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Exam (elaborations) TEST BANK BATES GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING 11TH EDITION
A) A new patient with the chief complaint of “I sprained my ankle”
B) An established patient with the chief complaint of “I have an upper respiratory
infection”
C) A new patient with the chief complaint of “I am here to establish care”
D) A new patient with the chief complaint of “I cut my hand”
Ans: C
Feedback:
This patient is here to establish care, and because she is new to you, a comprehensive
health history is appropriate.
2. The components of the health history include all of the following except which one?
A) Review of systems
B) Thorax and lungs
C) Present illness
D) Personal and social items
Ans: B
Feedback:
The thorax and lungs are part of the physical examination, not part of the health
history. The others answers are all part of a complete health history.
3. Is the following information subjective or objective?
Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with
activity and relieved by rest.
A) Subjective
B) Objective
Ans: A
Feedback:
This is information given by the patient about the circumstances of his chief
complaint. It does not represent an objective observation by the examiner.
4. Is the following information subjective or objective?
Mr. M. has a respiratory rate of 32 and a pulse rate of 120.
A) Subjective
B) Objective
Ans: B
Feedback:
This is a measurement obtained by the examiner, so it is considered objective data.
The patient is unlikely to be able to give this information to the examiner.
5. The following information is recorded in the health history: “The patient has had
abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and
goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and
vomiting. It is located in the mid-epigastric area.”
Which of these categories does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: B
Feedback:
This information describes the problem of abdominal pain, which is the present
illness. The interviewer has obtained the location, timing, severity, and associated
manifestations of the pain. The interviewer will still need to obtain information
concerning the quality of the pain, the setting in which it occurred, and the factors
that aggravate and alleviate the pain. You will notice that it does include portions of
the pertinent review of systems, but because it relates directly to the complaint, it is
included in the history of present illness.
6. The following information is recorded in the health history: “The patient completed
8th grade. He currently lives with his wife and two children. He works on old cars on
the weekend. He works in a glass factory during the week.”
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: C
Feedback:
Personal and social history information includes educational level, family of origin,
current household status, personal interests, employment, religious beliefs, military
history, and lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/
or drugs; and sexual preferences and history). All of this information is documented
in this example.
7. The following information is recorded in the health history: “I feel really tired.”
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: A
Feedback:
The chief complaint is an attempt to quote the patient's own words, as long as they
are suitable to print. It is brief, like a headline, and further details should be sought in
the present illness section. The above information is a chief complaint.
8. The following information is recorded in the health history: “Patient denies chest
pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea.”
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: D
Feedback:
Review of systems documents the presence or absence of common symptoms related
to each major body system. The absence of cardiac symptoms is listed in the above
example.
9. The following information is best placed in which category?
“The patient has had three cesarean sections.”
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: B
Feedback:
A cesarean section is a surgical procedure. Approximate dates or the age of the
patient at the time of the surgery should also be recorded.
10. 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
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 has never been intubated.”
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A
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.
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
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
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
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) Infectious
B) Inflammatory
C) Hematologic
D) Traumatic
Ans: B
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
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: C
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
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
Feedback:
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
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
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
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
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 problem
Ans: B
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
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
Feedback:
The problem list should have the most active and serious problem first. This new
complaint 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
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
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 to confirm 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.
Ans: A
Feedback:
The predictive value of a positive finding depends upon the prevalence of a given
disease in a population. The prevalence of malaria in the Midwest is almost zero,
except in people immigrating from areas of high prevalence. You will waste time and
resources applying these questions and maneuvers to all patients. It would be wise to
continue applying what you learned to those who are from areas of high prevalence
of a given disease. Likewise, physicians from Ghana should not ask about signs or
symptoms of multiple sclerosis, as it is found almost exclusively in northern
latitudes. You will learn to tailor your examination to the population you are serving.
