NSG 464 LATEST MIDTERM EXAM 2025 PHYSICAL
ASSESSMENT FOR ADVANCED PRACTICE CALIFORNIA
STATE UNIVERSITY
A 21 year-old college senior presents to your clinic, complaining of SOB and a nonproductive
nocturnal cough. She states she used to feel this way only with extreme exercise, but lately
has felt this way continuously. She denies any other upper respiratory symptoms, chest pain,
gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant
only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no
other medications. She has had no surgeries. Her mother has allergies and eczema and her
father has high blood pressure. She is an only child. She denies smoking and illegal drug use
but drinks 3-4 alcoholic beverages per weekend. She is a junior in finance at a local university
and she has recently started a job as a bartender in town. On examination she is in no acute
distress and her temperature is 98.6F. Her BP is 120/80, HR is 80, and RR is 20. Her head,
C. Asthma
Rationale: Asthma causes SOB and nocturnal cough. It is often less associated with a history of
allergies and can be made worse by exercise or irritants such as smoke in a bar. On auscultation
there can be normal to decreased air movement. Wheezing is heard on expiration and
sometimes inspiration. The duration of wheezing in expiration usually correlates with severity
of illness, so it is important to document this length (e.g. wheezes heard halfway through
exhalation). Realize that in severe asthma, wheezes may not be heard because of the lack of air
movement. Paradoxically, these pts. may have more wheezes after treatment, which actually
indicates an improvement in condition. Peak flow measurements help to discern this
A 47 year-old receptionist comes to your office complaining of fever, SOB, and productive
cough with golden sputum. She says she had a cold last week and her symptoms have only
gotten worse despite using OTC cold remedies. She denies any weight gain, weight loss, or
cardiac or GI symptoms. Her past medical history includes T2DM for 5 years and high
cholesterol. She take an oral medication for both diseases. She has had no surgeries. She
denies tobacco, alcohol, or drug use. Her mother has DM and HTN. Her father passed away
from colon cancer. On examination you see a middle-aged woman appearing her stated age.
She looks ill and her temperature is elevated at 101F. Her BP and HR are unremarkable. Her
HEENT examinations are unremarkable except for edema of the nasal turbinates. On
auscultation, she had deceased air movement and course crackles are heard over the LLL.
There is dullness on percussion, increased remits dur
,D. Pneumonia
Rationale: Pneumonia is usually associated with dyspnea, cough, fever. On auscultation there
can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is
dull and there is often and increase in fremitus. Egophony and pectriloquy are heard because of
increased transmission of high-pitched components of sounds. These higher frequencies are
usually filtered out by the multiple air-filled chambers of the alveoli.
A 17 y/o high school senior presents to your clinic in acute respiratory distress. Between
shallow breaths he states he was at home finishing his homework when he suddenly began
having right-sided chest pain and severe SOB. He denies any recent traumas or illnesses. His
past medical history is unremarkable. He doesn't smoke but drinks several beers on the
weekend. He has tried marijuana several times but denies any other illegal drugs. He is an
honors student and is on the basketball team. His parents are both in good health. He denies
and recent weight gain, weight loss, fever, or night sweats. His is diaphoretic and breathing at
a rate of 35 breaths/min. On auscultation you hear no breath sounds on the right side of his
superior chest wall. On percussion he is hyper-resonant over the RUL. With palpation he has
absent fremitus over the RUL. What disorder of the thorax best describes his symptoms?
A. Spontaneous pneu
A. Spontaneous pneumothorax
Rationale: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain
on the affected side. It is more common in thin young male. On auscultation of the affected
side, there will be no breath sounds; and on percussion there is hyperresonance or tympany.
There will be an absence of fremitus too palpation. Given this young man's habits and
pneumothorax, you may consider looking for features of Marfan syndrome. Read more about
this condition
A 62 year-old construction worker presents to your clinic complaining of almost a year
chronic cough and occasional SOB. Although he has had worsening of symptoms occasionally
with a cold, his symptoms have stayed about the same. The cough has occasional mucous
drainage but never any blood. He denies any chest pain. He has had no weight gain, weight
loss, fever, or night sweats. His past medical history is significant for HTN and arthritis. He has
smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal
drug use. He is married and has two children. He denies any foreign travel. His father died of
a heart attack and his mother died of Alzheimer's disease. On examination you see a man
looking slightly older than his stated age. HIs BP is 130/80, HR is 88. He is breathing
comfortably with RR 12. HIs HEENT examinations are unremarkable. His cardiac examination
is normal. On examination
,B. COPD
Rationale: This disorder is insidious in onset and generally affected the older population with a
smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest
elicits hyperresonance, and during auscultation there are often distant breath sounds. Coarse
breath sounds of rhonchi are also often heard. It is important to quantify this patient's exercise
capacity because it may affect his employment and also allows you to follow for progression of
his disease. You must offer smoking cessation as an option.
