Bates’ Guide To Physical Examination And History Taking 12th Edition By Lynn – Test Bank

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Bates’ Guide To Physical Examination And History Taking 12th Edition By Lynn – Test Bank

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Bates’ Guide to Physical Examination and History Taking, 12th Edition

 

 

Chapter 4: Beginning the Physical Examination: General Survey, Vital Signs, and Pain

 

 

 

 

Multiple Choice

 

 

 

 

  1. A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter’s You measure her daughter’s height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?
  2. Refer the patient to a nutritionist and a psychologist because the patient is
  3. Reassure the mother that this is a normal body
  4. Give the patient information about exercise because the patient is
  5. Give the patient information concerning reduction of fat and cholesterol in her diet because she is

 

Ans:    B Chapter:         04

 

Feedback:        The patient has a normal BMI; the range for a normal BMI is 18.5 to 24.9 kg/m2. You may be able to give the patient and her mother the lower limit of normal in pounds for her daughter’s height, or instruct her in how to use a BMI table.

 

 

 

 

  1. A 25-year-old radio announcer comes to the clinic for an annual His BMI is

26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit?

  1. Refer the patient to a nutritionist because he is
  2. Reassure the patient that he has a normal body
  3. Give the patient information about reduction of fat, cholesterol, and calories because he is
  4. Give the patient information about reduction of fat and cholesterol because he is

 

Ans:    C Chapter:         04

 

Feedback:        The patient has a BMI in the overweight range, which is 25.0 to 29.9 kg/m2.    It is

 

prudent to give him information about reducing calories, fat, and cholesterol in his diet to help prevent further weight gain.

 

 

 

 

  1. A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 0 kg/m2. What is the most appropriate amount for a weekly weight reduction goal?
  2. .5 to 1 pound per week
  3. 1 to 5 pounds per week
  4. 5 to 3.5 pounds per week
  5. 5 to 4.5 pounds per week

 

Ans:    A Chapter:         04

 

Feedback:        Based on the NIH Obesity Guidelines, this is the weekly weight loss goal to strive for to maintain long-term control of weight.                             More rapid weight loss than this does not result in a better outcome at one year.

 

 

 

 

  1. A 67-year-old retired janitor comes to the clinic with his She brought him in because she is concerned about his weight loss. He has a history of smoking 3 packs of cigarettes a day for 30 years, for a total of 90 pack-years. He has noticed a daily cough for the past several years, which he states is productive of sputum. He came into the clinic approximately 1 year ago, and at that time his weight was 140 pounds. Today, his weight is 110 pounds.

Which one of the following questions would be the most important to ask if you suspect that he has lung cancer?

  1. Have you tried to force yourself to vomit after eating a meal?
  2. Do you have heartburn/indigestion and diarrhea?
  3. Do you have enough food to eat?
  4. Have you tried to lose weight?

 

Ans:    D Chapter:         04

 

Feedback:        This is important: If the patient hasn’t tried to lose weight, then this weight loss is inadvertent and poses concern for a neoplastic process, especially given his smoking history.

 

 

 

 

  1. Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except:

 

  1. Changes in weight
  2. Fatigue and weakness
  3. Cough
  4. Fever and chills

 

Ans:    C Chapter:         04

 

Feedback:        This symptom is more appropriate to the respiratory review of systems.

 

 

 

 

  1. You are beginning the examination of a All of the following areas are important to observe as part of the General Survey except:
  2. Level of consciousness
  3. Signs of distress
  4. Dress, grooming, and personal hygiene
  5. Blood pressure

 

Ans:    D Chapter:         04

 

Feedback:        Blood pressure is a vital sign, not part of the General Survey.

 

 

 

 

  1. A 55-year-old bookkeeper comes to your office for a routine You note that on a previous visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior elevated readings and her family history is negative for hypertension. You measure her blood pressure in your office today. Which of the following factors can result in a false high reading?
  2. Blood pressure cuff is tightly
  3. Patient is seated quietly for 10 minutes prior to
  4. Blood pressure is measured on a bare
  5. Patient’s arm is resting, supported by your arm at her mid-chest level as you stand to measure the blood

 

Ans:    A Chapter:         04

 

Feedback:        A blood pressure cuff that is too tightly fitted can result in a false high reading. The other answers are important to observe to obtain an accurate blood pressure reading.

JNC-7 also mentions the importance of having the back supported when obtaining blood pressure in the sitting position.

 

 

 

 

 

  1. A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient’s complete history and physical examination. When you palpate the pulse, what do you expect to feel?
  2. Large amplitude, forceful
  3. Small amplitude, weak
  4. Normal
  5. Bigeminal

 

Ans:    B Chapter:         04

 

Feedback:        Congestive heart failure is characterized by decreased stroke volume or increased peripheral vascular resistance, which would result in a small-amplitude, weak pulse.                        Subtle differences in amplitude are usually best detected in large arteries close to the heart, like the carotid pulse.        You may not be able to notice these in other locations.

 

 

 

 

  1. An 18-year-old college freshman presents to the clinic for evaluation of You measure the patient’s temperature and it is 104 degrees Fahrenheit. What type of pulse would you expect to feel during his initial examination?
  2. Large amplitude, forceful
  3. Small amplitude, weak
  4. Normal
  5. Bigeminal

 

Ans:    A Chapter:         04

 

Feedback:        Fever results in an increased stroke volume, which results in a large-amplitude, forceful pulse.                    Later in the course of the illness, if dehydration and shock result, you may expect small amplitude and weak pulses.

 

 

 

 

  1. A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath and states that his blood sugar was 605 at You diagnose the patient with diabetic ketoacidosis. What is the expected pattern of breathing?
  2. Normal

 

  1. Rapid and shallow
  2. Rapid and deep
  3. Slow

 

Ans:    C Chapter:         04

 

Feedback:        This is the expected rate and depth in diabetic ketoacidosis.    The body is trying to rid itself of carbon dioxide to compensate for the acidosis.                       This is known as Kussmaul’s breathing and is seen in other causes of acidosis as well.

