Testbank Advanced Health Assessment Clinical Diagnosis in Primary Care 6th Edition Dains

Testbank Advanced Health Assessment Clinical Diagnosis in Primary Care 6th Edition DainsTable of Contents Chapter 1: Clinical reasoning, differential diagnosis, evidence-based practice, and symptom analysis ...................................... 2 Chapter 2. Evidence-based health screening .................................................................................................................................................... 5 Chapter 3. Abdomen ................................................................................................................................................................................................. 10 Chapter 4: Affective Changes ................................................................................................................................................................................ 30 Chapter 5: Amenorrhea ............................................................................................................................................................................................ 38 Chapter 6. Breasts lumps and nipple discharge .............................................................................................................................................. 40 Chapter 7. Breast Pain .............................................................................................................................................................................................. 45 Chapter 8: Chest Pain ................................................................................................................................................................................................ 48 Chapter 9. Confusion in older adults ................................................................................................................................................................. 52 Chapter 10: Constipation ......................................................................................................................................................................................... 56 Chapter 11: Cough ..................................................................................................................................................................................................... 58 Chapter 12: Diarrhea ................................................................................................................................................................................................ 61 Chapter 13: Dizziness ............................................................................................................................................................................................... 66 Chapter 14. Dyspnea ................................................................................................................................................................................................. 68 Chapter 15. Earache ................................................................................................................................................................................................. 79 Chapter 16: Fatigue ................................................................................................................................................................................................... 83 Chapter 17. Fever ....................................................................................................................................................................................................... 85 Chapter 18: Male Genitourinary Problems ........................................................................................................................................................ 88 Chapter 19. Headache .......................................................................................................................................................................................... 102 Chapter 20: Heartburn and indigestion ......................................................................................................................................................... 110 Chapter 21. Hoarseness ....................................................................................................................................................................................... 112 Chapter 22: Lower extremity limb pain ........................................................................................................................................................... 114 Chapter 23: Upper extremity limb pain ........................................................................................................................................................... 116 Chapter 24: Low back pain (acute) .................................................................................................................................................................... 118 Chapter 25.: Nasal symptoms and sinus congestion ................................................................................................................................. 120 Chapter 26: Palpitations....................................................................................................................................................................................... 124 Chapter 27 Penile Discharge ............................................................................................................................................................................... 127 Chapter 28 Rashes and skin lesions ................................................................................................................................................................. 138 Chapter 29: Rectal pain, itching, and bleeding ........................................................................................................................................... 148 Chapter 30. Red Eye ............................................................................................................................................................................................... 150 Chapter 31: Sleep Problems ................................................................................................................................................................................ 161 Chapter 32. Sore throat ......................................................................................................................................................................................... 168 Chapter 33: Syncope .............................................................................................................................................................................................. 171 Chapter 34 Urinary Incontinence ....................................................................................................................................................................... 