1. You are running late after your quarterly quality improvement meeting at the hospital
and have just gotten paged from the nurses' station because a family member of one
of your patients wants to talk with you about that patient's care. You have clinic this
afternoon and are double-booked for the first appointment time; three other patients
also have arrived and are sitting in the waiting room. Which of the following
demeanors is a behavior consistent with skilled interviewing when you walk into the
examination room to speak with your first clinic patient?
A) Irritability
B) Impatience
C) Boredom
D) Calm
Ans: D
Feedback:
The appearance of calmness and patience, even when time is limited, is the hallmark
of a skilled interviewer.
2. Suzanne, a 25 year old, comes to your clinic to establish care. You are the student
preparing to go into the examination room to interview her. Which of the following is
the most logical sequence for the patient–provider interview?
A) Establish the agenda, negotiate a plan, establish rapport, and invite the patient's
story.
B) Invite the patient's story, negotiate a plan, establish the agenda, and establish
rapport.
C) Greet the patient, establish rapport, invite the patient's story, establish the agenda,
expand and clarify the patient's story, and negotiate a plan.
D) Negotiate a plan, establish an agenda, invite the patient's story, and establish
rapport.
Ans: C
Feedback:
This is the most productive sequence for the interview. Greeting patients and
establishing rapport allows them to feel more comfortable before “inviting” them to
relate their story. After hearing the patient's story, together you establish the agenda
regarding the most important items to expand upon. At the end, together you
negotiate the plan of diagnosis and treatment.
3. Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The
pain is a dull ache, located in the right upper quadrant, that she rates as a 3 at the least
and an 8 at the worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a
time, it comes and goes, and it seems to be worse a couple of hours after eating. She
has noticed that it starts after eating greasy foods, so she has cut down on these as
much as she can. Initially it occurred once a week, but now it is occurring every other
day. Nothing makes it better. From this description, which of the seven attributes of a
symptom has been omitted?
A) Setting in which the symptom occurs
B) Associated manifestations
C) Quality
D) Timing
Ans: B
Feedback:
The interviewer has not recorded whether or not the pain has been accompanied by
nausea, vomiting, fever, chills, weight loss, and so on. Associated manifestations are
additional symptoms that may accompany the initial chief complaint and that help the
examiner to start refining his or her differential diagnosis.
4. Jason is a 41-year-old electrician who presents to the clinic for evaluation of
shortness of breath. The shortness of breath occurs with exertion and improves with
rest. It has been going on for several months and initially occurred only a couple of
times a day with strenuous exertion; however, it has started to occur with minimal
exertion and is happening more than a dozen times per day. The shortness of breath
lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain,
swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea.
Which of the following symptom attributes was not addressed in this description?
A) Severity
B) Setting in which the symptom occurs
C) Timing
D) Associated manifestations
Ans: A
Feedback:
The severity of the symptom was not recorded by the interviewer, so we have no
understanding as to how bad the symptom is for this patient. The patient could have
been asked to rate his pain on a 0 to 10 scale or used one of the other standardized
pain scales available. This allows the comparison of pain intensity before and after
an intervention.
5. You are interviewing an elderly woman in the ambulatory setting and trying to get
more information about her urinary symptoms. Which of the following techniques is
not a component of adaptive questioning?
A) Directed questioning: starting with the general and proceeding to the specific in a
manner that does not make the patient give a yes/no answer
B) Reassuring the patient that the urinary symptoms are benign and that she doesn't
need to worry about it being a sign of cancer
C) Offering the patient multiple choices in order to clarify the character of the urinary
symptoms that she is experiencing
D) Asking her to tell you exactly what she means when she states that she has a
urinary tract infection
Ans: B
Feedback:
Reassurance is not part of clarifying the patient's story; it is part of establishing
rapport and empathizing with the patient.
6. Mr. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to
be checked out for the symptom of chest pain. As you listen to him describe his
symptom in more detail, you say “Go on,” and later, “Mm-hmmm.” This is an
example of which of the following skilled interviewing techniques?
A) Echoing
B) Nonverbal communication
C) Facilitation
D) Empathic response
Ans: C
Feedback:
This is an example of facilitation. Facilitation can be posture [Show Less]