Bates' Guide To Physical Examination and History
Taking 13th Edition Bickley Test Bank
1. During a cardiovascular examination, you auscultate a high-frequency, decrescendo diastolic
murmur best heard at the left sternal border with the patient leaning forward and breath held in
expiration. Which of the following maneuvers would most likely decrease the intensity of this
murmur?
A. Sustained handgrip
B. Valsalva maneuver
C. Rapid squatting
D. Inspiration
Answer: B
Rationale: The murmur described is typical of aortic regurgitation. The Valsalva maneuver (straining
phase) decreases venous return and left ventricular preload, reducing the intensity of most murmurs
except hypertrophic cardiomyopathy and mitral valve prolapse. Sustained handgrip increases afterload
and can increase the murmur of aortic regurgitation. Rapid squatting increases preload and afterload,
often increasing the murmur. Inspiration does not consistently affect aortic regurgitation.
2. A patient presents with a history of progressive dysphagia, first to solids and then to liquids,
along with weight loss. On physical examination, there is no palpable lymphadenopathy. Which of
the following findings on a barium swallow study is most consistent with the suspected diagnosis?
A. Smooth, tapered narrowing of the distal esophagus with a 'bird-beak' appearance
B. Irregular, shouldered narrowing in the mid-esophagus with mucosal destruction
C. Multiple diverticula in the proximal esophagus
D. A thin, web-like narrowing in the cervical esophagus
Answer: B
Rationale: Progressive dysphagia with weight loss suggests esophageal carcinoma. The classic barium
swallow finding is an irregular, shouldered narrowing (rat-tail or apple-core lesion) with mucosal
destruction, often in the mid-esophagus. A smooth, tapered narrowing with a 'bird-beak' appearance is
more typical of achalasia. Multiple diverticula suggest esophageal diverticulosis. A thin, web-like
narrowing in the cervical esophagus is characteristic of an esophageal web (Plummer-Vinson
syndrome), which is not typically associated with progressive dysphagia and weight loss.
3. In a patient with chronic obstructive pulmonary disease (COPD), which of the following physical
examination findings is most indicative of the development of cor pulmonale?
A. Barrel chest with hyperresonance to percussion
B. Use of accessory muscles and pursed-lip breathing
C. Hepatojugular reflux and lower extremity edema
D. Decreased breath sounds with prolonged expiration
Page 1
,Answer: C
Rationale: Cor pulmonale is right heart failure due to pulmonary hypertension secondary to lung disease.
Hepatojugular reflux and lower extremity edema are signs of right ventricular failure, indicating cor
pulmonale. Barrel chest, hyperresonance, use of accessory muscles, pursed-lip breathing, decreased
breath sounds, and prolonged expiration are all signs of COPD itself, not specifically cor pulmonale.
4. A 30-year-old patient with no significant medical history presents with acute onset of severe,
sharp, pleuritic chest pain and dyspnea. On examination, the trachea is deviated to the right, and
there is hyperresonance to percussion with absent breath sounds on the left. Which of the following
is the most appropriate immediate next step in management?
A. Obtain a chest X-ray to confirm the diagnosis
B. Perform needle decompression at the second intercostal space, midclavicular line on the left
C. Administer high-flow oxygen and obtain a CT angiogram
D. Start antibiotics and perform thoracentesis
Answer: B
Rationale: The presentation is classic for tension pneumothorax (tracheal deviation away from the
affected side, hyperresonance, absent breath sounds, and hypotension if present). Needle decompression
is a life-saving emergency procedure that should not be delayed for imaging. Chest X-ray would confirm
but wastes critical time. CT angiogram is not indicated. Thoracentesis is for pleural effusion, not
pneumothorax.
5. During a neurological examination, you ask the patient to stand with feet together and eyes
closed. The patient sways and nearly falls. This finding localizes to which of the following
structures?
