Exam 2

Question 1

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

A) Tension
B) Migraine
C) Cluster
D) Analgesic rebound

Answer 1

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

Question 2

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

A) Tension
B) Migraine
C) Cluster
D) Analgesic rebound

Answer 2

Ans: A
Chapter: 07
Page and Header: 196, The Health History
Feedback: This is a description of a typical tension headache.

Question 3

Which of the following is a symptom involving the eye?

A) Scotomas
B) Tinnitus
C) Dysphagia
D) Rhinorrhea

Answer 3

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

Question 4

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

A) Benign positional vertigo
B) Vestibular neuronitis
C) Ménière’s disease
D) Acoustic neuroma

Answer 4

Ans: A
Chapter: 07
Page and Header: 252, Table 7–3
Feedback: This is a classic description of benign positional vertigo. The vertigo is episodic, lasting a few seconds to minutes, instead of continuous as in vestibular neuronitis. Also, there is no tinnitus or sensorineural hearing loss as occurs in Ménière’s disease and acoustic neuroma. You may choose to learn about Hallpike maneuvers, which are also helpful in the evaluation of vertigo.

Question 5

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

A) Benign positional vertigo
B) Vestibular neuronitis
C) Ménière’s disease
D) Acoustic neuroma

Answer 5

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

Question 6

A 73-year-old nurse comes to your office for evaluation of new onset of tremors. She is not on any medications and does not take herbs or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow movements and shuffling steps. She has decreased facial mobility and a blunt expression, without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the patient’s symptoms?

A) Cushing’s syndrome
B) Nephrotic syndrome
C) Myxedema
D) Parkinson’s disease

Answer 6

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

Question 7

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

A) Ptosis
B) Exophthalmos
C) Ectropion
D) Epicanthus

Answer 7

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

Question 8

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

A) Dacryocystitis
B) Chalazion
C) Hordeolum
D) Xanthelasma

Answer 8

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

Question 9

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

A) Conjunctivitis
B) Acute iritis
C) Corneal abrasion
D) Subconjunctival hemorrhage

Answer 9

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

Question 10

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

A) Corneal arcus
B) Cataracts
C) Corneal scar
D) Pterygium

Answer 10

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

Question 11

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

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

Answer 11

Ans: C
Chapter: 07
Page and Header: 196, The Health History
Feedback: A unilateral headache is often seen with migraines and may commonly be accompanied by phonophobia and photophobia. Pain over the sinuses from sinus congestion may also be unilateral and produce pain. Migraine and sinus headaches are common and generally benign. A new severe headache in someone over 50 can be associated with more serious etiologies for headache. Other red flags include: acute onset, “the worst headache of my life”; very high blood pressure; rash or signs of infection; known presence of cancer, HIV, or pregnancy; vomiting; recent head trauma; and persistent neurologic problems.

Question 12

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

A) Retinal detachment
B) Corneal ulcer
C) Acute glaucoma
D) Uveitis

Answer 12

Ans: A
Chapter: 07
Page and Header: 196, The Health History
Feedback: Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain. Retinal detachment is generally painless, as is chronic glaucoma.

Question 13

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

A) Vitreous hemorrhage
B) Central retinal artery occlusion
C) Macular degeneration
D) Optic neuritis

Answer 13

Ans: D
Chapter: 07
Page and Header: 196, The Health History
Feedback: In multiple sclerosis, sudden painful loss of vision may accompany optic neuritis. The other conditions are usually painless.

Question 14

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

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

Answer 14

Ans: D
Chapter: 07
Page and Header: 196, The Health History
Feedback: Double vision in one eye alone points to a problem in “processing” the light rays of an incoming image. The other causes of diplopia result in a misalignment of the two eyes.

Question 15

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

A) Intracranial hemorrhage
B) Hematemesis
C) Intestinal hemorrhage
D) Hematoma of the nasal septum

Answer 15

Ans: B
Chapter: 07
Page and Header: 196, The Health History
Feedback: Although the source of epistaxis may seem obvious, other bleeding locations should be on the differential. Hematemesis can mimic this and cause delay in life-saving therapies if not considered. Intracranial hemorrhage and septal hematoma are instances of contained bleeding. Intestinal hemorrhage may cause hematemesis if there is obstruction distal to the bleeding, but this is unlikely.

Question 16

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

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

Answer 16

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

Question 17

ery sensitive methods for detecting hearing loss include which of the following?

