PHARMACOLOGY Test Bank for All DERMATOLOGY

PHARMACOLOGY Test Bank for All DERMATOLOGY PHARMACOLOGY Test Bank for All DERMATOLOGY 1. A 35-year-old archaeologist comes to your office (located in Phoenix, Arizona) for a regular skin check-up. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this patient? a. Age b. Hair color c. Actinic lentigines d. Heavy sun exposure 2. You are speaking to an 8th grade class about health prevention and are preparing to discuss the ABCDEs of melanoma. Which of the following descriptions correctly defines the ABCDEs? a. A = actinic; B = basal cell; C = color changes, especially blue; D = diameter >6 mm; E = evolution b. A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6 mm; E = evolution c. A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E = evolution d. A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter >6 mm; E = evolution 3. You are beginning the examination of the skin on a 25-year-old teacher. You have previously elicited that she came to the office for evaluation of fatigue, weight gain, and hair loss. You strongly suspect that she has hypothyroidism. What is the expected moisture and texture of the skin of a patient with hypothyroidism? a. Moist and smooth b. Moist and rough c. Dry and smooth d. Dry and rough 4. A 28-year-old patient comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical examination, you note that the pattern of eruption is like a Christmas tree and that there are a variety of erythematous papules and macules on the cleavage lines of the back. Based on this description, what is the most likely diagnosis? a. Pityriasis rosea b. Tinea versicolor c. Psoriasis d. Atopic eczema 5. A 19-year-old construction worker presents for evaluation of a rash. He notes that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He does sweat more than before because being outdoors is part of his job. On physical examination, you note dark tan patches with a reddish cast that has sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is your most likely diagnosis? a. Pityriasis rosea b. Tinea versicolor c. Psoriasis d. Atopic eczema 6. A 68-year-old retired farmer comes to your office for evaluation of a skin lesion. On the right temporal area of the forehead, you see a flattened papule the same color as his skin, covered by a dry scale that is round and feels hard. He has several more of these scattered on the forehead, arms, and legs. Based on this description, what is your most likely diagnosis? a. Actinic keratosis b. Seborrheic keratosis c. Basal cell carcinoma d. Squamous cell carcinoma 7. A 58-year-old gardener comes to your office for evaluation of a new lesion on her upper chest. The lesion appears to be stuck on and is oval, brown, and slightly elevated with a flat surface. It has a rough, wartlike texture on palpation. Based on this description, what is your most likely diagnosis? a. Actinic keratosis b. Seborrheic keratosis c. Basal cell carcinoma d. Squamous cell carcinoma 8. A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on the ventilator for 3 weeks. You are completing your initial assessment and are evaluating her skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter, with damage to the subcutaneous tissue. The underlying muscle is not affected. You diagnose this as a pressure ulcer. What is the stage of this ulcer? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 9. An 8-year-old girl comes with her mother for evaluation of hair loss. She denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her hair in braids. On physical examination, you note a clearly demarcated, round patch of hair loss without visible scaling or inflammation. There are no hair shafts visible. Based on this description, what is your most likely diagnosis? a. Alopecia areata b. Trichotillomania c. Tinea capitis d. Traction alopecia 10. A mother brings her 11 month old to you because her mother-in-law and others have told her that her baby is jaundiced. She is eating and growing well and performing the developmental milestones she should for her age. On examination you indeed notice a yellow tone to her skin from head to toe. Her sclerae are white. To which area should your next questions be related? a. Diet b. Family history of liver diseases c. Family history of blood diseases d. Ethnicity of the child 11. A new mother is concerned that her child occasionally ìturns blue.î On further questioning, she mentions that this is at her hands and feet. She does not remember the child's lips turning blue. She is otherwise eating and growing well. What would you do now? a. Reassure her that this is normal b. Obtain an echocardiogram to check for structural heart disease and consult cardiology c. Admit the child to the hospital for further observation d. Question the validity of her story 12. You are examining an unconscious patient from another region and notice Beau's lines, a transverse groove across all of her nails, about 1 cm from the proximal nail fold. What would you do next? a. Conclude this is caused by a cultural practice. b. Conclude this finding is most likely secondary to trauma. c. Look for information from family and records regarding any problems which occurred 3 months ago. d. Ask about dietary intake. 