exam 3 Flashcards
Mr. O, age 50 years, comes for his annual health assessment, which is provided by his employer. During your initial history-taking interview, Mr. O mentions that he routinely engages in light exercise. At this time, you should
a. ask if he makes his own bed daily.
b. have the patient describe his exercise.
c. make a note that he walks each day.
d. record ―light exercise‖ in the history.
ANS: B
When Mr. O says that he engages in light exercise, have him describe his exercise. To qualify his use of the term light, ask him the type, length of time, frequency, and intensity of his activities.
Which of the following information belongs in the past medical history section related to heart and blood vessel assessment?
a. Adolescent inguinal hernia
b. Childhood mumps
c. History of bee stings
d. Previous unexplained fever
ANS: D
Previous unexplained fever should be included in the past medical history of a heart and blood vessel assessment. This incidence may be related to acute rheumatic fever, with potential heart
valve damage.
A patient you are seeing in the emergency department for chest pain is believed to be having a myocardial infarction. During the health history interview of his family history, he relates that
his father had died of ―heart trouble.‖ The most important follow-up question you should pose is which of the following?
a. ―Did your father have coronary bypass surgery?‖
b. ―Did your father’s father have heart trouble also?‖
c. ―What were your father’s usual dietary habits?‖
d. ―What age was your father at the time of his death?‖
D
A family history of sudden death, particularly in young and middle-aged relatives, significantly increases one’s chance of a similar occurrence
Which one of the following is a common symptom of cardiovascular disorders in the older adult?
a. Fatigue
b. Joint pain
c. Poor night vision
d. Weight gain
ANS: A
Common symptoms of cardiovascular disorders in older adults include confusion, dizziness, blackouts, syncope, palpitations, coughs and wheezes, hemoptysis, shortness of breath, chest
pains or tightness, impotence, fatigue, and leg edema.
squeezing, pressing, heavy pain
onset often occurs with exertion
severe to mild pain with a gradual build up
does not increase with inspiration or position change
may have associated symptoms of nausea & diaphoresis
Myocardial Ischemic Pain
Crushing substernal pain with radiation to neck or left arm
Pain >7
Association of exertion or stress and relief with rest
Duration of minutes
Associated symptoms: nausea, diaphoreses, weakness, SOB
angina
In the adult, the apical impulse should be most visible when the patient is in what position?
a. Supine
b. Upright
c. Lithotomy
d. Right lateral recumbent
ANS: B
In most adults, the apical impulse should be visible at about the midclavicular line in the fifth left intercostal space, but it is easily obscured by obesity, large breasts, or muscularity. The apical impulse may become visible only when the patient sits upright and the heart is brought closer to the anterior wall. A visible and palpable impulse when the patient is supine suggests an intensity that may be the result of a problem. In most adults, the apical impulse will not be
visible in the upright, lithotomy, or right lateral recumbent positions.
MI
Unstable angina
Symptoms start gradually
Last > 15 minutes
Unrelieved by rest/nitro
Acute coronary Syndromes
If the apical impulse is more vigorous than expected, it is called a
a. lift.
b. thrill.
c. bruit.
d. murmur
ANS: A
If the apical impulse is more vigorous than expected, it is referred to as a lift or heave. A thrill is a palpable murmur. A bruit is an auscultated arterial murmur. A murmur is an auscultated
sound caused by turbulent blood flow into, through, or out of the heart.
A palpable rushing vibration over the base of the heart at the second intercostal space is called a
a. heave.
b. lift.
c. thrill.
d. thrust.
ANS: C
A thrill is a fine, palpable, rushing vibration—a palpable murmur. Cardiac thrills generally indicate a disruption of the expected blood flow related to some defect in the closure of one of the semilunar valves (generally aortic or pulmonic stenosis), pulmonary hypertension, or atrial septal defect. A heave or lift is a more vigorous apical impulse. A lift is another term for a heave, which is a more vigorous apical impulse. A thrust is sudden, forcible forward
movement.
An apical PMI palpated beyond the fifth intercostal space may indicate
a. decreased cardiac output.
b. obesity.
c. left ventricular hypertrophy.
d. hyperventilation.
ANS: C
An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may be indicative of left ventricular hypertrophy. Obesity, large breasts, and muscularity can obscure the visibility of the apical impulse
chest pain where
Can be severe pain with nausea and diaphoreses
greater at night with lying down
GERD/PUD
chest pain where
Pain is colicky and often RUQ; fever, nausea
Choleycystitis
chest pain where
Severe “boring” pain, radiates from epigastric are to the back; N&V, tachycardia, hypotension and diaphoresis;
tender abdomen
Pancreatitis
A lift along the left sternal border is most likely the result of
a. aortic stenosis.
b. atrial septal defect.
c. pulmonary hypertension.
d. right ventricular hypertrophy.
ANS: D
A lift along the left sternal border may be caused by right ventricular hypertrophy. A thrill indicates a disruption of the expected blood flow related to a defect in the closure of one of the semilunar valves, which is seen in aortic or pulmonic stenosis, pulmonary hypertension, or atrial septal defect.
History of injury, heavy lifting, contact sports
Generally in younger population with no Cardiac symptoms.
