Real Estate Law Mid Term Exam |LATEST VERSION |NEW UPDATE |GUARANTEED PASS|2024- 2025, Exams of Insurance law

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Mid Term Exam |LATEST VERSION |NEW

UPDATE |GUARANTEED PASS|2024-

Which of the following Ohio licensees are allowed to work independently with no supervision?

• ANSWER Brokers All documentation related to an Ohio complaint, a complaint investigation, or any hearings resulting from the complaint must be sent ______.
  • ANSWER Via certified mail The Martins hired Janice to be their buyer's agent. Leaving their first property showing, the trio notices a property down the street with a for sale sign in the yard. Since the Martins are already here, they'd like to see that house, too. What's the best action to take?
  • ANSWER You should call the number on the sign to schedule a showing. If the Ohio real estate superintendent determines that a complaint has merit, what's the next step in the process?
• ANSWER Schedule a hearing. Five consumers won a judgment against an Ohio licensee for a total of $55,000. The consumers each applied to the recovery fund. How will they be paid?
  • ANSWER Consumers are paid in a ratio proportional to their losses. Which federal courts are known as the appellate courts?
  • ANSWER Circuit courts When you're putting together a listing presentation, which of these is a key point to address?
• ANSWER Buyers won't pay more for a home than the market dictates. ow are Ohio Real Estate Commission members selected?
  • ANSWER Appointed by the governor James, a seller, signed a listing agreement that allowed him to contract with multiple agents but only pay a commission to the agent who located a buyer. This type of listing agreement is called ______.
  • ANSWER Open Which of the listing agreements is the least exclusive?
  • ANSWER Open listing

In which type of listing agreement does a seller contract with one listing agent but reserve the right to locate the buyer and only pay the listing agent if an agent locates the buyer?

• ANSWER Exclusive agency Which of the following is true about positive misrepresentation?
• ANSWER A principal was harmed by the misstatement. After determining an ethical dilemma exists and evaluating the situation, what's the next step to handling the situation?
• ANSWER Explore the ethical choices. Darnell has been appointed an ancillary trustee for Hometown Realty in Ohio. Which of the following is a true statement?
• ANSWER He must withdraw all advertising. When the Ohio Division of Real Estate and Professional Licensing conducts a random audit, one of the things that will be reviewed is whether or not trust account records are maintained in a specific, required format. What format is required?
• ANSWER Columnar How long should you retain records?
• ANSWER You should maintain all transactional records for at least the period of time that your regulatory agency requires. Which of the following do an Ohio salesperson, an individual broker, and a corporate broker have in common?
• ANSWER Each is considered a licensee Jana has no experience in real estate, but just passed her Ohio salesperson's license exam. Which of the following is true about Jana's license?
• ANSWER Jana must be affiliated with a broker to get an active license. How will Ohio licensees find out when their licenses are up for renewal?
• ANSWER The superintendent will mail a notice of renewal. You work for XYZ Realty under the supervision of broker Luke. Your buddy in the next county gave you a referral fee. The check came to your office in your name. You deposit it. Is this okay?
• ANSWER No, because all compensation must come through your broker. Davidson Real Estate is an Ohio brokerage. Normal business hours are Tuesday through Sunday from 9 a.m. until 6 p.m. An audit is scheduled for 11 a.m. on Thursday. What is the broker expected to do?
• ANSWER Cooperate with the audit and give the auditor access to the items being audited.

Boy, have these last 18 years flown by. The Martins remember the day their son was born like it was yesterday. And here he is today, preparing to head off to college. Now that he'll be out of the house soon, the Martins really don't need a house this large. What type of buyer are the Martins?

• ANSWER Trade-down buyers Which phrase from the following description should be edited to meet fair housing guidelines? "These high-rise buildings are nestled along the Loring Greenway, which connects pedestrians to the Nicollet Mall and the riverfront. The location is exceptionally convenient for families, within an easy walk of downtown, Orchestra Hall, the Hennepin theater district, Walker Art Center, the Sculpture Garden, and numerous restaurants at all price levels. The neighborhood is well-served by bus routes."
• ANSWER "The location is exceptionally convenient for families" According to NAR's Code of Ethics, what responsibility do licensees have related to material facts?
• ANSWER Make a reasonable effort to ascertain all material facts concerning each property for which an agency is accepted If an Ohio partnership submits a broker's license application, what must it include? - ANSWER The names of all partners Ohio licensee Josie receives five offers for her seller client, Kali's, property. Which of the following is true of this situation?
• ANSWER She should present all the offers. Chester has been providing some real estate services for new buyer customer Tom. Which of these is a task that Chester may only perform if he signs an agency agreement with Tom?
• ANSWER Suggest negotiation terms for a listing Tom would like to buy. Who would apply for a foreign real estate license?
• ANSWER A licensee from another state or jurisdiction who wants to sell out-of-state real estate in Ohio Which of the following agency type is rarely seen in Ohio?
• ANSWER Sub-agent Byron placed his Ohio salesperson license on deposit when he joined the Air Force. Following discharge from the military, when does Byron need to renew his license, if he so chooses?
• ANSWER His first birthday following discharge. Which law source is actually a legal interpretation of other sources of law? - ANSWER Case law

What must a nonresident commercial broker have in order to participate in an Ohio commercial transaction?