13. Dakota is a 14-year-old boy who just noticed a rash at his ankles. There is no history of exposure to ill people or other agents in the environment. He has a slight fever in the office. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should you do? a. Prescribe a steroid cream to decrease inflammation. b. Consider admitting the patient to the hospital. c. Reassure the parents and the patient that this should resolve within a week. d. Tell him not to scratch them, and follow up in 3 days. 14. Mrs. Hill is a 28-year-old African-American with a history of SLE (systemic lupus erythematosus). She has noticed a raised, dark red rash on her legs. When you press on the rash, it doesn't blanch. What would you tell her regarding her rash? a. It is likely to be related to her lupus. b. It is likely to be related to an exposure to a chemical. c. It is likely to be related to an allergic reaction. d. It should not cause any problems. 15. Jacob, a 33-year-old construction worker, complains of a ìlump on his backî over his scapula. It has been there for about a year and is getting larger. He says his wife has been able to squeeze out a cheesy-textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely? a. An enlarged lymph node b. A sebaceous cyst c. An actinic keratosis d. A malignant lesion 16. A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small ìpitsî in his nails. What would account for these findings? a. Eczema b. Pityriasis rosea c. Psoriasis d. Tinea infection 17. Mrs. Anderson presents with an itchy rash which is raised and appears and disappears in various locations. Each lesion lasts for many minutes. What most likely accounts for this rash? a. Insect bites b. Urticaria, or hives c. Psoriasis d. Purpura 18. Ms. Whiting is a 68 year old who comes in for her usual follow-up visit. You notice a few flat red and purple lesions, about 6 centimeters in diameter, on the ulnar aspect of her forearms but nowhere else. She doesn't mention them. They are tender when you examine them. What should you do? a. Conclude that these are lesions she has had for a long time. b. Wait for her to mention them before asking further questions. c. Ask how she acquired them. d. Conduct the visit as usual for the patient. 19. A middle-aged man comes in because he has noticed multiple small, blood-red, raised lesions over his anterior chest and abdomen for the past several months. They are not painful and he has not noted any bleeding or bruising. He is concerned this may be consistent with a dangerous condition. What should you do? a. Reassure him that there is nothing to worry about. b. Do laboratory work to check for platelet problems. c. Obtain an extensive history regarding blood problems and bleeding disorders. d. Do a skin biopsy in the office. HEENT 1. A 38-year-old accountant comes to your clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region and is an 8 on a scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic and this results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache? a. Tension b. Migraine c. Cluster d. Analgesic rebound 2. A 29-year-old computer programmer comes to your office for evaluation of a headache. The tightening sensation is located all over the head and is of moderate intensity. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours each day at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain but not taken it away. Based on this description, what is your most likely diagnosis? a. Tension b. Migraine c. Cluster d. Analgesic rebound 3. Which of the following is a symptom involving the eye? a. Scotomas b. Tinnitus c. Dysphagia d. Rhinorrhea 4. A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You elicit the information that the dizziness is a spinning sensation of sudden onset, worse with head position changes. The episodes last a few seconds and then go away, and they are accompanied by intense nausea. She has vomited one time. She denies tinnitus. You perform a physical examination of the head and neck and note that the patient's hearing is intact to Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description, what is the most likely diagnosis? a. Benign positional vertigo b. Vestibular neuronitis c. Meniere's disease d. Acoustic neuroma 5. A 55-year-old bank teller comes to your office for persistent episodes of dizziness. The first episode started suddenly and lasted 3 to 4 hours. He experienced a lot of nausea with vomiting; the episode resolved spontaneously. He has had five episodes in the past weeks. He does note some tinnitus that comes and goes. Upon physical examination, you note that he has a normal gait. The Weber localizes to the right side and the air conduction is equal to the bone conduction in the right ear. Nystagmus is present. Based on this description, what is the most likely diagnosis? a. Benign positional vertigo b. Vestibular neuronitis c. Meniere's disease d. Acoustic neuroma 6. A 73-year-old nurse comes to your office for evaluation of new onset of tremors. She is not on any medications and does not take herbs or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow movements and shuffling steps. She has decreased facial mobility and a blunt expression, without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the patient's symptoms? a. Cushing's syndrome b. Nephrotic syndrome c. Myxedema d. Parkinson's disease 