A. Cerebellar vermis
B. Dorsal columns of the spinal cord
C. Vestibular apparatus
D. Basal ganglia
Answer: B
Rationale: The Romberg test (standing with feet together, eyes closed) assesses proprioception. A positive
test (increased sway with eyes closed) indicates loss of proprioceptive input from the dorsal columns (or
peripheral nerves). Cerebellar vermis lesions cause sway with eyes open and closed (not specifically
worse with eyes closed). Vestibular lesions cause vertigo and nystagmus, not primarily a Romberg sign.
Basal ganglia lesions cause extrapyramidal signs, not Romberg.
6. A patient with a history of hypertension and diabetes presents with acute onset of severe, tearing
chest pain radiating to the back. On examination, blood pressure is 210/120 mm Hg in the right
arm and 150/90 mm Hg in the left arm. There is a murmur of aortic regurgitation. Which of the
following physical findings would most strongly support the suspected diagnosis?
A. Pulsus paradoxus
B. Pulsus bisferiens
C. Pulsus alternans
D. Pulsus parvus et tardus
Page 2
,Answer: B
Rationale: The presentation suggests aortic dissection, and a murmur of aortic regurgitation is common.
Pulsus bisferiens (a biphasic carotid upstroke) can be seen in aortic regurgitation, which may
accompany aortic dissection if the dissection involves the aortic root. Pulsus paradoxus is associated
with cardiac tamponade. Pulsus alternans indicates severe left ventricular dysfunction. Pulsus parvus et
tardus is characteristic of aortic stenosis.
7. In a patient with suspected acute pancreatitis, which of the following physical examination
findings is most specific for severe disease and carries a high mortality?
A. Cullen sign
B. Grey Turner sign
C. Murphy sign
D. Rovsing sign
Answer: B
Rationale: Grey Turner sign (ecchymosis in the flank) indicates retroperitoneal hemorrhage and is
associated with severe necrotizing pancreatitis with a high mortality. Cullen sign (periumbilical
ecchymosis) is also seen in severe pancreatitis but is less specific and can occur in other
intra-abdominal catastrophes. Murphy sign is for cholecystitis. Rovsing sign is for appendicitis.
8. A patient with a history of alcohol use disorder presents with confusion, ataxia, and nystagmus.
On physical examination, you note ophthalmoplegia. Which of the following laboratory
abnormalities is most likely to be associated with this condition?
A. Elevated serum ammonia
B. Decreased serum thiamine
C. Increased serum osmolality
D. Decreased serum vitamin B12
Answer: B
Rationale: The triad of confusion, ataxia, and nystagmus with ophthalmoplegia is classic for Wernicke
encephalopathy, caused by thiamine (vitamin B1) deficiency, often in alcoholics. Elevated ammonia is
seen in hepatic encephalopathy, which can cause confusion but not typically ataxia and nystagmus.
Increased osmolality is seen in hyperosmolar states. Vitamin B12 deficiency causes subacute combined
degeneration of the cord, with sensory ataxia and paresthesias, but not acute ophthalmoplegia.
9. During a musculoskeletal examination of the knee, you perform the Lachman test. Which of the
following structures is primarily assessed by this maneuver?
A. Anterior cruciate ligament
B. Posterior cruciate ligament
C. Medial meniscus
D. Medial collateral ligament
Answer: A
Rationale: The Lachman test is the most sensitive test for anterior cruciate ligament (ACL) injury. It is
performed with the knee flexed at 20-30 degrees, stabilizing the femur and translating the tibia
anteriorly. Excessive anterior translation indicates ACL laxity. The posterior cruciate ligament is
assessed by the posterior drawer test. The medial meniscus is assessed by McMurray test. The medial
Page 3
, collateral ligament is assessed by valgus stress test at 0 and 30 degrees of flexion.
10. A patient presents with a thyroid nodule. On examination, you note that the nodule moves
upward with swallowing. Which of the following best explains this finding?