• ANSWER Partnership with an Ohio broker Which federal courts are known as the trial courts?
• ANSWER District courts n this description, which protected class is shown as a preference or discrimination? "Because of its location next to downtown (especially to the County Medical Center), Berglund Park neighborhood has been growing in population and becoming younger in age. The neighborhood's average income is lower than the citywide average, reflecting the senior housing, but this is improving as new families move into the area." - ANSWER Seniors are discriminated against and families are preferred. Tristan refused to let Marla list his property on the MLS, even though Marla told him that more exposure to the property would generate more potential buyers. Which two fiduciary duties are at odds in this situation?
• ANSWER Reasonable skill and care and obedience Marie's brokerage relationship with the Clarks has terminated. She has some paperwork she needs to send to them. When she provides this paperwork to them, what is this an example of?
• ANSWER Accounting A complaint against which of the following Ohio professionals would be handled by the division of real estate?
• ANSWER Real estate salesperson Maryjean placed her Ohio license on inactive status with the division of real estate while she dealt with some personal issues. When she finally completed all requirements for reactivation, the superintendent denied her reactivation application. What's the most likely reason why?
• ANSWER Maryjean was convicted of a felony while her license was inactive. Paulo is a property manager for several large properties. Which type of agent is he in relation to the landlord/client?
• ANSWER General Jeb's listing agreement expires on November 5. What does he need to do to terminate this agreement?
• ANSWER Nothing. It automatically expires on November 5. It's Friday afternoon, and Lori can't make it to the bank in time to deposit an earnest money check in the brokerage's escrow account, so she uses her mobile app to deposit

it into her personal checking account for safekeeping. What violation did Lori just commit?

• ANSWER Commingling You represent April, the seller, who is your Uncle Clyde's girlfriend. You receive an offer from Barry on behalf of a prospective buyer. Whose interests do you represent, and in what order?
  • ANSWER Only April's After determining that an ethical dilemma exists, what's the next step you should take? - ANSWER Evaluate the situation. Who's required to take 10 hours of post-license education during their first year after getting an initial Ohio real estate license?
  • ANSWER Brokers In Ohio, under what conditions must an inducement be disclosed in the purchase contract?
  • ANSWER When they're offered to motivate buyers and sellers to enter into a purchase contract Which of the following occurs when an Ohio licensee buys a principal's property without disclosing it to the principal?
• ANSWER Self-dealing Which of the following actions should be taken when holding an open house? - ANSWER Schedule the open house soon after the property hits the market. Identifying properties being sold by owners and persuading them to list with a licensee describes the ______ approach to finding listings.
  • ANSWER Owner sales Ohio trust account records must be maintained for ______, and failure to do so is reason for disciplinary action.
• ANSWER Three years As an ancillary trustee in Ohio, which of the following activities can Carl perform? - ANSWER Complete all real estate transactions already in progress. Which of the following best describes the Ohio Real Estate Commission?
  • ANSWER It consists of one unlicensed individual, four licensed brokers, and the superintendent. What's true about a real estate complaint mediation agreement in Ohio?
• ANSWER It's non-binding.

Dave is an Ohio broker who maintains a brokerage trust account. Which of the following do Ohio regulations stipulate?

• ANSWER The account must be in an Ohio financial institution. In Ohio, real estate salespeople must complete ______ hours of post-license education within the first year of initial licensing.
  • ANSWER 20 At a listing appointment, licensee Chet asks Sam, the seller, if his property is his own home or an investment property. Why would Chet ask this?
• ANSWER If the home is his own, he's likely to be purchasing a new one, so Chet has a chance to land two transactions. Dora just received her Ohio real estate broker license. What post-licensing requirements must she fulfill?
• ANSWER She must complete 10 hours of post-licensing within 12 months of broker license issuance. What happens to an Ohio license that's returned to the division of real estate because a licensee is terminated?
  • ANSWER It's suspended At what point must a listing agent disclose material facts to all parties involved in the transaction?
  • ANSWER As soon as possible A party who is involved in a transaction, but who is not your client, is ______. - ANSWER A third party Wright Realty's team of licensed Ohio real estate professionals is interested in taking a team photo and using it to advertise their services. Which of the following is a requirement when using a team photo? - ANSWER All unlicensed team members must be identified. Ohio property managers must provide financial reporting to property owners on at least a _________________ basis. - ANSWER Quarterly Which of the following requires that contracts transferring ownership of real property be in writing to be enforceable? - ANSWER Statute of frauds Vixen and Blitzen Donner have decided it's time to make their home in the North Pole. They simply can't get enough of the snow! In the listing agreement they sign with broker Elsa to sell their Ohio home, which of the following elements must be included? - ANSWER The commission they've agreed to pay Elsa

