COMBINED

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

A) About 10%

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

A) Breast tissue

Frank is a 24-year-old man who presents with multiple burning erosions on the shaft of his penis and some tender inguinal adenopathy. Which of the following is most likely? A) Primary syphilis B) Herpes simplex C) Chancroid D) Gonorrhea

B) Herpes simplex

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) Bleeding from a peptic ulcer

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

D) Irritable bowel syndrome

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

C) Determine liver span by percussion

Francis is a middle-aged man who noted right-sided lower abdominal pain after straining with yard work. Which of the following would make a hernia more likely? A) Absence of pain with straining B) Absence of bowel sounds in the scrotum C) Absence of a varicocele D) Absence of symmetry of the inguinal areas with straining

D) Absence of symmetry of the inguinal areas with straining

A 32-year=old male complains of a painless, cystic mass just above his left testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in question and transillumination in noted. What is the most likely diagnosis? a. Spermatocele b. Direct hernia c. Testicular torsion d. Indirect hernia e. Varicocele

a. Spermatocele

The human papilloma virus (HPV) can cause genital warts in males and females as well as vertical cancer in females. Vaccination against HPV is available and should be offered to males between what ages? a. 1-3 years b. 9-21 years c. 6-9 years d. 5-7 years e. 30-50 years

b. 9-21 years

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

Induration along the ventral surface of the penis suggests which of the following? A) Urethral stricture B) Testicular carcinoma C) Peyronie's disease D) Epidermoid cysts

A) Urethral stricture

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

B) Examination with the abdominal muscles tensed

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

B) His spleen is possibly enlarged and close attention should be paid to further examination.

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

B) Imbalance of hormones of puberty

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

A) Acute appendicitis

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

A) Acute diverticulitis

A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged and tender. He isn't sure if he has had burning with urination and he says he has never had sexual intercourse. He has had a sore throat, cough, and runny nose for the last 3 days. His past medical history is significant for a tonsillectomy as a small child. His father has high blood pressure and his mother is healthy. On examination you see a teenager in no acute distress. His temperature is 100.8 and his blood pressure and pulse are unremarkable. On visualization of his penis, he is uncircumcised and has no lesions or discharge. His scrotum is red and tense on the left and normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. The right testicle is unremarkable. An examining finger is put through both inguinal rings, and there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is also unremarkable. What abnormality of the testes does this teenager most likely have? A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis

A) Acute orchitis

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

A) Benign breast abnormality

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

B) Irregular, large liver

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

A) Breast cancer

A 20-year-old part-time college student comes to your clinic, complaining of growths on his penile shaft. They have been there for about 6 weeks and haven't gone away. In fact, he thinks there may be more now. He denies any pain with intercourse or urination. He has had three former partners and has been with his current girlfriend for 6 months. He says that because she is on the pill they don't use condoms. He denies any fever, weight loss, or night sweats. His past medical history is unremarkable. In addition to college, he works part-time for his father in construction. He is engaged to be married and has no children. His father is healthy and his mother has hypothyroidism. On examination the young man appears healthy. His vital signs are unremarkable. On visualization of his penis you see several moist papules along all sides of his penile shaft and even two on the corona. He has been circumcised. On palpation of his inguinal region there is no inguinal lymphadenopathy. Which abnormality of the penis does this patient most likely have? A) Condylomata acuminata B) Genital herpes C) Syphilitic chancre D) Penile carcinoma

A) Condylomata acuminata

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

A) First-degree relative with premenopausal breast cancer

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

A) Five to seven days following her menses

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

A) Hepatitis A

A 36-year-old security officer comes to your clinic, complaining of a painless mass in his scrotum. He found it 3 days ago during a testicular self-examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. His past medical history is notable for high blood pressure. He is married and has three healthy children. He denies using illegal drugs, smokes two to three cigars a week, and drinks six to eight alcoholic beverages per week. His mother is in good health and his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis, he is circumcised and has no lesions. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft cystic-like lesion measuring 2 cm over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight bearing there are no bulges. His prostate examination is unremarkable. What disorder of the scrotum does he most likely have? A) Hydrocele B) Scrotal hernia C) Testicular tumor D) Varicocele

A) Hydrocele

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

A) It is a splenic rub.

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

A) Nipple retraction

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

A) Obtain abdominal ultrasound

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

B) Lymphadenopathy of infectious origin

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

B) One breast larger than the other

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

B) 50%

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

B) Acanthosis nigricans

A 22-year-old unemployed roofer presents to your clinic, complaining of pain in his testicle and penis. He states the pain began last night and has steadily become worse. He states it hurts when he urinates and he has not attempted intercourse since the pain began. He has tried Tylenol and ibuprofen without improvement. He denies any fever or night sweats. His past medical history is unremarkable. He has had four previous sexual partners and has had a new partner for the last month. She is on oral contraceptives so he has not used condoms. His parents are both in good health. On examination you see a young man lying on his side. He appears mildly ill. His temperature is 100.2 and his blood pressure, respirations, and pulse are normal. On visualization of the penis he is circumcised, wi th no lesions or discharge from the meatus. Visualization of the scrotal skin appears unremarkable. Palpation of the testes shows severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells and bacteria. What diagnosis of the male genitalia is most likely in this case? A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis

B) Acute epididymitis

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

B) Breast cancer

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

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

B) Paget's disease

Which of the following conditions involves a tight prepuce which, once retracted, cannot be returned? A) Phimosis B) Paraphimosis C) Balanitis D) Balanoposthitis

B) Paraphimosis

Jim is a 47-year-old man who is having difficulties with sexual function. He is recently separated from his wife of 20 years. He notes that he has early morning erections but otherwise cannot function. Which of the following is a likely cause for his problem? A) Decreased testosterone levels B) Psychological issues C) Abnormal hypogastric arterial circulation D) Impaired neural innervation

B) Psychological issues

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

B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated

A 29-year-old married computer programmer comes to your clinic, complaining of "something strange" going on in his scrotum. Last month while he was doing his testicular self-examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable. What disorder of the testes is most likely the diagnosis? A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele

B) Scrotal hernia

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

B) They should be examined carefully along the surgical scar for masses.

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

B) Ureteral pain (from a kidney stone)

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

B) Urge incontinence

A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a "bag of worms" in the left scrotum, superior to the testicles. Which of the following is most likely? A) Hydrocele of the spermatic cord B) Varicocele C) Testicular carcinoma D) A normal vas deferens

B) Varicocele

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

C) A high proportion of breast masses are detected by breast self-examination.

Which of the following would lead you to suspect a hydrocele versus other causes of scrotal swelling? A) The presence of bowel sounds in the scrotum B) Being unable to palpate superior to the mass C) A positive transillumination test D) Normal thickness of the skin of the scrotum

C) A positive transillumination test

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

C) Esophageal varices

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

C) Every 3 years

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

C) Examine in lines resembling the back and forth pattern of mowing a lawn.

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

C) Inspection, auscultation, percussion, palpation

A 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

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

C) Ischemia

A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn't know if intercourse would hurt. He states he has become more tired lately and has also gained 10 pounds in the last month. He denies any fever or weight loss. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is married and has five children. He is currently on disability because of his health problems. Both of his parents died of complications of diabetes. On examination you see a pleasant male appearing chronically ill. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges. The prostate is smooth and nontender. What abnormality of the scrotum is most likely the diagnosis? A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele

C) Scrotal edema

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

C) Supernumerary nipple

A 28-year-old musician comes to your clinic, complaining of a "spot" on his penis. He states his partner noticed it 2 days ago and it hasn't gone away. He says it doesn't hurt. He has had no burning with urination and no pain during intercourse. He has had several partners in the last year and uses condoms occasionally. His past medical history consists of nongonococcal urethritis from Chlamydia and prostatitis. He denies any surgeries. He smokes two packs of cigarettes a day, drinks a case of beer a week, and smokes marijuana and occasionally crack. He has injected IV drugs before but not in the last few years. He is single and currently unemployed. His mother has rheumatoid arthritis and he doesn't know anything about his father. On examination you see a young man appearing deconditioned but pleasant. His vital signs are unremarkable. On visualization of his penis there is a 6-mm red, oval ulcer with an indurated base just proximal to the corona. There is no prepuce because of neonatal circumcision. On palpation the ulcer is nontender. In the inguinal region there is nontender lymphadenopathy. What disorder of the penis is most likely the diagnosis? A) Condylomata acuminata B) Genital herpes C) Syphilitic chancre D) Penile carcinoma

C) Syphilitic chancre

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

C) The presence of normal tympany over this area

A 15-year-old high school football player is brought to your office by his mother. He is complaining of severe testicular pain since exactly 8:00 this morning. He denies any sexual activity and states that he hurts so bad he can't even urinate. He is nauseated and is throwing up. He denies any recent illness or fever. His past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. On examination you see a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. His blood pressure is 150/100, his pulse is 110, and his respirations are 24. On visualization of the penis he is circumcised and there are no lesions and no discharge from the meatus. His scrotal skin is tense and red. Palpation of the left testicle causes severe pain and the patient begins to cry. His prostate examination is unremarkable. His cremasteric reflex is absent on the left but is normal on the right. By catheter you get a urine sample and the analysis is unremarkable. You send the boy with his mother to the emergency room for further workup. What is the most likely diagnosis for this young man's symptoms? A) Acute orchitis B) Acute epididymitis C) Torsion of the spermatic cord D) Prostatitis

C) Torsion of the spermatic cord

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

C) Ureteral stone

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

D) Acute pancreatitis

A tender, painful swelling of the scrotum should suggest which of the following? A) Acute epididymitis B) Strangulated inguinal hernia C) Torsion of the spermatic cord D) All of the above

D) All of the above

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

D) All of the above

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

D) Appendicitis

You are examining a newborn and note that the right testicle is not in the scrotum. What should you do next? A) Refer to urology B) Recheck in 6 months C) Tell the parent the testicle is absent but that this should not affect fertility D) Attempt to bring down the testis from the inguinal canal

D) Attempt to bring down the testis from the inguinal canal

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

D) Central

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

D) Enlarged bladder

A 45-year-old electrical engineer presents to your clinic, complaining of spots on his scrotum. He first noticed the spots several months ago, and they have gotten bigger. He denies any pain with urination or with sexual intercourse. He has had no fever, night sweats, weight gain, or weight loss. His past medical history consists of a vasectomy 10 years ago and mild obesity. He is on medication for hyperlipidemia. He denies any tobacco or illegal drug use and drinks alcohol socially. His mother has Alzheimer's disease and his father died of leukemia. On examination he appears relaxed and has unremarkable vital signs. On visualization of his penis, he is circumcised and has no lesions on his penis. Visualization of his scrotum shows three yellow nodules 2-3 millimeters in diameter. During palpation they are firm and nontender. What abnormality of the male genitalia is this most likely to be? A) Condylomata acuminata B) Syphilitic chancre C) Peyronie's disease D) Epidermoid cysts

D) Epidermoid cysts

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

D) Hypothyroidism

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

D) Listen closely to her abdomen

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

D) Tympany which changes location with patient position

A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn't change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He is a married hospital administrator with two children. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On examination you see a young man appearing his stated age with unremarkable vital signs. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down, you feel no bulges. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate examination is unremarkable. What abnormality of the scrotum does he most likely have? A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele

D) Varicocele

A 87-year-old retire man with history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is put up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticulitis were found on colonoscopy. He has not first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the US Preventive Services Task Force (USPSTF) screening recommendations for this patients? a. Continue annual FOBT screening until age 80 years b. Sigmoidoscopy every 5 years with FOBT every 3 years c. Report colonoscopy this year b. Do not screen routinely e. Continue annual FOBT screening until age 85 years

b. Do not screen routinely

While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to eh inguinal canal and related hernias. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region? a. External inguinal ring b. Internal inguinal ring c. Direct inguinal hernia d. Pubic tubercle e. Anterior superior iliac spine

b. Internal inguinal ring

A newborn baby has an embryologic defect affecting the aortic valve. What other cardiac valve is most likely to be affected? a) Pyloric valve b) Mitral valve c) Pulmonic valve d) Eustachian valve e) Tricuspid valve

c) Pulmonic valve The pulmonic and aortic valves are semilunar valves and have similar embryologic origin. The tricuspid and mitral valves are atrioventricular valves. The pyloric valve is located between the stomach and small intestine. The Eustachian valve lies at the junction of the inferior vena cava and right atrium.

A 59‐year‐old unemployed man complains of almost always feeling tired and hungry, despite getting sufficient rest and having a good appetite and access to sufficient food. The patient is obese and, despite the warm weather outside, wearing thermal socks with his sandals. He says this is because his feet are always cold and "feel funny." With which body system should the clinician begin the examination? a) Posterior thorax b) Head and neck c) Lower extremities d) Nervous system e) Abdomen

b) Head and neck The physical examination should proceed "head to toe" to optimize patient comfort; minimize the number of changes in patient position; and, because it is always done in the same way, to ensure that nothing is missed. Even though symptoms are reported in the lower extremities, the examination will attend to this region at the appropriate time. The same argument applies to the posterior thorax, abdomen, and nervous system.

A 14‐year‐old male presents to a new primary care provider after his family relocates to a state. The patient underwent treatment for sarcoma when he was age 11 years, including an above‐the‐ knee amputation. He has learned to successfully navigate with a prosthetic leg and even engage in competitive athletics at school. He does not like to speak of his experience with cancer and often makes up humorous stories to tell new acquaintances about his amputation (such as, "I got bit by a squirrel and they had to amputate."). Although he is very well engaged in most of the visit with the new clinician, when the topic of cancer arises, he demurs to his father, who accompanies him to this appointment. Which of the following statements is most likely to be helpful in cementing the patient's trust in the new provider? a) "That sounds like a frightening experience that you are recovering well from." b) "You have recovered well and should start moving on with your life." c) "You cannot rely on your father for support forever." d) "You need to see a counselor since you have not adjusted well to your new condition." e) "You are becoming an adult and must be able to talk about your health."

a) "That sounds like a frightening experience that you are recovering well from." This patient is exhibiting an emotional cue that bears exploring—that is, his reticence to speak of a difficult event and his deference to his parent when the topic arises. Drawing on strength and acknowledging the patient's struggle is the best way to open up conversations around behavioral health, transitioning his care to a more adult model, and future risks from the disease itself. "You are becoming an adult and must be able to talk about your health." is incorrect because the patient will eventually be responsible for his own health, this approach is somewhat accusatory and puts the patient in a situation of feeling that he is doing wrong. Moreover, at the age of 14, he still has several years during which adult support at his appointments is very appropriate. "You need to see a counselor since you have not adjusted well to your new condition." is incorrect because behavioral health support may be appropriate for a child who has survived cancer, there is no evidence that this patient has not adapted to his status as a cancer survivor in an age‐appropriate way. Behavioral health resources that are coerced are unlikely to be well accepted by patients of any age. "You have recovered well and should start moving on with your life." is incorrect because this patient has shown age‐appropriate adjustment to his condition, including re‐engaging in challenging activities such as sports. This response again puts the patient on the defensive, as it appears accusatory that he has done something wrong or inadequately. "You cannot rely on your father for support forever." is incorrect because this is technically correct, as the child is likely to outlive the father; this response appears condescending and accusatory at a time when the patient would benefit most from connection and rapport with the new provider.

The positive predictive value of a test is calculated as the number of true positives identified by the test divided by the total positives found by the test. If a novel test for strep throat yields 150 true‐positive results and 150 false‐positive results, what is the positive predictive value of this test? a) 50% b) 10% c) 75% d) 25% e) 100%

a) 50% According to the formula, the positive predictive value is calculated as the number of true positives identified by the test divided by the total positives found by the test, or 150÷(150 + 150) = 50%. 10%, 25%, 75%, and 100%are incorrect because these answers would not be obtained using the formula given above for positive predictive value.

A 70‐year‐old man complains of double vision. Which of the following associated symptoms or signs would be worrying about an underlying neurological problem (as opposed to pathology in the eye)? a) Abnormality in extraocular movements on examination b) Symptoms of flashing lights c) An associated conjunctivitis d) Diplopia persisting in the right eye when the left eye is closed e) Worsening vision bilaterally on examination

a) Abnormality in extraocular movements on examination Paralysis or weakness of extraocular muscles suggests a possible brainstem or cerebellar lesion. Diplopia persisting in the right eye when the left eye is closed is incorrect. Diplopia in one eye while the other eye is closed suggests a problem in the cornea or lens. An associated conjunctivitis is incorrect. Conjunctivitis is an independent problem and generally a minor one. Worsening vision bilaterally on examination is incorrect. Worsening bilateral vision is common among elderly patients. Symptoms of flashing lights is incorrect. Flashing lights suggest vitreous floaters, although it could suggest detached vitreous from the retina.

A 32‐year‐old office worker reports excessive stress at work and pain in the right lower quadrant. She states that last night she vomited twice. Her blood pressure is 120/75, heart rate 93 bpm. The patient looks pale and is sweating lightly. Which of the following is an objective finding? a) Accelerated heart rate b) Pain in the right lower quadrant c) History of vomiting d) Pale appearance e) High stress level

a) Accelerated heart rate Objective findings are those detected on physical examination by the clinician. A resting heart rate of 93bpm is higher than normal. Pain in the right lower quadrant, history of vomiting, and the patient's high stress level are all subjective findings because they rely on the patient's report. A pale appearance is not necessarily an objective finding, because what appears pale to one clinician might not appear pale to another.

A 16‐year‐old male high school student presents with a primary concern of acne. He relates a history of 2 years of moderate mild acne and closed comedones (whiteheads), which have recently worsened such that a classmate started calling him a pirate due to a large pustule that developed at the tip of his nose. He has increasing outbreaks of cyst‐like acne as well as a generally poor complexion with pitting and scarring from prior outbreaks. Which of the following best describes this condition in the adolescent population? a) Acne vulgaris is associated with blockage of sebaceous glands, stress, humidity, and heavy sweating as well as other contributory factors. b) Acne vulgaris affects <50% of the adolescent population. c) The primary hormonal stimulus for acne vulgaris is estrogen, causing preferentially worse cases in females and males with lower testosterone levels. d) Acne vulgaris is associated with an identified virus for which there is no definitive treatment. e) Acne vulgaris is always associated with underlying endocrine disorders and/or pituitary dysfunction.

a) Acne vulgaris is associated with blockage of sebaceous glands, stress, humidity, and heavy sweating as well as other contributory factors. Acne vulgaris is associated with blockage of sebaceous glands, stress, humidity, and heavy sweating as well as other contributory factors. Acne vulgaris is extremely common in adolescents and has many factors that modify its prevalence, including anatomic, hormonal, and behavioral components. Acne vulgaris affects <50% of the adolescent population is incorrect. This condition affects ~85% of adolescents. Acne vulgaris is associated with an identified virus for which there is no definitive treatment is incorrect. Acne is associated with the normal skin bacteria Propionibacterium acne, which is an anaerobic diphtheroid. Severe cases can be treated with daily antibiotics. The primary hormonal stimulus for acne vulgaris is estrogen, causing preferentially worse cases in females and males with lower testosterone levels is incorrect. Androgens, not estrogens, are the primary hormonal trigger for acne. Acne vulgaris is always associated with underlying endocrine disorders and/or pituitary dysfunction is incorrect. Though acne can be associated with endocrine disorders (such as polycystic ovarian syndrome in women, which results in an excess of androgens), most acne is not rooted in underlying disorders and does not require extensive evaluation.

A 13‐year‐old girl is brought by her mother to the clinic one day before the start of eighth grade because of a 3‐day history of episodes of shortness of breath. When she gets the shortness of breath, she also notices tingling around her lips. She has no fever, cough, sputum production, or chest pain. She has no history of serious illness and takes no medications. Vital signs are within normal limits. Cardiac, lung, and extremity examinations show no abnormalities. Which of the following is the most likely diagnosis? a) Anxiety b) Asthma c) Left‐sided heart failure d) Aspiration of a foreign body e) Pneumonia

a) Anxiety Tingling around the lips can be a symptom of anxiety. The start of a new school year can be anxiety provoking for children. The normal lung examination is consistent with anxiety. Aspiration of a foreign body is incorrect. She does not have a cough. Putting a foreign body in her mouth and aspirating it would be unusual at her age. Asthma is incorrect. Asthma is a possible cause of shortness of breath but is less likely in this girl because of the tingling around her lips and lack of cough or chest tightness, in addition to the lack of wheezing on examination. Left‐sided heart failure is incorrect. Left‐sided heart failure is uncommon in children. She also has no other symptoms of heart failure, such as orthopnea or paroxysmal nocturnal dyspnea. She has no history of heart disease, high blood pressure, or other conditions that could put at an increased risk of heart disease. She also has no crackles on lung auscultation, which can be heard in left‐sided heart failure. Pneumonia is incorrect. Pneumonia is less likely than anxiety because of the lack of other characteristic symptoms of pneumonia (fever, cough, sputum production, and chest pain) and the normal lung examination.

