Bate questions- Midterm to Final

An 85-year-old retired housewife comes with her daughter to establish care. Her daughter is concerned because her mother has started to fall more. As part of her physical examination, you ask her to walk across the examination room. Which of the following is not part of the stance phase of gait? A) Foot arched B) Heel strike C) Mid-stance D) Push-off

A) Foot arched Feedback: The foot when it is flat is part of the stance phase of gait, not the foot when it is arched.

Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass. Without any other information, what is the risk of this mass being cancerous? A) About 10% B) About 20% C) About 30% D) About 40%

A) About 10% Feedback: Eleven percent of women presenting with a breast mass will have breast cancer. This statistic can be reassuring to a patient, but the importance of further studies must be emphasized.

Pain, swelling, loss of both active and passive motion, locking, and deformity would be consistent with which of the following? A) Articular joint pain B) Bursitis C) Muscular injury D) Nerve damage

A) Articular joint pain Feedback: These features are consistent with articular joint pain, whereas the other problems are associated with extra-articular structures.

A 19-year-old female comes to your office, complaining of a clear discharge from her right breast for 2 months. She states that she noticed it when she and her boyfriend were "messing around" and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies using tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetric with no skin changes. You are able to express clear discharge from her right nipple. You feel no discrete masses and her axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative. What cause of nipple discharge is the most likely in her circumstance? A) Benign breast abnormality B) Breast cancer C) Nonpuerperal galactorrhea

A) Benign breast abnormality Feedback: Nipple discharge in benign breast abnormalities tends to be clear and unilateral. The discharge is usually not spontaneous. This patient needs to be told to stop compressing her nipple. If the problem still persists after the patient has stopped compressing the nipple, further workup is warranted.

A 63-year-old nurse comes to your office, upset because she has found an enlarged lymph node under her right arm. She states she found it last week while taking a shower. She isn't sure if she has any breast lumps because she doesn't know how to do self-exams. She states her last mammogram was 5 years ago and it was normal. Her past medical history is significant for high blood pressure and chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-packs/year history. She denies using any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and her father died of a stroke. She has no children. On examination you see an older female appearing her stated age. On visual inspection of her right axilla you see nothing unusual. Palpating this area, you feel a 2-cm hard, fixed lymph node. She denies any tenderness. Visualization of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On palpation of her right breast you feel a nontender 1-cm lump in the tail of Spence. What disorder of the axilla is most likely responsible for her symptoms? A) Breast cancer B) Lymphadenopathy of infectious origin C) Hidradenitis suppurativa

A) Breast cancer Feedback: Metastatic lymph nodes tend to be hard, nontender, and fixed, often to the rib cage. Although the patient has no family history of breast cancer, she is at a slightly increased risk due to her never having had children.

A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no diagnosis of breast cancer in his first-degree relatives. What is the most likely diagnosis? A) Breast tissue B) Fibrocystic disease C) Breast cancer D) Lymph node

A) Breast tissue Feedback: Approximately one third of adult men will have palpable breast tissue under the areola. While males can have breast cancer, this is much less common. There are no lymph nodes in this area.

You are conducting a mental status examination and note impairment of speech and judgement, but the rest of your examination is intact. Where is the most likely location of the problem? A) Cerebrum B) Cerebellum C) Brainstem D) Basal ganglia

A) Cerebrum Feedback: The cerebrum is responsible for higher cognitive functions such as speech and judgement.

You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward. This is most likely a problem with which part of the nervous system? A) Corticospinal tract B) Spinothalamic tract C) Thalamus D) Dorsal root ganglion

A) Corticospinal tract Feedback: This describes a pronator drift, which signifies decreased position sense involvement of the corticospinal tract. This tract does not travel through the thalamus. This is commonly tested as an early sign of stroke. This would not occur with a dorsal root ganglion problem.

A 40-year-old mother of two presents to your office for consultation. She is interested in knowing what her relative risks are for developing breast cancer. She is concerned because her sister had unilateral breast cancer 6 years ago at age 38. The patient reports on her history that she began having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco, alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable. Which risk factor of her personal and family history most puts her in danger of getting breast cancer? A) First-degree relative with premenopausal breast cancer B) Age at menarche of less than 12 C) First live birth between the ages of 25 and 29 D) First-degree relative with postmenopausal breast cancer

A) First-degree relative with premenopausal breast cancer Feedback: Having a first-degree relative with cancer before menopause gives a relative risk of 3.1.

When should a woman conduct breast self-examination with respect to her menses? A) Five to seven days following her menses B) Midcycle C) Immediately prior to menses D) During her menses

A) Five to seven days following her menses Feedback: The breast examination should be conducted during the time with the least estrogen stimulation of the breast tissue. This corresponds to five to seven days following menses.

22-year-old architecture major comes to your office, complaining of severe burning with urination, a fever of 101 degrees, and aching all over. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of severe acne. She is currently on an oral contraceptive. She has had no pregnancies or surgeries. She reports one new partner within the last month. She does not smoke but does drink occasionally. Her parents are both in good health. On examination you see a young woman appearing slightly ill. Her temperature is 100.3 and her pulse and blood pressure are unremarkable. Her head, ears, eyes, nose, throat, cardiac, pulmonary, and abdominal examinations are unremarkable. Palpation of the inguinal nodes shows lymphadenopathy bilaterally. On visualization of the perineum there are more than 10 shallow ulcers along each side of the vulva. Speculum and bimanual examination are unremarkable for findings, although she is very tender at the introitus. Urine analysis has some white blood cells but no red blood cells or bacteria. Her urine pregnancy test is negative. Which disorder of the vulva is most likely in this case? A) Genital herpes B) Condylomata acuminata C) Syphilitic chancre D) Epidermoid cyst

A) Genital herpes Feedback: Genital herpes consists of small, shallow, painful ulcers. Primary infections are often associated with fever, malaise, and regional lymphadenopathy. The outbreak occurs generally between 1 and 3 weeks after exposure. Herpes is contagious and the majority of transmission occurs without the presence of obvious lesions. Transmission during passage through the birth canal can cause serious illness in affected newborns.

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. These patients may also eat food on only one half of their plate. The other conditions would not account for this pattern.

. A 27-year-old woman is brought to your office by her mother. The mother tells you that her daughter has been schizophrenic for the last 8 years and is starting to decompensate despite medication. The patient states that she has been taking her antipsychotic and she is doing just fine. Her mother retorts that her daughter has become quite paranoid. When asked why, the mother gives an example about the mailman. She says that her daughter goes and gets the mail every day and then microwaves the letters. The patient agrees that she does this but only because she sees the mailman flipping through the envelopes and she knows he's putting anthrax on the letters. Her mother turns to her and says, "He's only sorting the mail!" Which best describes the patient's abnormality of perception? A) Illusion B) Hallucination C) Fugue state

A) Illusion An illusion is merely a misinterpretation of real external stimuli. In this case, the mailman is looking through the letters before he puts them in the box. The mother correctly assumes he is sorting the mail but her schizophrenic daughter attributes his actions to being part of a nefarious bioterrorism plot.

A patient comes to you because she is experiencing a tremor only when she reaches for things. This becomes worse as she nears the "target." When you ask her to hold out her hands, no tremor is apparent. What type of tremor does this most likely represent? A) Intention tremor B) Postural tremor C) Resting tremor D) Nervous tremor

A) Intention tremor Feedback: Because this tremor worsens as the target is approached, this represents an "intention" tremor. In this patient, one may suspect cerebellar pathway disease, possibly from multiple sclerosis (one could also look for an intranuclear ophthalmoplegia). A postural tremor occurs when a certain position is maintained, and resting tremors can occur in diseases such as Parkinson's. These do not occur during sleep.

Mrs. Fletcher complains of numbness of her right hand. On examination, sensation of the volar aspect of the web of the thumb and index finger and the pulp of the middle finger are normal. The pulp of the index finger has decreased sensation. Which of the following is affected? A) Median nerve B) Ulnar nerve C) Radial nerve

A) Median nerve Feedback: The pulp of the index finger is innervated by the median nerve. A decrease in sensation at this area would support a diagnosis of carpal tunnel syndrome. The pulp of the fifth finger is supplied by the ulnar nerve, and the dorsal web space of the thumb and index finger is supplied by the radial nerve.

