Advanced Health Assessment Midterm Review Q&A…., Exams of Nursing

Download Advanced Health Assessment Midterm Review Q&A…. and more Exams Nursing in PDF only on Docsity! Advanced Health Assessment Midterm Review Q&A…. For which of the following patients would a comprehensive health history be appropriate? A new patient with the chief complaint of "I sprained my ankle" An established patient with the chief complaint of "I have an upper respiratory infection" A new patient with the chief complaint of "I am here to establish care" A new patient with the chief complaint of "I cut my hand" - CORRECT ANSWER --A new patient with the chief complaint of "I am here to establish care" This patient is here to establish care, and because she is new to you, a comprehensive health history is appropriate. The components of the health history include all of the following except which one? Review of systems Thorax and lungs Present illness Personal and social items - CORRECT ANSWER --Thorax and lungs 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. 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. - CORRECT ANSWER --Subjective This is information given by the patient about the circumstances of his chief complaint. It does not represent an objective observation by the examiner. Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and a pulse rate of 120. - CORRECT ANSWER -- Objective 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. 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? Chief complaint Present illness Personal and social history Review of systems - CORRECT ANSWER --Present illness 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. 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? Chief complaint Present illness Personal and social history Review of systems - CORRECT ANSWER --Personal and social history 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. The following information is recorded in the health history: "I feel really tired." Which category does it belong to? Chief complaint Present illness Personal and social history Review of systems - CORRECT ANSWER --Chief complaint A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough? Ophthalmologic Auditory Cardiac Endocrine - CORRECT ANSWER --Cardiac 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. 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? Infectious Inflammatory Hematologic Traumatic - CORRECT ANSWER --Inflammatory 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. 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? Infectious Neoplastic Degenerative Traumatic - CORRECT ANSWER --Degenerative 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. 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? Infection Inflammation Allergic Vascular - CORRECT ANSWER --Allergic This description is most consistent with allergic rhinitis. 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? Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range of motion Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle spasm and limited range of motion to the right Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full range of motion - CORRECT ANSWER --Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion 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. 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? Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses. Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or guarding. 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. Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or guarding. - CORRECT ANSWER --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. 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. 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: One disease process More than one disease process - CORRECT ANSWER --More than one disease process 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. 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: One disease process More than one disease process - CORRECT ANSWER --One disease process 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. correlate with the finding. This same experience happens several times. What should you conclude? Consider not doing this test routinely. Use this test when you have a higher suspicion for a certain correlating condition. Continue using the test, perhaps doing less laboratory work and diagnostics. Omit this test from future examinations. - CORRECT ANSWER --Continue using the test, perhaps doing less laboratory work and diagnostics. 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. 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? Use this test when you have a higher suspicion for a certain correlating condition. Omit this test from future examinations. Continue doing the test, but rely more heavily on laboratory work and diagnostics. Continue performing it on all future examinations. - CORRECT ANSWER --Use this test when you have a higher suspicion for a certain correlating condition. 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. 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? Continue asking these questions in a more selective way. Stop asking these questions, because they are low yield. Question the validity of the questions. Ask these questions of all your patients. - CORRECT ANSWER --Continue asking these questions in a more selective way. 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. 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? Irritability Impatience Boredom Calm - CORRECT ANSWER --Calm The appearance of calmness and patience, even when time is limited, is the hallmark of a skilled interviewer. 