Parents bring in their 3‐year‐old toddler, stating that he has been pulling at his right ear and fussing all day. Examination of the auditory canal shows a small green plastic toy piece partially obstructing the passage. Which cranial nerve (CN) supplies the sensory innervation to that area and is conducting the boy's pain sensation? a) CN IX b) CN VII c) CN XI d) CN XII e) CN X

a) CN IX The glossopharyngeal nerve (CN IX) is a mixed sensorimotor nerve; it innervates the muscles of the pharynx and provides sensory fibers to portions of the tympanic membrane, auditory canal, pharynx, and the posterior third of the tongue. CN VII is incorrect because the facial nerve is a mixed sensorimotor nerve, innervates the muscles of facial expression, and supplies sensation for the anterior two thirds of the tongue. CN X is incorrect because the vagus nerve supplies sensorimotor innervation to the pharynx and larynx and motor innervation to the palate. CN XI is incorrect because the spinal accessory nerve is a motor nerve innervating the sternocleidomastoid and trapezius (upper portion) muscles. CN XII is incorrect because the hypoglossal is the motor nerve innervating the tongue.

A 59‐year‐old patient presents to his primary care provider with a history of several episodes of sharp epigastric pain. His father died of pancreatic cancer at age 52 years, and the patient recalls to the clinician that, "His pain was just like mine is now . . ." The patient then pauses several seconds. The clinician replies, "Just like?" after which the patient restarts his narrative. Which of the following is an example of the interviewing techniques employed by the clinician? a) Echoing b) Clarifying c) Eliciting a graded response d) Encouraging with continuers e) Asking a leading question

a) Echoing Echoing is the technique of repeating the patient's last words in a questioning voice to encourage the patient to continue their narrative. This approach demonstrates active listening and indicates the clinician's desire to hear in more detail without derailing the patient's narrative. Clarifying is incorrect because it (also an example of active listening) requires that the clinician repeat the patient's concerns alongside a question eliciting more detail (such as, "His pain . . . was that also located above the belly button as yours is?"). Encouraging with continuers is incorrect because this technique uses neutral words that encourage a patient to expand without exactly repeating the patient's words. "Mmm hmm . . ." and "Go on . . ." are examples of encouragement with continuers. Eliciting a graded response is incorrect because this allows a spectrum of responses, such as "How many steps can you climb?" This clinician is instead utilizing the technique of echoing. Asking a leading question is incorrect because it is one that pushes the patient to answer in the positive, such as, "That chest pain is probably from your heart, isn't it?" This is not an example of appropriate interviewing skills.

Concerning hallucinations, an abnormal perception experienced by a patient, which of the following statements is true about this abnormality? a) It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia. b) They include false perceptions associated with dreaming and occurring with falling asleep and awakening. c) Objective testing can be performed by a trained neuropsychologist to ascertain the correct diagnosis associated with this complaint. d) Although alcoholism may be associated with abnormalities of perception, it is not considered a cause of hallucinations as this finding is due to its direct toxic effects. e) By definition, hallucinations are confined to those abnormal perceptions that are either auditory or visual in nature.

a) It may occur in association with a number of conditions including delirium and dementia, posttraumatic stress disorder (PTSD), and schizophrenia. Hallucinations may be associated with a number of different primary diagnoses. By definition, they exclude perceptions occurring with dreaming or close to falling asleep or awakening. As hallucinations are a subjective patient self‐reported complaint, objective testing is not available. Alcohol is a known cause of hallucinations, and abnormal perceptions may include ones of a gustatory, olfactory, and tactile nature.

A first‐year medical student is examining a standardized patient with a structurally normal heart. The student is having difficulty auscultating the splitting of the second heart sound. At what area on the patient's chest would the student have the best opportunity of hearing this sound? a) Left second and third interspace b) Midsternum c) Right second interspace d) Lower left sternal border e) Apex

a) Left second and third interspace The pulmonic area is the left second and third interspace close to the sternum. The mitral area is at the apex. The right second interspace overlies the aortic valve. The tricuspid space is the lower left sternal border. The midsternum does not correspond to the anatomic location of any of the four cardiac valves; however, it is important to remember that murmurs radiate and must be interpreted in the setting of the clinical scenario.

A 47‐year‐old fitness trainer visits the physician assistant (PA) because of skin dryness, night sweats, and irregular menstrual periods. It is the PA's first contact with this patient. The patient notes that "My sex life has really gone downhill lately" and says that she is considering divorcing her husband of 20 years, stating that "He's not a bad guy. I just think that I can do better." In which of the following ways should the clinician proceed? a) Obtain a menstrual history for the previous 6 months. b) Help the patient review the pros and cons of divorce. c) Conduct a breast examination. d) Inform the patient that menopause is a normal part of aging. e) Determine the patient's out‐of‐country travel history.

a) Obtain a menstrual history for the previous 6 months. It is important to review the seven attributes of a patient's principal symptom(s), which in this case are skin dryness, night sweats, reduced interest in sex, and irregular menstrual periods. Helping the patient review the pros and cons of divorce would not address her physical symptoms. Informing the patient that menopause is a normal part of aging, although perhaps appropriate in the longer term, is premature since it has not been determined that she is perimenopausal. There are no symptoms that would prompt the clinician to conduct a breast examination. Symptoms that might lead one to determine the patient's out‐of‐country travel historyinclude a rash, fever, or other signs of infection, which are absent here.

A 29‐year‐old waiter comes to the clinic for a 2‐month history of a cough. When he lowers his gown so the clinician can listen to his lungs, the clinician notices a depression of the lower part of his sternum. Which of the following best describes the appearance of his chest? a) Pectus excavatum b) Flail chest c) Thoracic kyphoscoliosis d) Pigeon chest e) Barrel chest

a) Pectus excavatum Pectus excavatum is a congenital abnormality in which the inferior part of the sternum is displaced inward. Barrel chest is incorrect. In a barrel chest there is an increased anteroposterior diameter. A barrel chest often accompanies chronic obstructive pulmonary disease. Flail chest is incorrect. The injured area of a flail chest moves inward with inspiration and moves outward with expiration. Pigeon chest is incorrect. Pigeon chest, also known as pectus carinatum, is a congenital abnormality in which the sternum is displaced anteriorly. Thoracic kyphoscoliosis is incorrect. Thoracic kyphoscoliosis is characterized by abnormal spinal curvatures and vertebral rotation, which are visible posteriorly (rather than anteriorly).

An 82‐year‐old retired insurance broker complains of difficulty in walking, having to consciously lift up his feet so he does not trip, stumble, or fall. Both feet are affected equally; he has no sensory complaints or pain. This has been worsening over the past 3 years, and he has had to give up his beloved hiking. The symptoms are improved while wearing tall boots and worse when walking around the house with house slippers. What is the likely location of the pathology in this man? a) Peripheral nerve b) Brainstem c) Distal muscle d) Lumbar spinal cord e) Frontal motor area of the cerebral cortex

a) Peripheral nerve Pure motor neuropathy would first affect the distal extremity farthest away from the motor neuron based simply on the length of the nerve. The symptoms are symmetrical. Support of the tall, rigid boot would help to maintain the function of the weakened foot and ankle muscles; house slippers would do the opposite. Frontal motor area of the cerebral cortex is incorrect because the symptoms are bilateral, symmetrical, and distal; most bilateral, symmetrical distal motor symptoms are not caused by cortical pathology, which would require symmetrical, bilateral brain lesions. Brainstem is incorrect. Because the brainstem is compact, filled with multiple ascending and descending motor and sensory tracts to cranial and spinal nerves, lesions affecting bilateral descending motor tracts would also impinge on other structures, causing a multitude of other symptoms and signs. Lumbar spinal cord is incorrect because a spinal lesion causing this pattern of bilateral distal motor dysfunction would also affect sensory and autonomic functions. Distal muscle is incorrect because primary muscle conditions such as myopathy or muscular dystrophy generally will affect the larger, proximal muscles first, based on bulk and strength alone.

A 70‐year‐old retired business executive presents to the Emergency Department with progressive shortness of breath and two‐pillow orthopnea. On physical examination, the blood pressure is 145/90 mm Hg, there is jugular venous distension, lower extremity pitting edema to the knee, and a blowing holosystolic murmur heard best at the lower left sternal border. No other murmurs or thrills are auscultated on physical exam. Which of the following interventions is to most likely to improve the patient's symptoms? a) Removal of intravascular volume with diuresis b) Replacement of the mitral valve c) Replacement of the aortic valve d) Decrease in blood pressure e) Repair of a ventricular septal defect

a) Removal of intravascular volume with diuresis This patient is in heart failure based upon the symptoms and physical examination findings. The murmur is consistent with tricuspid regurgitation that may be the result of ventricular dilation and failure of the valve to completely close. Symptoms often improve with diuresis. Based upon the examination, the murmur is not consistent with underlying mitral or aortic valve disease. Although the blood pressure is high, it is not high enough to cause this degree of symptomatology. A ventricular septal defect is a holosystolic murmur heard within the left third to fifth interspaces, but is often associated with a thrill.

A 52‐year‐old male presents for an annual examination. He discloses on review of family history that his father has died of skin cancer since his last visit. He personally has had two actinic keratoses frozen and has further lesions that require evaluation today. He is very concerned about his personal and family history and would like to know more about the potential for skin cancer to spread and become a dangerous condition. Which of the following skin lesions is the least likely to metastasize? a) Seborrheic keratosis b) Basal cell carcinoma (BCC) c) Actinic keratosis d) Squamous cell carcinoma (SCC) e) Melanoma

a) Seborrheic keratosis Seborrheic keratoses are entirely benign lesions that do not carry any risk of local invasion or distal metastasis. SCC is incorrect. SCCs can metastasize but rarely, in <1% of cases. Actinic keratosis is incorrect. These are not malignant themselves, but ~1 in every 1,000 per year goes on to become SCCs, which can metastasize. Melanoma is incorrect. Melanoma is an aggressive skin cancer very likely to metastasize to distal organs, causing high rates of mortality. BCC is incorrect. Although considered malignant because of the potential to metastasize, BCCs tend to grow slowly and almost never spread to other organs.

A 35‐year‐old female patient has had migraines for much of her adult life. Ather regular checkup, she is healthy, takes no medications except oral contraceptive pills (OCPs), exercises, and has a steady job. Her only complaint is that her migraines seem to have become worse, and, for the past few weeks, she has been waking up at night with headache and also nausea. Which of the following is the best course of action? a) Take a further history and perform a very careful neurological examination. b) Prescribe a strong medication for her migraines. c) Reassure her that this is a common pattern with migraines. d) Order studies to evaluate potential transient ischemic attacks (TIAs) because she is on OCPs. e) Treat her for sinusitis.

a) Take a further history and perform a very careful neurological examination. The history of nightly awakening and nausea is concerning for increased intracranial pressure from a tumor or other mass. (Brain tumor is not common in a 35‐year‐old.) A careful neurological examination may uncover deficits. Reassure her that this is a common pattern with migraines is incorrect. The new symptoms are not typical of migraines. Order studies to evaluate potential TIAs because she is on OCPs is incorrect. Despite her being on OCPs, the new symptoms are not typical of TIAs or strokes. Treat her for sinusitis is incorrect. Headaches from sinusitis are typically frontal, worse when leaning forward, and do not typically cause such nighttime nausea. Prescribe a strong medication for her migraines is incorrect. Treatment without further workup is not prudent, particularly since these symptoms are not typical of migraines.

A 68‐year‐old retired college professor presents for routine physical examination. After the patient has been reading a novel in the waiting room for ~20 minutes, the technician records his blood pressure in both arms using an automated device. The technician notes a 20‐mm Hg difference in systolic blood pressure between the right and left arms; he repeats the readings 10 minutes later and records the same asymmetrical systolic blood pressure. Which of the following is true regarding this physical finding? a) This finding is clearly abnormal and requires immediate evaluation for possible cardiovascular emergency. b) The patient should commence an antihypertensive medication and return in 6 weeks to assure normalization of the asymmetry between the arms. c) The patient should undergo ambulatory blood pressure monitoring in both arms for 24 hours to confirm conflicting measurements in the office. d) The difference is likely secondary to white coat hypertension and should be followed up with three subsequent monthly readings to confirm. e) An arm‐to‐arm difference of up to 20 mm Hg in systolic blood pressure is considered the upper limits of normal.

a) This finding is clearly abnormal and requires immediate evaluation for possible cardiovascular emergency. A pressure difference of >10-15 mm Hg between the right and left arm should be recognized as abnormal and in need of further evaluation. Subclavian steal syndrome (reversal of blood flow in some arteries due to occlusion of the subclavian artery) and aortic dissection (a tearing of the inner layer of the aorta) may both present with this blood pressure discrepancy, and both are considered medical emergencies. Aortic dissection has a very high mortality rate even under optimal circumstances. An arm‐to‐arm difference of up to 20 mm Hg in systolic blood pressure is considered the upper limits of normal is incorrect. A discrepancy of 5-10 mm Hg between arms is considered normal, although 15 mm Hg is a threshold for considering this difference to be grossly abnormal. The difference is likely secondary to white coat hypertension and should be followed up with three subsequent monthly readings to confirm is incorrect. White coat hypertension presents as a uniform elevation in the systemic blood pressure, but would not account for bilateral asymmetry in the systolic pressures. This patient should not wait 3 months for confirmation of his blood pressure issues. The patient should undergo ambulatory blood pressure monitoring in both arms for 24 hours to confirm conflicting measurements in the office is incorrect. Ambulatory blood pressure monitoring can help diagnose or rule out hypertension but would not shed light on this patient's systolic pressure asymmetry. The patient should commence an antihypertensive medication and return in 6 weeks to assure normalization of the asymmetry between the arms is incorrect. An antihypertensive medication is unlikely to reverse this asymmetry; in addition, this patient should be evaluated immediately for underlying cardiovascular diseases listed above.

A 31‐year‐old day care worker presents with a worsening stiff, painful neck. On inspection, the patient's head is laterally deviated toward the shoulder and rotated. At this point of the examination, what is the most likely diagnosis? a) Torticollis b) Thoracic kyphosis c) Ankylosing spondylitis d) Spondylolisthesis e) Osteoarthritis (OA)

a) Torticollis The characteristic physical signs of torticollis are head rotation and lateral deviation. Spondylolisthesis is incorrect; spondylolisthesis is the slippage between vertebrae and does not present with the head rotated laterally and downward. OA is incorrect. Although it can cause a stiff and painful neck, it would not cause the head to be laterally deviated toward the shoulder and rotated. Thoracic kyphosis is incorrect; thoracic kyphosis is increased flexion of the thoracic vertebrae and occurs with aging. Ankylosing spondylitis is incorrect; ankylosing spondylitis does not present with the head rotated laterally and downward.

A 17‐year‐old male presents to a sexually transmitted disease clinic at the behest of his brother, who convinced the patient to attend the clinic after he disclosed that he prefers homosexual partners but is afraid that his last partner may have given him an infection. The patient expresses to the intake nurse that he is unashamed of his sexual orientation and will not stay through the visit if he feels that he is dismissed or discriminated against because of it. The nurse practitioner receives this communication prior to entering the examination room and decides to employ active listening to best connect with the patient at this critical juncture in his care with the clinic. Which of the following is an example of an active listening technique? a) Using nonverbal communication to encourage the patient to expand their narrative b) Considering a differential diagnosis while the patient is speaking to maximize the patient's time with the provider c) Paring down the patient's concerns to concrete medical needs d) Setting aside the patient's emotional state to focus on his medical needs e) Ignoring visual cues to focus on the patient's exact words

a) Using nonverbal communication to encourage the patient to expand their narrative Active listening is the core of the interview technique and demands such skills as setting aside diagnostic priorities in favor of open discussion; using verbal and non‐verbal skills to encourage the patient to engage fully with their own narrative, and being aware of the patient's emotional state. Ignoring visual cues to focus on the patient's exact words is incorrect because focusing on the patient's words is important, and other cues to concerns and discomforts may be gleaned from nonverbal cues such as posture and facial expression. Setting aside the patient's emotional state to focus on his medical needs is incorrect because except in emergent circumstances, laying a foundation of trust and emotional connection is critical prior to engaging in specific medical needs. Paring down the patient's concerns to concrete medical needs is incorrect because addressing the concrete medical needs at hand is a vital part of medical visits, without a greater understanding of the patient's concerns, fears, and anxieties, the patient is unlikely to feel satisfied on the end of the visit. Considering a differential diagnosis while the patient is speaking to maximize the patient's time with the provider is incorrect because this may save time for the provider, but it is unlikely to serve the patient best if the provider is distracted with complex thoughts and conjectures.

A 24-year-old graphic designer presents to clinic with a cancer for a breast mass. A rubbery, mobile, contender mass is palpated in the right breast as described by the patient, which is consistent with a fibroadenoma. In describing the location of the map, the examiner notes that it is 3 cm proximal and 3 cm to the left to eh nipple. Which of the following would be the most appropriate way to report this finding? a. "Rubbery mobile, nontender mass located in right breast, in the 10:30 position from the nipple" b. "Rubbery mobile, nontender mass located in right breast, in the lower outer quadrant" c. "Rubbery mobile, nontender mass located in right breast, in the upper inner quadrant" d. "Rubbery mobile, nontender mass located in right breast, in the 1:30 position from the nipple" e. "Rubbery mobile, nontender mass located in left breast, upper outer quadarnt"

a. "Rubbery mobile, nontender mass located in right breast, in the 10:30 position from the nipple"

A 67-year-old electronics technicians with history of hypertension and type 2 diabetes presents for his year physical examination and complains of progressively worsening erectile dysfunction (ED). While counseling him, the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most affected by vascular deficiencies related to his preexisting medical conditions and ice likely contributing to his symptoms? a. Corpora cavernosa b. Vas deferens c. Ejaculatory duct d. Seminal vesicle e. Epididymis

a. Corpora cavernosa

A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain, radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis? a. Fibrosis of the pancreas b. Reduced blood supply to the bowel c. Helicobacter pylori infection d. Inflammation of colonic diverticulum e. Inflammation of the gallbladder

a. Fibrosis of the pancreas

An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year-history of recurrent abdominal pain the last for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? a. Functional change in bowel movement b. Impairment of autonomic innervations c. Decreased fecal bulk d. Spasm of the external sphincter e. A large, firm fecal mass in the rectum

a. Functional change in bowel movement

A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a rupture aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92, repertory rate, 16; oxygen saturation 95%; and temperature, 36.2C. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following I she most signifiant risk factor for an AAA? a. History of smoking b. Female gener c. Hypertension d. Family history of rupture aneurysm e. Underweight

a. History of smoking

A 42- year-old female website developer presents for an annual preventive examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise healthy with no family history of breast, ovarian or colon cancer. Which of the following is true about MRI as a screening modality for breast cancer in the general population? a. Sensitivity of screening of breast cancer increases with breast MRI at the expense of specificity. b. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI. c. This patient is an ideal candidate for screening via breast MRI based on current evidence. d. Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI. e. Breast cancer screening by MRI has been well studied in the general population.

a. Sensitivity of screening of breast cancer increases with breast MRI at the expense of specificity.

A 22-year-old G0P0 undergraduate student presents to the clinic faster finding a breast mass on breast self-examination (BAE) at home. The mass is contender without skin changes, erythema, or overlying welling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast caner. Which of the following is true about bSE and self-detection of breast cancer? a. This patient is more likely to find a fibroadenoma than a cancer on self-examination. b. The most likely breast mass this patients I likely to find in herself is an abscess complication underlying mastitis. c. BSE is universally recommended because of very high sensitivity and specificity for finding cancerous lesions. d. Most masses that women find at home and bring to a provider's attention turn out to be malignant. e. Because of this patient's age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is low.

a. This patient is more likely to find a fibroadenoma than a cancer on self-examination.

