uld cause these symptoms as well, but the
combination of the heat and a recent infection make delirium much more likely. Though she was
prescribed an
... [Show More] antibiotic, she may not have improved because of bacterial resistance or because of
noncompliance due to cost, depression, or even an underlying mild dementia. Dementia should
not result in an acute mental status change, although illness may cause a worsening of dementia.
15. Blood pressure abnormalities found more commonly in Western elderly include which of the
following?
A) Isolated elevation of the diastolic BP
B) Narrow pulse pressure
C) Elevation of the systolic BP
D) Elevation of the BP with standing
Ans: C
Chapter: 20
Page and Header: 895, Anatomy and Physiology
Feedback: Isolated systolic hypertension is common in the elderly because of stiffening of the
large arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP
changes are often seen with postural changes and can account for falls as well.
16. Which of the following represents age-related changes in the lungs?
A) Decrease in chest wall compliance
B) Speed of expiration increases
C) Increase in respiratory muscle strength
D) Increased elastic recoil of lung tissue
Ans: A
Chapter: 20
Page and Header: 897, Anatomy and Physiology
Feedback: The lungs age along with the rest of the body. These changes include decreased lung
and chest wall compliance, increased expiratory time, decreased muscle strength and cough, and
decreased elastic recoil.
17. Mrs. Stanton is a 79-year-old widow who presents to your office for a routine BP visit. You
note a new pulsatile mass in the right neck at the carotid artery. Which of the following is the
most likely cause for this?
A) AnxietyB) Carotid artery aneurysm
C) Kinking of the artery
D) Tortuous aorta
Ans: C
Chapter: 20
Page and Header: 897, Anatomy and Physiology
Feedback: While a carotid artery aneurysm is a possibility, it is more likely due to kinking of the
carotid artery in this patient with HTN. A tortuous aorta will sometimes cause elevation of the
left jugular vein by impairing drainage within the thorax.
18. Mr. Chin is an 82-year-old man who comes to your office for a routine check. On
examination, you notice a somewhat high-pitched murmur in the second right intercostal space
during systole. It does not radiate and the rest of his examination is normal for his age. Which is
true of the most likely cause of this murmur?
A) It often decreases carotid upstroke.
B) It carries with it increased risk for cardiovascular disease.
C) It is usually accompanied by an S3 gallop.
D) It is found in 10% of otherwise normal elderly patients.
Ans: B
Chapter: 20
Page and Header: 898, Anatomy and Physiology
Feedback: This murmur most likely represents aortic sclerosis, a common murmur affecting
about one third of those near 60 years of age. It is caused by calcification of the valve and is
associated with cardiovascular risk. Aortic sclerosis does not usually cause obstruction to
normal flow, so carotid upstroke should be normal, and it is not associated with an S3 gallop.
19. Mrs. Buckley is a 75-year-old widow who wants you to look at her teeth because over the
past 2 weeks she has had right-sided jaw pain when eating. It does not occur otherwise. She
also has had a headache. Which of the following should be considered?
A) Palpation of her temples
B) Dental referral
C) Ultrasound of the gallbladder
D) Inquiry about anosmia
Ans: A
Chapter: 20
Page and Header: 898, Anatomy and Physiology
Feedback: This story can be consistent with temporal arteritis, which can cause blindness in15% of those affected. Early recognition is crucial. Most of these patients will have tenderness
over one or both of the temporal arteries, and some have diminished temporal pulses as well.
Early treatment with corticosteroids is indicated. It can also be associated with polymyalgia
rheumatic, a condition which causes pain in the shoulder girdles and pelvis.
20. Which of the following is commonly seen in aging men?
A) Erectile dysfunction in 20% of all men
B) Testicles ride higher within the scrotum
C) Strong response to visual erotic cues
D) Persistent sexual interest
Ans: D
Chapter: 20
Page and Header: 899, Anatomy and Physiology
Feedback: Erectile dysfunction affects about half of elderly men but sexual interest generally
remains intact. A decrease in sexual interest may indicate other problems such as depression.
Visual cues become less important and tactile stimulation more important. The testicles are
positioned lower in the scrotum.
