TEST BANK FOR ADVANCED ASSESSMENT- INTERPRETING FINDINGS AND FORMULATING DIFFERENTIAL DIAGNOSES

Chapter 1. Assessment and Clinical Decision-Making: Overview Multiple Choice Identify the choice that best completes the statement or answers the question. 1. 2. 3. 4. 5. 6. 7. Which type of clinical decision-making is most reliable? A. Intuitive B. Analytical C. Experiential D. Augenblick 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 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 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 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 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 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. 9. 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 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 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? A. Clinical practice guideline B. Clinical decision rule C. Clinical algorithm D. Clinical recommendation Chapter 1. Assessment and Clinical Decision-Making: Overview Answer Section MULTIPLE CHOICE 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 and paired 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 on a 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 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 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-based resources 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 Chapter 2. An Overview of Genetic Assessment 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 C. 25% chance children will carry the disease D. 10% chance children will be disease free 10. A woman with an X-linked dominant disorder will: A. Not be affected by the disorder herself B. Transmit the disorder to 50 % of her offspring (male or female) C. Not transmit the disorder to her daughters D. Transmit the disorder to only her daughters 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 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 abnormalappearing 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. Approximately what percentage of cancers is due to a single-gene mutation? A. 50% to 70% B. 30% to 40% C. 20% to 25% D. 5% to 10% 17. 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? A. Colon cancer in family member at age 70 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. In order to provide a comprehensive genetic history of a patient, the NP should: A. Ask patients to complete a family history worksheet B. Seek out pathology reports related to the patient’s disorder C. Interview family members regarding genetic disorders D. All of the above Chapter 2. An Overview of Genetic Assessment 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 who are 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. PTS: 1 5. ANS: B For adopted members of the family, use brackets as the appropriate standardized pedigree symbol ([e.g., brackets]). 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 next generation 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 with mental 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 (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 conception whenever possible. For example, 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 caféau-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 Chapter 3. Skin Multiple Choice Identify the choice that best completes the statement or answers the question. 1. 2. 3. 4. 5. 6. 7. When a patient presents with a skin-related complaint, it is important to first: A. Fully inspect all skin lesions before asking the patient how the lesion in question developed B. Obtain a full history about the development of the skin lesion prior to the physical examination C. Complete a full physical examination of the body prior to inspecting the skin lesion D. Examine the skin lesion without hearing a health history in order to not prejudice the diagnosis Jaundice is a state of high bilirubin in the bloodstream. It is most commonly seen first in the: A. Sclera B. Nailbeds C. Palms of the hands D. Unexposed skin areas Skin turgor is best assessed by pinching skin over the: A. Forehead B. Forearm C. Knees D. Dorsum of the hand What kind of lesions are caused by the herpes simplex virus? A. Scales B. Vesicles C. Plaques D. Urticaria A patient presents with vesicles on a reddened base in a symmetrical pattern on the lower neck and upper back, stating that he had noticed discomfort prior to the onset of the ―rash.‖ Which of the following should be considered in your differential diagnosis? A. Dermatitis herpetiformis B. Herpes zoster C. Dishydrosis D. Contact dermatitis Herpetic whitlow is commonly located on: A. The eyelid B. The scalp C. A finger D. Lip Which type of lesion is referred to as resembling ―a dew drop on a rose petal?‖ A. Varicella zoster 8. 9. B. Measles C. Rubella D. Tinea Which lesions are typically located along the distribution of dermatome? A. Scabies B. Herpes zoster C. Tinea D. Dishydrosis Folliculitis is most commonly due to: A. Contact dermatitis B. Varicella zoster C. Dermatophytes D. Staphylococcal infection 10. A patient presents with polymorphous lesions consisting of small, red papules and vesicles, with a few eroded and crusted lesions. Your differential diagnosis should include all except which of the following? A. Herpes simplex B. Varicella C. Bacterial folliculitis D. Contactdermatitis 11. The following has been associated with cervical and anal cancer: A. Secondary syphilis B. Human papilloma virus C. Herpes simplex D. Epstein-Barr virus 12. During a routine exam, you notice a 5 mm lesion on the right medial cheek. The border is raised and pearlescent in color and the area is crusted. The patient admits that it has been present for several months and has only recently become tender with the development of the crusting. This