Answers and Explanations

Chapter 2

Interviewing and the Health History Multiple Choice

1. The correct answer is (B) Quality

Quality is the only one of the seven attributes of a symptom listed that is not addressed. The patient has not described the kind of pain he is experiencing other than that it is in his chest. Pain may be an ache, a sharp sensation, a pressure-like sensation, or a burning sensation, which are all important descriptors in helping to determine your differential diagnosis.

Remitting or exacerbating factors would be an incorrect choice in that the patient states during the history that nothing has made the pain better or worse. Likewise, severity is addressed in that the patient rates the pain as a 9 out of a 10-point scale. Timing is also covered when he states that the pain started 30 minutes prior to his arrival at the emergency room and has not gone away.

2. The correct answer is (C) Facilitation

Facilitation is the type of interviewing technique that you have demonstrated. By maintaining eye contact and asking the patient to "go on," you have attempted to make her more comfortable in relating details about the concern that brought her into your office.

Echoing would be an incorrect choice in that it is a simple repetition of the patient's words; this was not done. Nor is direct questioning the correct choice since that is a technique in which you, the interviewer, use a series of questions to elicit more details about the patient's concern. Reassurance is incorrect as well: As the interviewer, you have not made an attempt to tell her that "everything will be alright," or words to that effect.

3. The correct answer is (C) Nonverbal communication

You have used nonverbal communication through the techniques of eye contact, sitting down, moving your body in slightly toward the patient, and nodding.

Echoing is not the correct response since it involves simple repetition of the patient's words, and, as the interviewer in this scenario, you haven't repeated the patient's words. Adaptive questioning is also incorrect. It involves using various questions to clarify the patient's story, and in this scenario, as the interviewer, you haven't asked any questions yet. Empathic response is not correct. You have not identified the patient's feelings; and she has not expressed any during the interview.

4. The correct answer is (B) Talkative patient

This patient wants to tell you her life's story. Remember to let this type of patient talk for approximately 5-10 minutes while you listen closely to how she expresses her ideas, note the use of nonverbal cues, and so forth. A helpful technique is to have the patient focus on the most important thing that concerns her at today's visit and to schedule a follow-up appointment, setting a specific time limit on the follow-up as well.

This patient is not anxious; she is relaxed and able to address completely all of the problems that brought her into the office. An anxious patient may give nonverbal clues, such as fidgeting and sitting tensely. Obviously, this patient is not angry; she has not expressed any anger or hostility toward the interviewer. Nor is she disruptive; she is friendly and interested in telling you all about herself. She is not silent: This patient is far from silent!

5. The correct answer is (A) Denial

This patient has not yet accepted the fact that she is dying. She is making plans for the future that seem inappropriate given the diagnosis, prognosis, and her overall physical decline.

The patient does not seem angry. She has not expressed anger about her condition or about the "unfairness" of her prognosis, nor toward the clinician for the diagnosis has been made. This scenario does not illustrate any evidence of bargaining. The patient has not expressed sadness nor depression. She has clearly not accepted her diagnosis.

Chapter 3

Beginning the Physical Examination: General Survey and Vital Signs Multiple Choice

1. The correct answer is (D) Obese

The patient is obese. Obesity is defined as a BMI over 30. This patient has a calculated BMI of 43. Underweight is defined as a BMI of less than 17; normal weight is defined as a BMI between 17 and 23; and Overweight is defined as a BMI between 23 and 30.

2. The correct answer is (C) Anorexia nervosa

This patient has a preoccupation with her weight and feels that she is too fat. She has a BMI of 15, which is underweight, and does not see herself as too thin. The patient's mother states that she barely eats, which is typical of patients with anorexia.

With a BMI of 15 and a daily exercise routine, the patient is hardly at risk for obesity. Although this patient is difficult to classify without further information, you believe her when she states that she doesn't eat excessively or make herself vomit. Patients with bulimia will go on binges of overeating, then make themselves vomit. Although normal adolescents are concerned with their body image, they do not exercise to the extent that this girl does nor do they typically have a BMI of 15 and barely eat.

3. The correct answer is (D) Respiratory distress

The patient has classic signs of respiratory distress. He is tachypneic — his respiratory rate is greater than 20 breaths/minute and he appears to have labored breathing. Normal oral temperature is between 96.4° F and 99.1°F, normal pulse is between 60 and 100 beats per minute, normal blood pressure is a systolic of 90/60 to 140/90, and a normal respiratory rate is between 14 and 20 breaths per minute.

The patient's signs are not consistent with pain from the cough. Pain may result in an elevated pulse and elevated respiratory rate; however, pain is unlikely to produce fever (temperature of 103°F) or a low blood pressure of 90/60. It is unlikely that the signs are caused by anxiety about the visit. Anxiety can result in an elevated pulse, respiratory rate, and labored breathing; however, anxiety is unlikely to produce fever or hypotension.

