Midterm Exam: NR 509/ NR509 (New 2026/ 2027 Update) Advanced Physical Assessment Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain.

…..DLDD Midterm Exam: NR 509/ NR509 (New 2026/ 2027 Update) Advanced Physical Assessment Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain. Q. A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to? A) Musculoskeletal B) Reproductive C) Urinary D) Endocrine ANSWER A) Musculoskeletal Chest pain may be due to a musculoskeletal condition, such as costochondritis or intercostal muscle cramp. This would be worsened by motion of the chest wall. Pleuritic chest pain is also a sharp chest pain which increases with a deep breath. This type of pain can occur with inflammation of the pleura from pneumonia or other conditions and pulmonary embolus. Q. A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom? A) Reproductive B) Urinary C) Cardiac D) Hematologic ANSWER C) Cardiac Cardiac disorders such as congestive heart failure are the most likely on this list to result in shortness of breath. There are cases within the other categories which may also result in shortness of breath, such as anemia in the hematologic category, pregnancy in the reproductive category, or sepsis with UTI in the urinary category. Q. A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough? A) Ophthalmologic B) Auditory C) Cardiac D) Endocrine ANSWER C) Cardiac The cardiac system can cause a cough if the patient has congestive heart failure. This results in fluid buildup in the lungs, which in turn can cause a cough that produces pink, frothy sputum. A foreign body in the ear may also cause a cough by stimulating Arnold's branch of the vagus nerve, but this is less likely to be seen clinically than heart failure. Q. A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new, located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash; she also denies recent travel or camping activities. She has a family history significant for rheumatoid arthritis. Based on this information, which of the following pathologic processes would be the most correct? A) Infectious B) Inflammatory C) Hematologic D) Traumatic ANSWER B) Inflammatory The description is most consistent with an inflammatory process, although all the other etiologies should be considered. Lyme disease is an infection which commonly causes arthritis, hemophilia is a hematologic condition which can cause bleeding in the joints, and trauma can obviously cause joint pain. Q. A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for several years. He normally takes over-the-counter medications to ease the pain, but this time they haven't worked as well and he still has discomfort. He recently wallpapered the entire second floor in his house, which caused him great discomfort. The pain resolved with rest. He denies fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this description, what is the most likely pathologic process? A) Infectious B) Neoplastic C) Degenerative D) Traumatic ANSWER C) Degenerative The description is most consistent with degenerative arthritis in the neck. The patient has had intermittent symptoms and the questions asked to elicit pertinent negative and positive findings are negative for infectious, traumatic, or neoplastic disease. Q. A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which is the most likely pathologic process? A) Infection B) Inflammation C) Allergic D) Vascular ANSWER C) Allergic This description is most consistent with allergic rhinitis. Q. A 19-year old-college student presents to the emergency room with fever, headache, and neck pain/stiffness. She is concerned about the possibility of meningococcal meningitis. Several of her dorm mates have been vaccinated, but she hasn't been. Which of the following physical examination descriptions is most consistent with meningitis? A) Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range of motion B) Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle spasm and limited range of motion to the right C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion D) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full range of motion ANSWER C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion Q. Blurred disc margins are consistent with papilledema, and neck tenderness and lack of range of motion are consistent with neck stiffness, which in this scenario is likely to be caused by meningeal inflammation. Kernig's and Brudzinski's signs are also helpful in testing for meningeal irritation on exam. A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods. Which one of the following physical examination descriptions would be most consistent with the diagnosis of cholecystitis? A) Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses. B) Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or guarding. C) Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the point of stopping inspiration, and there is no rebound or guarding. D) Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or guarding. ANSWER C) Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the point of stopping inspiration, and there is no rebound or guarding. In cholecystitis, the pain, which originates from the gallbladder, is located in the right upper quadrant. Severity of pain with inspiration that is sufficient to stop further inhalation is also known as Murphy's sign, which, if present, is further indicative of inflammation of the gallbladder. Q. A 55-year-old data entry operator comes to the clinic to establish care. She has the following symptoms: headache, neck pain, sinus congestion, sore throat, ringing in ears, sharp brief chest pains at rest, burning abdominal pain with spicy foods, constipation, urinary frequency that is worse with coughing and sneezing, and swelling in legs. This cluster of symptoms is explained by: A) One disease process B) More than one disease process ANSWER B) More than one disease process The patient appears to have several possible conditions: allergic rhinitis, arthritis, conductive hearing loss, pleuritic chest pains, heartburn, stress urinary incontinence, and venous stasis, among other conditions. Although we always try, it is very difficult to assign all of these symptoms to one cohesive diagnosis. Q. A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever, headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of symptoms is best explained by: A) One disease process B) More than one disease process ANSWER A) One disease process This cluster of symptoms is most consistent with sinusitis. The chance that all of these symptoms are caused by multiple synchronous conditions in the same patient is much less than the possibility of having one problem which accounts for all of them. Steve has just seen a 5-year-old girl who wheezes when exposed to cats. The patient's family history is positive for asthma. You think the child most likely has asthma. What