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Answers to Head and Neck Exam Questions

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					Head and Neck Exam- Answers (8)

1) Correct answer: C. The clinical vignette is a classic presentation of temporal
arteritis, with constitutional symptoms, unilateral headaches in the temporal region,
shoulder weakness characteristic of polymyalgia rheumatica (coexists in 40% of patients
with temporal arteritis), and vision loss.

Incorrect Answers:
A. . Ultrasound of the temporal artery, while not diagnostic, may yield a halo sign, which
is suggestive of temporal arteritis.
B. While a biopsy of the temporal artery is the gold standard for diagnosis of temporal
arteritis, empirical treatment with high-dose IV corticosteroids should be started
immediately once the diagnosis is suspected to prevent blindness, even before
confirmation by the biopsy.
 D. While most patients with temporal arteritis typically have a very high ESR, it may be
normal in approximately 20% of cases
E. Contrast enhanced brain MRI and CT are generally negative in this disorder.

2) Correct answer: B. Submental lymph nodes are characteristically found behind the
tip of the mandible. Another thing to note is that tender lymph nodes are indicative of
inflammation, whereas hard and firm lymph nodes are indicative of malignancy. A
combination of fever, severe headache, muscle pains and sore throat are characteristic of
influenza.

Incorrect Answers:
A.) Occipital nodes are found at the base of the skull posteriorly.
C.) Submandibular nodes are found midway between the angle and tip of the mandible.
D.) Superficial cervical nodes are found superficially to the sternomastoid.
E.) Supraclavicular nodes are found deep in the angle formed by the clavicle and the
sternomastoid.

3) Correct Answer: C maxillary sinus - located lateral to the nose and below the eyes, in
the maxillary bones

Incorrect answers
A) cavernous sinus is intracranial bordered by the sphenoid and temporal bones of the
skull
B) ethmoid sinuses are within the ethmoid bone between the nose and the eyes
D) frontal sinuses are over the eyes in the frontal bone
E) sphenoid sinuses are in the sphenoid bone at the center of the skull base under the
pituitary

4) Correct Answers: C. marked facial redness and distended neck veins are found in
Pemberton's sign

Incorrect Answers:
 A) ptosis, miosis, and anhidrosis--signs of horners syndrome
 B) coolness, pallor, and pulselessness in upper extremities--signs of thoracic outlet
syndrome
 D) burning, tingling, or numbness in fingers--signs of carpel tunnel syndrome
 E) nuchal rigidity, photophobia, and altered mental status--signs of meningitis

5) Correct answer: A. This scenario is a typical presentation of a patient with
temporomandibular (TMJ) dislocation. Patients report opening their jaw widely to yawn
or laugh, after which there is a click and subsequent inability to close the mouth. The
dislocation can be bilateral or unilateral - the examination may reveal a mandible that is
displaced to one side.

Incorrect Answers:
B. This would be more likely to produce symptoms of cerebrovascular disease.
C. A sprained muscle would not produce inability to close the jaw.
D. Patients with a maxillary fracture most often present with multisystem trauma and
many require resucitation.
E. Bell's palsy is a cause of facial paralysis, pain behind the ear, and loss of taste
sensation.

6) Correct Answer (D) Supraclavicular lymph nodes are the most likely nodes to be
involved in lung cancer.

7) 7) The correct answer is d) Cold Intolerance. Graves disease is characterized by
ophthalmopathy, dermopathy, and hyperthyroidism. The hyperthyroidism, produced in
this case by the agonist effect of TSH-R Ab, increases metabolism and would tend to
produce symptoms of heat intolerance rather than cold intolerance.

Incorrect answers:
a) Limited upward gaze Limited upward gaze, caused by extraocular muscle
dysfunction (specifically of the inferior rectus muscle) is a component of the
ophthalmopathy of Graves disease, wherein the extraocular muscles are weakened as the
retro-orbital space is infiltrated by T-cells, and hydrophilic glycosaminoglycans
accumulate. Inflammatory edema and swelling of the extraocular muscles may also be
present.
b) Loss of vision Loss of vision may accompany Graves disease if the optic nerve is
involved in the ophthalmopathy.
c) Thickening of the skin in the anterior tibial area The skin in the anterior tibial area
of a patient with Graves disease may be thickened as glycosaminoglycans and
lymphocytes collect in the skin. It is present in a minority of patients.
e) Proptosis Axial proptosis, in which the eyes appear to protrude abnormally, is a
component of the opthlmopathy of Graves disease and occurs as extracellular matrix
proteins (especially glycosaminoglycans) accumulate in the retro-orbital spaces and the
extraocular muscles grow fibrotic.
8) The correct answer is c) The patient is likely to be immunosuppressed. The lesion
described is characteristic for “thrush”- the pseudomembranous candidiasis associated
with some degree of immunosuppression.

Incorrect Answers:
 a) This is characteristic of an aphthous ulcer. An aphthous ulcer is typically a painful,
 shallow ulceration surrounded by an erythematous rim.
b) The white membrane is a leukoplakia. By definition, a leukoplakia cannot be
readily scraped away.
d)This is characteristic of ginigivitis. Gingivitis is characterized by redness, swelling
and often bleeding of the gums.
e) The patient probably wears ill-fitted dentures. Ill-fitted dentures are not particularly
associated with thrush.

Eye Exam ANSWERS
1) Correct Answer: D. The patient in the above case has a problem with their lateral
rectus muscle in their left eye. This muscle is innervated by CN 6 on the ipsilateral side.

Incorrect Answers:
A) CN 3 innervates medial rectus, inferior oblique, superior rectus, inferior rectus.
B) CN 4 innervates the superior oblique.
C) Right Cranial Nerve 6 innervates the Lateral Rectus muscle on the right side.
E) None of the above. This is incorrect because D is correct.

2) Correct Answer: D. CN 2 is the afferent sensory portion of the light reflex. CN 3 is
the efferent motor portion of the light reflex.

Incorrect Answer:
A) CN 2. This is only responsible for sensory portion of light reflex.
B) CN 5 is the sensory nerve of the face as well as being involved in the blink reflex.
C) CN 3. Only responsible for the efferent motor portion of the light reflex.
E) A & B. CN 5 is not involved in the light reflex.

3) Correct Answer: A. Syphilis eye involvement can present with an argyll robertson
pupil. The pupil can accomodate(constrict) on close focusing, but there will not be a
pupillary light response.

4) Correct Answer: E. All of the listed answers are possible manifestations of diabetic
retinopathy on fundoscopic exam.

5) Correct answer is C. A pituitary adenoma may first present with bitemporal
hemianopsia due to compression of the optic chiasm. In this case, confrontation would
be diminished bilaterally due to peripheral/temporal field vision loss in both eyes.
Another clue supporting pituitary adenoma is the change in libido the patient complains
of, which in this case, is due to a prolactinoma.
Incorrect Answers:
A) and B) are incorrect because homonymous hemianopsia would have a confrontation
defect unilaterally only
D) is incorrect because an occipital lobe lesion would not cause bitemporal hemianopsia.

6) Correct Answer: B. This is describing papilledema, which is caused by increased
intracranial pressure.

A) is due to hypertension
C) is due to increased intraocular pressure
D) is due to most often to diabetes
E) is due to hypertension and some other disorders

7) Correct Answer: B: This patient has a Prolactinoma of the pituitary gland.
Compression of the right optic tract by this tumor would affect vision coming from the
left temporal field (nasal fibers would cross over to the right optic tract) and the right
nasal field (temporal fibers would NOT cross over and therefore go to the right optic
tract)
Incorrect answers:
A) This would be caused by a growth of the pituitary which would compress the optic
chiasm- both temporal fields would be affected (since nasal fibers cross over to the
opposite optic tract)
C) This can be caused by many problems, ie: cataracts, macular degeneration, diabetic
retinopathy. A prolactinoma does not typically present with blurry vision, but more a
total loss of vision of the temporal fields of both eyes.
D) This would be the visual disturbance seen in patient with a prolactinoma or other
growth of the pituitary that compresses the left optic tract, not the right.


8) Correct Answer: D. This pt has tertiary syphilis (positive VDRL, FTA-ABS;
paresthesias and muscle aches potentially due to gummas; hx of painless chanres). A
syptom of tertiary syphilis is the Argyll Robertson pupil---pupils that accomodate but fail
to react.

Incorrect answers:
A) Bitemporal hemianopia is caused by compression of the center of the optic chiasm
(most commonly due to pituitary tumors).
B) The loa loa worm (nematode transmitted by deer fly) does not yield positive VDRL or
FTA-ABS. It can sometimes be seen on PE crawling through the conjunctiva.
C) Macular degeneration is most commonly attributed to DMII, not syphilis.
E) Scleral icterus (jaundice of the eye) indicates liver failure, not syphilis.

9) Correct Answer: B. In patients with Horner's syndrome, you expect to see drooping
of the upper eyelid and pupillary constriction ipsilateral to the lesion.

Incorrect answer:
A) Incorrect - In patients with Horner's syndrome, you expect to see drooping of the
upper eyelid and pupillary constriction (not dilation) ipsilateral to the lesion.
C) protruding eyes is unlikely in Horner's and may be more indicative of Grave's disease
D) Incorrect - the ipsilateral upper eyelid would be droopy, not normal
E) Incorrect - the ipsilateral pupil would be constricted, so the pupils would not be the
same size

10) Correct answer: E. Explanation: All of the conditions are associated with an
abnormal red reflex.

11) Correct Answer: C.

12) Correct Answer: B - what one could observe in papilledema, which is consistent
with the clinical vignette which describes the symptoms of increased intracranial pressure
due to epidural hematoma from trauma to the head.


Ear and Nose Exam
1) Correct Answer: C. With conductive hearing loss, bone conduction is better than air
conduction (negative Rinne test) and the Weber test will localize to the affected ear.

Incorrect answers:
A) Conductive hearing loss results in a negative Rinne test. This pattern is consistent
with left ear sensorineural hearing loss.
B) Conductive hearing loss results in a negative Rinne test. This pattern is consistent
with right ear sensorineural hearing loss.
D) This pattern is consistent with conductive hearing loss in the left ear.
E) With conductive hearing loss, the Weber should localize to the affected ear because it
is not receiving background noise to decrease the signal.

2) Correct answer: C. The ethymoid roof and cribiform plate can be fractured in
traumatic injuries to the nasal region. When this occurs, CSF can leak through the nose.
These patients often present with headaches that are worse when standing.

