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

 

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

 

 

Chapter 3: Interviewing and the Health History

 

 

 

 

Multiple Choice

 

 

 

 

  1. You are running late after your quarterly quality improvement meeting at the hospital and have just gotten paged from the nurses’ station because a family member of one of your patients wants to talk with you about that patient’s care. You have clinic this afternoon and are double-booked for the first appointment time; three other patients also have arrived and are sitting in the waiting room. Which of the following demeanors is a behavior consistent with skilled interviewing when you walk into the examination room to speak with your first clinic patient?
  2. A) Irritability
  3. B) Impatience
  4. C) Boredom
  5. D) Calm

 

Ans:  D

Chapter:  03

Page and Header:  58, Getting Ready: The Approach to the Interview

Feedback:  The appearance of calmness and patience, even when time is limited, is the hallmark of a skilled interviewer.

 

 

 

 

  1. Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient–provider interview?
  2. A) Establish the agenda, negotiate a plan, establish rapport, and invite the patient’s story.
  3. B) Invite the patient’s story, negotiate a plan, establish the agenda, and establish rapport.
  4. C) Greet the patient, establish rapport, invite the patient’s story, establish the agenda, expand and clarify the patient’s story, and negotiate a plan.
  5. D) Negotiate a plan, establish an agenda, invite the patient’s story, and establish rapport.

 

Ans:  C

Chapter:  03

Page and Header:  60, Learning About the Patient: The Sequence of the Interview

Feedback:  This is the most productive sequence for the interview. Greeting patients and establishing rapport allows them to feel more comfortable before “inviting” them to relate their story. After hearing the patient’s story, together you establish the agenda regarding the most important items to expand upon. At the end, together you negotiate the plan of diagnosis and treatment.

 

 

 

 

  1. Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The pain is a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and it seems to be worse a couple of hours after eating. She has noticed that it starts after eating greasy foods, so she has cut down on these as much as she can. Initially it occurred once a week, but now it is occurring every other day. Nothing makes it better. From this description, which of the seven attributes of a symptom has been omitted?
  2. A) Setting in which the symptom occurs
  3. B) Associated manifestations
  4. C) Quality
  5. D) Timing

 

Ans:  B

Chapter:  03

Page and Header:  65, The Seven Attributes of a Symptom

Feedback:  The interviewer has not recorded whether or not the pain has been accompanied by nausea, vomiting, fever, chills, weight loss, and so on. Associated manifestations are additional symptoms that may accompany the initial chief complaint and that help the examiner to start refining his or her differential diagnosis.

 

 

 

 

  1. Jason is a 41-year-old electrician who presents to the clinic for evaluation of shortness of breath. The shortness of breath occurs with exertion and improves with rest. It has been going on for several months and initially occurred only a couple of times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than a dozen times per day. The shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea.

Which of the following symptom attributes was not addressed in this description?

  1. A) Severity
  2. B) Setting in which the symptom occurs
  3. C) Timing
  4. D) Associated manifestations

 

Ans:  A

Chapter:  03

Page and Header:  65, The Seven Attributes of a Symptom

Feedback:  The severity of the symptom was not recorded by the interviewer, so we have no understanding as to how bad the symptom is for this patient.  The patient could have been asked to rate his pain on a 0 to 10 scale or used one of the other standardized pain scales available.  This allows the comparison of pain intensity before and after an intervention.

 

 

 

 

  1. You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning?
  2. A) Directed questioning: starting with the general and proceeding to the specific in a manner that does not make the patient give a yes/no answer
  3. B) Reassuring the patient that the urinary symptoms are benign and that she doesn’t need to worry about it being a sign of cancer
  4. C) Offering the patient multiple choices in order to clarify the character of the urinary symptoms that she is experiencing
  5. D) Asking her to tell you exactly what she means when she states that she has a urinary tract infection

 

Ans:  B

Chapter:  03

Page and Header:  68, Building a Therapeutic Relationship: The Techniques of Skilled Interviewing

Feedback:  Reassurance is not part of clarifying the patient’s story; it is part of establishing rapport and empathizing with the patient.