Chest pain can be severe (more localized)
Pain >’s with movement, cough and sometimes breathing
Chest wall pain and costochondritis
To estimate heart size by percussion, you should begin tapping at the
a. anterior axillary line.
b. left sternal border.
c. midclavicular line.
d. midsternal line.
ANS: A
Estimating the size of the heart can be done by percussion. Begin tapping at the anterior axillary line, moving medially along the intercostal spaces toward the sternal border. The change from a resonant to a dull note marks the cardiac border.
To hear diastolic heart sounds, you should ask patients to
a. lie on their back.
b. lie on their left side.
c. lie on their right side.
d. sit up and lean forward.
ANS: B
Left lateral recumbent is the best position to hear the low-pitched filling sounds in diastole with the bell of the stethoscope. Sitting up and leaning forward is the best position in which to hear relatively high-pitched murmurs with the diaphragm of the stethoscope. The right lateral recumbent position is the best position for evaluating the right rotated heart of dextrocardia
due to Inflammation
burning, stabbing, or cutting pain
exacerbated by coughing, deep breathing, and lying down
alleviated by leaning forward and remaining motionless
Pericardial Pain
You are listening to a patient’s heart sounds in the aortic and pulmonic areas. The sound becomes asynchronous during inspiration. The prevalent heart sound in this area is most likely
a. S1.
b. S2.
c. S3.
d. S4.
ANS: B
S2 marks the closure of the semilunar valves, which indicates the end of systole; it is best heard in the aortic and pulmonic areas. It is higher pitched and shorter than S1. S2 typically splits during inspiration.
Chest pain with an organic cause in a child is most likely the result of
a. cardiac disease.
b. asthma.
c. esophageal reflux.
d. arthritis.
ANS: B
Unlike chest pain in adults, chest pain in children and adolescents is seldom caused by a cardiac problem. More likely, the case is related to trauma, exercise-induced asthma, or cocaine use.
A condition that is likely to present with dizziness and syncope is
a. bacterial endocarditis.
b. hypertension.
c. sick sinus syndrome.
d. pericarditis.
ANS: C
Sick sinus syndrome (SSS) is a sinoatrial dysfunction that occurs secondary to hypertension, arteriosclerotic heart disease, or rheumatic heart disease. SSS causes dysrhythmia with
subsequent syncope, transient dizzy spells, light-headedness, seizures, palpitations, angina, or congestive heart failure (CHF). Bacterial endocarditis presents with prolonged fever, signs of
neurologic dysfunction, and sudden onset of CHF. Chest pain is an initial symptom in acute pericarditis, along with a triphasic friction rub.
Your patient, who abuses intravenous (IV) drugs, has a sudden onset of fever and symptoms of congestive heart failure. Inspection of the skin reveals nontender erythematic lesions to the
palms. These findings are consistent with the development of
a. rheumatic fever.
b. cor pulmonale.
c. pericarditis.
d. endocarditis.
ANS: D
Endocarditis is a bacterial infection of the endothelial layer of the heart. It should be suspected with at-risk patients (e.g., IV drug abusers) who present with fever and sudden onset of congestive heart symptoms. The lesions described are Janeway lesions.
The most helpful finding in determining left-sided heart failure is
a. dyspnea.
b. orthopnea.
c. jugular vein distention.
d. an S3 heart sound
ANS: C
Evidence-based research has shown that the most helpful clinical examination finding supportive of left-sided heart failure is jugular vein distention.
Your patient has been diagnosed with pericarditis. Which are signs and symptoms, or a precipitating factor? (Select all that apply.)
a. Sharp pain
b. Pain relieved by sitting up
c. Pain relieved by resting
d. Friction rub heard to right of sternum
e. History of kidney failure
f. Result of viral infection
g. Result of medications such as procainamide
ANS: A, B, E, F, G
Pericarditis may be seen with a viral infection, kidney failure, or medications such as procainamide. Symptoms include pain relieved by sitting up or leaning forward. A friction rub is heard at the left of the sternum, at the third or fourth intercostal space.
Induration, edema, and hyperpigmentation are common associated findings with which of the following?
a. Peripheral arterial disease
b. Venous ulcer
c. Arterial embolic disease
d. Venous thrombus
ANS: B
A venous ulcer also results from chronic venous insufficiency and demonstrates induration edema and hyperpigmentation. Peripheral arterial edema results in ischemia, in which the foot or leg is painful and cold; nonulceration is common as the muscles atrophy. Arterial embolic disease includes occlusion of the small arteries, resulting in blue toe syndrome and splinter hemorrhages in the nail bed. A venous thrombus presents with minimal ankle edema, low-grade fever, tachycardia, and possibly a positive Homan sign.
The most prominent component of the jugular venous pulse is the
a. a wave.
b. c wave.
c. v wave.
d. x slope.
ANS: A
The a wave is the first and most prominent component of the jugular venous pulse. The a wave represents a brief backflow of blood into the vena cava during right atrial contraction.
During a routine prenatal visit, Ms. T was noted as having dependent edema, varicosities of the legs, and hemorrhoids. She expressed concern about these symptoms. You explain to Ms.T that her enlarged uterus is compressing her pelvic veins and her inferior vena cava. You would further explain that these findings
a. are usual conditions during pregnancy.
b. indicate a need for hospitalization.
c. indicate the need for amniocentesis.
d. suggest that she is having twins.
