Chapter 18: Breasts and Axillae

1. A 44-year-old female mathematician presents to clinic with a complaint of a mass in the right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self-examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening test at age 43 years after a brief discussion with her primary care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group?

2. A 42-year-old female website developer presents for an annual preventive examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer. Which of the following is true about MRI as a screening modality for breast cancer in the general population?

3. A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This discharge started several weeks ago and has occurred at irregular intervals since that time. She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irregular periods over the last few months. On examination, she is able to express a small amount of discharge, which is sent to the laboratory and found to be consistent with breast milk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis?

4. A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on breast self-examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self-detection of breast cancer?

5. A 48-year-old female psychologist presents to clinic with concerns about her breast cancer risk after an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father’s side in as many years to be diagnosed with breast cancer, including the patient’s own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires further information about whether this would be appropriate for her. Which of the following is true about this patient’s indications for BRCA testing?

6. A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently

dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient?

7. A 66-year-old female museum curator presents for a routine annual examination. On examination, a notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy?

8. A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery, mobile, nontender mass is palpated in the right breast as described by the patient, which is consistent with a firbroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal to and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to report this finding?

9. A 54-year-old female dietician presents for a routine annual examination. On review of systems, she reports that she has had many breast findings over several years, including one biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changes in the breasts with menopause?

Chapter 19: Abdomen

1. An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β- human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis?
2. A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly?
3. A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA?
4. A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow- up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient?
5. An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1–2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation?
6. A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam?
7. An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis?
8. A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6–8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis?

10. A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic?

Chapter 20: Male Genitalia

1. A 67-year-old electronics technician with a history of hypertension and type 2 diabetes presents for his yearly physical examination and complains of progressively worsening erectile dysfunction (ED). While counseling him, the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most affected by vascular deficiencies related to his preexisting medical conditions and is likely contributing to his symptoms?

2. A 29-year-old graduate student states that he is able to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medications. What is the most likely cause of his problem?

3. Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from higher brain centers to the T11–L2 levels of the spinal cord and parasympathetic outflow from S2 to S4 reflex arcs. Local vasodilatation within the penis erectile tissue results from increased levels of which of the following?
4. The human papillomavirus (HPV) can cause genital warts in males and females as well as cervical cancer in females. Vaccination against HPV is available and should be offered to males between what ages?
5. A 32-year-old male complains of a painless, cystic mass just above his left testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in question and transillumination is noted. What is the most likely diagnosis?
6. A 25-year-old graduate student presents to the clinic complaining of scrotal pain, which has been increasing over the past 2 days. He is sexually active and has had unprotected intercourse with multiple partners in the past couple of weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpation of the right testicle are notes. What is the most likely diagnosis?
7. A 32-year-old elementary teacher requests a workup for infertility. He and his wife have been trying to conceive for the last 2 years. He reports that his wife has been evaluated and does not appear to have any infertility issues. The overall examination does not reveal any significant abnormalities. He is of average height and weight and has normal secondary sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility?
8. While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to the inguinal canal and related hernias. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region?
9. A 20-year-old college student presents for his annual physical examination. He recently became sexually active and is inquiring about the best means of preventing sexually transmitted infections (STIs). Of the following, which would be the most effective means of prevention?
10. A 21-year-old college student presents to the student health clinic for a full physical examination. He is generally healthy; however, he reports that he has had sexual intercourse with multiple partners in the past couple of months. He noticed a small lesion on the shaft of his penis a few days ago. While performing the examination, he unwillingly achieves an erection. How should the clinician proceed at this point?

Chapter 21: Female Genitalia

1. A 45-year-old driver’s education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding?

2. A 32-year-old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever since. She began oral contraceptive pills from when she got married until last year, when she began to try for a pregnancy.

Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient’s history, what is the best explanation for her infertility?