is most likely: A. Squamous cell carcinoma B. Epidermoid cyst C. Basal cell carcinoma D. Actinic keratosis 13. A patient has a tender, firm, nodular cystic lesion on his scalp that produces cheesy discharge with foul odor. This is most likely a: A. Bacterial folliculitis B. Basal cell carcinoma C. Bullous impetigo D. Epidermoid cyst 14. Which of the following is not associated with development of erythema multiforme? A. Herpes virus B. Mycoplasms This study source was downloaded by from CourseH on :32:37 GMT -05:00 C. Medications D. Trauma 15. Your patient complains of a progressive loss of pigment in various patches on the body. Affected skin surfaces are otherwise normal (e.g. no scaling, vesicles, elevation, or other changes). The most likely cause is: A. Vitiligo B. Acanthosis nigricans C. Psoriasis D. Pityriasis alba 16. A patient has an irregularly shaped, brown to black lesion on the upper arm that has changed color recently. The widest diameter is 6 mm. You should: A. Measure and record the dimensions and schedule follow-up to repeat measurement in 2 weeks B. Biopsy the lesion C. Obtain skin scraping for dermatophytes D. All of the above 17. Which of the following skin disorders is associated with diabetes? A. Acanthosis nigricans B. Vitiligo C. Impetigo D. Folliculitis 18. Which of the following disorders often presents in patients with café-au-lait spots ? A. Diabetes B. Malignancy C. Neurofibromatosis D. Autoimmune disease 19. Patient presents with complaint of a ―swollen node‖ under his arm. The area is tender and the node has progressed in size over the past few days. Which of the following should be included in your differential diagnosis? A. Hidradenitis suppurativa B. Epidermoid cyst C. Furuncle D. Both A and C 20. Which of the following skin conditions frequently heralds an anaphylactic reaction? A. Contact dermatitis B. Eczema C. Urticaria D. Erythema multiforme 21. A patient with sarcoidosis has firm, tender, reddened nodules, along the anterior aspect of the leg. These lesions are called: A. Erythema multiforme B. Erythema nodosum This study source was downloaded by from CourseH on :32:37 GMT -05:00 C. A discoid rash D. Lichen planus 22. A patient suffered a laceration of the shin three days ago, and today presents with a painful, warm, red swollen region around the area. The laceration has a purulent exudate. The clinician should recognize that the infected region is called: A. Contact dermatitis B. Folliculitis C. Hidradenitis suppurative D. Cellulitis 23. A woman complains of malaise and arthralgias. You note a butterfly-shaped, macular, erythematous rash across her cheeks and nose. These conditions are common in: A. Psoriasis B. Lichen planus C. Systemic lupus erythematosus D. Erythema nodosum 24. Which of the following characteristics is not helpful in differentiating between psoriasis and atopic dermatitis? A. Distribution B. Family history C. Lesion morphology D. Chronicity 25. A patient presents complaining of recent onset of aching and malaise followed by the development of a generalized rash. He denies previous rash although he does admit that about a month ago he had an open sore on his right hand that was nonpainful. The exam reveals a maculopapular rash and lymphadenopathy. This presentation is most consistent with: A. Pityriasis rosea B. Secondary syphilis C. Herpetic whitlow D. Pyogenic granuloma This study source was downloaded by from CourseH on :32:37 GMT -05:00 Chapter 3. Skin Answer Section MULTIPLE CHOICE 1. ANS: B When a patient presents with a skin-related complaint, there is an inclination to immediately examine the skin, as the lesion or change is often readily observable. However, it is crucial to obtain a history before proceeding to the examination in order to understand the background of the problem. A thorough symptom analysis is essential. PTS: 1 2. ANS: A Jaundice indicates an elevation in bilirubin and often is evident in the sclera and mucous membranes before it is obvious in the skin. PTS: 1 3. ANS: B The skin overlying the forehead or dorsal hand is more likely to provide a false impression of tenting or decreased elasticity; therefore, turgor should be tested by gently pinching a fold of skin over the abdomen, forearm, or sternum. PTS: 1 4. ANS: B The skin lesions of herpes consist of multiple vesicles, which cluster and are usually preceded by an area of tender erythema. The vesicles erode, forming ulcerations. PTS: 1 5. ANS: A Pruritus, burning, or stinging at the site often precedes the development of skin lesions. The lesions consist of clustered vesicles on a reddened base. The lesions have a herpetiform configuration, and the distribution is symmetrical. The extensor surfaces of the knees and elbows are often affected, as are the posterior scalp, neck, back, and thighs. PTS: 1 6. ANS: C Herpetic whitlow, a herpetic lesion on the finger, is usually a result of self-contamination of an infected patient to a skin break on the finger. PTS: 1 7. ANS: A Similar to other herpes lesions, varicella lesions progress from an area of redness to form a vesicle, then become pustular, and finally ulcerate. The vesicles look like a dewdrop on a rose petal. PTS: 1 This study source was downloaded by from CourseH on :32:37 GMT -05:00 8. ANS: B The distribution of herpes zoster lesions lie along a dermatome and are typically unilateral. There are many variations of the condition, depending on the affected dermatome. The healing of the lesions is frequently followed by development of postherpetic neuralgia. PTS: 1 9. ANS: D . Folliculitis is an inflammation of the hair follicles and is typically associated with staphylococci. Other microorganisms and causes include pseudomonas (associated with hot tubs), Candida, tinea barbae, and herpes. PTS: 1 10. ANS: C While all of the conditions listed