Review questions Thorax

Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound? A) It is a splenic rub. B) It is a variant of bowel noise. C) It represents borborygmi. D) It is a vascular noise.

A A rough, grating noise over this area represents a splenic rub, which can accompany splenic infarction. Rubs also occur over the liver and pleura and pericardium.

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology? A) Bronchitis B) Simple asthma C) Cystic fibrosis D) Heart failure

A Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis.

A daycare worker presents to your office with jaundice. She denies IV drug use, blood transfusion, and travel and has not been sexually active for the past 10 months. Which type of hepatitis is most likely? A) Hepatitis A B) Hepatitis B C) Hepatitis C D) Hepatitis D

A Feedback: The lack of contact with blood and body fluids makes hepatitis B, C, and D unlikely. She regularly changes the diapers of her clients and is at risk for hepatitis A. Vaccine against hepatitis A is recommended for daycare workers.

Which of the following conditions would produce a hyperresonant percussion note? A) Large pneumothorax B) Lobar pneumonia C) Pleural effusion D) Empyema

A There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. The other three conditions produce dullness by dampening the percussion note with fluid.

Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What should you do next? A) Obtain abdominal ultrasound B) Reassess by examination in 6 months C) Reassess by examination in 3 months D) Refer to a vascular surgeon

A A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 centimeters. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature.

A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent left-sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthy-appearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. Which disorder of the chest best describes these symptoms? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain

A Angina causes dull chest pain felt in the retrosternal area or anterior chest. It often radiates to the shoulders, arms, neck, and jaw. It is associated with shortness of breath, nausea, and sweating. The pain is generally relieved by rest or medication after several minutes. This patient needs to be admitted to the hospital for further workup for his accelerating symptoms.

A 26-year-old sports store manager comes to your clinic, complaining of severe right-sided abdominal pain for 12 hours. He began having a stomachache yesterday, with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 100.4 and his heart rate is 110. His bowel sounds are decreased and he has rebound and involuntary guarding, one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain? A) Acute appendicitis B) Acute mechanical intestinal obstruction C) Acute cholecystitis D) Mesenteric ischemia

A Appendicitis is common in the young and usually presents with periumbilical pain that localizes to the right lower quadrant in an area known as McBurney's Point, described above as one third of the way between the anterior superior iliac spine and the umbilicus on the right. Rebound and guarding are common. Remote rebound or Rovsing's sign is also seen commonly when the course of appendicitis is advanced. Bowel movements are usually unaffected.

A 76-year-old retired farmer comes to your office complaining of abdominal pain, constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or diarrhea. The only unusual thing he remembers eating is two bags of popcorn at the movies with his grandson, 3 days before his symptoms began. He denies any other recent illnesses. His past medical history is significant for coronary artery disease and high blood pressure. He has been married for over 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon cancer and his father had a stroke. On examination he appears his stated age and is in no acute distress. His temperature is 100.9 degrees and his other vital signs are unremarkable. His head, cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable and his fecal occult blood test is negative. His prostate is slightly enlarged but his testicular, penile, and inguinal examinations are all normal. Blood work is pending. What diagnosis for abdominal pain best describes his symptoms and signs? A) Acute diverticulitis B) Acute cholecystitis C) Acute appendicitis D) Mesenteric ischemia

A Diverticulitis is caused by localized infections within the colonic diverticula. Constipation, fever, and abdominal pain are common. Mesenteric ischemia classically presents in older people with a history of vascular disease elsewhere. The typical pain is unusual in that it is not made worse by examination despite being severe. Some mistake this feature to indicate malingering, with bad results.

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 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 is typically precipitated by repetitive motions, such as occurs with throwing or swimming. Crepitus/grating is noted in the shoulder with range of motion.

A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between shallow breaths, he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia

A Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds and on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan's syndrome.

