Exam 2

Which area of the fundus is the central focal point for incoming images? A) The fovea B) The macula C) The optic disk D) The physiologic cup

A) The fovea The fovea is the area of the retina which is responsible for central vision. It is surrounded by the macula, which is responsible for more peripheral vision. The optic disc and physiologic cup are where the optic nerve enters the eye.

A 72-year-old teacher comes to your clinic for an annual examination. She is concerned about her risk for peripheral vascular disease and states that there is a place in town that does tests to let her know her if she has this or not. Which of the following disease processes is a risk factor for peripheral vascular disease? A) Gastroesophageal reflux disease B) Coronary artery disease C) Migraine headaches D) Osteoarthritis

B) Coronary artery disease Evidence of coronary artery disease implies that there is most likely disease in other vessels; therefore, this is a risk factor for peripheral vascular disease. Conversely, the presence of peripheral vascular disease is also a risk factor for coronary artery disease, and if present, it should be considered in reduction of cardiac risk factors.

Blood pressure abnormalities found more commonly in Western elderly include which of the following? A) Isolated elevation of the diastolic BP B) Narrow pulse pressure C) Elevation of the systolic BP D) Elevation of the BP with standing

C) Elevation of the systolic BP Isolated systolic hypertension is common in the elderly because of stiffening of the large arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP changes are often seen with postural changes and can account for falls as well.

Which of the following correlates with a sustained, high-amplitude PMI? A) Hyperthyroidism B) Anemia C) Fever D) Hypertension

D) Hypertension While hyperthyroidism, anemia, and fever can cause a high-amplitude PMI, pressure work by the heart, as seen in hypertension, causes the PMI to be sustained.

A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You elicit the information that the dizziness is a spinning sensation of sudden onset, worse with head position changes. The episodes last a few seconds and then go away, and they are accompanied by intense nausea. She has vomited one time. She denies tinnitus. You perform a physical examination of the head and neck and note that the patient's hearing is intact to Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description, what is the most likely diagnosis? A) Benign positional vertigo B) Vestibular neuronitis C) Ménière's disease D) Acoustic neuroma

A) Benign positional vertigo This is a classic description of benign positional vertigo. The vertigo is episodic, lasting a few seconds to minutes, instead of continuous as in vestibular neuronitis. Also, there is no tinnitus or sensorineural hearing loss as occurs in Ménière's disease and acoustic neuroma. You may choose to learn about Hallpike maneuvers, which are also helpful in the evaluation of vertigo.

What is responsible for the inspiratory splitting of S2? A) Closure of aortic, then pulmonic valves B) Closure of mitral, then tricuspid valves C) Closure of aortic, then tricuspid valves D) Closure of mitral, then pulmonic valves

A) Closure of aortic, then pulmonic valves During inspiration, the closure of the aortic valve and the closure of the pulmonic valve separate slightly, and this may be heard as two audible components, instead of a single sound. Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, you may not hear it away from the left second intercostal space. Because it is a low-pitched sound, you may not hear it unless you use the bell of your stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting.

Which of the following represents age-related changes in the lungs? A) Decrease in chest wall compliance B) Speed of expiration increases C) Increase in respiratory muscle strength D) Increased elastic recoil of lung tissue

A) Decrease in chest wall compliance The lungs age along with the rest of the body. These changes include decreased lung and chest wall compliance, increased expiratory time, decreased muscle strength and cough, and decreased elastic recoil.

Which of the following is true of assessment of the vascular system in the elderly? A) Fewer than one third of patients with peripheral vascular disease have symptoms of claudication. B) An aortic width of 2.5 cm is abnormal. C) Bruits are commonly benign findings. D) Orthostatic blood pressure and pulse are not useful in this population

A) Fewer than one third of patients with peripheral vascular disease have symptoms of claudication. It is the minority of patients with peripheral vascular disease who experience claudication; therefore, ankle-brachial ratios should be performed more frequently. The aorta should be 3 cm or less. Bruits usually indicate pathology, and even when there is not a significant blockage, the risk of vascular disease throughout the body is increased. Orthostatic vital signs are very useful in this population. Remember to observe the pulse as well, as failure of the heart to increase its rate is a common cause of orthostatic hypotension. This can occur as a result of autonomic neuropathy or medications such as beta-blockers, among other causes.

You note that a patient has anisocoria on examination. Pathologic causes of this include which of the following? A) Horner's syndrome B) Benign anisocoria C) Differing light intensities for each eye D) Eye prosthesis

A) Horner's syndrome Anisocoria can be associated with serious pathology. Remember to exclude benign causes before embarking on an intensive workup. Testing the near reaction in this case may help you to find an Argyll Robertson or tonic (Adie's) pupil.

Where is the point of maximal impulse (PMI) normally located? A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum B) In the left 5th intercostal space, 10 to 12 cm lateral to the sternum C) In the left 5th intercostal space, in the anterior axillary line D) In the left 5th intercostal space, in the midaxillary line

A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral to the sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its size should not be greater than the size of a US quarter, or about an inch. Left ventricular enlargement should be suspected if it is larger. The PMI is often the best place to listen for mitral valve murmurs as well as S3 and S4. The PMI is often difficult to feel in normal patients.

Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination? A) Increased cup-to-disc ratio B) AV nicking C) Cotton wool spots D) Microaneurysms

A) Increased cup-to-disc ratio It is important to screen for glaucoma on funduscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.

A 57-year-old maintenance worker comes to your office for evaluation of pain in his legs. He has smoked two packs per day since the age of 16, but he is otherwise healthy. You are concerned that he may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system? A) Intermittent claudication B) Chest pressure with exertion C) Shortness of breath D) Knee pain

A) Intermittent claudication Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of patients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle brachial index can help detect this problem.

Which is true of splitting of the second heart sound? A) It is best heard over the pulmonic area with the bell of the stethoscope. B) It normally increases with exhalation. C) It is best heard over the apex. D) It does not vary with respiration.

A) It is best heard over the pulmonic area with the bell of the stethoscope. S2 splitting is best heard over the pulmonic area because this is the only place where both of its components can be heard well. The closure of the pulmonic valve is normally not loud because the right heart is a low-pressure system. The bell is best used because it is a low-pitched sound. S2 splitting normally increases with inhalation.

You are examining a patient with emphysema in exacerbation and are having difficulty hearing his heart sounds. What should you do to obtain a good examination? A) Listen in the epigastrium. B) Listen to the patient in the left lateral decubitus position. C) Ask the patient to hold his breath for 30 seconds. D) Listen posteriorly.

A) Listen in the epigastrium. It is often difficult to hear the heart well in a patient with emphysema. The shape of the chest as well as the interfering lung noise make examination challenging. By listening in the epigastrium, these barriers can be overcome. It is impractical to ask a patient who is short of breath to hold his breath for a prolonged period. Listening posteriorly would make the heart sounds even softer. It is always a good idea to listen to a patient in the left lateral decubitus position, but in this case it would not make auscultation easier.

A 72-year-old retired truck driver comes to the clinic with his wife for evaluation of hearing loss. He has noticed some decreased ability to hear what his wife and grandchildren are saying to him. He admits to lip-reading more. He has a history of noise exposure in his young adult years: He worked as a sound engineer at a local arena and had to attend a lot of concerts. Based on this information, what is the most likely finding regarding his hearing acuity? A) Loss of acuity for middle-range sounds B) Increase of acuity for low-range sounds C) Loss of acuity for high-range sounds D) Increase of acuity for high-range sounds

A) Loss of acuity for middle-range sounds Human speech is considered to be a middle-range sound. During the aging process there is a loss of acuity, starting with high-pitched sounds but extending to the middle range and then into the low range.

During cardiac examination you notice a new parasternal systolic murmur of 2/6 intensity. On palpation, the PMI is slightly higher than usual. What do you suspect? A) Mammary souffle B) Mitral stenosis C) Mitral regurgitation D) Aortic insufficiency

A) Mammary souffle Although a mammary souffle may be diastolic, the murmurs of mitral stenosis and aortic insufficiency cannot be heard in systole. Mitral regurgitation is a possibility, but the upward shift in PMI and lack of other symptoms make this less likely. Any new diastolic murmur should be investigated further.

A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur? A) Mitral B) Tricuspid C) Aortic D) Pulmonic

A) Mitral Mitral valve sounds are usually heard best at and around the cardiac apex.

A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely? A) Otosclerosis of the left ear B) Exposure to chronic loud noise of the right ear C) Otitis media of the right ear D) Perforation of the right eardrum

A) Otosclerosis of the left ear The above pattern is consistent with a conductive loss on the left side. Causes would include: foreign body, otitis media, perforation, and otosclerosis of the involved side.

You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid pulse? A) Palpable B) Soft, rapid, undulating quality C) Pulsation eliminated by light pressure on the vessel D) Level of pulsation changes with changes in position

A) Palpable The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.

How should you determine whether a murmur is systolic or diastolic? A) Palpate the carotid pulse. B) Palpate the radial pulse. C) Judge the relative length of systole and diastole by auscultation. D) Correlate the murmur with a bedside heart monitor.

A) Palpate the carotid pulse. Timing of a murmur is crucial for identification. The carotid pulse should be used because there is a delay in the radial pulse relative to cardiac events, which can lead to error. Some clinicians can estimate timing by the relative length of systole and diastole, but this method is not reliable at faster heart rates. A bedside monitor is not always available, nor are all designed to correlate in time with the actual pulse.

Mrs. Buckley is a 75-year-old widow who wants you to look at her teeth because over the past 2 weeks she has had right-sided jaw pain when eating. It does not occur otherwise. She also has had a headache. Which of the following should be considered? A) Palpation of her temples B) Dental referral C) Ultrasound of the gallbladder D) Inquiry about anosmia

A) Palpation of her temples This story can be consistent with temporal arteritis, which can cause blindness in 15% of those affected. Early recognition is crucial. Most of these patients will have tenderness over one or both of the temporal arteries, and some have diminished temporal pulses as well. Early treatment with corticosteroids is indicated. It can also be associated with polymyalgia rheumatic, a condition which causes pain in the shoulder girdles and pelvis.

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

A sudden, painless unilateral vision loss may be caused by which of the following? A) Retinal detachment B) Corneal ulcer C) Acute glaucoma D) Uveitis

A) Retinal detachment Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain. Retinal detachment is generally painless, as is chronic glaucoma.