21. Which of the following accompanies decreased ovarian function?
A) Increased sleep
B) Diminution of sexual interest
C) Enlargement of the clitoris
D) Decrease in vaginal secretions
Ans: D
Chapter: 20
Page and Header: 899, Anatomy and Physiology
Feedback: Menopause, or the cessation of menses for 1 year, commonly occurs in the late 40s to
early 50s. Many experience hot flashes, sweating, chills, anxiety, decreased sleep, and urge
incontinence. Dyspareunia is common secondary to decreased vaginal secretions. Sexual interest
does not normally decrease. The clitoris and length of the vaginal vault decrease in response to
decreased estrogen.
22. You are examining an elderly man and notice the following: decreased vibration sense in the
feet and ankles, diminished gag reflex, right patellar reflex less than the left, and diminished
abdominal reflexes. Which of these is abnormal?A) Decreased vibration sense
B) Diminished gag reflex
C) Diminished right patellar reflex compared to the left
D) Diminished abdominal reflexes
Ans: C
Chapter: 20
Page and Header: 901, Anatomy and Physiology
Feedback: Asymmetry on any examination is usually reason for concern. The other changes are
commonly associated with aging. You may consider looking for other neurologic signs on the
right, although occasionally you may mistake an abnormally brisk reflex to be normal when
compared to the other side. It is usually a good idea to question whether the opposite side is
actually the abnormal one when you find asymmetry on examination.
23. Mrs. Glynn is 90 years old and lives alone. She is able to bathe, dress, prepare her food, and
transfer from bed to chair independently. She has children in the area who help her with her
medications and transportation needs. Which of the following is considered an instrumental
activity of daily living?
A) Bathing
B) Dressing
C) Preparing food
D) Transferring from bed to chair
Ans: C
Chapter: 20
Page and Header: 906, The Health History
Feedback: Instrumental activities of daily living involve higher thought processes such as
preparing food, whereas bathing, dressing, and transferring are considered physical activities of
daily living.
24. Mr. Kelly comes to you today for a burning pain in his lower abdomen. This has gone on for
2 months. He has received radiation for prostatic cancer for the past quarter. What assumptions
could you draw from this?
A) This represents persistent pain.
B) His pain reporting is likely to be unreliable.
C) There are “red flags” present.
D) He is depressed.
Ans: C
Chapter: 20Page and Header: 906, The Health History
Feedback: This scenario is consistent with acute pain, although this may become persistent if it
lasts beyond 3 months. The burning quality to the pain should be a red flag, along with
descriptions of pain as “discomfort” or “soreness.” Depressed affect or changes in posture or
gait are also red flags. Studies have found that pain reporting in the elderly is accurate.
Although depression may be present, we have no indications of it in this scenario.
25. Mr. White's son brings him in today because he notes that Mr. White has not been himself
lately. He seems forgetful and has not taken care of himself as he normally does. He has
reported falling twice at home to his son and has telephoned late at night because of insomnia.
His blood pressure and diabetes have been difficult to control and his warfarin dosing has
become more difficult. Which of the following should you suspect?
A) Alzheimer's dementia
B) Alcohol use
C) Urinary tract infection
D) Stroke
Ans: B
Chapter: 20
Page and Header: 908, The Health History
Feedback: All of these answers are common diseases of the elderly and many have atypical
presentations in this age group. The fact that his hypertension has become more difficult to
control and his warfarin dosing is challenging to manage should lead you to consider that there is
alcohol use. Further questioning, quantifying his use of alcohol, and application of the CAGE
questionnaire may be useful.
26. Claire's daughter brings her in today after Claire fell at her home. Which assessments are
indicated at this time?
A) Orthostatic vital signs
B) Review of her medications
C) Assessment of gait and balance
D) All of the above
Ans: D
Chapter: 20
Page and Header: 913, Techniques of Examination
Feedback: Falls are common in the elderly and can often result in serious injuries. When
assessing the cause of falls, gait and balance should be checked first. Medication, particularly
use of more than three, is associated with falls. Vision problems, lower-limb joint problems, and
cardiovascular problems such as arrhythmias may be reasonable to search for. Orthostatic vitalsign changes should be sought.
27. Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar
aspects of her forearms and on her abdomen. She otherwise has no complaints and her diabetes
and hypertension are well managed. Her son from out of state accompanies her today and has
recently moved in to help her. What should you suspect?
