Bates’ Guide to Physical Examination and History Taking 11th Edition by Lynn Bickley – Test Bank

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Bates’ Guide to Physical Examination and History Taking 11th Edition by Lynn Bickley – Test Bank

 

 

Sample  Questions

 

Bates’ Guide to Physical Examination and History Taking, 11th Edition

 

 

Chapter 7: The Head and Neck

 

 

 

 

Multiple Choice

 

 

 

 

  1. 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?
  2. A) Tension
  3. B) Migraine
  4. C) Cluster
  5. D) Analgesic rebound

 

Ans:  B

Chapter:  07

Page and Header:  196, The Health History

Feedback:  This is a description of a common migraine (no aura).  Distinctive features of a migraine include phonophobia and photophobia, nausea, resolution with sleep, and unilateral distribution.  Only some of these features may be present.

 

 

 

 

  1. 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?
  2. A) Tension
  3. B) Migraine
  4. C) Cluster
  5. D) Analgesic rebound

 

Ans:  A

Chapter:  07

Page and Header:  196, The Health History

Feedback:  This is a description of a typical tension headache.

 

 

 

 

  1. Which of the following is a symptom involving the eye?
  2. A) Scotomas
  3. B) Tinnitus
  4. C) Dysphagia
  5. D) Rhinorrhea

 

Ans:  A

Chapter:  07

Page and Header:  196, The Health History

Feedback:  Scotomas are specks in the vision or areas where the patient cannot see; therefore, this is a common/concerning symptom of the eye.

 

 

 

 

  1. 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?
  2. A) Benign positional vertigo
  3. B) Vestibular neuronitis
  4. C) Ménière’s disease
  5. D) Acoustic neuroma

 

Ans:  A

Chapter:  07

Page and Header:  252, Table 7–3

Feedback:  This is a classic description of benign positional vertigo. The vertigo is episodic, lasting a few seconds to minutes, instead of continuous as in vestibular neuronitis. Also, there is no tinnitus or sensorineural hearing loss as occurs in Ménière’s disease and acoustic neuroma.  You may choose to learn about Hallpike maneuvers, which are also helpful in the evaluation of vertigo.

 

 

 

 

  1. A 55-year-old bank teller comes to your office for persistent episodes of dizziness. The first episode started suddenly and lasted 3 to 4 hours. He experienced a lot of nausea with vomiting; the episode resolved spontaneously. He has had five episodes in the past 1½ weeks. He does note some tinnitus that comes and goes. Upon physical examination, you note that he has a normal gait. The Weber localizes to the right side and the air conduction is equal to the bone conduction in the right ear. Nystagmus is present. Based on this description, what is the most likely diagnosis?
  2. A) Benign positional vertigo
  3. B) Vestibular neuronitis
  4. C) Ménière’s disease
  5. D) Acoustic neuroma

 

Ans:  C

Chapter:  07

Page and Header:  252, Table 7–3

Feedback:  Ménière’s disease is characterized by sudden onset of vertiginous episodes that last several hours to a day or more, then spontaneously resolve; the episodes then recur. On physical examination, sensorineural hearing loss is present. The patient does complain of tinnitus.

 

 

 

 

  1. 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?
  2. A) Cushing’s syndrome
  3. B) Nephrotic syndrome
  4. C) Myxedema
  5. D) Parkinson’s disease

 

Ans:  D

Chapter:  07

Page and Header:  253, Table 7–4

Feedback:  This is a typical description for a patient with Parkinson’s disease. Facial mobility is decreased, which results in a blunt expression—a “masked” appearance. The patient also has decreased blinking and a characteristic stare with an upward gaze.  In combination with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson’s is almost clinched.

 

 

 

 

  1. 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?
  2. A) Ptosis
  3. B) Exophthalmos
  4. C) Ectropion
  5. D) Epicanthus

 

Ans:  B

Chapter:  07

Page and Header:  255, Table 7–6

Feedback:  Exophthalmos is the condition when the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves’ disease. If it is unilateral, it could still be caused by Graves’ disease.  Alternatively, it could be caused by a tumor or inflammation in the orbit.

 

 

 

 

  1. 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?
  2. A) Dacryocystitis
  3. B) Chalazion
  4. C) Hordeolum
  5. D) Xanthelasma

 

Ans:  C

Chapter:  07

Page and Header:  256, Table 7–7

Feedback:  A hordeolum, or sty, is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

 

 

 

 

  1. A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?
  2. A) Conjunctivitis
  3. B) Acute iritis
  4. C) Corneal abrasion
  5. D) Subconjunctival hemorrhage

 

Ans:  D

Chapter:  07

Page and Header:  257, Table 7–8

Feedback:  A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turning yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure.  It is rarely caused by a serious condition, so reassurance is usually the only treatment necessary.

 

 

 

 

  1. 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?
  2. A) Corneal arcus
  3. B) Cataracts
  4. C) Corneal scar
  5. D) Pterygium

 

Ans:  D

Chapter:  07

Page and Header:  258, Table 7-9

Feedback:  A pterygium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening may occur, and it may interfere with vision as it encroaches on the pupil.  Otherwise, treatment is unnecessary.

 

 

 

 

  1. Which of the following is a “red flag” regarding patients presenting with headache?
  2. A) Unilateral headache
  3. B) Pain over the sinuses
  4. C) Age over 50
  5. D) Phonophobia and photophobia

 

Ans:  C

Chapter:  07

Page and Header:  196, The Health History

Feedback:  A unilateral headache is often seen with migraines and may commonly be accompanied by phonophobia and photophobia.  Pain over the sinuses from sinus congestion may also be unilateral and produce pain.  Migraine and sinus headaches are common and generally benign.  A new severe headache in someone over 50 can be associated with more serious etiologies for headache.  Other red flags include: acute onset, “the worst headache of my life”; very high blood pressure; rash or signs of infection; known presence of cancer, HIV, or pregnancy; vomiting; recent head trauma; and persistent neurologic problems.

 

 

 

 

  1. A sudden, painless unilateral vision loss may be caused by which of the following?
  2. A) Retinal detachment
  3. B) Corneal ulcer
  4. C) Acute glaucoma
  5. D) Uveitis

 

Ans:  A

Chapter:  07

Page and Header:  196, The Health History

Feedback:  Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain.  Retinal detachment is generally painless, as is chronic glaucoma.

 

 

 

 

  1. Sudden, painful unilateral loss of vision may be caused by which of the following conditions?
  2. A) Vitreous hemorrhage
  3. B) Central retinal artery occlusion
  4. C) Macular degeneration
  5. D) Optic neuritis

 

Ans:  D

Chapter:  07

Page and Header:  196, The Health History

Feedback:  In multiple sclerosis, sudden painful loss of vision may accompany optic neuritis.  The other conditions are usually painless.