3. A 24-year-old retail clerk presents to the clinic for an annual exam. Her last Pap was 3 years ago and was normal. She is a G0 and is currently not sexually active although she has had two lifetime partners. She is on oral contraceptive pills for cycle control and has no medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and places the speculum. There are two layers of cells, squamous and columnar. Where is the most important area to obtain cells for a Pap smear?

4. A 35-year-old grade school teacher presents for her annual exam. Her last Pap smear was 4 years ago and normal. She is a G1P1 with a 6-year-old child. She has had four lifetime partners but only one partner in the last 12 years. Otherwise she has no complaints. A speculum exam is done followed by a bimanual examination during which a rectovaginal mass is palpated. Which of the following exam findings would be most reassuring that this is not a colonic mass?

5. A 21-year-old college student presents for her first annual exam. She has been sexually active for 1 year and has had two partners. She is not aware of having had any sexually transmitted diseases (STIs). She is using condoms for birth control and STI prevention but admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description for these lesions?

6. A 23-year-old female comes to the clinic to discuss her birth control options. Although she has been sexually active since age 16 years, she has been with one partner for the last year. She has decided to discontinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam?

7. An 18-year-old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID?
8. A 27-year-old G0 bus driver presents to the clinic complaining of an itchy vaginal discharge for the last week. She reached menarche at age 12 years, became sexually active at age 18 years, and has had a total of five sexual partners. She has been with her current partner for 1 month. She is on oral contraceptive pills and does not use condoms as she is allergic to latex. Her last menstrual period was 3 weeks ago. She is not having any pelvic pain, fever, nausea, or vomiting. Her vitals are normal with a body mass index of 22. The clinician places the metal medium Graves speculum in the vagina but cannot find the cervix. What is the best next maneuver to visualize the cervix?
9. A 63-year-old office worker comes to the clinic for her women’s health exam. Her last Pap smear was 5 years ago and was normal. She is married and has been with the same sexual partner for the last 35 years. After performing the majority of the exam, the clinician decides to do a speculum exam to collect cytology for Pap smear. What is the correct position to have the patient in for her speculum exam?
10. A 68-year-old retired patient presents to the clinic complaining about feeling like something is falling out of her vagina. She is a G6P6007 and had all her children vaginally, even the twins. She went through menopause at age 55 years, and, for the last few months, she has felt this falling sensation. On exam, an anterior bulge in the vaginal wall is apparent when she bears down. Weakness in which muscle would best account for the anterior bulge in the vaginal wall?

Chapter 22: Anus, Rectum, and Prostate

1. A 49-year-old male nurse experiences fecal incontinence after a motor vehicle accident that left him paralyzed below the waist. He asks his rehabilitation physician about the control of this function in a person without his injuries. Which of the following is true regarding the muscle control of the anal sphincter?

2. A 62-year-old male who is undergoing evaluation for possible prostate cancer strongly declines a

rectal examination, stating that, “Some trainee once did that and it hurt badly.” Which of the following is true about the innervation of the anus and rectum that may explain this patient’s experience of discomfort?

3. A 54-year-old male with a strong family history of breast and prostate cancer presents to his primary care provider to discuss prostate screening. His father died at age 73 years from prostate cancer that was not detected on routine digital rectal examinations (DREs), and he would like to minimize his chance of a similar occurrence. Which of the following is true regarding the anatomy and screening of the prostate by DRE?

4. A third-year medical student rotating on the internal medicine service performs a digital rectal examination (DRE) on a 56-year-old female patient. The patient has been admitted for suspicion of a myocardial infarction, and confirmation that there is no blood in the stool is required before anticoagulation can be started. The student reports that the fecal occult blood test was negative but notes that he palpated a structure through the anterior rectum that he could not identify. The attending physician confirms normal anatomy and reviews with the student that the most likely identity of the structure palpable is which of the following

5. A 45-year-old female executive reports to her primary care provider that she has recently experienced a change in the patterns of her bowel movements. She expresses a great concern as her family history includes a maternal aunt who died of colon cancer at age 49 years; her mother has had colonoscopies every 3 years with numerous adenomatous polyps removed. Which of the following historical elements would be the most concerning for colon cancer in this patient?