A 44-year-old female mathematicians presents to clinic with a complaint of a mass in the right breast. Her partner notices this mass 2 days ago and the patient feels guilty because she has only had one mammogram and does not engage in breast self-examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening test at age 43 years after a brief discussion with he primary care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group? a. This patient was in compliance with the US Preventive Serves Task Force (USPSTF) recommendations for her age group and ask factors prior to her current complaint b. Breast cancer screening is extremely well studied, and no controversy exists on the recommended norms for screening and follow-up. c. BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced. d. Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to image accurately. e. Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examinations starting at age 30 years.

a. This patient was in compliance with the US Preventive Serves Task Force (USPSTF) recommendations for her age group and ask factors prior to her current complaint

A 45‐year‐old physician is placed on a β‐blocker for hypertension. Prior to medication administration, the patient's heart rate is 75 beats per minute with a cardiac output of 5 liters per minute. Following initiation of the medication, the heart rate decreases to 60 beats per minute without a change in stroke volume. What would be the expected new cardiac output? a) 5 liters per minute b) 4 liters per minute c) 10 liters per minute d) 3 liters per minute e) 6 liters per minute

b) 4 liters per minute Cardiac output is the product of heart rate and stroke volume. Therefore, if the heart rate decreases by 20%, the cardiac output would decrease by 20% if the stroke volume did not change.

A 65‐year‐old overweight male presents at the clinic with hoarseness which has lasted for around 2 months. He thinks it began along with a cold. He is not feeling badly other than frequent heartburn, and he has continued to work as a bartender (for the past 30 years), but he is having difficulty being heard and understood because of his hoarse voice. A diagnosis that is on the differential list includes which of the following? a) Voice strain from bartending and talking amidst loud ambient noise b) Acid reflux c) Inhalation of fumes d) Viral infection e) Environmental allergies

b) Acid reflux Acid reflux (also known as gastroesophageal reflux disease, or GERD) can cause hoarseness through damage to the laryngeal area due to acid stomach contents being refluxed to the vocal cords. Voice strain from bartending and talking amidst loud ambient noise is incorrect. Voice strain is unlikely to cause these problems right now. Viral infection is incorrect. Viral infections such as parainfluenza virus can certainly cause hoarseness, which can last for several weeks. However,2 months is too long a duration for a viral infection. Inhalation of fumes is incorrect. Inhalation of fumes is unlikely to cause symptoms for 2 months.Environmental allergies is incorrect. Environmental allergies tend to last for only a few weeks as the "season" for these allergies comes and goes.

A thin, 58‐year‐old patient complains of lower back pain for years. On examination, the clinician finds that the patient has tenderness over the sacroiliac area. Which of the following conditions is most consistent with this physical sign? a) Malignancy b) Ankylosing spondylitis c) Osteoporosis d) Torticollis e) Infection

b) Ankylosing spondylitis Tenderness over the sacroiliac joint is common in sacroilitis and also seen in ankylosing spondylitis. Osteoporosis is incorrect; osteoporosis may be associated with pain on percussion of the spine. Malignancy is incorrect; malignancy may be associated with pain on percussion of the spine. Infection is incorrect; infection may be associated with pain on percussion of the spine. Torticollis is incorrect; torticollis is caused by contraction of the sternocleidomastoid muscle and presents as lateral deviation and rotation of the head.

A 72‐year‐old retired woman presents to a primary care provider for evaluation of a suspicious mole. She noticed this lesion 3 weeks ago on her right flank in an area where she had previously seen no abnormality. She is very concerned about melanoma and asks if this could be a possible diagnosis and also wonders if this should have been noticed at her annual examination 7 months ago. Concerning the initial recognition of melanoma, which of the following is true? a) General screening programs conducted by medical facilities identify ~75% of melanomas. b) Approximately 50% of melanomas are initially noticed by patients then brought to the attention of a practitioner. c) Asymmetry of a mole is rarely associated with melanoma. d) Most melanomas are initially identified in individuals with positive family histories by DNA analysis for causative genes. e) The majority of melanomas are recognized during an annual physical examination.

b) Approximately 50% of melanomas are initially noticed by patients then brought to the attention of a practitioner. Effective screening for melanoma has not been identified, and the U.S. Preventive Services Task Force (USPSTF) thus recommends against routine screening. Consequently, most melanomas are first identified by patients rather than in the health care setting, which is consistent with this patient's history. The majority of melanomas are recognized during an annual physical examination is incorrect. Although there are instances in which melanoma is identified by a practitioner during a routine or focused physical examination, it is not the most common for the reasons noted above. General screening programs conducted by medical facilities identify ~75% of melanomas is incorrect. Although there is a role for education and reinforcement of skin cancer prevention, routine screening for skin cancer is not recommended by the USPSTF due to lack of evidence for reduction of morbidity and mortality. Most melanomas are initially identified in individuals with positive family histories by DNA analysis for causative genes is incorrect. Although there are genetic and inherited conditions associated with skin cancer, they represent <5% of all diagnosed skin cancers. Current technology and evidence does not support genetic testing as a routine part of skin cancer screening. Asymmetry of a mole is rarely associated with melanoma is incorrect. Asymmetry (the "A" in the ABCDE in mnemonic) is a well‐evidenced predictor of malignancy in moles.

After examining a patient who is in the hospital for shortness of breath, the clinician records the following for lung examination: "There is dullness to percussion over the right lung base. Breath sounds are absent at the right lung base. There are no crackles, wheezes, or rhonchi. There are no transmitted voice sounds." Which of the following is the most likely diagnosis? a) Pneumonia b) Atelectasis c) Pneumothorax d) Left‐sided heart failure e) Chronic obstructive pulmonary disease (COPD)

b) Atelectasis All of the physical examination findings are characteristic of atelectasis. They can also be seen with a pleural effusion, but that was not one of the answer options for this question. Left‐sided heart failure is incorrect. It characteristically has different findings for all the physical examination parameters mentioned and particularly late inspiratory crackles in the dependent portions of the lungs. Pneumonia is incorrect. Dullness to percussion can be seen with both atelectasis and pneumonia, but with pneumonia typically late inspiratory crackles are heard over the involved area and bronchophony, egophony, and whispered pectoriloquy can also be heard over the involved area. Pneumothorax is incorrect. Hyperresonance is characteristic of the percussion note with a pneumothorax, rather than dullness, which is characteristic of the percussion note with atelectasis. COPD is incorrect. Hyperresonance is characteristic of the percussion note with chronic obstructive pulmonary disease, rather than dullness, which is characteristic of the percussion note with atelectasis. Notice that the words "characteristic" and "typical" are used in the explanation rather than "always."

On routine physical examination, a 40‐year‐old teacher is found to have a single second heart sound. The most likely explanation for this finding is what? a) Auscultation occurred during inspiration. b) Auscultation occurred during expiration. c) The patient has a right bundle branch block. d) The patient has a left bundle branch block. e) The patient has pulmonic stenosis.

b) Auscultation occurred during expiration. During expiration, the components of S , A , and P fuse into a single sound. During inspiration, the right heart filling time is increased thereby delaying closure of the pulmonic valve and splitting S into two audible components. Pulmonic stenosis and a right bundle branch block delay the P component and cause fixed splitting of S . A left bundle branch block delays the A component and causes paradoxical splitting

A mother brings her 8‐year‐old daughter to the clinic because she found a tick in the girl's hair and would like her daughter to be tested for Lyme disease. The nurse practitioner (NP) explains that the enzyme‐linked immunosorbent assay (ELISA), an early test for Lyme disease, is effective in finding early cases of Lyme disease but can also give positive results in some people who do not have the disease, making additional testing necessary. This means that the ELISA test has which of the following? a) Low sensitivity, low specificity b) High sensitivity, low specificity c) Low sensitivity, high specificity d) Undetermined sensitivity and specificity e) High sensitivity, high specificity

b) High sensitivity, low specificity Sensitivity is a measure of a test's ability to detect disease in someone who has it ("true positives"), whereas specificity is a measure of a test's ability to determine who does not have the disease ("true negatives"). The mother was told that the ELISA test has a high true‐positive rate (high sensitivity) but also a relatively high false‐negative rate (low specificity) that the subsequent testing improves upon. Low sensitivity, high specificity is incorrect because, in general, screening tests such as the one described here have high sensitivity to pick up all possible cases; costlier and more invasive confirmatory tests employ higher specificity to then weed out the false positives picked up by the first test. High sensitivity, high specificity is incorrect because although this test has high sensitivity, it has low specificity, as evidenced by the need for a second test to weed through the false positives picked up by the first test. Low sensitivity, low specificity is incorrect because the scenario notes that the test is good at picking up true positives (high sensitivity), although it is also true that it picks up a number of false positives (low specificity). Undetermined sensitivity and specificity is incorrect because the scenario outlines a test that has a high true‐ positive pick‐up rate (high sensitivity) but also a high false‐positive rate (low specificity).

42‐year‐old architect presents with widespread pain complaints, including headaches almost daily, pain at the site of an old motor vehicle accident injury, and generalized achiness and hypersensitivity throughout the body. He recounts that his first episodes of ongoing pain occurred in his early 20s, and he has been to many practitioners over several years seeking a firm diagnosis and adequate treatment of his complaints. Which of the following statements is true regarding chronic pain? a) In primary care practices, non‐cancer-related chronic pain is seen in <10% of patients. b) Chronic pain is defined as pain not due to cancer or a recognized medical condition that persists for >3-6 months. c) Following assessment and evaluation, ~80% of patients with non‐cancer-related pain report control of their symptoms. d) Pain that recurs at intervals of months or years is never considered to be "chronic pain." e) Chronic pain is defined as focused pain lasting >8 months following acute injury or illness.

b) Chronic pain is defined as pain not due to cancer or a recognized medical condition that persists for >3-6 months. Although many definitions exist for this condition—which is often multifactorial and difficult to differentiate—the definition of chronic pain as pain not due to cancer or a recognized medical condition that persists for >3-6 months is supported by the American Medical Association and is useful in separating acute or focused pain from long‐ term chronic pain. Following assessment and evaluation, ~80% of patients with non‐cancer-related pain report control of their symptoms is incorrect. More than 40% of chronic pain patients report that their pain is poorly controlled. Chronic pain is defined as focused pain lasting >8 months following acute injury or illness is incorrect. This does not fit any common definition of chronic pain. In primary care practices, non‐ cancer-related chronic pain is seen in less than 10% of patients is incorrect. Up to a third of patients in primary care settings are affected by chronic pain. Pain that recurs at intervals of months or years is never considered to be "chronic pain" is incorrect. Under some definitions of chronic pain, pain from a single predictable source that recurs at wide intervals with interim times of notable relief may still be called chronic pain.

A 29‐year‐old electrician complains of persistent cough and wheezing, particularly when he exercises. He says he smokes "occasionally" but rarely so much that he needs to purchase cigarettes: "Mostly, I bum them," he says, chuckling. Upon hearing this information, what is the best next step on the part of the clinician? a) Explain the relationship between smoking and cancer. b) Determine the number of pack‐years the patient smokes. c) Determine the patient's exercise regimen. d) Conduct a mental status examination. e) Determine the patient's immunization history.

b) Determine the number of pack‐years the patient smokes. An accurate determination of a patient's tobacco use is important for assessing the overall health risk due to smoking. Although the patient minimizes his smoking, it is possible that the number of cigarettes smoked per day and the length of time he has smoked would result in a high pack‐year value. Although determining the patient's exercise regimen could be of value later on, it is not necessarily relevant to his presenting problem, which is coughing. Exercise simply precipitates this symptom. There are no signs such as memory loss or anxiety suggesting that a mental status examination would be helpful. At some point, it may become important to explain the relationship between smoking and cancer, but this would not be the best "next step" in fact‐finding. Similarly, determining a patient's immunization history is important for health maintenance, but is not necessary for the initial diagnosis of the causes of his problem.

A 33‐year‐old nurse presents with a history of weight gain, decreased energy, and menorrhagia over the past several months. Review of her family history reveals Hashimoto thyroiditis and hypothyroidism in four female first‐degree relatives (her mother and three sisters). Which of the following skin findings best supports a diagnosis of clinical hypothyroidism? a) Discoid rash, alopecia, oral ulcers, and Raynaud phenomenon b) Dry skin, myxedema, alopecia of the eyebrows, and brittle nails c) Thickened, taut skin with sclerodactyly and telangiectasia d) Warm moist skin, hyperpigmentation, and pretibial myxedema e) Spider angiomas, telangiectasia, palmar erythema, and Terry nails

b) Dry skin, myxedema, alopecia of the eyebrows, and brittle nails Dry skin, myxedema, alopecia of the eyebrows, and brittle nails are findings commonly associated with hypothyroidism. Myxedema is a swelling and thickening of local skin tissue due to deposition of mucopolysaccharides; this is considered a very severe manifestation of hypothyroidism. Discoid rash, alopecia, oral ulcers, and Raynaud phenomenon is incorrect. These are skin manifestations of systemic lupus erythematosus. Warm moist skin, hyperpigmentation, and pretibial myxedema is incorrect. These findings are typically associated with hyperthyroidism, not hypothyroidism. Spider angiomas, telangiectasia, palmar erythema, and Terry nails is incorrect. These findings are seen in chronic liver disease. Terry nails appear whitish with no lunula; decrease in vascularity in the nail bed may be responsible for this finding, which is notable in liver disease but also found in a number of other conditions. Thickened taut skin with sclerodactyly and telangiectasia is incorrect as this is a partial description of the CREST syndrome, a connective tissue disorder with many systemic effects. CREST stands for Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia

A 42‐year‐old female mathematician presents for follow‐up care regarding a new diagnosis of systemic lupus erythematosus 6 months ago after a lengthy diagnostic process during which she was debilitated with fatigue and joint pain. Since her diagnosis, she has been minimally compliant with medications and has switched her rheumatology provider twice. She continues to feel ill, and, in explanation for her lack of adherence to the prescribed treatment, she simply says, "I don't like it." At this initial visit with her third rheumatology provider, the clinician elects to explore the issues behind her noncompliance before engaging in diagnostics and treatment using the FIFE model. Which of the following best defines the elements of the FIFE model? a) Facts, intensity, focus, and evidence b) Feelings, ideas, function, and expectations c) Focus, intensity, function, and evaluation d) Facts, intelligence, fortuity, and eventuality e) Feelings, impression, fantasy, and emotion

b) Feelings, ideas, function, and expectations This model captures the patient's emotional landscape, intellectual landscape, current situation (function), and thoughts about future conditions. This breadth is important as aspects of a patient's illness experience may be missed without a wide exploration. For example, a clinician may deeply engage with a patient's emotional experience, but the lack of attention to a patient's ideas surrounding their care and treatment may be perceived as condescending—especially to a very well‐educated patient. Focus, intensity, function, and evaluation and facts, intensity, focus, and evidence are incorrect because these elements are very concrete in nature and may miss the emotional aspects of the patient's illness. Feelings, impression, fantasy, and emotion is incorrect because, in contrary to the above two answers, these elements are almost entirely rooted in the emotional landscape with little attention paid to the intellectual side of a patient's experience. Facts, intelligence, fortuity, and eventuality are incorrect because this group of elements (especially the latter two) does not clearly specify the topics that the clinician should explore.

A 25-year-old graduate student presents to he clinic complaining of scrotal pain, which has been increased over the past 2 days. He is sexually active and has had unprocessed intercourse with multipole partners in the past couple weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpation of the right testicle are noted. What is the most likely diagnosis? a. Testicular cancer b. Acute epididymitis c. Hydrocele d. Primary syphilis e. Spermatocele

b. Acute epididymitis

An 82‐year‐old gentleman seems to be speaking loudly during an examination, suggesting that he may not be hearing well. What is a good question to ask him to help identify whether or not he has hearing loss? a) Does he have vertigo? b) How well does he understand people in a noisy environment such as a restaurant? c) Does he have discharge from his ear? d) Has he been listening to loud music? e) Has he been having an earach

b) How well does he understand people in a noisy environment such as a restaurant? Patients with slowly progressive hearing loss may change their behavior gradually to accommodate—such as watching‐‐ the face of the speaking person, or moving closer to the person. However, in a noisy environment, the patient may have difficulty in understanding others. Has he been listening to loud music is incorrect as this would be very unusual for an elderly person. Does he have vertigo is incorrect. Vertigo can be associated with hearing loss but the question about vertigo by itself does not help identify whether or not the patient has hearing loss. Has he been having an earache is incorrect. An otitis media may result in hearing loss but again it is an associated diagnosis. Does he have discharge from his ear is incorrect. Discharge from ear may suggest wax, otitis externa or even a perforated tympanic membrane, but these are associated diagnoses rather than clues to whether or not the patient has hearing loss.

Concerning a patient that may demonstrate a diagnosis of aphasia, which of the following statements is true? a) It is best characterized by involuntary, rhythmic, repetitive movements involving the tongue and jaws making speech difficult to comprehend. b) It is defined as an inability to produce or understand language. c) It involves a loss of the voice or a slurring or hoarseness of speech secondary to pathology of the larynx or its nerve supply. d) The ability to write a full correct sentence does not rule out the presence of aphasia in a patient. e) It is best characterized by slurred speech with an associated defect in language control.

b) It is defined as an inability to produce or understand language. Aphasia, the inability to produce or understand language, includes two common subtypes: receptive and expressive. A loss of the voice or hoarseness defines aphonia and dysphonia, respectively. Slurred speech with intact language is dysarthria. Involuntary movements as described are characteristic for oral-facial dyskinesias. Because writing a sentence involves both understanding the question and executing the task (expressive), by definition, maintenance of language production and understanding effectively rules out aphasia.

A 63‐year‐old male presents to establish care at a new primary care clinic to discuss issues with pain and fatigue. The clinician conducting the visit begins with general historical questions but quickly becomes suspicious that the patient is suffering from decompensated heart failure. When the patient mentions that he has had vague chest pain since last night, the clinician feels that the focus must be redirected to this potentially emergent condition. Which of the following interview techniques is the most appropriate to effectively manage this visit? a) Providing serial reassurances such as, "Don't worry, you're going to be fine." b) Moving from open‐ended to focused questions c) Nonverbally cuing the patient to focus on his narrative regarding a motor vehicle accident (MVA) that led to back pain d) Asking a series of negative questions such as, "You don't have any swelling in your feet, do you?" e) Asking leading questions that focus on the presumed diagnosis of chest pain

b) Moving from open‐ended to focused questions By starting with open‐ended questions, the clinician acquires a sense of the patient's breadth of needs. Once an emergent issue arises, it is appropriate to shift to increasingly concrete questions to immediately rule in or rule out the condition of concern. Providing serial reassurances such as, "Don't worry, you're going to be fine" is incorrect as this is intended to be reassuring, and patients may interpret this as a dismissal of their concerns. Moreover, this may not be true for a patient who has immediate chest pain with a suspicion of myocardial infarction. Asking a series of negative questions such as, "You don't have any swelling in your feet, do you?" is incorrect because negative questions are likely to be met with negative answers whether true or not. Since lower extremity edema may be a sign of heart failure, this question should be asked without losing precision. Nonverbally cuing the patient to focus on his narrative regarding an MVA that led to back pain is incorrect because the patient may be focused on his narrative around back pain, and chest pain is clearly a more important priority. Asking leading questions that focus on the presumed diagnosis of chest pain is incorrect because overly positive (or "leading") questions tend to lead toward positive answers. As discussed above, precision in assessing this patient's risk of acute coronary disease is the key concept to his immediate safety.

A 65‐year‐old retired pilot visits the clinic because of recurrent headache. The patient reports dizziness of recent onset (previous 2 weeks) and occasional numbness on the left side. Which of the following systems or regions should be examined in the clinician's focused assessment? a) Gastrointestinal b) Nervous c) Respiratory d) Musculoskeletal e) Cardiovascular

b) Nervous The nervous system examination covers mental status, cranial nerves, motor and sensory systems, and reflexes. The presence of headache, dizziness, and numbness suggest nervous system involvement. Symptoms of cardiovascular involvement include palpitations, chest pain, edema, or heart murmurs, none of which are noted in the case description. Musculoskeletal problems are usually associated with muscle or joint pain or stiffness. The respiratory system should be examined when patients have a cough, difficulty breathing, or hemoptysis. The gastrointestinal system should be examined when patients complain of heartburn, irregular or bloody stools, or food intolerance (among other symptoms).

During an evaluation of an athletic 30‐year‐old patient, the clinician conducts an active range of motion evaluation at the neck. Which muscle is being assessed when the patient is asked to flex the neck? a) Sacrospinalis b) Sternocleidomastoid (SCM) c) Splenius cervicis d) Trapezius e) Splenius capitis

b) Sternocleidomastoid (SCM) The SCM muscle flexes and rotates the neck. Splenius capitis is incorrect; the splenius capitis extends the neck. Trapezius is incorrect; the trapezius extends the neck. Splenius cervicis is incorrect; the splenius cervicis attaches to the posterior aspect of the spine and extends the neck. Sacrospinalis is incorrect; the sacrospinalis attaches to the posterior aspect of the spine. When muscles attached to the posterior aspect of the spine contract, the spine extends.