4. The correct answer is (B) The length of the inflatable bladder was 50% of the upper arm circumference

The length of the inflatable bladder should be 80% of the upper arm circumference; if it is too short, then the blood pressure reading will be artificially increased.

Choice (A) is incorrect since the width of the inflatable bladder of the cuff should normally be 40% of the upper arm circumference in order to accurately measure the blood pressure of a patient. The anaeroid sphygnomanometer should be calibrated routinely in order to maintain the accuracy of measurement. Since it was just calibrated prior to the patient's measurement, this is not a factor in an inaccurate reading. In order to obtain a more accurate blood pressure measurement, the patient should be seated for at least 5 minutes before the blood pressure is taken; waiting a longer time period does not make the blood pressure reading more inaccurate.

5. The correct answer is (B) He drank a cup of coffee 10 minutes prior to his blood pressure measurement

Caffeine ingested within 30 minutes of checking a blood pressure measurement can artificially increase the patient's blood pressure reading.

Response (A) is not correct since, under optimal conditions, the patient should be in a quiet room seated for at least 5 minutes prior to obtaining the blood pressure measurement. Response (C) is incorrect since a bare arm is part of optimal conditions for measuring blood pressure. When the patient's arm is clothed, the blood pressure reading can be artificially inflated. If the patient is seated when his blood pressure is measured, his arm should be supported a little above the waist in order to obtain an optimal blood pressure measurement.

6. The correct answer is (C) Severe aortic stenosis

Severe aortic stenosis is one condition in which the pulse pressure is diminished and the pulse feels weak and small. Other conditions that could result in this same type of pulse include heart failure, hypovolemia, exposure to cold, and severe congestive heart failure.

Hypertrophic cardiomyopathy is not a correct response. The arterial pulse in hypertrophic cardiomyopathy is increased, with a double systolic peak, not small and weak. Premature contractions result in a bigeminal pulse, which is a normal beat alternating with a premature contraction; thus, choice (B) is not correct. Nor is constrictive pericarditis correct. It results in a paradoxical pulse, which is a palpable decrease in the pulse's amplitude with quiet inspiration.

Chapter 4 The Skin

Multiple Choice

1. The correct answer is (A) Scabies

The presence of a burrow is most diagnostic of scabies. A burrow is a minute, slightly raised tunnel in the epidermis commonly found on the finger webs and on the sides of the fingers. The patient experiences intense itching, which results in excoriations and lichenified areas secondary to the scratching.

Atopic dermatitis is an incorrect choice. It is more likely to present with thickening and roughening of the skin, with increased visibility of the normal skin furrows. There are burrows. Acne typically presents in the pubertal years and is characterized by comedones, which represents a plugged opening of a sebaceous gland. The comedones are more commonly found on the face as well as the upper back and chest, not in the finger webs. Choice (D) also is incorrect. Telangiectasias are more commonly found in an older population and are dilated small vessels that appear to be red or blue in color.

2. The correct answer is (C) Cherry angioma

Cherry angiomas are bright or ruby red, usually 1-3 mm in diameter, and round and flat, which may show partial blanching with pressure. They increase in size and number as a person ages and do not confer an increased risk of skin cancer.

Squamous cell carcinoma is an incorrect answer. It usually appears on sun-exposed skin; the face and back of the hands are areas typically affected. The lesions are red and firm and raised in appearance. Actinic keratosis is also incorrect. It is a skin lesion comprised of superficial, flattened papules covered by a dry scale. They are round or irregular and are pink, tan, or grayish. They typically appear on the face and hands. Spider angiomas are fiery red and range in size from very small to 2 cm. They have a central body and are sometimes raised, are surrounded by erythema, and have radiating legs. They blanch with pressure. The most common locations are on the face, neck, arms, and upper trunk.

3. The correct answer is (D) Basal cell carcinoma

A basal cell carcinoma usually appears on the face. Initially, it is a translucent nodule, which spreads, leaving a depressed center and a firm elevated border. Although it is a malignant tumor, it grows slowly and rarely metastasizes.

Actinic keratoses are superficial, flattened papules covered by a dry scale. There are often multiple lesions, which are usually pink, tan, or grayish in color. The most typical locations are on the face and hands. Seborrheic keratoses are yellowish to brown raised lesions, which feel slightly greasy and velvety or warty. There are often multiple lesions, which are symmetrically distributed on the trunk of older people. Although squamous cell carcinomas can appear on the sun-exposed areas of the skin such as the face, they are firm and red in appearance.

4. The correct answer is (B) Dysplastic nevus

A dysplastic nevus is varied in color, but often dark. It is larger than 6 mm and has irregular borders, which fade into the surround skin. Without further intervention, it is difficult to determine whether this patient's lesion is an early malignant melanoma or not.