A 56-year-old female comes to your clinic, complaining of her left breast looking unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-examinations, so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On examination you find a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels thickened. Lateral to the areola you palpate a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast and axilla examinations are unremarkable. What visible skin change of the breast does she have? A) Nipple retraction B) Paget's disease C) Peau d'orange sign

A) Nipple retraction Feedback: A retracted nipple is flattened or pulled inward or toward the medial, lateral, anterior, or posterior side of the breast. The surrounding skin can be thickened. This is a relatively late finding in breast cancer.

A 23-year-old waitress comes to your clinic complaining of severe pelvic pain radiating to her right side. The pain began yesterday and is getting much worse. She has had no burning with urination and denies any recent sexual activity. She has no nausea, vomiting, constipation, diarrhea, fever, or vaginal discharge. Her last period was 3 to 4 weeks ago. Her past medical history consists of severe acne, depression, and mild obesity. She has had no surgeries. She broke up with her boyfriend 6 months ago and denies dating anyone else. She smokes one pack of cigarettes a day, drinks three to four beers two to three times a week, and denies any illegal drug use. Her mother is diabetic and her father has coronary artery disease. On examination you see a mildly obese female in moderate distress. Her blood pressure is 130/80 and her pulse is 90. She is afebrile. On auscultation she has active bowel sounds. She has no rebound or guarding in any abdominal quadrant. Speculum examination shows no lesions on the cervix and no discharge or bleeding from the os. During the bimanual examination she has no cervical motion tenderness, but her right adnexal area is swollen and tender. A urine analysis is normal and the urine pregnancy test is pending. What disorder of the adnexa is most likely the diagnosis? A) Ovarian cyst B) Tubal pregnancy C) Pelvic inflammatory disease

A) Ovarian cyst Feedback: Ovarian cysts often occur just before the onset of menses. They are also common in a disease known as polycystic ovarian syndrome. Other symptoms of this disorder are acne, hirsutism (increased hair growth), irregular periods, obesity. This disorder runs in families and later manifestations include diabetes, high blood pressure, and coronary artery disease. Single cysts on the right side can mimic the symptoms of appendicitis.

A 41-year-old real estate agent comes to your office, complaining that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy and as the day progressed he was unable to close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. His past medical history is unremarkable. He is divorced and has one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination you ask him to close his eyes. He is unable to close his left eye. You ask him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. You then ask him to give you a big smile. The right corner of his mouth raises but the left side of his mouth remains the same. What type of facial paralysis does he have? A) Peripheral CN VII paralysis B) Central CN VII paralysis

A) Peripheral CN VII paralysis In a peripheral lesion the entire side of the face will be involved. This causes the inability to close the eye, raise the eyebrow, wrinkle the forehead, and smile on the affected side. Bell's palsy is an example of this type of paralysis and is probably what is affecting this patient.

A 17-year-old high school student is brought in to your emergency room in a comatose state. His friends have accompanied him and tell you that they have been shooting up heroin tonight and they think their friend may have had too much. The patient is unconscious and cannot protect his airway, so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. Preparing to finish the neurologic examination, you get a penlight. What size pupils do you expect to see in this comatose patient? A) Pinpoint pupils B) Large pupils C) Asymmetric pupils D) Irregularly shaped pupils

A) Pinpoint pupils Feedback: Narcotics and cholinergics cause very small (1 mm) pupils. Reactions to light can be appreciated with a magnifying glass.

A 77-year-old retired school superintendent comes to your office, complaining of unsteady hands. He says that for the past 6 months, when his hands are resting in his lap they shake uncontrollably. He says when he holds them out in front of his body the shaking diminishes, and when he uses his hands the shaking is also better. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for over 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister who has arthritis problems. His children are all essentially healthy. On examination you see a fine, pill-rolling tremor of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back toward you. He has almost no "arm swing" with his gait. What type of tremor is he most likely to have? A) Resting tremor B) Postural tremor C) Intention tremor

A) Resting tremor Resting tremors occur when the hands are literally at rest, such as sitting in the lap. These are slow, fine tremors, such as the pill-rolling seen in Parkinson's disease, which this patient most likely has. Decreased arm swing with ambulation is one of the earliest objective findings of Parkinson's disease.

A 38-year-old woman comes to you and has multiple small joints involved with pain, swelling, and stiffness. Which of the following is the most likely explanation? A) Rheumatoid arthritis B) Septic arthritis C) Gout D) Trauma

A) Rheumatoid arthritis Feedback: Rheumatoid arthritis is a systemic disease and accounts for multiple symmetrically involved joints. Septic arthritis is usually monoarticular, as are gout and trauma-related joint pain.

A 68-year-old retired banker comes to your clinic for evaluation of left shoulder pain. He swims for 30 minutes daily, early in the morning. He notes a sharp, catching pain and a sensation of something grating when he tries overhead movements of his arm. On physical examination, you note tenderness just below the tip of the acromion in the area of the tendon insertions. The drop arm test is negative, and there is no limitation with shoulder shrug. The patient is not holding his arm close to his side, and there is no tenderness to palpation in the bicipital groove when the arm is at the patient's side, flexed to 90 degrees, and then supinated against resistance. Based on this description, what is the most likely cause of his shoulder pain? A) Rotator cuff tendinitis B) Rotator cuff tear C) Calcific tendinitis D) Bicipital tendinitis

A) Rotator cuff tendinitis Feedback: Rotator cuff tendinitis is typically precipitated by repetitive motions, such as occurs with throwing or swimming. Crepitus/grating is noted in the shoulder with range of motion.

You are assessing a patient with joint pain and are trying to decide whether it is inflammatory or noninflammatory in nature. Which one of the following symptoms is consistent with an inflammatory process? A) Tenderness B) Cool temperature C) Ecchymosis D) Nodules

A) Tenderness Feedback: Tenderness implies an inflammatory process along with increased temperature and tenderness.

Louise, a 60-year-old, complains of left knee pain associated with tenderness throughout, redness, and warmth over the joint. Which of the following is least helpful in determining if a joint problem is inflammatory? A) Tenderness B) Pain C) Warmth D) Redness

B) Pain Feedback: Pain is present in both inflammatory and noninflammatory conditions. Warmth, redness, and tenderness to palpation should lead one to consider an inflammatory etiology for the pain.

A patient with a history of seizure disorder and on several seizure medications says a friend noted "jumping eye movements." The patient describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago. On examination you note that the eyes both slowly move to the right and then quickly jump to the left. Which of the following is true? A) This is called nystagmus to the left B) This is called saccadic eye movement C) This represents a subclinical seizure D) This most likely has an ominous cause

A) This is called nystagmus to the left Feedback: Nystagmus is named for the fast component, in this case, toward the left. Nystagmus is common with several seizure medications and in this case is likely due to the recent increase in medications rather than a more ominous cause. Saccadic eye movements are similar to nystagmus but represent fixations on apparently moving objects, like watching roadside trees from a moving vehicle. A subclinical seizure with bilateral findings and no effect on consciousness would be unusual.

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.

A high school football player injured his wrist in a game. He is tender between the two tendons at the base of the thumb. Which of the following should be considered? A) DeQuervain's tenosynovitis B) Scaphoid fracture C) Wrist sprain D) Rheumatoid arthritis

B) Scaphoid fracture Feedback: The "anatomic snuffbox" is found between the extensor and abductor tendons at the base of the thumb. Tenderness should make one think of a scaphoid fracture. Not only is this the most common carpal bone injury, but the poor blood supply puts the bone at risk for avascular necrosis when injured. This fracture is commonly missed on x-ray, so this is an important physical finding to support further or repeated studies.