During a musculoskeletal examination, the clinician instructs the patient to look over one shoulder, and then the other shoulder. This action assesses the movement of which muscle(s)? a) Prevertebral muscles b) Sternocleidomastoid (SCM) c) Scalenes d) Splenius capitis e) Splenius cervicis

b) Sternocleidomastoid (SCM) The action is rotation of the neck. The muscles responsible for rotation of the neck are the SCM and the small intrinsic neck muscles. Scalenes is incorrect; the action of the scalene muscle is to flex the neck. The scalenes also laterally bend the neck. Splenius capitis is incorrect; the action of the splenius capitis muscle is to extend the neck. Prevertebral muscles is incorrect; the action of the prevertebral muscles is to flex the neck. Splenius cervicis is incorrect; the action of the splenius cervicis muscle is to extend the neck.

A 14‐year‐old high school student comes to the clinic for a 3‐month history of periodic dyspnea when playing basketball. It resolves shortly after resting. He has not had fever, chills, cough, sputum production, or chest pain. He has no history of serious illness. Based on the boy's history, asthma is suspected. Which of the following sounds heard on expiration during lung auscultation would be most suggestive of asthma? a) Mediastinal crunch b) Wheezes c) Stridor d) Rhonchi e) Pleural rub

b) Wheezes Wheezes are suggestive of narrowed airways, as in asthma, chronic obstructive pulmonary disease, or bronchitis. Mediastinal crunch is incorrect. A mediastinal crunch is suggestive of pneumomediastinum, not asthma. Pleural rub is incorrect. A pleural rub can be suggestive of a pleural effusion or a pneumothorax, not asthma. Rhonchi are incorrect. Rhonchi are suggestive of secretions in larger airways, not asthma. Stridor is incorrect. Stridor is suggestive of partial obstruction of the larynx or trachea, not asthma.

An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of sever abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis? a. Pain with internal rotation of the right hip b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain c. Localized pain over McBurney point, which ties 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus d. Voluntary contractions the abdominal wall that persists over several examinations e. Abdominal pain that increases with hip flexion

b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain

A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk/ Her mother developed the disease in her 50s and died fro it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA 1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that his may contribute tot breast cancer risk. She has had several abnormal mammogram in her 50s for persistently dense breast with subtle finding, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient a. History of chest radiation is not risk factor for breast cancer and is thus not relevant to deciding whether MRI is appropriate in this patient. b. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of Marley decreased specificity (ie, the ability to rule out disease in healthy breast) c. No agency recommends breast MRI for patients such as this one, who has moderately but not extraordinary risk factors for breast cancer. d. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs over mammograms in patient such as this individual. e. The US Preventive Serves Task Force (USPSTF) recommends against screening with MRI for patient with such risk factors.

b. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of Marley decreased specificity (ie, the ability to rule out disease in healthy breast)

A 65-year-old farmer rarely seeks medical care but does have a remote history of coronary bypass surgery presents to the office with a 2-day history of increasing shortness of breath and abdominal discomfort. On exam, a protuberant abdomen and lower extremity edema is noted. The clinician is concerned about possible right-sided heart failure and associated ascites and decides to proceed with further physical exam techniques to assess for possible ascites. Which of the following findings will be supportive of ascites? a. Dullness to percussion of the upper quadrants and tympani in the lower quadrant b. Tapping on one flank sharply transits an impasse to he opposite flank c. Tympany predominant through the abdomen d. Dullness to percussion throughout the abdomen e. Border between tympani and dullness to percussion that does not shift with position

b. Tapping on one flank sharply transits an impasse to he opposite flank

A 23-year-old woman comes to the respirology clinic for follow0up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inverses and asks for physical exam. Which of the following descriptions best fits with findings on the abdominal exam? a. Liver dullness in the right upper quadrants that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease b. Tympanic to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant c. Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line b. Protuberant abdomen that has scattered areas of tympani and dullness; stool is felt on palpation e. A change in percussion from tympani to dullness in the left lower anterior chest wall on inspiration

b. Tympanic to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant

A 42‐year‐old woman presents with fatigue associated with a 40‐lb weight gain over the past 2 years. She had always struggled with her weight but has continued to gain despite various attempts at diet and exercise regimens; she inquires if she might be a candidate for gastric bypass surgery. In evaluating patients who are overweight, which of the following best defines obesity in medical terms? a) A patient with a waist‐to‐hip ratio (WHR) >1.75 b) A patient with a body mass index (BMI) <26 c) A patient with a body mass index (BMI) >30 d) A patient who weighs at least 1 standard deviation (SD) greater than the mean for his or her age and gender e) A patient consuming >1.5× the recommended daily caloric intake

c) A patient with a body mass index (BMI) >30 Obesity is defined by convention as a BMI >30. BMI is an index of measured height and weight calculated to a scale that is readily recognizable, with 20-25 representing normal weight, 25-30 representing overweight, and >30 representing obesity. A patient who weighs at least 1 SD greater than the mean for age and gender is incorrect as these statistical norms are not applied to BMI, which is the standard measure of obesity. A patient with a BMI <26 is incorrect as that patient would be normal weight (18.5-25) or underweight (<18.5). A patient consuming >1.5× the recommended daily caloric intake and a patient with a WHR >1.75 are incorrect as BMI is not measured by caloric intake or WHR but by the calculation described above.

The CAGE questionnaire is a short screening examination administered in the office to evaluate for which of the following? a) Bipolar disorder b) Risk for illicit substance abuse c) Alcohol misuse d) Major depressive disorder e) Likelihood that the patient complaints are "psychosomatic"

c) Alcohol misuse The CAGE questionnaire was developed to identify alcohol abuse. It comprises questions concerning Cutting down, Annoyance, Guilty feelings, and Eye‐openers. Although many patients may have dual diagnoses or multiple substances that they abuse, it has been validated as an effective tool in initial screening for alcohol abuse. A separate less widely used test is the Drug Abuse Screening Test (DAST) that focuses on non‐alcohol-related substance abuse. Although alcohol abuse can be seen in association with major depression, psychosomatic, and bipolar disorders, the CAGE questionnaire is not diagnostic of any of these conditions.

Abstract thinking is an important component of the human thought process. A person's ability to understand questions that test his or her ability to answer appropriately is dependent upon a number of factors. Which one of the following answers is true in identifying a patient with concrete thinking and a reduced ability to think abstractly? a) An inability to name the occupations of common well‐known public figures such as the President and Vice President b) An inability to correctly perform serial 7s c) An inability to discern the similarity between two words (e.g., a cat and a mouse by answering "The cat chases the mouse.") d) An inability to spell "world" backward e) An inability to draw a clock correctly including all numbers and make it tell time as requested (i.e., 10:15)

c) An inability to discern the similarity between two words (e.g., a cat and a mouse by answering "The cat chases the mouse.") An inability to link a cat and a mouse as both representing animals (abstraction) is an example of loss of the ability to think abstractly. Serial 7s is a simple math test that tests attention, not abstract thinking, and spelling "world" backward is another test for attention. These tests may be particularly difficult to perform for a person with a mild delirium, representing an inability to concentrate and maintain attention. Memory deficits are represented by the inability to name public figures, and clock‐drawing abnormalities are most associated with executive functioning deficits.

Disparities in pain treatment have been well described in numerous studies comparing Caucasian patients to those of African American and Hispanic origin. Which of the following statements is true concerning this issue? a) Biases of the treating clinician are associated with overtreatment of pain in minority patients and non‐English speakers. b) Racial and ethnic biases never involve two persons of the same race or ethnic group. c) Biases of the treating clinician are associated with under‐treatment of pain in minority patients and non‐English speakers. d) Language barriers do not contribute to the problem of racial and ethnic biases. e) Racial and ethnic biases are only relevant in geographic areas that have a history of racial and ethnic discrimination.

c) Biases of the treating clinician are associated with under‐treatment of pain in minority patients and non‐English speakers. Stereotypes, language barriers, and unconscious clinician biases have all been shown to contribute to disparities in pain treatment and other health measures in minority and non‐English speaking patients. Racial and ethnic biases never involve two persons of the same race or ethnic group is incorrect. Bias may occur even when the treatment provider is of the same minority group that the patient belongs to. Racial and ethnic biases are only relevant in geographic areas that have a history of racial and ethnic discrimination is incorrect. The problem of bias in medicine is widespread and not confined to geographic locations that have been foci of historical tension between ethnic and racial groups. Language barriers do not contribute to the problem of racial and ethnic biases is incorrect. Language barriers are one of many factors contributing to differential treatment of minority patients. Biases of the treating clinician are associated with overtreatment of pain in minority patients and non‐English speakers is incorrect. The reverse is true: Minority and non‐English speaking patients tend to be undertreated for pain.

A 19‐year‐old student of art history presents to clinic after a syncopal (fainting) episode at school. He is notably thin; on a thorough review of his medical history, he admits that he eats only minimally to maintain a very low body weight that he feels is ideal. He is embarrassed that his issues were discussed by peers after this episode, especially because he believes that this is a problem that is only faced by girls and women. Concerning the two most common eating disorders (anorexia nervosa and bulimia nervosa), which of the following statements is true? a) Men and women are both afflicted, but with a female:male prevalence ratio estimated at ~2:1. b) The prognosis is similar regardless of whether individuals are diagnosed and treated in the early or late stage of these disorders. c) Both of these eating disorders are associated with a real or imagined fear of appearing fat. d) Persons with eating disorders are generally easily identified by their appearance. e) Both of these eating disorders are associated with a body mass index (BMI) of <17.5.

c) Both of these eating disorders are associated with a real or imagined fear of appearing fat. A real or imagined fear of appearing fat is a common finding in both anorexia and bulimia—which sometimes overlap more than they present as distinct diagnoses. Both conditions are characterized by distorted perceptions of body image and weight. Men and women are both afflicted, but with a female:male prevalence ratio estimated at ~2:1 is incorrect. Both men and women suffer from eating disorders, but the ratio is closer to 5—10:1 (female:male). This pattern may change with evolving cultural norms. Both of these eating disorders are associated with a BMI of <17.5 is incorrect. Although anorexia is notable for a sustained low BMI, those suffering from bulimia (characterized by normal or high caloric intake followed by purging) may demonstrate normal BMI. Persons with eating disorders are generally easily identified by their appearance is incorrect. Concealing of the appearance is often an integral part of the disorder, making recognition of very underweight individuals difficult in street clothes. Prognosis is similar regardless of whether individuals are diagnosed and treated in the early or late stage of these disorders is incorrect as prognosis is improved by early identification and treatment of eating disorders.

A 14‐year‐old student comes with her family to the urgent care center, having been hit in the right eye with a plastic baseball during a family reunion. She complains of a painful, watery, red right eye and sensitivity to light. She has normal visual acuity in both eyes, no diplopia, and can open and close her eyes normally. The pupils are unequal in size, 3 mm in diameter on the left, 5 mm in diameter on the right. Which cranial nerve (CN) would be implicated as the cause of the photosensitivity complaint and the pupillary asymmetry? a) CN VI b) CN V c) CN III d) CN IV e) CN II

c) CN III The oculomotor nerve (CN III) is a pure motor nerve controlling pupillary constriction, eye opening, and most of the extraocular movements. Injury to this nerve and its peripheral fibers, as is the case here, could result in impaired pupillary constriction, leading to a complaint of sensitivity to light. CN II is incorrect because the optic nerve is a special sensory nerve and transmits signals related to vision. CN IV is incorrect because the trochlear nerve is a motor nerve, responsible for downward and internal rotation of the eye. CN V is incorrect because the trigeminal nerve is a mixed sensorimotor nerve innervating the temporal, masseter, and lateral pterygoid muscles and supplies sensation to the face. CN VI is incorrect because the abducens nerve is a motor nerve responsible for lateral deviation of the eye.

A young adult patient presents to the clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the examination continues, which of the following maneuvers would confirm a likely diagnosis? a) Assess the lateral bending movement of his neck b) Assess his ability to touch his toes c) Compare the strength of his trapezia muscles d) Check for listing of his trunk e) Assess his ability to extend his back

c) Compare the strength of his trapezia muscles One cause of winged scapula is the contralateral weakness of the trapezius muscle. As this patient has had his left arm immobilized for 8 weeks, he may have muscle wasting and weakness of the left trapezius relative to his right side. Assess his ability to touch his toes is incorrect; touching toes assesses the muscles that flex the back as well as looks for scoliosis (differences in the height of scapulae). Assess the lateral bending movement of his neck is incorrect; this action assesses the function of the scalene and small intrinsic neck muscles. Assess his ability to extend his back is incorrect; this action assesses the function of the deep intrinsic muscles of the back. Check for listing of his trunk is incorrect; this sign may be present with a herniated disk.

A 34‐year‐old male with a history of complex social and medical needs (including current substance abuse) presents to a primary care teaching clinic. The patient has experienced a number of adversarial relationships with prior clinicians, including voluntarily leaving two practices within the previous year and being asked to leave care at a third clinic due to misbehavior. The attending physician desires to utilize the approaches to this patient that are most likely lead to comprehensive care and patient compliance. Which of the following is the most appropriate interview style for the attending physician to use? a) Deferring respect, empathy, humility, and sensitivity in favor of the acquisition of concrete details about the patient's condition b) Taking a symptom‐focused approach to reduce the involvement of the patient's emotional difficulties c) Following the patient's lead to understand their thoughts, ideas, concerns, and requests d) Focusing on the need for immediate diagnostic certainty over personal connection e) Taking charge of the interaction to meet the clinician's desire to acquire diagnostic information

c) Following the patient's lead to understand their thoughts, ideas, concerns, and requests Following the patient's lead is the key concept of patient‐centered medical care. This approach helps to identify the personal context and address concerns as well as concrete maladies. Current evidence suggests that this technique is not only very satisfying to the patient and the clinician, but also leads to optimal outcomes. Focusing on the need for immediate diagnostic certainty over personal connection and taking charge of the interaction to meet the clinician's desire to acquire diagnostic information are incorrect because diagnostic certainty may be required in emergent conditions, whereas establishing personal connection with patients first may lead to improved long‐term care. Ignoring the personal connection with patients can lead to alienation and missed diagnoses as the patient is less likely to engage in care. Deferring respect, empathy, humility, and sensitivity in favor of the acquisition of concrete details about the patient's condition is incorrect because deferring respect for the patient in favor of concrete details is unlikely to engage the patient in his or her care. Taking a symptom‐ focused approach to reduce the involvement of the patient's emotional difficulties is incorrect because emotional issues may be at the forefront of a patient's issues (such as a diabetic who is unmotivated to control his diabetes due to concurrent depression), and sidelining the emotional needs may sabotage progress on medical issues.

A 70‐year‐old patient has suspected have???? chronic obstructive pulmonary disease. The clinician instructs the patient to take a deep breath in, and then with his mouth open, breathe out as fast and completely as he can. For what is the clinician checking? a) Whispered pectoriloquy b) Egophony c) Forced expiratory time d) Tactile fremitus e) Bronchophony

c) Forced expiratory time Forced expiratory time is assessed by asking the patient to take a deep breath in and then breathing out as fast and fully as he can with his mouth open. Bronchophony is incorrect. Testing for bronchophony is done by listening with a stethoscope while the patient says "ninety‐ nine." Egophony is incorrect. Testing for egophony is done by listening with the stethoscope while the patient says "ee." Tactile fremitus is incorrect. Testing for tactile fremitus is done by feeling for palpable vibrations on the chest wall while the patient says "ninety‐nine." Whispered pectoriloquy is incorrect. Testing for whispered pectoriloquy is done by listening with the stethoscope while the patient whispers "nine‐nine."

A 16‐year‐old boy is brought to the Emergency Department (ED) after a motor vehicle accident for shortness of breath for 1 hour. A chest x‐ray shows a rib fracture and a pneumothorax on the right side. The ED physician decides that a chest tube needs to be placed in the fourth intercostal space. How does he determine where the fourth intercostal space is? a) He finds the angle of Louis and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib. b) He finds the suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib. c) He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space. d) He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to the fourth intercostal space. e) He finds the clavicle. The second intercostal space is just below the clavicle. He then walks down to third rib, third intercostal space, fourth rib, and then the fourth intercostal space.

c) He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the second intercostal space, third rib, third intercostal space, fourth rib and then the fourth intercostal space. He finds the sternal angle and then moves his finger laterally to the second rib. He then walks down to the two intercostal space, third rib, third intercostal space, fourth rib, and then the fourth intercostal space. Conventionally, the sternal angle is used as the starting point for determining where the second rib is and then one walks down from there to find the intercostal spaces and other ribs. He finds the suprasternal notch and then moves his finger laterally to the third rib. The fourth intercostal space is just below the third rib is incorrect. The suprasternal notch is not the starting point and the third rib is not lateral to the suprasternal notch. In addition, the fourth intercostal space is just below the fourth rib, rather than the third rib. He finds the angle of Louis and then moves laterally to the first rib. He walks down from there to the fourth intercostal space is incorrect. The angle of Louis (sternal angle) is the starting point, but it is the second rib, rather than the first rib, that is lateral to it. He finds the clavicle. The second intercostal space is just below the clavicle. He then walks down to third rib, third intercostal space, fourth rib, and then the fourth intercostal space is just below the 4th rib, rather than the 3rd.

A 74‐year‐old bus driver is delivered to the hospital via emergency transport after an astute passenger noted that the patient exhibited drooping facial features and slurred speech. The patient was diagnosed rapidly with ischemic (nonhemorrhagic) stroke, and urgent intervention lead to a near complete recovery from his symptoms. The astute passenger was thanked and congratulated for recognizing the signs of acute stroke; this individual credited this recognition to a public safety awareness campaign that outlined the critical public health need to recognize strokes early. Which of the following statements is true for risks and rapid recognition of suspected strokes? ) Due to increasing public awareness, the median time for arrival to care for suspected stroke is <3 hours. b) Obesity with normal glucose tolerance is not a risk factor for stroke. c) Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke. d) Transient ischemic attacks (TIAs) that resolve within in 1 hour confer a 5% risk of death from stroke within the next 12 months. e) Atrial fibrillation is not a risk factor for ischemic stroke in individuals age ≥75 years.

c) Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke. Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke. Although many risk factors for stroke have been recognized, hypertension remains the greatest risk after smoking, high cholesterol, diabetes, elevated weight, and low exercise levels. Atrial fibrillation is not a risk factor for ischemic stroke in individuals age ≥75 years is incorrect because atrial fibrillation that is not recognized or not treated with anticoagulation confers a significant risk of stroke. Obesity with normal glucose tolerance is not a risk factor for stroke is incorrect because obesity doubles the risk of stroke even without associated glucose intolerance. TIAs that resolve within in 1 hour confer a 5% risk of death from stroke within the next 12 months is incorrect because TIAs are a significant predictor for risk of stroke, with 1‐year mortality of ~12% associated with them, regardless of the time it takes a TIA to resolve. Due to increasing public awareness, the median time for arrival to care for suspected stroke is <3 hours is incorrect because, unfortunately, most patients present after the third hour of symptoms with a median time for arrival of 3-6 hours. This is often outside of the window for intervention with thrombolytic therapy

A physician assistant (PA) has had a long day and has seen many patients. The last patient of the day is an 80‐year‐old woman brought to the office by her 35‐year‐old granddaughter. This is the patient's first visit to the office. As part of the patient's past history, the PA obtains information about childhood illnesses and adult illnesses and then moves on to inquire about the family history. Which important area of the past history has she omitted? a) Allergies b) Medications c) Immunizations d) Chief complaint e) Social history

c) Immunizations It is important to understand the three components of the past history: childhood illnesses, adult illnesses, and health maintenance behaviors including immunizations and screening tests. Understanding what conditions the patient is protected against is important for understanding the possible causes of the present illness. The patient's chief complaint(s) are, of course, highly significant, but they are not part of the past history. Allergies and medications also are relevant, but are part of the present illness, not the past history. Social history is its own category of investigation.