A 52-year-old secretary comes to your office, complaining about accidentally leaking urine when she coughs or sneezes. She says this has been going on for about a year now. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is significant for four spontaneous vaginal deliveries. She is married and has four children. She denies alcohol, tobacco, or drug use. During her pelvic examination you note some atrophic vaginal tissue, but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable. Which type of urinary incontinence does she have? A) Stress incontinence B) Urge incontinence C) Overflow incontinence

A Stress incontinence usually occurs when the intra-abdominal pressure goes up during coughing, sneezing, or laughing. This is usually due to a weakness of the pelvic floor, with inadequate muscle support of the bladder. Vaginal deliveries and pelvic surgery are often associated with these symptoms. Usually, female patients are postmenopausal when stress incontinence begins. Kegel exercises are usually recommended to strengthen the pelvic floor muscles.

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 implies an inflammatory process along with increased temperature and tenderness.

Which of the following anatomic landmark associations is correct? A) 2nd intercostal space for needle insertion in tension pneumothorax B) T6 for lower margin of endotracheal tube C) Sternal angle marks the 4th rib D) 5th intercostal space for chest tube insertion

A The 2nd intercostal space is correct location for insertion of a needle in tension pneumothorax. T4 marks the approximate bifurcation of the trachea and therefore marks the inferior limit for an endotracheal tube on chest X-ray. The sternal angle marks the 2nd rib, which helps establish the 2nd interspace for needle insertion as above or locations for cardiac auscultation (aortic and pulmonary areas). Finally, the 4th intercostal space is normally used for chest tube insertion.

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 The foot when it is flat is part of the stance phase of gait, not the foot when it is arched.

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 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.

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 These features are consistent with articular joint pain, whereas the other problems are associated with extra-articular structures.

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 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 grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you that it has been that way for quite awhile. He states he has no symptoms from it and he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was deployed to the Middle East. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. On examination you see a teenage boy appearing his stated age. On visual examination of his chest you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are unremarkable. What disorder of the thorax best describes your findings? A) Barrel chest B) Funnel chest (pectus excavatum) C) Pigeon chest (pectus carinatum) D) Thoracic kyphoscoliosis

B Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.

A patient with longstanding COPD was told by another practitioner that his liver was enlarged and this needed to be assessed. Which of the following would be reasonable to do next? A) Percuss the lower border of the liver B) Measure the span of the liver C) Order a hepatitis panel D) Obtain an ultrasound of the liver

B In this patient, measuring the span of the liver saved the patient an involved workup, because it was normal. His history of COPD is consistent with flattening of the diaphragms, which pushed the liver edge down while the actual size of the liver remained the same. Percussing the lower border of the liver alone caused this referral, because it was assumed that the liver was enlarged.

You are palpating the abdomen and feel a small mass. Which of the following would you do next? A) Ultrasound B) Examination with the abdominal muscles tensed C) Surgery referral D) Determine size by percussion

B It is easy to determine whether the mass is actually in the abdominal wall versus in the abdomen by palpating with the abdominal wall tensed. This can be accomplished by having the patient lift her head off the bed while supine. Usually, abdominal wall masses can be observed, whereas intra-abdominal masses are more concerning.

Which of the following is consistent with obturator sign? A) Pain distant from the site used to check rebound tenderness B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated C) Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion D) Pain that stops inhalation in the right upper quadrant

B Obturator sign is seen in appendicitis. Right hypogastric pain with the right hip and knee flexed and the hip internally rotated. It is pain with the stretching of the internal obturator muscle because of inflammation. Pain distant from the site used to check rebound tenderness is Rovsing's sign and is a reliable sign of peritonitis. Answer "C" describes psoas sign, which is also seen in appendicitis. Palpation in the right upper quadrant that causes pain severe enough to stop inhalation is consistent with inflammation of the gallbladder and is called Murphy's sign.

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 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 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 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.