 

 

 

 

  1. Diplopia, which is present with one eye covered, can be caused by which of the following problems?
  2. A) Weakness of CN III
  3. B) Weakness of CN IV
  4. C) A lesion of the brainstem
  5. D) An irregularity in the cornea or lens

 

Ans:  D

Chapter:  07

Page and Header:  196, The Health History

Feedback:  Double vision in one eye alone points to a problem in “processing” the light rays of an incoming image.  The other causes of diplopia result in a misalignment of the two eyes.

 

 

 

 

  1. A patient complains of epistaxis. Which other cause should be considered?
  2. A) Intracranial hemorrhage
  3. B) Hematemesis
  4. C) Intestinal hemorrhage
  5. D) Hematoma of the nasal septum

 

Ans:  B

Chapter:  07

Page and Header:  196, The Health History

Feedback:  Although the source of epistaxis may seem obvious, other bleeding locations should be on the differential.  Hematemesis can mimic this and cause delay in life-saving therapies if not considered.  Intracranial hemorrhage and septal hematoma are instances of contained bleeding.  Intestinal hemorrhage may cause hematemesis if there is obstruction distal to the bleeding, but this is unlikely.

 

 

 

 

  1. 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?
  2. A) Increased cup-to-disc ratio
  3. B) AV nicking
  4. C) Cotton wool spots
  5. D) Microaneurysms

 

Ans:  A

Chapter:  07

Page and Header:  201, Health Promotion and Counseling

Feedback:  It is important to screen for glaucoma on funduscopic examination.  The cup and disc are among the easiest features to find.  AV nicking and cotton wool spots are seen in hypertension.  Microaneurysms are seen in diabetes.

 

 

 

 

  1. Very sensitive methods for detecting hearing loss include which of the following?
  2. A) The whisper test
  3. B) The finger rub test
  4. C) The tuning fork test
  5. D) Audiometric testing

 

Ans:  D

Chapter:  07

Page and Header:  201, Health Promotion and Counseling

Feedback:  While it is important to screen for hearing complaints with methods available to you, it should be realized that some physical examination techniques are limited.   Nonetheless, you should be comfortable performing these tests, as audiometric testing is not always available.

 

 

 

 

  1. Which area of the fundus is the central focal point for incoming images?
  2. A) The fovea
  3. B) The macula
  4. C) The optic disk
  5. D) The physiologic cup

 

Ans:  A

Chapter:  07

Page and Header:  205, The Eyes

Feedback:  The fovea is the area of the retina which is responsible for central vision.  It is surrounded by the macula, which is responsible for more peripheral vision.  The optic disc and physiologic cup are where the optic nerve enters the eye.

 

 

 

 

  1. A light is pointed at a patient’s pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light.  Which of the following terms describes this latter phenomenon?
  2. A) Direct reaction
  3. B) Consensual reaction
  4. C) Near reaction
  5. D) Accommodation

 

Ans:  B

Chapter:  07

Page and Header:  205, The Eyes

Feedback:  The constriction of the contralateral pupil is called the consensual reaction.  The response of the ipsilateral eye is the direct response.  The dilation of the pupil when focusing on a close object is the near reaction.  Accommodation is the changing of the shape of the lens to sharply focus on an object.

 

 

 

 

  1. A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?
  2. A) She obtains a 20% correct score at 100 feet.
  3. B) She can accurately name 20% of the letters at 20 feet.
  4. C) She can see at 20 feet what a normal person could see at 100 feet.
  5. D) She can see at 100 feet what a normal person could see at 20 feet.

 

Ans:  C

Chapter:  07

Page and Header:  205, The Eyes

Feedback:  The denominator of an acuity score represents the line on the chart the patient can read.  In the example above, the patient could read the larger letters corresponding with what a normal person could see at 100 feet.

 

 

 

 

  1. On visual confrontation testing, a stroke patient is unable to see your fingers on his entire right side with either eye covered. Which of the following terms would describe this finding?
  2. A) Bitemporal hemianopsia
  3. B) Right temporal hemianopsia
  4. C) Right homonymous hemianopsia
  5. D) Binasal hemianopsia

 

Ans:  C

Chapter:  07

Page and Header:  211, Techniques of Examination

Feedback:  Because the right visual field in both eyes is affected, this is a right homonymous hemianopsia.  A bitemporal hemianopsia refers to loss of both lateral visual fields.  A right temporal hemianopsia is unilateral and binasal hemianopsia is the loss of the nasal visual fields bilaterally.

 

 

 

 

  1. You note that a patient has anisocoria on examination. Pathologic causes of this include which of the following?
  2. A) Horner’s syndrome
  3. B) Benign anisocoria
  4. C) Differing light intensities for each eye
  5. D) Eye prosthesis

 

Ans:  A

Chapter:  07

Page and Header:  211, Techniques of Examination

Feedback:  Anisocoria can be associated with serious pathology.  Remember to exclude benign causes before embarking on an intensive workup.  Testing the near reaction in this case may help you to find an Argyll Robertson or tonic (Adie’s) pupil.

 

 

 

 

  1. 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?
  2. A) Retinoblastoma
  3. B) Cataract
  4. C) Artificial eye
  5. D) Hypertensive retinopathy

 

Ans:  D

Chapter:  07

Page and Header:  211, Techniques of Examination

Feedback:  Hypertensive retinopathy requires a careful examination of the optic fundus.  It cannot be diagnosed or excluded merely from the red reflex.  Typically, the red reflex would be normal in this case.  The other conditions are all associated with an abnormal red reflex.

 

 

 

 

  1. 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?
  2. A) Otitis media
  3. B) External otitis
  4. C) Perforation of the tympanum
  5. D) Cholesteatoma

 

Ans:  B

Chapter:  07

Page and Header:  225, Techniques of Examination

Feedback:  These are classic history and examination findings for a patient suffering from external otitis.  Otitis media would not usually have pain with movement of the external ear, nor drainage unless the eardrum was perforated.  In this case the examination of the eardrum is recorded as normal.  Cholesteatoma is a growth behind the eardrum and would not account for these symptoms.  Otitis media would classically be accompanied by a bulging, erythematous eardrum.

 

 

 

 

  1. 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?
  2. A) Otosclerosis of the left ear
  3. B) Exposure to chronic loud noise of the right ear
  4. C) Otitis media of the right ear
  5. D) Perforation of the right eardrum

 

Ans:  A

Chapter:  07

Page and Header:  271, Table 7–21

Feedback:  The above pattern is consistent with a conductive loss on the left side.  Causes would include: foreign body, otitis media, perforation, and otosclerosis of the involved side.