A benign nevus is a flat or slightly raised, round or oval shaped lesion with sharply defined borders. It is usually of a uniform tan or brown color and less than 6 mm in diameter. This patient has many benign nevi, but they are not the lesion of concern in this scenario. Seborrheic keratoses are yellowish to brown raised lesions, which feel slightly greasy and velvety or warty. There are often multiple lesions, which are symmetrically distributed on the trunk of older people. Actinic keratoses are superficial, flattened papules covered by a dry scale. There are often multiple lesions, which are usually pink, tan, or grayish in color. The most typical locations are on the face and hands.

5. The correct answer is (B) Stage II

This patient has a stage II ulcer, which is a partial-thickness skin loss or ulceration that involves the epidermis, dermis, or both layers.

A stage I ulcer is defined as intact skin that has a change in temperature, consistency, sensation, or color. The temperature can be warm or cool; the consistency can be firm or boggy; the patient may experience pain or itching; the color may be red, blue, or purple. A stage III ulcer is a full-thickness skin loss, with evidence of damage to or necrosis of subcutaneous tissue, which may extend to, but not through, the underlying muscle. A stage IV ulcer involves full-thickness skin loss with destruction, tissue necrosis, or damage to underlying muscle, bone, or supporting structures.

6. The correct answer is (A) Stage I

The patient has a stage I ulcer, which is defined as intact skin that has a change in temperature, consistency, sensation, or color. The temperature can be warm or cool; the consistency can be firm or boggy; the patient may experience pain or itching; the color may be red, blue, or purple.

A stage II ulcer is a partial-thickness skin loss or ulceration, which involves the epidermis, dermis, or both layers. A stage III ulcer is a full-thickness skin loss with evidence of damage to or necrosis of subcutaneous tissue, which may extend to, but not through, the underlying muscle. A stage IV ulcer involves full-thickness skin loss with destruction, tissue necrosis, or damage to underlying muscle, bone, or supporting structures.

7. The correct answer is (D) Plantar wart

Plantar warts often occur on the metatarsal area, heels, and toes, where there has been slight trauma in the past. They cause thickened skin and can be very painful upon pressure. There are usually characteristic black dots associated with the wart, which are thrombosed capillaries. Corns are thickened skin, but they are caused by pressure against the foot. They occur most commonly on the lateral side of the 5th toe and between the 4th and 5th toes. Callus formations also occur at pressure points but at places where the skin is normally thick. Calluses are not painful and are usually located around the heel or over the plantar surface, just proximal to the great toe. They are not tender. Neuropathic ulcers also develop at pressure points, usually because of a lack of sensation. Although often deep and infected, they are not painful. They are usually red, warm, and sometimes drain serosanguinous fluid.

Chapter 5 Head and Neck

Multiple Choice

1. The correct answer is (A) Central innervation of cranial nerve VII (facial)

A review of the cranial nerves and their function support the symptoms presented. Facial muscles are mediated by cranial nerve Vll.

2. The correct answer is (C) Cluster headache

A cluster headache produces pain around the eye, temple, forehead, and cheek; it is unilateral and always on the same side of the head. The pain may be excruciating and can occur as often as twice a day. This type of headache is more common in men than in women.

3. The correct answer is (B) Sternomastoid and trapezius

The major anterior neck muscles are the trapezius and sternomastoid. They form two triangles on the side of the neck, which can be used as landmarks for lymph nodes and other vessels.

4. The correct answer is (C) Myxedema

Myxedema arises from hypothyroidism, or a deficiency of thyroid hormone. You may see a periorbital edema, coarse facial features, dry skin, and dry coarse hair and eyebrows.

Sclerodema is a rare autoimmune disorder affecting blood vessels and connective tissue, causing a tightening of the skin in the lower face. Cachexia refers to severe weight loss from poor nutrition, which may result in coarse hair but not puffiness. Cretinism arises from severe congenital hypothyroidism and is associated with dwarfism and mental retardation.

5. The correct answer is (C) Damage to cranial nerve V (trigeminal nerve)

Facial sensations of pain or touch are mediated by cranial nerve V.

Facial paralysis can be central or peripheral. Bell's palsy results from a peripheral lesion of cranial nerve VII—the patient cannot wrinkle the forehead on the affected side nor make a smile, so both the upper and lower facial muscles are involved. In central lesions of cranial nerve VII from cerebrovascular accidents, the patient can wrinkle both sides of the forehead but cannot make a smile.

6. The correct answer is (C) Area proximal to the enlarged node When nodes are abnormal, check the area from which they drain.

Chapter 6

The Thorax and Lungs

Case Study: Shortness of Breath

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