Which of the following occurs in respiratory distress? A) Speaking in sentences of 10-20 words B) Skin between the ribs moves inward with inspiration C) Neck muscles are relaxed D) Patient torso leans posteriorly

B Skin between the ribs moves inward with inspiration. This description is consistent with retractions that occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing, in which the patient exhales against his lips, which are pressed together.

Mrs. LaFarge is a 60-year-old who presents with urinary incontinence. She is unable to get to the bathroom quickly enough when she senses the need to urinate. She has normal mobility. Which of the following is most likely? A) Stress incontinence B) Urge incontinence C) Overflow incontinence D) Functional incontinence

B Stress incontinence occurs with increased intra-abdominal pressure such as with coughing, sneezing, or laughing. This history is most consistent with urge incontinence secondary to detrusor overactivity. Overflow incontinence occurs with anatomic obstruction such as prostatic hypertrophy (obviously not in this case, as the patient is a woman), urethral stricture, or neurogenic bladder. Functional incontinence results from lack of mobility severe enough to impair getting to the bathroom quickly enough.

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 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.

A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency or urgency with urination but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood cells. What type of urinary tract pain is she most likely to have? A) Kidney pain (from pyelonephritis) B) Ureteral pain (from a kidney stone) C) Musculoskeletal pain D) Ischemic bowel pain

B The pain from a kidney stone causes dramatic, severe, colicky pain at the costovertebral angle that radiates across the flank and down into the groin.

A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall. What disorder of the chest best describes this disorder? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain

B The pain from pericarditis is usually sharp and knifelike and is located over the left side of the chest. Change of position, breathing, and coughing often make the pain worse, whereas leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases such as systemic lupus and in patients with chronic kidney disease. Patients also experience this after a myocardial infarction. You can read more about Dressler's syndrome.

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 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.

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 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.

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 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

A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia

B This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance, and during auscultation there are often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this patient's exercise capacity because it may affect his employment and also allows you to follow for progression of his disease. You must offer smoking cessation as an option.

Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice dullness in the last intercostal space in the anterior axillary line on his left side with a deep breath. What does this indicate? A) His spleen is definitely enlarged and further workup is warranted. B) His spleen is possibly enlarged and close attention should be paid to further examination. C) His spleen is possibly enlarged and further workup is warranted. D) His spleen is definitely normal.

B This scenario is not uncommon in infectious mononucleosis. The presence of dullness with inspiration should definitely increase your attention to further examination of the spleen, although dullness can occur in normal patients too.

Which of the following percussion notes would you obtain over the gastric bubble? A) Resonance B) Tympany C) Hyperresonance D) Flatness

B Tympany The gastric bubble produces one of the longest percussion notes. A patient with COPD may have hyperresonance over his chest, while a normal person would have resonance. Dullness is heard over a normal liver, and flatness is heard if one percusses a large muscle.

Jim is a 60-year-old man who presents with vomiting. He denies seeing any blood with emesis, which has been occurring for 2 days. He does note a dark, granular substance resembling the coffee left in the filter after brewing. What do you suspect? A) Bleeding from a diverticulum B) Bleeding from a peptic ulcer C) Bleeding from a colon cancer D) Bleeding from cholecystitis

B When blood is exposed to the environment of the stomach, it often resembles "coffee grounds." This is not always recognized by patients as blood, so it is important to inquire about this. This symptom is not common in cholecystitis, and the other possibilities occur lower in the intestine. It should be noted that conversely, rapid bleeding from the stomach or other upper gastrointestinal source can produce bright red blood in the stool. Do not rule out proximal bleeding on the basis of the absence of "coffee grounds." Likewise, bright red blood seen with emesis may originate from the stomach. Black, sticky stools also can accompany upper GI bleeding

A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife's request. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for over 40 years. He denies any tobacco or drug use and has not drunk alcohol in over 40 years. His parents both died of cancer in their 60s. On examination his vital signs are normal. His head, cardiac, and pulmonary examinations are unremarkable. On abdominal examination you hear normal bowel sounds, but when you palpate his liver it is abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination? A) Smooth, large, nontender liver B) Irregular, large liver C) Smooth, large, tender liver

B With his past history of colon cancer and with recent weight loss and fatigue, a relapse of his colon cancer would be expected. Colon cancer usually metastasizes to the liver, creating hard, irregular nodules, which can sometimes be palpated on examination. A smooth, large liver which is tender is often seen in hepatitis.