A man's wife is upset because when she hugs him with her hands on his left shoulder blade, "it feels creepy." This came on gradually after a recent severe left-sided rotator cuff tear. How long does it usually take to develop muscular atrophy with increased prominence of the scapular spine following a rotator cuff tear? A) 1 week B) 2-3 weeks C) 1 month D) 2-3 months

B) 2-3 weeks Feedback: Prominence of the scapular spine occurs with generalized muscle wasting as well as with specific injuries such as a rotator cuff tear. It is easily palpable, even through indoor clothing, although the back should be exposed to make other important observations. Atrophy usually occurs several weeks following a rotator cuff tear.

A 51-year-old cook comes to your office for consultation. She recently found out that her 44-year-old sister with premenopausal breast cancer is positive for the BRCA1 gene. Your patient has been doing research on the Internet and saw that her chance of having also inherited the BRCA1 gene is 50%. She is interested in knowing what her risk of developing breast cancer would be if she were positive for the gene. She denies any lumps in her breasts and has had normal mammograms. She has had no weight loss, fever, or night sweats. Her mother is healthy and her father has prostate cancer. Two of her paternal aunts died of breast cancer. She is married. She denies using tobacco or illegal drugs and rarely drinks alcohol. Her breast and axilla examinations are unremarkable. At her age, what is her risk of getting breast cancer if she has the BRCA1 gene? A) 10% B) 50% C) 80%

B) 50% Feedback: At the age of 50, the risk of breast cancer for someone with the BRCA1 gene is 50%.

A 23-year-old computer programmer comes to your office for an annual examination. She has recently become sexually active and wants to be placed on birth control. Her only complaint is that the skin in her armpits has become darker. She states it looks like dirt, and she scrubs her skin nightly with soap and water but the color stays. Her past medical symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high blood pressure. The patient denies using tobacco but has four to five drinks on Friday and Saturday nights. She denies any illegal drug use. On examination you see a mildly obese female who is breathing comfortably. Her vital signs are unremarkable. Looking under her axilla, you see dark, velvet-like skin. Her annual examination is otherwise unremarkable. What disorder of the breast or axilla is she most likely to have? A) Peau d'orange B) Acanthosis nigricans C) Hidradenitis suppurativa

B) Acanthosis nigricans Feedback: Acanthosis nigricans can be associated with an internal malignancy, but in most cases it is a benign dermatologic condition associated with polycystic ovarian syndrome, consisting of acne, hirsutism, obesity, irregular periods, infertility, ovarian cysts, and early onset type 2 diabetes. It is also known to correlate with insulin resistance.

A 72-year-old retired saleswoman comes to your office, complaining of a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The patient denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetric, with no skin changes. You are able to express bloody discharge from her left nipple. You feel no discrete masses, but her left axilla has a hard, 1-cm fixed node. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. What cause of nipple discharge is the most likely in her circumstance? A) Benign breast abnormality B) Breast cancer C) Galactorrhea

B) Breast cancer Feedback: Nipple discharge in breast cancer is usually unilateral and can be clear or bloody. Although a breast mass is not palpated, in this case a fixed lymph node is palpated. Other forms of breast cancer can present as a chronic rash on the breast.

A 72-year-old African-American male is brought to your clinic by his daughter for a follow-up visit after his recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke. The patient was in rehab for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with the patient. You ask the patient how he thinks he is doing. Although it is hard for you to make out his words you believe his answer is "well . . . fine . . . doing . . . okay." His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. His blood pressure is 150/90 and his other vital signs are normal. Other than his weak right arm and leg his physical examination is unremarkable. What disorder of speech does he have? A) Wernicke's aphasia B) Broca's aphasia C) Dysarthria

B) Broca's aphasia In Broca's aphasia patients articulate very slowly and with a great deal of effort. Nouns, verbs, and important adjectives are usually present and only small grammatical words are dropped from speech. Broca's area is on the lateral portion of the frontal lobes.

A 48-year-old high school librarian comes to your clinic, complaining of 1 week of heavy discharge causing severe itching. She is not presently sexually active and has had no burning with urination. The symptoms started several days after her last period. She just finished a course of antibiotics for a sinus infection. Her past medical history consists of type 2 diabetes and high blood pressure. She is widowed and has three children. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died of diabetes complications. On examination you see a healthy-appearing woman. Her blood pressure is 130/80 and her pulse is 70. Her head, eyes, ears, nose, throat, cardiac, lung, and abdominal examinations are unremarkable. Palpation of the inguinal lymph nodes is unremarkable. On visualization of the vulva, a thick, white, curdy discharge is seen at the introitus. On speculum examination there is a copious amount of this discharge. The pH of the discharge is 4.1 and the KOH whiff test is negative, with no unusual smell. Wet prep shows budding hyphae. What vaginitis does this patient most likely have? A) Trichomonas vaginitis B) Candida vaginitis C) Bacterial vaginosis D) Atrophic vaginitis

B) Candida vaginitis Feedback: Candida is associated with a thick, white, curd-like discharge that causes severe pruritus. The pH will be normal (≤4.5) and the KOH whiff test will be normal. The wet prep often shows yeast spores and budding hyphae. Candida is very common in diabetics and after recent use of antibiotics. It is not thought to be sexually transmitted.

Mark is a contractor who recently injured his back. He was told he had a "bulging disc" to account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the spine involve which type of joint? A) Synovial B) Cartilaginous C) Fibrous D) Synostosis

B) Cartilaginous Feedback: The vertebral bodies of the spine are connected by cartilaginous joints involving the discs. The elbow would be an example of a synovial joint, and the sutures of the skull are an example of a fibrous joint.

You are examining a child with severe cerebral palsy. When you suddenly move his foot dorsally, a sustained "beating" of the foot against your hand ensues. What does this represent? A) A focal seizure B) Clonus C) Extinction D) Reinforcement

B) Clonus Feedback: Clonus is a sustained rhythmic "beating" which correlates with CNS disease and hyperreflexia. A focal seizure could be virtually ruled out by stopping the stimulus and watching the phenomenon stop. Extinction is a term applied to sensory testing where one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex. Reinforcement applies to enhancing reflex examination by distracting the patient, for example, by pulling his hands against each other.

A 37-year-old woman is brought into your emergency room comatose. The paramedics say her husband found her unconscious in her home. Her past medical history consists of type 1 diabetes and she is on insulin. In the ambulance the paramedics obtained a glucose check and her sugar was 15 (normal is 70 to 105). They began a dextrose saline infusion and intubated her to protect her airway. Despite their efforts, she is posturing in the emergency room with her arms straight at her side and her jaw clenched. Her legs are also straight and her feet are plantar flexed. What type of posturing is she showing? A) Decorticate rigidity B) Decerebrate rigidity C) Hemiplegia D) Chorea

B) Decerebrate rigidity In this type of rigidity the jaws are clenched and the neck is extended. The arms are adducted and stiffly extended at the elbows with forearms pronated and wrists and fingers flexed. The legs are stiffly extended at the knees with the feet plantar flexed. This posture occurs with lesions in the diencephalon, midbrain, or pons. It can also be seen with severe metabolic disorder such as hypoxia or hypoglycemia, as in this case.

A 35-year-old stockbroker comes to your office, complaining of feeling tired and irritable. She also says she feels like nothing ever goes her way and that nothing good ever happens. When you ask her how long she has felt this way she laughs and says, "Since when have I not?" She relates that she has felt pessimistic about life in general since she was in high school. She denies any problems with sleep, appetite, or concentration, and states she hasn't thought about killing herself. She reports no recent illnesses or injuries. She is single. She smokes one pack of cigarettes a day, drinks occasionally, and hasn't taken any illegal drugs since college. Her mother suffers from depression and her father has high blood pressure. On examination her vital signs and physical examination are unremarkable. What mental health disorder best describes her symptoms? A) Major depressive episode B) Dysthymic disorder C) Cyclothymic disorder

B) Dysthymic disorder Someone with dysthymia has a depressed mood and symptoms for most of the day, more days than not, for at least 2 years. The disorder generally begins in adolescence and is fairly stable throughout life. Although the symptoms are similar to those of major depression (in this case, fatigue and irritability), they are milder and fewer.