7. A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? a. Ptosis b. Exophthalmos c. Ectropion d. Epicanthus 8. A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? a. Dacryocystitis b. Chalazion c. Hordeolum d. Xanthelasma 9. A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? a. Conjunctivitis b. Acute iritis c. Corneal abrasion d. Subconjunctival hemorrhage 10. A 67-year-old lawyer comes to your clinic for an annual examination. He denies any history of eye trauma. He denies any visual changes. You inspect his eyes and find a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis? a. Corneal arcus b. Cataracts c. Corneal scar d. Pterygium 11. Which of the following is a red flag regarding patients presenting with headache? a. Unilateral headache b. Pain over the sinuses c. Age over 50 d. Phonophobia and photophobia 12. A sudden, painless unilateral vision loss may be caused by which of the following? a. Retinal detachment b. Corneal ulcer c. Acute glaucoma d. Uveitis 13. Sudden, painful unilateral loss of vision may be caused by which of the following conditions? a. Vitreous hemorrhage b. Central retinal artery occlusion c. Macular degeneration d. Optic neuritis 14. Diplopia, which is present with one eye covered, can be caused by which of the following problems? a. Weakness of CN III b. Weakness of CN IV c. A lesion of the brainstem d. An irregularity in the cornea or lens 15. A patient complains of epistaxis. Which other cause should be considered? a. Intracranial hemorrhage b. Hematemesis c. Intestinal hemorrhage d. Hematoma of the nasal septum 16. Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination? a. Increased cup-to-disc ratio b. AV nicking c. Cotton wool spots d. Microaneurysms 17. Very sensitive methods for detecting hearing loss include which of the following? a. The whisper test b. The finger rub test c. The tuning fork test d. Audiometric testing 18. Which area of the fundus is the central focal point for incoming images? a. The fovea b. The macula c. The optic disk d. The physiologic cup 19. A light is pointed at a patient's pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon? a. Direct reaction b. Consensual reaction c. Near reaction d. Accommodation 20. A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? a. She obtains a 20% correct score at 100 feet. b. She can accurately name 20% of the letters at 20 feet. c. She can see at 20 feet what a normal person could see at 100 feet. d. She can see at 100 feet what a normal person could see at 20 feet. 21. On visual confrontation testing, a stroke patient is unable to see your fingers on his entire right side with either eye covered. Which of the following terms would describe this finding? a. Bitemporal hemianopsia b. Right temporal hemianopsia c. Right homonymous hemianopsia d. Binasal hemianopsia 22. You note that a patient has anisocoria on examination. Pathologic causes of this include which of the following? a. Horner's syndrome b. Benign anisocoria c. Differing light intensities for each eye d. Eye prosthesis 23. A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally. Which of the following have you essentially excluded from your differential? a. Retinoblastoma b. Cataract c. Artificial eye d. Hypertensive retinopathy 24. A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient? a. Otitis media b. External otitis c. Perforation of the tympanum d. Cholesteatoma 25. A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely? a. Otosclerosis of the left ear b. Exposure to chronic loud noise of the right ear c. Otitis media of the right ear d. Perforation of the right eardrum 26. A young man is concerned about a hard mass he has just noticed in the midline of his palate. On examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis? a. Leukoplakia b. Torus palatinus c. Thrush (candidiasis) d. Kaposi's sarcoma 27. A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left. Which of the following is likely? a. CN IX lesion on the left b. CN IX lesion on the right c. CN X lesion on the left d. CN X lesion on the right 28. A college student presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this? a. Submandibular b. Tonsillar c. Occipital d. Posterior cervical 29. You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and side-to-side directions. Which of the following is most likely? a. Cancer b. Lymph node c. Deep scar d. Muscle 30. You are conducting a pupillary examination on a 34-year-old man. You note that both pupils dilate slightly. Both are noted to constrict briskly when the light is placed on the right eye. What is the most likely problem? a. Optic nerve damage on the right b. Optic nerve damage on the left c. Efferent nerve damage on the right d. Efferent nerve damage on the left PULMONOLOGY 1. A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently started a job as a bartender in town. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe? a. Spontaneous pneumothorax b. Chronic obstructive pulmonary disease (COPD) c. Asthma d. Pneumonia 2. A 47-year-old receptionist comes to your office, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated, at 101. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement, and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? a. Spontaneous pneumothorax b. Chronic obstructive pulmonary disease (COPD) c. Asthma d. Pneumonia 3. A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? a. Spontaneous pneumothorax b. Chronic obstructive pulmonary disease (COPD) c. Asthma d. Pneumonia 4. A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms? a. Spontaneous pneumothorax b. Chronic obstructive pulmonary disease (COPD) c. Asthma d. Pneumonia 5. A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall. What disorder of the chest best describes this disorder? a. Angina pectoris b. Pericarditis c. Dissecting aortic aneurysm d. Pleural pain 6. A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent left-sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthy-appearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. Which disorder of the chest best describes these symptoms? a. Angina pectoris b. Pericarditis c. Dissecting aortic aneurysm d. Pleural pain 7. A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior chest pain radiating to her back. She describes it as if someone is ripping out her heart. It began less than an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain better or worse. Her medical history consists of difficult-to-control hypertension and coronary artery disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger brother who has had bypass surgery. On examination you see an elderly female in a great deal of distress. She is lying on the table, curled up, holding her left and right arms against her chest and is restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and 130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital's ER for further evaluation. What disorder of the chest best describes her symptoms? a. Angina pectoris b. Pericarditis c. Dissecting aortic aneurysm d. Pleural pain 8. A 25-year-old accountant presents to your clinic, complaining of intermittent lower right-sided chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds, taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring. The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a deep breath. He has taken some Tylenol and put a heating pad on his side but neither has helped. He remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in good health. He has recently married, and his wife has a baby due in 2 months. He denies any smoking or illegal drug use. He drinks two to three beers once a month. He states that he eats a healthy diet and runs regularly, but not since his recent illness. He denies any cardiac, gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable. His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During palpation the ribs are nontender. What disorder of the chest best describes his symptoms? a. Pericarditis b. Chest wall pain c. Pleural pain d. Angina pectoralis 9. A 60-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can't do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination she is in no acute distress. Her blood pressure is 160/100 and her pulse is 100. She is afebrile and her respiratory rate is 16. With auscultation she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination the S1 and S2 are distant and an S3 is heard over the apex. What disorder of the chest best describes her symptoms? a. Pneumonia b. Chronic obstructive pulmonary disease (COPD) c. Pleural pain d. Left-sided heart failure 10. A grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you that it has been that way for quite awhile. He states he has no symptoms from it and he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was deployed to the Middle East. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. On examination you see a teenage boy appearing his stated age. On visual examination of his chest you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are unremarkable. What disorder of the thorax best describes your findings? a. Barrel chest b. Funnel chest (pectus excavatum) c. Pigeon chest (pectus carinatum) d. Thoracic kyphoscoliosis 11. Which of the following anatomic landmark associations is correct? a. 2nd intercostal space for needle insertion in tension pneumothorax b. T6 for lower margin of endotracheal tube c. Sternal angle marks the 4th rib d. 5th intercostal space for chest tube insertion 12. A 55 year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses should you consider because of her gesture? a. Bronchitis b. Costochondritis c. Pericarditis d. Angina pectoris 13. A 62-year-old smoker complains of coughing up small amounts of blood, so you consider hemoptysis. Which of the following should you also consider? a. Intestinal bleeding b. Hematoma of the nasal septum c. Epistaxis d. Bruising of the tongue 14. Which of the following occurs in respiratory distress? a. Speaking in sentences of 10ñ20 words b. Skin between the ribs moves inward with inspiration c. Neck muscles are relaxed d. Patient torso leans posteriorly 15. Which of the following is consistent with good percussion technique? a. Allow all of the fingers to touch the chest while performing percussion. b. Maintain a stiff wrist and hand. c. Leave the plexor finger on the pleximeter after each strike. d. Strike the pleximeter over the distal interphalangeal joint. 16. Which of the following percussion notes would you obtain over the gastric bubble? a. Resonance b. Tympany c. Hyperresonance d. Flatness 17. Which of the following conditions would produce a hyperresonant percussion note? a. Large pneumothorax b. Lobar pneumonia c. Pleural effusion d. Empyema 18. Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration? a. Bronchovesicular b. Vesicular c. Bronchial d. Tracheal 19. A patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most likely explanation for these? a. Asthma b. COPD c. Bronchiectasis d. Heart failure 20. When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology? a. Bronchitis b. Simple asthma c. Cystic fibrosis d. Heart failure 21. A patient with longstanding COPD was told by another practitioner that his liver was enlarged and this needed to be assessed. Which of the following would be reasonable to do next? a. Percuss the lower border of the liver b. Measure the span of the liver c. Order a hepatitis panel d. Obtain an ultrasound of the liver 22. You are at your family reunion playing football when your uncle takes a hit to his right lateral thorax and is in pain. He asks you if you think he has a rib fracture. You are in a very remote area. What would your next step be? a. Call a medevac helicopter b. Drive him to the city (4 hours away) c. Press on his sternum and spine simultaneously d. Examine him for tenderness over the injured area CARDIOVASCULAR 1. You are performing a thorough cardiac examination. Which of the following chambers of the heart can you assess by palpation? a. Left atrium b. Right atrium c. Right ventricle d. Sinus node 2. What is responsible for the inspiratory splitting of S2? a. Closure of aortic, then pulmonic valves b. Closure of mitral, then tricuspid valves c. Closure of aortic, then tricuspid valves d. Closure of mitral, then pulmonic valves 3. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur? a. Mitral b. Tricuspid c. Aortic d. Pulmonic 4. A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? a. Abdominal pain b. Orthopnea c. Hematochezia d. Tenesmus 5. You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this? a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension 6. You are participating in a health fair and performing cholesterol screens. One person has a cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease? a. Ethnicity b. Alcohol intake c. Gender d. Asthma 7. You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is well-controlled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. Which of the following conditions is considered to be a coronary heart disease risk equivalent? a. Hypertension b. Peripheral arterial disease c. Systemic lupus erythematosus d. Chronic obstructive pulmonary disease (COPD) 8. You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid pulse? a. Palpable b. Soft, rapid, undulating quality c. Pulsation eliminated by light pressure on the vessel d. Level of pulsation changes with changes in position 9. A 68-year-old mechanic presents to the emergency room for shortness of breath. You are concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated. Which one of the following conditions is a potential cause of elevated JVP? a. Left-sided heart failure b. Mitral stenosis c. Constrictive pericarditis d. Aortic aneurysm 10. You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse? a. Hypothyroidism b. Aortic stenosis, with pressure overload of the left ventricle c. Mitral stenosis, with volume overload of the left atrium d. Cardiomyopathy 11. You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position? a. Aortic b. Pulmonic c. Mitral d. Tricuspid 12. You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur? a. Upright b. Upright, but leaning forward c. Supine d. Left lateral decubitus 13. A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a cardiac examination and find that his pulse rate is less than 60. Which of the following conditions could be responsible for this heart rate? a. Second-degree A-V block b. Atrial flutter c. Sinus arrhythmia d. Atrial fibrillation 14. Where is the point of maximal impulse (PMI) normally located? a. In the left 5th intercostal space, 7 to 9 cm lateral to the sternum b. In the left 5th intercostal space, 10 to 12 cm lateral to the sternum c. In the left 5th intercostal space, in the anterior axillary line d. In the left 5th intercostal space, in the midaxillary line 15. Which of the following events occurs at the start of diastole? a. Closure of the tricuspid valve b. Opening of the pulmonic valve c. Closure of the aortic valve d. Production of the first heart sound (S1) 16. Which is true of a third heart sound (S3)? a. It marks atrial contraction. b. It reflects normal compliance of the left ventricle. c. It is caused by rapid deceleration of blood against the ventricular wall. d. It is not heard in atrial fibrillation. 17. Which is true of splitting of the second heart sound? a. It is best heard over the pulmonic area with the bell of the stethoscope. b. It normally increases with exhalation. c. It is best heard over the apex. d. It does not vary with respiration. 18. Which of the following is true of jugular venous pressure (JVP) measurement? a. It is measured with the patient at a 45-degree angle. b. The vertical height of the blood column in centimeters, plus 5 cm, is the JVP. c. A JVP below 9 cm is abnormal. d. It is measured above the sternal notch. 