In longstanding and poorly controlled hypertension, white matter tracts in the brain are subjected to ateriolosclerotic effects. Which one of the following is most vulnerable to this process? a) Diencephalon b) Reticular activating system c) Internal capsule d) Basal ganglia e) Thalamus

c) Internal capsule The internal capsule is a white matter structure in which myelinated axons from the cerebral cortex converge and descend into the brainstem. Blood supply is provided via arterioles and, as such, is especially vulnerable to the effects of ateriolosclerosis. Thalamus and basal ganglia are incorrect because these are gray matter structures deep in the brain. Diencephalon is incorrect because this posterior part of the forebrain connects the midbrain with the cerebral hemispheres, encloses the third ventricle, and contains the thalamus and hypothalamus. As such, it contains numerous structures of both gray and white matter. The reticular activating system is incorrect because, although a complex neural network in the central core of the brainstem, it monitors the state and function of the body in such processes as arousal, sleep, attention, and muscle tone. It contains both gray and white matter.

Which of the following statements is true concerning the mini‐mental status exam (MMSE)? a) It is recommended that clinicians perform the examination in all adults age >65 years regardless of symptoms. b) It is standardized and unaffected by education level or primary language. c) It is a proprietary screening test that is not diagnostic of probable causes. d) It identifies both memory deficits as well as early loss of executive functioning. e) It can provide a differential diagnosis as to probable causes of cognitive impairment.

c) It is a proprietary screening test that is not diagnostic of probable causes. The MMSE is a screening tool and, as such, suggest, that there is an abnormality present, but it does not provide for a differential diagnosis. Further testing is always required after implementing any screening test to render a definitive diagnosis. It is not recommended in persons who are asymptomatic, showing little value in that clinical setting. The MMSE tests for memory but does not have an executive function component, a common criticism of the test's broad applicability. The MMSE may clearly be influenced by both the education of a patient as well as its administration in a language that is not the primary one (resulting in a lower score).

A 42‐year‐old fair‐skinned woman of Irish origin presents with an abnormal skin growth that was first noted 7 years ago. On examination, a 2 × 3‐cm lesion is noted over her left bicep. Which of the following historical elements most increases the suspicion that the lesion is malignant? a) No evolution in size since onset, but mild intermittent pruritus over the last 2 years b) Proximal location, that is, over the bicep rather than the distal arm c) Minimal but discernible increase in size over the past 6 months d) No evolution in size since onset, but uniformly darkly pigmented color e) Presence of similar pinkish tan lesions on the sun‐exposed areas including the face and hands

c) Minimal but discernible increase in size over the past 6 months Regardless of the appearance of a lesion and its duration, any discernible change in size or other characteristics (such as color or regularity of borders) requires further evaluation. No evolution in size since onset, but mild intermittent pruritus over the last 2 years is incorrect. Although any skin lesion may evolve into a malignancy, a long‐ standing lesion that is essentially unchanged carries a very low likelihood of being malignant. No evolution in size since onset, but uniformly darkly pigmented color is incorrect. Although dark lesions are sometimes of concern, lesions should be evaluated specifically for variegation of color, especially blue and black mixed with white and red (which represents cycles of inflammation and scarring characteristic of melanoma). Presence of similar pinkish tan lesions on the sun‐exposed areas including the face and hands is incorrect. Generally, skin cancer is characterized by an initial focus of malignancy with distal metastases to organs other than the skin; multiple similar skin findings that do not meet the criteria in the ABCDE‐EFG mnemonic (Asymmetry, Border irregularity, Color variations, Diameter >6 mm, Evolving, Elevated, Firm, Growing) are more likely to be benign. Proximal location, that is, over the bicep rather than the distal arm is incorrect. Proximal versus distal location does not affect the likelihood of malignancy.

Which of the following statements is true concerning mental health disorders in primary care? a) Alcohol and substance abuse are not considered mental health disorders. b) Somatic symptom disorder (DSM‐5) is distinctly uncommon in this setting and constitutes less than 5% of these disorders. c) Mood disorders make up ~25% of all diagnoses. d) The prevalence for mental disorders is estimated to be ~10%, of which only 25% are not diagnosed. e) Anxiety disorders are the most prevalent of all diagnoses in this setting.

c) Mood disorders make up ~25% of all diagnoses. Mood disorders make up ~25% of all diagnoses. Mental health disorders of various types ranging from major mental illness to personality disorders are very common diagnoses encountered in primary health care. Approximately 20% of primary care patients are thought to suffer from mental disorders, of which 50%-75% goes undetected. Somatoform disorders are relatively common in the range of 10%-15%, while alcohol and substance abuse are important contributors to patient dysfunction and are considered under the broad designation of mental health disorders

A patient with cystic fibrosis (CF) has been complaining of fullness in his left nasal cavity. Examination of his nose using an otoscope and a speculum reveals a normal nasal septum, but a pale, saclike growth of inflamed tissue that is obstructing a large part of the nasal cavity. What is the most likely diagnosis? a) Allergic rhinitis b) Deviated nasal septum c) Nasal polyp d) Ulcer e) Viral rhiniti

c) Nasal polyp Nasal polyps are more likely in patients with CF (as well as other conditions such as allergic rhinitis, aspirin sensitivity, and chronic sinusitis). Ulcer is incorrect as an ulcer is not a mass but rather a tender denuded area. Viral rhinitis is incorrect as it should not produce a saclike structure. Allergic rhinitis is incorrect as it produces a pale and boggy mucosa but not a saclike structure. Deviated nasal septumis incorrect. The nasal septum was reported to be normal.

A 39‐year‐old nurse who is a well‐established patient complains of irregular menstrual periods and pelvic pain. She says that she is having trouble sleeping and asks whether she could be given a "sleeping pill." The patient also says she is thinking of leaving her job. What is the best "next step" in caring for this patient? a) Ask about recent travel destinations. b) Obtain a urine sample for testing. c) Obtain a more complete description of problems. d) Perform a pelvic examination. e) Obtain blood for testing.

c) Obtain a more complete description of problems. It is critical to thoroughly understand the patient's problem in order to narrow the focus of the examination. This is particularly true when symptoms are reported in multiple body systems, as in this case. To the extent possible, the seven attributes of each symptom should be explored. Although it may be necessary to perform a pelvic examination, the exam will yield more information if the clinician has determined, for example, the patient's pregnancy history. The clinician may need to obtain a urine sample for testing later but should have a possible diagnosis in mind when doing so. A similar argument applies regarding obtaining blood for testing—testing for what? Recent travel destinations should be elicited if there is a suspicion that an infectious agent was acquired somewhere else, but more information is needed to determine whether this would be a realistic suspicion.

The clinician is seeing a 58‐year‐old patient with a diagnosis of arthritis. The patient complains of pain in his knees, hips, hands, wrists, neck, and low back. Based on which joints are involved, the patient most likely has which joint problem? a) Polymyalgia rheumatica b) Rheumatoid arthritis (RA) c) Osteoarthritis (OA) d) Gout e) Psoriatic arthritis

c) Osteoarthritis (OA) The common locations of joints involved with OA are the knees, hips, hands, wrists, neck, and lower back. RA is incorrect; the common locations of joints involved with RA are the small joints of the hands, feet, wrists, and ankles, and also the joints of the elbows and knees. This patient has involvement of the hips, which is not characteristic of RA. Psoriatic arthritis is incorrect; psoriatic arthritis is a mono/oligoarthritis—involving one to three joints. This patient has at least six joints involved. Gout is incorrect; the common locations of joints involved with acute gout are the base of the big toe, foot, ankles, knees, and elbows. The common locations of joints involved with chronic tophaceous gout are the feet, ankles, wrists, fingers, and elbows. This patient has involvement of the hips, neck, and low back which is not characteristic of gout. Polymyalgia rheumatica is incorrect; the common locations of pain in polymyalgia rheumatica are the muscles surrounding the hip and shoulder joints.

A 55‐year‐old truck driver with obstructive sleep apnea has diastolic heart failure. An echocardiogram demonstrates significant biatrial enlargement. What portion of his electrocardiogram would likely be abnormal? a) S wave b) R wave c) P wave d) T wave e) QRS complex

c) P wave The P wave is the result of atrial depolarization and would therefore have changes associated with atrial enlargement. The QRS complex, R wave, and S wave are a result of ventricular depolarization, whereas the T wave is a result of ventricular repolarization.

A 63‐year‐old practicing attorney makes an appointment with the office urgently for pain in his right leg for 3 days. Since working in the garden moving heavy bags of mulch for his wife this past weekend, he has had intermittent but excruciating pain shooting down the posterior aspect of his right leg. On examination, sensory loss to light touch in the right leg posteriorly, corresponding to a sacral 1 (S1) dermatome, is noted. Which reflex would be expected to be decreased compared to the other side? a) Left knee b) Left plantar (Babinski) c) Right ankle d) Right knee e) Right plantar (Babinski) f) Left ankle

c) Right ankle An ipsilateral diminished reflex indicates impaired sacral 1 function on the right and corresponds to the patient's pattern of pain and sensory loss on examination. Right and left plantar (Babinski) are incorrect because a positive plantar response comes from a central nervous system lesion in the corticospinal pathway. Right and left knees are incorrect because the deep tendon reflex at the knee is mediated by lumbar 2, 3, 4 nerve roots and does not correspond to the spinal level of this patient's pattern of pain and sensory loss on examination. Left ankle is incorrect because the spinal level, sacral 1, is correct but is contralateral to the symptoms, neurological findings, and lesion.

A clinician is percussing the lungs of a patient with chronic obstructive pulmonary disease to see if they sound hyperresonant. Which of the following is an example of good technique for percussion? a) Put the third and fourth fingers next to each other on the chest. b) Strike using the finger pad of the fourth finger. c) Strike using the tip of the third finger. d) The proximal interphalangeal joint is the joint that is struck. e) The wrist is kept still during percussion.

c) Strike using the tip of the third finger. Strike using the tip of the third finger is a part of good technique for percussing the lungs and some other structures in the body. The proximal interphalangeal joint is the joint that is struck is incorrect. It is the distal interphalangeal joint that is struck in good percussion technique. Press the third and fourth fingers next to each other on the chest is incorrect. Only the third finger is pressed against the chest in good percussion technique. Strike using the finger pad of the fourth finger is incorrect. It is the tip of the third finger that is used in good percussion technique. The wrist is kept still during percussion is incorrect. A direct brisk yet relaxed wrist movement is used in good percussion technique.

A 17‐year‐old woman presents with her parents to her primary care provider. She desires to utilize a tanning facility ahead of an upcoming event. Her parents have heard that this is a dangerous practice, although the tanning facility insists it is safe without risk of skin cancer in the future after tanning. Which of the following is true regarding ultraviolet (UV) light exposure and subsequent risk of skin cancer? a) Water‐resistant sunscreens confer no advantage over water‐soluble products. b) Tanning beds and sunlamps do not increase risks of skin cancer as they utilize UV wavelengths that are not carcinogenic. c) Targeted messaging and practitioner reinforcement in primary care amplify sun‐ protective behaviors. d) Sunscreen with a sun protective factor (SPF) of 15 blocks ~50% of UV‐B light. e) Chronic sun exposure confers greater risk for skin cancer than intermittent intensive exposure.

c) Targeted messaging and practitioner reinforcement in primary care amplify sun‐protective behaviors. Reinforcement of recommendations by providers in the primary care setting has been shown to improve adherence to skin‐protective recommendations. Chronic sun exposure confers greater risk for skin cancer than intermittent intensive exposure is incorrect. The reverse is true: Intensive intermittent sun exposure confers a greater risk for skin cancer than chronic sun exposure. Tanning beds and sunlamps do not increase risks of skin cancer as they utilize UV wavelengths that are not carcinogenic is incorrect. Indoor tanning devices are considered to be frankly carcinogenic to humans, and many states have strictly regulated their use. Water‐resistant sunscreens confer no advantage over water‐ soluble products is incorrect. Both water and sweat may dilute or wash off sunscreen. Water‐resistant sunscreens last longer and confer greater protection than those that are water soluble. Sunscreen with an SPF of 15 blocks ~50% of UV‐B light is incorrect. SPF 15 blocks ~90% of UV‐B rays. The SPF rating is determined by comparing the number of minutes required to redden the skin under UV exposure with a given product as opposed to no protection.

A 62‐year‐old former tennis pro obtained a home blood pressure cuff after an office measurement revealed that his blood pressure fell in the hypertensive range. At a follow‐up visit, he questions the accuracy of the clinician's blood pressure cuff and the veracity of his diagnosis of hypertension. Which of the following is true regarding blood pressures recorded in a practitioner's office versus values obtained in the ambulatory setting? a) The American Heart Association (AHA) has issued consensus statements regarding the number and timeframe for blood pressure measurement to guide practitioners in diagnosing hypertension. b) Both systolic and diastolic measurements must be in the hypertensive range to confer cardiovascular risk on the patient. c) The accepted normal values for blood pressure are lower for ambulatory measurements compared with office measurements. d) The accepted normal values for blood pressure are the same for ambulatory measurements compared with office measurements. e) Masked hypertension is a phenomenon whereby ambulatory blood pressure is measured in the normal range but measurement in the office is elevated.

c) The accepted normal values for blood pressure are lower for ambulatory measurements compared with office measurements. Blood pressure <140/90 is considered normal for an in‐office measurement, whereas ambulatory measurements are considered normal only if they are <135/85. Masked hypertension is a phenomenon whereby ambulatory blood pressure is measured in the normal range but measurement in the office is elevated is incorrect. Masked hypertension occurs when ambulatory blood pressures are significantly higher than those measured in the office; this condition is particularly difficult to identify, but does confer cardiovascular risk on the patient. The accepted normal values for blood pressure are the same for ambulatory measurements compared with office measurements is incorrect. As above, blood pressure <140/90 is considered normal for an in‐office measurement, whereas ambulatory measurements are considered normal only if they are <135/85. Both systolic and diastolic measurements must be in the hypertensive range to confer cardiovascular risk on the patient is incorrect. Gross elevations of either systolic or diastolic pressure confer a risk of cardiovascular disease on the patient. The AHA has issued consensus statements regarding the number and timeframe for blood pressure measurement to guide practitioners in diagnosing hypertension is incorrect. No consensus guidelines currently exist on optimal number or interval of blood pressure measurements needed to diagnose hypertension

A 66-year-old female museum curators presents for a routine annual examination. On examination, a notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is contender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast umps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since menopause, through has has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy? a. Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly drains into the axilla. b. Supraclavicuar nodes are found along the anterior edge of the trapezius muscle in the neck. c. Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. d. Supraclaicular noes are generally considered benign and rehire no further evaluation or follow-up. e. Firm, rubbery lymph noes are generally considered to be benign.

c. Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes.

A 70‐year‐old male presents to the Emergency Department accompanied by his wife, who is concerned that he has experienced a stroke. She states that he awoke with drooping of the right side of his mouth. He has a history of hypertension and diet‐controlled diabetes, but no history of prior transient ischemic attacks (TIAs), strokes, or neurologic deficits. Physical examination reveals a well‐nourished, right‐handed male, who has an obvious flattening of the right nasolabial fold at rest. He is unable to close his right eye, wrinkle his forehead, or raise his eyebrows. The remainder of the neurologic examination is symmetric with intact strength and normal deep tendon reflexes. Based on this history and physical examination, which of the following statements is true? a) The patient most likely has a central process of unclear location; an acute ischemic event must be ruled out with an emergent computed tomography (CT) scan. b) The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) V, the trigeminal nerve. c) The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve. d) The patient most likely has a central upper motor neuron lesion involving cranial nerve (CN) VII (the facial nerve). e) The patient most likely has had an embolic affecting an upper motor neuron (UMN)

c) The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve. This patient most likely has an isolated peripheral LMN lesion involving CNVII, the facial nerve. Facial paralysis is a concerning finding in any patient, and it is critical to make the clinical distinction between Bell palsy (a facial nerve weakness due to primarily benign causes) and central lesions of the contralateral motor cortex (such as stroke or tumor). A peripheral (or LMN) lesion involves the entire affected side, whereas a central (UMN) lesion spares the upper face and selectively paralyzes the lower face. The patient most likely has a central UMN lesion involving CN VII (the facial nerve); the patient most likely has a central process of unclear location; an acute ischemic event must be ruled out with an emergent CT scan; and the patient most likely has had an embolic affecting a UMN are incorrect. All of these answers include a UMN lesion, while this patient has examination findings consistent with an LMN lesion. The patient most likely has an isolated peripheral LMN lesion involving CN V, the trigeminal nerve is incorrect because this nerve supplies sensory (not motor) innervation to the face, although it does innervate muscles of mastication.

A 23‐year‐old farm worker submits urine for testing. Three test strips from Container A show abnormally low pH levels in the urine. However, three test strips from Container B, purchased more recently, consistently indicate that the pH of this patient's urine is normal. Which of the following is a true statement about the test strips? a) The test strips demonstrate high specificity. b) The test strips demonstratehigh interobserver reliability. c) The test strips demonstrate high intraobserver reliability. d) The test strips demonstratelow intraobserver reliability. e) The test strips demonstrate high sensitivity.

c) The test strips demonstrate high intraobserver reliability. If the test strips demonstrate high intraobserver reliability, this means that the test strips from each container consistently provided the same result: Strips from Container A showed low pH levels, while strips from Container B showed normal pH levels. The test strips demonstratehigh interobserver reliability is incorrect because the test strips were quite inconsistent based on which container they came from: if the "observer" is the tool used to make the measurement (i.e., a container of test strips), then these two observers were internally consistent, but had very different measures from each other. The test strips demonstratelow intraobserver reliability is incorrect because the "observers" (i.e., containers of test strips) were quite different from each other; they were quite internally consistent at the same time. That is, they have high intraobserver reliability. The test strips demonstrate high sensitivity and the test strips demonstrate high specificityare incorrect because sensitivity is defined as the proportion of patients with true disease who are accurately identified as positive by a particular test; specificity is defined as the proportion of patients without disease who are accurately identified as negative by a particular test. The process described in this scenario is not seeking to rule in or rule out disease, so this concept does not apply.

An 82‐year‐old grandmother presents to the Emergency Department in the care of her extended family with new‐onset speech impairment. According to family members, the patient awoke with this symptom as well as difficulty in understanding questions or following commands. Her past medical history is remarkable for atrial fibrillation but no other notable conditions. On examination, her speech is verbose but poorly comprehensible and lacks meaning. She is unable to follow simple commands. Which of the following best describes her speech disorder? a) Broca aphasia b) Dysphonia with expressive deficit c) Wernicke aphasia d) Dysarthria e) Global aphasia

c) Wernicke aphasia The combination of both receptive and expressive aphasia is a characteristic of Wernicke aphasia, which is usually due to a lesion of the posterior superior temporal lobe. Dysphonia with expressive deficit is incorrect because it is an impairment of the voice due to dysfunction of vocal cords and related structures but does not affect the ability to understand or express oneself. Dysarthria is incorrect because it is an impairment of the voice due to dysfunction of the muscles that allow speech but does not affect the ability to understand or express oneself. Global aphasia is incorrect because it is a condition in which all communicative capacity is impaired, resulting in a complete inability to communicate with others. Broca aphasia (usually due to a lesion in the posterior inferior frontal lobe) is incorrect because it results in verbose, meaningless verbal expression but with sparing of language interpretation.

A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last epidote was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic? a. Exacerbating factor includes alcohol intake b. Vomiting of bile c. Associated right shoulder pain b. Positive McBurney point tenderness e. Poorly localized periumbilical pain

c. Associated right shoulder pain

A 54-year-old female dietician presents for a routine annual examination. On review of systems, she reports that she has had many breast finding over several years, including on biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changes in the breasts with menopause? a. Breast density has no genetic component and is entirely due to estrogen does from endogenous and exogenous sources over the lifetime. b. Mammography performs most poorly int the menopausal and postmenopausal age group and should be limited for that reason. c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules. d. Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of mammograms. e. Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause.

c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules.

A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen or diabetes mellitus and dyslipidemia. Electorlytes and liver enzymes were also measured. his albs are all normal expect for moderate elevation of aspartate aminotransferase, alanine aminotransferase, y-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following finding would be most consistent with hepatomegaly? a. Dullness to percussion over a span of 11 cm at the midclavicular line b. Dullness to percussion over a span of 8 cm at the midsternal line c. Liver palpable 4 cm below the right costal margin midclavicular line, on expiration d. Liver span of 11 cam at the midclavicular line e. Liver span of 8 cm at the midsternal line

c. Liver palpable 4 cm below the right costal margin mid clavicular line, on expiration

A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This discharge started several weeks ago and has occurred at irregular intervals since that time She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside fro slightly irregular periods over the last few months. ON examination, she is able to express a small mouth of discharge, which is sent to the laboratory and found to be consistent with bilk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thryoid-stimulating hormone, and human chorionic gonadotropin (HCG) even Further laboratories are still pending. Which of the following is the most likely diagnosis? a. Paget disease of the breast b. Mastitis c. Prolactinoma d. Occult pregnancy e. Ducal carcinoma in situ

c. Prolactinoma

A 29-year-old graduate student states that he ice Abel to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medications. What is the most likely cause of his problem? a. Androgen insufficiency b. Endocrine dysfunction c. Psychogenic d. Peyronie disease e. Sexually transmitted infection (STI)

c. Psychogenic

The negative predictive value of a test is calculated as the number of true negatives identified by the test divided by the total negatives found by the test. If a novel test for strep throat yields 85 true‐negative results and 15 false‐negative results, what is the negative predictive value of this test? a) 15% b) 75% c) 99% d) 85% e) 10%

d) 85% According to the formula, the negative predictive value is calculated as the number of true negatives divided by the total number of test negatives in the population, or 85÷(85 + 15) = 85%. 10, 15%, 75%, and 99%are incorrect because these values would not be obtained using the formula given above for negative predictive value.

