Summary NU 673 FINAL EXAM REVIEW LATEST GRADED A

NU 673 FINAL EXAM REVIEW LATEST GRADED A Which of the following statements is true concerning mental health disorders in primary care? a) Alcohol and substance abuse are not considered mental health disorders. b) Somatic symptom disorder (DSM‐5) is distinctly uncommon in this setting and constitutes less than 5% of these disorders. c) Mood disorders make up ~25% of all diagnoses. d) The prevalence for mental disorders is estimated to be ~10%, of which only 25% are not diagnosed. e) Anxiety disorders are the most prevalent of all diagnoses in this setting. c) Mood disorders make up ~25% of all diagnoses. Mood disorders make up ~25% of all diagnoses. Mental health disorders of various types ranging from major mental illness to personality disorders are very common diagnoses encountered in primary health care. Approximately 20% of primary care patients are thought to suffer from mental disorders, of which 50%-75% goes undetected. Somatoform disorders are relatively common in the range of 10%-15%, while alcohol and substance abuse are important contributors to patient dysfunction and are considered under the broad designation of mental health disorders Which of the following complaints/findings is considered to be a patient identifier for mental health screening? a) High use of health services due to chronic unstable medical diagnoses b) Acute pain syndromes of 10 days' duration that require opiates for relief c) A patient with type I diabetes and neuropathic pain d) Symptoms lasting for 2 weeks e) Substance abuse e) Substance abuse The answer is substance abuse. High use of health services in an unstable patient is frequently indicated; however, it is those without demonstrable problems that may require further evaluation, that is, mental health screening. Symptoms of a more chronic nature, namely 6 weeks, might warrant referral, but not 2 weeks. Acute pain should be managed in the context of the patient presentation, and type I diabetics frequently suffer from difficult to manage neuropathic pain, which is not easily treated but medically based and well‐described clinically. The CAGE questionnaire is a short screening examination administered in the office to evaluate for which of the following? a) Bipolar disorder b) Risk for illicit substance abuse c) Alcohol misuse d) Major depressive disorder e) Likelihood that the patient complaints are "psychosomatic" c) Alcohol misuse The CAGE questionnaire was developed to identify alcohol abuse. It comprises questions concerning Cutting down, Annoyance, Guilty feelings, and Eye‐openers. Although many patients may have dual diagnoses or multiple substances that they abuse, it has been validated as an effective tool in initial screening for alcohol abuse. A separate less widely used test is the Drug Abuse Screening Test (DAST) that focuses on non‐alcohol-related substance abuse. Although alcohol abuse can be seen in association with major depression, psychosomatic, and bipolar disorders, the CAGE questionnaire is not diagnostic of any of these conditions. "Instability in interpersonal relations, self‐image, and affective regulation; impulsivity" describes which personality disorder? a) Antisocial personality b) Avoidant personality c) Histrionic personality d) Narcissistic personality e) Borderline personality e) Borderline personality The DSM‐5 is published by the American Psychiatric Association based upon its professional definitions of mental disorders. Although at times controversial, it is generally considered the authoritative publication in the field. The example cited defines the borderline personality. Although these persons may demonstrate some selected characteristics of other disorders, this definition is the basis for the diagnosis. It is important to remember that mental disorders as well as physical ones may demonstrate substantial overlap making a definitive diagnosis difficult. The incorrect answers all have specific criteria as set out by the DSM‐5. A 38‐year‐old accountant presents to the office with a series of generalized complaints. He relates that he feels a loss of pleasure in daily activities, has difficulty sleeping, and is experiencing problems making decisions. Which of the following best explains the patient's presentation? a) Histrionic personality b) Antisocial personality c) Substance abuse with anhedonia d) Bipolar disorder in the early pre‐excitatory phase e) Depression e) Depression The complaints as presented are highly consistent with depression. It is important to note that few patients will articulate that they feel depressed. Rather, it is contingent upon the clinician to probe for more information and keep an open mind coupled with an index of suspicion. Because of the stigma associated with mental health problems, many patients initially present with nonspecific complaints that point to a nonmedical cause only with closer questioning. Anhedonia may be associated with depression but tends to be milder in its symptoms. The other entities demonstrate different complaints than those described by this patient. Concerning hallucinations, an abnormal perception experienced by a patient, which of the following statements is true about this abnormality? a) It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia. b) They include false perceptions associated with dreaming and occurring with falling asleep and awakening. c) Objective testing can be performed by a trained neuropsychologist to ascertain the correct diagnosis associated with this complaint. d) Although alcoholism may be associated with abnormalities of perception, it is not considered a cause of hallucinations as this finding is due to its direct toxic effects. e) By definition, hallucinations are confined to those abnormal perceptions that are either auditory or visual in nature. a) It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia. Hallucinations may be associated with a number of different primary diagnoses. By definition, they exclude perceptions occurring with dreaming or close to falling asleep or awakening. As hallucinations