ANS: A
Explain to the patient that these are usual conditions during pregnancy. Blood in the lower extremities tends to pool in later pregnancy because of the occlusion of the pelvic veins and
inferior vena cava from pressure created by the enlarged uterus. This occlusion results in an increase in dependent edema, varicosities of the legs and vulva, and hemorrhoids
Vascular changes expected in the older adult include
a. loss of vessel elasticity.
b. decreased peripheral resistance.
c. decreased pulse pressure.
d. constriction of the aorta and major bronchi.
ANS: A
With age, the walls of the arteries become calcified and they lose their elasticity and vasomotor tone; therefore, they lose their ability to respond appropriately to changing body needs. Increased peripheral vascular resistance occurs, causing an increase in blood pressure
You are examining Mr. S, a 79-year-old diabetic man complaining of claudication. Which of the following physical findings is consistent with the diagnosis of peripheral arterial disease?
a. Thick, calloused skin
b. Ruddy, thin skin
c. Warmer temperature of extremity in contrast to other body parts
d. Loss of hair over the extremities
ANS: D
An individual with peripheral artery disease or claudication will have thin skin with localized pallor and cyanosis, a loss of body warmth in the affected area, and loss of hair over the extremities.
You are performing a physical examination on a 46-year-old male patient. His examination findings include the following: positive peripheral edema, holosystolic murmur in the tricuspid region, and a pulsatile liver. His diagnosis is
a. an aortic aneurysm.
b. an arteriovenous fistula
c. tricuspid stenosis.
d. tricuspid regurgitation.
ANS: D
An aneurysm is a localized isolation that results in a pulsatile swelling and a thrill or bruit. An arteriovenous fistula is a pathologic communication between an artery and vein resulting in a
thrill or bruit and edema or ischemia in the involved extremity. Tricuspid regurgitation results in a holosystolic murmur in the tricuspid region, a pulsatile liver, and peripheral edema.
A characteristic distinguishing primary Raynaud phenomenon from secondary Raynaud phenomenon includes which of the following?
a. Vasospasm
b. Digital ischemia with pain
c. Triphasic demarcated skin
d. Cold and achy improving with warming
ANS: B
In primary Raynaud phenomenon, there is triphasic demarcation of the skin—white, cyanotic, and reperfused—and vasospasm that lasts a minutes to less than an hour, areas of cold, and an achy feeling that improves with rewarming. In secondary Raynaud phenomenon, there is intense pain from digital ischemia
In children, coarctation of the aorta should be suspected if you detect
a. a delay between the radial and femoral pulses.
b. a simultaneous radial and femoral pulse.
c. an absent femoral pulse on the left.
d. bilateral absence of femoral pulses.
ANS: A
Coarctation of the aorta is a congenital stenosis or narrowing seen most commonly in the descending aortic arch, near the origin of the left subclavian artery and ligamentum
arteriosum. Ordinarily, the radial and femoral pulses are palpated simultaneously. When there is a delay and/or a palpable diminution of amplitude of the femoral pulse, coarctation must be suspected. Differences in blood pressure taken in the arms and legs should confirm the suspicion. Coarctation of the aorta should not be suspected if the radial and femoral pulses are palpated simultaneously, if the femoral pulse on the left is absent, or if there is bilateral absence of femoral pulses.
Which of the following statements is true regarding the development of venous ulcers in older adults?
a. The major symptom is severe leg pain, especially when walking.
b. The affected leg is commonly pale and hairless, and pulses are difficult to palpate.
c. Diabetes, peripheral neuropathy, and nutritional deficiencies are causative factors.
ANS: C
Venous ulcers are generally found on the medial or lateral aspects of the lower limbs, most often in older adults. Induration, edema, and hyperpigmentation are common. Heart failure, hypoalbuminemia, peripheral neuropathy, diabetes mellitus, nutritional deficiencies, and
arterial disease cause the venous ulcers to develop. The major symptom of venous ulcers is not severe leg pain. In patients with venous ulcers, the affected leg is not commonly pale and
hairless, and pulses are not difficult to palpate. Venous ulcers are not generally located on the tips of toes.
When examining arterial pulses, the thumb may be used
a. especially if vessels have a tendency to move.
b. never for palpating pulses.
c. checking the jugular venous pressure.
d. during the Allen test
ANS: A
The thumb may be used, especially if the vessels have a tendency to move when probed by the fingers. The thumb is particularly useful in fixing the brachial and even the femoral pulses. You cannot palpate for jugular venous pressure waves. The Allen test is used to ensure ulnar patency prior to radial artery puncture.
To assess a patient’s jugular veins, the patient should first be placed in which position?
a. Supine
b. Semi-Fowler
c. Upright
d. Left lateral recumbent
ANS: A
To assess jugular veins, place the patient in the supine position. This causes engorgement of the jugular veins. Then gradually raise the head of the bed until the pulsations of the jugular vein become visible between the angle of the jaw and the clavicle. Jugular veins cannot be palpated.
Observation of hand veins can facilitate the assessment of
a. mitral valve competency.
b. a heart murmur.
c. right heart pressure.
d. left heart pressure.
ANS: C
Hand veins can be used as an auxiliary manometer of right heart pressure. Assess the hand veins while the hand is at the patient’s side. Then raise the hand until the veins collapse, and use a ruler to measure the vertical distance between the midaxillary line (level of the heart) and the level of the collapsed hand veins.