A. The nodule is attached to the strap muscles
B. The nodule is within the thyroid gland, which is enclosed in the pretracheal fascia
C. The nodule is a thyroglossal duct cyst
D. The nodule is fixed to the trachea
Answer: B
Rationale: The thyroid gland is enclosed in the pretracheal fascia, which is attached to the larynx and
trachea. When the patient swallows, the larynx and trachea elevate, causing the thyroid and any nodules
within it to move upward. This is a key feature distinguishing thyroid nodules from other neck masses. A
thyroglossal duct cyst moves upward with tongue protrusion, not necessarily with swallowing.
Attachment to strap muscles or fixation to trachea would limit mobility.
11. A patient with chronic obstructive pulmonary disease (COPD) presents with dyspnea and a
productive cough. On auscultation, you note decreased breath sounds and prolonged expiration.
Which of the following physical examination findings is most consistent with the presence of
pulmonary hyperinflation?
A. Increased tactile fremitus over the lung bases
B. Dullness to percussion over the liver
C. Decreased diaphragmatic excursion on percussion
D. Bronchophony heard over the trachea
Answer: C
Rationale: Pulmonary hyperinflation in COPD flattens the diaphragm, reducing its excursion. Tactile
fremitus increases with consolidation, not hyperinflation. Dullness over the liver is normal.
Bronchophony over the trachea is normal.
12. During a cardiac examination, you hear a high-pitched, decrescendo diastolic murmur best
heard at the left sternal border. Which of the following maneuvers would most likely increase the
intensity of this murmur?
A. Handgrip exercise
B. Valsalva maneuver
C. Rapid squatting
D. Inspiration
Answer: A
Rationale: The murmur described is aortic regurgitation. Handgrip increases afterload and systemic
vascular resistance, increasing the regurgitant flow and murmur intensity. Valsalva decreases venous
return and decreases most murmurs. Squatting increases preload and afterload, but the effect on aortic
regurgitation is less pronounced than handgrip. Inspiration has minimal effect on left-sided murmurs.
Page 4
Taking 13th Edition Bickley Test Bank
1. During a cardiovascular examination, you auscultate a high-frequency, decrescendo diastolic
murmur best heard at the left sternal border with the patient leaning forward and breath held in
expiration. Which of the following maneuvers would most likely decrease the intensity of this
murmur?
A. Sustained handgrip
B. Valsalva maneuver
C. Rapid squatting
D. Inspiration
Answer: B
Rationale: The murmur described is typical of aortic regurgitation. The Valsalva maneuver (straining
phase) decreases venous return and left ventricular preload, reducing the intensity of most murmurs
except hypertrophic cardiomyopathy and mitral valve prolapse. Sustained handgrip increases afterload
and can increase the murmur of aortic regurgitation. Rapid squatting increases preload and afterload,
often increasing the murmur. Inspiration does not consistently affect aortic regurgitation.
2. A patient presents with a history of progressive dysphagia, first to solids and then to liquids,
along with weight loss. On physical examination, there is no palpable lymphadenopathy. Which of
the following findings on a barium swallow study is most consistent with the suspected diagnosis?
A. Smooth, tapered narrowing of the distal esophagus with a 'bird-beak' appearance
B. Irregular, shouldered narrowing in the mid-esophagus with mucosal destruction
C. Multiple diverticula in the proximal esophagus
D. A thin, web-like narrowing in the cervical esophagus
Answer: B
Rationale: Progressive dysphagia with weight loss suggests esophageal carcinoma. The classic barium
swallow finding is an irregular, shouldered narrowing (rat-tail or apple-core lesion) with mucosal
destruction, often in the mid-esophagus. A smooth, tapered narrowing with a 'bird-beak' appearance is
more typical of achalasia. Multiple diverticula suggest esophageal diverticulosis. A thin, web-like
narrowing in the cervical esophagus is characteristic of an esophageal web (Plummer-Vinson
syndrome), which is not typically associated with progressive dysphagia and weight loss.