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? Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story. Invite the patient's story, negotiate a plan, establish the agenda, and establish rapport. Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan. Negotiate a plan, establish an agenda, invite the patient's story, and establish rapport. - CORRECT ANSWER --Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan. 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. 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? Setting in which the symptom occurs Associated manifestations Quality Timing - CORRECT ANSWER --Associated manifestations 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. 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? Severity Setting in which the symptom occurs Timing Staying calm Keeping your posture relaxed - CORRECT ANSWER --Avoiding admission that you had a part in provoking her anger because you were late In this scenario, the provider was 1 hour late in seeing the patient. The provider should acknowledge that he was late and apologize for this, no matter the reason for being late. It often helps to acknowledge that a patient's anger with you is understandable and that you might be angry in a similar situation. A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge. As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information? Are you sexually active? When was the last time you had intimate physical contact with someone, and did that contact include sexual intercourse? Do you have sex with men, women, or both? How many sexual partners have you had in the last 6 months? - CORRECT ANSWER --Are you sexually active? This is inappropriate because it is too vague. Given the complaint, you should probably assume that he is sexually active. Sometimes patients may respond to this question with the phrase No, I just lie there. A specific sexual history will help you to assess this patient's risk for other sexually transmitted infections Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has come to the office many times in the past with a variety of injuries, and you suspect that he has a problem with alcohol. Which one of the following questions will be most helpful in diagnosing this problem? You are an alcoholic, aren't you? When was your last drink? Do you drink 2 to 3 beers every weekend? Do you drink alcohol when you are supposed to be working? - CORRECT ANSWER --When was your last drink? This is a good opening question that is general and neutral in tone; depending on the timing, you will be able to ask for more specific information related to the patient's last drink. The others will tend to stifle the conversation because they are closed- ended questions. Answer D implies negative behavior and may also keep the person from sharing freely with you. On a very busy day in the office, Mrs. Donelan, who is 81 years old, comes for her usual visit for her blood pressure. She is on a low-dose diuretic chronically and denies any side effects. Her blood pressure is 118/78 today, which is well-controlled. As you are writing her script, she mentions that it is hard not having her husband Bill around anymore. What would you do next? Hand her the script and make sure she has a 3-month follow-up appointment. Make sure she understands the script. Ask why Bill is not there. Explain that you will have more time at the next visit to discuss this. - CORRECT ANSWER --Ask why Bill is not there. Sometimes, the patient's greatest need is for support and empathy. It would be inappropriate to ignore this comment today. She may have relied heavily upon Bill for care and may be in danger. She may be depressed and even suicidal, but you will not know unless you discuss this with her. Most importantly, you should empathize with her by saying something like It must be very difficult not to have him at home and allow a pause for her to answer. You may also ask What did you rely on him to do for you? Only a life-threatening crisis with another patient should take you out of her room at this point, and you may need to adjust your office schedule to allow adequate time for her today. A patient is describing a very personal part of her history very quickly and in great detail. How should you react to this? Write down as much as you can, as quickly as possible. Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every word. Tell her that she can go over the notes later to make sure they are accurate. Push away from the keyboard or put down your pen and listen. - CORRECT ANSWER --Push away from the keyboard or put down your pen and listen. This is a common event in clinical practice. It is much more important to listen actively with good eye contact at this time than to document the story verbatim. You want to minimize interruption (e.g., answer B). It is usually not appropriate to ask a patient to go over the written notes, but it would be a good idea to repeat the main ideas back to her. You should be certain she has completed her story before doing this. By putting down your pen or pushing away from the keyboard, you let the patient know that her story is the most important thing to you at this moment. You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire right side. She cannot speak (aphasia). You are supposed to examine her. You notice that the last examiner left her socks at the bottom of the bed, and although sensitive areas are covered by a sheet, the blanket is heaped by her feet at the bottom of the bed. What would you do next? Carry out your