Incorrect answers:
A.) This is incorrect because bacterial rhinitis will produce thick, yellow-green nasal
secretions.
B.) This is incorrect because the nasal exam in viral rhinitis would reveal reddened,
swollen mucosa along with watery, mucous nasal secretions.
D.) This is incorrect because trauma to the petrous part of the temporal bone allows CSF
to drain to the ear and this patient would present with otorrhea.
E.) Although basilar skull fractures can lead to CSF rhinorrhea and otorrhea, the patient
would present with a Raccoon's sign or Battle's sign. These fractures are rare are more
likely to occur with MVA that involve rapid deacceleration.
3) Correct answer: B. Inflammation of the ear canal causes pain during the tug test.

Explanations for incorrect answers:
A. Inflammation of the middle ear does not cause pain during the tug test. However,
tenderness may be present behind the ear.
C. Tymphanosclerosis is a deposition of hyaline material within the layers of the
tymphanic membrane that may follow a severe episode of otitis media. This should not
be painful during the tug test.
D. Serous effusions in the middle ear may be caused by viral upper respiratory tract
infections or sudden changes in atmospheric pressure. Serous effusions would not cause
pain during the tug test.
E. While exostoses do occur in the ear canal, they are nontender nodular swellings and
shouldn't cause pain during the tug test.

4) Correct Answer: D

Explanation: The Weber test is performed by placing the tuning fork on the midline
vertex of the head. In conductive hearing loss, the Weber lateralizes to the deaf ear, while
in sensorineural hearing loss the Weber lateralizes to the better ear. The Rinne test is
performed by placing a 512-Hz tuning fork over the mastoid process. When the vibration
is no longer heard via bone conduction, the tuning fork is placed near the ear to determine
if the vibration is heard. If the vibration is heard, then air conduction is greater than bone
conduction and the test is considered positive or normal. If the vibration is not heard, then
bone conduction is greater than air conduction and this negative Rinne test denotes
conductive hearing loss. Sensorineural hearing loss occurs when a positive or normal
Rinne test is complemented by a Weber test that lateralizes to the better ear.

5) Correct Answer: C.
This is the proper way to carry out the whisper voice test. As trivial as this test may
sound, it has an excellent sensitivity and, therefore, should be part of your routine
screening physical exam. It is carried out with your voice and not a tuning fork, therefore,
no equipment is needed. Each ear should be test individually since hearing loss can
localize to one side. The proper distance to stand away from the patient is 2 feet, roughly
one arm's length, to minimize the chance of the patient reading your lips.

6) Correct answer is B. Local sinus tenderness, together with symptoms such as pain,
fever and nasal discharge suggests acute sinusitis involving the frontal and maxillary
sinuses. Transillumination may be diagnostic.

Incorrect Answers:
A. While this can be the reason for absence of glow during transillumination, the history
and presentation is more indicative of acute sinusitis being the cause.
C. Nasal polyps are pale, semitranslucent masses that develop as a result of chronic
inflammation. Allergies predispose to formation of polyps. However,
polyps don't have this clinical presentation.
D. Cocaine use can lead to ulceration of the nasal mucosa, however the history and
clinical presentation does not suggest cocaine use to be the case. Ulcerations do not
present with sinus tenderness.
E. Deviation of the lower septum is common and it can seldom obstruct the air flow.
However, it is not a cause for this clinical presentation.

7) Correct Answer: B, in sensori-neural hearing loss, the weber test will lateralize to the
unaffected side and the the ratio of detection from bone conduction to air conduction
remains the same.

8) Correct Answer c, the patient had tenderness over their frontal sinuses, the maxillary
sinuses are clear and the pain is located away from the mastoid air cells. Spenoid
sinusitis would have a similar presentation but without finding of tenderness below the
brow ridge. Infection of the cavernous sinuses would be accompanied cranial nerve
findings

Oral Cavity and Pharynx Answers
1) Correct Answer: D
Taste in the anterior 2/3 of the tongue is innervated by CN VII; sensation is innervated by
CN V3; motor CN XII. Taste in the posterior 1/3 is innervated by CN IX; sensation is
innervated by CN IX; motor is also innervated by CN XII. All other combinations are
inaccurate innervations.

2) Correct Answer: B
Tobacco, alcohol and HPV are common causes of the more classic leukoplakia.
This is a case presentation for hairy leukoplakia, a pre-AIDS defining lesion caused by
the Epstein Barr Virus. His clinical and laboratory findings are consistent with his HIV
status.
Though Candida Albicans does appear as white and elevated patches, they are easily
scraped off.

3) Correct Answer: D. Koplik spots are pathognomonic for measles. They most
commonly appear on the buccal mucosa opposite the second molars. They usually
appear 24-48 hours after onset of the prodrome, and usually subside 48 hrs after onset of
the maculopapular rash.

Incorrect answers:
A--deep purple lesions on the hard palate are commonly seen in AIDS patients with
Kaposi's sarcoma.
B--aphthous ulcers on the labial mucosa of the lip are not pathognomonic for measles.
C--painful postauricular lymphadenopathy is commonly seen in Rubella, but not rubeola.
E--this characteristic rash is found in people with erythema infectiousum (fifth disease)

4) Correct Answer : D.

5) Correct Answer: E
Incorrect answers:
A/B) If a patient has no fever, exudates or cervical lymph node enlargement, infection is
less likely to be Group A strep or EBV. (232 Bates)
C) Diptheria would present with a dull red throat with gray exudates. (233 bates) D.
Measles would present with small red-based lesions with blue-white centers (234 Bates)
E) Pharyngitis is most likely caused by some other bacteria or virus. (232 Bates)

6) Correct answer: C. Media Rhomboid Glossitis. Flat, red, and symmetric is
descriptive for median rhomboid glossitis. There is a "kissing lesion" on the palate.

Incorrect:
B. Denture stomatitis occurs in the area in contact with dentures, not on tongue.
D. Leukoplakia is a white lesion.
E. Chilocandidiasis occures in the skin surrounding the mouth.
A. Erythorplakia is red, but it is often raised and more commonly on the lateral tongue.

7) Correct Answer: E. Corynebacterium diphtheriae
Diphtheria (an acute infection caused by Corynebacterium diphtheriae) has been nearly
eradicated in developed nations due to widespread vaccination, but it is still important.
Prompt diagnosis may lead to life-saving treatment. The throat is dull red, and a grey
exudate (pseudomembrane) is present on the uvula, pharynx, and tongue. The airway
may become obstructed. (Bates 2007 p.233)

Incorrect Answers:
A) Candida can cause thrush on the palate (Candidiasis). Signs include thick, white
plaques somewhat adherent on the underlying mucosa.
B) and C) Group A streptococci and Epstein-Barr virus (infectious mononucleosis) can
cause exudative tonsillitis. Signs include a red throat with white exudate on the tonsils,
together with fever and enlarged cervical nodes.
D) The human papilloma virus (HPV) is one of the most common virus groups in the
world to affect the skin and mucosal areas of the body. Over eighty types of HPV have
been identified. Different types of the human papillomavirus are known to infect different
parts of the body. It infects the epithelial cells of skin and mucosa. The epithelial surfaces
include all areas covered by skin and/or mucosa such as the mouth, throat, tongue,
tonsils, vagina, penis, and anus. Infection with the virus occurs when these areas come
into contact with a virus, allowing it to transfer between epithelial cells.

8) Correct Answer: D. NSAIDS have not been shown to cause gingival hyperplasia.

Incorrect answers:
 a) Phenytoin (Dilantin®), has been shown to cause gingivitis in some susceptible
individuals, as they may have gingival fibroblasts that are sensitive to the drug. It is
usually evident only after long-term use. (1, 3)
b) Pregnancy can cause a hormone-induced imbalance between opposing factors within
the local fibrinolytic system, leading to tissue destruction at an inflammatory site. It is
suggested that some women have a decreased production of Plasminogen Activating
Inhibitor 2 (PAI 2) during pregnancy. (2, 3)
c) Gingivitis may be seen in puberty due to an increase in steroid hormones and changes
in subgingival microbiota. (2, 3)
e) Gingivitis is associated with leukemia due to increased leukocyte infiltration of the
gingival tissues. (2, 3)


Musculoskeletal Exam Answers

1. Correct answer: C Both Bouchard's nodes and Heberden's nodes are seen in
osteoarthritis. These bony overgrowths are seen in middle aged/ elderly patients and are
hard and painless. Bouchard's nodes are found on the PIP joints whereas Heberden's
nodes are found on the DIP joints. The Swan neck and Boutonniere's deformities are
found in chronic rheumatoid arthritis. A Baker's cyst also called a popliteal cyst results
from the distension of the gastrocnemius semimembranosus bursa.

2. Correct answer: B The patient has symptoms of carpal tunnel syndrome, which is
entrapment of the medial nerve. Phalen's test compresses this nerve, and should elicit
similar symptoms in the patient.
Explanation of incorrect answers:
A) This test is done to test for DeQuervain's Tenosynovitis, which usually presents as
pain and swelling over the base of the thumb.
C) This assesses the function of the C5 dermatome, and the muscle is innervated by the
radial, not the median nerve
D) This test is done to assess arterial perfusion of the hand, and will not be changed in a
patient with carpal tunnel syndrome
E) This is a test of the knee to look for an ACL tear.

3. Correct answer: C The patient has a torn rotator cuff. The teres major is not one of
the SITS muscles (supraspinatus, infraspinatus, teres minor, subscapularis) comprising
the rotator cuff. Answers A, B, D, E comprise the rotator cuff muscles.

4. Correct answer: E The patient has carpal tunnel syndrome. This is the only answer
with the median nerve distribution of numbness and tingling.
A. This answer indicates multiple nerves (median, ulnar, and radial) are affected by
Phalen's test. Phalen's test is only for the median nerve.
B. This is in the C8 dermatomal distribution, not the distribution of the median nerve.
C. This is in the ulnar nerve distribution, not the median nerve distribution.
D. This is in the C7 dermatomal distribution; the median nerve does only the palmar
surface of these fingers as well as the palm and part of the thumb.

5. Correct answer: D This would test for a meniscal tear which often occurs along with
an ACL tear as part of the "unhappy triad".
A) Incorrect. This would test the LCL which might be torn as well but is not the most
probable additional injury. If a valgus stress test was performed, this would be an
appropriate test in these circumstances to rule out an MCL tear (part of the "unhappy
triad").
B) Incorrect. This is a valid test to perform because it would test the integrity of the
knee's reflex arc but it does not necessarily point towards a specific injury.
C) Incorrect. There would likely be an effusion in the joint but performing this test would
just confirm this and would not necessarily point towards any additional injury
E) Incorrect. This would test the PCL integrity which is not frequently compromised
concomitant with ACL integrity.