 

 

 

 

  1. Lenzo weighs herself every day with a very accurate balance-type scale. She has noticed that over the past 2 days she has gained 4 pounds.                                                          How would you best explain this?
  2. Attribute this to some overeating at the
  3. Attribute this to wearing different
  4. Attribute this to body
  5. Attribute this to instrument

 

Ans:    C Chapter:         04

 

Feedback:        This amount of weight over a short period should make one think of body fluid changes.       You may consider a kidney problem or heart failure in your differential.                                      The other reasons should be considered as well, but this amount of weight gain over a short period usually indicates causes other than excessive caloric intake. A rule of thumb for dieters is that an energy excess of 3500 calories will cause a 1-pound weight gain, if the increase is to be attributed to food intake.

 

 

 

 

  1. Curtiss has a history of obesity, diabetes, osteoarthritis of the knees, HTN, and obstructive sleep apnea. His BMI is 43 and he has been discouraged by his difficulty in losing weight. He is also discouraged that his goal weight is 158 pounds away.                     What would you tell him?
  2. “When you get down to your goal weight, you will feel so much ”
  3. “Some people seem to be able to lose weight and others just can’t, no matter how hard they ”
  4. “We are coming up with new medicines and methods to treat your conditions every ”
  5. “Even a weight loss of 10% can make a noticeable improvement in the problems you ”

 

Ans:    D

 

Chapter:        04

 

Feedback:   Many patients trying to change a habit are overwhelmed by how far they are from their goal.                    As the proverb says: “A journey of a thousand miles begins with one step.”     Many patients find it empowering to know that they can achieve a small goal, such as a loss of 1 pound per week.       They must be reminded that this process will take time and that slow weight loss is more successful long-term.            Research has shown that significant benefits often come with even a 10% weight loss.

 

 

 

 

  1. Jenny is one of your favorite patients who usually shares a joke with you and is nattily Today she is dressed in old jeans, lacks makeup, and avoids eye contact.                      To what do you attribute these changes?
  2. She is lacking
  3. She is fatigued from
  4. She is running into financial
  5. She is

 

Ans:    D Chapter:         04

 

Feedback:        It is important to use all of your skills and memory of an individual patient to guide your thought process.       She is not described as sleepy.                       Work fatigue would most likely not cause avoidance of eye contact. Financial difficulties would not necessarily deplete a nice wardrobe.     It is most likely that she is depressed or in another type of difficulty.

 

 

 

 

  1. You are seeing an older patient who has not had medical care for many Her vital signs taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain. You notice that she has some hypertensive changes in her retinas and you find mild proteinuria on a urine test in your office.              You expected the BP to be higher.                              She is not on any medications.       What do you think is causing this BP reading, which doesn’t correlate with the other findings?
  2. It is caused by an “auscultatory ”
  3. It is caused by a cuff size
  4. It is caused by the patient’s emotional
  5. It is caused by resolution of the process which caused her retinopathy and kidney

 

Ans:    A Chapter:         04

 

Feedback:        The blood pressure is unusual in this case in that the systolic pressure is normal

 

while the diastolic pressure is elevated.    Especially with the retinal and urinary findings, you should consider that the BP may be much higher and that an auscultatory gap was missed.                              This can be avoided by checking for obliteration of the radial pulse while the cuff is inflated.

Although a large cuff can cause a slightly lower BP on a patient with a small arm, this does not account for the elevated DBP.                             Emotional upset usually causes elevation of the BP.    Although a process which caused the retinopathy and kidney problems may have resolved, leaving these findings, it is a dangerous assumption that this is the sole cause of the problems seen in this patient.

 

 

 

 

  1. Despite having high BP readings in the office, Kelly tells you that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. How do you respond?
  2. You diagnose “white coat ”
  3. You assume he is quite nervous when he comes to your
  4. You question the accuracy of his
  5. You question the accuracy of your

 

Ans:    C Chapter:         04

 

Feedback:        It is not uncommon to see differences in a patient’s home measurements and your own in the office.                  Presuming that this is “white coat hypertension” can be dangerous because this condition is not usually treated.        This allows for the effects of a missed diagnosis of hypertension to go unchecked.   It is also very difficult to judge if a patient is outwardly      nervous.           You should always consider that your measurements are not accurate as well, but the fact that you and your staff are well-trained and perform this procedure on hundreds of patients a week makes this less likely.    Ideally, you would ask the patient to bring in his BP equipment and take a simultaneous reading with you to make sure that he is getting an accurate reading.

 

 

 

 

  1. You are observing a patient with heart failure and notice that there are pauses in hisOn closer examination, you notice that after the pauses the patient takes progressively deeper breaths and then progressively shallower breaths, which are followed by another apneic spell.    The patient is not in any distress.             You make the diagnosis of:
  2. Ataxic (Biot’s) breathing
  3. Cheyne-Stokes respiration
  4. Kussmaul’s respiration
  5. COPD with prolonged expiration

 

Ans:    B Chapter:         04

 

 

Feedback:        Cheyne-Stokes respiration can be seen in patients with heart failure and is usually not a sign of an immediate problem.            Ataxic breathing is very irregular in rhythm and depth and is seen with brain injury.                    Kussmaul’s respiration is seen in patients with a metabolic acidosis,  as they are trying to rid their bodies of carbon dioxide to compensate.                                                  Respirations in COPD are usually regular and are not usually associated with apneic episodes.

 

 

 

 

  1. Garcia comes to your office for a rash on his chest associated with a burning pain. Even a light touch causes this burning sensation to worsen. On examination, you note a rash with small blisters (vesicles) on a background of reddened skin.                The rash overlies an entire rib on his right side.                    What type of pain is this?
  2. Idiopathic pain
  3. Neuropathic pain
  4. Nociceptive or somatic pain
  5. Psychogenic pain

 

Ans:    B Chapter:         04

 

Feedback:  This vignette is consistent with a diagnosis of herpes zoster, or shingles.       This is caused by reemergence of dormant varicella (chickenpox) viruses from Mr. Garcia’s nerve root. The characteristic burning quality without a history of an actual burn makes one think of neuropathic pain. It will most likely remain for months after the rash has resolved.              There is no evidence of physical injury and this is a peculiar distribution, making nociceptive pain less  likely.                                                           There is no evidence of a psychogenic etiology for this, and the presence of a rash makes this possibility less likely as well.           Because of your astute diagnostic abilities, the pain is not idiopathic.