19. Which of the following regarding jugular venous pulsations is a systolic phenomenon? a. The y descent b. The x descent c. The upstroke of the ìaî wave d. The downstroke of the ìvî wave 20. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure? a. 25% b. 50% c. 75% d. 100% 21. In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines? a. Every 6 months b. Every year c. Every 2 years d. Every 5 years 22. Which of the following is a clinical identifier of metabolic syndrome? a. Waist circumference of 38 inches for a male b. Waist circumference of 34 inches for a female c. BP of 134/88 for a male d. BP of 128/84 for a female 23. Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52. What heart rate should she achieve? a. 80 b. 100 c. 120 d. 140 24. In measuring the jugular venous pressure (JVP), which of the following is important? a. Keep the patient's torso at a 45-degree angle. b. Measure the highest visible pressure, usually at end expiration. c. Add the vertical height over the sternal notch to a 5-cm constant. d. Realize that a total value of over 12 cm is abnormal. 25. You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you search out? a. Mitral valve prolapse b. Pulmonic stenosis c. Tricuspid insufficiency d. Aortic insufficiency 26. To hear a soft murmur or bruit, which of the following may be necessary? a. Asking the patient to hold her breath b. Asking the patient in the next bed to turn down the TV c. Checking your stethoscope for air leaks d. All of the above 27. Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell? a. Mitral stenosis murmur b. Opening snap of the mitral valve c. S3 and S4 gallops d. All of the above 28. How should you determine whether a murmur is systolic or diastolic? a. Palpate the carotid pulse. b. Palpate the radial pulse. c. Judge the relative length of systole and diastole by auscultation. d. Correlate the murmur with a bedside heart monitor. 29. Which of the following correlates with a sustained, high-amplitude PMI? a. Hyperthyroidism b. Anemia c. Fever d. Hypertension 30. You are examining a patient with emphysema in exacerbation and are having difficulty hearing his heart sounds. What should you do to obtain a good examination? a. Listen in the epigastrium. b. Listen to the patient in the left lateral decubitus position. c. Ask the patient to hold his breath for 30 seconds. d. Listen posteriorly. 31. You are listening carefully for S2 splitting. Which of the following will help? a. Using the diaphragm with light pressure over the 2nd right intercostal space b. Using the bell with light pressure over the 2nd left intercostal space c. Using the diaphragm with firm pressure over the apex d. Using the bell with firm pressure over the lower left sternal border 32. Which of the following is true of a grade 4-intensity murmur? a. It is moderately loud. b. It can be heard with the stethoscope off the chest. c. It can be heard with the stethoscope partially off the chest. d. It is associated with a thrill 33. Which valve lesion typically produces a murmur of equal intensity throughout systole? a. Aortic stenosis b. Mitral insufficiency c. Pulmonic stenosis d. Aortic insufficiency 34. You notice a patient has a strong pulse and then a weak pulse. This pattern continues. Which of the following is likely? a. Emphysema b. Asthma exacerbation c. Severe left heart failure d. Cardiac tamponade 35. Suzanne is a 20-year-old college student who complains of chest pain. This is intermittent and is located to the left of her sternum. There are no associated symptoms. On examination, you hear a short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2. This is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. Which of the following is the most likely diagnosis? a. Mitral stenosis b. Mitral insufficiency c. Mitral valve prolapse d. Mitral valve papillary muscle ischemia BREAST AND AXILLAE 1. A 72-year-old retired saleswoman comes to your office, complaining of a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The patient denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetric, with no skin changes. You are able to express bloody discharge from her left nipple. You feel no discrete masses, but her left axilla has a hard, 1-cm fixed node. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. What cause of nipple discharge is the most likely in her circumstance? a. Benign breast abnormality b. Breast cancer c. Galactorrhea 2. A 44-year-old female comes to your clinic, complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. On examination you find a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath you palpate a nontender 2-cm mass. The axilla contains only soft, moveable nodes. The left breast and axilla examination findings are unremarkable. What visible skin change of the breast does she have? a. Nipple retraction b. Paget's disease c. Peau d'orange sign 3. A 56-year-old female comes to your clinic, complaining of her left breast looking unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-examinations, so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On examination you find a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels thickened. Lateral to the areola you palpate a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast and axilla examinations are unremarkable. What visible skin change of the breast does she have? a. Nipple