6. Correct answer: D A lateral hit to the knee will most likely cause damage to the
medial collateral ligament (MCL), medial meniscus, and anterior cruciate ligament
(ACL). The anterior drawer sign which exams the integrity of the ACL, would therefore,
be positive in the patient's exam. A is wrong, as the test is used for a tear in the PCL. B is
wrong, as the test is used to show damage to gluteal nerves. C is wrong, as the test is
used in a hip examination. E is wrong, as the test is used to determine Achilles tendon
rupture.

7. Correct answer: A A lesion to the left superior gluteal nerve will result in weakness
of the left gluteus medius and minimus, and thus a positive Trendelenberg's Test when
standing on the left leg. Incorrect answers: b), c), d), & e) are not associated with
weakness of the hip abductors or with a positive Trendelenberg's Test.

8. Correct answer: D By being hit on the lateral aspect of his knee, this player has
received a lot of stress on the medial aspect of his knee. As a result, he has torn his
Medial Collateral Ligament. This is proven by the fact that his knee is looser when put
under valgus stress, which tests the integrity of the MCL. However, it is common to
injure other parts of the knee with such an injury. The fact that he does not show forward
excursion with a Lachman Test suggests that his Anterior Cruciate Ligament is most
likely intact. The Lachman Test puts the leg in slight flexion and external rotation, and
pulls the tibia forward while pushing the femur back. This motion tests the integrity of
the ACL. A negative Lachman rules out E, as well as A because an Unhappy Triad
would include a torn ACL, MCL, and medial meniscus.
A and E could also be ruled out by the fact that there were no pops or clicks heard on the
McMurray Test, suggesting that there is not a tear in the posterior portion of the medial
meniscus. Even though he was hit on the lateral side of his leg, the fact that his knee is
tight and symmetrical with the other side when put under varus stress suggests that his
Lateral Collateral Ligament is intact, ruling out C. Finally, this is not simply a bruise
because of the findings from the valgus stress, so B is ruled out.

9. Correct answer: A The long thoracic nerve runs very superficially along the lateral
aspects of the thorax and can be injured with penetrating trauma or lymph node dissection
during a mastectomy. The long thoracic nerve innervates the serratus anterior muscle,
which protracts the scapula and holds it against the thoracic wall and elevates the glenoid
cavity so the arm can be abducted more than 90 degrees. Answers B, D, and E are
incorrect because winging of the scapula is only seen with serratus anterior dysfunction.
C is incorrect because the lateral thoracic artery is the blood supply to the serratus
anterior, not the innervation.

10. Correct answer: D An unhappy triad (or terrible triad, or O'Donoghue's triad) is an
injury to the knee. It commonly occurs in contact sports (such as skiing or American
football). The mechanism for this injury occurs when a lateral (outside) force to the knee
is received while the foot is fixed on the ground in external rotation. This scenario causes
an injury to three knee structures: Anterior Cruciate Ligament, Medial Collateral
Ligament, Medial Meniscus.

11. Correct answer: B The rotator cuff muscles are composed of Supraspinatus,
Infraspinatus, Teres Minor and Subscapularis (remember SItS, little t for teres minor)

12. Correct answer: E - When evaluating back pain, it is always important to assess for
symptoms that radiate to the extremities. In this question, the patient's history and
clinical presentation are consistent with a herniated disc. An abnormal Achilles reflex
would help lead to the correct diagnosis. Other appropriate actions would include general
sensory testing of the lower extremities and a straight leg raise test.
Incorrect A - Though it is a test of the lower extremities, a positive McMurray's test
suggests an injured meniscus and would not be related to a herniated disc.
Incorrect B - A CT scan would eventually be an appropriate step, but it is important to
complete all clinical assessments before ordering imaging. And besides, this class is
physical diagnosis, not...imaging...diagnosis.
Incorrect C - An abdominal aortic aneurysm can lead to lower back pain, but the patient's
history is more suggestive of a disc problem.
Incorrect D - In patients with significant kyphoscoliosis, the abnormal curvature of their
spine can lead to mechanical breathing difficulties. There is nothing in this patient's
history to suggest a back problem that would lead to breathing issues.

13. Correct answer: A Standard presentation after a broken hip. The instability of the
proximal femur allows the leg to rotate externally. There also may be displacement of
the fractured bone, which is why the injured leg would be shorter in length. A positive
anterior drawer sign indicates a torn ACL (c). An absent patellar reflex would not be
caused by a broken hip, but more likely a compression of the nerve roots at the L2-L4
level (d). The valgus stress test assesses for an injured MCL (e).

14. Correct answer: B The described movement of the wrist is the Finkelstein test,
which exacerbates the pain due to inflammation of the synovial sheath surrounding the
abductor pollicus longus and brevis tendons. Gout tophi (a) normally present in the big
toe rather than the thumb, present as severe pain of acute onset, and are not associated
with weakness of grip. Colles fracture (c) is the fracture of the distal radius, most often
caused by trauma. A radial nerve injury (d) or carpal tunnel syndrome (e) would most
likely produce parasthesia or radiating pain in the distribution of the innervation, rather
than pain localized to the site of the synovial sheath.
15. Correct answer: C The achilles reflex checks the S1/S2 nerve roots. The achilles
muscle attaches the gastracnemius and the soleus muscles with the calcaneus bone. Loss
of the posterior tibial nerve innervates both of these muscles is innervated by the tibial
nerve. Common peroneal nerve injury would cause foot drop. Saphaneous nerve would
cause loss of sensation on the medial leg. Gluteus maximus muscle does not affect
achilles reflex and neither does the quadracepts femoris muscle.

16. Correct answer: D

Neurologic Exam
1. Correct answer: A This patient has a stacked deck for B12 deficiency and
consequently subacute combined degeneration. B12 deficiency can be due to a lack of
intrinsic factor, terminal ileum disease, or decreased dietary intake. Folic acid deficiency
does not often cause neurological symptoms. Pellagra is B3 deficiency and is
characterized by 3 D's: Diarrhea, Dementia, and Dermatitis. Osteomalacia is caused by
Vitamin D deficiency.

2. Correct answer: C This is a classic presentation for MS, a demyelinating syndrome
that has a relapsing-remitting course. GBS is associated with infections and symmetric
muscle weakness. Parkinson's is associated with resting tremor and cogwheel rigidity.
ALS shows upper motor neuron and lower motor neuron symptoms.

3. Correct answer: A Unilateral paralysis of CN XII leads to deviation of the tongue
towards the affected side.
B: This finding will be seen with right cranial nerve XII palsy.
C: The gag reflex is controlled by the glossopharyngeal nerve (cranial nerve IX) and not
by the hypoglossal nerve.
D and E: Taste in the anterior 2/3rds of the tongue is derived from the lingual nerve (a
branch of cranial nerve V3) and taste in the posterior 1/3rd of the tongue is derived from
the glossopharyngeal nerve (CN IX).

4. Correct answer: C The Romberg test is done on a patient while they stand with feet
together and head erect. Their balance is monitored before and after they close their
eyes, with notable unsteadiness when eyes are closed. Positive Romberg can indicate a
problem with the
dorsal columns (tabes dorsalis or vitamin B12 deficiency).

5. Correct answer: B Recalling the anatomy of the medial knee, the saphenous nerve
passes through the adductor canal to innervate the skin overlying the medial knee. The
patient has no gross meniscal or ligamentous injury as seen by the unremarkable physical
exam and radiology. Relief of pain by the peripheral nerve block using Bupivicaine is
confirmatory for saphenous neuritis.
Wrong Answers:
A. The common fibular nerve is a lateral knee structure.
C. A bucket-handle tear of the medial meniscus is possible, however the negative
physical exam (McMurray's test and joint line tenderness) and radiology make it
unlikely. Bucket-handle tears are usually due to trauma. Also the mention of adductor
canal abnormality and relief of pain by a peripheral nerve block also make the diagnosis
unlikely as a bucket handle tear is significant pathology.
D. The femoral nerve supplies sensation to the anterior thigh and does not pass through
the adductor canal.
E. Osteoarthritis is not seen on the x-ray and therefore not the most likely diagnosis.

6. Correct answer: A A positive Romberg sign is likely in a patient with tabes dorsalis
or other forms of bilateral damage to the posterior columns.
B. Incorrect: Temperature sensation from the face is transmitted through the trigeminal
nerve and does not travel in the spinal cord.
C. Incorrect: Temperature sensation from the body ascends in the spinothalamic tract of
the spinal cord.
D. Incorrect: Pain sensation from the body ascends in the spinothalamic tract.
E. Incorrect: Flaccid paralysis would be caused by damage to the anterior horn in the
spinal cord grey matter, or by damage to peripheral nerves.

7. Correct answer: C C6 dermatome is on the lateral forearum and the thumb and index
finger. It elicits the brachioradialis reflex.
A. Incorrect. C3 dermatome is on the back of the head. It elicits no reflex.
B. Incorrect. C4 dermatome is in the middle of the neck. It elicits no reflex.
D. Incorrect. C7 dermatome is on the back of the arm and the middle finger. It elicits the
triceps reflex.
E. Incorrect. C8 dermatome is on the medial forearm and the fifth finger. It elicits the
triceps reflex.

8. Correct answer: D The patient has Pancoast tumor with resultant Horner's
syndrome. Patient would most likely demonstrate ipsilateral anhidrosis during exertion.
Interruption of parasympathetic fibers would not produce miosis or ptosis -- the pupil
would instead not be able to constrict. Myasthenia gravis (choice b) produces muscular
weakness and fatigue that improves with rest. A 3rd cranial nerve palsy would present
with ptosis, diplopia, and down-and-out displacement of the involved eye.

