Exam 3 Quiz questions

Question 1

A 42-year-old G2P1 arrives at clinic for a routine prenatal visit late in her third trimester. On exam, the physician notes a subtle murmur; on further auscultation, it becomes apparent that the murmur occurs during the diastolic phase. The patient has minimal complaints but does reveal that she has had swelling in her feet and shortness of breath. Because these symptoms have been only slightly more severe than during her last pregnancy, she assumed this was normal for pregnancy. Which of the following is true about her presentation?

1. A leftward rotated apical impulse would confirm a diagnosis of heart failure in this patient.
2. A diastolic murmur during pregnancy is known as a venous hum.
3. Diastolic murmurs during pregnancy may be due to anemia.
4. Cardiomyopathy is very rare during and after pregnancy due to protective effects of estrogen and progesterone; it does not need to be considered on this patient’s differential diagnosis
5. A diastolic murmur during pregnancy is likely pathological and should always be investigated.

Answer 1

5) A diastolic murmur during pregnancy is likely pathological and should always be investigated.

Question 1

A 17-year-old G1P0 presents at a routine prenatal check. By last menstrual period (LMP), her gestational age at this visit is 36 weeks, 2 days. A first-trimester ultrasound confirmed her estimated delivery date. On exam, her fundus measures 31 centimeters. Ultrasound imaging might reveal which of the following anatomical findings that would explain this size?
1. Renal agenesis of the fetus resulting in intrauterine growth retardation
2. Twin pregnancy
3. Normal size, organs, and amniotic fluid for the gestational age
4. Extra amniotic fluid
5. Uterine leiomyomata that restrict fetal development

Answer 1

1. Renal agenesis of the fetus resulting in intrauterine growth retardation

Question 2

A 26-year-old G0P0 is interested in becoming pregnant and presents for prepregnancy counseling. She was not vaccinated as a child and unsure if she wishes to be vaccinated now. She asks if she can change her mind during pregnancy and receive vaccinations during that time. What should she be told?
1. Hepatitis B, measles/mumps/rubella (MMR), and influenza vaccines are safe during pregnancy.
2. No vaccines are safe during pregnancy, and the risks of vaccination outweigh the benefits of immunity to infectious diseases.
3. If a pregnant woman does not show sufficient titers to rubella, measles/mumps/rubella (MMR) vaccination should be given postpartum to protect future pregnancies from the effects of congenital rubella.
4. Polio and influenza vaccinations are not safe during pregnancy and should never be utilized.
5. RhoGAM is a vaccine specific to pregnancy that should be given to all pregnant women

Answer 2

3) If a pregnant woman does not show sufficient titers to rubella, measles/mumps/rubella (MMR) vaccination should be given postpartum to protect future

Question 3

A 34-year-old G3P2 at 27 weeks’ gestation is referred to the clinic upon discharge from a correctional institution where she has been incarcerated for 25 days for a drug offense. She denies any further substance abuse, but her behavior is concerning for intoxication, and she smells of alcohol and cigarettes. The clinician inquires about her drug use with open-ended questions and counsels her that which of the following is true?

1. Pregnant women are not routinely screened for hepatitis C, but this test should be added to the panel of prenatal blood tests for patients with a history of intravenous drug use.
2. Women can safely drink one alcoholic drink per day without risk of fetal alcohol syndrome.
3. Cigarettes are a rare cause of low birth weight in the growing fetus.
4. If a pregnant patient does not intend to quit tobacco, she should not bother to cut down as there is no benefit to the pregnancy from decreased use without cessation.
5. Tobacco is only associated with low birth weight; no other negative outcomes are known from cigarette use during pregnancy.

Answer 3

1. Pregnant women are not routinely screened for hepatitis C, but this test should be added to the panel of prenatal blood tests for patients with a history of intravenous drug use.

Question 4

A woman presenting in the late second trimester of her third pregnancy reports that she is experiencing several abdominal symptoms that she attributes to pregnancy: nausea, vomiting, urinary frequency, discomfort in the lower abdomen, tenderness over the suprapubic area, and severe constipation. Which of the following is true regarding these pregnancy symptoms?
1. Iron supplementation, hormonal changes, slowed intestinal transit, physical pressure from the gravid uterus, and increased blood volume all contribute to abdominal symptoms in pregnant women.
2. Round ligament pain presents as a severe, spontaneous, sudden-onset abdominal pain that is not provoked or relieved by changing position and may be accompanied by vaginal bleeding.
3. Pregnant women may safely lose >5% of prepregnancy weight due to nausea and vomiting.
4. Urinary frequency and suprapubic discomfort in second and third trimesters of pregnancy is inevitably due to the fetus pushing on the maternal bladder; no evaluation is necessary.
5. The hormone human placental lactogen is responsible for constipation by slowing intestinal transit.