A) Overuse of aspirin
B) Frequent falls
C) Elder abuse
D) Depression
Ans: C
Chapter: 20
Page and Header: 912, Health Promotion and Counseling
Feedback: The different colors of the bruising indicate that they have occurred at different times
and are unlikely to have resulted from a single fall. The location of the bruising on the ulnar
aspects of the forearms potentially indicates that she was trying to defend herself and are not
typical areas to be bruised by a fall. Depression may be evident, but this is more likely to be a
result rather than a cause of her situation today. While nothing is proven, it would be wise to
interview her without her son in the room. If in doubt, a social worker consult may be helpful to
determine if elder abuse is occurring.
28. A patient comes to you for the appearance of red patches on his forearms that have been
present for several months. They remain for several weeks. He denies a history of trauma.
Which of the following is likely?
A) Actinic keratoses
B) Pseudoscars
C) Actinic purpura
D) Cherry angiomas
Ans: C
Chapter: 20
Page and Header: 917, Techniques of Examination
Feedback: Actinic purpura is a common benign skin condition of the elderly, frequently
involving the forearms. Pseudoscars are white patches and cherry angiomas are bright-red raised
lesions usually found on the torso. Actinic keratoses are lesions resembling nevi, often with
features which would be concerning if considering melanoma (review the ABCDEs of
melanoma), but they produce a slightly greasy scale when scratched with a nail.29. On routine screening you notice that the cup-to-disc ratio of the patient's right eye is 1:2.
What ocular condition should you suspect?
A) Macular degeneration
B) Diabetic retinopathy
C) Hypertensive retinopathy
D) Glaucoma
Ans: D
Chapter: 20
Page and Header: 918, Techniques of Examination
Feedback: This cup-to-disc ratio means that the cup takes up 50% of the disc, which is
abnormally large. This is usually an indication of glaucoma, which is a common cause of visual
loss in the elderly. The cup-to-disc changes are not seen in diabetes, hypertension, or macular
degeneration. Many elderly do not have regular eye examinations and are not screened for
glaucoma.
30. Which of the following is true of assessment of the vascular system in the elderly?
A) Fewer than one third of patients with peripheral vascular disease have symptoms of
claudication.
B) An aortic width of 2.5 cm is abnormal.
C) Bruits are commonly benign findings.
D) Orthostatic blood pressure and pulse are not useful in this population.
Ans: A
Chapter: 20
Page and Header: 921, Techniques of Examination
Feedback: It is the minority of patients with peripheral vascular disease who experience
claudication; therefore, ankle–brachial ratios should be performed more frequently. The aorta
should be 3 cm or less. Bruits usually indicate pathology, and even when there is not a
significant blockage, the risk of vascular disease throughout the body is increased. Orthostatic
vital signs are very useful in this population. Remember to observe the pulse as well, as failure
of the heart to increase its rate is a common cause of orthostatic hypotension. This can occur as a
result of autonomic neuropathy or medications such as beta-blockers, among other causes.15. A daycare worker presents to your office with jaundice. She denies IV drug use, blood
transfusion, and travel and has not been sexually active for the past 10 months. Which type of
hepatitis is most likely?
A) Hepatitis A
B) Hepatitis B
C) Hepatitis C
D) Hepatitis D
Ans: A
Chapter: 11
Page and Header: 418, The Health History
Feedback: The lack of contact with blood and body fluids makes hepatitis B, C, and D unlikely.
She regularly changes the diapers of her clients and is at risk for hepatitis A. Vaccine against
hepatitis A is recommended for daycare workers.16. Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the
right side. The pain eventually moved to her lateral abdomen and then into her right lower
quadrant. Which is most likely, given this presentation?
A) Appendicitis
B) Dysmenorrhea
C) Ureteral stone
D) Ovarian cyst
Ans: C
Chapter: 11
Page and Header: 418, The Health History
Feedback: The presentation of right flank pain spiraling down to the groin is typical of a ureteral
stone. There would most likely be microscopic hematuria as well. The migration pattern of this
condition makes the others less likely.
17. Mrs. LaFarge is a 60-year-old who presents with urinary incontinence. She is unable to get
to the bathroom quickly enough when she senses the need to urinate. She has normal mobility.
Which of the following is most likely?