may progress from papules to erosive crusted lesions, folliculitis is associated with pustules, rather than vesicles. PTS: 1 11. ANS: B Human papilloma virus (HPV) is a viral cause of wart formation. In the perineal area, these are known as genital warts and they can lead to cancer of the cervix or anus. PTS: 1 12. ANS: C Basal cell carcinoma is the most common form of human malignancy and involves sun-exposed skin. This malignancy is generally very slow growing. However, it can become quite destructive and invasive if not diagnosed and treated in a timely manner. The typical complaint is of a nonhealing sore located on the face, ear, or other sun-exposed area. Although the lesions can vary, the typical lesion has a waxy/pearly appearance with a central indentation. PTS: 1 13. ANS: D With an epidermoid cyst, the patient complains of a cystic lesion that produces cheesy discharge with foul odor. The lesion is sometimes tender or painful. The lesion is nodular, round and firm, and subcutaneous; thus, it is flesh colored. The most common sites include the face, scalp, neck, upper trunk, and extremities. PTS: 1 14. ANS: D Erythema multiforme major usually occurs in association with herpes or mycoplasma infection or in response to medications, although a range of infections is implicated. PTS: 1 15. ANS: A This study source was downloaded by from CourseH on :32:37 GMT -05:00 With vitiligo, the patient often describes a history of the progressive development of small, multiple areas of depigmentation that, over time, become larger and confluent. There is no overlying scale or vesicle development. Any area of skin can be involved. The hair in the affected area may also lose pigmentation. There is a higher incidence of vitiligo in patients with autoimmune disorders, particularly those affecting the endocrine system, including hypothyroidism, diabetes mellitus, and Addison’s disease. PTS: 1 16. ANS: B In malignant melanoma, there is usually a history of a changing mole or other area of hyperpigmentation. The lesion is usually greater than 0.5 cm in diameter and has notched or irregular edges, irregular pigmentation, and asymmetry of shape. Like other skin disorders, there are variations in appearance, and there should be a high suspicion for melanoma in any changing pigmented skin lesion. Biopsy is diagnostic. PTS: 1 17. ANS: A Acanthosis nigricans is associated with insulin resistance. It is most prevalent in individuals who are obese and in Blacks and Hispanics. Onset is usually in youth. It is an area of darkly pigmented skin often within the skin folds. PTS: 1 18. ANS: C Café-au-lait spots are caused by increased melanin content and are associated with neurofibromatosis. The lesions vary in appearance and size, with color ranging from tan to brown. There frequently is a history of a variety of developmental and congenital conditions. The lesions are asymptomatic. They range in size from millimeters to over 10 cm and are usually flat macules or patches. Although the color varies, most are coffee colored. PTS: 1 19. ANS: D Hidradenitis suppurativa involves occlusions of hair follicles, which causes a red, fluctuant tender lesion. The site is commonly under the breast or in the axillae or groin. The clinician must differentiate this skin condition from an enlarged lymph node, which can appear similar. An enlarged lymph node is usually painless, whereas hidradenitis is usually tender. Furuncles are staphylococcal infections of hair follicles or sebaceous glands. Patients complain of pain, redness, and swelling at the affected site, commonly the axillae and groin. PTS: 1 20. ANS: C Urticaria, also commonly called hives, involves a histamine-mediated response that can be either acute or chronic. A wide range of situations are associated with hives, including a variety of infections, allergies to foods and medications, or underlying systemic disease. Urticaria are pink or red wheals that are very pruritic. Frequently they are associated with anaphylaxis and/or angioedema. This study source was downloaded by from CourseH on :32:37 GMT -05:00 PTS: 1 21. ANS: B Patients with autoimmune disease frequently experience isolated, multiple skin lesions that emerge as firm, tender, reddened nodules, usually along the anterior aspect of the leg, although other sites can be involved. Over a period of up to 2 weeks, the lesions fade in color and the degree of firmness decreases. PTS: 1 22. ANS: D In cellulitis, a patient often describes a history of a break in the skin from an injury, insect bite or sting, or previous procedure preceding the onset of redness, swelling, and pain at the site. The affected area is tender, swollen, reddened, and warm. Streptococcus or staphylococcal commonly causes the infection. The lower leg is a common site, usually unilateral. PTS: 1 23. ANS: C In systemic lupus erythematosus, the patient will have a range of symptoms relevant to the diagnosis, depending on the affected organs. There is often coexisting arthralgia and malaise. The rash is macular and erythematous. It is described as a ―butterfly rash‖ because the distribution resembles a butterfly’s wings overlying the forehead and cheeks. PTS: 1 24. ANS: D While patients with psoriasis or atopic dermatitis are often able to provide related family history and the distribution and appearance of the lesions are different, both conditions tend to be chronic in nature. PTS: 1 25. ANS: B The patient may provide the history of a more generalized rash developing 2 or more weeks following the primary lesion, which may still be evident. The primary lesion is usually an isolated, single red lesion, which ultimately ulcerates, forming a nontender chancre. There may be a period of malaise preceding the eruption of secondary lesions. These lesions vary in appearance and distribution, but the typical finding is of red maculopapular lesions smaller than 1 cm in diameter. Any portion of skin can be involved, including the scalp, mucous membranes, perineum, and the soles and palms. There is generalized lymphadenopathy. PTS: 1 This study source was downloaded by from CourseH on :32:37 GMT -05:00 Chapter 4. Head, Face, and Neck Multiple Choice Identify the choice that best completes the statement or answers the question. 