscess, especially in the presence of fever and chills. Rectal polyps are typically located in the rectum and, if palpated, feel soft to touch.

Answer 18

d. Crohn's disease **APEA Gastroenterology Crohn's disease usually presents with blood, mucus, or puss in the stool. Thin, pencil-like stool occurs in an obstructing "apple-core" lesion of the sigmoid colon. Constipation produces hard, dry stool. In the presence of hemorrhoids, the stool may appear blood streaked.

Answer 19

b. Hepatitis B **APEA Gastroenterology Hepatitis A is typically contracted via ingestion of food or water contaminated with the virus. Hepatitis C and D usually occur as a result of parenteral contact with body fluids infected with the virus. Hepatitis B can be transmitted from mothers to infants at time of birth or from a family member to the infant early in childhood.

Answer 20

c. Liver disease **APEA Gastroenterology Jaundice, spider angiomas and other telangiectasias, palmar erythema, Terry's nails, pruritis, purpura, and caput medusae are skin conditions associated with liver disease.

Answer 21

a. A gastric ulcer **APEA Gastroenterology Pain associated with peptic ulcers is dull and achy and usually occurs with eating. With a duodenal ulcer, the pain is relieved by eating. Dumping syndrome is usually seen following gastric surgery when the pylorus is bypassed. Depending on the time following ingestion of food, symptoms can include GI cramping, diarrhea, syncope, tachycardia, sweating, and high-pitched bowel sounds. Pancreatitis pain is caused by edema and inflammation and may be referred posteriorly because of its retro peritoneal position

Answer 22

b. liver **APEA Gastroenterology The liver is located in the RUQ below the right costal margin. The five percussion notes include: tympany, dullness, flatness, resonance, and hyperresonance. Tympanic or tympanitic, are drum-like sounds heard over air-filled structures during the abdominal exam. Hyperresonant (pneumothorax) sound similar to percussion of puffed up cheeks. Normal resonance/resonant is the sound produced by percussing a normal chest. A dull (consolidation) sound is similar to percussion of a mass such as a liver. Stony dull or flat sounds are produced on percussion from the pleximeter with no contribution from the underlying area.

Answer 23

b. A lesion in the sigmoid colon **APEA Gastroenterology

Answer 24

b. Ask the patient to cough prior to palpation **APEA Gastroenterology Abdominal pain and tenderness are usually associated with muscle spasms and suggest inflammation of the peritoneum. Before palpating the abdomen, ask the patient to cough because if coughing increases the abdominal pain this suggests inflammation. Deep palpation is not recommended with inflammation. When assessing for rebound tenderness, do it firmly and quickly. A bruit would not denote inflammation but it would denote arterial obstruction. Bowel sounds would be decreased and eventually absent in the presence of peritonitis or in an adynamic ileus.

Answer 25

b. Melena **APEA Gastroenterology Acholic refers to pale or clay-colored stools. A term used to describe red blood in the stool is hematochezia. Steatorrhea refers to the presence of excess fat in the stool.

Answer 26

b. Ascending colon **APEA Gastroenterology If blood occurs in the stool in right-sided colon cancers or gastric ulcers, the stool will be black and tarry. Bright red blood is more characteristic of left-sided colon cancer or rectal hemorrhoids.

Answer 27

a. Psoas sign **APEA Gastroenterology Flexion of the leg at the hip causes the psoas muscle to contract. If there is an increase in abdominal pain, this is a positive psoas sign. This is consistent with an inflamed appendix. Pain in the right lower quadrant during left-sided pressure is a positive Rovsing's sign. This can be positive with appendicitis. A sharp increase in tenderness is a positive Murphy's sign, and consistent with acute cholecystitis. Right hypogastric pain constitutes a positive obturator sign, from irritation of the obturator muscle by an inflamed appendix.

Answer 28

a. Cirrhosis **APEA Gastroenterology

Answer 29

d. Gastroesophageal reflux **APEA Gastroenterology GERD symptoms include dyspepsia, frequent belching with a sour taste, chest pain after eating or lying down, straining or lifting, increased salivation, and history of high stress levels.

Answer 30

d. Right scapula area **APEA Gastroenterology Acute cholecystitis presents with right upper quadrant and upper abdominal pain radiating to the right scapular area. It is usually steady and aching. Pain in the epigastric area could be associated with peptic ulcer or dyspepsia. Cancer of the stomach can present with epigastric pain. Acute mechanical colon obstruction presents with pain in the lower abdomen.

Answer 31

c. Travelers to endemic areas **APEA Gastroenterology Exposure to infected blood in ANY situation can be a risk. International travelers to endemic areas is consistent with risk factor for Hepatitis A, not Hepatitis B.

Answer 32

c. Anal abscess **APEA Gastroenterology If a tender, purulent, reddened mass is palpated, consider anal abscess, especially in the presence of fever and chills. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining anorectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Rectal carcinoma may present with pain but is not usually accompanied by fever. Other symptoms may include bleeding from the rectum and changes in bowel habits. Genital warts present as tiny growths and may increase in size to that of a pea. They are usually non-tender.

Answer 33

b. Lateral decubitus position **APEA Gastroenterology Left side-lying position (Lateral decubitus) is satisfactory for rectal exam and allows good visualization of the perianal and sacrococcygeal areas.

Answer 34

c. Density of tissues and organs **APEA Gastroenterology

Answer 35

b. Esophageal dysphagia **APEA Gastroenterology Pain associated with diabetic gastroparesis is located in the upper abdomen. The pain associated with oropharyngeal dysphagia is usually located in the cervical neck region. Esophageal varices may be retrosternal.

Answer 36

c. Acute pancreatitis **APEA Gastroenterology Inflammation of the pancreas is poorly localized in the abdomen, therefore can be epigastric and may radiate to the posterior trunk. Biliary colic, sudden obstruction of the cystic or common bile ducts by a gallstone is characterized by pain in the epigastric or right upper quadrant and may radiate to the right scapula or shoulder. Pain in the periumbilical area that radiates to the right lower quadrant is usually seen in patients who have appendicitis. Stomach cancer presents with pain in the patient's epigastric area.

Answer 37

c. A large solid tumor **APEA Gastroenterology A solid mass gives a dull sound on percussion.

Answer 38

d. Rhinitis **APEA Gastroenterology Respiratory symptoms associated with GERD may include coughing, wheezing, asthma, aspiration pneumonia.

Answer 39

b. An anal fissure **APEA Gastroenterology A linear crack or tear suggests an anal fissure from large hard stools, inflammatory bowel disease, or sexually transmitted diseases.

Answer 40

a. Rectal carcinoma **APEA Gastroenterology Syphilitic chancre appears as a firm, painless ulcer and suggests the chancre of primary syphilis. A tender, purulent, reddened mass palpated in the rectum would be consistent with an anal abscess, especially in the presence of fever and chills. Genital warts present as tiny growths and may increase in size to that of a pea and are usually non-tender and not associated with anal discharge.

Answer 41

d. Exposure to needle sticks **APEA Gastroenterology Risk factors for Hep A: Traveling internationally to endemic areas, eating food or drinking water contaminated with HAV, male-male partners, and persons with chronic liver disease. Being exposed to needlesticks on the job is a risk usually associated with Hepatitis B

Answer 42

d. Heartburn **APEA Gastroenterology Heartburn is a rising retrosternal burning pain or discomfort. Can be aggravated by chocolate, coffee, alcohol, onions, tomato sauce, or bending over or lifting. Dyspepsia is chronic or recurrent discomfort or pain centered in the upper abdomen. Odynophagia is pain on swallowing and could be associated with esophagitis, peptic strictures, or Barrett's esophagus. Dysphagia is difficulty swallowing and can be associated with some of the same conditions as odynophagia

Answer 43

c. Diarrhea. **APEA Gastroenterology Diabetic gastroparesis occurs as a result of damage to the vagus nerve (controls the movement of food through the digestive system). Signs and symptoms associated with diabetic gastroparesis may include vomiting of undigested food, weight loss, erratic glucose levels, and gastroesophageal reflux. Diarrhea is not associated with this condition.

Answer 44

d. Inguinal hernia **APEA Gastroenterology

Answer 45

c. Epigastric or right upper quadrant with radiation to the right scapula and shoulder. **APEA Gastroenterology A is more indicative of peptic ulcers or dyspepsia. B is more indicative of appendicitis. D is more indicative of diverticulitis.

Answer 46

d. Visible peristalsis **APEA Gastroenterology In pyloric stenosis, visible peristalsis is seen because the stomach works to empty itself but the lumen is obstructed by the hyperplasia and hypertrophy of the pyloric muscle. The stomach is empty, not distended, due to repeated vomiting of feedings. Distended superficial veins and ascites have no relationship with pyloric stenosis, they are observed in biliary atresia.

Answer 47

c. 16-20 **APEA Gastroenterology Children get their first 20 deciduous teeth between the ages of 6 months and 5 years. Permanent teeth begin to erupt around 6 years of age when the deciduous teeth begin to fall out. All 32 permanent teeth usually erupt by late adolescence.

Answer 48

c. Gastroesophageal reflux **APEA Gastroenterology Patient gestures may indicate the etiology of some types of chest pain. A clenched fist over the sternum may suggest angina pectoris. A finger pointing to a tender area on the chest wall may suggest musculoskeletal pain. A hand moving from the neck to the epigastrium may suggest GERD.

Answer 49

a. Diabetic gastroparesis **APEA Gastroenterology Complaints of unpleasant abdominal fullness after a light or moderate meal, or the inability to eat a full meal is often seen in patients with diabetic gastroparesis, gastric outlet obstruction, gastric cancer, early satiety in hepatitis, or those taking anticholinergic medications.

Answer 50

b. Thirst and urine specific gravity of 1.038 **APEA Gastroenterology

Answer 51

b. Cancer of the sigmoid colon **APEA Gastroenterology

Answer 52

a. right hypogastric area **APEA Gastroenterology Assessment of the obturator sign is performed by flexing. By flexing the patient's right thigh at the hip with knees bent, rotating the leg internally at the hip. If this causes pain in the right epigastric area, then the obturator sign is positive. Hypogastric pain occurs as the obturator muscle rubs an inflamed appendix.

Answer 53

d. Jaundice **APEA Gastroenterology Obstruction of the common bile duct results in reflux of bile into the liver, thus, producing jaundice. Although nausea and right upper quadrant pain would occur, jaundice is the result of the obstruction. Steatorrhea is the presence of excessive fat in the stool and can be seen in patients with Crohn's disease but is not present in cholelithiasis. Elevated cholesterol levels are not indicative of an obstructed common bile duct.

Answer 54

c. Ischemic colitis **APEA Gastroenterology

Answer 55

a. Pain localized halfway between the umbilicus and the right iliac crest **APEA Gastroenterology A positive response over McBurney's point, the area located halfway between the umbilicus and the right iliac crest, would be highly suspicious for appendicitis. Positive rebound tenderness may also be present. Pain in the left lower quadrant could be suggestive of diverticulitis. Pain radiating from the abdomen to the back could be related to a peptic ulcer, perforation, or even pancreatitis.

Answer 56

c. Murphy's sign **APEA Gastroenterology Inspiratory arrest with deep palpation of the RUQ constitutes a positive Murphy's sign and is consistent with acute cholecystitis. Flexion of the leg at the hip resulting in increased abdominal pain is positive psoas sign and is consistent with inflamed appendix Pain in RLQ that occurs with palpation of the RLQ is Rovsing's sign and is consistent with appendicitis. A positive obturator sign occurs when the obturator muscle rubs inflamed appendix and produces right hypogastric pain.

Answer 57

d. An abdominal aneurysm is suspected **APEA Gastroenterology

Answer 58

b. Early intestinal obstruction **APEA Gastroenterology Bowel sounds may be increased in the presence of diarrhea or early intestinal obstruction Bowel sounds are decreased, then absent in adynamic ileus and peritonitis. They are decreased in constipation.

Answer 59

d. Intraperitoneal hemorrhage **APEA Gastroenterology Ecchymosis of the abdominal wall is seen in intraperitoneal or retroperitoneal hemorrhage. Pink-purple striae may indicate Cushing's syndrome. Dilated veins may indicate hepatic cirrhosis or inferior vena cava obstruction. Colorectal cancer does not exhibit ecchymosis.

Answer 60

a. right shoulder **APEA Gastroenterology

Answer 61

c. A rectal polyp **APEA Gastroenterology Rectal polyps are typically located in the rectum and if palpated, feel soft to touch and may be pedunculated (attached to the base tissue by means of a stalk).

Answer 62

b. Hepatic cirrhosis **APEA Gastroenterology

Answer 63

d. A hydrocele A hydrocele is defined as swelling in the scrotum that lights up on transillumination. Inguinal hernia and cryptorchidism are diagnosed using palpation of the scrotum and testicle and are not associated with fluid collection. Swelling of the scrotum and collection of serous fluid are not normal findings. **APEA Men's Health

Answer 64

d. Prostate Cancer **APEA Men's Health

Answer 65

a. Low flow priapism **APEA Men's Health Low flow priapism is common in sickle cell patients. Priapism is a penile erection lasting more than 4 hours without stimulation. Peyronie disease, acute balanitis, and opioid side effects result in an inability to achieve or difficulty maintaining an erection.

Answer 66

a. Testicles should descend by 6 months of age **APEA Men's Health Male infants with cryptorchidism experience incomplete descent of one or both testicles into the scrotum. Urology evaluation should be considered if the testicle is not descended by 6 months of age. Orchiopexy surgery is not performed until symptoms persist after 1 year. 75% of full-term and 95% of premature cryptorchid testes descent spontaneously by 1 year of age.

Answer 67

a. Epididymitis **APEA Men's Health Epididymitis is commonly caused by a sexually transmitted infection (STI) and presents as scrotal irritation, bilateral testicular pain, and enlarged lymph nodes. Urinary tract infections (UTIs) include symptoms associated with urination and do not usually feature testicular or scrotal involvement. Testicular torsion causes acute, unilateral testicular pain. Idiopathic sacral edema presents as swelling of the scrotum with fluid accumulation. It presents as unilateral erythema of the scrotal skin.

Answer 68

b. Spermatocele of the epididymis **APEA Men's Health A painless, movable cystic mass just above the testicle suggests a spermatocele or an epididymal cyst. Both transilluminate and are difficult to distinguish clinically. An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testicle. Additionally, the scrotum may be reddened and the vas deferens inflamed. Coexisting urinary tract infection, or prostatitis, supports the diagnosis. Varicocele refers to varicose veins of the spermatic cord, usually found on the left. It feels like a soft "bag of worms" upon palpation of the scrotum. Torsion, or twisting, of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. The scrotum becomes red and edematous. There is no associated urinary infection.

Answer 69

c. Cystoscopy **APEA Men's Health Cystoscopy would be completed by a urologist, not in the PCP setting.

Answer 70

b. Erectile dysfunction APEA Men's Health Hypogonadism is caused by changes in testosterone. Prostate enlargement occurs in most older men and is not specifically related to heart disease. Urinary incontinence is a symptom associated with enlarged prostate and is not specific to atherosclerotic changes.

Answer 71

d. Hypospadias **APEA Men's health Balanitis is an inflammation of the glans of the penis. Posthitis is an inflammation of the foreskin. Phimosis is a congenital narrowing of the opening of the foreskin so that it cannot be retracted

Answer 72

a. Scratching the medial aspect of the thigh **APEA Men's Health To elicit the cremasteric reflex: examine child when he is relaxed and have him sit crossed legged on the table. Palpate the scrotum. The child can also blow into a balloon, this would cause an increase in intra-abdominal pressure and stimulate the reflex. The cremasteric reflex can be tested by scratching the inside of the child's thigh.

Answer 73

c. Cough **APEA Men's Health

Answer 74

a. A digital rectal examination (DRE) **APEA Men's Health

Answer 75

a. Varicocele of the spermatic cord **APEA Men's Health Varicocele refers to varicose veins of the spermatic cord, usually found on the left. It feels like a soft "bag of worms" upon palpation of the scrotum. An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testicle. The scrotum may be reddened and the vas deferens inflamed. Epididymitis occurs usually in adults, who are infected with Chlamydia. Coexisting UTI or prostatitis support the diagnosis. A painless, movable cystic mass just above the testicle suggests a spermatocele or an epididymal cyst. Both transilluminate. Torsion, or twisting, of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. The scrotum becomes red and edematous. There is no associated urinary infection.

Answer 76

c. Prompt an urge to urinate **APEA Men's Health

Answer 77

b. Acute bacterial prostatitis **APEA Men's Health As palpated through the anterior rectal wall, the normal prostate is a rounded, heart-shaped structure, somewhat rubbery and non-tender. It measures approximately 2.5 cm long. In a patient with BPH, the gland feels enlarged and increases with age. BPH is present in more than 50% of men by 50 years of age. Carcinoma of the prostate gland is suggested by an area of hardness in the gland. A distinct hard nodule that alters the contour of the gland may or may not be palpable. However, as the cancer enlarges, the prostate feels irregular and may extend beyond the confines of the gland.

Answer 78

d. Cryptorchidism **APEA Men's Health Epispadias is present when the urethral orifice is located on the dorsal surface of the glans or shaft of the penis. A hydrocele denotes fluid in the scrotal sac. Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, reducing the testicle's blood supply resulting in ischemia of that testicle. This is a medical emergency.

Answer 79

c. Benign prostatic hyperplasia **APEA Men's Health As palpated through the anterior rectal wall, the normal prostate is a rounded, heart-shaped structure, somewhat rubbery and non-tender. It measures approximately 2.5 cm long. In a patient with BPH, the gland feels enlarged and increases with age. BPH is present in more than 50% of men by 50 years of age. Carcinoma of the prostate gland is suggested by an area of hardness in the gland. A distinct hard nodule that alters the contour of the gland may or may not be palpable. However, as the cancer enlarges, the prostate feels irregular and may extend beyond the confines of the gland.

Answer 80

c. Estrogen **APEA Pregnancy Estrogen promotes endometrial growth that supports the early embryo. This hormone appears to stimulate prolactin output in the anterior lobe of the pituitary gland, which readies breast tissue for lactation. Estrogen also contributes to the hypercoagulable state that puts pregnant women at higher risk for thromboembolic events.

Answer 81

c. Striae gravidarum **APEA Pregnancy As the skin over the abdomen stretches to accommodate the fetus, purplish striae gravidarum "stretch marks" may appear. Linea nigra is a brownish black pigmented vertical stripe along the midline skin. Hegar's sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix. Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick's sign.

Answer 82

b. Colostrum **APEA Pregnancy

Answer 83

d. Multiple gestation **APEA Pregnancy

Answer 84

b. Vaginal wall relaxation **APEA Pregnancy

Answer 85

d. Erythropoietin **APEA Pregnancy Erythropoietin increases during pregnancy, which raises erythrocyte mass resulting in increased blood viscosity

Answer 86

c. 24 weeks **APEA Pregnancy Oral glucose tolerance test is used to screen for gestational diabetes between 24-28 weeks of pregnancy. It may also be used when the disease is suspected, even though fasting blood glucose level is normal.

Answer 87

d. Human placental lactogen **APEA Pregnancy

Answer 88

c. Mastitis **APEA Pregnancy

Answer 89

c. 18 weeks gestation **APEA Pregnancy Uterine fundal height measured in centimeters correlates with gestational age between 18-34 weeks. Fundal height is measured in centimeters from symphysis pubis to top of uterus. This is known as McDonald's rule.

Answer 90

c. Cervicitis **APEA Pregnancy Cervical erosion, erythema, discharge, or irritation might suggest cervicitis and warrants investigation for sexually transmitted infections (STIs). A pink cervix suggests a non-pregnant state.

Answer 91

c. Chronic hypertension **APEA Pregnancy Chronic HTN occurs when systolic BP >140 or diastolic BP >90 documented prior to pregnancy, before 20 weeks gestation, or beyond 12 weeks postpartum. Gestation HTN refers to elevated BP detected after 20 weeks gestation in the absence of proteinuria. Pre-eclampsia occurs in a woman who was previously normotensive but now has new onset hypertension with either proteinuria or end-organ damage. Primary hypertension, formerly known as essential hypertension, is a disorder which is associated with elevated blood pressure and an unidentifiable cause.

Answer 92

c. Venous hum **APEA Pregnancy A venous hum, or continuous mammary souffle, that occurs during pregnancy is due to increased blood flow through normal vessels. The mammary souffle is commonly heard during late pregnancy or lactation. It is heard loudest in the second or third intercostal space at the sternal border, and is typically both systolic and diastolic, though only the systolic component may be audible.

Answer 93

c. Earlier gestation than expected **APEA Pregnancy Lack of audible fetal heart tones (FHT) may indicate earlier gestation than expected, fetal demise, false pregnancy, or observer error. Inability to locate the FHT should always be investigated with ultrasound.

Answer 94

d. Vertex presentation **APEA Pregnancy When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the vertex or cephalic presentation. Additionally, if the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back, then the head is extended and the fetus is in face presentation. The top of the uterus (fundus) is palpated to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.

Answer 95

b. Preterm labor **APEA Pregnancy Before 37 weeks, regular uterine contractions with/without pain and bleeding are abnormal findings and may suggest preterm labor.

Answer 96

c. Preeclampsia **APEA Pregnancy

Answer 97

c. An ectopic pregnancy **APEA Pregnancy Adnexal tenderness or masses identified early in gestation require ultrasound evaluation to rule out ectopic pregnancy. An enlarged uterus may indicate multiple gestation or a fibroid tumor.

Answer 98

d. Relaxin **APEA Pregnancy

Answer 99

a. A common finding during pregnancy **APEA Pregnancy Gingival inflammation and swelling is common during pregnancy because of hormonal shifts that occur. Consequently, meticulous oral hygiene is important in pregnant women.

Answer 100

b. 400 mcg **APEA Pregnancy The daily suggested intake levels of folic acid are as follows: Men older than 13 years = 400 mcg. Women older than 13 years = 400-600 mcg. Pregnancy all ages = 400-600 mcg. Breastfeeding women of all ages = 500 mcg.

Answer 101

b. Preterm labor **APEA Pregnancy

Answer 102

b. Anemia **APEA Pregnancy

Answer 103

c. Tobacco **APEA Pregnancy

Answer 104

b. At the first prenatal visit **APEA Pregnancy The CDC recommends screening all pregnant women for HIV at the first prenatal visit. During the third trimester, women at high risk for acquiring HIV infection should be rescreened.

Answer 105

d. 28-40 lbs **APEA Pregnancy Weight gain should be closely monitored during pregnancy, as both excessive and inadequate weight gain are associated with poor birth outcomes. BMI of <18.5 should gain 28-40 lbs. BMI of 18.5-24.9 should gain 25-35 lbs BMI of 25-29.9 should gain 15-25 lbs BMI >30 should gain 11-20 lbs

Answer 106

c. Peripartum cardiomyopathy **APEA Pregnancy These symptoms raise concerns of possible infection, asthma, pulmonary embolus, or peripartum cardiomyopathy.

Answer 107

a. 11-20 lbs **APEA Pregnancy Weight gain should be closely monitored during pregnancy, as both excessive and inadequate weight gain are associated with poor birth outcomes. BMI of <18.5 should gain 28-40 lbs. BMI of 18.5-24.9 should gain 25-35 lbs BMI of 25-29.9 should gain 15-25 lbs BMI >30 should gain 11-20 lbs

Answer 108

c. Midline of the woman's lower abdomen **APEA Pregnancy After 18 weeks, the FHT are best heard over the back or chest and depends on fetal position

Answer 109

c. Contracting toxoplasmosis **APEA Pregnancy These foods should be avoided in pregnancy due to the risk of Listeria, Salmonella, and toxoplasmosis

Answer 110

b. Doppler **APEA Pregnancy

Answer 111

d. 35-37 weeks **APEA Pregnancy A vaginal swab for group B streptococcus should be done between 35-37 weeks gestation. Group B streptococcus can normally be found in 15-45% of all healthy adult women. It can commonly be found in the intestine, vagina, and rectal area. Most women who are carriers will not have any symptoms. However, under certain circumstances, infection of both the mother and/or the newborn can develop.

Answer 112

d. Lochia **APEA Pregnancy Lochia is a term given to the substance that is discharged from the uterus, through the vagina after childbirth. It consists of blood, mucus, and placental tissue.

Answer 113

c. 120-160 bpm **APEA Pregnancy

Answer 114

b. Preeclampsia **APEA Pregnancy Chronic HTN occurs when systolic BP >140 or diastolic BP >90 documented prior to pregnancy, before 20 weeks gestation, or beyond 12 weeks postpartum. Gestation HTN refers to elevated BP detected after 20 weeks gestation in the absence of proteinuria. Pre-eclampsia occurs in a woman who was previously normotensive but now has new onset hypertension with either proteinuria or end-organ damage. Primary hypertension, formerly known as essential hypertension, is a disorder which is associated with elevated blood pressure and an unidentifiable cause.

Answer 115

b. 15-25 lbs **APEA Pregnancy Weight gain should be closely monitored during pregnancy, as both excessive and inadequate weight gain are associated with poor birth outcomes. BMI of <18.5 should gain 28-40 lbs. BMI of 18.5-24.9 should gain 25-35 lbs BMI of 25-29.9 should gain 15-25 lbs BMI >30 should gain 11-20 lbs

Answer 116

c. 25-35 lbs Weight gain should be closely monitored during pregnancy, as both excessive and inadequate weight gain are associated with poor birth outcomes. BMI of <18.5 should gain 28-40 lbs. BMI of 18.5-24.9 should gain 25-35 lbs BMI of 25-29.9 should gain 15-25 lbs BMI >30 should gain 11-20 lbs

Answer 117

d. Genital herpes (HSV-2) **APEA Pregnancy Evidence does not support routine genital herpes (HSV-2) serologic testing among asymptomatic pregnant women. The CDC recommends screening for syphilis, gonorrhea, and hepatitis B at the first prenatal visit for all pregnant women.

Answer 118

d. Fetal anomaly **APEA Pregnancy If fundal height is >4 cm larger than expected, consider multiple gestation, a large fetus, extra amniotic fluid, or uterine leiomyoma. If fundal height is >4 cm smaller than expected, consider low level of amniotic fluid, missed abortion, intrauterine growth restriction, or fetal anomaly. All of these conditions should be investigated by ultrasound.

Answer 119

d. A normal finding If fetal movement cannot be perceived after 24 weeks, consider error in calculating gestational age, fetal death or severe morbidity, or false pregnancy. Confirm fetal health and gestational age with an ultrasound.

Answer 120

b. Suggestive of preeclampsia

Answer 121

d. Excessive weight loss **APEA Pregnancy Weight loss in excess of 5% of pre-pregnancy weight is considered excessive, representing hyperemesis gravidarum, and may lead to adverse pregnancy outcomes.

Answer 122

c. Face presentation **APEA Pregnancy When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the vertex or cephalic presentation. Additionally, if the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back, then the head is extended and the fetus is in face presentation. The top of the uterus (fundus) is palpated to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.

Answer 123

b. Alcohol **APEA Pregnancy Fetal alcohol syndrome, the neurodevelopmental sequela of alcohol exposure during fetal development, is the leading cause of preventable intellectual disability in the United States.

Answer 124

b. Transverse lie **APEA Pregnancy When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the vertex or cephalic presentation. Additionally, if the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back, then the head is extended and the fetus is in face presentation. The top of the uterus (fundus) is palpated to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.

Answer 125

d. Semi-sitting with knees bent **APEA Pregnancy

Answer 126

c. Anemia **APEA Pregnancy Murmurs audible during pregnancy may suggest anemia however, benign systolic murmurs can be heard in women after the first trimester.

Answer 127

b. Human chorionic gonadotropin (HCG) **APEA Pregnancy Human chorionic gonadotropin (HCG) is produced by the placenta and supports progesterone synthesis in the corpus luteum, effectively preventing the early embryo from being lost to menstruation

Answer 128

b. 26 weeks **APEA Pregnancy

Answer 129

a. Progesterone **APEA Pregnancy Progesterone affects numerous body systems. Rising progesterone leads to increased tidal volume and alveolar minute ventilation, though respiratory rate remains constant. Respiratory alkalosis and subjective shortness of breath result from these changes. Lower esophageal sphincter tone results from rising levels of estradiol and progesterone, contributing to gastroesophageal reflux. Progesterone relaxes tone in the ureters and bladder, causing hydronephrosis and an increased risk of bacteriuria.

Answer 130

c. Optimizes health and minimizes risk for mother and fetus **APEA Pregnancy

Answer 131

d. Intrauterine growth restriction **APEA Pregnancy If fundal height is >4 cm larger than expected, consider multiple gestation, a large fetus, extra amniotic fluid, or uterine leiomyoma. If fundal height is >4 cm smaller than expected, consider low level of amniotic fluid, missed abortion, intrauterine growth restriction, or fetal anomaly. All of these conditions should be investigated by ultrasound.

Answer 132

d. Cervical effacement **APEA Pregnancy Leopold maneuvers are used to determine the fetal position within the maternal abdomen beginning in the second trimester. Accuracy is greatest after 36 weeks gestation. These exam findings can help ascertain the adequacy of fetal growth and the readiness for vaginal birth. Since these maneuvers are performed on the maternal abdomen, cervical effacement is not included with these maneuvers. To determine cervical effacement, a vaginal exam would be performed.

Answer 133

c. Gestational diabetes **APEA Pregnancy

Answer 134

d. Linea nigra **APEA Pregnancy As the skin over the abdomen stretches to accommodate the fetus, purplish striae gravidarum "stretch marks" may appear. Heger's sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix. Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick's sign.

Answer 135

c. Folic acid **APEA Pregnancy

Answer 136

a. Hegar's sign **APEA Pregnancy Linea nigra is a brownish black pigmented vertical stripe along the midline skin of the abdomen As the skin over the abdomen stretches to accommodate the fetus, purplish striae gravidarum "stretch marks" may appear. Heger's sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix. Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick's sign.

Answer 137

a. Gestational hypertension **APEA Pregnancy Chronic HTN occurs when systolic BP >140 or diastolic BP >90 documented prior to pregnancy, before 20 weeks gestation, or beyond 12 weeks postpartum. Gestation HTN refers to elevated BP detected after 20 weeks gestation in the absence of proteinuria. Pre-eclampsia occurs in a woman who was previously normotensive but now has new onset hypertension with either proteinuria or end-organ damage. Primary hypertension, formerly known as essential hypertension, is a disorder which is associated with elevated blood pressure and an unidentifiable cause.

Answer 138

b. Vomiting, flu-like symptoms, and platelet count <100,000 **APEA Pregnancy HELLP syndrome is a life-threatening pregnancy complication usually considered to be a variant of pre-eclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth. Its characteristics are: H: Hemolysis EL: Elevated liver enzymes LP: Low platelet count

Answer 139

b. Chadwick's sign **APEA Pregnancy Linea nigra is a brownish black pigmented vertical stripe along the midline skin of the abdomen As the skin over the abdomen stretches to accommodate the fetus, purplish striae gravidarum "stretch marks" may appear. Heger's sign is the palpable softening of the cervical isthmus, the portion of the uterus that narrows into the cervix. Increased vascularity throughout the pelvis during pregnancy gives the vagina a bluish color, known as Chadwick's sign.

Answer 140

b. Supine hypotensive syndrome **APEA Pregnancy

Answer 141

c. Chloasma **APEA Pregnancy Chloasma, or Melasma, is also known as the "mask of pregnancy" and is considered a normal finding.

Answer 142

a. Cephalic longitudinal (vertical) lie **APEA Pregnancy When performing the third Leopold maneuver on a pregnant woman, the fetal head is the presenting part. This finding is referred to as the vertex or cephalic presentation. Additionally, if the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back, then the head is extended and the fetus is in face presentation. The top of the uterus (fundus) is palpated to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or buttocks (Breech) of the fetus is in the fundus, then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie.

Answer 143

b. Urinary output of 20 ml/hour The decrease in urine output is an indication of a decrease in glomerular filtration rate (GFR), which indicates a loss of renal perfusion. There is not a significant rise in blood pressure, the reflexes are normal at 2+, and the platelet count is normal, though at the lower end. The assessment finding of greatest concern is the decreased urine output.

Answer 144

b. 12 months **APEA Women's Health Menopause is diagnosed when no menstruation has occurred for 12 consecutive months, with no other identified biological of physiological cause.

Answer 145

c. Should be a smaller size **APEA Women's Health Performing a pelvic exam in an older woman, the nurse practitioner should separate the labia, press downward on the introitus to relax the levator muscles, and gently insert the speculum after moistening it with warm water or a water-soluble lubricant. If there is severe vaginal atrophy, a gaping introitus, or an introital stricture from estrogen loss, the size of the speculum may need to be adjusted to a smaller size.

Answer 146

b. Milk the urethra gently from the inside outward **APEA Women's Health When performing this procedure, note any discharge from or about the urethral meatus. If present, it should be cultured.

Answer 147

d. Bartholin gland infection **APEA Women's Health A Bartholin gland infection appears as a tense, hot, very tender abscess with labial swelling over the area of the Bartholin gland. A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues. A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus. A rectocele is a herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.

Answer 148

c. Rectocele **APEA Women's Health A Bartholin gland infection appears as a tense, hot, very tender abscess with labial swelling over the area of the Bartholin gland. A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues. When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge, a cystourethrocele is present. A rectocele is a herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.

Answer 149

c. Vaginal opening **APEA Women's Health

Answer 150

b. Rugae **APEA Women's Health The vaginal mucosa lies in transverse folds called rugae. The fornices (pleural of fornix) are used to describe the three recesses of the vagina: anterior, posterior, and lateral fornices. Corpus refers to the body of the uterus. Fornix refers to the upper third of the vagina when it terminates into a cuplike shape near the cervix.

Answer 151

b. Posteriorly **APEA Women's Health

Answer 152

b. The peau d'orange sign **APEA Women's Health Edema of the skin is caused by a lymphatic blockade. It appears as thickened skin with enlarged pores, commonly termed the peau d'orange (orange peel) sign. It is often seen first in the lower portion of the breast or areola and is considered a visible sign of breast cancer.

Answer 153

d. Cystourethrocele **APEA Women's Health When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge it is a cystourethrocele. A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues. A prolapsed urethral mucosa forms a swollen red ring around the urethral meatus. A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus.

Answer 154

c. Three to five years **APEA Women's Health

Answer 155

b. About midway between the umbilicus and symphysis pubis while elevating the cervix and uterus with the other hand **APEA Women's Health To palpate the uterus: one hand is placed on abdomen midway between umbilicus and symphysis pubis. The other hand is in vagina and elevates the cervix and uterus. Press the abdominal hand in and down, trying to grasp the uterus between the two hands.

Answer 156

b. Urethral caruncle **APEA Women's Health A prolapsed urethral mucosa forms a swollen red ring around the urethral meatus. A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus. A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues. When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge it is a cystourethrocele.

Answer 157

a. Pelvic inflammatory disease (PID) Abdominal or pelvic pain and fever are the most common clinical findings in patients with pelvic inflammatory disease (PID), although dysuria may also be present. The findings of mucopurulent endocervical discharge or cervical motion tenderness on pelvic examination are strongly suggestive of PID. Cervical motion tenderness and endocervical discharge are not found with pyelonephritis, nephrolithiasis, or urethritis

Answer 158

d. Palpate upward to just lateral to the pubic tubercles **APEA Women's Health

Answer 159

b. An epidermoid cyst **APEA Women's Health A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. They appear yellowish in color with a dark punctum marking the blocked opening of the gland. A syphilitic chancre appears as a firm, painless ulcer and suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected. Genital warts, or condylomata acuminata, are warty lesions on the labia and within the vestibule resulting from infection with HPV. Genital herpes appears as shallow, small, painful ulcers on red bases.

