Interactive questions for exam 1 review

A first-year medical student is examining a standardized patient with a structurally normal heart. The student is having difficulty auscultating the splitting of the second heart sound. At what area on the patient's chest would the student have the best opportunity of hearing this sound?

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

A 55-year-old truck driver with obstructive sleep apnea has diastolic heart failure. An echocardiogram demonstrates significant biatrial enlargement. What portion of his electrocardiogram would likely be abnormal?

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

A 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?

Both of these eating disorders are associated with a real or imagined fear of appearing fat. Rationale: 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.

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?

"That sounds like a frightening experience that you are recovering well from." Rationale: 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.

An 87-year-old woman who is generally healthy and cognitively sharp complains to the clinician of slow loss of vision, with similar problems in both eyes, particularly when she looks straight ahead. She is having difficulty reading of late. What is a reasonable response to her?

"This may be the onset of macular degeneration, which an ophthalmologist should confirm." Rationale: Macular degeneration is a common disease of the elderly and results in central vision loss. It is often bilateral. This particular patient likely has "dry" macular degeneration.

A 55-year-old actress sustains a heart attack and the follow-up electrocardiogram demonstrates a left bundle branch block. What would be the likely duration of the QRS complex?

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

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

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

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 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 Rationale: 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 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 comprehensive health history Rationale: 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.

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 patient with a body mass index (BMI) >30 Rationale: 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 70-year-old man complains of double vision. Which of the following associated symptoms or signs would be worrying about an underlying neurological problem (as opposed to pathology in the eye)?

Abnormality in extraocular movements on examination Rationale: Paralysis or weakness of extraocular muscles suggests a possible brainstem or cerebellar lesion. Diplopia in one eye while the other eye is closed suggests a problem in the cornea or lens. Flashing lights suggest vitreous floaters, although it could suggest detached vitreous from the retina.

A 32-year-old office worker reports excessive stress at work and pain in the right lower quadrant. She states that last night she vomited twice. Her blood pressure is 120/75, heart rate 93 bpm. The patient looks pale and is sweating lightly. Which of the following is an objective finding?

Accelerated heart rate Rationale: Objective findings are those detected on physical examination by the clinician. A resting heart rate of 93 bpm is higher than normal.

A 65-year-old overweight male presents at the clinic with hoarseness which has lasted for around 2 months. He thinks it began along with a cold. He is not feeling badly other than frequent heartburn, and he has continued to work as a bartender (for the past 30 years), but he is having difficulty being heard and understood because of his hoarse voice. A diagnosis that is on the differential list includes which of the following?

Acid reflux Rationale: Acid reflux (also known as gastroesophageal reflux disease, or GERD) can cause hoarseness through damage to the laryngeal area due to acid stomach contents being refluxed to the vocal cords.

The CAGE questionnaire is a short screening examination administered in the office to evaluate for which of the following?

Alcohol misuse Rationale: 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.

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?

Ambulatory monitoring over 2-24 hours is recommended because this rhythm produces variable and inconsistent blood pressures. Rationale: Multiple readings in the clinical and ambulatory setting best approximate the true blood pressure in persons with atrial fibrillation. Because pressures in these patients can vary greatly, single in-office measurements rarely provide a true picture of their blood pressure or adequately diagnose/rule out hypertension.

A 77-year-old man is experiencing progressive shortness of breath and dizziness. The patient undergoes cardiac catheterization, and the systolic blood pressure measured in the left ventricle is 180 mm Hg, while the systolic blood pressure measured in the aorta is 140 mm Hg. The patient is most likely experiencing symptoms related to what valvular condition?

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

A 53-year-old caterer comes to the clinic for a routine examination. She has type 2 diabetes mellitus, which is well controlled on medication. Her history from her last visit reveals that she smoked one pack of cigarettes a day at that time. The 5 As Model is a useful approach to take with trying to help patients to quit smoking. What is the 5 As Model?

Ask, advise, assess, assist, arrange Rationale: Ask, advise, assess, assist, and arrange are the 5 As in the 5 As Model. .

A 20-year-old college student is experiencing dyspnea on exertion and palpitations. On cardiac auscultation, the second heart sound is split and fixed on both inspiration and expiration. What is the most likely cardiac condition associated with this finding?