 

 

 

 

  1. 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?
  2. A) Leukoplakia
  3. B) Torus palatinus
  4. C) Thrush (candidiasis)
  5. D) Kaposi’s sarcoma

 

Ans:  B

Chapter:  07

Page and Header:  274, Table 7–23

Feedback:  Torus palatinus is relatively common and benign but can go unnoticed by the patient for many years.  The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation.  It can be premalignant.  Thrush is usually painful and is seen in immunosuppressed patients or those taking inhaled steroids for COPD or asthma.  Kaposi’s sarcoma is usually seen in HIV-positive individuals and is classically a deep purple.

 

 

 

 

  1. A young woman undergoes cranial nerve testing. On touching the soft palate, her uvula deviates to the left.  Which of the following is likely?
  2. A) CN IX lesion on the left
  3. B) CN IX lesion on the right
  4. C) CN X lesion on the left
  5. D) CN X lesion on the right

 

Ans:  D

Chapter:  07

Page and Header:  231, Mouth and Pharynx

Feedback:  The failure of the right side of the palate to rise denotes a problem with the right 10th cranial nerve.  The uvula deviates toward the properly functioning side.

 

 

 

 

  1. A college student presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils.  You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally.  What group of nodes is this?
  2. A) Submandibular
  3. B) Tonsillar
  4. C) Occipital
  5. D) Posterior cervical

 

Ans:  D

Chapter:  07

Page and Header:  236, The Neck

Feedback:  The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain.  These are common in mononucleosis.

 

 

 

 

  1. You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and side-to-side directions.   Which of the following is most likely?
  2. A) Cancer
  3. B) Lymph node
  4. C) Deep scar
  5. D) Muscle

 

Ans:  B

Chapter:  07

Page and Header:  236, The Neck

Feedback:  A useful maneuver for discerning lymph nodes from other masses in the neck is to check for their mobility in all directions.  Many other masses are mobile in only two directions.  Cancerous masses may also be “fixed,” or immobile.

 

 

 

 

  1. You are conducting a pupillary examination on a 34-year-old man. You note that both pupils dilate slightly.  Both are noted to constrict briskly when the light is placed on the right eye.  What is the most likely problem?
  2. A) Optic nerve damage on the right
  3. B) Optic nerve damage on the left
  4. C) Efferent nerve damage on the right
  5. D) Efferent nerve damage on the left

 

Ans:  B

Chapter:  07

Page and Header:  211, Techniques of Examination

Feedback:  Because both pupils can constrict, efferent nerve damage is unlikely.  When the light is placed on the left eye, neither a direct nor a consensual response is seen.  This indicates that the left eye is not perceiving incoming light.

 

 

 

Bates’ Guide to Physical Examination and History Taking, 11th Edition

 

 

Chapter 9: The Cardiovascular System

 

 

 

 

Multiple Choice

 

 

 

 

  1. You are performing a thorough cardiac examination. Which of the following chambers of the heart can you assess by palpation?
  2. A) Left atrium
  3. B) Right atrium
  4. C) Right ventricle
  5. D) Sinus node

 

Ans:  C

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  The right ventricle occupies most of the anterior cardiac surface and is easily accessible to palpation.  The other structures are less likely to have findings on palpation and the sinus node is an intracardiac structure.  You may be able to diagnose abnormal rhythms caused by the sinus node indirectly by palpation, but this is less obvious.

 

 

 

 

  1. What is responsible for the inspiratory splitting of S2?
  2. A) Closure of aortic, then pulmonic valves
  3. B) Closure of mitral, then tricuspid valves
  4. C) Closure of aortic, then tricuspid valves
  5. D) Closure of mitral, then pulmonic valves

 

Ans:  A

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  During inspiration, the closure of the aortic valve and the closure of the pulmonic valve separate slightly, and this may be heard as two audible components, instead of a single sound. Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve.  Because the pulmonic component is soft, you may not hear it away from the left second intercostal space.  Because it is a low-pitched sound, you may not hear it unless you use the bell of your stethoscope.  It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting.

 

 

 

 

  1. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur?
  2. A) Mitral
  3. B) Tricuspid
  4. C) Aortic
  5. D) Pulmonic

 

Ans:  A

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  Mitral valve sounds are usually heard best at and around the cardiac apex.

 

 

 

 

  1. A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?
  2. A) Abdominal pain
  3. B) Orthopnea
  4. C) Hematochezia
  5. D) Tenesmus

 

Ans:  B

Chapter:  09

Page and Header:  337, The Health History

Feedback:  Orthopnea, which is dyspnea that occurs when the patient is lying down and improves when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.

 

 

 

 

  1. You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this?
  2. A) Normal
  3. B) Prehypertension
  4. C) Stage 1 hypertension
  5. D) Stage 2 hypertension

 

Ans:  B

Chapter:  09

Page and Header:  339, Health Promotion and Counseling

Feedback:  Prehypertension is considered to be a systolic blood pressure from 120 to 139 and a diastolic BP from 80 to 89.  Previously, this was considered normal.  JNC 7 recommends taking action at this point to prevent worsening hypertension.  Research shows that this population is likely to progress to more serious stages of hypertension.

 

 

 

 

  1. You are participating in a health fair and performing cholesterol screens. One person has a cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease?
  2. A) Ethnicity
  3. B) Alcohol intake
  4. C) Gender
  5. D) Asthma

 

Ans:  C

Chapter:  09

Page and Header:  339, Health Promotion and Counseling

Feedback:  Gender is used in the calculation of the 10-year risk for developing coronary heart disease, because men have a higher risk than women.

 

 

 

 

  1. You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is well-controlled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. Which of the following conditions is considered to be a coronary heart disease risk equivalent?
  2. A) Hypertension
  3. B) Peripheral arterial disease
  4. C) Systemic lupus erythematosus
  5. D) Chronic obstructive pulmonary disease (COPD)

 

Ans:  B

Chapter:  09

Page and Header:  339, Health Promotion and Counseling

Feedback:  Peripheral arterial disease is considered to be a coronary heart disease risk equivalent, as are abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.

 

 

 

 

  1. You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid pulse?
  2. A) Palpable
  3. B) Soft, rapid, undulating quality
  4. C) Pulsation eliminated by light pressure on the vessel
  5. D) Level of pulsation changes with changes in position

 

Ans:  A

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.