Answer 4

1. Iron supplementation, hormonal changes, slowed intestinal transit, physical pressure from the gravid uterus, and increased blood volume all contribute to abdominal symptoms in pregnant women.

Question 5

A 42-year-old school teacher with a history of irregular periods who underwent successful intrauterine insemination (IUI) on January 25th presents to the clinic for care on March 19th. Her last menstrual period (LMP) was November 11th of the previous year. Which of the following is true about the gestational age of her pregnancy?

1. It is determined by date of insemination plus 2 weeks.
2. It is determined by the opinion of the specialist who completed the procedure.
3. It is 18 weeks and 2 days.
4. It is determined by her LMP.
5. It is indeterminate due to the IUI procedure.

Answer 5

1. It is determined by date of insemination plus 2 weeks.

Question 6

A 32-year-old patient with two prior pregnancies presents to clinic concerned that she may be pregnant after missing one cycle of her menses, which was previously very regular. A urine human chorionic gonadotropin (HCG) test is positive. Presuming a normal pregnancy, what can the physician expect to find on examination and ultrasound?
1. A uterine fundus that is palpable just below the umbilicus
2. An internal cervical os open to the width of a fingertip
3. A bluish hue of cervix known as the Chadwick sign
4. A cervix with a texture firmer than the nonpregnant cervix, known as the Hegar sign
5. Hyperexcitability of the facial nerve known as a Chvostek sign

Answer 6

3)A bluish hue of cervix known as the Chadwick sign

Question 7

A 31-year-old marathon runner presents for prenatal care with her first pregnancy. She is in her second trimester and is experiencing some fatigue and muscle aches. Her prepregnancy body mass index (BMI) was noted at 19.2. How should she be counseled on exercise and nutrition during pregnancy?
1. She should switch from running to weight-lifting (e.g., bench press) to maintain muscle mass while avoiding the stressors of running on the fetus.
2. She should avoid unpasteurized dairy products and delicatessen meats due to the risk of mycobacteria, shigellosis, and brucellosis.
3. She should gain at least 40 pounds during the pregnancy to account for being underweight at the time of conception.
4. Immersion in hot water is a safe and effective nonmedicinal way of coping with musculoskeletal complaints during pregnancy.
5. She should increase her calorie intake to 300 calories per day or more from her prepregnancy baseline

Answer 7

5) She should increase her calorie intake to 300 calories per day or more from her prepregnancy baseline

Question 8

A 22-year-old G1P0 presents for a routine prenatal visit at 32 weeks’ gestational age. Leopold maneuvers indicate that the fetus is in a transverse lie, with the fetal skull palpable at the woman’s left side. Fetal heart tones are heard at the uterine fundus with a baseline rate of 140 and beat-to-beat variability noted. Which of the following steps is appropriate to take at this time?
1. Order a stat cesarean section.
2. Perform an external version.
3. Plan for induction of labor at 36 weeks.
4. Admit the patient to labor and delivery for monitoring.
5. Schedule a return visit in ~2 weeks.

Answer 8

5. Schedule a return visit in ~2 weeks.

Question 9

A 29-year-old G2P1 presents to the clinic after a positive home pregnancy test. She confides at the appointment that her male partner has become increasingly abusive lately and once struck her while she was holding her older child. How should she be counseled?
1. Reassure her that she is safe as very few pregnant women are hurt or murdered by their partners, who generally become less violent during the vulnerable period of pregnancy.
2. Demand that she leaves the partner immediately and threaten to withhold care if she does not comply.
3. Reassure her that no matter what she reveals, all information she discloses will be kept strictly confidential.
4. Ask open-ended questions, allow her to make decisions that she feels are best for herself given the circumstance, and provide immediate or long-term referrals to domestic violence resources.
5. Ask that she bring the partner to all appointments so that he can be included in decisions and thus feel less threatened and less likely to harm the patient again.

Answer 9

4) Ask open-ended questions, allow her to make decisions that she feels are best for herself given the circumstance, and provide immediate or long-term referrals to domestic violence resources.

Question 10

Concerning alcohol consumption in older adults, which of the following is true?

a) The CAGE screening for alcohol abuse retains the same sensitivity and specificity it
has for younger populations.
b) Alcohol alone does not cause cognitive impairment in older patients.
c) Symptoms and signs of alcohol abuse are more overt and easier to notice during
outpatient encounters in older patients than in younger patients.
d) Alcohol consumption is responsible for 10% of all hospitalizations in patients age >65
years.
e) The detection of alcohol abuse is higher in older patients than younger patients due
to more frequent ambulatory interactions with health care providers.