have you just accomplished? A) You have tested your hypothesis. B) You have developed a plan. C) You have established a working diagnosis. D) You have created a hypothesis. D) You have created a hypothesis. As you go through a history and examination, you will start to generate ideas to explain the patient's symptoms. It is best to keep an open mind and make as many hypotheses as you can, to avoid missing a possibility. A common mistake is to latch onto one idea too early. Ms. Washington is a 67-year-old who had a heart attack last month. Now she complains of shortness of breath and not being able to sleep in a flat position (orthopnea). On examination you note increased jugular venous pressure, an S3 gallop, crackles low in the lung fields, and swollen ankles (edema). This is an example of a: A) Pathophysiologic problem B) Psychopathologic problem A) Pathophysiologic problem This is an example of a pathophysiologic problem because Ms. Washington's symptoms are consistent with a pathophysiologic process. The heart attack reduced the ability of her heart to handle her volume status and subsequently produced the many features of congestive heart failure. On the way to see your next patient, you glance at the calendar and make a mental note to buy a Mother's Day card. Your patient is Ms. Hernandez, a 76-year-old widow who lost her husband in May, two years ago. She comes in today with a headaches, abdominal pain, and general malaise. This happened once before, about a year ago, according to your detailed office notes. You have done a thorough evaluation but are unable to arrive at a consistent picture to tie these symptoms together. This is an example of a: A) Pathophysiologic problem B) Psychopathologic problem B) Psychopathologic problem It is not uncommon for patients to experience psychopathologic symptoms around the anniversary of a traumatic event. The time of year and the lack of an obvious connection between Ms. Hernandez's symptoms would make you consider this as a possibility. You will note that although this might have been an early consideration in your hypothesis generation, it is key to convince yourself that there is not a physiologic explanation for these symptoms, by performing a careful history and examination. Mr. Larson is a 42-year-old widowed father of two children, ages 4 and 11. He works in a sales office to support his family. Recently he has injured his back and you are thinking he would benefit from physical therapy, three times a week, for an hour per session. What would be your next step? A) Write the physical therapy prescription. B) Have your office staff explain directions to the physical therapy center. C) Discuss the plan with Mr. Larson. D) Tell Mr. Larson that he will be going to physical therapy three times a week. C) Discuss the plan with Mr. Larson. You should discuss your proposed plan with the patient before implementing it. In this case, you and Mr. Larson will need to weigh the benefit of physical therapy against the ability to provide for his family. You may need to consider other ways of helping the patient, perhaps through prescribed back exercises he can do at home. It is a common mistake to implement a plan without coming to an agreement with the patient first. You are seeing an elderly man with multiple complaints. He has chronic arthritis, pain from an old war injury, and headaches. Today he complains of these pains, as well as dull chest pain under his sternum. What would the order of priority be for your problem list? A) Arthritis, war injury pain, headaches, chest pain B) War injury pain, arthritis, headaches, chest pain C) Headaches, arthritis, war injury pain, chest pain D) Chest pain, headaches, arthritis, war injury pain D) Chest pain, headaches, arthritis, war injury pain The problem list should have the most active and serious problem first. This new complaint of chest pain is almost certainly a higher priority than his other, more chronic problems. You are excited about a positive test finding you have just noticed on physical examination of your patient. You go on to do more examination, laboratory work, and diagnostic tests, only to find that there is no sign of the disease you thought would correlate with the finding. This same experience happens several times. What should you conclude? A) Consider not doing this test routinely. B) Use this test when you have a higher suspicion for a certain correlating condition. C) Continue using the test, perhaps doing less laboratory work and diagnostics. D) Omit this test from future examinations. C) Continue using the test, perhaps doing less laboratory work and diagnostics. This is an example of a specific test that lacks sensitivity. With this scenario, when you finally find a positive, you might be very certain that a given condition is present. We generally develop our examinations to fit our clinical experiences. Sensitive tests are performed routinely on the screening examination, while specific tests are usually saved for the detailed or "branched" examinations. Branched examinations are further maneuvers we can perform to investigate positive findings on our screening examinations. Save this type of maneuver to confirm your hypothesis. You have recently returned from a medical missions trip to sub-Saharan Africa, where you learned a great deal about malaria. You decide to use some of the same questions and maneuvers in your "routine" when examining patients in the midwestern United States. You are disappointed to find that despite getting some positive answers and findings, on further workup, none of your patients has malaria except one, who recently emigrated from Ghana. How should you next approach these questions and maneuvers? A) Continue asking these questions in a more selective way. B) Stop asking these questions, because they are low yield. C) Question the validity of the questions. D) Ask these questions of all your patients. A) Continue asking these questions in a more selective way. The predictive value of a positive finding depends upon the prevalence of a given disease in a population. The prevalence of malaria in the Midwest is almost zero, except in people immigrating from areas of high prevalence. You will waste time and resources applying these questions and maneuvers to all patients. It would be wise to continue applying what you learned to those who are from areas of high prevalence of a given disease. You will learn to tailor your examination to the population you are serving. For which of the following patients would a comprehensive health history be appropriate? A) A new patient with the chief complaint of "I sprained my ankle". B) An established patient with the chief complaint of "I have an upper respiratory infection". C) A new patient with the chief complaint of "I am here to establish care". D) A new patient with the chief complaint of "I cut my hand". C) A new patient with the chief complaint of "I am here to establish care". This patient is here to establish care, and because she is new to you, a comprehensive health history is appropriate. The components of the health history include all of the following except which one? A) Review of systems B) Thorax and lungs C) Present illness D) Personal and social items B) Thorax and lungs The thorax and lungs are part of the physical examination, not part of the health history. Is the following information subjective or objective? Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity and relieved by rest. A) Subjective B) Objective A) Subjective This is information given by the patient about the circumstances of his chief complaint. It does not represent an objective observation by the examiner. Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and a pulse rate of 120. A) Subjective B) Objective B) Objective This is a measurement obtained by the examiner, so it is considered objective data. The patient is unlikely to be able to give this information to the examiner. The following information is recorded in the health history: "The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-epigastric area." Which of these categories does it belong to? A) Chief complaint B) Present illness C) Personal and social history D) Review of systems B) Present illness This information describes the problem of abdominal pain, which is the present illness. The interviewer has obtained the location, timing, severity, and associated manifestations of the pain. The interviewer will still need to obtain information concerning the quality of the pain, the setting in which it occurred, and the factors that aggravate and alleviate the pain. The following information is recorded in the health history: "The patient completed 8th grade. He currently lives with his wife and two children. He works on old cars on the weekend. He works in a glass factory during the week." Which category does it belong to? A) Chief complaint B) Present illness C) Personal and social history D) Review of systems C) Personal and social history. Personal and social history information includes educational level, family of origin, current household status, personal interests, employment, religious beliefs, military history, and lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and sexual preferences and history). The following information is recorded in the health history: "I feel really tired." Which category does it belong to? A) Chief complaint B) Present illness C) Personal and social history D) Review of systems A) Chief complaint The chief complaint is an attempt to quote the patient's own words. It is brief, like a headline, and further details should be sought in the present illness section. The following information is recorded in the health history: "Patient denies chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea." Which category does it belong to? A) Chief complaint B) Present illness C) Personal and social history D) Review of systems D) Review of systems Review of systems documents the presence or absence of common symptoms related to each major body system. The following information is best placed in which category? "The patient has had three cesarean sections." A) Adult illnesses B) Surgeries C) Obstetrics/gynecology D) Psychiatric B) Surgeries A cesarean section is a surgical procedure. Approximate dates or the age of the patient at the time of the surgery should also be recorded. The following information is best placed in which category? "The patient had a stent placed in the left anterior descending artery (LAD) in 1999." A) Adult illnesses B) Surgeries C) Obstetrics/gynecology D) Psychiatric A) Adult illnesses The adult illnesses category is reserved for chronic illnesses, significant hospitalizations, significant injuries, and significant procedures. A stent is a major procedure but does not involve a surgery. The following information is best placed in which category? "The patient was treated for an asthma exacerbation in the hospital last year; the patient has never been intubated." A) Adult illnesses B) Surgeries C) Obstetrics/gynecology D) Psychiatric A) Adult illnesses This is information about a significant hospitalization and should be placed in the adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider placing this info in the present illness section, because it relates to the chief complaint at that visit. You are running late after your quarterly quality improvement meeting at the hospital and have just gotten paged from the nurses' station because a family member of one of your patients wants to talk with you about that patient's care. You have clinic this afternoon and are double-booked for the first appointment time; three other patients also have arrived and are sitting in the waiting room. Which of the following demeanors is a behavior consistent with skilled interviewing when you walk into the examination room to speak with your first clinic patient? A) Irritability B) Impatience C) Boredom D) Calm D) Calm The appearance of calmness and patience, even when time is limited, is the hallmark of a skilled interviewer. Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient-provider interview? A) Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story. B) Invite the patient's story, negotiate a plan, establish the agenda, and establish rapport. C) Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan. D) Negotiate a plan, establish an agenda, invite the patient's story, and establish rapport. C) Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan. This is the most productive sequence for the interview. Greeting patients and establishing rapport allows them to feel more comfortable before "inviting" them to relate their story. After hearing the patient's story, together you establish the agenda regarding the most important items to expand upon. At the end, together you negotiate the plan of diagnosis and treatment. Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The pain is a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and it seems to be worse a couple of hours after eating. She has noticed that it starts after eating greasy foods, so she has cut down on these as much as she can. Initially it occurred once a week, but now it is occurring every other day. Nothing makes it better. From this description, which of the seven attributes of a symptom has been omitted? A) Setting in which the symptom occurs B) Associated manifestations C) Quality D) Timing B) Associated manifestations The interviewer has not recorded whether or not the pain has been accompanied by nausea, vomiting, fever, chills, weight loss, and so on. Associated manifestations are additional symptoms that may accompany the initial chief complaint and that help the examiner to start refining his or her differential diagnosis. Jason is a 41-year-old electrician who presents to the clinic for evaluation of shortness of breath. The shortness of breath occurs with exertion and improves with rest. It has been going on for several months and initially occurred only a couple of times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than a dozen times per day. The shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description? A) Severity B) Setting in which the symptom occurs C) Timing D) Associated manifestations A) Severity The severity of the symptom was not recorded by the interviewer, so we have no understanding as to how bad the symptom is for this patient. This allows the comparison of pain intensity before and after an intervention. You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning? A) Directed questioning: starting with the general and proceeding to the specific in a manner that does not make the patient give a yes/no answer B) Reassuring the patient that the urinary symptoms are benign and that she doesn't need to worry about it being a sign of cancer C) Offering the patient multiple choices in order to clarify the character of the urinary symptoms that she is experiencing D) Asking her to tell you exactly what she means when she states that she has a urinary tract infection B) Reassuring the patient that the urinary symptoms are benign and that she doesn't need to worry about it being a sign of cancer Reassurance is not part of clarifying the patient's story; it is part of establishing rapport and empathizing with the patient. Mr. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to be checked out for the symptom of chest pain. As you listen to him describe his symptom in more detail, you say "Go on," and later, "Mm-hmmm." This is an example of which of the following skilled interviewing techniques? A) Echoing B) Nonverbal communication C) Facilitation D) Empathic response C) Facilitation This is an example of facilitation. Facilitation can be posture, actions, or words that encourage the patient to say more. Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and doesn't say anything in response to your question. This is an example of which type of challenging patient? A) Talkative patient B) Angry patient C) Silent patient D) Hearing-impaired patient C) Silent patient This is one example of a silent patient. There are many possibilities for this patient's silence: depression, dementia, the manner in which you asked the question, and so on. Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular provider is on vacation and she wanted to be seen. You have heard about her many times from your colleague and are aware that she is a very talkative person. Which of the following is a helpful technique to improve the quality of the interview for both the provider and the patient? A) Allow the patient to speak uninterrupted for the duration of the appointment. B) Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you. C) Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview. D) Allow your impatience to show so that the patient picks up on your nonverbal cue that the appointment needs to end. B) Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you. You can also say, "I want to make sure I take good care of this problem because it is very important. We may need to talk about the others at the next appointment. Is that okay with you?" This is a technique that can help you to change the subject but, at the same time, validate the patient's concerns; it also can provide more structure to the interview. Mrs. H. comes to your clinic, wanting antibiotics for a sinus infection. When you enter the room, she appears to be very angry. She has a raised tone of voice and states that she has been waiting for the past hour and has to get back to work. She states that she is unimpressed by the reception staff, the nurse, and the clinic in general and wants to know why the office wouldn't call in an antibiotic for her. Which of the following techniques is not useful in helping to calm this patient? A) Avoiding admission that you had a part in provoking her anger because you were late B) Accepting angry feelings from the patient and trying not to get angry in return C) Staying calm D) Keeping your posture relaxed A) Avoiding admission that you had a part in provoking her anger because you were late In this scenario, the provider was 1 hour late in seeing the patient. The provider should acknowledge that he was late and apologize for this, no matter the reason for being late. It often helps to acknowledge that a patient's anger with you is understandable and that you might be angry in a similar situation. A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge. As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information? A) Are you sexually active? B) When was the last time you had intimate physical contact with someone, and did that contact include sexual intercourse? C) Do you have sex with men, women, or both? D) How many sexual partners have you had in the last 6 months? A) Are you sexually active? This is inappropriate because it is too vague. Given the complaint, you should probably assume that he is sexually active. A specific sexual history will help you to assess this patient's risk for other sexually transmitted infections. Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has come to the office many times in the past with a variety of injuries, and you suspect that he has a problem with alcohol. Which one of the following questions will be most helpful in diagnosing this problem? A) You are an alcoholic, aren't you? B) When was your last drink? C) Do you drink 2 to 3 beers every weekend? D) Do you drink alcohol when you are supposed to be working? B) When was your last drink? This is a good opening question that is general and neutral in tone; depending on the timing, you will be able to ask for more specific information related to the patient's last drink. The others will tend to stifle the conversation because they are closed-ended questions. On a very busy day in the office, Mrs. Donelan, who is 81 years old, comes for her usual visit for her blood pressure. She is on a low-dose diuretic chronically and denies any side effects. Her blood pressure is 118/78 today, which is well-controlled. As you are writing her script, she mentions that it is hard not having her husband Bill around anymore. What would you do next? A) Hand her the script and make sure she has a 3-month follow-up appointment. B) Make sure she understands the script. C) Ask why Bill is not there. D) Explain that you will have more time at the next visit to discuss this. C) Ask why Bill is not there. Sometimes, the patient's greatest need is for support and empathy. It would be inappropriate to ignore this comment today. She may have relied heavily upon Bill for care and may be in danger. She may be depressed and even suicidal, but you will not know unless you discuss this with her. Most