retraction b. Paget's disease c. Peau d'orange sign 4. A 19-year-old female comes to your office, complaining of a clear discharge from her right breast for 2 months. She states that she noticed it when she and her boyfriend were “messing around” and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies using tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetric with no skin changes. You are able to express clear discharge from her right nipple. You feel no discrete masses and her axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative. What cause of nipple discharge is the most likely in her circumstance? a. Benign breast abnormality b. Breast cancer c. Nonpuerperal galactorrhea 5. A 23-year-old computer programmer comes to your office for an annual examination. She has recently become sexually active and wants to be placed on birth control. Her only complaint is that the skin in her armpits has become darker. She states it looks like dirt, and she scrubs her skin nightly with soap and water but the color stays. Her past medical symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high blood pressure. The patient denies using tobacco but has four to five drinks on Friday and Saturday nights. She denies any illegal drug use. On examination you see a mildly obese female who is breathing comfortably. Her vital signs are unremarkable. Looking under her axilla, you see dark, velvet-like skin. Her annual examination is otherwise unremarkable. What disorder of the breast or axilla is she most likely to have? a. Peau d'orange b. Acanthosis nigricans c. Hidradenitis suppurativa 6. A 43-year-old store clerk comes to your office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago), and until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The patient does not smoke, drink, or use illegal drugs. Her father is in good health. On examination you see a tense female appearing her stated age. On visual inspection of her left axilla you see a tense red area. There is no scarring around the axilla. Palpating this area, you feel a 2-cm tender, movable lymph node underlying hot skin. Other shotty nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examining her left arm, you see a scabbed-over superficial laceration over her left hand. Upon your questioning, she remembers she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms? a. Breast cancer b. Lymphadenopathy of infectious origin c. Hidradenitis suppurativa 7. A 63-year-old nurse comes to your office, upset because she has found an enlarged lymph node under her right arm. She states she found it last week while taking a shower. She isn't sure if she has any breast lumps because she doesn't know how to do self-exams. She states her last mammogram was 5 years ago and it was normal. Her past medical history is significant for high blood pressure and chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-packs/year history. She denies using any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and her father died of a stroke. She has no children. On examination you see an older female appearing her stated age. On visual inspection of her right axilla you see nothing unusual. Palpating this area, you feel a 2-cm hard, fixed lymph node. She denies any tenderness. Visualization of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On palpation of her right breast you feel a nontender 1-cm lump in the tail of Spence. What disorder of the axilla is most likely responsible for her symptoms? a. Breast cancer b. Lymphadenopathy of infectious origin c. Hidradenitis suppurativa 8. A 40-year-old mother of two presents to your office for consultation. She is interested in knowing what her relative risks are for developing breast cancer. She is concerned because her sister had unilateral breast cancer 6 years ago at age 38. The patient reports on her history that she began having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco, alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable. Which risk factor of her personal and family history most puts her in danger of getting breast cancer? a. First-degree relative with premenopausal breast cancer b. Age at menarche of less than 12 c. First live birth between the ages of 25 and 29 d. First-degree relative with postmenopausal breast cancer 9. A 51-year-old cook comes to your office for consultation. She recently found out that her 44-year-old sister with premenopausal breast cancer is positive for the BRCA1 gene. Your patient has been doing research on the Internet and saw that her chance of having also inherited the BRCA1 gene is 50%. She is interested in knowing what her risk of developing breast cancer would be if she were positive for the gene. She denies any lumps in her breasts and has had normal mammograms. She has had no weight loss, fever, or night sweats. Her mother is healthy and her father has prostate cancer. Two of her paternal aunts died of breast cancer. She is married. She denies using tobacco or illegal drugs and rarely drinks alcohol. Her breast and axilla examinations are unremarkable. At her age, what is her risk of getting breast cancer if she has the BRCA1 gene? a. 10% b. 50% c. 80% 10. A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. On examination you see a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test. What