1. When obtaining a health history focusing on the patient’s head, face, and neck, which of the following is particularly important in regard to risk of disease? A. Past dental work B. Use of alcohol and tobacco C. History of tension headaches D. Use of aspirin 2. Which of the cranial nerves should be tested if the patient complains of numbness of the cheek? A. Cranial nerve III B. Cranial nerve V C. Cranial nerve VII D. Cranial nerve X 3. Which of the cranial nerves should be tested when a patient presents with right-sided facial droop and inability to close the right eye? A. Cranial nerve III B. Cranial nerve V C. Cranial nerve VII D. Cranial nerve X 4. A patient complains of pain with chewing, earache, and grinding her teeth when asleep. These are symptoms of: A. Temporomandibular joint syndrome B. Trigeminal neuralgia C. Facial nerve palsy D. Angina 5. Inflammation of the parotid gland can cause which of the following conditions? A. Trigeminal neuralgia B. Bruxism C. Mumps D. Temporomandibular joint syndrome 6. Calcium phosphate stones can develop within the salivary gland ducts. This can occur in the disorder called: This study source was downloaded by from CourseH on :32:45 GMT -05:00 A. Temporomandibular joint syndrome B. Mumps C. Trigeminal neuralgia D. Sialoadenitis 7. Your patient presents to the ER due to a bee sting on the cheek. As you are examining the patient, you note increasing facial swelling and redness as well as swelling of the lips and eyes. This condition is due to: A. Angioedema B. Parotitis C. Sinusitis D. Sialoadenitis 8. Your patient accidentally cut his cheek while shaving 3 days ago. Today, the region is warm, erythematous, swollen, and has the appearance of an orange peel. There is a serous exudate coming from the wound. This is most likely due to: A. Folliculitis B. Cellulitis C. Supurative Parotitis D. Sialoadenitis 9. A patient with systemic lupus erythematosus has been taking a prolonged course of steroids. She complains that her face appears swollen and has experienced a 10-pound weight gain. This is often referred to as: A. Angioedema B. Parotitis C. Cushingoid effect D. Myxedema 10. A patient with a positive Lyme titer presents with left-sided unilateral facial droop and inability to close the left eye. This is most likely due to: A. Trigeminal neuralgia B. Temporomandibular joint syndrome C. Multiple sclerosis D. Bell’s palsy 11. A solitary cold nodule on Radioactive Iodine (RAI) uptake on a thyroid scan is suspicious for: A. Hyperthyroidism This study source was downloaded by from CourseH on :32:45 GMT -05:00 B. Myxedema C. Trigeminal neuralgia D. Thyroid Cancer 12. A 6-year-old patient complains of a constantly itchy scalp that developed after returning home from school today. The most common cause for this condition in a child is: A. Seborrheic dermatitis B. Pediculosis C. Psoriasis D. Basal cell carcinoma 13. One of the most common signs of Epstein-Barr viral infection (infectious mononucleosis) is: A. Swelling of the face B. Parotitis C. Cervical lymphadenopathy D. Thyroid enlargement 14. A goiter is most commonly associated with: A. Hypothyroidism B. Hyperthyroidism C. Euthyroid function D. All of the above 15. On physical examination, your 55-year-old female patient has an enlarged thyroid gland. She complains of feeling hot all the time, nervousness, palpitations, tremor, and recent weight loss of 10 pounds over the past 3 weeks. These signs and symptoms are commonly due to: A. Hypothyroidism B. Hyperthyroidism C. Thyroid cancer D. All of the above 16. A patient complains of burning, epigastric pain, and regurgitation of food when lying flat. It is important to recognize that these symptoms are common in: A. Gastroesophageal reflux disease B. Neuromuscular disorders C. Esophageal cancer D. Achalasia 17. A patient presents with extremely tight, shiny skin over the hands and face. There is also a lack of nasolabial folds and blank facial expression. This is a common sign of: This study source was downloaded by from CourseH on :32:45 GMT -05:00 A. Bell’s palsy B. Trigeminal neuralgia C. Scleroderma D. Hypothyroid myxedema 18. Chronic abuse of alcohol and tobacco are associated with , which can present with lymphadenopathy of the head and neck. A. Lymphoma B. Squamous cell carcinoma C. Leukemia D. Thyroid cancer 19. Weight loss, fever, fatigue, cervical and mediastinal lymphadenopathy are often the presenting signs of: A. Hypothyroidism B. Scleroderma C. Esophageal cancer D. Lymphoma 20. The following is a sexually transmitted infection that can cause pharyngitis and cervical lymphadenopathy with oral sex: A. Hemolytic streptococcus B. Chlamydia trachomatis C. Epstein-Barr virus D. Cytomegalovirus Chapter 4. Head, Face, and Neck Answer Section MULTIPLE CHOICE 1. ANS: B Tobacco and/or EtOH use or abuse are the biggest risk factors for malignancies of the head and neck. PTS: 1 2. ANS: B Cranial nerve V, the trigeminal nerve, controls the sensation of the face and function of the masseter muscle. Cranial nerve VII, the facial nerve, controls facial expressions or motor function of the facial muscles. Cranial nerve III, the oculomotor nerve, controls the pupil and movement of eyes. Cranial nerve X is the vagus nerve, which is demonstrated by testing the gag reflex. PTS: 1 3. ANS: C This study source was downloaded by from CourseH on :32:45 GMT -05:00 Cranial nerve VII, the facial