Answer 160

a. Breast tissue sample **APEA Women's Health The other three options are indicative of screening tests and not always diagnostic of cancer.

Answer 161

c. Vulvar cancer **APEA Women's Health

Answer 162

c. 3 seconds **APEA Women's Health

Answer 163

b. An ovarian cyst **APEA Women's Health An ovarian cyst tends to be smooth and compressible and if uncomplicated, non-tender. Ovarian tumors appear more solid and often nodular. A right tubal pregnancy does not typically present with an ovarian lesion. A tubo-ovarian abscess is difficult to palpate and typically presents with severe pain and purulent vaginal discharge.

Answer 164

c. Yeast infection **APEA Women's Health A vaginal yeast infection is characterized by itching, burning, soreness, pain during intercourse and/or urination, and vaginal discharge that is typically cheesy in texture and white in color. Trichomoniasis, bacterial vaginosis, and gonorrhea do not have symptoms of vaginal itching or classic presentation of a cheesy white discharge

Answer 165

d. Appearance of breast buds **APEA Women's Health Breast buds are the first sign of puberty in girls. Body odor comes later as the apocrine glands develop. Menses first occurs about 1 year following the appearance of breast buds. Increased energy and appetite do not relate to the signs of puberty

Answer 166

b. Secondary amenorrhea **APEA Women's Health

Answer 167

b. Myoma **APEA Women's Health

Answer 168

c. Squamous epithelium **APEA Women's Health There are two types of epithelia that cover the cervix: A shiny, pink squamous epithelium, which resembles the vaginal epithelium. And the Deep, red columnar epithelium, which is continuous with the endocervical lining. These two epithelia meet at the squamocolumnar junction. When this junction is at or inside the cervical os, usually only the squamous epithelium is seen. A ring of columnar epithelium is often visible to a varying extent around the os. A retention cyst appears as a translucent nodule on the cervical surface. The endocervix is the mucous membrane lining the canal of the cervix.

Answer 169

d. Campylobacter ***APEA Women's Health Campylobacter is associated with bacterial infections of the GI tract and commonly produce diarrhea

Answer 170

b. An underlying breast mass **APEA Women's Health

Answer 171

b. Cystocele **APEA Women's Health Use of lower blade during bearing down helps expose anterior vaginal wall defects such as cystoceles. Use of the upper blade helps expose rectoceles. Prolapse of the urethral mucosa and Bartholin gland infection can be visualized without the use of the speculum

Answer 172

d. Mucopurulent cervicitis **APEA Women's Health Mucopurulent cervicitis produces purulent, yellow drainage from the cervical os, usually from Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes infection. Candidal vaginitis produces a white and curd-like, thin discharge from the vagina and does not originate from the cervix. Typically a cervical polyp does not produce a cervical discharge. Carcinoma of the cervix begins in an area of metaplasia and usually does not produce a mucopurulent cervical discharge.

Answer 173

b. Metastatic tissue in the rectouterine pouch **APEA Women's Health Widespread peritoneal metastases from any source may develop in the area of the peritoneal reflection anterior to the rectum. A firm to hard nodular rectal "Shelf" may be just palpable with the tip of the examining finger. In a woman, this shelf of metastatic tissue develops in the rectouterine pouch, behind the cervix and the uterus. Rectal polyps and carcinoma of the rectum, if palpable, are typically located in the lower section of the rectum. To palpate the ovaries, a bimanual pelvic examination would be more appropriate

Answer 174

d. A cervical polyp **APEA Women's health A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and fragile. A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. A retention cyst appears as a translucent nodule on the cervical surface. A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. A syphilitic chancre appears as a firm, painless ulcer and suggests the chancre of primary syphilis

Answer 175

c. Cystocele **APEA Women's Health A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues. When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge it is a cystourethrocele. A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus. A prolapsed urethral mucosa forms a swollen red ring around the urethral meatus.

Answer 176

b. Cervical cancer **APEA Women's Health Postcoital bleeding suggests cervical polyps, cervical cancer, or in an older woman, atrophic vaginitis. Postcoital bleeding is not usually noted in patients with endometriosis, early pregnancy, or menopause

Answer 177

d. Peptic ulcer disease **APEA Women's Health Chronic pelvic pain (CPP) refers to pain of at least 6 months duration that occurs below the umbilicus. While gynecologic etiologies are common, CPP may be secondary to conditions in the urinary tract, GI tract, musculoskeletal system, and in the setting of mental health issues. Peptic ulcer disease affects the upper GI tract and produces symptoms above the umbilicus.

Answer 178

b. A tilting backward of the uterus and cervix **APEA Women's Health Retroversion of the uterus refers to a tilting backward of the entire uterus, including both body and cervix. It is a common variant occurring in approximately 20% of women. A backward angulation of the uterus in relation to its cervix is referred to as retroflexion of the uterus. When the cervix is located at the introitus, and the uterus is in the vaginal canal, this is consistent with a third-degree uterine prolapse

Answer 179

c. Carcinoma of the cervix **APEA Women's Health Carcinoma of the cervix begins with an area of metaplasia. In its earliest stages, it cannot be distinguished from a normal cervix. In later stages, an extensive, irregular, cauliflower-like growth may develop. Warty lesions on the labia and within the vestibule suggest condyloma acuminatum, genital warts. A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and fragile. Genital herpes appears as shallow, small, painful ulcers on red bases and are typically noted on the vulva

Answer 180

b. A woman who is anxious **APEA Women's Health Normal ovaries are usually tender to palpation but could pose difficulty in some women. They are usually palpable in slender, relaxed women but are difficult or impossible to feel in women who are obese or anxious. Three to five years after menopause, ovaries are atrophic and usually non-palpable

Answer 181

b. An ovarian tumor **APEA Women's Health Ovarian tumors appear more solid and often nodular upon palpation. Ovarian cancer is relatively rare and usually presents at an advanced stage with symptoms of pelvic pain, increased abdominal size, and urinary tract symptoms. An ovarian cyst tends to be smooth and compressible and if uncomplicated, non-tender. A right tubal pregnancy does not typically present with an ovarian lesion. A tubo-ovarian abscess is difficult to palpate and typically presents with severe pain and purulent vaginal discharge.

Answer 182

d. And vagina are outside the introitus **APEA Women's Health Uterine prolapse occurs in progressive stages. The uterus becomes retroverted and descends down the vaginal canal to the exterior. In first degree prolapse, the cervix is still well within the vagina. In second degree prolapse, the cervix is at the introitus. In third-degree prolapse (procidentia), the cervix and vagina are outside the introitus

Answer 183

b. Attached to the rib or intercostal muscle **APEA Women's Health A mobile mass that becomes fixed when the arm relaxes is attached to the ribs and/or intercostal muscles. If fixed then the hand is pressed against the hip, it is attached to the pectoral fascia.

Answer 184

c. Psychosocial factors **APEA Women's Health

Answer 185

c. Gently tightening the thumb screw on the speculum **APEA Women's Health The other procedures are related to inserting the speculum, not to maintaining an open position.

Answer 186

d. Persistent infection with high-risk human papillomavirus (HPV) subtypes **APEA Women's health The most important risk factor for cervical cancer is persistent infection with HPV subtypes, especially HPV 16 or HPV 18. These two subtypes cause approximately 70% of cervical cancers, usually over the course of many years. Although the other choices pose a risk for developing cervical cancer, HPV infection is the most important risk factor.

Answer 187

a. Prolapse of the urethral mucosa **APEA Women's Health A prolapsed urethral mucosa forms a swollen red ring around the urethral meatus. A urethral caruncle is a small, red, benign tumor visible at the posterior part of the urethral meatus. A cystocele is a bulge of the upper 2/3 of the anterior vaginal wall and the bladder above it. It results from weakened supporting tissues. When the entire anterior vaginal wall, together with the bladder and urethra, is involved in the bulge it is a cystourethrocele.

Answer 188

c. Trichomonal vaginitis **APEA Women's health Trichomonas vaginalis causes trichomonal vaginitis. Presenting symptoms include a profuse, yellowish/green vaginal discharge that is malodorous. Candidal vaginitis produces a white and curd-like thin discharge that is rarely malodorous. With bacterial vaginosis, the discharge can be gray or white, thin, malodorous (fishy), and not usually profuse. The discharge associated with gonorrhea is usually thick and bloody

Answer 189

c. Pelvic inflammatory disease **APEA Women's health

Answer 190

c. Atrophic vaginitis **APEA Women's Health Typically, with atrophic vaginitis patients are more likely to experience postcoital bleeding as opposed to post-menopausal bleeding

Answer 191

a. Candidal vaginitis **APEA Women's health Trichomonas vaginalis causes trichomonal vaginitis. Presenting symptoms include a profuse, yellowish/green vaginal discharge that is malodorous. Candidal vaginitis produces a white and curd-like thin discharge that is rarely malodorous. With bacterial vaginosis, the discharge can be gray or white, thin, malodorous (fishy), and not usually profuse. The discharge associated with gonorrhea is usually thick and bloody

Answer 192

a. A malignancy **APEA Women's health Uterine enlargement may suggest pregnancy, uterine myomas (fibroids), or malignancy Retroversion or retroflexion of the uterus, and pelvic inflammatory disease do not present with enlargement of the uterus

Answer 193

b. Increased prostaglandin production during the luteal phase of the menstrual cycle **APEA Women's health Endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease, and endometrial polyps are secondary causes

Answer 194

a. Oligomenorrhea **APEA Women's health

Answer 195

a. Rectocele **APEA Women's health Use of the lower blade as a retractor during bearing down helps expose anterior vaginal wall defects such as cystoceles. Use of the upper blade as a retractor helps expose rectoceles. The other two can be visualized without the use of a speculum

Answer 196

a. Breast cancer **APEA Women's health Retraction of the nipple and areola are suggestive of an underlying tumor. Mastitis is an inflammation of the breast tissue. Paget's disease is an uncommon form of breast cancer that starts with a scaly, eczema-like lesion that may week, crust, or erode. Fibrocystic breast disease findings include lumps, thickening and swelling in the breast tissue, and becomes prominent immediately before onset of menses.

Answer 197

b. Has slipped but is well within the vagina **APEA Women's health Uterine prolapse occurs in progressive stages. The uterus becomes retroverted and descends down the vaginal canal to the exterior. In first degree prolapse, the cervix is still well within the vagina. In second degree prolapse, the cervix is at the introitus. In third-degree prolapse (procidentia), the cervix and vagina are outside the introitus

Answer 198

b. Pregnancy or elevated prolactin level **APEA Women's health

Answer 199

b. Bacterial vaginosis **APEA Women's health Trichomonas vaginalis causes trichomonal vaginitis. Presenting symptoms include a profuse, yellowish/green vaginal discharge that is malodorous. Candidal vaginitis produces a white and curd-like thin discharge that is rarely malodorous. With bacterial vaginosis, the discharge can be gray or white, thin, malodorous (fishy), and not usually profuse. The discharge associated with gonorrhea is usually thick and bloody

Answer 200

c. Assess an inguinal hernia **APEA Women's health The rectovaginal examination has three primary purposes: 1- To palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa; 2- To screen for colorectal cancer in women 50 years or older 3- To assess for pelvic pathology

Answer 201

b. A slit-like cervical os **APEA Women's health A slit-like cervical os is a normal variation

Answer 202

c. Pressure on a normal ovary **APEA Women's health In females, dyspareunia (painful intercourse) can occur at the vaginal opening, occurring at the start of intercourse, or when the partner is pushing deeper. It is important to differentiate the pain to determine the etiology. Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication. Deeper pain may be from pelvic disorders or pressure on a normal ovary

Answer 203

c. Metrorrhagia **APEA Women's health Metrorrhagia refers to intermenstrual bleeding. Polymenorrhea occurs when there are fewer than 21-day intervals between menses Oligomenorrhea is infrequent bleeding with menses occurring at greater than 35-day intervals, or 4-9 menstrual cycles per year. Menorrhagia refers to excessive or prolonged menstrual flow occurring at regular intervals

Answer 204

a. A retention cyst **APEA Women's health A retention cyst appears as a translucent nodule on the cervical surface. A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. A syphilitic chancre appears as a firm, painless ulcer and suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected. A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and fragile.

Answer 205

a. Cushing syndrome **APEA Endocrine

Answer 206

c. Hyperthyroidism **APEA Endocrine In hyperthyroidism, there is often a localized or continuous bruit audible over the lateral lobes of the thyroid gland.

Answer 207

b. Hypothyroidism **APEA Endocrine Myxedema is a deposition of mucopolysaccharides in the dermis that results in swelling of the affected area, giving the skin a waxy appearance. One manifestation of myxedema in the lower limb is pretibial myxedema, a hallmark of Graves' disease, an autoimmune form of hyperthyroidism. Myxedema can also occur in Hashimoto's thyroiditis and other longstanding forms of hypothyroidism. Myxedema is not associated with Addison's disease, thyroid nodule, or adrenal insufficiency

Answer 208

a. Hypothermia, thickening of the tongue, and disorientation **APEA Endocrine Myxedema coma is a loss of brain function as a result of severe, longstanding low level of thyroid hormone in the blood (hypothyroidism). Myxedema coma is considered a life-threatening complication of hypothyroidism and represents the far more serious side of the spectrum of thyroid disease. Symptoms include: hypothermia, significant edema, thickening of the tongue, difficulty breathing, constipation, and severe mental changes including hallucinations, disorientation, seizures, and ultimately deep coma

Answer 209

b. Hypoglycemia **APEA Endocrine Hypoglycemia symptoms: sweating, tremors, palpitations, hunger, headache, abnormal behavior, confusion. Syncope could present with nausea, vomiting, dizziness, and possible fainting. Postural hypotension usually occurs after one stands up. Usually there are no prodromal symptoms. The BP returns to normal when the patient lies down. Hypocapnia is decreased carbon dioxide and symptoms include dyspnea, palpitations, chest discomfort, numbness and tingling in the hands and around the mouth lasting for several minutes. Consciousness is maintained.

Answer 210

b. Addison's disease **APEA Endocrine Addison's disease: Hyperpigmentation AIDS: Hairy leukoplakia Cushing's: Striae, skin atrophy, purpura, ecchymosis, telangiectasias, acne, moon facies, buffalo hump, or hypertrichosis. Diabetes: Necrobiosis lipoidica diabeticorum, diabetic bullae, diabetic dermopathy, granuloma annulare, acanthosis nigricans, candidiasis, neuropathic ulcers, eruptive xanthomas, and PVD.

Answer 211

a. Craniopharyngioma **APEA Endocrine Craniopharyngiomas develop in the area of the brain near the pituitary gland and are derived from pituitary gland embryonic tissue. They are most common in children and in adults in their 50s and 60s. Almost all pituitary tumors are benign glandular tumors called pituitary adenoma. Examples include prolactin-producing adenomas (prolactinomas), gonadotropin-and growth hormone-secreting adenomas, and thyrotropin-secreting adenomas

Answer 212

a. Hypothyroidism **APEA Endocrine Sparse, coarse, and thin hair is more characteristic of hair seen in patients with hypothyroidism. Fine, silky hair may be seen in patients who have hyperthyroidism In celiac disease and type 2 diabetes, alopecia may be seen

Answer 213

d. Turner syndrome Turner Syndrome: Short stature, delayed growth, low-set ears, web-like neck, and in girls, underdeveloped ovaries. PCOS: Infertility, unwanted hair growth, weight gain, fatigue Prolactinoma: infertility, irregular menstrual periods, acne, and unwanted hair growth. Klinefelter: Hypogonadism, gynecomastia in late puberty, elevated urinary gonadotropin levels, and behavioral concerns in boys

Answer 214

b. Diabetes mellitus **APEA Endocrine Acanthosis nigricans is a skin condition characterized by dark velvety patches in the body folds and creases. It is typically noted in patients who are obese or who have diabetes.

Answer 215

a. A frequent cough **APEA Endocrine Because of the anatomic relationship of the thyroid gland to the trachea, larynx, superior and inferior laryngeal nerves, and esophagus, abnormal growth may cause a variety of compressive syndromes. These symptoms may include: wheezing, cough, globus hystericus, dysphagia, and vocal cord dysfunction and hoarseness. Compression of the venous outflow results in facial plethora and dilated neck and upper thoracic veins. Other symptoms include waking up from sleep with a sensation of being unable to breathe or feeling that food is stuck in the throat.

Answer 216

c. Cushing's disease **APEA Endocrine Addison's disease: Hyperpigmentation AIDS: Hairy leukoplakia Cushing's: Striae, skin atrophy, purpura, ecchymosis, telangiectasias, acne, moon facies, buffalo hump, or hypertrichosis. Diabetes: Necrobiosis lipoidica diabeticorum, diabetic bullae, diabetic dermopathy, granuloma annulare, acanthosis nigricans, candidiasis, neuropathic ulcers, eruptive xanthomas, and PVD.

Answer 217

c. Cystic fibrosis **APEA Endocrine A sweat test measures the amount of sodium and chloride in sweat and is used to assist in diagnosing cystic fibrosis. Patients with cystic fibrosis have 2-5 times the normal amount of sodium and chloride in their sweat.

Answer 218

b. Grave's disease **APEA Endocrine Disorders related to hypofunctioning of the thyroid gland include primary hypothyroidism, myxedema, Hashimoto's thyroiditis, iodine deficiency, and myxedema coma.

Answer 219

c. Hirsutism **APEA Endocrine Although hirsutism is broadly defined as excess hair, the common clinical use of the term refers to women with excess growth of terminal hair in a male pattern. Vellus hair is short, thin, slight-colored, and barely noticeable thin hair that develops on most of the body during childhood. Androgenic alopecia is a genetically determined disorder characterized by the gradual conversion of terminal hairs into indeterminate, and finally vellus hairs. Alopecia is a condition in which hair is lost from some or all areas of the body. It often results in bald spots.

Answer 220

a. Hyperthyroidism **APEA Endocrine Hyperthyroidism occurs due to excessive production of thyroid hormone by the thyroid gland. Thyrotoxicosis is a result of high levels of thyroid hormones and therefore includes hyperthyroidism. A thyroid nodule is an abnormal growth of thyroid cells that forms a lump within the thyroid gland. The majority are benign. A non-toxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function

Answer 221

d. 0.065 **APEA Endocrine Hemoglobin A1C levels between 5.7%-6.4% are reflective of impaired glucose metabolism. Type 2 diabetes is diagnosed when the A1C is 6.5% or greater

Answer 222

a. Weight loss **APEA Endocrine Cold intolerance, hair loss, and decreased perspiration are associated with Hashimoto's hypothyroidism. Weight loss is usually noted in patients with hyperthyroidism.

Answer 223

c. Grave's disease **APEA Endocrine Exophthalmos is an abnormal protrusion of the eye. When it presents bilaterally, it is suggestive of Grave's disease, a form of hyperthyroidism. Unilateral exophthalmos may be due to Grave's disease or to a tumor or inflammation of the orbit.

Answer 224

b. Atrial fibrillation **APEA Endocrine Hyperthyroidism is associated with atrial fibrillation, systolic murmur, and cardiac failure. Hypothyroidism is associated with sinus bradycardia, mild hypertension (diastolic), and narrowed pulse pressure. Supraventricular tachycardia may be associated with hyperthyroidism, however, ventricular tachycardia is not.

Answer 225

d. Ketoacidosis **APEA Endocrine These are signs of diabetic ketoacidosis (DKA) and can occur in diabetic patients with infections. DKA is characterized by elevated blood glucose (usually higher than 240 mg/dl) and ketonuria. The respiratory pattern is consistent with Kussmaul breathing and are signs of hyperglycemia.

Answer 226

a. Oligomenorrhea **APEA Endocrine

Answer 227

c. Hyperthyroidism **APEA Endoctine A systolic or continuous bruit auscultated with a stethoscope over an enlarged thyroid may be heard in hyperthyroidism. This is not a normal finding. A bruit is not usually associated with a thyroid malignancy

Answer 228

d. Proptosis **APEA Endocrine Proptosis is defined as a bulging of the eyes, which is a symptom of hyperthyroidism or Graves' disease. Weight gain, bradycardia, and anemia are associated with hypothyroidism

Answer 229

b. Hyperthyroidism **APEA Endocrine Symptoms of hyperthyroidism in children may include: anxiousness, irritability, nervousness, poor/restless sleet, increased activity/fidgeting, hyperactivity, increased appetite with or without weight loss, increased number of bowel movements per day, decreased/poor school performance, difficulty concentrating that may be diagnosed as "late-onset" attention deficit disorder, and a feeling of a "lump" in the throat.

Answer 230

b. A nodule **APEA Endocrine Thyroid nodule: Fixed, firm, non-tender large mass Thyroid cyst: Fluid-filled Goiter: causes visible swelling at the base of the neck Hyperplasia: abnormal increase in the volume of a tissue or organ caused by the formation and growth of new normal cells.

Answer 231

b. 160 mg/dL **APEA Endocrine Gestational diabetes mellitus (GDM) may be diagnosed between 24-28 weeks of pregnancy based on a fasting one-step or two-step glucose tolerance test (GTT). In one-step GTT, the patient receives 75 grams of oral glucose and plasma glucose is measured at 1 and 2 hours. GDM is diagnosed if: 1- Fasting blood glucose is >92 mg/dL. 2- 1-hour blood glucose is >180 mg/dL 3- 2-hour blood glucose is >153 mg/dL In two-step GTT, 50 gm of glucose is administered to the non-fasting patient. If the lood glucose is 130 mg/dL or higher, then a second test is performed fasting and 100 gm of glucose is administered. The patient is diagnosed with GDM if: 1- Fasting blood glucose is >95 mg/dL 2- 1-hour blood glucose is >180 mg/dL 3- 2-hour blood glucose is >155 mg/dL 4- 3-hour blood glucose is >140 mg/dL

Answer 232

c. Adrenarche **APEA Endocrine Adrenarche is the early presence of pubic hair in girls aged 5-8 years. Hypertrichosis is an abnormal amount of hair growth over the body. Thelarche is the onset of female breast development Adrenal hyperplasia is the excess production of male sex hormones that results in short height, early puberty, and in females, abnormal genital development

Answer 233

b. Respiratory failure **APEA Endocrine

Answer 234

d. Precocious puberty **APEA Endocrine Puberty that begins before age 8 in girls and before age 9 in boys is considered precocious puberty. Amenorrhea is the absence of menstruation. Gynecomastia is the swelling of breast tissue in boys or men Adrenarche is the early presence of pubic hair in girls aged 5-8 years old.

Answer 235

c. Polyuria **APEA Endocrine The classic symptoms of DM1 are polyuria, polydipsia, polyphagia, and unexplained weight loss. Obesity and elevated cholesterol are more consistent with DM2

Answer 236

c. Myxedema **APEA Endocrine Hyperfunctioning of the thyroid gland leads to a hypermetabolic state causing an increase in metabolic function, increased oxygen consumption by tissues, and heat production. Disorders include: Grave's disease, toxic goiter, thyroid storm (thyrotoxicosis). Myxedema is seen in hypofunctioning of the thyroid gland

Answer 237

d. Swallow water **APEA Endocrine Proper posterior assessment of the thyroid is performed by palpating between the cricoid cartilage and the suprasternal notch. One hand is used to slightly retract the sternocleidomastoid muscle, the other hand palpates the thyroid. The patient is asked to swallow a sip of water during palpation while the examiner feels for the upward movement of the thyroid gland. Abnormalities include asymmetry, masses, erythema, or deviation of the trachea.

Answer 238

b. Addison's disease **APEA Endocrine Addison's disease, also known as primary adrenal insufficiency and hypocortisolism, is a long-term endocrine disorder in which the adrenal glands do not produce adequate steroid hormones. Classic symptoms include fatigue, anorexia, chronic diarrhea, salt craving, mucosal pigmentation, and hair loss. Lab tests for adrenal function shows a subnormal rise in cortisol levels.

Answer 239

d. A high sperm count **APEA Endocrine Klinefelter syndrome is a chromosomal condition that affects male physical and cognitive development. S/Sx vary among patients. Low testosterone levels, micro-orchidism, gynecomastia, facial hair, baldness, and low sperm count are all associated with Klinefelter syndrome.

Answer 240

c. Acromegaly **APEA Endocrine Gigantism refers to abnormally high linear growth due to the excessive action of insulin-like growth factor 1 (IGF-1) while the epiphyseal growth plates are open during childhood. Acromegaly is the same disorder of excess IGF-1 but occurs after the growth plate cartilage fuses in adulthood. Excessive growth hormone is almost always caused by a non-cancerous (benign) pituitary tumor. A prolactinoma is a benign tumor (adenoma) of the pituitary gland that produces excessive prolactin resulting in decreased levels of some sex hormones. The term congenital adrenal hyperplasia (CAH) encompasses a group of autosomal recessive disorders, each of which involves a deficiency of an enzyme involved in the synthesis of cortisol, aldosterone, or both.

Answer 241

b. A goiter **APEA Endocrine

Answer 242

b. Thyroid gland **APEA Endocrine

Answer 243

b. Diabetic ketoacidosis **APEA Endocrine

Answer 244

d. Iodine **APEA Endocrine Hyperplasia of the thyroid gland (goiter) results from an iodine-deficient diet, which causes overgrowth of the thyroid gland

Answer 245

c. Tetany **APEA Endocrine A lack of PTH leads to decreased blood levels of calcium (hypocalcemia) and increased levels of blood phosphorus (hyperphosphatemia). Muscle cramps involving the lower back, legs, and feet are common in patients with hypoparathyroidism and hypocalcemia. Tetany develops if hypocalcemia is severe. In some patients, laryngospasm and bronchospasm may be life threatening

Answer 246

a. Polyuria **APEA Urology

Answer 247

b. Herpes simplex virus (HSV) **APEA Urology Approximately 90% of all cases of vaginitis are thought to be attributed to 3 causes: Bacterial vaginosis, vaginal candidiasis (or vulvovaginal candidiasis), and trichomonas vaginalis infection (trichomoniases. Herpes simplex virus does not cause vaginitis

Answer 248

c. Pasternacki's sign **APEA Urology Costovertebral angle tenderness (CVA), also known as Pasternacki's sign (Murphy's punch or Goldflam's sign) is a medical test in which findings of pain are elicited by percussion of the back over either kidney when infection is present. Murphy's sign assesses for cholecystitis. It is positive if deep palpation in the subcostal area occurs when a patient with gallbladder disease takes a deep breath and ceases inspiration. Psoas sign indicates irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates that the inflamed appendix is retrocecal in orientation. Rovsing's sign indicates peritoneal irritation. If palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis

Answer 249

b. 6 **APEA Urology The average urine pH is 5-6 Acidic urine pH is 4.5-5.5 Alkaline urine pH is 6.5-8

Answer 250

b. Hyperkalemic nephropathy **APEA Urology Kidney diseases such as hypokalemic nephropathy, lithium toxicity, uncontrolled diabetes, and disorders of the posterior pituitary and hypothalamus (ex. Hypogonadism) cause polyuria.

Answer 251

c. Have the child sit crossed legged on the examination table **APEA Urology Having the child sit crossed-legged would not expose the genitals. This position is useful when examining the male child and eliciting the cremasteric reflex

Answer 252

c. Overflow incontinence **APEA Urology This condition occurs in people who have a blockage of the bladder outlet (BPH, prostate cancer, or narrowing of the urethra) or when the muscle that expels urine from the b ladder is too weak to empty the bladder normally.

Answer 253

c. Urge incontinence **APEA Urology

Answer 254

b. Frequent anal intercourse **APEA Urology Proctitis is inflammation of the lining of the rectum leading to rectal pain, bleeding, and a continuous sensation to defecate. Causes may include: inflammatory bowel disease, sexually transmitted infections, radiation therapy, and frequent anal intercourse

Answer 255

b. Urethral stricture **APEA Urology A urethral stricture may occur in patients who have undergone hypospadias surgery and experience voiding symptoms such as urinary retention and straining to void. Neurogenic bladder symptoms include urinary retention and/or incontinence associated with other underlying chronic neurologic conditions (multiple sclerosis) or after spinal cord injury. BPH symptoms include daytime frequency, nocturia, urinary incontinence, and terminal dribbling. Prostate cancer is usually asymptomatic but can sometimes present with storage, voiding, or irritative symptoms

Answer 256

b. Acute pyelonephritis **APEA Urology Kidney pain in the flank area and groin that is accompanied by fever and chills is consistent with acute pyelonephritis. Renal or ureteral colic usually presents with a sudden onset of pain in the flank area, abdomen, or groin. Chills and fever do not generally accompany urinary calculi. In men, painful urination without frequency or urgency suggests urethritis Acute prostatitis presents with frequency, urgency, and dysuria

Answer 257

b. Polyruria **APEA Urology Acute glomerulonephritis symptoms include hematuria. This is a universal finding even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients, often manifesting as smoky, coffee, or cola-colored urine. Oliguria is seen. Hypertension, proteinuria, and edema (peripheral or periorbital) is reported in approximately 85% of pediatric patients. Edema may be mild (involving only the face) to severe, bordering on a nephrotic appearance. Headache may occur secondary to hypertension. Confusion may occur secondary to malignant hypertension in as many as 5% of patients. Shortness of breath, or dyspnea on exertion may occur secondary to heart failure or pulmonary edema. It is usually uncommon, particularly in children. Possible flank pain secondary to stretching of the renal capsule may occur.

Answer 258

b. Overflow incontinence **APEA Urology Overflow incontinence is associated with a neurological or anatomical obstruction from pelvic organs or the prostate which limits bladder emptying and causes a distended bladder. Stress incontinence is commonly seen in women and arises from decreased intraurethral pressure. This condition is noted when a patient coughs, sneezes, or laughs. In urge incontinence, urgency is followed by immediate involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance. Following an urge to void, there is an involuntary loss of urine. Functional incontinence usually arises from cognitive impairment, musculoskeletal problems, or immobility

Answer 259

c. Suprapubic pain **APEA Urology Proctitis is inflammation of the lining of the rectum leading to rectal pain, bleeding, and a continuous sensation to defecate (tenesmus). Additional symptoms may also include left-sided abdominal pain, diarrhea, pain with bowel movements, and a feeling of fullness in the rectum. Suprapubic pain is not generally associated with proctitis.

Answer 260

a. Nephrotic syndrome **APEA Urology Glomerulonephritis can lead to nephrotic syndrome, which is the loss of a large amount of protein in the urine that leads to sodium and fluid retention in the body. Complications of nephrotic syndrome include hypertension, hyperlipidemia, and peripheral edema

Answer 261

b. Third decade of life **APEA Urology In men, proliferation of prostate epithelial and stromal tissue, termed BPH, begins in the third decade. Symptoms occur in only about half of men with enlargement. Hyperplasia continues to increase prostate volume until the seventh decade, then appears to plateau. These changes are androgen dependent

Answer 262

b. Dysuria **APEA Urology

Answer 263

b. DIAPERS. **APEA Urology DIAPERS: Delirium Infection Atrophic urethritis/vaginitis Pharmaceuticals Excess urine output from conditions like hyperglycemia or heart failure Restricted mobility Stool impaction OR DDRRIIPP Delirium Drug side effects Retention of feces Restricted mobility Infection of urine Inflammation Polyuria Psychogenic

Answer 264

d. Hyperalbuminosa **APEA Urology

Answer 265

a. Interstitial cystitis **APEA Urology

Answer 266

b. Pyelonephritis **APEA Urology

Answer 267

a. Blood and protein **APEA Urology With post-streptococcal (strep) glomerulonephtiris, a child may have a recent strep infection (pharyngitis or impetigo). Proteinuria is secondary to altered glomerular structure and functioning. Gross hematuria causes the urine to be tea-colored. Bacteria, white blood cells, and mucus can be seen with urinary tract infections. Glucose and ketones present in the urine may be associated with diabetes

Answer 268

a. The kidneys have an inability to concentrate urine and adapt to fluid and electrolyte stress **APEA Urology In the neonate the kidneys are structurally complete but physiologically immature. The glomeruli have an inability to filter and concentrate urine, therefore glucose and amino acids escape and there is decreased ability to remove uric acid crystals which give the reddish appearance to the urine. There is an inability to adapt to fluid and electrolyte stress leading to loss of bicarbonate and poor reabsorption. This puts the neonate at increased risk of metabolic acidosis. The tubules are short/narrow which causes a problem with reabsorption. The nephrons function well within a month. ADH inhibits diuresis and the immature kidney causes an increased risk for dehydration

Answer 269

b. Urethritis **APEA Urology Cystitis would present with frequency and urgency. Constipation does not usually present with urinary tract symptoms. Acute prostatitis presents with frequency, urgency, and dysuria.

Answer 270

b. Smegma **APEA Urology Candida appears as a white substance usually causing vaginal itching Leukorrhea refers to thick whitish or yellowish vaginal discharge commonly seen during pregnancy Leukocoria is an abnormal white reflection from the retina of the eye and its presence could indicate retinoblastoma or a congenital cataract

Answer 271

c. Open angle glaucoma **APEA ENT The cup-to-disc ratio compares the diameter of the "cup" portion of the optic disc with the total diameter of the optic disc. In glaucoma, an increase in intraocular pressure will damage the delicate nerve fibers and produces additional cupping of the optic disc. As glaucoma worsens, the cup enlargens until it occupies most of the disc area.

Answer 272

d. Blepharitis **APEA ENT Blepharitis is an inflammation of eyelid margin, glands, and lash follicles. It presents with red-rimmed eyes, burning, itching of the eyelid margins, and mucous discharge with crusting and scaling of lid margins. Conjunctivitis is inflammation of the conjunctiva. It presents with erythematous conjunctiva and frequent discharge. Chalazion is a granulomatous eyelid cyst or nodule. Corneal ulcer of a local necrosis of the cornea caused

Answer 273

c. Glaucoma **APEA ENT Glaucoma is a leading cause of blindness in the United States. Glaucoma is a condition that produces optic nerve damage and visual field changes. The risk of glaucoma increases with age but can occur in anyone in any age group. Retinoblastoma is a rapidly developing tumor and is the most common malignant tumor of the eye in children. A cataract is an opacity of the lens and may be seen through the pupil Pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea and may interfere with vision but does not cause blindness.

Answer 274

b. Conductive hearing loss **APEA ENT The Rinne hearing test is used primarily for evaluated hearing in one ear as compared to the other ear. It compares the perception of sound transmitted by air conduction to those sounds transmitted by bone conduction through the mastoid. Therefore, it screens for conductive hearing loss.

Answer 275

b. A detached retina **APEA ENT A detached retina is the separation of the sensory layer of the retina from the choroid layer. Initially, the patient is aware of the presence of floaters or floating spots, and/or flashing lights. Macular degeneration is the degeneration of the macular area of the retina with a loss of central vision and intact peripheral vision. In patients who have glaucoma, there is damage to the optic nerve and a loss of peripheral vision, the appearance of halos around lights, and difficulty focusing on near objects.

Answer 276

c. Dilation of the pupils **APEA ENT Miosis refers to constriction of the pupils. Mydriasis refers to dilation of the pupils.