 

 

 

 

  1. Mr. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to be checked out for the symptom of chest pain. As you listen to him describe his symptom in more detail, you say “Go on,” and later, “Mm-hmmm.” This is an example of which of the following skilled interviewing techniques?
  2. A) Echoing
  3. B) Nonverbal communication
  4. C) Facilitation
  5. D) Empathic response

 

Ans:  C

Chapter:  03

Page and Header:  68, Building a Therapeutic Relationship: The Techniques of Skilled Interviewing

Feedback:  This is an example of facilitation. Facilitation can be posture, actions, or words that encourage the patient to say more.

 

 

 

 

  1. Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and doesn’t say anything in response to your question. This is an example of which type of challenging patient?
  2. A) Talkative patient
  3. B) Angry patient
  4. C) Silent patient
  5. D) Hearing-impaired patient

 

Ans:  C

Chapter:  03

Page and Header:  75, Adapting Your Interview to Specific Situations

Feedback:  This is one example of a silent patient. There are many possibilities for this patient’s silence: depression, dementia, the manner in which you asked the question, and so on.

 

 

 

 

  1. Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular provider is on vacation and she wanted to be seen. You have heard about her many times from your colleague and are aware that she is a very talkative person. Which of the following is a helpful technique to improve the quality of the interview for both the provider and the patient?
  2. A) Allow the patient to speak uninterrupted for the duration of the appointment.
  3. B) Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you.
  4. C) Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview.
  5. D) Allow your impatience to show so that the patient picks up on your nonverbal cue that the appointment needs to end.

 

Ans:  B

Chapter:  03

Page and Header:  75, Adapting Your Interview to Specific Situations

Feedback:  You can also say, “I want to make sure I take good care of this problem because it is very important.  We may need to talk about the others at the next appointment.  Is that okay with you?”  This is a technique that can help you to change the subject but, at the same time, validate the patient’s concerns; it also can provide more structure to the interview.

 

 

 

 

  1. Mrs. H. comes to your clinic, wanting antibiotics for a sinus infection. When you enter the room, she appears to be very angry. She has a raised tone of voice and states that she has been waiting for the past hour and has to get back to work. She states that she is unimpressed by the reception staff, the nurse, and the clinic in general and wants to know why the office wouldn’t call in an antibiotic for her. Which of the following techniques is not useful in helping to calm this patient?
  2. A) Avoiding admission that you had a part in provoking her anger because you were late
  3. B) Accepting angry feelings from the patient and trying not to get angry in return
  4. C) Staying calm
  5. D) Keeping your posture relaxed

 

Ans:  A

Chapter:  03

Page and Header:  75, Adapting Your Interview to Specific Situations

Feedback:  In this scenario, the provider was 1 hour late in seeing the patient. The provider should acknowledge that he was late and apologize for this, no matter the reason for being late.  It often helps to acknowledge that a patient’s anger with you is understandable and that you might be angry in a similar situation.

 

 

 

 

  1. A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge. As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information?
  2. A) Are you sexually active?
  3. B) When was the last time you had intimate physical contact with someone, and did that contact include sexual intercourse?
  4. C) Do you have sex with men, women, or both?
  5. D) How many sexual partners have you had in the last 6 months?

 

Ans:  A

Chapter:  03

Page and Header:  81, Sensitive Topics That Call For Specific Approaches

Feedback:  This is inappropriate because it is too vague. Given the complaint, you should probably assume that he is sexually active. Sometimes patients may respond to this question with the phrase “No, I just lie there.”  A specific sexual history will help you to assess this patient’s risk for other sexually transmitted infections.

 

 

 

 

  1. Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has come to the office many times in the past with a variety of injuries, and you suspect that he has a problem with alcohol. Which one of the following questions will be most helpful in diagnosing this problem?
  2. A) You are an alcoholic, aren’t you?
  3. B) When was your last drink?
  4. C) Do you drink 2 to 3 beers every weekend?
  5. D) Do you drink alcohol when you are supposed to be working?