nerve, controls facial expressions or motor function of the facial muscles. The disorder that causes unilateral facial muscle dysfunction and inability to close the eye is Bell’s palsy. Cranial nerve V, the trigeminal nerve, controls the sensation of the face and function of the masseter muscle. Cranial nerve III, the oculomotor nerve, controls the pupil and movement of eyes. Cranial nerve X is the vagus nerve, which is demonstrated by testing the gag reflex. PTS: 1 4. ANS: A The signs and symptoms of temporomandibular joint syndrome range from mild aching to severe, sharp pain in and around the TMJs. Typically, there is pain with movement of the joint, particularly with chewing. There is tenderness of the masticatory muscles. The pain is often referred to the ear, causing pain, tinnitus, and hearing difficulties. Stress can cause jaw clenching or bruxism, resulting in fatigue or spasm of the masticatory muscles and, in turn, TMJ pain. PTS: 1 5. ANS: C Parotid gland inflammation can occur with paramyxovirus infection, also called mumps. There is swelling of the preauricular regions of the face. PTS: 1 6. ANS: D The submandibular glands can become inflammed and develop stones in a condition called sialolithiasis. Often these patients have a history of recurrent sialadenitis, and the stones are composed of calcium phosphate as a result of the pH of the saliva. PTS: 1 7. ANS: A Angioedema is basically anaphylaxis that is restricted to the skin and is generally benign and self-limiting. The causes are numerous and include insect stings; atopic conditions; food allergies (typically nuts, eggs, shellfish, fruit, and sulfites); drug allergies; allergy desensitization injections; a reaction to blood products; a response to exercise, cold, or pressure; heredity; and vasculitis. PTS: 1 8. ANS: B Streptococcus is the most common organism responsible for superficial cellulitis. It can occur from a wound or bite or as a complication of infections of the eyes, ears, mouth, or nose. The symptoms include This study source was downloaded by from CourseH on :32:45 GMT -05:00 redness, warmth, edema, leukocyte infiltration, tenderness, and regional lymphadenopathy. The skin may have a thick, orange peel appearance, and the borders are usually indistinct. PTS: 1 9. ANS: C A cushingoid look can occur in patients who take long-term steroids for chronic diseases, including respiratory, hematologic, and autoimmune. The typical symptoms are those of Cushing’s disease, with a rounded ―moon face‖ appearance and truncal obesity. PTS: 1 10. ANS: D Bell’s palsy is a unilateral paralysis of the face. The etiology is uncertain, but the paralysis is thought to be due to an inflammation of cranial nerve (CN) VII. Lyme disease is a common cause. The onset of Bell’s palsy is sudden, and the symptoms are unilateral. The affected side of the face droops with asymmetrical facial movement; there is pain in or around the ear, excessive lacrimation and salivation, and inability to close the eye. PTS: 1 11. ANS: D Hyperthyroidism does not necessarily coincide with a thyroid nodule. Myxedema is a tissue swelling of the face and body due to hypothyroidism. Trigeminal neuralgia causes paroxysms of pain on one side of the face. Thyroid cancer presents as a solitary cold nodule on a thyroid ultrasound. Predisposing factors include female gender, positive family history, and history of radiation exposure to the head, face, or neck. PTS: 1 12. ANS: B It would be unusual for pruritus in the head and neck to indicate anything except a skin condition/disease or infestation. If the patient is a school-age child, pediculosis (head lice) is an obvious choice, and the child’s friends and school administrators should be questioned about recent outbreaks. Nits are lice eggs that are fixed to the hair shaft and are grayish-white in appearance. Unlike the flakiness of seborrhea or psoriasis, nits cannot be easily dislodged. Basal cell carcinoma is a slow-growing, invasive type of skin cancer that occurs on sun-exposed regions of the head, such as the nose. PTS: 1 13. ANS: C This study source was downloaded by from CourseH on :32:45 GMT -05:00 Sore throat, fever, and prominent cervical lymphadenopathy are key signs of Epstein-Barr virus, also called infectious mononucleosis. Parotitis is swelling of the parotid glands that occur in mumps. Swelling of the deep tissues of the face often occurs with myxedema, which occurs due to thyroid disease. PTS: 1 14. ANS: D A goiter, an enlargement of the thyroid gland, may be associated with hypothyroidism or hyperthyroidism, but patients with goiters may also be euthyroid, a condition termed nontoxic goiter. PTS: 1 15. ANS: B Clinical manifestations of Grave’s disease (hyperthyroidism) include diffuse goiter, nervousness, irritability, tremor, heat intolerance, weakness, tachycardia, palpitations, widened pulse pressure, increased sweating, weight loss, insomnia, frequent bowel movements, menstrual irregularities, exophthalmos, and infiltrative dermopathy. Patients older than 50 years often present with cardiac symptoms, such as hypertension, atrial fibrillation, or heart failure. PTS: 1 16. ANS: A The patient with gastroesophageal reflux disease (GERD) describes burning and pain in the esophagus with or without dysphagia. The symptoms may occur more with eating or drinking and at night when the patient is recumbent. Persons with neuromuscular disorders, achalasia, or esophageal cancer describe difficulty swallowing or feeling of a lump in the throat. PTS: 1 17. ANS: C Scleroderma is an autoimmune disease that causes infiltration of the skin with autoantibodies and immune complexes. Signs include extremely shiny and taut skin over the face, hands, and feet. PTS: 1 18. ANS: B The most common malignancies of the head and neck are squamous cell carcinomas of the