Bates' Guide to Physical Examination and History Taking 11th Edition by Lynn Bickley - Test Bank

Bates’ Guide to Physical Examination and History Taking, 11th Edition Chapter 4: Beginning the Physical Examination: General Survey, Vital Signs, and Pain Multiple Choice 1. A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter's weight. You measure her daughter's height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate? A) Refer the patient to a nutritionist and a psychologist because the patient is anorexic. B) Reassure the mother that this is a normal body weight. C) Give the patient information about exercise because the patient is obese. D) Give the patient information concerning reduction of fat and cholesterol in her diet because she is obese. Ans: B Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: The patient has a normal BMI; the range for a normal BMI is 18.5 to 24.9 kg/m2. You may be able to give the patient and her mother the lower limit of normal in pounds for her daughter's height, or instruct her in how to use a BMI table. 2. A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit? A) Refer the patient to a nutritionist because he is anorexic. B) Reassure the patient that he has a normal body weight. C) Give the patient information about reduction of fat, cholesterol, and calories because he is overweight. D) Give the patient information about reduction of fat and cholesterol because he is obese. Ans: C Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: The patient has a BMI in the overweight range, which is 25.0 to 29.9 kg/m2. It is prudent to give him information about reducing calories, fat, and cholesterol in his diet to help prevent further weight gain. 3. A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30.0 kg/m2. What is the most appropriate amount for a weekly weight reduction goal? A) .5 to 1 pound per week B) 1 to 2.5 pounds per week C) 2.5 to 3.5 pounds per week D) 3.5 to 4.5 pounds per week Ans: A Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: Based on the NIH Obesity Guidelines, this is the weekly weight loss goal to strive for to maintain long-term control of weight. More rapid weight loss than this does not result in a better outcome at one year. 4. A 67-year-old retired janitor comes to the clinic with his wife. She brought him in because she is concerned about his weight loss. He has a history of smoking 3 packs of cigarettes a day for 30 years, for a total of 90 pack-years. He has noticed a daily cough for the past several years, which he states is productive of sputum. He came into the clinic approximately 1 year ago, and at that time his weight was 140 pounds. Today, his weight is 110 pounds. Which one of the following questions would be the most important to ask if you suspect that he has lung cancer? A) Have you tried to force yourself to vomit after eating a meal? B) Do you have heartburn/indigestion and diarrhea? C) Do you have enough food to eat? D) Have you tried to lose weight? Ans: D Chapter: 04 Page and Header: 102, The Health History Feedback: This is important: If the patient hasn't tried to lose weight, then this weight loss is inadvertent and poses concern for a neoplastic process, especially given his smoking history. 5. Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except: A) Changes in weight B) Fatigue and weakness C) Cough D) Fever and chills Ans: C Chapter: 04 Page and Header: 102, The Health History Feedback: This symptom is more appropriate to the respiratory review of systems. 6. You are beginning the examination of a patient. All of the following areas are important to observe as part of the General Survey except: A) Level of consciousness B) Signs of distress C) Dress, grooming, and personal hygiene D) Blood pressure Ans: D Chapter: 04 Page and Header: 109, The General Survey Feedback: Blood pressure is a vital sign, not part of the General Survey. 7. A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior elevated readings and her family history is negative for hypertension. You measure her blood pressure in your office today. Which of the following factors can result in a false high reading? A) Blood pressure cuff is tightly fitted. B) Patient is seated quietly for 10 minutes prior to measurement. C) Blood pressure is measured on a bare arm. D) Patient's arm is resting, supported by your arm at her mid-chest level as you stand to measure the blood pressure. Ans: A Chapter: 04 Page and Header: 114, The Vital Signs Feedback: A blood pressure cuff that is too tightly fitted can result in a false high reading. The other answers are important to observe to obtain an accurate blood pressure reading. JNC-7 also mentions the importance of having the back supported when obtaining blood pressure in the sitting position. 8. A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient's complete history and physical examination. When you palpate the pulse, what do you expect to feel? A) Large amplitude, forceful B) Small amplitude, weak C) Normal D) Bigeminal Ans: B Chapter: 04 Page and Header: 114, The Vital Signs Feedback: Congestive heart failure is characterized by decreased stroke volume or increased peripheral vascular resistance, which would result in a small-amplitude, weak pulse. Subtle differences in amplitude are usually best detected in large arteries close to the heart, like the carotid pulse. You may not be able to notice these in other locations. 9. An 18-year-old college freshman presents to the clinic for evaluation of gastroenteritis. You measure the patient's temperature and it is 104 degrees Fahrenheit. What type of pulse would you expect to feel during his initial examination? A) Large amplitude, forceful B) Small amplitude, weak C) Normal D) Bigeminal Ans: A Chapter: 04 Page and Header: 114, The Vital Signs Feedback: Fever results in an increased stroke volume, which results in a large-amplitude, forceful pulse. Later in the course of the illness, if dehydration and shock result, you may expect small amplitude and weak pulses. 