Final Exam Practice Questions

A 25-year-old veterinarian presents to the clinic for evaluation of flank pain, dysuria, nausea, and fever. A urine pregnancy test is negative. A urine dipstick is positive for leukocyte esterase. On physical examination, what would be the most likely sign expected? (A) Psoas sign (B) CVA tenderness (C) Rovsing's sign (D) Murphy's sign

(B) CVA tenderness

A 6-month-old is brought to your clinic by his mother for a routine checkup. She is concerned, because he has large bluish marks on his buttocks and back. She is worried that people will think that she is harming him somehow. Based on your physical examination, he is completely healthy and his development is on track for his age. What is your most likely diagnosis of this skin rash? (A) Café au lait spots (B) Salmon patch/stork bite (C) Mongolian spots (D) Neurofibromatosis

(C) Mongolian spots Mongolian spots are more common among darker-skinned babies. They range from bluish-gray to deep brown or black. They disappear after a few years and usually fade by puberty.

A 6-month-old infant presents with her parents for a routine checkup. You obtain a history and ask questions to obtain information on developmental stage. The answers given by the parents indicate that the infant is significantly behind in her development. The infant is in the 50th percentile for weight, height, and head circumference. Which of the following conditions is a potential cause of developmental delay? (A) Otitis media (B) Overfeeding (C) Gastroesophageal reflux (D) Neonatal meningitis

(D) Neonatal meningitis Neonatal meningitis is a significant infection, which can result in significant developmental delay.

Which is palpable 6 cm below the right costal margin in the midclavicular line during inspiration? a) liver edge b) spleen edge

a) liver edge

Which is palpable deep to the left costal margin during inspiration? a) liver edge b) spleen edge

b) spleen edge

Pain elicited when the patient's right thigh is flexed at the hip with the knee bent, and the leg is internally rotated at the hip. This is described by: a) Rovsing's sign b) Psoas sign c) Obturator sign d) Cutaneous hyperesthesia

c) Obturator sign

A 32-year-old attorney comes to your clinic complaining of severe neck pain when he tries to turn his head to the right. He reports to you that he was the restrained driver in a MVA the day before, when he was hit from behind at approximately 40 mph. He states he did not hit his head and he did not lose consciousness. He refused to be evaluated by EMS at the scene. He states he felt okay after the accident but today woke up in extreme pain. He is having no numbness or tingling in his right hand and states he has no problems holding a pen. He has no symptoms below the neck. He has no significant past medical history. On exam, he has difficulty turning his head to the right or tilting it to the right. He also has difficulty with extending his head. He is able to flex his neck and turn and tilt to the left. On palpation, he is tender over the right trapezius and rhomboid muscles. He has no tenderness along the cervical

(A) Cervical sprain A cervical sprain is often associated with an injury such as occurs in a motor vehicle accident, heavy lifting, or impact against the neck. There is local tenderness over the cervical muscles and a decreased range of motion of the neck.

A 69-year-old woman presents to your office with the complaint of pain. She was diagnosed with breast cancer that has metastasized to the bone 6 months ago. At the time, she did not want radiation therapy even for relief of the pain. You then discussed with her that her prognosis is poor and that her time to live is limited. She was not interested in hearing about it. You observe that she has lost more weight and that she is even more anorexic than at her previous visit 1 month ago. Today, she is frustrated because she hurts when she gets up and tries to walk around. She has planned a trip to the Bahamas to take place in 4 more months. What stage of grief is this patient currently in? (A) Denial (B) Anger (C) Bargaining (D) Depression or sadness (E) Acceptance

(A) Denial This patient has not yet accepted the fact that she is dying. She is making plans for the future that seem inappropriate given the diagnosis, prognosis, and her overall physical decline. The patient does not seem angry. She has not expressed anger about her condition or about the "unfairness" of her prognosis, nor toward the clinician for the diagnosis has been made. This scenario does not illustrate any evidence of bargaining. The patient has not expressed sadness nor depression. She has clearly not accepted her diagnosis.

A 35-year-old accountant presents to the clinic for evaluation of sudden onset of pain in his rectum. On examination of the anus, you see a swollen, bluish, ovoid mass at the anal margin, located at the 8 o'clock position. What is your most likely diagnosis? (A) External hemorrhoid (B) Internal hemorrhoid (C) Rectal prolapse (D) Rectal polyp

(A) External hemorrhoid An external hemorrhoid is a dilation of the hemorrhoidal veins, which originate below the pectinate line and are covered with skin. They seldom produce symptoms unless thrombosis occurs. If thrombosis occurs, there is an acute onset of local pain, which is increased by defecation and by sitting. A tender, swollen, bluish, ovoid mass may be visible at the anal margin.

A 21-year-old female presents to your clinic for her annual exam. She informs you that for the last 3 months, she has felt a lump in her left breast above the nipple. She has had no discharge from the nipple. Her past medical history is nonsignificant. She has not been sexually active and is on no medication. She denies any tobacco, alcohol, or drug use. Her paternal grandmother had breast cancer in her seventies and did well with surgery and radiation. On physical exam, you feel a firm disc like lump at 12 o'clock on the left breast. It is easily delineated, mobile, and is nontender. The patient only has shoddy nodes in the left axilla. There are no unusual skin changes. The right breast and the remainder of her heart, lung, abdominal, and pelvic exam are unremarkable. What form of breast mass is she most likely to have? (A) Fibroadenoma (B) Cysts (C) Cancer

(A) Fibroadenoma Fibroadenomas often start during puberty and young adulthood. They may be single or multiple and are often round or disc-like. They can be soft but are usually firm. They are very mobile and delineated from the surrounding tissue. They are generally non-tender and show no signs of skin retraction.

A 28-year-old male waiter presents to your office complaining of a growth on the back of his left hand. He states it started slowly months ago but has now enlarged enough to be embarrassing. He states it only hurts when he is holding a tray of food up in the air with his left hand. He has no significant past medical history and no one else in the family has this problem. On exam, you 15-3 note a 2-cm round cystic-like lesion on the dorsum of his left wrist over the carpals. It is more prominent when he flexes his wrist. What is the most likely cause of his hand swelling? (A) Ganglion (B) Chronic tophaceous gout (C) Acute rheumatoid arthritis (D) Heberden's nodes

(A) Ganglion A ganglion is a growth along the tendon sheaths of joint capsules. Ganglions generally appear in young adults and are usually nontender. They are more prominent when the wrist is flexed.

What is the preferred order for examination of the abdomen? (A) Inspection, auscultation, percussion, palpation (B) Percussion, auscultation, palpation, inspection (C) Auscultation, inspection, palpation, percussion (D) Inspection, palpation, auscultation, percussion

(A) Inspection, auscultation, percussion, palpation

A 75-year-old widow presents to your office complaining of a painful black spot to her left third toe. She states that it started smaller but has grown over the last few days. Her past medical history is significant for an acute myocardial infarction 6 years ago, with three-vessel bypass surgery afterwards. She has also had high blood pressure for 15 years and was diagnosed with type-2 diabetes last fall. She denies any tobacco, alcohol, or drug use. On review of systems, she does note that she is unable to walk a half-mile anymore without needing to stop due to pain in her legs. On exam, you find an elderly patient in no acute distress. She has no swelling or edema in her legs, although the skin color is fairly red. You can palpate a weak posterior tibia pulse but no dorsal pedis pulses. The toe in question is black the last distal centimeter. What peripheral vascular disorder is most likely the cause of her ulcer?

(A) Insufficiency ulcer Ulcers from a decrease in arterial blood flow are often found at the distal portion of the extremities, such as the toes. The foot is generally red in color with no swelling. Pulses are often weak or absent.

A 25-year-old celebrity with a known history of intravenous drug use presents to the emergency room for evaluation of a 5-day history of nausea, emesis, and right-upper-quadrant abdominal pain. On general survey, he appears ill and his skin is distinctly yellow. He has a temperature of 102.5°F and a heart rate of 112 bpm. You provisionally diagnose him with acute hepatitis. What would you expect to find on abdominal examination? (A) Liver edge is tender and 4 to 5 finger-breadths below the RCM (B) Liver edge is nonpalpable (C) Liver edge is tender and 1 finger-breadth below the RCM (D) Liver edge is nontender and 4 to 5 finger-breadths below the RCM

(A) Liver edge is tender and 4 to 5 finger-breadths below the RCM

During your examination of a woman in her second trimester of pregnancy, you note the presence of a small amount of yellow drainage from the nipples. You know that this is: (A) Most likely to be colostrum and considered a normal finding this late in her pregnancy (B) A sign of breast cancer (C) Too early in the pregnancy for lactation to begin; the woman needs a referral to a specialist (D) An indication that the woman's milk is forming

(A) Most likely to be colostrum and considered a normal finding this late in her pregnancy During the second trimester, colostrum, the precursor of breast milk, may appear. Colostrum is yellow in color and contains more minerals and protein, but less sugar and fat than breast milk.