are a subjective patient self‐reported complaint, objective testing is not available. Alcohol is a known cause of hallucinations, and abnormal perceptions may include ones of a gustatory, olfactory, and tactile nature. A 24‐year‐old veteran returns from his second tour of duty in the Middle East. He was witness to a number of violent military encounters and experienced the death of several of his closest friends. He describes a number of problems including nightmares, poor sleep pattern, and mild panic attacks. In persons with trauma‐ and stress‐related disorders as well as other disorders that may be associated with hallucinations and illusions, which of the following statements is true that distinguishes these two entities from each other? a) Illusions occur only when awake, whereas hallucinations can occur both while awake and while sleeping. b) Illusions involve an irrational fear or perceptions, whereas hallucinations are a misinterpretation of real external stimuli. c) Hallucinations may be visual or auditory, causing an alteration of the real external world, whereas illusions are entirely imaginary. d) Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. e) Hallucinations by definition never include somatic perceptions, whereas illusions always involve at least some component of a somatic complaint. d) Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. Trauma‐ and stress‐related disorders are an increasingly recognized and appreciated cause of moderate‐to‐severe dysfunction both in the military as well as civilian populations. Both illusions and hallucinations may be associated with the disorder; however, the correct distinction between the two is contained in the correct answer. Both are subjective in nature; therefore, there is no objective testing available. The clinician relies on the patient history in the context of the clinical setting to discern the correct designation. The incorrect answers all contain components that are inaccurate descriptions based on their accepted definitions. Abstract thinking is an important component of the human thought process. A person's ability to understand questions that test his or her ability to answer appropriately is dependent upon a number of factors. Which one of the following answers is true in identifying a patient with concrete thinking and a reduced ability to think abstractly? a) An inability to name the occupations of common well‐known public figures such as the President and Vice President b) An inability to correctly perform serial 7s c) An inability to discern the similarity between two words (e.g., a cat and a mouse by answering "The cat chases the mouse.") d) An inability to spell "world" backward e) An inability to draw a clock correctly including all numbers and make it tell time as requested (i.e., 10:15) c) An inability to discern the similarity between two words (e.g., a cat and a mouse by answering "The cat chases the mouse.") An inability to link a cat and a mouse as both representing animals (abstraction) is an example of loss of the ability to think abstractly. Serial 7s is a simple math test that tests attention, not abstract thinking, and spelling "world" backward is another test for attention. These tests may be particularly difficult to perform for a person with a mild delirium, representing an inability to concentrate and maintain attention. Memory deficits are represented by the inability to name public figures, and clock‐drawing abnormalities are most associated with executive functioning deficits. Which of the following statements is true concerning the mini‐mental status exam (MMSE)? a) It is recommended that clinicians perform the examination in all adults age 65 years regardless of symptoms. b) It is standardized and unaffected by education level or primary language. c) It is a proprietary screening test that is not diagnostic of probable causes. d) It identifies both memory deficits as well as early loss of executive functioning. e) It can provide a differential diagnosis as to probable causes of cognitive impairment. c) It is a proprietary screening test that is not diagnostic of probable causes. The MMSE is a screening tool and, as such, suggest, that there is an abnormality present, but it does not provide for a differential diagnosis. Further testing is always required after implementing any screening test to render a definitive diagnosis. It is not recommended in persons who are asymptomatic, showing little value in that clinical setting. The MMSE tests for memory but does not have an executive function component, a common criticism of the test's broad applicability. The MMSE may clearly be influenced by both the education of a patient as well as its administration in a language that is not the primary one (resulting in a lower score). Concerning a patient that may demonstrate a diagnosis of aphasia, which of the following statements is true? a) It is best characterized by involuntary, rhythmic, repetitive movements involving the tongue and jaws making speech difficult to comprehend. b) It is defined as an inability to produce or understand language. c) It involves a loss of the voice or a slurring or hoarseness of speech secondary to pathology of the larynx or its nerve supply. d) The ability to write a full correct sentence does not rule out the presence of aphasia in a patient. e) It is best characterized by slurred speech with an associated defect in language control. b) It is defined as an inability to produce or understand language. Aphasia, the inability to produce or understand language, includes two common subtypes: receptive and expressive. A loss of the voice or hoarseness defines aphonia and dysphonia, respectively. Slurred speech with intact language is dysarthria. Involuntary movements as described are characteristic for oral-facial dyskinesias. Because writing a sentence involves both understanding the question and executing the task (expressive), by definition, maintenance of language production and understanding effectively rules out aphasia.   