3. In a patient with chronic obstructive pulmonary disease (COPD), which of the following physical
examination findings is most indicative of the development of cor pulmonale?
A. Barrel chest with hyperresonance to percussion
B. Use of accessory muscles and pursed-lip breathing
C. Hepatojugular reflux and lower extremity edema
D. Decreased breath sounds with prolonged expiration
Page 1
,Answer: C
Rationale: Cor pulmonale is right heart failure due to pulmonary hypertension secondary to lung disease.
Hepatojugular reflux and lower extremity edema are signs of right ventricular failure, indicating cor
pulmonale. Barrel chest, hyperresonance, use of accessory muscles, pursed-lip breathing, decreased
breath sounds, and prolonged expiration are all signs of COPD itself, not specifically cor pulmonale.
4. A 30-year-old patient with no significant medical history presents with acute onset of severe,
sharp, pleuritic chest pain and dyspnea. On examination, the trachea is deviated to the right, and
there is hyperresonance to percussion with absent breath sounds on the left. Which of the following
is the most appropriate immediate next step in management?
A. Obtain a chest X-ray to confirm the diagnosis
B. Perform needle decompression at the second intercostal space, midclavicular line on the left
C. Administer high-flow oxygen and obtain a CT angiogram
D. Start antibiotics and perform thoracentesis
Answer: B
Rationale: The presentation is classic for tension pneumothorax (tracheal deviation away from the
affected side, hyperresonance, absent breath sounds, and hypotension if present). Needle decompression
is a life-saving emergency procedure that should not be delayed for imaging. Chest X-ray would confirm
but wastes critical time. CT angiogram is not indicated. Thoracentesis is for pleural effusion, not
pneumothorax.
5. During a neurological examination, you ask the patient to stand with feet together and eyes
closed. The patient sways and nearly falls. This finding localizes to which of the following
structures?
A. Cerebellar vermis
B. Dorsal columns of the spinal cord
C. Vestibular apparatus
D. Basal ganglia
Answer: B
Rationale: The Romberg test (standing with feet together, eyes closed) assesses proprioception. A positive
test (increased sway with eyes closed) indicates loss of proprioceptive input from the dorsal columns (or
peripheral nerves). Cerebellar vermis lesions cause sway with eyes open and closed (not specifically
worse with eyes closed). Vestibular lesions cause vertigo and nystagmus, not primarily a Romberg sign.
Basal ganglia lesions cause extrapyramidal signs, not Romberg.
6. A patient with a history of hypertension and diabetes presents with acute onset of severe, tearing
chest pain radiating to the back. On examination, blood pressure is 210/120 mm Hg in the right
arm and 150/90 mm Hg in the left arm. There is a murmur of aortic regurgitation. Which of the
following physical findings would most strongly support the suspected diagnosis?
A. Pulsus paradoxus
B. Pulsus bisferiens
C. Pulsus alternans
D. Pulsus parvus et tardus
Page 2
,Answer: B
Rationale: The presentation suggests aortic dissection, and a murmur of aortic regurgitation is common.
Pulsus bisferiens (a biphasic carotid upstroke) can be seen in aortic regurgitation, which may
accompany aortic dissection if the dissection involves the aortic root. Pulsus paradoxus is associated
with cardiac tamponade. Pulsus alternans indicates severe left ventricular dysfunction. Pulsus parvus et
tardus is characteristic of aortic stenosis.
7. In a patient with suspected acute pancreatitis, which of the following physical examination
findings is most specific for severe disease and carries a high mortality?
A. Cullen sign
B. Grey Turner sign
C. Murphy sign
D. Rovsing sign
Answer: B
Rationale: Grey Turner sign (ecchymosis in the flank) indicates retroperitoneal hemorrhage and is
associated with severe necrotizing pancreatitis with a high mortality. Cullen sign (periumbilical
ecchymosis) is also seen in severe pancreatitis but is less specific and can occur in other
intra-abdominal catastrophes. Murphy sign is for cholecystitis. Rovsing sign is for appendicitis.