10. A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath and states that his blood sugar was 605 at home. You diagnose the patient with diabetic ketoacidosis. What is the expected pattern of breathing? A) Normal B) Rapid and shallow C) Rapid and deep D) Slow Ans: C Chapter: 04 Page and Header: 114, The Vital Signs Feedback: This is the expected rate and depth in diabetic ketoacidosis. The body is trying to rid itself of carbon dioxide to compensate for the acidosis. This is known as Kussmaul's breathing and is seen in other causes of acidosis as well. 11. Mrs. Lenzo weighs herself every day with a very accurate balance-type scale. She has noticed that over the past 2 days she has gained 4 pounds. How would you best explain this? A) Attribute this to some overeating at the holidays. B) Attribute this to wearing different clothing. C) Attribute this to body fluid. D) Attribute this to instrument inaccuracy. Ans: C Chapter: 04 Page and Header: 102, The Health History Feedback: This amount of weight over a short period should make one think of body fluid changes. You may consider a kidney problem or heart failure in your differential. The other reasons should be considered as well, but this amount of weight gain over a short period usually indicates causes other than excessive caloric intake. A rule of thumb for dieters is that an energy excess of 3500 calories will cause a 1-pound weight gain, if the increase is to be attributed to food intake. 12. Mr. Curtiss has a history of obesity, diabetes, osteoarthritis of the knees, HTN, and obstructive sleep apnea. His BMI is 43 and he has been discouraged by his difficulty in losing weight. He is also discouraged that his goal weight is 158 pounds away. What would you tell him? A) “When you get down to your goal weight, you will feel so much better.” B) “Some people seem to be able to lose weight and others just can't, no matter how hard they try.” C) “We are coming up with new medicines and methods to treat your conditions every day.” D) “Even a weight loss of 10% can make a noticeable improvement in the problems you mention.” Ans: D Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: Many patients trying to change a habit are overwhelmed by how far they are from their goal. As the proverb says: “A journey of a thousand miles begins with one step.” Many patients find it empowering to know that they can achieve a small goal, such as a loss of 1 pound per week. They must be reminded that this process will take time and that slow weight loss is more successful long-term. Research has shown that significant benefits often come with even a 10% weight loss. 13. Jenny is one of your favorite patients who usually shares a joke with you and is nattily dressed. Today she is dressed in old jeans, lacks makeup, and avoids eye contact. To what do you attribute these changes? A) She is lacking sleep. B) She is fatigued from work. C) She is running into financial difficulty. D) She is depressed. Ans: D Chapter: 04 Page and Header: 109, The General Survey Feedback: It is important to use all of your skills and memory of an individual patient to guide your thought process. She is not described as sleepy. Work fatigue would most likely not cause avoidance of eye contact. Financial difficulties would not necessarily deplete a nice wardrobe. It is most likely that she is depressed or in another type of difficulty. 14. You are seeing an older patient who has not had medical care for many years. Her vital signs taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain. You notice that she has some hypertensive changes in her retinas and you find mild proteinuria on a urine test in your office. You expected the BP to be higher. She is not on any medications. What do you think is causing this BP reading, which doesn't correlate with the other findings? A) It is caused by an “auscultatory gap.” B) It is caused by a cuff size error. C) It is caused by the patient's emotional state. D) It is caused by resolution of the process which caused her retinopathy and kidney problems. Ans: A Chapter: 04 Page and Header: 114, The Vital Signs Feedback: The blood pressure is unusual in this case in that the systolic pressure is normal while the diastolic pressure is elevated. Especially with the retinal and urinary findings, you should consider that the BP may be much higher and that an auscultatory gap was missed. This can be avoided by checking for obliteration of the radial pulse while the cuff is inflated. Although a large cuff can cause a slightly lower BP on a patient with a small arm, this does not account for the elevated DBP. Emotional upset usually causes elevation of the BP. Although a process which caused the retinopathy and kidney problems may have resolved, leaving these findings, it is a dangerous assumption that this is the sole cause of the problems seen in this patient. 15. Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. How do you respond? A) You diagnose “white coat hypertension.” B) You assume he is quite nervous when he comes to your office. C) You question the accuracy of his measurements. D) You question the accuracy of your measurements. Ans: C Chapter: 04 Page and Header: 114, The Vital Signs Feedback: It is not uncommon to see differences in a patient's home measurements and your own in the office. Presuming that this is “white coat hypertension” can be dangerous because this condition is not usually treated. This allows for the effects of a missed diagnosis of hypertension to go unchecked. It is also very difficult to judge if a patient is outwardly nervous. You should always consider that your measurements are not accurate as well, but the fact that you and your staff are well-trained and perform this procedure on hundreds of patients a week makes this less likely. Ideally, you would ask the patient to bring in his BP equipment and take a simultaneous reading with you to make sure that he is getting an accurate reading. 16. You are observing a patient with heart failure and notice that there are pauses in his breathing. On closer examination, you notice that after the pauses the patient takes progressively deeper breaths and then progressively shallower breaths, which are followed by another apneic spell. The patient is not in any distress. You make the diagnosis of: A) Ataxic (Biot's) breathing B) Cheyne-Stokes respiration C) Kussmaul's respiration D) COPD with prolonged expiration Ans: B Chapter: 04 Page and Header: 119, Respiratory Rate and Rhythm Feedback: Cheyne-Stokes respiration can be seen in patients with heart failure and is usually not a sign of an immediate problem. Ataxic breathing is very irregular in rhythm and depth and is seen with brain injury. Kussmaul's respiration is seen in patients with a metabolic acidosis, as they are trying to rid their bodies of carbon dioxide to compensate. Respirations in COPD are usually regular and are not usually associated with apneic episodes. 