9. Correct answer: C This patient has the classic symptoms of Myasthenia gravis, 80-
85 % of patients with Myasthenia Gravis are sero-positive for anti-Ach antibodies.
Classic signs & symptoms of myasthenia gravis include:
-Weakness that gets worse with repeated stimulation and improves with rest
-Proximal muscle weakness- such as difficulty raising arms overhead, climbing, stairs, or
getting out of a chair, difficulty holding head up (neck weakness)
-Facial weakness and ptosis
-Extraocular muscle weakness sparing the pupil
-Painless weakness of jaw closure
-Dysphagia- worse with further swallowing
-Effort related Dysarthria
-Dyspnea- worse with effort
INCORRECT ANSWERS
A-While botulism toxin inhibits Ach release from pre-synaptic nerve terminals leading to
flaccid paralysis, this patient has no GI symptoms and botulism often starts with cranial
nerve involvement especially sluggish or non-reactive pupils
B-Most patients with Lambert Eton myasthenic syndrome are positive for Ca++ channel
antibodies. 50-60% of E-L is associated with small cell carcinoma of the lung making
smoking history an important factor. However unlike MG patients with L-E will have
improvement of symptoms with repetitive stimulation. They will also often have
autonomic complaints (dry mouth, postural hypotension...)
D-Painless difficulty chewing suggests neurologic rather than local process
E- Dyspnea can deteriorate rapidly and lead to aspiration pneumonia or respiratory
failure. An ABG and RFTs should be performed to assess their status. In addition all
patients with progressive or worsening dysarthria or dysphagia should also be
hospitalized as they can deteriorate rapidly as well.

10. Correct answer: C This patient presents with signs of tertiary syphilis: Tabes
dorsalis, (+) Romberg, Charcot joint, skin gummas. You could expect to see (+) Argyl
Robertson "prostitutes pupil" bilaterally, with proper constriction with accommodation
but no pupillary light reflex caused by selective damage to the parasympathetic pathways
of the Edinger-Westphal nucleus.
A - Asteriognosis: unable to identify objects based on tactile clues, typically seen with
lesions of the somatosensory cortex
B - Deminished sensation to pain and temperature: seen with lesions of the spinothalamic
tracts in the spinal cord
D - Hyperreflexia: upper motor neuron lesion
E - Soft palate fails to elevate: bilateral medullary lesion in the nucleus ambiguous
possibly from PICA infarction

11. Correct answer: C CN I is the olfactory nerve and has nothing to do with vision.
The right CN II works because the right pupil constricts when the light is shined into it.
CN III carries the parasympathetic nerves (short cilliary nerves) responsible for dilation
of the pupil. We know both of these work because both eyes constricted when light was
shined in the right eye. The lesion must be in the left CN II, as the light signal from the
retina does not register in the brain.

12. Correct answer: A Cerebellar dysfunction is characterized by gait ataxia, an
intention tremor, postural instability, nystagmus, and dysarthria. It has a negative
Romberg's test, which helps to distinguish it from sensory ataxia.
Wrong answers:
B. Tabes Dorsalis affects the posterior columns and is a type of sensory ataxia. The
patient would have had a positive Romberg test
C. The patient had no nausea, vomiting, or vertigo, which would characterize vestibular
dysfunction
D. A sensory peripheral neuropathy would be a sensory ataxia with a positive Romberg
test
E. While visual input is needed for proper coordination, visual impairment doesn't
account for all of the patient's symptoms


Hematologic-Oncologic Exam Answers
1. Correct answer: C Vitamin K deficiency. This patient has vitamin K deficiency from
fat malabsorption due to alcoholic pancreatitis. Vitamin K is essential for factors 2, 7, 9
and 10 in the clotting cascade, as well as the coagulation inhibitors protein C and protein
S. A deficiency in these factors can cause easy bruising and a prolonged PT time.
A. Boxing causes bruising and nosebleeds, but there has been a status change in the ease
of bruising and frequency of nosebleeds.
B. Iron deficiency will cause anemia, but not easy bruising.
D. DIC will cause a bleeding disorder, but the patient's presentation puts this lower on
the list of differential diagnoses.
E. Hemophilia is an inherited disorder that would have been present throughout the
patients life. He would not have a recent onset of symptoms.


2. Correct answer: E Iron preparation. Main cause of all anemia is iron deficiency.
Not A)- because of no suggestion for megaloblastic anemia in clinical vignette. Could be
used to increase absorption of iron, but not as primary treatment.
Not B) because Erythropoietin would be indicated in chronic renal failure patients, no
clinic evidence for this.
Not C) because of no suggestion of megaloblastic anemia and or pernicious anemia.
Not D) because used for bone marrow failure, not suggestion of BM failure. Would
require history of infections

3. Correct answer: D A markedly enlarged spleen. The condition is hereditary
spherocytosis. Patients often present as children with pallor, jaundice, easy fatigue and
an enlarged spleen.
A. Incorrect: Pica, the consumption of non-foods (like dirt) is sometimes a sign of iron
deficiency. Iron deficiency anemia is not hereditary.
B. Incorrect: Not eating vegetables is unlikely to cause anemia in children, and
definitely is not a sign of a hereditary anemia.
C. Incorrect: Nervous symptom signs could be a sign of B12 deficiency, but are unlikely
in
a child. B12 deficiency anemia is not hereditary.
E. Incorrect: Hair loss is associated with iron deficiency. Iron deficiency anemia is not
hereditary.

4. Correct answer: D The patient currently has a 93 pack-year smoking history and is at
high risk for lung cancer
A. INCORRECT: While this may indicate the presence of a BRCA gene in the family it
does not increase the patient's risk of lung cancer
B. INCORRECT: This would indicate that the patient has possibly been exposed to
asbestos and
is therefore at risk for asbestosis, not lung cancer.
C. INCORRECT: Lack of education is not a risk factor for lung cancer
E. INCORRECT: His immigrant status doesn't drastically affect his risk for lung cancer.

5. Correct answer: A Patients who have a family history of breast cancer in a first-
degree relative should begin screening mammograms 10 years prior to the age of
diagnosis of their relative.
B. Incorrect - the patient may want to pursue genetic testing on her own, but in this case
it is inappropriate for the physician to mandate such testing.
C. Incorrect - it is important for a patient with a family history suggestive of a BRCA
mutation to start screening mammograms 10 years prior to the age of diagnosis of their
first degree relative.
D. Incorrect - The BRCA mutations are not associated with an increased risk of cervical
cancer. A yearly pelvic exam with a pap smear is the current recommendations for
cervical cancer screening.
E. Incorrect - this is not an appropriate course of treatment for this patient.

6. Correct answer: C Citrus fruits can cause apthous ulcers (canker sores) in some
people, but are in fact protective against oral cancer
A. Incorrect - tobacco is a major risk factor for leukoplakia and oral cancer.
B. Incorrect - alcohol is also a risk factor or oral cancer and pre-malignant oral lesions.
D. Incorrect - HPV is responsible for approximately 20% of oral cancers.
E. Incorrect - an immunocompromised state can predispose a patient to oral cancer.

7. Correct answer: D Moderate caffeine consumption is not a risk factor for DVT.
Smoking (A), hormonal contraception (B), and long periods of physical stasis (C) are all
risk factors for DVTs. Factor V Leiden (E) is an autosomal dominant clotting disorder
that leads to frequent life-threatening thromboses.

8. Correct answer: E Methotrexate blocks THF synthesis and leads to bone marrow
suppression, thus increasing anemic symptoms. It is not indicated in sickle cell disease
treatment. Rehydration and analgesic therapy (A) are used to reduce the pain and the
clumping of RBCs associated with vaso-occulsive crises in Sickle cell disease.
Hydroxyurea (B) stimulates fetal hemoglobin-Hb molecules that are less prone to
clumping. EPO Tx (C) are used to increase Hb levels and to induce fetal Hb production,
leading to a decrease in anemic symptoms. BMT (D) is used to generate healthy RBCs

9. Correct answer: D The actinic keratoses described in the stem of the question are
superficial, flattened papules covered by a dry scale. They appear on sun-exposed skin of
older, fair-skinned persons and grow back rapidly if scraped off. They are benign, but
may give rise to squamous cell carcinoma.
A. INCORRECT- Common moles can become atypical nevi if changes are seen
regarding the following features: shape, border, color, and size. An atypical nevus is
usually greater than 6mm in size and found primarily on the trunk. It is a precursor to
melanoma. B. INCORRECT- See answer choice A. The precursor to melanoma is
atypical nevi. Melanomas tend to be asymmetric with irregular borders. They also tend
to vary in color (mixtures of black, blue and red are common). Like atypical nevi, the
diameter of melanomas tends to be greater than 6mm.
C. INCORRECT- Actinic keratoses are described in the stem of the question. They are a
precursor to squamous cell carcinoma.
E. INCORRECT- Basal cell carcinoma is a translucent nodule with a depressed center
usually found on the face. It grows slowly, and there is no known precursor.

10. Correct answer: C This patient's symptoms represent the classic clinical
presentation of benign prostatic hyperplasia (BPH). A markedly enlarged and rubbery or
slightly elastic prostate gland would be expected on physical exam.
A INCORRECT, exam findings consistent with prostate cancer
B INCORRECT, normal exam findings
D INCORRECT, exam findings consistent with acute prostatitis
E INCORRECT, exam findings consistent with prostate cancer



The Chest Exam- Answers
1. Correct Answer: D. These findings are consistent with consolidation, in which alveoli
fill with fluid. The consolidation is due to pulmonary edema secondary to congestive
heart failure.

Incorrect Answers:
A) These findings are consistent with atelectasis (lobar obstruction).
B) These findings are consistent with a pneumothorax.
C) These findings are consistent with a pleural effusion.
E) These findings are consistent with COPD.

2. Correct Answer: A) This woman was likely infected with Coccidioides immitus and
developed pneumonia. African Americans, Filipinos and pregnant women in their third
trimester are more susceptible to infection by the fungus, which is endemic to the
Southwestern United States and Northern Mexico.

Incorrect Answers:
B) Patients with asthma present with episodic symptoms of wheezing, cough and chest
tightness.
C) Patients with acute pulmonary embolism present with dyspnea, often without
associated symptoms. Women are at increased risk postpartum.
D) Patients with bronchitis have a productive cough (yellowish-grey or green sputum),
sore throat, breathlessness, and wheezing.
E) Normal pregnancy changes include respiratory alkalosis, increased tidal volume and
increased minute ventilation.

3. Correct Answer: B. Bleomycin is associated with interstitial pneumonitis, which can
progress to pulmonary fibrosis.
Incorrect Answers:
A) Adriamycin is associated with cardiotoxicity, myelosuppression, alopecia, stomatitis,
and esophagitis.
C) Dacarbazine is associated with nausea, vomiting, and diarrhea in over 90% of
patients. Other side effects include leukopenia, thrombocytopenia, hepatotoxicity,
injection site pain, and a flu-like syndrome.
D) Prednisone can lead to exogenous Cushing syndrome.
E) Vinblastine is most associated with leukopenia. Other side effects include acute
dyspnea and bronchospasm, nausea and vomiting, hypertension, phlebitis, alopecia, and
ototoxicity.