173 Chapter 35 Urinary Problems in females and children .............................................................................................................................. 180 1 | P a g elOMoAR cPSD | 937 58 10 Chapter 36. Vaginal Bleeding.............................................................................................................................................................................. 183 Chapter 37. Vaginal Discharge and itching ................................................................................................................................................... 186 Chapter 38: Vision Loss ......................................................................................................................................................................................... 203 Chapter 39: Weight loss/gain(unintentional) ................................................................................................................................................ 215 Chapter 40: The abdominal x-ray ...................................................................................................................................................................... 220 Chapter 41: The chest x-ray ................................................................................................................................................................................. 228 Chapter 42. The Transgender Patient .............................................................................................................................................................. 232 2 | P a g elOMoAR cPSD | 937 58 10 Chapter 1: Clinical reasoning, differential diagnosis, evidence-based practice, and symptom analysis Multiple Choice Identify the choice that best completes the statement or answers the question. 1. Which type of clinical decision-making is most reliable? A. Intuitive B. Analytical C. Experiential D. Augenblick 2. Which of the following is false? To obtain adequate history, health-care providers must be: A. Methodical and systematic B. Attentive to the patient’s verbal and nonverbal language C. Able to accurately interpret the patient’s responses D. Adept at reading into the patient’s statements 3. Essential parts of a health history include all of the following except: A. Chief complaint B. History of the present illness C. Current vital signs D. All of the above are essential history components 4. Which of the following is false? While performing the physical examination, the examiner must be able to: A. Differentiate between normal and abnormal findings B. Recall knowledge of a range of conditions and their associated signs and symptoms C. Recognize how certain conditions affect the response to other conditions D. Foresee unpredictable findings 5. The following is the least reliable source of information for diagnostic statistics: A. Evidence-based investigations B. Primary reports of research C. Estimation based on a provider’s experience D. Published meta-analyses 6. The following can be used to assist in sound clinical decision-making: A. Algorithm published in a peer-reviewed journal article B. Clinical practice guidelines C. Evidence-based research D. All of the above 7. If a diagnostic study has high sensitivity, this indicates a: A. High percentage of persons with the given condition will have an abnormal result B. Low percentage of persons with the given condition will have an abnormal result C. Low likelihood of normal result in persons without a given condition D. None of the above 8. If a diagnostic study has high specificity, this indicates a: A. Low percentage of healthy individuals will show a normal result B. High percentage of healthy individuals will show a normal result C. High percentage of individuals with a disorder will show a normal result D. Low percentage of individuals with a disorder will show an abnormal result 9. A likelihood ratio above 1 indicates that a diagnostic test showing a: A. Positive result is strongly associated with the disease B. Negative result is strongly associated with absence of the disease C. Positive result is weakly associated with the disease D. Negative result is weakly associated with absence of the disease 3 | P a g elOMoAR cPSD | 937 58 10 10. Which of the following clinical reasoning tools is defined as evidence-based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients? 4 | P a g elOMoAR cPSD | 937 58 10 A. Clinical practice guideline B. Clinical decision rule C. Clinical algorithm MULTIPLE CHOICE ANSWERS 1. ANS: B Croskerry (2009) describes two major types of clinical diagnostic decision-making: intuitive and analytical. Intuitive decision- making (similar to Augenblink decision-making) is based on the experience and intuition of the clinician and is less reliable andpaired with fairly common errors. In contrast, analytical decision-making is based on careful consideration and has greater reliability with rare errors. PTS: 1 2. ANS: D To obtain adequate history, providers must be well organized, attentive to the patient’s verbal and nonverbal language, and able to accurately interpret the patient’s responses to questions. Rather than reading into the patient’s statements, they clarify any areas of uncertainty. PTS: 1 3. ANS: C Vital signs are part of the physical examination portion of patient assessment, not part of the health history. PTS: 1 4. ANS: D While performing the physical examination, the examiner must be able to differentiate between normal and abnormal findings, recall knowledge of a range of conditions, including their associated signs and symptoms, recognize how certain conditions affect the response to other conditions, and distinguish the relevance of varied abnormal findings. PTS: 1 5. ANS: C Sources for diagnostic statistics include textbooks, primary reports of research, and published meta-analyses. Another source of statistics, the one that has been most widely used and available for application to the reasoning process, is the estimation based ona provider’s experience, although these are rarely accurate. Over the past decade, the availability of evidence on which to base clinical reasoning is improving, and there is an increasing expectation that clinical reasoning be based on scientific evidence. Evidence-based statistics are also increasingly being used to develop resources to facilitate clinical decision-making. PTS: 1 6. ANS: D To assist in clinical decision-making, a number of evidence-based resources have been developed to assist the clinician. Resources, such as algorithms and clinical practice guidelines, assist in clinical reasoning when properly applied. PTS: 1 7. ANS: A The sensitivity of a diagnostic study is the percentage of individuals with the target condition who show an abnormal, or positive, result. A high sensitivity indicates that a greater percentage of persons with the given condition will have an abnormal result. PTS: 1 5 | P a g elOMoAR cPSD | 937 58 10 8. ANS: B The specificity of a diagnostic study is the percentage of normal, healthy individuals who have a normal result. The greater the specificity, the greater the percentage