You are assessing Mr. Z’s fluid volume status as a result of heart failure. If your finger depresses a patient’s edematous ankle to a depth of 6 mm, you should record this pitting as
a. 1+.
b. 2+.
c. 3+.
d. 4+.
ANS: C
Pitting edema to 6 mm represents a 3+ rating. This edema is noticeably deep and may last more longer a minute; the dependent extremity looks fuller and swollen. Edema is graded on a
scale of mild (1+) through worse (4+).
A bounding pulse in an infant may be associated with
a. patent ductus arteriosus.
b. coarctation of the aorta.
c. decreased cardiac output.
d. peripheral vaso-occlusion.
ANS: A
A bounding pulse is associated with a large left-to-right shunt produced by a patent ductus arteriosus. A weaker or thinner pulse represents diminished cardiac output or peripheral vasoconstriction. A difference in pulse amplitude between the upper extremities or between the femoral and radial pulses, and absence of the femoral pulse, suggests a coarctation of the aorta.
In infants or small children, a capillary refill time of 4 seconds
a. is normal.
b. indicates hypervolemia.
c. indicates dehydration or hypovolemic shock.
d. indicates renal artery stenosis.
c
Capillary refill time represents the time it takes the capillary bed to refill after being occluded by pressure to the nail bed for several seconds. Observe the time it takes for the nail to regain
its full color, which should be less than 2 seconds for an intact system. The capillary refill time will be longer than 2 seconds during arterial occlusion, hypovolemic shock, hypothermia, and dehydration.
A venous hum heard over the internal jugular vein of a child
a. usually signifies untreatable illness.
b. usually has no pathologic significance.
c. usually requires surgical intervention.
d. must be monitored until the child is grown.
ANS: B
A venous hum is caused by the turbulence of blood flow in the internal jugular veins. It is common in children and usually has no pathologic significance. To detect a venous hum, auscultate over the right supraclavicular space at the medial end of the clavicle and along the anterior border of the sternocleidomastoid muscle. It is louder during diastole.
You are palpating bilateral pedal pulses and cannot feel one of the pulses. The feet are equally warm. You find that both great toes are pink, with a capillary refill within 2 seconds. Which of the following statements is correct?
a. Immediate emergency surgery is indicated.
b. Pedal pulses are not always palpable.
c. Unilateral pulses are never normal.
d. Venogram studies will be needed.
ANS: B
Dorsalis pedis and posterior tibia pulses may be difficult to palpate or may not be palpable in some well persons. The feet are warm and capillary refill is less than 2 seconds; there is
adequate circulation to the feet. Immediate emergency surgery is not indicated. Unilateral pulses may be normal. Venogram studies will not be needed.
When palpating the carotid artery, which of the following is most important? (Select all that apply.)
a. Rotate the patient’s head to the side being examined to relax the
sternocleidomastoid.
b. Excessive carotid sinus massage can compromise blood flow to the brain.
c. Excessive carotid sinus massage can cause slowing of the pulse.
d. Palpate both sides simultaneously.
ANS: A, B, C
When palpating the carotid arteries, never palpate both sides simultaneously. Excessive carotid sinus massage can cause slowing of the pulse and a drop in blood pressure and can compromise blood flow to the brain, leading to syncope. If you have difficulty feeling the pulse, rotate the patient’s head to the side being examined to relax the sternocleidomastoid muscle
Which are risk factors for varicose veins? (Select all that apply.)
a. Gender
b. Alcohol use
c. Lower extremity trauma
d. Increased body mass
e. Hypertension
f. Diabetes
ANS: A, C, D
Gender (women are four times more likely than men to have varicose veins—genetic predisposition), tobacco use, increased body mass, age, and history of lower extremity trauma are all risk factors for varicose veins.
S1 increases in intensity with
high velocity states
mitral valve stenosis
S1 decreases in intensity
with
emphysema
obesity
S2 increases intensity
with
HTN, exercise
S2 decreases in intensity
with
obese, hypotension
louder at apex
coincides with carotid pulse
s1
type of abd pain that
diffuse & midline
results in restlessness
Visceral pain:
type of abd pain that localized & sharp
movement exacerbates pain
Parietal pain:
type of abd pain that
esophagus/stomach
Epigastric pain:
RUQ: abd pain can be what 3 things
gallbladder, thorax, liver
LUQ:
pain can be
spleen
RLQ: pain can be
PID, appendicitis, ectopic pregnancy
LLQ abd pain can be
LLQ: sigmoid colon
abd Pain with deep inspiration-
pleuritic pain or biliary colic
Infectious causes most common
self limited
abrupt onset that resolves within 3 weeks
associated with pain, N&V, fever
Acute
diarrhea
lasts > 4 weeks
parasites, medication
IBS or inflammatory bowel disease
lactose intolerance
chronic diarrhea
5 red flags for abd pain
**Progressive and persistent pain
Progressive distention
Hematemesis
Black tarry stool
Decreased urine output
**
In the absence of trauma or blood disorders, the appearance of ________is a valuable bedside clue to retroperitoneal or intraperitoneal hemorrhage.
Cullen’s sign
refers to bruising of the flanks.
This sign takes 24–48 hours. It can predict a severe attack of acute pancreatitis, with mortality rising from 8-10% to 40%.