A 15-year-old high school freshman is brought to the clinic by his mother because of chronic diarrhea. The mother states that for the past couple of years her son has had diarrhea after many meals. The patient states that the diarrhea seems the absolute worst after his school lunches. He describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or fatigue. He has had no recent illness, injuries, or foreign travel. His past medical history is unremarkable. He denies tobacco, alcohol, or drug use. His parents are both healthy. On examination you see a relaxed young man breathing comfortably. His vital signs are normal and his head, eyes, ears, throat, neck, cardiac, and pulmonary examinations are normal. His abdomen is soft and nondistended. His bowel sounds are active and he has no tenderness, no enlarged organs, and no rebound or guarding. His rectal examination is nontender with no blood on the glove. You collect a stool sample for further study. What is the most likely explanation for this patient's chronic diarrhea? A) Malabsorption syndrome B) Osmotic diarrhea C) Secretory diarrhea

B- Osmotic diarrhea Usually related to lactose intolerance, watery diarrhea often follows meal ingestion. Crampy abdominal pain, distension, and gas often accompany symptoms. Diarrhea is often provoked by pizza, milkshakes, yogurt, and other lactose-containing foods. This condition is more common in African-Americans, Latinos, Native Americans, and Asians.

A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior chest pain radiating to her back. She describes it as if someone is "ripping out her heart." It began less than an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain better or worse. Her medical history consists of difficult-to-control hypertension and coronary artery disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger brother who has had bypass surgery. On examination you see an elderly female in a great deal of distress. She is lying on the table, curled up, holding her left and right arms against her chest and is restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and 130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital's ER for further evaluation. What disorder of the chest best describes her symptoms? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain

C A dissecting aortic aneurysm is associated with a ripping or tearing sensation that radiates to the neck, back, or abdomen. Because blood supply to the brain and extremities is disrupted, syncope and paraplegia or hemiplegia can occur. Blood pressure will usually be different between the two arms, and the carotid pulses often show an asymmetry. This is because the aneurysm decreases flow distally and causes inequality of flow between sides.

A young patient presents with a left-sided mass in her abdomen. You confirm that it is present in the left upper quadrant. Which of the following would support that this represents an enlarged kidney rather than her spleen? A) A palpable "notch" along its edge B) The inability to push your fingers between the mass and the costal margin C) The presence of normal tympany over this area D) The ability to push your fingers medial and deep to the mass

C A left upper quadrant mass is more likely to be a kidney if there is no palpable "notch," you can push your fingers between the mass and the costal margin, there is normal tympany over this area, and you cannot push your fingers medial and deep to the mass. These findings are very difficult to appreciate in an obese patient.

Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which of the following would you do next? A) Check an ultrasound of the liver B) Obtain a hepatitis panel C) Determine liver span by percussion D) Adopt a "watchful waiting" approach

C A liver edge palpable this far below the costal arch should not be ignored. Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has developed emphysema with flattening of the diaphragms. This pushes a normal-sized liver below the costal arch so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall until dullness is heard. A measurement is then made between this point and the lower border of the liver to determine its span; 6-12 centimeters in the mid-clavicular line is normal. Percussion is the only way to assess liver size on examination, and in this case it saved the patient much inconvenience and expense.

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 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 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently started a job as a bartender in town. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia

C Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be made worse by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). Realize that in severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these patients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this.