4. Correct answer (D):
This patient's spontaneous pneumothorax may be caused by a ruptured bleb on the
visceral pleura that allowed air to fill the pleural space causing hyperresonance to
percussion. The absent lung sounds are likely due to associated collapse of the lung due
to the increased pleural pressure.

A and D) Dullness will not be observed in a spontaneous pneumothorax. The physical
findings in both answers are more characteristic of pulmonary consolidation, a pleural
effusion, or atelectasis.
  B) While hyperresonance is observed in pneumothorax it is more likely to be unilateral
and would not be associated with wheezes. This most likely describes chronic
obstructive pulmonary disease.
  C) This is the description of normal lungs.

5. Correct Answer: D

Explanation. The characteristics of a pleural effusion include: decreased vocal fremitus
(also seen with fibrosis and pneumothorax); decreased breath sounds and dullness to
percussion (seen when liquid or solid replaces air); decreased chest wall movement and
expansion (seen in fibrosis, pleuritis, or pneumonia); egophany or E-to-A change (seen in
consolidation).

6. Correct answer (B): This describes the proper ladder method for auscultation of the
lungs.
Incorrect answers:
A) Breathing should be done through the mouth while auscultating.
C) When auscultating, you should alternate between the lungs so that you can compare
any abnormalities.
D) Auscultation should also be done anteriorly.
E) Use a stethoscope for auscultation.

7. Correct answer (C): The patient should not be aware that his respiratory rate is being
counted because the patient will breathe differently if he is thinking about his breathing.
A good time to take the respiratory rate is while the patient is sitting quietly and you are
performing another part of the physical exam.
Incorrect answers:
A) This is not the proper technique. You do not want the patient to pass out.
B) Do not tell the patient that you are counting his respiratory rate.
D) The respiratory rate is an important part of the physical exam.
E) The respiratory rate should be taken while the patient is relaxed.

8. Correct Answers: B. is correct because wheezes are a prominent feature of acute
asthma, and will not clear with cough, unlike some other causes of wheezing.

A and C are incorrect because even though other adventitious lung sounds may be present
in the asthmatic patient, they are most often incidental findings and are likely to be
obliterated by loud wheezes.
D is incorrect because even though respiratory rate is likely to be increased, breath
sounds will not be normal (wheezing most likely)
E is incorrect because stridor is heard with upper airway obstruction above the
bronchiolar level affected in asthma (although stridor can often be heard by listening with
a "naked ear")

9. Correct Answer: A. The patient has Marfan syndrome, which is characterized by
pectus excavatum (a depression of the sternum) and mitral valve prolapse, which gives
rise to a late systolic murmur with a midsystolic click.

B. Marfan patients can also have pectus carinatum, an anterior protrusion of the sternum,
but pectus excavatum is more common. Pectus carinatum usually does not compromise
ventilation (versus pectus excavatum, which can impair respiratory function.)
C. A holosystolic, high-pitched blowing murmur is characteristic of mitral regurgitation.
D. As above.
E. Flail chest is when one chest wall moves paradoxically inward during respiration,
which can happen, for example, with multiple rib fractures.

10) Correct Answer: D. Crackles are common for patients who have been bedridden for
extended periods of time.

A:   Suggests consolidation, meaning pneumonia is likely still present.
B:   Suggests reinfection or infection with new pathogen
C:   Also suggests consolidation
E:   Presence of infection


The Heart Exam- Answers
1. Correct Answer: B. Aortic insufficiency presents as a high-pitched blowing diastolic
murmur heart heard best at the 4th left sternal border. It is a high pitched murmur that
may radiate to the apex. It is associated with large and bounding pulse pressures and, if
severe enough, head bobbing with the heartbeat (deMusset's sign). Patients have a wide
pulse pressure because of the increased stroke volume.
 A. Incorrect. Mitral stenosis presents following an opening snap after S2 during
diastole. It is a delayed rumbling and a late diastolic murmur. It is increased upon
expiration and heard best at 4th left intercostal space.
C. Incorrect. Aortic stenosis presents as a medium, harsh crescendo-decrescendo systolic
ejection murmur following an ejection click heard best at the 2nd right interspace. It may
radiate to the apex. A2 may be delayed and merge with P2, producing a single S2 on
expiration.
D. Incorrect. Mitral regurgitation is a holosystolic high-pitched "blowing" murmur heard
loudest at the apex and radiates to the axilla. It increases on expiration. An S3 is
sometimes associated with this condition because of the overload on the left ventricle.
E. Incorrect. Tricuspid regurgitation presents as a blowing holosystolic murmur that is
heard best at the left sternal border and increases upon inspiration. The jugular venous
pressure is often elevated, as illustrated by large v waves.

2. Correct Answer: A. The diaphragm is better at picking up high-pitched sounds while
the bell is more sensitive to low-pitched sounds. S1 and S2 are high-pitched sounds
representative of the closure of the mitral and tricuspid and the aortic and pulmonary
valves. S3 and S4 are due to rapid ventricular filling in early diastole and an "atrial kick"
that fills the ventricle in atrial systole respectively.

B. Incorrect:While the diaphragm is good at picking up high-pitched sounds such as those
of S1 and S2, the bell is the better choice for listening to lower pitched sounds such as S3
and S4. The diaphragm is a plastic disk. When placed on the body, the body's sounds
will vibrate the diaphragm and this sound is transmitted to the listener. The bell,
however, is a hollow cup. The vibrations of the skin directly produce acoustic pressure
waves that travel to the listener's ears.
C. Incorrect:S1 and S2 are both high-pitched because they represent closure of the mitral,
tricupsid, aortic and pulmonic valves. The diaphragm should therefore be used when
listening for these sounds, while the bell should be used when listening for the lower
pitched sounds of S3 and S4.
D. Incorrect: When choosing which part of the stethoscope to use during the
cardiovascular exam, the choice should be made based on the pitch of the sound that you
are listening for regardless of whether it is a normal heart sound or a murmur. Because
S1, S2, aortic and mitral regurgitation and pericardial friction rubs are all high-pitched,
the diaphragm should be used when listening for these sounds and murmurs. The bell,
however, should be used for low-pitched sounds and murmurs such as S3, S4 and mitral
stenosis.
E. Incorrect:When choosing which part of the stethoscope to use during the
cardiovascular exam, the choice should be made based on the pitch of the sound that you
are listening for regardless of whether it is a normal heart sound or a murmur. Because
S1, S2, aortic and mitral regurgitation and pericardial friction rubs are all high-pitched,
the diaphragm should be used when listening for these sounds and murmurs. The bell,
however, should be used for low-pitched sounds and murmurs such as S3, S4 and mitral
stenosis.
3. Correct Answer: D This is the position that will best bring out an aortic murmur.
While aortic stenosis may be easy to hear in any position, this position would help to
elicit aortic regurgitation.
A: This position would be most helpful to bring out left sided S3 and S4 and mitral
murmurs.
B: This position is appropriate when performing the lung exam.
C: This would not help to bring out an aortic murmur.
E: While squatting is a useful position to distinguish between a number of murmurs such
as mitral valve prolapse, hypertrophic cardiomyopathy and aortic stenosis, we are more
concerned with accentuating an aortic murmur and distinguishing between aortic
regurgitation and aortic stenosis. Therefore D would be a better first step.

4. Correct Answer: D. The bell is most useful for picking up low-pitched sounds like
S3, S4, and mitral stenosis. Use of the diapragm is better for hearing S1, S2, aortic or
mitral regurgitation, the higher-pitched heart sounds.


5. Correct Answer: C.
A. Incorrect: This is the pulmonic area for auscultation
B. Incorrect: This the tricuspid area for auscultation
D. Incorrect: This is the area to auscultate for femoral bruits related to atherosclerosis
and peripheral vascular disease
E. Incorrect: This is the area to palpate for the PMI

6. Correct Answer: C.
 A. Incorrect: Very loud murmur, with thrill. May be heard when the stethoscope is
partly off the chest
B. Incorrect: Very faint murmur, heard only after listener has "tuned in"; may not be
heard in all positions
D. Incorrect: Moderately loud murmur with no palpable thrill
E. Incorrect: Very loud murmur, with thrill, that may be heard with the stethoscope
entirely off of the chest

7. Correct Answer: E
A. Incorrect: The usual starting point is 30 degress
B. Incorrect: The JVP is a measurement of the jugular vein and is not related to the
carotid artery.
C. Incorrect: As the patient's position is changed, the level of pulsations change; as the
patient is lowered, the JVP will increase.
D. Incorrect: Normal is usually 3-4 cm.
E. Right-sided pathology such as congestive heart failure, or less commonly constrictive
pericarditis, tricuspid stenosis, or superior vena cava obstuction, will cause an increased
JVP.
Correct: Any increase in pressure caused by obstruction or inadequate emptying of the
heart chambers, especially the right side, will cause the jugular venous pressure to
increase.
8. Correct Answer: C. Mitral regurgitation is generally heard throughout systole and
heard best at the apex.

A. Incorrect: This is characteristic of aortic insufficiency
B. Incorrect: Mitral stenosis is a diastolic murmur heard better during exhalation.
E. Incorrect: This is characteristic of aortic stenosis.
9. CORRECT ANSWER: D.
Answer A: This indicates a mitral valve regurgitation problem.
Answer B: This finding indicates a pulmonary valve stenosis problem.
Answer C: This finding indicates an aortic valve insufficiency problem.
Answer E: This finding indicates a tricuspid valve regurgitation problem..

10. Correct answer: D - Carotid bruits are indicative of carotid atherosclerosis, which
puts patients at high risk for a TIA or stroke.

A. Bounding pulses and a decreased diastolic pressure indicate aortic insufficiency.
B. Heart sounds alone are often heard while listeining over the carotids. They do not
constitute a bruit.
C. This murmur best describes mitral regurgitation.
E. An opening snap indicates a stenotic mitral valve.

11. Correct Answer: C.) S2-opening snap interval is an indicator of severity...the
shorter the more severe.

A.)   Intensity...can determine severity in some cases, but not all
B.)   Irregular Rhythm...not involved with mitral stenosis
D.)   S3...absent in mitral stenosis
E.)   S4...absent in mitral stenosis

12. Correct Answer: C) Expiration...if sound is heard while lying on left side during
expiration, an S3 sound indicative of pathology, will be present

A.) Stress test...could accentuate the problem, but may be unsafe in a patient with CHF
B.) Sublingual Nitrous Oxide...similar to D and E
D.) Valsava Maneuver..would decrease venous return to the heart, masking the problem
rather than accentuating it
E.) Amyl Nitrate...would decrease venous return to the heart, masking the problem rather
than accentuating it.