6. A 49-year-old customer service representative presents to his gastroenterologist for follow-up of his long-standing inflammatory bowel disease (IBD). He was diagnosed with ulcerative colitis (UC) at age 37 years and has had irregular care for this condition since then. His sole colonoscopy was done at the time of diagnosis 12 years ago. His only relevant family history is of prostate cancer in his father; his mother and sisters are healthy. Which of the following is true about recommended screening for colon cancer in this patient?

7. A 49-year-old male with well-controlled HIV undergoes a proctoscopic examination as routine screening for anal cancer. The patient is asymptomatic and specifically denies complaints of frequent urination (frequency), large volume of urination (polyuria), or repeated urination at night (nocturia). Under direct visualization, the clinician observes a clear, circumferential demarcation of proximal versus distal tissue. This demarcation was not palpable on digital rectal examination (DRE) prior to proctoscopy. What is the most likely origin of this finding?

8. A 34-year-old female reports anal pain with defecation. She notes incidentally to this complaint that she has developed episodic abdominal discomfort and sores in her mouth. Anoscopic examination reveals anal fissures that appear to be her source of pain. Which of the following underlying conditions is the clinician most likely to find?

9. A 53-year-old African American advertising agent presents for discussion of his prostate cancer risk and possible screening for this disease. His father was diagnosed at age 82 years with prostate cancer but died recently at age 87 years from a myocardial infarction before the disease progressed. Family history also reveals that his mother died of ovarian cancer when he was age 10 years, and two of his maternal aunts had breast cancer. Which of the following is true about risk and screening for prostate cancer?
10. A 64-year-old retired architect presents to his primary care provider with a magazine article about

prostate cancer screening that states, “You should talk to your doctor about the ups and downs of

prostate cancer screening.” The patient hands this to the clinician and states, “Tell me about the ups and down of prostate screening.” Which of the following is true about prostate cancer screening?

Chapter23: Musculoskeletal System

1. A thin, 58-year-old patient complains of lower back pain for years. On examination, the clinician finds that the patient has tenderness over the sacroiliac area. Which of the following conditions is most consistent with this physical sign?

2. During an evaluation of an athletic 30-year-old patient, the clinician conducts an active range of motion evaluation at the neck. Which muscle is being assessed when the patient is asked to flex the neck?
3. An obese 50-year-old patient presents with a long history of back trouble. What structure in the spine

supports the body’s weight?

4. A 31-year-old day care worker presents with a worsening stiff, painful neck. On inspection, the patient’s head is laterally deviated toward the shoulder and rotated. At this point of the examination, what is the most likely diagnosis?
5. A young adult patient presents to the clinic stating that something is wrong as he looks in the mirror and sees that his shoulders are uneven. He fractured his left arm 8 weeks ago and remains in a cast. He noticed the uneven shoulders over the last week. Upon inspection, his shoulder heights are unequal and there is winging of the scapula. As the examination continues, which of the following maneuvers would confirm a likely diagnosis?
6. During a musculoskeletal examination, the clinician instructs the patient to look over one shoulder, and then the other shoulder. This action assesses the movement of which muscle(s)?
7. During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group?
8. The clinician is seeing a middle-aged patient who has a diagnosis of lumbar spinal stenosis. The patient’s history is consistent with this diagnosis as he has pain in the back with walking that improves with rest. Which physical sign(s) are most consistent with his diagnosis?
9. The clinician is seeing a 58-year-old patient with a diagnosis of arthritis. The patient complains of pain in his knees, hips, hands, wrists, neck, and low back. Based on which joints are involved, the patient most likely has which joint problem?
10. A 62-year-old patient with rheumatoid arthritis (RA) complains of increased joint stiffness. What characteristic(s) are consistent with her diagnosis of RA?

Chapter 24: Nervous System

1. A 55-year-old woman with a headache explains to the clinician that she has had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation?