Answer 277

a. A conjugate gaze **APEA ENT Conjugate, or normal gaze, the normal movement of the two eyes appears simultaneously in the same direction to bring something into view. With a left cranial nerve VI paralysis, a person's gaze would include eyes conjugate when looking to the right, esotropia (one or both eyes turn inward) in the left eye when looking straight ahead, and esotropia is maximum in the left eye when looking to the left. With a left cranial nerve III paralysis, upward, downward, or inward movements are impaired. The left eye is unable to look down when turned inward in a left cranial nerve IV paralysis.

Answer 278

b. Otitis externa **APEA ENT Otitis externa (swimmer's ear) is an infection or inflammation of the external ear or the ear canal. Symptoms include itching and tragal pain. The external canal may have a discharge. Otitis media is a middle ear infection and usually the tympanic membrane is bulging with fluid or pus behind it. Mastoiditis is an infection of the mastoid process (temporal bone adjacent to the middle ear). A ruptured tympanic membrane is usually secondary to infection that causes pus and fluid to build-up behind the eardrum and as the pressure increases, the eardrum may rupture. Ear pain decreases when the membrane ruptures and the discharge can be pus, blood, or a clear fluid

Answer 279

b. Dacryocystitis **APEA ENT Dacryocystitis is an infection and blockage of the lacrimal sac and duct. Symptoms include pain, warmth, redness, and swelling below the inner canthus toward the nose. Tearing is usually present and when pressure is applied to the lacrimal sac, a purulent discharge from the puncta can be noted. Blepharitis: Red, scaly, greasy flakes and thickened, crusted lid margins. Symptoms include burning, itching, tearing, foreign body sensation, and some pain. Hordeolum is an infection usually secondary to localized staphylococcal infection of the hair follicles at the lid margin.

Answer 280

c. Acute otitis media **APEA ENT Acute Otitis Media: red, bulging tympanic membrane may be found Acute otitis externa: Canal may be swollen, narrow, moist and pale with tenderness on touching. The ear drum is intact. Chronic otitis externa: Skin of canal may be thickened, red, and pruritic. The ear drum is usually unaffected. Serous effusion: the ear drum appears amber and there usually is no bulging of the eardrum.

Answer 281

c. Pale **APEA ENT Glacomatous cupping: A pale disc with a backward depression is characteristic of glaucomatous cupping. Papilledema: Pink and hyperemic disc Normal disk: yellowish-orange to creamy pink and the vessels are tiny with disc margins that appear sharp Optic atrophy: death of the optic nerve fibers leads to loss of the tiny disc vessels giving a white appearance.

Answer 282

b. Corneal scar **APEA ENT Corneal scar: Superficial grayish-white opacity in the cornea Corneal arcus: thin grayish-white arc noted on the lower end of the cornea. This is common during normal aging but can be seen in younger people and may be suggestive of dyslipidemia. Pterygium: triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea Cataract: opacity of the lens visible through the pupil

Answer 283

b. Tongue **APEA ENT Reddened areas, nodules, or ulcerations noted on the sides and undersurface of the tongue and the floor of the mouth would be suggestive of cancer. Cancer of the tongue is the second most common cancer of the mouth, the lip is number one.

Answer 284

b. 512 Hz **APEA Ent Tuning forks with a lower frequency may be better felt than heard, while tuning forks at higher frequency tend to lose vibratory energy quickly and are difficult to activate for them to be heard with moderate or severe sensorineural impairment. A tuning fork with a frequency of 512 Hz is the most effective in assessing for air and bone conduction of hearing

Answer 285

b. Rhinorrhea **APA ENT Rhinitis refers to inflammation in the nose Cerumen is the medical term for earwax Otorrhea refers to ear discharge

Answer 286

b. Precancerous **APEA ENT Leukoplakia are thickened white patches located on any area of the mouth. These patches cannot be rubbed off. Most are not serious but some can be considered precancerous. Therefore, they should be evaluated. These lesions are not considered normal findings. Periodontal disease usually includes an infection of the gums and may involve the teeth. Generally, the infection causes redness and swelling but not white patches.

Answer 287

d. Upward and back **APEA ENT To examine the ears of an infant it is usually necessary to pull the auricle backward and downward. In the older child, the external ear is pulled backward and upward.

Answer 288

d. Presbycusis **APEA ENT Presbycusis is the most common type of sensorineural hearing loss caused by the natural aging of the auditory system. It occurs gradually and initially affects the ability to hear higher-pitched (higher frequency) sounds. It also muffles the sounds of voices. Acoustic neuroma is a rare condition that develops from direct effects on the main nerve or from a tumor pressing on adjacent nerves or brain structures. It causes symptoms of dizziness, loss of balance, and facial numbness. Cholesteatoma and granulomatous disease present with physical symptoms of infectious ear drainage.

Answer 289

c. In patients diagnosed with diabetes **APEA ENT Gingival hyperplasia describes erythematous, swollen gums that are over grown. This condition can be seen in some patients during pregnancy or puberty, or those with leukemia. It is associated with certain medications: phenytoin, cyclosporine, and calcium antagonists. This condition is not characteristically seen in diabetes.

Answer 290

c. Angular cheilitis **APEA ENT Angular cheilitis begins with softening of the skin at the angle of the mouth with subsequent development of fissures. This condition may be seen in patients who have nutritional deficiencies or ill-fitting dentures. Actinic cheilitis typically results from excessive exposure to sunlight and generally affects the lower lip. The lip becomes slightly everted, scaly, somewhat thickened, and loses its red color. Herpes simplex presents with recurrent and painful vesicles on the lips and surrounding areas. Leukoplakia appears as thickened white patches anywhere in the oral mucosa

Answer 291

b. Peritonsillar abscess **APEA ENT Presence of swelling of the uvula with a deviation may be a strong indication of a peritonsillar abscess or parapharyngeal abscess. A deviated uvula with no evidence of swelling may be due to a vagus nerve (CN X) lesion. CN X innervates the uvula. Peritonsillar abscess and smoking may be associated with a swollen uvula but not associated with deviations of the uvula. A deviated uvula is not a common finding in the elderly but may be present if a person experiences a stroke.

Answer 292

d. It depends **APEA ENT It depends on the type of blindness. Pupillary reaction is controlled by the muscles which are innervated by nerves. As long as there is no damage to the nerve or the muscle, the pupil will still contract or dilate.

Answer 293

b. Constriction of the pupils **APEA ENT

Answer 294

b. Oculomotor nerve (CN III) paralysis **APEA ENT Oculomotor cranial nerve (CNIII) paralysis: dilated pupil is fixed to light and near accommodation. Ptosis and lateral deviation of the eye are usually present. Tonic Pupil (Adele's pupil): When the pupil is large, regular, and usually unilateral and the reaction to light is severely reduced and slowed, or even absent. Horner's syndrome: affected pupil reacts briskly to light and near effort but the pupil is small. Argyll Robertson: pupil appears small, irregular shaped and accommodate but do not react to light.

Answer 295

c. Pharyngitis **APEA ENT Pharyngitis is caused by swelling between the tonsils and the larynx secondary to either viral or bacterial infections. The most common bacterial pharyngeal infections in children are caused by group A beta-hemolytic strep. A patient with sinusitis is more likely to present with nasal congestion, nasal discharge, headache, and an absence of fever. Exudative tonsillitis presents with tonsillar exudate. There is no mention of this in the question stem. Influenza infection typically presents with cough, headache, and body aches.

Answer 296

d. An ulcerated lesion with indurated margins on the lateral tongue **APEA ENT Oral malignant lesions: usually present as ulcerated with indurated margins. They are not usually circular or smooth Dental abscess presents as a soft, solitary papule located apical to the molar. Canker sore is a small, shallow sore at the base of the gum

Answer 297

b. Glaucoma **APEA ENT Glaucoma: change in the color and size of the optic disc resulting in a gradual loss of vision. Macular degeneration: loss of vision in the central visual fields because of damage to the retina. Peripheral vision remains intact Cataracts: usually appear as cloudiness or opacity in the lens. Retinoblastoma- rapidly developing cancer of the retina and an absent red reflex is noted on opthalmoscopic exam

Answer 298

b. Clear frontal sinuses **APEA ENT Dim red glow would suggest a normal finding. An absence of this red glow could be suggestive of a thickened mucosa or the presence of secretions or lesions in the frontal sinuses. Absence of the red glow could also indicate the absence of the frontal sinuses

Answer 299

b. Place the tooth between the molars and the inside of the cheek **APEA ENT Saliva, saline, milk, and culture medias are physiologic medias for storing the tooth until it can be reimplanted. Tap water is avoided because the hypotonic environment causes rapid cell lysis and increased inflammation on reimplantation.

Answer 300

c. Rubeola **APEA ENT Five medical reasons for the appearance of strawberry tongue: Kawasaki disease, scarlet fever, folic acid and vitamin B12 deficiencies, bacterial toxic shock syndrome, and a geographic tongue. Rubeola does not present with a strawberry tongue. Koplik's spots are diagnostic of rubeola and they appear as clustered white lesions on the buccal mucosa.

Answer 301

b. Pale **APEA ENT Rhinitis is inflammation of the nasal mucosa and the mucosa appears somewhat redder than the oral mucosa. With allergic rhinitis, it appears pale, bluish, or a darker red than normal. In viral rhinitis, it tends to appear erythematous and swollen A yellow or green color may be due to the appearance of exudate in the nasal cavity

Answer 302

a. Dilate **APEA ENT

Answer 303

c. A normal eardrum **APEA ENT The normal eardrum or tympanic membrane appears pinkish gray. The handle and short process of the malleus and the cone of light are all clear and visible. The cone of light fans anteriorly and downward from the umbo putting it in the four-o-clock position. A perforation in the eardrum would appear as a hole in the membrane and the cone of light would be absent. In acute otitis media, the eardrum appears red with loss of landmarks and may or may not have a bulge. Tympanosclerosis is a deposit of hyaline material within the layers of the tympanic membrane that sometimes follow a severe episode of otitis media. It appears as a chalky white patch with irregular margins.

Answer 304

a. Vein "winds" down on either side of the artery **APEA ENT When the arterial walls lose their transparency, changes appear in the arteriovenous crossings. Decreased transparency of the retina probably contributes to AV nicking and AV tapering. In tapering, the vein appears to taper or "wind" down either side of the artery. In AV nicking, the vein appears to stop abruptly on either side of the artery. In the normal eye, the vein appears to cross beneath the artery With banking, the vein appears to be twisted on the distal side of the artery and forms a dark wide knuckle appearance.

Answer 305

a. Retinal detachment **APEA ENT If a patient reports sudden, unilateral visual loss that is painless, vitreous hemorrhage from diabetes or trauma may be considered. It could also be caused by macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion. If the loss is painful, causes may be associated with the cornea and anterior chamber. Examples include corneal ulcer, uveitis, traumatic hyphema, and acute glaucoma

Answer 306

b. An outward turning of the lower eyelid **APEA ENT Ectropion exhibits an outward turning of the lower eyelid exposing the palpebral conjunctiva. This condition is more common in the elderly. Entropion exhibits an inward turning of the lower eyelid with irritation to the conjunctiva and lower cornea. This condition is more common in the elderly. Ptosis presents as drooping of the eyelid caused by damage to the oculomotor nerve, myasthenia gravis, or damage to the sympathetic nervous system. Lid retraction and exophthalmos is a condition that appears as a wide-eyed stare and suggests retracted eyelids. This condition could be suggestive of hyperthyroidism

Answer 307

a. A tonic pupil **APEA ENT Oculomotor cranial nerve (CNIII) paralysis: dilated pupil is fixed to light and near accommodation. Ptosis and lateral deviation of the eye are usually present. Tonic Pupil (Adele's pupil): When the pupil is large, regular, and usually unilateral and the reaction to light is severely reduced and slowed, or even absent. Horner's syndrome: affected pupil reacts briskly to light and near effort but the pupil is small. Argyll Robertson: pupil appears small, irregular shaped and accommodate but do not react to light.

Answer 308

b. Blinks **APEA ENT The corneal reflex is the blink reflex and is an involuntary blinking of the eyelids. When the corneal reflex is stimulated, stimulation should elicit both a direct and consensual response of the opposite eye

Answer 309

b. At 20 feet the patient can read printed information that a person with normal vision could read at 200 feet. **APEA ENT

Answer 310

a. Acute iritis **APEA ENT Acute iritis: moderate aching deep within the eye. The pupils are small and irregular and vision is decreased and photophobia is present. The cornea is clear or slightly cloudy with injection confined to the corneal limbus. This is considered an emergency and is usually related to Herpes zoster infection of tuberculosis. Corneal injury or infection usually presents with watery or purulent ocular discharge and severe eye pain. Acute angle closure glaucoma: pain is severe, aching, and deep but the pupils are dilated and fixed and the cornea appears steamy or cloudy. If an increase in intraocular pressure is present in conjunction with these findings, this would be an emergency situation

Answer 311

b. Left cranial nerve III (oculomotor) paralysis **APEA ENT

Answer 312

c. Frontal sinuses **APEA ENT

Answer 313

d. Acute sinusitis of the frontal and maxillary sinuses **APEA ENT

Answer 314

d. Direct reaction to light **APEA ENT

Answer 315

b. Visual acuity of 20/200 or worse in the better eye with corrected lens **APEA ENT

Answer 316

c. Detachment of the vitreous from the retina **APEA ENT Flashing lights or new vitreous floaters suggest detachment of vitreous from the retina. A detached retina would present with a sudden loss of vision. With a lesion in the visual pathway, one may visualize fixed defects such as a scotoma. At any rate, this is not a normal finding even if the person was around bright lights.

Answer 317

d. Fair-skinned men who work outdoors **APEA ENT

Answer 318

c. Glossitis **APEA ENT

Answer 319

d. Acute angle closure glaucoma **APEA ENT With acute angle closure glaucoma, the pain is described as severe, aching, and deep. The pupils are dilated and fixed and the cornea appears steamy or cloudy. If increase in intraocular pressure is present, this would be an emergency situation. Acute iritis presents with a moderate aching pain deep within the eye. The pupils are small and irregular and vision is decreased and photophobia is usually present. The cornea is clear or slightly cloudy with injection confined to the corneal limbus. This is considered an emergency and is usually related to Herpes zoster infection or tuberculosis. Corneal injury or infection usually presents with watery or purulent ocular discharge and the pain is severe

Answer 320

b. Intranasal use of cocaine **APEA ENT

Answer 321

a. Are located between the eyes **APEA ENT Paranasal sinuses include the maxillary, frontal, ethmoidal, and sphenoidal sinuses. The ethmoidal sinuses are between the eyes, the frontal sinuses are above the eyes. The maxillary sinuses are located around the nasal cavity. The sphenoidal sinuses lie just behind the ethmoidal sinuses.

Answer 322

b. Gingivitis **APEA ENT

Answer 323

a. The presence of cerumen impaction **APEA ENT Sensorineural hearing loss involves problems with the transmission of sound from the inner ear to the 8th cranial nerve. It is a permanent condition that usually affects both ears. Sensorineural hearing loss can be present at birth or as a result of conditions acquired later in life. Examples include: Prolonged exposure to loud noise, infection, severe head injury, medication exposure, and some inherited diseases.

Answer 324

c. Strabismus **APEA ENT Strabismus (heterotropia) is a condition in which the eyes are misaligned. "cross-eyed", "wall eye" or "lazy eye" are all associated with strabismus. Hyperopia (farsightedness) occurs when light rays focus posterior to the retina. Myopia (Nearsightedness) occurs when light rays focus anterior to the retina Astigmatism- light rays do not focus correctly on the retina. This causes blurriness.

Answer 325

c. Perforated tympanic membrane **APEA ENT A perforated tympanic membrane is an example of a cause of a conductive hearing loss. Sensorineural hearing loss involves disorders of the cochlear nerve, cochlea, and an interruption in the neuronal impulse transmission to the brain. Causes include: exposure to loud noises, inner ear infections, acoustic neuroma, aging, and congenital and/or familial disorders.

Answer 326

b. Meniere's disease **APEA ENT Meniere's Disease: disorder of the middle ear with excessive endolymphatic fluid accumulation in the membranous labyrinth. It may be due to malabsorption or a blocked endolymphatic duct. Symptoms include recurrent attacks of dizziness, a sense of fullness in the ears with roaring or ringing tinnitus. There is gradual but progressive sensorineural hearing loss. It usually occurs in adults around forty years of age. Otosclerosis is a disorder of the labyrinthine capsule where abnormal bone growth occurs around the ossicles leading to a reduction of sound transmission to the inner ear. Paget's disease results in abnormal bone destruction or growth of bone. It is also a malignant disease of the breast. Mastoiditis is an infection of the mastoid process.

Answer 327

a. Weber test **APEA ENT The weber hearing screening test can detect unilateral conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear) hearing loss.

Answer 328

c. Buccal mucosa opposite the second molar **APEA ENT The largest salivary gland is the parotid gland and it lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. Its duct, Stensen's duct, runs forward to an opening on the buccal mucosa opposite the second molar. If blood comes out through the Stensen's duct when it is palpated, this could suggest parotid cancer. If pus is expelled, it suggests suppurative parotitis. With mumps, the orifice of the Stensen duct appears erythematous and enlarged. The submandibular gland is the size of a walnut. It lies beneath the mandible at the angle of the jaw. Wharton's duct runs up and forward to the floor of the mouth and opens at either side of the frenulum. The smallest, the almond-shaped sublingual gland, lies within the floor of the mouth under the tongue. It has many small openings along the sublingual fold under the tongue.

Answer 329

a. A hordeolum **APEA ENT Hordeolum: Localized staphylococcal infection of the hair follicles at the lid margin. (Stye). Symptoms include a painful, red, and swollen pustule at the lid margin. Rubbing the eyes can cause cross-contamination and development of another hordeolum. Blepharitis: Red, scaly, greasy flakes and thickened, crusted lid margins are consistent with blepharitis. Chalazion is a chronic inflammatory lesion that develops when a meibomian gland becomes obstructed. It produces a beady nodule on the lid. Dacryocystitis represents an infection of the lacrimal sac and duct

Answer 330

b. An obstructed nasolacrimal duct **APEA ENT Obstructed nasolacrimal duct would present with a mucopurulent discharge from the puncta of the eye. Conjunctivitis is an inflammation of the conjunctiva and findings include red, burning, and itchy eyes. Dacryocystitis represents an infection of the lacrimal duct and the lacrimal sac, the area between the lower eyelid and the nose. It presents as a painful, red, and tender area around the eye, especially near the nose. Pinguecula- harmless yellowish triangular nodule noted in the bulbar conjunctiva on either side of the iris. This finding may be seen in aging or in patients who are exposed chronically to dust

Answer 331

b. Corneal injury **APEA ENT

Answer 332

c. Less brilliant **APEA ENT In older adults, the fundi lose their youthful shine and light reflections. The arteries look narrowed, pale, straight, and less brilliant than in young or middle adults

Answer 333

c. Dacrocystitis **APEA ENT Dacryocystitis represents an infection of the lacrimal duct and the lacrimal sac, the area between the lower eyelid and the nose. It presents as a painful, red, and tender area around the eye, especially near the nose. Conjunctivitis is an inflammation of the conjunctiva and findings include red, burning, and itchy eyes. Obstructed nasolacrimal duct would present with a mucopurulent discharge from the puncta of the eye. Pinguecula- harmless yellowish triangular nodule noted in the bulbar conjunctiva on either side of the iris. This finding may be seen in aging or in patients who are exposed chronically to dust

Answer 334

b. Amblyopia. **APEA ENT Amblyopia results from anything that causes visual deprivation to the eye, including congenital cataracts, untreated strabismus, and refractive errors. With amblyopia, there is a reduction in vision in one or both eyes causing loss of binocular vision. Cataracts are visualized by a cloudiness or opacity in the lens. Macular degeneration is defined as degeneration of the macular area of the retina

Answer 335

d. Xanthelasma **APEA ENT Pinguecula- harmless yellowish triangular nodule noted in the bulbar conjunctiva on either side of the iris. This finding may be seen in aging or in patients who are exposed chronically to dust Chalazion is a chronic inflammatory lesion that develops when a meibomian gland becomes obstructed. It produces a beady nodule on the lid. Episcleritis- an ocular inflammation of the episcleral vessels Xanthelasma- Slightly raised, yellowish, well-circumscribed plaques appearing along the nasal areas of one or both eyelids, consistent with lipid disorders.

Answer 336

d. Bullous myringitis **APEA ENT Bullous myringitis: viral infection characterized by painful hemorrhagic vesicles on the tympanic membrane and/or in the ear canal. Hearing loss, blond-tinged discharge from the ear, and an earache are classic symptoms. Tympanosclerosis is a deposit of hyaline material within the layers of the tympanic membrane that sometimes follow a severe episode of otitis media. It appears as a chalky white patch with irregular margins. Otitis media with purulent effusion is usually bacterial and the eardrum is red and the landmarks are not visible. Otitis media with serous effusion is usually viral and amber fluid can be seen behind the eardrum

Answer 337

b. Increased mobility of the tympanic membrane **APEA ENT The hallmark of acute otitis media (AOM) is the recent onset of a middle ear infection manifesting one or more of the following signs or symptoms: Otalgia (tugging or rubbing of the ear in children <2 years), fever, irritability, anorexia, nausea, vomiting, diarrhea, rhinitis or purulent discharge in the ear canal accompanied by decreased mobility of the tympanic membrane (TM)

Answer 338

b. Blepharitis **APEA ENT Blepharitis: Red, scaly, greasy flakes and thickened, crusted lid margins are consistent with blepharitis. Chalazion is a chronic inflammatory lesion that develops when a meibomian gland becomes obstructed. It produces a beady nodule on the lid. Hordeolum: Localized staphylococcal infection of the hair follicles at the lid margin. (Stye). Symptoms include a painful, red, and swollen pustule at the lid margin. Rubbing the eyes can cause cross-contamination and development of another hordeolum. Dacryocystitis represents an infection of the lacrimal duct and the lacrimal sac, the area between the lower eyelid and the nose. It presents as a painful, red, and tender area around the eye, especially near the nose.

Answer 339

c. At the 7 o'clock to 8 o'clock position of the left tympanic membrane **APEA ENT

Answer 340

c. Drooping of the eyelid **APEA ENT

Answer 341

a. Vagus nerve lesion **APEA ENT A deviated ulna with no evidence of swelling may be due to a vagus nerve (CN X) lesion. CN X innervates the ulna. A deviated ulna with swelling may be a strong indication of a peritonsillar abscess or parapharyngeal abscess. Peritonsillar abscess and smoking may be associated with a swollen uvula but not with deviations of the uvula. A deviated uvula is not a common finding in the elderly but may be seen after a stroke

Answer 342

c. Presbycusis **APEA ENT Presbycusis is the most common type of sensorineural hearing loss caused by the natural aging of the auditory system. Most common hearing problem in people over age 50. It occurs gradually and initially affects the ability to hear higher-pitched (higher frequency) sounds. It also muffles the sounds of voices. Patients may have a hard time hearing what others are saying or may become sensitive to loud noises. Hearing loss is usually bilateral. Mastoiditis is an infection of the mastoid process (temporal bone adjacent to the middle ear) and generally results from inadequately treated otitis media. Otosclerosis is a sensorineural hearing loss because of reduced sound transmission to the middle ear. Meniere’s disease is a disorder of the middle ear due to impaired absorption of endolymph

Answer 343

b. Kaposi's sarcoma Kaposi's sarcoma: A low-grade vascular tumor associated with human herpes virus 8. Associated with flat or raised, deep purple-colored lesions of the mouth. Approximately 1/3 of patients with Kaposi's sarcoma have lesions in the oral cavity. Other sites that could be affected include the gastrointestinal tract and the lungs. Koplik's spots: Frequently seen in the early stage of measles (Roseola) and appear as small, white specks that resemble grains of salt on a red background on the buccal mucosa. Torus palatinus: develops as a bony growth in the hard palate and is common in adults. Fordyce spots: granules appear as yellow spots in the buccal mucosa or on the lips. They are considered normal sebaceous glands.

Answer 344

d. Rinne test **APEA ENT

Answer 345

b. Preretinal hemorrhages **APEA ENT Deep retinal hemorrhages: appear as small, rounded, slightly irregular red spots and are sometimes called dot or blot hemorrhages. They occur in a deeper layer of the retina than flame-shaped hemorrhages. Diabetes is a common cause. Preretinal hemorrhages lie anteriorly between the retina and the vitreous and are typically larger than retinal hemorrhages. These hemorrhages obscure any underlying retinal vessel. Superficial retinal hemorrhages appear as small, linear, flame-shaped, red streaks in the fundus and are seen in hypertension, papilledema, and occlusion of the retinal vein. Microaneurysms present as tiny, round, red spots commonly seen in and around the macular area. These are classic in diabetic retinopathy.

Answer 346

b. Aphthous ulcers **APEA ENT Leukoplakia appears as thickened white patches anywhere in the oral mucosa Aphthous ulcers: (Canker sore) can appear anywhere on the buccal mucosa or tongue. They usually appear as round or oval ulcers, can be white or yellowish gray in color, and are surrounded by a halo of reddened mucosa. They are usually painful. Koplik's spots: Frequently seen in the early stage of measles (Roseola) and appear as small, white specks that resemble grains of salt on a red background on the buccal mucosa. Ulcerative gingivitis is a painful form of gingivitis that is characterized by the development of ulcers in the interdental papillae. If untreated they can become necrotizing along the gum margins and appear as erythematous ulcers.

Answer 347

b. Nystagmus **APEA ENT

Answer 348

d. White **APEA ENT Papilledema: Pink and hyperemic disc Normal disk: yellowish-orange to creamy pink and the vessels are tiny with disc margins that appear sharp Optic atrophy: death of the optic nerve fibers leads to loss of the tiny disc vessels giving a white appearance. Glacomatous cupping: A pale disc with a backward depression is characteristic of glaucomatous cupping.

Answer 349

b. Likely communicate through gestures An infant with hearing loss: does not startle to loud noises, arouses to touch and not noise, does not turn head in response to sounds, and has little or no babbling or vocalization. A toddler with hearing loss: would communicate with gestures, exhibits little or no intelligible speech, and does not respond to surrounding noises. A school-aged child with hearing loss: would sit close to the television with the volume on high, may have poor school performance, speech problems, and inability to correctly respond unless directly in front of the speaker's face.

Answer 350

b. Press up on the maxillary sinus **APEA ENT

Answer 351

d. Scotomas **APEA ENT Scotomas, or fixed defects: lesions appear in the retina or visual pathways of a certain area of the field of vision. Vitreous floaters: moving specks or strands. Specks can be seen throughout the visual fields. A detached retina is the separation of the sensory layer of the retina from the choroid layer. Initially, the patient is aware of the presence of floaters or floating spots, and/or flashing lights. Macular degeneration is the degeneration of the macular area of the retina with a loss of central vision and intact peripheral vision.

Answer 352

c. Include the cardinal directions of gaze **APEA ENT

Answer 353

b. Surround the nasal cavity **APEA ENT

Answer 354

b. Vein is twisted on the distal side of the artery **APEA ENT When the arterial walls lose their transparency, changes appear in the arteriovenous crossings. Decreased transparency of the retina probably contributes to AV nicking and AV tapering. AV nicking: The vein appears to stop abruptly on either side of the artery. AV tapering: The vein appears to taper down either side of the artery. Normal eye: Vein appears to cross beneath the artery AV banking: Vein appears to be twisted on the distal side of the artery and forms a dark wide knuckle appearance

Answer 355

b. Episcleritis **APA ENT Episcleritis: condition of the sclera when the vessels appear movable over the scleral surface. The appearance may be nodular or show only redness and dilated vessels. This condition can be seen in rheumatoid arthritis, Sjogren's syndrome, and herpes zoster. Scleroderma: Characterized by thickened, hardened skin. It may be accompanied by multisystem involvement. Conjunctivitis is an inflammation of the conjunctiva and findings include red, burning, and itchy eyes. Pinguecula- harmless yellowish triangular nodule noted in the bulbar conjunctiva on either side of the iris. This finding may be seen in aging or in patients who are exposed chronically to dust

Answer 356

d. Deep retinal hemorrhages **APEA ENT Deep retinal hemorrhages: appear as small, rounded, slightly irregular red spots and are sometimes called dot or blot hemorrhages. They occur in a deeper layer of the retina than flame-shaped hemorrhages. Diabetes is a common cause. Preretinal hemorrhages lie anteriorly between the retina and the vitreous and are typically larger than retinal hemorrhages. These hemorrhages obscure any underlying retinal vessel. Superficial retinal hemorrhages appear as small, linear, flame-shaped, red streaks in the fundus and are seen in hypertension, papilledema, and occlusion of the retinal vein. Microaneurysms present as tiny, round, red spots commonly seen in and around the macular area. These are classic in diabetic retinopathy.

Answer 357

c. Presbyopia **APEA ENT Presbyopia may begin in the 5th or 6th decade. Symptoms include diminished ability to focus on near objects. Hyperopia (farsightedness): occurs when light rays focus posterior to the retina. Myopia (nearsightedness): occurs when light rays focus anterior to the retina. Strabismus (heterotropia): a condition in which the eyes are misaligned. Cross-eyed, wall-eye, or lazy eye are all associated with strabismus.

Answer 358

c. Strabismus **APEA ENT Strabismus (heterotropia): a condition in which the eyes are misaligned. Cross-eyed, wall-eye, or lazy eye are all associated with strabismus. Can be detected with the cover-uncover and the Hirschberg test. With the cover-uncover test, eye muscle weakness is seen as eye deviation when the eye is uncovered. With Hirchberg's test, an asymmetric light reflex indicates a deviation.

Answer 359

b. A myringotomy **APEA ENT Myringotomy: Surgical perforation of the tympanic membrane to allow drainage of the middle ear secretions and to relieve pain and pressure from a bulging ear drum. Otosclerosis: abnormal bone growth that occurs around the ossicles. Tympanocentesis: Procedure where a fine needle is inserted into the tympanic membrane to relieve pressure, pain, and to drain secretions, or to obtain a culture of the fluid. Tympanoplasty: Surgical reconstruction of the ossicles and tympanic membrane to help restore hearing.

Answer 360

c. General hearing loss **APEA ENT

Answer 361

d. Radiation exposure **APEA ENT Sudden, bilateral vision loss that is painful: Can result from exposure to chemicals or radiation Sudden, bilateral vision loss that is painless: Can result from certain medications including cholinergics, anticholinergics, and steroids.

Answer 362

b. Depress both lower lids with your thumbs, exposing the sclera and conjunctiva **APEA ENT

Answer 363

a. Retinal detachment If a patient reports a change in vision and states that the vision loss was sudden, this is suggestive of retinal detachment, vitreous hemorrhage, or occlusion of the central retinal artery. Immediate ophthalmology consultation is needed. Macular degeneration is the degeneration of the macular area of the retina with a loss of central vision and intact peripheral vision. Hyperopia (farsightedness): occurs when light rays focus posterior to the retina. Hyperglycemia can cause blurring, but not a loss of vision.

Answer 364

a. The presence of cerumen impaction **APEA ENT

Answer 365

c. Angina **APEA Cardiovascular

Answer 366

d. Arterial occlusive disease **APEA Cardiovascular Absent or diminished pulses at the wrist are found in arterial occlusive disease such as acute embolic occlusion, in Buerger's disease, or thromboangiitis obliterans. Varicosities, venous insufficiency, and right-sided heart failure are consistent with venous conditions.

Answer 367

a. Hiccoughs **APEA Cardiovascular Pacemaker failure is uncommon. Most malfunctions are caused by electrode dislocation, poor contact, or interference by other tissues. Symptoms include dizziness, lightheadedness, hiccoughs, sudden changes in heart rate, electric shock feeling in the chest. Chest pain is usually absent. Wheezing and hypertension are not specifically characteristic of pacemaker malfunction.

Answer 368

c. Deep vein thrombosis **APEA Cardiovascular DVT: Venous disorder. Patient often describes the pain as tight and bursting around the affected area. The pain may be accompanied by swelling and tenderness. Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress. Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds.

Answer 369

d. Respiratory rate greater than 30 **APEA Cardiovascular Orthostatic hypotension: Occurs in 20% of older adults and in up to 50% of frail nursing home residents. Common when first arising in the morning. Symptoms include lightheadedness, weakness, unsteadiness, visual blurring, and in 20-30% of patients syncope occurs.

Answer 370

c. Pericarditis **APEA Cardiovascular Persistent, Sharp, and knife-like pain: Characteristic of pericarditis and pleuritic pain. Pressing, squeezing, tight, heavy, and occasionally burning: Characteristic of myocardial infarction Stabbing, sticking, dull, or aching pain: Characteristic of costochondritis Ripping and tearing pain: Dissecting aortic aneurysm

Answer 371

b. Sinus tachycardia **APEA Cardiovascular Rates that exceed 180 beats per minute are usually supraventricular. Normal sinus rhythm is a measurement of the heart's electrical activity, not mechanical activity. Ventricular tachycardia is rapid and chaotic ventricular activity.

Answer 372

c. Position the patient in the lying or sitting positions **APEA Cardiovascular The carotid artery should be palpated gently and while the patient is sitting or lying down. The patient's chin should be elevated to allow easy palpation and yet not enough to tighten the neck muscles. Stimulating its baroreceptors with low palpation can provoke severe bradycardia or cause cardiac arrest in some sensitive persons. Carotid arteries should never be palpated at the same time, this may limit blood flow to the head possibly leading to fainting or cerebral ischemia. Carotid pulse is palpable between the anterior border of the sternocleidomastoid muscle, above the hyoid bone and lateral to the thyroid cartilage

Answer 373

d. Feet appear pale on elevation and dusky red on dependency **APEA Cardiovascular Arterial insufficiency: Skin becomes pale on elevation and a dusky red color on dependency. Skin is cool to touch. Intermittent claudication symptoms (intermittent pain). Venous insufficiency: Persistent leg pain is noted. Skin color appears normal or may be cyanotic on dependency. Petechia occur initially, then progress to brown pigmentation. Feet are usually warm to the touch.

Answer 374

b. A ventricular septal defect, an overriding aorta, pulmonary stenosis, and right ventricular hypertrophy **APEA Cardiovascular

Answer 375

b. Mitral regurgitation **APEA Cardiovascular Tricuspid regurgitation: Audible loudest at the left sternal border with radiation to the right sternal border, xiphoid area, or to the left midclavicular line. Produces a blowing sound and is pansystolic. Mitral regurgitation: Pansystolic, harsh murmur. Heard loudest at the apex with radiation toward the left axilla. The intensity of the murmur can be soft or if there is an atrial thrill it can be loud. Ventricular Septal Defect: High pitch and is usually heard throughout systole. Innocent murmur: Heard loudest at mid systole near the second to fourth intercostal spaces between the left sternal border and the apex. Usually decreases or disappears when sitting.

Answer 376

b. Peripheral artery disease **APEA Cardiovascular

Answer 377

c. Renal disease **APEA Cardiovascular

Answer 378

b. Between the 2nd and 3rd intercostal spaces at the right upper sternal border **APEA Cardiology

Answer 379

c. Between the 2nd and 3rd intercostal spaces at the left sternal border. **APEA Cardiology

Answer 380

d. Aortic stenosis **APEA Cardiovascular Aortic Stenosis: Murmur is audible loudest in the right second intercostal space and radiates to the carotid arteries, down the left sternal border, or the apex. There is a crescendo-decrescendo pitch audible at the apex. The murmur is heard best with the patient sitting and leaning forward. Pulmonic Stenosis: soft intensity murmur with a crescendo-decrescendo pitch. It is loudest at the 2nd or 3rd intercostal spaces and radiates to the left shoulder and neck. Tricuspid regurgitation: Audible loudest at the left sternal border with radiation to the right sternal border, xiphoid area, or to the left midclavicular line. Produces a blowing sound and is pansystolic. The intensity may increase with inspiration. Mitral regurgitation: Pansystolic, harsh murmur. Heard loudest at the apex with radiation toward the left axilla. The intensity of the murmur can be soft or if there is an atrial thrill it can be loud.

