Health Assessment Exam 1 The Point Practice Questions

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.

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 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 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 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 history include a rash, fever, or other signs of infection, which are absent here.

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 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 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 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.

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 associate 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

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 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.

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 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).

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 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 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.

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 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 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.

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

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 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? a) 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 approximates 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 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.

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

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 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 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

"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 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 non-medical 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

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.

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) Paralanguage

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 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.

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 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.