of individuals who will have negative, or normal, results if they do not have the target condition. PTS: 1 9. ANS: A The likelihood ratio is the probability that a positive test result will be associated with a person 6 | P a g elOMoAR cPSD | 937 58 10 who has the target condition and a negative result will be associated with a healthy person. A likelihood ratio above 1 indicates that a positive result is associated with the disease; a likelihood ratio less than 1 indicates that a negative result is associated with an absence of the disease PTS: 1 10. ANS: B Clinical decision (or prediction) rules provide another support for clinical reasoning. Clinical decision rules are evidence-basedresources that provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met with regard to the prognosis of patients with specific findings. Decision rules use mathematical models and are specific to certain situations, settings, and/or patient characteristics. PTS: 1 7 | P a g elOMoAR cPSD | 937 58 10 Chapter 2. Evidence-based health screening Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The first step in the genomic assessment of a patient is obtaining information regarding: A. Family history B. Environmental exposures C. Lifestyle and behaviors D. Current medications 2. An affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained is called a(n): A. Consultand B. Consulband C. Index patient D. Proband 3. An autosomal dominant disorder involves the: A. X chromosome B. Y chromosome C. Mitochondrial DNA D. Non-sex chromosomes 4. To illustrate a union between two second cousin family members in a pedigree, draw: A. Arrows pointing to the male and female B. Brackets around the male and female C. Double horizontal lines between the male and female D. Circles around the male and female 5. To illustrate two family members in an adoptive relationship in a pedigree: A. Arrows are drawn pointing to the male and female B. Brackets are drawn around the male and female C. Double horizontal lines are drawn between the male and female D. Circles are drawn around the male and female 6. When analyzing the pedigree for autosomal dominant disorders, it is common to see: A. Several generations of affected members B. Many consanguineous relationships C. More members of the maternal lineage affected than paternal D. More members of the paternal lineage affected than maternal 7. In autosomal recessive (AR) disorders, individuals need: A. Only one mutated gene on the sex chromosomes to acquire the disease B. Only one mutated gene to acquire the disease C. Two mutated genes to acquire the disease D. Two mutated genes to become carriers 8. In autosomal recessive disorders, carriers have: A. Two mutated genes; one from each parent that cause disease B. A mutation on a sex chromosome that causes a disease C. A single gene mutation that causes the disease D. One copy of a gene mutation but not the disease 9. With an autosomal recessive disorder, it is important that parents understand that if they both carry a mutation, the following are the risks to each of their offspring (each pregnancy): A. 50% chance that offspring will carry the disease B. 10% chance of offspring affected by disease 8 | P a g elOMoAR cPSD | 937 58 10 11. In creating your female patient’s pedigree, you note that she and both of her sisters were affected by the same genetic disorder. Although neither of her parents had indications of the disorder, her paternal 9 | P a g elOMoAR cPSD | 937 58 10 grandmother and her paternal grandmother’s two sisters were affected by the same condition. This pattern suggests: A. Autosomal dominant disorder B. Chromosomal disorder C. Mitochondrial DNA disorder D. X-linked dominant disorder 12. A woman affected with an X-linked recessive disorder: A. Has one X chromosome affected by the mutation B. Will transmit the disorder to all of her children C. Will transmit the disorder to all of her sons D. Will not transmit the mutation to any of her daughters 13. Which of the following are found in an individual with aneuploidy? A. An abnormal number of chromosomes B. An X-linked disorder C. Select cells containing abnormal-appearing chromosomes D. An autosomal recessive disorder 14. The pedigree of a family with a mitochondrial DNA disorder is unique in that: A. None of the female offspring will have the disease B. All offspring from an affected female will have disease C. None of the offspring of an affected female will have the disease D. All the offspring from an affected male will have disease 15. Which population is at highest risk for the occurrence of aneuploidy in offspring? A. Mothers younger than 18 B. Fathers younger than 18 C. Mothers over age 35 D. Fathers over age 35 16. A. B. C. D. 17. Approximately what percentage of cancers is due to a single-gene mutation? 50% to 70% 30% to 40% 20% to 25% 5% to 10% According to the Genetic Information Nondiscrimination Act (GINA): A. NPs should keep all genetic information of patients confidential B. NPs must obtain informed consent prior to genetic testing of all patients C. Employers cannot inquire about an employee’s genetic information D. All of the above 18. The leading causes of death in the United States are due to: A. Multifactorial inheritance B. Single gene mutations C. X-linked disorders D. Aneuploidy 19. Which of the following would be considered a “red flag” that requires more investigation in a patient assessment? 10 | P a g eA. Colon cancer in family member at age 70 lOMoA R c PSD| 93758 10 B. Breast cancer in family member at age 75 C. Myocardial infarction in family member at age 35 D. All of the above 20. When patients express variable forms of the same hereditary disorder, this is due to: A. Penetrance B. Aneuploidy C. De novo mutation D. Sporadic inheritance 21. Your 2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as: A. Variable expressivity related to inherited disease B. Dysmorphic features related to genetic disease C. De novo mutations of genetic disease D. Different penetrant signs of genetic disease 22. A. Ask patients to complete a family history worksheet In order to provide a comprehensive genetic history of a patient, the NP should: B. Seek out pathology reports related to the patient’s disorder C. Interview family members regarding genetic disorders D. All of the above Answer Section MULTIPLE CHOICE 1. ANS: A A critical first step in genomic assessment, including assessment of risk, is the use of family history. Family history is considered the first genetic screen (Berry & Shooner 2004) and is a critical component of care because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury 2003). PTS: 1 2. ANS: D A proband is defined as the affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained (Pagon et al. 1993– 2013). The proband is the affected individual that brings the family to medical attention. PTS: 1 3. ANS: D Autosomal dominant (AD) inheritance is a result of a gene mutation in one of the 22 autosomes. PTS: 1 4. ANS: C A consanguineous family is related by descent from a common ancestry and is defined as a “union between two individuals whoare related as second cousins or closer” (Hamamy 2012). Consanguinity, if present in the family history, is portrayed using two horizontal lines to establish the relationship between the male and female partners. 