2. In the case of a middle-aged female with a pounding headache, what is an effective question to ask the patient?
3. A 35-year-old female patient has had migraines for much of her adult life. Ather regular checkup, she is healthy, takes no medications except oral contraceptive pills (OCPs), exercises, and has a steady job. Her only complaint is that her migraines seem to have become worse, and, for the past few weeks, she has been waking up at night with headache and also nausea. Which of the following is the best course of action?
4. An 82-year-old grandmother presents to the Emergency Department in the care of her extended family with new-onset speech impairment. According to family members, the patient awoke with this symptom as well as difficulty in understanding questions or following commands. Her past medical history is remarkable for atrial fibrillation but no other notable conditions. On examination, her speech is verbose but poorly comprehensible and lacks meaning. She is unable to follow simple commands. Which of the following best describes her speech disorder?
5. A 74-year-old bus driver is delivered to the hospital via emergency transport after an astute passenger noted that the patient exhibited drooping facial features and slurred speech. The patient was diagnosed rapidly with ischemic (nonhemorrhagic) stroke, and urgent intervention lead to a near complete recovery from his symptoms. The astute passenger was thanked and congratulated for recognizing the signs of acute stroke; this individual credited this recognition to a public safety awareness campaign that outlined the critical public health need to recognize strokes early. Which of the following statements is true for risks and rapid recognition of suspected strokes?
6. A 70-year-old male presents to the Emergency Department accompanied by his wife, who is concerned that he has experienced a stroke. She states that he awoke with drooping of the right side of his mouth. He has a history of hypertension and diet-controlled diabetes, but no history of prior transient ischemic attacks (TIAs), strokes, or neurologic deficits. Physical examination reveals a well- nourished, right-handed male, who has an obvious flattening of the right nasolabial fold at rest. He is unable to close his right eye, wrinkle his forehead, or raise his eyebrows. The remainder of the neurologic examination is symmetric with intact strength and normal deep tendon reflexes. Based on this history and physical examination, which of the following statements is true?
7. In longstanding and poorly controlled hypertension, white matter tracts in the brain are subjected to ateriolosclerotic effects. Which one of the following is most vulnerable to this process?
8. A 14-year-old student comes with her family to the urgent care center, having been hit in the right eye with a plastic baseball during a family reunion. She complains of a painful, watery, red right eye and sensitivity to light. She has normal visual acuity in both eyes, no diplopia, and can open and close her eyes normally. The pupils are unequal in size, 3 mm in diameter on the left, 5 mm in diameter on the right. Which cranial nerve (CN) would be implicated as the cause of the photosensitivity complaint and the pupillary asymmetry?
9. Parents bring in their 3-year-old toddler, stating that he has been pulling at his right ear and fussing all day. Examination of the auditory canal shows a small green plastic toy piece partially obstructing the passage. Which cranial nerve (CN) supplies the sensory innervation to that area and is conducting the boy’s pain sensation?
10. A new mother brings in her 6-month-old baby for not being able to keep his eyes together when looking to the left. On examination, both of his eyes appear in alignment (conjugate) when looking to

the right. However, when looking to the left, the baby’s left eye stays in the forward gaze position, while the right continues on with full adduction to the left. The eyes appear to be out of alignment (dysconjugate). Which cranial nerve (CN) is responsible for the dysfunction in looking left?

11. A 45-year-old physician is having increasing difficulty with speech for the past 6 months. She is less precise in pronunciation of words (dysarthria), has found it more effortful to speak, and finds that her voice sounds more nasal than usual. On examination, her articulation is less than precise, especially with rapid repetition of single syllables, such as “ta-ta-ta-ta,” “go-go-go-go,” “la-la-la-la,” and “ba-ba-ba.” Her neurological examination is otherwise normal. Which nervous system pathway is responsible for control of the muscles producing this symptom?
12. A 63-year-old practicing attorney makes an appointment with the office urgently for pain in his right leg for 3 days. Since working in the garden moving heavy bags of mulch for his wife this past weekend, he has had intermittent but excruciating pain shooting down the posterior aspect of his right leg. On examination, sensory loss to light touch in the right leg posteriorly, corresponding to a sacral 1 (S1) dermatome, is noted. Which reflex would be expected to be decreased compared to the other side?
13. An 82-year-old retired insurance broker complains of difficulty in walking, having to consciously lift up his feet so he does not trip, stumble, or fall. Both feet are affected equally; he has no sensory complaints or pain. This has been worsening over the past 3 years, and he has had to give up his beloved hiking. The symptoms are improved while wearing tall boots and worse when walking around the house with house slippers. What is the likely location of the pathology in this man?