Ray works a physical job and notes pain when he attempts to lift his arm over his head. When you move the shoulder passively, he has full range of motion without pain and there is no gross swelling or tenderness. What type of joint disease does this most likely represent? A) Articular B) Extra-articular C) Neither D) Both

B) Extra-articular Feedback: This description fits extra-articular disease. Articular disease typically involves swelling and tenderness of the entire joint and limits both active and passive range of motion. This is most likely extra-articular because it affects a certain portion of the range of motion, is not painful with passive range of motion, and is not associated with gross swelling or tenderness

29-year-old woman comes to your office. As you take the history, you notice that she is speaking very quickly, and jumping from topic to topic so rapidly that you have trouble following her. You are able to find some connections between ideas, but it is difficult. Which word describes this thought process? A) Derailment B) Flight of ideas C) Circumstantiality D) Incoherence

B) Flight of ideas This represents flight of ideas because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses. Circumstantiality is characterized by the patient speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use. Although severe flight of ideas can produce this condition, evidence is not present in this vignette.

A 7-year-old child is brought to your clinic by her mother. The mother states that her daughter is doing poorly in school because she has some kind of "ADD" (attention deficit disorder). You ask the mother what makes her think the child has ADD. The mother tells you that both at home and at school her daughter will just zone out for several seconds and lick her lips. She states it happens at least four to six times an hour. She says this has been happening for about a year. After several seconds of lip-licking her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The patient's parents are both healthy and no other family members have had these symptoms. What type of seizure disorder is she most likely to have? A) Generalized tonic-clonic seizure B) Generalized absence seizure C) Simple partial seizure (Jacksonian) D) Complex partial seizure

B) Generalized absence seizure In an absence seizure there is no tonic-clonic activity. There is a sudden, brief lapse of consciousness with blinking, staring, lip-smacking, or hand movements that resolve quickly to full consciousness. It is easily mistaken for daydreaming or ADD. Some will try to induce these episodes with hyperventilation.

order. The patient was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and you need to raise it. He states that his son has been hearing things that don't exist. You ask the young man what is going on and he tells you that his father is just jealous because his sister talks only to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this patient's abnormality of perception? A) Illusion B) Hallucination C) Fugue state

B) Hallucination A hallucination is a subjective sensory perception in the absence of real external stimuli. The patient can hear, see, smell, taste, or feel something that does not exist in reality. In this case, his sister has passed away and cannot be speaking to him, although in his mind he can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.

You are testing the biceps strength in a young man following a spinal trauma from a motor vehicle accident. He cannot lift his hand upward, but if the arm is abducted to 90 degrees, he can then move his forearm side to side. This would represent which muscle strength grading? A) I B) II C) III D) IV

B) II Feedback: The ability to move an extremity, but not against gravity, represents a strength of 2 out of 5. Zero represents no muscular contraction detected (not even a "flicker"); one represents a contraction but no movement of the extremity; three means that the extremity can move against gravity but not against resistance; four means perceived weakness but the patient can oppose some resistance; and five is normal.

A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. On examination you see a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test. What is the most likely cause of his gynecomastia? A) Breast cancer B) Imbalance of hormones of puberty C) Drug use

B) Imbalance of hormones of puberty Feedback: Approximately one third of teenage boys develop gynecomastia during puberty. It is not surprising that the two older brothers did not have this.

A 43-year-old store clerk comes to your office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago), and until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The patient does not smoke, drink, or use illegal drugs. Her father is in good health. On examination you see a tense female appearing her stated age. On visual inspection of her left axilla you see a tense red area. There is no scarring around the axilla. Palpating this area, you feel a 2-cm tender, movable lymph node underlying hot skin. Other shotty nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examining her left arm, you see a scabbed-over superficial laceration over her left hand. Upon your questioning, she remembers she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms? A) Breast cancer B) Lymphadenopathy of infectious origin C) Hidradenitis suppurativa

B) Lymphadenopathy of infectious origin Feedback: A lymph node enlarged because of infection is generally hot, tender, and red. Close examination of the skin that drains to that lymph node region is advised. Often there will be a cut or scratch over the involved arm that has an infectious agent. An example is cat scratch disease.

8. A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. He says that she hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up over $1,000 on their credit cards. While he is talking, the patient interrupts him frequently and declares this is all untrue and she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview you find out she has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy but the husband has heard rumors about an aunt with similar symptoms. She and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain-smoking in the last 2 weeks), drinks four to six drinks a week, and smokes marijuana occasionally. On examination she is very loud and outspoken. Her physical examination is unremarkable. Which mood disorder does she most likely have? A) Major depressive episode B) Manic episode C) Dysthymic disorder

B) Manic episode Mania consists of a persistently elevated mood for at least 1 week with symptoms such as inflated self-esteem, decreased need for sleep, pressured speech, racing thoughts, and involvement in high-risk activities (such as drug use, spending sprees, and indiscriminate sexual activity). In this case, the patient has racing thoughts and pressured speech, has a decreased need for sleep, and is engaging in high-risk activities (spending sprees).

A patient with alcoholism is brought in with confusion. You ask him to "stop traffic" with his palms and notice that every few seconds his palms suddenly move toward the floor. What does this indicate? A) Stroke B) Metabolic problems C) Carpal tunnel syndrome D) Severe fatigue and weakness

B) Metabolic problems Feedback: This is asterixis and represents the inability to maintain a sustained contraction of the muscles. It is usually due to various metabolic diseases. A variant of this is called "milkmaid's grip" in which the patient is asked to grasp two fingers. A positive occurs if the patient is unable to sustain the grip and it feels as if the patient is trying to milk a cow. Most would consider checking an ammonia level in this patient. A stroke is less likely to produce bilateral symptoms. Carpal tunnel represents a sensory loss in the median nerve distribution.

You examine a "sleepy" patient. You note that she will open her eyes and look at you but responds slowly and is confused. She does not appear interested in her surroundings. How would you describe her level of consciousness? A) Lethargic B) Obtunded C) Stuporous D) Comatose

B) Obtunded Feedback: An obtunded patient is responsive but slow speaking and is less interested in her surroundings. A patient with lethargy opens her eyes to verbal cues and may respond appropriately but promptly falls back to sleep. The stuporous patient responds only to painful stimuli, and when the stimulus is withdrawn lapses into unconsciousness again. Such patients have little awareness of self or the environment. The comatose patient has no obvious response to external stimuli.

Which of the following is most likely benign on breast examination? A) Dimpling of the skin resembling that of an orange B) One breast larger than the other C) One nipple inverted D) One breast with dimple when the patient leans forward

B) One breast larger than the other Feedback: Asymmetry in size of the breasts is a common benign finding. The others are concerning for underlying malignancy.

A 44-year-old female comes to your clinic, complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. On examination you find a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath you palpate a nontender 2-cm mass. The axilla contains only soft, moveable nodes. The left breast and axilla examination findings are unremarkable. What visible skin change of the breast does she have? A) Nipple retraction B) Paget's disease C) Peau d'orange sign

B) Paget's disease Feedback: This uncommon form of breast cancer starts as an eczema-like, scaly skin change around the areola. The lesion may weep, crust, or erode. It can be associated with an underlying mass, but the skin change can also be found alone. Any eczema-like area around the nipple that does not respond to topical treatment needs to be evaluated for breast cancer.

A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a set of boxes that were heavier than usual. He also states that he has numbness and tingling in the left leg. He wants to know if he needs to be off of work. What test should you perform to assess for a herniated disc? A) Leg-length test B) Straight-leg raise C) Tinel's test D) Phalen's test

B) Straight-leg raise Feedback: The straight-leg raise involves having the patient lie supine with the examiner raising the leg. If the patient experiences a sharp pain radiating from the back down the leg in an L5 or S1 distribution, that suggests the presence of a herniated disc.