Answer 381

c. An aortic dissection **APEA Cardiology Aortic Dissection: Ripping and tearing pain. Sudden, sharp pain that radiates to the back or into the neck. Myocardial Infarction: Pressing, squeezing, tight, heavy, and occasionally burning. Retrosternal type pain that often radiates up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm. Angina: Exertional pain. Pericarditis: Persistent, Sharp, and knife-like pain. May radiate to the tip of the shoulder and to the neck.

Answer 382

c. Atherosclerotic peripheral vascular disease **APEA Cardiology Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress. Neurogenic Claudication: Pain with walking or prolonged standing, radiating from the psinal area into the buttocks, thighs, lower legs, or feet. Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion. Atherosclerotic peripheral vascular disease: Symptomatic limb ischemia with exertion.

Answer 383

a. Neurogenic claudication **APEA Cardiovascular Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress. Neurogenic Claudication: Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet. Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion. Atherosclerotic peripheral vascular disease: Symptomatic limb ischemia with exertion.

Answer 384

b. Intermittent claudication --APEA Cardiovascular Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress. Neurogenic Claudication: Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet. Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion. Atherosclerotic peripheral vascular disease: Symptomatic limb ischemia with exertion.

Answer 385

a. Renal artery stenosis **APEA Cardiovascular Pulmonic Stenosis: soft intensity murmur with a crescendo-decrescendo pitch. It is loudest at the 2nd or 3rd intercostal spaces and radiates to the left shoulder and neck. Renal Artery Stenosis: A bruit heard in the epigastric area, upper quadrants, or in the costovertebral region that has both systolic and diastolic components. Aortic regurgitation: Could be evidenced by the presence of S2, S2, and a diastolic murmur. Aortic Aneurysm: A pulsation visible or palpable in the epigastrium could be consistent with aortic aneurysm

Answer 386

d. Was a 2-year-old with a congenital heart defect **APEA Cardiovascular A heart murmur is classified an organic murmur if there is an anatomic cardiac defect with or without a physiologic abnormality. If a murmur was heard and the child presents with fever or anemia, the murmur is considered a non-organic or physiologic. The 3-year-old with the upper respiratory infection without fever would be an example of an innocent murmur since there is an absence of an anatomic or physiological condition.

Answer 387

a. Pericarditis **APEA Cardiovascular Pericarditis: Persistent, Sharp, and knife-like pain. May radiate to the tip of the shoulder and to the neck. Myocardial Infarction: Pressing, squeezing, tight, heavy, and occasionally burning. Retrosternal type pain that often radiates up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm. Aortic Dissection: Ripping and tearing pain. Sudden, sharp pain that radiates to the back or into the neck. Angina: Exertional pain.

Answer 388

b. Sitting leaning forward **APEA Cardiovascular

Answer 389

a. Myocardial infarction **APEA Cardiovascular Pericarditis: Persistent, Sharp, and knife-like pain. May radiate to the tip of the shoulder and to the neck. Myocardial Infarction: Pressing, squeezing, tight, heavy, and occasionally burning. Retrosternal type pain that often radiates up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm. Costochondritis: Stabbing, sticking, dull, or aching pain Aortic Dissection: Ripping and tearing pain. Sudden, sharp pain that radiates to the back or into the neck.

Answer 390

b. Furosemide (Lasix) **APEA Cardiovascular Loop diuretics can produce decreased potassium levels. Potassium is WNL between 3.5-5.3. 3.1 is a low value. The other medications are not known for excessive potassium losses.

Answer 391

c. Coarctation of the aorta (COA) **APEA Cardiovascular In coarctation of the aorta (COA), there is a disparity of pulses between the upper and lower extremities due to the narrowing of the descending aorta resulting in decreased blood flow to the lower extremities.

Answer 392

a. Hypertension **APEA Cardiovascular An S4 heart sound occurs when the atria contract and force blood into a left ventricle that is non-compliant. This can be the result of diastolic heart failure, hypertension, infarction, or others. It is known as the "atrial gallop" and is always an abnormal finding.

Answer 393

b. A mid-systolic click **APEA Cardiovascular Mitral valve prolapse: Mid-systolic click. Mitral stenosis: Opening snap Aortic stenosis: Flat blowing pitch or a fourth heart sound (S4)

Answer 394

d. Femoral vein **APEA Cardiovascular The great saphenous vein originates on the dorsum of the foot, joins the femoral vein of the deep venous system below the inguinal ligament

Answer 395

a. Resonant **APEA Cardiovascular With left sided heart failure, increased pressure in the pulmonary veins causes congestion and interstitial edema. Percussed sounds emitted would most likely be resonant. Consolidation in the lungs produces a dull sound on percussion. Tympany (low-high pitched musical sound) is usually audible when percussing a distended abdomen or when a pneumothorax is present. Chronic obstructive lung disease produces diffusely hyperresonant sound on percussion.

Answer 396

b. Rheumatic heart disease **APEA Cardiovascular Classic symptoms of rheumatic heart disease include: Erythema marginatum, chorea, murmur, joint pain, and shortness of breath. These are usually preceded by history of a recent streptococcal infection. Kawasaki disease presents with unexplained fever for five days along with 4/5 of these symptoms: Bilateral non-purulent conjunctivitis, cervical lymphadenopathy, edema of the hands and/or feet, strawberry tongue, and a macular rash. Endocarditis presents with fever, lethargy, petechiae, neurological involvement, Janeway lesions and Osler's nodes. Sickle cell disease may present with several symptoms: chronic hemolytic anemia, delayed growth and development, renal and neurological dysfunction, and retinopathy

Answer 397

b. Volume and pressure overload resulting in decreased cardiac output **APEA Cardiovascular

Answer 398

d. Thromboangiitis obliterans **APEA Cardiovascular DVT: Venous disorder. Patient often describes the pain as tight and bursting around the affected area. The pain may be accompanied by swelling and tenderness. Thromboangiitis obliterans (Buerger’s disease): inflammatory and thrombotic occlusions of small arteries and also of veins, usually occurring in smokers. Symptoms include intermittent claudication especially in the arch of the foot and pain at rest in the toes or fingers. Other symptoms may include distal coldness or cyanosis. Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress. Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion.

Answer 399

b. Thready **APEA Cardiovascular The amplitude of the pulse correlates with pulse pressure. Small, thready, or weak pulses occur in patients in cardiogenic shock. Bounding pulses are seen in patients in aortic insufficiency. A bruit is not typically associated with pulse amplitude, but is associated with stenosis or turbulent arterial blood flow.

Answer 400

d. Sit up, lean forward, exhale **APEA Cardiovascular

Answer 401

b. Heart failure **APEA Cardiovascular S3: Suggests dilation of the left ventricle from heart failure or cardiomyopathy. S3 is produced when blood strikes a compliant left ventricle. It commonly accompanies fluid overload. It may be normal in children or pregnant women

Answer 402

c. Orthopnea **APEA Cardiovascular

Answer 403

b. A brownish discoloration just above the malleolus **APEA Cardiovascular

Answer 404

d. Cutis marmorata **APEA Cardiovascular Cutis Marmorata: marbled or mottled look about the skin of a newborn caused by the uneven distribution of blood flow about the skin. The cause is due to both the immature vascular and neurologic systems in the newborn. Mongolian spots are blue-gray spots that are flat, "bruise-like" areas of skin. Usually confined to the back and buttocks. Acrocyanosis is a bluish discoloration of the hands, feet, and lips. The phenomenon is considered normal to newborns because of immature circulation and underdeveloped capillaries.

Answer 405

b. Minus diastolic blood pressure **APEA Cardiovascular

Answer 406

a. Hypertension **APEA Cardiovascular

Answer 407

d. Impaired visual acuity **APEA CArdiovascular

Answer 408

b. Angina pectoris **APEA Cardiovascular

Answer 409

b. Apical pulse between the 3rd and 4th intercostal space in the left midclavicular line **APEA Cardiovascular

Answer 410

b. Brachial artery **APEA Cardiovascular

Answer 411

a. Smoking **APEA Cardiovascular

Answer 412

b. Identifying the pulsations of the right jugular vein **APEA Cardiovascular

Answer 413

d. Thrills **APEA Cardiovascular

Answer 414

a. Splenomegaly **APEA Cardiovascular

Answer 415

d. Between the 3rd, 4th, 5th, and 6th intercostal spaces at the left lower sternal border. **APEA Cardiovascular Mitral Point: near the apex of the heart between the 5th and 6th intercostal spaces in the mid-clavicular line Aortic Point: Between the 2nd and 3rd intercostal spaces in the right upper sternal border (RUSB). Pulmonic point: between the 2nd and 3rd intercostal spaces at the left sternal border (LUSB) Tricuspid point: between the 3rd, 4th, 5th, and 6th intercostal spaces at the left lower sternal border (LLSB)

Answer 416

b. Fifth intercostal space to the left of the midclavicular line **APEA Cardiovascular

Answer 417

b. Raynaud's disease **APEA Cardiovascular Raynaud’s disease: Usually affects the distal portions of the fingers and causes pain especially with exposure to cold or stress. Intermittent claudication: Episodic muscular ischemia induced by exercise. Due to atherosclerosis of large or medium-sized arteries. The pain is usually associated with the calf muscles, but also may be in the buttock, hip, thigh, or foot depending on the level of obstruction. Rest usually stops the pain within a few seconds. Pain or cramping in the legs that occurs with exertion. DVT: Venous disorder. Patient often describes the pain as tight and bursting around the affected area. The pain may be accompanied by swelling and tenderness.

Answer 418

c. Turn to the left side **APEA Cardiovascular

Answer 419

b. Standing **APEA Cardiovascular

Answer 420

d. Cyanosis **APEA Cardiovascular

Answer 421

c. Auscultate the heart sounds in all four cardiac areas **APEA Cardiovascular In cardiac assessments of children, heart sounds should be auscultated in all 4 cardiac areas: Aortic, pulmonic, tricuspid, and mitral areas. In children younger than 7 years old, the point of maximum impact (PMI) is auscultated at the 3rd of 4th intercostal spaces.

Answer 422

b. A sign of valvular heart disease **APEA Cardiovasular

Answer 423

a. Intermittent claudication **APEA Cardiovascular

Answer 424

a. Pericardial friction rub **APEA Cardiovasular Pericardial friction rub: Scratchy, scraping sound with a high pitch. Best heard with the diaphragm and are associated with friction from cardiac movement in the pericardial sac. If they are heard in atrial systole and ventricular systole and diastole, then the diagnosis is made. Venous hum: benign sounds resulting from turbulence in the jugular veins. They can produce a humming or roaring sound and are heard best wit hthe bell of the stethoscope during diastole. Venous hums are common in children and may be present in patients who have anemia or hyperthyroidism. Patent ductus arteriosus: harsh, machine-like sound, loudest during late systole. Ventricular septal defect: high pitch and is usually heard throughout systole.

Answer 425

c. The development of heart rhythm changes leading to syncope **APEA Cardiovascular

Answer 426

c. Dusky cyanotic when crying **APEA Cardiovascular

Answer 427

b. Fifth intercostal space to the left of the midclavicular line **APEA Cardiovascular

Answer 428

a. Bronchial **APEA Respiratory Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the trachea and larynx. Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. They are normally heard over the hilar region (center of the lungs near the heart). Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung field.

Answer 429

c. A partial obstruction in the larynx **APEA Respiratory A wheeze that is entirely or predominately inspiratory is termed stridor. It is often louder in the neck than over the chest wall and indicates a partial obstruction of the larynx or trachea and is considered an emergency. An obstruction in the alveoli or bronchioles are generalized wheezes heard throughout the chest. With an obstruction in the main bronchus, the wheeze would be persistent and more localized

Answer 430

b. Scapular line **APEA Respiratory

Answer 431

c. Supraclavicular retractions **APEA Respiratory A 4-year-old has diaphragmatic breathing so using the abdominal muscles would be normal. Eupneic respirations is a term for normal breathing. Vesicular sounds in the chest periphery is considered normal for this age group.

Answer 432

b. Around the seventh or eighth rib **APEA Respiratory

Answer 433

b. Tenacious sputum is consistent with patients who have cystic fibrosis **APEA Respiratory Purulent sputum is yellow or green. Mucoid sputum is translucent, white, or gray. Foul-smelling sputum is present in anaerobic lung abscess Tenacious sputum is present in patients who have cystic fibrosis. Large volumes of purulent sputum are present in bronchiectasis or lung abscess

Answer 434

d. Popping, frying sounds, may be low or high-pitched and usually heard on inspiration **APEA Respiratory Crackles: Coarse, medium, or fine. Usually produce a popping, frying sound. Coarse crackles are low-pitched while fine crackles are high-pitched. Course sounds are heard on inspiration and sometimes expiration. Medium crackles are heard in the middle of inspiration. Fine crackles are heard at the end of inspiration. Rhonchi: Continuous, low-pitched. Heard on expiration. Wheezes: Continuous high-pitched and musical. Pleural friction rub: Dry, grating sound

Answer 435

b. Hilar area **APEA Respiratory Retractions are a pulling inward of the soft tissue and are associated with respiratory difficulty. Usually retractions are noted in the supraventricular, intercostal, and costal margin areas of the chest.

Answer 436

a. Standing on the side rather than directly behind the patient **APEA Respiratory

Answer 437

c. Bronchovesicular **APEA Respiratory

Answer 438

c. Chemical, thermal, and mechanical factors **APEA Respiratory Several factors influence respiration: Breathing is initiated by a lack of oxygen and a high level of carbon dioxide in the blood stream. This stimulates the respiratory center in the medulla of the brain. Initiation of respiration is aided by the compression of the chest wall during the birth process, the cool air on the wet face, and the general handling of the body and limbs. A healthy baby cries almost immediately, but he has to breathe to be able to cry. With the first breath, the blood vessels in the lung expand. Spontaneous breathing is now established. Pulmonary venous return to the heart increases. This results in left arterial pressure exceeding right arterial pressure. Right to left shunting through the foramen ovale is reduced.

Answer 439

b. 14 pack year history **APEA Respiratory

Answer 440

b. Suprasternal notch **APEA Respiratory

Answer 441

c. Hemoptysis is common in children with cystic fibrosis **APEA Respiratory

Answer 442

c. Pneumonia **APEA Pneumonia Tracheal deviation results from unequal intrathoracic pressure within the chest cavity. When the deviation occurs, the trachea will follow the direction of less pressure. Tracheal deviation can be caused by pneumothorax, atelectasis, pleural effusion, some cancers within the pleural cavity, and pleural fibrosis. Pneumonia is not associated with tracheal deviation

Answer 443

d. Bases of the lungs The bases of the lungs refers to the lowermost portion of the lungs The visceral surface refers to the pleural space that covers the outer surface of the lungs. The parietal pleura lines the inner rib cage and the upper surface of the diaphragm

Answer 444

c. Epigastric area **APEA Respiratory Referred pain is defined as pain that is felt in more distal sites than the initial pain site. Pain from pleurisy or inferior wall myocardial infarction may be referred to the epigastric area. Pain from the biliary tree may be perceived in the right shoulder or the right posterior chest. Referred pain of duodenal or pancreatic origin may be referred to the back. Heartburn may be associated with retrosternal burning pain

Answer 445

c. Posterior chest at the cervical 7 level **APEA Respiratory To auscultate all the lung fields, begin by placing the diaphragm of the stethoscope on the posterior chest and listen from the apices (cervical 7 level) to the bases located around thoracic 10 level. Then listen laterally from the axilla to the 7th or 8th ribs, then repeat the entire assessment from the anterior chest.

Answer 446

b. Chronic obstructive pulmonary disease **APEA Respiratory People who have COPD experience shortness of breath and dyspnea. Breathing with pursed lips and use of abdominal muscles help reduce shortness of breath and dyspnea. Leaning forward while seated and having arms supported on the table facilitate breathing.

Answer 447

c. An abnormal finding warranting further evaluation **APEA Respiratory

Answer 448

b. Between the spine and the lateral chest **APEA Respiratory Palpate midway between the spine and the lateral chest to identify its free tip. As you palpate toward the vertebral column, you may lose contact with the twelfth rib because it is deep to the quadratus lumborum muscle

Answer 449

b. Lung density in the area **APEA Respiratory Bronchophony: indicates density and usually repeating the words ninety-nine produces that sound. If the word is clearly heard it is indicative of lung density in the area Egophony: saying ee-ee-ee-ee, is indicative of consolidation or compression in the area. It will sound like Ay for an abnormal finding Whispered pectoriloquy: Whispering one-two-three. More faint than bronchophony, you can hear the words over areas of consolidation.

Answer 450

d. COPD **APEA Respiratory

Answer 451

d. A foreign object lodged in the upper trachea **APEA Respiratory

Answer 452

a. Mediastinum **APEA Respiratory Mediastinum: The middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels. Pleural cavities: right and left pleural cavities are on either side of the mediastinum and those contain the lungs. Visceral pleura: encloses the lung Pericardium: surrounds the heart

Answer 453

b. The child's febrile state **APEA Respiratory In children, heart and respiratory rates will increase with fever. For every degree of fever the respiratory rate will increase 3-4 breaths/minute and the heart rate will increase 8-10 beats per minute

Answer 454

c. Bronchiectasis **APEA Respiratory Tracheobronchitis: Acute viral illness that presents with a burning retrosternal discomfort and a dry cough. Laryngitis: Acute, mild illness often associated with viral nasopharyngitis and hoarseness. The initial cough is dry and non-productive but may become productive over time. Chronic bronchitis: Cough is characteristically productive with mucoid to purulent sputum and may be blood-tinged. Bronchiectasis: produces a chronic cough with sputum that is copious and foul-smelling. It may be blood-tinged.

Answer 455

c. Percuss the areas over the scapulae **APEA Respiratory

Answer 456

c. Obstructive sleep apnea (OSA) **APEA Respiratory OSA: Presents as daytime sleepiness, unrestful sleep, and loud snoring. Narcolepsy: Presents with symptoms of cataplexy, sleep paralysis, hypnogogic hallucinations, and excessive daytime sleepiness. Nocturnal asthma: Symptoms include chest tightness, shortness of breath, cough, and wheezing. COPD: Symptoms include nighttime wheezing, coughing, chest tightness, morning phlegm and cough

Answer 457

b. Ask the patient to take a deep breath and note any delay in expansion during inhalation **APEA Respiratory During this assessment the thumbs should move evenly away from the vertebrae during inspiration and there should be no delay in expansion

Answer 458

d. Assessment for tactile fremitus **APEA Respiratory

Answer 459

a. Tracheobronchitis **APEA Respiratory Tracheobronchitis: Acute viral illness that presents with a burning retrosternal discomfort and a dry cough. Laryngitis: Acute, mild illness often associated with viral nasopharyngitis and hoarseness. The initial cough is dry and non-productive but may become productive over time. Chronic bronchitis: Cough is characteristically productive with mucoid to purulent sputum and may be blood-tinged. Bronchiectasis: produces a chronic cough with sputum that is copious and foul-smelling. It may be blood-tinged.

Answer 460

a. Lobar pneumonia **APEA Respiratory If dullness replaces resonance, consider a lung with fluid or solid tissue replacing the air. Examples include: pleural effusion, hemothorax, lobar pneumonia, or empyema. Emphysema, asthma, and a pneumothorax produce hyperresonance when the lungs are percussed.

Answer 461

c. Bronchovesicular **APEA Respiratory Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the trachea and larynx. Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. They are normally heard over the hilar region (center of the lungs near the heart). Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung field.

Answer 462

b. Placing the thumbs of the examiner at about the level of the tenth ribs with the fingers loosely grasping and parallel to the lateral rib cage. **APEA Respiratory

Answer 463

c. A neoplasm of the lung **APEA Respiratory

Answer 464

b. Where the right and left costal margins form an angle where they meet at the xiphoid process **APEA Respiratory

Answer 465

a. A two-week-old infant with nasal congestion and a respiratory rate of 64 breaths/minute **APEA Respiratory Normal respiratory function is a high priority in the newborn. Nasal congestion and increased respiratory rate are the beginning signs of respiratory distress. Any situation in which respiratory function is impaired should be assessed immediately. Diaper rash can be treated at home and does not necessitate immediate care. It is not unusual for breast fed infants to have loose stools after each feeding. A temperature of 99 F is within normal limits for an infant

Answer 466

b. Midclavicular line **APEA Respiratory

Answer 467

d. Infrascapular **APEA Respiratory

Answer 468

d. Movement of the chest, trunk, and arms **APEA Respiratory

Answer 469

c. Interscapular **APEA Respiratory

Answer 470

c. Runs down from the apex of the axilla and lies between and parallel to the anterior and posterior lines **APEA Respiratory

Answer 471

d. Percussion **APEA Respiratory

Answer 472

a. The area around the heart **APEA Respiratory The area around the heart near the center of the lungs describes the hilar region. The hila are structures consisting of the major bronchi and pulmonary veins and arteries. Hilar lymph nodes are not normally visible on chest x-ray

Answer 473

c. Obstructive sleep apnea (OSA) **APEA Respiratory

Answer 474

a. On the manubrium and body of the sternum **APEA Respiratory The sternal angle or the "angle of Louis" is the articulation of the manubrium and body of the sternum. It is continuous with the second rib. This angle is a useful place to start counting ribs, which helps localize respiratory finding horizontally

Answer 475

a. Vesicular **APEA Respiratory Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the trachea and larynx. Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. They are normally heard over the hilar region (center of the lungs near the heart). Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung field.

Answer 476

c. Pneumothorax **APEA Respiratory Subcutaneous emphysema is the condition described in the question. This can be caused by pneumothorax because this condition allows air to be introduced into the tissue. Hemothorax refers to blood in the chest and crepitus is not associated with this condition Pneumonia and bronchitis do not produce subcutaneous emphysema

Answer 477

b. Pulmonary embolus **APEA respiratory **Orthopnea is defined as dyspnea that occurs when the patient is lying down and improves when the patient sits or stands up. It is generally seen in patients with mitral stenosis, left ventricular hypertrophy, and in obstructive lung disease. With a pulmonary embolus, the dyspnea is sudden and uncomfortable in any position.

Answer 478

d. Vesicular **APEA Respiratory

Answer 479

Cranial nerve VII Nerves V and VII are the Trigeminal or facial nerves.

Answer 480

Worsen as the target gets closer. Tremors are rhythmic oscillatory movements. Intention tremors, absent at rest, appear with movement and often worsen as the target gets closer. Causes include disorders of cerebellar pathways as in MS or diseases of the cerebellum.

Answer 481

Sacral 2, 3, and 4

Answer 482

Proprioception or position sensation in the big toe.

Answer 483

Motor Response Based on Motor responsiveness, verbal performance, and eye opening to appropriate stimuli, the Glasgow Coma Scale was designed and should be used to assess the depth and duration of coma and impaired consciousness.

Answer 484

Vestibular System

Answer 485

Parkinson's Disease

Answer 486

with voluntary movement

Answer 487

Lumbar 5 and Sacral 1

Answer 488

Grand mal seizure

Answer 489

Shingles A band of skin innervated by the sensory root of a single spinal nerve is a dermatome.

Answer 490

Uncontrollable cerebral edema and hypoxia Can lead to symptoms of blindness, inability to perform previously learned milestones and very flaccid muscle tone.

Answer 491

Three of the five

Answer 492

A myoclonic atonic seizure.

Answer 493

Global Aphasia Broca's aphasia, speech is confluent, slow, with few words, and laborious effort. With anomic aphasia, the person has word-finding difficulties and because of the difficulties the person struggles to find the right words for speaking and writing.

Answer 494

Cranial Nerve XII- Hypoglossal Nerve.

Answer 495

Both Arms There are 4 different patterns of weakness: Proximal, distal, symmetric, and asymmetric.

Answer 496

Brudzinski's Sign

Answer 497

Cranial Nerve VII Other maneuvers could include having the patient puff out cheeks, show upper and lower teeth, and closing both eyes tightly without opening them when the examiner tries to.

Answer 498

Walking heel-to-toe in a straight line

Answer 499

Cervical 5 and 6 The segmented levels of the deep tendon reflexes are: ankle: Sacral 1 Knee: Lumbar 2, 3, 4 Supinator and biceps: Cervical 5 and 6 Triceps: Cervical 6 and 7

Answer 500

Cranial Nerve V

Answer 501

Written Language

Answer 502

I - Olfactory

Answer 503

Thoracic 10, 11, and 12

Answer 504

Alcohol Myopathy Can also occur due to glucocorticoids and inflammatory muscle disorders like myositis and dermatomyositis

Answer 505

Opioid Intoxication

Answer 506

Cluster Headaches Cluster headaches are more common in men than woman

Answer 507

b. Antisocial **APEA Psychiatry Antisocial personality disorder is characterized by habitual and pervasive disregard for or violation of the rights and considerations of others without remorse. Borderline personality disorder is defined as a pervasive pattern of instability with interpersonal relationships, self-image, and affect, as well as marked impulsivity. Histrionic personality disorder is characterized by patterns of attention-seeking, often dramatic behavior to gain the approval of others. Narcissistic personality disorder is described as a long-term pattern of abnormal behavior characterized by exaggerated feelings of self-importance, and excessive need for admiration, and a lack of understanding of others' feelings

Answer 508

Herpes Simplex Virus Type I

Answer 509

c. Exhibiting symptoms of insomnia, restless sleep, and occasional noctambulism **APEA psychiatry ADHD is a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Six or more of the symptoms must persist for at least 6 months, to a degree that is inconsistent with developmental level and that negatively impacts social and academic/occupational activities. Some of the symptoms of ADHD include: difficulty organizing tasks and activities, inability to quietly play or engage in leisure activities, inability to follow instructions, and failing to finish schoolwork.

Answer 510

Meningococcemia

Answer 511

c. Depression **APEA psychiatry Flat affect occurs in depression, Parkinson's disease, or Alzheimer's disease

Answer 512

c. Face the patient and speak in high tones **APEA psychiatry Low tone should be used rather than a high tone.

Answer 513

a. Histrionic **APEA psychiatry Antisocial personality disorder is characterized by habitual and pervasive disregard for or violation of the rights and considerations of others without remorse. Borderline personality disorder is defined as a pervasive pattern of instability with interpersonal relationships, self-image, and affect, as well as marked impulsivity. Histrionic personality disorder is characterized by patterns of attention-seeking, often dramatic behavior to gain the approval of others. Narcissistic personality disorder is described as a long-term pattern of abnormal behavior characterized by exaggerated feelings of self-importance, and excessive need for admiration, and a lack of understanding of others' feelings

Answer 514

b. Instrumental activities of daily living **APEA psychiatry ADLs consist of basic self-care abilities: bathing, dressing, toileting, transferring, continence, and feeding. Higher level functions are referred to as the instrumental activities of daily living (IADLS) and include: using the telephone, shopping, preparing food, laundry, and taking medicine

Answer 515

6 months At 9 months the child uses the thumb and pointer finger to pick up objects and this is called the pincer grasp. A 12-month old would be able to use the entire hand and fingers to pick up items. At 2 years old, Children have full dexterity and movement.

Answer 516

c. Functionality **APEA psychiatry 10-minute screener is a tool used for functional assessment in the older adult. It assesses: vision, hearing, leg mobility, urinary incontinence, nutrition and weight loss, memory, depression, and physical disability.

Answer 517

Alzheimer's Disease Including short term memory, but with sparing of memory for remote events, subtle language errors, visuospatial perceptual difficulties, and changes in executive function, or the ability to perform sequential tasks such as instrumental activities of daily living.

Answer 518

d. Frailty **APEA psychiatry Frailty: A multifactorial geriatric condition or syndrome characterized by an age-related lack of adaptive physiological capacity occurring in the absence of identifiable illness. Delirium: Serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking. In the older adult, it is defined as a geriatric syndrome or condition occurring as a temporary state of confusion and may be the first clue to infection or problems with medications. Cognitive impairment: intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia. Functional impairment: A health condition in which the normal function of a part of the body is less than full capacity. One of the defining characteristics of functional impairments is that the reduction in physical or mental capacity is sufficient to interfere with managing day-to-day tasks.

Answer 519

b. Severely mentally retarded **APEA psychiatry Mild mental retardation: Person is educable with a mental age of 8-12 years old. Moderate mental retardation: Trainable with a mental age of 3-7 years and an IQ of 35-55. Severe mental retardation: Person has an IQ between 25-40, limited communication, capable of learning certain self-care activities, and the mental age of a toddler. Profound mental retardation: IQ less than 20, the mental age of an infant, and requires complete custodial care.

Answer 520

Babinski's sign

Answer 521

Cranial Nerve IX Unilateral absence of the gag reflex suggests a lesion of CN IX or X. The glossopharyngeal and vagus nerves.

Answer 522

d. Agoraphobia **APEA psychiatry A mood disorder is defined as a prolonged emotional state that affects a person's life and personality. All of the examples listed are included except agoraphobia, a fear of being in a public place where escape may not be possible or help not available, is considered a phobic disorder.

Answer 523

A brain Tumor May also present with Nausea and Vomiting

Answer 524

b. Have you ever been found guilty of driving under the influence of alcohol? **APEA psychiatry

Answer 525

Hearing Antibiotics can be ototoxic.

Answer 526

Broca's aphasia Small grammatical words are often dropped as well.

Answer 527

b. Anxiety disorders **APEA Psychiatry Anxiety disorders: This includes separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalized anxiety disorder.

Answer 528

b. Cognitive impairment **APEA psychiatry Frailty: A multifactorial geriatric condition or syndrome characterized by an age-related lack of adaptive physiological capacity occurring in the absence of identifiable illness. Delirium: Serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking. In the older adult, it is defined as a geriatric syndrome or condition occurring as a temporary state of confusion and may be the first clue to infection or problems with medications. Cognitive impairment: intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia. Functional impairment: A health condition in which the normal function of a part of the body is less than full capacity. One of the defining characteristics of functional impairments is that the reduction in physical or mental capacity is sufficient to interfere with managing day-to-day tasks.

Answer 529

d. A 52-year-old white man **APEA psychiatry

Answer 530

a. Histrionic **APEA psychiatry Antisocial personality disorder is characterized by habitual and pervasive disregard for or violation of the rights and considerations of others without remorse. Borderline personality disorder is defined as a pervasive pattern of instability with interpersonal relationships, self-image, and affect, as well as marked impulsivity. Histrionic personality disorder is characterized by patterns of attention-seeking, often dramatic behavior to gain the approval of others. Narcissistic personality disorder is described as a long-term pattern of abnormal behavior characterized by exaggerated feelings of self-importance, and excessive need for admiration, and a lack of understanding of others' feelings

Answer 531

c. During the physical exam, when others are asked to leave the room **APEA psychiatry

Answer 532

b. Child unable to sit still in the desk and often blurts out the answer before the teacher finishes asking the question **APEA psychiatry Symptoms of ADD or ADHD are inattention, daydreaming, inability to stay focused or follow multiple steps in directions/instructions. These children commonly engage in risk taking and so accidents are common. Other symptoms include constant motion without purpose, hyperactivity, impulsivity, poor school performance and poor self-esteem. The other choices are more consistent with conduct disorder and oppositional defiant disorder (ODD). The child who is social is acceptable behavior for the age group.

Answer 533

b. Sexual development **APEA psychiatry Pre-adolescents who have a cognitive dysfunction may have normal sexual development without age appropriate emotional and cognitive abilities. It is important to assist the family and child through this developmental stage. Pre-adolescence does not require the child to be institutionalized. By the time a child reaches pre-adolescence, the family should have received instructions on ways to encourage and reinforce self-care activities and strategies to enhance the environment to encourage growth and development.

Answer 534

b. Attention **APEA psychiatry The mental status exam assesses attention, memory, orientation, perception, thought process, thought content, insight, judgment, affect, mood, language, and cognitive function. Attention is described as the ability to focus or concentrate over time on a particular stimulus or activity. An inattentive person is easily distractible and may have difficulty giving a history or responding to a question. Perception is the sensory awareness of an object in the environment. Orientation is awareness of identity, place, and time. Thought process is the logic and relevance of the patient's thought as it leads to selected goal.

Answer 535

a. Activities of daily living **APEA psychiatry

Answer 536

c. Functional impairment **APEA psychiatry Frailty: A multifactorial geriatric condition or syndrome characterized by an age-related lack of adaptive physiological capacity occurring in the absence of identifiable illness. Delirium: Serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking. In the older adult, it is defined as a geriatric syndrome or condition occurring as a temporary state of confusion and may be the first clue to infection or problems with medications. Cognitive impairment: intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia. Functional impairment: A health condition in which the normal function of a part of the body is less than full capacity. One of the defining characteristics of functional impairments is that the reduction in physical or mental capacity is sufficient to interfere with managing day-to-day tasks.

Answer 537

d. Intact attention and concentration **APEA psychiatry Delirium: Acute, abrupt-onset confusional state characterized by the symptoms listed below as well as disorientation, disturbed perception, and emotional disturbances. Serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking. In the older adult, it is defined as a geriatric syndrome or condition occurring as a temporary state of confusion and may be the first clue to infection or problems with medications.

Answer 538

a. Dysphoric mood **APEA psychiatry Affect, mood, language, and cognitive function are observed assessments that make up the mental status examination. Affect is a fluctuating pattern of observable behaviors that express feelings or emotions through tone of voice, facial expressions, and demeanor. Mood is a separate assessment of the mental status examination that observes a more pervasive emotion that describes a person's perception of the world. Language is a complex symbolic system for comprehending words and cognitive function.

Answer 539

c. Obsessive-compulsive disorder (OCD) **APEA psychiatry OCD: Anxiety disorder that causes unwanted repeated thoughts, feelings, images, and sensations (obsessions) and prompts patients to engage in behaviors or mental acts in response to these thoughts or obsessions. MDD: characterized by an overwhelming feeling of sadness, isolation, and despair lasting 2 weeks or longer. GAD: Characterized by persistent and excessive worry about a number of different things. People with GAD may anticipate disaster and may be overly concerned about money, health, family, work, or other issues. Patients with GAD find it difficult to control their worry. Somatic symptom disorder (SSD) causes extreme anxiety about physical symptoms such as pain or fatigue. The person has intense thoughts, feelings, and behaviors about the symptoms that interfere with daily life.

Answer 540

c. He seems to be speaking less and less **APEA psychiatry Communication difficulties are common in the child with autism spectrum disorder. They often speak very little or lose language abilities if early interventions are not started that encourage and build language/communication abilities. The other choices are consistent in children with Attention Deficit Hyperactivity Disorder (ADHD).

Answer 541

d. Somatic symptom disorder (SSD) **APEA psychiatry Somatic symptom disorder (SSD): occurs when a person feels extreme anxiety about physical symptoms such as pain or fatigue. The person has intense thoughts, feelings, and behaviors related to the symptoms that interfere with daily life.

Answer 542

c. Borderline **APEA psychiatry Borderline personality disorder: a pervasive pattern of instability with interpersonal relationships, self-image and affect, as well as marked impulsivity.

Answer 543

b. Animal abuse **Animal abuse is often seen in children who display conduct disorder behaviors and would be a topic of concern if the child was abusing animals. Stuttering, worrying excessively about mother, and refusing to perform chores fall into other behavioral disorders.