After agency terminates, which of the following fiduciary duties do Ohio licensees continue to owe their former clients? - ANSWER Confidentiality Edna is a listing agent on a property and has received two offers: one at list price and one slightly below. The offer that's slightly below list price is from a buyer Edna's cousin represents. What should Edna do? - ANSWER Edna should present all offers, discuss the facts of each, and disclose that her cousin represents one of the buyers. Which body is composed of appointed members who oversee license law in Ohio? - ANSWER Real estate commission When the Ohio Real Estate Commission imposes and collects a fine for a license law violation, where are the collected funds deposited? - ANSWER Real estate recovery fund Which agency or department does the superintendent of real estate oversee in Ohio? - ANSWER Division of Real Estate and Professional Licensing Which of the following statements is true of independent contractor licensees? - ANSWER They're paid by the job. What's the principal broker's responsibility with regard to licensees who want to gain competency in a specific area of real estate? - ANSWER Ensure they work with another affiliated and competent licensee to gain competency in the area. For tax purposes, employees are required to complete IRS form W-4. Which IRS form or forms are independent contractors required to complete? - ANSWER W-9 form What happens when two fiduciary duties conflict? For instance, your clients ask you not to show their property on evenings and weekends, when most showings occur. To obey (a fiduciary duty) means to fail in reasonable skill and care (another fiduciary duty). What should you do? - ANSWER Discuss the issue with your clients and let them decide Under Ohio law, Clive is breaching his duty to his seller client if he provides prospective buyers with ________. - ANSWER Information about his client's motivation for selling James, an Ohio licensee, is a huge fan of offering inducements in his real estate practice. Under what conditions must an inducement be disclosed in the purchase contract? - ANSWER When it's offered to motivate buyers and sellers to enter into a purchase contract. When using the farming approach to find listings, what factors are important when identifying an area? - ANSWER Turnover, affinity, diversity

Which of the following provides an example of a universal agent? - ANSWER A court- appointed guardian Jamie, an Ohio broker, has waited two years and is now returning disputed earnest money funds to the buyer involved in a transaction that failed to close. She isn't required to provide notice to either party. Which of the following must be true? - ANSWER The purchase agreement contained a provision for returning the funds to the buyer. Real estate licensees may be classified as ______ for tax purposes, even though they're subject to supervision from a more experienced broker. - ANSWER Independent contractors Samantha is a real estate professional. She's showing her client a property when the client asks about some spots on the ceiling and wonders if they're an indication of a roof leak. What should Samantha do? - ANSWER Suggest that her client contact a roofing expert to make this determination. What does the Ohio Real Estate Commission have the regulatory power to do? - ANSWER Discipline real estate licensees. When using Internet advertising, Ohio licensees must update information how soon after it becomes outdated or expires? - ANSWER 14 days What is puffery? - ANSWER A statement of opinion or exaggeration that's generally understood not to be a statement of fact How much time does an Ohio brokerage audit typically take? - ANSWER Less than one day What's the main point of the statute of frauds? - ANSWER Real estate purchase and sale contracts must be in writing to be enforceable. In Ohio, all pre-licensing education must have been completed within what period prior to taking the licensing exam? - ANSWER 10 years Which of the following is true about inadvertent misrepresentation? - ANSWER A false statement was made. How many residential leases must an Ohio licensee negotiate and sign, as either a landlord's agent or a tenant's agent, to count as one transaction? - ANSWER Four Which of the following is a true statement about Ohio real estate teams? - ANSWER Unlicensed team members must be identified in all advertising.

The licensees who work in Brett Foster's Ohio brokerage have decided to form a team called "Brett's Brokers." When they advertise, which of the following must they include?

• ANSWER The broker/brokerage name When multiple offers are received, which of the following is something a licensee should do? - ANSWER Prepare net proceeds statements on all offers. What's the purpose of a buyer presentation? - ANSWER To build rapport with the buyer Ohio has ________ with eight other states, allowing license applicants from those other states to pursue an abbreviated license process in Ohio. - ANSWER Limited reciprocity In Ohio, what's the pre-licensing education requirement for salespeople? - ANSWER 120 hours Jill needs to pay the web developer who created a new website for her brokerage, but her checking account is low, so she floats herself a loan from earnest money kept in the brokerage's escrow account to pay the developer. Which answer correctly identifies the violation(s) Jill has committed? - ANSWER Commingling and conversion Which of these duties is outside the scope of Ohio's superintendent of real estate? - ANSWER Evaluating commission splits between licensees If the ______ determines that no licensing violation has occurred, then a complaint against an Ohio licensee will be dropped. - ANSWER Superintendent You're a buyer's agent, meeting with the buyer and the buyer's lender, Chuck, who is a ______ the transaction. - ANSWER Third party to Which of the following costs are eligible for disbursement from the Ohio real estate recovery fund? - ANSWER The claimant's actual loss When working with a client on a real estate sale, a real estate licensee is usually acting as which type of agent? - ANSWER Special In addition to the real estate commission, which Ohio group is asked to supply names of candidates for the superintendent of real estate? - ANSWER Real estate appraiser board Breast Exam - ANSWER - 5 - 7 days after the first day of menstruation
• Inspect for symmetry, contours, and retractions
• Palpitation with patient supine with arm above head
• Palpate in ladder pattern, circular motion for each location Lactation - ANSWER - Physiological secretion with pregnancy, lactation, chest wall stimulation, sleep and stress.