Weight change may indicate the presence of important underlying pathology requiring further investigation. Which of the following best describes a significant weight change that requires further evaluation? a) A 31‐year‐old male with a baseline body mass index (BMI) of 20 who loses 3 lb after a prolonged bout of infectious gastroenteritis b) A 32‐year‐old female with a baseline weight of 175 lb who checks her weight irregularly but reports a 5‐lb unintended weight loss over 3 months c) A 45‐year‐old recently menopausal female who gains 5% beyond her baseline weight of 140 lb in 6 months d) A 45‐year‐old male with baseline weight of 280 lb who decides to undertake a light exercise regimen and loses 15% of his total body weight in 3 months e) A 26‐year‐old female with a baseline body mass index (BMI) of 25 who loses 5% of her body weight with 6 months of diet and exercise modification

d) A 45‐year‐old male with baseline weight of 280 lb who decides to undertake a light exercise regimen and loses 15% of his total body weight in 3 months A safe rate of intentional weight loss is no more than 2 lb/week; this patient has lost about 3.5 lb/week. In addition, it would be reasonable to question why he experienced such rapid weight loss from such a small deviation in his baseline activity. A 32‐year‐old female with a baseline weight of 175 lb who checks her weight irregularly but reports a 5‐lb unintended weight loss over 3 months is incorrect. Regular fluctuations in weight are normal; this patient has lost <3% of her baseline weight—a matter of only minor concern. A 45‐year‐old recently menopausal female who gains 5% beyond her baseline weight of 140 lb in 6 months is incorrect. Weight gain around menopause is normal, although excessive weight gain may bear review for thyroid status, changes in diet/exercise, etc. A 26‐year‐old female with a BMI of 25 who loses 5% of her body weight with 6 months of diet and exercise modification is incorrect. This is well within the reasonable range of weight loss for a healthy adult who changes diet and exercise patterns. A 31‐year‐old male with a baseline BMI of 20 who loses 3 lb after a prolonged bout of infectious gastroenteritis is incorrect. Although a clinician may be duly concerned about this patient's health, the etiology is already clear and does not need a new evaluation for cause.d) A 45‐year‐old male with baseline weight of 280 lb who decides to undertake a light exercise regimen and loses 15% of his total body weight in 3 months A safe rate of intentional weight loss is no more than 2 lb/week; this patient has lost about 3.5 lb/week. In addition, it would be reasonable to question why he experienced such rapid weight loss from such a small deviation in his baseline activity. A 32‐year‐old female with a baseline weight of 175 lb who checks her weight irregularly but reports a 5‐lb unintended weight loss over 3 months is incorrect. Regular fluctuations in weight are normal; this patient has lost <3% of her baseline weight—a matter of only minor concern. A 45‐year‐old recently menopausal female who gains 5% beyond her baseline weight of 140 lb in 6 months is incorrect. Weight gain around menopause is normal, although excessive weight gain may bear review for thyroid status, changes in diet/exercise, etc. A 26‐year‐old female with a BMI of 25 who loses 5% of her body weight with 6 months of diet and exercise modification is incorrect. This is well within the reasonable range of weight loss for a healthy adult who changes diet and exercise patterns. A 31‐year‐old male with a baseline BMI of 20 who loses 3 lb after a prolonged bout of infectious gastroenteritis is incorrect. Although a clinician may be duly concerned about this patient's health, the etiology is already clear and does not need a new evaluation for cause.

A 28‐year‐old male business executive presents to a primary care provider with concerns about hair loss. He is otherwise healthy without chronic medical conditions or current medications. He has a chart history of allergy to sulfa medications, although this happened when he was a young child, and he does not recall the incident or the reaction. He is unsure at what age his father went bald, as he never remembers his father having hair. He remarks jokingly that he is losing more hair than his dogs at home, who shed frequently but are otherwise healthy. On examination, he has a single uniform oval patch of hair loss over the left temporal area without any scaling, inflammation, or other skin changes where the hair is missing. Which of the following is the most likely explanation for his hair loss? a) Tinea capitis, as evidenced by his exposure to animals that may carry this pathogen b) Male pattern baldness, as evidenced by his father's baldness at a young age c) Drug rash, as evidenced by his allergy to sulfa drugs d) Alopecia areata, as evidenced by patchy hair loss without associated skin changes e) Trichotillomania, as evidenced by his anxiety and need to diffuse uncomfortable situations with inappropriate humor

d) Alopecia areata, as evidenced by patchy hair loss without associated skin changes Alopecia areata is likely an autoimmune disease as the patchy hair loss (without associated skin findings) responds to the application of topical steroids. Male pattern baldness, as evidenced by his father's baldness at a young age is incorrect. The information about his father's balding is a false lead, as this patient's presentation is consistent with alopecia areata, not male pattern balding in which hair density is lost around the frontal and temporal regions first. Tinea capitis, as evidenced by his exposure to animals that may carry this pathogen is incorrect. Again, the information about the dog is misleading; tinea capitis, which may be spread from animals, appears as scaling skin with broken‐off hair—not unaffected skin with no hair as this patient exhibits. Trichotillomania, as evidenced by his anxiety and need to diffuse uncomfortable situations with inappropriate humor is incorrect. While the nature of humor is up for debate, this patient has uniform hair loss, whereas trichotillomania results in patches of hair torn out and other patches left remaining. Drug rash, as evidenced by his allergy to sulfa drugs is incorrect as this patient is taking no medications at this time; in addition, allergies to sulfa drugs usually cause widespread urticaria rather than hair loss.

A 72‐year‐old retiree presents to the cardiology clinic with palpitations after several months of symptoms. An electrocardiogram (ECG) shows a tachyarrhythmia, which the cardiologist diagnoses as atrial fibrillation. In measuring the blood pressure of a patient with chronic atrial fibrillation, which of the following statements is true? va) The precise blood pressure is measured by taking the average of three pressures in both arms over a span of 20 minutes. b) Because atrial fibrillation is an uncommon arrhythmia, blood pressure management of these patients does not have widespread significance in office or ambulatory practice. c) Measuring blood pressure in patients with atrial fibrillation is no different than measuring blood pressure in patients with normal cardiac rhythms. d) Ambulatory monitoring over 2-24 hours is recommended because this rhythm produces variable and inconsistent blood pressures. e) Single automated measurement in the office setting provides a reliable value for the true blood pressure

d) Ambulatory monitoring over 2-24 hours is recommended because this rhythm produces variable and inconsistent blood pressures. Multiple readings in the clinical and ambulatory setting best approximate the true blood pressure in persons with atrial fibrillation. Because pressures in these patients can vary greatly, single in‐office measurements rarely provide a true picture of their blood pressure or adequately diagnose/rule out hypertension. The precise blood pressure is measured by taking the average of three pressures in both arms over a span of 20 minutes is incorrect. Because the blood pressure can change over hours, ambulatory monitoring over a 2-24‐hour period is recommended. Single automated measurement in the office setting provides a reliable value for the true blood pressure and measuring blood pressure in patients with atrial fibrillation is no different than measuring blood pressure in patients with normal cardiac rhythms are incorrect. As above, standard means of measuring blood pressure in the office fail to capture the variation in pressure in patients with this condition, because the filling pressure in the left ventricle (and, thus, the systemic blood pressure) vary over time. Because atrial fibrillation is an uncommon arrhythmia, blood pressure management of these patients does not have widespread significance in office or ambulatory practice is incorrect. Atrial fibrillation is a very common arrhythmia.

A 77‐year‐old man is experiencing progressive shortness of breath and dizziness. The patient undergoes cardiac catheterization, and the systolic blood pressure measured in the left ventricle is 180 mm Hg, while the systolic blood pressure measured in the aorta is 140 mm Hg. The patient is most likely experiencing symptoms related to what valvular condition? a) Mitral stenosis b) Aortic insufficiency c) Mitral regurgitation d) Aortic stenosis e) Pulmonic stenosis

d) Aortic stenosis Patients with aortic stenosis often experience dyspnea with exertion, chest pain, or dizziness. The calcification of the aortic valve and narrowing of the valve area effectively decreases the blood flow from the left ventricle to the aorta. Given the obstruction created from the narrowing of the aortic valve, the pressure within the left ventricle is often higher than that seen in the aorta. Aortic insufficiency is associated with blood flow from the aorta to the left ventricle during diastole and is often not associated with differences in systolic blood pressure. Mitral stenosis involves narrowing of the valve between the left atrium and left ventricle while mitral regurgitation involves the flow of blood from the left ventricle to the left atrium during systole when the mitral valve is normally closed. Pulmonic stenosis involves valvular obstruction between the right ventricle and pulmonary artery.

A 53‐year‐old caterer comes to the clinic for a routine examination. She has type 2 diabetes mellitus, which is well controlled on medication. Her history from her last visit reveals that she smoked one pack of cigarettes a day at that time. The 5 As Model is a useful approach to take with trying to help patients to quit smoking. What is the 5 As Model? a) Affable, associated manifestations, ask, admonish, available b) Arrange, aggravating factors, action, attitude, able c) Agitate, assist, alleviating factors, able, action d) Ask, advise, assess, assist, arrange e) Admonish, action, available, assess, alleviating factors

d) Ask, advise, assess, assist, arrange Ask, advise, assess, assist, and arrange are the 5 As in the 5 As Model. Admonish, action, available, assess, alleviating factors is incorrect. Only assess is part of the 5 As Model. Agitate, assist, alleviating factors, able, action is incorrect. Only assist is part of the 5 As Model. Affable, associated manifestations, ask, admonish, available is incorrect. Only ask is part of the 5 As Model. Arrange, aggravating factors, action, attitude, able is incorrect. Only arrange is part of the 5 As Model.

A 72‐year‐old woman presents with concerns about several ruby‐red spots on her chest and abdomen. She reports that these are growing in both size and number over time. On examination, the provider notes a number of cherry angiomas at the locations indicated by the patient. No other abnormalities are noted. Which of the following best describes the clinical characteristics and significance of a cherry angioma? a) Cherry angiomas are a marker for underlying pathology that requires additional evaluation. b) Cherry angiomas rarely occur on the trunk and are most often noted on the legs near veins. c) Cherry angiomas are associated with liver disease and B vitamin deficiencies. d) Cherry angiomas are benign and may increase in size and number with aging. e) Cherry angiomas never show blanching under pressure.

d) Cherry angiomas are benign and may increase in size and number with aging. Cherry angiomas are benign and may increase in size and number with aging. Though they can appear alarming, cherry angiomas are of no clinical significance. They do not undergo malignant transformation and do not need to be excised or sent for tissue diagnosis. Cherry angiomas never show blanching under pressure is incorrect. They may demonstrate partial blanching, especially blanching of the edges. Cherry angiomas are associated with liver disease and B vitamin deficiencies is incorrect. Cherry angiomas are not associated with these diseases, though spider angiomas are. Cherry angiomas rarely occur on the trunk and are most often noted on the legs near veins is incorrect. These lesions are commonly found on the trunk and, less commonly, extremities. Cherry angiomas are a marker for underlying pathology that requires additional evaluation is incorrect. As above, cherry angiomas are not malignant, nor are they outward signs of internal disease.

A 54‐year‐old diplomat working at the United Nations reports occasional chest pain and a sense of tightness in his chest when particularly stressed over work deadlines. The patient is 6 feet 4 inches tall. He has a temperature of 98.6ºF and blood pressure of 140/78. He has a cut over one eye that he says is "from shaving."Which of the following represents subjective information about this patient? a) Blood pressure of 140/78 b) Employment at the United Nations c) Temperature of 98.6ºF d) Cut over eye from shaving e) Height of 6 feet 4 inches

d) Cut over eye from shaving Subjective information is any information that the patient reports but that is not directly observable or measurable. In this case, the cut is observable but the manner in which the cut was sustained is not. Shaving injuries are not usually seen above an eye, so this part of the patient's report could be explored further. Temperature, blood pressure, and height are incorrect because these were measured by the clinician. Employment at the United Nations is incorrect because, although this was not measured by the clinician, it is a fact that can be verified objectively.

In the case of a middle‐aged female with a pounding headache, what is an effective question to ask the patient? a) Is she feeling stressed? b) Does she think she is losing her memory? c) Has she ever seen anyone with a stroke? d) Does the patient have any aura prior to the headaches? e) How old is the patient?

d) Does the patient have any aura prior to the headaches? An aura or a prodrome of unusual feelings or neurological symptoms may increase the likelihood that this is a migraine. "How old is the patient?" is incorrect. Age of the patient does not produce a useful clue. "Is she feeling stressed?" is incorrect. Most patients report feeling stressed. Also, headaches themselves can stress out a patient. "Does she think she is losing her memory?" is incorrect. Losing memory may be an early symptom of dementia but is not typically linked to headaches. "Has she ever seen anyone with a stroke?" is incorrect. This is unlikely to be a stroke, and asking such a question will only increase the patient's stress.

One important examination technique involves using the third fingers of each hand to determine the health of internal organs. What is the name of this technique? a) Inspection b) Listening c) Auscultation d) Percussion e) Palpation

d) Percussion Percussion involves striking the middle finger of one hand against the middle finger of the other, with the latter laid on the skin of the chest or abdomen, and listening for the sound and feeling for the vibration so produced. It is a way of determining the size and health of the internal organs. Auscultation involves listening with the stethoscope. Inspection is close observation of the patient's appearance, behavior, and movement. Palpation is gentle pressure with the fingers to identify areas of skin elevation, temperature change, or alterations in tissue density. Listening is not a cardinal technique of the physical examination.

A 39‐year‐old architect comes to the clinic for a 2‐day history of fever, chills, cough productive of green sputum, and dyspnea. He has no history of serious illness. His temperature is 101.2ºF. His other vital signs are within normal limits. Late inspiratory crackles are heard on auscultation over the left lower lung posteriorly. When the clinician listens over that area and instructs the patient to say "ee," it sounds like "A." Which of the following would most likely be found on percussion of his lungs? a) Stridor b) Flatness c) Hyperresonance d) Dullness e) Tympany

d) Dullness This patient has symptoms and signs of pneumonia. With pneumonia, a type of consolidation, dullness can be noted on percussion over the area of the pneumonia. Flatness is incorrect. Flatness is not noted on percussion over an area of pneumonia. Flatness is noted on percussion over muscles. Hyperresonance is incorrect. Hyperresonance is not noted on percussion over an area of pneumonia. Stridor is incorrect. Stridor is a type of adventitial (added) lung sound, rather than a sound noted on percussion. Stridor is also not an adventitial lung sound heard in a patient with pneumonia. Tympany is incorrect. Tympany is not noted on percussion over an area of pneumonia. Tympany is noted over percussion of the gastric air bubble.

The clinician is seeing a middle‐aged patient who has a diagnosis of lumbar spinal stenosis. The patient's history is consistent with this diagnosis as he has pain in the back with walking that improves with rest. Which physical sign(s) are most consistent with his diagnosis? a) Thoracic kyphosis b) Pelvic tilt or drop c) Positive straight‐leg raise d) Flexed forward posture with lower extremity weakness e) Hyperreflexia of the lower limb

d) Flexed forward posture with lower extremity weakness The physical signs of lumbar spinal stenosis include flexed forward posture and weakness of the lower extremities. Hyperreflexia of the lower limb is incorrect; hyporeflexia of the lower extremities is consistent with lumbar spinal stenosis. Pelvic tilt or drop is incorrect; weakness of the pelvic stabilizers—the gluteus medius and minimus are not consistent with lumbar spinal stenosis. Thoracic kyphosis is incorrect; thoracic kyphosis is not associated with lumbar spinal stenosis. Positive straight leg raise is incorrect; the straight‐leg test is usually negative in lumbar spinal stenosis.

A 45‐year‐old forklift driver presents to the clinic at 4 o'clock in the afternoon complaining of intense substernal chest pain and nausea. He appears pale and sweaty. At work that day, he filled in for an absent co‐worker and was asked to perform heavy lifting not normally a part of his job. The physician assistant (PA) questions the patient in detail about his nausea, eating habits, and digestive history. Which of the following steps of clinical reasoning has the PA failed to follow? a) Elicit information about the patient's family history of digestive disorders b) Match findings against conditions that could cause them c) Localize findings anatomically d) Give special consideration to potential life‐threatening problems e) Elicit information about the patient's gastrointestinal (GI) system

d) Give special consideration to potential life‐threatening problems This patient may be experiencing a myocardial infarction (MI), a much more serious disorder than a chronic digestive condition; this possibility should be ruled out first as a "worst‐case scenario." Elicit information about the patient's GI system is incorrect because this task has already been completed. Localize findings anatomically is incorrect because this has been attempted (although perhaps for the wrong system). Match findings against conditions that could cause them is incorrect because although the PA did match findings to conditions that may have caused them, he ignored only the most important findings and the most critical potential condition (MI). Elicit information about the patient's family history of digestive disorders is incorrect because it is not the most important next step in a patient who is probably suffering from a far graver condition (possible MI).

A 24‐year‐old veteran returns from his second tour of duty in the Middle East. He was witness to a number of violent military encounters and experienced the death of several of his closest friends. He describes a number of problems including nightmares, poor sleep pattern, and mild panic attacks. In persons with trauma‐ and stress‐related disorders as well as other disorders that may be associated with hallucinations and illusions, which of the following statements is true that distinguishes these two entities from each other? a) Illusions occur only when awake, whereas hallucinations can occur both while awake and while sleeping. b) Illusions involve an irrational fear or perceptions, whereas hallucinations are a misinterpretation of real external stimuli. c) Hallucinations may be visual or auditory, causing an alteration of the real external world, whereas illusions are entirely imaginary. d) Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. e) Hallucinations by definition never include somatic perceptions, whereas illusions always involve at least some component of a somatic complaint.

d) Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. Illusions are a misinterpretation of real stimuli, whereas hallucinations are subjective perceptions in the absence of real stimuli. Trauma‐ and stress‐related disorders are an increasingly recognized and appreciated cause of moderate‐to‐severe dysfunction both in the military as well as civilian populations. Both illusions and hallucinations may be associated with the disorder; however, the correct distinction between the two is contained in the correct answer. Both are subjective in nature; therefore, there is no objective testing available. The clinician relies on the patient history in the context of the clinical setting to discern the correct designation. The incorrect answers all contain components that are inaccurate descriptions based on their accepted definitions.