A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation, but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a junior in college majoring in accounting. She smokes when she drinks alcohol but denies using any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What is most likely the etiology of her diarrhea? A) Secretory infections B) Inflammatory infections C) Irritable bowel syndrome D) Malabsorption syndrome

C Irritable bowel syndrome will cause loose bowel movements with cramps but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse, as do certain foods.

An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect? A) Malingering B) Neuropathy C) Ischemia D) Physical abuse

C Ischemic pain can be severe but is not made worse with palpation. The history of bypass could be a clue that there is vascular narrowing elsewhere. Malingering is less likely, and neuropathic pain, as seen in herpes zoster, would worsen with touch. You are to be commended if you considered elder abuse, because this is frequently missed. Ordinarily, this pain would be worse with examination because of the preceding trauma.

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 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.

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 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.

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 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.

Which is the proper sequence of examination for the abdomen? A) Auscultation, inspection, palpation, percussion B) Inspection, percussion, palpation, auscultation C) Inspection, auscultation, percussion, palpation D) Auscultation, percussion, inspection, palpation

C The abdominal examination is conducted in a sequence different from other systems, for which the usual order is inspection, percussion, palpation, and auscultation. Because palpation may actually cause some bowel noise when the bowels are not moving, auscultation is performed before percussion and palpation in an abdominal examination.

You are at your family reunion playing football when your uncle takes a hit to his right lateral thorax and is in pain. He asks you if you think he has a rib fracture. You are in a very remote area. What would your next step be? A) Call a medevac helicopter B) Drive him to the city (4 hours away) C) Press on his sternum and spine simultaneously D) Examine him for tenderness over the injured area

C The area involved in the injury will of course be tender. If you press in an area remote to the injury, but over the same bone which may be involved, you can produce tenderness at the site of injury. This would indicate that there may be a fracture at the lateral ribs. Fortunately, this maneuver did not reproduce pain remotely, and your uncle simply sat on the sidelines for the rest of the game.

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 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.

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 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 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 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.

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 The presence of bowel and bladder symptoms associated with back pain is worrisome and should suggest impingement of nerve roots S2-S4. 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.

Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely, given this presentation? A) Appendicitis B) Dysmenorrhea C) Ureteral stone D) Ovarian cyst

C The presentation of right flank pain spiraling down to the groin is typical of a ureteral stone. There would most likely be microscopic hematuria as well. The migration pattern of this condition makes the others less likely.

Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration? A) Bronchovesicular B) Vesicular C) Bronchial D) Tracheal

C These sounds are consistent with bronchial breath sounds. Be alert for these, as they may occur elsewhere and indicate a pneumonia or other pathology. The current explanation for this phenomenon is that the sound from the trachea is carried very well to the chest wall by fluid. This same explanation explains "ee" to "aa" changes, whispered pectoriloquy, bronchophony, and other circumstances in which high-frequency sounds, normally blocked by the air-filled alveoli, could be transmitted to the chest wall.

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 This maneuver is called the McMurray test. Along with the medial joint line tenderness, you should suspect a medial meniscus injury. 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. Cruciate ligament tears should cause an anterior or posterior "drawer sign."

A 25-year-old accountant presents to your clinic, complaining of intermittent lower right-sided chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds, taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring. The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a deep breath. He has taken some Tylenol and put a heating pad on his side but neither has helped. He remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in good health. He has recently married, and his wife has a baby due in 2 months. He denies any smoking or illegal drug use. He drinks two to three beers once a month. He states that he eats a healthy diet and runs regularly, but not since his recent illness. He denies any cardiac, gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable. His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During palpation the ribs are nontender. What disorder of the chest best describes his symptoms? A) Pericarditis B) Chest wall pain C) Pleural pain D) Angina pectoralis

C This pain is sharp and knifelike and occurs over the affected area of pleura. Breathing deeply usually makes the pain worse, whereas lying quietly on the affected side makes the pain better. Pleurisy often occurs from inflammation due to an infection, neoplasm, or autoimmune disease.