Montgomery glands - ANSWER sebaceous glands that secrete a protective lipid substance during lactation Galactorrhea - ANSWER a milky discharge from the nipple unrelated to normal breast feeding Mammary souffle - ANSWER "puff of air" heard during pregnancy and lactation (venous hum) Breast Cancer - ANSWER - Redness

• Peau d'orange: thickening and prominent pores
• Flattening instead of normal convexity
• Asymmetry
• Change in nipple direction
• Paget disease: rash, scaling, ulceration of nipple and areola Breast cancer risk factors - ANSWER - Increasing age
• First degree family member
• Genetic mutations (BRCA1 & BRCA2)
• Personal history of precancerous breast mass
• Denser breast (confirmed by a mammogram)
• High dose radiation exposure
• High levels estrogen hormones Abdominal Exam - ANSWER Inspection-contours Auscultation-bowel sounds/bruits Percussion-liver size, dullness or tympany in colon Palpation-liver size, splenomegaly, masses in colon (fecal matter, cancer, diverticulitis) Special maneuvers- murphy (gallbladder), appendix tests Abdominal Pain: Visceral - ANSWER Hollow abdominal organs forcefully contract or distention
• nonspecific, difficult to localize
• Gnawing, cramping, aching
• Sweating, pallor, nausea, vomiting, restlessness Abdominal Pain: Somatic/parietal - ANSWER Inflammation of the parietal peritoneum
• localized or diffuse
• Steady and aching pain, more severe than visceral
• Aggravated by movement or coughing GERD - ANSWER - Rising retrosternal burning pain or discomfort
• Aggravated by certain foods (alcohol, chocolate, citrus, coffee. onions, peppermint) and positional changes (supine or bending forward)
• Coughing after eating or laying down

Risk factor for Barretts's esophagus - ANSWER Esophageal cancer PUD - ANSWER Common causes: H.Pylori and NSAIDs Pain after meals (2-3 hr delay for duodenal) GERD Hematemesis Melena Treat with PPI, H2RA, antacids Appendicitis - ANSWER McBurney's point: tenderness on direct palpation Rovsing: rebound tenderness when palpating LLQ Psoas: raise thigh (flexion), contracts psoas muscle Obturator: flex the right thigh at the hip, bend knee, rotate leg internally, contracts obturator muscle Rectal exam: right side rectal tenderness Pelvic exam: palpable appendix through the pelvis May also presents with leukocytosis, high fever, nausea, vomiting, bowel changes Diverticulitis - ANSWER Diverticulosis: benign form (pockets only) LLQ pain, rebound tenderness Constipation (abdominal mass) Leukocytosis Hematochezia Hepatitis A - ANSWER fecal/oral route, usually not chronic Hepatitis B - ANSWER Injection, contact with body fluid Hepatitis C - ANSWER Injection, blood transfusion (most prevalent chronic bloodborne disease) Alcohol hepatitis= - ANSWER alcoholic cirrhosis Cholecystitis - ANSWER - Intermittent pain caused by obstruction, blockage, or back up at the bile system.

• Usually related to gallstones
• Liver assessment (palpitation and percussion to determine size)
• Murphy's sign for cholecystitis IBS (irritable bowel syndrome) - ANSWER - Mucous in stool
• Bloating
• Changes in frequency/consistency of stools
• Diagnosis of exclusion, intermittent pain for at least 12 weeks over a year, relief with defecation, changes in stool frequency and consistency
• Commonly associated with food intolerances

IBD (inflammatory bowel disease) - ANSWER - Mucous in stool

• Bloating
• Pain with defecation
• Chronic diarrhea
• Hematochezia
• Anal fissures-Crohn's
• Colonoscopy shows skip lesion or cobblestoning (Crohn), continuous inflammation (UC)
• Strong family link Colon Cancer - ANSWER - Changes in stool
• Palpable mass (late stage)
• Pencil-thin stools
• Hematochezia
• (+) Cologuard/fecal tests=colonoscopy Risk factors for colon cancer - ANSWER - African American
• Men
• Elderly
• IBD
• Family history
• Inactivity
• Low fiber diet
• Obesity
• Alcohol
• Cigarette smoking Rectal Exam - ANSWER - Side lying (preferred for elderly, obese)
• Standing bent forward
• Bear down to get past external sphincter
• Asses glove for bleeding, discharge, or fecal matter
• Masses: Moveable-fecal matter Immovable-prostate nodule, hemorrhoid, or fecal matter
• Rectal lesion, fissures, modules, skin tags Prostate Cancer risk factors - ANSWER - Higher risk at age 40, increases rapidly after age 50
• African American higher incidence and mortality
• Agent orange
• High fat diet
• Obesity
• Cigarette smoking
• Cadmium exposure What is the primary screening test for prostate cancer? - ANSWER PSA

What is Proctitis cause by? - ANSWER IBD, STIs, trauma, bacterial infections, radiation therapy (especially for prostate cancer treatment) Proctitis - ANSWER - Anorectal pain

