REVIEW FOR FINAL

Question 1

Medication Management

• Adults over 65 recieve approx. how much of all presciptions? ⭐️

Answer 1

• Adults over 65 receive approx. 30% of all prescriptions

Question 2

⭐️

Vital signs in older people:
* How does BP change?

Answer 2

• Blood Pressure – aorta and large arteries stiffen and become atherosclerotic, systolic blood pressure rises. (WIDENS)

Question 3

What are normal skin, nails and hair changes in older people?

Answer 3

Know women develop coarse hair on chin

Question 4

What happens to CV system in preg people? ⭐️
* Output, BV, HR, heart sounds, valves, and murmurs

Answer 4

• Increased output
• Increased blood volume
• Resting heart rate elevated
• BP decrease
• S3 is a normal finding in pregnancy
• S4 may be present in ~15%
• Mitral stenosis, aortic stenosis and tricuspid sounds are accentuated
• Systolic Murmur may be heard late in pregnancy (typically resolves 1-3 weeks post delivery)

Question 5

What is expected for the vagina/cervix, vaginal secretions, the cervix in preg people?

Answer 5

• Vagina/Cervix – increased vascularity causes a blueish tint to the vaginal walls and cervix, this is termed “Chadwick” sign 🌟
• Vaginal secretions may become thicker, white – termed “leukorrhea of pregnancy”
• The cervix softens and turns cyanotic due to increased vascularity, edema and glandular hyperplasia.

Question 6

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 6

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

Question 7

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 7

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 8

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 8

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 9

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 9

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 10

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 10

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

Question 11

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 11

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

Question 12

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 12

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

Question 13

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 13

5. Schedule a return visit in ~2 weeks.

Question 14

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 14

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

Question 15

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 15

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

Question 16

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 16

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

Question 17

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 17

d) Age‐related cognitive decline

Question 18

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 18

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

Question 19

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 19

d) Evaluate geriatric conditions in terms of functionality and quality of life rather than via traditional disease models

Question 20

What is syndactyly (Know what it looks like)

Answer 20

• The condition of having some or all fingers or toes wholly or partly united
• Usually an isolated finding and often has no impact on function.

Question 21

What is barlow and ortolani (⭐️)?

Answer 21

• Barlow maneuver: A test used to identify an unstable hip that can be passively dislocated. The infant is placed in a supine position with the hip flexed to 90o and in neutral rotation. The examiner adducts the hip while applying a posterior force on the knee to cause the head of the femur to dislocate posteriorly from the acetabulum. A palpable clunk or “hip click” may be detected as the femoral head exits the acetabulum.
• Ortolani maneuver: Identifies a dislocated hip that can be reduced. The infant is positioned in the same manner as for the Barlow maneuver, in a supine position with the hip flexed to 90o. From an adducted position, the hip is gently abducted while lifting or pushing the femoral trochanter anteriorly. In a positive finding, there is a palpable clunk or “hip click” as the hip reduces back into position.

Question 22

What measurment of cobb angle defines scoliosis? ⭐️

Answer 22

• > 10° of curvature measured by the Cobb angle defines scoliosis
• Curves with Cobb angle ≤10° are within the normal limits of spinal asymmetry and have no long-term clinical significance

Question 23

What is months 4-9 gross motor skills?

Answer 23

4 Months
*Sits with trunk support
*No head lag when pulled to sit *Rolls front to back

5 Months
*Rolls back to front

6 Months
*Sits momentarily propped on hands “tripod sitting”

7 Months
*Sits without support (steady)

9 Months
*Pulls to stand
*Crawls with all 4 limbs

Question 24

What is months 10,12, 15, 18, 24 gross motor skills?

Answer 24

10 Months
* Cruises around furniture

12 Months
* Stands independent well
* Walking (few steps)

15 Months
* Walks backwards
* Creeps up stairs

18 Months
* Runs
* Throws object while standing

24 Months
* Walks up and down stairs

Question 25

What is 2.5 years, 3, 4, 5 years gross motor skills?

Answer 25

2 ½ years (30 Months)
* Jumps with both feet
* Throws ball overhand

3 Years
* Alternate feet going up stairs
* Pedals tricycle

4 Years
* Hops, skips
* Alternate feet going down stairs

5 Years
* Jumps over obstacles

Question 26

What are the fine motor skills for month 2,4,5,6, and 9?

Answer 26

2 Months
*Holds rattle if placed in hand *Holds hand together
*Hands unfisted 50%

4 Months
*Plays with rattle
*Brings hand to midline
*Hands mostly open

5 Months
*Transfers objects

6 Months
*Uses raking grasp ⭐️

9 Months
*Uses pincer grasp one
*Holds bottle

Question 27

What are the fine motor skills for months 12,15,18, 21, and 24

Answer 27

12 Months
*Holds crayon and scribbles with imitation

15 Months
*Builds 2 block tower

18 Months
*Scribbles spontaneously
*Builds 3 block tower
*Turns 2-3 pages at a time

21 Months
*Builds 5 block tower

24 Months
*Builds 7 block tower
*Turns one page at a time
*Removes shoes

Question 28

What are the fine motor skills for 2.5, 3, 4, 5 years?

Answer 28

2 1⁄2 years (30 Months)
*Holds pencil
*Unbuttons clothing

3 Years
*Copies circle
*Fully undresses self

4 Years
*Copies square
*Buttons clothing
*Catches ball

5 Years
*Copies triangle
*Ties shoes

Question 29

Define this:

• “Gelling” phenomenon:
• 4 Cardinal features of inflammation:

Answer 29

• “Gelling” phenomenon – decreased active and passive ROM and stiffness upon awakening (this is a sign of articular pain) -> FOR OA
• 4 Cardinal features of inflammation – swelling, warmth, redness in combination with pain

Question 30

What does lupus often presents?

Answer 30

joint pain, typically symmetric, with erythema, most often seen in knees, fingers, hands and wrists

inflammation disease

Question 31

• What tests do you do for rotator cuff, tendinitis/tendonosus?
• What tests do you do for rotator cuff tears?
• AC issues? ⭐️

Answer 31

• Rotator Cuff Tendinitis/Tendonosus (Impingement Syndrome) – Empty Can, Neer, Hawkins, Painful Arc
• Rotator Cuff Tears – Drop Arm, Lift-Off (Belly Press)
• Neer and Hawkins

Question 32

What is Spondylosis, Scoliosis and Spondylolisthesis?

Answer 32

• Spondylosis: degeneration of the intervertebral disc
• Scoliosis: sideways curve of the spine
• Spondylolisthesis: where one of the bones in your spine, called a vertebra, slips forward (Dog)

Question 33

What is the drawer test?

Answer 33

Draw test can do PCL or ACL

Question 34

What is the lachman test?

Answer 34

ALC injury

Question 35

What are the signs of meniscal tears?

Answer 35

• Late swelling-after 12 or 24 hours
• locking: physical sign so need to go to OR
• Pain at the joint line
• Pain at the extremes of flexion and extensions (everything else is good)
• Baker’s cyst (back of knee)

Question 36

• How do you test meniscal tears?

Answer 36

Test with McMurray’s and Thessaly’s

Question 37

What is the mcmurray test? ⭐️

Answer 37

The hip and knee are flexed, and the clinician stabilizes the lower leg with one hand and laterally rotates the tibia. The other hand is placed over the anterior knee with the fingers on the joint line. The clinician slowly extends the leg. If a loose body is in the medial meniscus, this action causes a snap or click. Internally rotating the leg and repeating the test with the thumb over the lateral joint line tests for lateral meniscus damage.

Question 38

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 38

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 39

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 39

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 40

Examination of external genitalia:
* Assist patient into what? ⭐️

Answer 40

• Assist patient into lithotomy position

Question 41

What is a bartholin cyst and the location?

Answer 41

• Bartholin cyst: normal but appearance can be scary. Only worry about it if red, inflammed and non-motile
• Below vaginal orfice

Question 42

Pelvic exam:
* Move the cervix how and why? ⭐️

Answer 42

• Move the Cervix up and down with inserted fingers – you are checking for “cervical motion tenderness” (Chandelier sign for PID)

Question 43

What are visually inspecting of the breasts? (AKA what are some abnormals)

Answer 43

check for abnormal fullness, dimpling, abnormal appearance of the nipple

BREAST CANCER

Question 44

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 44

d) Lithotomy

Question 45

• What is the anterior fontanelle (soft spot)?
• When does it close?

Answer 45

• This is the junction where the 2 frontal and 2 parietal bones meet.
• The anterior fontanelle remains soft until about 12 months to 2 years of age.

Question 46

• What is the posterior fontanelle?
• When does it closed?

Answer 46

• This is the junction of the 2 parietal bones and the occipital bone.
• The posterior fontanelle usually closes first between 2-3 months after birth.

Question 47

What is this?

Answer 47

Caput succedaneum: An edematous swelling caused by the pressure of the presenting part against the dilating cervix, overlies the periosteum with poorly defined margins and extends across the midline and over suture lines. Usually resolves over the first few days.

Cross over the midline (side to slide)
From pushing down in cerivical a.

Question 48

What is this?

Answer 48

CEPHALOHEMATOMA: Collection of blood secondary to rupture of blood vessels under the periosteum of a skull bone that does not cross suture lines.

• Firm and bulging
• One sided-> does not cross medline
• More prone to get jandice
• Have it for months d/t having it for a long time

Question 49

What is cleft palate and what are problems that are caused by it? ⭐️ What happened to cause the cleft palate?

Answer 49

• Opening in the palate (roof of mouth)that are often associated with feeding problems, speech problems, hearing problems, and frequent ear infections. ⭐️
• The two plates of the skull that form the hard palate (roof of the mouth) are not completely joined.

Question 50

For LNs: hard or fixed LN means what?

Answer 50

Malignancy

Question 51

What is protrusion, esotropia, exotropia, hypertropia, hypotropia?

Answer 51

• Protrusion: proptosis
• Esotropia: inward deviation
• Exotropia: outward deviation
• Hypertropia: upward deviation
• Hypotropia: downward deviation

Question 52

What is miosis and mydriasis?

Answer 52

• Miosis: constriction
• Mydriasis: dilation

Question 53

What do you note for a ophthalmoscopic exam?

Answer 53

• Sharpness or clarity of the disc outline
• Color of the disc: yellowish-orange to creamy pink. White or pigmented crescents may ring disc, normal finding
• Size of central physiologic cup. Yellowish-white: Horizontal diameter is usually less than half the horizontal diameter of the disc

Question 54

How do an ophthalmoscopic exam (aka what to look for)

Answer 54

Question 55

What does the papilledema signals? What does it look like?

Answer 55

Increased intracranial pressure

Question 56

What is AV nicking? Seen in who?

Answer 56

• The vein appears to stop abruptly on either side of the artery: arterial walls lose their transparency
• Seen in patients with hypertensive retinopathy

Question 57

What is drusen?

Answer 57

• Normal aging
• age related macular degeneration

Question 58

What is this?

Answer 58

Cotton wool spots

Question 59

What is retinoblastoma? What type of reflex?

Answer 59

• Congenital malignant tumor occuring in first two years of life
• White “cat’s eye” reflex
• Chalky-white areas of calcification

Question 60

If hearing loss or difficulty is present, determine sensorineural or conductive via what?

Answer 60

Tuning fork tests
* Test lateralization if unilateral hearing loss or difficulty (weber’s) is present
* Compare air conduction vs bone conduction (Rinne)

Question 61

What are tuning fork tests for? What may it help determine?

Answer 61

• For patients that fail the whisper test
• May help determine if the hearing loss is conductive or sensorineural in origin

Question 62

What is the weber test?

Answer 62

Question 63

Failed weber test suggests what?

Answer 63

Otosclerosis, otitis media, perforation of the eardrum, cerumen

Question 64

What is the rinne test?

Answer 64

Question 65

For the rinne test: what is normal, conductive and sensorineural hearing loss?

Answer 65

Question 66

What is a fissured tongue, candidasia, black hairy tongue, smooth tongue, oral hairy leukoplakia

Answer 66

Question 67

During the different age groups, where are the children during the visit?

Answer 67

Question 68

What must you did every single visit?

Answer 68

You need to identify who you are interviewing
* Parent, Step-parent, Adoptive parent
* Grandparent and Other Relatives
* Caregiver- Foster Parent
* Nanny
* Friend of family Patient

You must document in the chart who the history is being taken from at each visit.

Question 69

When can a minor seek care without consent? (7)

Answer 69

• Sexually Transmitted Diseases
• Birth Control
• Pregnancy and the child
• Substance Abuse
• Physical or Sexual Abuse
• Crisis Intervention
• Mental health diagnostic or evaluative services: age 13+ (can not give medication without consent)

Issue is with billing with insurance

Question 70

Temperature:
* When can it fluctuate?
* What is normal temp?
* What is a fever?

Answer 70

• Body temperature may fluctuate depending upon the time of day
• Normal temperature may range between 97.0 F (36.1 C) and 100.3 F (37.9 C)
• A rectal temperature of 100.4 F (38.0 C) or higher is considered a fever ⭐️

Question 71

What are the weight status categories with the corresponding percentile range?

Answer 71

Question 72

What is the first dose to babies?

Answer 72

Hep b

Question 73

What shots are only given at one?

Answer 73

MMR and Varicella (VAR)

Question 74

How to approach to examining children (adapting to child’s age)? (5)

Answer 74

• Babies in first months best examined on examination couch with parents next to them
• A toddler is initally examined best on moms lap or over parents shoulder
• Preschool children may be examined while playing
• Older children and teenagers, cocerned about privacy
• Teenages in presence of mother, nurse or chaperone. Be aware of sensitivites in ethnic groups

Question 75

What is this?

Answer 75

Lanugo: The downy hair seen over shoulder is lanugo. Although this is present to much greater degree in preture infants, term babies also have variable amounts of lanugo present at birth

Question 76

What is this? What is the most common spot?

Answer 76

Slate grey patches (mongolian spots): Dark blue-grey lesions most commonly seen in darker-skinned infants. The sacrum is the most commonly affected area. These lesions tend to fade over several years but may not completely disappear

Question 77

What is this?

Answer 77

Left: salmon patch (100% goes away)
Right: Stork bite (same as salmon patch but may stay)
* Pink patches also known as nevus simplex or “angel kisses”, these are a common capillary malformations that are present at birth.

THESE WERE PRESSURE POINTS WHEN IN UTERO

Question 78

What is this?

Answer 78

Hemangioma: Lesions often start flat, circular area (halo) of pallor with central area of telangiectasia. Later develop raised red appearance
* Grow up to 6 months then stays for years as the body breaks them down

Question 79

What is this? ⭐️

Answer 79

Milia: White papules on the skin that are keratin filled epithethial cysts which occur in up to 40% of newborns. Spontaneous exfoliation and resolution is expected within a few weeks.

Question 80

What is this?

Answer 80

Sebaceous hyperplasia: The lesions are more yellow than milia and are the result of maternal androgen exposure in utero. Sebaceous hyperplasia is a benign finding and spontaneously resolves with time.

Question 81

What is this?

Answer 81

Acrocyanosis: Painless condition where the small blood vessels in your skin constrict, turning the color of your hands and feet bluish. The blue color comes from the decrease in blood flow and oxygen moving through the narrowed vessels to your extremities.

VASCULAR IS DIFFERENT FIRST BORN

Question 82

What is this?

Answer 82

JUNCTIONAL MELANOCYTIC NEVUS: The lesion is completely flat and is medium to dark brown in color. It may become slightly raised as the infant grows and may become a compound nevus if intradermal melanocytes develop. It is considered a benign lesion.