Answer 544

c. Ask open-ended questions **APEA psychiatry

Answer 545

d. Relieve suffering and improve quality of life **APEA psychiatry

Answer 546

c. Depression **APEA psychiatry Depression is more common in individuals with significant medical conditions, including several neurologic disorders (dementia, epilepsy, multiple sclerosis, and Parkinson disease). Patients who present with depression may actually have bipolar disorder and so screening should always take place. Patients who are depressed may be suicidal. Consequently, in order for appropriate treatment to occur, appropriate diagnosis must occur.

Answer 547

b. Under the supervision of adults other than the abuser, the patient does not exhibit symptoms **APEA psychiatry If the patient is removed from the caregiver, the symptoms usually resolve and the patient's condition improves. Self-inflicted injuries are consistent with Munchausen Syndrome. By proxy means someone is inflicting the injury on the victim. The caregivers are most likely the ones involved and the caregiver/abuser's behavior requires long-term psychiatric treatment and also includes removing the patient from the abuser.

Answer 548

b. Body dysmorphic disorder **APEA psychiatry Russell's sign is defined as calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time. The condition generally arises from the patient's knuckles making contact with the incisor teeth during the act of inducing the gag reflex at the back of the throat with their finger and is associated with bulimia nervosa, anorexia nervosa, and binge eating disorder. Body dysmorphic disorder (BDD) is a debilitating disorder characterized by obsessions and compulsions relating specifically to perceived appearance

Answer 549

c. Cyclic alternating periods of coherence with periods of confusion **APEA psychiatry Sundown symptoms become evident around sunset each day. Medically, it refers to nocturnal delirium, and is associated with increased disorientation, confusion and agitation in late afternoon. The other symptoms are associated with delirium but not with sundown syndrome.

Answer 550

d. Intimate partner and domestic violence **APEA psychiatry **Intimate partner and domestic violence is the leading cause of serious injury and the second leading cause of death among U.S. women of reproductive age. The U.S preventive services task force recommends routine screening of all women of childbearing age for intimate partner violence and referring those who screen positive to intervention services.

Answer 551

c. Post-traumatic stress disorder **PTSD is a constellation of maladaptive symptoms that persist beyond 30 days after exposure to a traumatic event, for example military combat or physical assault. Adjustment, panic, and depression are symptoms related to PTSD

Answer 552

a. Delirium **APEA psychiatry

Answer 553

c. CAGE **APEA psychiatry The CAGE assessment is a quick questionnaire to help determine if an alcohol assessment is needed. If a person answers yes to two or more questions, a complete assessment is advised. The Kessler 6 and Kessler 10 are mental health screening tools used with a general adult population. Patient Health Questionnaire (PHQ-9) is the most common screening tool to identify depression. The Colombia-Suicide Severity Scale (C-SSRS) is a questionnaire used for suicide assessment

Answer 554

Nuchal Rigidity

Answer 555

Noticeable bleeding between the dura and the cerebrum on X-ray

Answer 556

Cerebellar System

Answer 557

Dysesthesia

Answer 558

Walk heel-to-toe

Answer 559

XI Spinal accessory nerve.

Answer 560

dysesthesia Dysesthesia: distortion of any sense, especially that of touch. Absence of sensation is the inability to feel pain or sensation when touched. Paresthesia is a sensation of tingling, tickling, prickling, pricking, or burning of a person's skin

Answer 561

Oral Facial Dyskinesias Grimacing, pursing the lips, protrusions of the tongue, opening and closing of the mouth, and deviations of the jaw.

Answer 562

Cerebellar Dysfunction

Answer 563

Liver disease Normally, the scapula lie close to the thorax.

Answer 564

Kernig's Sign

Answer 565

Graphesthesia

Answer 566

III, IV, VI Oculomotor, Trochlear, and abducens

Answer 567

Vasovagal Syncope

Answer 568

The straight leg raise

Answer 569

Cranial Nerve IV

Answer 570

Suggestive of ataxia related to dorsal column disease This is also known as Positive Romberg Test suggestive of ataxia

Answer 571

Headache upon awakening Headache and projectile vomiting are associated with shunt malfunction as well as signs of increased intracranial pressure.

Answer 572

Polyneuropathy Happens in diabetes

Answer 573

Drowsiness Increased ICP includes drowsiness, separated sutures on the skull, bulging fontanel, and vomiting.

Answer 574

Lumbar 2, 3, and 4

Answer 575

Parkinson's disease

Answer 576

Tense bulging fontanels An infant with newly diagnosed hydrocephalus present with a shrill and high-pitched cry.

Answer 577

Neuropathic Ulcer It is painless due to diminished or absent pain sensation as seen in diabetic neuropathy.

Answer 578

Wernicke's aphasia Speech is fluent, often rapid, voluble, and effortless.

Answer 579

Confusion Assessment Method Provides the best supportive data for bedside use and takes 5 minutes to complete.

Answer 580

Glossopharyngeal Nerve IX This never assesses swallowing, salivation, taste perception and voice quality

Answer 581

Focal Seizure with impairment of consciousness

Answer 582

b. Erythroderma **Dermatology Erythroderma occurs when a skin condition affects the whole body or nearly the whole body, resulting in a red appearance all over. Eschar: Dark-colored adherent crust of dead tissue found on some ulcers Excoriation: Scratch mark or surface injury penetrating the dermis. Exfoliation: peeling skin

Answer 583

b. Stage II **Dermatology

Answer 584

b. Skin that is dry, flaky, rough, and often itchy **Dermatology Asteatosis: skin appears dry, flaky, rough, and itchy Sun Damage: Skin appears weather beaten, thickened, yellowed, and deeply furrowed. Seborrheic keratoses: appear as raised, yellowish lesions that feel greasy, velvety, or warty. Herpes zoster: Painful vesicular lesions in a dermatomal distribution

Answer 585

c. Stage III **Dermatology

Answer 586

d. Herpes simplex or varicella **Dermatology

Answer 587

b. Turgor **Dermatology

Answer 588

c. Psoriasis **Dermatology Psoriasis: presents as silvery, scaly papules or plaques, mainly on the extensor surfaces of the skin. Scleroderma: skin is thickened, taut, and shiny

Answer 589

d. Stage IV **Dermatology

Answer 590

c. Leukonychia **Dermatology Leukonychia: white discoloration appearing on nails. Most common cause is injury to the base of the nail (the matrix) where the nail is formed. Psoriasis of the nails: may appear as small pits in the nail Paronychia: red, swollen, tender inflammation of the nail folds. Onycholysis: separation of the nail plate from the nail bed. The nail may crumble or break with loosening of the nail plate, usually beginning at the distal edge and progressing proximally.

Answer 591

d. Jaudice **Dermatology

Answer 592

b. Bright red, moist patches with sharply demarcated borders, some loose scales noted in the diaper area. **Dermatology Candidiasis: characteristic rash appearing with bright red, moist patches with sharply demarcated borders, with some loose scales noted in the diaper area. Diaper Dermatitis: Red, moist, maculopapular patch with poorly defined borders in diaper area. Impetigo: Moist, thin-roofed vesicles with a thin, erythematous base. Hives: erythematous and symmetric and can be generalized over the body, including the diaper area.

Answer 593

a. Hypothyroidism Hyperthyroid skin: Velvety appearance and is usually warm to the touch Hypothyroid skin: Dry, rough skin that is cool to the touch Psoriasis: presents as silvery, scaly papules or plaques, mainly on the extensor surfaces of the skin. Scleroderma: skin is thickened, taut, and shiny

Answer 594

d. Scleroderma **APEA Dermatology Psoriasis: presents as silvery, scaly papules or plaques, mainly on the extensor surfaces of the skin. Scleroderma: skin is thickened, taut, and shiny Hyperthyroid skin: Velvety appearance and is usually warm to the touch Hypothyroid skin: Dry, rough skin that is cool to the touch

Answer 595

b. HARMM **Dermatology The National Melanoma/Skin Cancer Screening Program of the American Academy of Dermatology validates the HARMM model for designating risk factors for melanoma. H- History A- Age R- Regular dermatologist absent M- Mole changing M- Male gender ABCDE nomenclature: method used in recognizing characteristics of possible melanomas. A- Asymmetry B- Borders C- Color D- Diameter E- Evolution BCRAT is the breast cancer risk assessment tool. NHANES: National Health and Nutrition Examination Survey. Used to predict diabetes prevalence

Answer 596

b. Actinic purpura **Dermatology Actinic purpura: skin on the backs of the hands and forearms appears thin, fragile, loose, and transparent. There may be purple patches or macules, termed actinic purpura that fade over time. These spots and patches come from blood that has leaked through poorly supported capillaries and spread within the dermis.

Answer 597

d. Dysplastic nevus **Dermatology Dysplastic Nevus: type of mole that looks different from a common mole. It may be bigger than a common mole, and its color, surface, and border may be different. It is usually more than 5 millimeters wide and can have a mixture of several colors, from pink to dark brown. Usually, it is flat with a smooth, slightly scaly, or pebbly surface, and it has an irregular edge that may fade into the surrounding skin. Basal Cell Carcinoma: Usually arises in sun-exposed areas and classically appears as pearly erythematous, translucent papules, but may also be subtle red macules or exhibit other morphologies. Squamous Cell Carcinoma: Crusted hyperkeratotic lesions with a rough surface or flat, reddish patches with an inflamed or ulcerated appearance. Melanomas: arise from the pigment-producing melanocytes in the epidermis. These melanocytes give skin its color and appear as dark, raised, asymmetric lesions with irregular borders.

Answer 598

a. Eschar ***Dermatology Erythroderma occurs when a skin condition affects the whole body or nearly the whole body, resulting in a red appearance all over. Eschar: Dark-colored adherent crust of dead tissue found on some ulcers Excoriation: Scratch mark or surface injury penetrating the dermis. Exfoliation: peeling skin

Answer 599

a. Circular and begins in center and spreads to periphery **Dermatology Annular Lesions: described as circular lesions that begin in the center and spreads to the periphery as with tinea and ringworm lesions. Confluent lesions: appear as if the lesions run together and are characteristic of hives. Discrete lesions: Appear as distinct, individual lesions that remain separate as in acne. Target lesions: Resemble the iris of the eye and appear with concentric rings of color in the lesions. These are seen in erythema multiforme

Answer 600

b. Atopic dermatitis **Dermatology Atopic Dermatitis: presents with erythematous papules and vesicles with weeping, oozing, and crusts. Lesions usually appear in characteristic areas: the scalp, forehead, cheeks, forearms, wrists, elbows, and backs of knees. Paroxysmal and severe pruritus can be present. There is usually a family and/or personal history of allergies. An allergic reaction to something usually presents with a generalized rash that resembles hives. Erythematous and symmetric rash. Contact dermatitis: Associated with a reaction in the area that the object touched. Erythema becomes evident initially, followed by swelling, wheals (or urticaria), or maculopapular vesicles, scales. This is often accompanied by intense pruritus. Psoriasis: presents as silvery, scaly papules or plaques, mainly on the extensor surfaces of the skin.

Answer 601

b. Onychomycosis **Dermatology Paronychia: Red, swollen, tender inflammation of the nail folds. Onychomycosis: slow, persistent fungal infection of fingernails and toenails causing change in color, texture, and thickness. The nail may crumble or break with loosening of the nail plate, usually beginning at the distal edge and progressing proximally. Leukonychia: White discoloration appearing on nails. The most common cause is injury to the base of the nail (the matrix) where the nail is formed. Psoriasis of the nails: May appear as small pits in the nail.

Answer 602

a. Impetigo **Dermatology Impetigo: Moist, thin-roofed vesicles with a thin, erythematous base. Appear as red crusty lesions on the face, especially around a child’s nose and mouth. The lesions burst and develop honey-colored crusts. Varicella: Characteristic of papules, vesicles, and crusted lesions occurring simultaneously. Herpes Simplex: On the lips and mouth appear as small vesicles or blisters and are termed "fever blisters" or "cold sores". Shingles: Appear as vesicles or blisters in clusters along the entire path of the nerve or in certain areas supplied by the nerve.

Answer 603

c. Callus **Dermatology Callus: usually develops on the soles of the feet where the skin is thick and is exposed to constant pressure. It is tender to direct pressure Plantar wart: Hyperkeratotic lesion caused by human papillomavirus and is usually seen in the sole of the foot. Characteristically, small dark spots give a stippled appearance to a wart and normal skin lines stop at the wart's edge. Tenderness occurs if pinched side to side. Corn: Painful conical thickening of skin that results from recurrent pressure on normally thin skin and characteristically occur over bony prominences such as the fifth toe. Neuropathic ulcer: Appears as a deep, infected, and indolent lesion on the sole of the foot. It is painless due to diminished or absent pain sensation as seen in diabetic neuropathy

Answer 604

b. Corn **APEA dermatology Callus: usually develops on the soles of the feet where the skin is thick and is exposed to constant pressure. It is tender to direct pressure Plantar wart: Hyperkeratotic lesion caused by human papillomavirus and is usually seen in the sole of the foot. Characteristically, small dark spots give a stippled appearance to a wart and normal skin lines stop at the wart's edge. Tenderness occurs if pinched side to side. Corn: Painful conical thickening of skin that results from recurrent pressure on normally thin skin and characteristically occur over bony prominences such as the fifth toe. Neuropathic ulcer: Appears as a deep, infected, and indolent lesion on the sole of the foot. It is painless due to diminished or absent pain sensation as seen in diabetic neuropathy

Answer 605

c. Malignant melanoma **Dermatology

Answer 606

c. Petechia **Dermatology Macule: Small, flat spot measuring no larger than 1 cm. Examples are a freckle and petechiae. Papule: Raised above the level of skin. Example: Nevus Crust: dried residue of pus, serum, or blood. Example: Impetigo Scale: Thin flake of exfoliated epidermis. Dandruff, dry skin, and psoriasis are examples.

Answer 607

b. Gluteus maximus **Dermatology

Answer 608

b. Chronic renal failure Skin conditions in chronic renal failure include: Pallor, xerosis, pruritus, hyperpigmentation, uremic frost, calciphylaxis, "half & half" nails.

Answer 609

d. Exfoliation **Dermatology

Answer 610

b. A squamous cell carcinoma **Dermatology Cutaneous Cyst: Benign, closed sac that lies in the dermis, forming a dome shaped lump. Chondrodermatitis Nodularis Helicis: a condition with painful nodules that develop on the rim of the helix (where there is no subcutaneous tissue). This develops as a result of repetitive mechanical pressure or environmental trauma (sunlight). They are small, indurated, dull red, poorly defined, and painful. Basal Cell Carcinoma: Red raised nodule with a lustrous surface and telangiectatic vessels with or without ulceration. Usually arises in sun-exposed areas and classically appears as pearly erythematous, translucent papules, but may also be subtle red macules or exhibit other morphologies. Squamous Cell Carcinoma: Raised, crusted border with central ulceration on the lesion. Crusted hyperkeratotic lesions with a rough surface or flat, reddish patches with an inflamed or ulcerated appearance.

Answer 611

a. Paronychia **Dermatology Paronychia: Red, swollen, tender inflammation of the nail folds. Acute paronychia is usually secondary to a bacterial infection. Chronic paronychia is often secondary to a fungal infection from a break in the cuticle in those who perform "wet" work. Onychomycosis: A slow, persistent fungal infection of fingernails and toenails causing change in color, texture, and thickness. The nail may crumble or break with loosening of the nail plate, usually beginning at the distal edge and progressing proximally. Leukonychia: A white discoloration appearing on the nails. The most common cause is injury to the base of the nail (the matrix) where the nail is formed. Psoriasis of the nails may appear as small pits in the nails.

Answer 612

b. Beau's lines **APEA Dermatology Beau’s Lines: Deep grooved lines that run from side-to-side on the fingernail. They appear as transverse depressions of the nail plates, usually bilateral, resulting from temporary disruption of proximal nail growth from systemic illness, such as severe illness, cold stress in the presence of Reynaud’s disease, and trauma. Terry’s Nails: The nail plate turns white with a ground-glass appearance, a distal band of reddish brown, and obliteration of the lunula. Mees’ lines present as curving transverse white bands that cross the nail parallel to the lunula. They arise from the disrupted matrix of the proximal nail, vary in width, and move distally as the nail grows out. These lines are seen in arsenic poisoning, heart failure, Hodgkin’s disease, chemotherapy, carbon monoxide poisoning, and leprosy. Pitting nails present as punctate depressions of the nail plate caused by defective layering of the superficial nail plate by the proximal nail matrix. They may be associated with psoriasis, but are also seen in Reiter’s syndrome, sarcoidosis, alopecia areata, and localized atopic or chemical dermatitis.

Answer 613

c. Rocky Mountain spotted fever, Lyme disease, tularemia **APEA dermatology

Answer 614

c. A melanoma **APEA dermatology

Answer 615

a. whiteheads **APEA Dermatology

Answer 616

a. Stage I **APEA Dermatology

Answer 617

b. Vitiligo **APEA dermatology

Answer 618

c. Basal cell carcinoma **APEA dermatology Cutaneous Cyst: Benign, closed sac that lies in the dermis, forming a dome shaped lump. Basal Cell Carcinoma: Red raised nodule with a lustrous surface and telangiectatic vessels with or without ulceration. Usually arises in sun-exposed areas and classically appears as pearly erythematous, translucent papules, but may also be subtle red macules or exhibit other morphologies. Squamous Cell Carcinoma: Raised, crusted border with central ulceration on the lesion. Crusted hyperkeratotic lesions with a rough surface or flat, reddish patches with an inflamed or ulcerated appearance. Tophi: Deposits of uric acid crystals secondary to gout and appear as hard nodules in the helix or antihelix

Answer 619

b. Dorsal surface of the hand **APEA dermatology

Answer 620

b. Furuncles **APEA dermatology Vesicles: Also known as blisters. Small lesions filled with a clear fluid. Furuncles: Also known as boils. Painful lesions that develop within hair follicles. They usually begin as papules on the skin, then develop a white or soft center. Nevi/Nevus: Moles. Pigmented area on the epidermis. Ulcers: Occurs on the skin or a mucous membrane accompanied by the disintegration of tissue.

Answer 621

d. Basal cell carcinoma **APEA dermatology Basal Cell Carcinoma of Eyelid: Uncommon. Occurs most often on the lower lid and medial canthus. It looks like a papule with an ulcerated center. Metastasis is rare but should be referred for removal. Dacrocystitis: An infection and blockage of the lacrimal sac and duct Hordeolum: Often secondary to localized staphylococcal infection of the hair follicles at the lid margin. Chalazion: beady nodule protruding on the lid.

Answer 622

a. Cavernous hemangioma **APEA dermatology Cavernous Hemangioma: Appears as a reddish blue, irregularly shaped, solid and spongy mass of blood vessels. It may be present at birth, may enlarge during the first 10-15 months, and will not involute spontaneously Strawberry Mark: A type of hemangioma that has a raised bright red area with well-defined borders about 2-3 cm in diameter. It does not blanch with pressure. Telangiectasia: Caused by vascular dilation and are permanently dilated blood vessels that are visible on the skin surface. Port-Wine Stain: A large, flat, macular dark red or purplish patch covering the scalp or face, frequently along the distribution of cranial nerve V and intensifies with crying, exertion, or exposure to heat or cold.

Answer 623

b. Ecchymoses on both forearms **APEA dermatology Ecchymoses in the elderly is not a sign of aging and should be evaluated for injury or abuse. Brown macular spots, age spots, on the hands are related to sun exposure Seborrheic keratoses: thickened lesions on the skin that range from tan to brown to black with a clear border and develop on the trunk but can also occur on the hands, feet, face, and scalp. Not considered harmful Cherry angiomas: Common type of skin lesion that first occurs in early adulthood and continues with age. These round lesions typically develop on the trunk, hands, and feet. They range from bright to dark red and are asymptomatic with no reported clinical consequences.

Answer 624

b. Dusky red **APEA dermatology

Answer 625

D. Koplik spots **APEA dermatology Koplik Spots: Seen with measles. They are small, white spots (often on a reddened background that occur on the inside of the cheeks early in the course of red measles, rubeola. Pastia’s Spots: Pink or red lines that are formed of confluent petechiae found in skin creases and are seen in patients who have scarlet fever. Aphthous ulcers are recurrent small, round, or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or gray floors occurring in the mouth

Answer 626

b. Ecchymosis **APEA dermatology Ecchymosis: Purple or bluish purple area that fades to green, yellow, and brown with time. It is generally larger than petechia and can be round, oval, or take on an irregular shape. It does not blanch with pressure and does not pulsate. These lesions are termed bruises and occur secondary to trauma. Petechia and purpura are deep red or reddish purple and fade with time. Spider vein: Bluish in color and mostly seen on the legs near veins

Answer 627

d. Dysplastic nevus **APEA dermatology

Answer 628

c. 27% **APEA dermatology

Answer 629

B. Rheumatic fever **APEA Orthopedics Gout: Usually involves one joint and typically affects the first toe. Migratory pattern. Pain migrates from joint to joint or steadily spreading from one joint to multiple joints. Examples of this type of joint pain migration is seen in patients who have rheumatic fever or gonococcal arthritis. Bursitis: Consistent with extra-articular pain that occurs in inflammatory conditions Osteomyelitis: Usually presents suddenly with a swollen joint and pain. This is more commonly seen in children.

Answer 630

b. Subacromial bursitis **APEA Orthopedics

Answer 631

c. Flexion **APEA Orthopedics

Answer 632

c. Nursemaid's elbow. **APEA Orthopedics Golfer’s Elbow: Medial epicondylitis. Also known as pitcher’s elbow. Tenderness over the median epicondyle Lateral Epicondylitis: Tennis Elbow or Quarterback Elbow. Tenderness with or without effusion over the olecranon process and the lateral epicondyle. Nursemaid’s Elbow: A dislocation of the elbow joint caused by the sudden pull on the extended pronated forearm

Answer 633

d. A ruptured Achilles tendon **APEA orthopedics Ruptured Achilles Tendon: A defect in the gastrocnemius and soleus muscles with tenderness and swelling Achilles Tendinitis: Tenderness and thickening of the tendon above the calcaneus, sometimes with a protuberant posterolateral bony process of the calcaneus. Fibromyalgia and osteoarthritis do not usually exhibit tenderness and swelling in these muscles

Answer 634

b. Arthritis **APEA orthopedics

Answer 635

c. Ankylosing spondylitis **APEA orthopedics

Answer 636

d. Thoracic kyphosis **APEA orthopedic Thoracic kyphosis: Presents with back pain and stiffness as well as a curvature of the thoracic spine Scoliosis: Presents with lateral curvature of the spine Vertebral fracture: Vertebral tenderness Spinal compression: Back pain, muscle weakness, bowel or bladder impairment

Answer 637

d. Place the fingers and thumbs in the neutral position with the palm up and them move the thumb anteriorly away from the palm. **APEA orthopedic Abduction: Place the fingers and thumbs in the neutral position with the palm up and moving the thumb anteriorly away from the palm assesses abduction. Flexion: Ask the patient to move thumb to touch the base of the fifth finger Extension: Ask the patient to move thumb from the base of fifth finger, across the palm, and then as far away from the palm as possible. Opposition: Touching the thumb to each of the other fingers Adduction: Moving the thumb back to its neutral position assesses adduction

Answer 638

d. Medial meniscal tear **APEA Orthopedic Lateral collateral ligament (LCL) tear: Assessed with the Adduction (Varus) Stress Test. Medial collateral ligament (MCL) tear: Assessed with the Abduction (Valgus) Stress Test Posterior cruciate ligament (PCL) tear: Tested with the Drawer Sign Medial meniscal tear: Test by placing patient in dorsal decubitus position. Have them slowly extend the knee while maintaining the varus stress and external rotation. If a snap on the medial joint line is palpated, this may be a positive test. (McMurray Test)

Answer 639

b. Torticollis **APEA Orthopedic

Answer 640

A. Medial meniscus **APEA orthopedic The medial and lateral meniscus are crescent-shaped cartilage in the knee joint. These ligaments rest between the femur and the tibia. The medial meniscus is located on the inside, or medial, side of the knee. McMurray Test: Passive flexion, valgus stress, and internal rotation of the lower leg evaluates the medial meniscus. The McMurray test performed with passive flexion, varus stress, and external rotation of the lower leg evaluates the lateral meniscus.

Answer 641

b. Second and third fingers **APEA orthopedic

Answer 642

a. Weakness in the triceps and finger flexors and extensors **APEA Orthopedics Cervical Radiculopathy: from nerve root compression. Physical signs include weakness in the triceps and finger flexors and extensors. Cervical myelopathy: from cervical cord compression. Physical signs include hyperreflexia, clonus at the wrist, knee, or ankle, gait disturbances, and a positive Lhermitte’s sign (neck flexion with resulting sensation of electrical shock radiating down the spine). Mechanical neck pain: local neck muscle tenderness.

Answer 643

c. Lateral epicondyle of the humerus

Answer 644

c. Sciatica Sciatica is characterized as a constant pain in one side of the buttock that radiates to the leg. The pain worsens while sitting. Osteoporosis: Patients with osteoporosis have no symptoms until bone fracture occurs. Degenerative disc disease (DDD): Chronic lower back or neck pain and spasms. Cauda equina: Lower back pain, weakness, numbness of lower extremities, and possible loss of bladder control.

Answer 645

a. Alignment of the legs and feet

Answer 646

b. Radial nerve **APEA Orthopedics Radial Nerve: Innervates the dorsal web space of the thumb and index finger. Ulnar Nerve: Innervates half of the fourth digit and the entire fifth digit. Median Nerve: Provides sensation to the palm and palmar surface of most of the thumb, second and third fingers, and half of the fourth digit.

Answer 647

c. A vertebral fracture **APEA Orthopedics

Answer 648

c. Osteomyelitis

Answer 649

a. A bone spur

Answer 650

d. Rheumatoid arthritis

Answer 651

c. Supination

Answer 652

d. Synovitis

Answer 653

c. Osteogenesis imperfecta

Answer 654

b. Limited abduction of the affected leg

Answer 655

c. Frozen shoulder

Answer 656

c. Examine the clavicle

Answer 657

c. Phalen's test

Answer 658

a. Anterior cruciate ligament (ACL) Anterior Cruciate Ligament (ACL): Lachman Test is used to assess instability. The knee is passively held in 30 degrees of flexion and the patient is asked to relax. With one hand, the distal femur is stabilized and with the other hand a gentle anterior force on the proximal tibia is applied. Comparison with the contralateral knee is essential.

Answer 659

c. Achilles tendinitis

Answer 660

a. Flexion of the lumbar spine

Answer 661

b. Gelling

Answer 662

b. Rheumatoid arthritis

Answer 663

a. Osteopenia

Answer 664

c. Pain and tenderness in the metatarsals Metatarsalgia: Term used to describe pain and tenderness in the metatarsals. Activities such as running and jumping and wearing ill-fitting shoes can cause this condition

Answer 665

c. Anterior dislocation of the humerus

Answer 666

c. Genu Valgum Genu-Valgum: “Knock Knees”: Normal for children around age 3, usually not treated unless it continues after age 7, then a night brace may be used. Genu Varum: “Bow legged”: Normal in infants because of their folded position in the mother’s womb. Legs begin to straighten once the child starts to walk (about 12-18 months)

Answer 667

a. Furrowing in the spaces between the metacarpals

Answer 668

c. Flexion

Answer 669

d. Synovitis of the glenhumeral joint

Answer 670

d. Metatarsophalangeal joint

Answer 671

b. Subluxation Tenderness at cervical vertebrae 1-2 (C1-2) in a patient with rheumatoid arthritis suggests possible risk for subluxation and high cervical cord compression. This condition would need prompt attention.

Answer 672

a. Adduction

Answer 673

b. Posterior aspect of the thigh

Answer 674

c. Active movement of the body part with gravity eliminated

Answer 675

d. Thumb abduction

Answer 676

b. Mechanical neck pain with whiplash Mechanical Neck Pain with Whiplash: Paracervical pain and stiffness begins the day after injury and may be accompanied by occipital headaches, dizziness, and malaise. Mechanical Neck Pain: Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm, stiffness, and tightness in the upper back and shoulder, lasting up to 6 weeks. Cervical Radiculopathy: Nerve root compression is the etiology. Symptoms may include sharp burning or tingling pain in the neck and one arm with associated paresthesias. Cervical myelopathy (Cervical cord compression): The neck pain is associated with bilateral weakness and paresthesias in both upper and lower extremities.

Answer 677

c. Observing the back while the child is bending forward

Answer 678

a. Radicular low back pain Sciatica (Radicular low back pain) is characterized as a constant pain in one side of the buttock that radiates to the leg. The pain worsens while sitting. Shooting pains below the knee, into the lateral leg or posterior calf. It may be accompanied by paresthesias and/or weakness in the affected leg. Mechanical low back pain: Often arises from muscle and ligament injuries or age-related intervertebral disc or facet disease. Common symptoms include aching pain in the lumbosacral area that radiates to the upper leg. Common risk factors include heavy lifting, poor conditioning, and obesity. Lumbar Spinal Stenosis (Pseudoclaudication): Refers to pain in the back or legs with walking that improves with rest, lumbar flexion, or both.

Answer 679

d. Paralysis of the legs

Answer 680

c. Monoarticular joint pain

Answer 681

c. Cervical radiculopathy Cervical Radiculopathy: from nerve root compression. Physical signs include weakness in the triceps and finger flexors and extensors. Cervical myelopathy: from cervical cord compression. Physical signs include hyperreflexia, clonus at the wrist, knee, or ankle, gait disturbances, and a positive Lhermitte’s sign (neck flexion with resulting sensation of electrical shock radiating down the spine). Mechanical Neck Pain with Whiplash: Paracervical pain and stiffness begins the day after injury and may be accompanied by occipital headaches, dizziness, and malaise. Mechanical Neck Pain: Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm, stiffness, and tightness in the upper back and shoulder, lasting up to 6 weeks.

Answer 682

d. Extension SHOULDER ROM Adduction: Patient crosses arm in front of their body. Abduction: Patient moves arms away from the body laterally and overhead Flexion: Move arm forward in front and overhead. Tests the anterior and lateral deltoid, pectoralis major, coracobrachialis and biceps brachii muscles. Extension: Patient moves arm behind themself

Answer 683

c. Upper edge of the tibial plateau Medial Meniscus: Palpate by slightly internally rotating the tibia and palpating the medial soft tissue along the upper edge of the tibial plateau. Lateral Meniscus: Palpated on the lateral joint line by placing the patient’s knee in slight flexion. Tibiofemoral joint: Palpate by facing the patient’s knee and placing the thumbs in the soft tissue depressions on either side of the patellar tendon.

Answer 684

d. Trauma Popliteal or “Baker’s” cyst: Arises from distention of the gastrocnemius semimembranous bursa from underlying arthritis or trauma. Anserine bursitis arises from running, valgus knee deformity, fibromyalgias, and osteoarthritis Prepatellar bursitis “housemaid’s knee” arises from excessive kneeling.

Answer 685

d. Active movement against full resistance without fatigue

Answer 686

d. Posterior surface of the lower leg

Answer 687

b. Thich pain after 30 seconds of lumbar extension

Answer 688

A decrease in the degree of density in a bone that results in fragile bones is referred to as: Osteopenia: Condition of bone that makes it slightly less dense than normal bone but not as severe as in osteoporosis. Osteomyelitis: Usually presents suddenly with a swollen joint and pain. This is more commonly seen in children. Usually caused by Staphylococcus. Typical symptoms include elevated temperature, chills, restlessness, severe bone pain unrelieved by analgesics or rest. There is usually swelling, redness and warmth at the site. Osteoporosis: Characterized by a severe decrease in the density of bone, decreasing its strength and resulting in fragile bones. Leads to abnormally porous bone that is compressible, like a sponge. Usually seen in adults, not known to produce bone pain. Osteoarthritis: A term used to describe degenerative joint disease

Answer 689

b. Limb paralysis Flexion Contracture: Inability to extend fully. Seen in hamstring tightness or limb paralysis. Swelling over the patella: Suggests prepatellar bursitis. Stumbling or “giving way” of the knee during the heel strike phase of gait suggests quadriceps weakness or abnormal patellar tracking.

Answer 690

b. Bow leggedness Genu-Valgum: “Knock Knees”: Normal for children around age 3, usually not treated unless it continues after age 7, then a night brace may be used. Genu Varum: “Bow legged”: Normal in infants because of their folded position in the mother’s womb. Legs begin to straighten once the child starts to walk (about 12-18 months)

Answer 691

b. Adhesive capsulitis **APEA Orthopedics Adhesive capsulitis, or frozen shoulder, refers to fibrosis of the glenohumeral joint capsule redulting in a dull aching pain in the shoulder. It progresses to restriction of active and passive range of motion and tenderness with external rotation. Complete rotator cuff tear: Active abduction and forward flexion at the glenohumeral joint are severely impaired. The characteristic shrug of the shoulder is noted with a positive arm drop on the affected side. Rotator Cuff Tendonitis: Reports of sharp “catches” of pain, grating, and weakness in the shoulder when lifting the arm overhead are symptoms suggestive of rotator cuff tendonitis or impingement syndrome. Calcific tendonitis: involves the supraspinatus tendon and is associated with deposition of calcium salts. This results in disabling attacks of shoulder pain severely limiting motions due to the pain.

Answer 692

b. Excessive kneeling **APEA orthopedics Prepatellar bursitis “housemaid’s knee” arises from excessive kneeling. Popliteal or “Baker’s” cyst: Arises from distention of the gastrocnemius semimembranous bursa from underlying arthritis or trauma. Anserine bursitis arises from running, valgus knee deformity, fibromyalgias, and osteoarthritis

Answer 693

c. Flexion **APEA orthopedic Adduction: Patient crosses arm in front of their body. Abduction: Patient moves arms away from the body laterally and overhead Flexion: Move arm forward in front and overhead. Tests the anterior and lateral deltoid, pectoralis major, coracobrachialis and biceps brachii muscles. Extension: Patient moves arm behind themself

Answer 694

a. Anterior shoulder dislocation **APEA orthopedic

Answer 695

b. Bursitis **APEA orthopedics

Answer 696

c. Median nerve **APEA orthopedic Medial Nerve: Provides sensation to the palm and palmar surface of most of the thumb, second and third fingers, and half of the fourth digit. Ulnar Nerve: Innervates half of the fourth digit and the fifth digit. Radial nerve: innervates the dorsal web space of thumb and index finger.

Answer 697

c. A partial or complete patellar tendon tear **APEA orthopedic Tenderness over the patellar tendon or inability to extend the knee suggests a partial or complete tear of the patellar tendon. Pain and crepitus over the patella suggest roughening of the patellar undersurface that articulates with the femur. Pain and compression and patellar movement during quadriceps contraction is noted with a degenerative patella. Swelling above and adjacent to the patella suggests synovial thickening or effusion of the knee joint.

Answer 698

d. Numbness of the last two digits of the hand **APEA orthopedic

Answer 699

c. Osteoarthritis **Orthopedic Dupuytren's contracture affects the hands. Torticollis would present a lateral deviation and rotation of the head. Kyphosis affects the thoracic spine.