larynx, palatine tonsil, and hypopharynx. More than 80% of patients with these cancers have a history of tobacco and/or EtOH use or abuse. PTS: 1 This study source was downloaded by from CourseH on :32:45 GMT -05:00 19. ANS: D Cervical and mediastinal lymphadenopathy are often the presenting complaints of lymphoma and generally precede systemic symptoms, which include fever, night sweats, weight loss, and fatigue. PTS: 1 20. ANS: B Gonococcus or Chlamydia trachomatis are sexually transmitted infections that can cause pharyngitis and lymphadenopathy. EpsteinBarr virus causes infectious mononucleosis, which is not regarded as a sexually transmitted infection. Strep throat is pharyngitis caused by group A beta hemolytic streptococcus. Streptococcal pharyngitis is not a sexually transmitted infection. PTS: 1 This study source was downloaded by from CourseH on :32:45 GMT -05:00 Chapter 5. The Eye Multiple Choice Identify the choice that best completes the statement or answers the question. 1. 2. 3. 4. 5. 6. 7. The most common type of eye disorder is: A. Refractive errors B. Macular conditions C. Neurological conditions D. Astigmatisms Which of the following findings should trigger an urgent referral to a cardiologist or neurologist? A. History of bright flash of light followed by significantly blurred vision B. History of transient and painless monocular loss of vision C. History of monocular severe eye pain, blurred vision, and ciliary flush D. All of the above The first assessment to complete related to the eyes is: A. Eye lids B. Visual acuity C. Extraocular movements D. Peripheral vision It is important to not dilate the eye if is suspected. A. Cataract B. Macular degeneration C. Acute closed-angle glaucoma D. Chronic open-angle glaucoma Which of the following is true concerning adjustment of diopters during funduscopic exam? A. Moving towards more positive diopters shifts examiner’s focus posteriorly B. Moving towards more negative diopters shifts examiner’s focus anteriorly C. Moving towards more positive diopters broadens the examiner’s field of view D. Moving towards more negative diopters broadens the examiner’s field of view A clinician can assess the alignment of the eyes by all except: A. Checking for a symmetric light reflex B. Observing eye movements C. Performing cover/uncover exam D. Measuring the palpebral gap The fundoscopic examination allows the clinician to directly observe: A. Cranial nerve I B. Cranial nerve II C. Cranial nerve III D. Cranial nerve IV This study source was downloaded by from CourseH on :32:53 GMT -05:00 8. 9. Shining a light directly on one pupil should make the other pupil constrict. This is called the: A. Accommodation response B. Red reflex C. Corneal light reflex D. Consensual pupil response Your patient describes blurry vision as well as halos and glares in response to bright lights or when driving in the dark. There is no pain. These are symptoms of: A. Glaucoma B. Macular degeneration C. Cataracts D. Diabetic retinopathy 10. While assessing visual acuity, you notice that the patient is turning his head ―side-to-side‖ for an oblique, or peripheral, view of the Snellen chart, raising your suspicion that the patient may suffer from: A. Glaucoma B. Cataract C. Macular degeneration D. Amaurosis fugax 11. When examining the six cardinal fields of gaze, the clinician is assessing function of: A. CN III B. CN IV C. CN VI D. All of the above 12. Your patient has been treated for glaucoma for 5 years. Which of the following will provide indication of the level of progression during the funduscopic examination for this patient? A. Checking the macula B. Estimating cup-to-disk ratio C. Verifying a red reflex D. Extraocular movements 13. A patient describes a brief episode of visual impairment where it was as if a dark shade was gradually coming down over one eye. The vision returned a moment later. This is most commonly described in which condition? A. Glaucoma B. Cataracts C. Amaurosis fugax D. Macular degeneration 14. A Marcus-Gunn effect involves: A. Abnormal pupillary responses B. Abnormal visual acuity C. Abnormal funduscopic findings D. All of the above This study source was downloaded by from CourseH on :32:53 GMT -05:00 15. In the following condition, patients often describe a sudden, large flash of light with gradual loss of vision in one eye. A. Amaurosis fugax B. Acute glaucoma C. Temporal arteritis D. Retinal detachment 16. Macular degeneration is a visual disturbance due to: A. Sudden head trauma B. Ischemia of the central retinal artery C. Elevated intraocular pressure D. Physiological aging 17. An Amsler grid is used to evaluate which of the following conditions? A. Optic neuritis B. Macular degeneration C. Amaurosis fugax D. Retinal detachment 18. The most common cause of eye redness is: A. Conjunctivitis B. Acute glaucoma C. Head trauma D. Corneal abrasion 19. A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely with: A. Bacterial conjunctivitis B. Allergic conjunctivitis C. Chemical conjunctivitis D. Viral conjunctivitis 20. Your patient with Crohn’s Disease complains of eye pain and photophobia. This is likely related to: A. Symptoms of temporal arteritis B. Altered pupil response due to uveitis C. Blurry vision due to bilateral cataracts D. Subconjunctival hemorrhage 21. Your patient is suffering from herpes zoster along the trigeminal nerve distribution of the face. You should carefully assess for the presence of: A. Keratitis B. Uveitis C. Scleritis D. Conjunctivitis 22. A 4-day-old newborn presents with redness and tearing of one eye. Slight pressure over the lacrimal sac produces white discharge. The clinician should be aware that the following condition is common in newborns: This study source was downloaded by from CourseH on :32:53 GMT -05:00 A. Conjunctivitis B. Sinus infection