ROUNDER BOARDERS

Question 83

What is this?

Answer 83

Cafe au lait spot: Lighter in color than melanocytic nevi and caused by an increased amount of melanin in both melanocytes and epidermal cells and may increase in number with age.

CRAZY SHAPES

Question 84

What is this?

Answer 84

Harlequin color change: Well-demarcated color change, with one half of the body displaying erythema and the other half pallor. Usually occurring between two and five days of age in 10% of infants. The condition is benign, and the change of color fades away in 30 seconds to 20 minutes. It may recur when the infant is placed on her or his side.

Question 85

What is the exam sequence? what is the exceptation? ⭐️

Answer 85

• Inspect, palpation, percussion, auscultation
• Except for abdomen, you want to go inspect, auscultation, palpation and percussion

Question 86

Palpation:
* What do you use for sensitivity, vibration and temperature?

Answer 86

• Use palmar surface & finger pads for sensitivity
• Use ulnar surface of hands to discern vibration
• Use dorsal surface of hands to discern temperature

Question 87

What are the parts of a stethoscope?

Answer 87

• Bell – transmits low frequency sounds (when held lightly against the area of auscultation)
• Diaphragm – transmits high frequency sounds

Question 88

What is the technique for two sided stethoscope?

Answer 88

• Less pressure for bell
• More pressure for diaphragm

Question 89

For mental status examinations, what does it consist of?

Answer 89

• Appearance and behavior
• Speech and language
• Mood and Affect
• Thoughts and perceptions
• Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability

Question 90

What is lethargic, obtunded, stupor, coma?

⭐️

Answer 90

• Lethargic: drowsy, open eyes and look at you, respond to questions, and then fall asleep
• Obtunded: open their eyes and look at you, but respond slowly and are somewhat confused
• Stupor: Completely unarousable except by painful stimuli (sternal rub)
• Coma: Completely un-anarousable

Question 91

What are the five components of attentions?

Answer 91

• Alert: the patient is awake and aware
• Lethargic: you must speak to the patient in a loud forceful manner to get a response
• Obtunded: you must shake a patient to get a response
• Stuporous: the patient is unarousable except by painful stimuli (sternal rub)
• Coma: the patient is completely unarousable

Question 92

What is perceptions, insight, thought processes, judgment?

Answer 92

Question 93

What are the different moods a patient can be in? (3)

Answer 93

Ststained emotion of the patient:
* euthymic-normal
* dysthymic-depressed
* manic-elated

Question 94

What is higher cognitive functions?

Answer 94

Level of intelligence assessed by vocab, knowledge base, calculations and abstract thinking

Question 95

Fluency:

• What is circumlocutions?
• What is paraphasias?

Answer 95

• Circumlocutions: words or phrases are substituted for the word a person cannot remember; e.g., “the thing you write with” for a pen
• Paraphasias: words are malformed (“I write with a den”), wrong (“I write with a bar”), or invented (“I write with a dar”)

Question 96

⭐️

T/F: person who can write a correct sentence does not have aphasia

Answer 96

True

Question 97

Abnormal thought processes

What is Incoherence

Answer 97

speech that is incomprehensible and illogical (severe psychotic abnormal thought processes continued disturbances; usually schizophrenia)

Question 98

Abnormal thought processes

what is Blocking

Answer 98

sudden interruption of speech, before the completion of an idea, occurs in normal people

Question 99

Abnormal thought processes

What is confabulation?

Answer 99

fabrication of facts to hide memory impairment (Kosakoff syndrome from alcoholism)

Question 100

Abnormal thought processes

What is perseveration

Answer 100

persistent repetition of words or ideas

Question 101

Abnormal thought processes

What is echolalia:

Answer 101

repetition of the words or phrases of others

Question 102

Abnormal thought

What is clanging:

Answer 102

choosing a word on the basis of sound rather than meaning

Question 103

Abnormalities of Thought Content

What are these?
* Compulsions:
* Obsessions:
* Phobias:
* Anxieties:

Answer 103

• Compulsions: repetitive behaviors that a person feels driven to perform in response to an obsession, aimed at preventing or reducing anxiety or a dreaded event or situation
• Obsessions: recurrent persistent thoughts,images, or urges experienced as intrusive and unwanted that the person tries to ignore, suppress, or neutralize with other thoughts or actions
• Phobias: persistent irrational fears, accompanied by a compelling desire to avoid the provoking stimulus
• Anxieties: Apprehensive anticipation of future danger or misfortune accompanied by feelings of worry, distress, and/or somatic symptoms of tension

Question 104

Abnormalities of thought content

• What is feelings of unreatlity?
• What is feelings of depersonaliziation?

Answer 104

• Feelings of Unreality: A sense that the environment is strange, unreal, or remote
• Feelings of Depersonalization: A sense that one’s self or identity is different, changed, unreal; lost; or detached from one’s
  mind or body

Question 105

What is delusions and what are the different types?

Answer 105

Question 106

Abnormalities of Perception:

What are illusions and hallucinations?

⭐️

Answer 106

Question 107

Cognitive functions

What are ways we test attention? (3)

⭐️

Answer 107

• Digital span: give the patient a series of digits to recite back to you. Start with two at a time, 1 per second. Can increase
• Serial 7s: ask the patient to subtract serial “7s” from 100
• Spelling backward: ask the patient to spell W-O-R-L-D backwards ⭐️

Question 108

Higher Cognitive Functions: Calculating ability

Higher Cognitive Functions: Calculating ability
* How do you test this?

Answer 108

• Simple addition and multiplication; 4 + 3, 5 x 6 then progress to longer or more difficult; 15 + 12, 25 x 6

OR practical application:

• If something costs 78 cents and you give the cashier 1 dollar, how much change would you get back?

Question 109

Higher Cognitive Functions: abstract thinking
* What are examples of proverbs?
* What are similarities?

Answer 109

Question 110

how do we test constructional ability?

Answer 110

• Give the pt a piece of blank unlined paper
• Show them one figure at a time and have them copy the object
• Increase in difficulty
• OR
• Ask them to draw a clock face with numbers and hands

Question 111

Hair:
What is vellus and terminal hair?

Answer 111

• Vellus hair – short, fine, less pigmentation
• Terminal hair – coarser, pigmented (scalp/eyebrows)

Question 112

What is the ABCDE?

⭐️

Answer 112

Screening Moles for Possible Melanoma

Question 113

What are additional risk factors for melanoma?

Answer 113

Question 114

What are the characterisitics to note of the physical exam of the skin?

Answer 114

• Color
• Moisture
• Temperature
• Texture
• Mobility and turgor
• Lesions

Question 115

How do you assess pallor?
How do you assess central cyanosis?
How do you assess jaundice?

Answer 115

• Pallor best assessed at fingertips, lips, and mucous membranes
• For central cyanosis, look in lips, oral mucosa, and tongue as well as nails, hands, and feet
• Jaundice – sclera, conjunctiva, lips, hard palate, tongue, and skin (used penlight if needed)

Question 116

How do you record your finding for skin lesions and raches?

LY for test

Answer 116

• Number-Solitary or multiple, estimate total number
• Size-Measure in mm or cm
• Color-Including erythematous if blanching; if nonblanching, vascular-like cherry angiomas and vascular malformations, petachiae, or purpura. (Blanching-pressing it firmly with your finger to see if redness lightens then refills)
• Shape-Circular, oval, annular (ring-like with central clearing), nummular (coin-like with no central clearing, or polygonal
• Texture-Smooth, fleshy, verrucous or warty, keratotic; greasy if scaling
• Primary Lesion-flat: macule vs. patch; raised: papule vs. plaque; fluid- filled-vesicle vs. bulla (will define later)
• Location-including measured distance from other landmarks
• Configuration-grouped, annular, or linear

Question 117

What are the primary skin lesion-flat or raised?

Low yield

Answer 117

Question 118

What are vesicles? (grouped)

Answer 118

• Grouped 2–5-mm vesicles on erythematous base on left upper abdomen and trunk in a dermatomal distribution that does not cross the midline; herpes zoster or “shingles”

Question 119

Secondary lesions:
* Scales:
* Crusts:

Answer 119

• Scales, which are shed dead keratinized cells, occur with psoriasis and eczema. They’re irregular, flaky, and variable in size. Usually silver, white, or tan, they can be thick, thin, dry, or oily.
• Crusts, in contrast, are dried exudates. Slightly elevated, they vary in size and color depending on the amount and type of exudate. Abrasion scabs and impetigo are examples of crusts.

Question 120

Secondary lesions:
* Excoriations:
* Erosions:

Answer 120

• Excoriations such as abrasions represent a loss of epidermis and an exposed dermis. They may be linear or have hollowed-out crusted areas.
• Erosions resemble excoriations, except that the depressed area is moist and glistening. They follow a vesicular rupture. An example of this type of lesion occurs with varicella.

Question 121

Secondary lesions:
* Ulcers:
* Fissures:

Answer 121

• Ulcers are also concave, exudative, and variable in size. Some types, such as pressure ulcers and those caused by diabetic neuropathy, are graded according to depth and severity.
• Fissures are linear breaks in the skin extending from the epidermis to the dermis. Fissures are usually small, deep, and red. Tinea pedis (a fungal infection better known as athlete’s foot) commonly produces fissures.

Question 122

Secondary lesions:
* Scars:

Answer 122

• Scars are collagenous tissues that permanently replace injured dermis. Scars appear over healed wounds and surgical incisions. Typically irregular, they may be thick or thin and hypertrophic or atrophic. Red, blue, white, and silver are common colors for scars.

Question 123

Secondary lesions:
* Keloids:

Answer 123

Keloids are progressively enlarging scars that grow beyond the boundaries of the initial wound or incision. Excessive collagen production during healing is generally responsible for keloid formation

Question 124

What is the most common cause of acute cough? ⭐️

Answer 124

Viral UR infection

Question 125

What are other causes of acute cough?

Answer 125

Also consider acute bronchitis, pneumonia, left-sided heart failure, asthma, foreign body, smoking, and ace-inhibitor therapy

Question 126

What can cause subacute cough?

Answer 126

Post infectious cough, pertussis, acid reflux, bacterial sinusitis, and asthma

Question 127

Where can chronic cough be seen in?

Answer 127

in postnasal drip, asthma, gastroesophageal reflux, chronic bronchitis, and bronchiectasis (in children)

Question 128

What signals hypoxia?

Answer 128

Cyanosis of lips, tongue, and oral muscosa

Question 129

What are you listening for with audible sounds of breathing?

Answer 129

• High-pitched inspiratory whistling, or stridor, is an ominous sign of upper airway obstruction.
• Wheezing is either expiratory or continuous

Question 130

What is the tri-pod position?

Answer 130

In cases of real distress, pts may lean forward, resting their hands on their knees. In emphysema will purse their lips

Common in COPD and lung cancer pts

Question 131

What should the anteroposterior diameter be? What is it in COPD?

Answer 131

• Ratio of the anteroposterior (AP) diameter to lateral chest diameter is 0.7 up to 0.9 and increases with aging
• > 0.9 in COPD, producing barrel-chest appearance

Question 132

What is funnel chest (pectus excavatum)? What can it cause?

Answer 132

• Note depression in the lower portion of the sternum.
• Compression of the heart and great vessels may cause murmurs

Question 133

What is barrel chest? Common in who?

Answer 133

• There is an increased AP diameter.
• This shape is normal during infancy, and often accompanies aging and chronic obstructive pulmonary disease.

Question 134

What is Pigeon Chest (Pectus Carinatum)

Answer 134

• The sternum is displaced anteriorly, increasing the AP diameter.
• The costal cartilages adjacent to the protruding sternum are depressed.

Question 135

What is Traumatic Flail Chest? What does it look like for respiration?

Answer 135

Multiple rib fractures may result in paradoxical movements of the thorax.
As descent of the diaphragm decreases intrathoracic pressure, on inspiration, the injured area caves inward; on expiration, it moves outward.

Question 136

Tenderness, bruising, and bony “step-offs” are common in what?

Answer 136

over a fractured rib

Question 137

• What is tactile fremitus?
• Where is Fremitus more prominent?

Answer 137

• Fremitus refers to the palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking normal.
• Fremitus is more prominent in the interscapular area than the lower lung fields.

Question 138

What is indicative of fremitus is decreased or absent?

Answer 138

• voice is higher pitched or soft
• Impeded by a thick chest wall, an obstructed bronchus, COPD, pleural effusion, fibrosis, air (pneumothorax)

Question 139

Tactile fremitus: What does it feel like
* Increased:
* Decreased:

Answer 139

• Increased: coarser or rougher
• Decreased: feels muffled or diminised

Question 140

Occurs when sound vibrations travel through medium of abnormal density
* What does it mean when it is increased and decreased for tacile fremitus?

Answer 140

Increased
* Consolidation: Lobar pneumonia, tumor
* Heavy bronchial secretions
* Segmental atelectasis

Decreased
* Emphysema
* Pleural effusion, fibrosis or thickening
* Massive pulmonary edema
* Hemothorax (one sided)

Question 141

What do these percussion sounds mean:
* Resonant:
* Hyperresonant:
* Hyperresonant on one side:
* Dullness:

Answer 141

• Resonant = Normal
• Hyperresonant = hyperinflated. COPD, ASTHMA
• Hyperresonant on one side = pneumothorax
• Dullness = Fluid or solid

Question 142

Fill this in for breath sounds ⭐️

Answer 142

Question 143

What are adventitious breath sounds?

Answer 143

• May be continuous
• Cont. long sounds are divided into wheezes and rhonchi
• Discontinuous lung sounds are called crackles
• Stridor: inspiratory and expiratory, harsh wheeze like accompanied by retractions

If a patient is sick, have them cough deep to hopefully clean up so there is no more rhonchi

Question 144

For friction rub: what do you hear? (pitch, quality, and timing)

Answer 144

• Pitch: Low to medium
• Quality: Raspy, dry, scratchy (e.g. leather rubbing on leather)
• Timing: I, E, or both, usually loudest at end inspiration and early expiration; sound disappears with breath holding

Question 145

• What is egophony?
• What is bronchophony?
• What is the whispered pectoriloquy?

⭐️

Answer 145

• Egophony – ask the patient to say “eeeee” then it should sound like a muffled long E. If it sounds like an “A”, egophony is present and may indicate lung pathology
• Bronchophony – ask the patient to say “ninety-nine”, should sound muffled, if the sound is loud, may indicate lung pathology
• Whispered pectoriloquy – ask the patient to whisper “ninety-nine”, should sound like a whisper, if loud and clear, may indicate lung pathology

Question 146

Fill in

Answer 146

Question 147

A 39-year-old architect comes to the clinic for a 2-day history of fever, chills, cough productive of green sputum, and dyspnea. He has no history of serious illness. His temperature is 101.2ºF. His other vital signs are within normal limits. Late inspiratory crackles are heard on auscultation over the left lower lung posteriorly. When the clinician listens over that area and instructs the patient to say “ee,” it sounds like “A.” Which of the following would most likely be found on percussion of his lungs?