Answer 10

a) The CAGE screening for alcohol abuse retains the same sensitivity and specificity it

Question 11

An 80‐year‐old woman who lives alone at home presents with concerns about maintaining her independent living status. She continues to drive and care for herself and her pet dog but reports two falls over the past 4 months. During one fall, she struck her head, causing a bruise over the right eye. She attributes these episodes to environmental factors: Once she tripped over a rug,
and once she misjudged the depth of the curb while crossing the street. Which of the following would be the best approach to this patient?

a) Order a computed tomography (CT) scan of the head to rule out cerebellar pathology.
b) Advise her that falls are associated with aging and that no preventive measures have
proven effective.
c) Perform a comprehensive assessment of fall risk and plan preventive interventions.
d) Advise the patient to be more careful and attentive to her surroundings and provide
reassurance that two episodes is not a cause for concern.
e) Advise her that she may require a walker or a cane to provide better balance.

Answer 11

c) Perform a comprehensive assessment of fall risk and plan preventive interventions.

Question 12

Which of the following is true about hair in the aging adult?
a) Women may experience the development of sparse coarse facial hair in their mid‐50s.
b) Age‐related hair changes are the same for all individuals regardless of ethnicity or
race.
c) Age‐related hair loss in males is normal only after age 50 years.
d) Although hair loss occurs in both sexes, hair on the head, trunk, legs, and pubic hair
is invariably spared any age‐related changes.
e) Age‐related hair loss on the scalp is abnormal in women and should be evaluated to
rule out underlying pathology.

Answer 12

a) Women may experience the development of sparse coarse facial hair in their mid‐50s.

Question 13

A 75‐year‐old female in generally good health presents to a new primary care provider after she
recently moved to a new city. She takes no prescribed medications, but she has been told in the
past that her blood pressure was borderline elevated and might require treatment at some time
in the future. Which of the following findings during the physical examine is consistent with the
normal aging process and not a sign of cardiovascular disease?
a) An unchanged pulse pressure with equal increases in both systolic and diastolic
pressures
b) A widened pulse pressure with increased systolic pressure (up to 140) and decreased
diastolic pressure
c) A narrowed pulse pressure with increased systolic and diastolic components
d) An isolated increase in systolic blood pressure to >150 mm Hg
e) A drop in systolic pressure of 25 mm Hg when rising from a supine to standing
position

Answer 13

b) A widened pulse pressure with increased systolic pressure (up to 140) and decreased diastolic pressure

Question 14

Which of the following is true about the presentation of pain in the older adult?
a) Older patients are more likely to report pain symptoms than younger patients.
b) The prevalence of pain is greater in community‐dwelling older adults compared to those living in nursing homes.
c) Pain is often overtreated in the aging population due to overreporting and exaggeration of symptoms.
d) The majority of pain complaints in this population are due to cardiac or gastrointestinal (GI) syndromes.
e) The American Geriatrics Society (AGS) prefers the term “persistent pain” over the term “chronic pain.”

Answer 14

e) The American Geriatrics Society (AGS) prefers the term “persistent pain” over the term “chronic pain.”

Question 15

A 78‐year‐old woman presents to clinic with her two daughters, who are concerned about hercontinued ability to live independently. She has thus far been highly self‐reliant and is opposed to the idea of leaving of her home of 30 years. The clinician performs a complete history and physical exam (including mental status and memory testing) as well as orders laboratory tests before providing the patient and her family the finding that she has age‐appropriate changes that do not reflect any particular disease process. Which of the following findings is most consistent with the normal aging process and does not impair the ability to live alone?

a) Decreased level of thyroid hormone
b) Mild cognitive impairment
c) Decreased adipose‐to‐muscle ratio
d) Age‐related cognitive decline
e) Persistent urinary incontinence

Answer 15

d) Age‐related cognitive decline

Question 16

Medications carry both risks and benefits for older patients. Although the risks of polypharmacy
(the use of many medications at once) are very well known, many older patients take many
medications for a variety of conditions. Which of the following best describes medication prescribing and utilization in the older adult population?
a) Only half of all older patients take at least one drug daily.
b) Older patients rarely take or have adverse effects from sleep medications.
c) Individuals age >65 years account for 30% of all prescribed drugs.
d) Although older patients take more medications than younger adults, their rate of hospitalization for drug‐related adverse reactions is the same.
e) Medications prescribed for known indications are not considered to be a modifiable risk factor for adverse events.

Answer 16

c) Individuals age >65 years account for 30% of all prescribed drugs.

Question 17

Which of the following best describes the role of the health practitioner in caring for the aging American population?
a) Prepare all persons age ≥65 years for the eventuality that they will become frail.
b) Assure that all elders complete an annual physical examination.
c) Employ the same disease models used to treat younger patients with chronic disease.
d) Evaluate geriatric conditions in terms of functionality and quality of life rather than via traditional disease models.
e) Understand that the older population is generally homogenous with little variation in needs.