 

Ans:  B

Chapter:  03

Page and Header:  81, Sensitive Topics That Call for Specific Approaches

Feedback:  This is a good opening question that is general and neutral in tone; depending on the timing, you will be able to ask for more specific information related to the patient’s last drink.  The others will tend to stifle the conversation because they are closed-ended questions.  Answer D implies negative behavior and may also keep the person from sharing freely with you.

 

 

 

 

  1. On a very busy day in the office, Mrs. Donelan, who is 81 years old, comes for her usual visit for her blood pressure. She is on a low-dose diuretic chronically and denies any side effects.  Her blood pressure is 118/78 today, which is well-controlled.  As you are writing her script, she mentions that it is hard not having her husband Bill around anymore. What would you do next?
  2. A) Hand her the script and make sure she has a 3-month follow-up appointment.
  3. B) Make sure she understands the script.
  4. C) Ask why Bill is not there.
  5. D) Explain that you will have more time at the next visit to discuss this.

 

Ans:  C

Chapter:  03

Page and Header:  81, Sensitive Topics That Call for Specific Approaches

Feedback:  Sometimes, the patient’s greatest need is for support and empathy.  It would be inappropriate to ignore this comment today.  She may have relied heavily upon Bill for care and may be in danger.  She may be depressed and even suicidal, but you will not know unless you discuss this with her.  Most importantly, you should empathize with her by saying something like “It must be very difficult not to have him at home” and allow a pause for her to answer.  You may also ask “What did you rely on him to do for you?”   Only a life-threatening crisis with another patient should take you out of her room at this point, and you may need to adjust your office schedule to allow adequate time for her today.

 

 

 

 

  1. A patient is describing a very personal part of her history very quickly and in great detail. How should you react to this?
  2. A) Write down as much as you can, as quickly as possible.
  3. B) Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every word.
  4. C) Tell her that she can go over the notes later to make sure they are accurate.
  5. D) Push away from the keyboard or put down your pen and listen.

 

Ans:  D

Chapter:  03

Page and Header:  58, Getting Ready: The Approach to the Interview

Feedback:  This is a common event in clinical practice.  It is much more important to listen actively with good eye contact at this time than to document the story verbatim.  You want to minimize interruption (e.g., answer B).  It is usually not appropriate to ask a patient to go over the written notes, but it would be a good idea to repeat the main ideas back to her. You should be certain she has completed her story before doing this.  By putting down your pen or pushing away from the keyboard, you let the patient know that her story is the most important thing to you at this moment.

 

 

 

 

  1. You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire right side. She cannot speak (aphasia).  You are supposed to examine her.  You notice that the last examiner left her socks at the bottom of the bed, and although sensitive areas are covered by a sheet, the blanket is heaped by her feet at the bottom of the bed.  What would you do next?
  2. A) Carry out your examination, focusing on the neurologic portion, and then cover her properly.
  3. B) Carry out your examination and let the nurse assigned to her “put her back together.”
  4. C) Put her socks back on and cover her completely before beginning the evaluation.
  5. D) Apologize for the last examiner but let the next examiner dress and cover her.

 

Ans:  C

Chapter:  03

Page and Header:  58, Getting Ready: The Approach to the Interview

Feedback:  It is crucial to make an effort to make a patient comfortable.  In this scenario, the patient can neither speak nor move well.  Take a moment to imagine yourself in her situation.  As a matter of respect as well as comfort, you should cover the patient appropriately and consider returning a little later to do your examination if you feel she is cold.  While it is her nurse’s job to keep her comfortable, it is also your responsibility, and you should do what you can.  It is unacceptable to leave the patient in the same state in which you found her.

 

 

 

 

  1. When you enter your patient’s examination room, his wife is waiting there with him. Which of the following is most appropriate?
  2. A) Ask if it’s okay to carry out the visit with both people in the room.
  3. B) Carry on as you would ordinarily. The permission is implied because his wife is in the room with him.
  4. C) Ask his wife to leave the room for reasons of confidentiality.
  5. D) First ask his wife what she thinks is going on.