1. Stridor
2. Dullness
3. Hyperresonance
4. Tympany
5. Flatness

Answer 147

2. Dulliness

REASON:
This patient has symptoms and signs of pneumonia. With pneumonia, a type of consolidation, dullness can be noted on percussion over the area of the pneumonia. Flatness is incorrect. Flatness is not noted on percussion over an area of pneumonia. Flatness is noted on percussion over muscles. Hyperresonance is incorrect. Hyperresonance is not noted
on percussion over an area of pneumonia. Stridor is incorrect. Stridor is a type of adventitial (added) lung sound, rather than a sound noted on percussion. Stridor is also not an adventitial lung sound heard in a patient with pneumonia. Tympany is incorrect. Tympany is not noted on
percussion over an area of pneumonia. Tympany is noted over percussion of the gastric air bubble.

Question 148

After examining a patient who is in the hospital for shortness of breath, the clinician records the following for lung examination: “There is dullness to percussion over the right lung base. Breath sounds are absent at the right lung base. There are no crackles, wheezes, or rhonchi. There are no transmitted voice sounds.” Which of the following is the most likely diagnosis?

1. Pneumonia
2. Atelectasis
3. Chronic obstructive pulmonary disease (COPD)
4. Left-sided heart failure
5. Pneumothorax

Answer 148

2. Aterlectasis

Question 149

A 13-year-old girl is brought by her mother to the clinic one day before the start of eighth grade because of a 3-day history of episodes of shortness of breath. When she gets the shortness of breath, she also notices tingling around her lips. She has no fever, cough, sputum production, or chest pain. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Cardiac, lung, and extremity examinations show no abnormalities. Which of the following is the most likely diagnosis?

1. Left-sided heart failure
2. Asthma
3. Anxiety
4. Aspiration of a foreign body
5. Pneumonia

Answer 149

3. Anxiety
   REASON:
   Tingling around the lips can be a symptom of anxiety. The start of a new school year can be anxiety provoking for children. The normal lung examination is consistent with anxiety. Aspiration of a foreign body is incorrect. She does not have a cough. Putting a foreign body in her mouth and aspirating it would be unusual at her age. Asthma is
   incorrect. Asthma is a possible cause of shortness of breath but is less likely in this girl because of the tingling around her lips and lack of cough or chest tightness, in addition to the lack of wheezing on examination. Left‐sided heart failure is incorrect. Left‐sided heart failure is uncommon in children. She also has no other symptoms of heart failure, such as orthopnea or paroxysmal nocturnal dyspnea. She
   has no history of heart disease, high blood pressure, or other conditions that could put at an increased risk of heart disease. She also has no crackles on lung auscultation, which can be heard in left‐sided heart failure. Pneumonia is incorrect. Pneumonia is less likely than anxiety
   because of the lack of other characteristic symptoms of pneumonia (fever, cough, sputum production, and chest pain) and the normal lung examination.

Question 150

A 70-year-old patient has suspected chronic obstructive pulmonary disease. The clinician instructs the patient to take a deep breath in, and then with his mouth open, breathe out as fast and completely as he can. For what is the clinician checking?

1. Bronchophony
2. Tactile fremitus
3. Whispered pectoriloquy
4. Egophony
5. Forced expiratory time

Answer 150

5. Forced expiratory time

REASON:
Forced expiratory time is assessed by asking the patient to take a deep breath in and then breathing out as fast and fully as he can with his mouth open. Bronchophony is incorrect. Testing for bronchophony is done by listening with a stethoscope while the patient says “ninety‐ nine.” Egophony is incorrect. Testing for egophony is done by listening
with the stethoscope while the patient says “ee.” Tactile fremitus is incorrect. Testing for tactile fremitus is done by feeling for palpable vibrations on the chest wall while the patient says “ninety‐nine.” Whispered pectoriloquy is incorrect. Testing for whispered pectoriloquy is done by listening with the stethoscope while the patient whispers
“nine‐nine.”

Question 151

A 16-year-old boy is brought to the Emergency Department (ED) after a motor vehicle accident for shortness of breath for 1 hour. A chest x-ray shows a rib fracture and a pneumothorax on the right side. The ED physician decides that a chest tube needs to be placed in the fourth intercostal space. How does he determine where the fourth intercostal space is?

1. He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to the fourth intercostal space.
2. He finds the suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
3. He finds the clavicle. The second intercostal space is just below the clavicle. He then walks down to third rib, third intercostal space, fourth rib, and then the fourth intercostal space.
4. He finds the angle of Louis and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
5. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space.

Answer 151

Number 5: He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space.

https://quizlet.com/195966978/8-the-point-flash-cards/ for REASON

Question 152

A 14-year-old high school student comes to the clinic for a 3-month history of periodic dyspnea when playing basketball. It resolves shortly after resting. He has not had fever, chills, cough, sputum production, or chest pain. He has no history of serious illness. Based on the boy’s history, asthma is suspected. Which of the following sounds heard on expiration during lung auscultation would be most suggestive of asthma?

1. Stridor
2. Pleural rub
3. Rhonchi
4. Mediastinal crunch
5. Wheezes

Answer 152

Wheezes

REASON: Wheezes are suggestive of narrowed airways, as in asthma, chronic obstructive pulmonary disease, or bronchitis. Mediastinal crunch is incorrect. A mediastinal crunch is suggestive of pneumomediastinum, not asthma. Pleural rub is incorrect. A pleural rub can be suggestive of a pleural effusion or a pneumothorax, not asthma. Rhonchi are incorrect. Rhonchi are suggestive of secretions in larger airways, not asthma. Stridor is incorrect. Stridor is suggestive of partial obstruction of the larynx or trachea, not asthma.

Question 153

A 29-year-old waiter comes to the clinic for a 2-month history of a cough. When he lowers his gown so the clinician can listen to his lungs, the clinician notices a depression of the lower part of his sternum. Which of the following best describes the appearance of his chest?

1. Pigeon chest
2. Barrel chest
3. Flail chest
4. Thoracic kyphoscoliosis
5. Pectus excavatum

Answer 153

Pectus excavatum

REASON: Pectus excavatum is a congenital abnormality in which the inferior part of the sternum is displaced inward. Barrel chest is incorrect. In a barrel chest there is an increased anteroposterior diameter. A barrel chest
often accompanies chronic obstructive pulmonary disease. Flail chest is incorrect. The injured area of a flail chest moves inward with inspiration and moves outward with expiration. Pigeon chest is incorrect. Pigeon chest, also known as pectus carinatum, is a congenital abnormality in which the sternum is displaced anteriorly. Thoracic kyphoscoliosis is
incorrect. Thoracic kyphoscoliosis is characterized by abnormal spinal curvatures and vertebral rotation, which are visible posteriorly (rather than anteriorly).

Question 154

A clinician is percussing the lungs of a patient with chronic obstructive pulmonary disease to see if they sound hyperresonant. Which of the following is an example of good technique for percussion?

1. Put the third and fourth fingers next to each other on the chest.
2. Strike using the finger pad of the fourth finger.
3. The proximal interphalangeal joint is the joint that is struck.
4. Strike using the tip of the third finger.
5. The wrist is kept still during percussion.

Answer 154

Strike using the tip of the third finger.

Question 155

After examining a patient who is in the hospital for shortness of breath, the clinician records the following for lung examination: “There is dullness to percussion over the right lung base. Breath sounds are absent at the right lung base. There are no crackles, wheezes, or rhonchi. There are no transmitted voice sounds.” Which of the following is the most likely diagnosis?

1. Pneumonia
2. Chronic obstructive pulmonary disease (COPD)
3. Left-sided heart failure
4. Atelectasis
5. Pneumothorax

Answer 155

4. Atelectasis

Question 156

A 16-year-old boy is brought to the Emergency Department (ED) after a motor vehicle accident for shortness of breath for 1 hour. A chest x-ray shows a rib fracture and a pneumothorax on the right side. The ED physician decides that a chest tube needs to be placed in the fourth intercostal space. How does he determine where the fourth intercostal space is?

A. He finds the angle of Louis and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
B. He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to the fourth intercostal space.
C. He finds the suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib.
D. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space.
E. He finds the clavicle. The second intercostal space is just below the clavicle. He then walks down to third rib, third intercostal space, fourth rib, and then the fourth intercostal space.

Answer 156

D. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space.

Question 157

A 39-year-old architect comes to the clinic for a 2-day history of fever, chills, cough productive of green sputum, and dyspnea. He has no history of serious illness. His temperature is 101.2ºF. His other vital signs are within normal limits. Late inspiratory crackles are heard on auscultation over the left lower lung posteriorly. When the clinician listens over that area and instructs the patient to say “ee,” it sounds like “A.” Which of the following would most likely be found on percussion of his lungs?

A. Dullness
B. Hyperresonance
C. Stridor
D. Tympany
E. Flatness

Answer 157

A.dullness

Question 158

A 70-year-old patient has suspected chronic obstructive pulmonary disease. The clinician instructs the patient to take a deep breath in, and then with his mouth open, breathe out as fast and completely as he can. For what is the clinician checking?

A. Whispered pectoriloquy
B. Egophony
C. Forced expiratory time
D. Bronchophony
E. Tactile fremitus

Answer 158

C. Forced expiratory time

Question 159

A 14-year-old high school student comes to the clinic for a 3-month history of periodic dyspnea when playing basketball. It resolves shortly after resting. He has not had fever, chills, cough, sputum production, or chest pain. He has no history of serious illness. Based on the boy’s history, asthma is suspected. Which of the following sounds heard on expiration during lung auscultation would be most suggestive of asthma?

A. Mediastinal crunch
B. Pleural rub
C. Stridor
D. Rhonchi
E. Wheezes

Answer 159

E. Wheezes

Question 160

A 13-year-old girl is brought by her mother to the clinic one day before the start of eighth grade because of a 3-day history of episodes of shortness of breath. When she gets the shortness of breath, she also notices tingling around her lips. She has no fever, cough, sputum production, or chest pain. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Cardiac, lung, and extremity examinations show no abnormalities. Which of the following is the most likely diagnosis?

A. Left-sided heart failure
B. Asthma
C. Anxiety
D. Aspiration of a foreign body
E. Pneumonia

Answer 160

C. Anxiety

Question 161

A 29-year-old waiter comes to the clinic for a 2-month history of a cough. When he lowers his gown so the clinician can listen to his lungs, the clinician notices a depression of the lower part of his sternum. Which of the following best describes the appearance of his chest?

A. Flail chest
B. Pectus excavatum
C. Thoracic kyphoscoliosis
D. Pigeon chest
E. Barrel chest

Answer 161

B. Pectus excavatum

Question 162

A student is practicing the performance of a lung examination on a classmate. Which of the following is the correct order for performing the components of the lung examination?

Answer 162

Inspection, palpation, percussion, and auscultation

Question 163

A clinician is percussing the lungs of a patient with chronic obstructive pulmonary disease to see if they sound hyperresonant. Which of the following is an example of good technique for percussion?

Answer 163

Strike using the tip of the third finger.

Question 164

What are some asymptomatic arrhythmias in children?

Answer 164

● Sinus arrhythmia
● Ventricular premature beats (VPBs) or Premature ventricular contractions (PVCs)
●Atrial premature beats (APBs) or Premature atrial contractions (PACs)

Question 165

What is sinus arrhythmia? When can it be hard to hear?

Answer 165

A normal physiologic variant that is characterized by an increased heart rate during inspiration and a decreased heart rate during expiration which is a benign condition
* Hard to hear in slow HRs for example athletic children

Question 166

What are some arrhythmias of symptomatic children?

Answer 166

● Atrial arrhythmias
● Supraventricular tachycardia (common)
● Ventricular tachycardia
● Sinus node dysfunction
● Second degree heart block

Question 167

What are the causes of arrhythmias?

Answer 167

*Infections: via vag canal, in utero, and in the world
*Chemical imbalances: electrolytes
*Fever: need to be careful because it can instestify
*Medications: albuterol
*Heart defect: could happen so need echo and EKG
*Cardiomyopathy (disease of the heart muscle)

Question 168

Supraventricular Tachycardia (SVT):
* What is it? ⭐️
* Most common what? ⭐️

• Majority of patients presenting with SVT have what?

Answer 168

• Definition: abnormally rapid heart rhythm originating above the ventricles
• Most common rhythm disturbance in children
• Majority of patients presenting with SVT have structurally normal hearts.

Question 169

Supraventricular Tachycardia (SVT):
* The heart rate is _ dependent
* What are the HR typical ranges for infants and children+adolescents? ⭐️
* What is the duration of event?

Answer 169

Heart rate - age-dependent

Typical ranges
● Infants: 220 - 280 beats per minute (bpm)
● Children and adolescents: 180 - 240 bpm

Duration of event
● average duration is 10 - 15 minutes, some episodes last only one to two minutes, while others persist for hours

Question 170

What are the symptoms of SVT in infants?

Answer 170

• Pallor, fussiness, irritability, poor feeding, and/or cyanosis
• The symptoms can be subtle, and tachycardia may go unrecognized for long periods of time
• Infants often present with symptoms of heart failure (ex: tachypnea, fatigue with feeding, poor weight gain)

Question 171

What are the symptoms of SVT in children and adolescents?

Answer 171

• Palpitations, chest discomfort, fatigue, lightheadedness
• Syncope is less common and may be a warning sign for increased risk of sudden death

Question 172

What is dextrocardia?

Answer 172

an abnormal condition in which the heart is situated on the right side and the great blood vessels of the right and left sides are reversed

Question 173

What are the common causes of murmurs in neonates and infants?

Answer 173

• Patent ductus arteriosus
• Tricuspid regurgitation
• Ventricular septal defects
• Peripheral pulmonary stenosis
• Pulmonary stenosis
• Aortic stenosis
• Coarctation of the aorta (check pulses)

Question 174

Patent ductus arteriosus:
* Presents when? Occurs as what?
* Best heard where?
* Closes when?
* Prolonged PDA occurs in who?

Answer 174

• PDA present just after birth, as part of a normal transition, it usually occurs as a soft systolic murmur which disappears in a few hours or a few days.
• Best heard at the left upper sternal border and often described as a continuous “washing machine-like“ sound
• Closes in approximately 90% of full-term neonates by 48 hours
• Prolonged PDA occurs most commonly in premature infants

PDA is normal for a few hours in the left (sternal) corner of the laundry mat (washing machine)

Question 175

What does PDA sound like? ⭐️

Answer 175

“washing machine-like“ sound

Question 176

What is the most common cardiac abnormality?

Answer 176

VSD

Question 177

🌟

VENTRICULAR SEPTAL DEFECT (VSD):
* When is it heard?
* Best heard where?
* What type of murmur?
* Many VSDs will do what?

Answer 177

• VSD is the most common cardiac abnormality
• Often not heard at birth, but as the ductus arteriosus closes and the pressure gradient between the two ventricles becomes greater the murmur intensifies
• Best heard at the left lower sternal border as a harsh murmur often on day 2 or 3.
• Holo- or pansystolic murmur
• Many VSDs will close spontaneously over the course of several weeks to months.

Question 178

What are common causes of murmurs in children (over a year old)

Answer 178

• Innocent Still murmur ⭐️
• Cervical venous hum ⭐️
• Atrial septal defect
• Mitral regurgitation
• Bicuspid aortic valve
• Pericarditis

⭐️ =most common

Question 179

INNOCENT STILL MURMUR-
* Where is the max intensity?
* What does it sound like?
* When is it louder?

CERVICAL VENOUS HUM-
* Best heard where?
* When is it the loudest?

Answer 179

INNOCENT STILL MURMUR-
* Maximum intensity at the left lower sternal border or between the left lower sternal border and apex.
* Systolic Murmur with a characteristic vibratory or musical quality.
* Louder supine than in the sitting position and in hyperdynamic states (fever, anxiety)

CERVICAL VENOUS HUM-
* Heard best at the left or right upper sternal borders or infraclavicular or supraclavicular regions.
* Continuous Murmur that is loudest when the patient is sitting with head extended.