Mrs. Fletcher comes to your office with unilateral pain during chewing, which is chronic. She does not have facial tenderness or tenderness of the scalp. Which of the following is the most likely cause of her pain? A) Trigeminal neuralgia B) Temporomandibular joint syndrome C) Temporal arteritis D) Tumor of the mandible

B) Temporomandibular joint syndrome Feedback: Temporomandibular joint syndrome is a very common cause of pain with chewing. Ischemic pain with chewing, or jaw claudication, can occur with temporal arteritis, but the lack of tenderness of the scalp overlying the artery makes this less likely. Trigeminal neuralgia can be associated with extreme tenderness over the branches of the trigeminal nerve. While a tumor of the mandible is possible, is it much less likely than the other choices.

Which is true of women who have had a unilateral mastectomy? A) They no longer require breast examination. B) They should be examined carefully along the surgical scar for masses. C) Lymphedema of the ipsilateral arm usually suggests recurrence of breast cancer. D) Women with breast reconstruction over their mastectomy site no longer require examination.

B) They should be examined carefully along the surgical scar for masses. Feedback: A woman who has had breast cancer remains at high risk for recurrence, especially in the contralateral breast. The mastectomy site should be carefully examined for local recurrence as well. Lymphedema or swelling of the ipsilateral arm following mastectomy is common and does not usually indicate recurrence. Women with breast reconstruction must also undergo careful examination.

A 34-year-old married daycare worker comes to your office, complaining of severe pelvic pain for the last 6 hours. She states that the pain was at first cramp-like but is now sharp. Nothing makes the pain better or worse. She has had no vaginal bleeding or discharge. She has had no pain with urination. She has had some nausea for the last few days but denies vomiting, constipation, or diarrhea. She states she feels so bad that when she stands up she has fainted. Her past medical history consists of two prior cesarean sections and an appendectomy. She is married and has two children. She denies any tobacco, alcohol, or drug use. Her parents are both healthy. On examination you find a pale young woman who is obviously in a great deal of pain. She is lying on her right side with her eyes closed. Her blood pressure is 90/60 and her pulse is 110. She is afebrile. She has bowel sounds and her abdomen is soft. The speculum examination reveals a bluish cervix but no blood or purulent discharge at the os. There is a mild amount of tenderness with palpation of the cervix. The uterus is nongravid but the right adnexal area is swollen and very tender. Urine analysis is normal and the urine pregnancy test is pending. What type of adnexal disorder is causing her pain? A) Ovarian cysts B) Tubal pregnancy C) Pelvic inflammatory disease

B) Tubal pregnancy Feedback: Tubal pregnancies start to cause pain as the fetus grows too large to be contained in the tube. Eventually the tube begins to rupture and bleeding ensues, leading to hypotension, tachycardia, and syncope. On visualization of the cervix, the purple to bluish color of pregnancy may be seen.

Which of the following is true regarding breast self-examination? A) It has been shown to reduce mortality from breast cancer. B) It is recommended unanimously by organizations making screening recommendations. C) A high proportion of breast masses are detected by breast self-examination. D) The undue fear caused by finding a mass justifies omitting instruction in breast self-examination.

C) A high proportion of breast masses are detected by breast self-examination. Feedback: Although self-examination has not been shown to reduce mortality and is not recommended by all groups making screening recommendations, many choose to teach women a systematic method in which to examine their breasts. A high proportion of breast masses are detected by breast self-examination.

A young woman comes in today, complaining of fatigue, irregular menses, and polyuria which have gradually increased over the past few months. Which eye findings would be consistent with her condition? A) An upper quadrantanopsia B) A lower quadrantanopsia C) A bitemporal hemianopsia D) An increased cup-to-disc ratio

C) A bitemporal hemianopsia Feedback: These symptoms are consistent with a pituitary lesion. Enlargement of a tumor in this area would compress the fibers responsible for the lateral visual fields. A quadrantanopsia would usually be caused by a lesion in the optic radiations in the parietal lobe of the cerebrum. Glaucoma would cause a narrowing of the entire visual field, not just the lateral aspects.

Which is true of examination of the olfactory nerve? A) It is not tested for laterality. B) The smell must be identified to declare a normal response. C) Abnormal responses may be seen in otherwise normal elderly. D) Allergies are unrelated to testing of this nerve.

C) Abnormal responses may be seen in otherwise normal elderly. Feedback: Abnormal olfactory nerve examination findings may be seen in otherwise normal elderly but may also be associated with other conditions such as Parkinson's disease. You should try to determine if only one side is abnormal by occluding the contralateral nostril. The smell must only be detected, not identified by name, to indicate a normal examination. If nasal occlusion occurs for other reasons, such a allergic rhinitis or anatomic abnormalities, the nerve cannot be tested and may seem to be abnormal for unrelated reasons.

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type? A) Pseudoseizure B) Tonic-clonic seizure C) Absence D) Myoclonus

C) Absence Feedback: This is a common description and scenario for absence seizures. These are generally brief (less than 10 seconds, "petit mal"). These generally occur without warning and generally do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic-clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs.

Phil comes to your office with left "shoulder pain." You find that the pain is markedly worse when his left arm is drawn across his chest (adduction). Which of the following would you suspect? A) Rotator cuff tear B) Subacromial bursitis C) Acromioclavicular joint involvement D) Adhesive capsulitis

C) Acromioclavicular joint involvement Feedback: Adduction of the patient's arm across his chest can cause pain if the acromioclavicular joint is involved. In adhesive capsulitis, this maneuver may not be possible due to limited range of motion. Subacromial bursitis would present with tenderness inferior to the acromion. Rotator cuff injury would ordinarily not be associated with pain during this maneuver.

A 30-year-old paralegal analyst comes to your clinic, complaining of a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. She tried douching but it did not help. She has had no pain with urination or with sexual intercourse. She has noticed the smell increased after intercourse and during her period last week. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of one spontaneous vaginal delivery. She is married and has one child. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died from a heart disease. On examination she appears healthy and has unremarkable vital signs. On examination of the perineum there are no lesions noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5 and there is a fishy odor when potassium hydroxide (KOH) is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells). What type of vaginitis best describes her findings? A) Trichomonas vaginitis B) Candida vaginitis C) Bacterial vaginosis D) Atrophic vaginitis

C) Bacterial vaginosis Feedback: Bacterial vaginosis generally has a homogenous, grayish-white, thin discharge. The pH will be over 4.5 and the KOH wet prep releases a strong fishy odor, known as a "positive whiff test." Any basic pH fluid (semen or blood) will cause the fish-like odor to occur, often after intercourse, as with this patient. The wet prep will show clue cells, which are epithelial cells with borders stippled by bacteria.

Marion presents to your office with back pain associated with constipation and urinary retention. Which of the following is most likely? A) Sciatica B) Epidural abscess C) Cauda equina D) Idiopathic low back pain

C) Cauda equina Feedback: The presence of bowel and bladder symptoms associated with back pain is worrisome and should suggest impingement of nerve roots S2-S4. For this reason idiopathic low back pain is unlikely. Epidural abscess may present with midline pain which can be increased with percussion over the spinous processes. Sciatica is associated with pain which radiates into the buttocks and/or down the posterior leg in the S1 distribution.

A 28-year-old married clothing sales clerk comes to your clinic for her annual examination. She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal deliveries. Her past six Pap smears have all been normal. She is married and has two children. Her mother is in good health and her father has high blood pressure. On examination you see a young woman appearing healthy and relaxed. Her vital signs are unremarkable and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness and both ovaries are palpated and nontender. What is the most likely diagnosis for the abnormality of her cervix? A) Carcinoma of the cervix B) Mucopurulent cervicitis C) Cervical polyp D) Retention cyst

C) Cervical polyp Feedback: Cervical polyps are polyps of endometrial cells arising from either the uterus or the cervix. They are benign and usually painless but can bleed during intercourse.

A 50-year-old realtor comes to your office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she didn't think that she needed to go to the emergency room at that time. Now, she has severe pain and stiffness in her neck. On physical examination, you note pain and spasm over the paraspinous muscles on the left side of the neck, and pain when you make the patient do active range of motion of the cervical spine. What is the most likely cause of this neck pain? A) Simple stiff neck B) Aching neck C) Cervical sprain D) Cervical herniated disc

C) Cervical sprain Feedback: The patient most likely has an acute whiplash injury secondary to the collision. The features of the physical examination, local tenderness and pain on movement, are consistent with cervical sprain.