It may be accompanied by Cullen’s sign, which may then be indicative of pancreatic necrosis with retroperitoneal or intraabdominal bleeding.
Grey Turner’s sign
can include entire GI tract, ulcers, fissures, discontinuous and stepwise lesions.
Cobblestone appearance
Crohn’s disease
continuous inflammation from rectum proximal
tenesmus
Surgery to remove damaged colon
Ulcerative Colitis
Noninflammatory enlargement of male breast tissue.
It is physiologic at puberty, unilateral, usually mild and transient.
Occurs commonly in aging men due to changing hormone levels.
It is usually bilateral and may be tender.
Can occur with exogenous hormone: estrogen for prostate cancer, anabolic steroids, marijuana, thryrotoxicosis,
Gynecomastia
Solid tumor
Men age 20-40
Risk factors
Cryptoorchidism
Caucasian
FH of testicular cancer
S&S
Firm painless mass
c/o “heavy feeling in scrotum”
No transillumination
testicular cancer
Inflammation of testicles
Causes
Sex, infection, instrumentation
Gradual onset
One sided
Urinary S&S
Urethral discharge
PE
Tender testes
Swelling
Testes are normal
Epididymitis
Scrotal swelling
Shiny, without rugae
Transillumination
Hydrocele
Emergency
Twisting of spermatic cord
Sudden onset of pain
Radiates groin
N&V
NO urinary S&S, not related to sex, no discharge
Testicular tortion
Aging
Irritative S&S
Frequency, nocturia, urgency
Obstructive S&S
Weak urinary stream, < force of stream, interrupted stream
PE
Firm, smooth, obliterated sulcus
Health maintenance
AUA screen p. 260 Dains
BPH
Inflammation
Bacterial/nonbacterial
Acute
u/a
> WBC and bacteria
Tenderness
Systemic S&S
Fever, chills, malaise
Low back pain
Urinary S&S
Pain
Peri area, suprapubic,
Sexual dysfunction
pain with sex
Chronic
Gradual onset of urinary S&S
May have history of recurrent & difficult to treat UTI
Prostatitis
Enlarged prostate
Biopsy
PSA
Ultrasound
Prostate Cancer
Infects urethra in men
Painful urination
Dyspareunia
Painful testis
Discharge
Silent epidemic in women
75% have no symptoms
Chlamydia
The family history of a patient with diarrhea and abdominal pain should include inquiry about cystic fibrosis because it is
a. a common genetic disorder.
b. one cause of malabsorption syndrome.
c. a curable condition with medical intervention.
d. the most frequent cause of diarrhea in general practice.
ANS: B
Cystic fibrosis is an uncommon, chronic genetic disorder affecting multiple systems. In the gastrointestinal tract, it causes malabsorption syndrome because of pancreatic lipase
deficiency. Steatorrhea and abdominal pain from increased gas production are frequent complaints.
Mrs. James is 7 months’ pregnant and states that she has developed a problem with constipation. She eats a well-balanced diet and is usually regular. You should explain that constipation is common during pregnancy because of changes in the colorectal areas, such as
a. decreased movement through the colon and increased water absorption from the
stool.
b. increased movement through the colon and increased salt taken from foods.
c. looser anal sphincter and fewer nutrients taken from foods.
d. tighter anal sphincter and less iron eliminated in the stool.
ANS: A
Constipation and flatus are more common during pregnancy because the colon is displaced, peristalsis is decreased, and water absorption is increased. Movement through the colon is decreased during pregnancy. The colon does not absorb nutrients. A tighter sphincter tone is not related to pregnancy
The family history of a patient with diarrhea and abdominal pain should include inquiry about cystic fibrosis because it is
a. a common genetic disorder.
b. one cause of malabsorption syndrome.
c. a curable condition with medical intervention.
d. the most frequent cause of diarrhea in general practice.
ANS: B
Cystic fibrosis is an uncommon, chronic genetic disorder affecting multiple systems. In the gastrointestinal tract, it causes malabsorption syndrome because of pancreatic lipase
deficiency. Steatorrhea and abdominal pain from increased gas production are frequent complaints.
When assessing abdominal pain in a college-age woman, one must include
a. history of interstate travel
b. food likes and dislikes.
c. age at completion of toilet training.
d. the first day of the last menstrual period.
ANS: D
Exploring abdominal pain complaints in a young woman can reveal multiple causes related to the menstrual cycle, including menstrual pain, ovulation discomfort, and abnormal menses. Asking the patient to tell you the first day of her last menstrual period can help discriminate among these factors. History of international travel and traveler’s diarrhea can be related to abdominal pain, but interstate travel usually does not. Food preferences and age at completion
of toilet training are not relevant
Infants born weighing less than 1500 g are at higher risk for
a. hepatitis A.
b. necrotizing enterocolitis.
c. urinary urgency.
d. pancreatitis.
ANS: B
Necrotizing enterocolitis is a gastrointestinal disease that mostly affects premature infants. It involves infection and inflammation that cause destruction of the bowel, and it becomes more apparent after feedings.
You are completing a general physical examination on Mr. Rock, a 39-year-old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient
a. hold his or her breath.
b. sit upright.
c. flex his or her knees.
d. raise his or her head off the pillow.
ANS: C
To help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other techniques are not helpful because they increase muscle flexion.