examination, focusing on the neurologic portion, and then cover her properly. Carry out your examination and let the nurse assigned to her "put her back together." Put her socks back on and cover her completely before beginning the evaluation. Apologize for the last examiner but let the next examiner dress and cover her. - CORRECT ANSWER --Put her socks back on and cover her completely before beginning the evaluation. It is crucial to make an effort to make a patient comfortable. In this scenario, the patient can neither speak nor move well. Take a moment to imagine yourself in her situation. As a matter of respect as well as comfort, you should cover the patient appropriately and consider returning a little later to do your examination if you feel she is cold. While it is her nurse's job to keep her comfortable, it is also your responsibility, and you should do what you can. It is unacceptable to leave the patient in the same state in which you found her. When you enter your patient's examination room, his wife is waiting there with him. Which of the following is most appropriate? Ask if it's okay to carry out the visit with both people in the room. Carry on as you would ordinarily. The permission is implied because his wife is in the room with him. Ask his wife to leave the room for reasons of confidentiality. First ask his wife what she thinks is going on. - CORRECT ANSWER --Ask if it's okay to carry out the visit with both people in the room. Even in situations involving people very familiar with each other, it is important to respect individual privacy. There is no implicit consent merely because he has allowed his wife to be in the room with him. On the other hand, it is inappropriate to assume that his wife should leave the room. Remember, the patient is the focus of the visit, so it would be appropriate to allow him to control who is in the room with him and inappropriate to address his wife first. Although your duty is to the patient, you may get optimal information by offering to speak to both people confidentially. This situation is analogous to an adolescent's visit. A patient complains of knee pain on your arrival in the room. What should your first sentence be after greeting the patient? How much pain are you having? Give the patient information about exercise because the patient is obese. Give the patient information concerning reduction of fat and cholesterol in her diet because she is obese. - CORRECT ANSWER --Reassure the mother that this is a normal body weight. The patient has a normal BMI; the range for a normal BMI is 18.5 to 24.9 kg/m2. You may be able to give the patient and her mother the lower limit of normal in pounds for her daughter's height, or instruct her in how to use a BMI table. A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit? Refer the patient to a nutritionist because he is anorexic. Reassure the patient that he has a normal body weight. Give the patient information about reduction of fat, cholesterol, and calories because he is overweight. Give the patient information about reduction of fat and cholesterol because he is obese. - CORRECT ANSWER --Give the patient information about reduction of fat, cholesterol, and calories because he is overweight. The patient has a BMI in the overweight range, which is 25.0 to 29.9 kg/m2. It is prudent to give him information about reducing calories, fat, and cholesterol in his diet to help prevent further weight gain. A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30.0 kg/m2. What is the most appropriate amount for a weekly weight reduction goal? .5 to 1 pound per week 1 to 2.5 pounds per week 2.5 to 3.5 pounds per week 3.5 to 4.5 pounds per week - CORRECT ANSWER --.5 to 1 pound per week Based on the NIH Obesity Guidelines, this is the weekly weight loss goal to strive for to maintain long-term control of weight. More rapid weight loss than this does not result in a better outcome at one year. Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except: Changes in weight Fatigue and weakness Cough Fever and chills - CORRECT ANSWER --Cough This symptom is more appropriate to the respiratory review of systems. You are beginning the examination of a patient. All of the following areas are important to observe as part of the General Survey except: Level of consciousness Signs of distress Dress, grooming, and personal hygiene Blood pressure - CORRECT ANSWER --Blood pressure Blood pressure is a vital sign, not part of the General Survey A 15-month-old is brought to you for a fever of 38.6 degrees Celsius and fussiness. The ear examination is as follows: external ear, normal appearance and no tenderness with manipulation; canal, normal diameter without evidence of inflammation; tympanic membrane, bulging, erythematous, and opaque. Insufflation is deferred due to pain. What is your diagnosis? Otitis externa Cholesteatoma Ruptured tympanic membrane Otitis media - CORRECT ANSWER --Otitis media There is no inflammation of the outer ear, including the canal, thus excluding otitis externa. Cholesteatoma is a painless white lesion behind the TM. There is no drainage from the TM; thus, rupture is unlikely. This is a classic description of otitis media. Many examiners will forego insufflation if the diagnosis is clear, because this can cause discomfort in an already uncomfortable ear. Which of the following changes are expected in vision as part of the normal aging process? Cataracts Glaucoma Macular degeneration Blurring of near vision - CORRECT ANSWER --Blurring of near vision The lens loses its elasticity over time as part of the normal aging process, and the eye is less able