• Tenesmus
• Discharge
• Bleeding
• Anal fissures Hernias - ANSWER Protrusion of a loop of an organ or tissue through an abnormal opening Which hernias are at a higher risk for incarceration and strangulation? - ANSWER Femoral hernias Incarcerate hernia - ANSWER contents cannot be returned to abdominal cavity Stangulation - ANSWER Blood supply is compromised Assessment for hernias is best with? - ANSWER Patient standing If fingers can go above the mass it is likely? - ANSWER A hydrocele Cryptorchidism - ANSWER undescended testicles Occluded follicles / epidermoid cyst - ANSWER dome-shaped white or yellow lesions Testicular torsion - ANSWER Tender, painful, scrotal swelling Hydrocele - ANSWER Fluid filled lesion, transilluminates Varicocele - ANSWER Varicose vein of spermatic cord, thick rope-like texture Testicular Cancer - ANSWER - Painless nodule
• Peak incidence 15-34 years old
• Palpable inguinal lymph nodes
• Self testicular exam after warm shower Pelvic Exam - ANSWER - Always have a chaperone
• External examination
• Don't use lubricant, especially near the end of speculum
• 30 degree downward angle
• PAP smear
• Bimanual exam Chlamydia - ANSWER White discharge in men, yellow in women

Gonorrhea - ANSWER Yellow in men and women Syphilis - ANSWER Primary chancre, secondary flat top lesions in women Genital wart - ANSWER Severely raise, can be erythematous Herpes - ANSWER Smaller lesion, can be normal pigmentation, erythematous, crusted Pubic lice - ANSWER severe excoriation Normal Discharge - ANSWER clear, white, may have white clumps, not odorous Candidiasis - ANSWER thick, white, and curdy discharge, not odorous, with pruritus, vaginal soreness, pain with urination, dyspareunia BV - ANSWER gray, white, thin discharge, very odorous, worse after intercourse Uterine Tumors - ANSWER - Myomas: benign uterine tumors

• Referred to as fibroids
• Can be mistaken for ovarian mass if projecting laterally PID - ANSWER - most common cause of acute pelvic pain
• secondary to most STD
• ectopic pregnancy
• recent IUD insertion Cervical cancer - ANSWER extensive cauliflower like growth Risk factors for cervical cancer - ANSWER - immunosuppression
• long term OC
• chlamydia infection
• precancerous lesions
• in utero exposure to DES
• more than 3 full term pregnancies Increased risk for cervical cancer - ANSWER - early age intercourse
• frequent intercourse
• multiple partners
• smoking
• HPV MS Assessment - ANSWER - IPROMS
• Articular-altered active AND passive ROM
• Nonarticular- altered active ROM

Scapular winging - ANSWER extend both arms, push against hand Crossover/crossed body abduction - ANSWER AC joint, cross the arm straight over Apley scratch test - ANSWER touch opposite scapula from above and below, tests external and internal rotation Painful arc test - ANSWER abduct arm from down at side to straight up Neer Impingement sign - ANSWER press on scapula, raise arm straight up, tests Hawkins impingement sign - ANSWER bend elbow at shoulder level with arm internally rotated External rotation lag test - ANSWER arm flexed at elbow with palm up, rotate the arm inward and hold Internal rotation lag test - ANSWER back of hand positioned behind lower back, moved towards examiner and held Drop arm test - ANSWER arm straight out to side, slowly lower External rotation resistance test - ANSWER palms up bend at elbow, resistance on wrists and patient pushes arm out Empty can test - ANSWER thumbs facing down, arms straight out, raise arms on resistance Midline back pain causes: - ANSWER ligament injury, disc herniation, degenerative disc/faucet joints, vertebral fracture, spinal cord metastases or abscess Off midline - ANSWER muscle strain, myofascial pain (trigger points), sacroiliitis, greater trochanteric pain syndrome, hip arthritis, renal pain and sciatica Low back pain + bowel/bladder incontinence + saddle seat anesthesia = - ANSWER cauda equina syndrome Osetoarthritis - ANSWER - Age > 60 years

• "Wear and tear" locations/degenerative
• Heberden nodes (DIP)
• Bouchard nodes (PIP)
• Wide base stance
• Pain worse with activity rheumatoid arthritis - ANSWER - Tender
• Painful

• Stiff
• Symmetric
• Ulnar deviation
• Pain worse at rest
• Morning stiffness Gout - ANSWER - Uric acid buildup
• Crystal deposits in joints
• Erythema
• Deformities
• Most common in big toe, distal locations Pseudogout - ANSWER Calcium crystals NOT urate Muscle strength rating - ANSWER 0: no contraction (flaccid) 1: barely detachable movement 2: movement, not against gravity, not against resistance 3: movement against gravity, not against resistance 4: movement against gravity, some resistance 5: full movement with full resistance An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-human chorionic gonadotropin (β- hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis? - ANSWER Ruptured tubal (or ectopic) pregnancy A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, y-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs on abdominal exam to assess his liver. Which of the following would be most consistent with hepatmegaly. - ANSWER Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital

signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA? - ANSWER History of smoking A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventative health care. He has a positive FOBT on on occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S Preventative Services Task Force (USPSTF) screening recommendations for this patient? - ANSWER Do not screen routinely An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3- year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? - ANSWER Functional change in bowel movement A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam? - ANSWER Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant. An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1 - day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis? - ANSWER Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis? - ANSWER Fibrosis of the pancreas