Mrs. Little is a 44-year-old patient who presents to the office with abdominal pain and fever.During your examination, you ask the patient to raise her head and shoulders while she lies in a supine position. A midline abdominal ridge rises. You document this observation as a(n)
a. small inguinal hernia.
b. large epigastric hernia.
c. abdominal lipoma.
d. diastasis recti.
ANS: D
A diastasis recti occurs when the abdominal contents bulge between two abdominal muscles to form a midline ridge as the head is lifted. It has little clinical significance and usually occurs in women who have had repeated pregnancies and in obese patients.
Mr. Robins is a 45-year-old man who presents to the emergency department with a complaint of constipation. During auscultation, you note borborygmi sounds. This is associated with
a. gastroenteritis.
b. peritonitis.
c. satiety.
d. paralytic ileus.
ANS: A
Borborygmi are prolonged loud gurgles that occur with gastroenteritis, early intestinal
obstruction, or hunger. Peritonitis and paralytic ileus result in hypoactive bowel sounds. Food
satiety does not stimulate growling sounds as does hunger.
To document absent bowel sounds correctly, one must listen continuously for
a. 30 seconds.
b. 1 minute.
c. 3 minutes.
d. 5 minutes.
ANS: D
Absent bowel sounds are confirmed after listening to each quadrant for 5 minutes.
Percussion of the abdomen begins with establishing
a. liver dullness.
b. spleen dullness.
c. gastric bubble tympany.
d. overall dullness and tympany in all quadrants.
ANS: D
Percussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs.
When percussing a spleen, Traube space is a
a. semilunar region.
b. splenic percussion sign.
c. left-sided pleural effusion.
d. solid mass.
ANS: A
Percussion of the spleen is more difficult because percussion tones elicited may be caused by other conditions. Traube space is a semilunar region defined by the sixth ribs superiorly, the
midaxillary line laterally, and the left costal margin inferiorly.
Your patient is complaining of acute, intense, sharp epigastric pain that radiates to the back and left scapula, with nausea and vomiting. Based on this history, your prioritized physical examination should be to
a. percuss for ascites.
b. assess for rebound tenderness.
c. inspect for ecchymosis of the flank.
d. auscultate for abdominal bruits.
ANS: C
Abdominal pain that radiates to the back could be caused by pancreatitis or a gastric ulcer, gallbladder pain usually radiates to the right or left scapula but not to the back, pancreatitis pain can radiate to the left shoulder or scapula, and nausea and vomiting usually occur with gallbladder, pancreas, or appendix conditions. Pancreatitis is a differential diagnosis for all these symptoms, so begin the examination by inspecting the flanks for the Grey Turner sign, an indication of pancreatitis
To assess for liver enlargement in the obese person, you should
a. use the hook method.
b. have the patient lean over at the waist.
c. auscultate using the scratch technique.
d. attempt palpation during deep exhalation.
ANS: C
If the abdomen is obese or distended, or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver.
Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition?
a. Positive psoas sign
b. Positive McBurney sign
c. Consistent right lower quadrant (RLQ) pain
d. Rebound tenderness
ANS: C
A positive psoas sign, McBurney point pain, rebound tenderness, and periumbilical pain that migrates to the RLQ are signs of appendicitis. The absence of pain migration makes appendicitis less likely.
. When using the bimanual technique for palpating the abdomen, you should
a. push down with the bottom hand and the other hand on top.
b. push down with the top hand and concentrate on sensation with the bottom hand.
c. place the hands side by side and push equally.
d. place one hand anteriorly and the other hand posteriorly, squeezing the hands
together.
ANS: B
The bimanual technique uses one hand on top of the other. Exert pressure with the top hand while concentrating on sensation with the other hand.
Flatulence, diarrhea, dysuria, and tenderness with abdominal palpation are findings usually associated with
a. diverticulitis.
b. pancreatitis.
c. ruptured ovarian cyst.
d. splenic rupture.
ANS: A
Only diverticulitis has all these presenting symptoms.
A 51-year-old woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to
a. use a topical, over-the-counter hemorrhoid treatment for 1 week.
b. exercise and eat more fiber.
c. come to the laboratory for a stool guaiac test.
d. eat six small meals a day.
ANS: C
Blood in the stool is an abnormal finding that should never be ignored, even if it can be explained by conditions other than colon cancer. She should have her stool checked for blood
now as well as annually because she is older than 50 years.
Costovertebral angle tenderness should be assessed whenever you suspect that the patient may have
a. cholecystitis.
b. pancreatitis.
c. pyelonephritis.
d. ulcerative colitis.
ANS: C
Pyelonephritis is characterized by flank pain and costovertebral angle tenderness.
In older adults, overflow fecal incontinence is commonly caused by
a. malabsorption.
b. parasitic diarrhea.
c. fecal impaction
d. fistula formation.
ANS: C
Constipation with overflow occurs when the rectum contains hard stool and soft feces above a
leak around the mass of stool.