Answer 700

b. Spondylolisthesis **Orthopedics

Answer 701

b. Lateral meniscus **APEA orthopedics

Answer 702

b. Bicipital tendinitis **APEA Orthopedics

Answer 703

b. Dupuytren's contracture

Answer 704

d. Local neck muscle tenderness **APEA orthopedics Mechanical Neck Pain with Whiplash: Results in decreased range of motion, perceived weakness of the upper extremities, and paracervical tenderness.Paracervical pain and stiffness begins the day after injury and may be accompanied by occipital headaches, dizziness, and malaise. Mechanical Neck Pain: Local neck muscle tenderness. Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm, stiffness, and tightness in the upper back and shoulder, lasting up to 6 weeks. Cervical Radiculopathy: Weakness in the triceps and finger flexors and extensors. Caused by nerve root compression. Symptoms may include sharp burning or tingling pain in the neck and one arm with associated paresthesias. Cervical myelopathy (Cervical cord compression): Physical signs include hyperreflexia, clonus at the wrists, knee, or ankle, gait disturbances, and positive Lhermitte’s sign (neck flexion resulting in a sensation of electrical shock radiating down the spine. The neck pain is associated with bilateral weakness and paresthesias in both upper and lower extremities.

Answer 705

d. Unequal leg lengths **APEA orthopedics

Answer 706

b. Finkelstein’s test **APEA Orthopedics

Answer 707

b. Scoliosis **APEA orthopedics Asymmetry: Shoulder asymmetry could be indicative of scoliosis. Rounded lateral aspect of the shoulder appears flattened in an anterior dislocation Atrophy of the supraspinatus and infraspinatus with increased prominence of the scapular spine can appear within 2-3 weeks of a rotator cuff tear.

Answer 708

d. Osteoarthritis **APEA orthopedics

Answer 709

b. One one side, hip flexed, and internally rotated **APEA orthopedic

Answer 710

b. Osteoarthritis **APEA orthopedics

Answer 711

a. Anterior talofibular ligament **APEA orthopedics The three ligaments of the foot with higher risk for injury are the: 1- Anterior talofibular ligament: Most at risk from injury from inversion (heel bows inward) injuries 2- Calcaneofibular ligament 3- Posterior talofibular ligament

Answer 712

a. Median nerve **APEA orthopedics The median nerve is located on the ventral forearm and is just medial to the brachial artery in the antecubital fossa. The ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process. The radial nerve originates in the axilla and travels down the arm in a shallow depression (radial groove) on the surface of the humerus. The brachial plexus runs from the spine through the neck, the axilla, and into the arm.

Answer 713

d. Posterior portion of the medial meniscus **APEA orthopedics

Answer 714

b. Acute gouty arthritis **APEA orthopedic Gout: Usually involves one joint and typically affects the first toe. The metatarsophalangeal joint of the great toe is the initial site of attack in 50% of the episodes of acute gouty arthritis. It is characterized by a very painful and tender, hot, dusky red swelling that extends beyond the margin of the joint. It is easily mistaken for cellulitis, however with cellulitis the dermis and subcutaneous tissue is involved as opposed to the joint.

Answer 715

d. Internal rotation **APEA orthopedics

Answer 716

b. Extension of the lumbar spine **APEA orthopedics

Answer 717

b. Olecranon bursa **APEA orthopedic

Answer 718

c. Internal rotation **APEA orthopedic Flexion: Move arm forward in front and overhead. Tests the anterior and lateral deltoid, pectoralis major, coracobrachialis and biceps brachii muscles. Extension: Patient moves arm behind themself Internal rotation: Instruct the patient to place one hand behind their back and touch their shoulder blade. External rotation: Ask patient to raise arm to shoulder, bend elbow, and rotate forearm toward ceiling

Answer 719

c. Cushion the action of the femur on the tibia **APEA orthopedics

Answer 720

b. Ulnar nerve **APEA orthopedics The median nerve is located on the ventral forearm and is just medial to the brachial artery in the antecubital fossa. The ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process. The radial nerve originates in the axilla and travels down the arm in a shallow depression (radial groove) on the surface of the humerus. The brachial plexus runs from the spine through the neck, the axilla, and into the arm.

Answer 721

d. Tibial tendinitis **APEA orthopedics Tibial tendinitis: Tenderness along the posterior medial malleolus. Bone spurs: may be present on the calcaneus as bony projections and may cause numbness, tenderness, or pain. Localized tenderness on examination of the ankle joint could be suggestive of arthritis, infection of the ankle, or ligamentous injury. Focal heel tenderness on palpation of the plantar fascia suggests plantar fasciitis.

Answer 722

b. A median nerve disorder **APEA orthopedics Thenar atrophy suggests a median nerve disorder such as carpal tunnel syndrome. This is evidenced by muscle wasting in the palm of the hand.

Answer 723

b. Limitation of abduction of the affected extremity, shortening of the femur and positive Ortolani’s sign (it clicks when maneuvered) **APEA orthopedics

Answer 724

d. Pronation **APEA orthopedic

Answer 725

b. Posterior cruciate ligament (PCL) **APEA orthopedic

Answer 726

a. Swing phase of gait **APEA orthopedics Two phases of gait: Stance and swing. Swing phase occurs when the foot moves forward and does not bear weight. The stance phase occurs when the foot is on the ground bearing weight.

Answer 727

d. Quadriceps weakness **APEA orthopedics Flexion Contracture: Inability to extend fully. Seen in hamstring tightness or limb paralysis. Swelling over the patella: Suggests prepatellar bursitis. Stumbling or “giving way” of the knee during the heel strike phase of gait suggests quadriceps weakness or abnormal patellar tracking

Answer 728

c. Touch his left scapula with his right hand **APEA orthopedics

Answer 729

b. Rheumatoid arthritis **APEA orthopedic OA usually affects a single joint with brief stiffness in the early morning and after a period of inactivity. Gouty arthritis often affects the big toe, less often the dorsa of foot, ankles, knees, and elbows. The swelling is usually around the joint and accompanied by extreme tenderness, erythema, and very warm to the touch. Polymyalgia rheumatica affects the muscles rather than the joints.

Answer 730

b. A ganglion cyst **APEA orthopedic Ganglion cyst: ganglia are cystic, round, usually non-tender swellings along tendon sheaths or joint capsules, frequently at the dorsum of the wrist. Flexion of the wrist makes ganglia more prominent. Extension tends to obscure them.

Answer 731

b. An ankle fracture **APEA orthopedic

Answer 732

c. Crepitus **APEA orthopedic Synovitis: A term used to describe a palpable bogginess or doughiness over a joint area. Crepitus: An audible or palpable “crunching” during movement of tendons or ligaments over bone or areas of cartilage loss. This may occur painlessly in joints but is more significant when associated with symptoms or signs. Edema: The build-up of excess fluid in surrounding tissues. Tissue Tenderness: Term used to describe an area that is sensitive to tough, usually related to trauma.

Answer 733

a. Pain in the lateral joint line **APEA orthopedic Lateral collateral ligament (LCL) tear: Assessed with the Adduction (Varus) Stress Test. To perform the test, the knee is held in 30 degrees of flexion. With one hand on the medial side of the knee and one hand on the ankle, an adduction force is gently applied. If pain is noted in the lateral joint line, this could be indicative of a lateral collateral ligament tear. When tenderness extends more to the proximal or distal joint line, the collateral ligament may be the cause of pain instead of the meniscus.

Answer 734

d. External rotation **APEA orthopedic Flexion: Patient bends their knee Extension: Patient straightens leg Internal rotation: Have the patient swing lower leg toward midline while sitting External rotation: Instruct the patient to swing leg away from midline while sitting.

Answer 735

c. A ligamentous injury **APEA orthopedic Tibial tendinitis: Tenderness along the posterior medial malleolus. Bone spurs: may be present on the calcaneus as bony projections and may cause numbness, tenderness, or pain. Localized tenderness on examination of the ankle joint could be suggestive of arthritis, infection of the ankle, or ligamentous injury.

Answer 736

a. Ulnar nerve **APEA orthopedic Radial Nerve: Innervates the dorsal web space of the thumb and index finger. Originates in the axilla and travels down the arm in a shallow depression (radial groove) on the surface of the humerus. Ulnar Nerve: Innervates half of the fourth digit and the entire fifth digit. Runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process. The ulnar nerve runs posteriorly in the ulnar groove between the medial epicondyle and the olecranon process. Median Nerve: Provides sensation to the palm and palmar surface of most of the thumb, second and third fingers, and half of the fourth digit. Located on the ventral forearm and is just medial to the brachial artery in the antecubital fossa. The flexor retinaculum is a ligament

Answer 737

c. Rotator cuff tendinitis **APEA orthopedic Adhesive capsulitis, or frozen shoulder, refers to fibrosis of the glenohumeral joint capsule resulting in a dull aching pain in the shoulder. It progresses to restriction of active and passive range of motion and tenderness with external rotation. Complete rotator cuff tear: Active abduction and forward flexion at the glenohumeral joint are severely impaired. The characteristic shrug of the shoulder is noted with a positive arm drop on the affected side. Rotator Cuff Tendonitis (impingement): Reports of sharp “catches” of pain, grating, and weakness in the shoulder when lifting the arm overhead are symptoms suggestive of rotator cuff tendonitis or impingement syndrome. Calcific tendonitis: involves the supraspinatus tendon and is associated with deposition of calcium salts. This results in disabling attacks of shoulder pain severely limiting motions due to the pain.

Answer 738

b. Shoulder girdle **APEA orthopedic

Answer 739

a. Glenohumeral joint Glenohumeral joint: where the head of the humerus articulates with the shallow glenoid fossa of the scapula. This joint is deeply situated and not normally palpable. Acromioclavicular joint: Lies at the lateral end of the clavicle and articulates with the acromion process of the scapula. The convex medial end of the clavicle articulates with the concave hollow in the upper sternum to form the sternoclavicular joint. There is no manubrium joint, it is a broad upper part of the sternum.

Answer 740

a. Atrophic glossitis **APEA hematology Atrophic glossitis: Occurs when a large number of papillae are lost, resulting in changes to the tongue’s color and texture. This type of glossitis typically turns the tongue dark red and is a symptom of iron deficiency anemia. Oral candida: White paste on the tongue. Most common type of oral candida is Candida albicans fungus. Melanoglossia: a medical condition in which the tongue is blackened. Usually caused by a bacterial infection or allergic reaction. Transient lingual papillitis is a common painful inflammatory condition affecting one or several fungiform papillae on the tongue.

Answer 741

b. Timing of the onset of the jaundice **APEA hematology Physiologic Jaundice: Identified after 24 hours Pathologic Jaundice: Identified before the infant is 24 hours of age. The fetus produces more red blood cells (RBCs) than the normal adult or child has, with a hematocrit of up to 60% being normal. At birth, structural and functional changes take place which enable the fetus to breathe room air, bringing the baby’s paO2 up to the normal child-adult range. Thus, the excess RBCs are no longer needed for O2 carrying capacity, and they begin to break down. This is a normal, physiologic change that occurs at birth

Answer 742

d. Iron **APEA hematology Pica is characterized by an appetite for substances that are non-nutritive, such as ice, starch, or clay. This finding is associated with iron-deficiency anemia. Pica is considered an eating disorder in the DSM-5 criteria

Answer 743

a. Acute chest syndrome **APEA hematology Acute Chest Syndrome: A vaso-occlusive crisis of the pulmonary vasculature commonly seen in patients with sickle cell anemia. It is often precipitated by a respiratory infection and symptoms include: fever, cough, excruciating pain, sputum production, shortness of breath, or low oxygen levels.

Answer 744

a. VIII **APEA hematology Hemophilia is an inherited disorder in which a person lacks adequate clotting factors. Type A is lacking of clotting factor VIII (90% of cases). Type B is lacking clotting factor IX. Type C is lacking clotting factor XI

Answer 745

b. Black Glucose-6-phosphate-dehydrogenase (G-6-PD) deficiency is a condition in which red blood cells break down when the body is exposed to certain drugs (aspirin, antimalaria drugs) or the stress of infection. G-6-PD is most prevalent in people of Mediterranean and African descent, and specifically common in Saudi Arabian, African, and black patients.

Answer 746

d. Hypertension **APEA hematology Class IV (severe) hemorrhagic shock: Refers to a medical condition in which rapid fluid loss results in multiple organ failure due to inadequate circulating volume and subsequent inadequate perfusion. Symptoms of severe hemorrhagic shock include tachycardia, hypotension, decreased or no urinary output, loss of consciousness, cold and pale skin, and tachypnea.

Answer 747

c. Ecchymosis **APEA hematology Von Willebrand disease is a group of congenital bleeding disorders caused by a deficiency of the protein von Willebrand factor (vWF). Defective vWF interaction between platelets and the vessel wall impairs primary hemostasis. Symptoms include: bruising (ecchymosis), menorrhagia, recurrent epistaxis, petechiae, and hemorrhage.

Answer 748

c. Hematocrit (HCT) of 55% **APEA hematology With chronic hypoxia, the body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increasing the oxygen carrying capacity of the blood. This condition is termed polycythemia. Clubbing is a classic symptom of chronic hypoxia. Lab values denoting increased RBC such as HCT of 55-60% would be indicative of polycythemia. Pulmonary hypertension is a clinical consequence of increased pressure in the pulmonary arteries and is seen in children with congenital heart defects but it is not a direct result of hypoxia. Dehydration can occur rapidly in children with cyanotic heart defects, however it is not a compensatory mechanism of chronic hypoxia. Anemia may develop as a result of poot tissue oxygenation secondary to decreased blood viscosity not increased as in polycythemia.

Answer 749

b. 5 mcg/dL **APEA hematology In children, a blood lead level of 5 mcg/dL or 0.24 Umol/L or greater requires further testing and monitoring. The source of lead must be found and removed. A lead level greater than 45 mcg/dL or 2.17 Umol/L in a child's blood usually indicates the need for chelation.

Answer 750

a. At the angle of the mandible **APEA hematology

Answer 751

b. Deep in the angle formed by the clavicle and the sternomastoid muscle **APEA hematology

Answer 752

a. Dairy **APEA hematology Foods high in folic acid include green leafy vegetables, meat from animal sources, fruits, nuts, liver, and foods containing yeast. Dairy foods such as cheese, milk, and yogurt do not contain folic acid unless they have been specifically fortified to include this vitamin.

Answer 753

d. Superficial to the mastoid process **APEA hematology

Answer 754

d. Osteoporosis **APEA hematology Mild to moderate normochromic, normocytic anemia is associated with chronic disease. Anemia has been identified as a risk factor for osteoporosis, however, osteoporosis does not cause anemia. Anemia of chronic disease is associated with diseases such as systemic lupus, rheumatoid arthritis, and osteomyelitis.

Answer 755

b. In front of the ear **APEA hematology

Answer 756

d. Supraclavicular **APEA hematology Supraclavicular: The supraclavicular lymph nodes are located: Deep in the angle formed by the clavicle and the sternomastoid muscle. Enlargement, especially on the left, would be suggestive of metastasis from a thoracic or abdominal malignancy.

Answer 757

c. Constipation **APEA hematology Constipation is a common side effect of iron supplements. Iron causes dysbiosis (microbes imbalance) which slows peristalsis. This results in longer bowel retention, which causes more water uptake and leads to dry feces, resulting in constipation. Steatorrhea is a greasy, foul-smelling stool associated with cystic fibrosis. Hematochezia is a passage of fresh blood through the anus and is commonly associated with lower gastrointestinal bleeding. Beeturia is red-colored feces after consuming beets. It occurs due to insufficient metabolism of red pigment.

Answer 758

b. Systemic lupus erythematosus **APEA hematology Some joint disorders can be linked to organ systems outside the musculoskeletal system. A patient who presents with joint pain and an accompanying butterfly rash on the face could have SLE. Gonococcal arthritis may have an accompanying rash on the distal extremities. The rash may appear as papules, pustules, or vesicles on reddened bases. In fifth's disease, the rash appears as a "slapped" cheek. Acute rheumatic fever may be preceded by a sore throat and progress with musculoskeletal involvement.

Answer 759

c. Infants acquire active immunity in response to infections and immunizations **APEA hematology Infants acquire long-term active immunity from exposure to certain diseases (antigens) and vaccines. Active immunity develops in response to immunizations. The infants passive immunity is acquired from the mother and dissipates around 6 months of age.

Answer 760

d. Anterior chest wall **APEA hematology Axillary lymph node: Drainage areas include the breast, upper part of the abdominal wall, the upper part of the back, pectoral region, and upper limbs. Anterior pectoral nodes: drained the anterior chest and much of the lymphatic fluid from the breast

Answer 761

c. Superficial to the sternomastoid muscle **APEA hematology

Answer 762

b. Sequestration crisis **APEA hematology Sequestration occurs when RBC's are trapped or sequestered in the spleen causing it to enlarge; therefore, there would be tenderness in the LUQ and the child may have tachypnea as well. Aplastic crisis occurs when RBC production is decreased. Symptoms include pallor, decreased hemoglobin and decreased RBSc. Vaso-occlusion usually involves pain but no increase in spleen size. Hemiarthrosis is usually seen in hemophilia and where there is joint involvement, but not spleen involvement.

Answer 763

b. Refinishing of all painted woodwork has occurred recently in the child's home **APEA hematology Painted woodwork may contain lead, especially in older homes and during refinishing, the paint would have to be scraped off placing it in easy reach of a one year old.

Answer 764

b. Tender and movable **APEA hematology Small, mobile, discrete, non-tender (shotty) nodes are frequently identified as normal findings. Nodes that are tender suggest inflammation. Hard and fixed nodes suggest malignancy

Answer 765

b. Residing in a home built before 1988 **APEA hematology Risks for lead toxicity may include occupation as a plumber, having a history of gout, living near a busy highway or hazardous waste dump, and residing in a home built before 1978.

Answer 766

Mouth, throat, and face **APEA hematology

Answer 767

a. Headache upon awakening **Headache and projectile vomiting are associated with shunt malfunction as well as signs of increased intracranial pressure. Fever can be associated with shunt infection.

Answer 768

b. A nasal swab **Respiratory Influenza is diagnosed based on the results of a flu swab and the patient's clinical presentation. A patient with influenza usually demonstrates influenza A (the most predominant strain during an outbreak) or influenza B (the strain identified occasionally during flu season but more often throughout the rest of the year) if he is infected.

Answer 769

c. Pertussis **Respiratory Pertussis is also called "whooping cough". This is a highly communicable respiratory disease caused by Bordetella pertussis. There are three recognized stages of pertussis: the catarrhal phase, the paroxysmal phase, and convalescence. More adults than children have contracted pertussis in the last decade. Since the outbreak of pertussis in Iowa in 2005, diminished titers were recognized and adolescents are being given a booster with TdaP at 11-12 years of age.

Answer 770

c. Can cough or wheeze **Respiratory The second leading cause of cough in adults is asthma. Cough due to asthma is often accompanied by episodic wheezing or dyspnea, though some patients with asthma only cough. This is termed "cough variant asthma". The clinical presentation of asthma varies but hyper-responsiveness of the airways is a typical finding.

Answer 771

c. This will decrease your risk of all cause mortality 5 years after stopping **Respiratory Smoking cessation at any age is beneficial to the person engaging in smoking cessation. Data demonstrates that after 5 years of smoking cessation, there is a significant decrease in the risk of death from coronary disease, cancer, and COPD.

Answer 772

a. He should receive another one today **Respiratory This patient should receive another one today because he is 65 years old and at least 5 years has elapsed since his last one. The CDC does not recommend immunizing this patient every 5 years. Two immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should be administered today. PPSV23 should be administered at least 1 year later.

Answer 773

a. Dry cough **Respiratory A common side effect of ACE inhibitors is dry cough. Though estimates vary, 5-20% of patients who receive ACE inhibitors develop a cough. Angiotension converting enzyme is believed to be responsible for metabolism of bradykinin in the lungs. Bradykinin is thought to be responsible for the cough because it induces production of arachidonic acid metabolites and nitric oxide. These substances may promote cough. The cough associated with ACE inhibitors appears to be a class effect.

Answer 774

a. Pneumonia **Respiratory The finding of infiltrates on CXR, in conjunction with clinical findings of fever and cough, should direct the examiner to consider pneumonia as the diagnosis. Other common clinical findings with pneumonia include chest pain, dyspnea, and sputum production. Though not common, some patients with pneumonia exhibit gastrointestinal symptoms like nausea, vomiting, and diarrhea

Answer 775

a. Fever **Respiratory The presence of fever should trigger the practitioner to consider pneumonia. The other symptoms are most likely secondary to asthma. Coughing may be due to asthma and pneumonia

Answer 776

b. Obstructed airways **Respiratory COPD is characterized by obstructed airways. The obstruction is NOT completely reversible even with medication use. Productive cough is likely present in patients with chronic bronchitis but not necessarily emphysema. Shortness of breath does not have to be present (or perceived in patients with COPD). Hypercapnia is more prevalent in patients with emphysema since air trapping occurs.

Answer 777

c. Increase the dose of the inhaled steroid, refill the albuterol **Respiratory The patient is using his short-acting bronchodilator excessively if he needs a refill of his inhaler in only 5 weeks. Inhalers typically contain 200 puffs. They should be used two or fewer times per week. His inhaled steroid dose should be increased and his albuterol inhaler should be refilled. In fact, he should not be without a prescription for the albuterol. Consideration could be given to prescribing a long-acting bronchodilator and increasing the steroid, but this is not the best choice because this does not include a refill of the albuterol and this patient cannot be without access to a rescue inhaler.

Answer 778

d. A disease with extrapulmonary manifestations **Respiratory Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to diagnose because symptoms can be varied and involve multiple body systems (extrapulmonary manifestations). Infection with Mycoplasma may present with a normal white blood cell count, maculopapular rash, GI symptoms, tender joints and aches, and, though rare, cardiac rhythm disturbances. Respiraotyr symptoms may not be pronounced. On CXR there are some unique findings (peribronchial pattern) with Mycoplasma. These include thickened bronchial shadow, streaks of interstitial infiltration, and atelectasis. These are more likely to occur in the lower lobes.

Answer 779

b. Amoxicillin **Respiratory The preferred treatment for this child will be based on your suspicion of the causative organism. Without a sputum culture, you will be treating this patient empirically. This child does not likely have a viral pathogen because viral infections usually have a gradual onset. The cause is likely bacterial. When bacterial cause is suspected, treatment is recommended to prevent symptom progression. In this case, the child could develop moderate to severe respiratory distress. Your next step in the treatment of this child is to determine whether the bacterial pathogen is typical or atypical. Both typical and atypical pathogens can cause an abrupt onset of fever in children >5 years old. Thus, making this determination is difficult based on symptoms alone. Your best course is to treat the most common typical pathogen in this age group, shich is streptococcus pneumoniae. The drug of choice is Amoxicillin.

Answer 780

b. Leukocytosis **Respiratory An increased white count is typical in patients with bacterial pneumonia such as pneumococcal pneumonia. Eosinophils can be increased in patients who develop pneumonia secondary to exposure to a very irritating substance like a toxic gas. Gram stain can demonstrate gram-positive or negative pathogens. Leukopenia is an ominous finding, especially in older patients. This indicates a poor prognosis because it means that the immune system is not responding to a potentially fatal pathogen.

Answer 781

d. Obesity **Respiratory

Answer 782

a. Timolol ophthalmic drops **Respiratory Timolol is a beta-blocker. This class of medications can precipitate bronchoconstriction in patients who have asthma. Even though timolol is being administered in the eye, it is absorbed through mucous membranes and can exert systemic effects. Beta blockers should be avoided in patients with asthma and used cautiously in patients with COPD. The other medications listed have no specific contraindications for patients with asthma.

Answer 783

d. Amoxicillin **Respiratory The most recent evidence-based guidelines recommend amoxicillin 1 gram TID for initial treatment of uncomplicated pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. Azithromycin and doxycycline are listed as conditional recommendations first line to treat this patient. Sulfamethoxazole-Trimethoprim and Cefdinir are not evidence-based choices and thus should not be used. Fluoroquinolones, like levofloxacin are commonly used first line in patients who have comorbidities or who have had recent antibiotic exposure, or recent contact with the healthcare system.

Answer 784

b. A TB skin test **Respiratory Mantoux test first. A CXR is performed after a positive skin test. A sputum specimen is used for diagnosis, not screening. A questionnaire is used for screening patients who have had a history of a positive TB skin test.

Answer 785

d. Equal to head circumference **Respiratory The chest circumference is not routinely measured at well-child visits, but is assessed if there is concern about the circumference of either the head or the chest. An exception to this observation can occur in premature infants where the head grows very rapidly. Normally, the head exceeds the chest circumference from birth until 6 months. Between 6-24 months the head and chest circumference should be about equal and by 2 years of age the chest should be larger than the head. The chest circumference is measured at the nipple line.

Answer 786

d. A viral infection **Respiratory In children who are 6 months to 5 years of age, the most common cause of pneumonia is a viral pathogen. Rarely are studies performed to identify viral pathogens, however one of the most common viral pathogens is respiratory syncytial virus (RSV). S. pneumoniae is a common cause of pneumonia in very young children, it is also implicated in older adults as a causative agent in pneumonia. In young and middle adults, Mycoplasma is a common pathogen.

Answer 787

b. Symptoms occurring more than twice weekly **Respiratory Mild persistent asthma is characterized by symptoms that occur more than twice weekly but not daily; or 3-4 nocturnal awakenings per month due to asthma. It is treated with an inhaled steroid daily and a bronchodilator PRN for exacerbations. If symptoms occur more than twice weekly, therapy should be stepped up. Generally, a long-acting bronchodilator is added to the steroid when therapy is stepped up.

Answer 788

c. Pneumonia **Respiratory More than 90% of deaths associated with influenza occur in older adults. Pneumonia is the most common cause of death and most common reason for hospital admission in older patients with influenza. Annual influenza immunization is recommended for all adults in the United States

Answer 789

a. Vesicular **Respiratory The three normal breath sounds are vesicular, bronchovesicular, and bronchial. Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung fields. Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the trachea and larynx. Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. They are normally heard over the hilar region. Crackles are adventitious sounds heard in the lungs and may be due to abnormalities in the lungs.

Answer 790

a. Anxiety or depression **Respiratory About 40% of older patients who have COPD have concomitant anxiety and/or depression. It should be treated because it affects the overall management of COPD. COPD is characterized by airflow limitation and dyspnea. This may contribute to feelings of chronic anxiety. Additionally, many chronic diseases are associated with depression. This is the case with COPD.

Answer 791

d. Streptococcus pneumoniae **Respiratory Clinical descriptions of mucus do not really help in clinical decision-making regarding pneumonia, but certain clinical characteristics are associated with specific types of pneumonia. Strep pneumonia, also known as pneumococcal pneumonia, is associated with rust-colored sputum. Scant or watery sputum is associated with atypical pathogens like Mycoplasma and Chlamydophila pneumonia. Thick, discolored sputum may be associated with bacterial pneumonia.

Answer 792

d. Amoxicillin **Respiratory Amoxicillin (strong recommendation) 1 gram three times daily for initial treatment of uncomplicated pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. Azithromycin and doxycycline are listed as conditional recommendations first line to treat this patient. Fluoroquinolones are commonly used first line in patients who have comorbidities or who have had recent antibiotic exposure or recent contact with the healthcare system.

Answer 793

c. Pulmonary function tests or spirometry **Respiratory Spirometry or pulmonary function tests (PFTs) are essential to diagnose COPD. The most important measures are the FEV1 (forced expiratory volume in one second) and FVC (forced vital capacity). Chest radiograph has a poor sensitivity in diagnosing COPD. Only about half of patients with moderately severe COPD can be diagnosed using chest radiography alone. CT scan is able to identify emphysema, but not chronic bronchitis. Arterial blood gases demonstrate hypoxia, but a specific cause is not able to be determined from this test alone.

Answer 794

d. Propanolol **Respiratory Propranolol is a nonselective beta blocker and might be potentially more harmful in a patient who has COPD than a cardioselective beta blocker. Nonselective beta blockers can exert their effect on the beta receptors in the lungs. This could produce shortness of breath and would be described as a drug-disease interaction.

Answer 795

c. Azithromycin **Respiratory Streptococcus pneumonia is the most common bacterial pathogen in all age groups. Atypical pathogens such as Mycoplasma pneumoniae and Chlamydia pneumoniae are common in children >5 years of age who present with abrupt onset of symptoms including malaise, cough, sore throat and headache, but are not ill enough for hospitalization. The initial, preferred antibiotic to treat atypical community acquired pneumonia is a macrolide antibiotic (i.e. azithromycin). Alternative options include levofloxacin and doxycycline if the patient cannot take a macrolide. Amoxicillin would be an appropriate choice for the patient with pneumonia related to S. pneumonia.

Answer 796

b. Mycoplasma pneumoniae **Respiratory In patients who have atypical pneumonia, Mycoplasma is the most common pathogen. M. Pneumoniae is so named because of its atypical appearance on CXR. This organism is responsible for "walking pneumonia" that is prevalent in a young adult population. This accounts for about 15% of pneumonia and is transmitted via respiratory droplet

Answer 797

a. S. pneumoniae **Respiratory Streptococcus pneumoniae (s. pneumo) is the most common pathogen in community-acquired pneumonia worldwide. It is more common in age extremes (the very young and very old) and during winter months.

Answer 798

c. Change antibiotics to a penicillin **Respiratory Improvement should be seen within 24-48 hours if on appropriate antibiotic therapy. Azithromycin treats atypical pathogens like Mycoplasma and Chlamydia, but it has poor strep coverage.

Answer 799

b. Long-acting bronchodilator **Respiratory LABA can be used to treat asthma when it is used in combination with an inhaled steroid. Otherwise, it is contraindicated d/t increased risk of sudden death.

Answer 800

c. A sputum specimen **Respiratory Screening for TB is performed with a skin test known as the Mantoux. CXR is typically performed after a positive skin test, but is not diagnostic since TB can affect organs other than the lungs. A sputum specimen is used for definitive diagnosis. A questionnaire is used for screening patients who have a history of positive TB skin test.

Answer 801

b. Once weekly **Respiratory Good asthma management is characterized by using SABA (rescue medication) no more than twice weekly during daytime or twice monthly at nighttime. Using SABA 2 times weekly necessitates use of prophylactic medications such as inhaled steroids and possible use of long-acting bronchodilators in conjunction with inhaled steroids

Answer 802

a. Discuss PCV13 vaccination with the patient **Respiratory The CDC recommends shared decision making for the patient with COPD. The NP should discuss PCV13 vaccination with the patient. The patient and provider should decide together if PCV13 is appropriate. If administered, it should be followed by one dose of PPSV23 at least 1 year later. If the patient and provider decide against the PCV13 vaccine, one dose of PPSV23 should be administered now. If the PPSV23 immunization was given prior to age 65 years, 5 years should elapse before another PPSV23 vaccine is given

Answer 803

a. Antipyretics **Respiratory Bronchiolitis is a viral infection and antibiotics would be inappropriate. Fever commonly accompanies bronchiolitis.

Answer 804

c. Cause atypical pneumonia **Respiratory These two organisms are common causes of pneumonia. They are called atypical pathogens because they produce atypical pneumonia. They are transmitted via respiratory droplets from the nose and throat of infected people. Prolonged close contact is probably needed for transmission to occur. Patients are usually contagious for 10 days or so. Most commonly, these infections occur in younger patients, but all ages may be affected. Generally, the atypical pathogens are eradicated with macrolide antibiotics or tetracyclines

Answer 805

a. COPD **Respiratory First-line treatment for patients with COPD who have intermittent symptoms of shortness of breath is an anticholinergic medication because it improves lung function. Alternatively, a short-acting beta agonist may be used. Anticholinergic medications are not used as a lone agents to manage symptoms of asthma; inhaled steroids usually are. Bronchitis is a viral infection that is self-limited and usually does not require an inhaled medication. Bronchiectasis is a disease in which the respiratory tubules are permanently enlarged. Symptoms include chronic production of purulent mucous.

Answer 806

c. This may cause tachycardia **Respiratory SABAs stimulate the beta receptors in the lungs and in the heart. This helps the patient breathe better because it produces bronchodilation, but it potentially can produce arrhythmias or angina because beta receptors in the heart can become stimulated too. The dose for a patient with underlying cardiac problems is half the dose (and used with caution). Common side effects of these agents are jitteriness, tremor, nervousness, and potentially hypokalemia if used on a regular basis

Answer 807

a. Be screened for osteoporosis **Respiratory Older females are at higher risk than others for osteoporosis. This female patient, who has used inhaled steroids, is at increased risk for osteoporosis. Additionally, she probably has emphysema because she smoked (or still smokes). If she is Asian or Caucasian, she has still another risk factor.

Answer 808

b. It decreases parasympathetic tone and produces bronchodilation **Respiratory Ipratropium is the most widely studied anticholinergic medication used to treat patients with COPD. It produces its helpful effects by reducing cholinergic tone in the lungs. It may be used with a beta agonist if shortness of breath is present. However, beta agonists increase side effects like tachycardia and tremor and do not improve efficacy.

Answer 809

a. Levalbuterol **Respiratory Examples of SABAs are albuterol or levalbuterol. They provide rapid dilation of the bronchioles and can give immediate relief for shortness of breath; hence the term for this class of medications is rescue medications. Salmeterol is a long-acting beta agonist. These should never be used without an inhaled steroid to treat a patient with asthma. Mometasone and beclomethasone are steroids commonly used to treat asthma

Answer 810

b. A 65-year-old with emphysema **Respiratory FEV1: Forced expiratory volume in 1 second. This is the volume of air that is forcibly exhaled in the first second of exhalation after a deep breath. Patients with emphysema are not able to do this efficiently because their alveoli are stretched, and mostly contain trapped air. FEV1 is used to assess airway obstruction.

Answer 811

c. Viral etiology **Respiratory This constellation of symptoms is typical of a viral infection. Group A streptococcus is usually not accompanied by coryza (inflammation and irritation of the mucous membrane of the nose). H. parainfluenzae is not a common cause of pharyngitis. Mycoplasma usually is associated with lower respiratory tract infections

Answer 812

b. Shifted the pathogenesis to fewer cases of S. pneumoniae **Respiratory The heptavalent pneumococcal conjugate vaccine (PCV13), Prevnar, protects children from 13 types of pneumococcal bacteria. It has reduced the incidence of ear infections caused by S pneumo and has reduced the incidence of recurrent ear infections and tube placement by 10-20%. The pathogenesis of acute otitis media has shifted to more cases of H. influenzae, but this organism is less likely to become resistant.

Answer 813

d. Pertussis **Respiratory Pertussis should always be considered in adults who present with acute cough of greater than 5 days duration. The incubation period for pertussis is about 7-10 days. Patients who present with URI symptoms for 1-2 weeks. The classic paroxysmal cough usually begins in the second week of the illness. The duration of symptoms and cough are about 3 months even when treated with antibiotics. This is highly infectious and is a reportable disease.

Answer 814

b. Amlodipine **Cardiovascular This patient has isolated systolic hypertension. According to many learned authorities, this is best treated with a long-acting calcium channel blocker, particularly the ones that end in "pine". These belong to the class of calcium channel blockers termed dihydropyridines. Thiazide diuretics are not potent enough to decrease this patient's blood pressure into normal range, and its effect is not additive when combined with calcium channel blockers.

Answer 815

c. Usually begins within 2 weeks of starting therapy **Cardiovascular The cough associated with use of an ACE inhibitor is typically dry and nonproductive. It is more common in women than men and is thought to be due to the buildup of bradykinin. Bradykinin is partly degraded by ACE (angiotensin converting enzyme). Degradation of bradykinin and conversion of antiotensin I to angiotensin II by ACE occurs in the lung. When degradation is impaired, bradykinin can accumulate and cough can ensue.