The Abdominal Exam- Answers.
1. The correct answer is D. Rupture of a colonic diverticulum, with resulting fecal
peritonitis, is a catastrophic complication of diverticulitis, particularly in the elderly, with
a mortality near 50%. The rupture frequently involves a diverticulum that is inflamed;
consequently, the rupture may be inapparent due to the pain subsiding, at least initially.
However, shock secondary to septicemia develops rapidly.

Acute appendicitis (choice A), acute cholecystitis with gallbladder rupture (choice B),
and gastric rupture (choice C) are all uncommon in this age group. A rupture of an
ovarian cyst (choice E) can't be the answer since this is a male.
Reference: Kaplan QBank
2. Correct answer: C
Explanation: This patient has acute cholecystitis. The quality, location, radiation, and
duration of the pain, as well as her gender, weight, and a description of previous
symptomatic gallstones lead you to consider this diagnosis. Murphy's Sign--elicited
when the physician palpates the liver head while the patient is supine and inspiring--is
specific for cholecystitis. A positive sign is when the patient stops inspiring due to the
severe pain.

Rovsing's, Psoas, and Obturator signs are all special tests for peritoneal irritation
(appendicitis). Tinel's sign tests for compression of the median nerve (carpal tunnel
syndrome).

3. Correct answer is D. Gluten sensitivity (Celiac sprue) is classically associated with
crampy abdominal pain, chronic diarrhea, bloating, weight loss, and steatorrhea. IgA
deposits in the skin manifest as dermatitis herpetiformis. Malabsorption of vitamin K
leads to easy bruising.

Choice A (duodenal peptic ulcer) is unlikely to be associated with fatty stools.
Choice B (acute pancreatitis) would likely present with acute onset periumbilical pain,
possibly radiating to the back.
Choice C (intestinal blockage) is unlikely due to the length of time involved, the lack of
severe pain, and the passage of diarrhea.
Choice E (Crohn's disease) is not associated with dermatitis herpetiformis.

4. Correct Answer: B - positive test for shifting dullness, seen with ascites

A:   suggests appendicitis
C:   suggests cholecystitis
D:   positive Rovsing's sign suggesting appendicitis
E:   not consistent with this patient's presentation

5. Correct answer: B When the spleen enlarged, it expands anteriorly, downward and
medially, moving toward the front of the abdomen. By placing the patient in the RIGHT
lateral decubitis position, you allow gravity to pull the spleen more anterior-medially and
thus enhance your ability to palpate it when enlarged. Choice C says Left lateral, a former
teaching, which actually allows the spleen to fall under the ribcage more easily.
Choice A describes Murphy's sign, for acute cholysistitis.
Choice D describes the splenic percussion sign, which when present does indicate the
need for careful palpation. However, percussion of the spleen is never confirmatory for
enlargement.
Choice E askes for deep palpation on expiration. Given the anatomical relationship to the
diaphragm, INSPIRATION forces the spleen out from underneath the costal margin.
Expiration is likely to have a null or negative effect.

6. Correct answer: D This case presentation describes acute appendicitis. Pain in the
right lower quadrant during left-sided deep palpation is called Rovsing's sign, and
suggests appendicitis. So does lower quadrant pain on quick withdrawal (referred
rebound tenderness). Other findings suggestive of appendicitis include a positive Psoas
sign - increased abdominal pain when the patient lies on her left side and extends her
right leg at the hip against resistance, suggesting irritation of the psoas muscle by an
inflamed appendix; and a positive Obturator sign - right hypogastric pain when the
patient's right knee is bent and the thigh is flexed and internally rotated at the hip,
suggesting irritation of the obturator muscle from an inflamed appendix. Choice B is
incorrect because it involved external rotation of the patient's left leg.
Choice A describes the "fluid wave test" for ascites. Choice C describes the maneuver to
elicit Murphy's sign, which suggests acute cholecystitis. Choice E is incorrect because
pain with fist percussion on the back, or acute costovertebral tenderness, is suggestive of
pyelonephritis or a musculoskeletal cause.


7. Correct Answer: B) T: You would expect to find increased anal tone and pain on
rectal examination

Explanation of Incorrect Answers:

a) F: Bright red blood is more typical of hemorrhoids
c) F: This pattern is more often represents high rectal lesions such as carcinoma,
    angiodysplasia, or inflamed diverticula
d) F: Blood loss from simple ano-rectal conditions is rarely severe enough to result
    in anemia- carcinoma, IBD, or angiodysplasia are more likely
e) F: This is would be more of a characteristic feature of diverticulitis

8. Correct Answer: E. A thru D are all stigmata of liver disease. E is most likely to be
an umbilical hernia and is not associated with liver disease.

9. Correct answer is C. This is a positive grey turner sign that is often present in acute
pancreatitis. A or E are associated with liver or gall bladder disease. B is associated
with infectious diseases such as syphilis and rocky mountain spotted fever. D polyuria is
associated with diabetes, seen in long standing chronic pancreatitis.

10. Correct Answer: C. Situs inversus is the rare congenital anomaly where the visceral
structures in the thorax and abdomen are reversed through the sagittal plane. In patients
without situs inversus, the liver is located in the RUQ and the stomach is located in the
LUQ. In patients with situs inversus, the placement of the abdominal organs is reversed.
The stomach will be found in the RUQ and the liver will be found in the LUQ.
   Percussion over any solid structure (such as the liver) will be dull. Percussion over
any air filled structure (such as the gastric bubble of the stomach) will be tympanic.

A. False. This describes the physical findings in patients without situs inversus.
   Dullness is noted where the liver is found and tympany is noted where the gastric
   bubble is found.
B. False. Tympany over the RUQ and dullness over the LUQ is expected in this patient.
   However, such marked asymmetry between the RLQ and LLQ would not be a normal
   finding.
C. True. This describes the physical findings in patients with situs inversus. Since the
   liver is located in the LUQ, dullness will be noted there. Since the gastric bubble of
   the stomach is located in the RUQ, tympany will be noted there.
D. False. Eating lunch will not result in dullness of the entire abdomen. It would only
   result in dullness over the stomach.
E. False. Even though the patient did not eat lunch, the liver would still be dull.

11. Correct answer is b. This child is presenting with congenital pyloric stenosis.
Vomitting usually begins 2-4 weeks after birth and is due to progressive hypertrophy of
the pylorus which prevents gastric emptying.

a. Melena is a description of black, tarry stools that one sees in patients presenting with
upper GI bleeds. Upper GI bleeding is not commonly associated with congenital pyloric
stenosis.
c. Absent bowel sounds are associated with small bowel infarction, typically not seen in
this condition.
d. A simian crease is often seen in patients with Down Syndrome. Down syndrome is
associated with duodenal atresia which presents with vomiting, stained with bile, on the
day of birth
e. Shifting dullness is associated with ascites, which is not seen with congenital pyloric
stenosis.

12. Correct Answer (A) - the pain will usually radiate from the right epigastric area to
the right area of the shoulder.
(B) - Left shoulder pain is significant of pain occurring when patient is having a heart
attack
(C) - LLQ pain more reflective of pain due to appendicitis
(D) - RLQ seen in bowl, sigmoid disease
(E) - periumbilical pain from abdominal aorta

13. Correct Answer: D
 Incorrect Answers:
A - rebound tenderness is a NON-SPECIFIC sign of peritonitis
B - rebound tenderness is induced when the hand is WITHDRAWN during deep
palpation
C - rebound tenderness is induced when the hand is WITHDRAWN during deep
palpation
E - rebound tenderness is not commonly associated with the game of basketball
14. Correct Answer: D
Explanation: In this exam, auscultation is performed right after inspection, so that
bowel sounds are not altered by manual stimulation from the examiner. While this
may not be firmly grounded in evidence-based medicine, it is the current standard.

The Pelvic and GU Exam- Answers
1. Correct Answer: a (Klinefelter syndrome)

Wrong answers:
B= Hypopituitarism, cirrhosis
C= Cryptorchidism
D= Testicular cancer
E= Tuberculous Epididymitis

2. Correct Answer: e (candidal vaginitis)

Wrong answer:
A= Mucopurulent cervicitis caused by Gonorrhea or Chlamydia infection
B= Trichomonal vaginitis
C= Bacterial vaginosis (Gardnerella vaginalis)
D= Uterine Leiomyosarcoma

3. The correct answer is B. This is a Bartholin's gland abscess, which is a common
problem in women of reproductive age. Bartholin's glands are located bilaterally at the
posterior introitus and drain through ducts that empty into the vestibule at approximately
the 4 o'clock and 8 o'clock positions. These normally pea-sized glands are palpable only
if the duct becomes cystic or a gland abscess develops (infection most often caused by
Neisseria gonorrhoeae)

Condyloma acuminatum (A) would have presented as a papillary lesion/warts.
Gartner's duct cyst (C) is a remnant of Wolffian duct which presents on lateral wall of the
vagina.
Lichen sclerosis (D) usually in post-menopausal women with parchment-like thinned
epidermis.
Vulvar squamous hyperplasia (E) usually presents as a white plaque.

4. Correct answer is A. This patient is suffering from an ectopic pregnancy likely due to
PID. Some of the most common signs and symptoms include lower abdominal pain,
irregular vaginal bleeding and pain while the cervix is being manipulated due to pressure
on the fallopian tubes. hCG levels are typically elevated but not as high as normal
pregnancies. Assuming the patient has salpingitis from PID, there will not be any
findings in the uterine upon ultrasound since the ectopic pregnancy is in the tubes.

Incorrect answer:
B- Leads to appendicitis. Not associated with vaginal bleeding.
C- Marker for ovarian cancer which would probably not present acutely.
D- Associated with LLQ pain and no vaginal bleeding.
E- Rarely associated with acute pain.

5. Correct Answer: D-The BP, HR, and syncope indicate that the patient is suffering
from some type of hemorrhage. Ovarian cysts, ruptured tubal pregnancy and PID can all
present as adnexal masses are associated with, however of these only ruptured tubal
pregnancy is associated with significant bleeding.

Incorrect Answers:
A-PID is associated with is associated with bilateral adnexal masses and is not associated
with hemorrhage.

B-A ruptured appendix often comes along with fever, chills, shaking, changes in
defecation patterns, and loss of appetite. It is not usually associated with hemorrhage.

C-The uterus can prolapse into the vagina when the muscles of the pelvic floor weaken.
Prolapsed uterus is accompanied by difficulty urinating, lower back pain, a feeling of
fullness in the pelvis, and painful sexual intercourse.