Your patient is a 48-year-old woman with complaints of severe cramping pain in the abdomen and right flank. Her past medical history includes a history of bladder calculi. You diagnose
her with renal calculi at this time. Which of the following symptoms would you expect with her diagnosis? (Select all that apply.)
a. Abdominal pain on palpation
b. Blumberg sign
c. Cullen sign
d. CVA tenderness
e. Fever
f. Grey Turner sign
g. Hematuria
h. Nausea
ANS: A, D, E, G
Abdominal pain on palpation, CVA tenderness, fever, hematuria, and nausea are all signs and symptoms of renal calculi. The Cullen sign is ecchymosis around the umbilicus, the Blumberg sign is rebound tenderness for appendicitis, the Grey Turner sign is ecchymosis in the flanks, and the McBurney sign is rebound tenderness at McBurney’s point.
Your patient returns to the office with multiple complaints regarding her abdomen. Which of the following are objective findings? (Select all that apply.)
a. Nausea
b. Dullness on percussion
c. Rebound tenderness
d. Vomiting
e. Diarrhea
f. Burning pain in epigastrium
ANS: B, C, E, F
Nausea, vomiting and diarrhea, and burning pain in epigastrium are subjective signs. Dullness on percussion and rebound tenderness are objective findings.
In an uncircumcised male, retraction of the foreskin may reveal a cheesy white substance. This is usually
a. evidence of a fungal infection.
b. a collection of sebaceous material.
c. indicative of penile carcinoma.
d. suggestive of diabetes.
ANS: B
In the uncircumcised male, smegma is formed by the secretion of sebaceous material by the glans and the desquamation of epithelial cells from the prepuce. It appears as a cheesy white substance on the glans and in the fornix of the foreskin. Smegma lubricates the cavity between the foreskin of the penis and the glans, allowing smooth movement between them during intercourse. It is not usually evidence of a fungal infection, penile carcinoma, or diabetes
Inspection of the scrotum should reveal
a. lightly pigmented skin.
b. two testes per sac.
c. smooth scrotal sacs.
d. the left scrotal sac lower than the right
ANS: D
The left cord is longer than the right; consequently, the left testis hangs somewhat lower. The skin of the scrotum is more darkly pigmented. The scrotum has one testis per sac. The scrotum has small epidermoid cysts that give it a lumpy appearance
Expected genitalia changes that occur as men age include that
a. the ejaculatory volume decreases with age.
b. erections develop more quickly.
c. the viability of sperm increases.
d. the scrotum becomes more pendulous
ANS: D
Ejaculatory volume increases with age, erections develop more slowly, sperm viability decreases, and the scrotum becomes more pendulous with age.
Inspection of the male urethral orifice requires the examiner to
a. ask the patient to bear down.
b. insert a small urethral speculum.
c. press the glans between the thumb and forefinger.
d. transilluminate the penile shaft
ANS: C
Inspection of the urethral orifice is accomplished by pressing the glans between the examiner’s thumb and forefinger. This maneuver opens the slitlike orifice for further inspection.
You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should
a. chart the finding as paraphimosis.
b. inquire about previous penile infections.
c. retract the foreskin firmly.
d. transilluminate the glans.
ANS: B
This condition is phimosis and is usually congenital, or it may be related to recurrent infections or poorly controlled diabetes. You should not chart this finding as paraphimosis. Retracting the foreskin forcibly would lead to further adhesion formation and worsening
phimosis. Transillumination is indicated for masses of the scrotum.
Which type of hernia lies within the inguinal canal?
a. Umbilical
b. Direct
c. Indirect
d. Femoral
ANS: C
Hernias found within the inguinal canal are called indirect hernias
Which condition is of minor consequence in an adult male?
a. Adhesions of the foreskin
b. Continuous penile erection
c. Lumps in the scrotal skin
d. Venous dilation in the spermatic cord
ANS: C
Lumps in the scrotal skin are related to numerous sebaceous cysts and are within normal limits.
Mr. L has an unusually thick scrotum, with edema and pitting. He has a history of cardiac problems. The appearance of his scrotum is most likely a(n)
a. congenital defect that has worsened.
b. indication of general fluid retention.
c. normal consequence of aging.
d. complication of the development of mumps.
b
General fluid retention can cause scrotal thickening and pitting edema, and is usually seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia, but rather a condition of these related systems.
A characteristic related to syphilis or diabetic neuropathy is testicular
a. dropping, with asymmetry.
b. enlargement.
c. insensitivity to painful stimulation.
d. recession into the abdomen.
ANS: C
Diabetic neuropathy or syphilis can cause a marked reduction of tactile perceptions. Asymmetry is a normal finding; enlargement and recession are not related to diabetes or syphilis
On palpation, a normal vas deferens should feel
a. beaded.
b. smooth.
c. ridged.
d. spongy.
ANS: B
The vas deferens should feel smooth and discrete as it is palpated from the testicle to the inguinal ring. A beaded or lumpy vas deferens might indicate diabetes or the presence of old inflammatory changes.
A premature infant’s scrotum will appear
a. bifid.
b. loose.
c. ridged.
d. smooth.
ANS: D
The premature male scrotum will appear underdeveloped, smooth, without rugae, and without testes; the full-term infant should have a loose, pendulous scrotum, with rugae and a midline
raphe
An enlarged painless testicle in an adolescent or adult male may indicate
a. epididymitis.
b. testicular torsion.
c. a tumor.
d. an undescended testicle.
ANS: C
A hard, enlarged, painless testicle can indicate a tumor in the adolescent or adult male. Epididymitis and torsion are painful; an undescended testicle is common in infants and is
usually resolved by 12 months.