Answer 816

C. Abdominal ultrasound **Cardiovascular While an abdominal aortic aneurysm (AAA) might be detected by multiple modalities, including a plain film of the abdomen, it is most cost effectively and efficiently identified using ultrasound. The sensitivity and specificity for AAA identification with ultrasound is nearly 100%. Both CT and MRI are very accurate in identifying AAA, but they are both more expensive than ultrasound.

Answer 817

c. Increased potassium level **Cardiovascular Lisinopril is an ACE inhibitor. This medication causes retention of potassium. A potassium level should be measured about 1 month after initiating therapy and after each dose change. The other laboratory values are not specific to changes that can take place when a patient takes an ACE inhibitor.

Answer 818

d. A 75-year-old male **Cardiovascular Nearly 25% of the US population has hypertension. The greatest incidence is in older adults because of changes in the intima of vessels as aging and calcium deposition occur. Males of any age are more likely to be hypertensive than females of the same age. African-American adults have the highest incidence in the general population. Among adolescents, African-Americans and Hispanics have the highest rates. Hypertension occurs in 5-10% of pregnancies

Answer 819

c. Echocardiography **Cardiovascular Echocardiography is of greatest value when evaluating valves, chamber size, cardiac output, and overall function of the myocardium. It is noninvasive and allows specific measurement of chamber size and thickness of the myocardium. The chest film is important in identification of chamber enlargement, but its primary importance is in assessment of the pulmonary vasculature. Electrocardiography (ECG) provides information about the heart's conduction system and identifies cardiac rhythm, though ventricular enlargement can be identified on ECG. Doppler ultrasound identifies intracardiac flow velocities and can assist in quantifying the severity of regurgitation or stenosis.

Answer 820

d. Sucralfate and cholestyramine **Cardiovascular The drugs listed in choice D will decrease INR in patients who take warfarin concurrently. Sucralfate and calcium carbonate decrease absorption of warfarin. The drugs listed in the other choices will increase INR. Major interactions can occur with celecoxib, ketoprofen, and naproxen. These three NSAIDs are commonly taken by older adults, so this should be part of education with a patient who takes warfarin

Answer 821

c. It should be measured annually **Cardiovascular Beginning at 3 years of age, blood pressure is measured annually. It continues to be measured annually through adulthood. Prior to age 3 years, blood pressure is not routinely measured. BP is assessed in all four extremities at birth to assess for coarctation of the aorta, patent ductus arteriosus (PDA), other cardiovascular abnormalities, or significant murmurs. If BP is only assessed at well-child visits for older children, it will not occur annually.

Answer 822

b. Metoprolol **Cardiovascular Beta blockers like metoprolol are indicated to alleviate atrial or ventricular arrhythmias associated with mitral valve prolapse. However, long-term effectiveness of beta blockers is uncertain. Most patients with MVP who do not have symptoms of arrhythmias or ectopy at rest usually do not require further evaluation. However, they should be monitored at least annually for a change in their condition.

Answer 823

b. A thyroid stimulating hormone level **Cardiovascular If a patient's lipids are elevated, a TSH should be performed. If the TSH is elevated, it may be a secondary cause of hyperlipidemia. It is considered safe practice to NOT treat elevated lipid levels until the TSH level has decreased to at least 10 mU/L. If the lipids are still elevated, consideration should be given to treatment.

Answer 824

a. A thiazide diuretic **Cardiovascular Thiazide diuretics have the secondary effect of increasing serum calcium by decreasing fluid. This makes more calcium available for absorption. This would not be used to treat a patient with osteoporosis, but this mechanism of action could be helpful as an adjunct for patients who are receiving other forms of treatment for osteoporosis. The other agents listed would have no effect on osteoporosis. Calcium channel blockers impede movement of calcium into cells. This has no effect on available serum calcium.

Answer 825

b. Hearing loss, hypertension, arthritis **Cardiovascular Hypertension and arthritis are the two most common ailments in older adults. Hearing loss occurs in half to almost 2/3 of older adults. The most common form is known as presbycusis. There is no consensus for the frequency of screening for hearing loss in older patients, but minimally, it should be grossly evaluated at each visit and screened more thoroughly if deficits are observed. Blood pressure should be screened annually, but it is usually screened at each visit. Arthritis is not routinely screened.

Answer 826

c. Vessels affected **Cardiovascular Varicose veins and arteriosclerosis are very different disease processes. While differences can be found in the gender affected, the major difference between the two diseases is the vessel affected. Arteriosclerosis affects the arteries, varicose veins affect the veins. While there is a predilection for the lower extremities in varicose veins, peripheral artery disease (PAD) is most common in the lower extremities too. Varicose veins are especially common in women 2:1; PAD is more common in men 2:1 after age 70 years. Pain is a subjective measure.

Answer 827

a. Long asymptomatic period followed by exercise intolerance, then dyspnea at rest **Cardiovascular The natural course of aortic regurgitation (AR) is that the patient has a long asymptomatic period with slowing of activities but remains essentially asymptomatic. Shortness of breath develops with activity and finally, shortness of breath at rest. The left ventricle eventually fails unless the aortic valve is replaced.

Answer 828

a. Is benign **Cardiovascular The usual course of mitral valve prolapse (MVP) is benign, and most patients who have MVP are asymptomatic. A murmur may be present and is best auscultated with the diaphragm of the stethoscope over the cardiac apex. In a minority of patients, symptoms of heart failure or sudden death may occur. When heart failure results, it is usually a result of mitral regurgitation. Embolization may occur, but, this is not common or usual in the majority of patients.

Answer 829

d. Amlodipine **Cardiovascular Amlodipine is a calcium channel blocker and its use does not warrant monitoring potassium levels. Fosinopril is an ACE inhibitor and candesartan is an ARB. Both warrant monitoring potassium levels because both have the potential to produce hyperkalemia, especially in patients who have renal impairment or heart failure. Hydrochlorothiazide has the potential to produce hypokalemia, so, it too warrants monitoring of potassium levels.

Answer 830

c. Calcium channel blocker **Cardiovascular This patient is 77 years old and should have a goal blood pressure of <150/90 mmHg according to JNC8. A thiazide diuretic is not a good first choice in this patient because it will not be potent enough to decrease blood pressure by about 20 points to get him to goal. A long-acting calcium channel blocker is appropriate for patients who have isolated systolic hypertension and will be more likely to get this patient to goal pressure than HCTZ. Beta blockers are no longer recommended first line for uncomplicated hypertension. ACE inhibitors are very effective in patients who are high renin producers. Older patients tend to produce lower amounts of renin.

Answer 831

c. Hydrochlorothiazide **Cardiovascular This patient's allergy to "sulfa" sounds like Stevens-Johnson Syndrome, a potentially life-threatening allergic reaction. Hydrochlorothiazide has a sulfonamide ring in its chemical structure, generally referred to as "sulfa". This sulfonamide ring can initiate an allergic reaction in patients with sulfa allergy. Since the patient's allergic reaction to sulfa was so serious, other sulfonamide medications should be completely avoided until consultation with an allergist. The other medications can be used without concern in the presence of a patient with a sulfa allergy because there is no sulfonamide component.

Answer 832

b. INR of 8, no significant bleeding **Cardiovascular INR is a good measure of the clotting status in an outpatient who takes an oral anticoagulant like warfarin. When warfarin is overdosed and INR climbs, or when warfarin is overdosed because of food or medication that produces deleterious side effects, warfarin doses may be omitted or discontinued until the INR is in a more acceptable range. Generally, one or two doses may be omitted before rechecking INR and resuming warfarin or decreasing the dose.

Answer 833

c. She does not need any testing because she is asymptomatic **Cardiovascular The obvious risk of starting a new exercise program is the risk of cardiac events. Evidence does not support routine EKG or cardiac testing in patients who are asymptomatic. She should be told about symptoms to watch for and to stop immediately if chest pain or shortness of breath develops.

Answer 834

a. Once for all males aged 65-75 who have ever smoked **Cardiovascular The prevalence of abdominal aortic aneurysm (AAA) is greater in men than women. American Heart Association and USPSTF recommend screening males once between ages 65-75 years if they have ever smoked. Smoking increases the risk of AAA. The USPSTF does not recommend routinely screening for AAA in women or screening for AAA in men who have never smoked. Screening may be considered in men aged 65-75 years if they have a first-degree relative who required repair of AAA.

Answer 835

c. Add a drug from another class to the daily 25 mg hydrochlorothiazide **Cardiovascular The recommended target blood pressure, according to JNC 8 for this 50-year-old patient is <140/90 mmHg. The current plan has not allowed this patient to meet this goal so it is not acceptable to continue current dose. Increasing HCTZ dose will only result in increased potassium loss, not further decrease in blood pressure

Answer 836

a. To fast for 12-14 hours **Cardiovascular Serum total and HDL cholesterol is fine to measure fasting or nonfasting but triglyceride levels will elevate 3-4 hours after eating and there may be several peaks during a 12-hour period.

Answer 837

b. Anticoagulation **Cardiovascular The most common arrhythmia associated with mitral regurgitation (MR) is atrial fibrillation. Anticoagulation with warfarin will help prevent arterial embolism that can result in stroke or myocardial infarction. Atrial fibrillation occurs because the fibers in the atrium are stretched as the atrium dilates. The stretch results in conduction defects, notably atrial fibrillation.

Answer 838

b. Anticoagulation **Cardiovascular

Answer 839

b. Pregnancy occurs **Cardiovascular ACE inhibitors are contraindicated during pregnancy because of teratogenic effects on the renal system of the developing fetus. ACE inhibitors may cause increased potassium levels, not decreased. Gout is not exacerbated by ACE inhibitor use

Answer 840

b. Refer to cardiology **Cardiovascular In patients with known aortic stenosis who have been asymptomatic, one should be alert for symptoms that will precede angina, heart failure, and syncope. Dizziness precedes syncope in these patients and so this is an early indication that the patient is becoming symptomatic. Once symptoms develop, there is a rapid downhill course. Therefore, dizziness, chest discomfort, or exercise intolerance are important symptoms to assess in previously asymptomatic patients who have AS. This patient should be referred to cardiology.

Answer 841

c. 10 years of age **Cardiovascular Age 4-6: average HR between 60-140, by age 10 it is more close to an adult normal which is 60-100 beats per minute.

Answer 842

c. This is indicative of generalized atherosclerosis **Cardiovascular Asymptomatic bruits in the carotid area are more indicative of atherosclerotic disease than increased stroke risk. A symptomatic bruit requires immediate attention. Patients with carotid artery disease are more likely to die of cardiovascular disease than cerebrovascular disease.

Answer 843

d. Diabetes mellitus **Cardiovascular

Answer 844

d. Potassium level **Cardiovascular ACE inhibitors work in the kidney in the renin angiotensin aldosterone system and can impair renal excretion of potassium in patients who have normal kidney function. In patients who have impaired renal blood flow and/or function, the risk of hyperkalemia is increased. Common practice is to monitor potassium, BUN, and Cr at about 1 week after initiation of an ACE inhibitor and with each increase in dosage in a patient who has heart failure and who receives an ACE inhibitor.

Answer 845

c. LDL LDL cholesterol promotes atherosclerosis via several different mechanisms. Consequently, LDL cholesterol tends to be the primary target when patients are treated pharmacologically for elevated lipid levels. Low HDL levels and elevated triglyceride levels can accelerate atherogenesis.

Answer 846

c. This is a normal exam. Sinus arrhythmia occurs when an irregular heart rate increases with inspiration and decreases with respiration and is considered normal in children. There is no need for an echo or referral to a cardiologist nor should the child be evaluated for caffeine intake.

Answer 847

c. echocardiography. The best means to identify mitral valve prolapse (MVP) is with echocardiography. It will identify bulging of either, or both, of the leaflets (anterior or posterior) into the left atrium. Approximately 2% of the US population is identified to have MVP. A chest X-ray will not enable visualization of the mitral leaflets. Electrocardiography identifies the heart's electrical activity. A physical exam may provide great clues to MVP, but in the absence of definitive mid to late systolic clicks, a diagnosis cannot be confirmed.

Answer 848

c. Add a drug from another class to the daily 25 mg hydrochlorothiazide. The recommended target blood pressure, according to JNC 8, for this 50-year-old patient is <140/90 mmHg. The current plan has not allowed this patient to meet this goal, so it is not acceptable to continue the current dose. Increasing the hydrochlorothiazide to 50 mg daily will not result in a decrease in blood pressure, only an increase in potassium loss. Adding a drug from a different medication class is a good choice because the combined effects of antihypertensive medications nearly always produce a decrease in blood pressure and both drugs can be maintained in low doses to minimize side effects.

Answer 849

d. diastolic blood pressure decreases. As age increases (>60 years), systolic blood pressure tends to increase, but diastolic blood pressure tends to decrease. This is evidenced by the observation of isolated systolic hypertension, seen almost exclusively in the older population. This results in a widening pulse pressure, a predictor of cardiovascular events in older adults. The pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. Measurements greater than 60-70 points indicate "stiffening" of the vessels. Stiffening commonly occurs as aging occurs.

Answer 850

c. 10 years of age. Normal heart rate varies with age. Generally, as the heart becomes more efficient, the rate begins to decrease. This occurs with age. 4- and 6-year old children can be expected to have normal heart rates between 60 and 140 beats per minute. By age 10 years, the usual heart rate more closely approximates that of an adult, 60-100 beats per minute.

Answer 851

c. It should be measured annually. Beginning at 3 years of age, blood pressure is measured annually. It continues to be measured annually through adulthood. Prior to age 3 years, blood pressure is not routinely measured. Blood pressure is assessed in all four extremities at birth to assess for coarctation of the aorta, patent ductus arteriosus (PDA), other cardiovascular abnormalities, or significant murmurs. If blood pressure is only assessed at well-child visits for older children, it will not occur annually.

Answer 852

a. to fast for 12-14 hours. Serum total and HDL cholesterol can be measured in fasting or nonfasting patients. There are very small and clinically insignificant differences in these values whether fasting or not. The primary effect of eating on a patient's lipid values is elevation of the triglyceride levels. The maximum elevation of triglyceride levels occurs at 3-4 hours after eating, but there may be several peaks during a 12-hour period. Therefore, the most accurate triglyceride levels will be obtained following a 12-hour fast.

Answer 853

a. is benign. The usual course of mitral valve prolapse (MVP) is benign, and most patients who have MVP are asymptomatic. A murmur may be present and is best auscultated with the diaphragm of the stethoscope over the cardiac apex. In a minority of patients, symptoms of heart failure or sudden death may occur. When heart failure results, it is usually a result of mitral regurgitation. Embolization may occur, but, this is not common or usual in the majority of patients.

Answer 854

b. Amlodipine This patient has isolated systolic hypertension. According to many learned authorities, this is best treated with a long-acting calcium channel blocker, particularly the ones that end in "pine." These belong to the class of calcium channel blockers termed dihydropyridines. Thiazide diuretics are not potent enough to decrease this patient's blood pressure into normal range, and its effect is not additive when combined with calcium channel blockers.

Answer 855

b. hearing loss, hypertension, arthritis. Hypertension and arthritis are the two most common ailments in older adults. Hearing loss occurs in half to almost 2/3 of older adults. The most common form is known as presbycusis. There is no consensus for the frequency of screening for hearing loss in older patients, but minimally, it should be grossly evaluated at each visit and screened more thoroughly if deficits are observed. Blood pressure should be screened annually, but it is usually screened at each visit. Arthritis is not routinely screened.

Answer 856

c. this is indicative of generalized atherosclerosis. Asymptomatic bruits in the carotid area are more indicative of atherosclerotic disease than increased stroke risk. A symptomatic bruit requires immediate attention. Patients with carotid artery disease are more likely to die of cardiovascular disease when cerebrovascular disease. The Framingham heart Study found that patients with an asymptomatic carotid bruit were at increased risk of stroke, but the majority of strokes occurred in an area away from the carotid artery. The overall risk of stroke was insignificant when an asymptomatic carotid bruit was identified.

Answer 857

c. Calcium channel blocker This patient is 77 years old and should have a goal blood pressure of <150/90 mmHg according to JNC8. A thiazide diuretic is not a good first choice in this patient because it will not be potent enough to decrease blood pressure by about 20 points to get him to goal. A long-acting calcium channel blocker is appropriate for patients who have isolated systolic hypertension and will be more likely to get this patient to goal pressure than HCTZ. Beta blockers are no longer recommended first line for uncomplicated hypertension. ACE inhibitors are very effective in patients who are high renin producers. Older patients tend to produce lower amounts of renin.

Answer 858

b. metoprolol. Beta blockers like metoprolol are indicated to alleviate atrial or ventricular arrhythmias associated with mitral valve prolapse. However, long--term effectiveness of beta blockers is uncertain. Most patients with MVP who do not have symptoms of arrhythmias or ectopy at rest usually do not require further evaluation. However, they should be monitored at least annually for a change in their condition.

Answer 859

c. usually begins within 2 2eeks of starting therapy. The cough associated with use of an ACE inhibitor is typically dry and nonproductive. It is more common in women than men and is thought to be due to the buildup of bradykinin. Bradykinin is partly degraded by ACE (angiotensin converting enzyme). Degradation of bradykinin and conversion of angiotensin I to angiotensin II by ACE occurs in the lung. When degradation is impaired, bradykinin can accumulate and cough can ensue.

Answer 860

a. Long asymptomatic period followed by exercise intolerance, then dyspnea at rest The natural course of aortic regurgitation (AR) is that the patient has a long asymptomatic period with slowing of activities but remains essentially asymptomatic. Shortness of breath develops with activity and finally, shortness of breath at rest. The left ventricle eventually fails unless the aortic valve is replaced.

Answer 861

d. Amlodipine Amlodipine is a calcium channel blocker and its use does not warrant monitoring potassium levels. Fosinopril is an ACE inhibitor and candesartan is an ARB. Both warrant monitoring potassium levels because both have the potential to produce hyperkalemia, especially in patients who have renal impairment or heart failure. Hydrochlorothiazide has the potential to produce hypokalemia, so, it too warrant monitoring of potassium levels.

Answer 862

b. refer to cardiology. In a patient with known aortic stenosis (AS) who has been asymptomatic for decades, one should be alert for symptoms that will precede angina, heart failure, and syncope. Dizziness precedes syncope in these patients and so this is an early indication that the patient is becoming symptomatic from his AS. Once symptoms develop, there is a rapid downhill course. Therefore, dizziness, chest discomfort, or exercise intolerance are important symptoms to assess in previously asymptomatic patients who has AS. This patient should be referred to cardiology.

Answer 863

b. A thyroid stimulating hormone (TSH) level If a patient's lipids are elevated, a TSH should be performed. If the TSH is elevated, it may be a secondary cause of hyperlipidemia. It is considered safe practice to NOT treat elevated lipid levels until the TSH level has decreased to at lest 10 mU/L. If the lipids are still elevated, consideration should be given to treatment.

Answer 864

a. A thiazide diuretic Thiazide diuretics have the secondary effect of increasing serum calcium by decreasing fluid. This makes more calcium available for absorption. This would not be used to treat a patient with osteoporosis, but this mechanism of action could be helpful as an adjunct for patients who are receiving other forms of treatment for osteoporosis. The other agents listed would have no effect on osteoporosis. Calcium channel blockers impede movement of calcium into cells. This has no effect on available serum calcium.

Answer 865

b. INR of 8, no significant bleeding INR is a good measure of the clotting status in an outpatient who takes an oral anticoagulant like warfarin. When warfarin is overdosed and INR climbs, or when warfarin is overdosed because of food or medication that produces deleterious side effects, warfarin doses may be omitted or discontinued until the INR is in a more acceptable range. Generally, one of two doses may be omitted before rechecking INR and resuming warfarin or decreasing the dose.

Answer 866

c. 5th ICS, left of MCL. The PMI or apical impulse is produces when the left ventricle moves anteriorly and touches the chest wall during contraction. This is normally found at the 5th intercostal space, midclavicular line. Certain conditions and diseases like heart failure or cardiomyopathy may account for this; or left ventricular hypertrophy from prolonged hypertension can displace the apical impulse. The displacement usually occurs left and laterally from is usual location. Thus, 5th ICS, left of midclavicular line. Conditions like pregnancy may displace the apical impulse upward and to the left.

Answer 867

b. erectile dysfunction. Several studies have demonstrated that erectile dysfunction (ED) is associated with use of thiazide diuretics, specifically chlorthalidone. When ED was evaluated in patients taking chlorthalidone, acebutolol, amlodipine, enalapril, and doxazosin (medications from major antihypertensive drug classes), the thiazide diuretic chlorthalidone had the greatest incidence of ED. The other drugs in the study were no more likely to cause ED than a placebo. however, a common complaint of men on antihypertensive medications is ED. This should always be evaluated as a side effect of antihypertensive treatment.

Answer 868

d. A 75-year-old male Nearly 25% of the US population has hypertension. The greatest incidence is in older adults because of changes in the intima of vessels as aging and calcium deposition occur. Males of any age are more likely to be hypertensive than females of the same age. African American adults have the highest incidence in the general population. Among adolescents, African Americans and Hispanics have the highest rates. Hypertension occurs in 5-10% of pregnancies.

Answer 869

a. left ventricular hypertrophy. The most common manifestation of end-organ damage in hypertensive adolescents is left ventricular hypertrophy (LVH). According to the National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents, as many as 41% of children who have hypertension have LVH identifiable on ECG.

Answer 870

d. Diabetes mellitus In determining whether a patient should be treated for hyperlipidemia, a patient's risk factors must be determined. After assessing fasting lipids, specifically LDLs, CHD equivalents must be identified. These are diabetes, symptomatic carotid artery disease, peripheral artery disease, abdominal aortic aneurysm, and multiple risk factors that confer a 10-year risk of CHD > 20%. Major CHD risk factors are elevated LDL cholesterol, cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD [in male first-degree relatives (FDR) < 55 years; female FDR, 65 years], and age (men >45 years, women >55 years). Patients with 2 or more risk factors should have a 10-year risk assessment performed and be treated accordingly.

Answer 871

c. Lisinopril in a 35-year-old Caucasian male An ACE inhibitor is a preferred initial medication choice in a nonblack patient according to JNC8. Beta blockers may mask the signs and symptoms of hypoglycemia in patients who have diabetes and so are not preferred. ACE inhibitors decrease potassium loss and so should not be routinely used in patients who are on potassium=sparing diuretics because hyperkalemia may result. Diuretics can produce hyperuricemic states due to fluid loss. Therefore, they should be avoided in patients with history of gout.

Answer 872

a. 3 years Blood pressure should be measured immediately after birth and anytime a cardiac problem is suspected. After this time, blood pressure screening should begin at 3 years of age and then, annually. A pediatric blood pressure table must be used because normal blood pressure varies with age, gender, and height. A pediatric blood pressure table will display the maximum systolic and diastolic blood pressure expected for the child. Taller and heavier children will have higher blood pressures.

Answer 873

b. Daily proton pump inhibitor (PPI) Aspirin does increase the risk of gastrointestinal bleeding, especially if it is given in combination with oral steroids. Most learned authorities and ACOVE (Assessing Care of Vulnerable Elders) agree that when two or more risk factors for GI bleed are present, aspirin should not be added without some form of protection for the GI tract (misoprostol or a daily PPI). In considering all the risks for GI bleed, the most significant ones are age >75 years, history of GI bleeding, warfarin use, daily NSAID use, and chronic steroid use.

Answer 874

a. hypertension, diabetes with proteinuria, heart failure. ACE inhibitors have numerous indications. Three are indicated in the first choice. ACE inhibitors are also indicated in patients who have renal insufficiency. However, ACE inhibitors can worsen renal insufficiency, so the patients must be monitored closely with lab tests for BUN, Cr, and potassium. Diabetes without proteinuria is not a specific indication for ACE inhibitors use, though they are used by some healthcare providers in this way. This is an off-label use.

Answer 875

c. vessels affected. Varicose veins and arteriosclerosis are very different disease processes. While the differences can be found in the gender affected, the major difference between the two diseases is the vessel affected. Arteriosclerosis affects the arteries, varicose veins affect the veins. While there is a predilection for the lower extremities in varicose veins, peripheral artery disease (PAD) is most common in the lower extremities too. Varicose veins are especially common in women 2:1; PAD is more common in men 2:1 after age 70 years. Pain is a subjective measure.

Answer 876

d. ACE, ASA, beta blocker, and statin After a myocardial event, an aspirin, ACE inhibitor, beta blocker, and statin should be dosed daily. The aspirin will provide anticoagulation; the ACE inhibitor, statin and beta blocker are associated with reduced morbidity and mortality if given soon after ACS.

Answer 877

a. once for all males aged 65-75 who have ever smoked. The prevalence of abdominal aortic aneurysm (AAA) is greater in men than women. American Heart Association and USPSTF recommend screening males once between ages 65-75 years if they have ever smokes. Smoking increases the risk of AAA. The USPSTF does not recommend routinely screening for AAA in women or screening for AAA in men who have never smokes. Screening may be considered in men aged 65-75 years if they have a first-degree relative who required repair of AAA.

Answer 878

a. Metoprolol Metoprolol is a cardioselective beta blocker that decreases heart rate. A patient who has acute heart failure will compensate by increasing heart rate to maintain cardiac output (CO). Metoprolol impairs the patient's ability to increase heart rate when needed to maintain cardiac output (CO=stroke volume x heart rate). Consequently, the use of beta blockers in patients with heart failure should be monitored carefully. Furosemide may actually improve shortness of breath in a patient with heart failure. Insulin and acetaminophen have no direct effect on cardiac output in a patient with heart failure.

Answer 879

c. Mitral valve prolapse Mitral valve prolapse (MVP) is the most common adult murmur. It is best heard with the diaphragm of the stethoscope over the cardiac apex. It is a result of redundancy of the mitral valve leaflets and subsequent degeneration of the mitral tissue. The posterior leaflet is more commonly affected than the anterior leaflet. The valve's annulus becomes enlarged in conjunction with elongation of the chordae tendineae.

Answer 880

b. pregnancy occurs. Benazepril is an ACE inhibitor and this class of drugs is contraindicated during pregnancy because of teratogenic effects on the renal system of the developing fetus. Dry cough is an aggravating side effect that occurs in some patients who take ACE inhibitors, but discontinuation is elective. ACE inhibitor use is associated with increased potassium levels, not decreased levels. Gout is not exacerbated by ACE inhibitor use.

Answer 881

a. Naproxen Naproxen is an NSAID. NSAIDs cause sodium retention and thus, water retention. A single dose of naproxen is unlikely to produce HF symptoms, but repeated subsequent doses are very likely to produce water retention sufficient to cause edema and possible shortness of breath in susceptible people. The other medications lister are unlikely to have any direct effect on cardiac output in a patient who has HF.

Answer 882

b. Headache Fatigue is a common symptom in cardiac patients, and it can represent a worsening of many cardiac diseases, such as coronary artery disease, heart failure, or valvular dysfunction. Orthopnea and cough, especially nocturnal, are classic symptoms of worsening heart failure. Headache is a nonspecific symptom and is not typical of heart failure.

Answer 883

c. swelling, pain, and discoloration in lower extremity. Swelling, pain, and discoloration from impaired blood flow are the classic symptoms. Choice A could describe infection, like cellulitis, and is not classic for DVT. Redness is an inconsistent sign of DVT as is a positive Homan's sign. A history of exercise actually decreases the risk of DVT. Pain secondary to DVT is not relieved by walking. The lower extremities are the most likely location of DVT, but symptoms don't always correlate with location of the thrombosis. Patients must be asked about history, family history of DVT, and precipitation conditions.

Answer 884

c. Increased potassium level Lisinopril is an ACE inhibitor. This medication causes retention of potassium. A potassium level should be measured about 1 month after initiating therapy and after each dose change. The other laboratory values are not specific to changes that can take place when a patient takes an ACE inhibitor.

Answer 885

d. Sucralfate and cholestyramine The drugs listed in choice D will decrease international normalized ratio (INR) in patients who take warfarin concurrently. Sucralfate and calcium carbonate decrease absorption of warfarin. The drugs listed in the other choices will increase INR. Major interactions can occur with celecoxib, ketoprofen, and naproxen. These three NSAIDs are commonly taken by older adults, so this should be part of education with a patient who takes warfarin.

Answer 886

c. Furosemide Gout is characterized by hyperuricemia. Uris acid levels are increased when a patient consumes any medication that results in less circulating fluid volume, specifically, any diuretic. Diuretics such as furosemide will produce hyperuricemia and thus increase the risk of gout in susceptible patients. Diuretics should be avoided when possible in patients who have a history of gout.

Answer 887

c. She does not need any testing because she is asymptomatic. The obvious risk of starting a new exercise program is the risk of cardiac events. Evidence does not support routine EKG or cardiac testing in patients who are asymptomatic. She should be told about symptoms to watch for and to stop immediately if chest pain or shortness of breath develops. A 74-year-old who retires last year will benefit from any type of exercise. She will develop improved conditioning, reduce her risk of many chronic diseases including cardiovascular disease, reduce the risk of falls, and decrease functional limitations. Exercised for older adults fall into four categories: aerobic, muscle strengthening, flexibility and balance.

Answer 888

d. in conjunction with diet and exercise. Statins are used to reduce elevated levels of lipids in conjunction with modifications in diet and exercise. The timing of statin dosing and indication with food (or not) is specific to each statin. Many patients who take statins are also candidates for aspirin as primary or secondary prevention, but aspirin is not beneficial in reducing lipid levels. Statins are correctly taken once daily but not necessarily in the AM.

Answer 889

b. potassium supplements. An ACE inhibitor potentially can produce hyperkalemia because its mechanism of action is to spare potassium in the renin angiotensin aldosterone system. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia can be great.

Answer 890

b. potassium supplements. An ARB like candesartan potentially can produce hyperkalemia because its mechanism of action is to spare potassium in the renin angiotensin aldosterone system. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia will be great.

Answer 891

c. 160/60 mmHg Nearly 2/3 of all older adults who are hypertensive have isolated systolic hypertension, i.e., the systolic blood pressure is elevated, the diastolic is normal. This probably occurs because the vessels stiffen as people age and a higher systolic is required to move blood through stiffened vessels. Elevated systolic blood pressure is an important risk factor for cardiovascular disease and stroke in older adults.

Answer 892

c. 160/60 mmHg Nearly 2/3 of all older adults who are hypertensive have isolated systolic hypertension, i.e., the systolic blood pressure is elevated, the diastolic is normal. This probably occurs because the vessels stiffen as people age and a higher systolic is required to move blood through stiffened vessels. Elevated systolic blood pressure is an important risk factor for cardiovascular disease and stroke in older adults.

Answer 893

c. By comparing upper and lower extremity blood pressures Coarctation is frequently missed on initial assessment. This disorder is characterized by elevated blood pressures in the upper extremities and diminished blood pressures in the lower extremities. It can be assessed by measuring and comparing blood pressures in the upper and lower extremities.

Answer 894

d. any antihypertensive medication. Any antihypertensive medication could have an additive effect with sildenafil (or another medication in this class). Caution is advised and sildenafil should only be used if the male has stable blood pressure. A specific drug-drug interaction to be aware of is the one that can occur with sildenafil and alpha blockers like tamsulosin, alfuzosin, prazosin, doxazosin, or terazosin. This combination of medications may increase the risk of symptomatic hypotension because the effect of these two drugs is additive.

Answer 895

c. Echocardiography Echocardiography is of greatest value when evaluating valves, chamber size, cardiac output, and overall function of the myocardium. It is noninvasive and allows specific measurement of chamber size and thickness of the myocardium. The chest film is important in identification of chamber enlargement, but its primary importance is in assessment of the pulmonary vasculature. Electrocardiography (ECG) provides information about he heart's conduction system and identifies cardiac rhythm, though ventricular enlargement can be identified on ECG. Doppler ultrasound identifies intracardiac flow velocities and can assist in quantifying the severity of regurgitation or stenosis.

Answer 896

b. rheumatic fever. Rheumatic fever is the correct answer. The immune response involves not just the heart, but can affect the joints, skin, and central nervous system. 0.1-0.3% of untreated or undertreated infections involving Group A beta hemolytic Strep can result in rheumatic fever. More often than not, this involves an infection in the upper airways. The most common age group affected is 5-15 years. however, the residual effect of rheumatic fever is realized into the later decades of life.

Answer 897

b. The child should be referred to cardiology. The child should be referred to pediatric cardiology. A grade 4 designation for a murmur indicates that a murmur is loud and has a thrill associated with it. The finding of a thrill (characteristic of a grade 4 murmur) is always an abnormal finding and requires a referral. A thrill can be palpated with the examiner's hand over the anterior chest in the area of the point of maximal impulse (PMI).

Answer 898

d. 70-year-old African American male Two groups of patients typically experience adverse blood pressure effects from consumption of sodium greater than 2,000 mg daily. Those patients considered to be most sodium sensitive are elderly patients and African American patients. Thus, choice d is the best choice listed.

Answer 899

c. Abdominal ultrasound While an abdominal aortic aneurysm (AAA) might be detected by multiple modalities, including a plain film of the abdomen, it is most cost effectively and efficiently identified using ultrasound. The sensitivity and specificity for AAA identification with ultrasound is nearly 100%. Both CT and MRI are very accurate in identifying AAA, but they are both more expensive than ultrasound.

Answer 900

c. Hydrochlorothiazide This patient's allergy to "sulfa" sounds like Stevens-Johnson Syndrome, a potentially life-threatening allergic reaction. Hydrochlorothiazide has a sulfonamide rind in its chemical structure, generally referred to as "sulfa." This sulfonamide ring can initiate an allergic reaction in patients with sulfa allergy. Since the patient's allergic reaction to sulfa was so serious, other sulfonamide medications should be completely avoided until consultation with an allergist. The other medications can be used without concern in the presence of a patient with a sulfa allergy because there is no sulfonamide component.

Answer 901

b. in the calf muscle. This patient's symptoms are typical of arteriosclerosis. The term used to describe this patient's symptom is intermittent claudication. When there is compromised arterial blood flow in the lower legs, a common complaint is reproducible pain in a specific group of muscles. The pain occurs because there is an incongruence between blood supply and demand. This produces pain that causes a patient to stop exercising in order to obtain pain relief.

Answer 902

a. Annually Screening should take place annually for patients who have coronary artery disease and other risk factors like diabetes, peripheral artery disease, or prior stroke. These patients are at very high risk and annual screening is economically justified. In a setting of low-risk patient who does have any of the above mentioned risk factors, United States Preventive Services Task Force recommends screening every 5 years.

Answer 903

b. Naproxen Naproxen is an NSAID. NSAIDs produce sodium retention and hence, water retention. This produces many systemic effects, such as an increase in blood pressure, lower extremity edema, increased workload on the heart, and inhibition of prostaglandin syntheses. Patients with hypertension and heart failure should use NSAIDs cautiously. Lovastatin, fluticasone, and amoxicillin would not be expected to increase or decrease blood pressure.

Answer 904

c. ACE inhibitors ACE inhibitors are commonly used in patients with systolic dysfunction because they reduce morbidity and mortality, i.e. these medications alter prognosis. They also improve symptoms of fatigue, shortness of breath, and exercise intolerance. Lop and thiazide diuretics improve symptoms, but do not alter long-term prognosis with heart failure. Beta blockers should be used in conjunction with ACE inhibitors and diuretics, but not as solo agents. Beta blockers can potentially worsen heart failure, so their use in patients with heart failure should be monitored carefully. Despite this fact, beta blockers decrease morbidity and mortality associated with heart failure.