8. A patient with a history of alcohol use disorder presents with confusion, ataxia, and nystagmus.
On physical examination, you note ophthalmoplegia. Which of the following laboratory
abnormalities is most likely to be associated with this condition?
A. Elevated serum ammonia
B. Decreased serum thiamine
C. Increased serum osmolality
D. Decreased serum vitamin B12
Answer: B
Rationale: The triad of confusion, ataxia, and nystagmus with ophthalmoplegia is classic for Wernicke
encephalopathy, caused by thiamine (vitamin B1) deficiency, often in alcoholics. Elevated ammonia is
seen in hepatic encephalopathy, which can cause confusion but not typically ataxia and nystagmus.
Increased osmolality is seen in hyperosmolar states. Vitamin B12 deficiency causes subacute combined
degeneration of the cord, with sensory ataxia and paresthesias, but not acute ophthalmoplegia.
9. During a musculoskeletal examination of the knee, you perform the Lachman test. Which of the
following structures is primarily assessed by this maneuver?
A. Anterior cruciate ligament
B. Posterior cruciate ligament
C. Medial meniscus
D. Medial collateral ligament
Answer: A
Rationale: The Lachman test is the most sensitive test for anterior cruciate ligament (ACL) injury. It is
performed with the knee flexed at 20-30 degrees, stabilizing the femur and translating the tibia
anteriorly. Excessive anterior translation indicates ACL laxity. The posterior cruciate ligament is
assessed by the posterior drawer test. The medial meniscus is assessed by McMurray test. The medial
Page 3
, collateral ligament is assessed by valgus stress test at 0 and 30 degrees of flexion.
10. A patient presents with a thyroid nodule. On examination, you note that the nodule moves
upward with swallowing. Which of the following best explains this finding?
A. The nodule is attached to the strap muscles
B. The nodule is within the thyroid gland, which is enclosed in the pretracheal fascia
C. The nodule is a thyroglossal duct cyst
D. The nodule is fixed to the trachea
Answer: B
Rationale: The thyroid gland is enclosed in the pretracheal fascia, which is attached to the larynx and
trachea. When the patient swallows, the larynx and trachea elevate, causing the thyroid and any nodules
within it to move upward. This is a key feature distinguishing thyroid nodules from other neck masses. A
thyroglossal duct cyst moves upward with tongue protrusion, not necessarily with swallowing.
Attachment to strap muscles or fixation to trachea would limit mobility.
11. A patient with chronic obstructive pulmonary disease (COPD) presents with dyspnea and a
productive cough. On auscultation, you note decreased breath sounds and prolonged expiration.
Which of the following physical examination findings is most consistent with the presence of
pulmonary hyperinflation?
A. Increased tactile fremitus over the lung bases
B. Dullness to percussion over the liver
C. Decreased diaphragmatic excursion on percussion
D. Bronchophony heard over the trachea
Answer: C
Rationale: Pulmonary hyperinflation in COPD flattens the diaphragm, reducing its excursion. Tactile
fremitus increases with consolidation, not hyperinflation. Dullness over the liver is normal.
Bronchophony over the trachea is normal.
12. During a cardiac examination, you hear a high-pitched, decrescendo diastolic murmur best
heard at the left sternal border. Which of the following maneuvers would most likely increase the
intensity of this murmur?
A. Handgrip exercise
B. Valsalva maneuver
C. Rapid squatting
D. Inspiration
Answer: A
Rationale: The murmur described is aortic regurgitation. Handgrip increases afterload and systemic
vascular resistance, increasing the regurgitant flow and murmur intensity. Valsalva decreases venous
return and decreases most murmurs. Squatting increases preload and afterload, but the effect on aortic
regurgitation is less pronounced than handgrip. Inspiration has minimal effect on left-sided murmurs.
Page 4