A 36 year-old teacher presents to your clinic complaining of sharp, knifelike pain on the side
of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting
forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to
any other area. She denies any upper respiratory or GI symptoms. Her past medical history
consists of systemic lupus. Her mother has hypothyroidism and her father has HTN. On exam
you find her to be distressed, leaning over and holding her left arm and hand to her left chest.
Her BP is 130/70, RR 12, HR 90. On auscultation her lung fields have normal breath sounds
with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable.
Auscultation of her heart has S1 and S2 with no S3 or S4. A scratching noise is heard at the
lower left sternal border consistent with systole; leaning forward relieves some of her pain.
She is tender
B. Pericarditis
Rationale: The pain from pericarditis is usually sharp and knifelike and is located over the left
side of the chest. Change of position, breathing, and coughing often make the pain worse;
whereas leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases
such as systemic lupus and in patient with chronic kidney disease. Patients also experience this
after a myocardial infarction. You can read more about Dressler's syndrome
A 68 year-old retired postman presents to your clinic complaining of dull intermittent left-
sided chest pain over the last few weeks. Th pain occurs after he mows his lawn or chops
wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt
light-headed and nauseated with the pain but has no other symptoms. He states when he sits
down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not
improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats.
He has a past medical history of HTN and arthritis. He quit smoking 10 years ago after
smoking one pack a day for 40 years. He denies any recent alcohol use use and reports no
drug use. He is married and has 2 healthy children. His mother died of breast cancer and his
father died of a stroke. His younger brother has has bypass surgery. On examination you find
him healthy-appearin
, A. Angina pectoris
Rationale: Angina causes dull chest pain felt in the retrosternal area or anterior chest. It often
radiates to the shoulders, arms, neck, and jaw. It is associated with SOB, nausea, and sweating.
The pain is generally relieved by rest or medication after several minutes. This patient needs to
be admitted to the hospital for further workup for his accelerating symptoms
A 75 year-old retired teacher presents to your clinic complaining of severe unrelenting
anterior chest pain radiating to her back. She describes it as if someone is
"ripping out her heart". It began less than an hour ago. She states she is feeling very
nauseated and might pass out. She denies any trauma or recent illnesses. She states she has
never had pain like this before. Nothing seems to make the pain better or worse. Her medical
history consists of difficult-to-control HTN and CAD requiring two stents in the past. She is a
widow. She denies alcohol, tobacco, and illegal drug use. Her mother died of a stroke and her
father died of a heart attack. She has one younger brother who has had bypass surgery. On
examination you see an elderly female in a great deal of distress. She is lying on the table,
curled up, holding her left and right arms against her chest and is restless trying to find a
comfortable position. H
C. Dissecting aortic aneurysm
Rationale: A dissecting aortic aneurysm is associated with a ripping or tearing sensation that
radiates to the neck, back, or abdomen. Because blood supply to the brain and extremities is
disrupted, syncope and paraplegia or hemiplegia can occur. BP will usually be different between
the two arms, and the carotid pulses often show asymmetry. This is because the aneurysm
decreases flow distally and causes inequality of flow between sides
A 19 y/o college student, Todd, is brought to your clinic by his mother. She is concerned that
there is something seriously wrong with him. She states for the past 6 months his behavior
has become peculiar and he has flunked out of college. Todd denies any recent illness or
injuries. His past medical history is remarkable only for a broken foot. His parents are both
healthy. He has a paternal uncle who had similar symptoms in college. The patient admits to
smoking cigarettes and drinking alcohol. He also admits to marijuana use but none in the last
week. He denies using any other substances. He denies any feelings of depression or anxiety.