Which of the following is a symptom involving the eye? A) Scotomas B) Tinnitus C) Dysphagia D) Rhinorrhea

A) Scotomas Scotomas are specks in the vision or areas where the patient cannot see; therefore, this is a common/concerning symptom of the eye.

A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a cardiac examination and find that his pulse rate is less than 60. Which of the following conditions could be responsible for this heart rate? A) Second-degree A-V block B) Atrial flutter C) Sinus arrhythmia D) Atrial fibrillation

A) Second-degree A-V block A second-degree A-V block can result in a pulse rate less than 60. Atrial flutter and atrial fibrillation do not cause bradycardia unless there is a significant accompanying block. Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart rate.

A 29-year-old computer programmer comes to your office for evaluation of a headache. The tightening sensation is located all over the head and is of moderate intensity. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours each day at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain but not taken it away. Based on this description, what is your most likely diagnosis? A) Tension B) Migraine C) Cluster D) Analgesic rebound

A) Tension This is a description of a typical tension headache.

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 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.

Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52. What heart rate should she achieve? A) 80 B) 100 C) 120 D) 140

B) 100 Maximum heart rate is calculated by subtracting the patient's age from 220. For Mrs. Adams, 60% of this number is about 100. She must also be instructed in how to measure her own pulse or have a device to do so. Most people are able to carry on a conversation at this level of exertion.

You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse? A) Hypothyroidism B) Aortic stenosis, with pressure overload of the left ventricle C) Mitral stenosis, with volume overload of the left atrium D) Cardiomyopathy

B) Aortic stenosis, with pressure overload of the left ventricle Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the apical impulse or not be palpable at all.

A light is pointed at a patient's pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon? A) Direct reaction B) Consensual reaction C) Near reaction D) Accommodation

B) Consensual reaction The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.

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 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? A) Ptosis B) Exophthalmos C) Ectropion D) Epicanthus

B) Exophthalmos Exophthalmos is the condition when the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease. If it is unilateral, it could still be caused by Graves' disease. Alternatively, it could be caused by a tumor or inflammation in the orbit.

A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient? A) Otitis media B) External otitis C) Perforation of the tympanum D) Cholesteatoma

B) External otitis These are classic history and examination findings for a patient suffering from external otitis. Otitis media would not usually have pain with movement of the external ear, nor drainage unless the eardrum was perforated. In this case the examination of the eardrum is recorded as normal. Cholesteatoma is a growth behind the eardrum and would not account for these symptoms. Otitis media would classically be accompanied by a bulging, erythematous eardrum.

An infant presents with a heart rate of 180, a respiratory rate of 68, and an enlarged liver. What diagnosis does this suggest? A) Pneumonia B) Heart failure C) Sepsis D) Necrotizing enterocolitis

B) Heart failure Heart failure presents differently in infants than in adults. This triad should suggest this diagnosis. Pneumonia, necrotizing enterocolitis, and sepsis should not necessarily cause hepatomegaly. Observe closely for central cyanosis of the lips and tongue. Peripheral cyanosis alone does not mean much in infants. Perform a careful cardiac examination in as quiet a setting as possible, perhaps while the infant is in the mother's arms, to look for evidence of valvular disease.

A patient complains of epistaxis. Which other cause should be considered? A) Intracranial hemorrhage B) Hematemesis C) Intestinal hemorrhage D) Hematoma of the nasal septum

B) Hematemesis Although the source of epistaxis may seem obvious, other bleeding locations should be on the differential. Hematemesis can mimic this and cause delay in life-saving therapies if not considered. Intracranial hemorrhage and septal hematoma are instances of contained bleeding. Intestinal hemorrhage may cause hematemesis if there is obstruction distal to the bleeding, but this is unlikely.

Mr. Chin is an 82-year-old man who comes to your office for a routine check. On examination, you notice a somewhat high-pitched murmur in the second right intercostal space during systole. It does not radiate and the rest of his examination is normal for his age. Which is true of the most likely cause of this murmur? A) It often decreases carotid upstroke. B) It carries with it increased risk for cardiovascular disease. C) It is usually accompanied by an S3 gallop. D) It is found in 10% of otherwise normal elderly patients.

B) It carries with it increased risk for cardiovascular disease. This murmur most likely represents aortic sclerosis, a common murmur affecting about one third of those near 60 years of age. It is caused by calcification of the valve and is associated with cardiovascular risk. Aortic sclerosis does not usually cause obstruction to normal flow, so carotid upstroke should be normal, and it is not associated with an S3 gallop.

You have been unable to hear normal S2 splitting in children up to this point. What technique will maximize your chances of hearing this phenomenon? A) Listen with the diaphragm over the left lower sternal border. B) Listen with the bell over the 2nd left intercostal space. C) Listen with the bell over the apex. D) Listen with the diaphragm in the axilla.

B) Listen with the bell over the 2nd left intercostal space .S2 is made of aortic and pulmonic components. Of these, the pulmonic component is much softer and heard best over the pulmonic area. Even in the proper location, the pulmonic component may be difficult to hear with the diaphragm because it is a soft, low-pitched sound. For this reason, the bell should be used to listen for S2 splitting over the pulmonic area during inspiration, when splitting should be maximized. Breathing also changes heart rate more rapidly in children. One may think an arrhythmia is present until she notices that this rate change is related to the respiratory cycle.