You palpate a soft, slightly tender mass in the right scrotum of an adult male. You attempt to reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is to
a. use two fingers to attempt to reduce the mass.
b. palpate the left scrotum simultaneously.
c. lift the right testicle and then compare pain level.
d. transilluminate the mass.
ANS: D
A soft mass is a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is
suspected.
The most common cancer in young men ages 15 to 30 years is
a. testicular.
b. penile.
c. prostate.
d. anal.
ANS: A
Because testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.
The most emergent cause of testicular pain in a young male is
a. testicular torsion.
b. epididymitis.
c. tumor.
d. hydrocele
ANS: A
Testicular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.
An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your priority action should be to
a. obtain urine and DNA probe urethral samples.
b. lift the left scrotum to confirm epididymitis.
c. establish absent cremasteric reflex.
d. transilluminate the left and right scrotum.
ANS: C
The patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.
. The most common type of hernia occurring in young males is
a. hiatal.
b. incarcerated femoral.
c. indirect inguinal.
d. umbilical
ANS: C
The most common type of hernia in children and young males is an indirect inguinal hernia.
Difficulty replacing the retracted foreskin of the penis to its normal position is called
a. paraphimosis.
b. Peyronie disease.
c. phimosis.
d. priapism
ANS: A
Paraphimosis refers to the inability to replace the foreskin to its original position after it has been retracted behind the glans.
Which genital virus infection is known to have a latent phase followed by the production of viral DNA capsids and particles?
a. Condyloma acuminatum
b. Molluscum contagiosum
c. Herpetic lesions
d. Lymphogranuloma venereum
ANS: A
Condyloma acuminatum (genital warts) are soft, reddish lesions commonly present on the prepuce, glans penis, and shaft. These lesions can undergo latency, followed by viral DNA capsids and particles, which are produced in the host cells.
Pearly gray, smooth, dome-shaped, often umbilicated lesions of the glans penis are probably
a. herpetic lesions.
b. condylomata.
c. molluscum contagiosum.
d. chancres
ANS: C
Smooth, dome-shaped lesions with an umbilicated center of a pearly gray color are indicative of molluscum contagiosum.
A 12-year-old boy relates that his left scrotum has a soft swollen mass. The scrotum is not painful on palpation. The left inguinal canal is without masses. The mass transilluminates with a penlight. This collection of symptoms is consistent with
a. orchitis.
b. a hydrocele.
c. a rectocele.
d. a scrotal hernia
ANS: B
A hydrocele is a soft scrotal mass that occurs as a result of fluid accumulation and therefore transilluminates. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal.
Which condition is a complication of mumps in the adolescent or adult?
a. Cystitis
b. Epididymitis
c. Orchitis
d. Paraphimosis
ANS: C
Orchitis is uncommon unless seen as a complication of mumps in the adolescent or adult.
Parents of a 6-year-old boy should be asked if he has
a. erections.
b. nocturnal emissions.
c. rapid detumescence.
d. scrotal swelling.
ANS: D
Scrotal swelling, especially with crying or with bowel movements, signals the presence of a hernia. The questions about erections and rapid detumescence are for the older male. The question about nocturnal emissions is asked of adolescents.
. The male with Peyronie disease will usually complain of
a. painful, inflamed testicles.
b. deviation of the penis during erection.
c. lack of sexual interest.
d. painful lesions of the penis.
ANS: B
Peyronie disease is characterized by a fibrous band in the corpus cavernous. It results in unilateral deviation of the penis during erection
. A cremasteric reflex should result in
a. testicular and scrotal rise on the stroked side.
b. penile deviation to the left side.
c. bilateral elevation of the scrotum.
d. immediate erection of the penis.
ANS: A
On stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.
In males, which surface of the prostate gland is accessible by digital examination?
a. Median lobe
b. Posterior
c. Superior
d. Anterior
ANS: B
The posterior surface of the prostate gland lies close to the anterior wall of the rectum and is palpable through digital rectal examination
The prostatic sulcus
a. divides the right and left lateral lobes.
b. is the site of the seminal vesicle emergence.
c. refers to the anterior aspect of the prostate.
d. secretes clear viscous mucus
ANS: A
The prostatic sulcus divides the two lateral lobes and is palpated as a shallow groove.
The rectal past medical history of all patients should include inquiry about
a. bowel habits.
b. dietary habits.
c. hemorrhoid surgery.
d. laxative use.
ANS: C
Past medical history should include inquiry about hemorrhoids, spinal cord injury, benign prostatic hypertrophy (BPH), prostate, colorectal, breast, ovarian, or endometrial cancers, and episiotomies of fourth-degree lacerations during delivery. Habits are part of the personal and social history; the use of laxatives is part of the history of the present illness
The effects of aging on the gastrointestinal system leads to more frequent experiences of
a. constipation.
b. prolonged satiety.
c. diarrhea.
d. prostate glandular atrophy.
ANS: A
Older adults experience an elevated pressure threshold for the sensation of rectal distention and are therefore susceptible to constipation. They also experience early satiety, fecal incontinence, and prostate glandular hypertrophy.
Factors associated with increased risk of prostate cancer include
a. African descent.
b. cigarette smoking.
c. a low-fat diet.
d. alcoholism.
ANS: A
The incidence rate of prostate cancer is 50% higher for African American men compared with white American men. African American men also have a higher mortality rate.