 

 

 

 

  1. A 68-year-old mechanic presents to the emergency room for shortness of breath. You are concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated. Which one of the following conditions is a potential cause of elevated JVP?
  2. A) Left-sided heart failure
  3. B) Mitral stenosis
  4. C) Constrictive pericarditis
  5. D) Aortic aneurysm

 

Ans:  C

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  One cause of increased jugular venous pressure is constrictive pericarditis.  Others include right-sided heart failure, tricuspid stenosis, and superior vena cava syndrome.  You may wish to read about these conditions.

 

 

 

 

  1. You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse?
  2. A) Hypothyroidism
  3. B) Aortic stenosis, with pressure overload of the left ventricle
  4. C) Mitral stenosis, with volume overload of the left atrium
  5. D) Cardiomyopathy

 

Ans:  B

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse.  The other conditions should decrease amplitude of the apical impulse or not be palpable at all.

 

 

 

 

  1. You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?
  2. A) Aortic
  3. B) Pulmonic
  4. C) Mitral
  5. D) Tricuspid

 

Ans:  C

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard.  If you do not listen to the heart in this position with both the diaphragm and bell in a quiet room, it is possible to miss significant murmurs such as mitral stenosis.

 

 

 

 

  1. You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur?
  2. A) Upright
  3. B) Upright, but leaning forward
  4. C) Supine
  5. D) Left lateral decubitus

 

Ans:  B

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). You can further your ability to hear this soft murmur by having the patient hold his breath in exhalation.

 

 

 

 

  1. A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a cardiac examination and find that his pulse rate is less than 60. Which of the following conditions could be responsible for this heart rate?
  2. A) Second-degree A-V block
  3. B) Atrial flutter
  4. C) Sinus arrhythmia
  5. D) Atrial fibrillation

 

Ans:  A

Chapter:  09

Page and Header:  375, Table 9–1

Feedback:  A second-degree A-V block can result in a pulse rate less than 60.  Atrial flutter and atrial fibrillation do not cause bradycardia unless there is a significant accompanying block.  Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart rate.

 

 

 

 

  1. Where is the point of maximal impulse (PMI) normally located?
  2. A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum
  3. B) In the left 5th intercostal space, 10 to 12 cm lateral to the sternum
  4. C) In the left 5th intercostal space, in the anterior axillary line
  5. D) In the left 5th intercostal space, in the midaxillary line

 

Ans:  A

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral to the sternal border.  If it is located more laterally, it usually represents cardiac enlargement.  Its size should not be greater than the size of a US quarter, or about an inch.  Left ventricular enlargement should be suspected if it is larger.  The PMI is often the best place to listen for mitral valve murmurs as well as S3 and S4.  The PMI is often difficult to feel in normal patients.

 

 

 

 

  1. Which of the following events occurs at the start of diastole?
  2. A) Closure of the tricuspid valve
  3. B) Opening of the pulmonic valve
  4. C) Closure of the aortic valve
  5. D) Production of the first heart sound (S1)

 

Ans:  C

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  At the beginning of diastole, the valves which allow blood to exit the heart close.  It is thought that the closure of the aortic valve produces the second heart sound (S2).  Closure of the mitral valve is thought to produce the first heart sound (S1).

 

 

 

 

  1. Which is true of a third heart sound (S3)?
  2. A) It marks atrial contraction.
  3. B) It reflects normal compliance of the left ventricle.
  4. C) It is caused by rapid deceleration of blood against the ventricular wall.
  5. D) It is not heard in atrial fibrillation.

 

Ans:  C

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  The S3 gallop is caused by rapid deceleration of blood against the ventricular wall.  S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason.  It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.

 

 

 

 

  1. Which is true of splitting of the second heart sound?
  2. A) It is best heard over the pulmonic area with the bell of the stethoscope.
  3. B) It normally increases with exhalation.
  4. C) It is best heard over the apex.
  5. D) It does not vary with respiration.

 

Ans:  A

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  S2 splitting is best heard over the pulmonic area because this is the only place where both of its components can be heard well.  The closure of the pulmonic valve is normally not loud because the right heart is a low-pressure system.  The bell is best used because it is a low-pitched sound.  S2 splitting normally increases with inhalation.

 

 

 

 

  1. Which of the following is true of jugular venous pressure (JVP) measurement?
  2. A) It is measured with the patient at a 45-degree angle.
  3. B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP.
  4. C) A JVP below 9 cm is abnormal.
  5. D) It is measured above the sternal notch.

 

Ans:  B

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  Measurement of the JVP is important to assess a patient’s fluid status.  Although it may be measured at 45°, it is important to adjust the level of the patient’s torso so that the blood column is visible.  This may be with the patient completely supine or sitting completely upright, depending on the patient.  Any measurement greater than 4 cm above the sternal angle is abnormal.  This would correspond to a JVP of 9 cm because we add a constant of 5 cm, which is an estimate of the height of the sternal notch above the right atrium.

 

 

 

 

  1. Which of the following regarding jugular venous pulsations is a systolic phenomenon?
  2. A) The “y” descent
  3. B) The “x” descent
  4. C) The upstroke of the “a” wave
  5. D) The downstroke of the “v” wave

 

Ans:  B

Chapter:  09

Page and Header:  323, Anatomy and Physiology

Feedback:  The most prominent upstrokes of jugular venous pulsations are diastolic phenomena.  These can be timed using the carotid pulse.  The only event listed above which is a systolic phenomenon is the “x” descent.

 

 

 

 

  1. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure?
  2. A) 25%
  3. B) 50%
  4. C) 75%
  5. D) 100%

 

Ans:  D

Chapter:  09

Page and Header:  339, Health Promotion and Counseling

Feedback:  Each increase of BP by 20 systolic and 10 diastolic doubles the risk of cardiovascular disease.  Being “low risk” by JNC 7 criteria confers a 72%–85% reduction in CVD mortality and 40%–58% reduction in overall mortality.

 

 

 

 

  1. In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines?
  2. A) Every 6 months
  3. B) Every year
  4. C) Every 2 years
  5. D) Every 5 years

 

Ans:  C

Chapter:  09

Page and Header:  339, Health Promotion and Counseling

Feedback:  AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse.

 

 

 

 

  1. Which of the following is a clinical identifier of metabolic syndrome?
  2. A) Waist circumference of 38 inches for a male
  3. B) Waist circumference of 34 inches for a female
  4. C) BP of 134/88 for a male
  5. D) BP of 128/84 for a female

 

Ans:  C

Chapter:  09

Page and Header:  339, Health Promotion and Counseling

Feedback:  The physical examination criteria for identifying metabolic syndrome include a waist of 40 inches or greater for a male, a waist of 35 inches or greater for a female, and a blood pressure of 130/85 or greater.  Other criteria include triglycerides greater than or equal to 150 mg/dL, fasting glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less than 50 for women.