Answer 17

d) Evaluate geriatric conditions in terms of functionality and quality of life rather than

Question 18

A 66‐year‐old recently retired restaurant worker presents to his primary care provider with a oncern about hearing loss. He relates a history of difficulty distinguishing voices in crowded settings when significant background noise exists, which hastened his retirement. Which of the following is true about this patient’s experience with hearing and the aging process?

a) Any hearing impairment that causes functional decline warrants formal testing and evaluation.
b) Early age‐related hearing loss initially affects lower‐pitched sounds.
c) Decreased hearing acuity associated with aging is formally known as hypoacusis.
d) Age‐related declines in hearing does not begin until age ≥75 years.
e) His experience is consistent with the normal aging process.

Answer 18

a) Any hearing impairment that causes functional decline warrants formal testing and evaluation

Question 19

A 62-year-old patient with rheumatoid arthritis (RA) complains of increased joint stiffness. What characteristic(s) are consistent with her diagnosis of RA?
1. Swelling of the synovial tissue is seen in joints and tendon sheaths.
2. Joint distribution is asymmetrical.
3. Tophi are found in the subcutaneous tissue.
4. It most frequently involves the first metatarsophalangeal joint.
5. Stiffness follows joint activity.

Answer 19

1. Swelling of the synovial tissue is seen in joints and tendon sheaths.

Question 20

During an evaluation of an athletic 30-year-old patient, the clinician conducts an active range of motion evaluation at the neck. Which muscle is being assessed when the patient is asked to flex the neck?
1. Trapezius
2. Sacrospinalis
3. Splenius cervicis
4. Splenius capitis
5. Sternocleidomastoid

Answer 20

5. Sternocleidomastoid (SCM)

Rationale:
The SCM muscle flexes and rotates the neck. Splenius capitis is incorrect; the splenius capitis extends the neck. Trapezius is incorrect; the trapezius extends the neck. Splenius cervicis is incorrect; the splenius cervicis attaches to the posterior aspect of the spine and extends the neck. Sacrospinalis is incorrect; the sacrospinalis attaches to the posterior aspect of the spine. When muscles attached to the posterior aspect of the spine contract, the spine extends.

Question 21

An obese 50-year-old patient presents with a long history of back trouble. What structure in the spine supports the body’s weight?
1. Vertebral body
2. Transverse process
3. Vertebral arch
4. Intervertebral disk
5. Spinous process

Answer 21

1. Vertebral body

Rationale:
The vertebral body is a weight-bearing structure of the spine. Vertebral arch is incorrect; the vertebral arch encloses the spinal cord. Intervertebral disk is incorrect; the intervertebral disk provides a cushion between the vertebrae. Transverse process and Spinous process are incorrect; these structures serve as a site of muscle attachment.

Question 22

During a musculoskeletal examination, the clinician instructs the patient to look over one shoulder, and then the other shoulder. This action assesses the movement of which muscle(s)?
1. Scalenes
2. Prevertebral muscles
3. Splenius cervicis
4. Sternocleidomastoid (SCM)
5. Splenius capitis

Answer 22

4. Sternocleidomastoid (SCM)

Rationale:
The action is rotation of the neck. The muscles responsible for rotation of the neck are the SCM and the small intrinsic neck muscles. Scalenes is incorrect; the action of the scalene muscle is to flex the neck. The scalenes also laterally bend the neck. Splenius capitis is incorrect; the action of the splenius capitis muscle is to extend the neck. Prevertebral muscles is incorrect; the action of the prevertebral muscles is to flex the neck. Splenius cervicis is incorrect; the action of the splenius cervicis muscle is to extend the neck.

Question 23

During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group?
1. Flexion of the spine
2. Lateral bending of the spine
3. Rotation of the spine
4. Extension of the spine
5. Rotation and lateral bending of the spine

Answer 23

4. Extension of the spine

Rationale:
The erector spinae muscle group is one of the deep intrinsic muscle groups of the back that extend the spine. Rotation of the spine is incorrect; the muscles that rotate the spine are the abdominal muscles and the intrinsic muscles of the back. Flexion of the spine is incorrect; the muscles that flex the spine are the psoas major and minor, quadratus lumborum, and the abdominal muscles. Lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back. Rotation and lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back.