importantly, you should empathize with her by saying something like "It must be very difficult not to have him at home" and allow a pause for her to answer. You may also ask "What did you rely on him to do for you?" A patient is describing a very personal part of her history very quickly and in great detail. How should you react to this? A) Write down as much as you can, as quickly as possible. B) Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every word. C) Tell her that she can go over the notes later to make sure they are accurate. D) Push away from the keyboard or put down your pen and listen. D) Push away from the keyboard or put down your pen and listen. This is a common event in clinical practice. It is much more important to listen actively with good eye contact at this time than to document the story verbatim. You want to minimize interruption (e.g., answer B). It is usually not appropriate to ask a patient to go over the written notes, but it would be a good idea to repeat the main ideas back to her. You should be certain she has completed her story before doing this. You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire right side. She cannot speak (aphasia). You are supposed to examine her. You notice that the last examiner left her socks at the bottom of the bed, and although sensitive areas are covered by a sheet, the blanket is heaped by her feet at the bottom of the bed. What would you do next? A) Carry out your examination, focusing on the neurologic portion, and then cover her properly. B) Carry out your examination and let the nurse assigned to her "put her back together." C) Put her socks back on and cover her completely before beginning the evaluation. D) Apologize for the last examiner but let the next examiner dress and cover her. C) Put her socks back on and cover her completely before beginning the evaluation. It is crucial to make an effort to make a patient comfortable. In this scenario, the patient can neither speak nor move well. Take a moment to imagine yourself in her situation. As a matter of respect as well as comfort, you should cover the patient appropriately and consider returning a little later to do your examination if you feel she is cold. When you enter your patient's examination room, his wife is waiting there with him. Which of the following is most appropriate? A) Ask if it's okay to carry out the visit with both people in the room. B) Carry on as you would ordinarily. The permission is implied because his wife is in the room with him. C) Ask his wife to leave the room for reasons of confidentiality. D) First ask his wife what she thinks is going on. A) Ask if it's okay to carry out the visit with both people in the room. Even in situations involving people very familiar with each other, it is important to respect individual privacy. There is no implicit consent merely because he has allowed his wife to be in the room with him. On the other hand, it is inappropriate to assume that his wife should leave the room. Remember, the patient is the focus of the visit, so it would be appropriate to allow him to control who is in the room with him and inappropriate to address his wife first. A patient complains of knee pain on your arrival in the room. What should your first sentence be after greeting the patient? A) How much pain are you having? B) Have you injured this knee in the past? C) When did this first occur? D) Could you please describe what happened? D) Could you please describe what happened? When looking into a complaint, it is best to start with an invitation for the patient to tell you in his or her own words. More specific questions should be used later in the interview to fill in any gaps. You have just asked a patient how he feels about his emphysema. He becomes silent, folds his arms across his chest and leans back in his chair, and then replies, "It is what it is." How should you respond? A) "You seem bothered by this question." B) "Next, I would like to talk with you about your smoking habit." C) "Okay, let's move on to your other problems." D) "You have adopted a practical attitude toward your problem." A) "You seem bothered by this question." You have astutely noted that the patient's body language changed at the time you asked this question, and despite the patient's response, you suspect there is more beneath the surface. By sharing your observation and leaving a pause, he may begin to talk about some issues which are very important to him. A patient tells you about her experience with prolonged therapy for her breast cancer. You comment, "That must have been a very trying time for you." What is this an example of? A) Reassurance B) Empathy C) Summarization D) Validation D) Validation This is an example of validation to legitimize her emotional experience. You are performing a young woman's first pelvic examination. You make sure to tell her verbally what is coming next and what to expect. Then you carry out each maneuver of the examination. You let her know at the outset that if she needs a break or wants to stop, this is possible. You ask several times during the examination, "How are you doing, Brittney?" What are you accomplishing with these techniques? A) Increasing the patient's sense of control B) Increasing the patient's trust in you as a caregiver C) Decreasing her sense of vulnerability D) All of the above D) All of the above These techniques minimize the effects of transitions during an examination and empower the patient. Especially during a sensitive examination, it is important to give the patient as much control as possible. When using an interpreter to facilitate an interview, where should the interpreter be positioned? A) Behind you, the examiner, so that the lips of the patient and the patient's nonverbal cues can be seen B) Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of the patient C) Between you and the patient so all parties can make the necessary observations D) In a corner of the room so as to provide minimal distraction to the interview B) Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of the patient Interpreters are invaluable in encounters where the examiner and patient do not speak the same language, including encounters with the deaf. It should be noted that deaf people from different regions of the world use different sign languages. The priority is for you to have a good view of the patient. A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter's weight. You measure her daughter's height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate? A) Refer the patient to a nutritionist and a psychologist because the patient is anorexic. B) Reassure the mother that this is a normal body weight. C) Give the patient information about exercise because the patient is obese. D) Give the patient information concerning reduction of fat and cholesterol in her diet because she is obese. B) Reassure the mother that