to accommodate and focus on near objects; therefore, the patient will be expected to have blurring of near vision. A 72-year-old retired truck driver comes to the clinic with his wife for evaluation of hearing loss. He has noticed some decreased ability to hear what his wife and grandchildren are saying to him. He admits to lip-reading more. He has a history of noise exposure in his young adult years: He worked as a sound engineer at a local arena and had to attend a lot of concerts. Based on this information, what is the most likely finding regarding his hearing acuity? Loss of acuity for middle-range sounds Increase of acuity for low-range sounds Loss of acuity for high-range sounds Increase of acuity for high-range sounds - CORRECT ANSWER --Loss of acuity for middle-range sounds Human speech is considered to be a middle-range sound. During the aging process there is a loss of acuity, starting with high-pitched sounds but extending to the middle range and then into the low range. A 70-year-old retired auto mechanic comes to your office because his neighbor is concerned about his memory. The patient himself admits to misplacing his keys more often and forgets what he is supposed to buy from the grocery store and where he has parked the car. He denies getting lost in familiar places. Upon further questioning, he states that his wife of 40 years died 8 months ago; his three children live in three different states; and he has limited his activities because the people he interacted with were "his wife's friends, not his." He drinks a six-pack of beer daily; he does not smoke or use illicit drugs. You perform a mini-mental state examination and obtain a total score of 24 out of 28. Based on this information, what is your most likely diagnosis? Benign forgetfulness Dementia Meningitis Depression - CORRECT ANSWER --Depression The patient has symptoms of depression: His wife died, he has no real social support system, and he has isolated himself from his usual activities. He also drinks a considerable amount of alcohol on a daily basis, which can further depress his mood. Depression can masquerade as dementia in the elderly and must be considered in a patient with memory loss. Orthostatic vital signs Review of her medications Assessment of gait and balance All of the above - CORRECT ANSWER --All of the above 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 vital sign changes should be sought. 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? Macular degeneration Diabetic retinopathy Hypertensive retinopathy Glaucoma - CORRECT ANSWER --Glaucoma 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. A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely? Otitis media of the right ear Exposure to chronic loud noise of the right ear Perforation of the right eardrum Otosclerosis of the left ear - CORRECT ANSWER --Otosclerosis of the left ear A patient complains of epistaxis. Which other cause should be considered? Hematemesis Hematoma of the nasal septum Intracranial hemorrhage Intestinal hemorrhage - CORRECT ANSWER --Hematemesis A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? Xanthelasma Hordeolum Dacryocystitis Chalazion - CORRECT ANSWER --Hordeolum Which area of the fundus is the central focal point for incoming images? The optic disk The macula The fovea The physiologic cup - CORRECT ANSWER --The fovea A 38-year-old accountant comes to your clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region and is an 8 on a scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic and this results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache? Tension Analgesic rebound Migraine Cluster - CORRECT ANSWER --Migraine Which of the following is a "red flag" regarding patients presenting with headache? Phonophobia and photophobia Pain over the sinuses Unilateral headache Age over 50 - CORRECT ANSWER --Age over 50 A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient? External otitis Cholesteatoma Perforation of the tympanum Otitis media - CORRECT ANSWER --External otitis A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? Exophthalmos Ectropion Epicanthus Ptosis - CORRECT ANSWER --Exophthalmos A 73-year-old nurse comes to your office for evaluation of new onset of tremors. She is not on any medications and does not take herbs or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow movements and shuffling steps. She has decreased facial mobility and a blunt expression, without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the patient's symptoms? Myxedema Parkinson's disease Nephrotic syndrome Cushing's syndrome - CORRECT ANSWER --Parkinson's disease Corneal scar Cataracts Corneal arcus - CORRECT ANSWER --Pterygium A patient is examined with the ophthalmoscope and found to have red reflexes bilaterally. Which of the following have you essentially excluded from your differential? Hypertensive retinopathy Retinoblastoma Cataract Artificial eye - CORRECT ANSWER --Hypertensive retinopathy Diplopia, which is present with one eye covered, can be caused by which of the following problems? Weakness of CN IV Weakness of CN III An irregularity in the cornea or lens A lesion of the brainstem - CORRECT ANSWER --An irregularity in the cornea or lens You feel a small mass that you think is a lymph node. It is mobile in both the up-and- down and side-to-side directions. Which of the following is most likely? Cancer Lymph node Muscle Deep scar - CORRECT ANSWER --Lymph node You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward. This is most likely a problem with which part of the nervous system? Dorsal root ganglion Spinothalamic