11 | P a g ePTS: 1 5. ANS: B For adopted members of the family, use brackets as the appropriate standardized pedigree symbol ([e.g., brackets]). 12 | P a g elOMoAR cPSD | 937 58 10 PTS: 1 6. ANS: A Pedigrees associated with autosomal dominant (AD) disorders typically reveal multiple affected family members with the disease or syndrome. When analyzing the pedigree for AD disorders or syndromes, it is common to see a “vertical” pattern denoting several generations of affected members. PTS: 1 7. ANS: C In autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents. Autosomal recessive disorders must be inherited through both parents (Nussbaum et al. 2007). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. PTS: 1 8. ANS: D Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutation is on an autosome. PTS: 1 9. ANS: A It is important that parents understand that if they both carry a mutation, the risk to each of their offspring (each pregnancy) is an independent event: 25% disease free, 25% affected, and 50% carrier. PTS: 1 10. ANS: B Everyone born with an X-linked dominant disorder will be affected with the disease. Transmission of the disorder to the nextgeneration varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female). PTS: 1 11. ANS: D A man with an X-linked dominant disorder will transmit the mutation to 100% of his daughters (they receive his X chromosome) and none of his sons (they receive his Y chromosome). The pedigree of a family with an X-linked dominant disorder would reveal all the daughters and none of the sons affected with the disorder if the father has an X-linked disorder. PTS: 1 12. ANS: C An X-linked recessive disorder means that in a woman, both X chromosomes must have the mutation if she is to be affected. Because males have only one copy of the X chromosome, they will be affected if their X chromosome carries the mutation. PTS: 1 13. ANS: A An individual with an abnormal number of chromosomes has a condition called aneuploidy, which is frequently associated withmental problems or physical problems or both (Jorde, Carey, & Bamshad 2010; Nussbaum et al. 2007). PTS: 1 14. ANS: B Mitochondrial DNA is inherited from the ovum and, therefore, from the mother. The pedigree of a family with a mitochondrial DNA disorder is unique in that all offspring 13 | P a g elOMoAR cPSD | 937 58 10 (regardless of gender) of an affected female will have the disease, and none of the offspring from an affected male will have the disease. PTS: 1 15. ANS: C Some individuals or couples have unique identifiable risks that should be discussed prior to 14 | P a g elOMoAR cPSD | 937 58 10 conception whenever possible. Forexample, women who will be 35 years of age or older at delivery (advanced maternal age) are at increased risk for aneuploidy. PTS: 1 16. ANS: D The majority of cancers are sporadic or multifactorial due to a combination of genetic and environmental factors; however, approximately 5% to 10% of all cancers are due to a single-gene mutation (Garber & Offit 2005). PTS: 1 17. ANS: D On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based upon their genetic information when it comes to health insurance and employment, paving the way for patient personalized genetic medicine without fear of discrimination (National Human Genome Research Institute 2012). PTS: 1 18. ANS: A Most disease-causing conditions are not due to a single-gene disorder but are due to multifactorial inheritance, a result of genomics and environmental or behavioral influences. In fact, the leading causes of mortality in the United States—heart disease, cerebrovascular disease, diabetes, and cancer—are all multifactorial. Most congenital malformation, hypertension, arthritis, asthma, obesity, epilepsy, Alzheimer’s, and mental health disorders are also multifactorial. PTS: 1 19. ANS: C Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders. PTS: 1 20. ANS: A Some disorders have a range of expression from mild to severe. This variability is referred to as the penetrance of genetic disease. For example, patients with neurofibromatosis (NF1), an AD disorder of the nervous system, may manifest with many forms of the disease. For instance, some patients with NF1 may have mild symptoms, like café-au-lait spots or freckling on the axillary or skin, while others may have life-threatening spinal cord tumors or malignancy (Jorde, Carey, & Bamshad 2010; Nussbaum et al. 2007). PTS: 1 21. ANS: B Assessing for dysmorphic features may enable identification of certain syndromes or genetic or chromosomal disorders (Jorde, Carey, & Bamshad 2010; Prichard & Korf 2008). Dysmorphology is defined as “the study of abnormal physical development” (Jorde, Carey, & Bamshad 2010, 302). PTS: 1 22. ANS: D Asking the patient to complete a family history worksheet prior to the appointment saves time in the visit while offering the patient an opportunity to contribute to the collection of an accurate family history. Reviewing the family information can also help establish family rapport while verifying medical conditions in individual family members. If a hereditary condition is being considered but family medical information is unclear or unknown, requesting medical records and pathology or autopsy reports may be warranted. PTS: 1 15 | P a g elOMoAR cPSD | 937 58 10 Chapter 3. Abdomen Multiple Choice Identify the choice that best completes the statement or answers the question. 1. When performing abdominal assessment, the clinician should perform examination techniques in the following order: A. Inspection, palpation, percussion, and auscultation B. C. Inspection, percussion, palpation, and auscultation Inspection, auscultation, percussion, and palpation D. Auscultation, palpation, percussion, and inspection 2. The clinician should auscultate the abdomen to listen for possible bruits of the: A. Aorta B. Renal artery C. Iliac artery D. All of the above 3. On abdominal examination, which of the following is assessed using percussion? A. Liver B. Kidneys C. Pancreas D. Esophagus 4. In abdominal assessment, a digital rectal examination is performed to assess for: A. Hemorrhoids B. Prostate size C. Blood in stool D. Ureteral stenosis 5. Rebound tenderness of the abdomen is a sign of: A. Constipation B. Peritoneal inflammation C. Elevated venous pressure D. Peritoneal edema 6. While assessing the abdomen, the clinician deeply palpates the left lower quadrant of the abdomen, and this causes pain in the patient’s right lower abdomen. This is most commonly indicative of: A. Constipation B. Diverticulitis C. Appendicitis D. Hepatitis 7. Your patient complains of severe right lower quadrant abdominal pain. To assess the patient for peritoneal inflammation, the examiner should: A. Percuss the right lower quadrant of the abdomen B. Deeply palpate the right lower quadrant of the abdomen C. Auscultate the right lower quadrant for hyperactive bowel sounds D. Strike the plantar surface of the patient’s heel while the patient is supine 8. Your patient is lying supine and you ask him to raise his leg