 

Ans:  A

Chapter:  03

Page and Header:  60, Learning About the Patient: The Sequence of the Interview

Feedback:  Even in situations involving people very familiar with each other, it is important to respect individual privacy.  There is no implicit consent merely because he has allowed his wife to be in the room with him.  On the other hand, it is inappropriate to assume that his wife should leave the room.  Remember, the patient is the focus of the visit, so it would be appropriate to allow him to control who is in the room with him and  inappropriate to address his wife first.  Although your duty is to the patient, you may get optimal information by offering to speak to both people confidentially.  This situation is analogous to an adolescent’s visit.

 

 

 

 

  1. A patient complains of knee pain on your arrival in the room. What should your first sentence be after greeting the patient?
  2. A) How much pain are you having?
  3. B) Have you injured this knee in the past?
  4. C) When did this first occur?
  5. D) Could you please describe what happened?

 

Ans:  D

Chapter:  03

Page and Header:  60, Learning About the Patient: The Sequence of the Interview

Feedback:  When looking into a complaint, it is best to start with an invitation for the patient to tell you in his or her own words.  More specific questions should be used later in the interview to fill in any gaps.

 

 

 

 

  1. You have just asked a patient how he feels about his emphysema. He becomes silent, folds his arms across his chest and leans back in his chair, and then replies, “It is what it is.”  How should you respond?
  2. A) “You seem bothered by this question.”
  3. B) “Next, I would like to talk with you about your smoking habit.”
  4. C) “Okay, let’s move on to your other problems.”
  5. D) “You have adopted a practical attitude toward your problem.”

 

Ans:  A

Chapter:  03

Page and Header:  60, Learning About the Patient: The Sequence of the Interview

Feedback:  You have astutely noted that the patient’s body language changed at the time you asked this question, and despite the patient’s response, you suspect there is more beneath the surface.  Maybe he is afraid of being browbeaten about his smoking, maybe a relative has recently died from this disorder, or maybe a friend told him 20 years ago that he would eventually get emphysema.  Regardless, by sharing your observation and leaving a pause, he may begin to talk about some issues which are very important to him.

 

 

 

 

  1. A patient tells you about her experience with prolonged therapy for her breast cancer. You comment, “That must have been a very trying time for you.”  What is this an example of?
  2. A) Reassurance
  3. B) Empathy
  4. C) Summarization
  5. D) Validation

 

Ans:  D

Chapter:  03

Page and Header:  68, Building a Therapeutic Relationship: The Techniques of Skilled Interviewing

Feedback:  This is an example of validation to legitimize her emotional experience.  “Now that you have had your treatment, you should not have any further troubles” is an example of reassurance.  “I understand what you went through because I am a cancer survivor myself” is an example of empathy.  “So, you have had a lumpectomy and multiple radiation treatments” is an example of summarization as applied to this vignette.

 

 

 

 

  1. You are performing a young woman’s first pelvic examination. You make sure to tell her verbally what is coming next and what to expect.   Then you carry out each maneuver of the examination.  You let her know at the outset that if she needs a break or wants to stop, this is possible.  You ask several times during the examination, “How are you doing, Brittney?”  What are you accomplishing with these techniques?
  2. A) Increasing the patient’s sense of control
  3. B) Increasing the patient’s trust in you as a caregiver
  4. C) Decreasing her sense of vulnerability
  5. D) All of the above

 

Ans:  D

Chapter:  03

Page and Header:  68, Building a Therapeutic Relationship: The Techniques of Skilled Interviewing

Feedback:  These techniques minimize the effects of transitions during an examination and empower the patient.  Especially during a sensitive examination, it is important to give the patient as much control as possible.

 

 

 

 

  1. When using an interpreter to facilitate an interview, where should the interpreter be positioned?
  2. A) Behind you, the examiner, so that the lips of the patient and the patient’s nonverbal cues can be seen
  3. B) Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of the patient
  4. C) Between you and the patient so all parties can make the necessary observations
  5. D) In a corner of the room so as to provide minimal distraction to the interview

 

Ans:  B

Chapter:  03

Page and Header:  75, Adapting Your Interview to Specific Situations

Feedback:  Interpreters are invaluable in encounters where the examiner and patient do not speak the same language, including encounters with the deaf.  It should be noted that deaf people from different regions of the world use different sign languages.  The priority is for you to have a good view of the patient.  Remember to use short, simple phrases while speaking directly to the patient and ask the patient to repeat back what he or she understands.

