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2024 UPDATE GUARANTEE PASS NR 509
Advanced Physical Assessment midterm
Exam
A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to? A) Musculoskeletal B) Reproductive C) Urinary D) Endocrine - SOLUTION A) Musculoskeletal 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 comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom? A) Reproductive B) Urinary C) Cardiac D) Hematologic - SOLUTION C) Cardiac 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.
A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough? A) Ophthalmologic B) Auditory C) Cardiac D) Endocrine - SOLUTION C) Cardiac The cardiac system can cause a cough if the patient has congestive heart failure. This results in fluid buildup in the lungs, which in turn can cause a cough that produces pink, frothy sputum. A foreign body in the ear may also cause a cough by stimulating Arnold's branch of the vagus nerve, but this is less likely to be seen clinically than heart failure. A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new, located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash; she also denies recent travel or camping activities. She has a family history significant for rheumatoid arthritis. Based on this information, which of the following pathologic processes would be the most correct? A) Infectious B) Inflammatory C) Hematologic D) Traumatic - SOLUTION B) Inflammatory The description is most consistent with an inflammatory process, although all the other etiologies should be considered. Lyme disease is an infection which commonly causes arthritis, hemophilia is a hematologic condition which can cause bleeding in the joints, and trauma can obviously cause joint pain. 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
of motion B) Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle spasm and limited range of motion to the right C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion D) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full range of motion - SOLUTION C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion Blurred disc margins are consistent with papilledema, and neck tenderness and lack of range of motion are consistent with neck stiffness, which in this scenario is likely to be caused by meningeal inflammation. Kernig's and Brudzinski's signs are also helpful in testing for meningeal irritation on exam. A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods. Which one of the following physical examination descriptions would be most consistent with the diagnosis of cholecystitis? A) Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses. B) Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or guarding. C) Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the point of stopping inspiration, and there is no rebound or guarding. D) Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or guarding. - SOLUTION C) Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the point of stopping inspiration, and there is no rebound or guarding.
In cholecystitis, the pain, which originates from the gallbladder, is located in the right upper quadrant. Severity of pain with inspiration that is sufficient to stop further inhalation is also known as Murphy's sign, which, if present, is further indicative of inflammation of the gallbladder. A 55-year-old data entry operator comes to the clinic to establish care. She has the following symptoms: headache, neck pain, sinus congestion, sore throat, ringing in ears, sharp brief chest pains at rest, burning abdominal pain with spicy foods, constipation, urinary frequency that is worse with coughing and sneezing, and swelling in legs. This cluster of symptoms is explained by: A) One disease process B) More than one disease process - SOLUTION B) More than one disease process The patient appears to have several possible conditions: allergic rhinitis, arthritis, conductive hearing loss, pleuritic chest pains, heartburn, stress urinary incontinence, and venous stasis, among other conditions. Although we always try, it is very difficult to assign all of these symptoms to one cohesive diagnosis. A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever, headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of symptoms is best explained by: A) One disease process B) More than one disease process - SOLUTION A) One disease process This cluster of symptoms is most consistent with sinusitis. The chance that all of these symptoms are caused by multiple synchronous conditions in the same patient is much less than the possibility of having one problem which accounts for all of them.
notes. You have done a thorough evaluation but are unable to arrive at a consistent picture to tie these symptoms together. This is an example of a: A) Pathophysiologic problem B) Psychopathologic problem - SOLUTION B) Psychopathologic problem It is not uncommon for patients to experience psychopathologic symptoms around the anniversary of a traumatic event. The time of year and the lack of an obvious connection between Ms. Hernandez's symptoms would make you consider this as a possibility. You will note that although this might have been an early consideration in your hypothesis generation, it is key to convince yourself that there is not a physiologic explanation for these symptoms, by performing a careful history and examination. Mr. Larson is a 42-year-old widowed father of two children, ages 4 and 11. He works in a sales office to support his family. Recently he has injured his back and you are thinking he would benefit from physical therapy, three times a week, for an hour per session. What would be your next step? A) Write the physical therapy prescription. B) Have your office staff explain directions to the physical therapy center. C) Discuss the plan with Mr. Larson. D) Tell Mr. Larson that he will be going to physical therapy three times a week. - SOLUTION C) Discuss 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.