 

 

 

 

  1. A 50-year-old body builder is upset by a letter of denial from his life insurance He is very lean but has gained 2 pounds over the past 6 months. You personally performed his health assessment and found no problems whatsoever.                       He says he is classified as “high risk” because of obesity.                        What should you do next?
  2. Explain that even small amounts of weight gain can classify you as
  3. Place him on a high-protein, low-fat
  4. Advise him to increase his aerobic exercise for calorie
  5. Measure his

 

Ans:    D Chapter:         04

 

Feedback:        The patient most likely had a high BMI because of increased muscle mass.     In this situation, it is important to measure his waist.              It is most likely under 40 inches, which makes obesity unlikely (even to an insurance company).                           It is important that you personally contact the company and explain your reasoning.    Be prepared to back your argument with data.                                               A special diet is unlikely to be of much use, and more aerobic exercise, while probably a good idea for most, is redundant for this individual.

 

 

 

 

  1. Wright comes to your office, complaining of palpitations. While checking her pulse you notice an irregular rhythm.            When you listen to her heart, every fourth beat sounds different.       It sounds like a triplet rather than the usual “lub dup.” How would you document your examination?
  2. Regular rate and rhythm
  3. Irregularly irregular rhythm
  4. Regularly irregular rhythm
  5. Bradycardia

 

Ans:    C Chapter:         04

 

Feedback:  Because this unusual beat occurs every fourth set of heart sounds, it is regularly irregular.        This is most consistent with ventricular premature contractions (or VPCs).                                   This is generally a common and benign rhythm.                       An irregularly irregular rhythm is a classic finding in atrial fibrillation.                   The rhythm is very random in character.                 Bradycardia refers to the rate, not the rhythm.

Bates’ Guide to Physical Examination and History Taking, 12th Edition

 

 

Chapter 6: The Skin, Hair, and Nails

 

 

 

 

Multiple Choice

 

 

 

 

  1. A 35-year-old archaeologist comes to your office (located in Phoenix, Arizona) for a regular skin check-up. She has just returned from her annual dig site in She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this patient?
  2. Age
  3. Hair color
  4. Actinic lentigines
  5. Heavy sun exposure

 

Ans:    A Chapter:         06

 

Feedback: The risk for melanoma is increased in people over the age of 50; our patient is 35 years old. The other answers represent known risk factors for melanoma. Especially with a family history of melanoma, she should be instructed to keep her skin covered when in the sun and use strong sunscreen on exposed areas.

 

 

 

 

  1. You are speaking to an 8th grade class about health prevention and are preparing to discuss the ABCDEs ofWhich of the following descriptions correctly defines the ABCDEs?
  2. A = actinic; B = basal cell; C = color changes, especially blue; D = diameter >6 mm; E = evolution
  3. A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6 mm; E = evolution
  4. A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E = evolution
  5. A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter

>6 mm; E = evolution

 

Ans:    B Chapter:         06

 

 

Feedback:        This is the correct description for the mnemonic.

 

 

 

 

  1. You are beginning the examination of the skin on a 25-year-old You have previously elicited that she came to the office for evaluation of fatigue, weight gain, and hair loss. You strongly suspect that she has hypothyroidism. What is the expected moisture and texture of the skin of a patient with hypothyroidism?
  2. Moist and smooth
  3. Moist and rough
  4. Dry and smooth
  5. Dry and rough

 

Ans:    D Chapter:         06

 

Feedback:        A patient with hypothyroidism is expected to have skin that is dry as well as rough. This is a good example of how the skin can give clues to systemic diseases.

 

 

 

 

  1. A 28-year-old patient comes to the office for evaluation of a At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical examination, you note that the pattern of eruption is like a Christmas tree and that there are a variety of erythematous papules and macules on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?
  2. Pityriasis rosea
  3. Tinea versicolor
  4. Psoriasis
  5. Atopic eczema

 

Ans:    A Chapter:         06

 

Feedback:        This is a classic description of pityriasis rosea. The description of a large single or “herald” patch preceding the eruption is a good way to distinguish this rash from other conditions.

 

 

 

 

  1. A 19-year-old construction worker presents for evaluation of a He notes that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He

 

does sweat more than before because being outdoors is part of his job. On physical examination, you note dark tan patches with a reddish cast that has sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is your most likely diagnosis?

  1. Pityriasis rosea
  2. Tinea versicolor
  3. Psoriasis
  4. Atopic eczema

 

Ans:    B Chapter:         06

 

Feedback:         This is a typical description of tinea versicolor. The information that the patient is sweating more also helps support this diagnosis, because tinea is a fungal infection and is promoted by moisture.

 

 

 

 

  1. A 68-year-old retired farmer comes to your office for evaluation of a skin On the right temporal area of the forehead, you see a flattened papule the same color as his skin, covered by a dry scale that is round and feels hard. He has several more of these scattered on the  forehead, arms, and legs. Based on this description, what is your most likely diagnosis?
  2. Actinic keratosis
  3. Seborrheic keratosis
  4. Basal cell carcinoma
  5. Squamous cell carcinoma

 

Ans:    A Chapter:        06

 

Feedback:         This is a typical description of actinic keratosis. Actinic keratosis may be easier to feel than to see. If left untreated, approximately 1% of cases can develop into squamous cell carcinoma.

 

 

 

 

  1. A 58-year-old gardener comes to your office for evaluation of a new lesion on her upper The lesion appears to be “stuck on” and is oval, brown, and slightly elevated with a flat surface. It has a rough, wartlike texture on palpation. Based on this description, what is your most likely diagnosis?
  2. Actinic keratosis
  3. Seborrheic keratosis
  4. Basal cell carcinoma
  5. Squamous cell carcinoma

 

 

Ans:    B Chapter:         06

 

Feedback:        This is a typical description for seborrheic keratosis. The “stuck on” appearance and the rough, wartlike texture are key features for the diagnosis. They often produce a greasy scale when scratched with a fingernail, which further helps to distinguish them from other lesions.

Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important to distinguish these lesions to prevent unnecessary biopsy.                          It is important to consider biopsy whenever there is any doubt, though.

 

 

 

 

  1. A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 She was treated for sepsis and respiratory failure and had to be on the ventilator for 3 weeks. You are completing your initial assessment and are evaluating her skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter, with damage to the subcutaneous tissue. The underlying muscle is not affected. You diagnose this as a pressure ulcer. What is the stage of this ulcer?
  2. Stage 1
  3. Stage 2
  4. Stage 3
  5. Stage 4

 

Ans:    C Chapter:         06

 

Feedback:        A stage 3 ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle.