A) The whisper test
B) The finger rub test
C) The tuning fork test
D) Audiometric testing

Answer 17

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

Question 18

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

A) The fovea
B) The macula
C) The optic disk
D) The physiologic cup

Answer 18

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

Question 19

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

A) Direct reaction
B) Consensual reaction
C) Near reaction
D) Accommodation

Answer 19

Ans: B
Chapter: 07
Page and Header: 205, The Eyes
Feedback: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.

Question 20

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

A) She obtains a 20% correct score at 100 feet.
B) She can accurately name 20% of the letters at 20 feet.
C) She can see at 20 feet what a normal person could see at 100 feet.
D) She can see at 100 feet what a normal person could see at 20 feet.

Answer 20

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

Question 21

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

A) Bitemporal hemianopsia
B) Right temporal hemianopsia
C) Right homonymous hemianopsia
D) Binasal hemianopsia

Answer 21

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

Question 22

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

A) Horner’s syndrome
B) Benign anisocoria
C) Differing light intensities for each eye
D) Eye prosthesis

Answer 22

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

Question 23

A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally. Which of the following have you essentially excluded from your differential?

A) Retinoblastoma
B) Cataract
C) Artificial eye
D) Hypertensive retinopathy

Answer 23

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

Question 24

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

A) Otitis media
B) External otitis
C) Perforation of the tympanum
D) Cholesteatoma

Answer 24

Ans: B
Chapter: 07
Page and Header: 225, Techniques of Examination
Feedback: These are classic history and examination findings for a patient suffering from external otitis. Otitis media would not usually have pain with movement of the external ear, nor drainage unless the eardrum was perforated. In this case the examination of the eardrum is recorded as normal. Cholesteatoma is a growth behind the eardrum and would not account for these symptoms. Otitis media would classically be accompanied by a bulging, erythematous eardrum.

Question 25

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

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

Answer 25

Ans: A
Chapter: 07
Page and Header: 271, Table 7–21
Feedback: The above pattern is consistent with a conductive loss on the left side. Causes would include: foreign body, otitis media, perforation, and otosclerosis of the involved side.

Question 26

A young man is concerned about a hard mass he has just noticed in the midline of his palate. On examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis?

A) Leukoplakia
B) Torus palatinus
C) Thrush (candidiasis)
D) Kaposi’s sarcoma

Answer 26

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

Question 27

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

A) CN IX lesion on the left
B) CN IX lesion on the right
C) CN X lesion on the left
D) CN X lesion on the right

Answer 27

Ans: D
Chapter: 07
Page and Header: 231, Mouth and Pharynx
Feedback: The failure of the right side of the palate to rise denotes a problem with the right 10th cranial nerve. The uvula deviates toward the properly functioning side.

Question 28

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

A) Submandibular
B) Tonsillar
C) Occipital
D) Posterior cervical

Answer 28

Ans: D
Chapter: 07
Page and Header: 236, The Neck
Feedback: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.

Question 29

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

A) Cancer
B) Lymph node
C) Deep scar
D) Muscle

Answer 29

Ans: B
Chapter: 07
Page and Header: 236, The Neck
Feedback: A useful maneuver for discerning lymph nodes from other masses in the neck is to check for their mobility in all directions. Many other masses are mobile in only two directions. Cancerous masses may also be “fixed,” or immobile.

Question 30

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

A) Optic nerve damage on the right
B) Optic nerve damage on the left
C) Efferent nerve damage on the right
D) Efferent nerve damage on the left

Answer 30

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

Question 31

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

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

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

Answer 31

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

Question 32

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

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

Answer 32

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

Question 33

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

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

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

Answer 33

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

Question 34

A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer’s disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus.

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

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

Answer 34

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

Question 35

A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall.

What disorder of the chest best describes this disorder?

A) Angina pectoris
B) Pericarditis
C) Dissecting aortic aneurysm
D) Pleural pain

Answer 35

Ans: B
Chapter: 08
Page and Header: 312, Table 8–1
Feedback: The pain from pericarditis is usually sharp and knifelike and is located over the left side of the chest. Change of position, breathing, and coughing often make the pain worse, whereas leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases such as systemic lupus and in patients with chronic kidney disease. Patients also experience this after a myocardial infarction. You can read more about Dressler’s syndrome.

Question 36

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

Which disorder of the chest best describes these symptoms?