Atrial septal defect Rationale: Patients with an atrial septal defect often experience dyspnea as well as atrial arrhythmias. Fixed splitting of the second heart sound occurs in atrial septal defects and right heart failure and does not vary with respiration. A left bundle branch block causes paradoxical splitting secondary to the delayed closure of the aortic valve. Wide splitting of the second heart sound is secondary to a delayed closure of the pulmonic valve and is often found in right bundle branch blocks and pulmonic stenosis. Tricuspid stenosis would not usually affect the second heart sound as it is a component of S1.

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?

Percussion Rationale: 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 61-year-old retired librarian was recently diagnosed with ovarian cancer. She was otherwise healthy until her recent cancer diagnosis. She has not been feeling well lately and has had a cough and some mild shortness of breath for the past couple of days. She now presents to the clinic complaining of pain and swelling in her right groin and leg, which she says is been there for about a week but is worsening. On physical examination, 2+ edema of the right leg up to the thigh; 1+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses; and no significant erythema are noted. What is the chief concern with this patient?

Pulmonary embolism (PE) Rationale: Cancer patients are at high risk of deep venous thrombosis (DVT), and, with the presenting symptoms of swelling and pain in her groin, along with recent history of cough and shortness of breath, this patient's presentation is suspicious for PE. Patients with DVT in the proximal leg veins are at high risk of thromboembolism. Acute arterial occlusion should not cause significant edema, and pulses would likely be absent. The constellation of symptoms and history in this patient also does not suggest an acute arterial occlusion. Superficial thrombophlebitis typically only causes mild local swelling, redness, and warmth along with a subcutaneous cord. Acute lymphangitis typically presents with red streaks from an infection passing through lymph channels.

On routine physical examination, a 40-year-old teacher is found to have a single second heart sound. The most likely explanation for this finding is what?

Auscultation occurred during expiration. Rationale: During expiration, the components of S2, A2, and P2 fuse into a single sound. During inspiration, the right heart filling time is increased thereby delaying closure of the pulmonic valve and splitting S2 into two audible components. Pulmonic stenosis and a right bundle branch block delay the P2 component and cause fixed splitting of S2. A left bundle branch block delays the A2 component and causes paradoxical splitting.

When assessing for the femoral pulse, where should the clinician begin deeply palpating?

Below the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis Rationale: The clinician would begin deeply palpating below the inguinal ligament, midway between the anterior superior iliac spine in the symphysis pubis. The external iliac artery transitions into the femoral artery at the level of the inguinal ligament. Therefore, palpating above the inguinal ligament would be assessing the external iliac artery. The femoral artery is typically located midway between the anterior superior iliac spine in the symphysis pubis in most patients.

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?

Biases of the treating clinician are associated with under-treatment of pain in minority patients and non-English speakers. Rationale: 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.

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?

Explain how the examination will proceed. Rationale: 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.

A patient that has a known history of cardiovascular disease including a myocardial infarction and positive ankle-brachial index indicating peripheral arterial disease in his left leg is now having some issues with erectile dysfunction (ED). The clinician suspects it may be due to medications or further vascular disease. He does not complain of any other symptoms. If his symptoms are related to vascular disease, where would the lesion likely be located?

Iliac pudendal Rationale: The internal pudendal artery, which is a branch off of the internal iliac artery, is the major blood supply for the penis.

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?

Immunizations Rationale: 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.

An elderly patient with a history of smoking two packs of cigarettes a day for 50 years complains to her physician of progressive shortness of breath. On cardiac examination, the physician feels the most prominent palpable impulse to be in the xiphoid area. This is most likely a result of what condition?

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

A newborn baby has an embryologic defect affecting the aortic valve. What other cardiac valve is most likely to be affected?

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

A 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?

Recognizing the patient's emotions by asking or confirming how she feels about the event Rationale: This patient expresses notable ambiguity about her experience of her husband's death and her desire to speak openly of those events.

A 74-year-old man is being seen because of a 1-day history of a painful right eye. He also mentions that he has blurred vision in that eye. He thought something had blown into his eye, but after flushing it out, the pain and blurred vision remains. What is the best course of action?

Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma. Rationale: A unilateral, painful eye may be due to acute glaucoma or corneal pathology (foreign body, ulcer, uveitis, etc.). The pain from a foreign body tends to resolve rather quickly once it is removed. Visual exam should be performed even if referral to an ophthalmologist is urgently needed. Although a vision examination is always good, unilateral pain/blurriness indicates pathology in a single eye. A complete neurological examination is never harmful, but not highest priority for this patient who clearly has single eye pathology. Hypertension does not cause these symptoms.