 

 

 

 

  1. Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52.  What heart rate should she achieve?
  2. A) 80
  3. B) 100
  4. C) 120
  5. D) 140

 

Ans:  B

Chapter:  09

Page and Header:  339, Health Promotion and Counseling

Feedback:  Maximum heart rate is calculated by subtracting the patient’s age from 220.  For Mrs. Adams, 60% of this number is about 100.  She must also be instructed in how to measure her own pulse or have a device to do so.  Most people are able to carry on a conversation at this level of exertion.

 

 

 

 

  1. In measuring the jugular venous pressure (JVP), which of the following is important?
  2. A) Keep the patient’s torso at a 45-degree angle.
  3. B) Measure the highest visible pressure, usually at end expiration.
  4. C) Add the vertical height over the sternal notch to a 5-cm constant.
  5. D) Realize that a total value of over 12 cm is abnormal.

 

Ans:  B

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  In measuring JVP, the angle of the patient’s torso must be varied until the highest oscillation point, or meniscus is visible.  This varies.  The landmark used is actually the sternal angle, not the sternal notch.  We assign a constant height of 5 cm above the right atrium to this landmark.  A value of over 8 cm total (more than 3 cm vertical distance above the sternal angle, plus the 5 cm constant) is considered abnormal.

 

 

 

 

  1. You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you search out?
  2. A) Mitral valve prolapse
  3. B) Pulmonic stenosis
  4. C) Tricuspid insufficiency
  5. D) Aortic insufficiency

 

Ans:  D

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  Bounding carotid pulses would be found in aortic insufficiency.  This should be sought by listening over the third left intercostal space, with the patient leaning forward in held exhalation.  This is a very soft diastolic murmur usually.  A bounding pulse may also be seen in any condition which increases cardiac output, including stimulant use, anxiety, hyperthyroidism, fever, etc.

 

 

 

 

  1. To hear a soft murmur or bruit, which of the following may be necessary?
  2. A) Asking the patient to hold her breath
  3. B) Asking the patient in the next bed to turn down the TV
  4. C) Checking your stethoscope for air leaks
  5. D) All of the above

 

Ans:  D

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  All examiners should carefully search for soft murmurs and bruits.  These can have great clinical significance.  A quiet patient and room, as well as an intact stethoscope, will greatly increase your ability to hear soft sounds.

 

 

 

 

  1. Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell?
  2. A) Mitral stenosis murmur
  3. B) Opening snap of the mitral valve
  4. C) S3 and S4 gallops
  5. D) All of the above

 

Ans:  D

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  Placing the patient in the left lateral decubitus position and auscultating with the bell will enable you to hear these sounds, which would otherwise be missed.

 

 

 

 

  1. How should you determine whether a murmur is systolic or diastolic?
  2. A) Palpate the carotid pulse.
  3. B) Palpate the radial pulse.
  4. C) Judge the relative length of systole and diastole by auscultation.
  5. D) Correlate the murmur with a bedside heart monitor.

 

Ans:  A

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  Timing of a murmur is crucial for identification.  The carotid pulse should be used because there is a delay in the radial pulse relative to cardiac events, which can lead to error.  Some clinicians can estimate timing by the relative length of systole and diastole, but this method is not reliable at faster heart rates.  A bedside monitor is not always available, nor are all designed to correlate in time with the actual pulse.

 

 

 

 

  1. Which of the following correlates with a sustained, high-amplitude PMI?
  2. A) Hyperthyroidism
  3. B) Anemia
  4. C) Fever
  5. D) Hypertension

 

Ans:  D

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  While hyperthyroidism, anemia, and fever can cause a high-amplitude PMI, pressure work by the heart, as seen in hypertension, causes the PMI to be sustained.

 

 

 

 

  1. You are examining a patient with emphysema in exacerbation and are having difficulty hearing his heart sounds. What should you do to obtain a good examination?
  2. A) Listen in the epigastrium.
  3. B) Listen to the patient in the left lateral decubitus position.
  4. C) Ask the patient to hold his breath for 30 seconds.
  5. D) Listen posteriorly.

 

Ans:  A

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  It is often difficult to hear the heart well in a patient with emphysema.   The shape of the chest as well as the interfering lung noise make examination challenging.  By listening in the epigastrium, these barriers can be overcome.  It is impractical to ask a patient who is short of breath to hold his breath for a prolonged period.  Listening posteriorly would make the heart sounds even softer.  It is always a good idea to listen to a patient in the left lateral decubitus position, but in this case it would not make auscultation easier.

 

 

 

 

  1. You are listening carefully for S2 splitting. Which of the following will help?
  2. A) Using the diaphragm with light pressure over the 2nd right intercostal space
  3. B) Using the bell with light pressure over the 2nd left intercostal space
  4. C) Using the diaphragm with firm pressure over the apex
  5. D) Using the bell with firm pressure over the lower left sternal border

 

Ans:  B

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  S2 splitting is composed of an aortic and pulmonic component.  Because the pulmonic component is softer, it can usually be heard only over the 2nd left intercostal space.  It is a low-pitched sound and thus should be sought using the bell with light pressure.  Conversely, the diaphragm is best used with firm pressure.

 

 

 

 

  1. Which of the following is true of a grade 4-intensity murmur?
  2. A) It is moderately loud.
  3. B) It can be heard with the stethoscope off the chest.
  4. C) It can be heard with the stethoscope partially off the chest.
  5. D) It is associated with a “thrill.”

 

Ans:  D

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  The grade 4 murmur is differentiated from those below it by the presence of a palpable thrill.  A murmur cannot be graded as a 4 unless this is present.  The thrill is a “buzzing” feeling over the area where the murmur is loudest.  For practice, you may often feel a thrill over a dialysis fistula.

 

 

 

 

  1. Which valve lesion typically produces a murmur of equal intensity throughout systole?
  2. A) Aortic stenosis
  3. B) Mitral insufficiency
  4. C) Pulmonic stenosis
  5. D) Aortic insufficiency

 

Ans:  B

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  This description fits a holosystolic murmur.  Because aortic and pulmonic stenosis murmurs vary with the flow of blood during systole, they typically produce a crescendo–decrescendo murmur.  The murmur of aortic insufficiency represents backleak across the valve in diastole.  It is a decrescendo pattern murmur, which gets softer as the pressure gradient decreases.