How often, according to American Cancer Society recommendations, should a woman undergo a screening breast examination by a skilled clinician? A) Every year B) Every 2 years C) Every 3 years D) Every 4 years

C) Every 3 years Feedback: The current recommendation for screening by breast examination is every 3 years.

Which is the most effective pattern of palpation for breast cancer? A) Beginning at the nipple, make an ever-enlarging spiral. B) Divide the breast into quadrants and inspect each systematically. C) Examine in lines resembling the back and forth pattern of mowing a lawn. D) Beginning at the nipple, palpate outward in a stripe pattern.

C) Examine in lines resembling the back and forth pattern of mowing a lawn. Feedback: The vertical strip pattern has been shown to be the most effective pattern for palpation of the breast. The most important aspect, however, is to be systematic. The tail of Spence, located on the upper anterior chest, is an area commonly missed on examination.

A 28-year-old graduate student comes to your clinic for evaluation of pain "all over." With further questioning, she is able to relate that the pain is worse in the neck, shoulders, hands, low back, and knees. She denies swelling in her joints; she states that the pain is worse in the morning; there is no limitation in her range of motion. On physical examination, she has several points on the muscles of the neck, shoulders, and back that are tender to palpation; muscle strength and range of motion are normal. Which of the following is likely the cause of her pain? A) Rheumatoid arthritis B) Osteoarthritis C) Fibromyalgia D) Polymyalgia rheumatica

C) Fibromyalgia Feedback: The patient has pain in specific trigger point areas on the muscles, with normal strength and range of motion. This is an indication for fibromyalgia.

A young woman comes to you with a cut on her finger caused by the lid of a can she was opening. She is pacing about the room, crying loudly, and through her sobs she says, "My career as a pianist is finished!" Which personality type exhibits these features? A) Narcissistic B) Paranoid C) Histrionic D) Avoidant

C) Histrionic The theatrical nature of her behavior as well as her overreaction lead to a diagnosis of histrionic character disorder.

Jim is an HIV-positive patient who complains about back pain in addition to several other problems. On percussion, there is slight tenderness over the T7 vertebrae, and when you flex his thigh to 90 degrees and extend his lower legs, you meet strong resistance at about 45 degrees of extension. What are likely causes of this constellation of symptoms? A) Fractured vertebrae B) Malingering C) Infection D) Medication side effect

C) Infection Feedback: This represents Kernig's sign. When present bilaterally it often indicates meningeal irritation. (Kernig was a physician in eastern Europe and treated many children with tuberculous meningitis.) It is useful in cases when there has been chronic inflammation of the meninges, as seen in TB and cryptococcal disease. There was no trauma reported, and these signs are too important to ascribe them to malingering. Such localized physical findings are unlikely to be caused by medication side effects.

In obtaining a history, you note that a patient uses the word "largely" repeatedly, to the point of being a distraction to your task. Which word best describes this speech pattern? A) Clanging B) Echolalia C) Confabulation D) Perseveration

D) Perseveration Perseveration is the repetition of words or ideas. Echolalia differs in that the patient repeats what is said to him. Clanging is the repetition of the same sounds in different words. Confabulation is making up a story in response to a question. This is sometimes seen in chronic alcohol use with Korsakoff's syndrome.

A 37-year-old insurance agent comes to your office, complaining of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn't feel particularly nervous when this occurs but she worries that other people will think she has an anxiety disorder or that she's a drinker. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married and has three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form she has obvious tremors in her dominant hand. What type of tremor is she most likely to have? A) Resting tremor B) Postural tremor C) Intention tremor

C) Intention tremor Intention tremors are absent at rest or in a postural position and occur only with intentional movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) or in multiple sclerosis. This patient's tremor, fatigue, bladder problems, and visual problems are suggestive of multiple sclerosis.

Two weeks ago, Mary started a job which requires carrying 40-pound buckets. She presents with elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor. What condition does she have? A) Medial epicondylitis (golfer's elbow) B) Olecranon bursitis C) Lateral epicondylitis (tennis elbow) D) Supracondylar fracture

C) Lateral epicondylitis (tennis elbow) Feedback: Mary's injury probably occurred by lifting heavy buckets with her palms down (toward the bucket). This caused her chronic overuse injury at the lateral epicondyle. Medial epicondylitis has reproducible pain when palmar flexion against resistance is performed and also features tenderness over the involved epicondyle. Olecranon bursitis produces erythema and swelling over the olecranon process. A supracondylar fracture of the humerus is a major injury and would present more acutely.

You are assessing a patient with diffuse joint pains and want to make sure that only the joints are the problem, and that the pain is not related to other diseases. Which of the following is a systemic cause of joint pain? A) Gout B) Osteoarthritis C) Lupus D) Spondylosis

C) Lupus Feedback: Lupus is a systemic disease, one symptom of which may be joint pain. It is important to consider the presence of a systemic illness when a patient presents with arthritis.

4. A 32-year-old white female comes to your clinic, complaining of overwhelming sadness. She says for the past 2 months she has had crying episodes, difficulty sleeping, and problems with overeating. She says she used to go out with her friends from work but now she just wants to go home and be by herself. She also thinks that her work productivity has been dropping because she just is too tired to care or concentrate. She denies any feelings of guilt or any suicidal ideation. She states that she has never felt this way in the past. She denies any recent illness or injuries. Her past medical history consists of an appendectomy when she was a teenager; otherwise, she has been healthy. She is single and works as a clerk in a medical office. She denies tobacco, alcohol, or illegal drug use. Her mother has high blood pressure and her father has had a history of mental illness. On examination you see a woman appearing her stated age who seems quite sad. Her facial expression does not change while you talk to her and she makes little eye contact. She speaks so softly you cannot always understand her. Her thought processes and content seem unremarkable. What type of mood disorder do you think she has? A) Dysthymic disorder B) Manic (bipolar) disorder C) Major depressive episode

C) Major depressive episode Major depression occurs in a person with a previously normal state of mood. The symptoms often consist of a combination of sadness, decreased interest, sleeping problems (insomnia or hypersomnia), eating problems (decreased or increased appetite), feelings of guilt, decreased energy, decreased concentration, psychomotor changes (retardation or agitation), and a preoccupation with thoughts of death or suicide. There must be at least five symptoms for a diagnosis of major depression. This patient has six: (1) sadness, (2) trouble sleeping, (3) overeating, (4) fatigue, (5) difficulty with concentration, and (6) no interest in doing things.

A 33-year-old construction worker comes for evaluation and treatment of acute onset of low back pain. He notes that the pain is an aching located in the lumbosacral area. It has been present intermittently for several years; there is no known trauma or injury. He points to the left lower back. The pain does not radiate and there is no numbness or tingling in the legs or incontinence. He was moving furniture for a friend over the weekend. On physical examination, you note muscle spasm, with normal deep tendon reflexes and muscle strength. What is the most likely cause of this patient's low back pain? A) Herniated disc B) Compression fracture C) Mechanical low back pain D) Ankylosing spondylitis

C) Mechanical low back pain Feedback: The case is an example of mechanical low back pain; in a large percentage of cases there is no known underlying cause. The pain is often precipitated by moving, lifting, or twisting motions and relieved by rest.