A 48-year-old unemployed man comes into the urgent care clinic complaining of increased swelling in his lower extremities. He states that he has had swelling for a number of months but that the swelling worsened last night. He complains of no ulcers or pain in the legs. His medical history reveals a past diagnosis of "liver problems." He isn't sure what the exact diagnosis was. He states he used to drink a case of beer a night but he has recently cut back to a six-pack. He has smoked one pack of cigarettes a day for over 30 years and denies any IV drug use. On exam, you note that both legs are swollen, with no skin thickening or ulcerations. Pressing your thumb against his tibia reveals soft edema. Auscultation of his lungs reveals no crackles. His heart sounds are regular, with no murmurs, rubs, or gallops. His abdomen reveals a small liver but no discernable fluid wave. What diagnosis of peripheral causes of edema

(A) Pitting edema Pitting edema is the result of an interstitial leak from the vessels due to hypervolemia or from a decrease in oncotic pressure of the fluid, allowing fluid to leave the vessels. In this case, probable cirrhosis of the liver leads to malnutrition, resulting in low albumin, which is causing the oncotic leak. The swelling in the extremities is always bilateral, with generally no skin thickening or ulcerations.

A 7-year-old elementary school child presents with her mother to the clinic for evaluation of itching. They deny any exposure to new soaps or detergents, pollens or grasses, or new foods. On physical examination, there are small papules, pustules, lichenified areas, and excoriations. Using a magnifying lens, you identify a burrow on the finger webs. What is the most likely diagnosis? (A) Scabies (B) Atopic dermatitis (C) Acne (D) Telangiectasias

(A) Scabies The presence of a burrow is most diagnostic of scabies. A burrow is a minute, slightly raised tunnel in the epidermis commonly found on the finger webs and on the sides of the fingers. The patient experiences intense itching, which results in excoriations and lichenified areas secondary to the scratching.

A 55-year-old retired woman comes to your office complaining of worsening problems with walking accompanied by falling down. She states that she has to watch the ground while she is walking or she will often misstep and fall. She has a 20-year history of type-2 diabetes and has had a history of diabetic foot ulcers in the past. She denies any smoking, drug, or alcohol use. On exam, you note that she has decreased feeling on the planter surfaces of her feet. She cannot remain steady with her feet together and her eyes closed; she remains steady with her eyes open. While watching her walk, you also note that she has a wide gait with slapping motion with her feet on the floor. What abnormalities of gait best describe her symptoms and signs? (A) Sensory ataxia (B) Cerebellar ataxia (C) Parkinsonian gait (D) Steppage gait

(A) Sensory ataxia Sensory ataxia is associated with loss of position of the feet and legs often due to peripheral neuropathies such as those associated with diabetes. The gait is generally wide based and unsteady. The patients usually will throw their feet down heavily forward and outward. They must also watch the ground for guidance and usually cannot stand steady with their feet together (positive Rhomberg sign).

A 68-year-old tax attorney is in the hospital with a stroke. He has residual left-sided paralysis and is bed-ridden. On examination of the skin, you notice an area on his sacrum that is red with a boggy consistency, and you diagnose a pressure ulcer. What stage is this pressure ulcer? (A) Stage I (B) Stage II (C) Stage III (D) Stage IV

(A) Stage I The patient has a stage I ulcer, which is defined as intact skin that has a change in temperature, consistency, sensation, or color. The temperature can be warm or cool; the consistency can be firm or boggy; the patient may experience pain or itching; the color may be red, blue, or purple.

A 26 year old woman presents for eval of hair loss. She also has noticed increased weight loss and diarrhea. You diagnose Grave's disease (hyperthyroidism). On physical examination of the hair, what would you expect to find? (A) Fine texture (B) Coarse texture (C) Oily hair (D) Dry hair

(A) fine texture

A 55-year-old disabled Vietnam veteran comes into the ER complaining of severe pain in his left arm, which occurred suddenly approximately 2 hours ago. He also states that the arm is numb and feels cold to him from the elbow down. He has had similar episodes in the past with his legs, which required amputation at the mid-thigh bilaterally. He has a 20-year history of hypertension and a 60-pack-year history of smoking. He is a recovering alcoholic but denies any drug use. His father passed away from a stroke at the age of 65. On exam, he is anxious and appears to be in a great deal of pain. The left arm appears pale and cool to the touch. No peripheral pulses in either the radial or ulna arteries are palpated. The pulses also cannot be elicited by Doppler. Reflexes in the brachioradialis tendon are decreased. He has decreased strength in his wrist and hand and cannot discern two-point discrimination. What peripheral v

(B) Acute arterial occlusion The throwing of an embolism, or thrombosis, causes sudden symptoms associated with a cold, pale, pulseless extremity.

A 13-year-old boy is brought into the urgent care clinic by his father with a complaint of swelling around his right elbow. He is in 8th grade football and has been lifting weights, despite having just started puberty. He has no significant past medical history and recalls no specific incident of trauma to the elbow. On exam, the patient has a soft swelling around the posterior of the elbow. He has no redness or warmth and minimal pain. He is nontender over the bony prominences of the ulna, radial head, and humorous. What disorder of the elbow is the most likely diagnosis? (A) Arthritis (B) Olecranon bursitis (C) Epicondylitis (D) Rheumatoid nodules

(B) Olecranon bursitis Sudden and repetitive trauma often causes swelling and inflammation in the bursa. In this case, the repetitive injury of inappropriate weightlifting led to the accumulation of fluid in the bursa sac.

A 28-year-old bus driver presents to the emergency room for pain and drainage from an area at the bottom of her spine. This has never occurred before. On examination of the rectum, a small opening is identified in the midline superficial to the lower sacrum. There is a surrounding halo of erythema. It is tender to palpation and purulent material is expressed. Your most likely diagnosis of this condition is? (A) Anorectal fistula (B) Pilonidal cyst (C) Anal fissure (D) Thrombosed external hemorrhoid

(B) Pilonidal cyst A pilonidal cyst is identified by the opening of a sinus tract on the skin. It is usually located in the midline superficial to the coccyx or the lower sacrum. There may be a small tuft of hair at the opening, and it may be surrounded by a halo of erythema.

A 43-year-old female kindergarten teacher presents to your office with the complaint of fainting this morning. She reports this occurred after standing up from her bed after having been sick all night with diarrhea and vomiting. She has had no fever and is unable to keep fluids down. She has had no chest pain, shortness of breath, or palpitations. Her past medical history is significant for two spontaneous vaginal deliveries and a 10-year-history of hypothyroidism. On exam, she has a fast heart rate of 110 bpm. Her abdomen is tender, with no signs of a surgery. What is the most likely underlying cause of her fainting? (A) Vasodepressor syncope (B) Postural (orthostatic) hypotension (C) Cardiac arrhythmia (D) Hysterical faint

(B) Postural (orthostatic) hypotension Orthostatic hypotension can often be due to hypovolemia, which in this case is from vomiting and diarrhea. It generally occurs upon standing up after being in a recumbent position.

A 19-year-old male college student presents to your clinic with a complaint of tremors in his hands. He states that it embarrasses him in front of his friends. He notices it only when he isn't doing anything with his hands; it gets better when he drinks alcohol. He has no significant past medical history but does relate that his older sister and mother have had similar problems. Upon exam, he holds his hands out in front of him revealing a fine tremor. There are no additional movements with his fingers. When he does purposeful movement, the tremors disappear. What involuntary movement disorder best describes his symptoms and signs? (A) Resting tremors (B) Postural tremors (C) Intention tremors (D) Athetosis

(B) Postural tremors Postural tremors occur when a person is holding the affected part of his body in a postural position. These tremors are often associated with hyperthyroidism, anxiety, and benign familial essential tremors, such as is the case here. Intentional movement can either worsen or improve the tremors.

A 20-year-old college junior presents to the clinic for a physical; he is going to be a camp counselor for the summer. He is healthy and exercises regularly. His BMI is 22. You take his blood pressure and obtain a value of 160/100. Which of the following is the most likely reason for the unexpected blood pressure measurement? (A) The width of the inflatable bladder of the cuff was 40% of the upper arm circumference (B) The length of the inflatable bladder was 50% of the upper arm circumference (C) The aneroid sphygmomanometer was calibrated just prior to measuring this patient's blood pressure (D) The patient had sat for 15 minutes prior to the measurement of his blood pressure

(B) The length of the inflatable bladder was 50% of the upper arm circumference The length of the inflatable bladder should be 80% of the upper arm circumference; if it is too short, then the blood pressure reading will be artificially increased.

A newborn infant has a 1-minute Apgar score of 6. Which of the following statements is correct? (A) This infant is normal (B) This infant has some nervous system depression (C) This infant has severe depression and requires immediate resuscitation (D) This infant is at high risk for subsequent central nervous system and other organ system dysfunction

(B) This infant has some nervous system depression An Apgar score that is between 5 and 7 at 1 minute of life indicates some nervous system depression. A normal Apgar score at 1 minute of life is between 8 and 10. An Apgar score of 0-4 at 1 minute of life indicates severe depression, requiring immediate resuscitation. An Apgar score at 5 minutes of life that is between 0 and 7 indicates that the infant is at high risk for subsequent central nervous system and other organ system dysfunction.