 

 

 

 

  1. You notice a patient has a strong pulse and then a weak pulse. This pattern continues.  Which of the following is likely?
  2. A) Emphysema
  3. B) Asthma exacerbation
  4. C) Severe left heart failure
  5. D) Cardiac tamponade

 

Ans:  C

Chapter:  09

Page and Header:  348, Techniques of Examination

Feedback:  This finding is consistent with pulsus alternans, which is associated with severe left heart failure.  Occasionally, a monitor will read only half of the beats because half are too weak to detect.  There may also be electrical alternans on EKG.  This can be detected by using a blood pressure cuff and lowering the pressure slowly.  At one point the rate of Korotkoff sounds will double, because the weaker beats can then “make it through.”  The other findings are associated with paradoxical pulse.

 

 

 

 

  1. Suzanne is a 20-year-old college student who complains of chest pain. This is intermittent and is located to the left of her sternum.  There are no associated symptoms.  On examination, you hear a short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2.  This is heard best over the apex.  When she squats, this noise moves later in systole along with the murmur.  Which of the following is the most likely diagnosis?
  2. A) Mitral stenosis
  3. B) Mitral insufficiency
  4. C) Mitral valve prolapse
  5. D) Mitral valve papillary muscle ischemia

 

Ans:  C

Chapter:  09

Page and Header:  382, Table 9–8

Feedback:  The description above is classic for mitral valve prolapse.  The extra sound is a midsystolic click,  which is typically a short, high-pitched sound.  Mitral stenosis is a soft, low-pitched rumbling murmur which is difficult to hear unless the bell is used in the left lateral decubitus position.  Mitral insufficiency is a holosystolic murmur heard best over the apex, and papillary muscle ischemia often creates a mitral insufficiency with its accompanying murmur.

 

 

 

Bates’ Guide to Physical Examination and History Taking, 11th Edition

 

 

Chapter 17: The Nervous System

 

 

 

 

Multiple Choice

 

 

 

 

  1. A 28-year-old book editor comes to your clinic, complaining of strange episodes. He states that about once a week for the last 3 months his left hand and arm will stiffen and then start jerking. He says that after a few seconds his whole left arm and then his left leg will also start to jerk. He denies any loss of consciousness or loss of bowel or bladder control. When the symptoms resolve, his arm and leg feel tired but otherwise he feels fine. His past medical history is significant for a cyst in his brain that was removed 6 months ago. He is married and has two children. His parents are both healthy. On examination you see a scar over the right side of his head but otherwise his neurologic examination is unremarkable.

What type of seizure disorder is he most likely to have?

  1. A) Generalized tonic–clonic seizure
  2. B) Generalized absence seizure
  3. C) Simple partial seizure (Jacksonian)
  4. D) Complex partial seizure

 

Ans:  C

Chapter:  17

Page and Header:  718, Table 17-3

Feedback:  Simple partial seizures start with a unilateral symptom, involve no loss of consciousness, and have a normal postictal state. In a Jacksonian seizure the symptoms start with one body part and “march” along the same side of the body.

 

 

 

 

  1. A 7-year-old child is brought to your clinic by her mother. The mother states that her daughter is doing poorly in school because she has some kind of “ADD” (attention deficit disorder). You ask the mother what makes her think the child has ADD. The mother tells you that both at home and at school her daughter will just zone out for several seconds and lick her lips. She states it happens at least four to six times an hour. She says this has been happening for about a year. After several seconds of lip-licking her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The patient’s parents are both healthy and no other family members have had these symptoms.

What type of seizure disorder is she most likely to have?

  1. A) Generalized tonic–clonic seizure
  2. B) Generalized absence seizure
  3. C) Simple partial seizure (Jacksonian)
  4. D) Complex partial seizure

 

Ans:  B

Chapter:  17

Page and Header:  718, Table 17-3

Feedback:  In an absence seizure there is no tonic–clonic activity. There is a sudden, brief lapse of consciousness with blinking, staring, lip-smacking, or hand movements that resolve quickly to full consciousness.  It is easily mistaken for daydreaming or ADD.  Some will try to induce these episodes with hyperventilation.

 

 

 

 

  1. 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?

  1. A) Resting tremor
  2. B) Postural tremor
  3. C) Intention tremor

 

Ans:  C

Chapter:  17

Page and Header:  720, Table 17-4

Feedback:  Intention tremors are absent at rest or in a postural position and occur only with intentional movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) or in multiple sclerosis. This patient’s tremor, fatigue, bladder problems, and visual problems are suggestive of multiple sclerosis.

 

 

 

 

  1. 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-rolling tremor of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back toward you. He has almost no “arm swing” with his gait.

What type of tremor is he most likely to have?

  1. A) Resting tremor
  2. B) Postural tremor
  3. C) Intention tremor

 

Ans:  A

Chapter:  17

Page and Header:  720, Table 17-4

Feedback:  Resting tremors occur when the hands are literally at rest, such as sitting in the lap. These are slow, fine tremors, such as the pill-rolling seen in Parkinson’s disease, which this patient most likely has.  Decreased arm swing with ambulation is one of the earliest objective findings of Parkinson’s disease.

 

 

 

 

  1. 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 movement does she have?

  1. A) Chorea
  2. B) Asbestosis
  3. C) Tic
  4. D) Dystonia

 

Ans:  D

Chapter:  17

Page and Header:  720, Table 17-4

Feedback:  Dystonia involves large movements of the body, such as with the head or trunk, leading to grotesque twisted postures. Some medications (such as one commonly used for gastroparesis) often cause dystonia.

 

 

 

 

  1. 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 mouth remains the same.

What type of facial paralysis does he have?

  1. A) Peripheral CN VII paralysis
  2. B) Central CN VII paralysis

 

Ans:  A

Chapter:  17

Page and Header:  676, Techniques of Examination

Feedback:  In a peripheral lesion the entire side of the face will be involved. This causes the inability to close the eye, raise the eyebrow, wrinkle the forehead, and smile on the affected side. Bell’s palsy is an example of this type of paralysis and is probably what is affecting this patient.

 

 

 

 

  1. A 60-year-old retired seamstress comes to your office, complaining of decreased sensation in her hands and feet. She states that she began to have the problems in her feet a year ago but now it has started in her hands also. She also complains of some weakness in her grip. She has had no recent illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children. Her mother has Alzheimer’s disease and coronary artery disease. Her father died of a stroke and also had diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration on both feet. She has decreased two-point discrimination on her hands. Her grip strength is decreased and her plantar and dorsiflexion strength is decreased.

Where is the disorder of the peripheral nervous system in this patient?