Question 180

• Innocent still murmur= _
• Cervical venous hum= _

Answer 180

• Innocent still murmur= systolic murmur
• Cervical venous hum= continuous murmur

Question 181

• What is a Foramen Ovale?
• What happens during fetal development?
• What happens after birth?

Answer 181

• An opening in the septum between the two atria of the heart that is normally present only in the fetus
• During fetal development the oxygenation of the blood is via the placenta and not the lungs. The foramen ovale allows blood from the venous system to bypass the lungs and go to the systemic circulation. A layer of tissue begins to cover the foramen ovale during fetal development, and will close it completely soon after birth.
• After birth, the pressure in the pulmonary circulation drops, and the foramen ovale closes.

Question 182

What is a patent foramen ovale? When does it close usually and if does not close?

Answer 182

• NOT a congential heart disease
• Flap fusion is complete by age two in 70 - 75 % of children, the remaining 25% have a PFO which persists into adulthood.
• Most patients with a PFO remain asymptomatic

Question 183

What is cyanosis?

Answer 183

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

Question 184

What are noncardiac causes of cyanosis?

Answer 184

• Pulmonary disorders
• Persistent pulmonary hypertension
• Poor peripheral perfusion
• Acrocyanosis

Question 185

What is Peripheral Cyanosis- Acrocyanosis? Where does the blue color come from?

Answer 185

• Painless condition where the small blood vessels in your skin constrict, turning the color of your hands and feet bluish
• The blue color comes from the decrease in blood flow and oxygen moving through the narrowed vessels to your extremities

Question 186

What are the cardiac causes of cyanosis 🌟

Answer 186

●Transposition of the great arteries (TGA)
●Tetralogy of Fallot (TOF)
●Truncus arteriosus
●Total anomalous pulmonary venous return (TAPVR)
●Tricuspid valve abnormalities

Question 187

A patient that has a known history of cardiovascular disease including a myocardial infarction and positive ankle-brachial index indicating peripheral arterial disease in his left leg is now having some issues with erectile dysfunction (ED). The clinician suspects it may be due to medications or further vascular disease. He does not complain of any other symptoms. If his symptoms are related to vascular disease, where would the lesion likely be located?

A. Superficial femoral
B. Popliteal
C. Common femoral
D. Aortorenal
E. Iliac pudendal

Answer 187

E. Iliac pudendal

Question 188

A 61-year-old retired librarian was recently diagnosed with ovarian cancer. She was otherwise healthy until her recent cancer diagnosis. She has not been feeling well lately and has had a cough and some mild shortness of breath for the past couple of days. She now presents to the clinic complaining of pain and swelling in her right groin and leg, which she says is been there for about a week but is worsening. On physical examination, 2+ edema of the right leg up to the thigh; 1+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses; and no significant erythema are noted. What is the chief concern with this patient?

A. Acute arterial occlusion
B. Superficial thrombophlebitis
C. Ovarian metastasis
D. Acute lymphangitis
E. Pulmonary embolism (PE)

Answer 188

E. Pulmonary embolism (PE)

Cancer patients are at high risk of deep venous thrombosis (DVT), and, with the presenting symptoms of swelling and pain in her groin, along with recent history of cough and shortness of breath, this patient’s presentation is suspicious for PE.

Question 189

A 68-year-old retired administrative assistant complains of a 3-month history of recurring pain after ambulating that radiates from her back in the upper lumbar region into both buttocks, bilateral thighs, and mid-calf regions. Her pain is typically improved by sitting or by leaning forward. The origin of her pain is likely secondary to which of the following?

A. Peripheral arterial disease (PAD)
B. Acute arterial occlusion
C. Venous stasis
D. Neurogenic claudication
E. Abdominal aortic aneurysm

Answer 189

D. Neurogenic claudication
* Neurogenic claudication can mimic PAD by causing pain related to walking; however, it is typically relieved simply by sitting or by leaning forward

Question 190

A 73-year-old retired salesman presents to the Emergency Department complaining of chest pain that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x-ray are normal. The nurse notes that his blood pressures in the right arm are significantly lower than of blood pressures in his left arm. Based on history and physical examination, which of the following will most likely explain his signs and symptoms?

A. Dissecting aortic aneurysm
B. Myocardial infarction (MI)
C. Pericarditis
D. Pulmonary embolism (PE)
E. Coarctation of the aorta

Answer 190

A. Dissecting aortic aneurysm

Question 191

A 19-year-old carwash attendant sustained a laceration to the ulnar aspect of his mid-forearm while at work last week. He did not have it evaluated at that time and is now noticing purulent discharge and increasing pain from the wound along with fever and chills. Where would the clinician expect to find the first signs of lymphadenopathy?

A. Epitrochlear nodes
B. Infraclavicular nodes
C. Central axillary nodes
D. Lateral axillary nodes
E. Cervical chain nodes

Answer 191

A. Epitrochlear nodes

Question 192

A 44-year-old retail salesperson has noticed an increasing dilatation of the veins in her legs. Upon inspection, it is noted that she has significant varicosities on the posterior aspects of both legs which begin in the lateral side of the foot and pass upward along the posterior calf. The remainder of the veins in the legs appears normal at this time. Which veins are currently affected?

A. Femoral
B. Great saphenous
C. Small saphenous
D. Dorsal venous arch
E. Perforating

Answer 192

C. Small saphenous

Question 193

A clinician, evaluating a patient for valvular competency in the communicating veins of the saphenous system, starts with the patient supine, then elevates one leg to about 90° to empty it of venous blood. Next, the great saphenous vein in the upper part of the thigh is occluded with manual compression, and the patient stands. The clinician keeps the vein occluded while watching for venous filling in the leg. Which test is being performed?

A. Ankle-brachial index
B. Allen
C. Trendelenburg
D. Romberg
E. Straight-leg raise

Answer 193

C. Trendelenburg

Question 194

The clinician is palpating pulses in the foot of a diabetic patient while in the clinic. A strong pulse is felt located on the dorsum of the foot, just lateral to the extensor tendon of the big toe. Which artery is being assessed?

Answer 194

Dorsal Pedis

Question 195

A 32-year-old cabdriver complains of pain in his left leg. He has a history of type 2 diabetes, is a smoker, and recently was diagnosed with hypertension. He does not remember injuring his leg; however, he notes that there is a small wound on the lateral aspect of his mid-shin. Upon examination, some mild erythema surrounding the wound and flat, nonpalpable red streaks progressing up his leg are noted. What do these streaks likely represent?

A. Occluded arterial vessels
B. Dilated arterioles
C. Dilated veins secondary to incompetent valves
D. Draining lymphatic channels
E. Thrombus formation in a superficial vein

Answer 195

D. Draining lymphatic channels

Acute lymphangitis is typically caused from an acute bacterial infection of the skin that causes red streaks from distal drainage through the lymphatic system. The streaks are typically flat, not palpable cords as found in thrombus formation in a superficial vein

Question 196

When assessing for the femoral pulse, where should the clinician begin deeply palpating?

A. Below the inguinal ligament, just medial to the anterior superior iliac spine
B. Below the inguinal ligament, just lateral to the symphysis pubis
C. Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis
D. Above the inguinal ligament, just medial to the anterior superior iliac spine
E. Above the inguinal ligament, just lateral to the symphysis pubis

Answer 196

C. Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis

Question 197

History Taking of Problems of the Abdomen: GI Tract

• What is regurgitation?
• What is retching? What do you need to ask about vomiting?

Answer 197

Regurgitation: the reflux of food and stomach acid back into the mouth; brine- like taste

retching (spasmodic movement of the chest and diaphragm like vomiting, but no stomach contents are passed)
* Ask about the amount of vomit
* Ask about the type of vomit: food, green- or yellow-colored bile, mucus, blood, coffee ground emesis (often old blood)
o Blood or coffee ground emesis is known as hematemesis

Question 198

What are the three qualifying pains about the abdomen?

Answer 198

• Visceral pain: when hollow organs (stomach, colon) forcefully contract or become distended. Solid organs (liver, spleen) can also generate this type of pain when they swell against their capsules. Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize (hepatitis)
• Parietal pain: when there is inflammation from the hollow or solid organs that affect the parietal peritoneum. Parietal pain is more severe and is usually easily localized (appendicitis) -> More painful, usually sharp
• Referred pain: originates at different sites but shares innervation from the same spinal level (gallbladder pain in the shoulder)

Question 199

• Why is it hard to determine ovary and tube pain?
• What is bilateral and unilateral kidney pain mean?

Answer 199

• Hard because close to bladder and uterus
• Bilateral: pelvic inflammatory disease or pyelonephritis
• Unilateral: kidney stones

Question 200

What are the causes of RUQ pain? (5)

Answer 200

• Acute Cholecystitis
• Duodenal Ulcer
• Hepatitis
• Hepatomegaly
• Pneumonia

Gallbladder, liver and lung

Question 201

What are the causes of pain in LUQ? (6)

Answer 201

• Pancreatitis
• Gastric Ulcer
• Ruptured Spleen
• Aortic aneurysm
• Perforated colon
• Pneumonia

Spleen, stomach, colon, pancreas

Question 202

What are the causes of RLQ pain? (7)

Answer 202

• Appendicitis
• Salpingitis
• Ovarian Cyst
• Ruptured ectopic pregnancy
• Renal/ureteral stone
• Strangulated hernia
• Perforated cecum

Question 203

What are the causes of LLQ pain? (8)

Answer 203

• Diverticulitis
• Salpingitis
• Ovarian cyst
• Ruptured ectopic pregnancy
• Renal/ureteral stone
• Strangulated hernia
• Perforated colon
• Ulcerative colitis

Question 204

What are some causes of periumbilical pain?

Answer 204

• Intestinal obstruction
• Early appendicitis (then moves to RLQ)
• Mesenteric ischemia (dying bowels)
• Aortic aneurysm

Question 205

What is the classic presentation of acute appendicitis?

Answer 205

• Diffuse periumbilical pain and anorexia early
• Pain localizes to RLQ as peritonitis develops
• Low grade fever, nausea and vomiting may not be present
• X-rays and other tests are often negative so you need to be careful (CT will show us)
• WBC might go up

Question 206

What is the classic presentation of acute cholecystitis?

Answer 206

• Localized or diffuse RUQ pain
• Radiation to right scapula
• Vomiting and constipation
• Low grade fever

Question 207

What is the classic presentation of acute renal colic?

Answer 207

• Severe flank pain (possible no pain because stone is smaller)
  * Pain comes into waves
• Radiation to groin
• Vomiting and urinary symptoms
• Blood in the urine (esp young people)

Question 208

Where does ulcer, biliary, renal, uterus and renal pain radiate to?

Answer 208

• Perforated Ulcer (shoulder)
• Biliary Colic (under right scapula)
• Renal Colic (all over)
• Renal Colic (Groin)

Question 209

Physical Examination of the Abdomen: Auscultation
* How do you do this?

Answer 209

• Always auscultate before palpating or percussing the abdomen ⭐️

Question 210

Where do you percuss the liver? What indicates a smaller and largers liver?

Answer 210

Percuss over the liver in both the midclavicular line and at the midsternal line
* Midclavicular percussion should be 6–12 cm; longer than this indicates an enlarged liver
* Midsternal line percussion should be 4–8 cm; shorter than this can indicate a small, hard cirrhotic liver

Question 211

For percussion, where is tympany and dullness?

Answer 211

• Tympany is normally present over most of the abdomen in the supine position.
• Unusual dullness may be a clue to an underlying abdominal mass (liver)

Question 212

Physical Examination of the Liver-Key Points

• Lower border of a normal liver is often palpable where?
• Normally the liver edge is what?
• The cirrhotic liver edge is what?
• Individual cirrhotic nodules are what?
• Discernable lumps suggest what?

Answer 212

Lower border of a normal liver is often palpable at or slightly below the right costal margin

Quality of the liver on palpation is as important as its size
* Normally the liver edge is rubbery-soft, sharp and smooth
* The cirrhotic liver edge is usually firm, blunt, and irregular
* Individual cirrhotic nodules are rarely palpable
* Discernable lumps suggest malignancy

Cancer loves the liver

Question 213

For palpation of aorta: Assess what? What is an abdominal aortic aneurysm?

Answer 213

Question 214

Costovertebral Angle Tenderness:
* CVA tenderness is often associated with what?
* How do you check?

Answer 214

• CVA tenderness is often associated with renal disease.
• Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.

Question 215

What are the appendicitis tests and signs?

Answer 215

1. Iliopsoas (Psoas) Sign: Appendicitis
2. Obturator Sign: Appendicitis
3. Rovsing’s sign: Appendicitis
4. McBurney’s Sign: Appendicitis

Question 216

• What is the iliopsoas muscle test?
• What is unexpected?

Answer 216

Question 217

• What is the obturator muscle test?
• What is unexpected?

Answer 217

Question 218

What is the Rovsing’s sign?

Answer 218

• Right lower quadrant pain intensified by left lower quadrant abdominal palpation
• Associated condition - Appendicitis

Question 219

What is mcburney’s point?

Answer 219

• Rebound tenderness and sharp pain when McBurney’s point is palpated
• Associated condition - Appendicitis

Question 220

What is ascites? When is it present?

Answer 220

• Free fluid in the peritoneal cavity
• In liver disease, ascites indicates a chronic or subacute disorder and does not occur in acute conditions (uncomplicated viral hepatitis, drug reactions, biliary obstruction)

Question 221

What does it mean to shift dullness in ascites?

Answer 221

• Supine: Dull over lateral regions dt fluid. Tympanic over non-fluid areas
• On side: Tympanic on side dt fluid moving

Question 222

What are the special techniques for ascites?

Answer 222

• A protuberant abdomen with bulging flanks is suspicious for ascites (fluid in the abdomen from diseases such as cancer).
• Percuss the abdomen for areas of tympany and dullness. Due to gravity, dullness should be located along the lateral sides of the abdomen, while the anterior portion should be tympanitic.
• Test for shifting dullness: after mapping out the areas of tympany and dullness, have the patient roll to one side. Remap the areas of tympany and dullness. In ascites, there should be a shift due to free fluid moving with gravity.
• Test for a fluid wave: have the patient or an assistant press hands firmly down the midline. This pressure stops the transmission of the wave through fat tissue. Now tap on one flank sharply and feel with your own hand if the wave transmits to the other side of the flank.

Question 223

What is caput medusae? What is this caused by?

Answer 223

• Dilated veins seen on the abdomen of a patient with cirrhosis of the liver.
• Portal hypertension results from the abnormal blood flow pattern in liver created by cirrhosis.

Question 224

For each test, what are they for:
* Murphy’s sign
* Cullen’s sign
* Grey Turner’s sign
* Kehr’s sign

Answer 224

1. Murphy’s Sign: Acute Cholecystitis (Only one on Checklist)
   - Felt after fatty meal
   - Pain in RUQ, right scapula
   - Nausa and vomit
2. Cullen’s Sign: Necrotizing Pancreatitis
3. Grey Turner’s Sign: Necrotizing Pancreatitis
4. Kehr’s Sign: Splenic Rupture &Ectopic Pregnancy Rupture

Question 225

How do you preform a murphy’s sign? What is a positive sign?

Answer 225

.

Question 226

What is the cullen and grey turner signs?