A) Stress incontinence
B) Urge incontinence
C) Overflow incontinence
D) Functional incontinence
Ans: B
Chapter: 11
Page and Header: 418, The Health History
Feedback: Stress incontinence occurs with increased intra-abdominal pressure such as with
coughing, sneezing, or laughing. This history is most consistent with urge incontinence
secondary to detrusor overactivity. Overflow incontinence occurs with anatomic obstruction such
as prostatic hypertrophy (obviously not in this case, as the patient is a woman), urethral stricture,
or neurogenic bladder. Functional incontinence results from lack of mobility severe enough to
impair getting to the bathroom quickly enough.
18. Which is the proper sequence of examination for the abdomen?
A) Auscultation, inspection, palpation, percussion
B) Inspection, percussion, palpation, auscultationC) Inspection, auscultation, percussion, palpation
D) Auscultation, percussion, inspection, palpation
Ans: C
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: The abdominal examination is conducted in a sequence different from other systems,
for which the usual order is inspection, percussion, palpation, and auscultation. Because
palpation may actually cause some bowel noise when the bowels are not moving, auscultation is
performed before percussion and palpation in an abdominal examination.
19. A 62-year-old woman has been followed by you for 3 years and has had recent onset of
hypertension. She is still not at goal despite three antihypertensive medicines, and you strongly
doubt nonadherence. Her father died of a heart attack at age 58. Today her pressure is 168/94 and
pressure on the other arm is similar. What would you do next?
A) Add a fourth medicine
B) Refer to nephrology
C) Get a CT scan
D) Listen closely to her abdomen
Ans: D
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: At this point, it is important to consider secondary causes for this woman's
hypertension because of its severity, rapidity of progression, and lack of response to therapy.
While you will most likely add a fourth medicine, it is important to carefully examine the
abdomen for the presence of renal artery bruits. These are usually heard best in the upper
quadrants. It may be necessary to have the patient hold her breath, to have a very quiet room, and
to listen with the diaphragm for a very soft, high-pitched sound with systole. It may also help to
simultaneously feel the patient's pulse (a bruit with both a systolic and diastolic component is
very specific for a significant blockage, while a lone systolic bruit may not be abnormal).
Obtaining a CT scan is not likely to be useful, and you may save the delay, expense, and
inconvenience of a nephrology referral if you can hear a bruit.
20. Mr. Patel is a 64-year-old man who was told by another care provider that his liver is
enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no
knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below
the costal arch. Which of the following would you do next?
A) Check an ultrasound of the liver
B) Obtain a hepatitis panelC) Determine liver span by percussion
D) Adopt a “watchful waiting” approach
Ans: C
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A liver edge palpable this far below the costal arch should not be ignored. Ultrasound
and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has
developed emphysema with flattening of the diaphragms. This pushes a normal-sized liver below
the costal arch so that it appears to be enlarged. A liver span should be determined by percussing
down the chest wall until dullness is heard. A measurement is then made between this point and
the lower border of the liver to determine its span; 6–12 centimeters in the mid-clavicular line is
normal. Percussion is the only way to assess liver size on examination, and in this case it saved
the patient much inconvenience and expense.
21. Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with
fairly significant left upper quadrant pain. On examination of this area a rough grating noise is
heard. What is this sound?
A) It is a splenic rub.
B) It is a variant of bowel noise.
C) It represents borborygmi.
D) It is a vascular noise.
Ans: A
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A rough, grating noise over this area represents a splenic rub, which can accompany
splenic infarction. Rubs also occur over the liver and pleura and pericardium.
22. You are palpating the abdomen and feel a small mass. Which of the following would you do
next?
A) Ultrasound
B) Examination with the abdominal muscles tensed
C) Surgery referral
D) Determine size by percussion
Ans: B
Chapter: 11
Page and Header: 451, Recording Your Findings
Feedback: It is easy to determine whether the mass is actually in the abdominal wall versus inthe abdomen by palpating with the abdominal wall tensed. This can be accomplished by having
the patient lift her head off the bed while supine. Usually, abdominal wall masses can be
observed, whereas intra-abdominal masses are more concerning.
23. Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice
dullness in the last intercostal space in the anterior axillary line on his left side with a deep
breath. What does this indicate?
A) His spleen is definitely enlarged and further workup is warranted.
B) His spleen is possibly enlarged and close attention should be paid to further examination.
C) His spleen is possibly enlarged and further workup is warranted.