  1. A) Anterior horn cell
  2. B) Spinal root and nerve
  3. C) Peripheral polyneuropathy
  4. D) Neuromuscular junction

 

Ans:  C

Chapter:  17

Page and Header:  727, Table 17-9

Feedback:  With peripheral polyneuropathy there will be distal extremity symptoms before proximal symptoms. There will be weakness and atrophy and decreased sensory sensations. There is often the classic glove-stocking distribution pattern of the lower legs and hands. Causes include diabetic neuropathy, as in this case, alcoholism, and vitamin deficiencies.

 

 

 

 

  1. 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?

  1. A) Sensory ataxia
  2. B) Parkinsonian gait
  3. C) Steppage gait
  4. D) Spastic hemiparesis

 

Ans:  C

Chapter:  17

Page and Header:  730, Table 17-10

Feedback:  This gait is associated with foot drop, usually secondary to a lower motor neuron disease. This is often seen with a herniated disc, such as in this patient.

 

 

 

 

  1. 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?

  1. A) Pinpoint pupils
  2. B) Large pupils
  3. C) Asymmetric pupils
  4. D) Irregularly shaped pupils

 

Ans:  A

Chapter:  17

Page and Header:  731, Table 17-11

Feedback:  Narcotics and cholinergics cause very small (1 mm) pupils. Reactions to light can be appreciated with a magnifying glass.

 

 

 

 

  1. 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?

  1. A) Decorticate rigidity
  2. B) Decerebrate rigidity
  3. C) Hemiplegia
  4. D) Chorea

 

Ans:  B

Chapter:  17

Page and Header:  733, Table 17-13

Feedback:  In this type of rigidity the jaws are clenched and the neck is extended. The arms are adducted and stiffly extended at the elbows with forearms pronated and wrists and fingers flexed. The legs are stiffly extended at the knees with the feet plantar flexed. This posture occurs with lesions in the diencephalon, midbrain, or pons. It can also be seen with severe metabolic disorder such as hypoxia or hypoglycemia, as in this case.

 

 

 

 

  1. 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?
  2. A) This represents a central lesion.
  3. B) This represents a CN IV lesion.
  4. C) This may be related to travel.
  5. D) This most likely represents a stroke.

 

Ans:  C

Chapter:  17

Page and Header:  725, Table 17-7

Feedback:  Because the forehead is also involved, this represents a peripheral nerve lesion of CN VII and does not represent a classic middle cerebral artery stroke.  The latter would spare the upper face but include speech difficulties as well as upper extremity weakness on the ipsilateral side.  One cause of this type of lesion is Lyme disease and relates to travel to endemic areas, so a careful travel history should be sought.

 

 

 

 

  1. Which is true of examination of the olfactory nerve?
  2. A) It is not tested for laterality.
  3. B) The smell must be identified to declare a normal response.
  4. C) Abnormal responses may be seen in otherwise normal elderly.
  5. D) Allergies are unrelated to testing of this nerve.

 

Ans:  C

Chapter:  17

Page and Header:  658, Anatomy and Physiology

Feedback:  Abnormal olfactory nerve examination findings may be seen in otherwise normal elderly but may also be associated with other conditions such as Parkinson’s disease.  You should try to determine if only one side is abnormal by occluding the contralateral nostril.  The smell must only be detected, not identified by name, to indicate a normal examination.  If nasal occlusion occurs for other reasons, such a allergic rhinitis or anatomic abnormalities, the nerve cannot be tested and may seem to be abnormal for unrelated reasons.

 

 

 

 

  1. Steve has had a stroke and comes to you for follow-up today. On examination you find that he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements.  He most likely has involvement of which of the following?
  2. A) The corticospinal tract
  3. B) The cerebellum
  4. C) The cerebrum
  5. D) The basal ganglia

 

Ans:  D

Chapter:  17

Page and Header:  656, Anatomy and Physiology

Feedback:  These findings are typical of disease in the basal ganglia.

 

 

 

 

  1. You are conducting a mental status examination and note impairment of speech and judgement, but the rest of your examination is intact.  Where is the most likely location of the problem?
  2. A) Cerebrum
  3. B) Cerebellum
  4. C) Brainstem
  5. D) Basal ganglia

 

Ans:  A

Chapter:  17

Page and Header:  656, Anatomy and Physiology

Feedback:  The cerebrum is responsible for higher cognitive functions such as speech and judgement.

 

 

 

 

  1. A patient presents with a daily headache which has worsened over the past several months. On funduscopic examination, you notice that the disk edge is indistinct and the veins do not pulsate.  Which is most likely?
  2. A) Migraine
  3. B) Glaucoma
  4. C) Visual acuity problem
  5. D) Increased intracranial pressure

 

Ans:  D

Chapter:  17

Page and Header:  673, Techniques of Examination

Feedback:  This is a description of papilledema, which should make you think of increased intracranial pressure.  This can be a critical finding.  This patient may have a brain tumor or benign intracranial hypertension.  These findings cannot be ignored and should be acted upon quickly.

 

 

 

 

  1. A young woman comes in today, complaining of fatigue, irregular menses, and polyuria which have gradually increased over the past few months. Which eye findings would be consistent with her condition?
  2. A) An upper quadrantanopsia
  3. B) A lower quadrantanopsia
  4. C) A bitemporal hemianopsia
  5. D) An increased cup-to-disc ratio

 

Ans:  C

Chapter:  17

Page and Header:  673, Techniques of Examination

Feedback:  These symptoms are consistent with a pituitary lesion.  Enlargement of a tumor in this area would compress the fibers responsible for the lateral visual fields.  A quadrantanopsia would usually be caused by a lesion in the optic radiations in the parietal lobe of the cerebrum.  Glaucoma would cause a narrowing of the entire visual field, not just the lateral aspects.

 

 

 

 

  1. A patient with a history of seizure disorder and on several seizure medications says a friend noted “jumping eye movements.” The patient describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago.  On examination you note that the eyes both slowly move to the right and then quickly jump to the left.  Which of the following is true?
  2. A) This is called nystagmus to the left
  3. B) This is called saccadic eye movement
  4. C) This represents a subclinical seizure
  5. D) This most likely has an ominous cause

 

Ans:  A

Chapter:  17

Page and Header:  674, Techniques of Examination

Feedback:  Nystagmus is named for the fast component, in this case, toward the left.  Nystagmus is common with several seizure medications and in this case is likely due to the recent increase in medications rather than a more ominous cause.  Saccadic eye movements are similar to nystagmus but represent fixations on apparently moving objects, like watching roadside trees from a moving vehicle.  A subclinical seizure with bilateral findings and no effect on consciousness would be unusual.