You feel a small mass that you think is a lymph node. It is mobile in both theup-and-down and side-to-side directions. Which of the following is most likely? A) Cancer B) Lymph node C) Deep scar D) Muscle

B) Lymph node A useful maneuver for discerning lymph nodes from other masses in the neck is to check for their mobility in all directions. Many other masses are mobile in only two directions. Cancerous masses may also be "fixed," or immobile.

In measuring the jugular venous pressure (JVP), which of the following is important? A) Keep the patient's torso at a 45-degree angle. B) Measure the highest visible pressure, usually at end expiration. C) Add the vertical height over the sternal notch to a 5-cm constant. D) Realize that a total value of over 12 cm is abnormal.

B) Measure the highest visible pressure, usually at end expiration. In measuring JVP, the angle of the patient's torso must be varied until the highest oscillation point, or meniscus is visible. This varies. The landmark used is actually the sternal angle, not the sternal notch. We assign a constant height of 5 cm above the right atrium to this landmark. A value of over 8 cm total (more than 3 cm vertical distance above the sternal angle, plus the 5 cm constant) is considered abnormal.

A 38-year-old accountant comes to your clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region and is an 8 on a scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic and this results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache? A) Tension B) Migraine C) Cluster D) Analgesic rebound

B) Migraine This is a description of a common migraine (no aura). Distinctive features of a migraine include phonophobia and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.

Which valve lesion typically produces a murmur of equal intensity throughout systole? A) Aortic stenosis B) Mitral insufficiency C) Pulmonic stenosis D) Aortic insufficiency

B) Mitral insufficiency This description fits a holosystolic murmur. Because aortic and pulmonic stenosis murmurs vary with the flow of blood during systole, they typically produce a crescendo-decrescendo murmur. The murmur of aortic insufficiency represents backleak across the valve in diastole. It is a decrescendo pattern murmur, which gets softer as the pressure gradient decreases.

You are conducting a pupillary examination on a 34-year-old man. You note that both pupils dilate slightly. Both are noted to constrict briskly when the light is placed on the right eye. What is the most likely problem? A) Optic nerve damage on the right B) Optic nerve damage on the left C) Efferent nerve damage on the right D) Efferent nerve damage on the left

B) Optic nerve damage on the left Because both pupils can constrict, efferent nerve damage is unlikely. light is placed on the left eye, neither a direct nor a consensual response is seen. that the left eye is not perceiving incoming light.When the This indicates

A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? A) Abdominal pain B) Orthopnea C) Hematochezia D) Tenesmus

B) Orthopnea Orthopnea, which is dyspnea that occurs when the patient is lying down and improves when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.

You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is well-controlled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. Which of the following conditions is considered to be a coronary heart disease risk equivalent? A) Hypertension B) Peripheral arterial disease C) Systemic lupus erythematosus D) Chronic obstructive pulmonary disease (COPD)

B) Peripheral arterial disease Peripheral arterial disease is considered to be a coronary heart disease risk equivalent, as are abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.

You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this? A) Normal B) Prehypertension C) Stage 1 hypertension D) Stage 2 hypertension

B) Prehypertension Prehypertension is considered to be a systolic blood pressure from 120 to 139 and a diastolic BP from 80 to 89. Previously, this was considered normal. JNC 7 recommends taking action at this point to prevent worsening hypertension. Research shows that this population is likely to progress to more serious stages of hypertension.

A 78-year-old retired seamstress comes to the office for a routine check-up. You obtain an ECG (electrocardiogram) because of her history of hypertension. You diagnose a previous myocardial infarction and ask her if she had any symptoms related to this. Which of the following symptoms would be more common in this patient's age group for an acute myocardial infarction? A) Chest pain B) Syncope C) Pain radiating into the left arm D) Pain radiating into the jaw

B) Syncope This is an atypical symptom and more likely to be seen in this patient's age group.

Which of the following regarding jugular venous pulsations is a systolic phenomenon? A) The "y" descent B) The "x" descent C) The upstroke of the "a" wave D) The downstroke of the "v" wave

B) The "x" descent The most prominent upstrokes of jugular venous pulsations are diastolic phenomena. These can be timed using the carotid pulse. The only event listed above which is a systolic phenomenon is the "x" descent.

Which of the following is true of jugular venous pressure (JVP) measurement? A) It is measured with the patient at a 45-degree angle. B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP. C) A JVP below 9 cm is abnormal. D) It is measured above the sternal notch.

B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP. Measurement of the JVP is important to assess a patient's fluid status. Although it may be measured at 45°, it is important to adjust the level of the patient's torso so that the blood column is visible. This may be with the patient completely supine or sitting completely upright, depending on the patient. Any measurement greater than 4 cm above the sternal angle is abnormal. This would correspond to a JVP of 9 cm because we add a constant of 5 cm, which is an estimate of the height of the sternal notch above the right atrium.

You are assessing an infant and notice that his nares flare, he has a soft grunt with each breath, and the skin between his ribs is pulled inward with inhalation. What is the significance of these findings? A) These are indicative of a CNS process. B) These are indicative of respiratory distress. C) These are indicative of muscular dystrophy. D) These are frequently accompanied by stridor.