17. Mr. Garcia comes to your office for a rash on his chest associated with a burning pain. Even a light touch causes this burning sensation to worsen. On examination, you note a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. What type of pain is this? A) Idiopathic pain B) Neuropathic pain C) Nociceptive or somatic pain D) Psychogenic pain Ans: B Chapter: 04 Page and Header: 121, Acute and Chronic Pain Feedback: This vignette is consistent with a diagnosis of herpes zoster, or shingles. This is caused by reemergence of dormant varicella (chickenpox) viruses from Mr. Garcia's nerve root. The characteristic burning quality without a history of an actual burn makes one think of neuropathic pain. It will most likely remain for months after the rash has resolved. There is no evidence of physical injury and this is a peculiar distribution, making nociceptive pain less likely. There is no evidence of a psychogenic etiology for this, and the presence of a rash makes this possibility less likely as well. Because of your astute diagnostic abilities, the pain is not idiopathic. 18. A 50-year-old body builder is upset by a letter of denial from his life insurance company. He is very lean but has gained 2 pounds over the past 6 months. You personally performed his health assessment and found no problems whatsoever. He says he is classified as “high risk” because of obesity. What should you do next? A) Explain that even small amounts of weight gain can classify you as obese. B) Place him on a high-protein, low-fat diet. C) Advise him to increase his aerobic exercise for calorie burning. D) Measure his waist. Ans: D Chapter: 04 Page and Header: 104, Health Promotion and Counseling Feedback: The patient most likely had a high BMI because of increased muscle mass. In this situation, it is important to measure his waist. It is most likely under 40 inches, which makes obesity unlikely (even to an insurance company). It is important that you personally contact the company and explain your reasoning. Be prepared to back your argument with data. A special diet is unlikely to be of much use, and more aerobic exercise, while probably a good idea for most, is redundant for this individual. 19. Ms. Wright comes to your office, complaining of palpitations. While checking her pulse you notice an irregular rhythm. When you listen to her heart, every fourth beat sounds different. It sounds like a triplet rather than the usual “lub dup.” How would you document your examination? A) Regular rate and rhythm B) Irregularly irregular rhythm C) Regularly irregular rhythm D) Bradycardia Ans: C Chapter: 04 Page and Header: 119, Heart Rate and Rhythm Feedback: Because this unusual beat occurs every fourth set of heart sounds, it is regularly irregular. This is most consistent with ventricular premature contractions (or VPCs). This is generally a common and benign rhythm. An irregularly irregular rhythm is a classic finding in atrial fibrillation. The rhythm is very random in character. Bradycardia refers to the rate, not the rhythm. Bates’ Guide to Physical Examination and History Taking, 11th Edition Chapter 7: The Head and Neck Multiple Choice 1. A 38-year-old accountant comes to your clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region and is an 8 on a scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic and this results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache? A) Tension B) Migraine C) Cluster D) Analgesic rebound Ans: B Chapter: 07 Page and Header: 196, The Health History Feedback: This is a description of a common migraine (no aura). Distinctive features of a migraine include phonophobia and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present. 2. A 29-year-old computer programmer comes to your office for evaluation of a headache. The tightening sensation is located all over the head and is of moderate intensity. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours each day at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain but not taken it away. Based on this description, what is your most likely diagnosis? A) Tension B) Migraine C) Cluster D) Analgesic rebound Ans: A Chapter: 07 Page and Header: 196, The Health History Feedback: This is a description of a typical tension headache. 3. Which of the following is a symptom involving the eye? A) Scotomas B) Tinnitus C) Dysphagia D) Rhinorrhea Ans: A Chapter: 07 Page and Header: 196, The Health History Feedback: Scotomas are specks in the vision or areas where the patient cannot see; therefore, this is a common/concerning symptom of the eye. 4. A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You elicit the information that the dizziness is a spinning sensation of sudden onset, worse with head position changes. The episodes last a few seconds and then go away, and they are accompanied by intense nausea. She has vomited one time. She denies tinnitus. You perform a physical examination of the head and neck and note that the patient's hearing is intact to Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description, what is the most likely diagnosis? A) Benign positional vertigo B) Vestibular neuronitis C) Ménière's disease D) Acoustic neuroma Ans: A Chapter: 07 Page and Header: 252, Table 7–3 Feedback: This is a classic description of benign positional vertigo. The vertigo is episodic, lasting a few seconds to minutes, instead of continuous as in vestibular neuronitis. Also, there is no tinnitus or sensorineural hearing loss as occurs in Ménière's disease and acoustic neuroma. You may choose to learn about Hallpike maneuvers, which are also helpful in the evaluation of vertigo. 5. A 55-year-old bank teller comes to your office for persistent episodes of dizziness. The first episode started suddenly and lasted 3 to 4 hours. He experienced a lot of nausea with vomiting; the episode resolved spontaneously. He has had five episodes in the past 1½ weeks. He does note some tinnitus that comes and goes. Upon physical examination, you note that he has a normal gait. The Weber localizes to the right side and the air conduction is equal to the bone conduction in the right ear. Nystagmus is present. Based on this description, what is the most likely diagnosis? A) Benign positional vertigo B) Vestibular neuronitis C) Ménière's disease D) Acoustic neuroma Ans: C Chapter: 07 Page and Header: 252, Table 7–3 Feedback: Ménière's disease is characterized by sudden onset of vertiginous episodes that last several hours to a day or more, then spontaneously resolve; the episodes then recur. On physical examination, sensorineural hearing loss is present. The patient does complain of tinnitus. 