Answer 226

Question 227

Inflammation of peritoneum (Peritonitis) is characterized by pain that is worse with what? (4)

Answer 227

• coughing
• when you remove your hand from deep palpation (rebound tenderness)
• when you bump into the patient’s bed
• when you hit the patient’s heel (heel jar test)

Question 228

What are the Peritoneal Signs/Tests (2)?

Answer 228

Rebound Tenderness/Blumberg Sign
* Palpate deeply and then quickly release pressure.
* If it hurts more when you release, the patient has rebound tenderness.

Markle (heel jar)
* Patient stands with straightened knees, then raises up on toes, relaxes, and allows heels to hit floor, thus jarring body. Action will cause abdominal pain if positive
* Associated with peritoneal irritation; appendicitis

Question 229

An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1–2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation?

1. Decreased fecal bulk
2. Impairment of autonomic innervations
3. Functional change in bowel movement
4. Spasm of the external sphincter
5. A large, firm fecal mass in the rectum

Answer 229

Functional change in bowel movement

Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea predominant, constipation-predominant, or mixed. Other functional causes for her constipation should be excluded prior to making this diagnosis.

A large firm fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden individuals.

Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that increasing fiber helps her constipation.

Spasm of the external sphincter is associated with painful anal lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known diagnosis that would increase suspicion of neurological impairment.

Question 230

A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam?

1. Liver dullness in the right upper quadrant that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease
2. Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation
3. Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line
4. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant
5. A change in percussion from tympany to dullness in the left lower anterior chest wall on inspiration

Answer 230

4. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant

Rationale: Situs inversus is a rare condition in which organs are reversed and is associated with Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on the left.
A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is likely constipation. None of these findings suggest organ reversal.
Liver dullness will occur in the left upper quadrant with organ reversal.
Findings given in the remaining answer choices are both associated with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis.

Question 231

A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic?

1. Positive McBurney point tenderness
2. Poorly localized periumbilical pain
3. Associated right shoulder pain
4. Exacerbating factor includes alcohol intake
5. Vomiting of bile

Answer 231

3. Associated right shoulder pain

Rationale: Pain with biliary colic can produced referred pain to the right shoulder or scapula due to irritation of the right hemidiaphragm.

Alcohol is not an exacerbating factor for biliary colic.

Positive McBurney point tenderness is associated with acute appendicitis.

The Murphy sign is associated with acute cholecystitis.

Poorly localized periumbilical pain is associated with early stages of acute appendicitis.

Vomiting bile is associated with small bowel obstruction.

Question 232

An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis?

1. Ruptured ovarian cyst
2. Perforated bowel wall
3. Ruptured tubal (or ectopic) pregnancy
4. Acute cholecystitis
5. Ruptured appendix

Answer 232

3. Ruptured tubal (or ectopic) pregnancy

Question 233

An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis?

1. Voluntary contraction of the abdominal wall that persists over several examinations
2. Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus
3. Pain with internal rotation of the right hip
4. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain
5. Abdominal pain that increases with hip flexion

Answer 233

4. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain

Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of peritonitis.

Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over several examinations describes rigidity.

Abdominal pain that increases with hip flexion is not suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal peritoneum. They often walk bent forward at the hips for this reason.

Localized pain over McBurney point is certainly suggestive of appendicitis, but not suggestive of peritonitis. Similarly pain with internal rotation of the right hip, or a positive obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but not peritonitis.

Question 234

A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6–8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis?

1. Inflammation of colonic diverticulum
2. Fibrosis of the pancreas
3. Helicobacter pylori infection
4. Reduced blood supply to the bowel
5. Inflammation of the gallbladder

Answer 234

2. Fibrosis of the pancreas

Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency and diabetes mellitus.

H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually associated with diarrhea.

Inflammation of the colonic diverticulum is diverticulitis and typically causes left-lower-quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an acute disease.

Reduced blood supply to the bowel characterizes mesenteric ischemia. It can be acute or chronic in presentation and causes diffuse abdominal pain, vomiting, diarrhea, or constipation. It is associated with older age and vascular risk factors such as coronary artery disease.

Question 235

A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA?

1. Family history of ruptured aneurysm
2. Female gender
3. Hypertension
4. Underweight
5. History of smoking

Answer 235

5. History of smoking

Rationale: History of smoking is her most significant risk factor for an AAA.

Male gender, not female gender, is considered as risk factor.

Underweight is not a risk factor for AAA. Family history of ruptured aneurysm is vague and could be a cerebral aneurysm.

Further, her family history is in a first-degree cousin not a first-degree relative (biologic parents, siblings, and children).

Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based on one elevated blood pressure reading.

Question 236

A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly?

1. Liver span of 11 cm at the midclavicular line
2. Dullness to percussion over a span of 8 cm at the midsternal line
3. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
4. Dullness to percussion over a span of 11 cm at the midclavicular line
5. Liver span of 8 cm at the midsternal line

Answer 236

3. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration

Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would be considered normal on inspiration when the liver is pushed down into the abdominal cavity on inspiration, but is abnormal on expiration.

Findings to support hepatomegaly would be more convincing if, by percussion, the liver span was >12 cm at the midclavicular line.

For patients with obstructive lung disease, air trapping in the lungs may displace the liver downwards into the abdominal cavity.

The liver span and dullness to percussion refer to the same measurement. Measurements of 6-12 cm at the mid-clavicular line and 4-8 cm at the midsternal line are considered normal.

Question 237

A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient?

1. Do not screen routinely
2. Sigmoidoscopy every 5 years with FOBT every 3 years
3. Continue annual FOBT screening until age 80 years
4. Continue annual FOBT screening until age 85 years
5. Repeat colonoscopy this year

Answer 237

1. Do not screen routinely
   The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and benefits with the patient.

Annual FOBT screening may continue until age 80-85 years if benefits to doing so outweigh risks for the individual patient; however, screening should not be routinely continued. In general, a life expectancy >7 years is necessary for screening to be potentially beneficial.

There is no indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his colonoscopy 10 years ago.

Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option, but again screening is not routinely recommended for patients age >75 years.

Question 238

1. A 42-year-old female mathematician presents for follow-up care regarding a new diagnosis of systemic lupus erythematosus 6 months ago after a lengthy diagnostic process during which she was debilitated with fatigue and joint pain. Since her diagnosis, she has been minimally compliant with medications and has switched her rheumatology provider twice. She continues to feel ill, and, in explanation for her lack of adherence to the prescribed treatment, she simply says, “I don’t like it.” At this initial visit with her third rheumatology provider, the clinician elects to explore the issues behind her noncompliance before engaging in diagnostics and treatment using the FIFE model. Which of the following best defines the elements of the FIFE model?

a) Facts, intensity, focus, and evidence
b) Feelings, ideas, function, and expectations
c) Focus, intensity, function, and evaluation
d) Facts, intelligence, fortuity, and eventuality

Answer 238

b. Feelings, ideas, function, and expectations

Question 239

A 23‐year‐old physician assistant (PA) student found that she felt nervous when called upon to examine men in her age group. On one occasion, she encountered a young male patient who appeared embarrassed to see her walk into the room. What should the PA do to minimize their mutual discomfort?
a) Adjust lighting so it is tangential to the patient’s body.
b) Ask the patient where he comes from.
c) Explain that she is a PA student.
d) Provide ongoing interpretation of findings.
e) Explain how the examination will proceed.

Answer 239

e) Explain how the examination will proceed

Question 240

A 34‐year‐old male with a history of complex social and medical needs (including current substance abuse) presents to a primary care teaching clinic. The patient has experienced a number of adversarial relationships with prior clinicians, including voluntarily leaving two practices within the previous year and being asked to leave care at a third clinic due to misbehavior. The attending physician desires to utilize the approaches to this patient that are most likely lead to comprehensive care and patient compliance. Which of the following is the most appropriate interview style for the attending physician to use?

a) Deferring respect, empathy, humility, and sensitivity in favor of the acquisition of concrete details about the patient’s condition
b) Taking a symptom‐focused approach to reduce the involvement of the patient’s
emotional difficulties
c) Following the patient’s lead to understand their thoughts, ideas, concerns, and requests
d) Focusing on the need for immediate diagnostic certainty over personal connection
e) Taking charge of the interaction to meet the clinician’s desire to acquire diagnostic
information

Answer 240

c) Following the patient’s lead to understand their thoughts, ideas, concerns, and requests

Question 241

A 17‐year‐old male presents to a sexually transmitted disease clinic at the behest of his brother, who convinced the patient to attend the clinic after he disclosed that he prefers homosexual partners but is afraid that his last partner may have given him an infection. The patient expresses to the intake nurse that he is unashamed of his sexual orientation and will not stay through the visit if he feels that he is dismissed or discriminated against because of it. The nurse practitioner receives this communication prior to entering the examination room and decides to employ active listening to best connect with the patient at this critical juncture in his care with the clinic. Which of the following is an example of an active listening technique?

a) Using nonverbal communication to encourage the patient to expand their narrative
b) Considering a differential diagnosis while the patient is speaking to maximize the
patient’s time with the provider
c) Paring down the patient’s concerns to concrete medical needs
d) Setting aside the patient’s emotional state to focus on his medical needs
e) Ignoring visual cues to focus on the patient’s exact words

Answer 241

a) Using nonverbal communication to encourage the patient to expand their narrative

Question 242

A 29‐year‐old female professional athlete presents to a new primary care provider with chronic menstrual complaints. She remarks to the nursing staff that, in the past, she has experienced a dismissal of her complaints because of her high level of physical fitness and conditioning. She is seeking a care provider who will explore the issue in more detail and work with her particular concerns. Which of the following is the description of the patient‐centered care this individual
seeks?

a) Affirming and reassuring with close‐ended questions
b) Factual and structured with active listening
c) Structured and clinician‐centered with open‐ended questions
d) Dismissive and concrete with open‐ended questions
e) Validating and empathetic with open‐ended questions

Answer 242

e) Validating and empathetic with open‐ended questions

Question 243

A 36‐year‐old female air traffic controller presents to her primary care provider for a routine visit 3 months after losing her spouse to a lengthy battle with a neurodegenerative disease. The patient denies any psychiatric symptoms on review of systems and, in fact, states that she has slept better in the last month than she had in the previous years. She endorses a healthy support system, including the extended family of her deceased spouse, with whom she is still close. She becomes wistful and briefly tearful when speaking of the plans that they had when they first married that were never fulfilled; she then changes the subject rapidly to whether her Pap smear is due. Which of the following is an example of an empathetic response to this patient?

a) By allowing the crying patient to look around the room for tissues to permit her an excuse to hide her face and defer her emotions
b) Narrowing the understanding of the patient’s emotional response to only thoughts and feelings that have been verbalized
c) Presuming that the patient’s emotions meet social expectations, such as being depressed and even traumatized by her spouse’s death
d) Assuming that the event caused her to become depressed and expressing the same feeling on behalf of the patient
e) Recognizing the patient’s emotions by asking or confirming how she feels about the event

Answer 243

e) Recognizing the patient’s emotions by asking or confirming how she feels about the event

Question 244

A 39‐year‐old nurse who is a well‐established patient complains of irregular menstrual periods and pelvic pain. She says that she is having trouble sleeping and asks whether she could be given a “sleeping pill.” The patient also says she is thinking of leaving her job. What is the best “next step” in caring for this patient?

a) Ask about recent travel destinations.
b) Obtain a urine sample for testing.
c) Obtain a more complete description of problems.
d) Perform a pelvic examination.
e) Obtain blood for testing.

Answer 244

c) Obtain a more complete description of problems.

Question 245

A 14‐year‐old male presents to a new primary care provider after his family relocates to a state. The patient underwent treatment for sarcoma when he was age 11 years, including an above‐the‐knee amputation. He has learned to successfully navigate with a prosthetic leg and even engage in competitive athletics at school. He does not like to speak of his experience with cancer and often makes up humorous stories to tell new acquaintances about his amputation (such as, “I got bit by a squirrel and they had to amputate.”). Although he is very well engaged in most of the visit with the new clinician, when the topic of cancer arises, he demurs to his father, who accompanies him to this appointment. Which of the following statements is most likely to be helpful in cementing the patient’s trust in the new provider?

a) “That sounds like a frightening experience that you are recovering well from.”
b) “You have recovered well and should start moving on with your life.”
c) “You cannot rely on your father for support forever.”
d) “You need to see a counselor since you have not adjusted well to your new
condition.”
e) “You are becoming an adult and must be able to talk about your health.”

Answer 245

a) “That sounds like a frightening experience that you are recovering well from.”

Question 246

A 63‐year‐old male presents to establish care at a new primary care clinic to discuss issues with pain and fatigue. The clinician conducting the visit begins with general historical questions but quickly becomes suspicious that the patient is suffering from decompensated heart failure. When the patient mentions that he has had vague chest pain since last night, the clinician feels that the focus must be redirected to this potentially emergent condition. Which of the following interview techniques is the most appropriate to effectively manage this visit?

a) Providing serial reassurances such as, “Don’t worry, you’re going to be fine.”
b) Moving from open‐ended to focused questions
c) Nonverbally cuing the patient to focus on his narrative regarding a motor vehicle
accident (MVA) that led to back pain
d) Asking a series of negative questions such as, “You don’t have any swelling in your
feet, do you?”
e) Asking leading questions that focus on the presumed diagnosis of chest pain

Answer 246

b) Moving from open‐ended to focused questions

Question 247

A 47‐year‐old fitness trainer visits the physician assistant (PA) because of skin dryness, night
sweats, and irregular menstrual periods. It is the PA’s first contact with this patient. The patient notes that “My sex life has really gone downhill lately” and says that she is considering divorcing her husband of 20 years, stating that “He’s not a bad guy. I just think that I can do better.” In which of the following ways should the clinician proceed?

a) Obtain a menstrual history for the previous 6 months.
b) Help the patient review the pros and cons of divorce.
c) Conduct a breast examination.
d) Inform the patient that menopause is a normal part of aging.
e) Determine the patient’s out‐of‐country travel history.

Answer 247

a) Obtain a menstrual history for the previous 6 months.

Question 248

A 32‐year‐old office worker reports excessive stress at work and pain in the right lower quadrant. She states that last night she vomited twice. Her blood pressure is 120/75, heart rate 93 bpm. The patient looks pale and is sweating lightly. Which of the following is an objective finding?

a) Accelerated heart rate
b) Pain in the right lower quadrant
c) History of vomiting
d) Pale appearance
e) High stress level

Answer 248

a) Accelerated heart rate

Question 249

A 54‐year‐old diplomat working at the United Nations reports occasional chest pain and a sense of tightness in his chest when particularly stressed over work deadlines. The patient is 6 feet 4
inches tall. He has a temperature of 98.6ºF and blood pressure of 140/78. He has a cut over one eye that he says is “from shaving.” Which of the following represents subjective information about
this patient?

a) Blood pressure of 140/78
b) Employment at the United Nations
c) Temperature of 98.6ºF
d) Cut over eye from shaving
e) Height of 6 feet 4 inches

Answer 249

d) Cut over eye from shaving

Question 250

A 26‐year‐old homeless male presents for a new‐patient evaluation at a community health center.
He has a history of intravenous drug use, from which he contracted hepatitis C. He also suffers from uncontrolled asthma that he has had since childhood, with treatment including frequent doses of oral steroids when he cannot keep inhalers in his possession. Two years ago, he was diagnosed with bipolar disorder. On today’s visit, his main concern is a small abscess in his right antecubital fossa at a heroin injection site. Which of the following is the best approach to the health history for this patient at his first visit?

a) A clinician‐centered health history
b) A problem‐focused health history
c) A review of systems (ROS) only
d) A health history with only yes-no options
e) A comprehensive health history

Answer 250

e) A comprehensive health history

Question 251

A 29‐year‐old electrician complains of persistent cough and wheezing, particularly when he exercises. He says he smokes “occasionally” but rarely so much that he needs to purchase cigarettes: “Mostly, I bum them,” he says, chuckling. Upon hearing this information, what is the best next step on the part of the clinician?

a) Explain the relationship between smoking and cancer.
b) Determine the number of pack‐years the patient smokes.
c) Determine the patient’s exercise regimen.
d) Conduct a mental status examination.
e) Determine the patient’s immunization history.