C. Dacryocystitis D. Herpes infection 23. Ptosis is commonly the first sign of: A. Stevens-Johnson syndrome B. Hyperthyroidism C. Temporal arteritis D. Myasthenia gravis 24. A 9-month-old patient presents with fever and large areas of redness and bullae over the trunk, palms, legs, and sole of the feet. There is redness and swelling of the conjunctiva and lips. The clinician should recognize this condition as: A. Giant cell arteritis B. Stevens-Johnson syndrome C. Botulism D. Myasthenia gravis 25. In assessing the eyes, which of the following is considered a ―red flag‖ finding when associated with eye redness? A. History of prior red-eye episodes B. Grossly visible corneal defect C. Exophthalmos D. Photophobia This study source was downloaded by from CourseH on :32:53 GMT -05:00 Chapter 5. The Eye Answer Section MULTIPLE CHOICE 1. ANS: A The most common forms of visual impairment are refractive errors. In fact, over 150 million Americans are reported to use corrective lenses for refractive errors. PTS: 1 2. ANS: B Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist. PTS: 1 3. ANS: B The eye examination begins with determination of the patient’s visual acuity. Next, the examiner typically inspects the external and accessory structures before concentrating inward to include the eye. PTS: 1 4. ANS: C If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute closed-angle glaucoma is present because dilating the eye may increase the intraocular pressure. PTS: 1 5. ANS: B As the dial on the ophthalmoscope is moved counterclockwise, the diopters shift from positive to negative. Because the more negative diopters direct the focus posteriorly, by moving from the positive to negative diopters, your focus will shift from the anterior eye to the posterior eye, retina, and optic disk. PTS: 1 6. ANS: D Alignment is evaluated by observing eye motion, performing the cover/uncover test, and assessing the light reflex. PTS: 1 7. ANS: B This study source was downloaded by from CourseH on :32:53 GMT -05:00 The optic nerve (CN II) is directly observed during the fundoscopic examination. PTS: 1 8. ANS: D The pupillary reflex is elicited by holding the light source in front of the patient so that it is directed toward one eye. At this point, observe both pupils, noting the direct response of the eye receiving the direct light and the consensual response in the opposite eye. PTS: 1 9. ANS: C Patients with cataracts generally describe progressive and painless decreased visual acuity. The altered vision includes general blurring, dimming, and haziness of vision as well as the development of halos and glares in response to bright lights or when driving in the dark. The opacities may be visible as gray or whitening areas over the pupil. PTS: 1 10. ANS: C Visual loss associated with macular degeneration can be progressive, unilateral or bilateral, and starts centrally. PTS: 1 11. ANS: D The six cardinal fields of gaze are testing the extraocular muscles, which are innervated by the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI). PTS: 1 12. ANS: B In glaucoma, inspection may identify cup/disk ratio change; late afferent effect is possible. PTS: 1 13. ANS: C In amaurosis fugax, the patient often describes an episode as if a shade had been pulled over one eye in a descending fashion and then, a short time later, the shade was raised and vision restored. PTS: 1 14. ANS: A Note whether the pupil response is a slight constriction, slightly more pronounced with direct light, which is normal, or the pupil slightly relaxes so that the response is slightly less pronounced with direct light, which is an abnormal, Marcus-Gunn effect. PTS: 1 15. ANS: D This study source was downloaded by from CourseH on :32:53 GMT -05:00 With retinal detachment, the patient usually provides a history of a contributing condition or trauma, followed by a sudden visual disturbance, such as flashing light, floaters, or scotoma. The visual defect may advance or progress as the retinal detachment enlarges, but central vision will be retained unless the macula is involved. PTS: 1 16. ANS: D Most commonly, macular degeneration is associated with aging and results either from atrophy of the macula or exudation and hemorrhage of the vessels in the macular region. PTS: 1 17. ANS: B With macular degeneration, a commonly used test, the Amsler grid, assesses the patient’s ability to accurately see a set of grids. PTS: 1 18. ANS: A The most common cause of eye redness is conjunctivitis (see Plate 38), which involves an inflammation of one or more areas of the conjunctiva. It is important to discriminate between allergic, viral, bacterial, and other causes of conjunctivitis in order to provide definitive treatment. Infectious conjunctivitis is usually caused by viral organisms, although bacterial infections are also common and can be secondary to viral infections. Allergies are the most frequent cause of noninfectious conjunctivitis. Other causes include chemical reactions. PTS: 1 19. ANS: D Preauricular nodes are nonpalpable and nontender in allergic conjunctivitis, usually nonpalpable in bacterial conjunctivitis, and palpable in viral conjunctivitis. PTS: 1 20. ANS: B Uveitis involves inflammation of the uveal tract, including the iris. The inflammation may be caused either by infection or as part of a reaction associated with a systemic disorder. For instance, an increased incidence of uveitis is associated with autoimmune disorders, such as Crohn’s disease, ankylosing spondylitis, and HIV infection. The vision changes associated with uveitis stem from altered responsiveness of the pupil and lens. Patients commonly experience both photophobia and eye pain. There is a ciliary flush and, usually, a constricted pupil. PTS: 1 21. ANS: A This study source was downloaded by from CourseH on :32:53 GMT -05:00 