6. A 73-year-old nurse comes to your office for evaluation of new onset of tremors. She is not on any medications and does not take herbs or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow movements and shuffling steps. She has decreased facial mobility and a blunt expression, without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the patient's symptoms? A) Cushing's syndrome B) Nephrotic syndrome C) Myxedema D) Parkinson's disease Ans: D Chapter: 07 Page and Header: 253, Table 7–4 Feedback: This is a typical description for a patient with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression—a “masked” appearance. The patient also has decreased blinking and a characteristic stare with an upward gaze. In combination with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is almost clinched. 7. A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? A) Ptosis B) Exophthalmos C) Ectropion D) Epicanthus Ans: B Chapter: 07 Page and Header: 255, Table 7–6 Feedback: Exophthalmos is the condition when the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease. If it is unilateral, it could still be caused by Graves' disease. Alternatively, it could be caused by a tumor or inflammation in the orbit. 8. A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? A) Dacryocystitis B) Chalazion C) Hordeolum D) Xanthelasma Ans: C Chapter: 07 Page and Header: 256, Table 7–7 Feedback: A hordeolum, or sty, is a painful, tender, erythematous infection in a gland at the margin of the eyelid. 9. A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? A) Conjunctivitis B) Acute iritis C) Corneal abrasion D) Subconjunctival hemorrhage Ans: D Chapter: 07 Page and Header: 257, Table 7–8 Feedback: A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turning yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rarely caused by a serious condition, so reassurance is usually the only treatment necessary. 10. A 67-year-old lawyer comes to your clinic for an annual examination. He denies any history of eye trauma. He denies any visual changes. You inspect his eyes and find a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis? A) Corneal arcus B) Cataracts C) Corneal scar D) Pterygium Ans: D Chapter: 07 Page and Header: 258, Table 7-9 Feedback: A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere with vision as it encroaches on the pupil. Otherwise, treatment is unnecessary. 11. Which of the following is a “red flag” regarding patients presenting with headache? A) Unilateral headache B) Pain over the sinuses C) Age over 50 D) Phonophobia and photophobia Ans: C Chapter: 07 Page and Header: 196, The Health History Feedback: A unilateral headache is often seen with migraines and may commonly be accompanied by phonophobia and photophobia. Pain over the sinuses from sinus congestion may also be unilateral and produce pain. Migraine and sinus headaches are common and generally benign. A new severe headache in someone over 50 can be associated with more serious etiologies for headache. Other red flags include: acute onset, “the worst headache of my life”; very high blood pressure; rash or signs of infection; known presence of cancer, HIV, or pregnancy; vomiting; recent head trauma; and persistent neurologic problems. 12. A sudden, painless unilateral vision loss may be caused by which of the following? A) Retinal detachment B) Corneal ulcer C) Acute glaucoma D) Uveitis Ans: A Chapter: 07 Page and Header: 196, The Health History Feedback: Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain. Retinal detachment is generally painless, as is chronic glaucoma. 13. Sudden, painful unilateral loss of vision may be caused by which of the following conditions? A) Vitreous hemorrhage B) Central retinal artery occlusion C) Macular degeneration D) Optic neuritis Ans: D Chapter: 07 Page and Header: 196, The Health History Feedback: In multiple sclerosis, sudden painful loss of vision may accompany optic neuritis. The other conditions are usually painless. 14. Diplopia, which is present with one eye covered, can be caused by which of the following problems? A) Weakness of CN III B) Weakness of CN IV C) A lesion of the brainstem D) An irregularity in the cornea or lens Ans: D Chapter: 07 Page and Header: 196, The Health History Feedback: Double vision in one eye alone points to a problem in “processing” the light rays of an incoming image. The other causes of diplopia result in a misalignment of the two eyes. 15. A patient complains of epistaxis. Which other cause should be considered? A) Intracranial hemorrhage B) Hematemesis C) Intestinal hemorrhage D) Hematoma of the nasal septum Ans: B Chapter: 07 Page and Header: 196, The Health History Feedback: Although the source of epistaxis may seem obvious, other bleeding locations should be on the differential. Hematemesis can mimic this and cause delay in life-saving therapies if not considered. Intracranial hemorrhage and septal hematoma are instances of contained bleeding. Intestinal hemorrhage may cause hematemesis if there is obstruction distal to the bleeding, but this is unlikely. 16. Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination? A) Increased cup-to-disc ratio B) AV nicking C) Cotton wool spots D) Microaneurysms Ans: A Chapter: 07 Page and Header: 201, Health Promotion and Counseling Feedback: It is important to screen for glaucoma on funduscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes. 17. Very sensitive methods for detecting hearing loss include which of the following? A) The whisper test B) The finger rub test C) The tuning fork test D) Audiometric testing Ans: D Chapter: 07 Page and Header: 201, Health Promotion and Counseling Feedback: While it is important to screen for hearing complaints with methods available to you, it should be realized that some physical examination techniques are limited. Nonetheless, you should be comfortable performing these tests, as audiometric testing is not always available. 