A 35-year-old male athlete comes into the ER complaining of severe lower abdominal pain and vomiting. He relates the pain began several hours ago after he cycled at the gym and lifted weights. He states he has had occasional lower abdominal pain with lifting weights in the past but nothing like this. He has no significant past medical history and denies any tobacco, drug, or alcohol use. On exam, you find a young man who appears very ill. He is pale and vomiting clear green liquid. As you examine him, his emesis becomes darker and malodorous. On exam, he has high-pitched increased bowel sounds and has voluntary guarding and rebound. His testicles are descended bilaterally, and his right testicle seems tender and enlarged. Auscultating it, you also hear bowel sounds. What diagnosis is most likely the cause of his pain? (A) Acute pancreatitis (B) Acute mechanical intestinal obstruction (C) Acute cholecystitis (D) Me

(B) Acute mechanical intestinal obstruction Mechanical obstructions are often cause by tumors, surgical adhesions, and, in this case, hernia. Often straining will cause a weakened inguinal area to herniated, leading to an incarcerated hernia. Symptoms include bilious vomiting, which can become fecal in material, and the development of a rigid abdomen.

A 39-year-old seamstress presents to the ER complaining of severe upper abdominal pain that started about 2 hours ago. She had eaten a cheeseburger and fries 45 minutes before the pain began. She tried taking some calcium stomach tablets, but they didn't help. She states the pain is a 10 on a 10-point scale and is starting to hurt in her back. She says she is nauseated and needs to vomit. She does admit to having had milder pains similar in the past but never to this extent. Her past medical history is significant for high blood pressure and two caesarean sections. Her older sister and mother have had to have gallbladder surgery. She denies any tobacco, drug, or alcohol use. Her review of systems is noncontributory. On examination, you find a mildly obese woman in severe distress. She is lying on the stretcher, but she cannot find a comfortable position. Her blood pressure is mildly elevated at 140/85, and her heart

(B) Biliary colic Biliary colic is caused by a sudden obstruction in the cystic duct or the common bile duct by a gallstone. A fatty meal can precipitate the attack. The pain is usually severe and steady and can radiate to the scapula. Nausea, vomiting, and restlessness are common. A positive Murphy's sign is often found.

A 31-year-old nurse presents to your office complaining about a painful lump in her right breast next to the nipple. She states it has been there for several months and won't go away. She recently started taking birth control pills after remarrying. Her past medical history is significant for asthma and two spontaneous vaginal deliveries. Family history reveals no breast or ovarian disorders. She denies any tobacco or drug use and drinks alcohol socially. On exam, you feel a 1-cm lump medial to her areola. It is round soft and very tender. There are no skin retractions and no palpable lymph nodes in the axilla. Her left breast also has a ½-cm soft lump medial to the areola that is not quite as tender. The patient states she hadn't noticed that area before. What type of breast mass is the most likely cause of her pain? (A) Fibroadenoma (B) Cysts (C) Cancer

(B) Cysts Cysts often start in women between 30 and 50 years of age. They tend to be round but can be soft or firm. They are mobile and well delineated. Generally they are tender, and they can change in size during the menstrual cycle. They become more pronounced in some women on oral contraceptives. Careful evaluation is still warranted due the rare possibility of breast cancer in this age group.

A 71-year-old woman is brought to the ER by her family, who state that she is not acting like herself. They say that several hours ago she began to slur her words as she started wandering around the house. They heard her calling to her husband, who has been deceased for over 10 years. After several minutes of this, she said she wasn't feeling well and laid down on the sofa; 16-5 she became sleepy. When they tried to ask her what was wrong, she snapped at them. Although the woman is retired, she is very active in her church and senior citizens club. Her past medical history is significant for 3 vaginal deliveries, 10 years of hypertension, and 5 years of type-2 diabetes. She does not smoke, drink alcohol, or take drugs. Review of systems reveals that she had mentioned to her daughter the day before that urinating is painful and that her back is sore. On exam, you find an elderly woman who is lethargic. You have to spe

(B) Delirium The hallmark of delirium is that it occurs acutely. The course can be fluctuating, and the level of consciousness is disturbed. The patient can become somnolent, as in this case, or agitated. Illusions and hallucinations are common. Patients are often disoriented to place and time but not to person. Metabolic changes, poisonings, sepsis, and delirium tremens are causes. This episode probably began as a urinary tract infection that became uroseptic.

A 35-year-old swimming teacher presents to the office for an annual skin examination. She has several tan, flat, round and oval lesions with sharply defined borders. The lesions are less than 6 mm in diameter. She has one lesion that is dark, 6.5 mm, and has an irregular border, which fades into the surrounding skin. It is not elevated. What is your most likely diagnosis of this lesion? (A) Benign nevus (B) Dysplastic nevus (C) Seborrheic keratosis (D) Actinic keratosis

(B) Dysplastic nevus A dysplastic nevus is varied in color, but often dark. It is larger than 6 mm and has irregular borders, which fade into the surround skin. Without further intervention, it is difficult to determine whether this patient's lesion is an early malignant melanoma or not.

A 14-day-old infant presents to the clinic for a follow-up visit from the newborn nursery. On examination, she has yellow-white pustules surrounded by a red base, which are scattered diffusely over the face and trunk. What is the most likely diagnosis for this rash? (A) Neonatal acne (B) Erythema toxicum (C) Seborrhea (D) Jaundice

(B) Erythema toxicum Erythema toxicum consists of yellow or white pustules, which are surrounded by a red base. The rash is scattered diffusely over the infant's body and frequently changes location. The palms and soles are often spared.

A 68-year-old homemaker presents to your clinic complaining of difficulty swallowing. It began several months ago when she would attempt to eat steak. Over time, it has progressed to the point that she can only sip on soups and broths. She has sometimes had to regurgitate her food back up to get relief from the pain in her chest when she attempts to eat. Her past medical history is significant for diet controlled, type-2 diabetes. She had a 60-pack-year smoking history but quit smoking 15 years ago. She denies any drug or alcohol abuse. On review of systems, she has lost approximately 15 lbs in the past 3 months. She denies any heartburn, constipation, or diarrhea. On exam, you find a pleasant elderly woman in no acute distress. Her cardiac, pulmonary, and abdominal exams are all normal. What disorder of dysphagia is the most likely cause for her symptoms? (A) Esophageal stricture (B) Esophageal cancer (C) Esophag

(B) Esophageal cancer Esophageal cancer often is slowly progressive but invariably leads to difficulty in swallowing liquids. Weight loss often develops as the disease progresses. Risk factors include tobacco and alcohol use.

You are palpating the abdomen of a 35-week pregnant woman and note that the fetal head is facing downward toward the pelvis. You would document this as: (A) Fetal lie (B) Fetal presentation (C) Fetal attitude (D) Fetal variety

(B) Fetal presentation Fetal presentation describes the part of the fetus that is entering the pelvis first. Fetal lie is orientation of the fetal spine to the maternal spine. Attitude is the position of the fetal parts in relation to each other, and fetal variety is the location of the fetal back to the maternal pelvis.

A 22-year-old social worker comes into the clinic for a routine checkup. His blood pressure is 155/102. In each of his previous visits, including one 2 weeks ago for treatment of an upper respiratory infection, his blood pressure has been 130s/80s. He has no family history of high blood pressure. He has no symptoms of headache, blurred vision, or chest pain. What is the most likely reason for his blood pressure being elevated today? (A) He sat down for 10 minutes prior to this measurement being obtained (B) He drank a cup of coffee 10 minutes prior to his blood pressure measurement (C) His arm was bare when the blood pressure was measured (D) He was seated and his arm was supported a little above his waist when the measurement was obtained

(B) He drank a cup of coffee 10 minutes prior to his blood pressure measurement Caffeine ingested within 30 minutes of checking a blood pressure measurement can artificially increase the patient's blood pressure reading.

When performing a genitourinary assessment, you note that the urethral meatus is positioned ventrally. This is most likely to be: (A) A stricture (B) Hypospadius (C) The result of a circumcision (D) Related to the aging process

(B) Hypospadius Hypospadius is a congenital displacement of the urethral meatus to the inferior surface of the penis. A groove extends from the displaced urethral meatus to its normal location on the tip of the glans. There is no association between aging and displacement of the urethral meatus.

A 19-year-old male college student presents to your clinic the week following spring break complaining of 1-day abdominal pain and watery diarrhea. He thinks he has seen blood mixed with his stool. He has had some nausea but no vomiting. He had recently traveled to Central America over the break to go scuba diving. His past medical history is not significant. He drinks six to eight beers during the weekend but denies any tobacco or drug use. On review of symptoms, he does have night sweats and rigors. On exam, you find he is febrile at 102.3°F and he is tachycardic at 115 bpm. Otherwise, his heart and lung exam are normal. Upon auscultation, he has increased bowel sounds, and on palpation, he is diffusely tender. He has no rebound or guarding, but his rectal is guaiac positive. What cause of diarrhea is most likely? (A) Secretory infections (B) Inflammatory infections (C) Irritable bowel syndrome (D) Malabsorpti

(B) Inflammatory infections Bloody diarrhea with a fever after foreign travel is often indicative of invasion of the intestinal mucosa by enteropathic bacteria. An in-depth travel history of different foods and liquids is often warranted

A 24-year-old housewife and mother presents to the clinic for evaluation of rectal bleeding. She has intermittent constipation and frequently has to use a laxative to have a bowel movement. On examination of the anus, you see a reddish, moist, protruding mass located at the 5 o'clock position. What is your most likely diagnosis? (A) Hemorrhoid (B) Internal hemorrhoid (C) External rectal prolapse (D) Rectal polyp

(B) Internal hemorrhoid An internal hemorrhoid is an enlargement of the normal vascular cushions that are located above the pectinate line. During defecation, they may cause bleeding. If they prolapse, they are visible as a reddish, moist, protruding mass.