You are seeing an elderly man with multiple complaints. He has chronic arthritis, pain from an old war injury, and headaches. Today he complains of these pains, as well as dull chest pain under his sternum. What would the order of priority be for your problem list? A) Arthritis, war injury pain, headaches, chest pain B) War injury pain, arthritis, headaches, chest pain C) Headaches, arthritis, war injury pain, chest pain D) Chest pain, headaches, arthritis, war injury pain - SOLUTION D) Chest pain, headaches, arthritis, war injury pain The problem list should have the most active and serious problem first. This new complaint of chest pain is almost certainly a higher priority than his other, more chronic problems. You are excited about a positive test finding you have just noticed on physical examination of your patient. You go on to do more examination, laboratory work, and diagnostic tests, only to find that there is no sign of the disease you thought would correlate with the finding. This same experience happens several times. What should you conclude? A) Consider not doing this test routinely. B) Use this test when you have a higher suspicion for a certain correlating condition. C) Continue using the test, perhaps doing less laboratory work and diagnostics. D) Omit this test from future examinations. - SOLUTION C) Continue using the test, perhaps doing less laboratory work and diagnostics. This is an example of a specific test that lacks sensitivity. With this scenario, when you finally find a positive, you might be very certain that a given condition is present. We generally develop our examinations to fit our clinical experiences. Sensitive tests are
A) A new patient with the chief complaint of "I sprained my ankle". B) An established patient with the chief complaint of "I have an upper respiratory infection". C) A new patient with the chief complaint of "I am here to establish care". D) A new patient with the chief complaint of "I cut my hand". - SOLUTION C) A new patient with the chief complaint of "I am here to establish care". This patient is here to establish care, and because she is new to you, a comprehensive health history is appropriate. The components of the health history include all of the following except which one? A) Review of systems B) Thorax and lungs C) Present illness D) Personal and social items - SOLUTION B) Thorax and lungs The thorax and lungs are part of the physical examination, not part of the health history. Is the following information subjective or objective? Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity and relieved by rest. A) Subjective B) Objective - SOLUTION A) Subjective This is information given by the patient about the circumstances of his chief complaint. It does not represent an objective observation by the examiner. Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and a pulse rate of 120. A) Subjective B) Objective - SOLUTION B) Objective
This is a measurement obtained by the examiner, so it is considered objective data. The patient is unlikely to be able to give this information to the examiner. The following information is recorded in the health history: "The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-epigastric area." Which of these categories does it belong to? A) Chief complaint B) Present illness C) Personal and social history D) Review of systems - SOLUTION B) Present illness This information describes the problem of abdominal pain, which is the present illness. The interviewer has obtained the location, timing, severity, and associated manifestations of the pain. The interviewer will still need to obtain information concerning the quality of the pain, the setting in which it occurred, and the factors that aggravate and alleviate the pain. The following information is recorded in the health history: "The patient completed 8th grade. He currently lives with his wife and two children. He works on old cars on the weekend. He works in a glass factory during the week." Which category does it belong to? A) Chief complaint B) Present illness C) Personal and social history D) Review of systems - SOLUTION C) Personal and social history.