Question 24

A thin, 58-year-old patient complains of lower back pain for years. On examination, the clinician finds that the patient has tenderness over the sacroiliac area. Which of the following conditions is most consistent with this physical sign?
1. Torticollis
2. Infection
3. Osteoporosis
4. Ankylosing spondylitis
5. Malignancy

Answer 24

4. Ankylosing spondylitis

Rationale:
Tenderness over the sacroiliac joint is common in sacroilitis and also seen in ankylosing spondylitis. Osteoporosis is incorrect; osteoporosis may be associated with pain on percussion of the spine. Malignancy is incorrect; malignancy may be associated with pain on percussion of the spine. Infection is incorrect; infection may be associated with pain on percussion of the spine. Torticollis is incorrect; torticollis is caused by contraction of the sternocleidomastoid muscle and presents as lateral deviation and rotation of the head.

Question 25

The clinician is seeing a middle-aged patient who has a diagnosis of lumbar spinal stenosis. The patient’s history is consistent with this diagnosis as he has pain in the back with walking that improves with rest. Which physical sign(s) are most consistent with his diagnosis?
1. Positive straight-leg raise
2.Hyperreflexia of the lower limb
3. Thoracic kyphosis
4. Flexed forward posture with lower extremity weakness
5. Pelvic tilt or drop

Answer 25

4. Flexed forward posture with lower extremity weakness

Rationale:
The physical signs of lumbar spinal stenosis include flexed forward posture and weakness of the lower extremities. Hyperreflexia of the lower limb is incorrect; hyporeflexia of the lower extremities is consistent with lumbar spinal stenosis. Pelvic tilt or drop is incorrect; weakness of the pelvic stabilizers—the gluteus medius and minimus are not consistent with lumbar spinal stenosis. Thoracic kyphosis is incorrect; thoracic kyphosis is not associated with lumbar spinal stenosis. Positive straight leg raise is incorrect; the straight-leg test is usually negative in lumbar spinal stenosis.

Question 26

A 31-year-old day care worker presents with a worsening stiff, painful neck. On inspection, the patient’s head is laterally deviated toward the shoulder and rotated. At this point of the examination, what is the most likely diagnosis?
1. Spondylolisthesis
2. Torticollis
3. Ankylosing spondylitis
4. Thoracic kyphosis
5. Osteoarthritis (OA)

Answer 26

2. Torticollis

Rationale:
The characteristic physical signs of torticollis are head rotation and lateral deviation. Spondylolisthesis is incorrect; spondylolisthesis is the slippage between vertebrae and does not present with the head rotated laterally and downward. OA is incorrect. Although it can cause a stiff and painful neck, it would not cause the head to be laterally deviated toward the shoulder and rotated. Thoracic kyphosis is incorrect; thoracic kyphosis is increased flexion of the thoracic vertebrae and occurs with aging. Ankylosing spondylitis is incorrect; ankylosing spondylitis does not present with the head rotated laterally and downward.

Question 27

The clinician is seeing a 58-year-old patient with a diagnosis of arthritis. The patient complains of pain in his knees, hips, hands, wrists, neck, and low back. Based on which joints are involved, the patient most likely has which joint problem?
1. Osteoarthritis (OA)
2.Psoriatic arthritis
3. Rheumatoid arthritis (RA)
4. Gout
5. Polymyalgia rheumatica

Answer 27

1. Osteoarthritis (OA)

Rationale:
The common locations of joints involved with OA are the knees, hips, hands, wrists, neck, and lower back. RA is incorrect; the common locations of joints involved with RA are the small joints of the hands, feet, wrists, and ankles, and also the joints of the elbows and knees. This patient has involvement of the hips, which is not characteristic of RA. Psoriatic arthritis is incorrect; psoriatic arthritis is a mono/oligoarthritis—involving one to three joints. This patient has at least six joints involved. Gout is incorrect; the common locations of joints involved with acute gout are the base of the big toe, foot, ankles, knees, and elbows. The common locations of joints involved with chronic tophaceous gout are the feet, ankles, wrists, fingers, and elbows. This patient has involvement of the hips, neck, and low back which is not characteristic of gout. Polymyalgia rheumatica is incorrect; the common locations of pain in polymyalgia rheumatica are the muscles surrounding the hip and shoulder joints.

Question 28

A young adult patient presents to the clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the examination continues, which of the following maneuvers would confirm a likely diagnosis?
1. Compare the strength of his trapezia muscles
2. Assess his ability to extend his back
3. Check for listing of his trunk
4. Assess the lateral bending movement of his neck
5. Assess his ability to touch his toes

Answer 28

1. Compare the strength of his trapezia muscles

Rationale:
One cause of winged scapula is the contralateral weakness of the trapezius muscle. As this patient has had his left arm immobilized for 8 weeks, he may have muscle wasting and weakness of the left trapezius relative to his right side. Assess his ability to touch his toes is incorrect; touching toes assesses the muscles that flex the back as well as looks for scoliosis (differences in the height of scapulae). Assess the lateral bending movement of his neck is incorrect; this action assesses the function of the scalene and small intrinsic neck muscles. Assess his ability to extend his back is incorrect; this action assesses the function of the deep intrinsic muscles of the back. Check for listing of his trunk is incorrect; this sign may be present with a herniated disk.