A concerned mother brings her 9‐year‐old daughter to the clinic with several days of a diffuse rash on the trunk. The child was previously healthy and is current on her vaccinations. The mother relates a history of decreased appetite, easy fatigue, and low‐grade subjective fevers. On examination, temperature is recorded at 100.5ºF, the rash is confirmed as described by the mother, and additional physical findings of a strawberry tongue and erythema of the palms and soles are noted. Nonpainful peeling of the skin of the child's fingertips is noted incidentally. Based on the history and physical findings, which is the most likely diagnosis and course of action? a) Strep throat, for which amoxicillin is indicated b) Measles, for which review of the vaccination history is critical c) Contact dermatitis, for which antihistamines are indicated d) Kawasaki disease, for which close monitoring and possibly hospitalization might be required e) Nonspecific viral exanthem, for which observant management is advised

d) Kawasaki disease, for which close monitoring and possibly hospitalization might be required Kawasaki disease, also known as "mucocutaneous lymph node syndrome," is an inflammatory condition that presents with a variable rash, "strawberry tongue," and later desquamation of the fingertips. It is treatable with immune globulin but can be fatal if not treated. Nonspecific viral exanthem, for which observant management is advised is incorrect. Desquamation of the fingertips is an alarming symptom that should never be attributed to a benign cause such as a viral exanthem. Contact dermatitis, for which antihistamines are indicated is incorrect. Contact dermatitis can be focal to exposed areas or generalized, but again should not include desquamation of the fingertips. Measles, for which review of the vaccination history is critical is incorrect. Measles present with a global maculopapular rash that starts at the head and spreads down and outward. If a measles case is identified, priorities like isolation, treatment, and contact tracing take precedence of reviewing vaccination status, as vaccination at this stage will not help with the course of the illness. Strep throat, for which amoxicillin is indicated is incorrect. Strep throat can present with a rash known as scarlet fever, but again, desquamation of the fingertips points to a far more serious etiolog

A 55‐year‐old air traffic control agent reports his home blood pressure log to clinic after he was diagnosed with hypertension at a prior visit. He notes that he consistently measures within the normal range at home, but seems to fall outside the normal range every time he comes to the clinic. Which of the following blood pressure measurements is considered to be most accurate (i.e., reflecting the patient's "true" blood pressure)? a) Blood pressure recorded in three positions in the health practitioner's office after resting for a 10‐minute period in a supine position b) Three separate blood pressure measurements recorded by a medical technician within 90 minutes of awakening in the morning in an office setting using an automated device c) A total of six blood pressures averaged over three visits to a health practitioner's office over a 3‐month period d) Regular ambulatory monitoring recorded outside of the office setting e) Blood pressure recorded in three positions in the health practitioner's office

d) Regular ambulatory monitoring recorded outside of the office setting Single or even multiple blood pressure readings may be influenced by a number of factors, such as the stress of presenting to a clinician ("white coat hypertension"). Persistent recorded blood pressure measurements with automated cuffs in the ambulatory setting best represent the true blood pressure. Three separate blood pressure measurements recorded by a medical technician within 90 minutes of awakening in the morning in an office setting using an automated device is incorrect. Timing through the day/night cycle is not a recognized variable in blood pressure measurement and first‐morning blood pressure is not a "truer" measurement of hypertension than during any other part of the day. Blood pressure recorded in three positions in the health practitioner's office and blood pressure recorded in three positions in the health practitioner's office after resting for a 10‐minute period in a supine position are incorrect. These are variations on the technique used to determine if a patient has orthostatic hypotension but do not add sensitivity or specificity to the diagnosis of hypertension. A total of six blood pressures averaged over three visits to a health practitioner's office over a 3‐month period is incorrect. Averaging blood pressure measurements is not a validated means of finding a "true" blood pressure or diagnosing hypertension.

A 62‐year‐old manual laborer presents to an annual physical examination with concerns about skin cancer screening. He does not have any lesions of concern but was recently told by a friend that he should have his skin checked by a doctor yearly. What is the best advice for this patient according to the U.S. Preventive Services Task Force (USPSTF) recommendations on skin cancer screening from 2009? a) The USPSTF recommends skin cancer screening only in sun‐exposed areas of fair‐ skinned individuals every 6 months. b) The USPSTF recommends that all individual age >50 years be screened yearly for skin cancer regardless of risk factors. c) The USPSTF recommendations mirror those of the American Cancer Society (ACS) and American Academy of Dermatologists (AAD) in recommending and annual skin cancer screening for patients age >50 years. d) The USPSTF recommends against routine screening for skin cancer due to lack of evidence for this intervention across the general population. e) The USPSTF recommends focused screening of individuals with a history of dysplastic nevus syndrome.

d) The USPSTF recommends against routine screening for skin cancer due to lack of evidence for this intervention across the general population. According to the 2009 guidelines, the USPSTF finds insufficient evidence to justify yearly screening for skin cancer, though other professional organizations differ in their interpretations of the evidence. Note that this recommendation applies to screening (defined as routine validated checks of asymptomatic individuals with average risk level) for skin cancer and does not apply to patients who present with a focal complaint. The USPSTF further recommends that providers "remain alert for skin lesions with malignant features." The USPSTF recommends that all individual age >50 years be screened yearly for skin cancer regardless of risk factors is incorrect. As above, the USPSTF finds insufficient evidence to justify yearly screening for skin cancer, though other professional organizations differ in their interpretations of the evidence. The USPSTF recommendations mirror those of the ACS and AAD in recommending annual skin cancer screening for patients age >50 years is incorrect. The USPSTF differs from both the ACS and the AAD on this topic; both of the latter agencies recommend clinician screening for skin cancer yearly for individuals age >50 years, whereas the USPSTF states that there is insufficient evidence to justify thisrecommendation. The USPSTF recommends skin cancer screening only in sun‐exposed areas of fair‐skinned individuals every 6 months is incorrect. This is not a recommendation promoted by any professional agency. The USPSTF recommends focused screening of individuals with a history of dysplastic nevus syndrome is incorrect. This is a recommendation of the ACS and AAD, but not the USPSTF.

A first‐semester physician assistant student reports to his supervisor that he has trouble determining the diastolic blood pressure. On manual blood pressure, which of the following provides the best estimate of the true diastolic blood pressure? a) The average reading between the onset of the auscultatory gap and the resumption of Korotkoff sounds. b) The point at which Korotkoff sounds first muffle after systolic blood pressure is discerned. c) The recommencement of Korotkoff sounds following the lower point of the auscultatory gap. d) The disappearance of Korotkoff sounds following initial muffling. e) The average between the highest and lowest points of the auscultatory gap

d) The disappearance of Korotkoff sounds following initial muffling. By convention, it is the disappearance of Korotkoff sounds, not the muffing, that determines diastolic blood pressure. The point at which Korotkoff sounds first muffle after systolic blood pressure is discerned is incorrect. As above, by common definition the diastolic blood pressure has not been reached until all Korotkoff sounds have disappeared. The average between the highest and lowest points of the auscultatory gap and the average reading between the onset of the auscultatory gap and the resumption of Korotkoff sounds are incorrect. The auscultatory gap —a silent interval between the systolic and diastolic measurements— does not reflect the diastolic pressure. Care should be taken not to confuse an auscultatory gap with the disappearance of Korotkoff sounds altogether. The recommencement of Korotkoff sounds following the lower point of the auscultatory gap is incorrect. This pressure would be notable higher than the pressure measured when Korotkoff sounds disappear.

A 55‐year‐old woman with a headache explains to the clinician that she has had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation? a) The patient lost her glasses. b) The headache comes and goes. c) The headache is similar in nature to prior ones she has had for decades but more severe. d) The patient also has developed fever and night sweats and thinks she lost some weight. e) The patient had a car accident and minor head trauma about 3 months ago.

d) The patient also has developed fever and night sweats and thinks she lost some weight. Concomitant fever, night sweats, and weight loss are concerning systemic symptoms and suggest a serious underlying cause of the headaches. The headache is similar in nature to prior ones she has had for decades but more severe is incorrect. Most headaches follow a classic pattern and even if this one is more severe, the same pattern to prior headaches makes this one likely to be benign. The patient had a car accident and minor head trauma about three months ago is incorrect. Although recent head trauma is a concerning history, trauma 3 months ago is unlikely to have produced changes that lead to a headache at this time. The headache comes and goes is incorrect. Headaches that come and go tend to be benign. For example, migraines come and go. The patient lost her glasses is incorrect. Losing glasses can cause squinting and subsequent development of headache. In any case, this is not a serious concern although she should get new glasses.

A 21‐year‐old college student experiences tachycardia following a night of heavy drinking. She is advised to undergo a stress electrocardiogram (ECG). As she exercises, the recently calibrated pulse oximeter records a heart rate ranging from 25 beats per minute (bpm) at rest to 50 bpm while jogging. The test is stopped and re‐started twice, and each time the pulse oximeter yields a resting heart rate of 25 and a jogging heart rate of 50. Which aspect of this instrument does the ECG technician question? a) Sensitivity b) Predictive value c) Prevalence d) Validity e) Specificity

d) Validity Validity is a measure of "the true state of affairs" or accuracy: it is extremely unlikely for a conscious, interacting person to have a heart rate of 25 bpm, and so the validity of this measurement is very strongly under question. It quite likely states that there is a flaw in the measurement rather than with the patient's physiology. Prevalence is incorrect as this is a measure of the proportion of a population with a particular condition at a particular moment in time. This concept is clearly not applicable to this scenario. Sensitivity and specificity are incorrect because sensitivity is defined as the proportion of patients with true disease who are accurately identified as positive by a particular test; specificity is defined as the proportion of patients without disease who are accurately identified as negative by a particular test. The process described in this scenario is not seeking to rule in or rule out disease, so this concept does not apply. Predictive value is incorrect because this term refers to the extent to which a particular sign or symptom predicts illness; in this case, neither the abnormal result has been confirmed, nor is it being used to predict any particular pathology.

An obese 50‐year‐old patient presents with a long history of back trouble. What structure in the spine supports the body's weight? a) Spinous process b) Intervertebral disk c) Transverse process d) Vertebral body e) Vertebral arch

d) Vertebral body The vertebral body is a weight‐bearing structure of the spine. Vertebral arch is incorrect; the vertebral arch encloses the spinal cord. Intervertebral disk is incorrect; the intervertebral disk provides a cushion between the vertebrae. Transverse process and Spinous process are incorrect; these structures serve as a site of muscle attachment.

A 25‐year‐old construction worker is complaining of a swishing noise in both ears that never goes away and has occurred for about 6 months. He is otherwise healthy, is able to work on his job (operating large, vibrating machinery) without problems, and is not taking any medications. A complete examination reveals an abnormality. Which of the following abnormality is most often associated with tinnitus? a) Headache b) Wax in both ears c) Mild tremor d) Vertigo e) Bilateral earache

d) Vertigo Vertigo and tinnitus together comprise a syndrome called Ménière disease, which may affect young adults. A more common diagnosis in this case would have been tinnitus resulting from the loud noise of the machinery he is working with. Bilateral earache is incorrect. Otitis media can cause pounding in the ear but not tinnitus, and it is rarely bilateral. Wax in both ears is incorrect. Cerumen can push against the tympanic membrane and can cause a dull sound and pressure, but not typically tinnitus. Headache is incorrect as it can be associated with tinnitus in the case of a brain lesion, but this is rare.A mild tremor is incorrect as it would be unusual at this age but it is sometimes a normal variant, and in this case might be associated with his work.

A 26-year-old graduate student in physical anthropology presents for a routine annual examination. In discussing the risk and benefits of breast self-examination (BSE), she requests a technical definition of area covered by the breast (and thus covered in BSE) in keeping with her background. Which of the following accurately describes the layout of the human breast? a. Against the anterior thoracic wall, from the 5th to 13th rib, and from the sternum to midaxillary line. b. Against the anterior thoracic wall, from the 5th to 13th rib, and from the midclavicular to midaxillary line. c. Against the posterior thoracic wall, from the 2nd to 6th rib, and from the sternum to midaxillary line. d. Against the anterior thoracic wall, from the 2nd to 6th rib, and from the sternum to midaxillary line. e. Against the anterior thoracic wall, from the 2nd to 6th rib, and from the midclavicular to midaxillary line.

d. Against the anterior thoracic wall, from the 2nd to 6th rib, and from the sternum to midaxillary line.

A 21-year-old college student present to the student health clinic for a full physical examination. He is generally healthy; however, he reports that he has had sexual intercourse with multiple partners in the past couple of months. He noticed a small lesion on the shaft of his penis a few days ago. While performing the examination, he unwillingly achieves an erection. How would the clinician proceed at this point? a. Stop the examination immediately b. Assume that he is malingering c. Tell him the examination cannot proceed until the erection subsides d. Explain this is a normal response and finish the examination e. Have him return to see another provider

d. Explain this is a normal response and finish the examination

An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concurred about this possibility. She has not had any vomiting or diarrhea. She had. abnormal bowel movement this morning. Her B-human chorionic gonadotropin (B-hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 119; blood pressure 86/68; respiratory rate, 20/min; oxygen saturation, 99%' and temperature 37.3C orally. The clinician performs and abdominal exam prior to her pelvic exam and, on palpation on her abdomen, find involuntary rigidity and round tenderness. What is the most likely diagnosis? a. Acute cholecystitis b. Ruptured appendix c. Ruptured ovarian cyst d. Ruptured tubal (or ectopic pregnancy) e. Perforated bowel wall

d. Ruptured tubal (or ectopic pregnancy)

A 48-year-old female psychologist presents to clinic with concerns about her breast cancer risk after an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member on her fathers' side in as many years to be diagnosed with breast cancer, including the patient's own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has litter other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War 2 and were among very few members of the their family that survived the war. The patient has read about testing of the breast cancer genes (BRCA1 and BRCA2) and desired further information about whether this would be appropriate for her. Which of the following int rue about this patients' indications of rBRCA testing? a. Even if this patient is BRCA positive, no changes in screening or treatment are recommending for patients with this genetic mutation, so the test is not recommended. b. Breast concern a male relative does not add significant weight to the decision to test for the BRCA genes in this patient. c. Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in assessing her risk for these genes. d. This patients carriers several risk factors that together justify BRCA testing. e. The BRCAPRO calculator does not add any further clinical information to this patient's risk of r carrying the BRCA gene.

d. This patients carriers several risk factors that together justify BRCA testing.

A 38‐year‐old accountant presents to the office with a series of generalized complaints. He relates that he feels a loss of pleasure in daily activities, has difficulty sleeping, and is experiencing problems making decisions. Which of the following best explains the patient's presentation? a) Histrionic personality b) Antisocial personality c) Substance abuse with anhedonia d) Bipolar disorder in the early pre‐excitatory phase e) Depression

e) Depression The complaints as presented are highly consistent with depression. It is important to note that few patients will articulate that they feel depressed. Rather, it is contingent upon the clinician to probe for more information and keep an open mind coupled with an index of suspicion. Because of the stigma associated with mental health problems, many patients initially present with nonspecific complaints that point to a nonmedical cause only with closer questioning. Anhedonia may be associated with depression but tends to be milder in its symptoms. The other entities demonstrate different complaints than those described by this patient.

An 87‐year‐old woman who is generally healthy and cognitively sharp complains to the clinician of slow loss of vision, with similar problems in both eyes, particularly when she looks straight ahead. She is having difficulty reading of late. What is a reasonableresponse to her? a) "Are you experiencing depression or stress?" b) "This is a common occurrence with aging and unlikely to have a diagnosis." c) "This is an unusual occurrence, even among elderly, and may be due to a problem within the brain (since it is bilateral)." d) "This is a classic 'floater' and no cause for concern." e) "This may be the onset of macular degeneration, which an ophthalmologist should confirm."

e) "This may be the onset of macular degeneration, which an ophthalmologist should confirm." Macular degeneration is a common disease of the elderly and results in central vision loss. It is often bilateral. This particular patient likely has "dry" macular degeneration. "This is a common occurrence with aging and unlikely to have a diagnosis" is incorrect. Although this is common among elderly patients, there is likely to be a diagnosis. "This is an unusual occurrence, even among elderly, and may be due to a problem within the brain (since it is bilateral)" is incorrect. Although central lesions can cause bilateral visual defects, this will not be central visual loss but rather a particular portion of the visual field. "Are you experiencing depression or stress?" is incorrect. Depression or stress will not by themselves cause central visual loss. "This is a classic 'floater'and no cause for concern" is incorrect. Floaters are transient and unlikely to be bilaterally symmetric.

A 55‐year‐old actress sustains a heart attack and the follow‐up electrocardiogram demonstrates a left bundle branch block. What would be the likely duration of the QRS complex? a) 95 milliseconds b) 100 milliseconds c) 75 milliseconds d) 90 milliseconds e) 125 milliseconds

e) 125 milliseconds The QRS complex is the duration of ventricular depolarization and is normally less than 100 milliseconds. Therefore, a left bundle branch block would extend ventricular depolarization and cause lengthening of the QRS complex and its duration.

A 26‐year‐old homeless male presents for a new‐patient evaluation at a community health center. He has a history of intravenous drug use, from which he contracted hepatitis C. He also suffers from uncontrolled asthma that he has had since childhood, with treatment including frequent doses of oral steroids when he cannot keep inhalers in his possession. Two years ago, he was diagnosed with bipolar disorder. On today's visit, his main concern is a small abscess in his right antecubital fossa at a heroin injection site. Which of the following is the best approach to the health history for this patient at his first visit? a) A clinician‐centered health history b) A problem‐focused health history c) A review of systems (ROS) only d) A health history with only yes-no options e) A comprehensive health history

e) A comprehensive health history Almost all new patients should undergo a comprehensive health history including the history of present illness (HPI), past medical history, family history, personal and social history, and ROS. This patient, in particular, has a complex past with a number of current issues; becoming acquainted with the whole picture of his health and health care at the first visit can make future visits more streamlined and fruitful. In this patient's case, he has one very acute issue that must be addressed that day (the abscess), but his other chronic conditions can wait until future visits for more thorough treatment. A clinician‐ centered health history is incorrect because it is structured toward discrete data items desired by the clinician, such as ticking boxes for billing reasons. This approach may not best serve the needs of a patient with such a complex medical and social history. A health history with only yes-no options is incorrect because this may be helpful in the ROS portion of a history, such an approach is unlikely to elicit this patient's full range of conditions and needs. An ROS only is incorrect because it is a very limited portion of the examination that often covers areas not mentioned in the HPI. Performing this portion alone is inadequate for any patient or conditions. A problem‐focused health history is incorrect because this patient's abscess may require a brief problem‐focused assessment (when did it start? how painful it is? any associated symptoms?), his overall care demands a more thorough subjective history to establish appropriate care.

A 20‐year‐old college student is experiencing dyspnea on exertion and palpitations. On cardiac auscultation, the second heart sound is split and fixed on both inspiration and expiration. What is the most likely cardiac condition associated with this finding? a) Pulmonic stenosis b) Left bundle branch block c) Right bundle branch block d) Tricuspid stenosis e) Atrial septal defect

e) Atrial septal defect Patients with an atrial septal defect often experience dyspnea as well as atrial arrhythmias. Fixed splitting of the second heart sound occurs in atrial septal defects and right heart failure and does not vary with respiration. A left bundle branch block causes paradoxical splitting secondary to the delayed closure of the aortic valve. Wide splitting of the second heart sound is secondary to a delayed closure of the pulmonic valve and is often found in right bundle branch blocks and pulmonic stenosis. Tricuspid stenosis would not usually affect the second heart sound as it is a component of S .

"Instability in interpersonal relations, self‐image, and affective regulation; impulsivity" describes which personality disorder? a) Antisocial personality b) Avoidant personality c) Histrionic personality d) Narcissistic personality e) Borderline personality

e) Borderline personality The DSM‐5 is published by the American Psychiatric Association based upon its professional definitions of mental disorders. Although at times controversial, it is generally considered the authoritative publication in the field. The example cited defines the borderline personality. Although these persons may demonstrate some selected characteristics of other disorders, this definition is the basis for the diagnosis. It is important to remember that mental disorders as well as physical ones may demonstrate substantial overlap making a definitive diagnosis difficult. The incorrect answers all have specific criteria as set out by the DSM‐5.

A 45‐year‐old physician is having increasing difficulty with speech for the past 6 months. She is less precise in pronunciation of words (dysarthria), has found it more effortful to speak, and finds that her voice sounds more nasal than usual. On examination, her articulation is less than precise, especially with rapid repetition of single syllables, such as "ta‐ta‐ta‐ta," "go‐go‐go‐go," "la‐la‐la‐ la," and "ba‐ba‐ba." Her neurological examination is otherwise normal. Which nervous system pathway is responsible for control of the muscles producing this symptom? a) Cerebellar system b) Spinothalamic tract c) Posterior column system d) Corticospinal tract e) Corticobulbar tract

e) Corticobulbar tract The corticobulbar tract is a motor tract that mediates voluntary movement, including skilled, complex, and fine movements (such as what are involved in speech) in the muscles of the face, head, and neck innervated by the cranial nerves. Corticospinal tract is incorrect because this is a motor tract mediating voluntary movement in the body below the neck. Spinothalamic system is incorrect because this is a sensory pathway transmitting impulses from nerve endings registering pain and temperature in the body up to the thalamus. Cerebellar system is incorrect because this system consists of sensorimotor control pathways coordinating motor activity, equilibrium, and posture. Posterior column system is incorrect because this is an afferent sensory pathway that transmits the sensations of vibration, proprioception, kinesthesia, pressure, and light touch.