 

 

 

 

  1. An 8-year-old girl comes with her mother for evaluation of hair She denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her hair in braids. On physical examination, you note a clearly demarcated, round patch of hair loss without visible scaling or inflammation. There are no hair shafts visible. Based on this description, what is your most likely diagnosis?
  2. Alopecia areata
  3. Trichotillomania
  4. Tinea capitis
  5. Traction alopecia

 

Ans:    A Chapter:         06

 

 

Feedback:        This is a typical description for alopecia areata. There are no risk factors for trichotillomania or for traction alopecia. The physical examination is not consistent with tinea capitis because the skin is intact.

 

 

 

 

  1. A mother brings her 11 month old to you because her mother-in-law and others have told her that her baby is She is eating and growing well and performing the developmental milestones she should for her age.       On examination you indeed notice a yellow tone to her skin from head to toe.      Her sclerae are white.         To which area should your next questions be related?
  2. Diet
  3. Family history of liver diseases
  4. Family history of blood diseases
  5. Ethnicity of the child

 

Ans:    A Chapter:         06

 

Feedback:  The lack of jaundice in the sclerae is an important clue.       Typically, this is the first place where one sees jaundice.                               This examination should also be carried out in natural light (sunlight) as opposed to fluorescent lighting, which can alter perceived colors.         Many infants this age have a large proportion of carrots, tomatoes, and yellow squash, which are rich in carotene.        Liver and blood diseases can cause jaundice, but this should involve the sclerae.

The ethnicity of the child should not cause a perceived change from her usual skin tone.

 

 

 

 

  1. A new mother is concerned that her child occasionally “turns ” On further questioning, she mentions that this is at her hands and feet.                                                               She does not remember the child’s lips turning blue. She is otherwise eating and growing well.                      What would you do now?
  2. Reassure her that this is normal
  3. Obtain an echocardiogram to check for structural heart disease and consult cardiology
  4. Admit the child to the hospital for further observation
  5. Question the validity of her story

 

Ans:    A Chapter:         06

 

Feedback:        This is an example of peripheral cyanosis.      This is a very common and benign condition which typically occurs when the child is slightly cold and his peripheral circulation is adjusting to keep his core warm.                    Without other problems, there is no need for further workup. If the lips or other central locations are involved, you must consider other etiologies.

 

 

 

 

 

  1. You are examining an unconscious patient from another region and notice Beau’s lines, a transverse groove across all of her nails, about 1 cm from the proximal nail What would you do next?
  2. Conclude this is caused by a cultural
  3. Conclude this finding is most likely secondary to
  4. Look for information from family and records regarding any problems which occurred 3 months
  5. Ask about dietary

 

Ans:    C Chapter:         06

 

Feedback:        These lines can provide valuable information about previous significant illnesses, some of which are forgotten or are not able to be reported by the patient.     Because the fingernails grow at about 0.1 mm per day, you would ask about an illness 100 days ago.                   This patient may have been hospitalized for endocarditis or may have had another significant illness which should be sought.    Trauma to all 10 nails in the same location is unlikely.   Dietary intake at this time would not be related to this finding. Do not assume a finding is necessarily related to a patient’s culture unless you have good knowledge of that culture.

 

 

 

 

  1. Dakota is a 14-year-old boy who just noticed a rash at his There is no history of exposure to ill people or other agents in the environment.                                           He has a slight fever in the office. The rash consists of small, bright red marks.                                                When they are pressed, the red color remains. What should you do?
  2. Prescribe a steroid cream to decrease
  3. Consider admitting the patient to the
  4. Reassure the parents and the patient that this should resolve within a
  5. Tell him not to scratch them, and follow up in 3

 

Ans:    B Chapter:         06

 

Feedback:        Although this may not be an impressive rash, the fact that they do not “blanch” with pressure is very concerning.  This generally means that there is pinpoint bleeding under the skin, and while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia.        You should always report this feature of a rash immediately to a supervisor or teacher.

 

 

 

 

  1. Hill is a 28-year-old African-American with a history of SLE (systemic lupus erythematosus). She has noticed a raised, dark red rash on her legs. When you press on the rash, it doesn’t blanch.     What would you tell her regarding her rash?
  2. It is likely to be related to her
  3. It is likely to be related to an exposure to a
  4. It is likely to be related to an allergic
  5. It should not cause any

 

Ans:    A Chapter:         06

 

Feedback:        A “palpable purpura” is usually associated with a vasculitis.     This is an inflammatory condition of the blood vessels often associated with systemic rheumatic disease. It can cut off circulation to any portion of the body and can mimic many other diseases in this manner.                      While allergic and chemical exposures may be a possible cause of the rash, this patient’s SLE should make you consider vasculitis.

 

 

 

 

  1. Jacob, a 33-year-old construction worker, complains of a “lump on his back” over his It has been there for about a year and is getting larger.              He says his wife has been able to squeeze out a cheesy-textured substance on occasion.                            He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?
  2. An enlarged lymph node
  3. A sebaceous cyst
  4. An actinic keratosis
  5. A malignant lesion

 

Ans:    B Chapter:         06

 

Feedback:        This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland.                    The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely.                                        This would be an unusual location for a lymph node, and these do not usually drain to the skin.

 

 

 

 

  1. A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several It seems to be worse in the winter and improves

 

with some sun exposure.    On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small “pits” in his nails.                             What would account for these findings?

  1. Eczema
  2. Pityriasis rosea
  3. Psoriasis
  4. Tinea infection

 

Ans:    C Chapter:         06

 

Feedback:        This is a classic presentation of plaque psoriasis.      Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces.   Pityriasis usually is limited to the trunk and proximal extremities.                                           Tinea has a much finer scale associated with it, almost like powder, and is found in dark and moist areas.

 

 

 

 

  1. Anderson presents with an itchy rash which is raised and appears and disappears in various locations.                                                       Each lesion lasts for many minutes. What most likely accounts for this rash?
  2. Insect bites
  3. Urticaria, or hives
  4. Psoriasis
  5. Purpura

 

Ans:    B Chapter:         06

 

Feedback:        This is a typical case of urticaria.     The most unusual aspect of this condition is that the lesions “move” from place to place.                      This would be distinctly unusual for the other causes listed.