A 46-year-old former salesman presents to the ER, complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. On examination you find a man appearing older than his stated age. His skin has a yellowish tint and he is thin, with a prominent abdomen. You note multiple "spider angiomas" at the base of his neck. Otherwise, his heart and lung examinations are normal. On inspection, he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs? A) Infectious diarrhea B) Mallory-Weiss tear C) Esophageal varices

C Varices are often found in alcoholic patients, but only when they have a diagnosis of significant cirrhosis. This patient has symptoms of cirrhosis, including jaundice, ascites, spider hemangiomas, and dilated veins on his abdomen (caput medusa). Esophageal varices are abnormal, enlarged veins in the tube that connects the throat and stomach

A 62-year-old smoker complains of "coughing up small amounts of blood," so you consider hemoptysis. Which of the following should you also consider? A) Intestinal bleeding B) Hematoma of the nasal septum C) Epistaxis D) Bruising of the tongue

C When you suspect hemoptysis, you must consider other etiologies for bleeding. Commonly, epistaxis can mimic this as well as bleeding from the gastrointestinal tract.

Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or more at a time and has started recently. Which of the following should be considered? A) Peptic ulcer B) Pancreatitis C) Myocardial ischemia D) All of the above

D Epigastric pain can have many causes. History and physical will help discern which causes are most likely, but it is important to realize that any of the above, including myocardial ischemia, is always a possibility. Pneumonia and gallbladder pain can also cause pain in this location.

Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites? A) Bilateral flank tympany B) Dullness which remains despite change in position C) Dullness centrally when the patient is supine D) Tympany which changes location with patient position

D A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float so that dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany which changes location with patient position ("shifting dullness") would support the presence of ascites. A fluid wave and edema would support this diagnosis as well.

A 22-year-old law student comes to your office, complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank something like 14 drinks. On examination you find a young male appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending. What etiology of abdominal pain is most likely causing his symptoms? A) Peptic ulcer disease B) Biliary colic C) Acute cholecystitis D) Acute pancreatitis

D Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates into the back. There is often a history of long-standing gallbladder disease or recent alcohol ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump inhibitors can also cause pancreatitis in people without these other risk factors. Treatment includes hydration, pain management, and bowel rest.

Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely? A) Colon cancer B) Cholecystitis C) Inflammatory bowel disease D) Irritable bowel syndrome

D Although colon cancer should be a consideration, these symptoms are intermittent and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely. This is a very common condition which can be triggered by certain foods and stress.

A 62-year-old woman has been followed by you for 3 years and has had recent onset of hypertension. She is still not at goal despite three antihypertensive medicines, and you strongly doubt nonadherence. Her father died of a heart attack at age 58. Today her pressure is 168/94 and pressure on the other arm is similar. What would you do next? A) Add a fourth medicine B) Refer to nephrology C) Get a CT scan D) Listen closely to her abdomen

D At this point, it is important to consider secondary causes for this woman's hypertension because of its severity, rapidity of progression, and lack of response to therapy. While you will most likely add a fourth medicine, it is important to carefully examine the abdomen for the presence of renal artery bruits. These are usually heard best in the upper quadrants. It may be necessary to have the patient hold her breath, to have a very quiet room, and to listen with the diaphragm for a very soft, high-pitched sound with systole. It may also help to simultaneously feel the patient's pulse (a bruit with both a systolic and diastolic component is very specific for a significant blockage, while a lone systolic bruit may not be abnormal). Obtaining a CT scan is not likely to be useful, and you may save the delay, expense, and inconvenience of a nephrology referral if you can hear a bruit.

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 Bursitis is usually accompanied by tenderness on examination. 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.

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 is the only choice which is a known risk factor for osteoporosis. 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.

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 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.

