Advanced Health Assessment Midterm Review 2024-2025. All Questions & Answers., Exams of Health sciences

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Advanced Health Assessment Midterm

Review 2024-2025. All Questions &

Answers.

______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 - ansallergic rhinitis 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 - ansHordeolum 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 - ansOtitis 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. A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter's weight. You measure her daughter's height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate? Refer the patient to a nutritionist and a psychologist because the patient is anorexic. Reassure the mother that this is a normal body weight. 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. - ansReassure 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 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 - ansAllergic This description is most consistent with allergic rhinitis. A 17-year-old high school student is brought in to your emergency room in a comatose state. His friends have accompanied him and tell you that they have been 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 - ansPinpoint pupils 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 - ansHead 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 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 - ansSteppage gait 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 - ansInflammatory 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 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? - ansAre 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 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.

• ansGive 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 29-year-old computer programmer comes to your office for evaluation of a headache. The tightening sensation is located all over the head and is of moderate intensity. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours each day at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain but not taken it away. Based on this description, what is your most likely diagnosis? Migraine Cluster Tension Analgesic rebound - ansTension 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 - ansExophthalmos A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30. 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 - ans.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. 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 Postural tremor Intention tremor - ansIntention tremor 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. - ansAbdomen 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 37-year-old woman is brought into your emergency room comatose. The paramedics say her husband found her unconscious in her home. Her past medical history consists of type 1 diabetes and she is on insulin. In the ambulance the paramedics obtained a glucose check and her sugar was 15 (normal is 70 to 105). They began a dextrose saline infusion and intubated her to protect her airway. Despite their efforts, she is posturing in the emergency room with her arms straight at her side and her jaw clenched. Her legs are also straight and her feet are plantar flexed. What type of posturing is she showing? Hemiplegia Decorticate rigidity Decerebrate rigidity Chorea - ansDecerebrate rigidity 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 - ansMigraine 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 - ansPeripheral CN VII paralysis 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 - ansDegenerative 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 48-year-old grocery store manager comes to your clinic, complaining of her head being "stuck" to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot get it moved back to normal. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and

gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is on oral medication for each. She is married and has three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. On examination you see a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left but otherwise her examination is normal. What form of involuntary movemen - ansDystonia A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You elicit the information that the dizziness is a spinning sensation of sudden onset, worse with head position changes. The episodes last a few seconds and then go away, and they are accompanied by intense nausea. She has vomited one time. She denies tinnitus. You perform a physical examination of the head and neck and note that the patient's hearing is intact to Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description, what is the most likely diagnosis? Benign positional vertigo Vestibular neuronitis Ménière's disease Acoustic neuroma - ansBenign positional vertigo 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 - ansMore 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 - ansOne 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. A 67-year-old lawyer comes to your clinic for an annual examination. He denies any history of eye trauma. He denies any visual changes. You inspect his eyes and find a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis? Pterygium Corneal scar Cataracts Corneal arcus - ansPterygium A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type? Tonic-clonic seizure Absence Pseudoseizure Myoclonus - ansAbsence 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 - ansDepression 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. 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 - ansLoss 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 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 - ansParkinson's disease

A 77-year-old retired school superintendent comes to your office, complaining of unsteady hands. He says that for the past 6 months, when his hands are resting in his lap they shake uncontrollably. He says when he holds them out in front of his body the shaking diminishes, and when he uses his hands the shaking is also better. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for over 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister who has arthritis problems. His children are all essentially healthy. On examination you see a fine, pill-ro - ansResting tremor A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom? Reproductive Urinary Cardiac Hematologic - ansCardiac 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. 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 - ansIntention tremor A patient complains of epistaxis. Which other cause should be considered?

Hematemesis Hematoma of the nasal septum Intracranial hemorrhage Intestinal hemorrhage - ansHematemesis 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? Have you injured this knee in the past? When did this first occur? Could you please describe what happened? - ansCould you please describe what happened? When looking into a complaint, it is best to start with an invitation for the patient to tell you in his or her own words. More specific questions should be used later in the interview to fill in any gaps. A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? She can accurately name 20% of the letters at 20 feet. She can see at 20 feet what a normal person could see at 100 feet. She can see at 100 feet what a normal person could see at 20 feet. She obtains a 20% correct score at 100 feet. - ansShe can see at 20 feet what a normal person could see at 100 feet. 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. - ansPush 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. 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 - ansHypertensive retinopathy A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough? Ophthalmologic Auditory Cardiac Endocrine - ansCardiac 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 patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to? Musculoskeletal Reproductive