Chapter 11 An overweight 26‐year‐old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light‐headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β‐human chorionic gonadotropin (β‐hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis? a) Acute cholecystitis b) Ruptured appendix c) Ruptured ovarian cyst d) Ruptured tubal (or ectopic) pregnancy e) Perforated bowel wall d) Ruptured tubal (or ectopic) pregnancy The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β‐hCG, and findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured ectopic pregnancy with significant intra‐abdominal bleeding leading to peritoneal signs. This case is emergent and requires immediate treatment of her hypotension and presumed blood loss as well as gynecological consult for emergent surgery. Ruptured ectopic pregnancies can lead to life‐ threatening intra‐abdominal bleeding. Although acute cholecystitis, ruptured appendix, bowel wall perforation, and ruptured ovarian cyst are all possibilities, the positive β‐hCG testing and her unstable vital signs make ruptured ectopic pregnancy more likely. A 63‐year‐old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ‐glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow‐up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly? a) Liver span of 11 cm at the midclavicular line b) Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration c) Dullness to percussion over a span of 11 cm at the midclavicular line d) Dullness to percussion over a span of 8 cm at the midsternal line e) Liver span of 8 cm at the midsternal line b) Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration The liver being palpable 3 cm below the right costal margin, midclavicular line, would be considered normal on inspiration when the liver is pushed down into the abdominal cavity on inspiration, but is abnormal on expiration. Findings to support hepatomegaly would be more convincing if, by percussion, the liver span was 12 cm at the midclavicular line. For patients with obstructive lung disease, air trapping in the lungs may displace the liver downwards into the abdominal cavity. The liver span and dullness to percussion refer to the same measurement. Measurements of 6-12 cm at the mid‐clavicular line and 4-8 cm at the midsternal line are considered normal. Upgrade to remove ads Only $1/month A 63‐year‐old underweight administrative clerk with a 50‐pack‐year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA? a) Family history of ruptured aneurysm b) Underweight c) Female gender d) Hypertension e) History of smoking e) History of smoking History of smoking is her most significant risk factor for an AAA. Male gender, not female gender, is considered as risk factor. Underweight is not a risk factor for AAA. Family history of ruptured aneurysm is vague and could be a cerebral aneurysm. Further, her family history is in a first‐degree cousin not a first‐degree relative (biologic parents, siblings, and children). Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based on one elevated blood pressure reading. A 76‐year‐old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow‐up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first‐degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient? a) Do not screen routinely b) Repeat colonoscopy this year c) Continue annual FOBT screening until age 80 years d) Continue annual FOBT screening until age 85 years e) Sigmoidoscopy every 5 years with FOBT every 3 years a) Do not screen routinely The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and benefits with the patient. Annual FOBT screening may continue until age 80-85 years if benefits to doing so outweigh risks for the individual patient; however, screening should not be routinely continued. In general, a life expectancy 7 years is necessary for screening to be potentially beneficial. There is no indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option, but again screening is not routinely recommended for patients age 75 years. An otherwise healthy 31‐year‐old accountant presents to an outpatient clinic with a 3‐year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over‐the‐counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? a) Functional change in bowel movement b) A large, firm fecal mass in the rectum c) Spasm of the external sphincter d) Decreased fecal bulk e) Impairment of autonomic innervations a) Functional change in bowel movement Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea predominant, constipation predominant, or mixed. Other functional causes for her constipation should be excluded prior to making this diagnosis. A large firm fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that increasing fiber helps her constipation. Spasm of the external sphincter is associated with painful anal lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known diagnosis that would increase suspicion of neurological impairment. A 65‐year‐old farmer who rarely seeks medical care but does have a remote history of coronary bypass surgery presents to the office with a 2‐day history of increasing shortness of breath and abdominal discomfort. On exam, a protuberant abdomen and lower extremity edema is noted. The clinician is concerned about possible right‐sided heart failure and associated ascites and decides to proceed with further physical exam techniques to assess for possible ascites. Which of the following findings will be supportive of ascites? a) Tapping on one flank sharply transmits an impulse to the opposite flank b) Dullness to percussion throughout the abdomen c) Tympany predominant throughout the abdomen d) Border between tympany and dullness to percussion that does not shift with position e) Dullness to percussion of the upper quadrants and tympany in the lower quadrants a) Tapping on one flank sharply transmits an impulse to the opposite flank Tapping on one flank sharply transmitting an impulse to the opposite flank is a positive fluid wave test finding and is suggestive of ascites, but neither sensitive nor specific for ascites. With ascites, the dependent portions of the abdomen tend to be dull to percussion while the top