A) Angina pectoris
B) Pericarditis
C) Dissecting aortic aneurysm
D) Pleural pain

Answer 36

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

Question 37

A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior chest pain radiating to her back. She describes it as if someone is “ripping out her heart.” It began less than an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain better or worse. Her medical history consists of difficult-to-control hypertension and coronary artery disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger brother who has had bypass surgery. On examination you see an elderly female in a great deal of distress. She is lying on the table, curled up, holding her left and right arms against her chest and is restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and 130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital’s ER for further evaluation.

What disorder of the chest best describes her symptoms?

A) Angina pectoris
B) Pericarditis
C) Dissecting aortic aneurysm
D) Pleural pain

Answer 37

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

Question 38

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

What disorder of the chest best describes his symptoms?

A) Pericarditis
B) Chest wall pain
C) Pleural pain
D) Angina pectoralis

Answer 38

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

Question 39

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

What disorder of the chest best describes her symptoms?

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

Answer 39

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

Question 40

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

What disorder of the thorax best describes your findings?

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

Answer 40

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

Question 41

Which of the following anatomic landmark associations is correct?

A) 2nd intercostal space for needle insertion in tension pneumothorax
B) T6 for lower margin of endotracheal tube
C) Sternal angle marks the 4th rib
D) 5th intercostal space for chest tube insertion

Answer 41

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

Question 42

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

A) Bronchitis
B) Costochondritis
C) Pericarditis
D) Angina pectoris

Answer 42

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

Question 43

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

A) Intestinal bleeding
B) Hematoma of the nasal septum
C) Epistaxis
D) Bruising of the tongue

Answer 43

Ans: C
Chapter: 08
Page and Header: 290, The Health History
Feedback: When you suspect hemoptysis, you must consider other etiologies for bleeding. Commonly, epistaxis can mimic this as well as bleeding from the gastrointestinal tract. The other answers, although they involve bleeding, are contained or distant from the pharynx.

Question 44

Which of the following occurs in respiratory distress?

A) Speaking in sentences of 10–20 words
B) Skin between the ribs moves inward with inspiration
C) Neck muscles are relaxed
D) Patient torso leans posteriorly

Answer 44

Ans: B
Chapter: 08
Page and Header: 297, Examination of the Posterior Chest
Feedback: This description is consistent with retractions that occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing, in which the patient exhales against his lips, which are pressed together.

Question 45

Which of the following is consistent with good percussion technique?

A) Allow all of the fingers to touch the chest while performing percussion.
B) Maintain a stiff wrist and hand.
C) Leave the plexor finger on the pleximeter after each strike.
D) Strike the pleximeter over the distal interphalangeal joint.

Answer 45

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

Question 46

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

A) Resonance
B) Tympany
C) Hyperresonance
D) Flatness

Answer 46

Ans: B
Chapter: 08
Page and Header: 296, Techniques of Examination
Feedback: The gastric bubble produces one of the longest percussion notes. A patient with COPD may have hyperresonance over his chest, while a normal person would have resonance. Dullness is heard over a normal liver, and flatness is heard if one percusses a large muscle.

Question 47

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

A) Large pneumothorax
B) Lobar pneumonia
C) Pleural effusion
D) Empyema

Answer 47

Ans: A
Chapter: 08
Page and Header: 296, Techniques of Examination
Feedback: There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. The other three conditions produce dullness by dampening the percussion note with fluid.

Question 48

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

A) Bronchovesicular
B) Vesicular
C) Bronchial
D) Tracheal

Answer 48

Ans: C
Chapter: 08
Page and Header: 296, Techniques of Examination
Feedback: These sounds are consistent with bronchial breath sounds. Be alert for these, as they may occur elsewhere and indicate a pneumonia or other pathology. The current explanation for this phenomenon is that the sound from the trachea is carried very well to the chest wall by fluid. This same explanation explains “ee” to “aa” changes, whispered pectoriloquy, bronchophony, and other circumstances in which high-frequency sounds, normally blocked by the air-filled alveoli, could be transmitted to the chest wall.

Question 49

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

A) Asthma
B) COPD
C) Bronchiectasis
D) Heart failure

Answer 49

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

Question 50

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

A) Bronchitis
B) Simple asthma
C) Cystic fibrosis
D) Heart failure

Answer 50

Ans: A
Chapter: 08
Page and Header: 296, Techniques of Examination
Feedback: Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis. The other conditions would not be associated with findings that cleared with a cough.