An 18-year-old college freshman comes to your clinic, complaining of severe left-sided lower abdominal pain and a foul yellow discharge. The pain began last night while she was having intercourse with her boyfriend. Afterward the pain became more severe and the discharge started. By this morning she had a fever of 101 degrees and walking was making the pain worse. Only lying very still makes the pain better. She has tried ibuprofen and acetaminophen without any improvement. She denies any nausea, vomiting, diarrhea, or constipation. Her past medical history is unremarkable. She has had two past sexual partners. She uses the birth control patch instead of condoms. She smokes a half pack of cigarettes a day and drinks four to five beers per weekend night. She denies any illegal drug use. Her parents are both healthy. On examination you find a young woman who appears ill. Her temperature is 102 degrees and her pulse is elevated at 110. She is tender in the left lower quadrant but has no guarding or rebound. Speculum examination reveals yellow purulent drainage from the os. On palpation there is cervical motion tenderness and the left adnexa is swollen and tender. A urine analysis is unremarkable and the urine pregnancy test is pending. What is the best choice of diagnosis for this adnexal swelling? A) Ovarian cyst B) Tubal pregnancy C) Pelvic inflammatory disease

C) Pelvic inflammatory disease Feedback: PID is common in young sexually active woman and is usually caused by bacteria that have been sexually transmitted. It is often associated with fever, pelvic pain, and a purulent cervical discharge. On examination there is often cervical motion tenderness and adnexal swelling and pain. A purulent discharge is often seen in the cervical os. Causes of cervical infection are gonorrhea, Chlamydia, and sometimes herpes. This woman should be made aware that barrier methods of contraception may prevent transmission of these diseases, whereas the contraceptive patch or pill will not. It would be prudent to consider further history and screening for HIV in this patient.

A 60-year-old retired seamstress comes to your office, complaining of decreased sensation in her hands and feet. She states that she began to have the problems in her feet a year ago but now it has started in her hands also. She also complains of some weakness in her grip. She has had no recent illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children. Her mother has Alzheimer's disease and coronary artery disease. Her father died of a stroke and also had diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration on both feet. She has decreased two-point discrimination on her hands. Her grip strength is decreased and her plantar and dorsiflexion strength is decreased. Where is the disorder of the peripheral nervous system in this patient? A) Anterior horn cell B) Spinal root and nerve C) Peripheral polyneuropathy D) Neuromuscular junction

C) Peripheral polyneuropathy With peripheral polyneuropathy there will be distal extremity symptoms before proximal symptoms. There will be weakness and atrophy and decreased sensory sensations. There is often the classic glove-stocking distribution pattern of the lower legs and hands. Causes include diabetic neuropathy, as in this case, alcoholism, and vitamin deficiencies.

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 28-year-old book editor comes to your clinic, complaining of strange episodes. He states that about once a week for the last 3 months his left hand and arm will stiffen and then start jerking. He says that after a few seconds his whole left arm and then his left leg will also start to jerk. He denies any loss of consciousness or loss of bowel or bladder control. When the symptoms resolve, his arm and leg feel tired but otherwise he feels fine. His past medical history is significant for a cyst in his brain that was removed 6 months ago. He is married and has two children. His parents are both healthy. On examination you see a scar over the right side of his head but otherwise his neurologic examination is unremarkable. What type of seizure disorder is he most likely to have? A) Generalized tonic-clonic seizure B) Generalized absence seizure C) Simple partial seizure (Jacksonian) D) Complex partial seizure

C) Simple partial seizure (Jacksonian) Simple partial seizures start with a unilateral symptom, involve no loss of consciousness, and have a normal postictal state. In a Jacksonian seizure the symptoms start with one body part and "march" along the same side of the body.

A 26-year-old violinist comes to your clinic, complaining of anxiety. He is a first chair violinist in the local symphony orchestra and has started having symptoms during performances, such as sweating, shaking, and hyperventilating. It has gotten so bad that he has thought about giving up his first chair status so he does not have to play the solo during one of the movements. He says that he never has these symptoms during rehearsals or when he is practicing. He denies having any of these symptoms at any other time. His past medical history is unremarkable. He denies any tobacco use, drug use, or alcohol abuse. His parents are both healthy. On examination you see a young man who appears worried. His vital signs and physical examination are unremarkable. What type of anxiety disorder best describes his situation? A) Panic disorder B) Specific phobia C) Social phobia D) Generalized anxiety disorder

C) Social phobia Social phobia is a marked, persistent fear of social or performance situations.

A 21-year-old engineering student comes to your office, complaining of leg and back pain and of tripping when he walks. He states this started 3 months ago with back and buttock pain but has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific traumatic incidences but he was a defensive lineman in high school and junior college. His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy. On examination he is tender over the lumbar spine and he has a positive straight-leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching his gait you notice he has to pick his left foot up high in order not to trip. What abnormality of gait does he most likely have? A) Sensory ataxia B) Parkinsonian gait C) Steppage gait D) Spastic hemiparesis

C) Steppage gait This gait is associated with foot drop, usually secondary to a lower motor neuron disease. This is often seen with a herniated disc, such as in this patient.

A patient is concerned about a dark skin lesion on her anterolateral abdomen. It has not changed, and there is no discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion? A) Melanoma B) Dysplastic nevus C) Supernumerary nipple D) Dermatofibroma

C) Supernumerary nipple Feedback: This represents a supernumerary nipple. These occur along the "milk line" and do not exhibit features of more concerning lesions.

Which of the following synovial joints would be an example of a condylar joint? A) Hip B) Interphalangeal joints of the hand C) Temporomandibular joint D) Intervertebral joint

C) Temporomandibular joint Feedback: The TMJ is an example of a condylar joint because it involves the movement of two surfaces which are not dissociable. The hip would be an example of a spheroidal joint and the interphalangeal joints of the hand are hinge joints. The intervertebral joints are not synovial joints at all, but rather cartilaginous joints.

A patient presents with a left-sided facial droop. On further testing, you note that he is unable to wrinkle his forehead on the left and has decreased taste. Which of the following is true? A) This represents a central lesion. B) This represents a CN IV lesion. C) This may be related to travel. D) This most likely represents a stroke.

C) This may be related to travel. Feedback: Because the forehead is also involved, this represents a peripheral nerve lesion of CN VII and does not represent a classic middle cerebral artery stroke. The latter would spare the upper face but include speech difficulties as well as upper extremity weakness on the ipsilateral side. One cause of this type of lesion is Lyme disease and relates to travel to endemic areas, so a careful travel history should be sought.

Sarah presents with left lateral knee pain and has some locking in full extension. There is tenderness over the medial joint line. When the knee is extended with the foot externally rotated and some valgus stress is applied, a click is noted. What is the most likely diagnosis? A) Torn anterior cruciate ligament B) Torn posterior cruciate ligament C) Torn medial meniscus D) Torn lateral meniscus

C) Torn medial meniscus Feedback: This maneuver is called the McMurray test. Along with the medial joint line tenderness, you should suspect a medial meniscus injury. Cruciate ligament tears should cause an anterior or posterior "drawer sign." Although we can't rule out a lateral meniscus tear, the tenderness along the medial joint line makes this the more likely site of injury.

Adam is a very successful 15-year-old student and athlete. His mother brings him in today because he no longer studies, works out, or sees his friends. This has gone on for a month and a half. When you speak with him alone in the room, he states it "would be better if he were not here." What would you do next? A) Tell him that he has a very promising career in anything he chooses and soon he will feel better. B) Tell him that he needs an antidepressant and it will take about 4 weeks to work. C) Speak with his mother about getting him together more with his friends. D) Assess his suicide risk.

D) Assess his suicide risk. His lack of interest in usual activities and duration of symptoms should make you suspicious for depression. Despite his very successful academic and athletic performance, you should recognize this last phrase indicating suicide risk. You could ask if he has had thoughts about hurting himself and, if so, how he would carry this out. Ask about firearms and other weapons at home. Adam needs immediate psychiatric referral if these risks are found, or admission to the hospital for observation if referral is not available in a timely fashion.

A 55-year-old married homemaker comes to your clinic, complaining of 6 months of vaginal itching and discomfort with intercourse. She has not had a discharge and has had no pain with urination. She has not had a period in over 2 years. She has no other symptoms. Her past medical history consists of removal of her gallbladder. She denies use of tobacco, alcohol, and illegal drugs. Her mother has breast cancer and her father has coronary artery disease, high blood pressure, and Alzheimer's disease. On examination she appears healthy and has unremarkable vital signs. There is no lymphadenopathy with palpation of the inguinal nodes. Visualization of the vulva shows dry skin but no lesions or masses. The labia are somewhat smaller than usual. Speculum examination reveals scant discharge and the vaginal walls are red, dry, and bleed easily. Bimanual examination is unremarkable. The KOH whiff test produces no unusual odor and there are no clue cells on the wet prep. What form of vaginitis is this patient most likely to have? A) Trichomonas vaginitis B) Candida vaginitis C) Bacterial vaginosis D) Atrophic vaginitis

D) Atrophic vaginitis Feedback: The itching and pain with intercourse in atrophic vaginitis are due to the decreased amount of estrogen after menopause. There is generally scant discharge and the wet prep and KOH whiff test are unremarkable. Use of vaginal lubricants or hormonal replacement in selected patients often corrects the problem.