D) His spleen is definitely normal.
Ans: B
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: This scenario is not uncommon in infectious mononucleosis. The presence of
dullness with inspiration should definitely increase your attention to further examination of the
spleen, although dullness can occur in normal patients too.
24. A young patient presents with a left-sided mass in her abdomen. You confirm that it is
present in the left upper quadrant. Which of the following would support that this represents an
enlarged kidney rather than her spleen?
A) A palpable “notch” along its edge
B) The inability to push your fingers between the mass and the costal margin
C) The presence of normal tympany over this area
D) The ability to push your fingers medial and deep to the mass
Ans: C
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A left upper quadrant mass is more likely to be a kidney if there is no palpable
“notch,” you can push your fingers between the mass and the costal margin, there is normal
tympany over this area, and you cannot push your fingers medial and deep to the mass. These
findings are very difficult to appreciate in an obese patient.
25. Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the
midline which is minimally tender. There is dullness to percussion up to 6 centimeters above thesymphysis pubis. What does this most likely represent?
A) Sigmoid mass
B) Tumor in the abdominal wall
C) Hernia
D) Enlarged bladder
Ans: D
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: It is possible that this represents a sigmoid colon mass, but this is less likely than an
enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently
cause partial urinary obstruction with bladder enlargement. If the mass resolves with
catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic
bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A
hernia would most likely not be dull to percussion. Midline abdominal wall tumors of this size
would be unusual but could be discerned by having the patient tense his abdominal muscles.
26. Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note
that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What
should you do next?
A) Obtain abdominal ultrasound
B) Reassess by examination in 6 months
C) Reassess by examination in 3 months
D) Refer to a vascular surgeon
Ans: A
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A pulsatile mass in this man should be followed up with ultrasound as soon as
possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4
centimeters. It would be inappropriate to recheck him at a later time without taking action.
Likewise, referral to a vascular surgeon before ultrasound may be premature.
27. Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the
following would argue for the presence of ascites?
A) Bilateral flank tympany
B) Dullness which remains despite change in position
C) Dullness centrally when the patient is supine
D) Tympany which changes location with patient positionAns: D
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A diagnosis of ascites is supported by findings that are consistent with movement of
fluid and gas with changes in position. Gas-filled loops of bowel tend to float so that dullness
when supine would argue against this. Likewise, because fluid gathers in dependent areas, the
flanks should ordinarily be dull with ascites. Tympany which changes location with patient
position (“shifting dullness”) would support the presence of ascites. A fluid wave and edema
would support this diagnosis as well.
28. Which of the following is consistent with obturator sign?
A) Pain distant from the site used to check rebound tenderness
B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated
C) Pain with extension of the right thigh while the patient is on her left side or while pressing
her knee against your hand with thigh flexion
D) Pain that stops inhalation in the right upper quadrant
Ans: B
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: Obturator sign is seen in appendicitis. It is pain with the stretching of the internal
obturator muscle because of inflammation. Pain distant from the site used to check rebound
tenderness is Rovsing's sign and is a reliable sign of peritonitis. Answer “C” describes psoas
sign, which is also seen in appendicitis. Palpation in the right upper quadrant that causes pain
severe enough to stop inhalation is consistent with inflammation of the gallbladder and is called
Murphy's sign.
29. An elderly woman with a history of coronary bypass comes in with severe, diffuse,
abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on
the abdomen. What do you suspect?
A) Malingering
B) Neuropathy
C) Ischemia
D) Physical abuse
Ans: C
Chapter: 11
Page and Header: 454, Table 11–1
Feedback: Ischemic pain can be severe but is not made worse with palpation. The history of
bypass could be a clue that there is vascular narrowing elsewhere. Malingering is less likely, andneuropathic pain, as seen in herpes zoster, would worsen with touch. You are to be commended if
you considered elder abuse, because this is frequently missed. Ordinarily, this pain would be
worse with examination because of the preceding trauma.
Bates’ Guide to Physical Examination and History Taking, 12th Edition
Chapter 12: The Peripheral Vascular System
Multiple Choice
1. A 57-year-old maintenance worker comes to your office for evaluation of pain in his legs. He
has smoked two packs per day since the age of 16, but he is otherwise healthy. You are
concerned that he may have peripheral vascular disease. Which of the following is part of
common or concerning symptoms for the peripheral vascular system?