18. Which area of the fundus is the central focal point for incoming images? A) The fovea B) The macula C) The optic disk D) The physiologic cup Ans: A Chapter: 07 Page and Header: 205, The Eyes Feedback: The fovea is the area of the retina which is responsible for central vision. It is surrounded by the macula, which is responsible for more peripheral vision. The optic disc and physiologic cup are where the optic nerve enters the eye. 19. A light is pointed at a patient's pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon? A) Direct reaction B) Consensual reaction C) Near reaction D) Accommodation Ans: B Chapter: 07 Page and Header: 205, The Eyes Feedback: The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object. 20. A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? A) She obtains a 20% correct score at 100 feet. B) She can accurately name 20% of the letters at 20 feet. C) She can see at 20 feet what a normal person could see at 100 feet. D) She can see at 100 feet what a normal person could see at 20 feet. Ans: C Chapter: 07 Page and Header: 205, The Eyes Feedback: The denominator of an acuity score represents the line on the chart the patient can read. In the example above, the patient could read the larger letters corresponding with what a normal person could see at 100 feet. 21. On visual confrontation testing, a stroke patient is unable to see your fingers on his entire right side with either eye covered. Which of the following terms would describe this finding? A) Bitemporal hemianopsia B) Right temporal hemianopsia C) Right homonymous hemianopsia D) Binasal hemianopsia Ans: C Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Because the right visual field in both eyes is affected, this is a right homonymous hemianopsia. A bitemporal hemianopsia refers to loss of both lateral visual fields. A right temporal hemianopsia is unilateral and binasal hemianopsia is the loss of the nasal visual fields bilaterally. 22. You note that a patient has anisocoria on examination. Pathologic causes of this include which of the following? A) Horner's syndrome B) Benign anisocoria C) Differing light intensities for each eye D) Eye prosthesis Ans: A Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Anisocoria can be associated with serious pathology. Remember to exclude benign causes before embarking on an intensive workup. Testing the near reaction in this case may help you to find an Argyll Robertson or tonic (Adie's) pupil. 23. A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally. Which of the following have you essentially excluded from your differential? A) Retinoblastoma B) Cataract C) Artificial eye D) Hypertensive retinopathy Ans: D Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Hypertensive retinopathy requires a careful examination of the optic fundus. It cannot be diagnosed or excluded merely from the red reflex. Typically, the red reflex would be normal in this case. The other conditions are all associated with an abnormal red reflex. 24. A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient? A) Otitis media B) External otitis C) Perforation of the tympanum D) Cholesteatoma Ans: B Chapter: 07 Page and Header: 225, Techniques of Examination Feedback: These are classic history and examination findings for a patient suffering from external otitis. Otitis media would not usually have pain with movement of the external ear, nor drainage unless the eardrum was perforated. In this case the examination of the eardrum is recorded as normal. Cholesteatoma is a growth behind the eardrum and would not account for these symptoms. Otitis media would classically be accompanied by a bulging, erythematous eardrum. 25. A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely? A) Otosclerosis of the left ear B) Exposure to chronic loud noise of the right ear C) Otitis media of the right ear D) Perforation of the right eardrum Ans: A Chapter: 07 Page and Header: 271, Table 7–21 Feedback: The above pattern is consistent with a conductive loss on the left side. Causes would include: foreign body, otitis media, perforation, and otosclerosis of the involved side. 26. A young man is concerned about a hard mass he has just noticed in the midline of his palate. On examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis? A) Leukoplakia B) Torus palatinus C) Thrush (candidiasis) D) Kaposi's sarcoma Ans: B Chapter: 07 Page and Header: 274, Table 7–23 Feedback: Torus palatinus is relatively common and benign but can go unnoticed by the patient for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and is seen in immunosuppressed patients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive individuals and is classically a deep purple. 27. A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left. Which of the following is likely? A) CN IX lesion on the left B) CN IX lesion on the right C) CN X lesion on the left D) CN X lesion on the right Ans: D Chapter: 07 Page and Header: 231, Mouth and Pharynx Feedback: The failure of the right side of the palate to rise denotes a problem with the right 10th cranial nerve. The uvula deviates toward the properly functioning side. 28. A college student presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this? A) Submandibular B) Tonsillar C) Occipital D) Posterior cervical Ans: D Chapter: 07 Page and Header: 236, The Neck Feedback: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis. 29. You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and side-to-side directions. Which of the following is most likely? A) Cancer B) Lymph node C) Deep scar D) Muscle Ans: B Chapter: 07 Page and Header: 236, The Neck Feedback: A useful maneuver for discerning lymph nodes from other masses in the neck is to check for their mobility in all directions. Many other masses are mobile in only two directions. Cancerous masses may also be “fixed,” or immobile. 