E- Fibroids are firm irregular nodules in continuity with the uterine surface. They can be
single and unilateral or multiple and bilateral, varying in size. Fibroids often present with
backache, increased menstrual cramping, abdominal bloating, and constipation. Fibroids
may be associated with heavier or prolonged menstrual flow but are not associated with
massive hemorrhage.

6. Correct Answer: B-While all others are specific indications for pelvic exams in
adolescence (see Bates p. 439) initiation of sexual activity is not necessarily an indication
for a pelvic exam in this population.

7. Correct answer: B- This is genital herpes as evidenced by a sexually active male
presenting with a cluster of vesicles which eventually become non-indurated ulcers on
red bases. Additionally, it is painful. It is separated from Chancroid by the negative
gram stain.

A. Condyloma acuminatum- These are not red and ulcerative. Additionally, history and
exam would have most likely revealed moist and malodorous excrescences.
C. Primary syphilis presents as a painless, not painful chancre.
D. Chancroid does present as a painful ulcer, but gram stain would have revealed a
    "school of fish" appearance.
E. Peyronie's Disease presents as palpable non-tender hard plaques beneath the skin
     on the dorsum of the penis.

8. Correct answer is A. A hydrocele is a serous, fluid-filled sac surrounding a testicle
that results in swelling of the scrotum. All swelling of the scrotum should be evaluated
by transillumination, and swellings containing serous fluid (including hydroceles) will
light up with a red glow or transilluminate, while those containing blood or tissue due
not. Also, when a hydrocele is present the examiner is able to place fingers above the
mass while palpating the scrotum, in comparison to a scrotal hernia in which the
examiner is unable to place fingers above the mass.

A scrotal hernia (B) would come through the external inguinal ring and therefore the
examiner would be unable to get fingers above the mass within the scrotum.
In acute orchitis (C) testis would present as painful and tender.
Cryptorchidism (D) presents as atrophied testis and undeveloped scrotum.
Acute epididymitis (E) would be acutely inflamed, tender and swollen.

9. Correct Answer: D. it is correct to begin the examination by telling the patient that
she will feel the examiner's hand first on her leg, and then the exam will begin

A-   interactions should be kept professional; jokes may be seen as inappropriate
B-   patients should be informed of all of the steps of the exam
C-   it is more comfortable to empty the bladder prior to examination
E-   patients should be informed of all of the steps of the exam


10. Correct Answer: C. Testicular torsion. While the cremasteric reflex is generally
non-specific, it is often absent in patients with testicular torsion.

The other answers are incorrect, as they would rarely interrupt the innervation of the
testes.

The History Answers (24)

1) A- correct because the chief complaint is written in the patients own words and
includes duration of symptom

B- Incorrect because it uses medical jargon
C- Incorrect because it is not the patient's complaint
D- Incorrect because it is not the patient's complaint
E- Incorrect because it does not include the duration of symptoms

2) A- correct because unless information is recorded it will be assumed that the
question has not been asked

B- Incorrect because the recorded history omits mention of whether the cough was
productive or not
C- Incorrect because the verbal history makes no mention of the cough
D- Incorrect because the recorded history makes no mention of the cough
E- Incorrect because the verbal history only notes that a cough was present
3) D. CORRECT because it describes a psychiatric illness that would be
placed in the past history

A. it describes the patient's marital status and should be part of the social history.
B. it describes his past and current employment and should be part of the social history.
C. it describes his hobbies and should be part of the social history.
E. it describes his recent travel history and should be part of the social history.

4) B - Information about a patients habits (smoking, drinking, sleeping, attention to
personal health care, illicit drug use etc.) should be included under the Social
History.

Incorrect choices: A, C, D, E
Childhood diseases, previous hospitalizations, therapeutic diets, and medication
information should all be included in a patients Past Medical History.

5) C. this belongs in the past medical history, not the history of present illness, as it
describes a previous medical illness that is not directly related to his recent episode
of symptoms

A. it establishes the onset of the current symptoms.
B. it describes the location of the symptoms which is an important component of the
history of present illness.
D. it describes a factor that alleviates the symptom. It is directly related to the current
episode of symptoms
E. although this describes an event from the past it establishes that the patient had
symptoms like this before, therefore it belongs in the HPI.

6) Correct Answer: B. Even though his diagnosis of melanoma was revealed while
going through a review of systems, this information belongs in the past medical history.
The order in which the information was obtained does not necessarily correlate with the
order and categorization of the written history.

7) A. Correct- Any relevant past history should be included in the History of
Present Illness.

B. A list of medications would be included in her Past Medical History.
C. Illnesses/conditions of family members would be included in Family History.
D. Immunizations would be included in her Past Medical History.
E. Symptoms (or lack thereof) not relevant to the present illness should be recorded in the
Review of Systems.

8) A. Correct - Address the patient directly using nonverbal behaviors.

B. The interpreter can be used as a cultural resource.
C. Like the physician-patient relationship, the interview will go more smoothly if a
rapport is established between the interpreter and patient.
D. Keeping sentences short and simple will allow the interpreter to translate everything
instead of condensing or summarizing.
E. Use trained interpreter. In some cases speakerphone translators are available.

9) "A" is correct because the information is pertinent to the present illness, and
therefore it would go in the HPI.

"b)" is incorrect because the information relates to the patients family and not to him.
"c)" Would normally be correct because the information relates to the patient's family's
medical record, but since it is pertinent to the current illness, it would go in the HPI. "d)"
is wrong because this information does not relate to the patients social habits, and "e)" is
wrong because the only information included in the chief complaint is the initial
symptom(s) which have caused the patient to seek medical aid.

10) C - Not a high-yield question in setting of chest pain.

A: Important question in any history of pain.
B. Rule out GERD.
D. Helpful in diagnosing MI.
E. DDx anxiety attack.

11) The correct answer is E. All of these are relevant parts of a patient's history. A
relates to the history of the present illness. B, the patient's age, is a part of her identifying
data. C is a negative review of systems response, and negative responses are as important
to include as positive ones. D is a portion of her occupational/social history and therefore
should be included.

12) The correct answer is D. Objective data is obtained on physical exam, and this is
how the the bruit was found. Anything a patient tells you is considered subjective data.
This includes the history from chief complaint through review of systems. Therefore,
choices A, B, and C are considered subjective. E is incorrect because D is an example of
objective data.

13) Correct answer: C. The patient's right side is drawn to the left of the diagram.
Lower motor neuron damage is consistent with a zero-grade reflex, indicated by a
downward arrow in the diagram. The C7/C8 level is consistent with a triceps reflex
(drawn below the elbow joint).

A. Incorrect because this indicates a diminished biceps reflex, not triceps.
B. Incorrect because this indicates a left-sided deficit.
D. A 3+ reflex is inconsistent with lower motor neuron damage.
   (Brisker-than-normal reflexes may indicate UMN damage.)
E. Ditto.
14) Correct Answer: C) This frames the topic and prepares the patient for further
inquiries into their sexual history.

A) This is an inappropriate question, and does not address whether or not the patient is
sexually active.
B) You should not make an assumption about the sexual orientation of a patient.
D) This is an inappropriate and close ended question, and may be shocking or offensive
to the patient.
E) A sexual history is an integral part of taking a complete history.

15) Correct choice: E Location, quantity/severity, onset, duration, and
aggravating/relieving factors should be asked and included in the HPI.

16) Correct Choice: C Explanation: Changes in weight can be included in the HPI, if
relevant, or ROS, not in the Social History. Education, job history, and exercise/diet are
all commonly included in the Social History.

17) D - The mother's input is valuable but you should still focus your questioning
towards a pediatric patient

A - ignoring the child impairs the physician-patient relationship
B - same as A
C - eliminating the parent as a source of information limits your knowledge
E - same as C with the addition of alienating the mother

18) Correct Answer: C - medications used to treat problems do not belong in the CC

19) Correct Answer: C - While all of these may be done during a cardiac exam, the
history provides the most information and aids in creating a differential diagnosis.

20) Correct Answer: A - allergies belong in the medical allergies section

B: incorrect - important information that likely contributed/triggered her COPD
exacerbation
C: incorrect - this is likely a COPD exacerbation episode
D: incorrect - important information regarding her medical management in the ED and
relevant to her current management
E: incorrect - important information to rule out a cardiac event

21) Answer is B. B is incorrect because the CAGE questionnaire includes asking the
patient
whether he/she has felt the need to cut down on drinking, ever felt annoyed by criticism
of drinking, felt guilty about drinking or ever needed a drink first thing in the
morning. It does not include asking the patient if they have ever endangered their life
while drinking.
22) Answer is C. There are many techniques which can be employed in interviewing a
patient. A- Correct. Summarization is repeating back a summarized version of a patient's
story.
B- Correct. Reassurance involves identifying and acknowledging a patients feelings and
dealing with his or her concerns
C- Incorrect. Sharing a personal anecdote is not a helpful technique as it shifts the
focus on the interview from the patient to the physician.
D- Correct. Partnering refers to making clear your intention to work with the patient. E-
Correct. Active Listening is the process of attending to a patients verbal or nonverbal
communication, being aware of her/her emotional state and encouraging him/her to
speak.

23) Choice C is correct. The chief complaint should consist of what the patient
describes as their main problem(s), written is the patient's own words as much as
possible.

24) Choice C is correct. It is important for a physician to let a patient speak
uninterrupted, as this will enable a physician to receive a full answer to the question.
Most patients will have finished answering the question with in 2 minutes.

Preventative Health and Nutrition Answers (15)

1) Correct Answer: A. These are findings that indicate diabetes mellitus, and because
the patient is obese and older, most likely type 2. Diabetes mellitus increases the risk of
early and accelerated atherosclerosis. Decreasing total caloric intake, particularly
saturated fats, can help reduce the risk of coronary artery disease.

B: Fiber is known to help reduce the risk of diverticulosis.
C: Vitamin A - no known effect of atherogenesis
D: Reducing sodium helps to reduce blood pressure
E: Drinking more fluids can aid in renal function.

2) Correct Answer: B. These findings are classic of Kwashiorkor disease. These
patients have adequate calorie intake consisting mainly of carbohydrates however no
protein in their diets. The edema is caused by hypoalbuminemia and loss of plasma
oncotic pressure.

A: These are signs of Marasmus which is a dietary deficiency of Calories and Protein
C: Normal body weight would not be found in a patient with Kwashiorkor.
D: You would expect to find pitting edema and physical findings.
E: These physical findings are classic presentations of Vitamin E toxicity not a
nutritional deficiency.