portions are tympanic. One would not expect a difference in percussion to upper and lower quadrants. Tympany predominant throughout the abdomen suggests a gas filled abdomen and not ascites. Shifting dullness is characterized by dullness to percussion shifting to the dependent side and tympany shifting to the top with changes in position and is supportive of ascites. Dullness to percussion throughout the abdomen would be characteristic of a stool filled abdomen, a large mass, or enlarged organ. A 23‐year‐old woman comes to the respirology clinic for follow‐up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam? a) Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant b) A change in percussion from tympany to dullness in the left lower anterior chest wall on inspiration c) Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line d) Liver dullness in the right upper quadrant that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease e) Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation a) Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant Situs inversus is a rare condition in which organs are reversed and is associated with Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on the left. A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is likely constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left upper quadrant with organ reversal. Findings given in the remaining answer choices are both associated with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis. An otherwise healthy 28‐year‐old lawyer presents to the Emergency Department with a 1‐day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis? a) Abdominal pain that increases with hip flexion b) Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain c) Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus d) Pain with internal rotation of the right hip e) Voluntary contraction of the abdominal wall that persists over several examinations b) Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over several examinations describes rigidity. Abdominal pain that increases with hip flexion is not suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal peritoneum. They often walk bent forward at the hips for this reason. Localized pain over McBurney point is certainly suggestive of appendicitis, but not suggestive of peritonitis. Similarly pain with internal rotation of the right hip, or a positive obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but not peritonitis. A 58‐year‐old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4‐month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis? a) Helicobacter pylori infection b) Inflammation of colonic diverticulum c) Inflammation of the gallbladder d) Reduced blood supply to the bowel e) Fibrosis of the pancrea e) Fibrosis of the pancreas Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency and diabetes mellitus. H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually associated with diarrhea. Inflammation of the colonic diverticulum is diverticulitis and typically causes left‐ lower‐quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an acute disease. Reduced blood supply to the bowel characterizes mesenteric ischemia. It can be acute or chronic in presentation and causes diffuse abdominal pain, vomiting, diarrhea, or constipation. It is associated with older age and vascular risk factors such as coronary artery disease. A 46‐year‐old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3‐month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic? a) Associated right shoulder pain b) Positive McBurney point tenderness c) Poorly localized periumbilical pain d) Exacerbating factor includes alcohol intake e) Vomiting of bile a) Associated right shoulder pain Pain with biliary colic can produced referred pain to the right shoulder or scapula due to irritation of the right hemidiaphragm. Alcohol is not an exacerbating factor for biliary colic. Positive McBurney point tenderness is associated with acute appendicitis. The Murphy sign is associated with acute cholecystitis. Poorly localized periumbilical pain is associated with early stages of acute appendicitis. Vomiting bile is associated with small bowel obstruction. 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 A) Stress incontinence 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 C) Esophageal varices Upgrade to remove ads Only $1/month 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 C) Irritable bowel syndrome 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 D) Hypothyroidism 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 symptoms? A) Peptic ulcer disease B) Biliary colic C) Acute cholecystitis D) Acute pancreatitis D) Acute pancreatitis A 76-year-old retired farmer comes to your office complaining of abdominal pain, constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or diarrhea. The only unusual thing he remembers eating is two bags of popcorn at the movies with his grandson, 3 days before his symptoms began. He denies any other recent illnesses. His past medical history is significant for coronary artery disease and high blood pressure. He has been married for over 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon cancer and his father had a stroke. On examination he appears his stated age and is in no acute distress. His temperature is 100.9 degrees and his other vital signs are unremarkable. His head, cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable and his fecal occult blood test is negative. His prostate is slightly enlarged but his testicular, penile, and inguinal examinations are all normal. Blood work is pending. What diagnosis for abdominal pain best describes his symptoms and signs? A) Acute diverticulitis B) Acute cholecystitis C) Acute appendicitis D) Mesenteric ischemia A) Acute diverticulitis A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife's request. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for over 40 years. He denies any tobacco or drug use and has not drunk alcohol in over 40 years. His parents both died of cancer in their 60s. On examination his vital signs are normal. His head, cardiac, and pulmonary examinations are unremarkable. On abdominal examination you hear normal bowel sounds, but when you palpate his liver it is abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination? A) Smooth, large, nontender liver B) Irregular, large liver C) Smooth, large, tender liver B) Irregular, large liver A 26-year-old sports store manager comes to your clinic, complaining of severe right-sided abdominal pain for 12 hours. He began having a stomachache yesterday, with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 100.4 and his heart rate is 110. His bowel sounds are decreased and he has rebound and involuntary guarding, one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain? A) Acute appendicitis B) Acute mechanical intestinal obstruction C) Acute cholecystitis D) Mesenteric ischemia A) Acute appendicitis 15-year-old high school freshman is brought to the clinic by his mother because of chronic diarrhea. The mother states that for the past couple of years her son has had diarrhea after many meals. The patient states that the diarrhea seems the absolute worst after his school lunches. He describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or fatigue. He has had no recent illness, injuries, or foreign travel. His past medical history is unremarkable. He denies tobacco, alcohol, or drug use. His parents are both healthy. On examination you see a relaxed young man breathing comfortably. His vital signs are normal and his head, eyes, ears, throat, neck, cardiac, and pulmonary examinations are normal. His abdomen is soft and nondistended. His bowel sounds are active and he has no tenderness, no enlarged organs, and no rebound or guarding. His rectal examination is nontender with no blood on the glove. You collect a stool sample for further study. What is the most likely explanation for this patient's chronic diarrhea? A) Malabsorption syndrome B) Osmotic diarrhea C) Secretory diarrhea B) Osmotic diarrhea A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency or urgency with urination but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood cells. What type of urinary tract pain is she most likely to have? A) Kidney pain (from pyelonephritis) B) Ureteral pain (from a kidney stone) C) Musculoskeletal pain D) Ischemic bowel pain B) Ureteral pain (from a kidney stone) Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely? A) Peptic ulcer B) Cholecystitis C) Pancreatitis D) Appendicitis D) Appendicitis Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or more at a time and has started recently. Which of the following should be considered? A) Peptic ulcer B) Pancreatitis C) Myocardial ischemia D) All of the above D) All of the above Upgrade to remove ads Only $1/month Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely? A) Colon cancer B) Cholecystitis C) Inflammatory bowel disease D) Irritable bowel syndrome D) Irritable bowel syndrome im is a 60-year-old man who presents with vomiting. He denies seeing any blood with emesis, which has been occurring for 2 days. He does note a dark, granular substance resembling the coffee left in the filter after brewing. What do you suspect? A) Bleeding from a diverticulum B) Bleeding from a peptic ulcer C) Bleeding from a colon cancer D) Bleeding from cholecystitis B) Bleeding from a peptic ulcer A daycare worker presents to your office with jaundice. She denies IV drug use, blood transfusion, and travel and has not been sexually active for the past 10 months. Which type of hepatitis is most likely? A) Hepatitis A B) Hepatitis B C) Hepatitis C D) Hepatitis D A) Hepatitis A Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely, given this presentation? A) Appendicitis B) Dysmenorrhea C) Ureteral stone D) Ovarian cyst C) Ureteral stone Mrs. LaFarge is a 60-year-old who presents with urinary incontinence. She is unable to get to the bathroom quickly enough when she senses the need to urinate. She has normal mobility. Which of the following is most likely? A) Stress incontinence B) Urge incontinence C) Overflow incontinence D) Functional incontinence B) Urge incontinence Which is the proper sequence of examination for the abdomen? A) Auscultation, inspection, palpation, percussion B) Inspection, percussion, palpation, auscultation C) Inspection, auscultation, percussion, palpation D) Auscultation, percussion, inspection, palpation C) Inspection, auscultation, percussion, palpation A 62-year-old woman has been followed by you for 3 years and has had recent onset of hypertension. She is still not at goal despite three antihypertensive medicines, and you strongly doubt nonadherence. Her father died of a heart attack at age 58. Today her pressure is 168/94 and pressure on the other arm is similar. What would you do next? A) Add a fourth medicine B) Refer to nephrology C) Get a CT scan D) Listen closely to her abdomen D) Listen closely to her abdomen Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which of the following would you do next? A) Check an ultrasound of the liver B) Obtain a hepatitis panel C) Determine liver span by percussion D) Adopt a "watchful waiting" approach C) Determine liver span by percussion Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound? A) It is a splenic rub. B) It is a variant of bowel noise. C) It represents borborygmi. D) It is a vascular noise. A) It is a splenic rub. You are palpating the abdomen and feel a small mass. Which of the following would you do next? A) Ultrasound B) Examination with the abdominal muscles tensed C) Surgery referral D) Determine size by percussion B) Examination with the abdominal muscles tensed Upgrade to remove ads Only $1/month Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice dullness in the last intercostal space in the anterior axillary line on his left side with a deep breath. What does this indicate? A) His spleen is definitely enlarged and further workup is warranted. B) His spleen is possibly enlarged and close attention should be paid to further examination. C) His spleen is possibly enlarged and