D) Psychiatric - SOLUTION B) Surgeries A cesarean section is a surgical procedure. Approximate dates or the age of the patient at the time of the surgery should also be recorded. The following information is best placed in which category? "The patient had a stent placed in the left anterior descending artery (LAD) in 1999." A) Adult illnesses B) Surgeries C) Obstetrics/gynecology D) Psychiatric - SOLUTION A) Adult illnesses The adult illnesses category is reserved for chronic illnesses, significant hospitalizations, significant injuries, and significant procedures. A stent is a major procedure but does not involve a surgery. The following information is best placed in which category? "The patient was treated for an asthma exacerbation in the hospital last year; the patient has never been intubated." A) Adult illnesses B) Surgeries C) Obstetrics/gynecology D) Psychiatric - SOLUTION A) Adult illnesses This is information about a significant hospitalization and should be placed in the adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider placing this info in the present illness section, because it relates to the chief complaint at that visit. You are running late after your quarterly quality improvement meeting at the hospital and have just gotten paged from the nurses' station because a family member of one of your patients
wants to talk with you about that patient's care. You have clinic this afternoon and are double-booked for the first appointment time; three other patients also have arrived and are sitting in the waiting room. Which of the following demeanors is a behavior consistent with skilled interviewing when you walk into the examination room to speak with your first clinic patient? A) Irritability B) Impatience C) Boredom D) Calm - SOLUTION D) Calm The appearance of calmness and patience, even when time is limited, is the hallmark of a skilled interviewer. Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient-provider interview? A) Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story. B) Invite the patient's story, negotiate a plan, establish the agenda, and establish rapport. C) Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan. D) Negotiate a plan, establish an agenda, invite the patient's story, and establish rapport. - SOLUTION C) Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan. This is the most productive sequence for the interview. Greeting patients and establishing rapport allows them to feel more comfortable before "inviting" them to relate their
however, it has started to occur with minimal exertion and is happening more than a dozen times per day. The shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description? A) Severity B) Setting in which the symptom occurs C) Timing D) Associated manifestations - SOLUTION A) Severity 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. This allows the comparison of pain intensity before and after an intervention. You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning? A) Directed questioning: starting with the general and proceeding to the specific in a manner that does not make the patient give a yes/no answer B) Reassuring the patient that the urinary symptoms are benign and that she doesn't need to worry about it being a sign of cancer C) Offering the patient multiple choices in order to clarify the character of the urinary symptoms that she is experiencing D) Asking her to tell you exactly what she means when she states that she has a urinary tract infection - SOLUTION B) Reassuring the patient that the urinary symptoms are benign and that she doesn't need to worry about it being a sign of cancer Reassurance is not part of clarifying the patient's story; it is part of establishing
rapport and empathizing with the patient. Mr. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to be checked out for the symptom of chest pain. As you listen to him describe his symptom in more detail, you say "Go on," and later, "Mm-hmmm." This is an example of which of the following skilled interviewing techniques? A) Echoing B) Nonverbal communication C) Facilitation D) Empathic response - SOLUTION C) Facilitation This is an example of facilitation. Facilitation can be posture, actions, or words that encourage the patient to say more. 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? A) Talkative patient B) Angry patient C) Silent patient D) Hearing-impaired patient - SOLUTION C) Silent 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
B) Accepting angry feelings from the patient and trying not to get angry in return C) Staying calm D) Keeping your posture relaxed - SOLUTION A) Avoiding admission that you had a part in provoking her anger because you were late In this scenario, the provider was 1 hour late in seeing the patient. The provider should acknowledge that he was late and apologize for this, no matter the reason for being late. It often helps to acknowledge that a patient's anger with you is understandable and that you might be angry in a similar situation. A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge. As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information? A) Are you sexually active? B) When was the last time you had intimate physical contact with someone, and did that contact include sexual intercourse? C) Do you have sex with men, women, or both? D) How many sexual partners have you had in the last 6 months? - SOLUTION A) Are you sexually active? This is inappropriate because it is too vague. Given the complaint, you should probably assume that he is sexually active. A specific sexual history will help you to assess this patient's risk for other sexually transmitted infections. Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has come to the office many times in the past with a variety of injuries, and you suspect that he has a problem with alcohol. Which one of the following questions will be most helpful in diagnosing this problem? A) You are an alcoholic, aren't you? B) When was your last drink? C) Do you drink 2 to 3 beers every weekend? D) Do you drink alcohol when you are supposed to be working? - SOLUTION B) When was your last drink?
This is a good opening question that is general and neutral in tone; depending on the timing, you will be able to ask for more specific information related to the patient's last drink. The others will tend to stifle the conversation because they are closed- ended questions. 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/ 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? A) Hand her the script and make sure she has a 3-month follow-up appointment. B) Make sure she understands the script. C) Ask why Bill is not there. D) Explain that you will have more time at the next visit to discuss this. - SOLUTION C) Ask why Bill is not there. Sometimes, the patient's greatest need is for support and empathy. It would be inappropriate to ignore this comment today. She may have relied heavily upon Bill for care and may be in danger. She may be depressed and even suicidal, but you will not know unless you discuss this with her. Most importantly, you should empathize with her by saying something like "It must be very difficult not to have him at home" and allow a pause for her to answer. You may also ask "What did you rely on him to do for you?" A patient is describing a very personal part of her history very quickly and in great detail. How should you react to this? A) Write down as much as you can, as quickly as possible. B) Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every word.