While speaking with Todd and his mother you do a complete physical examination, which is
essentially normal. When you question him on how he is feeling, he says that he is very
worried that Microsoft has stolen his software for creating a better browser. He tells you he
has seen a
ASSESSMENT FOR ADVANCED PRACTICE CALIFORNIA
STATE UNIVERSITY
A 21 year-old college senior presents to your clinic, complaining of SOB and a nonproductive
nocturnal cough. She states she used to feel this way only with extreme exercise, but lately
has felt this way continuously. She denies any other upper respiratory symptoms, chest pain,
gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant
only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no
other medications. She has had no surgeries. Her mother has allergies and eczema and her
father has high blood pressure. She is an only child. She denies smoking and illegal drug use
but drinks 3-4 alcoholic beverages per weekend. She is a junior in finance at a local university
and she has recently started a job as a bartender in town. On examination she is in no acute
distress and her temperature is 98.6F. Her BP is 120/80, HR is 80, and RR is 20. Her head,
C. Asthma
Rationale: Asthma causes SOB and nocturnal cough. It is often less associated with a history of
allergies and can be made worse by exercise or irritants such as smoke in a bar. On auscultation
there can be normal to decreased air movement. Wheezing is heard on expiration and
sometimes inspiration. The duration of wheezing in expiration usually correlates with severity
of illness, so it is important to document this length (e.g. wheezes heard halfway through
exhalation). Realize that in severe asthma, wheezes may not be heard because of the lack of air
movement. Paradoxically, these pts. may have more wheezes after treatment, which actually
indicates an improvement in condition. Peak flow measurements help to discern this
A 47 year-old receptionist comes to your office complaining of fever, SOB, and productive
cough with golden sputum. She says she had a cold last week and her symptoms have only
gotten worse despite using OTC cold remedies. She denies any weight gain, weight loss, or
cardiac or GI symptoms. Her past medical history includes T2DM for 5 years and high
cholesterol. She take an oral medication for both diseases. She has had no surgeries. She
denies tobacco, alcohol, or drug use. Her mother has DM and HTN. Her father passed away
from colon cancer. On examination you see a middle-aged woman appearing her stated age.
She looks ill and her temperature is elevated at 101F. Her BP and HR are unremarkable. Her
HEENT examinations are unremarkable except for edema of the nasal turbinates. On
auscultation, she had deceased air movement and course crackles are heard over the LLL.
There is dullness on percussion, increased remits dur
,D. Pneumonia
Rationale: Pneumonia is usually associated with dyspnea, cough, fever. On auscultation there
can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is
dull and there is often and increase in fremitus. Egophony and pectriloquy are heard because of
increased transmission of high-pitched components of sounds. These higher frequencies are
usually filtered out by the multiple air-filled chambers of the alveoli.
A 17 y/o high school senior presents to your clinic in acute respiratory distress. Between
shallow breaths he states he was at home finishing his homework when he suddenly began
having right-sided chest pain and severe SOB. He denies any recent traumas or illnesses. His
past medical history is unremarkable. He doesn't smoke but drinks several beers on the
weekend. He has tried marijuana several times but denies any other illegal drugs. He is an
honors student and is on the basketball team. His parents are both in good health. He denies
and recent weight gain, weight loss, fever, or night sweats. His is diaphoretic and breathing at
a rate of 35 breaths/min. On auscultation you hear no breath sounds on the right side of his
superior chest wall. On percussion he is hyper-resonant over the RUL. With palpation he has
absent fremitus over the RUL. What disorder of the thorax best describes his symptoms?
A. Spontaneous pneu
A. Spontaneous pneumothorax
Rationale: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain
on the affected side. It is more common in thin young male. On auscultation of the affected
side, there will be no breath sounds; and on percussion there is hyperresonance or tympany.
There will be an absence of fremitus too palpation. Given this young man's habits and
pneumothorax, you may consider looking for features of Marfan syndrome. Read more about
this condition
A 62 year-old construction worker presents to your clinic complaining of almost a year
chronic cough and occasional SOB. Although he has had worsening of symptoms occasionally
with a cold, his symptoms have stayed about the same. The cough has occasional mucous
drainage but never any blood. He denies any chest pain. He has had no weight gain, weight
loss, fever, or night sweats. His past medical history is significant for HTN and arthritis. He has
smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal
drug use. He is married and has two children. He denies any foreign travel. His father died of
a heart attack and his mother died of Alzheimer's disease. On examination you see a man
looking slightly older than his stated age. HIs BP is 130/80, HR is 88. He is breathing
comfortably with RR 12. HIs HEENT examinations are unremarkable. His cardiac examination
is normal. On examination
,B. COPD
Rationale: This disorder is insidious in onset and generally affected the older population with a
smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest
elicits hyperresonance, and during auscultation there are often distant breath sounds. Coarse
breath sounds of rhonchi are also often heard. It is important to quantify this patient's exercise
capacity because it may affect his employment and also allows you to follow for progression of
his disease. You must offer smoking cessation as an option.