Question 29

A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient?

1. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts).
2. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs over mammograms in patients such as this individual.
3. History of chest radiation is not a risk factor for breast cancer and is thus not relevant to deciding whether MRI is appropriate in this patient.
4. No agency recommends breast MRI for a patient such as this one, who has moderately but not extraordinary risk factors for breast cancer.
5. The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for patients with such risk factors.

Answer 29

1. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts).

• This patient presents with an extraordinary risk profile
  o Strong family history of breast cancer (suggestive of BRCA linkage to disease but without clear diagnosis)
  o History of chest radiation between the ages of 10-30 convers high risk of breast cancer
  o Dense breasts requiring prior biopsies to rule out malignancy

Question 30

A 22‐year‐old G0P0 undergraduate student presents to clinic after finding a breast mass on breast self‐examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self‐detection of breast cancer?
a) BSE is universally recommended because of very high sensitivity and specificity for finding cancerous lesions.
b) Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low.
c) This patient is more likely to find a fibroadenoma than a cancer on self‐examination.
d) The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying mastitis.
e) Most masses that women find at home and bring to a provider’s attention turn out to be malignant.

Answer 30

c) This patient is more likely to find a fibroadenoma than a cancer on self‐examination.

• Palpable fibroadenomas are more likely to be found in the age range: 15-25

Question 31

A 24‐year‐old graphic designed presents to clinic with a concern for a breast mass. A rubbery, mobile, nontender mass is palpated in the right breast as described by the patient, which is consistent with a fibroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal and 3 cm to the left to the nipple. Which of the following would be the most appropriate way to report this finding?
a) “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”
b) “Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple”
c) “Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant”
d) “Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant”
e) “Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant”

Answer 31

a) “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”

Question 32

A 44‐year‐old female mathematician presents to clinic with a complaint of a mass in the right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self‐examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening test at age 43 years after a brief discussion with her primary care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group?
a) BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced.
b) This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint.
c) Breast cancer screening is extremely well studied, and no controversy exists on the recommended norms for screening and follow‐up.
d) Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to image accurately.
e) Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examinations starting at age 30 years.

Answer 32

b) This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint.

Question 33

A 48‐year‐old female psychologist presents to clinic with concerns about her breast cancer risk after an age‐matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father’s side in as many years to be diagnosed with breast cancer, including the patient’s own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires further information about whether this would be appropriate for her. Which of the following is true about this patient’s indications for BRCA testing?
a) The BRCAPRO calculator does not add any further clinical information to this patient’s risk for carrying the BRCA gene.
b) Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in assessing her risk for these genes.
c) Even if this patient is BRCA positive, no changes in screening or treatment are recommended for patients with this genetic mutation, so the test is not recommended.
d) Breast cancer in a male relative does not add significant weight to the decision to test for the BRCA genes in this patient.
e) This patient carries several risk factors that together justify BRCA testing.

Answer 33

e) This patient carries several risk factors that together justify BRCA testing.

Question 34

A 54‐year‐old female dietician presents for a routine annual examination. On review of systems, she reports that she has had many breast findings over several years, including one biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changes in the breasts with menopause?
a) Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause.
b) Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous sources over the lifetime.
c) Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited for that reason.
d) Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of mammograms.
e) Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules

Answer 34

e) Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules

Question 35

A 66‐year‐old female museum curator presents for a routine annual examination. On examination, a notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy?
a) Supraclavicular nodes are generally considered benign and require no further evaluation or follow‐up.
b) Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla.
c) Firm, rubbery lymph nodes are generally considered to be benign.
d) Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes.
e) Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck.

Answer 35

d) Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes.

Question 36

A 42‐year‐old female website developer presents for an annual preventive examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer. Which of the following is true about MRI as a screening modality for breast cancer in the general population?
a) Breast cancer screening by MRI has been well studied in the general population.
b) Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.
c) Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI
d) This patient is an ideal candidate for screening via breast MRI based on current evidence
e) Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI

Answer 36

b) Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.

