NR509 Final Exam Chamberlain

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?

A.    BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced

B.    Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examination starting at age 30 years

C.     The patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current compliant

D.    Mammography is most sensitive an specific for women in their 40’s, when breast tissue is still dense enough to image accurately

E.     Breast cancer screening is extremely well studied, and no controversy exists on the recommended norms for screening and follow up

C – The patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group an risk factors prior to her current compliant

Rationale: This patient was in compliance with the USPSTF recommendations for her age group and risk factors prior to her current complaint. The USPSTF recommends that women age <50 years discuss risks and benefits with their provider and decide on appropriate screening for their individual preferences and needs. These recommendations are controversial and likely to change again over time, but they are underpinned by one key issue: Mammograms have low sensitivity and specificity in younger women with higher levels of estrogen, which keeps breast tissue dense and obscures lesions. This patient should be reassured that her decision not to screen further was well reasoned and did not lead to morbidity in her case. BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced is incorrect. BSE is also extremely controversial and may lead to high rates of invasive testing for finding that are not malignant. Recommending agencies disagree greatly on this particular screening modality. CBE is superior to self breast examination and should be a routine part of annual examinations starting at age 30 years is incorrect. CBE is also fraught with variable sensitivity and specificity and may lead to invasive interventions for nonmalignant lesions. Recommending agencies also disagree greatly on this particular screening modality. Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to image accurately is incorrect. The reverse is true: Mammography suffers low sensitivity and specificity when high estrogen levels feed dense tissue that obscures lesions; the test becomes much more accurate after menopause. Breast cancer screening is extremely well studied and no controversy exists on the recommended norms for screening and follow-up is incorrect. Although this topic is quite widely studied, interpretations of the data are filtered through issues of cultural norms (and even financial gain, in some cases) that make this topic very challenging for patients and providers alike.

   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?

A.    Breast cancer screening by MRI has been well studied in general population

B.    Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity

C.     The patient is an ideal candidate for screening via breast MRI based on current evidence

D.    Women at low lifetime risk of breast cancer (<20%) are recommendations to undergo screening MRI

E.     Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI

B- Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity

Rationale: Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. Increased sensitivity (in this case, higher-resolution imaging to pick up subtler disease) is often traded for reduced specificity (in the form of discovering many small items of no pathological significance). This is a core concept in designing screening tests—very sensitive tests often pick up false positives, while very specific tests often rule out disease effectively by missing many actual cases. Balance must be sought between these two when setting thresholds for positive and negative screens. Breast cancer screening by MRI has been well studied in the general population is incorrect. This screening modality has only been studied in high-risk populations. This patient is an ideal candidate for screening via breast MRI based on current evidence is incorrect. This patient meets no known criteria for screening with breast MRI (known BRCA mutation, history of chest radiation, etc.). Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI is incorrect. Only women at high lifetime risk (>20%) are current recommended to utilize breast MRI as a screening tool. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI is incorrect. The >20% of breast cancer over a lifetime, which is considered sufficient criteria for BRCA1 or BRCA2 mutation confers a risk screening with MRI rather than mammogram.

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?

A.    Mastitis

B.    Ductal carcinoma in situ

C.     Paget disease of the breast

D.    Occult pregnancy

E.     Prolactinoma

E- Prolactinoma

Rationale: Prolactinomas are pituitary tumors that secrete prolactin, which causes the production of breast milk and can suppress menstruation. Mastitis is incorrect. Mastitis is a breast infection that is typically painful and characterized by a focal area of redness and tenderness in one breast. Ductal carcinoma in situ is incorrect. While nipple discharge should raise suspicion for breast cancer, in this case the discharge is neither bloody nor purulent, and it is notably bilateral. A prudent provider may still order a mammogram and/or ultrasound, but the answer is unlikely to be breast cancer. Paget disease of the breast is incorrect. This condition may present with nipple discharge, but it is usually bloody. Occult pregnancy is incorrect. This patient has a negative HCG test, which is the standard hormonal laboratory examination used to determine pregnancy in both urine and serum tests.

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?

A.    Most masses that women find at home and bring to a providers attention turn out to be malignant

B.    The patient is more likely to find a fibroadenoma than a cancer on self examination

C.     The most likely breast mass this patient is likely to find in herself is an abscess complication underlying mastitis

D.    Because of this patients age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low

E.     BSE is universally recommended because of very high sensitivity and specificity for finding cancerous lesions

B- The patient is more likely to find a fibroadenoma than a cancer on self examination

Rationale: This patient is more likely to find a fibroadenoma than a cancer on self-examination. In this patient’s age range (15–25 years), palpable masses are most likely to be benign fibroadenomas. Most masses that women find at home and bring to a provider’s attention turn out to be malignant is incorrect. About 11% of complaints of breast masses turn out to be malignant, leaving the vast majority (89%) noncancerous. The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying mastitis is incorrect. This patient has neither the symptoms of mastitis (localized swelling/erythema/tenderness with generalized fever) nor the risk factors for this condition (pregnancy and/or breastfeeding), making mastitis a very unlikely diagnosis. Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low is incorrect. Though the risk of cancer in this patient is low, the consequence of missing a cancer diagnosis is quite high; for that reason, definitive diagnosis should be pursued for almost all breast masses. Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low is incorrect. BSE suffers from notoriously low sensitivity and specificity, making it a very controversial recommendation as it tends to overestimate disease in healthy breasts and miss cancer in breasts with subtle disease

1)    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?