Answer 251

b) Determine the number of pack‐years the patient smokes.

Question 252

One important examination technique involves using the third fingers of each hand to determine the health of internal organs. What is the name of this technique?

a) Inspection
b) Listening
c) Auscultation
d) Percussion
e) Palpation

Answer 252

d) Percussion

Question 253

A 65‐year‐old retired pilot visits the clinic because of recurrent headache. The patient reports dizziness of recent onset (previous 2 weeks) and occasional numbness on the left side. Which of the following systems or regions should be examined in the clinician’s focused assessment?

a) Gastrointestinal
b) Nervous
c) Respiratory
d) Musculoskeletal
e) Cardiovascular

Answer 253

b) Nervous

Question 254

A 59‐year‐old unemployed man complains of almost always feeling tired and hungry, despite getting sufficient rest and having a good appetite and access to sufficient food. The patient is obese and, despite the warm weather outside, wearing thermal socks with his sandals. He says this is because his feet are always cold and “feel funny.” With which body system should the clinician begin the examination?

a) Posterior thorax
b) Head and neck
c) Lower extremities
d) Nervous system
e) Abdomen

Answer 254

b) Head and neck

Question 255

The CAGE questionnaire is a short screening examination administered in the office to evaluate
for which of the following?

a) Bipolar disorder
b) Risk for illicit substance abuse
c) Alcohol misuse
d) Major depressive disorder
e) Likelihood that the patient complaints are “psychosomatic

Answer 255

c) Alcohol misuse

Question 256

A physician assistant (PA) has had a long day and has seen many patients. The last patient of theday is an 80‐year‐old woman brought to the office by her 35‐year‐old granddaughter. This is the patient’s first visit to the office. As part of the patient’s past history, the PA obtains information about childhood illnesses and adult illnesses and then moves on to inquire about the family
history. Which important area of the past history has she omitted?

a) Allergies
b) Medications
c) Immunizations
d) Chief complaint
e) Social history

Answer 256

c) Immunizations

Question 257

A 42‐year‐old woman presents with fatigue associated with a 40‐lb weight gain over the past 2 years. She had always struggled with her weight but has continued to gain despite various attempts at diet and exercise regimens; she inquires if she might be a candidate for gastric bypass surgery. In evaluating patients who are overweight, which of the following best defines obesity in medical terms?

a) A patient with a waist‐to‐hip ratio (WHR) >1.75
b) A patient with a body mass index (BMI) <26
c) A patient with a body mass index (BMI) >30
d) A patient who weighs at least 1 standard deviation (SD) greater than the mean for his or her age and gender
e) A patient consuming >1.5× the recommended daily caloric intake

Answer 257

c) A patient with a body mass index (BMI) >30

Question 258

A 53 year old caterer comes to the clinic for a routine examination. She has type 2 diabetes mellitus, which is well controlled on medication. Her history from her last visit reveals that she smoked one pack of cigarettes a day at that time. The 5 As Model is a useful approach to take with trying to help patients to quit smoking. What is the 5 As Model?

a. agitate, assist,alleviating, factors, able, action
b. arrange, aggravating factors, action, attitude, able
c. affable, associated manisfestation, ask, admonish, available
d. ask, advise, assess, assist, arrange

Answer 258

d. ask, advise, assess, assist, arrange

Question 259

The negative predictive value of a test is calculated as the number of true negatives identified by the test divided by the total negatives found by the test. If a novel test for strep throat yields 85 true-negative results and 15 false-negative results, what is the negative predictive value of this test?

Answer 259

85%

Question 260

A 21‐year‐old college student experiences tachycardia following a night of heavy drinking. She is advised to undergo a stress electrocardiogram (ECG). As she exercises, the recently calibrated pulse oximeter records a heart rate ranging from 25 beats per minute (bpm) at rest to 50 bpm
while jogging. The test is stopped and re‐started twice, and each time the pulse oximeter yields a resting heart rate of 25 and a jogging heart rate of 50. Which aspect of this instrument does the ECG technician question?

a) Sensitivity
b) Predictive value
c) Prevalence
d) Validity
e) Specificity

Answer 260

d) Validity

Question 261

A 58‐year‐old carpenter presents for his annual physical examination. The physician assistant
notes a systolic murmur on auscultation of the aorta. However, she does not immediately conclude that this patient has aortic stenosis. Which of the following is the reason that she seeks additional information?

a) Systolic murmurs have low sensitivity and low specificity for aortic stenosis.
b) Systolic murmurs have low sensitivity but high specificity for aortic stenosis.
c) Systolic murmurs are unrelated to aortic stenosis.
d) Systolic murmurs have high sensitivity and high specificity for aortic stenosis.
e) Systolic murmurs have high sensitivity but low specificity for aortic stenosis.

Answer 261

e) Systolic murmurs have high sensitivity but low specificity for aortic stenosis.

Question 262

A 51‐year‐old moderately overweight college professor visits the clinic with a complaint of chest pain after tennis matches. He jokes that his tennis partner “is in a lot better shape than I am” but says that he is trying to keep up. Later in the day, a 28‐year‐old female student at the same college reports that “my chest often feels hot and tight.” She also feels stressed on the evening before mid‐term exams. The clinician recommends an immediate evaluation for coronary artery disease (CAD) for the professor, but not for the student. Why?

a) Negative predictive value of an observation is higher in a group with a higher prevalence of disease.
b) Positive predictive value of an observation is lower in a group with a higher prevalence of disease.
c) Negative predictive value of an observation is lower in a group with a higher prevalence of disease.
d) Positive predictive value of an observation is greater in older people than in younger people.
e) Positive predictive value of an observation is higher in a group with a higher prevalence of disease.

Answer 262

e) Positive predictive value of an observation is higher in a group with a higher prevalence of disease.

Question 263

A mother brings her 8‐year‐old daughter to the clinic because she found a tick in the girl’s hair and would like her daughter to be tested for Lyme disease. The nurse practitioner (NP) explains that the enzyme‐linked immunosorbent assay (ELISA), an early test for Lyme disease, is effective in finding early cases of Lyme disease but can also give positive results in some people who do not have the disease, making additional testing necessary. This means that the ELISA test has which of the following?

a) Low sensitivity, low specificity
b) High sensitivity, low specificity
c) Low sensitivity, high specificity
d) Undetermined sensitivity and specificity
e) High sensitivity, high specificity

Answer 263

b) High sensitivity, low specificity

Question 264

A 62‐year‐old former tennis pro obtained a home blood pressure cuff after an office measurement revealed that his blood pressure fell in the hypertensive range. At a follow‐up visit, he questions the accuracy of the clinician’s blood pressure cuff and the veracity of his diagnosis of hypertension. Which of the following is true regarding blood pressures recorded in a practitioner’s office versus values obtained in the ambulatory setting?

a) The American Heart Association (AHA) has issued consensus statements regarding the number and timeframe for blood pressure measurement to guide practitioners in diagnosing hypertension.
b) Both systolic and diastolic measurements must be in the hypertensive range to
confer cardiovascular risk on the patient.
c) The accepted normal values for blood pressure are lower for ambulatory measurements compared with office measurements.
d) The accepted normal values for blood pressure are the same for ambulatory measurements compared with office measurements.
e) Masked hypertension is a phenomenon whereby ambulatory blood pressure is measured in the normal range but measurement in the office is elevated.

Answer 264

c) The accepted normal values for blood pressure are lower for ambulatory measurements compared with office measurements.

Question 265

A 19‐year‐old student of art history presents to clinic after a syncopal (fainting) episode at school.
He is notably thin; on a thorough review of his medical history, he admits that he eats only minimally to maintain a very low body weight that he feels is ideal. He is embarrassed that his issues were discussed by peers after this episode, especially because he believes that this is a problem that is only faced by girls and women. Concerning the two most common eating disorders (anorexia nervosa and bulimia nervosa), which of the following statements is true?

a) Men and women are both afflicted, but with a female:male prevalence ratio estimated at ~2:1.
b) The prognosis is similar regardless of whether individuals are diagnosed and treated in the early or late stage of these disorders.
c) Both of these eating disorders are associated with a real or imagined fear of appearing fat.
d) Persons with eating disorders are generally easily identified by their appearance.
e) Both of these eating disorders are associated with a body mass index (BMI) of <17.5.

Answer 265

c) Both of these eating disorders are associated with a real or imagined fear of appearing fat.

Question 266

A 72‐year‐old retiree presents to the cardiology clinic with palpitations after several months of
symptoms. An electrocardiogram (ECG) shows a tachyarrhythmia, which the cardiologist diagnoses
as atrial fibrillation. In measuring the blood pressure of a patient with chronic atrial fibrillation, which of the following statements is true?

a) The precise blood pressure is measured by taking the average of three pressures in both arms over a span of 20 minutes.
b) Because atrial fibrillation is an uncommon arrhythmia, blood pressure management of
these patients does not have widespread significance in office or ambulatory practice.
c) Measuring blood pressure in patients with atrial fibrillation is no different than measuring blood pressure in patients with normal cardiac rhythms.
d) Ambulatory monitoring over 2-24 hours is recommended because this rhythm produces variable and inconsistent blood pressures.
e) Single automated measurement in the office setting provides a reliable value for the true blood pressure

Answer 266

d) Ambulatory monitoring over 2-24 hours is recommended because this rhythm produces variable and inconsistent blood pressures.

Question 267

A first‐semester physician assistant student reports to his supervisor that he has trouble determining the diastolic blood pressure. On manual blood pressure, which of the following provides the best estimate of the true diastolic blood pressure?

a) The average reading between the onset of the auscultatory gap and the resumption of Korotkoff sounds.
b) The point at which Korotkoff sounds first muffle after systolic blood pressure is discerned.
c) The recommencement of Korotkoff sounds following the lower point of the auscultatory gap.
d) The disappearance of Korotkoff sounds following initial muffling.
e) The average between the highest and lowest points of the auscultatory gap

Answer 267

d) The disappearance of Korotkoff sounds following initial muffling.

Question 268

42‐year‐old architect presents with widespread pain complaints, including headaches almost daily, pain at the site of an old motor vehicle accident injury, and generalized achiness and hypersensitivity throughout the body. He recounts that his first episodes of ongoing pain occurred in his early 20s, and he has been to many practitioners over several years seeking a firm diagnosis and adequate treatment of his complaints. Which of the following statements is true regarding chronic pain?

a) In primary care practices, non‐cancer-related chronic pain is seen in <10% of patients.
b) Chronic pain is defined as pain not due to cancer or a recognized medical condition that persists for >3-6 months.
c) Following assessment and evaluation, ~80% of patients with non‐cancer-related pain report control of their symptoms.
d) Pain that recurs at intervals of months or years is never considered to be “chronic pain.”
e) Chronic pain is defined as focused pain lasting >8 months following acute injury or illness.

Answer 268

b) Chronic pain is defined as pain not due to cancer or a recognized medical condition that persists for >3-6 months.

Question 269

A 55‐year‐old air traffic control agent reports his home blood pressure log to clinic after he was
diagnosed with hypertension at a prior visit. He notes that he consistently measures within the normal range at home, but seems to fall outside the normal range every time he comes to the clinic. Which of the following blood pressure measurements is considered to be most accurate (i.e., reflecting the patient’s “true” blood pressure)?

a) Blood pressure recorded in three positions in the health practitioner’s office after resting for a 10‐minute period in a supine position
b) Three separate blood pressure measurements recorded by a medical technician within 90 minutes of awakening in the morning in an office setting using an automated device
c) A total of six blood pressures averaged over three visits to a health practitioner’s office over a 3‐month period
d) Regular ambulatory monitoring recorded outside of the office setting
e) Blood pressure recorded in three positions in the health practitioner’s office

Answer 269

d) Regular ambulatory monitoring recorded outside of the office setting

Question 270

Disparities in pain treatment have been well described in numerous studies comparing Caucasian patients to those of African American and Hispanic origin. Which of the following statements is true concerning this issue?

a) Biases of the treating clinician are associated with overtreatment of pain in minority patients and non‐English speakers.
b) Racial and ethnic biases never involve two persons of the same race or ethnic group.
c) Biases of the treating clinician are associated with under‐treatment of pain in minority patients and non‐English speakers.
d) Language barriers do not contribute to the problem of racial and ethnic biases.
e) Racial and ethnic biases are only relevant in geographic areas that have a history of racial and ethnic discrimination.

Answer 270

c) Biases of the treating clinician are associated with under‐treatment of pain in minority patients and non‐English speakers.

Question 271

A 68‐year‐old retired college professor presents for routine physical examination. After the patient has been reading a novel in the waiting room for ~20 minutes, the technician records his blood pressure in both arms using an automated device. The technician notes a 20‐mm Hg difference in systolic blood pressure between the right and left arms; he repeats the readings 10 minutes later and records the same asymmetrical systolic blood pressure. Which of the following is true regarding this physical finding?

a) This finding is clearly abnormal and requires immediate evaluation for possible cardiovascular emergency.
b) The patient should commence an antihypertensive medication and return in 6 weeks to assure normalization of the asymmetry between the arms.
c) The patient should undergo ambulatory blood pressure monitoring in both arms for 24
hours to confirm conflicting measurements in the office.
d) The difference is likely secondary to white coat hypertension and should be followed up with three subsequent monthly readings to confirm.
e) An arm‐to‐arm difference of up to 20 mm Hg in systolic blood pressure is considered the upper limits of normal

Answer 271

a) This finding is clearly abnormal and requires immediate evaluation for possible cardiovascular emergency.

Question 272

Which of the following statements is true concerning mental health disorders in primary care?
a) Alcohol and substance abuse are not considered mental health disorders.
b) Somatic symptom disorder (DSM‐5) is distinctly uncommon in this setting and constitutes less than 5% of these disorders.
c) Mood disorders make up ~25% of all diagnoses.
d) The prevalence for mental disorders is estimated to be ~10%, of which only 25% are not diagnosed.
e) Anxiety disorders are the most prevalent of all diagnoses in this setting.

Answer 272

c) Mood disorders make up ~25% of all diagnoses.

Question 273

Concerning hallucinations, an abnormal perception experienced by a patient, which of the following statements is true about this abnormality?

a) It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia.
b) They include false perceptions associated with dreaming and occurring with falling asleep and awakening.
c) Objective testing can be performed by a trained neuropsychologist to ascertain the correct diagnosis associated with this complaint.
d) Although alcoholism may be associated with abnormalities of perception, it is not considered a cause of hallucinations as this finding is due to its direct toxic effects.
e) By definition, hallucinations are confined to those abnormal perceptions that are either auditory or visual in nature.

Answer 273

a) It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia.