 

 

 

 

  1. You are testing the biceps strength in a young man following a spinal trauma from a motor vehicle accident. He cannot lift his hand upward, but if the arm is abducted to 90 degrees, he can then move his forearm side to side.  This would represent which muscle strength grading?
  2. A) I
  3. B) II
  4. C) III
  5. D) IV

 

Ans:  B

Chapter:  17

Page and Header:  680, Techniques of Examination

Feedback:  The ability to move an extremity, but not against gravity, represents a strength of 2 out of 5.  Zero represents no muscular contraction detected (not even a “flicker”); one represents a contraction but no movement of the extremity; three means that the extremity can move against gravity but not against resistance; four means perceived weakness but the patient can oppose some resistance; and five is normal.

 

 

 

 

  1. You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward.  This is most likely a problem with which part of the nervous system?
  2. A) Corticospinal tract
  3. B) Spinothalamic tract
  4. C) Thalamus
  5. D) Dorsal root ganglion

 

Ans:  A

Chapter:  17

Page and Header:  689, Techniques of Examination

Feedback:  This describes a pronator drift, which signifies decreased position sense involvement of the corticospinal tract.  This tract does not travel through the thalamus.  This is commonly tested as an early sign of stroke.  This would not occur with a dorsal root ganglion problem.

 

 

 

 

  1. You are examining a child with severe cerebral palsy. When you suddenly move his foot dorsally, a sustained “beating” of the foot against your hand ensues.  What does this represent?
  2. A) A focal seizure
  3. B) Clonus
  4. C) Extinction
  5. D) Reinforcement

 

Ans:  B

Chapter:  17

Page and Header:  696, Techniques of Examination

Feedback:  Clonus is a sustained rhythmic “beating” which correlates with CNS disease and hyperreflexia.  A focal seizure could be virtually ruled out by stopping the stimulus and watching the phenomenon stop.  Extinction is a term applied to sensory testing where one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex.  Reinforcement applies to enhancing reflex examination by distracting the patient, for example, by pulling his hands against each other.

 

 

 

 

  1. 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?
  2. A) Fractured vertebrae
  3. B) Malingering
  4. C) Infection
  5. D) Medication side effect

 

Ans:  C

Chapter:  17

Page and Header:  703, Techniques of Examination

Feedback:  This represents Kernig’s sign.  When present bilaterally it often indicates meningeal irritation. (Kernig was a physician in eastern Europe and treated many children with tuberculous meningitis.) It is useful in cases when there has been chronic inflammation of the meninges, as seen in TB and cryptococcal disease. There was no trauma reported, and these signs are too important to ascribe them to malingering.  Such localized physical findings are unlikely to be caused by medication side effects.

 

 

 

 

  1. 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?
  2. A) Stroke
  3. B) Metabolic problems
  4. C) Carpal tunnel syndrome
  5. D) Severe fatigue and weakness

 

Ans:  B

Chapter:  17

Page and Header:  704, Techniques of Examination

Feedback:  This is asterixis and represents the inability to maintain a sustained contraction of the muscles.  It is usually due to various metabolic diseases.  A variant of this is called “milkmaid’s grip” in which the patient is asked to grasp two fingers.  A positive occurs if the patient is unable to sustain the grip and it feels as if the patient is trying to milk a cow.  Most would consider checking an ammonia level in this patient.  A stroke is less likely to produce bilateral symptoms.  Carpal tunnel represents a sensory loss in the median nerve distribution.

 

 

 

 

  1. You examine a “sleepy” patient. You note that she will open her eyes and look at you but responds slowly and is confused.  She does not appear interested in her surroundings.  How would you describe her level of consciousness?
  2. A) Lethargic
  3. B) Obtunded
  4. C) Stuporous
  5. D) Comatose

 

Ans:  B

Chapter:  17

Page and Header:  706, Techniques of Examination

Feedback:  An obtunded patient is responsive but slow speaking and is less interested in her surroundings.  A patient with lethargy opens her eyes to verbal cues and may respond appropriately but promptly falls back to sleep.  The stuporous patient responds only to painful stimuli, and when the stimulus is withdrawn lapses into unconsciousness again.  Such patients have little awareness of self or the environment.  The comatose patient has no obvious response to external stimuli.

 

 

 

 

  1. 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?
  2. A) Micturition syncope
  3. B) Postural hypotension
  4. C) Cardiac arrhythmia
  5. D) Vasovagal syncope

 

Ans:  D

Chapter:  17

Page and Header:  715, Table 17-2

Feedback:  This is a classic description of vasodepressor or vasovagal syncope with the feeling of warmth, while bystanders note paleness.  The lack of injury is also helpful because she has maintained her protective reflexes.  Injuring oneself can indicate that a cardiac origin for syncope may be present.  Micturition syncope occurs with urination, and there are no postural changes mentioned, making postural hypotension unlikely.

 

 

 

 

  1. 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?
  2. A) Pseudoseizure
  3. B) Tonic–clonic seizure
  4. C) Absence
  5. D) Myoclonus

 

Ans:  C

Chapter:  17

Page and Header:  718, Table 17-3

Feedback:  This is a common description and scenario for absence seizures.  These are generally brief (less than 10 seconds, “petit mal”).  These generally occur without warning and generally do not have a post-ictal confused state.  Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic–clonic seizures.  Myoclonus represents a single brief jerk of the trunk and limbs.

 

 

 

 

  1. 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?
  2. A) Intention tremor
  3. B) Postural tremor
  4. C) Resting tremor
  5. D) Nervous tremor

 

Ans:  A

Chapter:  17

Page and Header:  720, Table 17-4

Feedback:  Because this tremor worsens as the target is approached, this represents an “intention” tremor.  In this patient, one may suspect cerebellar pathway disease, possibly from multiple sclerosis (one could also look for an intranuclear ophthalmoplegia).  A postural tremor occurs when a certain position is maintained, and resting tremors can occur in diseases such as Parkinson’s.  These do not occur during sleep.

 

 

 

 

  1. 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?
  2. A) Tics
  3. B) Dystonia
  4. C) Athetosis
  5. D) Chorea

 

Ans:  D

Chapter:  17

Page and Header:  720, Table 17-4

Feedback:  These represent chorea because they are brief, rapid, unpredictable, and irregular.  Tics are irregular but tend to be stereotyped and can be vocal (throat-clearing), facial expressions, or shoulder shrugging.  Athetosis is a slow, squirming motion usually affecting the face and distal extremities.  Dystonia is similar to athetosis but the movements are more coarse and can involve twisted postural changes.