Question 51

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

A) Percuss the lower border of the liver
B) Measure the span of the liver
C) Order a hepatitis panel
D) Obtain an ultrasound of the liver

Answer 51

Ans: B
Chapter: 08
Page and Header: 296, Techniques of Examination
Feedback: In this patient, measuring the span of the liver saved the patient an involved workup, because it was normal. His history of COPD is consistent with flattening of the diaphragms, which pushed the liver edge down while the actual size of the liver remained the same. Percussing the lower border of the liver alone caused this referral, because it was assumed that the liver was enlarged.

Question 52

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

A) Call a medevac helicopter
B) Drive him to the city (4 hours away)
C) Press on his sternum and spine simultaneously
D) Examine him for tenderness over the injured area

Answer 52

Ans: C
Chapter: 08
Page and Header: 309, Special Techniques
Feedback: The area involved in the injury will of course be tender. If you press in an area remote to the injury, but over the same bone which may be involved, you can produce tenderness at the site of injury. This would indicate that there may be a fracture at the lateral ribs. Fortunately, this maneuver did not reproduce pain remotely, and your uncle simply sat on the sidelines for the rest of the game.

Question 53

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

A) Left atrium
B) Right atrium
C) Right ventricle
D) Sinus node

Answer 53

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

Question 54

What is responsible for the inspiratory splitting of S2?

A) Closure of aortic, then pulmonic valves
B) Closure of mitral, then tricuspid valves
C) Closure of aortic, then tricuspid valves
D) Closure of mitral, then pulmonic valves

Answer 54

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

Question 55

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

A) Mitral
B) Tricuspid
C) Aortic
D) Pulmonic

Answer 55

Ans: A
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: Mitral valve sounds are usually heard best at and around the cardiac apex.

Question 56

A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?

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

Answer 56

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

Question 57

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

A) Normal
B) Prehypertension
C) Stage 1 hypertension
D) Stage 2 hypertension

Answer 57

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

Question 58

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

A) Ethnicity
B) Alcohol intake
C) Gender
D) Asthma

Answer 58

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

Question 59

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

A) Hypertension
B) Peripheral arterial disease
C) Systemic lupus erythematosus
D) Chronic obstructive pulmonary disease (COPD)

Answer 59

Ans: B
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: Peripheral arterial disease is considered to be a coronary heart disease risk equivalent, as are abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.

Question 60

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

A) Palpable
B) Soft, rapid, undulating quality
C) Pulsation eliminated by light pressure on the vessel
D) Level of pulsation changes with changes in position

Answer 60

Ans: A
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.

Question 61

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

A) Left-sided heart failure
B) Mitral stenosis
C) Constrictive pericarditis
D) Aortic aneurysm

Answer 61

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

Question 62

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

A) Hypothyroidism
B) Aortic stenosis, with pressure overload of the left ventricle
C) Mitral stenosis, with volume overload of the left atrium
D) Cardiomyopathy

Answer 62

Ans: B
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the apical impulse or not be palpable at all.

Question 63

You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?

A) Aortic
B) Pulmonic
C) Mitral
D) Tricuspid

Answer 63

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

Question 64

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

A) Upright
B) Upright, but leaning forward
C) Supine
D) Left lateral decubitus

Answer 64

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

Question 65

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

A) Second-degree A-V block
B) Atrial flutter
C) Sinus arrhythmia
D) Atrial fibrillation

Answer 65

Ans: A
Chapter: 09
Page and Header: 375, Table 9–1
Feedback: A second-degree A-V block can result in a pulse rate less than 60. Atrial flutter and atrial fibrillation do not cause bradycardia unless there is a significant accompanying block. Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart rate.

Question 66

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

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

Answer 66

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

Question 67

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

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

Answer 67

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

Question 68

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

A) It marks atrial contraction.
B) It reflects normal compliance of the left ventricle.
C) It is caused by rapid deceleration of blood against the ventricular wall.
D) It is not heard in atrial fibrillation.

Answer 68

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

Question 69

Which is true of splitting of the second heart sound?

A) It is best heard over the pulmonic area with the bell of the stethoscope.
B) It normally increases with exhalation.
C) It is best heard over the apex.
D) It does not vary with respiration.

Answer 69

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

Question 70

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

A) It is measured with the patient at a 45-degree angle.
B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP.
C) A JVP below 9 cm is abnormal.
D) It is measured above the sternal notch.

Answer 70

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

Question 71

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

A) The “y” descent
B) The “x” descent
C) The upstroke of the “a” wave
D) The downstroke of the “v” wave

Answer 71

Ans: B
Chapter: 09
Page and Header: 323, Anatomy and Physiology
Feedback: The most prominent upstrokes of jugular venous pulsations are diastolic phenomena. These can be timed using the carotid pulse. The only event listed above which is a systolic phenomenon is the “x” descent.