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)?

Regular ambulatory monitoring recorded outside of the office setting Rationale: 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.

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?

The disappearance of Korotkoff sounds following initial muffling. Rationale: By convention, it is the disappearance of Korotkoff sounds, not the muffing, that determines diastolic blood pressure.

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?

This finding is clearly abnormal and requires immediate evaluation for possible cardiovascular emergency. Rationale: 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.

A clinician, evaluating a patient for valvular competency in the communicating veins of the saphenous system, starts with the patient supine, then elevates one leg to about 90° to empty it of venous blood. Next, the great saphenous vein in the upper part of the thigh is occluded with manual compression, and the patient stands. The clinician keeps the vein occluded while watching for venous filling in the leg. Which test is being performed?

Trendelenburg Rationale: The Trendelenburg, or retrograde filling test, is used to evaluate the competency of venous valves in the lower extremities. The Allen test is used to evaluate adequate perfusion of the hand from the ulnar and radial arteries. The straight-leg raise test is used to evaluate for radiculopathy from the lumbosacral regions. Romberg is a test for position sense.

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?

Using nonverbal communication to encourage the patient to expand their narrative Rationale: 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.

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?

Validating and empathetic with open-ended questions Rationale: 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.

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

Vertigo

Mitral stenosis

involves narrowing of the valve between the left atrium and left ventricle

Mitral regurgitation

involves the flow of blood from the left ventricle to the left atrium during systole when the mitral valve is normally closed.

Pulmonic stenosis

involves valvular obstruction between the right ventricle and pulmonary artery.

Aortic insufficiency

is associated with blood flow from the aorta to the left ventricle during diastole and is often not associated with differences in systolic blood pressure.

A 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?

Chronic pain is defined as pain not due to cancer or a recognized medical condition that persists for >3-6 months. Rationale: 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.

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?

Cut over eye from shaving Rationale: 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.

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?

Determine the number of pack-years the patient smokes. Rationale: 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.

A 73-year-old retired salesman presents to the Emergency Department complaining of chest pain that started about 2 hours ago. Electrocardiogram, cardiac enzymes, and chest x-ray are normal. The nurse notes that his blood pressures in the right arm are significantly lower than of blood pressures in his left arm. Based on history and physical examination, which of the following will most likely explain his signs and symptoms?

Dissecting aortic aneurysm Rationale: Patients with dissecting aortic aneurysms typically present with chest pain, many times described as a "tearing" type pain. They are usually elderly, and, due to the dissection of the aorta, asymmetric pulses in blood pressures in the extremities may be present. Coarctation of the aorta can also cause similar symptoms; however, it would be unlikely due to the patient's age as this is a congenital defect. MI, PE, and pericarditis are also common causes of concerning chest pain; however, neither typically will cause asymmetric blood pressures or pulses in the extremities.

The clinician is palpating pulses in the foot of a diabetic patient while in the clinic. A strong pulse is felt located on the dorsum of the foot, just lateral to the extensor tendon of the big toe. Which artery is being assessed?

Dorsalis pedis Rationale: The dorsalis pedis artery is usually palpable on the dorsum of the foot just lateral to the extensor tendon of the big toe. The arterial arch of the foot is more distal and runs transversely and is not usually palpable. The posterior tibial artery is found behind the medial malleolus of the ankle. The popliteal and femoral pulses are found more proximally at the knee and near the groin, respectively.

A 32-year-old cabdriver complains of pain in his left leg. He has a history of type 2 diabetes, is a smoker, and recently was diagnosed with hypertension. He does not remember injuring his leg; however, he notes that there is a small wound on the lateral aspect of his mid-shin. Upon examination, some mild erythema surrounding the wound and flat, nonpalpable red streaks progressing up his leg are noted. What do these streaks likely represent?

Draining lymphatic channels Rationale: Acute lymphangitis is typically caused from an acute bacterial infection of the skin that causes red streaks from distal drainage through the lymphatic system. The streaks are typically flat, not palpable cords as found in thrombus formation in a superficial vein. Dilated veins also are not flat. Occluded arterial vessels are not superficial or visible. Dilated arterioles are still too small to be visible at the skin surface.