A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic? - ANSWER Associated right shoulder pain A 49-year-old male nurse experiences fecal incontinence after a motor vehicle accident that left him paralyzed below the waist. He asked his rehabilitation physician about the control of this function in a person without his injuries. Which of the following is true regarding the muscle control of the anal sphincter? - ANSWER The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. A 62-year-old male who is undergoing evaluation for possible prostate cancer strongly declines a rectal examination, stating that, "Some trainee once did that and it hurt badly." Which of the following is true about the innervation of the anus and rectum that may explain this patient's experience of discomfort? - ANSWER The anal canal has a rich somatosensory innervation, making poorly directed examinations painful in this area. A 54-year-old male with a strong family history of breast and prostate cancer presents to his primary care provider to discuss prostate screening. His father died at age 73 years from prostate cancer that was not detected on routine digital rectal examination (DREs), and he would like to minimize his chance of a similar occurrence. Which of the following is true regarding the anatomy and screening of the prostate by DRE? - ANSWER The median love of the prostate is located anterior to the urethra and is not palpable on DRE. A third-year medical student rotating on the internal medicine service performs digital rectal examination (DRE) on a 56-year-old female patient. The patient has been admitted for suspicion of a myocardial infarction, and confirmation that this is no blood in the stool is required before anticoagulation can be started. The student reports that the fecal occult blood test was negative but notes that he palpated a structure through the anatomy and reviews with the student that the most likely identity of the structure palpable is which of the following? - ANSWER Cervix A 45-year-old female executive reports to her primary care provider that she has recently experienced a change in the patterns of her bowel movements. She expresses a great concern as her family history includes a maternal aunt who died of colon cancer at ag 49 years; her mother has had colonoscopies every 3 years with numerous adenomatous polyps removed. Which of the following historical elements would be the most concerning for colon cancer in this patient? - ANSWER Recent onset of small- caliber stools

A 49-year-old customer service representative presents to his gastroenterologist for follow-up of this long-standing inflammatory bowel disease (IBD). He was diagnosed with ulcerative colitis (UC) at age 37 years and had had irregular care for this conditions since then. His sole colonoscopy was done at the time of diagnosis 12 years ago. His only relevant family history is of prostate cancer in his father; his mother and sisters are health. Which of the following is true about recommended screening for colon cancer in this patient? - ANSWER The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer A 49-year-old male with well controlled HIV undergoes a proctoscopic examination as routine screening for anal cancer. This patient is asymptomatic and specifically denies complaints of frequent urination (frequency), large volume of urination (polyuria), or repeated urination at night (nocturia). Under visual visualization , the clinician observes a clear, circumferential demarcation of proximal versus distal tissue. This demarcation was not palpable on a digital rectal exam (DRE) prior to proctoscopy. What is the most likely origin of this finding? - ANSWER Normal anatomy of the mucosal surface A 34-year-old female reports anal pain with defecation. She notes incidentally to this complaint that she has developed episodic abdominal discomfort and sores in her mouth. Anoscopic examination reveals anal fissures that appear to be her source of pain. Which of the following underlying conditions is the clinician most likely to find? - ANSWER Inflammatory bowel disease (IBD) A 53-year-old African American advertising agent presents for discussion of his prostate cancer risk and possible screening for this disease. His father was diagnosed at age 82 years with prostate cancer by died recently at age 87 years from a myocardial infarction before the disease progressed. Family history also reveals that his mother died of ovarian cancer when he was age 10 years, and two of his maternal aunts had breast cancer. Which of the following is true about risk and screening for prostate cancer? - ANSWER This patient is at an elevate risk of prostate cancer due to his family history, thus screening modalities should be discussed between the patient and provider. A 64-year-old retired architect presents to his primary care provider with a magazine article about prostate cancer screening that states, "You states talk to your doctor about the ups and downs of prostate cancer screening." The patient hands this to the clinician and states, "Tell me about the ups and down of prostate screen." Which of the following is true about prostate cancer screening? - ANSWER Setting normal cut-offs for prostate-specific antigen (PSA) testing that relies on balancing the risk of overdiagnosis with the risk of underdiagnosis. A thin, 58-year-old patient complains of lower back pain for years. On examination, the clinician finds that the patient has tenderness over the sacroiliac area. Which of the the following conditions is most consistent with this physical sign? - ANSWER Ankylosing spondylitis