while you place resistance against the thigh. The examiner is testing the patient for: A. Psoas sign B. Obturator sign 16 | P a g eC. Rovsing’s sign D. Murphys’ sign lOMoAR cPSD | 937 58 10 9. A patient is lying supine and the clinician deeply palpates the right upper quadrant of the abdomen 17 | P a g elOMoAR cPSD | 937 58 10 while the patient inhales. The examiner is testing the patient for: A. Psoas sign B. Obturator sign C. Rovsing’s sign D. Murphys’ 10. Your patient has abdominal pain, and it is worsened when the examiner rotates the patient’s right hip inward with the knee bent and the obturator internus muscle is stretched. This is a sign of: A. Diverticulitis B. Cholecystitis C. Appendicitis D. Mesenteric adenitis 11. On abdominal examination as the clinician presses on the right upper quadrant to assess liver size, jugular vein distension becomes obvious. Hepatojugular reflux is indicative of: A. Acute hepatitis B. Right ventricular failure C. Cholecystitis D. Left ventricular failure 12. of: A. Cholecyst itis B. Appendici tis C. Ascites D. Hepatitis 13. Your 44-year-old female patient complains of right upper quadrant pain. Her skin and sclera are yellow, and she has hyperbilirubinemia and elevated liver enzymes. The clinician should suspect: A. Acute pancreatitis B. Biliary duct obstruction C. Acute hepatitis D. Atypical appendicitis 14. The most common cause of acute pancreatitis is: A. Trauma B. Hepatitis virus A C. Hyperlipide m ia D. Alcohol abuse 15. is a risk of: A. Pleural involvement B. Alcoholism C. High mortality D. Bile duct obstruction 16. Your patient complains of left upper quadrant pain, fever, extreme fatigue, and spontaneous bruising. The clinician should recognize that these symptoms are often related to: 18 | P a g e Your patient with pancreatitis has a Ranson rule score of 8. The clinician should recognize that this Your patient demonstrates positive shifting dullness on percussion of the abdomen. This is indicativelOMoAR cPSD | 937 58 10 A. Hematopoetic disorders B. Hepatomegaly C. Esophageal varices D. Pleural effusion 19 | P a g elOMoAR cPSD | 937 58 10 17. A 16-year-old patient presents with sore throat, cervical lymphadenopathy, fever, extreme fatigue, and left upper quadrant pain. The physical examination reveals splenomegaly. The clinician should recognize the probability of: A. Bacterial endocarditis B. Infectious mononucleosis C. Pneumonia with pleural effusion D. Pancreatic cancer 18. Your patient complains of lower abdominal pain, anorexia, extreme fatigue, unintentional weight loss of 10 pounds in last 3 weeks, and you find a positive hemoccult on digital rectal examination. Laboratory tests show iron deficiency anemia. Theclinician needs to consider: A. Diverticulitis B. Appendicitis C. Colon cancer 20 | P a g elOMoAR cPSD | 937 58 10 D. Peptic ulcer disease 19. A. Decreased lower esophageal sphincter tone Which of the following is the most common cause of heartburn-type epigastric pain? B. Helicobacteria pylori infection of stomach C. Esophageal spasm D. Excess use of NSAIDs 20. A 22-year-old female enters the emergency room with complaints of right lower quadrant abdominal pain, which has been worsening over the last 24 hours. On examination of the abdomen, there is a palpable mass and rebound tenderness over theright lower quadrant. The clinician should recognize the importance of: A. Digital rectal examination B. Endoscopy C. Ultrasound D. Pelvic examination 21. A. Sudden onset of severe epigastric pain The major sign of ectopic pregnancy is: B. Amenorrhea with unilateral lower quadrant pain C. Lower back and rectal pain D. Palpable abdominal mass 22. When ruptured ectopic pregnancy is suspected, the following procedure is most important: A. Culdocentesis B. CT scan C. Abdominal x-ray D. Digital rectal examination 23. The majority of colon cancers are located in the: A. Transverse colon B. Cecum C. Rectosigmoid region The following symptom(s) in the patient’s history should raise the clinician’s suspicion of colon cancer: 24. A. Alternating constipation and diarrhea B. Narrowed caliber of stool C. Hematochezia D. All of the above 25. A patient presents to the emergency department with nausea and severe, colicky back pain that radiates into the groin. When asked to locate the pain, he points to the right costovertebral angle region. His physical examination is unremarkable. Which of the following lab tests is most important for 21 | P a g e D. Ascending colonlOMoAR cPSD | 937 58 10 the diagnosis? A. Urinalysis B. Serum electrolyte levels C. Digital rectal exam D. Lumbar x-ray 22 | P a g elOMoAR cPSD | 937 58 10 26. Your 34-year-old female patient complains of a feeling of “heaviness” in the right lower quadrant, achiness, and bloating. On pelvic examination, there is a palpable mass in the right lower quadrant. Urine and serum pregnancy tests are negative. The diagnostic tool that would be most helpful is: A. Digital rectal exam B. Transvaginal ultrasound C. Pap smear D. Urinalysis 27. Your 54-year-old male patient complains of a painless “lump” in his lower left abdomen that comes and goes for the past couple of weeks. When examining the abdomen, you should have the patient: A. Lie flat and take a deep breath B. Stand and bear down against your hand C. Prepare for a digital rectal examination 23 | P a g elOMoAR cPSD | 937 58 10 D. Lie in a left lateral recumbent position 28. A nurse practitioner reports that your patient’s abdominal x-ray demonstrates multiple air-fluid levels in the bowel. This is a diagnostic finding found in: A. Appendicitis B. Cholecystitis C. Bowel obstruction D. Diverticulitis 29. A 76-year-old patient presents to the emergency department with severe left lower quadrant abdominal pain, diarrhea, and fever. On physical examination, you note the patient has a positive heel strike, and left lower abdominal rebound tenderness.These are typical signs and symptoms of which of the following conditions? A. Diverticulitis B. Salpingitis C. Inflammatory bowel disease D. Irritable bowel syndrome 30. Which of the following conditions is the most common cause of nausea, vomiting, and diarrhea? A. Viral gastroenteritis B. Staphylococcal food poisoning C. Acute hepatitis A D. E.coli gastroenteritis 31. A patient presents to the emergency department with complaints of vomiting and abdominal pain. You note that the emesis contains bile. On physical examination, there is diffuse tenderness, abdominal distension, and rushing, high-pitched bowelsounds. Which of the following diagnoses would be most likely? A. Gastric outlet obstruction B. Small bowel obstruction C. Distal intestinal blockage D. Colonic obstruction 32. Your 5-year-old female patient presents to the emergency department with sore throat, vomiting, ear ache, 103 degree fever, photophobia, and nuchal rigidity. She has an episode of projectile vomiting while you are examining her. The clinician should recognize that the following should be done: A. Abdominal x-ray B. Fundoscopic examination C. Lumbar puncture D. Analysis of vomitus 33. A 9-year-old boy accompanied by his mother reports that since he came home from summer camp, he has had fever, nausea, vomiting, severe abdominal cramps and watery stools that contain blood and mucus. 