 

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

 

 

Chapter 17: The Nervous System

 

 

 

 

Multiple Choice

 

 

 

 

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

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

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

 

Ans:  C

Chapter:  17

Page and Header:  718, Table 17-3

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

 

 

 

 

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

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

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

 

Ans:  B

Chapter:  17

Page and Header:  718, Table 17-3

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

 

 

 

 

  1. A 37-year-old insurance agent comes to your office, complaining of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn’t feel particularly nervous when this occurs but she worries that other people will think she has an anxiety disorder or that she’s a drinker. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married and has three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form she has obvious tremors in her dominant hand.

What type of tremor is she most likely to have?

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

 

Ans:  C

Chapter:  17

Page and Header:  720, Table 17-4

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

 

 

 

 

  1. A 77-year-old retired school superintendent comes to your office, complaining of unsteady hands. He says that for the past 6 months, when his hands are resting in his lap they shake uncontrollably. He says when he holds them out in front of his body the shaking diminishes, and when he uses his hands the shaking is also better. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for over 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister who has arthritis problems. His children are all essentially healthy. On examination you see a fine, pill-rolling tremor of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back toward you. He has almost no “arm swing” with his gait.

What type of tremor is he most likely to have?

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

 

Ans:  A

Chapter:  17

Page and Header:  720, Table 17-4

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

 

 

 

 

  1. A 48-year-old grocery store manager comes to your clinic, complaining of her head being “stuck” to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot get it moved back to normal. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is on oral medication for each. She is married and has three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. On examination you see a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left but otherwise her examination is normal.

What form of involuntary movement does she have?

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

 

Ans:  D

Chapter:  17

Page and Header:  720, Table 17-4

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

 

 

 

 

  1. A 41-year-old real estate agent comes to your office, complaining that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy and as the day progressed he was unable to close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. His past medical history is unremarkable. He is divorced and has one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination you ask him to close his eyes. He is unable to close his left eye. You ask him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. You then ask him to give you a big smile. The right corner of his mouth raises but the left side of his mouth remains the same.

What type of facial paralysis does he have?

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

 

Ans:  A

Chapter:  17

Page and Header:  676, Techniques of Examination

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

 

 

 

 

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

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

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

 

Ans:  C

Chapter:  17

Page and Header:  727, Table 17-9

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

 

 

 

 

  1. A 21-year-old engineering student comes to your office, complaining of leg and back pain and of tripping when he walks. He states this started 3 months ago with back and buttock pain but has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific traumatic incidences but he was a defensive lineman in high school and junior college. His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy. On examination he is tender over the lumbar spine and he has a positive straight-leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching his gait you notice he has to pick his left foot up high in order not to trip.

What abnormality of gait does he most likely have?

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

 

Ans:  C

Chapter:  17

Page and Header:  730, Table 17-10

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

 

 

 

 

  1. A 17-year-old high school student is brought in to your emergency room in a comatose state. His friends have accompanied him and tell you that they have been shooting up heroin tonight and they think their friend may have had too much. The patient is unconscious and cannot protect his airway, so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. Preparing to finish the neurologic examination, you get a penlight.

What size pupils do you expect to see in this comatose patient?

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

 

Ans:  A

Chapter:  17

Page and Header:  731, Table 17-11

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

 

 

 

 

  1. A 37-year-old woman is brought into your emergency room comatose. The paramedics say her husband found her unconscious in her home. Her past medical history consists of type 1 diabetes and she is on insulin. In the ambulance the paramedics obtained a glucose check and her sugar was 15 (normal is 70 to 105). They began a dextrose saline infusion and intubated her to protect her airway. Despite their efforts, she is posturing in the emergency room with her arms straight at her side and her jaw clenched. Her legs are also straight and her feet are plantar flexed.

What type of posturing is she showing?

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

 

Ans:  B

Chapter:  17

Page and Header:  733, Table 17-13

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

 

 

 

 

  1. A patient presents with a left-sided facial droop. On further testing, you note that he is unable to wrinkle his forehead on the left and has decreased taste.  Which of the following is true?
  2. A) This represents a central lesion.
  3. B) This represents a CN IV lesion.
  4. C) This may be related to travel.
  5. D) This most likely represents a stroke.