B) These are indicative of respiratory distress. It is critical to notice these findings of respiratory distress. Muscular dystrophy may not allow the appearance of these signs because they are caused by muscular effort. It is hard to find a cause for these signs in the CNS. Stridor is usually inspiratory, so while nasal flaring and retractions may occur, grunting is unusual because exhalation is unimpeded.

A young man is concerned about a hard mass he has just noticed in the midline of his palate. On examination, it is indeed hard and in the midline. There are no mucosalabnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis? A) Leukoplakia B) Torus palatinus C) Thrush (candidiasis) D) Kaposi's sarcoma

B) Torus palatinus Torus palatinus is relatively common and benign but can go unnoticed by the patient for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and is seen in immunosuppressed patients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive individuals and is classically a deep purple.

You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur? A) Upright B) Upright, but leaning forward C) Supine D) Left lateral decubitus

B) Upright, but leaning forward Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). You can further your ability to hear this soft murmur by having the patient hold his breath in exhalation.

You are listening carefully for S2 splitting. Which of the following will help? A) Using the diaphragm with light pressure over the 2nd right intercostal space B) Using the bell with light pressure over the 2nd left intercostal space C) Using the diaphragm with firm pressure over the apex D) Using the bell with firm pressure over the lower left sternal border

B) Using the bell with light pressure over the 2nd left intercostal space S2 splitting is composed of an aortic and pulmonic component. Because the pulmonic component is softer, it can usually be heard only over the 2nd left intercostal space. It is a low-pitched sound and thus should be sought using the bell with light pressure. Conversely, the diaphragm is best used with firm pressure.

A young woman comes in today, complaining of fatigue, irregular menses, and polyuriawhich 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 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. 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.

Which of the following is a "red flag" regarding patients presenting with headache? A) Unilateral headache B) Pain over the sinuses C) Age over 50 D) Phonophobia and photophobia

C) Age over 50 A unilateral headache is often seen with migraines and may commonly be accompanied by phonophobia and photophobia. Pain over the sinuses from sinus congestion may also be unilateral and produce pain. Migraine and sinus headaches are common and generally benign. A new severe headache in someone over 50 can be associated with more serious etiologies for headache. Other red flags include: acute onset, "the worst headache of my life"; very high blood pressure; rash or signs of infection; known presence of cancer, HIV, or pregnancy; vomiting; recent head trauma; and persistent neurologic problems.

Which of the following is a clinical identifier of metabolic syndrome? A) Waist circumference of 38 inches for a male B) Waist circumference of 34 inches for a female C) BP of 134/88 for a male D) BP of 128/84 for a female

C) BP of 134/88 for a male The physical examination criteria for identifying metabolic syndrome include a waist of 40 inches or greater for a male, a waist of 35 inches or greater for a female, and a blood pressure of 130/85 or greater. Other criteria include triglycerides greater than or equal to 150 mg/dL, fasting glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less than 50 for women.

Which of the following events occurs at the start of diastole? A) Closure of the tricuspid valve B) Opening of the pulmonic valve C) Closure of the aortic valve D) Production of the first heart sound (S1)

C) Closure of the aortic valve At the beginning of diastole, the valves which allow blood to exit the heart close.It is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the mitral valve is thought to produce the first heart sound (S1).

A 68-year-old mechanic presents to the emergency room for shortness of breath. You are concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated. Which one of the following conditions is a potential cause of elevated JVP? A) Left-sided heart failure B) Mitral stenosis C) Constrictive pericarditis D) Aortic aneurysm

C) Constrictive pericarditis One cause of increased jugular venous pressure is constrictive pericarditis. Others include right-sided heart failure, tricuspid stenosis, and superior vena cava syndrome. You may wish to read about these conditions.

In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines? A) Every 6 months B) Every year C) Every 2 years D) Every 5 years

C) Every 2 years AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse.

You are participating in a health fair and performing cholesterol screens. One person has a cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease? A) Ethnicity B) Alcohol intake C) Gender D) Asthma

C) Gender Gender is used in the calculation of the 10-year risk for developing coronary heart disease, because men have a higher risk than women.

A 35-year-old bus driver comes to your office for a prenatal visit. She is approximately 28 weeks pregnant and has had no complications. She is complaining only of heartburn and has had no fatigue, headaches, leg swelling, contractions, leakage of fluid, or bleeding. On examination her blood pressure is 142/92 and her urine shows no glucose, protein, or leukocytes. Her weight gain is appropriate, with no large recent increases. Fetal tones are 140 and her uterus measures 32 cm from the pubic bone. Looking back through her chart, you see her prenatal blood pressure was 120/70 and her blood pressures during the first 20 weeks were usually 120 to 130/70 to 80. What type of blood pressure is this? A) Normotensive for pregnancy B) Chronic hypertension C) Gestational hypertension D) Preeclampsia

C) Gestational hypertension Gestational hypertension occurs in women who are normotensive before pregnancy and develop systolic pressures over 140 and diastolic pressures over 90 after week 20 of pregnancy. There will be no protein in the urine and no symptoms of preeclampsia such as rapid weight gain, leg edema, or headaches. These patients must be cautioned about symptoms of preeclampsia and receive aggressive follow-up.