During an evaluation of an athletic 30-year-old patient, the clinician conducts an active range of motion evaluation at the neck. Which muscle is being assess when the patient is asked to flex the neck? - ANSWER Sternocleidomastoid (SCM) An obese 50-year-old patient presents with a long history of back trouble. What structure in the spine supports the body's weight? - ANSWER Vertebral body A 31-year-old day care worker presents with worsening stiff, painful neck. On inspection, that patient's head is laterally deviated toward the shoulder and rotated. At this point of the examination, what is the most likely diagnosis? - ANSWER Torticollis A young adult patient presents tot he clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the examination continues, which of the following maneuvers would confirm a likely diagnosis. - ANSWER Compare the strength of his trapezia muscles During a musculoskeletal examination, the clinician instructs the patient to look over one shoulder, and then the other shoulder. This action assess the movement of which muscle(s)? - ANSWER Sternocleidomastoid (SCM) During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group? - ANSWER Extension of the spine The clinician is seeing a middle-aged patient who has a diagnosis of lumbar spinal stenosis. The patient's history is consistent with this diagnosis as he has pain in the back with walking that improves with rest. Which physical sign(s) are most consistent with his diagnosis? - ANSWER Flexed forward posture with lower extremity weakness The clinician is seeing a 58-year-old patient with a diagnosis of arthritis. The patient complains of pain in his knees, hips, hands, wrists, neck, and low back. Based on which joints are involved, the patient most likely has which joint problem? - ANSWER Osteoarthritis (OA) A 62-year-old patient with rheumatoid arthritis (RA) complains of increased joint stiffness. What characteristic(s) are consistent with her diagnosis of RA? - ANSWER Swelling of the synovial tissue is seen in joints and tendon sheaths. A 55-year-old woman with a headache explains to the clinician that she has had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation? - ANSWER The patient also has developed fever and nigh sweats and thinks she has lost some weight. In the case of a middle‐aged female with a pounding headache, what is an effective question to

ask the patient? a) Is she feeling stressed? b) Does she think she is losing her memory? c) Has she ever seen anyone with a stroke? d) Does the patient have any aura prior to the headaches? e) How old is the patient? - ANSWER Does the patient have an aura prior to the headaches? A 35-year-old female patient has had migraines for much of her adult life. After regular checkups, she is healthy, takes no medications except oral contraceptive pills (OCPs), exercise, and has a steady job. Her only complaint is that her migraines seem to have become worse, and, for the past few weeks, she has been waking up at night with headache and also nausea. Which of the following is the best course of action? - ANSWER Take a further history and perform a very careful neurological examination. An 82-year-old grandmother presents to the Emergency Department in the care of her extended family with new-onset speech impairment. According to family members, the patient awake with this symptom as well as difficulty in understanding questions or following commands. Her past medical history is remarkable for atrial fibrillation but no other notable conditions. On examination, her speech is verbose but poorly comprehensible and lacks meaning. She is unable to follow simple commands. Which of the following best describes her speech disorder? - ANSWER Wernicke aphasia. A 74-year-old bus driver is delivered to the hospital via emergency transport after an astute passenger noted that the patient exhibited drooping facial features and slurred speech. The patient was diagnosed rapidly with ischemic (nonhemorrhagic) stroke, and urgent intervention lead to a near complete recovery from his symptoms. The astute passenger was thanked and congratulated for recognizing for signs of acute stroke; this individual credited this recognition to a public safety awareness campaign that outlined the critical public health need to recognize strokes early. Which of the following statements is true for risk and rapid recognition of suspected strokes? - ANSWER Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke A 70-year-old male presents to the Emergency Department accompanied by his wife, who is concerned that he has experienced a stroke. She states that he awake with drooping of the right side of his mouth. HE had a history of hypertension and diet- controlled diabetes, but no history of prior transient ischemic attacks (TIAs), strokes, or neurologic deficits. Physical examination reveals a well-nourished, right handed male, who had an obvious flattening of the right nasolabial fold at rest. He is unable to close his right eye, wrinkle his forehead, or raise his eyebrows. The remainder of the neurological examination is symmetric with intact strength and normal deep tendon reflexes. Based on this history and physical examination, which of the following statements is true? - ANSWER The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve.

In longstanding and poorly controlled hypertension, white matter tracts in the brain are subjected to ateriolosclerotic effect. Which one of the following is most vulnerable to this process? - ANSWER Internal capsule A 14-year-old student comes with her family to the urgent care center, having been hit in the right eye with a plastic baseball during a family reunion. She complains of a painful, watery, red right eye and sensitivity to light. She has normal visual acuity in both eyes, no diplopia, and can open and close her eyes normally. The pupils are unequal in size, 3 mm in diameter on the left, 5 mm in diameter on the right. Which cranial nerve (CN) would be implicated as the cause of photosensitivity complaint and the pupillary asymmetry? - ANSWER CN III Parents bring in their 3-year-old toddler, stating that he has been pulling at his right ear and fussing all day. Examination of the auditory canal shows a small green plastic toy piece partially obstructing the passage. Which cranial nerve (CN) supplies the sensory innervation to that area and is conducting the boy's pain sensation? - ANSWER CN IX A new mother brings in her 6-month-old baby for not being able to keep his eyes together when looking to the left. On examination, both of his eyes appear in alignment (conjugate) when looking to the right. However, when looking to the leg, the baby's left eye stays in the forward gaze position, white the right continues on with full adduction to the left. The eyes appear to be out of alignment (dysconjugate). Which cranial nerve (CN) is responsible for the dysfunction in looking left? - ANSWER Left abducens nerve (CN VI) A 45-year-old physician is having increasing difficulty with speech for the past 6 months. She is less precise in pronunciation of words (dysarthria), has found it more effortful to speak, and finds that her voice sounds more nasal than usual. On examination, her articulation is less than precise, especially with rapid repetition of single syllables, such as "ta-ta-ta-ta," "go-go-go-go," "la-la-la-la," and "ba-ba-ba." Her neurological examination is otherwise normal. Which nervous system pathway is responsible for control of the muscles producing this symptom? - ANSWER Corticobulbar tract A 63-year-old practicing attorney makes an appointment with the office urgently for pain in his right leg for 3 days. Since working in the garden moving heavy bags of mulch for his wife this past weekend, he had had intermittent but excruciating pain shooting down the posterior aspect of his right leg. On examination, sensory loss to light touch in the right leg posteriorly, corresponding to a sacral 1 (S1) dermatome, is noted. which reflex would be expected to be decreased compared to the other side? - ANSWER Right ankle An 82-year-old retired insurance broker complains of difficulty in walking, having to consciously lift up his feet so he does not trip, stumble, or fall. Both feet are affected equally; he has no sensory complaints or pain. This has been worsening over the past 3 years, and he had had to give up his beloved hiking. The symptoms are improved while