A 36 year-old teacher presents to your clinic complaining of sharp, knifelike pain on the side
of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting
forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to
any other area. She denies any upper respiratory or GI symptoms. Her past medical history
consists of systemic lupus. Her mother has hypothyroidism and her father has HTN. On exam
you find her to be distressed, leaning over and holding her left arm and hand to her left chest.
Her BP is 130/70, RR 12, HR 90. On auscultation her lung fields have normal breath sounds
with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable.
Auscultation of her heart has S1 and S2 with no S3 or S4. A scratching noise is heard at the
lower left sternal border consistent with systole; leaning forward relieves some of her pain.
She is tender
B. Pericarditis
Rationale: The pain from pericarditis is usually sharp and knifelike and is located over the left
side of the chest. Change of position, breathing, and coughing often make the pain worse;
whereas leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases
such as systemic lupus and in patient with chronic kidney disease. Patients also experience this
after a myocardial infarction. You can read more about Dressler's syndrome
A 68 year-old retired postman presents to your clinic complaining of dull intermittent left-
sided chest pain over the last few weeks. Th pain occurs after he mows his lawn or chops
wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt
light-headed and nauseated with the pain but has no other symptoms. He states when he sits
down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not
improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats.
He has a past medical history of HTN and arthritis. He quit smoking 10 years ago after
smoking one pack a day for 40 years. He denies any recent alcohol use use and reports no
drug use. He is married and has 2 healthy children. His mother died of breast cancer and his
father died of a stroke. His younger brother has has bypass surgery. On examination you find
him healthy-appearin
, A. Angina pectoris
Rationale: Angina causes dull chest pain felt in the retrosternal area or anterior chest. It often
radiates to the shoulders, arms, neck, and jaw. It is associated with SOB, nausea, and sweating.
The pain is generally relieved by rest or medication after several minutes. This patient needs to
be admitted to the hospital for further workup for his accelerating symptoms
A 75 year-old retired teacher presents to your clinic complaining of severe unrelenting
anterior chest pain radiating to her back. She describes it as if someone is
"ripping out her heart". It began less than an hour ago. She states she is feeling very
nauseated and might pass out. She denies any trauma or recent illnesses. She states she has
never had pain like this before. Nothing seems to make the pain better or worse. Her medical
history consists of difficult-to-control HTN and CAD requiring two stents in the past. She is a
widow. She denies alcohol, tobacco, and illegal drug use. Her mother died of a stroke and her
father died of a heart attack. She has one younger brother who has had bypass surgery. On
examination you see an elderly female in a great deal of distress. She is lying on the table,
curled up, holding her left and right arms against her chest and is restless trying to find a
comfortable position. H
C. Dissecting aortic aneurysm
Rationale: A dissecting aortic aneurysm is associated with a ripping or tearing sensation that
radiates to the neck, back, or abdomen. Because blood supply to the brain and extremities is
disrupted, syncope and paraplegia or hemiplegia can occur. BP will usually be different between
the two arms, and the carotid pulses often show asymmetry. This is because the aneurysm
decreases flow distally and causes inequality of flow between sides
A 19 y/o college student, Todd, is brought to your clinic by his mother. She is concerned that
there is something seriously wrong with him. She states for the past 6 months his behavior
has become peculiar and he has flunked out of college. Todd denies any recent illness or
injuries. His past medical history is remarkable only for a broken foot. His parents are both
healthy. He has a paternal uncle who had similar symptoms in college. The patient admits to
smoking cigarettes and drinking alcohol. He also admits to marijuana use but none in the last
week. He denies using any other substances. He denies any feelings of depression or anxiety.
While speaking with Todd and his mother you do a complete physical examination, which is
essentially normal. When you question him on how he is feeling, he says that he is very
worried that Microsoft has stolen his software for creating a better browser. He tells you he
has seen a