 

 

 

 

  1. Whiting is a 68 year old who comes in for her usual follow-up visit. You notice a few flat red and purple lesions, about 6 centimeters in diameter, on the ulnar aspect of her forearms but nowhere else. She doesn’t mention them. They are tender when you examine them.    What should you do?
  2. Conclude that these are lesions she has had for a long
  3. Wait for her to mention them before asking further
  4. Ask how she acquired
  5. Conduct the visit as usual for the

 

Ans:    C Chapter:         06

 

Feedback:        These are consistent with ecchymoses, or bruises.     It is important to ask about antiplatelet medications such as aspirin, trauma history, and history of blood disorders in the patient and her family.                    Because of the different ages of the bruises and the isolation of them to the ulnar forearms, these may be a result of abuse or other violence.                                     It is your duty to investigate the cause of these lesions.

 

 

 

 

  1. A middle-aged man comes in because he has noticed multiple small, blood-red, raised lesions over his anterior chest and abdomen for the past several They are not painful and he has not noted any bleeding or bruising.     He is concerned this may be consistent with a dangerous condition.           What should you do?
  2. Reassure him that there is nothing to worry
  3. Do laboratory work to check for platelet
  4. Obtain an extensive history regarding blood problems and bleeding
  5. Do a skin biopsy in the

 

Ans:    A Chapter:         06

 

Feedback:  These represent cherry angiomas, which are very common, benign lesions.             Further workup such as laboratory work, skin biopsy, or even further questions are not necessary at this time.          It would be wise to ask the patient to report any changes in any of his skin lesions, and tell him that you would need to see him at that time.

Bates’ Guide to Physical Examination and History Taking, 12th Edition

Chapter 11: The Abdomen

Multiple Choice

  1. A 52-year-old secretary comes to your office, complaining about accidentally leaking urine

when she coughs or sneezes. She says this has been going on for about a year now. She relates

that she has not had a period for 2 years. She denies any recent illness or injuries. Her past

medical history is significant for four spontaneous vaginal deliveries. She is married and has four

children. She denies alcohol, tobacco, or drug use. During her pelvic examination you note some

atrophic vaginal tissue, but the remainder of her pelvic, abdominal, and rectal examinations are

unremarkable.

Which type of urinary incontinence does she have?

  1. A) Stress incontinence
  2. B) Urge incontinence
  3. C) Overflow incontinence

Ans: A

Chapter: 11

Feedback: Stress incontinence usually occurs when the intra-abdominal pressure goes up

during coughing, sneezing, or laughing. This is usually due to a weakness of the pelvic floor,

with inadequate muscle support of the bladder. Vaginal deliveries and pelvic surgery are often

associated with these symptoms. Usually female patients are postmenopausal when stress

incontinence begins. Kegel exercises are usually recommended to strengthen the pelvic floor

muscles.

  1. A 46-year-old former salesman presents to the ER, complaining of black stools for the past

few weeks. His past medical history is significant for cirrhosis. He has gained weight recently,

especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and

has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and

smoked crack in the past. He denies any recent use. He is currently unemployed and has never

been married. On examination you find a man appearing older than his stated age. His skin has a

yellowish tint and he is thin, with a prominent abdomen. You note multiple “spider angiomas” at

the base of his neck. Otherwise, his heart and lung examinations are normal. On inspection he

.

has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation.

Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small

and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his

rectal examination.

What cause of black stools most likely describes his symptoms and signs?

  1. A) Infectious diarrhea
  2. B) Mallory-Weiss tear
  3. C) Esophageal varices

Ans: C

Chapter: 11

Feedback: Varices are often found in alcoholic patients, but only when they have a diagnosis of

significant cirrhosis. This patient has symptoms of cirrhosis, including jaundice, ascites, spider

hemangiomas, and dilated veins on his abdomen (caput medusa).

  1. A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states

that the stools are very loose and there is some cramping beforehand. She states this has occurred

on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool.

Occasionally she has periods of constipation, but that is rare. She thinks the diarrhea is much

worse when she is nervous. Her past medical history is not significant. She is single and a junior

in college majoring in accounting. She smokes when she drinks alcohol but denies using any

illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable.

What is most likely the etiology of her diarrhea?

  1. A) Secretory infections
  2. B) Inflammatory infections
  3. C) Irritable bowel syndrome
  4. D) Malabsorption syndrome

Ans: C

Chapter: 11

Feedback: Irritable bowel syndrome will cause loose bowel movements with cramps but no

systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely in young

women with alternating symptoms of loose stools and constipation. Stress usually makes the

symptoms worse, as do certain foods.

  1. A 42-year-old florist comes to your office, complaining of chronic constipation for the last 6

months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She

denies any recent illnesses or injuries. She denies any changes to her diet or exercise program.

.

She is on no new medications. During the review of systems you note that she has felt fatigued,

had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is

significant for one vaginal delivery and two cesarean sections. She is married, has three children,

and owns a flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2

diabetes and her father has coronary artery disease. There is no family history of cancers. On

examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose,

throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are

also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed

in response to a blow with the hammer, especially the Achilles tendons.

What is the best choice for the cause of her constipation?

  1. A) Large bowel obstruction
  2. B) Irritable bowel syndrome
  3. C) Rectal cancer
  4. D) Hypothyroidism

Ans: D

Chapter: 11

Feedback: Many metabolic conditions can interfere with bowel motility. In this case the patient

has many symptoms of hypothyroidism, including cold intolerance, weight gain, fatigue,

constipation, and irregular menstrual cycles. On examination, thyromegaly and delayed reflexes

can help to make the diagnosis. Medication will usually correct these symptoms.

  1. A 22-year-old law student comes to your office, complaining of severe abdominal pain

radiating to his back. He states it began last night after hours of heavy drinking. He has had

abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep

any food or water down, and these symptoms have been going on for almost 12 hours. He has

had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking

or using illegal drugs but admits to drinking 6 to 10 beers per weekend night. He admits that last

night he drank something like 14 drinks. On examination you find a young male appearing his

stated age in some distress. He is leaning over on the examination table and holding his abdomen

with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal

examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and

epigastric area. He has no Murphy’s sign or tenderness in the right lower quadrant. The

remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular

examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood

work is pending.