3) (Correct answer: D) Vitamin C deficiency results from a diet lacking in fruits and
vegetables, historically common among sailors at sea longer than perishable fruits and
vegetables could be stored. Vitamin C deficiency leads to reduced tensile strength of
collagen resulting in weak capillaries and venules. Accordingly, physical findings include
skin ecchymoses, perifollicular hemorrhage, hemarthrosis, bleeding gums, and anemia.

(A) Vitamin A deficiency while caused by a lack of yellow and green vegetables,
commonly presents as impaired night vision, blindness, and hyperkeratosis.
(B):Vitamin B1 (thiamine) deficiency, commonly associated with chronic alcoholism in
the United States, classically presents as Korsakoff's syndrome (anterograde and/or
retrograde amnesia with confabulation) and Wernicke's encephalopathy (confusion,
nystagmus, and ataxia)
(C):Vitamin B3 (niacin) deficiency is most commonly caused by corn-based diets
(deficient in tryptophan and niacin), Hartnup disease, or carcinoid syndrome. Clinical
findings of niacin deficiency, or pellagra, include dermatitis, diarrhea, and dementia.
(E): The commonest causes of vitamin D deficiency include renal failure, inadequate
exposure to sunlight, fat malabsorption, and chronic liver disease. Furthermore,
presentation of vitamin D deficiency in adults invariably involves pathologic fractures.

4) Correct Answer: B) Folic Acid: adequate folic acid in a mother's diet during the
periconceptional period (both immediately before and after conception) has been shown
to significantly decrease the incidence of neural tube defects such as spina bifida.

A) Calcium: Ca is needed in pregnant mothers to prevent bone loss. If there is not enough
exogenous Calcium in the mothers diet, the mother's bones with release Ca in order to
supply the growing fetus with Ca. This leads to weak bones and pathological fractures.
C) Vitamin K: because newborns do not have bacterial colonization of the large bowel,
they lack vitamin K. To prevent hemorrhagic disease, all newborns in this country are
given a shot of vitamin K. Vitamin K, however, has no effects on neural tube defects
D) Iron: During pregnancy, the mother's plasma volume and hematocrit increase. In order
to prevent anemia, Iron is needed to form the new hemoglobin necessary for the increase
in hematocrit.
E) Vitamin D: Vitamin D is necessary for correct Ca absorption. Lack of vitamin D can
lead to low levels of Ca absorption. IN order to maintain high blood Ca levels for the
fetus, the mother's bones will then release Ca, resulting in weak bones and pathologic
fractures.

5) Correct answer: E. Niacin (B3) deficiency is characterized by diarrhea, dermatitis
(hyperpigmentation in sun-exposed areas), and dementia. This condition is also known
as pellagra.

A: B12 deficiency--megaloblastic anemia, neurologic disease, glossitis. No rash
B: B6 = Pyridoxine--deficiency results in convulsions, hyperirritability, peripheral
neuropathy
C: Vit D deficiency--can cause muscle aches, muscle weakness, and bone pain at any age
D: Cobalamin = B12

6) Correct Answer: C (overweight). In this category BMI is between 25 and 29.9
A. Underweight <18.5
B. Normal weight 18.5 - 24.9
D. Obese > 30
E. Currently the NIH does not have a separate category for morbidly obese, but other
resources calculate it as >40.

7) Correct Answer: A (smoking)

B, C, D, E are all diagnostic criteria of metabolic syndrome in addition to HDL < 50
mg/dl. These cut off values are for females.

8) Correct Answer: D (vitamin A) - The infant's symptoms and positive sweat chloride
test indicate Cystic Fibrosis. While there are many complications of CF, one notable one
is fat malabsorption due to atrophy of the dehydrated pancreatic exocrine glands. The fat
soluble vitamins (A, K, E, D) require proper fat absorption to avoid deficiency.

(A) Vitamin B12 is incorrect because it is a water-soluble vitamin and does not require
fats for proper absorption.
(B) Vitamin C is also a water-soluble vitamin and deficiency is implicated as the etiology
of Scurvy.
(C) Folic acid is also a water-soluble vitamin and is found in green, leafy vegetables.
(E) Vitamin water is not a vitamin, even though the corporation who makes it might try
to convince you otherwise.

9) Correct Answer: C - Neurologic deficits, such as optic neuropathy and posterior
column disease (vibration and proprioception), are characteristic of vitamin B12
deficiency. The most common cause is pernicious anemia, an autoimmune disorder
usually in the elderly where there are antibodies produced against the parietal cells in the
stomach that produce intrinsic factor (necessary cofactor for B12 absorption in the ileum)

a) Deficiency of vitamin B3 (niacin) results in pellagra, characterized by the "3 D's" -
diarrhea, dermatitis, and dementia. The diet must be lacking in tryptophan to result in
this vitamin deficiency since it can be synthesized from this amino acid.
b) Vitamin B6 (pyridoxine) deficiency is most often a manifestation of chronic
alcoholism or isoniazid, a TB drug that is a competitive inhibitor for pyridoxine binding
sites
d) Vitamin A deficiency usually causes ocular abnormalities (i.e. night blindness) and is
precipitated by dietary deficiency or fat malabsorption of this fat-soluble vitamin
e) Vitamin K is necessary for the post-translational modification of clotting factors II,
VII, IX, X, and proteins C and S. This vitamin is produced by normal intestinal flora and
a deficiency can be caused by antibiotics acting against these bacteria in the intestine or
fat malabsorption. Patient will often present with abnormal bleeding.

10) Correct Answer: E- Height and weight. Body Mass Index is defined as the weight
of a person (in kilograms) divided by the square of the height of that person (in meters)
and is used as an indicator of whether or not a person is over- or underweight.
A- Weight circumference and blood glucose levels are relevant in assessing someone for
metabolic syndrome.
B- These are vital signs that should be measured in all patients, but would not be used to
calculate BMI.
C- Diaphragm excursion is part of the pulmonary exam and curvature of finger and toe
nails would be noted to assess for clubbing, a physical finding in many disease states, but
neither are used to calculate BMI.
D- Get up and go time is used to assess mobility and pupil diameter is measured as part
of an eye and neurological exam.

11) Correct Answer: C - Calcium: It's what bones are made of. RCTs have shown that
adequate intake of calcium decreases the risk of fracture and osteoporotic deformity.

A. Potassium: While our little old lady may be at risk for hypokalemia secondary to
vomiting, that does not have much bearing on her potential osteoporosis.
B. Vitamin A: Some studies have suggested that excessive supplementation with Vit A
can increase the risk of fracture in at-risk populations. However, calcium is still the more
important topic, as far as bones are concerned.
C. Calcium
D. Sodium: Not especially relevant to bones.
E. None of the above: Don't be put off by her dismissive comments about your shoes.
They're nice shoes. Really.

12) Correct Answer: C - Vitamin D deficiency. Vit. D, also known as 1,25-
dihydroxycholecalciferol, is important for increasing serum Ca++ and phosphate levels in
the ECF to help mineralize new bone. Vit. D deficiency in adults is called osteomalacia,
and the more serious form in children is called rickets. The symptoms of Vit. D
deficiency are mild and occur insidiously, they included dull bone pain, fatigue, muscle
weakness, and factures with little trauma.

A) This could be likely, but the symptoms she describes along with the lack of UV
radiation and avoidance of foods fortified with Vit. D makes answer C more likely.
B) Calcitonin works to decrease Ca++ levels by blocking bone resorption.
D) Vit. C deficiency causes scurvy
E) FM usually occurs presents in the 25-55 age group and is associated with more global
pain.

13) The correct answer is E. Abrasion. A scraping injury produces an abrasion, but
the skin is not broken. An incision (A) is made with a sharp instrument such as a knife,
leaving clean edges. A contusion (B) is a bruise with extravasation of blood into soft
tissues. Lacerations (C) break the skin or other organs in an irregular fashion. A burn
injury (D) causes coagulative necrosis without mechanical obstruction.

14) D is correct
Underweight <18.5
Normal 18.5 - 24.9
Overweight 25.0 - 29.9
Obesity class I 30.0 - 34.9
Obesity class II 35.0 - 39.9
Obesity class III 40+

15) B is correct

Choice A due to beriberi (vit b1 def)
Choice B due to pellagra (vit b3 def)
Choice C due to kwashiorkor (protein malnutrition)
Choice D due to marasmus (energy malnutrition)
Choice E due to scurvy (vit c def)


Breast exam Answer (8)

1) Correct answer is C. Breast self-examination has not been validated as a method for
detecting breast cancer, although they are supported by clinicians and recent guidelines.
However, women choosing to do self-examinations should be instructed on proper
technique (answer D) and to report any new changes or symptoms (answer E). The
American Cancer Society recommends clinical breast examination by a health
professional annually after age 40 (answer A) and an annually mammography beginning
at age 40 (answer B).

2) Answer E: All of the above are correct.
  A. Unilateral discharge is suggestive of local breast disease; bilateral
discharge is suggestive of a hormonal cause such as pregnancy or increased
prolactin levels.
  B. Discharge associated with nipple stimulation is considered physiologic.
  C. The patient's menstraul cycle can help determine the potential for
pregnancy as being responsible for the discharge.
  D. Blood in the discharge
is suggestive of local breast disease or breast cancer.

3) A is correct because the upper outer quadrant has a higher proportion of breast
tissue, thus increasing the frequency of upper outer quadrant carcinomas. This is
reflective of the anatomy of the upper outer quadrant that includes the axillary tail.

4) (C) Axillary lymph nodes are usually the first site of regional spread and contain the
sentinel lymph node. This is a reflection of the regional flow of lymph out of the breast,
passing through the axillary nodes first.

5) D: Smoking is not a primary risk factor for male breast cancer.
All of the other answers are risk factors for male breast cancer, in addition to liver
disease, alcohol, excess weight, and exposure to estrogen.

6) C: 35
Women with first degree relatives who had breast cancer should begin screening with
mamograms 10 years prior to the age at which their relative was diagnosed. Therefore if
the patient's mother was diagnosed at age 45, she should begin mammograms at age 35.

7) B. A breast exam must be done in a mastectomy patient. Special care must be
given to examination of these patients.
Choices A, C, D, E are all incorrect.
 A---necessary to watch for recurrence
 C---lymphadema in axilla because of impaired lymph drainage
 D---part of any breast exam
 E---incisions may be sensitive for the patient.

8) D. all of the above. All of these processes can cause nipple retraction

				
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