Question 274

Which of the following complaints/findings is considered to be a patient identifier for mental
health screening?

a) High use of health services due to chronic unstable medical diagnoses
b) Acute pain syndromes of 10 days’ duration that require opiates for relief
c) A patient with type I diabetes and neuropathic pain
d) Symptoms lasting for >2 weeks
e) Substance abuse

Answer 274

e) Substance abuse

Question 275

Concerning a patient that may demonstrate a diagnosis of aphasia, which of the following statements is true?

a) It is best characterized by involuntary, rhythmic, repetitive movements involving the tongue and jaws making speech difficult to comprehend.
b) It is defined as an inability to produce or understand language.
c) It involves a loss of the voice or a slurring or hoarseness of speech secondary to pathology of the larynx or its nerve supply.
d) The ability to write a full correct sentence does not rule out the presence of aphasia in a patient.
e) It is best characterized by slurred speech with an associated defect in language control.

Answer 275

b) It is defined as an inability to produce or understand language.

Question 276

A 24‐year‐old veteran returns from his second tour of duty in the Middle East. He was witness to a number of violent military encounters and experienced the death of several of his closest friends. He describes a number of problems including nightmares, poor sleep pattern, and mild panic
attacks. In persons with trauma‐ and stress‐related disorders as well as other disorders that may be associated with hallucinations and illusions, which of the following statements is true that distinguishes these two entities from each other?

a) Illusions occur only when awake, whereas hallucinations can occur both while awake
and while sleeping.
b) Illusions involve an irrational fear or perceptions, whereas hallucinations are a misinterpretation of real external stimuli.
c) Hallucinations may be visual or auditory, causing an alteration of the real external world, whereas illusions are entirely imaginary.
d) Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective
perceptions in the absence of real stimuli.
e) Hallucinations by definition never include somatic perceptions, whereas illusions always involve at least some component of a somatic complaint.

Answer 276

d) Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective
perceptions in the absence of real stimuli.

Question 277

A 72‐year‐old woman presents with concerns about several ruby‐red spots on her chest and abdomen. She reports that these are growing in both size and number over time. On examination, the provider notes a number of cherry angiomas at the locations indicated by the patient. No other abnormalities are noted. Which of the following best describes the clinical characteristics and significance of a cherry angioma?

a) Cherry angiomas are a marker for underlying pathology that requires additional evaluation.
b) Cherry angiomas rarely occur on the trunk and are most often noted on the legs near veins.
c) Cherry angiomas are associated with liver disease and B vitamin deficiencies.
d) Cherry angiomas are benign and may increase in size and number with aging.
e) Cherry angiomas never show blanching under pressure

Answer 277

d) Cherry angiomas are benign and may increase in size and number with aging.

Question 278

A 52‐year‐old male presents for an annual examination. He discloses on review of family history
that his father has died of skin cancer since his last visit. He personally has had two actinic keratoses frozen and has further lesions that require evaluation today. He is very concerned about his personal and family history and would like to know more about the potential for skin cancer to spread and become a dangerous condition. Which of the following skin lesions is the least likely to metastasize?

a) Seborrheic keratosis
b) Basal cell carcinoma (BCC)
c) Actinic keratosis
d) Squamous cell carcinoma (SCC)
e) Melanoma

Answer 278

a) Seborrheic keratosis

Question 279

A 33‐year‐old nurse presents with a history of weight gain, decreased energy, and menorrhagia over the past several months. Review of her family history reveals Hashimoto thyroiditis and hypothyroidism in four female first‐degree relatives (her mother and three sisters). Which of the following skin findings best supports a diagnosis of clinical hypothyroidism?

a) Discoid rash, alopecia, oral ulcers, and Raynaud phenomenon
b) Dry skin, myxedema, alopecia of the eyebrows, and brittle nails
c) Thickened, taut skin with sclerodactyly and telangiectasia
d) Warm moist skin, hyperpigmentation, and pretibial myxedema
e) Spider angiomas, telangiectasia, palmar erythema, and Terry nails

Answer 279

b) Dry skin, myxedema, alopecia of the eyebrows, and brittle nails

Question 280

A 72‐year‐old retired woman presents to a primary care provider for evaluation of a suspicious mole. She noticed this lesion 3 weeks ago on her right flank in an area where she had previously seen no abnormality. She is very concerned about melanoma and asks if this could be a possible diagnosis and also wonders if this should have been noticed at her annual examination 7 months ago. Concerning the initial recognition of melanoma, which of the following is true?

a) General screening programs conducted by medical facilities identify ~75% of melanomas.
b) Approximately 50% of melanomas are initially noticed by patients then brought to the attention of a practitioner.
c) Asymmetry of a mole is rarely associated with melanoma.
d) Most melanomas are initially identified in individuals with positive family histories by DNA analysis for causative genes.
e) The majority of melanomas are recognized during an annual physical examination

Answer 280

b) Approximately 50% of melanomas are initially noticed by patients then brought to the attention of a practitioner.

Question 281

A 16‐year‐old male high school student presents with a primary concern of acne. He relates a history of 2 years of moderate mild acne and closed comedones (whiteheads), which have recently worsened such that a classmate started calling him a pirate due to a large pustule that developed at the tip of his nose. He has increasing outbreaks of cyst‐like acne as well as a generally poor complexion with pitting and scarring from prior outbreaks. Which of the following best describes this condition in the adolescent population?

a) Acne vulgaris is associated with blockage of sebaceous glands, stress, humidity, and heavy sweating as well as other contributory factors.
b) Acne vulgaris affects <50% of the adolescent population.
c) The primary hormonal stimulus for acne vulgaris is estrogen, causing preferentially worse cases in females and males with lower testosterone levels.
d) Acne vulgaris is associated with an identified virus for which there is no definitive treatment.
e) Acne vulgaris is always associated with underlying endocrine disorders and/or pituitary dysfunction.

Answer 281

a) Acne vulgaris is associated with blockage of sebaceous glands, stress, humidity, and heavy sweating as well as other contributory factors.

Question 282

A 28‐year‐old male business executive presents to a primary care provider with concerns about hair loss. He is otherwise healthy without chronic medical conditions or current medications. He has a chart history of allergy to sulfa medications, although this happened when he was a young child, and he does not recall the incident or the reaction. He is unsure at what age his father went bald, as he never remembers his father having hair. He remarks jokingly that he is losing more hair than his dogs at home, who shed frequently but are otherwise healthy. On examination, he has a single uniform oval patch of hair loss over the left temporal area without any scaling, inflammation, or other skin changes where the hair is missing. Which of the following is the most likely explanation for his hair loss?

a) Tinea capitis, as evidenced by his exposure to animals that may carry this pathogen
b) Male pattern baldness, as evidenced by his father’s baldness at a young age
c) Drug rash, as evidenced by his allergy to sulfa drugs
d) Alopecia areata, as evidenced by patchy hair loss without associated skin changes
e) Trichotillomania, as evidenced by his anxiety and need to diffuse uncomfortable situations with inappropriate humor

Answer 282

d) Alopecia areata, as evidenced by patchy hair loss without associated skin changes

Question 283

A concerned mother brings her 9‐year‐old daughter to the clinic with several days of a diffuse rash
on the trunk. The child was previously healthy and is current on her vaccinations. The mother
relates a history of decreased appetite, easy fatigue, and low‐grade subjective fevers. On examination, temperature is recorded at 100.5ºF, the rash is confirmed as described by the mother, and additional physical findings of a strawberry tongue and erythema of the palms and soles are noted. Nonpainful peeling of the skin of the child’s fingertips is noted incidentally. Based on the history and physical findings, which is the most likely diagnosis and course of action?

a) Strep throat, for which amoxicillin is indicated
b) Measles, for which review of the vaccination history is critical
c) Contact dermatitis, for which antihistamines are indicated
d) Kawasaki disease, for which close monitoring and possibly hospitalization might be required
e) Nonspecific viral exanthem, for which observant management is advised

Answer 283

d) Kawasaki disease, for which close monitoring and possibly hospitalization might be required

Question 284

A 62‐year‐old manual laborer presents to an annual physical examination with concerns about skin
cancer screening. He does not have any lesions of concern but was recently told by a friend that he should have his skin checked by a doctor yearly. What is the best advice for this patient according to the U.S. Preventive Services Task Force (USPSTF) recommendations on skin cancer screening from 2009?

a) The USPSTF recommends skin cancer screening only in sun‐exposed areas of fair‐ skinned individuals every 6 months.
b) The USPSTF recommends that all individual age >50 years be screened yearly for skin cancer regardless of risk factors.
c) The USPSTF recommendations mirror those of the American Cancer Society (ACS) and American Academy of Dermatologists (AAD) in recommending and annual skin cancer screening for patients age >50 years.
d) The USPSTF recommends against routine screening for skin cancer due to lack of evidence for this intervention across the general population.
e) The USPSTF recommends focused screening of individuals with a history of dysplastic nevus syndrome

Answer 284

d) The USPSTF recommends against routine screening for skin cancer due to lack of evidence for this intervention across the general population.

Question 285

A 17‐year‐old woman presents with her parents to her primary care provider. She desires to utilize a tanning facility ahead of an upcoming event. Her parents have heard that this is a dangerous practice, although the tanning facility insists it is safe without risk of skin cancer in the future after tanning. Which of the following is true regarding ultraviolet (UV) light exposure and subsequent risk of skin cancer?

a) Water‐resistant sunscreens confer no advantage over water‐soluble products.
b) Tanning beds and sunlamps do not increase risks of skin cancer as they utilize UV wavelengths that are not carcinogenic.
c) Targeted messaging and practitioner reinforcement in primary care amplify sun‐ protective behaviors.
d) Sunscreen with a sun protective factor (SPF) of 15 blocks ~50% of UV‐B light.
e) Chronic sun exposure confers greater risk for skin cancer than intermittent intensive
exposure.

Answer 285

c) Targeted messaging and practitioner reinforcement in primary care amplify sun‐ protective behaviors.

Question 286

A 42‐year‐old fair‐skinned woman of Irish origin presents with an abnormal skin growth that was
first noted 7 years ago. On examination, a 2 × 3‐cm lesion is noted over her left bicep. Which of the following historical elements most increases the suspicion that the lesion is malignant?

a) No evolution in size since onset, but mild intermittent pruritus over the last 2 years
b) Proximal location, that is, over the bicep rather than the distal arm
c) Minimal but discernible increase in size over the past 6 months
d) No evolution in size since onset, but uniformly darkly pigmented color
e) Presence of similar pinkish tan lesions on the sun‐exposed areas including the face and hands

Answer 286

c) Minimal but discernible increase in size over the past 6 months

Question 287

An 87‐year‐old woman who is generally healthy and cognitively sharp complains to the clinician of slow loss of vision, with similar problems in both eyes, particularly when she looks straight ahead. She is having difficulty reading of late. What is a reasonable response to her?

a) “Are you experiencing depression or stress?”
b) “This is a common occurrence with aging and unlikely to have a diagnosis.”
c) “This is an unusual occurrence, even among elderly, and may be due to a problem within the brain (since it is bilateral).”
d) “This is a classic ‘floater’ and no cause for concern.”
e) “This may be the onset of macular degeneration, which an ophthalmologist should confirm.”

Answer 287

e) “This may be the onset of macular degeneration, which an ophthalmologist should confirm.”

Question 288

A 70‐year‐old man complains of double vision. Which of the following associated symptoms or signs would be worrying about an underlying neurological problem (as opposed to pathology in the eye)?

a) Abnormality in extraocular movements on examination
b) Symptoms of flashing lights
c) An associated conjunctivitis
d) Diplopia persisting in the right eye when the left eye is closed
e) Worsening vision bilaterally on examination

Answer 288

a) Abnormality in extraocular movements on examination

Question 289

A 74‐year‐old man is being seen because of a 1‐day history of a painful right eye. He also mentions that he has blurred vision in that eye. He thought something had blown into his eye, but after flushing it out, the pain and blurred vision remains. What is the best course of action?

a) Check his blood pressure.
b) Perform a complete neurological examination.
c) Perform a vision examination.
d) Reassure him that pain from a foreign body can remain for a day or two (even after the foreign body is removed).
e) Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma.

Answer 289

e) Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma

Question 290

A patient with cystic fibrosis (CF) has been complaining of fullness in his left nasal cavity. Examination of his nose using an otoscope and a speculum reveals a normal nasal septum, but a pale, saclike growth of inflamed tissue that is obstructing a large part of the nasal cavity. What is the most likely diagnosis?

a) Allergic rhinitis
b) Deviated nasal septum
c) Nasal polyp
d) Ulcer
e) Viral rhiniti

Answer 290

c) Nasal polyp

Question 291

An 82‐year‐old gentleman seems to be speaking loudly during an examination, suggesting that he may not be hearing well. What is a good question to ask him to help identify whether or not he has hearing loss?

a) Does he have vertigo?
b) How well does he understand people in a noisy environment such as a restaurant?
c) Does he have discharge from his ear?
d) Has he been listening to loud music?
e) Has he been having an earach

Answer 291

b) How well does he understand people in a noisy environment such as a restaurant?

Question 292

A 25‐year‐old construction worker is complaining of a swishing noise in both ears that never goes away and has occurred for about 6 months. He is otherwise healthy, is able to work on his job (operating large, vibrating machinery) without problems, and is not taking any medications. A complete examination reveals an abnormality. Which of the following abnormality is most often associated with tinnitus?

a) Headache
b) Wax in both ears
c) Mild tremor
d) Vertigo
e) Bilateral earache

Answer 292

d) Vertigo

Question 293

A 65‐year‐old overweight male presents at the clinic with hoarseness which has lasted for around 2 months. He thinks it began along with a cold. He is not feeling badly other than frequent heartburn, and he has continued to work as a bartender (for the past 30 years), but he is having difficulty being heard and understood because of his hoarse voice. A diagnosis that is on the differential list includes which of the following?

a) Voice strain from bartending and talking amidst loud ambient noise
b) Acid reflux
c) Inhalation of fumes
d) Viral infection
e) Environmental allergies

Answer 293

b) Acid reflux

Question 294

An infant is born 4 weeks preterm to a mother with a history of hypertension, severe diabetes, and alcohol abuse. The infant is noted to be small for gestational age (SGA), weighing just 1,500 g. Which of the following is the most important reason for assessing both gestational age and birth
weight for any infant?

a) Full‐term, appropriate‐for‐gestational age (AGA) infants having a high risk of long‐ term problems.
b) These two factors help to anticipate certain medical and developmental problems.
c) A SGA infant is at low risk for neonatal problems.
d) The parents should be informed of these.
e) A premature infant with a weight appropriate for gestational age has a very low risk
for neonatal problems.

Answer 294

b) These two factors help to anticipate certain medical and developmental problems.

Question 295

A mother brings her 9‐month‐old son to the practice for the first time, concerned that he is not yet sitting by himself. After taking a careful history, the physician notes that the infant has good head control and can grasp a rattle but is unable to roll over, crawl, or pull to stand. What should the clinician explain to the mother?

a) Her child is progressing normally and does not need further evaluation.
b) Gross motor development proceeds from peripheral skills, such as finger feeding, to
central skills, such as sitting.
c) Delays in gross motor skills are usually because of lack of coordination and catch up as the child ages.
d) As long as the child is babbling, delays in gross motor skills are not a concern.
e) The delay in his physical motor skills is concerning and warrants a more complete developmental history and possible referral for early intervention

Answer 295

e) The delay in his physical motor skills is concerning and warrants a more complete developmental history and possible referral for early intervention

Question 296

In caring for children, physicians and other clinicians need to understand child development. Of
the following, which is a principle of normal child development?

a) All delays in development can be explained by one or two risk factors.
b) Child development proceeds along a predictable pathway in a healthy child.
c) Regression in developmental skills is not a cause for concern.
d) There is minimal variation in when children achieve milestones.
e) A child’s developmental level can be ignored in conducting an examination.