30. You are conducting a pupillary examination on a 34-year-old man. You note that both pupils dilate slightly. Both are noted to constrict briskly when the light is placed on the right eye. What is the most likely problem? A) Optic nerve damage on the right B) Optic nerve damage on the left C) Efferent nerve damage on the right D) Efferent nerve damage on the left Ans: B Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Because both pupils can constrict, efferent nerve damage is unlikely. When the light is placed on the left eye, neither a direct nor a consensual response is seen. This indicates that the left eye is not perceiving incoming light. Bates’ Guide to Physical Examination and History Taking, 11th Edition Chapter 13: Male Genitalia and Hernias Multiple Choice 1. A 28-year-old musician comes to your clinic, complaining of a “spot” on his penis. He states his partner noticed it 2 days ago and it hasn't gone away. He says it doesn't hurt. He has had no burning with urination and no pain during intercourse. He has had several partners in the last year and uses condoms occasionally. His past medical history consists of nongonococcal urethritis from Chlamydia and prostatitis. He denies any surgeries. He smokes two packs of cigarettes a day, drinks a case of beer a week, and smokes marijuana and occasionally crack. He has injected IV drugs before but not in the last few years. He is single and currently unemployed. His mother has rheumatoid arthritis and he doesn't know anything about his father. On examination you see a young man appearing deconditioned but pleasant. His vital signs are unremarkable. On visualization of his penis there is a 6-mm red, oval ulcer with an indurated base just proximal to the corona. There is no prepuce because of neonatal circumcision. On palpation the ulcer is nontender. In the inguinal region there is nontender lymphadenopathy. What disorder of the penis is most likely the diagnosis? A) Condylomata acuminata B) Genital herpes C) Syphilitic chancre D) Penile carcinoma Ans: C Chapter: 13 Page and Header: 516, Table 13–2 Feedback: Primary syphilis causes a larger ulcer that is firm and painless. Syphilis is fairly uncommon but does occur in the highly promiscuous population, especially when coupled with illegal drug use. You should consider further questions and workup regarding HIV status. 2. A 20-year-old part-time college student comes to your clinic, complaining of growths on his penile shaft. They have been there for about 6 weeks and haven't gone away. In fact, he thinks there may be more now. He denies any pain with intercourse or urination. He has had three former partners and has been with his current girlfriend for 6 months. He says that because she is on the pill they don't use condoms. He denies any fever, weight loss, or night sweats. His past medical history is unremarkable. In addition to college, he works part-time for his father in construction. He is engaged to be married and has no children. His father is healthy and his mother has hypothyroidism. On examination the young man appears healthy. His vital signs are unremarkable. On visualization of his penis you see several moist papules along all sides of his penile shaft and even two on the corona. He has been circumcised. On palpation of his inguinal region there is no inguinal lymphadenopathy. Which abnormality of the penis does this patient most likely have? A) Condylomata acuminata B) Genital herpes C) Syphilitic chancre D) Penile carcinoma Ans: A Chapter: 13 Page and Header: 516, Table 13–2 Feedback: Warts are generally painless papules along the shaft and corona. They are likely to spread and are caused by the human papilloma virus, transmitted through sexual contact. You should discuss prevention of STIs with him. Although his girlfriend's contraceptive pill protects her from pregnancy, he and she are unprotected from sharing STIs. She should receive regular Pap examinations and consider the HPV vaccine. 3. A 29-year-old married computer programmer comes to your clinic, complaining of “something strange” going on in his scrotum. Last month while he was doing his testicular self-examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable. What disorder of the testes is most likely the diagnosis? A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele Ans: B Chapter: 13 Page and Header: 519, Table 13–5 Feedback: Scrotal hernias occur when the small intestine passes through a weak spot of the inguinal ring. The examiner cannot get a finger above the hernia into the ring. Hernias are often caused by increased abdominal pressure, such as in weight lifting. Patients who have a hernia on one side often have another hernia on the opposite side. In this patient's case, a right-sided hernia was repaired as an infant. 4. A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn't change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He is a married hospital administrator with two children. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On examination you see a young man appearing his stated age with unremarkable vital signs. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down, you feel no bulges. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate examination is unremarkable. What abnormality of the scrotum does he most likely have? A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele Ans: D Chapter: 13 Page and Header: 518, Table 13–4 Feedback: Varicoceles are varicose veins surrounding the spermatic cord, coming through the inguinal ring. These veins feel like spaghetti and are often referred to as a “bag of worms.” The increased number of veins affects the temperature of the testes, often causing infertility problems. Like most varicose veins in any area, varicoceles can cause a nonspecific aching. Although usually benign, a unilateral varicocele on the right or a varicocele which does not resolve in the supine position deserves further workup. 5. A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn't know if intercourse would hurt. He states he has become more tired lately and has also gained 10 pounds in the last month. He denies any fever or weight loss. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is married and has five children. He is currently on disability because of his health problems. Both of his parents died of complications of diabetes. On examination you see a pleasant male appearing chronically ill. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges. The prostate is smooth and nontender. What abnormality of the scrotum is most likely the diagnosis? A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele Ans: C Chapter: 13 Page and Header: 515, Table 13–1 Feedback: Scrotal edema is a generalized swelling of the scrotum due to a systemic illness. No discrete masses are palpated. In this case, with the history of diabetes, hypertension, and coronary artery disease, the symptom of weight gain, and the signs of crackles in the lungs and an extra heart sound, the patient is probably suffering from congestive heart failure. This is also seen in patients with edema from hypoalbuminemia. 6. A 36-year-old security officer comes to your clinic, complaining of a painless mass in his scrotum. He found it 3 days ago during a testicular self-examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. His past medical history is notable for high blood pressure. He is married and has three healthy children. He denies using illegal drugs, smokes two to three cigars a week, and drinks six to eight alcoholic beverages per week. His mother is in good health and his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis, he is circumcised and has no lesions. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft cystic-like lesion measuring 2 cm over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight bearing there are no bulges. His prostate examination is unremarkable. What disorder of the scrotum does he most likely have? A) Hydrocele B) Scrotal hernia C) Testicular tumor D) Varicocele Ans: A Chapter: 13 Page and Header: 515, Table 13–1 Feedback: The hydrocele is a fluid-filled cyst originating within the tunica vaginalis. An examining finger can be placed over the mass into the inguinal ring. An outside light source can be placed beneath the scrotum. Hydroceles often transilluminate light, whereas solid tumors do not. 7. A 22-year-old unemployed roofer presents to your clinic, complaining of pain in his testicle and penis. He states the pain began last night and has steadily become worse. He states it hurts when he urinates and he has not attempted intercourse since the pain began. He has tried Tylenol and ibuprofen without improvement. He denies any fever or night sweats. His past medical history is unremarkable. He has had four previous sexual partners and has had a new partner for the last month. She is on oral contraceptives so he has not used condoms. His parents are both in good health. On examination you see a young man lying on his side. He appears mildly ill. His temperature is 100.2 and his blood pressure, respirations, and pulse are normal. On visualization of the penis he is circumcised, with no lesions or discharge from the meatus. Visualization of the scrotal skin appears unremarkable. Palpation of the testes shows severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells and bacteria. What diagnosis of the male genitalia is most likely in this case? A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis Ans: B Chapter: 13 Page and Header: 518, Table 13–4 Feedback: Epididymitis is an infection of the epididymis superior to the testicle. It can often be caused by sexually transmitted disease and can cause burning with urination and scrotal pain. Palpate the spermatic cord through the scrotum by pinching medially and sliding your pinched fingers laterally. The spermatic cord, including the epididymis, will pass between your fingers and be tender if involved. 8. A 15-year-old high school football player is brought to your office by his mother. He is complaining of severe testicular pain since exactly 8:00 this morning. He denies any sexual activity and states that he hurts so bad he can't even urinate. He is nauseated and is throwing up. He denies any recent illness or fever. His past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. On examination you see a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. His blood pressure is 150/100, his pulse is 110, and his respirations are 24. On visualization of the penis he is circumcised and there are no lesions and no discharge from the meatus. His scrotal skin is tense and red. Palpation of the left testicle causes severe pain and the patient begins to cry. His prostate examination is unremarkable. His cremasteric reflex is absent on the left but is normal on the right. By catheter you get a urine sample and the analysis is unremarkable. You send the boy with his mother to the emergency room for further workup. What is the most likely diagnosis for this young man's symptoms? A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis Ans: C Chapter: 13 Page and Header: 518, Table 13–4 Feedback: Torsion is caused by the twisting of the testicle on its spermatic cord and blood vessels, leading to severe pain. The scrotum becomes red and tense. Torsion is usually seen in adolescents and is a true surgical emergency. If not quickly surgically repaired, the testicle's function is lost and it has to be removed. The presence of a cremasteric reflex is reassuring, but in this case a thorough evaluation must take place as soon as possible. 9. A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged and tender. He isn't sure if he has had burning with urination and he says he has never had sexual intercourse. He has had a sore throat, cough, and runny nose for the last 3 days. His past medical history is significant for a tonsillectomy as a small child. His father has high blood pressure and his mother is healthy. On examination you see a teenager in no acute distress. His temperature is 100.8 and his blood pressure and pulse are unremarkable. On visualization of his penis, he is uncircumcised and has no lesions or discharge. His scrotum is red and tense on the left and normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. The right testicle is unremarkable. An examining finger is put through both inguinal rings, and there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is also unremarkable. What abnormality of the testes does this teenager most likely have? A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis Ans: A Chapter: 13 Page and Header: 517, Table 13–3 Feedback: Acute orchitis causes an inflamed, tender testicle. The scrotum will be red and tense. Orchitis is usually unilateral and often associated with viral infections such as mumps. 10. A 45-year-old electrical engineer presents to your clinic, complaining of spots on his scrotum. He first noticed the spots several months ago, and they have gotten bigger. He denies any pain with urination or with sexual intercourse. He has had no fever, night sweats, weight gain, or weight loss. His past medical history consists of a vasectomy 10 years ago and mild obesity. He is on medication for hyperlipidemia. He denies any tobacco or illegal drug use and drinks alcohol socially. His mother has Alzheimer's disease and his father died of leukemia. On examination he appears relaxed and has unremarkable vital signs. On visualization of his penis, he is circumcised and has no lesions on his penis. Visualization of his scrotum shows three yellow nodules 2–3 millimeters in diameter. During palpation they are firm and nontender. What abnormality of the male genitalia is this most likely to be? A) Condylomata acuminata B) Syphilitic chancre C) Peyronie's disease D) Epidermoid cysts Ans: D Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: Epidermoid cysts are firm, yellowish, painless cysts on the scrotal skin. They are very common and are benign. 