Chapter 25: Children: Infancy through Adolescence

1. A mother brings her 15-month-old toddler to the clinic for his preventive health care visit. The

clinician takes the history and observes the child’s interactions and behaviors and is then ready to begin the rest of the examination. Which of the following best describes the general approach to the pediatric examination of the young child?

2. In caring for children, physicians and other clinicians need to understand child development. Of the following, which is a principle of normal child development?
3. The parents of a 21-month-old child explain that their son used to speak nearly 50 words and was using 2-word phrases. In the last month or so, the child has not been using as many words and tends to echo what is being said to him rather than use language spontaneously. They want to know if this is normal. After taking a thorough developmental history, the clinician finds that the child makes poor eye contact and does not play with toys in a purposeful manner. The physical examination is normal except for the child’s limited social interactions. There is a family history of autism in two first cousins. Which of the following would be the best response to the parents at this time?
4. A clinician is meeting the mother of a 5-year-old with asthma for the first time. The mother notes that the asthma has been poorly controlled and that the child has had multiple hospitalizations. The clinician inquires about family stressors and finds that the parents are divorced, the mother recently lost her job, and the child spent 2 months living with her grandparents who both smoke. Which of the following is the best example of the role of health promotion with this family?
5. A clinician is reading the chart of a full-term newborn whose mother had an uneventful pregnancy in

the hospital for the first time on the day of birth. In reviewing the infant’s chart, the clinician notes that,in the delivery room, at 5 minutes, the infant had a heart rate >100, strong respiratory effort, was crying vigorously, moving actively, and had good color except for some acrocyanosis of the hands and feet. This infant’s APGAR score is closest to which of the following?

6. A newborn who is floppy and limp, blue in color, with a heart rate of 60, and minimal respiratory effort has just been delivered. The infant has no grimace and only a very weak cry. What is the best immediate response to the infant in this situation?
7. An infant is born 4 weeks preterm to a mother with a history of hypertension, severe diabetes, and alcohol abuse. The infant is noted to be small for gestational age (SGA), weighing just 1,500 g. Which of the following is the most important reason for assessing both gestational age and birth weight for any infant?
8. A clinician arrives at the hospital several hours after the birth of a full-term infant. The infant is rooming in with her parents and appears to be doing well. There were no problems with the pregnancy, labor, or delivery. The nurse asks if the baby should be taken back to the nursery for examination. What is the best response to the nurse?
9. The nurse in the newborn nursery reports that she is concerned about Baby Boy Jones, who was born full-term by cesarean section for failure to progress. The pregnancy was complicated only by a maternal urinary tract infection in the first trimester. He had APGARs of 9 and 10 at 1 and 5 minutes, respectively, and had been doing well. However, now, on the fourth day of life, the infant has developed a tremor. Which of the following factors would cause the most concern about the tremor?
10. A mother brings her 9-month-old son to the practice for the first time, concerned that he is not yet sitting by himself. After taking a careful history, the physician notes that the infant has good head control and can grasp a rattle but is unable to roll over, crawl, or pull to stand. What should the clinician explain to the mother?

Chapter 26: Pregnant Women

1. A 42-year-old school teacher with a history of irregular periods who underwent successful intrauterine insemination (IUI) on January 25th presents to the clinic for care on March 19th. Her last menstrual period (LMP) was November 11th of the previous year. Which of the following is true about the gestational age of her pregnancy?