Answer 905

d. Losartan Naproxen and furosemide should be stopped for 24 hours prior to the catheterization. Metformin should be stopped 48 hours prior to the catheterization. Furosemide is stopped because it contributes to volume depletion. NSAIDs like naproxen are withheld because of the impact on renal prostaglandin production. Metformin has been implicated in lactic acidosis when combines with contract dye in an impaired kidney.

Answer 906

b. potassium supplements. An ARB potentially can produce hyperkalemia because its mechanism of action is in the renin-angiotensin-aldosterone system, where potassium is spared. If potassium is taken in the form of potassium supplements, the effect will be additive and the risk of hyperkalemia can be great.

Answer 907

d. It is probably related to amlodipine. Amlodipine is a long-acting calcium blocker (CCB). Calcium is responsible for muscle contraction. Sometimes CCBs worsen or produce urinary incontinence by impairing detrusor contraction. A lower dose of calcium channel blocker could be tried, a different class could be tried, or as a last resort, incontinence products could be used.

Answer 908

b. anticoagulation. The most common arrhythmia associated with mitral regurgitation (MR) is atrial fibrillation. Anticoagulation with warfarin will help prevent arterial embolism that can result in stroke or myocardial infarction. Atrial fibrillation occurs because the fibers in the atrium are stretched as the atrium dilates. The stretch results in conduction defects, notable, atrial fibrillation.

Answer 909

c. Amlodipine This patient has isolated systolic hypertension (ISH), common in older adults. Long-acting calcium channel blockers (CCB), specifically those with the suffix "pine," and thiazide diuretics, are recommended for starting treatment in patients with ISH. Amlodipine is probably a better choice in this patient because she needs a substantial decrease in her systolic blood pressure. Thiazide-type diuretics produce an average decrease of 2-8 points in the systolic blood pressure. The CCBs are more potent and a more significant decrease in blood pressure could be expected.

Answer 910

c. diabetics with hypertension. Pharmacologic treatment should be initiated for children who have both hypertension and diabetes, symptomatic hypertension, hypertension >95th percentile, when end-organ damage is present. Obesity is a risk factor, but it is not a sole indicator of treatment.

Answer 911

c. hypokalemia. HCTZ is a thiazide diuretic that is potassium-wasting. Patients can become hypokalemic and experience side effects of this. A common one is muscle cramps.

Answer 912

c. metoprolol. Metoprolol is a cardioselective beta blocker. It can produce bradycardia that is responsible for exercise intolerance. As a patient exercises, a concomitant increase in heart rate allows for an increase in cardiac output. If the heart rate is not able to increase because of beta blocker influence, neither can the cardiac output. The patient will necessarily slow down his physical activity. Choices a and d have no direct effect on heart rate. Amlodipine is a calcium channel blocker that does not decrease heart rate.

Answer 913

c. secondary hypertension. Secondary hypertension is more common in preadolescence, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension.

Answer 914

a. an hypertrophied left ventricle. The left ventricle enlarges as blood regurgitates from the aorta. Atrial fibrillation is not typical or usual in aortic regurgitation (AR), since neither atrium is affected. Pulmonary congestion is seen later in the pathogenesis of AR. The blood pressure in patients with AR is characterized by an elevated systolic and decreased diastolic pressure. This is termed a wide pulse pressure.

Answer 915

b. development of heart failure (HF). The symptoms of dyspnea on exertion and peripheral edema are symptoms of HF. Long standing hypertension is a risk factor for HF. Acute myocardial infarction would result in acute symptoms, not development of symptoms over the past several days. Noncompliance with medication and fluid or sodium excess might result in peripheral edema and development of heart failure.

Answer 916

c. Ciprofloxacin Quinolones such as ciprofloxacin and levofloxacin are often used to treat urinary tract infections, especially in older adults. All of the quinolones have been implicated in possible QT interval prolongation. Knowing this should cause prescribers to use care, especially when using these or other quinolones in adults who have underlying conduction defects. This is especially the case if a patient is concurrently taking other drugs that can prolong the QT interval.

Answer 917

b. Diabetes Maternal diabetes increases the risk of the above names diseases. Congenital infections like cytomegalovirus, herpesvirus, rubella, or coxsackie virus can increase the risk of many cardiac structural abnormalities. TORCH is an acronym used to describe five maternal infections that are deleterious to the fetus. The acronym TORCH stands for Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus (CMV), Herpes simples virus (HSV).

Answer 918

b. for any type of hypertension. Hypertension management has been found to be beneficial in preventing stroke and cardiac events in all ages. Treatment should begin without regard to age. Older adults are more likely to exhibit isolated systolic hypertension. This has been found to be a strong predictor of cardiac and cerebral events if not managed appropriately.

Answer 919

d. Infants that burp frequently when feeding. Infants who burp frequently probably are swallowing too much air with feeding. This is likely not related to congenital heart disease. Some red flags associated with feeding that should prompt the examiner to assess for congenital heart disease include feedings interrupted by choking, gagging, or vomiting. Some infants have rapid breathing with feeding or a persistent cough or wheeze. These should be assessed and CHD should be considered.

Answer 920

b. superficial partial thickness burn. Types of burn injuries are chemical, electric, radiation, or thermal. They are classified by the depth of damaged skin. Symptoms of superficial partial thickness burns include: moist areas that are red to ivory white in color, immediate blister formation and painful to touch (pain receptors are intact). Superficial thickness burns appear erythematous without blisters and usually have local pain. Deep partial thickness burns have a dry, waxy, whitish appearance and resemble full thickness burns. Sometimes grafts are needed. Full thickness burns involve the destruction of all skin elements with coagulation of subdermal plexus, muscle, and or tendons.

Answer 921

c. terbinafine is an inhibitor of the CYP 2D6 enzymes. Many oral antifungal agents inhibit the 3A4 or 2D6 enzymes in the cytochrome P450 system. This is why they must be used with extreme caution (or not used) in patients who consume medications that need 3A4 or 2D6 enzymes for metabolism. And, liver enzymes must be monitored in patients who take oral antifungal medications and discontinued if elevations are >2.5 times the upper limits of normal. No oral agent has a 95% cure rate for fingernail fungus (tinea unguium). This can be a difficult infection to clear even if oral antifungal agents are utilized. A topical antifungal agent typically will not clear the infection if the nail matrix is involved. There is anecdotal evidence that menthol ointments or bleach may cause resolution when used topically. Generally, resolution of fingernail fungus occurs more rapidly than toenail fungus because toenails grow at slower rates than fingernails.

Answer 922

d. Encourage the caregiver to change the infant's head position In a normally developing infant, an alopecic area at the occipital area generally develops because the infant has been placed in the supine position during sleeping and waking hours. Prolonged pressure on the occipital area can restrict hair growth. This is normal and will resolve when the infant begins to have better head control and movement; and she begins to have less pressure on the occipital area. Sometimes coarse, dry hair can be indicative of hypothyroidism; not necessarily alopecia.

Answer 923

b. aspirin. Aspirin should always be avoided in the case of viral infections in children and adolescents. The incidence of Reye syndrome is increased if aspirin is given. This is especially true with varicella and influenza infections. The typical constellation of symptoms occurs during a bout of chickenpox and includes nausea, vomiting, headache, excitability, delirium, and combativeness with progression to coma. Since aspirin use has declined sharply, Reye syndrome has too.

Answer 924

b. pus. Folliculitis is a superficial inflammation of hair follicles usually caused by bacteria. As a superficial infection, it involves only the epidermis. When this occurs, there are usually numerous pustular lesions. The composition of pus is dead white cells and other cellular debris.

Answer 925

d. Report the bite to animal control and administer appropriate medical care. All 50 states require reporting of animal bites to animal control or the state's appropriate authority for reporting animal bites. It sounds unlikely that the dog could be infected with rabies, but rabies prophylaxis must be considered after all history and information has been gathered.

Answer 926

a. itching. Atopic dermatitis is diagnosed on clinical presentation and includes evidence of pruritic skin. It is recurrent and often begins in childhood. For decades the "atopic triad" has been used to refer to patients with atopic dermatitis, asthma, and allergic rhinitis. This has recently been called into question. A similar triad, knows as Samter's triad, consists of asthma, aspirin sensitivity, and nasal polyps. Samter's triad is not the same as the atopic triad.

Answer 927

d. Genitalia Genitalia have the highest percutaneous absorption across the entire body. this is important because low-potency creams will act with greater potency in this area. Low-potency creams/lotions should be used initially for treating skin conditions involving the genitalia. The sole of the foot has the lower percutaneous absorption, followed by the scalp, forehead, and genitalia. Therefore, the sole of the foot will require more potent vehicles to enhance absorption.

Answer 928

d. 3-4 weeks ago. The incubation period for scabies is about 3-4 weeks after primary infection. Patients with subsequent infections with scabies will develop symptoms in 1-3 days. The classic symptom is itching that is worse at night, couples with a rash that appears in new areas over time.

Answer 929

b. antihistamines. The primary cause of pruritus associated with hives is histamine release. Histamine is released from mast cells with other substances of anaphylaxis. Antihistamines are the primary therapeutic intervention. Topical steroid use is not helpful. Calcium channel blockers (nifedipine) are used as a "last resort" for refractory cases of urticaria. Steroids do not inhibit mast cell degradation and so are less helpful than thought. Steroids can be used for persistent attacks of acute urticaria if antihistamines are not helpful.

Answer 930

a. should be started within 72 hours of the onset of symptoms. This patient has been diagnosed with shingles. This can produce a painful neuritis. Shingles is treated with an oral antiviral agent, preferably within 72 hours of onset of the symptoms. Treating shingles with an oral antiviral agent shortens the severity and duration of shingles. It may also help decrease the incidence of post-herpetic neuralgia.

Answer 931

c. Ciprofloxacin Many medications can produce a phototoxic reaction when a patient is exposed to sunlight. Antibiotics are especially notable for this. Common antibiotics associated with photosensitivity are tetracyclines, sulfa drugs, and fluoroquinolones. Ciprofloxacin is a fluoroquinolone. Amoxicillin and cephalexin are beta lactam antibiotics. Azithromycin is a macrolide antibiotic. Other common medication/classes that increase photosensitivity are hydrochlorothiazide, diltiazem, selective serotonin reuptake inhibitors, antihistamines, ibuprofen, and naproxen.

Answer 932

b. The rash will blanch. This describes a patient with roseola or exanthem subitum. This is a common viral exanthem found in young children caused by human herpes virus 6. It is characterized by high fever for 3 days followed by the abrupt cessation of fever and the appearance of a maculopapular rash. This usually resolved in a few days. The child may return to school or daycare when he has been fever-free for 24 hours.

Answer 933

b. papule. A papule is an elevated solid mass up to 1.0 cm. in diameter. A macule is flat and small, like a freckle. A vesicle is filled with a serous fluid and less than 1.0 cm in diameter. A bullae is fluid filled and larger than 1.0 cm in diameter.

Answer 934

b. 5-fluorouracil. Several treatments exist for basal and squamous cell carcinoma. The majority are simple procedures like cryotherapy, electrodessication, surgical excision, and a topical treatment like 5-fluorouracil (5-FU). The other agents listed are not used to treat basal or squamous cell carcinoma. 5-FU works by inhibiting DNA synthesis. It is effective if used for superficial basal cell carcinomas. It is available in cream and solution and is usually applied twice daily for 3-6 weeks.

Answer 935

b. Tachyphylaxis Tachyphylaxis is the word used to describe when a medication becomes progressively less effective after repetitive administration. This is particularly true of topical glucocorticoids, bronchodilators, nitroglycerine, and antihistamines when they are overused. The rebound effect describes a condition in which initial clinical improvement occurred, but worsening has occurred. Lichenification refers to a thickening of the skin. Drug-free intervals are important to prevent tachyphylaxis.

Answer 936

b. Amoxicillin Amoxicillin, doxycycline, and cefuroxime have all been shown to have equivalent efficacy for treatment of Lyme disease. However, because this patient is 6 years old, he should not be given doxycycline as a first line treatment unless the other regimens are contraindicated. Macrolides like azithromycin should not be used first line because they are poorly effective at eradicating infection. They may be used in patients who are intolerance of penicillins and cephalosporins and who cannot take doxycycline. first-generation cephalosporins like cephalexin are poorly effective and should not be used.

Answer 937

c. Border The mnemonic is helpful when looking at skin lesions, but it is primarily used for patient education. The "A" represents asymmetry (asymmetrical lesions are worrisome), "B" is border (irregular borders), "C" is color (colored lesions have more melanin and may be associated with malignant melanoma), "D" is diameter (larger than a pencil eraser [6 mm] is concerning), and "E" represent enlarging or elevated (lesions that are actively enlarging are growing; elevated lesions are concerning).

Answer 938

c. ulcerative colitis. These nodules describe erythema nodosum. These are most common in women aged 15-40 years old. They are typically found in pretibial locations and can be associated with infections agents, drugs, or systemic inflammatory disease like ulcerative colitis. They probably occur as a result of a delayed hypersensitivity reaction to antigens. It is not unusual to find polyarthralgia, fever, and/or malaise that precede or accompany the skin nodules.

Answer 939

a. actinic keratosis. Actinic keratoses (AK) are a result of solar damage to the skin. They are most common on the face, bald scalp, and forearms. Patients who present with AK usually have multiple of them. A characteristic that helps identification of AK is an area of erythema that surrounds the lesion. AK is sometimes easier felt than seen.

Answer 940

d. Fungal Under microscopic exam, hyphae are long, thin and branching and indicate dermatophytic infections. Hyphae are typical in tinea pedis, tinea cruris, and tinea corporis.

Answer 941

c. After all lesions have crusted Chickenpox is highly contagious and can be spread via respiratory secretions from an infected person or by direct contact from the vesicle fluid from lesions on the skin or mucus membranes. The usual incubation period is about 2 weeks but can be as long as 21 days or as short at 10 days. The greatest period of infectivity is 48 hours prior to the onset of the rash and until all the skin lesions have crusted over.

Answer 942

b. Single dermatome affected Shingles is herpes zoster. It characteristically affects a shingle dermatome. Grouped vesicle on an erythematous base may occur in some patients with shingles, but this is not unique to shingles. In fact, it is typical in many viral infections. Crusting may be seen with shingles, chicken pox, or impetigo. Pain, burning, and itching are symptoms that some patients have with shingles, but not all patients report itching with shingles.

Answer 943

b. Dyshidrotic dermatitis This dermatitis is intensely pruritic and involves the palms and soles and lateral aspects of the fingers. Over a couple of weeks, the vesicles desquamate. Recurrences are common. Seborrheic dermatitis affects only hairy areas of the body. The vesicles might raise suspicion of a viral infection, but this is not present in this case.

Answer 944

a. Once A single whole-body application of permethrin is usually successful in eradicating infection with scabies. It is applied over the entire body from the neck down. The lotion is left on and then showered off 8-12 hours later. All contact must be treated at the same time and all potential fomites (bed linen, mattresses, cloth furniture, etc.) must be treated as well. Permethrin can be sprayed on cloth fomites, or the fomite can be bagged for several days, washed, and dried in a washing machine and dryer. Ironing clothes after washing them is acceptable.

Answer 945

a. Pull it off with tweezers Use tweezers to pull it off. If tweezers are not available, protected fingers should be used. The person removing the tick should take care NOT to crush the tick because it may contain infectious organisms. After the tick is removed, the skin should be washed well with soap and water. If mouth parts remain after the tick has been removed, they should NOT be removed. They will be expelled on their own and removed of these parts may cause significant skin trauma. The area should be monitored for 30 days for erythema migrans.

Answer 946

c. ELISA A detailed history should always precede testing for Lyme disease. The red circle with the white center is likely erythema migrans (EM). EM is the characteristic skin lesion of Lyme disease (and other illnesses) and usually occurs within 1 month following the tick bite. Many learned authorities, including the Infections Diseases Society of America, conclude that individuals should not be screened/tested for Lyme disease unless they have a high probability of having Lyme disease. In this case, historical features coupled with physical exam support the diagnosis, and thus screening. The most common initial serologic test for screening is an ELISA. If it is positive, it should be confirmed with a Western blot. Unfortunately, there are a large number of false positives and so a confirmation should be performed.

Answer 947

a. honey-colored crusts. Impetigo is a superficial bacterial infection of the skin characterized by honey-colored crusts. Another form of impetigo is characterized by the presence of bullae. These infections are treated with topical antibiotics, good hygiene, and frequent hand washing. It is usually caused by Staphylococcus or Group A Streptococcus.

Answer 948

c. a herald patch. Pityriasis rosea is a viral rash that is common in older children and young adults. It typically begins with a herald patch, a single round pink or salmon-colored, nonpruritic plaque on the chest, neck, or back. It is often mistaken for ringworm prior to the eruption of the Christmas tree pattern rash. The rash occurs within 1-2 weeks after the appearance of the herald patch. Scabies typically presents as a pruritic eruption characterized by small, erythematous, nondescript papules. Its prominent clinical feature is pruritus. Most cases of eczema initially occur by the age of five years, but can manifest in adults as an area os pruritic, thickened (lichenified), and excoriated skin in the flexural area. Psoriasis may present as silvery scales or plaques.

Answer 949

a. Basal cell carcinoma Basal cell's classic description is "a pearly-domes nodule with a telangiectatic vessel". It is commonly found on sun-exposed areas like the head or neck. Sending the patient to dermatology (since these represent skin cancer) best treats these lesions. Sometimes these lesions can be treated with a topical agent like 5-fluorouracil if they are superficial; others require surgical removal.

Answer 950

a. Intertrigo This is not unusual in adults with pendulous breasts. Intertrigo is common in areas between skin folds, under the breasts, between the scrotum and inner thigh, or between the toes. These are moist lesions that can be easily treated if the skin can be separated from touching the adjoining skin and the area can be kept dry. A topical powder with an antifungal would likely resolve this if used twice daily for 7-14 days. A diagnosis of diabetes should be considered if this is resistant to treatment or if it recurs.

Answer 951

b. Erysipelas Erysipelas is characterized by an acute onset of symptoms as described in this scenario. Fever and chills are common. Patients with cellulitis tend to have a more gradual course, with development of symptoms over several days. The erythema noted in erysipelas is well demarcated and raised above the level of the skin. This elevation reflects that the more superficial dermis is involved.

Answer 952

d. you are eligible to receive it but you still may get shingles. Patients must be at least 50 years old to receive the recombinant zoster vaccine (Shingrix). Shingrix provides strong protection against acquiring herpes zoster (shingles) and against developing postherpetic neuralgia (PHSN), which is a complication of herpes zoster infection. in an immunocompetent patient, 2 doses of Shingrix administered 2-6 months apart is more than 90% effective at preventing shingles and PHN. According to the Advisory Committee on Immunization Practices (ACIP), protection level remains at about 5% for at least 4 years after vaccination. Despite the vaccine's high rate of effectiveness, there is a chance that patients may develop shingles after immunization. The risk of developing complication (e.g., PHN) from shingles increases with age and with immunocompromise. The vaccine may be offered regardless of whether the patient has a prior history of shingles. It may also be offered if the patient received Zostavax, which is no longer available in the U.S.

Answer 953

c. Tinea versicolor Tinea versicolor is typically visualized during the spring and summer months when a patient has become darkened after sun exposure. the areas that are infected do not tan and so become very noticeable. The chest and back are common areas to observe tinea versicolor. There can be 100 or more in some infections. This can be treated with topical selenium sulfide or an oral antifungal agent.

Answer 954

c. tolerability of the medication. The most efficacious agents used to treat toenail fungus are the oral antifungal agents. They must be taken daily for 8-16 weeks (or longer) for adequate length of treatment. Additionally, the real difficulty lies in the ability of the older adult's liver to handle this medication. Oral antifungal agents require great amounts of the liver's resources for metabolism. A topical agent or toenail removal may be a better choice for an older adult.

Answer 955

b. Strept infection. Streptococcal infections can present as a sandpaper-textured rash that initially is felt on the trunk. Rubeola, measles, produces a blanching erythematous "brick-red" maculopapular rash that begins on the back of the neck and spreads around the trunk and then extremities. Varicella infection produces the classic crops of eruptions on the trunk that spread to the face. The rash is maculopapular initially and then crusts. Roseola produces a generalized maculopapular rash preceded by 3 days of high fever.

Answer 956

a. It should be given to immunocompetent adults age 50 and older. CDC's recommendation for the recombinant zoster vaccine (Shingrix) is for administration in immunocompetent adults aged 50 years and older. Shingrix is an inactivated (not live) vaccine and while not contraindicated in patients who are immunocompromised, it is not currently recommended by the Advisory Council on Immunization Practices (ACIP). It should not be administered during an acute outbreak of shingles, but can be administered as soon as the acute phase has resolved. Shingrix is given in a two-dose series, with the second dose administered in 2 to 6 months. If it has been longer than 6 months from the first dose; just give the second dose, there is no need to restart the series. there is no need to screen the patient for a prior history of varicella nor to obtain serologic testing for antibodies.

Answer 957

c. found on the inside of the cheek and are granular. Koplik's spots are found in the oral cavity, especially on the buccal mucosa opposite the first and second molars. the spots are white and granular and are circled by an erythematous ring. The spots are pathognomonic for measles. The exanthem associated with measles is typical described as cranial to caudal in progression. The lesions become confluent and last for approximately 4 days before fading begins.

Answer 958

b. Complete blood count koilonychia is the term that describes spoon-shaped nails. Spoon-shaped nails may be present in patients who have longstanding iron deficiency anemia. A CBC should be performed to assess for anemia. The most common symptoms of iron deficiency anemia are weakness, headache, irritability, fatigue, and exercise intolerance.

Answer 959

b. Pityriasis rosea Pityriasis rosea (PR) is a self-limiting exanthematous skin disorder characterized by several unique findings. It is more common in young adults. A characteristic finding is the "herald" or "mother" patch found on trunk. This looks like a ringworm and precedes the generalized "Christmas tree" pattern rash. The lesions associated with the rash are salmon-colored and oval in shape. Most cases clear in 4-6 weeks, but the plaques may last for several months.

Answer 960

b. a positive rapid Strept test. A patient with scarlet fever (scarlatina) has a common childhood disease that is characterized by sore throat, fever, and a scarlet "sandpaper" rash. The causative organism is Group A beta hemolytic Streptococcus pyogenes. The patient's rapid Strep test will likely be positive. Diarrhea with abdominal cramps is not specific to scarlet fever. Petechiae represent an extravasation of blood under the skin and are not present with scarlet fever unless some other disease process is present. Petechiae should be considered to be a serious finding.

Answer 961

b. On the chest The herald patch associated with pityriasis rosea is most commonly found on the trunk. It precedes the generalized Christmas tree pattern rash that is easily noted on the rest of the body. Because it appears round and has a darkened center, it looks like a ringworm. In fact, it is commonly mistaken for ringworm until the Christmas tree pattern rash appears. It would be unusual to identify the herald patch on a body part other than the trunk, but there are case reports of this.

Answer 962

b. Stage II Stage I is characterized by intact skin and nonblanchable redness of a localized area (usually over a bony prominence). Compared to adjacent tissue. the area may be painful, firm, soft, warmer or cooler. Stage II is characterized by partial-thickness loss of dermis presenting as a shallow open ulcer or a re-pink wound bed, absent sloughing. It may also present as an intact or open/ruptured serum-filled blister. Stage III is characterized by full-thickness tissue loss with or without visible subcutaneous fat; bone, tendon, and muscle are not exposed. Sloughing may be present but does not obscure the depth of tissue loss. The depth varies by anatomical location. Stage IV is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Sloughing or eschar may be present on some parts of the wound bed. The depth varies by anatomical location.

Answer 963

d. Silvery scales that are mildly pruritic There are many different presentations of psoriasis. Plaque psoriasis, which is described in this question, is usually found in a symmetrical distribution on the scalp, elbows, knees, and/or back. The size of the lesions ranges from 1-10 cm in diameter. The plaques may be asymptomatic, but pruritis is a common finding. Scaly lesions found on the scalp are not specific to psoriasis and could be seborrheic dermatitis. A scaly border around the plaque could describe the lesions associated with pityriasis rosea.

Answer 964

b. face. The most common presentation of basal cell carcinoma (BCC) is on the face. This is probably because BCC occurs secondary to sun damage. The most common sun exposure occurs on the face. In fact, 70% of BCC occurs on the face; 15% occurs on the trunk.

Answer 965

a. examine his skin monthly for changes. Patients should be examined periodically for evidence of skin cancer by a professional examiner (NP, MD or PA). The frequency and type of examination depends on the risk level, and personal and family history of the patient. However, a patient should examine his own skin regularly for changes. Once he has begun to examine his skin, research demonstrates that he will identify early changes and can make his provider aware of them.

Answer 966

a. Use a petroleum-based product Xerosis is dry skin. It is common in patients who have eczema. Using thick creams or ointments can prevent xerosis. Lotions should be avoided because they have high water content that promotes evaporation of water from the skin. Hypoallergenic refers to the allergenicity of a product. This is not related to the water content of products.

Answer 967

d. Complete blood count (CBC) Herpes viruses are the causative agents in shingles, chickenpox, genital herpes, and oral fever blister. Diagnosis is usually made on clinical presentation. However, in questionable cases, lab tests may be employed. A Tzanck preparation is a rapid test used to diagnose infections due to herpes viruses. Cell taken from a blister's fluid are smeared on a slide and stained with a Wright's stain, or the fluid can be used for other methods of testing. DFA is the most common test employed for shingles diagnosis because it can be rapidly performed and offers results in about 90 minutes. PCR may be performed on skin scraping, serum or blood for herpetic diagnosis. CBC may indicate a patient with a viral infection, but it is nonspecific for herpetic infections.

Answer 968

a. cephalexin. Two common first-generation cephalosporins used to treat skin and skin structure infections are cephalexin and cefadroxil. These are taken two to four times daily and are generally well tolerated. These antibiotics provide coverage against Staphylococcus and Streptococcus, common skin pathogens.

Answer 969

d. basal cell carcinoma 5-FU is a topical agent that can be used to treat basal cell carcinoma (BCC). it is most effective on rapidly proliferating cells. This treatment should only be used on superficial BCCs. If it is used on more invasive BCC, the cure rate is significantly lower. Therefore, 5-FU should be used only on superficial BCCs in noncritical locations. It is does as a 5% formulations twice daily for 3-6 weeks.

Answer 970

a. Call the dermatologist to report the elevated BP The nurse practitioner is responsible for treated the sinus infection but has also become aware of a potentially harmful situation involving the elevated blood pressure and oral contraceptive use. The safest and most professional action is to call the dermatologist to discuss your concerns regarding the elevated BP and concomitant oral contraceptive use since this potentially increases the risk of stroke in this adolescent. Care and processional courtesy should be exercised when discontinuing a medication that another provider has initiated. Professional courtesy is extended to the prescriber by calling them prior to discontinuing a medication they have ordered.

Answer 971

c. these may bleed profusely if ruptured. Cherry angiomas are mature capillary proliferations that are more common in middle-aged and older adults. They blanch with pressure and are usually 0.1-0.4 cm in diameter. They are commonly found on the trunk as multiple lesions. Because they are a proliferation of capillaries, they will bleed significantly if they rupture. The bleed is not life threatening, but in older adults who take aspirin, the bleeding will be worse. Pressure should be held over the ruptured area until bleeding stops. These are not precursors of skin malignancies.

Answer 972

d. Actinic keratosis Actinic keratosis is a premalignant condition of the skin and is considered an evolving carcinoma in situ. It is a precursor of squamous cell carcinoma. The lesion are usually multiple in occurrence and sit on an erythematous base. They appear dry, scaly, and flat and are usually secondary to sun damaged skin. Thus they are found on sun-exposed areas. The most common sites are the face, ears, lateral forearms, and tops of hands.

Answer 973

c. Hyphae A Wood's lamp emits ultraviolet light when turned on. If an area fluoresces under Wood's lamp illumination, a fungal (and sometimes bacterial) infection should be suspected. Hyphae are associated with fungal infections. The test is most effectively performed in a darkened room so the fluorescence can be more easily identified. Deodorant, soap, and makeup may also fluoresce. About one-third of hyphae fluoresce.

Answer 974

c. "No, transmission does not occur from the blister's contents" The skin reaction seen after exposure to poison ivy (or any other skin irritant), takes place because of contact with the offending substance. In the case of poison ivy, the harmful exposure occurs from contact with oil from the plant. The eruptions seen are NOT able to transmit the reaction to other people unless oil from the plant remains on the skin and someone touches the oil. The fluid found in the blisters is NOT able to transmit poison ivy to anyone; only the oil from the plant can do that. After oil has touched the skin, some time must pass for the reaction to occur. Therefore, reaction times vary depending on skin thickness and quantity of oil contacting the skin.

Answer 975

a. He should receive doxycycline for Lyme disease. The first serologic test for Lyme disease is the ELISA. If this is positive, it should be confirmed. In this case, it was confirmed by a Western blot and it is positive. This patient can be diagnosed with Lyme disease. The appropriate treatment for erythema migrans is doxycycline, amoxicillin, or cefuroxime for 21 days. All three medications were found to be of equal efficacy.

Answer 976

a. No treatment is needed. Many factors must be present for a patient to develop Lyme disease from a tick bite. First, the tick must belong to lxodes species. The tick must have been attached for at least 48 hours before disease can be spread. Time of year and stage of organism development affect transmission. There is no need for prophylactic treatment in this case because the tick has not been present long enough, though many patients will feel antibiotics are necessary. He could be checked to ensure that the entire tick has been removed.

Answer 977

b. Hepatic cirrhosis Rounding of the distal phalanx describes clubbing. Clubbing of fingers is most often associated with chronic hypoxia as seen in cigarette smokers and patients with COPD or lung cancer. Other causes are cirrhosis, cystic fibrosis, pulmonary fibrosis and cyanotic heart disease.

Answer 978

a. Permethrin Scabies is eradicated by using permethrin and good hygiene. All household and personal contact must be treated simultaneously, and meticulous care must be exercised to prevent transmission by cross contamination. All clothing, stuffed animals, linens, mattresses, and cloth furniture must be treated to prevent further transmission.

Answer 979

a. hyphae. Under microscopic exam, hyphae are long, thin and branching, and indicate dermatophytic infections. Hyphae are typical in tinea pedis, tinea cruris, and tinea corporis. Yeasts are usually seen in candidal infections. Cocci and rods are specific to bacterial infections.

Answer 980

a. Chronic "Silvery scales" describes the hallmark finding in psoriasis. This is a chronic condition. It is not infectious, contagious, or acute. There are several variants, but "silvery scales" is the most common form.

Answer 981

b. Order a CBC The presence of petechiae on the lower legs (or anywhere on the body) should prompt the NP to consider a problem that is related to a low platelet count. A CBC should be checked to assess the platelet count and for any evidence of anemia from blood loss. If the platelet count is found to be low, referral to hematology should be done. Blood cultures are of no value in this patient, who is otherwise asymptomatic.

Answer 982

b. basal cell carcinoma. Skin cancers are divided into two major groups: nonmelanoma and melanoma skin cancer. Basil cell carcinoma is considered nonmelanoma skin cancer and is the most common form of skin cancer in the US. It is most common in 40- to 60-year-olds, but can occur at any age if the skin is regularly exposed to sunlight or ultraviolet radiation. Basal cell carcinoma grows slowly, and if not treated it can spread to surrounding areas of tissue or bone.

Answer 983

c. There is a risk of fetal death if she becomes infected. Pregnant mother should avoid exposure to patients with known Fifth disease. However, the risk of transmission is very low. She should avoid exposure to aplastic patients who are infected because they are highly contagious. Infection during pregnancy is associated with 10% risk of fetal death. There is no need for an ultrasound today. This pregnant patient does not have evidence of disease. She should be monitored for a rash which could indicate infection.

Answer 984

c. scalp edema. Caput succedaneum is a common finding in newborns. It is a result of pressure over the presenting part. This results in some ecchymosis of the scalp. While this may be disturbing to new parents who observe this in their newborn, it will resolve in a few days and is harmless.

Answer 985

c. well marginated half-moon macules on the inner thigh. Tinea cruris, "jock itch" is common during warm months and in humid areas. It is a fungal infection that affects the scrotum and inner thighs, but never affects the penis and is never evidence by scrotal swelling. He is probably at increased risk because he is working as a lifeguard and may wear damp or wet swim trunks during work. He should be treated with a topical antifungal cream, advised to dry off after swimming, and to put on dry swim trunks.

Answer 986

c. is immune to hepatitis B. This patient is immune to hepatitis B because he has a positive hepatitis B surface antibody. He does not need immunization. his immunity is due to immunization because he has a negative core antibody. The finding of a positive surface antibody and a negative core antibody in this patient indicates immunity from hepatitis B from innumization. If his immunity had been derived from infection, his core antibody would have been positive.

Answer 987

c. Opioid use Opioids can cause severe constipation. At end of life, this can be a significant cause of discomfort for the patient. Measures for relief of constipation should be instituted.

Answer 988

c. international travel. Traveling internationally is the most common risk factor. Hepatitis A (HAV) is spread via the fecal-oral route (and is highly contagious), though most people have no recollection of eating or drinking contaminated food/drink. Mexico, Central and South America are countries with the highest reported rates of HAV. Other risk factors are contract with infected family or close contact and homosexual activity among men. Hepatitis A has declined since vaccination in the US has become widespread.

Answer 989

c. It is not advised in this patient at this time Prior to any screening test such as colonoscopy, consideration must be given to the patient's overall health status, colorectal cancer risk, and desire to pursue treatment if cancer or disease is diagnosed. The United States Preventive Services Task Force, American College of Physicians, and American College of Gastroenterology do no recommend screening an 86-year-old for colorectal cancer. As a general rule, patients with a life expectancy of less that 5-10 years should forego colorectal cancer screening via colonoscopy. Colonoscopy enables the examiner to visualize the entire colon and is a superior screening tool for colorectal cancer, but there are significant risks of bleeding and perforation in older adults. Additionally, the colon prep can produce massive shifts in electrolytes that can increase the likelihood of arrhythmias, heart failure, weakness, and falls.

Answer 990

d. Pantoprazole If a patient has been diagnosed with GERD and he is symptomatic on an H2 blocker like ranitidine, a proton pump inhibitor (PPI) should be considered. An example of a proton pump inhibitor is pantoprazole. Relief of symptoms after using a PPI does not indicate a benign condition. This patient could have esophageal erosions, Barrett's esophagitis, or esophageal cancer. He should be screened for risk factors for these conditions and then a discussion to refer this patient to gastroenterology can be made.

Answer 991

a. A viral infection When WBCs are found in stool specimens, it is indicative of infection or inflammation. In the case of a patient with symptoms suggestive of an infections etiology, bacterial or viral infections should be considered. When considering a differential diagnosis and no infection etiology is likely, Crohn's disease or ulcerative colitis could be considered.

Answer 992

c. Daily grapefruit consumption for the past 10 days Grapefruit is a potent inhibitor of the cytochrome P450 enzyme system. Statins and calcium channel blockers are two infamous drug interactions that occur with grapefruit and grapefruit juice. Because they inhibit metabolism of the statin, the patient continues to have statin in circulation because he cannot significantly metabolize the medication. When the next day's dose is taken, its effect is coupled with the effect of the previous day's dose. The effect is cumulative. Hepatoxicity can quickly develop. The simvastatin must be stopped immediately! The liver enzymes must be followed until they return to normal; which could take weeks, months or even longer.

Answer 993

B. Topical antifungal cream The finding of satellite lesions associated with diaper dermatitis indicates a candidal infection. This patient will be most effectively treated with a topical antifungal agent, allowing the lesions to be exposed to air for periods of time (like during a nap)