Which of the following lymph node groups is most commonly involved in breast cancer? A) Lateral B) Subscapular C) Pectoral D) Central

D) Central Feedback: The central nodes at the apex of the axilla are most commonly involved in breast cancer. The axilla can be viewed roughly as a four-sided pyramid. An examination covering all sides and the apex is unlikely to miss a significant node.

A young woman comes in with brief, rapid, jerky, irregular movements. They can occur at rest or during other intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements? A) Tics B) Dystonia C) Athetosis D) Chorea

D) Chorea Feedback: These represent chorea because they are brief, rapid, unpredictable, and irregular. Tics are irregular but tend to be stereotyped and can be vocal (throat-clearing), facial expressions, or shoulder shrugging. Athetosis is a slow, squirming motion usually affecting the face and distal extremities. Dystonia is similar to athetosis but the movements are more coarse and can involve twisted postural changes.

An obese 55-year-old woman went through menarche at age 16 and menopause 2 years ago. She is concerned because an aunt had severe osteoporosis. Which of the following is a risk factor for osteoporosis? A) Obesity B) Late menopause C) Having an aunt with osteoporosis D) Delayed menarche

D) Delayed menarche Feedback: Obesity and late menopause are not associated with osteoporosis. Having a first-degree relative with osteoporosis is a risk factor, but an aunt is a second-degree relative. Delayed menarche is the only choice which is a known risk factor for osteoporosis.

A 48-year-old grocery store manager comes to your clinic, complaining of her head being "stuck" to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot get it moved back to normal. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is on oral medication for each. She is married and has three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. On examination you see a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left but otherwise her examination is normal. What form of involuntary movement does she have? A) Chorea B) Asbestosis C) Tic D) Dystonia

D) Dystonia Dystonia involves large movements of the body, such as with the head or trunk, leading to grotesque twisted postures. Some medications (such as one commonly used for gastroparesis) often cause dystonia.

A 42-year-old realtor comes to your clinic, complaining of "growths" in her vulvar area. She is currently undergoing a divorce and is convinced she has a sexually transmitted disease. She denies any vaginal discharge or pain with urination. She has had no fever, malaise, or night sweats. Her past medical history consists of depression and hypothyroidism. She has had two spontaneous vaginal deliveries and one cesarean section. She has had no other surgeries. She denies smoking or drug use. She has two to three drinks weekly. Her mother also has hypothyroidism and her father has high blood pressure and hypercholesterolemia. On examination you see a woman who is anxious but appears otherwise healthy. Her blood pressure, pulse, and temperature are unremarkable. On visualization of the perineum you see two 2- to 3-mm, round, yellow nodules on the left labia. On palpation they are nontender and quite firm. What diagnosis best fits this description of her examination? A) Genital herpes B) Condylomata acuminata C) Syphilitic chancre D) Epidermoid cyst

D) Epidermoid cyst Feedback: These cysts are small, firm, round cystic nodules in the labia that are nonpainful. These do not represent a sexually transmitted infection, but rather a blocked sebaceous gland.

You are working in a college health clinic and seeing a young woman with a red, painful, swollen DIP joint on the left index finger. There are also a few papules, pustules, and vesicles on reddened bases, located on the distal extremities. This would be consistent with which of the following? A) Lyme disease B) Systemic lupus erythematosus C) Hives (urticaria) D) Gonococcal arthritis

D) Gonococcal arthritis Feedback: The presentation of a monoarthritis in this age group should lead one to think of gonococcal disease. Skin findings are often seen in conjunction with arthritis. Lyme disease is associated with an expanding erythematous patch. Lupus is associated with a "butterfly" rash on the cheeks, while serum sickness and drug reactions can be associated with hives.

A patient presents with a daily headache which has worsened over the past several months. On funduscopic examination, you notice that the disk edge is indistinct and the veins do not pulsate. Which is most likely? A) Migraine B) Glaucoma C) Visual acuity problem D) Increased intracranial pressure

D) Increased intracranial pressure Feedback: This is a description of papilledema, which should make you think of increased intracranial pressure. This can be a critical finding. This patient may have a brain tumor or benign intracranial hypertension. These findings cannot be ignored and should be acted upon quickly.

A 19-year-old college sophomore comes to the clinic for evaluation of joint pains. The student has been back from spring break for 2 weeks; during her holiday, she went camping. She notes that she had a red spot, shaped like a target, but then it started spreading, and then the joint pains started. She used insect repellant but was in an area known to have ticks. She has never been sick and takes no medications routinely; she has never been sexually active. What is the most likely cause of her joint pain? A) Trauma B) Gonococcal arthritis C) Psoriatic arthritis D) Lyme disease

D) Lyme disease Feedback: Lyme disease is characterized by a target-shaped red spot at the site of the bite, which disappears, then reappears and starts spreading (erythema migrans). Lyme disease can also result in joint pain as well as cardiac and neurologic manifestations.

A 58-year-old man comes to your office complaining of bilateral back pain that now awakens him at night. This has been steadily increasing for the past 2 months. Which one of the following is the most reassuring in this patient with back pain? A) Age over 50 B) Pain at night C) Pain lasting more than 1 month or not responding to therapy D) Pain that is bilateral

D) Pain that is bilateral Feedback: While bilateral pain can be associated with serious illness, it is not one of the "red flags" of back pain. Red flags should make one suspicious for serious underlying systemic disease such as cancer, infection, or others. This list includes: age over 50, history of cancer, unexplained weight loss, pain lasting more than 1 month or not responding to treatment, pain at night or increased by rest, history of intravenous drug use, or presence of infection. The presence of one of these with low back pain indicates a 10% probability of a serious systemic disease.

1. 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 high school soccer player "blew out his knee" when the opposing goalie's head and shoulder struck his flexed knee while the goalie was diving for the ball. All of the following structures were involved in some way in his injury, but which of the following is actually an extra-articular structure? A) Synovium B) Joint capsule C) Juxta-articular bone D) Tendons

D) Tendons Feedback: Extra-articular structures include the periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin. The articular structures include the joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone.

Steve has had a stroke and comes to you for follow-up today. On examination you find that he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the following? A) The corticospinal tract B) The cerebellum C) The cerebrum D) The basal ganglia

D) The basal ganglia Feedback: These findings are typical of disease in the basal ganglia.

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. This will allow her to be treated more expediently. You may tell the patient you have not found an answer yet, but you must also tell her that you will not stop looking until you have helped her.

A 50-year-old woman presents with "left hip pain" of several weeks duration. There is marked tenderness when you press over her proximal lateral thigh. What do you think she has? A) Osteoarthritis B) Rheumatoid arthritis C) Sciatica D) Trochanteric bursitis

D) Trochanteric bursitis Feedback: Bursitis is usually accompanied by tenderness on examination. This location is consistent with trochanteric bursitis. Osteoarthritis would generally not be tender and would more likely have decreased range of motion. Rheumatoid arthritis and sciatica would not likely be tender over this area.

A woman experiences syncope after hearing that her son was severely injured. She becomes pale and collapses to the ground without injuring herself. On waking, she states that she feels very warm. She denies any other symptoms. There are no findings on examination. What caused her loss of consciousness? A) Micturition syncope B) Postural hypotension C) Cardiac arrhythmia D) Vasovagal syncope

D) Vasovagal syncope Feedback: This is a classic description of vasodepressor or vasovagal syncope with the feeling of warmth, while bystanders note paleness. The lack of injury is also helpful because she has maintained her protective reflexes. Injuring oneself can indicate that a cardiac origin for syncope may be present. Micturition syncope occurs with urination, and there are no postural changes mentioned, making postural hypotension unlikely.