24 | P a g elOMoAR cPSD | 937 58 10 The clinician should recognize theimportance of: A. Stool for ova and parasites B. Abdominal x-ray C. Stool for clostridium D. Fecal occult blood 25 | P a g elOMoAR cPSD | 937 58 10 test 34. A 56-year-old male complains of anorexia, changes in bowel habits, extreme fatigue, and unintentional weight loss. At times he is constipated and other times he has episodes of diarrhea. His physical examination is unremarkable. It is important for the clinician to recognize the importance of: A. CBC with differential B. Stool culture and sensitivity C. Abdominal x-ray D. Colonoscopy 35. A 20-year-old engineering student complains of episodes of abdominal discomfort, bloating, and episodes of diarrhea. The symptoms usually occur after eating, and pain is frequently relieved with bowel movement. She is on a “celiac diet” and the episodic symptoms persist. Physical examination and diagnostic tests are negative. Colonoscopy is negative for any abnormalities. This is a history and physical consistent with: A. Inflammatory bowel disease B. Irritable bowel syndrome 26 | P a g elOMoAR cPSD | 937 58 10 C. Laxative abuse D. Norovirus gastroenteritis 36. A 78-year-old female patient is suffering from heart failure, GERD, diabetes, and depression. She presents with complaints of frequent episodes of constipation. Her last bowel movement was 1 week ago. Upon examination, you palpate a hard mass is the left lower quadrant of the abdomen. You review her list of medications. Which of the following of her medications cause constipation? A. Digitalis (Lanoxin) B. Amlodipine (Norvasc) C. Sertraline (Zoloft) D. Metformin (Glucophage) 37. You are examining a 55-year-old female patient with a history of alcohol abuse. She complains of anorexia, nausea, pruritus, and weight loss over the last month. On physical examination, you note yellow hue of the skin and sclera. Which of thefollowing physical examination techniques is most important? A. Scratch test B. Heel strike C. Digital rectal examination D. Pelvic examination 38. You observe Charcot’s triad of sign and symptoms in a patient under your care. This is commonly seen in which of the following disorders? A. Cirrhosis B. Pancreatitis C. Cholangitis D. Portal hypertension 39. A 59-year-old patient with history of alcohol abuse is admitted for hematemesis. On physical examination, you note ascites and caput medusa. A likely cause for the hematemesis is: A. Peptic ulcer disease B. Barrett’s esophagus C. Pancreatitis D. Esophageal varices 40. A 16-year-old female with anorexia and bulimia is admitted for hematemesis. She admits to inducing vomiting often. On physical examination, you note pallor, BMI less than 15, and hypotension. A likely reason for hematemesis is: A. Mallory-Weiss tear B. Cirrhosis C. Peptic ulcer disease D. Esophageal varies 27 | P a g elOMoAR cPSD | 937 58 10 41. An 82-year-old female presents to the emergency department with epigastric pain and weakness. She admits to having dark, tarry stools for the last few days. She reports a long history of pain due to osteoarthritis. She self-medicates daily with ibuprofen, naprosyn, and aspirin for joint pain. On physical examination, she has orthostatic hypotension and pallor. Fecal occult blood test is positive. A 28 | P a g elOMoAR cPSD | 937 58 10 likely etiology of the patient’s problem is: A. Mallory-Weiss tear B. Esophageal varices C. Gastric ulcer D. Colon cancer 42. A 48-year-old male presents to the clinic with complaints of anorexia, nausea, weakness, and unintentional weight loss over the last few weeks. On physical examination, the patient has jaundice of the skin as well as sclera and a palpable mass in the epigastric region. In addition to CBC and bilirubin levels, all of the following tests would be helpful except: A. Liver enzymes B. Amylase C. Lipase D. Uric acid 43. Your 66-year-old male patient complains of weakness, fatigue, chronic constipation for the last month, and dark stools. On CBC, his results show iron deficiency anemia. Colon cancer is diagnosed. Which of the following laboratory tests is used tofollow progress of colon cancer? 29 | P a g elOMoAR cPSD | 937 58 10 A. Alpha fetoprotein (AFP) B. Carcinogenic embryonic antigen (CEA) C. Carcinoma antigen 125 (CA-125) D. Beta-human chorionic gonadotropin (beta HCG) 44. and itching. She reports bright red blood on the toilet tissue. The clinician should recognize the need for: A. Digital rectal exam B. CEA blood test C. Colonoscopy D. Fecal occult blood test Your patient is a 33-year-old female gave birth last week. She complains of constipation, rectal pain, 30 | P a g elOMoAR cPSD | 937 58 10 Answer Section MULTIPLE CHOICE 1. ANS: C The abdominal examination begins with inspection, followed by auscultation, percussion, and palpation. Light palpation shouldprecede deep palpation. Auscultating before percussion or palpation allows the examiner to listen to the abdominal sounds undisturbed. Moreover, if pain is present, it is best to leave palpation until last and to gather other data before possibly causing the patient discomfort. PTS: 1 2. ANS: D Perform auscultation before palpation so as to hear unaltered bowel sounds. Listen for bruits over the aorta and the iliac, renal, and femoral arteries. PTS: 1 3. ANS: A The purpose of liver percussion is to measure the liver size. The technique used to percuss the liver is as follows: 1. Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move down. 2. Percuss inferiorly until dullness denotes the liver's upper border (usually at fifth intercostal space in MCL). 3. Resume percussion from below the umbilicus on the midclavicular line in an area of tympany. 4. Percuss superiorly until dullness indicates the liver's inferior border. 5. Measure span in centimeters. Normal liver span: clinically estimated at midclavicular line: 6- 12 cm and midsternal line: 4-8cm. PTS: 1 4. ANS: D A digital rectal examination is included in the abdominal examination. Note skin changes or lesions in the perianal region or the presence of external hemorrhoids. Insert the gloved index finger into the anus with the patient either leaning over or side-lying onthe examination table, and note any internal hemorrhoids or fissures. Check the stool for occult blood. For males, the rectal examination is necessary for direct examination of the prostate. Ureteral stenosis is detected by angiographt. PTS: 1 5. ANS: B Rebound tenderness is tested by slowly pressing over the abdomen with your fingertips, holding the position until pain subsides or the patient adjusts to the discomfort, and then quickly removing the pressure. Rebound pain, a sign of peritoneal inflammation, is present if the patient experiences a sharp discomfort over the inflamed site when pressure is released. PTS: 1 6. ANS: C Appendicitis is suggested by a positive Rovsing’s sign. This sign is positive when there is referred rebound pain in the right lower quadrant when the examiner presses deeply in the left lower quadrant and then quickly releases the pressure. PTS: 1 7. ANS: D Ask the patient to stand with straight legs and to raise up on toes. Then ask the patient to relax, allowing the heel to strike the floor, thus jarring the body. A positive heel strike is indicative of appendicitis and peritoneal irritation. Alternatively, strike theplantar surface of the heel with your fist while the patient rests supine on the examination table. 