wearing tall boots and worse when walking around the house with house slippers. What is the likely location of the pathology in this man? - ANSWER Peripheral nerve A 44-year-old female with mathematician presents to clinic with a complaint of a mass in the right breast. Her partner noticed his mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self- examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening at age 43 years after a brief discussion with her primary care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group? - ANSWER This patient was in compliance with the U.S Preventative Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint A 42-year-old female website developer presents for an annual preventative examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mammography and is interest in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise health with no family history of breast, ovarian, or colon cancer. Which of the following is true about MRI as a screening modality for breast cancer in the general population? - ANSWER Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This discharge started several weeks ago and has occurred at irregular intervals since that time. She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irregular periods over the last few months. On examination, she is able to express a small amount of discharge, which is sent to the laboratory and found to be consistent with breast milk but without signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis? - ANSWER Prolactinoma A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on breast self-examination (BSE) at home. The mass is non-tender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by the patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self-detection of breast cancer? - ANSWER This patient is more likely to find a fibroadenoma than a cancer on self- examination A 48-year-old female psychologist presents to clinic with concerns about her breast cancer risk after an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father's side in as many yers to be diagnosed with breast cancer, including the patient's own father, who had surgery and subsequent

treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA 1 and BRAC2) and desires further information about whether this would be appropriate for her. Which of the following is true about this patient's indication for BRCA testing? - ANSWER This patient carries several risk factors that together justify BRCA testing A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance Imaging (MRI) screening of this patient. - ANSWER Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (the ability to rule out disease in healthy breasts) A 66-year-old female museum curator presents for a routine annual examination. On examination, a notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is non tender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking conjugated estrogen tables for 9 years since menopause, though she had no taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy? - ANSWER Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery, mobile, non tender mass is palpated in the right breast as described by the patient, which is consistent with a fibroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal to and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to report this finding. - ANSWER Rubbery, mobile non tender mass located in right breast, in the 10:30 position from the nipple. A 54-year-old female dietician presents for a routine annual examination. On review of systems, she reports that she has had many breast findings over several years, including one biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changed in the breast with menopause? - ANSWER Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules.

A 67-year-old electronics technician with a history of hypertension and type 2 diabetes present for his yearly physical examination and complains of progressively worsening erectile dysfunction (ED). While counseling him the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most affected by vascular deficiencies related to his preexisting medical conditions and is likely contributing to his symptoms? - ANSWER Corpora cavernosa A 29-year-old graduate student states that he is able to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medication. What is the most likely cause of his problem? - ANSWER Psychogenic Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from high brain centers to the T11-L2 levels of the spinal cord and parasympathetic outflow from S2d and S4 reflex arcs. Local vasodilation within the penis erectile tissue results from increased levels of which of the following? - ANSWER Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) The human papillomavirus (HPV) can cause genital warts in males and females as well as cervical cancer in females. Vaccinations against HPV is available and should be offered to males between what ages? - ANSWER 9-21 years A 32-year-old male complains of a painless, cystic mass just above his lest testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in questions and transillumination is notes. What is the most likely diagnosis? - ANSWER Spermatocele A 25-year-old graduate student presents to the clinic complaining of scrotal pain, which has been increasing over the past 2 days. He is sexually active and has had unprotected intercourse with multiple partners in the past couple of weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpitation the right testicles are noted. Which is the most likely diagnosis? - ANSWER Acute epididymitis A 32-year-old elementary teacher requests a workup for infertility. He and his wife have been trying to conceive for the last 2 years. He reports that his wife has been evaluated and does not appear to have any infertility issues. The overall examination does not reveal any significant abnormalities. He is average height and weight and has normal secondary sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility? - ANSWER Follicle-stimulating hormone (FSH) While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to the inguinal canal and related hernias. Which of the following is not palpable during external examination of the abdominal wall or inguinal region? - ANSWER Internal inguinal ring