this is a normal body weight. The patient has a normal BMI; the range for a normal BMI is 18.5 to 24.9 kg/m2. You may be able to give the patient and her mother the lower limit of normal in pounds for her daughter's height, or instruct her in how to use a BMI table. A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit? A) Refer the patient to a nutritionist because he is anorexic. B) Reassure the patient that he has a normal body weight. C) Give the patient information about reduction of fat, cholesterol, and calories because he is overweight. D) Give the patient information about reduction of fat and cholesterol because he is obese. C) Give the patient information about reduction of fat, cholesterol, and calories because he is overweight. The patient has a BMI in the overweight range, which is 25.0 to 29.9 kg/m2. It is prudent to give him information about reducing calories, fat, and cholesterol in his diet to help prevent further weight gain. A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30.0 kg/m2. What is the most appropriate amount for a weekly weight reduction goal? A) .5 to 1 pound per week B) 1 to 2.5 pounds per week C) 2.5 to 3.5 pounds per week D) 3.5 to 4.5 pounds per week A) .5 to 1 pound per week Based on the NIH Obesity Guidelines, this is the weekly weight loss goal to strive for to maintain long-term control of weight. More rapid weight loss than this does not result in a better outcome at one year. A 67-year-old retired janitor comes to the clinic with his wife. She brought him in because she is concerned about his weight loss. He has a history of smoking 3 packs of cigarettes a day for 30 years, for a total of 90 pack-years. He has noticed a daily cough for the past several years, which he states is productive of sputum. He came into the clinic approximately 1 year ago, and at that time his weight was 140 pounds. Today, his weight is 110 pounds. Which one of the following questions would be the most important to ask if you suspect that he has lung cancer? A) Have you tried to force yourself to vomit after eating a meal? B) Do you have heartburn/indigestion and diarrhea? C) Do you have enough food to eat? D) Have you tried to lose weight? D) Have you tried to lose weight? This is important: If the patient hasn't tried to lose weight, then this weight loss is inadvertent and poses concern for a neoplastic process, especially given his smoking history. Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except: A) Changes in weight B) Fatigue and weakness C) Cough D) Fever and chills C) Cough This symptom is more appropriate to the respiratory review of systems. You are beginning the examination of a patient. All of the following areas are important to observe as part of the General Survey except: A) Level of consciousness B) Signs of distress C) Dress, grooming, and personal hygiene D) Blood pressure D) Blood pressure Blood pressure is a vital sign, not part of the General Survey. A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior elevated readings and her family history is negative for hypertension. You measure her blood pressure in your office today. Which of the following factors can result in a false high reading? A) Blood pressure cuff is tightly fitted. B) Patient is seated quietly for 10 minutes prior to measurement. C) Blood pressure is measured on a bare arm. D) Patient's arm is resting, supported by your arm at her mid-chest level as you stand to measure the blood pressure. A) Blood pressure cuff is tightly fitted. A blood pressure cuff that is too tightly fitted can result in a false high reading. The other answers are important to observe to obtain an accurate blood pressure reading. JNC-7 also mentions the importance of having the back supported when obtaining blood pressure in the sitting position. A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient's complete history and physical examination. When you palpate the pulse, what do you expect to feel? A) Large amplitude, forceful B) Small amplitude, weak C) Normal D) Bigeminal B) Small amplitude, weak Congestive heart failure is characterized by decreased stroke volume or increased peripheral vascular resistance, which would result in a small-amplitude, weak pulse. Subtle differences in amplitude are usually best detected in large arteries close to the heart, like the carotid pulse. You may not be able to notice these in other locations. An 18-year-old college freshman presents to the clinic for evaluation of gastroenteritis. You measure the patient's temperature and it is 104 degrees Fahrenheit. What type of pulse would you expect to feel during his initial examination? A) Large amplitude, forceful B) Small amplitude, weak C) Normal D) Bigeminal A) Large amplitude, forceful Fever results in an increased stroke volume, which results in a large-amplitude, forceful pulse. Later in the course of the illness, if dehydration and shock result, you may expect small amplitude and weak pulses. A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath and states that his blood sugar was 605 at home. You diagnose the patient with diabetic ketoacidosis. What is the expected pattern of breathing? A) Normal B) Rapid and shallow C) Rapid and deep D) Slow C) Rapid and deep The body is trying to rid itself of carbon dioxide to compensate for the acidosis. This is known as Kussmaul's breathing and is seen in other causes of acidosis as well. Mrs. Lenzo weighs herself every day with a very accurate balance-type scale. She has noticed that over the past 2 days she has gained 4 pounds. How would you best explain this? A) Attribute this to some overeating at the holidays. B) Attribute this to wearing different clothing. C) Attribute this to body fluid. D) Attribute this to instrument inaccuracy. C) Attribute this to body fluid. This amount of weight over a short period should make one think of body fluid changes. You may consider a kidney problem or heart failure in your differential. The other reasons should be considered as well, but this amount of weight gain over a short period usually indicates causes other than excessive caloric intake. Mr. Curtiss has a history of obesity, diabetes, osteoarthritis of the knees, HTN, and obstructive sleep apnea. His BMI is 43 and he has been discouraged by his difficulty in losing weight. He is also discouraged that his goal weight is 158 pounds away. What would you tell him? A) "When you get down to your goal weight, you will feel so much better." B) "Some people seem to be able to lose weight and others just can't, no matter how hard they try." C) "We are coming up with new medicines and methods to treat your conditions every day." D) "Even a weight loss of 10% can make a noticeable improvement in the problems you mention." D) "Even a weight loss of 10% can make a noticeable improvement in the problems you mention." Many patients trying to change a habit are overwhelmed by how far they are