further workup is warranted. D) His spleen is definitely normal. B) His spleen is possibly enlarged and close attention should be paid to further examination. A young patient presents with a left-sided mass in her abdomen. You confirm that it is present in the left upper quadrant. Which of the following would support that this represents an enlarged kidney rather than her spleen? A) A palpable "notch" along its edge B) The inability to push your fingers between the mass and the costal margin C) The presence of normal tympany over this area D) The ability to push your fingers medial and deep to the mass C) The presence of normal tympany over this area Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the symphysis pubis. What does this most likely represent? A) Sigmoid mass B) Tumor in the abdominal wall C) Hernia D) Enlarged bladder D) Enlarged bladder Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What should you do next? A) Obtain abdominal ultrasound B) Reassess by examination in 6 months C) Reassess by examination in 3 months D) Refer to a vascular surgeon A) Obtain abdominal ultrasound Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites? A) Bilateral flank tympany B) Dullness which remains despite change in position C) Dullness centrally when the patient is supine D) Tympany which changes location with patient position D) Tympany which changes location with patient position Which of the following is consistent with obturator sign? A) Pain distant from the site used to check rebound tenderness B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated C) Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion D) Pain that stops inhalation in the right upper quadrant B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect? A) Malingering B) Neuropathy C) Ischemia D) Physical abuse C) Ischemia   Chapter 12 A 68‐year‐old retired administrative assistant complains of a 3‐month history of recurring pain after ambulating that radiates from her back in the upper lumbar region into both buttocks, bilateral thighs, and mid‐calf regions. Her pain is typically improved by sitting or by leaning forward. The origin of her pain is likely secondary to which of the following? a) Neurogenic claudication b) Abdominal aortic aneurysm c) Peripheral arterial disease (PAD) d) Venous stasis e) Acute arterial occlusion a) Neurogenic claudication Neurogenic claudication can mimic PAD by causing pain related to walking; however, it is typically relieved simply by sitting or by leaning forward. Many patients with spinal stenosis of the lumbar spine have pain that originates in the spinal region and radiates into the areas noted. PAD is not typically relieved just by sitting alone and usually will take some time. PAD also does not typically improve with bending over. Acute arterial occlusion does not cause recurring symptoms and is not usually bilateral. Abdominal aortic aneurysms may cause similar pain as well; however, they typically do not have the same palliating factors. A patient that has a known history of cardiovascular disease including a myocardial infarction and positive ankle-brachial index indicating peripheral arterial disease in his left leg is now having some issues with erectile dysfunction (ED). The clinician suspects it may be due to medications or further vascular disease. He does not complain of any other symptoms. If his symptoms are related to vascular disease, where would the lesion likely be located? a) Iliac pudendal b) Popliteal c) Aortorenal d) Superficial femoral e) Common femoral a) Iliac pudendal The internal pudendal artery, which is a branch off of the internal iliac artery, is the major blood supply for the penis. A lesion in the aortorenal region would be unlikely to cause isolated symptoms of ED. The common femoral, superficial femoral, and popliteal arteries are all distal from the iliac arteries and would not cause symptoms as described. Upgrade to remove ads Only $1/month A 73‐year‐old retired salesman presents to the Emergency Department complaining of chest pain that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x‐ray are normal. The nurse notes that his blood pressures in the right arm are significantly lower than of blood pressures in his left arm. Based on history and physical examination, which of the following will most likely explain his signs and symptoms? a) Pulmonary embolism (PE) b) Myocardial infarction (MI) c) Coarctation of the aorta d) Pericarditis e) Dissecting aortic aneurysm e) Dissecting aortic aneurysm Patients with dissecting aortic aneurysms typically present with chest pain, many times described as a "tearing" type pain. They are usually elderly, and, due to the dissection of the aorta, asymmetric pulses in blood pressures in the extremities may be present. Coarctation of the aorta can also cause similar symptoms; however, it would be unlikely due to the patient's age as this is a congenital defect. MI, PE, and pericarditis are also common causes of concerning chest pain; however, neither typically will cause asymmetric blood pressures or pulses in the extremities. A 19‐year‐old carwash attendant sustained a laceration to the ulnar aspect of his mid‐forearm while at work last week. He did not have it evaluated at that time and is now noticing purulent discharge and increasing pain from the wound along with fever and chills. Where would the clinician expect to find the first signs of lymphadenopathy? a) Epitrochlear nodes b) Cervical chain nodes c) Infraclavicular nodes d) Central axillary nodes e) Lateral axillary nodes a) Epitrochlear nodes The epitrochlear nodes are the first nodes in the drainage region from the ulnar surface of the forearm and hand, little and ring fingers, and adjacent surface of the middle finger. Axillary nodes, infraclavicular nodes, and cervical chain nodes are all distal to this area and may show evidence of lymphadenopathy as well; however, that would be secondary after the epitrochlear nodes. When assessing for the femoral pulse, where should the clinician begin deeply palpating? a) Below the inguinal ligament, just medial to the anterior superior iliac spine b) Above the inguinal ligament, just medial to the anterior superior iliac spine c) Above the inguinal ligament, just lateral to the symphysis pubis d) Below the inguinal ligament, just lateral to the symphysis pubis e) Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis e) Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis The clinician would begin deeply palpating below the inguinal ligament, midway between the anterior superior iliac spine in the symphysis pubis. The external iliac artery transitions into the femoral artery at the level of the inguinal ligament. Therefore, palpating above the inguinal ligament would be assessing the external iliac artery. The femoral artery is typically located midway between the anterior superior iliac spine in the symphysis pubis in most patients. The clinician is palpating pulses in the foot of a diabetic patient while in the clinic. A strong pulse is felt located on the dorsum of the foot, just lateral to the extensor tendon of the big toe. Which artery is being assessed? a) Arterial arch of the foot b) Posterior tibial c) Dorsalis pedis d) Femoral e) Popliteal c) Dorsalis pedis The dorsalis pedis artery is usually palpable on the dorsum of the foot just lateral to the extensor tendon of the big toe. The arterial arch of the foot is more distal and runs transversely and is not usually palpable. The posterior tibial artery is found behind the medial malleolus of the ankle. The popliteal and femoral pulses are found more proximally at the knee and near the groin, respectively. A 61‐year‐old retired librarian was recently diagnosed with ovarian cancer. She was otherwise healthy until her recent cancer diagnosis. She has not been feeling well lately and has had a cough and some mild shortness of breath for the past couple of days. She now presents to the clinic complaining of pain and swelling in her right groin and leg, which she says is been there for about a week but is worsening. On physical examination, 2 edema of the right leg up to the thigh; 1 femoral, popliteal, dorsalis pedis, and posterior tibial pulses; and no significant erythema are noted. What is the chief concern with this patient? a) Acute arterial occlusion b) Pulmonary embolism (PE) c) Superficial thrombophlebitis d) Ovarian metastasis e) Acute lymphangitis b) Pulmonary embolism (PE) Cancer patients are at high risk of deep venous thrombosis (DVT), and, with the presenting symptoms of swelling and pain in her groin, along with recent history of cough and shortness of breath, this patient's presentation is suspicious for PE. Patients with DVT in the proximal leg veins are at high risk of thromboembolism. Acute arterial occlusion should not cause significant edema, and pulses would likely be absent. The constellation of symptoms and history in this patient also does not suggest an acute arterial occlusion. Superficial thrombophlebitis typically only causes mild local swelling, redness, and warmth along with a subcutaneous cord. Acute lymphangitis typically presents with red streaks from an infection passing through lymph channels. A 32‐year‐old cabdriver complains of pain in his left leg. He has a history of type 2 diabetes, is a smoker, and recently was diagnosed with hypertension. He does not remember injuring his leg; however, he notes that there is a small wound on the lateral aspect of his mid‐shin. Upon examination, some mild erythema surrounding the wound and flat, nonpalpable red streaks progressing up his leg are noted. What do these streaks likely represent? a) Thrombus formation in a superficial vein b) Dilated arterioles c) Occluded arterial vessels d) Dilated veins secondary to incompetent valves e) Draining lymphatic channels e) Draining lymphatic channels Acute lymphangitis is typically caused from an acute bacterial infection of the skin that causes red streaks from distal drainage through the lymphatic system. The streaks are typically flat, not palpable cords as found in thrombus formation in a superficial vein. Dilated veins also are not flat. Occluded arterial vessels are not superficial or visible. Dilated arterioles are still too small to be visible at the skin surface. A clinician, evaluating a patient for valvular competency in the communicating veins of the saphenous system, starts with the patient supine, then elevates one leg to about 90° to empty it of venous blood. Next, the great saphenous vein in the upper part of the thigh is occluded with manual compression, and the patient stands. The clinician keeps the vein occluded while watching for venous filling in the leg. Which test is being performed? a) Romberg b) Trendelenburg c) Ankle-brachial index d) Allen e) Straight‐leg raise b) Trendelenburg The Trendelenburg, or retrograde filling test, is used to evaluate the competency of venous valves in the lower extremities. The Allen test is used to evaluate adequate perfusion of the hand from the ulnar and radial arteries. The straight‐leg raise test is used to evaluate for radiculopathy from the lumbosacral regions. Romberg is a test for position sense A 44‐year‐old retail salesperson has noticed an increasing dilatation of the veins in her legs. Upon inspection, it is noted that she has significant varicosities on the posterior aspects of both legs which begin in the lateral side of the foot and pass upward along the posterior calf. The remainder of the veins in the legs appears normal at this time. Which veins are currently affected? a) Great saphenous b) Small saphenous c) Femoral d) Perforating e) Dorsal venous arch b) Small saphenous The small saphenous vein typically runs in the described pattern. The great saphenous vein originates on the dorsum of the foot it passes just anterior to the medial malleolus and continues of the medial aspect of the leg joining the femoral vein of the deep venous system below the inguinal ligament. Perforating veins are not visible as they connect the deep and superficial veins. The femoral is proximal as described, and the dorsalis pedis vein is distal to the described area. Chapter 12 A 68‐year‐old retired administrative assistant complains of a 3‐month history of recurring pain after ambulating that radiates from her back in the upper lumbar region into both buttocks, bilateral thighs, and mid‐calf regions. Her pain is typically improved by sitting or by leaning forward. The origin of her pain is likely secondary to which of the following? a) Neurogenic claudication b) Abdominal aortic aneurysm c) Peripheral arterial disease (PAD) d) Venous stasis e) Acute arterial occlusion a) Neurogenic claudication Neurogenic claudication can mimic PAD by causing pain related to walking; however, it is typically relieved simply by sitting or by leaning forward. Many patients with spinal stenosis of the lumbar spine have pain that originates in the spinal region and radiates into the areas noted. PAD is not typically relieved just by sitting alone and usually will take some time. PAD also does not typically improve with bending over. Acute arterial occlusion does not cause recurring symptoms and is not usually bilateral. Abdominal aortic aneurysms may cause similar pain as well; however, they typically do not have the same palliating factors. A patient that has a known history of cardiovascular disease including a myocardial infarction and positive ankle-brachial index indicating peripheral arterial disease in his left leg is now having some issues with erectile dysfunction (ED). The clinician suspects it may be due to medications or further vascular disease. He does not complain of any other symptoms. If his symptoms are related to vascular disease, where would the lesion likely be located? a) Iliac pudendal b) Popliteal c) Aortorenal d) Superficial femoral e) Common femoral a) Iliac pudendal The internal pudendal artery, which is a branch off of the internal iliac artery, is the major blood supply for the penis. A lesion in the aortorenal region would be unlikely to cause isolated symptoms of ED. The common femoral, superficial femoral, and popliteal arteries are all distal from the iliac arteries and would not cause symptoms as described. A 73‐year‐old retired salesman presents to the Emergency Department complaining of chest pain that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x‐ray are normal. The nurse notes that his blood pressures in the right arm are significantly lower than of blood pressures in his left arm. Based on history and physical examination, which of the following will most likely explain his signs and symptoms? a) Pulmonary embolism (PE) b) Myocardial infarction (MI) c) Coarctation of the aorta d) Pericarditis e) Dissecting aortic aneurysm e) Dissecting aortic aneurysm Patients with dissecting aortic aneurysms typically present with chest pain, many times described as a "tearing" type pain. They are usually elderly, and, due to the dissection of the aorta, asymmetric pulses in blood pressures in the extremities may be present. Coarctation of the aorta can also cause similar symptoms; however, it would be unlikely due to the patient's age as this is a congenital defect. MI, PE, and pericarditis are also common causes of concerning chest pain; however, neither typically will cause asymmetric blood pressures or pulses in the extremities. A 19‐year‐old carwash attendant sustained a laceration to the ulnar aspect of his mid‐forearm while at work last week. He did not have it evaluated at that time and is now noticing purulent discharge and increasing pain from the wound along with fever and chills. Where would the clinician expect to find the first signs of lymphadenopathy? a) Epitrochlear nodes b) Cervical chain nodes c) Infraclavicular nodes d) Central axillary nodes e) Lateral axillary nodes a) Epitrochlear nodes The epitrochlear nodes are the first nodes in the drainage region from the ulnar surface of the forearm and hand, little and ring fingers, and adjacent surface of the middle finger. Axillary nodes, infraclavicular nodes, and cervical chain nodes are all distal to this area and may show evidence of lymphadenopathy as well; however, that would be secondary after the epitrochlear nodes. When assessing for the femoral pulse, where should the clinician begin deeply palpating? a) Below the inguinal ligament, just medial to the anterior superior iliac spine b) Above the inguinal ligament, just medial to the anterior superior iliac spine c) Above the inguinal ligament, just lateral to the symphysis pubis d) Below the inguinal ligament, just lateral to the symphysis pubis e) Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis e) Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis The clinician would begin deeply palpating below the inguinal ligament, midway between the anterior superior iliac spine in the symphysis pubis. The external iliac artery transitions into the femoral artery at the level of the inguinal ligament. Therefore, palpating above the inguinal ligament would be assessing the external iliac artery. The femoral artery is typically located midway between the anterior superior iliac spine in the symphysis pubis in most patients. The clinician is palpating pulses in the foot of a diabetic patient while in the clinic. A strong pulse is felt located on the dorsum of the foot, just lateral to the extensor tendon of the big toe. Which artery is being assessed? a) Arterial arch of the foot b) Posterior tibial c) Dorsalis pedis d) Femoral e) Popliteal c) Dorsalis pedis The dorsalis pedis artery is usually palpable on the dorsum of the foot just lateral to the extensor tendon of the big toe. The arterial arch of the foot is more distal and runs transversely and is not usually palpable. The posterior tibial artery is found behind the medial malleolus of the ankle. The popliteal and femoral pulses are found more proximally at the knee and near the groin, respectively. A 61‐year‐old retired librarian was recently diagnosed with ovarian cancer. She was otherwise healthy until her recent cancer diagnosis. She has not been feeling well lately and has had a cough and some mild shortness of breath for the past couple of days. She now presents to the clinic complaining of pain and swelling in her right groin an