What etiology of abdominal pain is most likely causing his symptoms?

  1. A) Peptic ulcer disease
  2. B) Biliary colic
  3. C) Acute cholecystitis
  4. D) Acute pancreatitis

.

Ans: D

Chapter: 11

Feedback: Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates

into the back. There is often a history of long-standing gallbladder disease or recent alcohol

ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump

inhibitors can also cause pancreatitis in people without these other risk factors. Treatment

includes hydration, pain management, and bowel rest.

  1. A 76-year-old retired farmer comes to your office complaining of abdominal pain,

constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or

diarrhea. The only unusual thing he remembers eating is two bags of popcorn at the movies with

his grandson, 3 days before his symptoms began. He denies any other recent illnesses. His past

medical history is significant for coronary artery disease and high blood pressure. He has been

married for over 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon

cancer and his father had a stroke. On examination he appears his stated age and is in no acute

distress. His temperature is 100.9 degrees and his other vital signs are unremarkable. His head,

cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over

the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable

and his fecal occult blood test is negative. His prostate is slightly enlarged but his testicular,

penile, and inguinal examinations are all normal. Blood work is pending.

What diagnosis for abdominal pain best describes his symptoms and signs?

  1. A) Acute diverticulitis
  2. B) Acute cholecystitis
  3. C) Acute appendicitis
  4. D) Mesenteric ischemia

Ans: A

Chapter: 11

Feedback: Diverticulitis is caused by localized infections within the colonic diverticula.

Constipation, fever, and abdominal pain are common. Mesenteric ischemia classically presents in

older people with a history of vascular disease elsewhere. The typical pain is unusual in that it is

not made worse by examination despite being severe. Some mistake this feature to indicate

malingering, with bad results.

  1. A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife’s

request. He has recently been losing weight and has felt very fatigued. He has had no chest pain,

shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer,

for which he had surgery, and arthritis. He has been married for over 40 years. He denies any

.

tobacco or drug use and has not drunk alcohol in over 40 years. His parents both died of cancer

in their 60s. On examination his vital signs are normal. His head, cardiac, and pulmonary

examinations are unremarkable. On abdominal examination you hear normal bowel sounds, but

when you palpate his liver it is abnormal. His rectal examination is positive for occult blood.

What further abnormality of the liver was likely found on examination?

  1. A) Smooth, large, nontender liver
  2. B) Irregular, large liver
  3. C) Smooth, large, tender liver

Ans: B

Chapter: 11

Feedback: With his past history of colon cancer and with recent weight loss and fatigue, a

relapse of his colon cancer would be expected. Colon cancer usually metastasizes to the liver,

creating hard, irregular nodules, which can sometimes be palpated on examination. A smooth,

large liver which is tender is often seen in hepatitis.

  1. A 26-year-old sports store manager comes to your clinic, complaining of severe right-sided

abdominal pain for 12 hours. He began having a stomachache yesterday, with a decreased

appetite, but today the pain seems to be just on the lower right side. He has had some nausea and

vomiting but no constipation or diarrhea. His last bowel movement was last night and was

normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical

history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six

beers per week. His mother has breast cancer and his father has coronary artery disease. On

examination he appears ill and is lying on his right side. His temperature is 100.4 and his heart

rate is 110. His bowel sounds are decreased and he has rebound and involuntary guarding, one

third of the way between the anterior superior iliac spine and the umbilicus in the right lower

quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal.

What is the most likely cause of his pain?

  1. A) Acute appendicitis
  2. B) Acute mechanical intestinal obstruction
  3. C) Acute cholecystitis
  4. D) Mesenteric ischemia

Ans: A

Chapter: 11

Feedback: Appendicitis is common in the young and usually presents with periumbilical pain

that localizes to the right lower quadrant in an area known as McBurney’s Point, described above

as one third of the way between the anterior superior iliac spine and the umbilicus on the right.

Rebound and guarding are common. Remote rebound or Rovsing’s sign is also seen commonly

when the course of appendicitis is advanced. Bowel movements are usually unaffected.

.

  1. A 15-year-old high school freshman is brought to the clinic by his mother because of chronic

diarrhea. The mother states that for the past couple of years her son has had diarrhea after many

meals. The patient states that the diarrhea seems the absolute worst after his school lunches. He

describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are

watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or

fatigue. He has had no recent illness, injuries, or foreign travel. His past medical history is

unremarkable. He denies tobacco, alcohol, or drug use. His parents are both healthy. On

examination you see a relaxed young man breathing comfortably. His vital signs are normal and

his head, eyes, ears, throat, neck, cardiac, and pulmonary examinations are normal. His abdomen

is soft and nondistended. His bowel sounds are active and he has no tenderness, no enlarged

organs, and no rebound or guarding. His rectal examination is nontender with no blood on the

glove. You collect a stool sample for further study.

What is the most likely explanation for this patient’s chronic diarrhea?

  1. A) Malabsorption syndrome
  2. B) Osmotic diarrhea
  3. C) Secretory diarrhea

Ans: B

Chapter: 11

Feedback: Usually related to lactose intolerance, watery diarrhea often follows meal ingestion.

Crampy abdominal pain, distension, and gas often accompany symptoms. Diarrhea is often

provoked by pizza, milkshakes, yogurt, and other lactose-containing foods. This condition is

more common in African-Americans, Latinos, Native Americans, and Asians.

  1. A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back

pain radiating down into her groin. It began in the middle of the night and woke her up suddenly.

It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency

or urgency with urination but she has seen blood in her urine. She has had nausea with the pain

but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history

is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high

blood pressure and her father is healthy. On examination she looks her stated age and is in

obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and

abdominal examinations are unremarkable. She has tenderness just inferior to the left

costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood

cells.

What type of urinary tract pain is she most likely to have?

  1. A) Kidney pain (from pyelonephritis)
  2. B) Ureteral pain (from a kidney stone)
  3. C) Musculoskeletal pain

.

  1. D) Ischemic bowel pain

Ans: B

Chapter: 11

Feedback: The pain from a kidney stone causes dramatic, severe, colicky pain at the

costovertebral angle that radiates across the flank and down into the groin.

  1. Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at

his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable

position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk,

because any motion makes the pain much worse. It is localized just medial and inferior to his

iliac crest on the right. Which of the following is most likely?