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?

Echoing Rationale: 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.

A 19-year-old carwash attendant sustained a laceration to the ulnar aspect of his mid-forearm while at work last week. He did not have it evaluated at that time and is now noticing purulent discharge and increasing pain from the wound along with fever and chills. Where would the clinician expect to find the first signs of lymphadenopathy?

Epitrochlear nodes Rationale: The epitrochlear nodes are the first nodes in the drainage region from the ulnar surface of the forearm and hand, little and ring fingers, and adjacent surface of the middle finger. Axillary nodes, infraclavicular nodes, and cervical chain nodes are all distal to this area and may show evidence of lymphadenopathy as well; however, that would be secondary after the epitrochlear nodes.

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?

Feelings, ideas, function, and expectations Rationale: This model captures the patient's emotional landscape, intellectual landscape, current situation (function), and thoughts about future conditions.

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?

Following the patient's lead to understand their thoughts, ideas, concerns, and requests Rationale: 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.

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?

Head and neck Rationale: 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.

An 82-year-old gentleman seems to be speaking loudly during an examination, suggesting that he may not be hearing well. What is a good question to ask him to help identify whether or not he has hearing loss?

How well does he understand people in a noisy environment such as a restaurant?

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?

Moving from open-ended to focused questions Rationale: 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.

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

Nasal polyp

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?

Nervous Rationale: 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 68-year-old retired administrative assistant complains of a 3-month history of recurring pain after ambulating that radiates from her back in the upper lumbar region into both buttocks, bilateral thighs, and mid-calf regions. Her pain is typically improved by sitting or by leaning forward. The origin of her pain is likely secondary to which of the following?

Neurogenic claudication Rationale: Neurogenic claudication can mimic PAD by causing pain related to walking; however, it is typically relieved simply by sitting or by leaning forward. Many patients with spinal stenosis of the lumbar spine have pain that originates in the spinal region and radiates into the areas noted. PAD is not typically relieved just by sitting alone and usually will take some time. PAD also does not typically improve with bending over. Acute arterial occlusion does not cause recurring symptoms and is not usually bilateral. Abdominal aortic aneurysms may cause similar pain as well; however, they typically do not have the same palliating factors.

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?

Obtain a menstrual history for the previous 6 months. Rationale: 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.

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?

Obtain a more complete description of problems. Rationale: 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.

A 70-year-old retired business executive presents to the Emergency Department with progressive shortness of breath and two-pillow orthopnea. On physical examination, the blood pressure is 145/90 mm Hg, there is jugular venous distension, lower extremity pitting edema to the knee, and a blowing holosystolic murmur heard best at the lower left sternal border. No other murmurs or thrills are auscultated on physical exam. Which of the following interventions is to most likely to improve the patient's symptoms?

Removal of intravascular volume with diuresis Rationale: This patient is in heart failure based upon the symptoms and physical examination findings. The murmur is consistent with tricuspid regurgitation that may be the result of ventricular dilation and failure of the valve to completely close. Symptoms often improve with diuresis. A ventricular septal defect is a holosystolic murmur heard within the left third to fifth interspaces, but is often associated with a thrill.

A 44-year-old retail salesperson has noticed an increasing dilatation of the veins in her legs. Upon inspection, it is noted that she has significant varicosities on the posterior aspects of both legs which begin in the lateral side of the foot and pass upward along the posterior calf. The remainder of the veins in the legs appears normal at this time. Which veins are currently affected?

Small saphenous Rationale: The small saphenous vein typically runs in the described pattern. The great saphenous vein originates on the dorsum of the foot it passes just anterior to the medial malleolus and continues of the medial aspect of the leg joining the femoral vein of the deep venous system below the inguinal ligament. Perforating veins are not visible as they connect the deep and superficial veins. The femoral is proximal as described, and the dorsalis pedis vein is distal to the described area.

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?

The accepted normal values for blood pressure are lower for ambulatory measurements compared with office measurements. Rationale: Blood pressure <140/90 is considered normal for an in-office measurement, whereas ambulatory measurements are considered normal only if they are <135/85.

Aortic stenosis

The calcification of the aortic valve and narrowing of the valve area effectively decreases the blood flow from the left ventricle to the aorta. Given the obstruction created from the narrowing of the aortic valve, the pressure within the left ventricle is often higher than that seen in the aorta.