Question 37

A 35‐year‐old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This discharge started several weeks ago and has occurred at irregular intervals since that time. She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irregular periods over the last few months. On examination, she is able to express a small amount of discharge, which is sent to the laboratory and found to be consistent with breast milk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid‐stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis?
a) Occult pregnancy
b) Prolactinoma
c) Paget disease of the breast
d) Ductal carcinoma in situ
e) Mastitis

Answer 37

b) Prolactinoma
Prolactinoma: pituitary tumors that secrete prolactin, which causes the production of breast milk and can suppress menstruation

Question 38

A 24‐year‐old retail clerk presents to the clinic for an annual exam. Her last Pap was 3 years ago and was normal. She is a G0 and is currently not sexually active although she has had two lifetime partners. She is on oral contraceptive pills for cycle control and has no medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and places the speculum. There are two layers of cells, squamous and columnar. Where is the most important area to obtain cells for a Pap smear?

a) Zona reticularis
b) Squamous zone
c) Columnar zone
d) Linea nigra
e) Transformation zone

Answer 38

e) Transformation zone

Question 39

An 18‐year‐old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID?

a) Bartholin gland opening
b) Posterior fornix
c) Cervical os
d) Anterior fornix
e) Skene gland opening

Answer 39

c) Cervical os

Question 40

A 23‐year‐old female comes to the clinic to discuss her birth control options. Although she has been sexually active since age 16 years, she has been with one partner for the last year. She has decided to discontinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam?

a) She is on her menses.
b) She has only one current partner and does not need STI testing.
c) She has been using condoms.
d) She should not be sexually active.
e) She had a normal Pap smear within the last 3 years.

Answer 40

a) She is on her menses.

Question 41

A 27‐year‐old G0 bus driver presents to the clinic complaining of an itchy vaginal discharge for the last week. She reached menarche at age 12 years, became sexually active at age 18 years, and has had a total of five sexual partners. She has been with her current partner for 1 month. She is on oral contraceptive pills and does not use condoms as she is allergic to latex. Her last menstrual period was 3 weeks ago. She is not having any pelvic pain, fever, nausea, or vomiting. Her vitals are normal with a body mass index of 22. The clinician places the metal medium Graves speculum in the vagina but cannot find the cervix. What is the best next maneuver to visualize the cervix

a) Replace the speculum with a larger one (large Graves).
b) Withdraw the speculum slightly and reposition it on a different slope.
c) Replace the speculum with a plastic one with a better light source.
d) Discontinue the speculum exam and treat empirically.
e) Withdraw the speculum and do a bimanual exam to find the cervix.

Answer 41

b) Withdraw the speculum slightly and reposition it on a different slope.

Question 42

A 21‐year‐old college student presents for her first annual exam. She has been sexually active for 1 year and has had two partners. She is not aware of having had any sexually transmitted diseases (STIs). She is using condoms for birth control and STI prevention but admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description for these lesions?

a) Several shallow ulcers with a red base
b) Bright red, soft lesion arising from the cervical canal
c) Translucent nodules
d) Strawberry cervix (small red granular spots or petechiae)
e) Raised friable or lobed lesions

Answer 42

e) Raised friable or lobed lesions

Question 43

A 45‐year‐old driver’s education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding?

a) Bartholin gland enlargement
b) Ovarian mass
c) 4‐Month pregnancy
d) Large colonic stool
e) Fibroids

Answer 43

e) Fibroids

Question 44

A 32‐year‐old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever since. She began oral contraceptive pills from when she got married until last year, when she began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient’s history, what is the best explanation for her infertility?

a) Prior Bartholin gland infection
b) Prior pelvic inflammatory disease (PID)
c) Metabolic disorder with subsequent hormonal irregularities leading to anovulation
d) Secondary amenorrhea
e) Prior herpes infection

Answer 44

b) Prior pelvic inflammatory disease (PID)

Question 45

A 63‐year‐old office worker comes to the clinic for her women’s health exam. Her last Pap smear was 5 years ago and was normal. She is married and has been with the same sexual partner for the last 35 years. After performing the majority of the exam, the clinician decides to do a speculum exam to collect cytology for Pap smear. What is the correct position to have the patient in for her speculum exam?

a) Trendelenburg
b) Prone
c) Sitting
d) Lithotomy
e) Supine

Answer 45

d) Lithotomy

Question 46

A 68‐year‐old retired patient presents to the clinic complaining about feeling like something is falling out of her vagina. She is a G6P6007 and had all her children vaginally, even the twins. She went through menopause at age 55 years, and, for the last few months, she has felt this falling sensation. On exam, an anterior bulge in the vaginal wall is apparent when she bears down. Weakness in which muscle would best account for the anterior bulge in the vaginal wall?

a) Levatori ani
b) Pubis symphysis
c) Bulbocavernosus muscle
d) Ischiocavernosus muscle
e) Anal sphincter

Answer 46

a) Levatori ani

Question 47

A 35‐year‐old grade school teacher presents for her annual exam. Her last Pap smear was 4 years ago and normal. She is a G1P1 with a 6‐year‐old child. She has had four lifetime partners but only one partner in the last 12 years. Otherwise she has no complaints. A speculum exam is done followed by a bimanual examination during which a rectovaginal mass is palpated. Which of the following exam findings would be most reassuring that this is not a colonic mass?