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? A) Dacryocystitis B) Chalazion C) Hordeolum D) Xanthelasma

C) Hordeolum A hordeolum, or sty, is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

A mother brings her infant to you because of a "rattle" in his chest with breathing. Which of the following would you hear if there were a problem in the upper airway? A) Different sounds from the nose and chest B) Asymmetric sounds C) Inspiratory sounds D) Sounds louder in the lower chest

C) Inspiratory sounds It is important to distinguish upper airway sounds from lower because many benign conditions cause upper airway noise, such as viral upper respiratory infections. It is reassuring to hear the same noises at the nose as at the chest. Lower respiratory conditions also are generally symmetric, and sounds are louder at the upper chest versus the lower chest. They are usually very harsh and loud, which concerns parents.

Which is true of a third heart sound (S3)? A) It marks atrial contraction. B) It reflects normal compliance of the left ventricle. C) It is caused by rapid deceleration of blood against the ventricular wall. D) It is not heard in atrial fibrillation.

C) It is caused by rapid deceleration of blood against the ventricular wall. The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.

Mrs. Stanton is a 79-year-old widow who presents to your office for a routine BP visit. You note a new pulsatile mass in the right neck at the carotid artery. Which of the following is the most likely cause for this? A) Anxiety B) Carotid artery aneurysm C) Kinking of the artery D) Tortuous aorta

C) Kinking of the artery While a carotid artery aneurysm is a possibility, it is more likely due to kinking of the carotid artery in this patient with HTN. A tortuous aorta will sometimes cause elevation of the left jugular vein by impairing drainage within the thorax.

You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position? A) Aortic B) Pulmonic C) Mitral D) Tricuspid

C) Mitral The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If you do not listen to the heart in this position with both the diaphragm and bell in a quiet room, it is possible to miss significant murmurs such as mitral stenosis.

Suzanne is a 20-year-old college student who complains of chest pain. This is intermittent and is located to the left of her sternum. There are no associated symptoms. On examination, you hear a short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2. This is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. Which of the following is the most likely diagnosis? A) Mitral stenosis B) Mitral insufficiency C) Mitral valve prolapse D) Mitral valve papillary muscle ischemia

C) Mitral valve prolapse The description above is classic for mitral valve prolapse. The extra sound is a midsystolic click, which is typically a short, high-pitched sound. Mitral stenosis is a soft, low-pitched rumbling murmur which is difficult to hear unless the bell is used in the left lateral decubitus position. Mitral insufficiency is a holosystolic murmur heard best over the apex, and papillary muscle ischemia often creates a mitral insufficiency with its accompanying murmur.

A 55-year-old bank teller comes to your office for persistent episodes of dizziness. The first episode started suddenly and lasted 3 to 4 hours. He experienced a lot of nausea with vomiting; the episode resolved spontaneously. He has had five episodes in the past 11⁄2 weeks. He does note some tinnitus that comes and goes. Upon physical examination, you note that he has a normal gait. The Weber localizes to the right side and the air conduction is equal to the bone conduction in the right ear. Nystagmus is present. Based on this description, what is the most likely diagnosis? A) Benign positional vertigo B) Vestibular neuronitis C) Ménière's disease D) Acoustic neuroma

C) Ménière's disease Ménière's disease is characterized by sudden onset of vertiginous episodes that last several hours to a day or more, then spontaneously resolve; the episodes then recur. On physical examination, sensorineural hearing loss is present. The patient does complain of tinnitus.

A 6-month-old infant is brought in for a well check. It is noted his head circumference is off the chart and at a much higher percentile than was previously measured. What should you do next? A) Recommend a neurology consult. B) Order a CT of the head. C) Remeasure the circumference. D) Admit the child to the hospital for further workup.

C) Remeasure the circumference. It is difficult to obtain accurate measurements of a squirming infant. The first step would be to remeasure. Some recommend starting with three measurements and averaging or picking the middle measurement. Height is technically not measured until a child is standing, so infants' measurements are recorded as length.

On visual confrontation testing, a stroke patient is unable to see your fingers on his entire right side with either eye covered. Which of the following terms would describe this finding? A) Bitemporal hemianopsia B) Right temporal hemianopsia C) Right homonymous hemianopsia D) Binasal hemianopsia

C) Right homonymous hemianopsia Because the right visual field in both eyes is affected, this is a right homonymous hemianopsia. A bitemporal hemianopsia refers to loss of both lateral visual fields. A right temporal hemianopsia is unilateral and binasal hemianopsia is the loss of the nasal visual fields bilaterally.

You are performing a thorough cardiac examination. Which of the following chambers of the heart can you assess by palpation? A) Left atrium B) Right atrium C) Right ventricle D) Sinus node

C) Right ventricle The right ventricle occupies most of the anterior cardiac surface and is easily accessible to palpation. The other structures are less likely to have findings on palpation and the sinus node is an intracardiac structure. You may be able to diagnose abnormal rhythms caused by the sinus node indirectly by palpation, but this is less obvious.

You notice a patient has a strong pulse and then a weak pulse. This pattern continues. Which of the following is likely? A) Emphysema B) Asthma exacerbation C) Severe left heart failure D) Cardiac tamponade

C) Severe left heart failure This finding is consistent with pulsus alternans, which is associated with severe left heart failure. Occasionally, a monitor will read only half of the beats because half are too weak to detect. There may also be electrical alternans on EKG. This can be detected by using a blood pressure cuff and lowering the pressure slowly. At one point the rate of Korotkoff sounds will double, because the weaker beats can then "make it through." The other findings are associated with paradoxical pulse.