A 42-year-old homemaker presents to your office complaining of swelling and pain in her right lower leg. She states it developed yesterday upon returning from a driving vacation to the Grand Canyon. She also informs you that she hiked and climbed all through the canyon with no pain in her legs or shortness of breath. Her past medical history is significant for one spontaneous vaginal delivery and one caesarean section for fetal distress. She is on a daily multi-vitamin and a low-estrogen birth control pill. She drinks socially one to two times a month and denies any tobacco or drug use. Her father has type-2 diabetes since his early 50s. On exam, you see that her right lower leg does look larger than the left. You measure 15 cm above the heel on each leg and find that the right leg is 3 cm larger than the left. There is no redness or heat over the calf. Placing your thumb over the tibia shows pitting edema. Palpating

(D) Deep venous thrombosis Deep venous thrombosis is from clot formation in the deep draining veins of the calves and thighs. It can cause an aching pain and swelling of the extremity. Cords, which are associated with more superficial thrombosis, are generally not felt.

A 26-year-old woman follows up at your office for her 6-week postpartum visit. She complains of severe constipation problems since the birth of her last child. Although she says she is eating healthy and drinking plenty of fluids, the problem persists. She does complain of pain with defecation. She denies any abdominal pain, nausea, vomiting, or diarrhea. She has never had problems with constipation except for during her pregnancies. Her past medical history is significant for two vaginal deliveries. She denies any tobacco, drug, or alcohol use. She is currently taking only prenatal vitamins. She has no family history of any bowel problems. On exam, she has normal bowel sounds, and her abdomen is soft with no rebound or guarding. Her pelvic exam reveals that her uterus has returned to nongravid size and that her episiotomy site has healed. Her rectal exam is painful and is positive for occult blood. What is the best

(D) Painful anal lesions Any lesion around the anus, including hemorrhoids (common in pregnancy), or the repair of a perineal birth injury can cause pain severe enough that it can lead to constipation. In this case, the positive occult blood was from enlarged painful internal hemorrhoids.

A 37-year-old female bank teller presents to your office complaining about accidentally urinating on herself. She relates this has happened several times in the last month. She states she realizes that she has to go to the bathroom, but before she can make it to the toilet, she soils herself. Upon further questioning, it is revealed that for years she has had to urinate frequently during the day and at night. She had thought these were bladder infections, but the urine lab tests were always normal. Her past medical history is significant for migraines and depression. She denies any tobacco or drug use. She drinks alcohol socially several times a year. On review of systems, she relates pelvic pain with sexual intercourse. On exam, she has a normal abdominal, rectal, and pelvic exam. Her bladder is appropriate in size, and her urinary analysis is negative for blood or signs of infection. Which type of urinary incontine

(B) Urge incontinence Strong detrussor contractions of the bladder overcome normal urethral resistance, causing urge incontinence. In this patient's case, a condition called interstitial cystitis has caused a deconditioning of voiding reflexes. Frequency, urgency, and voiding small amounts of urine are also often associated with urge incontinence.

A 2-year-old child presents for his annual checkup. You obtain a history and perform a physical examination. All of the findings are normal. When you do a visual acuity test, what is your most likely finding? (A) Eyes converge (B) -20/200 (C) 20/40 (D) 20/30

(C) 20/40 Children under 4 years of age have an expected visual acuity of 20/40. Eyes converging is an expected finding in children aged 0-3 months. This patient is 2 years old. The second response (-20/200) is incorrect; this is an expected finding in children who are 12 months of age. The fourth response (20/30) is likewise incorrect. Children over the age of 4 have an expected visual acuity of 20/30.

The following finding is considered normal when assessing an aging male: (A) A decrease in scrotal color (B) Enlargement of the testes and scrotum (C) A decrease in the size of the penis (D) The presence of a hydrocele, or fluid in the scrotum

(C) A decrease in the size of the penis In the older male, you may note thinner, more sporadic gray pubic hair and a decrease in the size of the penis. A change in color, size, and scrotal fluid are symptoms requiring further investigation and are not associated with aging.

When palpating the fundus, you know that: (A) Fundal height is usually less than the number of weeks gestation, unless there is an abnormal condition such as too much amniotic fluid present (B) The fundus should be hard and slightly tender to palpation during the first trimester (C) After 20 weeks gestation, the number of centimeters should approximate the number of weeks gestation (D) Fetal movement should be felt by the examiner at the beginning of the second trimester

(C) After 20 weeks gestation, the number of centimeters should approximate the number of weeks' gestation After 20 weeks, the number of centimeters should approximate the number of weeks gestation. Also, at 20 weeks the examiner may feel fetal movement, and the head can be balloted.

When performing a genitourinary assessment on an adolescent male you notice a swelling in the scrotum, which increases with increased intraabdominal pressure and decreases when lying down. The young man complains of pain when straining. This history best describes: (A) An incisional hernia (B) A direct inguinal hernia (C) An indirect inguinal hernia (D) A femoral hernia

(C) An indirect inguinal hernia An indirect hernia generally causes pain with straining and a soft swelling in the scrotum that enlarges with increased intraabdominal pressure. It originates above the inguinal ligament near the midpoint and touches the examining finger during examination. This is the most common type of hernia, found in all ages and both sexes.

An 83-year-old woman presents to the ER the afternoon of Thanksgiving complaining of severe abdominal pain. She states it was at first cramping around her navel but has now radiated to the rest of her abdomen. She also complains of some vomiting and bloody diarrhea. About 1 hour before the pain started, she had a large traditional holiday meal. She states she generally only eats about half a sandwich and some soup at meals. She denies any earlier history of similar pain. Her past medical history is significant for coronary artery disease, for which she has had a stent placed in the past. She is only taking medicines related to her heart condition. She denies any alcohol, drug, or tobacco use. Her review of systems is positive for soreness in her legs while walking and occasional chest pain on exertion. On exam, you find an elderly woman in great distress. She is pale and tachycardic. Examining her abdomen, you hear d

(D) Mesenteric ischemia Mesenteric ischemia is caused from thrombosis, emboli, or hypoperfusion. It often begins periumbilically, radiating diffusely. Severe pain, vomiting, and bloody diarrhea are common. In this patient it is not surprising, in light of known cardiac and peripheral vascular disease, that a large meal would have precipitated such a condition.

You have just completed your examination and you document that the patient is unable to differentiate between sharp and dull touch bilaterally. You interpret this as: (A) Bell's palsy (B) Scleroderma of the face and cheeks (C) Damage to cranial nerve V (trigeminal nerve) (D) Paralysis

(C) Damage to cranial nerve V (trigeminal nerve) Facial sensations of pain or touch are mediated by cranial nerve V. Facial paralysis can be central or peripheral. Bell's palsy results from a peripheral lesion of cranial nerve VII—the patient cannot wrinkle the forehead on the affected side nor make a smile, so both the upper and lower facial muscles are involved. In central lesions of cranial nerve VII from cerebrovascular accidents, the patient can wrinkle both sides of the forehead but cannot make a smile.

A 25-year-old swim instructor presents to your clinic complaining of an itchy scalp. You diagnose seborrheic dermatitis. What physical findings are most consistent with this diagnosis? (A) Erythema of the scalp (B) Pustules on the scalp (C) Dry, flaking areas on the scalp (D) Ecchymoses on the scalp

(C) Dry, flaking areas on the scalp

A 15-year-old high-school student presents to your office for a sports physical He is 65 inches in height and weighs 250 pounds. His BMI falls in which category? (A) Underweight (B) Normal weight (C) Overweight (D) Obese

(D) Obese The patient is obese. Obesity is defined as a BMI over 30. This patient has a calculated BMI of 43. Underweight is defined as a BMI of less than 17; normal weight is defined as a BMI between 17 and 23; and Overweight is defined as a BMI between 23 and 30. Calculation of BMI: weight in kilograms divided by height in meters squared.

A 25-year-old graduate student presents to your clinic; she is concerned about her exposure to a communicable disease that occurred at a party she recently attended. You, the interviewer, enter the room and greet the patient and then ask what brought her into your office today. She states that she wants to establish care, so you start by asking her if she has any specific concerns that she would like you to address. She states that she is concerned that she may have gotten an STD. You continue to maintain eye contact and state, "Go on." Which type of interviewing technique have you demonstrated? (A) Echoing (B) Directed questioning (C) Facilitation (D) Reassurance

(C) Facilitation Facilitation is the type of interviewing technique that you have demonstrated. By maintaining eye contact and asking the patient to "go on," you have attempted to make her more comfortable in relating details about the concern that brought her into your office.

A 7-year-old boy is brought to the ER by EMS and is accompanied by his parents. They report that he had a spell an hour before, during which his body stiffened, he lost consciousness, and then started jerking. They also report that he bit his tongue. He was sitting quietly in the living room playing video games when this occurred. The parents state that the child has never had any problems like this in the past. Upon exam, he is pale and confused. He says he is sleepy and would like every one to go away. You notice blood in his mouth and that his shorts and underwear are soiled with urine. What is the mostly likely reason for this "spell?" (A) Simple partial seizure (B) Complex partial seizure (C) Generalized tonic clonic (grand mal) seizure (D) Absence seizure

(C) Generalized tonic clonic (grand mal) seizure Patients who experience a grand mal seizure often lose consciousness suddenly, with a stiffening of the body. This is often followed by the clonic jerking of the muscles. Tongue biting and urinary incontinence are often noted. The patient will then have a pronounced postictal state of confusion and drowsiness.

A 42-year-old female office worker presents to your clinic complaining of awakening with an exquisitely tender, red, swollen right knee. She has never had this occur before and has had no history of trauma or recent illness. She has no significant past medical history. A family history reveals that her father had similar problems in middle age. On exam, she has a red, warm, tender right knee with decreased range of motion. Tapping the fluid in the knee showed no signs of infection indicating a probable arthritic cause. The most likely form of arthritis would be: (A) Rheumatoid arthritis (B) Degenerative joint disease (C) Gouty arthritis (D) Polymyalgia rheumatica

(C) Gouty arthritis Gouty arthritis usually occurs spontaneously, after a night in bed or a large meal. It results in swollen, red, warm, very tender joints. It is caused by an increase in crystals within the joint.

You have just completed a vaginal examination of a woman who is 6 weeks pregnant. You read on her chart that her cervix is softened and looks cyanotic. You know that she is exhibiting which of the following signs? (A) Chadwick's sign and Hegar's sign (B) Goodell's sign and Chadwick's sign (C) Hegar's sign and Goodell's sign (D) Tanner's sign and Hegar's sign

(C) Hegar's sign and Goodell's sign Shortly after the first missed menstrual period, the female genitalia show signs of the hormonal changes of pregnancy. The cervix softens (Goodell's sign) at 4-6 weeks, and the vaginal mucosa and the isthmus of the uterus softens (Hegar's sign) at 6-8 weeks. The cervix looks cyanotic (Chadwick's sign) at 8-12 weeks. These changes reflect increased vascularity and edema of the cervix, and hypertrophy and hyperplasia of the cervical glands. Tanner's signs refer to sexual maturity ratings in adolescents.

A 60-year-old homemaker presents to your office complaining of swelling to her left lower leg. She states that it has been developing over the last few weeks since her surgery for ovarian cancer. She has a past medical history significant for four spontaneous vaginal deliveries and the recent diagnosis of ovarian cancer. She denies any drug, tobacco, or alcohol use. On review of systems, she denies any chest pain, palpitations, or shortness of breath. On exam, you note that not only are her leg and ankle swollen but so are her toes. The skin appears to be thicker than usual, but there are no signs of ulceration. What cause of peripheral edema is the most likely in her case? (A) Pitting edema (B) Chronic venous insufficiency (C) Lymphedema

(C) Lymphedema Lymphedema is swelling in the extremities caused by blockage in lymphatic return. This obstruction is often due to tumor, trauma, inflammation; it is rarely infectious. The swelling includes the toes and often causes thickening of the skin. Ulcerations are rare. In this case, the damage to the lymph ducts occurred during surgery.

A 40-year-old flight attendant presents to your office for evaluation of abdominal pain. It is worse after eating, especially if she has a meal that is spicy or high in fat. She has tried over-the-counter antacids, but they have not helped the pain. After examining her abdomen, you strongly suspect cholecystitis. Which sign on examination increases your suspicion for this diagnosis? (A) Psoas sign (B) Rovsing's sign (C) Murphy's sign (D) Grey Turner's sign

(C) Murphy's sign

During your examination you note that your client's eyes are puffy. You further assess coarse and dry hair. You suspect: (A) Scleroderma (B) Cachexia (C) Myxedema (D) Cretinism

(C) Myxedema Myxedema arises from hypothyroidism, or a deficiency of thyroid hormone. You may see a periorbital edema, coarse facial features, dry skin, and dry coarse hair and eyebrows. Sclerodema is a rare autoimmune disorder affecting blood vessels and connective tissue, causing a tightening of the skin in the lower face. Cachexia refers to severe weight loss from poor nutrition, which may result in coarse hair but not puffiness. Cretinism arises from severe congenital hypothyroidism and is associated with dwarfism and mental retardation.

A 68-year-old house painter comes to your office complaining of an ulcer on his right foot. He just noticed it yesterday, although he thinks it is quite large. He finds this strange because it doesn't hurt at all. He wears heavy work boots and does a good deal of climbing on ladders. He doesn't recall stepping on any nails. His past medical history is significant for 15 years of type-2 diabetes. He states the first 5 years following his diagnosis, he didn't take the medicine as he should have and that he is now on insulin shots. He also has 10 years of high blood pressure. He has smoked two packs of cigarettes for the last 50 years, but he denies recent alcohol or drug use. His family history is significant for a mother and aunt with high blood pressure and diabetes. On exam, you see a 2-cm ulcer over the plantar surface of the foot proximal to the great toe. There is callus formation around the edge of the ulcer. Th

(C) Neuropathic ulcer Neuropathic ulcers appear at areas of pressure points because the person affected is unable to perceive that there is pain in the area. The peripheral neuropathy accounts for the lack of pain and the occasional late diagnosis.

A 24-year-old male graduate student is brought into the ER following a two-vehicle MVA. He is on a backboard and has obvious bruises and lacerations to his head and extremities. On exam, he does not respond to either conversation or even shaking. He does arouse to a deep sternal chest rub and mumbles incoherently. When the stimulus ceases, he lapses back into an unresponsive state. What level of consciousness best describes his response? (A) Lethargic (B) Obtunded (C) Stuporous (D) Comatose

(C) Stuporous A stuporous patient only responds to painful stimuli such as a sternal rub or the pinching of a tendon. When the painful stimulus is removed, he becomes unresponsive again. A lethargic patient awakens to conversation, answers questions, and then returns to sleep. An obtunded patient often must be shaken to respond. He often looks confused and gives slow answers. A comatose patient will not respond to any external stimuli and will remain in an unarousable state.

In performing the bimanual examination, you note that the cervix feels smooth and firm, is round, and is fixed. Your cervical palpation produces some pain. The best interpretation of these results is: (A) These findings are well within normal limits (B) It is unusual to have pain when palpating the cervix, but the rest of the findings are within normal limits (C) The cervix should move when palpated; an immobile cervix may indicate malignancy (D) The cervical consistency should be soft and velvety and not firm

(C) The cervix should move when palpated; an immobile cervix may indicate malignancy. Characteristics of a normal cervix are: consistency is smooth and firm; contour is evenly rounded; and mobility is flexible. An abnormal cervix would be firm, fixed, possibly nodular, and painful when moved.

When observing the vestibule, you should be able to see which of the following anatomic structures? (A) Urethral meatus and paraurethral (Skene's) glands (B) Vaginal orifice and vestibular (Bartholin's) glands (C) Urethral meatus and vaginal orifice (D) Paraurethral (Skene's) and vestibular (Bartholin's) glands

(C) Urethral meatus and vaginal orifice The labial structures encircle a boat-shaped space called the vestibule. Within it are several openings. The urethral meatus appears as a small, raised structure between the clitoris and the vagina. Just posterior to the urethral meatus at the 5 and 7 o'clock positions are the tiny openings of the paraurethral (Skene's) glands. The vaginal orifice is posterior to the urethral meatus. On either side and posterior to the vaginal orifice are two vestibular (Bartholin's) glands, which secrete a clear lubricating mucus during intercourse. Their ducts are not visible but open in the groove between the labia minora and the hymen.

When instructing patients about how to perform a testicular self-exam, which of the following statements is most correct: (A) "A good time to examine your testicles is just before you take a shower." (B) "Perform the testicular exam at least once a week to detect the early stages of cancer." (C) "The testicle should feel firm and has a lumpy consistency, be movable, and shaped like an egg." (D) "If you notice any change from what you normally see or feel, call your health care provider."

(D) "If you notice any change from what you normally see or feel, call your health care provider." A firm painless lump, a hard area, or an enlarged testicle is each an abnormal and unexpected finding, which should be assessed by a trained clinician. Time of week and time of day are not factors men should consider relating to self-testicular examination. Regular examination should be encouraged, and changes or abnormal findings need to be reported.

Mrs. W is in her first trimester of pregnancy. She is experiencing significant nausea and vomiting and asks if it will get better. Your response is: (A) "At about the time the baby moves, it will get better.'' (B) "Many women experience nausea and vomiting until the third trimester." (C) "Did your mother have significant nausea and vomiting?" (D) "Usually, by the beginning of the second trimester, the nausea and vomiting improve."

(D) "Usually, by the beginning of the second trimester, the nausea and vomiting improve." The nausea, vomiting, and the fatigue of pregnancy usually improve by weeks 12-16. Fetal movement occurs at approximately 20 weeks gestation.

A 32-year-old farmer presents to the clinic for evaluation of pain with defecation as well as rectal bleeding. His family history is negative for inflammatory diseases of the bowel and for colon cancer. On physical examination, there is a swollen skin tag, and, with gentle separation of the anal margin, a thin line of ulceration is visible. What is your most likely diagnosis? (A) Pilonidal cyst (B) Anorectal fistula (C) External thrombosed hemorrhoid (D) Anal fissure

(D) Anal fissure An anal fissure is a painful oval ulceration of the anal canal and is found most commonly in the midline posteriorly inside the rectum/anal canal. Inspection of the anus may show a swollen "sentinel" skin tag just below it, and gentle separation of the anal margins may reveal the lower edge of the fissure.

A 55-year-old realtor presents to your office for evaluation of a skin lesion that has been present for a long time. She came in because her daughter had been reading about skin cancer in her favorite women's magazine and was worried about her mother. The lesion is located on her right cheek. There is a central depression and a firm elevated border. Initially, when it first appeared 5 years ago, it was translucent. What is the most likely diagnosis? (A) Actinic keratosis (B) Seborrheic keratosis (C) Squamous cell carcinoma (D) Basal cell carcinoma

(D) Basal cell carcinoma A basal cell carcinoma usually appears on the face. Initially, it is a translucent nodule, which spreads, leaving a depressed center and a firm elevated border. Although it is a malignant tumor, it grows slowly and rarely metastasizes.

A 38-year-old unemployed man presents to the ER complaining of black tarry stools that now have blood in them. He states he has also had some severe pain in his stomach for the last few days. He vomited once and thinks he saw some blood. His past medical history is significant for pancreatitis and asthma. He has smoked two packs of cigarettes for 25 years and drinks approximately 12 beers a day. He denies any IV drug use. He has had no recent out-of-state travel. On review of symptoms, he notes that he has fainted in the last day. On exam, you find a cachetic man appearing older than his stated age. He is afebrile but tachycardic, at 120 bpm. Otherwise, his heart and lung exam are normal. On inspection, he has no dilated veins around his umbilicus or skin of an unusual color. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness, which is more severe in the epigastric area. His li

A) Gastritis Severe gastritis is often caused by alcohol ingestion. Bleeding from acute gastritis will be black when the transit time from the colon is slow. When the transit time increases, frank blood can be present. Bowel sounds are often increased, and the abdomen can be diffusely tender.

You are on rounds at the nursing home when you are asked to see an 83-year-old retired farmer who is bed-ridden. The aide is concerned because she has noticed an area on his coccyx that is broken down. You examine the skin and determine that there is a partial thickness skin loss, which involves the epidermis. What stage is this pressure ulcer? (A) Stage I (B) Stage II (C) Stage III (D) Stage IV

B) Stage II This patient has a stage II ulcer, which is a partial-thickness skin loss or ulceration that involves the epidermis, dermis, or both layers. A stage I ulcer is defined as intact skin that has a change in temperature, consistency, sensation, or color. The temperature can be warm or cool; the consistency can be firm or boggy; the patient may experience pain or itching; the color may be red, blue, or purple. A stage III ulcer is a fullthickness skin loss, with evidence of damage to or necrosis of subcutaneous tissue, which may extend to, but not through, the underlying muscle. A stage IV ulcer involves full-thickness skin loss with destruction, tissue necrosis, or damage to underlying muscle, bone, or supporting structures

Pain in the right lower quadrant during palpation of the left lower quadrant. This is described by: a) Rovsing's sign b) Psoas sign c) Obturator sign d) Cutaneous hyperesthesia

a) Rovsing's sign

Examiner's hand is placed on the patient's right knee and the patient is asked to raise his or her right thigh against the examiner's hand. This is described by: a) Rovsing's sign b) Psoas sign c) Obturator sign d) Cutaneous hyperesthesia

c) Obturator sign

Pain elicited by gently picking up a fold of abdominal skin anteriorly. This is described by: a) Rovsing's sign b) Psoas sign c) Obturator sign d) Cutaneous hyperesthesia

d) Cutaneous hyperesthesia

A patient demonstrates left facial droop but can wrinkle both sides of the forehead. The examiner should suspect a problem with: (A) Central innervation of cranial nerve VII (facial) (B) Cranial nerve V (trigeminal) (C) Peripheral innervation of cranial nerve VII (D) Frontalis muscle

(A) Central innervation of cranial nerve VII (facial) A review of the cranial nerves and their function support the symptoms presented. Facial muscles are mediated by cranial nerve Vll.

Mr. T. is complaining of a headache. He has just awakened from a nap and states that the headache always begins behind one eye, "feels like an icepick," and is accompanied by tearing and a runny nose. You suspect Mr. T has: (A) Migraine headache (B) Tension headache (C) Cluster headache (D) A stroke

(C) Cluster headache A cluster headache produces pain around the eye, temple, forehead, and cheek; it is unilateral and always on the same side of the head. The pain may be excruciating and can occur as often as twice a day. This type of headache is more common in men than in women.

To correctly insert the speculum: (A) Instruct the woman to bear down, open the speculum blades and apply in a swift upward movement (B) Press the inferior margin of the introitus down to enlarge the vaginal opening, open, insert the speculum with the blades at an oblique downward angle, and apply gentle downward pressure (C) Insert the blades of the speculum on a horizontal plane, turning them to a 45° angle as you continue to insert them; ask the woman to bear down to ease insertion (D) Lock the blades open by turning the thumbscrew. Once you have them open, apply pressure to the introitus and insert the blades at a 45° angle downward to bring the cervix into view

(B) Press the inferior margin of the introitus down to enlarge the vaginal opening, open, insert the speculum with the blades at an oblique downward angle, and apply gentle downward pressure Hold the speculum in your right hand with the index and the middle fingers surrounding the blades and your thumb under the thumbscrew. This prevents the blades from opening painfully during insertion. With your left index and middle fingers, push the introitus down and open to relax the pubococcygeal muscle. Tilt the width of the blades at an oblique angle and insert the speculum past your left fingers, applying any pressure downward. This avoids pressure on the sensitive urethra above it. Ease insertion by asking the woman to bear down. This relaxes the perineal muscles and opens the introitus. As the blades pass your left fingers, withdraw the fingers. Now turn the width of the blades horizontally and continue to insert at a 45° angle downward toward the small of the woman's back. This matches the angle of the vagina vault.

An 18-year-old college student presents to the clinic with the complaint that her heart is "racing." You obtain blood for thyroid studies and diagnose her with Graves' disease (hyperthyroidism). On physical examination of her eyes, what would you expect to see? (A) Recession (B) Protrusion (C) Clouding of the cornea (D) Ciliary injection

(B) Protrusion

A 55-year-old postal worker presents to the emergency room with chest pain. On a scale of 1 to 10, he rates the pain a 9. It started 30 minutes ago and hasn't gone away. He has never had it before. He denies any injury or trauma; he has no medical conditions that are being treated. Nothing makes the pain better or worse. When questioned further, he has noticed nausea and increased sweating with the pain. Based on this description, which of the seven attributes of this symptom have not been addressed? (A) Remitting or exacerbating factors (B) Quality (C) Severity (D) Timing

(B) Quality Quality is the only one of the seven attributes of a symptom listed that is not addressed. The patient has not described the kind of pain he is experiencing other than that it is in his chest. Pain may be an ache, a sharp sensation, a pressure-like sensation, or a burning sensation, which are all important descriptors in helping to determine your differential diagnosis.

Correct instructions about the self-breast examination (BSE) are: (A) Tell the woman that the best time to perform BSE is in the middle of the menstrual cycle (B) Recommend that the best time to perform BSE is 4-7 days after the first day of the menstrual period (C) Tell the woman that if she is pregnant, she should not perform BSE until the baby is born (D) Urge the woman that she needs to do BSE bimonthly unless she has fibrocystic breast tissue

(B) Recommend that the best time to perform BSE is 4-7 days after the first day of the menstrual period Help each woman establish a regular schedule of self-care. The best time to conduct breast self-examination is right after the menstrual period, or the fourth through the seventh day of the menstrual cycle, when estrogen stimulation is low and the breasts are least congested. Advise the pregnant woman or menopausal woman who is not having menstrual periods to select a familiar date to examine her breasts each month, for example, her birth date or the day the rent is due.

The muscles in the neck that are innervated by cranial nerve XI are: (A) Spinal accessory and omohyoid (B) Sternomastoid and trapezius (C) Trapezius and sternomandibular (D) Sternomandibular and spinal accessory

(B) Sternomastoid and trapezius The major anterior neck muscles are the trapezius and sternomastoid. They form two triangles on the side of the neck, which can be used as landmarks for lymph nodes and other vessels.

A 22-year-old female college student presents to your clinic for a post-hospitalization follow-up. She was admitted last week for appendicitis and had an appendectomy. She states that she is having no abdominal pain but is having pain on the back of her left wrist. She states that 2 days after she was discharged the area became painful, red, and swollen. She does think there was an IV line there, but she isn't sure. Her past medical history is non-significant and she denies any tobacco, drug, or alcohol use. On exam, the dorsum of her left hand is tender, warm, and red, with some minimal swelling. On palpation, you feel a hard knot 2 cm by 3 cm long. What is the peripheral vascular disorder most likely causing her problem? (A) Raynaud's disease (B) Superficial thrombophlebitis (C) Acute arterial occlusion (D) Deep venous thrombosis

(B) Superficial thrombophlebitis Superficial thrombophlebitis is caused by the clotting of superficial veins; it is often due to trauma. There is localized redness, swelling, warmth, and pain. It can be accompanied by fever.

A 55-year-old legal secretary comes into your office to establish care. She starts the interview by telling you her whole life story, tells you about her husband, children, and grandchildren, and then pulls out a written list of 20 different items that relate to her health that she wants to address with you in today's interview. She is very friendly and relaxed. What specific type of patient is this? (A) Anxious patient (B) Talkative patient (C) Angry or disruptive patient (D) Silent patient

(B) Talkative patient This patient wants to tell you her life's story. Remember to let this type of patient talk for approximately 5-10 minutes while you listen closely to how she expresses her ideas, note the use of nonverbal cues, and so forth. A helpful technique is to have the patient focus on the most important thing that concerns her at today's visit and to schedule a follow-up appointment, setting a specific time limit on the follow-up as well.

A 55-year-old construction worker presents to the clinic for evaluation of fatigue and weakness. During the course of the interview, the patient reveals that he has noticed both an increase in his ring size and his shoe size; you ask to look at his driver's license and also at any pictures that he has in his wallet of himself from an earlier time period. Upon looking at these pictures, you are able to strongly theorize that he has acromegaly. Which physical finding is most consistent with this diagnosis? (A) High forehead (B) Small, recessed jaw (C) Coarsening of the facial features (D) Ptosis

(C) Coarsening of the facial features

A 16-year-old sophomore presents to the clinic for a sports physical; she is accompanied by her mother. She is involved in gymnastics and has been since age 5. In addition to training for the gymnastics team, she runs 10 miles per day. She is proud of her athleticism and states that she is still too fat and wants to lose more weight. You note that her BMI is 15. She denies eating excessively or making herself vomit. The patient's mother states she barely eats. This patient is at risk for which medical problem? (A) Obesity (B) Bulimia (C) Anorexia nervosa (D) Not at risk; normal adolescence

(C) Anorexia nervosa This patient has a preoccupation with her weight and feels that she is too fat. She has a BMI of 15, which is underweight, and does not see herself as too thin. The patient's mother states that she barely eats, which is typical of patients with anorexia. With a BMI of 15 and a daily exercise routine, the patient is hardly at risk for obesity. Although this patient is difficult to classify without further information, you believe her when she states that she doesn't eat excessively or make herself vomit. Patients with bulimia will go on binges of overeating, then make themselves vomit. Although normal adolescents are concerned with their body image, they do not exercise to the extent that this girl does nor do they typically have a BMI of 15 and barely eat.

A 63-year-old high school coach presents to your office complaining of weakness in both of his hands. He states that he has trouble writing out test questions and gripping the baseball bat in practice. He also complains that the muscles in his forearms are twitching. He has a 10-year history of hypertension, which is well controlled, and has no history of trauma. He has a 50-year history of chewing tobacco and drinks three to four beers two to three times per month. He denies any cigarette or drug use. On exam, his grip strength is greatly decreased bilaterally but his sensation is normal. His brachioradialis reflexes are also decreased. You note some wasting of the muscles between the thumbs and fingers on the dorsal surface of both hands. In what part of the peripheral nervous system is he most likely to have a disorder? (A) Spinal roots (B) Neuromuscular junction (C) Anterior horn cells (D) Muscle fibers

(C) Anterior horn cells In anterior horn cell disease, there is both weakness and atrophy in a focal or segmental pattern. Sensation remains intact, while reflexes are decreased. When seen in childhood, the problem is often polio; in older adults, it is often amyotrophic lateral sclerosis (Lou Gehrig's disease). Fasciculations in the muscle fibers are often felt and seen.

You notice that your patient's submental lymph nodes are enlarged. You would then assess the: (A) Supraclavicular area (B) Infraclavicular area (C) Area proximal to the enlarged node (D) Area distal to the enlarged node

(C) Area proximal to the enlarged node When nodes are abnormal, check the area from which they drain.

An 85-year-old retired secretary presents to your office complaining of severe lower back pain. She states that it started 4-5 months ago and has gradually been getting worse. She takes Daypro for arthritis but that hasn't helped her very much. She says that lying down or sleeping does not seem to help. She doesn't recall any trauma to her back. She has had no unusual problems with strength in her legs or bowel or bladder control. Her past medical history is significant for 30 years of hypertension and right-sided breast cancer 10 years ago. She had a mastectomy and radiation therapy. She did not take any chemotherapy. She denies tobacco or alcohol use. On exam, you find a thin, cachectic-appearing woman in no acute distress. Her heart and lung exam are normal. She is tender over the L4 and L5 vertebrae. She has normal sensation, strength, and reflexes in her lower extremities. She is nontender over the para spinal m

(C) Back pain from metastatic disease Back pain from metastatic disease occurs even when the patient is at rest. It generally does not radiate, and the patient has normal reflexes, strength, and sensation. Often there is point tenderness where the metastatic disease is located. The pain in this patient most likely represents breast cancer metastasis.

A 65-year-old gardener presents to the office for difficulty with urination. Increasingly, he has noticed feeling like his bladder has not emptied completely and his urinary stream has a decreased force. He experiences dribbling after he completes urination. These symptoms have been going on for several years, but his level of discomfort has increased over the past few months. On physical examination, you feel a symmetrically enlarged, smooth, and firm prostate gland, which seems to protrude more into the rectal lumen without any discrete lesions. What is your most likely diagnosis? (A) Normal prostate (B) Prostatitis (C) Benign prostatic hyperplasia (D) Prostate cancer

(C) Benign prostatic hyperplasia The patient's symptoms and physical exam are most consistent with benign prostatic hyperplasia. The affected prostate gland is symmetrically enlarged, smooth and firm, although slightly elastic. It may protrude more into the rectal lumen. The median sulcus may be obliterated as well. Further diagnostic tests may be required to rule out prostate cancer.

A 48-year-old homemaker comes to your office complaining of a breast lump she found under her right arm while showering. She says it hasn't been there during past checks and it doesn't hurt when she examined it. She admits she hadn't done a self-breast exam in almost 1 year. She states she has had three normal mammograms during the last 8 years. The last mammogram was 18 months ago. Her past medical history is significant for one spontaneous vaginal delivery at age 38. She went through menopause 3 years ago and is on estrogen and progesterone replacement. She has smoked one pack of cigarettes daily for the past 25 years but denies any alcohol or drug abuse. Past medical history reveals that her maternal aunt had breast cancer in her thirties and her maternal grandmother had ovarian cancer in her seventies. Review of systems is noncontributory. On exam, you feel a hard, approximately 2-cm lump in the tail of Spence un

(C) Cancer Breast cancer is very rarely seen under the age of 30 and usually strikes middle-aged and elderly women. It can start either before or after menopause. There is usually a single lump. The masses are usually irregular in shape, hard, and non-tender. They can be fixed to underlying tissue. In advanced cases, skin retractions are noted.

A 68-year-old retired mechanic comes to the office for an annual checkup. He is concerned that the small red areas on his skin may be cancer. On physical examination, you see round, bright, ruby-red lesions that are 1-3 mm in diameter and scattered on the anterior chest; they partially blanch with pressure. What is the most likely diagnosis? (A) Squamous cell carcinoma (B) Actinic keratosis (C) Cherry angioma (D) Spider angioma

(C) Cherry angioma Cherry angiomas are bright or ruby red, usually 1-3 mm in diameter, and round and flat, which may show partial blanching with pressure. They increase in size and number as a person ages and do not confer an increased risk of skin cancer.

A 22-year-old woman comes to your office complaining of a white discharge from her breasts, which has been occurring for 2 months. She also states that she hasn't had her period in 6 months. She denies any chance of pregnancy since she hasn't been sexually active in over 1 year. She is on no medications except a multivitamin. Her past medical history is significant for allergies only. Past medical history reveals a mother with cystic breasts and a great aunt with breast cancer. Review of systems is noncontributory. On exam, her breasts are symmetrical, with no skin changes. You are able to express milky discharge from each nipple. You feel no discrete masses, and her axillae are normal. The remainder or her heart, lung, abdominal, and pelvic exam are unremarkable. What cause of nipple discharge is the most likely in her circumstance? (A) Benign breast abnormality (B) Breast cancer (C) Nonpuerperal galactorrhea

(C) Nonpuerperal galactorrhea Galactorrhea, or milky discharge, when not due to pregnancy or lactation is called nonpuerperal. It is usually has hormonal or pharmacologic associations. In this case, a prolactinoma in the pituitary gland would be at the top of the differential, given the galactorrhea and the amenorrhea. Nipple discharge in benign breast abnormalities tends to be clear and unilateral. Nipple discharge in breast cancer is usually unilateral and can be clear or bloody.

A 42-year-old retail manager is sitting in your clinic exam room, waiting for a routine checkup for hypertension. You enter the room and sit down, making eye contact, and move your body slightly toward the patient. You nod your head as the patient begins to bring you up to date on his life since his last appointment. This interviewing technique is an example of: (A) Echoing (B) Adaptive questioning (C) Nonverbal communication (D) Empathic responses

(C) Nonverbal communication You have used nonverbal communication through the techniques of eye contact, sitting down, moving your body in slightly toward the patient, and nodding. Echoing is not the correct response since it involves simple repetition of the patient's words, and, as the interviewer in this scenario, you haven't repeated the patient's words. Adaptive questioning is also incorrect. It involves using various questions to clarify the patient's story, and in this scenario, as the interviewer, you haven't asked any questions yet. Empathic response is not correct. You have not identified the patient's feelings; and she has not expressed any during the interview.

A 76-year-old widow comes to your clinic to establish care. She admits that she hasn't seen a clinician in over 5 years, but her daughter has been nagging her to be seen. She states she has noticed that an area to the outside of her left breast feels enlarged, and there are some different changes to the skin in the area. Her past medical history is significant for two spontaneous vaginal deliveries and diet-controlled diabetes. She denies any tobacco or drug use and no alcohol abuse. Her review of systems is remarkable for a 10-pound weight loss in the last 6 months and some recent fatigue. On exam, you find an elderly woman appearing her stated age. Inspection of her left breast reveals some thickening of the skin lateral to her areola, with enlarged pores. You feel a non-tender 5-cm mass. The axilla has at least two enlarged lymph nodes, which are adherent to the underlying ribs. The right breast and axilla are unr

(C) Peau d'orange sign Peau d'orange, or orange-peel sign, is caused by local lymphatic blockage due to tumor. The involved skin then becomes thickened, and the pores become more prominent. This is usually a late sign of breast cancer. Choice (A) is incorrect. A retracted nipple is flattened or pulled inward. The surrounding skin is not thickened, nor are there enlarged pores. Paget's disease is also incorrect. This uncommon form of breast cancer starts as an eczema-like scaly skin change around the areola. The lesion may weep, crust, or erode.

A 38-year-old landscape designer presents to the clinic to be evaluated for a cough. His vital signs show a temperature of 103ºF, a pulse of 120, and a blood pressure of 88/55. His respiratory rate is 28. He appears to have labored breathing. All of these indicators are signs of: (A) Pain from the cough (B) Anxiety about the visit (C) Respiratory distress

(C) Respiratory distress The patient has classic signs of respiratory distress. He is tachypneic — his respiratory rate is greater than 20 breaths/minute and he appears to have labored breathing. Normal oral temperature is between 96.4º F and 99.1ºF, normal pulse is between 60 and 100 beats per minute, normal blood pressure is a systolic of 90/60 to 140/90, and a normal respiratory rate is between 14 and 20 breaths per minute.

A 15-year-old high school student presents to the clinic with a 1-day history of nausea and anorexia. He describes the pain as generalized yesterday, but today it has localized to the right lower quadrant. You palpate the left lower quadrant and the patient experiences pain in the right lower quadrant. What is the name of this sign? (A) Psoas sign (B) Obturator sign (C) Rovsing's sign (D) Cutaneous hyperesthesia

(C) Rovsing's sign

A 58-year-old college professor presents to your clinic to establish care. In taking vital signs, you feel the patient's radial pulse. The pulse pressure is diminished, and the pulse feels weak and small. The upstroke feels a little slow, and the peak is prolonged. You immediately suspect that this patient may have which of the following diagnoses? (A) Hypertrophic cardiomyopathy (B) Premature atrial contractions (C) Severe aortic stenosis (D) Constrictive pericarditis

(C) Severe aortic stenosis Severe aortic stenosis is one condition in which the pulse pressure is diminished and the pulse feels weak and small. Other conditions that could result in this same type of pulse include heart failure, hypovolemia, exposure to cold, and severe congestive heart failure.

Which of the findings is a normal finding when examining the glands? (A) The skin is wrinkled and without lesions (B) The dorsal vein may be visible (C) Smegma may be present under the foreskin of an uncircumcised male (D) There is no hair

(C) Smegma may be present under the foreskin of an uncircumcised male Some cheesy smegma may collect under the foreskin of an uncircumcised male. The glans looks smooth and without lesions. Pubic lice and nits settle in the base of the penis and excoriations or wrinkling may suggest activity. Hair distribution is variable.

A 15-year-old boy comes to your clinic complaining about pain for the past 2 weeks on the bottom of his left foot. He states that he stepped on a sticker outside and ever since he has had a spot there that hurts. He has no significant past medical history. On exam, you note an 8-mm area of thickened skin just proximal to the great toe on his left foot. There is no redness, warmth, or drainage from the area. There are, however, small dark dots present underneath the thickened skin. Pressing against the area causes the patient significant pain. What disorder of the foot is most likely the diagnosis for his case? (A) Corn (B) Callus (C) Neuropathic ulcer (D) Plantar wart

(D) Plantar wart Plantar warts often occur on the metatarsal area, heels, and toes, where there has been slight trauma in the past. They cause thickened skin and can be very painful upon pressure. There are usually characteristic black dots associated with the wart, which are thrombosed capillaries. Corns are thickened skin, but they are caused by pressure against the foot. They occur most commonly on the lateral side of the 5th toe and between the 4th and 5th toes. Callus formations also occur at pressure points but at places where the skin is normally thick. Calluses are not painful and are usually located around the heel or over the plantar surface, just proximal to the great toe. They are not tender. Neuropathic ulcers also develop at pressure points, usually because of a lack of sensation. Although often deep and infected, they are not painful. They are usually red, warm, and sometimes drain serosanguinous fluid.

A 36-year-old computer programmer presents to the office with pain with urination, and fever. On palpation of the prostate, his gland is swollen, tender, and warm to the touch. Your most likely diagnosis is? (A) Normal prostate (B) Benign prostatic hyperplasia (C) Prostate cancer (D) Prostatitis

(D) Prostatitis In acute prostatitis, the patient typically has fever and dysuria. The gland is very tender, swollen, firm, and warm to touch.

A 54-year-old woman who works at a dry cleaners presents to your office complaining that she cannot do overhead work with her right arm. She states that she can no longer lift her arm over her head without using her other arm to prop it up. She remembers no specific injury but has been doing overhead work at the dry cleaners for over 15 years. Her past medical history is significant for three spontaneous vaginal deliveries and 15 years of hypertension. On exam, she has demonstrative weakness with internal and external rotation on the right. When she attempts to abduct her arm, there is obvious shrugging of the shoulder. On inspection of her back, you note atrophy of the muscles surrounding the shoulder and scapula. She is nontender over any boney prominence in the shoulder. Her passive range of motion is normal, while on active range of motion she is unable to elevate her arm more than 12 inches and cannot raise it t

(D) Rotator cuff tear Rotator cuff tear is often seen in people over 40 due to a sudden trauma or repeated impingement weakening the rotator cuff group. This often eventually leads to a complete tear. Weakness is common, as is atrophy of the muscles. With a complete tear, active abduction and flexion causes shoulder shrugging.

A 20-year-old college junior is brought to your office by classmates who state that she is acting strangely. She has been seen talking to herself around campus and has told people that she has been awarded the Nobel Prize for her study in physics. Her friends tell you that until 2 months ago she seemed a normal, happy young woman with no medical problems. They had heard mention of an older brother with mental problems. They tell you she drinks alcohol on the weekends but has never gotten drunk and has never done any drugs. On exam, you find you cannot understand her because she speaks in a nonsensible manner by repeating phrases and shifting her ideas. She is oriented to person, place, and time; her math calculations are correct, but she cannot explain any proverbs. You also notice that her blouse is on backwards. What is the most likely cause of her mental health problem? (A) Major depression (B) Bipolar disorder

(D) Schizophrenia Schizophrenia often starts suddenly in young adults with strong family history of mental health problems. Delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms (flat affect, lack of interest or drive) are often present. In this case, the young woman has delusions (winning the Nobel Prize as a college student), hallucinations (apparent when she is seen having conversations with herself), disorganized speech (with shifting of ideas and clanging speech), and disorganized behavior (wearing clothes backwards).

You are in the emergency room assessing a patient with abdominal pain and fever. You are performing an abdominal examination to assess for peritoneal signs. Which one of the following is NOT a peritoneal sign? (A) Rebound tenderness (B) Involuntary guarding (C) Rigidity of the abdomen (D) Voluntary guarding

(D) Voluntary guarding

Which of the following statements is true when performing a male genital examination? (A) Auscultate for the presence of bowel sounds over the scrotum in all males (B) Palpate for the vertical chain of lymph nodes along the groin inferior to the inguinal ligament (C) Palpate the inguinal canal only if there is a bulge present in the inguinal region during inspection (D) When palpating for a hernia on the right side, have the client shift his standing weight onto the left leg

(D) When palpating for a hernia on the right side, have the client shift his standing weight onto the left leg Positioning to the left leg allows the examiner to follow the inguinal canal and document any hernia-related bulge.