A) Intermittent claudication
B) Chest pressure with exertion
C) Shortness of breath
D) Knee pain
Ans: A
Chapter: 12
Page and Header: 477, The Health History
Feedback: Intermittent claudication is leg pain that occurs with walking and is relieved by rest.
It is a key symptom of peripheral vascular disease. This symptom is present in only about one
third of patients with significant arterial disease and, if found, calls for more aggressive
management of cardiovascular risk factors. Screening with ankle brachial index can help detect10. The following information is best placed in which category?
“The patient had a stent placed in the left anterior descending artery (LAD) in 1999.”
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A
Chapter: 01
Page and Header: 9, Past History
Feedback: The adult illnesses category is reserved for chronic illnesses, significant
hospitalizations, significant injuries, and significant procedures. A stent is a major procedure but
does not involve a surgeon.
11. The following information is best placed in which category?
“The patient was treated for an asthma exacerbation in the hospital last year; the patient hasnever been intubated.”
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A
Chapter: 01
Page and Header: 9, Past History
Feedback: This is information about a significant hospitalization and should be placed in the
adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider
placing this information in the present illness section, because it relates to the chief complaint at
that visit.
Bates’ Guide to Physical Examination and History Taking, 12th Edition
Chapter 2: Clinical Reasoning, Assessment, and Recording Your Findings
Multiple Choice
1. A patient presents for evaluation of a sharp, aching chest pain which increases with breathing.
Which anatomic area would you localize the symptom to?
A) Musculoskeletal
B) Reproductive
C) Urinary
D) Endocrine
Ans: A
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: Chest pain may be due to a musculoskeletal condition, such as costochondritis or
intercostal muscle cramp. This would be worsened by motion of the chest wall. Pleuritic chest
pain is also a sharp chest pain which increases with a deep breath. This type of pain can occur
with inflammation of the pleura from pneumonia or other conditions and pulmonary embolus.2. A patient comes to the emergency room for evaluation of shortness of breath. To which
anatomic region would you assign the symptom?
A) Reproductive
B) Urinary
C) Cardiac
D) Hematologic
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: Cardiac disorders such as congestive heart failure are the most likely on this list to
result in shortness of breath. There are cases within the other categories which may also result in
shortness of breath, such as anemia in the hematologic category, pregnancy in the reproductive
category, or sepsis with UTI in the urinary category. This demonstrates the “tension” in clinical
reasoning between making sure all possibilities are covered, while still being able to pick the
most likely cause.
3. A patient presents for evaluation of a cough. Which of the following anatomic regions can be
responsible for a cough?
A) Ophthalmologic
B) Auditory
C) Cardiac
D) Endocrine
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: The cardiac system can cause a cough if the patient has congestive heart failure. This
results in fluid buildup in the lungs, which in turn can cause a cough that produces pink, frothy
sputum. A foreign body in the ear may also cause a cough by stimulating Arnold's branch of the
vagus nerve, but this is less likely to be seen clinically than heart failure.
4. A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new,
located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash;
she also denies recent travel or camping activities. She has a family history significant for
rheumatoid arthritis. Based on this information, which of the following pathologic processes
would be the most correct?
A) InfectiousB) Inflammatory
C) Hematologic
D) Traumatic
Ans: B
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: The description is most consistent with an inflammatory process, although all the
other etiologies should be considered. Lyme disease is an infection which commonly causes
arthritis, hemophilia is a hematologic condition which can cause bleeding in the joints, and
trauma can obviously cause joint pain. Your clinical reasoning skills are important for sorting
through all of the data to arrive at the most likely conclusion.
5. A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for
several years. He normally takes over-the-counter medications to ease the pain, but this time they
haven't worked as well, and he still has discomfort. He recently wallpapered the entire second
floor in his house, which caused him great discomfort. The pain resolved with rest. He denies
fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this
description, what is the most likely pathologic process?
A) Infectious
B) Neoplastic
C) Degenerative
D) Traumatic
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: The description is most consistent with degenerative arthritis in the neck. The patient
has had intermittent symptoms and the questions asked to elicit pertinent negative and positive
findings are negative for infectious, traumatic, or neoplastic disease.
6. A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history
of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which
is the most likely pathologic process?