  1. A) Peptic ulcer
  2. B) Cholecystitis
  3. C) Pancreatitis
  4. D) Appendicitis

Ans: D

Chapter: 11

Feedback: This is a classic history for appendicitis. Notice that the pain has changed from

visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong

consideration.

  1. Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or

more at a time and has started recently. Which of the following should be considered?

  1. A) Peptic ulcer
  2. B) Pancreatitis
  3. C) Myocardial ischemia
  4. D) All of the above

Ans: D

Chapter: 11

Feedback: Epigastric pain can have many causes. History and physical will help discern which

causes are most likely, but it is important to realize that any of the above, including myocardial

ischemia, is always a possibility. Pneumonia and gallbladder pain can also cause pain in this

location.

.

  1. Monique is a 33-year-old administrative assistant who has had intermittent lower

abdominal pain approximately one week a month for the past year. It is not related to her

menses. She notes relief with defecation, and a change in form and frequency of her bowel

movements with these episodes. Which of the following is most likely?

  1. A) Colon cancer
  2. B) Cholecystitis
  3. C) Inflammatory bowel disease
  4. D) Irritable bowel syndrome

Ans: D

Chapter: 11

Feedback: Although colon cancer should be a consideration, these symptoms are intermittent

and no note is made of progression. Cholecystitis usually presents with right upper quadrant

pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there

is relief with defecation and there are no mentioned structural or biochemical abnormalities,

irritable bowel syndrome seems most likely. This is a very common condition which can be

triggered by certain foods and stress.

  1. Jim is a 60-year-old man who presents with vomiting. He denies seeing any blood with

emesis, which has been occurring for 2 days. He does note a dark, granular substance resembling

the coffee left in the filter after brewing. What do you suspect?

  1. A) Bleeding from a diverticulum
  2. B) Bleeding from a peptic ulcer
  3. C) Bleeding from a colon cancer
  4. D) Bleeding from cholecystitis

Ans: B

Chapter: 11

Feedback: When blood is exposed to the environment of the stomach, it often resembles

“coffee grounds.” This is not always recognized by patients as blood, so it is important to inquire

about this. This symptom is not common in cholecystitis, and the other possibilities occur lower

in the intestine. It should be noted that conversely, rapid bleeding from the stomach or other

upper gastrointestinal source can produce bright red blood in the stool. Do not rule out proximal

bleeding on the basis of the absence of “coffee grounds.” Likewise, bright red blood seen with

emesis may originate from the stomach. Black, sticky stools also can accompany upper GI

bleeding.

.

  1. A daycare worker presents to your office with jaundice. She denies IV drug use, blood

transfusion, and travel and has not been sexually active for the past 10 months. Which type of

hepatitis is most likely?

  1. A) Hepatitis A
  2. B) Hepatitis B
  3. C) Hepatitis C
  4. D) Hepatitis D

Ans: A

Chapter: 11

Feedback: The lack of contact with blood and body fluids makes hepatitis B, C, and D

unlikely. She regularly changes the diapers of her clients and is at risk for hepatitis A. Vaccine

against hepatitis A is recommended for daycare workers.

  1. Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the

right side. The pain eventually moved to her lateral abdomen and then into her right lower

quadrant. Which is most likely, given this presentation?

  1. A) Appendicitis
  2. B) Dysmenorrhea
  3. C) Ureteral stone
  4. D) Ovarian cyst

Ans: C

Chapter: 11

Feedback: The presentation of right flank pain spiraling down to the groin is typical of a

ureteral stone. There would most likely be microscopic hematuria as well. The migration pattern

of this condition makes the others less likely.

  1. Mrs. LaFarge is a 60-year-old who presents with urinary incontinence. She is unable to get

to the bathroom quickly enough when she senses the need to urinate. She has normal mobility.

Which of the following is most likely?

  1. A) Stress incontinence
  2. B) Urge incontinence
  3. C) Overflow incontinence
  4. D) Functional incontinence

Ans: B

.

Chapter: 11

Feedback: Stress incontinence occurs with increased intra-abdominal pressure such as with

coughing, sneezing, or laughing. This history is most consistent with urge incontinence

secondary to detrusor overactivity. Overflow incontinence occurs with anatomic obstruction such

as prostatic hypertrophy (obviously not in this case, as the patient is a woman), urethral stricture,

or neurogenic bladder. Functional incontinence results from lack of mobility severe enough to

impair getting to the bathroom quickly enough.

  1. Which is the proper sequence of examination for the abdomen?
  2. A) Auscultation, inspection, palpation, percussion
  3. B) Inspection, percussion, palpation, auscultation
  4. C) Inspection, auscultation, percussion, palpation
  5. D) Auscultation, percussion, inspection, palpation

Ans: C

Chapter: 11

Feedback: The abdominal examination is conducted in a sequence different from other

systems, for which the usual order is inspection, percussion, palpation, and auscultation. Because

palpation may actually cause some bowel noise when the bowels are not moving, auscultation is

performed before percussion and palpation in an abdominal examination.

  1. A 62-year-old woman has been followed by you for 3 years and has had recent onset of

hypertension. She is still not at goal despite three antihypertensive medicines, and you strongly

doubt nonadherence. Her father died of a heart attack at age 58. Today her pressure is 168/94 and

pressure on the other arm is similar. What would you do next?

  1. A) Add a fourth medicine
  2. B) Refer to nephrology
  3. C) Get a CT scan
  4. D) Listen closely to her abdomen

Ans: D

Chapter: 11

Feedback: At this point, it is important to consider secondary causes for this woman’s

hypertension because of its severity, rapidity of progression, and lack of response to therapy.

While you will most likely add a fourth medicine, it is important to carefully examine the

abdomen for the presence of renal artery bruits. These are usually heard best in the upper

quadrants. It may be necessary to have the patient hold her breath, to have a very quiet room, and

.

to listen with the diaphragm for a very soft, high-pitched sound with systole. It may also help to

simultaneously feel the patient’s pulse (a bruit with both a systolic and diastolic component is

very specific for a significant blockage, while a lone systolic bruit may not be abnormal).

Obtaining a CT scan is not likely to be useful, and you may save the delay, expense, and

inconvenience of a nephrology referral if you can hear a bruit.

  1. Mr. Patel is a 64-year-old man who was told by another care provider that his liver is

enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no

knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below

the costal arch. Which of the following would you do next?