Urinary Endocrine - ansMusculoskeletal 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. A patient presents with a left-sided facial droop. On further testing, you note that he is unable to wrinkle his forehead on the left and has decreased taste. Which of the following is true? This may be related to travel. This represents a CN IV lesion. This most likely represents a stroke. This represents a central lesion. - ansThis may be related to travel. 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 - ansExternal otitis A patient tells you about her experience with prolonged therapy for her breast cancer. You comment, "That must have been a very trying time for you." What is this an example of? Reassurance Empathy

Summarization Validation - ansValidation This is an example of validation to legitimize her emotional experience. Now that you have had your treatment, you should not have any further troubles is an example of reassurance. I understand what you went through because I am a cancer survivor myself is an example of empathy. So, you have had a lumpectomy and multiple radiation treatments is an example of summarization as applied to this vignette. 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 - ansMetabolic problems 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 - ansOtosclerosis of the left ear A woman experiences syncope after hearing that her son was severely injured. She becomes pale and collapses to the ground without injuring herself. On waking, she states that she feels very warm. She denies any other symptoms. There are no findings on examination. What caused her loss of consciousness? Cardiac arrhythmia Postural hypotension Vasovagal syncope

Micturition syncope - ansVasovagal syncope A young man is concerned about a hard mass he has just noticed in the midline of his palate. On examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis? Kaposi's sarcoma Torus palatinus Leukoplakia Thrush (candidiasis. - ansTorus palatinus 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 - ansChorea 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 - ansAssociated 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. Claire's daughter brings her in today after Claire fell at her home. Which assessments are indicated at this time? Orthostatic vital signs Review of her medications Assessment of gait and balance All of the above - ansAll 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. 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 - ansCough This symptom is more appropriate to the respiratory review of systems. 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 - ansAn irregularity in the cornea or lens

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" - ansA 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. Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination? Cotton wool spots AV nicking Increased cup-to-disc ratio Microaneurysms - ansIncreased cup-to-disc ratio Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and a pulse rate of 120. - ansObjective 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. 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. - ansSubjective This is information given by the patient about the circumstances of his chief complaint. It does not represent an objective observation by the examiner. It is summer and an 82-year-old woman is brought to you from her home after seeing her primary care doctor 2 days ago. She was started on an antibiotic at that time. Today, she comes to the emergency room not knowing where she is or what year it is. What could be a likely cause of this?

Alzheimer's dementia Stroke Delirium Meningitis - ansDelirium These are not signs of normal aging and seem to be of acute onset. This makes Alzheimer's less likely. Stroke and meningitis could 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 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. 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 Associated manifestations - ansSeverity 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. 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 - ansInfection 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? Write the physical therapy prescription. Have your office staff explain directions to the physical therapy center. Discuss the plan with Mr. Larson. Tell Mr. Larson that he will be going to physical therapy three times a week. - ansDiscuss the plan with Mr. Larson. 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. 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? - ansWhen 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. 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? Echoing Nonverbal communication Facilitation Empathic response - ansFacilitation This is an example of facilitation. Facilitation can be posture, actions, or words that encourage the patient to say more. 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? Alzheimer's dementia Alcohol use Urinary tract infection Stroke - ansAlcohol use 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. 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?

Palpation of her temples Dental referral Ultrasound of the gallbladder Inquiry about anosmia - ansPalpation of her temples This story can be consistent with temporal arteritis, which can cause blindness in 15% 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. Mrs. H. comes to your clinic, wanting antibiotics for a sinus infection. When you enter the room, she appears to be very angry. She has a raised tone of voice and states that she has been waiting for the past hour and has to get back to work. She states that she is unimpressed by the reception staff, the nurse, and the clinic in general and wants to know why the office wouldn't call in an antibiotic for her. Which of the following techniques is not useful in helping to calm this patient? Avoiding admission that you had a part in provoking her anger because you were late Accepting angry feelings from the patient and trying not to get angry in return Staying calm Keeping your posture relaxed - ansAvoiding 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. Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and doesn't say anything in response to your question. This is an example of which type of challenging patient? Talkative patient Angry patient

Silent patient Hearing-impaired patient - ansSilent patient This is one example of a silent patient. There are many possibilities for this patient's silence: depression, dementia, the manner in which you asked the question, and so on. Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular provider is on vacation and she wanted to be seen. You have heard about her many times from your colleague and are aware that she is a very talkative person. Which of the following is a helpful technique to improve the quality of the interview for both the provider and the patient? Allow the patient to speak uninterrupted for the duration of the appointment. Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you. Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview. Allow your impatience to show so that the patient picks up on your nonverbal cue that the appointment needs to end. - ansBriefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you. You can also say, I want to make sure I take good care of this problem because it is very important. We may need to talk about the others at the next appointment. Is that okay with you? This is a technique that can help you to change the subject but, at the same time, validate the patient's concerns; it also can provide more structure to the interview. 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: Pathophysiologic problem Psychopathologic problem - ansPathophysiologic problem 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.

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. - ansAsk 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. 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 - ansGlaucoma 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. 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,