is the most likely cause of his gynecomastia? a. Breast cancer b. Imbalance of hormones of puberty c. Drug use 11. A patient is concerned about a dark skin lesion on her anterolateral abdomen. It has not changed, and there is no discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion? a. Melanoma b. Dysplastic nevus c. Supernumerary nipple d. Dermatofibroma 12. A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no diagnosis of breast cancer in his first-degree relatives. What is the most likely diagnosis? a. Breast tissue b. Fibrocystic disease c. Breast cancer d. Lymph node 13. Which of the following lymph node groups is most commonly involved in breast cancer? a. Lateral b. Subscapular c. Pectoral d. Central 14. When should a woman conduct breast self-examination with respect to her menses? a. Five to seven days following her menses b. Midcycle c. Immediately prior to menses d. During her menses 15. Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass. Without any other information, what is the risk of this mass being cancerous? a. About 10% b. About 20% c. About 30% d. About 40% 16. How often, according to American Cancer Society recommendations, should a woman undergo a screening breast examination by a skilled clinician? a. Every year b. Every 2 years c. Every 3 years d. Every 4 years 17. Which of the following is most likely benign on breast examination? a. Dimpling of the skin resembling that of an orange b. One breast larger than the other c. One nipple inverted d. One breast with dimple when the patient leans forward 18. Which is the most effective pattern of palpation for breast cancer? a. Beginning at the nipple, make an ever-enlarging spiral. b. Divide the breast into quadrants and inspect each systematically. c. Examine in lines resembling the back and forth pattern of mowing a lawn. d. Beginning at the nipple, palpate outward in a stripe pattern. 19. Which is true of women who have had a unilateral mastectomy? a. They no longer require breast examination. b. They should be examined carefully along the surgical scar for masses. c. Lymphedema of the ipsilateral arm usually suggests recurrence of breast cancer. d. Women with breast reconstruction over their mastectomy site no longer require examination. 20. Which of the following is true regarding breast self-examination? a. It has been shown to reduce mortality from breast cancer. b. It is recommended unanimously by organizations making screening recommendations. c. A high proportion of breast masses are detected by breast self-examination. d. The undue fear caused by finding a mass justifies omitting instruction in breast self-examination. THE ABDOMEN 1. A 52-year-old secretary comes to your office, complaining about accidentally leaking urine when she coughs or sneezes. She says this has been going on for about a year now. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is significant for four spontaneous vaginal deliveries. She is married and has four children. She denies alcohol, tobacco, or drug use. During her pelvic examination you note some atrophic vaginal tissue, but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable. Which type of urinary incontinence does she have? a. Stress incontinence b. Urge incontinence c. Overflow incontinence 2. A 46-year-old former salesman presents to the ER, complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. On examination you find a man appearing older than his stated age. His skin has a yellowish tint and he is thin, with a prominent abdomen. You note multiple spider angiomas at the base of his neck. Otherwise, his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs? a. Infectious diarrhea b. Mallory-Weiss tear c. Esophageal varices 3. A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation, but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a junior in college majoring in accounting. She smokes when she drinks alcohol but denies using any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What is most likely the etiology of her diarrhea? a. Secretory infections b. Inflammatory infections c. Irritable bowel syndrome d. Malabsorption syndrome 4. A 42-year-old florist comes to your office, complaining of chronic constipation for the last 6 months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies any recent illnesses or injuries. She denies any changes to her diet or exercise program. She is on no new medications. During the review of systems you note that she has felt fatigued, had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one vaginal delivery and two cesarean sections. She is married, has three children, and owns a flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has coronary artery disease. There is no family history of cancers. On examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the Achilles tendons. What is the best choice for the cause of her constipation? a. Large bowel obstruction b. Irritable bowel syndrome c. Rectal cancer d. Hypothyroidism 5. A 22-year-old law student comes to your office, complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank something like 14 drinks. On examination you find a young male appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending. What etiology of abdominal pain is most likely causing his symp