Physical Examination Multiple Choice

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1. An 83-year-old woman presents to the ER the afternoon of Thanksgiving complaining of severe abdominal pain. She states it was at first cramping around her navel but has now radiated to the rest of her abdomen. She also complains of some vomiting and bloody diarrhea. About 1 hour before the pain started, she had a large traditional holiday meal. She states she generally only eats about half a sandwich and some soup at meals. She denies any earlier history of similar pain. Her past medical history is significant for coronary artery disease, for which she has had a stent placed in the past. She is only taking medicines related to her heart condition. She denies any alcohol, drug, or tobacco use. Her review of systems is positive for soreness in her legs while walking and occasional chest pain on exertion. On exam, you find an elderly woman in great distress. She is pale and tachycardic. Examining her abdomen, you hear decreased bowel sounds. On palpitation, her abdomen is rigid with voluntary guarding and rebound. Her rectal exam shows grossly bloody stool. What diagnosis for abdominal pain best describes her symptoms and signs?

(A) Acute pancreatitis

(B) Acute cholecystitis

(C) Acute appendicitis

(D) Mesenteric ischemia

2. A 35-year-old male athlete comes into the ER complaining of severe lower abdominal pain and vomiting. He relates the pain began several hours ago after he cycled at the gym and lifted weights. He states he has had occasional lower abdominal pain with lifting weights in the past but nothing like this. He has no significant past medical history and denies any tobacco, drug, or alcohol use. On exam, you find a young man who appears very ill. He is pale and vomiting clear green liquid. As you examine him, his emesis becomes darker and malodorous. On exam, he has high-pitched increased bowel sounds and has voluntary guarding and rebound. His testicles are descended bilaterally, and his right testicle seems tender and enlarged. Auscultating it, you also hear bowel sounds. What diagnosis is most likely the cause of his pain?

(A) Acute pancreatitis

(B) Acute mechanical intestinal obstruction

(C) Acute cholecystitis

(D) Mesenteric ischemia

3. A 39-year-old seamstress presents to the ER complaining of severe upper abdominal pain that started about 2 hours ago. She had eaten a cheeseburger and fries 45 minutes before the pain began. She tried taking some calcium stomach tablets, but they didn't help. She states the pain is a 10 on a 10-point scale and is starting to hurt in her back. She says she is nauseated and needs to vomit. She does admit to having had milder pains similar in the past but never to this extent. Her past medical history is significant for high blood pressure and two caesarean sections. Her older sister and mother have had to have gallbladder surgery. She denies any tobacco, drug, or alcohol use. Her review of systems is noncontributory. On examination, you find a mildly obese woman in severe distress. She is lying on the stretcher, but she cannot find a comfortable position. Her blood pressure is mildly elevated at 140/85, and her heart rate is 110. Her temperature is normal. Her abdominal exam reveals normal bowel sounds, but she is tender in the right upper quadrant. She has a positive Murphy's sign. The remainder of her abdominal exam is normal. Her rectal is heme negative, and her pelvic exam is normal. What etiology of abdominal pain is most likely causing her symptoms?


Peptic ulcer disease


Biliary colic


Acute cholecystitis


Acute pancreatitis

4. A 68-year-old homemaker presents to your clinic complaining of difficulty swallowing. It began several months ago when she would attempt to eat steak. Over time, it has progressed to the point that she can only sip on soups and broths. She has sometimes had to regurgitate her food back up to get relief from the pain in her chest when she attempts to eat. Her past medical history is significant for diet controlled, type-2 diabetes. She had a 60-pack-year smoking history but quit smoking 15 years ago. She denies any drug or alcohol abuse. On review of systems, she has lost approximately 15 lbs in the past 3 months. She denies any heartburn, constipation, or diarrhea. On exam, you find a pleasant elderly woman in no acute distress. Her cardiac, pulmonary, and abdominal exams are all normal. What disorder of dysphagia is the most likely cause for her symptoms?

(A) Esophageal stricture

(B) Esophageal cancer

(C) Esophageal spasm

(D) Scleroderma

5. A 26-year-old woman follows up at your office for her 6-week postpartum visit. She complains of severe constipation problems since the birth of her last child. Although she says she is eating healthy and drinking plenty of fluids, the problem persists. She does complain of pain with defecation. She denies any abdominal pain, nausea, vomiting, or diarrhea. She has never had problems with constipation except for during her pregnancies. Her past medical history is significant for two vaginal deliveries. She denies any tobacco, drug, or alcohol use. She is currently taking only prenatal vitamins. She has no family history of any bowel problems. On exam, she has normal bowel sounds, and her abdomen is soft with no rebound or guarding. Her pelvic exam reveals that her uterus has returned to nongravid size and that her episiotomy site has healed. Her rectal exam is painful and is positive for occult blood. What is the best choice for the cause of her constipation?

(A) Obstructing lesion

(B) Irritable bowel syndrome

(C) Rectal cancer

(D) Painful anal lesions

6. A 19-year-old male college student presents to your clinic the week following spring break complaining of 1-day abdominal pain and watery diarrhea. He thinks he has seen blood mixed with his stool. He has had some nausea but no vomiting. He had recently traveled to Central America over the break to go scuba diving. His past medical history is not significant. He drinks six to eight beers during the weekend but denies any tobacco or drug use. On review of symptoms, he does have night sweats and rigors. On exam, you find he is febrile at 102.3°F and he is tachycardic at 115 bpm. Otherwise, his heart and lung exam are normal. Upon auscultation, he has increased bowel sounds, and on palpation, he is diffusely tender. He has no rebound or guarding, but his rectal is guaiac positive. What cause of diarrhea is most likely?

(A) Secretory infections

(B) Inflammatory infections

(C) Irritable bowel syndrome

(D) Malabsorption syndrome

7. A 38-year-old unemployed man presents to the ER complaining of black tarry stools that now have blood in them. He states he has also had some severe pain in his stomach for the last few days. He vomited once and thinks he saw some blood. His past medical history is significant for pancreatitis and asthma. He has smoked two packs of cigarettes for 25 years and drinks approximately 12 beers a day. He denies any IV drug use. He has had no recent out-of-state travel. On review of symptoms, he notes that he has fainted in the last day. On exam, you find a cachetic man appearing older than his stated age. He is afebrile but tachycardic, at 120 bpm. Otherwise, his heart and lung exam are normal. On inspection, he has no dilated veins around his umbilicus or skin of an unusual color. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness, which is more severe in the epigastric area. His liver percusses 12 cm in the right midclavicular line, and he has no fluid wave. He is grossly positive for blood on his rectal exam. What cause of black stools most likely describes his symptoms and signs?

(A) Gastritis

(B) Inflammatory infectious diarrhea

(C) Mallory-Weiss tear

(D) Esophageal varices

8. A 37-year-old female bank teller presents to your office complaining about accidentally urinating on herself. She relates this has happened several times in the last month. She states she realizes that she has to go to the bathroom, but before she can make it to the toilet, she soils herself. Upon further questioning, it is revealed that for years she has had to urinate frequently during the day and at night. She had thought these were bladder infections, but the urine lab tests were always normal. Her past medical history is significant for migraines and depression. She denies any tobacco or drug use. She drinks alcohol socially several times a year. On review of systems, she relates pelvic pain with sexual intercourse. On exam, she has a normal abdominal, rectal, and pelvic exam. Her bladder is appropriate in size, and her urinary analysis is negative for blood or signs of infection. Which type of urinary incontinence does she have?

(A) Stress incontinence

(B) Urge incontinence

(C) Overflow incontinence

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