Summary Bates' Guide To Physical Examination and History Taking - Chapters for Midterm Summer 2023_ Questions & Answers.

Bates' Guide To Physical Examination and History Taking - Chapters for Midterm 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 A physician assistant (PA) has had a long day and has seen many patients. The last patient of the day 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 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. 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 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 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 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 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. 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. 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. 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 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. A 23‐year‐old farm worker submits urine for testing. Three test strips from Container A show abnormally low pH levels in the urine. However, three test strips from Container B, purchased more recently, consistently indicate that the pH of this patient's urine is normal. Which of the following is a true statement about the test strips? a) The test strips demonstrate high specificity. b) The test strips demonstrate high interobserver reliability. c) The test strips demonstrate high intraobserver reliability. d) The test strips demonstrate low intraobserver reliability. e) The test strips demonstrate high sensitivity. A 45‐year‐old forklift driver presents to the clinic at 4 o'clock in the afternoon complaining of intense substernal chest pain and nausea. He appears pale and sweaty. At work that day, he filled in for an absent co‐worker and was asked to perform heavy lifting not normally a part of his job. The physician assistant (PA) questions the patient in detail about his nausea, eating habits, and digestive history. Which of the following steps of clinical reasoning has the PA failed to follow? a) Elicit information about the patient's family history of digestive disorders b) Match findings against conditions that could cause them c) Localize findings anatomically d) Give special consideration to potential life‐threatening problems e) Elicit information about the patient's gastrointestinal (GI) system The positive predictive value of a test is calculated as the number of true positives identified by the test divided by the total positives found by the test. If a novel test for strep throat yields 150 true‐positive results and 150 false‐positive results, what is the positive predictive value of this test? a) 50% b) 10% c) 75% d) 25% e) 100% 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? a) 15% b) 75% c) 99% d) 85% e) 10% 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. 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 A theoretical laboratory test for infection with HIV is known to have high sensitivity. This means that the test has which of the following? a) Good ability to diagnose AIDS b) High intraobserver reliability c) Good ability to rule in HIV in those who do have HIV d) High interobserver reliability e) Good ability to rule out HIV in those who do not have HIV A theoretical new laboratory test for strep throat has high specificity. When a test has high specificity, clinicians can be confident in which of the following aspects? a) If the test result is positive, a confirmatory test should be performed. b) If the test result is positive, the patient probably does not have strep throat. c) If the test result is negative, the patient probably does not have strep throat. d) If the test result is negative, the patient probably has strep throat. e) If the test result is positive, the patient probably has strep throat. 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 Weight change may indicate the presence of important underlying pathology requiring further investigation. Which of the following best describes a significant weight change that requires further evaluation? a) A 31‐year‐old male with a baseline body mass index (BMI) of 20 who loses 3 lb after a prolonged bout of infectious gastroenteritis b) A 32‐year‐old female with a baseline weight of 175 lb who checks her weight irregularly but reports a 5‐lb unintended weight loss over 3 months c) A 45‐year‐old recently menopausal female who gains 5% beyond her baseline weight of 140 lb in 6 months d) A 45‐year‐old male with baseline weight of 280 lb who decides to undertake a light exercise regimen and loses 15% of his total body weight in 3 months e) A 26‐year‐old female with a baseline body mass index (BMI) of 25 who loses 5% of her body weight with 6 months of diet and exercise modification 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. . 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 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. . 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. 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 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 . 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. 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. . 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. 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 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" "Instability in interpersonal relations, self‐image, and affective regulation; impulsivity" describes which personality disorder? a) Antisocial personality b) Avoidant personality c) Histrionic personality d) Narcissistic personality e) Borderline personality A 38‐year‐old accountant presents to the office with a series of generalized complaints. He relates that he feels a loss of pleasure in daily activities, has difficulty sleeping, and is experiencing problems making decisions. Which of the following best explains the patient's presentation? a) Histrionic personality b) Antisocial personality c) Substance abuse with anhedonia d) Bipolar disorder in the early pre‐excitatory phase e) Depression 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. 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. Abstract thinking is an important component of the human thought process. A person's ability to understand questions that test his or her ability to answer appropriately is dependent upon a number of factors. Which one of the following answers is true in identifying a patient with concrete thinking and a reduced ability to think abstractly? a) An inability to name the occupations of common well‐known public figures such as the President and Vice President b) An inability to correctly perform serial 7s c) An inability to discern the similarity between two words (e.g., a cat and a mouse by answering "The cat chases the mouse.") d) An inability to spell "world" backward e) An inability to draw a clock correctly including all numbers and make it tell time as requested (i.e., 10:15) Which of the following statements is true concerning the mini‐mental status exam (MMSE)? a) It is recommended that clinicians perform the examination in all adults age >65 years regardless of symptoms. b) It is standardized and unaffected by education level or primary language. c) It is a proprietary screening test that is not diagnostic of probable causes. d) It identifies both memory deficits as well as early loss of executive functioning. e) It can provide a differential diagnosis as to probable causes of cognitive impairment. 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. 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 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. . 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 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. 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. 