31 | P a g elOMoAR cPSD | 937 58 10 PTS: 1 8. ANS: A To examine the patient for appendicitis, the clinician can test the patient for psoas sign. This is done in the following manner: Place a hand on the patient’s thigh just above the knee and ask the patient to raise the thigh against your hand. This contracts thepsoas muscle and produces pain in patients with an inflamed appendix. PTS: 1 9. ANS: D Murphy’s Sign is elicited by deeply palpating the right upper quadrant of the abdomen. Pain is present on deep inspiration when an inflamed gallbladder is palpated by pressing the fingers under the rib cage. Murphy’s sign is positive in cholecystitis. PTS: 1 10. ANS: C A positive obturator sign indicates appendicitis. Pain is elicited by inward rotation of the right hip with the knee bent so that the obturator internus muscle is stretched. PTS: 1 11. ANS: B Hepatojugular reflux is elicited by applying firm, sustained hand pressure to the abdomen in the midepigastric region while the patient breathes regularly. Observe the neck for elevation of the jugular venous pressure (JVP) with pressure of the hand and a sudden drop of the JVP when the hand pressure is released. Hepatojugular reflux is exaggerated in right heart failure. PTS: 1 12. ANS: C To assess the patient for ascites, test for shifting of the peritoneal fluid to the dependent side by rolling the patient side to side and percussing for dullness on the dependent side of the abdomen. PTS: 1 13. ANS: B In cholecystitis, acute colicky pain is localized in the RUQ and is often accompanied by nausea and vomiting. Murphy’s sign is frequently present. Fever is low grade, and the increase in neutrophilic leukocytes in the blood is slight. Acute cholecystitis improves in 2 to 3 days and resolves within a week; however, recurrences are common. If acute cholecystitis is accompanied byjaundice and cholestasis (arrest of bile excretion), suspect common duct obstruction. PTS: 1 14. ANS: D Biliary tract disease and alcoholism account for 80% or more of the pancreatitis admissions. Other causes include hyperlipidemia, drugs, toxins, infection, structural abnormalities, surgery, vascular disease, trauma, hyperparathyroidism and hypercalcemia, renal transplantation, and hereditary pancreatitis. The most common cause of pancreatitis is alcohol abuse. PTS: 1 15. ANS: C The Ranson rule uses a score determined by MRI results, with an index possible range of 0 to 32 | P a g elOMoAR cPSD | 937 58 10 10. A categorization of patients indicates the risk of both mortality and complication from pancreatitis. Patients at the low end of the index (1–3) are predicted tohave a low risk of mortality (3%) and complications (8%), whereas patients scoring at the high end (7–10) of the index are predicted to have a higher incidence of mortality (17%) and/or complications (92%). PTS: 1 16. ANS: A 33 | P a g elOMoAR cPSD | 937 58 10 LUQ pain can be associated with stomach or spleen disorders; however, it is often associated with causes that are outside the abdomen. Hematopoietic malignancies, such as lymphomas and leukemias, and other hematologic disorders, such as thrombocytopenia, polycythemia, myelofibrosis, and hemolyticanemia, often cause enlargement of the spleen, leading to LUQ pain. In addition to questions about the specific characteristics of the pain, it is important to ask the patient about fever, unusual bleeding or bruising, recent diagnosis of mononucleosis, fatigue, malaise, lymphadenopathy, cough, arthralgias, anorexia, weight loss, jaundice, high blood pressure, and headache. PTS: 1 17. ANS: B Hypersplenism is secondary to other primary disorders, most commonly cytopenic hematologic disorders, such as lymphoma, leukemia, thrombocytopenia, polycythemia, myelofibrosis, and haemolytic anemias. With the sore throat and cervical 34 | P a g elOMoAR cPSD | 937 58 10 lymphadenopathy, infection due to Epstein-Barr virus is common in adolescents. Infectious mononucleosis is an important disorder to consider. Splenomegaly often occurs in infectious mononucleosis. PTS: 1 18. ANS: C A positive hemoccult on rectal examination may indicate an upper GI bleed or malignancy. Malignancy should also be suspectedif there is weight loss and/or a palpable abdominal mass. PTS: 1 19. ANS: A GERD is the most common organic cause of heartburn. GERD is caused by decreased lower esophageal sphincter (LES) tone. LES control can be decreased by several medications (e.g., theophylline, dopamine, diazepam, calcium-channel blockers), foods and/or beverages (caffeine, alcohol, chocolate, fatty foods), and tobacco use. When LES tone is lower than normal, secretions are allowed to reflux into the esophagus, causing discomfort. PTS: 1 20. ANS: D A female with abdominal pain can have a GI or GU disorder or gynecologic problem. It is imperative to ask about the last menstrual period (LMP) and about birth control methods in order to rule out ectopic pregnancy. A history of miscarriages and/or sexually transmitted diseases (STDs) can give more clues for the risk of ectopic pregnancy. Safe sex practices and the number ofsexual partners can alert the practitioner to the risk for pelvic inflammatory disease. No complaint of lower abdominal pain in a female should be evaluated without performing a pelvic examination. PTS: 1 21. ANS: B The most obvious sign of ectopic pregnancy is amenorrhea followed by spotting and sudden onset of severe lower quadrant pain. A stat pregnancy test should be performed. There is tenderness on pelvic examination, and a pelvic mass may be palpated. Blood is present in the cul-de-sac. Shock and hemorrhage occur if the pregnancy ruptures. Abdominal distention with peritoneal signs will ensue. Immediate laparoscopy or laparotomy is indicated because this condition is life threatening. PTS: 1 22. ANS: A The most obvious sign of ectopic pregnancy is amenorrhea followed by spotting and sudden onset of severe lower quadrant pain. A stat pregnancy test should be performed. The diagnosis of ectopic pregnancy can be made with urine human chorionic gonadotropin (hCG) or stat serum hCG, pelvic ultrasound, and, if necessary, culdocentesis to detect blood in the cul-de- sac. There is tenderness on pelvic examination, and a pelvic mass may be palpated. Blood is present in the cul-de-sac. Shock and hemorrhage occur if the pregnancy ruptures. Abdominal distension with peritoneal signs will ensue. Immediate laparoscopy or laparotomy is indicated because this condition is life threatening. PTS: 1 23. ANS: C Colorectal cancer is the second leading cause of death from malignancies in the United States. Over half are located in the rectosigmoid region and are typically adenocarcinomas. Risk 35 | P a g elOMoAR cPSD | 937 58 10 factors include a history of polyps, positive family history of colon cancer or familial polyposis, ulcerative colitis, granulomatous colitis, and a diet low