Answer 296

b) Child development proceeds along a predictable pathway in a healthy child.

Question 297

The nurse in the newborn nursery reports that she is concerned about Baby Boy Jones, who was born full‐term by cesarean section for failure to progress. The pregnancy was complicated only by a maternal urinary tract infection in the first trimester. He had APGARs of 9 and 10 at 1 and 5 minutes, respectively, and had been doing well. However, now, on the fourth day of life, the infant has developed a tremor. Which of the following factors would cause the most concern
about the tremor?

a) The infant lies in a symmetric position with limbs flexed when relaxed.
b) The infant’s vital signs are normal.
c) The infant also has asymmetric limb movements.
d) The tremor is brief and only present when the infant is crying vigorously.
e) There is a history of benign tremor in elderly family members

Answer 297

c) The infant also has asymmetric limb movements.

Question 298

A newborn who is floppy and limp, blue in color, with a heart rate of 60, and minimal respiratory
effort has just been delivered. The infant has no grimace and only a very weak cry. What is the
best immediate response to the infant in this situation?

a) Order a chest x‐ray.
b) Suction the infant’s mouth while waiting to calculate the 5‐minute APGAR score.
c) Dry the infant off and swaddle him.
d) Discuss the infant’s poor appearance with the parents who are both in the room.
e) Begin neonatal resuscitation.

Answer 298

e) Begin neonatal resuscitation.

Question 299

A mother brings her 15‐month‐old toddler to the clinic for his preventive health care visit. The clinician takes the history and observes the child’s interactions and behaviors and is then ready to begin the rest of the examination. Which of the following best describes the general approach to the pediatric examination of the young child?

a) Begin with least invasive parts of the examination first.
b) Children age <2 years do not need to be examined.
c) Always give immunizations prior to beginning the examination.
d) Examine the child in the same order as for an adult patient.
e) Never examine a young child in the mother’s lap

Answer 299

a) Begin with least invasive parts of the examination first.

Question 300

A clinician is reading the chart of a full‐term newborn whose mother had an uneventful pregnancy
in the hospital for the first time on the day of birth. In reviewing the infant’s chart, the clinician
notes that, in the delivery room, at 5 minutes, the infant had a heart rate >100, strong
respiratory effort, was crying vigorously, moving actively, and had good color except for some
acrocyanosis of the hands and feet. This infant’s APGAR score is closest to which of the following

a) 9
b) 7
c) 3
d) 5
e) 1

Answer 300

a) 9

Question 301

A clinician is meeting the mother of a 5‐year‐old with asthma for the first time. The mother notes that the asthma has been poorly controlled and that the child has had multiple hospitalizations. The clinician inquires about family stressors and finds that the parents are divorced, the mother recently lost her job, and the child spent 2 months living with her grandparents who both smoke. Which of the following is the best example of the role of health promotion with this family

a) Postpone vision and hearing screening because the child may not pass.
b) Reassure the parent that the family stressors are not impacting the child’s asthma.
c) Delay immunizations because of the family stressors.
d) Plan less frequent pediatric visits because the family will take too much time.
e) Develop a health promotion plan that includes more frequent visits and guidance to assist family with stressors and improve the child’s asthma symptoms.

Answer 301

e) Develop a health promotion plan that includes more frequent visits and guidance to assist family with stressors and improve the child’s asthma symptoms.

Question 302

The parents of a 21‐month‐old child explain that their son used to speak nearly 50 words and was using 2‐word phrases. In the last month or so, the child has not been using as many words and tends to echo what is being said to him rather than use language spontaneously. They want to know if this is normal. After taking a thorough developmental history, the clinician finds that the child makes poor eye contact and does not play with toys in a purposeful manner. The physical examination is normal except for the child’s limited social interactions. There is a family history of autism in two first cousins. Which of the following would be the best response to the parents at
this time?

a) Send the child to the Emergency Department (ED).
b) Refer the parents for mental health counseling.
c) Refer the child to a developmental and behavioral pediatrician.
d) Reassure the parents that all toddlers lose skills at some point in development.
e) Reassure the parents that the child is fine as long as he has not lost skills in other domains

Answer 302

c) Refer the child to a developmental and behavioral pediatrician.

Question 303

A clinician arrives at the hospital several hours after the birth of a full‐term infant. The infant is rooming in with her parents and appears to be doing well. There were no problems with the pregnancy, labor, or delivery. The nurse asks if the baby should be taken back to the nursery for examination. What is the best response to the nurse?

a) State that the infant should be examined in the presence of the parents so they can be taught about what their newborn can do.
b) Refer the parents to a good book on newborns and wheel the infant back to the newborn nursery to conduct the examination.
c) State that it will be much more efficient to conduct the examination in the nursery.
d) Note that the infant already had an examination in the delivery room and does not need another examination so soon.
e) Note that the lighting is better in the newborn nursery.

Answer 303

a) State that the infant should be examined in the presence of the parents so they can be taught about what their newborn can do.

Question 304

Heart Murmurs

• Distinct heart sounds distinguished by what?
• Attributed to turbulent blood flow and usually indicate what?

Answer 304

• Distinct heart sounds distinguished by their pitch and their longer duration
• Attributed to turbulent blood flow and usually indicate VALVULAR HEART DISEASE

Question 305

What is stenosis and regurgitation?

Answer 305

• Stenosis: stenotic valve has abnormally narrowed orifice that obstructs blood flow; such as aortic stenosis
• Regurgitation: Valves closing abnormally, result in regurgitation. Blood leaks backward in a retrograde direction and produces a regurgitant murmur

Question 306

Fill in

Answer 306

Question 307

What does jugular veins provide?

Answer 307

provide index of right heart pressures and cardiac function

Question 308

What occurs in aortic dissection?

Answer 308

*Anterior chest pain, often tearing or ripping and radiating into the back or neck, occurs in acute aortic dissection
*Tearing, ripping = aortic dissection

Question 309

What can palpitations be associated with? (not heart disease)

Answer 309

• Anxiety
• Hyperthyroid (women over 40)
• Electrolyte imbalance (high or low potassium)
• Drug or stimulant

Question 310

What is dyspnea? What are causes?

Answer 310

Dyspnea is an uncomfortable awareness of breathing that is inappropriate to a given level of exertion.
* Cardiac or pulmonary
* Sudden dyspnea occurs in pulmonary embolus,
spontaneous pneumothorax, and anxiety

Question 311

What is orthopnea? How is it quantified?

Answer 311

Orthopnea is dyspnea that occurs when the pt is supine and improves when sits up
* Quantified by the number of pillows pt uses for sleeping or by the fact that the pt needs to sleep sitting up (recliner)

Question 312

What is Paroxysmal Nocturnal Dyspnea(PND)

Answer 312

awakens pt suddenly about 1-2 hours after falling asleep due SOB

Question 313

What are edema casues?

Answer 313

• Cardiac: right or left ventricular dysfunction, pulmonary hypertension
• Pulmonary: obstructive lung disease
• Nutrition: hypoalbuminemia
• Nephrotic syndrome (rings and eyes)
• Positional: dependent edema
• Anasarca: severe generalized edema extending to the sacrum and abdomen

Question 314

Key components of the CV exam

• What do you need to auscultate (not carotid)?

Answer 314

• Auscultate and recognize abnormal sounds in early diastole, including an S3 and OS of mitral stenosis and an S4 later in diastole.

Question 315

What are we looking for with JVP?

Answer 315

JVP measured at >3 cm above the sternal angle, or more than 8 cm in total distance above the right atrium, is considered elevated above normal.

Question 316

Answer 316

Question 317

What are you feeling for in palpations? (precordium)

Answer 317

• Heave
• Thrill
• Apical impulse and PMI

Question 318

What are heaves and thrills? What causes them?

Answer 318

.

Question 319

For the Point of Maximal Impulse (PMI), What do you locate and describe?

Answer 319

• Locate two points: intercostal spaces (usually 5th, maybe 4th) and distance in cm from the midclavicular line or midsternal line
• Describe the PMI in relation to the midsternal or midclavicular line, or anterior axillary line if displaced

Question 320

For heart murmurs: what do you need to do?

Answer 320

• Time the murmur – Systole or diastole? Duration?
  * Murmurs that coincide with the carotid upstroke are systolic
• Location on the precordium the murmur is loudest – at the base, along the sternal border, at the apex? Does it radiate?
• Conduct any necessary maneuvers, such as lean forward and exhale or turn to the left lateral decubitus position to accentuate the murmurs

Question 321

What are systolic murmurs?

Answer 321

Murmurs that coincide with the carotid upstroke are systolic

Question 322

What should you do for mitral stenosis in the left lateral decubitus?

Answer 322

• Brings LV closer to the chest wall
• Place the bell (if you have a bell) of your stethoscope lightly on the apical impulse

Question 323

What do you do for Aortic Regurgitation with pt leaning forward?

Answer 323

• Ask the patient to sit up, lean forward, exhale completely, and stop breathing
• Use diaphragm, listen along the left sternal border and at the apex

Question 324

Crescendo, decrescendo, or both (sometimes called diamond-shaped), is an example of what?

Answer 324

Systolic Murmur of aortic stenosis

Question 325

For a plateu shape, what is an example?

Answer 325

holosystolic murmur of mitral regurgitation

Question 326

What are murmur graded on intensity?

Answer 326

Intensity: grade the murmur on a scale of 1 to 6
* Grades 4 through 6 must have accompanying thrill

Question 327

Answer 327

Question 328

What does a mitral and aortic regurgitation sound like?

Answer 328

• Harsh 2/6 medium-pitched holosystolic murmur best heard at the apex describes mitral regurgitation
• Soft, blowing 3/6 decrescendo diastolic murmur best heard at the lower left sternal border describes aortic regurgitation

Question 329

What are the arterial pulses in arms (3)

Answer 329

o Brachial: at bend of elbow just medial to biceps tendon
o Radial: lateral flexor surface at wrist
o Ulnar: medial flexor surface (overlying tissues may obscure)

Question 330

What are the arterial pulses in the legs (4)?

Answer 330

o Femoral: below inguinal ligament
o Popliteal: passes medially behind the femur; palpable behind knee
o Dorsalis pedis: dorsum of foot; lateral to extensor tendon of big toe
o Posterior tibial: behind medial malleolus of ankle

Question 331

What are these?

Answer 331

Epitrochlear nodes

Question 332

What is the grading amplitude of the arterial pulses?

Answer 332

Question 333

How you do grade edema? ⭐️

Answer 333

• 1+ Slight pitting, no visible distortion, disappears rapidly
• 2+ Somewhat deeper pit than in 1+, but again no readily detectable distortion, & disappears in 10 to 15 seconds
• 3+ Pit is noticeably deep & may last more than a minute; the dependent extremity looks fuller & swollen
• 4+ Pit is very deep, lasts as long as 2-5 min, & dependent extremity is grossly distorted

Question 334

What should you suspect if the edema is unilateral? bilateral? Edema without pitting?

Answer 334

• If edema unilateral, suspect occlusion of a major vein
• If edema bilateral, consider CHF
• If edema occurs without pitting, suspect arterial disease & occlusion

Question 335

What is the allen test?

Answer 335

Question 336

What are signs of venous insufficiency?

Answer 336

• Thrombosis
• Varicose veins
• Edema

Question 337

What are signs of DVT?

Answer 337

Increase calf size, red, warm, painful

Question 338

On routine physical examination, a 40-year-old teacher is found to have a single second heart sound. The most likely explanation for this finding is what?

A. Auscultation occurred during inspiration.
B. The patient has a right bundle branch block.
C. Auscultation occurred during expiration.
D. The patient has pulmonic stenosis.
E. The patient has a left bundle branch block

Answer 338

C. Auscultation occurred during expiration.

Question 339

A first-year medical student is examining a standardized patient with a structurally normal heart. The student is having difficulty auscultating the splitting of the second heart sound. At what area on the patient’s chest would the student have the best opportunity of hearing this sound?

A. Left second and third interspace
B. Lower left sternal border
C. Apex
D. Right second interspace
E. Midsternum

Answer 339

A. Left second and third interspace

Question 340

77-year-old man is experiencing progressive shortness of breath and dizziness. The patient undergoes cardiac catheterization, and the systolic blood pressure measured in the left ventricle is 180 mm Hg, while the systolic blood pressure measured in the aorta is 140 mm Hg. The patient is most likely experiencing symptoms related to what valvular condition?

A. Aortic stenosis
B. Pulmonic stenosis
C. Aortic insufficiency
D. Mitral stenosis
E. Mitral regurgitation

Answer 340

A. Aortic stenosis

Question 341

A 45-year-old physician is placed on a β-blocker for hypertension. Prior to medication administration, the patient’s heart rate is 75 beats per minute with a cardiac output of 5 liters per minute. Following initiation of the medication, the heart rate decreases to 60 beats per minute without a change in stroke volume. What would be the expected new cardiac output?

Answer 341

4 L per min

CO = HR x SV

Question 342

An elderly patient with a history of smoking two packs of cigarettes a day for 50 years complains to her physician of progressive shortness of breath. On cardiac examination, the physician feels the most prominent palpable impulse to be in the xiphoid area. This is most likely a result of what condition?

A. Mitral regurgitation
B. Pulmonary hypertension
C. Aortic stenosis
D. Hypertrophic cardiomyopathy
E. Hypertension

Answer 342

B. Pulmonary hypertension

Question 343

A 55-year-old actress sustains a heart attack and the follow-up electrocardiogram demonstrates a left bundle branch block. What would be the likely duration of the QRS complex?

100 milliseconds

75 milliseconds

95 milliseconds

125 milliseconds

90 milliseconds

Answer 343

125 ms

Question 344

A newborn baby has an embryologic defect affecting the aortic valve. What other cardiac valve is most likely to be affected?

A. Pulmonic valve
B. Pyloric valve
C. Mitral valve
D. Eustachian valve
E. Tricuspid valve

Answer 344

A. Pulmonic valve

Question 345

A 55-year-old truck driver with obstructive sleep apnea has diastolic heart failure. An echocardiogram demonstrates significant biatrial enlargement. What portion of his electrocardiogram would likely be abnormal?

QRS complex

S wave

R wave

P wave

T wave

Answer 345

P wave
* P wave is the result of atrial depolarization and would therefore have changes associated with atrial enlargement

Question 346

A 70-year-old retired business executive presents to the Emergency Department with progressive shortness of breath and two-pillow orthopnea. On physical examination, the blood pressure is 145/90 mm Hg, there is jugular venous distension, lower extremity pitting edema to the knee, and a blowing holosystolic murmur heard best at the lower left sternal border. No other murmurs or thrills are auscultated on physical exam. Which of the following interventions is to most likely to improve the patient’s symptoms?

A. Repair of a ventricular septal defect
B. Decrease in blood pressure
C. Replacement of the mitral valve
D. Replacement of the aortic valve
E. Removal of intravascular volume with diuresis

Answer 346

E. Removal of intravascular volume with diuresis

Question 347

A 20-year-old college student is experiencing dyspnea on exertion and palpitations. On cardiac auscultation, the second heart sound is split and fixed on both inspiration and expiration. What is the most likely cardiac condition associated with this finding?

A. Right bundle branch block
B. Tricuspid stenosis
C. Pulmonic stenosis
D. Left bundle branch block
E. Atrial septal defect

Answer 347

E. Atrial septal defect