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 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. 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. 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 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 A 55‐year‐old woman with a headache explains to the clinician that she has had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation? a) The patient lost her glasses. b) The headache comes and goes. c) The headache is similar in nature to prior ones she has had for decades but more severe. d) The patient also has developed fever and night sweats and thinks she lost some weight. e) The patient had a car accident and minor head trauma about 3 months ago. In the case of a middle‐aged female with a pounding headache, what is an effective question to ask the patient? a) Is she feeling stressed? b) Does she think she is losing her memory? c) Has she ever seen anyone with a stroke? d) Does the patient have any aura prior to the headaches? e) How old is the patient? A 35‐year‐old female patient has had migraines for much of her adult life. Ather regular checkup, she is healthy, takes no medications except oral contraceptive pills (OCPs), exercises, and has a steady job. Her only complaint is that her migraines seem to have become worse, and, for the past few weeks, she has been waking up at night with headache and also nausea. Which of the following is the best course of action? a) Take a further history and perform a very careful neurological examination. b) Prescribe a strong medication for her migraines. c) Reassure her that this is a common pattern with migraines. d) Order studies to evaluate potential transient ischemic attacks (TIAs) because she is on OCPs. e) Treat her for sinusitis. 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. 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." 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 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 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 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 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 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) Stridor b) Flatness c) Hyperresonance d) Dullness e) Tympany 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? a) Auscultation, inspection, palpation, and percussion b) Palpation, inspection, auscultation, and percussion c) Auscultation, percussion, palpation, and inspection d) Inspection, auscultation, percussion, and palpation e) Auscultation, inspection, palpation, and percussion f) Inspection, palpation, percussion, and auscultation 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) Wheezes c) Stridor d) Rhonchi e) Pleural rub 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? a) Put the third and fourth fingers next to each other on the chest. b) Strike using the finger pad of the fourth finger. c) Strike using the tip of the third finger. d) The proximal interphalangeal joint is the joint that is struck. e) The wrist is kept still during percussion. 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) Pectus excavatum b) Flail chest c) Thoracic kyphoscoliosis d) Pigeon chest e) Barrel chest 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) Anxiety b) Asthma c) Left‐sided heart failure d) Aspiration of a foreign body e) Pneumonia 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) Tactile fremitus e) Bronchophony 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? a) Pneumonia b) Atelectasis c) Pneumothorax d) Left‐sided heart failure e) Chronic obstructive pulmonary disease (COPD) 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 suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib. c) 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. d) He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to 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. 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) Affable, associated manifestations, ask, admonish, available b) Arrange, aggravating factors, action, attitude, able c) Agitate, assist, alleviating factors, able, action d) Ask, advise, assess, assist, arrange e) Admonish, action, available, assess, alleviating factors 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) Neurogenic claudication b) Abdominal aortic aneurysm c) Peripheral arterial disease (PAD) d) Venous stasis e) Acute arterial occlusion 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) Iliac pudendal b) Popliteal c) Aortorenal d) Superficial femoral e) Common femoral 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) Pulmonary embolism (PE) b) Myocardial infarction (MI) c) Coarctation of the aorta d) Pericarditis e) Dissecting aortic aneurysm 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) Cervical chain nodes c) Infraclavicular nodes d) Central axillary nodes e) Lateral axillary nodes 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) Above the inguinal ligament, just medial to the anterior superior iliac spine c) Above the inguinal ligament, just lateral to the symphysis pubis d) Below the inguinal ligament, just lateral to the symphysis pubis e) Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis 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? a) Arterial arch of the foot b) Posterior tibial c) Dorsalis pedis d) Femoral e) Popliteal 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) Pulmonary embolism (PE) c) Superficial thrombophlebitis d) Ovarian metastasis e) Acute lymphangitis 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) Thrombus formation in a superficial vein b) Dilated arterioles c) Occluded arterial vessels d) Dilated veins secondary to incompetent valves e) Draining lymphatic channels 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) Romberg b) Trendelenburg c) Ankle-brachial index d) Allen e) Straight‐leg raise 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) Great saphenous b) Small saphenous c) Femoral d) Perforating e) Dorsal venous arch 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) Aortic stenosis c) Hypertrophic cardiomyopathy d) Hypertension e) Pulmonary hypertension A newborn baby has an embryologic defect affecting the aortic valve. What other cardiac valve is most likely to be affected? a) Pyloric valve b) Mitral valve c) Pulmonic valve d) Eustachian valve e) Tricuspid valve A 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) Mitral stenosis b) Aortic insufficiency c) Mitral regurgitation d) Aortic stenosis e) Pulmonic stenosis 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) Auscultation occurred during expiration. c) The patient has a right bundle branch block. d) The patient has a left bundle branch block. e) The patient has pulmonic stenosis. (ANSWER- b) Auscultation occurred during expiration. 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) Midsternum c) Right second interspace d) Lower left sternal border e) Apex 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) Pulmonic stenosis b) Left bundle branch block c) Right bundle branch block d) Tricuspid stenosis e) Atrial septal defect 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) Removal of intravascular volume with diuresis b) Replacement of the mitral valve c) Replacement of the aortic valve d) Decrease in blood pressure e) Repair of a ventricular septal defect 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? a) 95 milliseconds b) 100 milliseconds c) 75 milliseconds d) 90 milliseconds e) 125 milliseconds 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? a) S wave b) R wave c) P wave d) T wave e) QRS complex 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? a) 5 liters per minute b) 4 liters per minute c) 10 liters per minute d) 3 liters per minute e) 6 liters per minute