Question 72

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

A) 25%
B) 50%
C) 75%
D) 100%

Answer 72

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

Question 73

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

A) Every 6 months
B) Every year
C) Every 2 years
D) Every 5 years

Answer 73

Ans: C
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse.

Question 74

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

A) Waist circumference of 38 inches for a male
B) Waist circumference of 34 inches for a female
C) BP of 134/88 for a male
D) BP of 128/84 for a female

Answer 74

Ans: C
Chapter: 09
Page and Header: 339, Health Promotion and Counseling
Feedback: The physical examination criteria for identifying metabolic syndrome include a waist of 40 inches or greater for a male, a waist of 35 inches or greater for a female, and a blood pressure of 130/85 or greater. Other criteria include triglycerides greater than or equal to 150 mg/dL, fasting glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less than 50 for women.

Question 75

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

A) 80
B) 100
C) 120
D) 140

Answer 75

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

Question 76

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

A) Keep the patient’s torso at a 45-degree angle.
B) Measure the highest visible pressure, usually at end expiration.
C) Add the vertical height over the sternal notch to a 5-cm constant.
D) Realize that a total value of over 12 cm is abnormal.

Answer 76

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

Question 77

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

A) Mitral valve prolapse
B) Pulmonic stenosis
C) Tricuspid insufficiency
D) Aortic insufficiency

Answer 77

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

Question 78

o hear a soft murmur or bruit, which of the following may be necessary?

A) Asking the patient to hold her breath
B) Asking the patient in the next bed to turn down the TV
C) Checking your stethoscope for air leaks
D) All of the above

Answer 78

Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: All examiners should carefully search for soft murmurs and bruits. These can have great clinical significance. A quiet patient and room, as well as an intact stethoscope, will greatly increase your ability to hear soft sounds.

Question 79

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

A) Mitral stenosis murmur
B) Opening snap of the mitral valve
C) S3 and S4 gallops
D) All of the above

Answer 79

Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Placing the patient in the left lateral decubitus position and auscultating with the bell will enable you to hear these sounds, which would otherwise be missed.

Question 80

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

A) Palpate the carotid pulse.
B) Palpate the radial pulse.
C) Judge the relative length of systole and diastole by auscultation.
D) Correlate the murmur with a bedside heart monitor.

Answer 80

Ans: A
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Timing of a murmur is crucial for identification. The carotid pulse should be used because there is a delay in the radial pulse relative to cardiac events, which can lead to error. Some clinicians can estimate timing by the relative length of systole and diastole, but this method is not reliable at faster heart rates. A bedside monitor is not always available, nor are all designed to correlate in time with the actual pulse.

Question 81

Which of the following correlates with a sustained, high-amplitude PMI?

A) Hyperthyroidism
B) Anemia
C) Fever
D) Hypertension

Answer 81

Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: While hyperthyroidism, anemia, and fever can cause a high-amplitude PMI, pressure work by the heart, as seen in hypertension, causes the PMI to be sustained.

Question 82

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

A) Listen in the epigastrium.
B) Listen to the patient in the left lateral decubitus position.
C) Ask the patient to hold his breath for 30 seconds.
D) Listen posteriorly.

Answer 82

Ans: A
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: It is often difficult to hear the heart well in a patient with emphysema. The shape of the chest as well as the interfering lung noise make examination challenging. By listening in the epigastrium, these barriers can be overcome. It is impractical to ask a patient who is short of breath to hold his breath for a prolonged period. Listening posteriorly would make the heart sounds even softer. It is always a good idea to listen to a patient in the left lateral decubitus position, but in this case it would not make auscultation easier.

Question 83

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

A) Using the diaphragm with light pressure over the 2nd right intercostal space
B) Using the bell with light pressure over the 2nd left intercostal space
C) Using the diaphragm with firm pressure over the apex
D) Using the bell with firm pressure over the lower left sternal border

Answer 83

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

Question 84

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

A) It is moderately loud.
B) It can be heard with the stethoscope off the chest.
C) It can be heard with the stethoscope partially off the chest.
D) It is associated with a “thrill.”

Answer 84

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

Question 85

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

A) Aortic stenosis
B) Mitral insufficiency
C) Pulmonic stenosis
D) Aortic insufficiency

Answer 85

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

Question 86

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

A) Emphysema
B) Asthma exacerbation
C) Severe left heart failure
D) Cardiac tamponade

Answer 86

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

Question 87

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

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

Answer 87

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