11. Jim is a 47-year-old man who is having difficulties with sexual function. He is recently separated from his wife of 20 years. He notes that he has early morning erections but otherwise cannot function. Which of the following is a likely cause for his problem? A) Decreased testosterone levels B) Psychological issues C) Abnormal hypogastric arterial circulation D) Impaired neural innervation Ans: B Chapter: 13 Page and Header: 504, The Health History Feedback: The fact that he has an early morning erection is indicative of normal physiologic function. You may consider looking further into psychological issues, perhaps related to his marital difficulties. If the patient is unsure of whether early morning erections are occurring, some recommend the postage stamp test in which a ring of postage stamps or other perforated stickers is placed around the penis while in the flaccid state. If the perforations are broken, it is likely an erection has occurred. Do not perform this test without perforations in the stickers, or the ring may function as a tourniquet. 12. Which of the following conditions involves a tight prepuce which, once retracted, cannot be returned? A) Phimosis B) Paraphimosis C) Balanitis D) Balanoposthitis Ans: B Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: This describes paraphimosis. Phimosis describes a foreskin which cannot be retracted. Balanitis involves an inflammation of the glans, whereas balanoposthitis involves inflammation of both the glans and the prepuce. 13. Induration along the ventral surface of the penis suggests which of the following? A) Urethral stricture B) Testicular carcinoma C) Peyronie's disease D) Epidermoid cysts Ans: A Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: Urethral stricture may cause induration of the ventral surface of the penis. It more rarely represents a local carcinoma. A testicular carcinoma would be much more likely to occur in the scrotum. Peyronie's disease often causes induration on the dorsal proximal penis, and epidermoid cysts are benign findings on the scrotum. 14. A tender, painful swelling of the scrotum should suggest which of the following? A) Acute epididymitis B) Strangulated inguinal hernia C) Torsion of the spermatic cord D) All of the above Ans: D Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: A tender, painful swelling of the scrotum can be a medical emergency. All of these conditions should be considered, as well as acute orchitis. 15. A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a “bag of worms” in the left scrotum, superior to the testicles. Which of the following is most likely? A) Hydrocele of the spermatic cord B) Varicocele C) Testicular carcinoma D) A normal vas deferens Ans: B Chapter: 13 Page and Header: 508, Techniques of Examination Feedback: Varicoceles are common in normal men. They are often found in the left scrotum or bilaterally and should normally resolve in the supine position. This is because they represent varicosities within the scrotum. These require further investigation if they occur only on the right side or do not resolve in the supine position. They can contribute to infertility because the testicles are unable to achieve a cool enough temperature for sperm production, due to increased blood flow from the varicocele. A hydrocele would be a painless mass on the spermatic cord and the vas deferens is palpated as part of the spermatic cord. You should lightly pinch the scrotum medially and move laterally until you feel the spermatic cord pass between your fingers. 16. Which of the following would lead you to suspect a hydrocele versus other causes of scrotal swelling? A) The presence of bowel sounds in the scrotum B) Being unable to palpate superior to the mass C) A positive transillumination test D) Normal thickness of the skin of the scrotum Ans: C Chapter: 13 Page and Header: 515, Table 13–1 Feedback: A cystic structure will often transilluminate well. While a transilluminator head for your battery handle is ideal, it is possible to use an otoscope to transilluminate the scrotum. You should be able to get above the mass on palpation and bowel sounds should not be present. If they are, it should lead you to consider an inguinal hernia. Scrotal edema involves thickened skin which can be measured by gently pinching a section of the scrotum itself. 17. You are examining a newborn and note that the right testicle is not in the scrotum. What should you do next? A) Refer to urology B) Recheck in 6 months C) Tell the parent the testicle is absent but that this should not affect fertility D) Attempt to bring down the testis from the inguinal canal Ans: D Chapter: 13 Page and Header: 517, Table 13–3 Feedback: This is not an uncommon finding, and the testis must often be “milked” into the scrotum from the inguinal canal. Six months is too long to wait, but urology referral is unnecessary unless the testicle cannot be brought into the scrotum. An intra-abdominal testis is at much higher risk for testicular cancer. 18. Francis is a middle-aged man who noted right-sided lower abdominal pain after straining with yard work. Which of the following would make a hernia more likely? A) Absence of pain with straining B) Absence of bowel sounds in the scrotum C) Absence of a varicocele D) Absence of symmetry of the inguinal areas with straining Ans: D Chapter: 13 Page and Header: 519, Table 13–5 Feedback: Even in the presence of a hernia, absolute symmetry to inspection may be preserved. The action of straining and increasing intra-abdominal pressure causes the hernia to protrude. Hernias will not necessarily be present on CT scans either unless this maneuver is undertaken. Pain with straining and bowel sounds heard in the scrotum further support the diagnosis of indirect hernia. 19. Frank is a 24-year-old man who presents with multiple burning erosions on the shaft of his penis and some tender inguinal adenopathy. Which of the following is most likely? A) Primary syphilis B) Herpes simplex C) Chancroid D) Gonorrhea Ans: B Chapter: 13 Page and Header: 516, Table 13–2 Feedback: The multiplicity of lesions as well as the burning quality of the pain would lead one to suspect herpes simplex. Syphilis usually presents with a single chancre which is generally painless. Chancroid forms a single, jagged, deep ulcer and gonorrhea usually results in a burning discharge without skin lesions.