A 23‐year‐old physician assistant (PA) student found that she felt nervous when called upon to examine men in her age group. On one occasion, she encountered a young male patient who appeared embarrassed to see her walk into the room. What should the PA do to minimize their mutual discomfort? a) Adjust lighting so it is tangential to the patient's body. b) Ask the patient where he comes from. c) Explain that she is a PA student. d) Provide ongoing interpretation of findings. e) Explain how the examination will proceed.

e) Explain how the examination will proceed. Patient comfort is a primary concern in setting the stage for the examination, and, if patients know how the exam will proceed, they are likely to feel more relaxed. In addition, explaining a routine may help remind the PA student of the routine she will follow. Adjusting lighting so that it is tangential to the patient's body is important for accurate visualization of body structures but does not necessarily reduce the patient's embarrassment. Asking the patient where he comes from would move the situation away from the professional to the personal, which could enhance discomfort. Explaining that she is a PA student may reduce the PA's own anxiety but will not necessarily calm the patient. Providing ongoing interpretation of findings is not advisable for beginners, who are not primary caregivers and may make errors.

During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group? a) Rotation of the spine b) Rotation and lateral bending of the spine c) Flexion of the spine d) Lateral bending of the spine e) Extension of the spine

e) Extension of the spine The erector spinae muscle group is one of the deep intrinsic muscle groups of the back that extend the spine. Rotation of the spine is incorrect; the muscles that rotate the spine are the abdominal muscles and the intrinsic muscles of the back. Flexion of the spine is incorrect; the muscles that flex the spine are the psoas major and minor, quadratus lumborum, and the abdominal muscles. Lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back. Rotation and lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back.

A theoretical laboratory test for infection with HIV is known to have high sensitivity. This means that the test has which of the following? a) Good ability to diagnose AIDS b) High intraobserver reliability c) Good ability to rule in HIV in those who do have HIV d) High interobserver reliability e) Good ability to rule out HIV in those who do not have HIV

e) Good ability to rule out HIV in those who do not have HIV High sensitivity means that a test is positive for most of the people who actually have the condition tested for, and thus a negative result strongly predicts that the person does not have disease. Because high sensitivity does not address false positives (positive results in individuals that do not have the disease), a highly sensitive test is good at ruling out true negative cases but may or may not be good at ruling it truly positive cases (this is determined by specificity). Good ability to rule in HIV in those who do have HIV is incorrect because the ability to rule in a test is determined by the specificity, and not the sensitivity. High specificity means that a test is negative for most of the people who actually do not have the condition tested for, thus a negative result strongly predicts that the person does not have the disease. Because high specificity does not address false negatives (negative results in individuals who actually have the disease), a highly specific test is good at ruling out true positive cases but may or may not be good at ruling it truly negative cases (this is determined by sensitivity). High intraobserver reliability and high interobserver reliability are incorrect because sensitivity in no way reflects intraobserver or interobserver reliability. Good ability to diagnose AIDSis incorrect because AIDS is a distinct syndrome that results from a progressive infection of the HIV virus. Tests for HIV do not test for the presence of the AIDS syndrome. This test's diagnostic capabilities are limited to detect the presence of HIV, an infection, not AIDS, a disease.

A theoretical new laboratory test for strep throat has high specificity. When a test has high specificity, clinicians can be confident in which of the following aspects? a) If the test result is positive, a confirmatory test should be performed. b) If the test result is positive, the patient probably does not have strep throat. c) If the test result is negative, the patient probably does not have strep throat. d) If the test result is negative, the patient probably has strep throat. e) If the test result is positive, the patient probably has strep throat.

e) If the test result is positive, the patient probably has strep throat. High specificity means that a test is negative for most of the people who actually do not have the condition tested for, thus a negative result strongly predicts that the person does not have disease. Because high specificity does not address false negatives (negative results in individuals who actually have the disease), a highly specific test is good at ruling out true positive cases but may or may not be good at ruling it truly negative cases (this is determined by sensitivity). In this case, if a test shows that the patient is positive for strep, the patient is very likely to have strep, because the specificity is high. If the test result is positive, the patient probably does not have strep throat is incorrect. As mentioned above, high specificity is effective at ruling in a condition. If the test is positive, it is likely that the patient has the condition. If the test result is negative, the patient probably has strep throat and if the test result is negative, the patient probably does not have strep throat both are incorrect as the ability to rule out a disease depends on the sensitivity, and not the specificity (see above). Because there is no information about the sensitivity of the test, one cannot say that either of these is correct. If the test result is positive, a confirmatory test should be performed is incorrect. Because of the high specificity, a positive result is very likely to be accurate as discussed above. In that case, no confirmatory test is needed, as the patient almost certainly has the disease.

A 29‐year‐old female bookseller presents to her primary care provider with a complaint of depression. She has two young children at home and expresses worries about her ability to support them. When asked about the role of her partner (who also receives care at the clinic and has visited this clinician with the patient before), the patient's voice wavers and becomes lower in pitch as she replies, "He's fine." The clinician notes the change in her tone and queries further, only to find out that recent financial stressors have reactivated the partner's prior abusive behavior. Which of the following best describes the form of communication that helped the clinician identify this issue? a) Echoing b) Verbalization c) Nonverbal communication d) Posturing e) Paralanguag

e) Paralanguage Paralanguage consists of the tone, pacing, and volume of speech that provides indirect verbal clues to the patient's mood, intent, etc. Without attention to this form of communication, a less astute provider may have missed the key to this patient's condition. Nonverbal communication is incorrect because this patient's concern was verbalized indirectly through her paralanguage. Echoing is incorrect as it is a technique used by the clinicians to elicit further narrative by repeating parts of the patient's last phrases in a questioning tone. It does not describe the patient's action in this case, although the patient's may also use echoing to encourage providers to share more. Posturing is incorrect because this patient's posture may match her concerns (e.g., slumping, downward‐glancing, etc.); in this case, her posture was not described. Verbalization is incorrect as the patient's direct verbal speech in fact contradicted her true concerns, while her paralanguage revealed the nature of her condition.

A 51‐year‐old moderately overweight college professor visits the clinic with a complaint of chest pain after tennis matches. He jokes that his tennis partner "is in a lot better shape than I am" but says that he is trying to keep up. Later in the day, a 28‐year‐old female student at the same college reports that "my chest often feels hot and tight." She also feels stressed on the evening before mid‐term exams. The clinician recommends an immediate evaluation for coronary artery disease (CAD) for the professor, but not for the student. Why? a) Negative predictive value of an observation is higher in a group with a higher prevalence of disease. b) Positive predictive value of an observation is lower in a group with a higher prevalence of disease. c) Negative predictive value of an observation is lower in a group with a higher prevalence of disease. d) Positive predictive value of an observation is greater in older people than in younger people. e) Positive predictive value of an observation is higher in a group with a higher prevalence of disease.

e) Positive predictive value of an observation is higher in a group with a higher prevalence of disease. The predictive value of a test or observation depends heavily on the prevalence of the condition of the test or the observation measures in the population being studied. As the prevalence of a disease increases, the predictive value of a positive observation increases; conversely, as the prevalence of a disease decreases, the predictive value of a positive observation also decreases. In this case, CAD is more prevalent in older, overweight men than in young, female college students, so that the utility of the chest pain in predicting CAD is higher in the older male than in the younger female. Positive predictive value of an observation is lower in a group with a higher prevalence of disease is incorrect because the positive predictive value of an observation is higher in a group with a higher prevalence of disease rather than lower. Negative predictive value of a symptom is lower in a group with a higher prevalence of disease and negative predictive value of a symptom is higher in a group with a higher prevalence of disease are incorrect because both patients mentioned in the question have the symptom (chest pain), thus negative predictive value does not apply. If, for example, the older male patient did not have chest pain but wanted to know if he was at risk for an immediate myocardial infarction, one coulduse the lack of chest pain as a negative predictor of his likelihood of having an immediate cardiac event. Positive predictive value of a symptom is greater in older people than in younger peopleis incorrect because the positive predictive value of a symptom depends simply on the prevalence of the condition in the population studied, not age itself.

An elderly patient with a history of smoking two packs of cigarettes a day for 50 years complains to her physician of progressive shortness of breath. On cardiac examination, the physician feels the most prominent palpable impulse to be in the xiphoid area. This is most likely a result of what condition? a) Mitral regurgitation b) Aortic stenosis c) Hypertrophic cardiomyopathy d) Hypertension e) Pulmonary hypertension

e) Pulmonary hypertension Pulmonary hypertension may arise from underlying lung disease from smoking such as emphysema or chronic obstructive pulmonary disease. Pulmonary hypertension often results in right ventricular hypertrophy. Aortic stenosis, hypertrophic cardiomyopathy, and hypertension all cause left ventricular hypertrophy and would displace the point of maximal impulse (PMI) lateral to the midclavicular line. Mitral regurgitation is often not associated with ventricular hypertrophy.

A 36‐year‐old female air traffic controller presents to her primary care provider for a routine visit 3 months after losing her spouse to a lengthy battle with a neurodegenerative disease. The patient denies any psychiatric symptoms on review of systems and, in fact, states that she has slept better in the last month than she had in the previous years. She endorses a healthy support system, including the extended family of her deceased spouse, with whom she is still close. She becomes wistful and briefly tearful when speaking of the plans that they had when they first married that were never fulfilled; she then changes the subject rapidly to whether her Pap smear is due. Which of the following is an example of an empathetic response to this patient? a) By allowing the crying patient to look around the room for tissues to permit her an excuse to hide her face and defer her emotions b) Narrowing the understanding of the patient's emotional response to only thoughts and feelings that have been verbalized c) Presuming that the patient's emotions meet social expectations, such as being depressed and even traumatized by her spouse's death d) Assuming that the event caused her to become depressed and expressing the same feeling on behalf of the patient e) Recognizing the patient's emotions by asking or confirming how she feels about the event

e) Recognizing the patient's emotions by asking or confirming how she feels about the event This patient expresses notable ambiguity about her experience of her husband's death and her desire to speak openly of those events. Empathizing with her emotions without understanding them better may lead to alienation from the clinician; for example, she may be more relieved than being sad about his death after a lengthy illness, and may feel guilty if she feels the clinician seems to prefer the expression of sadness. Assuming that the event caused her to become depressed and expressing the same feeling on behalf of the patient and presuming that the patient's emotions meet social expectations, such as being depressed and even traumatized by her spouse's death are incorrect because assumptions about a patient's emotional landscape may not be correct and, as above, may lead to alienation if the patient feels she must play a role to be accepted by the clinician. By allowing the crying patient to look around the room for tissues to permit her an excuse to hide her face and defer her emotions is incorrect because a patient who is obvious in attempting to hide or maintain privacy may well be given the latitude and respect to do so, a more compassionate gesture maybe to find the tissue and hand it to her. Narrowing the understanding of the patient's emotional response to only thoughts and feelings that have been verbalized is incorrect because this patient's emotional landscape is likely rich and nuanced with grief, relief, regret, and many other emotions—little of which is verbalized in the few lines she shares. Undisclosed responses may be even more significant to her than those few she shared.

A 74‐year‐old man is being seen because of a 1‐day history of a painful right eye. He also mentions that he has blurred vision in that eye. He thought something had blown into his eye, but after flushing it out, the pain and blurred vision remains. What is the best course of action? a) Check his blood pressure. b) Perform a complete neurological examination. c) Perform a vision examination. d) Reassure him that pain from a foreign body can remain for a day or two (even after the foreign body is removed). e) Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma.

e) Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma. A unilateral, painful eye may be due to acute glaucoma or corneal pathology (foreign body, ulcer, uveitis, etc.). Reassure him that pain from a foreign body can remain for a day or two (even after the foreign body is removed) is incorrect. The pain from a foreign body tends to resolve rather quickly once it is removed. Perform a vision examination is incorrect. (Visual exam should be performed even if referral to an ophthalmologist is urgently needed. Extra information can be added to this option to make it completely incorrect.) Although a vision examination is always good, unilateral pain/blurriness indicates pathology in a single eye. Perform a complete neurological examination is incorrect. A complete neurological examination is never harmful, but not highest priority for this patient who clearly has single eye pathology. Check his blood pressure is incorrect. Hypertension does not cause these symptoms.

Which of the following complaints/findings is considered to be a patient identifier for mental health screening? a) High use of health services due to chronic unstable medical diagnoses b) Acute pain syndromes of 10 days' duration that require opiates for relief c) A patient with type I diabetes and neuropathic pain d) Symptoms lasting for >2 weeks e) Substance abuse

e) Substance abuse The answer is substance abuse. High use of health services in an unstable patient is frequently indicated; however, it is those without demonstrable problems that may require further evaluation, that is, mental health screening. Symptoms of a more chronic nature, namely 6 weeks, might warrant referral, but not 2 weeks. Acute pain should be managed in the context of the patient presentation, and type I diabetics frequently suffer from difficult to manage neuropathic pain, which is not easily treated but medically based and well‐described clinically.

A 62‐year‐old patient with rheumatoid arthritis (RA) complains of increased joint stiffness. What characteristic(s) are consistent with her diagnosis of RA? a) Joint distribution is asymmetrical. b) Tophi are found in the subcutaneous tissue. c) Stiffness follows joint activity. d) It most frequently involves the first metatarsophalangeal joint. e) Swelling of the synovial tissue is seen in joints and tendon sheaths.

e) Swelling of the synovial tissue is seen in joints and tendon sheaths. The physical signs of RA include frequent swelling of the synovial tissue in joints or tendon sheaths. Stiffness follows joint activity is incorrect; joint stiffness is usually present after periods of inactivity in RA. Joint distribution is asymmetrical is incorrect; the distribution of involved joints is usually symmetrical in RA. It most frequently involves the first metatarsophalangeal joint is incorrect; the involvement of the first metatarsophalangeal joint is typical of acute gout. Tophi are found in the subcutaneous tissue is incorrect; tophi in the subcutaneous tissue is typical of chronic tophaceous gout.

A 58‐year‐old carpenter presents for his annual physical examination. The physician assistant notes a systolic murmur on auscultation of the aorta. However, she does not immediately conclude that this patient has aortic stenosis. Which of the following is the reason that she seeks additional information? a) Systolic murmurs have low sensitivity and low specificity for aortic stenosis. b) Systolic murmurs have low sensitivity but high specificity for aortic stenosis. c) Systolic murmurs are unrelated to aortic stenosis. d) Systolic murmurs have high sensitivity and high specificity for aortic stenosis. e) Systolic murmurs have high sensitivity but low specificity for aortic stenosis.

e) Systolic murmurs have high sensitivity but low specificity for aortic stenosis. Most people who have aortic stenosis have a systolic murmur, but there are many other causes of systolic murmurs besides aortic stenosis. Using the presence of a murmur as the only criterion for diagnosing aortic stenosis would lead to too many false‐positive diagnoses. Systolic murmurs have high sensitivity and high specificity for aortic stenosis, systolic murmurs have low sensitivity and low specificity for aortic stenosis, and systolic murmurs have low sensitivity but high specificity for aortic stenosisare incorrect because systolic murmurs have high sensitivity but low specificity for aortic stenosis. Systolic murmurs are unrelated to aortic stenosisis incorrect because this sign has high specificity for aortic stenosis.

A 29‐year‐old female professional athlete presents to a new primary care provider with chronic menstrual complaints. She remarks to the nursing staff that, in the past, she has experienced a dismissal of her complaints because of her high level of physical fitness and conditioning. She is seeking a care provider who will explore the issue in more detail and work with her particular concerns. Which of the following is the description of the patient‐centered care this individual seeks? a) Affirming and reassuring with close‐ended questions b) Factual and structured with active listening c) Structured and clinician‐centered with open‐ended questions d) Dismissive and concrete with open‐ended questions e) Validating and empathetic with open‐ended questions

e) Validating and empathetic with open‐ended questions Patient‐centered care is loosely structured, supportive, aimed at meeting the patient where they are in their disease process, and characterized by open‐ended questions. Structured and clinician‐ centered with open‐ended questions is incorrect because open‐ended questions are consistent with patient‐centered care, and the description specifically endorses clinician‐centered care. Dismissive and concrete with open‐ended questions is incorrect because open‐ended questions are consistent with patient‐centered care, whereas concrete questions are left out in favor of unstructured discussion. A dismissive attitude is never appropriate in patient care. Affirming and reassuring with close‐ended questions is incorrect because it is consistent with patient‐centered care, whereas close‐ended questions are best left to structured visits around singular and concrete conditions, such as an acute urinary tract infection. Factual and structured with active listening is incorrect because active listening is important in patient‐ centered care, whereas the factual and structured approach is more appropriate to evaluate concrete and limited conditions as noted above.

A 32-year-old elementary teacher requests a workup for internality. He and his wife have been trying to conceive for the last 2 years. He repots that his wife has been evaluated and odes onto appear to have any infertility attunes. The over examination does not reveal any significant abnormalities. He is of average height and weight and has normal secondary sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility? a. 5a-Reductase b. 5a-Dihydortestosterone c. Luteinizing hormone (LH) d. Thyroid-stimulating hormone (TSH) e. Follicle-stimulating hormone (FSH)

e. Follicle-stimulating hormone (FSH)

A 20-year-old college student presents for his annual physical examination. He recently became sexually active and is inquiring about the best means of preventing sexually transmitted infections (STIs). Of the following, which would be the most effective means of prevention? a. Diaphragms b. Spermicides c. Early withdrawal d. Cervical caps e. Male condoms

e. Male condoms

Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from higher brain centers to the T11-L2 levels of the spinal cord and parasympathetic outflow from S2 to S4 reflex arcs. Local vasodilation within the penis erectile tissue results for increased levels of which of the following? a. Leuteinizng hormone b. gonadotropin-releasing hormone (GRH) c. Testosterone d. Follicle-stimulation hormone (FSH) e. Nitric oxide (NO) and cyclone guanosine monophosphate (cGMP)

e. Nitric oxide (NO) and cyclone guanosine monophosphate (cGMP)

A student is practicing the performance of a lung examination on a classmate. Which of the following is the correct order for performing the components of the lung examination? a) Auscultation, inspection, palpation, and percussion b) Palpation, inspection, auscultation, and percussion c) Auscultation, percussion, palpation, and inspection d) Inspection, auscultation, percussion, and palpation e) Auscultation, inspection, palpation, and percussion f) Inspection, palpation, percussion, and auscultation

f) Inspection, palpation, percussion, and auscultation The orderly fashion in which lung examination is performed is inspection, palpation, percussion, and auscultation. With this order, information is gathered from the first three components to allow the examiner to be more informed when performing the last component, auscultation. Auscultation is the most important examination technique for assessing air flow through the tracheobronchial tree. Auscultation, inspection, palpation, and percussion is incorrect. That is not the orderly fashion in which lung examination is performed. With that order, the clues gathered from inspection, palpation, and percussion to guide in auscultation would be missed. Auscultation, percussion, palpation, and inspection is incorrect. That is not the orderly fashion in which lung examination is performed. With that order, the clues gathered from inspection, palpation, and percussion to guide in auscultation would be missed. Auscultation, inspection, palpation, and percussion is incorrect. That is not the orderly fashion in which lung examination is performed. With that order, the clues gathered from inspection, palpation, and percussion to guide in auscultation would be missed. Inspection, auscultation, percussion, and palpation is incorrect. That is not the orderly fashion in which lung examination is performed. However, it is the orderly fashion in which abdominal examination is performed. With that order, the clues gathered from palpation and percussion to guide in auscultation would be missed. Palpation, inspection, auscultation, and percussion is incorrect. That is not the orderly fashion in which lung examination is performed. With that order, the clues gathered from percussion to guide in auscultation would be missed.

A new mother brings in her 6‐month‐old baby for not being able to keep his eyes together when looking to the left. On examination, both of his eyes appear in alignment (conjugate) when looking to the right. However, when looking to the left, the baby's left eye stays in the forward gaze position, while the right continues on with full adduction to the left. The eyes appear to be out of alignment (dysconjugate). Which cranial nerve (CN) is responsible for the dysfunction in looking left? ) The left oculomotor nerve (CN III) b) The right abducens nerve (CN VI) c) The right trochlear nerve (CN IV) d) The right oculomotor nerve (CN III) e) The left trochlear nerve (CN IV) f) The left abducens nerve (CN VI)

f) The left abducens nerve (CN VI) The left abducens nerve (CN VI) moves the left eye outward to the left. Paresis or weakness of this muscle will produce the inability of the baby to move the left eye out to the left. The right oculomotor nerve (CN III) is incorrect because this nerve moves the right eye inward, up and in, up and out, and down and out. The right trochlear nerve (CN IV) is incorrect because this nerve moves the right eye downward and in. The right abducens nerve (CN VI) is incorrect because this nerve moves the right eye outward to the right. The left oculomotor nerve (CN III) is incorrect because this nerve moves the left eye inward, up and in, up and out, and down and out. The left trochlear nerve (CN IV) is incorrect because this nerve moves the left eye downward and in.