in fiber and high in animal protein, fat, and refined carbohydrates. PTS: 1 24. ANS: D Colon cancer may be present for several years before symptoms appear. Complaints include fatigue, weakness, weight loss, alternating constipation and diarrhea, a change in the caliber of 36 | P a g elOMoAR cPSD | 937 58 10 stool, tenesmus, urgency, and hematochezia. Physical examination is usually normal except in advanced disease, when the tumor can be palpated or hepatomegaly is present, owing to metastatic disease. PTS: 1 25. ANS: A Urinary calculi can occur anywhere in the urinary tract; therefore, pain can originate in the flank or kidney area and radiate into the RLQ or LLQ and then to the suprapubic area as the stone attempts to move down the tract. The pain is severe, acute, and colicky and may be accompanied by nausea and vomiting. If the stone becomes lodged at the ureterovesical junction, the patient will complain of urgency and frequency. Blood will be present in the urine. PTS: 1 37 | P a g elOMoAR cPSD | 937 58 10 26. ANS: B Ovarian masses are often asymptomatic, but symptoms may include pressure-type pain, heaviness, aching, and bloating. Masses are typically detected on pelvic examination. In advanced malignancies, ascites is often present. An elevated cancer antigen 125 (CA-125) result indicates the likelihood that the mass is malignant. A transvaginal pelvic ultrasound has a higher diagnostic sensitivity than transabdominal ultrasound. If diagnosis is unclear, CT, MRI, or PET scan can be performed. A laparoscopy or exploratory laparotomy is necessary for staging, tumor debulking, and resection. PTS: 1 27. ANS: B In the majority of hernia cases, a history of heavy physical labor or heavy lifting can be elicited. Right or left lower quadrant pain that may radiate into the groin or testicle is typical. The pain is usually dull or aching unless strangulated, in which case the pain is more severe. The pain increases with straining, lifting, or movement of the lower extremities. Physical examination includes palpating the femoral area and inguinal ring for bulging or tenderness. Ask the patient to bear down against your hand. PTS: 1 28. ANS: C The most common causes of mechanical obstruction are adhesions, almost exclusively in patients with previous abdominal surgery, hernias, tumors, volvulus, inflammatory bowel disease (Crohn’s disease, colitis), Hirschsprung’s disease, fecal impaction, and radiation enteritis. Initially, the patient complains of a cramping periumbilical pain that eventually becomes constant. Physical examination reveals mild, diffuse tenderness without peritoneal signs, and possibly visible peristaltic waves. Inearly obstruction, tinkles, rushes, and borborygmi can be heard. In late obstruction, bowel sounds may be absent. The diagnosis can be made with flat and upright abdominal films looking for bowel distension and the presence of multiple air-fluid levels. CT or MRI may be necessary for confirmation. PTS: 1 29. ANS: A Diverticular disease is prevalent in patients over 60 years of age. Since the sigmoid colon has the smallest diameter of any portion of the colon, it is the most common site for the development of diverticula. Although the pain can be generalized, it is typically localized to the left lower abdomen and is accompanied by tenderness, fever, and leukocytosis. Other symptoms can include constipation or loose stools, nausea, vomiting, and positive stool occult blood. With diverticulitis, there is an increased risk of perforation, which presents with a more dramatic clinical picture as a result of peritonitis. Look for signs of peritonitis, such as a positive heel strike test and/or rebound tenderness. PTS: 1 30. ANS: A Viral gastroenteritis is the most common cause of nausea, vomiting, and diarrhea. At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and astrovirus. PTS: 1 31. ANS: B The contents of the vomitus commonly vary according to the level of obstruction. Gastric 38 | P a g elOMoAR cPSD | 937 58 10 outlet obstruction is associated with emesis containing undigested food. Proximal small intestinal blockage is likely to be bile-stained. Distal intestinal blockage is more likely to contain fecal matter. The degree of cramping and pain is often related to the proximity of the obstruction, so that obstructions of the lower intestines may have less severe cramping, vomiting, and/or pain. Bowel sounds often are high pitched and metallic sounding but may later become absent. Tenderness may be localized or diffuse. Distention as well as a succussion splash may be present. 39 | P a g elOMoAR cPSD | 937 58 10 PTS: 1 32. ANS: C The range of neurologic disorders that result in nausea and/or vomiting is broad. Included are meningitis, increased intracranial pressure (ICP), migraines, a space-occupying lesion, and Ménière’s disorder. Central nervous system-related vomiting is often projectile and may not be preceded by nausea. Papilledema may accompany increased ICP. Neurological deficits may be evident with increased ICP, space-occupying lesions, and meningitis. Nuchal rigidity is a classic finding for meningitis. PTS: 1 33. ANS: A Parasites causing diarrhea usually enter the body through the mouth. They are swallowed and can remain in the intestine or burrow through the intestinal wall and invade other organs. Certain parasites, most commonly Giardia lamblia, transmitted by fecally contaminated water or food, can cause diarrhea, bloating, flatulence, cramps, nausea, anorexia, weight loss, greasy stools because of its interference with fat absorption, and occasionally fever. Symptoms usually occur about 2 weeks after exposure and 40 | P a g elOMoAR cPSD | 937 58 10 can last 2 to 3 months. Often, the symptoms are vague and intermittent, which makes diagnosis more difficult. Serial stoolsamples for O&P should be ordered because a single sample may not reveal the offending parasite. PTS: 1 34. ANS: D The symptoms and severity of the diarrhea vary according to the underlying cause. The symptoms of carcinomas are generally insidious. The diarrhea is mild and intermittent. Often malignancies are found on routine hemoccults, sigmoidoscopy, or colonoscopy. There should be a high index of suspicion with unexplained weight loss or new-onset iron-deficiency anemia in apatient over 40 years old. PTS: 1 35. ANS: B Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by mild to severe abdominal pain, discomfort, bloating, and alteration of bowel habits. The exact cause is unknown. In some cases, the symptoms are relieved by bowel movements. Diarrhea or constipation may predominate, or they may be mixed (classified as IBS-D, IBS-C, or IBS-M, respectively). IBS may begin after an infection (postinfectious, IBS-PI) or a stressful life event. IBS is a motility disorder involving the upper and lower GI tracts that causes intermittent nausea, abdominal pain and distention, flatulence, pain relieved by defecation, diarrhea, and/or constipation. Symptoms usually occur in the waking hours and may be worsened or triggered bymeals. It is three times more prevalent in women, accounts for more than half of all GI referrals, and is highly correlated with emotional factors, part