  1. A) Check an ultrasound of the liver
  2. B) Obtain a hepatitis panel
  3. C) Determine liver span by percussion
  4. D) Adopt a “watchful waiting” approach

Ans: C

Chapter: 11

Feedback: A liver edge palpable this far below the costal arch should not be ignored.

Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel

has developed emphysema with flattening of the diaphragms. This pushes a normal-sized liver

below the costal arch so that it appears to be enlarged. A liver span should be determined by

percussing down the chest wall until dullness is heard. A measurement is then made between this

point and the lower border of the liver to determine its span; 6–12 centimeters in the

mid-clavicular line is normal. Percussion is the only way to assess liver size on examination, and

in this case it saved the patient much inconvenience and expense.

  1. Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents

with fairly significant left upper quadrant pain. On examination of this area a rough grating noise

is heard. What is this sound?

  1. A) It is a splenic rub.
  2. B) It is a variant of bowel noise.
  3. C) It represents borborygmi.
  4. D) It is a vascular noise.

Ans: A

Chapter: 11

Feedback: A rough, grating noise over this area represents a splenic rub, which can accompany

splenic infarction. Rubs also occur over the liver and pleura and pericardium.

.

  1. You are palpating the abdomen and feel a small mass. Which of the following would you

do next?

  1. A) Ultrasound
  2. B) Examination with the abdominal muscles tensed
  3. C) Surgery referral
  4. D) Determine size by percussion

Ans: B

Chapter: 11

Feedback: It is easy to determine whether the mass is actually in the abdominal wall versus in

the abdomen by palpating with the abdominal wall tensed. This can be accomplished by having

the patient lift her head off the bed while supine. Usually, abdominal wall masses can be

observed, whereas intra-abdominal masses are more concerning.

  1. Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice

dullness in the last intercostal space in the anterior axillary line on his left side with a deep

breath. What does this indicate?

  1. A) His spleen is definitely enlarged and further workup is warranted.
  2. B) His spleen is possibly enlarged and close attention should be paid to further examination.
  3. C) His spleen is possibly enlarged and further workup is warranted.
  4. D) His spleen is definitely normal.

Ans: B

Chapter: 11

Feedback: This scenario is not uncommon in infectious mononucleosis. The presence of

dullness with inspiration should definitely increase your attention to further examination of the

spleen, although dullness can occur in normal patients too.

  1. A young patient presents with a left-sided mass in her abdomen. You confirm that it is

present in the left upper quadrant. Which of the following would support that this represents an

enlarged kidney rather than her spleen?

  1. A) A palpable “notch” along its edge
  2. B) The inability to push your fingers between the mass and the costal margin
  3. C) The presence of normal tympany over this area

.

  1. D) The ability to push your fingers medial and deep to the mass

Ans: C

Chapter: 11

Feedback: A left upper quadrant mass is more likely to be a kidney if there is no palpable

“notch,” you can push your fingers between the mass and the costal margin, there is normal

tympany over this area, and you cannot push your fingers medial and deep to the mass. These

findings are very difficult to appreciate in an obese patient.

  1. Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the

midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the

symphysis pubis. What does this most likely represent?

  1. A) Sigmoid mass
  2. B) Tumor in the abdominal wall
  3. C) Hernia
  4. D) Enlarged bladder

Ans: D

Chapter: 11

Feedback: It is possible that this represents a sigmoid colon mass, but this is less likely than an

enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently

cause partial urinary obstruction with bladder enlargement. If the mass resolves with

catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic

bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A

hernia would most likely not be dull to percussion. Midline abdominal wall tumors of this size

would be unusual but could be discerned by having the patient tense his abdominal muscles.

  1. Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note

that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What

should you do next?

  1. A) Obtain abdominal ultrasound
  2. B) Reassess by examination in 6 months
  3. C) Reassess by examination in 3 months
  4. D) Refer to a vascular surgeon

Ans: A

Chapter: 11

.

Feedback: A pulsatile mass in this man should be followed up with ultrasound as soon as

possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4

centimeters. It would be inappropriate to recheck him at a later time without taking action.

Likewise, referral to a vascular surgeon before ultrasound may be premature.

  1. Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the

following would argue for the presence of ascites?

  1. A) Bilateral flank tympany
  2. B) Dullness which remains despite change in position
  3. C) Dullness centrally when the patient is supine
  4. D) Tympany which changes location with patient position

Ans: D

Chapter: 11

Feedback: A diagnosis of ascites is supported by findings that are consistent with movement of

fluid and gas with changes in position. Gas-filled loops of bowel tend to float so that dullness

when supine would argue against this. Likewise, because fluid gathers in dependent areas, the

flanks should ordinarily be dull with ascites. Tympany which changes location with patient

position (“shifting dullness”) would support the presence of ascites. A fluid wave and edema

would support this diagnosis as well.

  1. Which of the following is consistent with obturator sign?
  2. A) Pain distant from the site used to check rebound tenderness
  3. B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated
  4. C) Pain with extension of the right thigh while the patient is on her left side or while pressing

her knee against your hand with thigh flexion

  1. D) Pain that stops inhalation in the right upper quadrant

Ans: B

Chapter: 11

Feedback: Obturator sign is seen in appendicitis. It is pain with the stretching of the internal

obturator muscle because of inflammation. Pain distant from the site used to check rebound

tenderness is Rovsing’s sign and is a reliable sign of peritonitis. Answer “C” describes psoas

sign, which is also seen in appendicitis. Palpation in the right upper quadrant that causes pain

severe enough to stop inhalation is consistent with inflammation of the gallbladder and is called

Murphy’s sign.

.

  1. An elderly woman with a history of coronary bypass comes in with severe, diffuse,

abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on

the abdomen. What do you suspect?

  1. A) Malingering
  2. B) Neuropathy
  3. C) Ischemia
  4. D) Physical abuse

Ans: C

Chapter: 11

Feedback: Ischemic pain can be severe but is not made worse with palpation. The history of

bypass could be a clue that there is vascular narrowing elsewhere. Malingering is less likely, and

neuropathic pain, as seen in herpes zoster, would worsen with touch. You are to be commended

if you considered elder abuse, because this is frequently missed. Ordinarily, this pain would be

worse with examination because of the preceding trauma.

.

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