from their goal. Many patients find it empowering to know that they can achieve a small goal, such as a loss of 1 pound per week. Research has shown that significant benefits often come with even a 10% weight loss. Jenny is one of your favorite patients who usually shares a joke with you and is nattily dressed. Today she is dressed in old jeans, lacks makeup, and avoids eye contact. To what do you attribute these changes? A) She is lacking sleep. B) She is fatigued from work. C) She is running into financial difficulty. D) She is depressed. D) She is depressed. It is important to use all of your skills and memory of an individual patient to guide your thought process. She is not described as sleepy. Work fatigue would most likely not cause avoidance of eye contact. Financial difficulties would not necessarily deplete a nice wardrobe. It is most likely that she is depressed or in another type of difficulty. You are seeing an older patient who has not had medical care for many years. Her vital signs taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain. You notice that she has some hypertensive changes in her retinas and you find mild proteinuria on a urine test in your office. You expected the BP to be higher. She is not on any medications. What do you think is causing this BP reading, which doesn't correlate with the other findings? A) It is caused by an "auscultatory gap." B) It is caused by a cuff size error. C) It is caused by the patient's emotional state. D) It is caused by resolution of the process which caused her retinopathy and kidney problems. A) It is caused by an "auscultatory gap." The blood pressure is unusual in this case in that the systolic pressure is normal while the diastolic pressure is elevated. Especially with the retinal and urinary findings, you should consider that the BP may be much higher and that an auscultatory gap was missed. This can be avoided by checking for obliteration of the radial pulse while the cuff is inflated. Although a large cuff can cause a slightly lower BP on a patient with a small arm, this does not account for the elevated DBP. Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. How do you respond? A) You diagnose "white coat hypertension." B) You assume he is quite nervous when he comes to your office. C) You question the accuracy of his measurements. D) You question the accuracy of your measurements. C) You question the accuracy of his measurements. It is not uncommon to see differences in a patient's home measurements and your own in the office. Presuming that this is "white coat hypertension" can be dangerous because this condition is not usually treated. This allows for the effects of a missed diagnosis of hypertension to go unchecked. It is also very difficult to judge if a patient is outwardly nervous. You should always consider that your measurements are not accurate as well, but the fact that you and your staff are well-trained and perform this procedure on hundreds of patients a week makes this less likely. Ideally, you would ask the patient to bring in his BP equipment and take a simultaneous reading with you to make sure that he is getting an accurate reading. You are observing a patient with heart failure and notice that there are pauses in his breathing. On closer examination, you notice that after the pauses the patient takes progressively deeper breaths and then progressively shallower breaths, which are followed by another apneic spell. The patient is not in any distress. You make the diagnosis of: A) Ataxic (Biot's) breathing B) Cheyne-Stokes respiration C) Kussmaul's respiration D) COPD with prolonged expiration B) Cheyne-Stokes respiration Cheyne-Stokes respiration can be seen in patients with heart failure and is usually not a sign of an immediate problem. Mr. Garcia comes to your office for a rash on his chest associated with a burning pain. Even a light touch causes this burning sensation to worsen. On examination, you note a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. What type of pain is this? A) Idiopathic pain B) Neuropathic pain C) Nociceptive or somatic pain D) Psychogenic pain B) Neuropathic pain This vignette is consistent with a diagnosis of herpes zoster, or shingles. The characteristic burning quality without a history of an actual burn makes one think of neuropathic pain. It will most likely remain for months after the rash has resolved. There is no evidence of physical injury and this is a peculiar distribution, making nociceptive pain less likely. There is no evidence of a psychogenic etiology for this, and the presence of a rash makes this possibility less likely as well. A 50-year-old body builder is upset by a letter of denial from his life insurance company. He is very lean but has gained 2 pounds over the past 6 months. You personally performed his health assessment and found no problems whatsoever. He says he is classified as "high risk" because of obesity. What should you do next? A) Explain that even small amounts of weight gain can classify you as obese. B) Place him on a high-protein, low-fat diet. C) Advise him to increase his aerobic exercise for calorie burning. D) Measure his waist. D) Measure his waist. The patient most likely had a high BMI because of increased muscle mass. In this situation, it is important to measure his waist. It is most likely under 40 inches, which makes obesity unlikely (even to an insurance company). It is important that you personally contact the company and explain your reasoning. Ms. Wright comes to your office, complaining of palpitations. While checking her pulse you notice an irregular rhythm. When you listen to her heart, every fourth beat sounds different. It sounds like a triplet rather than the usual "lub dup." How would you document your examination? A) Regular rate and rhythm B) Irregularly irregular rhythm C) Regularly irregular rhythm D) Bradycardia C) Regularly irregular rhythm Because this unusual beat occurs every fourth set of heart sounds, it is regularly irregular. This is most consistent with premature ventricular contractions (or PVCs). This is generally a common and benign rhythm. A 19-year-old college student, Todd, is brought to your clinic by his mother. She is concerned that there is something seriously wrong with him. She states for the past 6 months his behavior has become peculiar and he has flunked out of college. Todd denies any recent illness or injuries. His past medical history is remarkable only for a broken foot. His parents are both healthy. He has a paternal uncle who had similar symptoms in college. The patient admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but none in the last week. He denies using any other substances. He denies any feelings of depression or anxiety. While speaking with Todd and his mother you do a complete physical examination, which is essentially normal. When you question him on how he is feeling, he says that he is very worried that Microsoft has stolen his software for creating a better browser. He tells you he has seen a black van in his neighborhood at night and he is sure that it is full of computer tech workers stealing his work through special gamma waves. You ask him why he believes they are trying to steal his programs. He replies that the technicians have been telepathing their intents directly into his head. He says he hears these conversations at night so he knows this is happening. Todd's mother then tells you, "See, I told you . . . he's crazy. What do I do about it?" While arranging for a psychiatry consult, what psychotic disorder do you think Todd has? A) Schizoaffective disorder B) Psychotic disorder due to a medical illness C) Substance-induced psychotic disorder D) Schizophrenia D) Schizophrenia Schizophrenia generally occurs in the late teens to early 20s. It often is seen in other family members, as in this case. Symptoms must be present for at least 6 months and must have at least two features of (1) delusions (e.g., Microsoft is after his programs), (2) hallucinations (e.g., technicians sending telepathic signals), (3) disorganized speech, (4) disorganized behavior, and (5) negative symptoms such as a flat affect. A 24-year-old secretary comes to your clinic, complaining of difficulty sleeping, severe nightmares, and irritability. She states it all began 6 months ago when she went to a fast food restaurant at midnight. While she was waiting in her car a man entered through the passenger door and put a gun to her head. He had her drive to a remote area, where he took her money and threatened to kill her. When the gun jammed he panicked and ran off. Ever since this occurred the patient has been having these symptoms. She states she jumps at every noise and refuses to drive at night. She states her anxiety has had such a marked influence on her job performance she is afraid she will be fired. She denies any recent illnesses or injuries. Her past medical history is unremarkable. On examination you find a nervous woman appearing her stated age. Her physical examination is unremarkable. You recommend medication and counseling. What anxiety disorder to you think this young woman has? A) Specific phobia B) Acute stress disorder C) Post-traumatic stress disorder D) Generalized anxiety disorder C) Post-traumatic stress disorder Post-traumatic stress disorder is the fearful response (nightmares, avoidance of areas, irritability) to an event that occurred at least 1 month prior to presentation. The patient's fears and reactions cause marked distress and impair social and occupational functions. A 75-year-old homemaker brings her 76-year-old husband to your clinic. She states that 4 months ago he had a stroke and ever since she has been frustrated with his problems with communication. They were at a restaurant after church one Sunday when he suddenly became quiet. When she realized something was wrong he was taken to the hospital by EMS. He spent 2 weeks in the hospital with right-sided weakness and difficulty speaking. After hospitalization he was in a rehab center, where he regained the ability to walk and most of the use of his right hand. He also began to speak more, but she says that much of the time "he doesn't make any sense." She gives an example that when she reminded him the car needed to be serviced he told her "I will change the Kool-Aid out of the sink myself with the ludrip." She says that these sayings are becoming frustrating. She wants you to tell her what is wrong and what you can do about it. While you write up a consult to neurology, you describe the syndrome to her. What type of aphasia does he have? A) Wernicke's aphasia B) Broca's aphasia C) Dysarthria A) Wernicke's aphasia With Wernicke's aphasia the patient can speak effortlessly and fluently, but his words often make no sense. Words can be malformed or completely invented. Wernicke's area is found on the temporal lobes. Susanne is a 27 year old who has had headaches, muscle aches, and fatigue for the last 2 months. You have completed a thorough history, examination, and laboratory workup but have not found a cause. What would your next action be? A) A referral to a neurologist B) A referral to a rheumatologist C) To tell the patient you can't find anything D) To screen for depression D) To screen for depression Although you may consider referrals to help with the diagnosis and treatment for this patient, screening is a time-efficient way to recognize depression. You ask a patient to draw a clock. He fills in all the numbers on the right half of the circle. What do you suspect? A) Hemianopsia B) Fatigue C) Oppositional defiant disorder D) Depression A) Hemianopsia You should suspect a visual problem because there is no writing on one half of the circle. This is consistent with a hemianopsia, sometimes seen in stroke. 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 A) Age The risk for melanoma is increased in people over the age of 50; our patient is 35 years old. The other answers represent known risk factors for melanoma. Especially with a family history of melanoma, she should be instructed to keep her skin covered when in the sun and use strong sunscreen on exposed areas. 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 B) A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter 6 mm; E = evolution 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 D) Dry and rough A patient with hypothyroidism is expected to have skin that is dry as well as rough. This is a good example of how the skin can give clues to systemic diseases. 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 A) Pityriasis rosea This is a classic description of pityriasis rosea. The description of a large single or "herald" patch preceding the eruption is a good way to distinguish this rash from other conditions. 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 B) Tinea versicolor This is a typical description of tinea versicolor. The information that the patient is sweating more also helps support this diagnosis, because tinea is a fungal infection and is promoted by moisture. 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 This is a typical description of actinic keratosis. Actinic keratosis may be easier to feel than to see. If left untreated, approximately 1% of cases can develop into squamous cell carcinoma. 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 B) Seborrheic keratosis This is a typical description for seborrheic keratosis. The "stuck on" appearance and the rough, wartlike texture are key features for the diagnosis. They often produce a greasy scale when scratched with a fingernail, which further helps to distinguish them from other lesions. Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important to distinguish these lesions to prevent unnecessary biopsy. 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