A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? A) She obtains a 20% correct score at 100 feet. B) She can accurately name 20% of the letters at 20 feet. C) She can see at 20 feet what a normal person could see at 100 feet. D) She can see at 100 feet what a normal person could see at 20 feet.

C) She can see at 20 feet what a normal person could see at 100 feet. The denominator of an acuity score represents the line on the chart the patient can read. In the example above, the patient could read the larger letters corresponding with what a normal person could see at 100 feet.

You are examining a 5-year-old before he begins school. You notice a systolic, gradeII/VI vibratory murmur over the LLSB and apex with normal S2 splitting. He has normal pulses as well. Which of the following is most likely? A) Tricuspid stenosis B) Mitral stenosis C) Still's murmur D) Venous hum

C) Still's murmur This description is consistent with Still's murmur, a very common and benign murmur of childhood. Tricuspid and mitral stenosis would be diastolic murmurs and the venous hum is usually not heard in this area. Further evaluation is usually not necessary.

A mother is upset because she was told by another provider that her child has a worrisome murmur. You listen near the clavicle and notice both a systolic and diastolic sound. You remember that diastolic murmurs are usually indicative of bad pathology. What would you do next? A) Cardiology referral B) Echocardiogram C) Supine examination D) Reassure the mother

C) Supine examination The next step would be to examine the patient in the supine position. If this is a venous hum, this murmur will resolve almost completely in the supine position. This is a very common phenomenon in school-aged children, particularly over the clavicle, but can also occur outside this range. Reassurance cannot be given without further examination, especially with a diastolic murmur. Cardiology referral and echocardiography are unnecessary if examination in the supine position reveals no murmur.

A woman in her 24th week of pregnancy notices she feels faint when lying down for a period. What would you suspect as a cause for this? A) Adrenal insufficiency B) Orthostatic hypotension C) Supine hypotensive syndrome D) Hypoglycemia

C) Supine hypotensive syndrome It is unusual to become lightheaded in the supine position. The gravid uterus can cause decreased blood return through the inferior vena cava. Orthostatic hypotension as seen in adrenal insufficiency and with moderate dehydration will cause these symptoms in the upright position. Hypoglycemia should not be positional.

A patient presents with a left-sided facial droop. On further testing, you note that he isunable 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. 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.

How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure? A) 25% B) 50% C) 75% D) 100%

D) 100% Each increase of BP by 20 systolic and 10 diastolic doubles the risk of cardiovascular disease. Being "low risk" by JNC 7 criteria confers a 72%-85% reduction in CVD mortality and 40%-58% reduction in overall mortality.

To hear a soft murmur or bruit, which of the following may be necessary? A) Asking the patient to hold her breath B) Asking the patient in the next bed to turn down the TV C) Checking your stethoscope for air leaks D) All of the above

D) All of the above All examiners should carefully search for soft murmurs and bruits. These can have great clinical significance. A quiet patient and room, as well as an intact stethoscope, will greatly increase your ability to hear soft sounds.

Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell? A) Mitral stenosis murmur B) Opening snap of the mitral valve C) S3 and S4 gallops D) All of the above

D) All of the above Placing the patient in the left lateral decubitus position and auscultating with the bell will enable you to hear these sounds, which would otherwise be missed.

Diplopia, which is present with one eye covered, can be caused by which of the following problems? A) Weakness of CN III B) Weakness of CN IV C) A lesion of the brainstem D) An irregularity in the cornea or lens

D) An irregularity in the cornea or lens Double vision in one eye alone points to a problem in "processing" the light rays of an incoming image. The other causes of diplopia result in a misalignment of the two eyes.

You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you search out? A) Mitral valve prolapse B) Pulmonic stenosis C) Tricuspid insufficiency D) Aortic insufficiency

D) Aortic insufficiency Bounding carotid pulses would be found in aortic insufficiency. This should be sought by listening over the third left intercostal space, with the patient leaning forward in held exhalation. This is a very soft diastolic murmur usually. A bounding pulse may also be seen in any condition which increases cardiac output, including stimulant use, anxiety, hyperthyroidism, fever, etc.

Very sensitive methods for detecting hearing loss include which of the following? A) The whisper test B) The finger rub test C) The tuning fork test D) Audiometric testing

D) Audiometric testing While it is important to screen for hearing complaints with methods available to you, it should be realized that some physical examination techniques are limited. Nonetheless, you should be comfortable performing these tests, as audiometric testing is not always available.

Which of the following changes are expected in vision as part of the normal aging process? A) Cataracts B) Glaucoma C) Macular degeneration D) Blurring of near vision

D) Blurring of near vision The lens loses its elasticity over time as part of the normal aging process, and the eye is less able to accommodate and focus on near objects; therefore, the patient will be expected to have blurring of near vision.

A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left. Which of the following is likely? A) CN IX lesion on the left B) CN IX lesion on the right C) CN X lesion on the left D) CN X lesion on the right

D) CN X lesion on the right The failure of the right side of the palate to rise denotes a problem with the right 10th cranial nerve. The uvula deviates toward the properly functioning side.