tract Thalamus Corticospinal tract - CORRECT ANSWER --Corticospinal tract A patient with alcoholism is brought in with confusion. You ask him to "stop traffic" with his palms and notice that every few seconds his palms suddenly move toward the floor. What does this indicate? Stroke Carpal tunnel syndrome Metabolic problems Severe fatigue and weakness - CORRECT ANSWER --Metabolic problems A 41-year-old real estate agent comes to your office, complaining that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy and as the day progressed he was unable to close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. His past medical history is unremarkable. He is divorced and has one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination you ask him to close his eyes. He is unable to close his left eye. You ask him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. You then ask him to give you a big smile. The right corner of his mouth raises but the left side of his m - CORRECT ANSWER --Peripheral CN VII paralysis A patient comes to you because she is experiencing a tremor only when she reaches for things. This becomes worse as she nears the "target." When you ask her to hold out her hands, no tremor is apparent. What type of tremor does this most likely represent? Intention tremor Nervous tremor Postural tremor Resting tremor - CORRECT ANSWER --Intention tremor A 21-year-old engineering student comes to your office, complaining of leg and back pain and of tripping when he walks. He states this started 3 months ago with back and buttock pain but has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific traumatic incidences but he was a defensive lineman in high school and junior college. His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy. On examination he is tender over the lumbar spine and he has a positive straight-leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching his gait you notice he has to pick his left foot up high in order not to trip. What abnormality of gait does he most likely have? Parkinsonian gait Steppage gait Spastic hemiparesis Sensory ataxia - CORRECT ANSWER --Steppage gait A young woman comes in with brief, rapid, jerky, irregular movements. They can occur at rest or during other intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements? Athetosis Tics Dystonia Chorea - CORRECT ANSWER --Chorea You are testing the biceps strength in a young man following a spinal trauma from a motor vehicle accident. He cannot lift his hand upward, but if the arm is abducted to 90 degrees, he can then move his forearm side to side. This would represent which muscle strength grading? IV III II I - CORRECT ANSWER --II A 37-year-old insurance agent comes to your office, complaining of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn't feel particularly nervous when this occurs but she worries that other people will think she has an anxiety disorder or that she's a drinker. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married and has three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form she has obvious tremors in her dominant hand. What type of tremor is she most likely to have? Resting tremor shooting up heroin tonight and they think their friend may have had too much. The patient is unconscious and cannot protect his airway, so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. Preparing to finish the neurologic examination, you get a penlight. What size pupils do you expect to see in this comatose patient? Asymmetric pupils Irregularly shaped pupils Pinpoint pupils Large pupils - CORRECT ANSWER --Pinpoint pupils You examine a "sleepy" patient. You note that she will open her eyes and look at you but responds slowly and is confused. She does not appear interested in her surroundings. How would you describe her level of consciousness? Comatose Lethargic Stuporous Obtunded - CORRECT ANSWER --Obtunded You are examining a child with severe cerebral palsy. When you suddenly move his foot dorsally, a sustained "beating" of the foot against your hand ensues. What does this represent? A focal seizure Reinforcement Clonus Extinction - CORRECT ANSWER --Clonus Jim is an HIV-positive patient who complains about back pain in addition to several other problems. On percussion, there is slight tenderness over the T7 vertebrae, and when you flex his thigh to 90 degrees and extend his lower legs, you meet strong resistance at about 45 degrees of extension. What are likely causes of this constellation of symptoms? Medication side effect Malingering Infection Fractured vertebrae - CORRECT ANSWER --Infection You are conducting a mental status examination and note impairment of speech and judgement, but the rest of your examination is intact. Where is the most likely location of the problem? Cerebellum Cerebrum Brainstem Basal ganglia - CORRECT ANSWER --Cerebrum Which of the following is true about hallucinations? experiences may or may not be recognized by the person as false Hallucinations may be auditory, visual, olfactory, gustatory, tactile or somatic Do not include false perceptions associated with dreaming and falling asleep All of the above - CORRECT ANSWER --All of the above ______is an allergic inflammation of the nasal airways. It occurs when an allergen, such as pollen, dust or animal dander is inhaled by an individual with a sensitized immune system. In such individuals; the allergen triggers the production of the antibody immunoglobulin E (IgE), which binds to mast cells and basophils containing histamine. allergic rhinitis decompensation deficiency degeneration - CORRECT ANSWER --allergic rhinitis