2. A 32-year-old patient with two prior pregnancies presents to clinic concerned that she may be pregnant after missing one cycle of her menses, which was previously very regular. A urine human

chorionic gonadotropin (HCG) test is positive. Presuming a normal pregnancy, what can the physician expect to find on examination and ultrasound?

3. A 22-year-old G1P0 presents for a routine prenatal visit at 32 weeks’ gestational age. Leopold maneuvers indicate that the fetus is in a transverse lie, with the fetal skull palpable at the woman’s left side. Fetal heart tones are heard at the uterine fundus with a baseline rate of 140 and beat-to-beat variability noted. Which of the following steps is appropriate to take at this time?

4. A woman presenting in the late second trimester of her third pregnancy reports that she is experiencing several abdominal symptoms that she attributes to pregnancy: nausea, vomiting, urinary frequency, discomfort in the lower abdomen, tenderness over the suprapubic area, and severe constipation. Which of the following is true regarding these pregnancy symptoms?

5. A 42-year-old G2P1 arrives at clinic for a routine prenatal visit late in her third trimester. On exam, the physician notes a subtle murmur; on further auscultation, it becomes apparent that the murmur occurs during the diastolic phase. The patient has minimal complaints but does reveal that she has had swelling in her feet and shortness of breath. Because these symptoms have been only slightly more severe than during her last pregnancy, she assumed this was normal for pregnancy. Which of the following is true about her presentation?

6. A 17-year-old G1P0 presents at a routine prenatal check. By last menstrual period (LMP), her gestational age at this visit is 36 weeks, 2 days. A first-trimester ultrasound confirmed her estimated delivery date. On exam, her fundus measures 31 centimeters. Ultrasound imaging might reveal which of the following anatomical findings that would explain this size?

7. A 26-year-old G0P0 is interested in becoming pregnant and presents for prepregnancy counseling. She was not vaccinated as a child and unsure if she wishes to be vaccinated now. She asks if she can change her mind during pregnancy and receive vaccinations during that time. What should she be told?

8. A 31-year-old marathon runner presents for prenatal care with her first pregnancy. She is in her second trimester and is experiencing some fatigue and muscle aches. Her prepregnancy body mass index (BMI) was noted at 19.2. How should she be counseled on exercise and nutrition during pregnancy?

9. A 29-year-old G2P1 presents to the clinic after a positive home pregnancy test. She confides at the appointment that her male partner has become increasingly abusive lately and once struck her while she was holding her older child. How should she be counseled?

10. A 34-year-old G3P2 at 27 weeks’ gestation is referred to the clinic upon discharge from a correctional institution where she has been incarcerated for 25 days for a drug offense. She denies any further substance abuse, but her behavior is concerning for intoxication, and she smells of alcohol and cigarettes. The clinician inquires about her drug use with open-ended questions and counsels her that which of the following is true?

Chapter 27: Older Adult

1. A 78-year-old woman presents to clinic with her two daughters, who are concerned about her continued ability to live independently. She has thus far been highly self-reliant and is opposed to the idea of leaving of her home of 30 years. The clinician performs a complete history and physical exam (including mental status and memory testing) as well as orders laboratory tests before providing the patient and her family the finding that she has age-appropriate changes that do not reflect any particular disease process. Which of the following findings is most consistent with the normal aging process and does not impair the ability to live alone?

2. Which of the following best describes the role of the health practitioner in caring for the aging American population?
3. Which of the following is true about hair in the aging adult?
4. A 75-year-old female in generally good health presents to a new primary care provider after she recently moved to a new city. She takes no prescribed medications, but she has been told in the past that her blood pressure was borderline elevated and might require treatment at some time in the future. Which of the following findings during the physical examine is consistent with the normal aging process and not a sign of cardiovascular disease?
5. A 66-year-old recently retired restaurant worker presents to his primary care provider with a concern about hearing loss. He relates a history of difficulty distinguishing voices in crowded settings when significant background noise exists, which hastened his retirement. Which of the following is true about this patient’s experience with hearing and the aging process?

7. Medications carry both risks and benefits for older patients. Although the risk