a) The mass dents with digital pressure
b) Both adnexa are nontender
c) No pus from the os
d) No cervical motion tenderness
e) The perineum has no lesions

Answer 47

a) The mass dents with digital pressure

Question 48

A 29‐year‐old graduate student states that he is able to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medications. What is the most likely cause of his problem?
a) Psychogenic
b) Androgen insufficiency
c) Peyronie disease
d) Endocrine dysfunction
e) Sexually transmitted infection (STI)

Answer 48

a) Psychogenic

Question 49

A 25‐year‐old graduate student presents to the clinic complaining of scrotal pain, which has been increasing over the past 2 days. He is sexually active and has had unprotected intercourse with multiple partners in the past couple of weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpation of the right testicle are notes. What is the most likely diagnosis?
a) Spermatocele
b) Primary syphilis
c) Hydrocele
d) Acute epididymitis
e) Testicular cancer

Answer 49

d) Acute epididymitis

Question 50

A 32‐year‐old elementary teacher requests a workup for infertility. He and his wife have been trying to conceive for the last 2 years. He reports that his wife has been evaluated and does not appear to have any infertility issues. The overall examination does not reveal any significant abnormalities. He is of average height and weight and has normal secondary sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility
a) Follicle‐stimulating hormone (FSH)
b) Luteinizing hormone (LH)
c) Thyroid‐stimulating hormone (TSH)
d) 5α‐Dihydrotestosterone
e) 5α‐Reductase

Answer 50

a) Follicle‐stimulating hormone (FSH)

Question 51

A 67‐year‐old electronics technician with a history of hypertension and type 2 diabetes presents for his yearly physical examination and complains of progressively worsening erectile dysfunction (ED). While counseling him, the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most affected by vascular deficiencies related to his preexisting medical conditions and is likely contributing to his symptoms?
a) Vas deferens
b) Seminal vesicle
c) Corpora cavernosa
d) Epididymis
e) Ejaculatory duct

Answer 51

c) Corpora cavernosa
- Corpora cavernosa: a conduit for seminal fluid from the seminal vesicle and terminal vas deferens to the urethra and is not involved in the process of an erection
- Epididymis: a structure on top of each of the testicles that provides a reservoir for storage, saturation, and transport of sperm from the testes and is also not involved in the process of erection
- Seminal vesicles: produces secretions that contribute to the seminal fluid and is also not involved in the process of an erection
- Vas deferens: a cord-like structure that transports sperm from the tail of the epididymis to the urethra - not involved in the process of an erection

Question 52

The human papillomavirus (HPV) can cause genital warts in males and females as well as cervical cancer in females. Vaccination against HPV is available and should be offered to males between what ages?
a) 1-3 years
b) 9-21 years
c) 5-7 years
d) 30-50 years
e) 6-9 months

Answer 52

b) 9-21 years

Question 53

A 20‐year‐old college student presents for his annual physical examination. He recently became sexually active and is inquiring about the best means of preventing sexually transmitted infections (STIs). Of the following, which would be the most effective means of prevention?
a) Cervical caps
b) Spermicides
c) Early withdrawal
d) Male condoms
e) Diaphragms

Answer 53

d) Male condoms

Question 54

Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from higher brain centers to the T11-L2 levels of the spinal cord and parasympathetic outflow from S2 to S4 reflex arcs. Local vasodilatation within the penis erectile tissue results from increased levels of which of the following?
a) Testosterone
b) Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP)
c) Luteinizing hormone (LH)
d) Follicle‐stimulating hormone (FSH)
e) Gonadotropin‐releasing hormone (GRH)

Answer 54

b) Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP)

Question 55

A 21‐year‐old college student presents to the student health clinic for a full physical examination. He is generally healthy; however, he reports that he has had sexual intercourse with multiple partners in the past couple of months. He noticed a small lesion on the shaft of his penis a few days ago. While performing the examination, he unwillingly achieves an erection. How should the clinician proceed at this point?
a) Explain this is a normal response and finish the examination.
b) Have him return to see another provider.
c) Tell him the examination cannot proceed until the erection subsides.
d) Assume that he is malingering.
e) Stop the examination immediately.

Answer 55

a) Explain this is a normal response and finish the examination.

Question 56

While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to the inguinal canal and related hernias. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region?

a) Pubic tubercle
b) Internal inguinal ring
c) Direct inguinal hernia
d) Anterior superior iliac spine
e) External inguinal ring

Answer 56

b) Internal inguinal ring

Question 57

A 32‐year‐old male complains of a painless, cystic mass just above his left testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in question and transillumination is noted. What is the most likely diagnosis?
a) Spermatocele
b) Varicocele
c) Testicular tumor
d) Indirect hernia
e) Direct hernia

Answer 57

a) Spermatocele