A) Infection
B) Inflammation
C) Allergic
D) Vascular
Ans: CChapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: This description is most consistent with allergic rhinitis.
7. A 19-year-old-college student presents to the emergency room with fever, headache, and neck
pain/stiffness. She is concerned about the possibility of meningococcal meningitis. Several of
her dorm mates have been vaccinated, but she hasn't been. Which of the following physical
examination descriptions is most consistent with meningitis?
A) Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range of
motion
B) Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle
spasm and limited range of motion to the right
C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to
palpation, unable to perform range of motion
D) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full
range of motion
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: Blurred disc margins are consistent with papilledema, and neck tenderness and lack
of range of motion are consistent with neck stiffness, which in this scenario is likely to be caused
by meningeal inflammation. Later, you will learn about Kernig's and Brudzinski's signs, which
are helpful in testing for meningeal irritation on examination.
8. A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The
pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods.
Which one of the following physical examination descriptions would be most consistent with the
diagnosis of cholecystitis?
A) Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses.
B) Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or
guarding.
C) Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the
point of stopping inspiration, and there is no rebound or guarding.
D) Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or
guarding.
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical ReasoningFeedback: In cholecystitis, the pain, which originates from the gallbladder, is located in the right
upper quadrant. Severity of pain with inspiration that is sufficient to stop further inhalation is
also known as Murphy's sign, which, if present, is further indicative of inflammation of the
gallbladder.
9. A 55-year-old data entry operator comes to the clinic to establish care. She has the following
symptoms: headache, neck pain, sinus congestion, sore throat, ringing in ears, sharp brief chest
pains at rest, burning abdominal pain with spicy foods, constipation, urinary frequency that is
worse with coughing and sneezing, and swelling in legs. This cluster of symptoms is explained
by:
A) One disease process
B) More than one disease process
Ans: B
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: The patient appears to have several possible conditions: allergic rhinitis, arthritis,
conductive hearing loss, pleuritic chest pains, heartburn, stress urinary incontinence, and venous
stasis, among other conditions. Although we always try, it is very difficult to assign all of these
symptoms to one cohesive diagnosis.
10. A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever,
headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of
symptoms is best explained by:
A) One disease process
B) More than one disease process
Ans: A
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: This cluster of symptoms is most consistent with sinusitis. The chance that all of
these symptoms are caused by multiple synchronous conditions in the same patient is much less
than the possibility of having one problem which accounts for all of them.
11. Steve has just seen a 5-year-old girl who wheezes when exposed to cats. The patient's
family history is positive for asthma. You think the child most likely has asthma. What have you
just accomplished?A) You have tested your hypothesis.
B) You have developed a plan.
C) You have established a working diagnosis.
D) You have created a hypothesis.
Ans: D
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: As you go through a history and examination, you will start to generate ideas to
explain the patient's symptoms. It is best to keep an open mind and make as many hypotheses as
you can, to avoid missing a possibility. A common mistake is to latch onto one idea too early.
Once you have committed your mind to a diagnosis, it is difficult to change to another. To think
about looking for wheezes on examination would be an example of testing your new hypothesis.
Starting a patient on an inhaled medicine would be a plan. It is too early to commit to a working
diagnosis, given the amount of information you have gathered.
12. Ms. Washington is a 67-year-old who had a heart attack last month. Now she complains of
shortness of breath and not being able to sleep in a flat position (orthopnea). On examination
you note increased jugular venous pressure, an S3 gallop, crackles low in the lung fields, and
swollen ankles (edema). This is an example of a:
A) Pathophysiologic problem
B) Psychopathologic problem
Ans: A
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: This is an example of a pathophysiologic problem because Ms. Washington's
symptoms are consistent with a pathophysiologic process. The heart attack reduced the ability of
her heart to handle her volume status and subsequently produced the many features of congestive
heart failure.
13. On the way to see your next patient, you glance at the calendar and make a mental note to
buy a Mother's Day card. Your patient is Ms. Hernandez, a 76-year-old widow who lost her
husband in May, two years ago. She comes in today with a headaches, abdominal pain, and
general malaise. This happened once before, about a year ago, according to your detailed office
notes. You have done a thorough evaluation but are unable to arrive at a consistent picture to tie
these symptoms together. This is an example of a:
A) Pathophysiologic problem
B) Psychopathologic problemAns: B
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: It is not uncommon for patients to experience psychopathologic symptoms around the
anniversary of a traumatic event. The time of year and the lack of an obvious connection
between Ms. Hernandez's symptoms would make you consider this as a possibility. You will
note that although this might have been an early consideration in your hypothesis generation, it is
key to convince yourself that there is not a physiologic explanation for these symptoms, by
performing a careful history and examination.