Keratitis is inflammation of the cornea that can lead to blindness in the affected eye. Keratitis is commonly caused by herpetic and other infections, ischemia, chemical exposures, foreign bodies, or corneal abrasions. Keratitis is noteworthy because it can lead to ulcerations, opacities, and blindness of the affected eye; thus, patients suspected of this disorder should be immediately referred to an ophthalmologist. PTS: 1 22. ANS: C Dacryocystitis is an infection of the lacrimal sac and is most common in infants, secondary to congenital stenosis of the lacrimal duct. If the duct is occluded, constant tearing may occur. The lacrimal sac may be edematous, red, and tender. Pressure over the sac produces purulent discharge. PTS: 1 23. ANS: D Ptosis, or drooping of an eyelid, can be related to simple aging, with natural loss of elasticity and lid drooping, or it can result from a variety of other causes. The causes of ptosis are often categorized as congenital and acquired. Causes occurring after birth include trauma, conditions adding mass to the eyelid, and conditions that affect the nerves or muscles controlling the lid’s position. In 75% of the cases, the first manifestation of myasthenia gravis is ptosis. PTS: 1 24. ANS: B Stevens-Johnson syndrome, also called erythema multiforme, involves inflammation of the mucous membranes and skin. It is often related to an infection or can be due to almost any medication. Often, no specific cause is identified. The condition can be fatal. It is important to immediately recognize and treat. The patient appears acutely ill and has systemic symptoms, including malaise, fever, and arthralgias, so that the eye findings are not isolated. Conjunctival bullae and ulcerations may develop. Patients develop erythematous lesions and bullae over the skin and hemorrhagic lesions of the mucous membranes. In addition to the eye tissue, the palms, soles, anus, vagina, nose, and mouth are commonly affected. PTS: 1 25. ANS: B Red flag warnings for eye redness include pain (not discomfort or irritation), decreased vision, profuse discharge, and corneal defect grossly visible. PTS: 1 This study source was downloaded by from CourseH on :32:53 GMT -05:00 Chapter 6. Ear, Nose, Mouth, and Throat Multiple Choice Identify the choice that best completes the statement or answers the question. 1. 2. 3. 4. 5. 6. 7. Upon physical examination of a 1-year-old patient, you note abnormal placement of the ears, hypertelorism, and strabismus. These are often signs of: A. Genetic conditions B. Deafness C. Birth injury D. Physical abuse An 86-year-old patient who wears a hearing aid complains of poor hearing in the affected ear. In addition to possible hearing aid malfunction, this condition is often due to: A. Acoustic neuroma B. Cerumen impaction C. Otitis media D. Ménière’s disease A patient presents to the emergency department due to head trauma related to a motorcycle accident. On physical examination, you note clear, serous discharge from the ear. This is commonly a sign of: A. Basilar skull fracture B. Injury of the auricle C. Otitis discharge D. Tympanic membrane perforation A pneumatic otoscopic examination is used to assess: A. Inner ear conditions B. Otitis externa C. Cerumen impaction D. Tympanic membrane mobility In examination of the nose, the clinician observes gray, pale mucous membranes with clear, serous discharge. This is most likely indicative of: A. Bacterial sinusitis B. Allergic rhinitis C. Drug abuse D. Skull fracture With inspection of the mouth and buccal mucosa, Stensen’s duct can be seen on the: A. Underside of the tongue B. Buccal mucosa opposite the lower molars C. Buccal mucosa opposite the upper molars D. Soft palate To examine if there is an intact gag reflex, ask the patient to say ―ah‖ as you observe the: 8. 9. A. Movement of the uvula to the left B. Movement of uvula to the right C. Tongue extension in the midline D. Upward movement of the uvula in the midline Malignant oral cancerous lesions are most frequently located on the: A. Tongue B. Tonsils C. Gums D. Hard palate Ear pain related to tenderness over the auricle and ear canal is most commonly related to: A. Excessive exposure to noise B. Cerumen impaction C. Otitis externa D. Ménière’s disease 10. A 6-year-old child presents with complaints of unilateral ear pain, fever, and sore throat. The clinician should recognize that this is most commonly due to: A. Otitis externa B. Inner ear infection C. Sinusitis D. Otitis media 11. Which of the following symptoms is common with acute otitis media? A. Bulging tympanic membrane B. Bright light reflex of tympanic membrane C. Increased tympanic membrane mobility D. All of the above 12. Which of the following microorganisms commonly causes otitis externa? A. Streptococcus pneumoniae B. Pseudomonas C. Moraxella catarrhalis D. Haemophilus influenza 13. A 5-year-old patient with a history of chronic otitis media complains of severe unilateral ear pain that worsens at night. The pain has progressively worsened over the past 3 days. Your examination reveals tenderness, erythema, and swelling below the right ear, and diminished hearing on the right. Which of the following is a likely diagnosis? A. Sinus infection B. Skull fracture C. Mastoiditis D. Foreign body 14. Presbycusis is the hearing impairment that is associated with: A. Physiologic aging B. Ménière’s disease C. Cerumen impaction D. Herpes zoster 15. A nonmalignant cancerous tumor affecting cranial nerve VIII that causes unilateral hearing loss, tinnitus, and vertigo is: A. Otosclerosis B. Acoustic neuroma C. Cholesteatoma D. Squamous cell carcinoma 16. Epistaxis can be a symptom of: A. Over-anticoagulation B. Hematologic malignancy C. Cocaine abuse D. All of the above 17. Nasal discharge of green-yellow mucus, pharyngitis, and otitis media commonly indicate: