Chapters 1-4

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?

Validation

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?

"You seem bothered by this question."

For which of the following patients would a comprehensive health history be appropriate?

A new patient with the chief complaint of "I am here to establish care"

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?

Ask why Bill is not there.

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?

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.

The following information is best placed in which category? "The patient had a stent placed in the left anterior descending artery (LAD) in 1999."

Adult illnesses

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."

Adult illnesses

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?

Allergic

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?

Are you sexually active?

When you enter your patient's examination room, his wife is waiting there with him. Which of the following is most appropriate?

Ask if it's okay to carry out the visit with both people in the room.

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?

Associated manifestations

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?

Avoiding admission that you had a part in provoking her anger because you were late

The following information is recorded in the health history: "I feel really tired." Which category does it belong to?

Chief complaint

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?

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 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?

Calm

A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom?

Cardiac

A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough?A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough?

Cardiac

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?

Chest pain, headaches, arthritis, war injury pain

. 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?

Continue asking these questions in a more selective way.

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?

Continue using the test, perhaps doing less laboratory work and diagnostics.

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?

Personal and social history

A patient complains of knee pain on your arrival in the room. What should your first sentence be after greeting the patient?

Could you please describe what happened?

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?

Degenerative

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?

Discuss the plan with Mr. Larson.

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?

Facilitation

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?

Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan.

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?

Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion

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?

Inflammatory

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:

More than one disease process

A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to?

Musculoskeletal

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of the patient

Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and a pulse rate of 120.

Objective

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:

One disease process

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:

Pathophysiologic problem

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."

Present illness

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:

Psychopathologic problem

A patient is describing a very personal part of her history very quickly and in great detail. How should you react to this?

Push away from the keyboard or put down your pen and listen.

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?

Put her socks back on and cover her completely before beginning the evaluation.

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?

Reassuring the patient that the urinary symptoms are benign and that she doesn't need to worry about it being a sign of cancer

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?

Review of systems

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?

Severity

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?

Silent patient

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.

Subjective

The following information is best placed in which category? "The patient has had three cesarean sections."

Surgeries

The components of the health history include all of the following except which one?

Thorax and lungs

You are growing fatigued of performing a maneuver on examination because you have never found a positive and are usually pressed for time. How should you next approach this maneuver?

Use this test when you have a higher suspicion for a certain correlating condition.

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?

When was your last drink?

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?

You have created a hypothesis.

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?

•Increasing the patient's sense of control •Increasing the patient's trust in you as a caregiver •Decreasing her sense of vulnerability