14. Mr. Larson is a 42-year-old widowed father of two children, ages 4 and 11. He works in a
sales office to support his family. Recently he has injured his back and you are thinking he
would benefit from physical therapy, three times a week, for an hour per session. What would be
your next step?
A) Write the physical therapy prescription.
B) Have your office staff explain directions to the physical therapy center.
C) Discuss the plan with Mr. Larson.
D) Tell Mr. Larson that he will be going to physical therapy three times a week.
Ans: C
Chapter: 02
Page and Header: 30, Develop a Plan Agreeable to the Patient
Feedback: You should discuss your proposed plan with the patient before implementing it. In
this case, you and Mr. Larson will need to weigh the benefit of physical therapy against the
ability to provide for his family. You may need to consider other ways of helping the patient,
perhaps through prescribed back exercises he can do at home. It is a common mistake to
implement a plan without coming to an agreement with the patient first.
15. You are seeing an elderly man with multiple complaints. He has chronic arthritis, pain from
an old war injury, and headaches. Today he complains of these pains, as well as dull chest pain
under his sternum. What would the order of priority be for your problem list?
A) Arthritis, war injury pain, headaches, chest pain
B) War injury pain, arthritis, headaches, chest pain
C) Headaches, arthritis, war injury pain, chest pain
D) Chest pain, headaches, arthritis, war injury pain
Ans: D
Chapter: 02
Page and Header: 37, Generating the Problem List
Feedback: The problem list should have the most active and serious problem first. This newcomplaint of chest pain is almost certainly a higher priority than his other, more chronic
problems.
16. You are excited about a positive test finding you have just noticed on physical examination
of your patient. You go on to do more examination, laboratory work, and diagnostic tests, only
to find that there is no sign of the disease you thought would correlate with the finding. This
same experience happens several times. What should you conclude?
A) Consider not doing this test routinely.
B) Use this test when you have a higher suspicion for a certain correlating condition.
C) Continue using the test, perhaps doing less laboratory work and diagnostics.
D) Omit this test from future examinations.
Ans: C
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: This is an example of a sensitive physical finding that lacks specificity. This does not
make this a useless test, because the purpose of a screening physical is to find disease. This
finding made you consider the associated condition as one of your hypotheses, and this in itself
has value. Other possibilities are that you may be doing the maneuver incorrectly or using it on
the wrong population. It is important to ask for hands-on help from your instructor when you
have a question about a maneuver. Make sure that your information about the maneuver comes
from a reliable source as well. All of this information also applies to history questions.
17. You are growing fatigued of performing a maneuver on examination because you have never
found a positive and are usually pressed for time. How should you next approach this
maneuver?
A) Use this test when you have a higher suspicion for a certain correlating condition.
B) Omit this test from future examinations.
C) Continue doing the test, but rely more heavily on laboratory work and diagnostics.
D) Continue performing it on all future examinations.
Ans: A
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: This is an example of a specific test that lacks sensitivity. With this scenario, when
you finally find a positive, you might be very certain that a given condition is present. We
generally develop our examinations to fit our clinical experiences. Sensitive tests are performed
routinely on the screening examination, while specific tests are usually saved for the detailed or
“branched” examinations. Branched examinations are further maneuvers we can perform to
investigate positive findings on our screening examinations. Save this type of maneuver toconfirm your hypothesis. All of this information also applies to history questions.
18. You have recently returned from a medical missions trip to sub-Saharan Africa, where you
learned a great deal about malaria. You decide to use some of the same questions and maneuvers
in your “routine” when examining patients in the midwestern United States. You are
disappointed to find that despite getting some positive answers and findings, on further workup,
none of your patients has malaria except one, who recently emigrated from Ghana. How should
you next approach these questions and maneuvers?
A) Continue asking these questions in a more selective way.
B) Stop asking these questions, because they are low yield.
C) Question the validity of the questions.
D) Ask these questions of all your patients. [Show Less]