A 60-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can't do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination she is in no acute distress. Her blood pressure is 160/100 and her pulse is 100. She is afebrile and her respiratory rate is 16. With auscultation she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination the S1 and S2 are distant and an S3 is heard over the apex. What disorder of the chest best describes her symptoms? A) Pneumonia B) Chronic obstructive pulmonary disease (COPD) C) Pleural pain D) Left-sided heart failure

D In left-sided heart failure, fluid starts "backing up" into the lungs because the heart is unable to handle the volume. The excess fluid collects in the dependent areas, causing crackles in the bases of the lower lobes. Sitting up allows patients to breathe easier. The two main causes are chronic high blood pressure and coronary artery disease, which lead to myocardial ischemia and decreased contractility of the heart.

Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the symphysis pubis. What does this most likely represent? A) Sigmoid mass B) Tumor in the abdominal wall C) Hernia D) Enlarged bladder

D It is possible that this represents a sigmoid colon mass, but this is less likely than an enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently cause partial urinary obstruction with bladder enlargement. If the mass resolves with catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A hernia would most likely not be dull to percussion. Midline abdominal wall tumors of this size would be unusual but could be discerned by having the patient tense his abdominal muscles.

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 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 42-year-old florist comes to your office, complaining of chronic constipation for the last 6 months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies any recent illnesses or injuries. She denies any changes to her diet or exercise program. She is on no new medications. During the review of systems you note that she has felt fatigued, had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one vaginal delivery and two cesarean sections. She is married, has three children, and owns a flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has coronary artery disease. There is no family history of cancers. On examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the Achilles tendons. What is the best choice for the cause of her constipation? A) Large bowel obstruction B) Irritable bowel syndrome C) Rectal cancer D) Hypothyroidism

D Many metabolic conditions can interfere with bowel motility. In this case the patient has many symptoms of hypothyroidism, including cold intolerance, weight gain, fatigue, constipation, and irregular menstrual cycles. On examination, thyromegaly and delayed reflexes can help to make the diagnosis. Medication will usually correct these symptoms.

A 47-year-old receptionist comes to your office, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated, at 101. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation, she has decreased air movement, and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia

D Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation, there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of the increased transmission of high-pitched components of sounds. These higher frequencies are usually filtered out by the multiple air-filled chambers of the alveoli.

Which of the following is consistent with good percussion technique? A) Allow all of the fingers to touch the chest while performing percussion. B) Maintain a stiff wrist and hand. C) Leave the plexor finger on the pleximeter after each strike. D) Strike the pleximeter over the distal interphalangeal joint.

D Strike the pleximeter over the distal interphalangeal joint. Percussion takes practice to master. Most struggle initially with keeping the wrist and hand relaxed. Other challenges include removing the plexor quickly and keeping the other fingers off the chest wall. These can dampen the sound you are trying to obtain. The ideal target for the plexor is the distal interphalangeal joint.

A 55-year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses should you consider because of her gesture? A) Bronchitis B) Costochondritis C) Pericarditis D) Angina pectoris

D The clenched fist of Levine's sign, while not completely specific for ischemic pain, should definitely cause you to consider this etiology. Bronchitis is usually painless and pericarditis can produce a sharp pain which worsens with inspiration. This is called pleuritic pain and can be associated with pneumonia and other chest diseases. Costochondritis is a parasternal pain, usually well localized. It is exquisitely tender.

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 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 complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most likely explanation for these? A) Asthma B) COPD C) Bronchiectasis D) Heart failure

D The timing of crackles within inspiration provides important clues. These late inspiratory crackles that appeared suddenly would be most consistent with heart failure. COPD and asthma usually produce early inspiratory crackles. Bronchiectasis, as seen in cystic fibrosis, classically produces mid-inspiratory crackles, but this is not always reliable. Interestingly, end-expiratory crackles can be heard in asthma on occasion.

Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely? A) Peptic ulcer B) Cholecystitis C) Pancreatitis D) Appendicitis

D This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.

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 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.