 

Ans:  C

Chapter:  17

Page and Header:  725, Table 17-7

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

 

 

 

 

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

 

Ans:  C

Chapter:  17

Page and Header:  658, Anatomy and Physiology

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

 

 

 

 

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

 

Ans:  D

Chapter:  17

Page and Header:  656, Anatomy and Physiology

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

 

 

 

 

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

 

Ans:  A

Chapter:  17

Page and Header:  656, Anatomy and Physiology

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

 

 

 

 

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

 

Ans:  D

Chapter:  17

Page and Header:  673, Techniques of Examination

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

 

 

 

 

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

 

Ans:  C

Chapter:  17

Page and Header:  673, Techniques of Examination

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

 

 

 

 

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

 

Ans:  A

Chapter:  17

Page and Header:  674, Techniques of Examination

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

 

 

 

 

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

 

Ans:  B

Chapter:  17

Page and Header:  680, Techniques of Examination

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

 

 

 

 

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

 

Ans:  A

Chapter:  17

Page and Header:  689, Techniques of Examination

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

 

 

 

 

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

 

Ans:  B

Chapter:  17

Page and Header:  696, Techniques of Examination

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

 

 

 

 

  1. Jim is an HIV-positive patient who complains about back pain in addition to several other problems. On percussion, there is slight tenderness over the T7 vertebrae, and when you flex his thigh to 90 degrees and extend his lower legs, you meet strong resistance at about 45 degrees of extension.  What are likely causes of this constellation of symptoms?
  2. A) Fractured vertebrae
  3. B) Malingering
  4. C) Infection
  5. D) Medication side effect

 

Ans:  C

Chapter:  17

Page and Header:  703, Techniques of Examination

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

 

 

 

 

  1. A patient with alcoholism is brought in with confusion. You ask him to “stop traffic” with his palms and notice that every few seconds his palms suddenly move toward the floor.  What does this indicate?
  2. A) Stroke
  3. B) Metabolic problems
  4. C) Carpal tunnel syndrome
  5. D) Severe fatigue and weakness

 

Ans:  B

Chapter:  17

Page and Header:  704, Techniques of Examination

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

 

 

 

 

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

 

Ans:  B

Chapter:  17

Page and Header:  706, Techniques of Examination

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

 

 

 

 

  1. A woman experiences syncope after hearing that her son was severely injured. She becomes pale and collapses to the ground without injuring herself.  On waking, she states that she feels very warm.  She denies any other symptoms.  There are no findings on examination.  What caused her loss of consciousness?
  2. A) Micturition syncope
  3. B) Postural hypotension
  4. C) Cardiac arrhythmia
  5. D) Vasovagal syncope

 

Ans:  D

Chapter:  17

Page and Header:  715, Table 17-2

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

 

 

 

 

  1. A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen “staring off into space” and not paying attention.  If this is a seizure, it most likely represents which type?
  2. A) Pseudoseizure
  3. B) Tonic–clonic seizure
  4. C) Absence
  5. D) Myoclonus

 

Ans:  C

Chapter:  17

Page and Header:  718, Table 17-3

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

 

 

 

 

  1. A patient comes to you because she is experiencing a tremor only when she reaches for things. This becomes worse as she nears the “target.”  When you ask her to hold out her hands, no tremor is apparent.  What type of tremor does this most likely represent?
  2. A) Intention tremor
  3. B) Postural tremor
  4. C) Resting tremor
  5. D) Nervous tremor

 

Ans:  A

Chapter:  17

Page and Header:  720, Table 17-4

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

 

 

 

 

  1. A young woman comes in with brief, rapid, jerky, irregular movements. They can occur at rest or during other intentional movements and involve mostly her face, head, lower arms, and hands.  How would you describe these movements?
  2. A) Tics
  3. B) Dystonia
  4. C) Athetosis
  5. D) Chorea

 

Ans:  D

Chapter:  17

Page and Header:  720, Table 17-4

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