You are examining an infant in the nursery and notice a soft bump over the posterior right side of the skull. It is not evident on the left. What does this represent? A) Caput succedaneum B) Plagiocephaly C) Craniosynostosis D) Cephalohematoma

D) Cephalohematoma Cephalohematoma represents bleeding under the periosteum, which is why this lesion does not cross the midline. The blood can contribute to neonatal jaundice as it breaks down. Caput succedaneum is commonly seen as a spongy mass over the vertex, particularly when vacuum extraction is used. Craniosynostosis describes a premature closure of bony skull sutures, and plagiocephaly is a flattening of the parieto-occipital region on one side of the skull, which is frequently thought to be positional.

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.

Which of the following is worrisome in Melissa, a woman in her 26th week of pregnancy? A) Generalized hair loss B) A hyperpigmented rash over the maxillary region bilaterally C) Nosebleeds D) Facial edema

D) Facial edema Generalized hair loss, hyperpigmented maxillary rash (chloasma), and nosebleeds are usually benign and common in pregnancy. Facial edema after the 24th week of gestation may indicate gestational hypertension.

Lucille is in her 24th week. You notice a new onset of high blood pressure readings. Today's value is 168/96. Her urine is normal. What do you suspect? A) Preeclampsia B) Chronic hypertension C) Supine hypotensive syndrome D) Gestational hypertension

D) Gestational hypertension Because Lucille's BP is greater than 140/90 with onset after the 20th week and no proteinuria, this is gestational hypertension. Chronic hypertension, while the same BP cutoff is used, is present before the 20th week. If this patient had accompanying proteinuria, preeclampsia could be considered. Supine hypotensive syndrome does not cause hypertension.

On routine screening you notice that the cup-to-disc ratio of the patient's right eye is 1:2. What ocular condition should you suspect? A) Macular degeneration B) Diabetic retinopathy C) Hypertensive retinopathy D) Glaucoma

D) Glaucoma This cup-to-disc ratio means that the cup takes up 50% of the disc, which is abnormally large. This is usually an indication of glaucoma, which is a common cause of visual loss in the elderly. The cup-to-disc changes are not seen in diabetes, hypertension, or macular degeneration. Many elderly do not have regular eye examinations and are not screened for glaucoma.

A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally. Which of the following have you essentially excluded from your differential? A) Retinoblastoma B) Cataract C) Artificial eye D) Hypertensive retinopathy

D) Hypertensive retinopathy Hypertensive retinopathy requires a careful examination of the optic fundus. It cannot be diagnosed or excluded merely from the red reflex. Typically, the red reflex would be normal in this case. The other conditions are all associated with an abnormal red reflex.

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 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.

Which of the following is true of a grade 4-intensity murmur? A) It is moderately loud. B) It can be heard with the stethoscope off the chest. C) It can be heard with the stethoscope partially off the chest. D) It is associated with a "thrill."

D) It is associated with a "thrill." The grade 4 murmur is differentiated from those below it by the presence of a palpable thrill. A murmur cannot be graded as a 4 unless this is present. The thrill is a "buzzing" feeling over the area where the murmur is loudest. For practice, you may often feel a thrill over a dialysis fistula.

Sudden, painful unilateral loss of vision may be caused by which of the following conditions? A) Vitreous hemorrhage B) Central retinal artery occlusion C) Macular degeneration D) Optic neuritis

D) Optic neuritis In multiple sclerosis, sudden painful loss of vision may accompany optic neuritis. The other conditions are usually painless.

A 15-month-old is brought to you for a fever of 38.6 degrees Celsius and fussiness. The ear examination is as follows: external ear, normal appearance and no tenderness with manipulation; canal, normal diameter without evidence of inflammation; tympanic membrane, bulging, erythematous, and opaque. Insufflation is deferred due to pain. What is your diagnosis? A) Otitis externa B) Cholesteatoma C) Ruptured tympanic membrane D) Otitis media

D) Otitis media There is no inflammation of the outer ear, including the canal, thus excluding otitis externa. Cholesteatoma is a painless white lesion behind the TM. There is no drainage from the TM; thus, rupture is unlikely. This is a classic description of otitis media. Many examiners will forego insufflation if the diagnosis is clear, because this can cause discomfort in an already uncomfortable ear.

A 73-year-old nurse comes to your office for evaluation of new onset of tremors. She is not on any medications and does not take herbs or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow movements and shuffling steps. She has decreased facial mobility and a blunt expression, without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the patient's symptoms? A) Cushing's syndrome B) Nephrotic syndrome C) Myxedema D) Parkinson's disease

D) Parkinson's disease This is a typical description for a patient with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression—a "masked" appearance. The patient also has decreased blinking and a characteristic stare with an upward gaze. In combination with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is almost clinched.

A college student presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this? A) Submandibular B) Tonsillar C) Occipital D) Posterior cervical

D) Posterior cervical The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.

A 67-year-old lawyer comes to your clinic for an annual examination. He denies any history of eye trauma. He denies any visual changes. You inspect his eyes and find a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis? A) Corneal arcus B) Cataracts C) Corneal scar D) Pterygium

D) Pterygium A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere with vision as it encroaches on the pupil. Otherwise, treatment is unnecessary.

A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? A) Conjunctivitis B) Acute iritis C) Corneal abrasion D) Subconjunctival hemorrhage

D) Subconjunctival hemorrhage A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turning yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rarely caused by a serious condition, so reassurance is usually the only treatment necessary.