A.    Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in assessing her risk for these genes

B.    Breast cancer in a male relative does not add significant weight to the decision to test the BRCA genes in this patient

C.     The BRCAPRO calculator does not add any further clinical information to this patients risk carrying the BRCA gene

D.    This patient carries several risk factors that together justify BRCA testing

E.     Even if this patient is BRCA positive, no changes in screening or treatment are recommended for patients with this genetic mutation, so the test is not recommended

D- This patient carries several risk factors that together justify BRCA testing

Rationale: This patient has both a first-degree male relative with breast cancer and several relatives in the same lineage with breast cancer. Both of these suggest risk for genes, but the BRCAPRO calculator can further refine the numerical risk and help decide if screening might be helpful. Her familial lineage is irrelevant to her risk genes, and should be discounted in assessing her risk for these genes is incorrect. Ashkenazi-Jewish heritage is a risk factor for carrying the BRCA genes, and for obvious reasons, historical events in the last century obscured the family history of many Jewish families from Europe. Though this patient does not overtly describe Jewish heritage, her family’s story certainly raises concern that she may carry some genetic lineage that is at risk for this mutation. Breast cancer in a male relative does not significant weight to the decision to test for the BRCA genes in this patient is incorrect. Breast cancer is quite rare in men, and any case of it should raise concerns for the presence of the BRCA genes. The BRCAPRO calculator does not add any further clinical information to this patient’s risk for carrying the calculator offers a numerical estimation of the patient’s risk of carrying a BRCA gene is incorrect. The BRCAPRO based on risk factors. It does not, however, analyze risk of developing breast cancer based on those risks. Even if this patient is BRCA positive, no changes in screening or treatment are recommended for patients with this genetic mutation, so the test is not recommended is incorrect. BRCA positive individuals may undergo prophylactic mastectomy, oophorectomy, and increased screening with magnetic resonance imaging instead of mammography to find early cases of breast cancer.

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 suffered from lymphoma in her 20s and had radiation to the chest. She did take and BRCA2 genes. In addition, the patient 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?

A. No agency recommends breast MRI for a patient such as this one, who has

moderately but not extraordinary risk factors for breast cancer

B. The U.S. Preventative Services Task Force (USPSTF) recommends against screening with MRI for patients with such risk factors

C. Regardless of recommendations, this high sensitivity of breast MRI comes at the expense of markedly decreased specificity ( i.e. the ability to rule out disease in healthy breasts)

D. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs over mammograms in patients such as this individual

E. History of chest radiation is not a risk factor for breast cancer and is thus not relevant to deciding whether MRI is appropriate in this patient

C- Regardless of recommendations, this high sensitivity of breast MRI comes at the expense of markedly decreased specificity ( i.e. the ability to rule out in healthy breasts)

Rationale: Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in health breasts). Sensitivity and specificity of screening test are almost always trade-offs; that is, a test that picks up more true cases is also very likely to then pick up more false positives, and vice versa. With breast MRI, the pick-up rate of true disease is almost double that of mammograms, but at the expense of double the false positives. No agency recommends breast MRI for a patient such as this one, who has moderately but not extraordinary risk factors for breast cancer is incorrect. This patient presents with an extraordinary risk profile, including strong family history of breast cancer (suggestive linkage to disease but without clear diagnosis), history of chest radiation, and dense breasts requiring prior biopsies to rule out malignancy. She meets the American Cancer Society (ACS) criteria for annual breast MRI, though the USPSTF does not agree that the evidence exists to support this recommendation. The USPSTF recommends against screening with MRI for patients with such risk factors is incorrect. The USPSTF, recognizing the limited data available on this screening test, states that there is insufficient evidence to state one way or another whether this test is appropriate for high-risk patients. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs over mammograms in patients such as this individual is incorrect. Breast density is both a risk factor for breast cancer and a factor that hampers effective screening with mammograms; per the ACS, it may be criteria to screen by MRI. History of chest radiation is not a risk factor for breast cancer and is thus not relevant to deciding whether MRI is appropriate in this patient is incorrect. Chest radiation between the ages of 10 and 30 years confers high risk of later breast cancer; per the ACS, this risk is sufficient to warrant screening by MRI.

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?

A.    Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla

B.    Supraclavicular nodes are generally considered benign and require no further evaluation or follow up

C.     Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck

D.    Firm, rubbery lymph nodes are generally considered to be benign

E.     Metastatic breast cancer cells spread directly into the infraclavicular and then supra clavicular nodes without first causing notables changes in the axillary nodes

E. Metastatic breast cancer cells spread directly into the infraclavicular and the supra clavicular nodes without first causing notables changes in the axillary nodes

Rationale: Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. Though axillary lymphadenopathy should be evaluated with age-appropriate imaging to rule out breast cancer, cells that are metastasizing from the breasts can pass directly to the infraclavicular, then supraclavicular nodes. Lack of axillary adenopathy should not be considered grounds to exclude a breast cancer diagnosis. Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla is incorrect for reasons noted above. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up is incorrect. Supraclavicular lymph nodes are uniformly considered malignant until proven otherwise. The differential diagnosis for these malignancies is wide but includes cancers of the breast, lung, head, and neck, esophagus, pancreas, etc. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck is incorrect. This describes the location of the posterior cervical chain of lymph nodes. Supraclavicular nodes are found deep in the angle formed by the clavicle and the sternocleidomastoid muscle. Firm, rubbery lymph nodes are generally considered to be benign is incorrect. Firm or fixed lymph nodes are of concern for malignancy; tender nodes suggest inflammation.

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 fibroadenoma. 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?

A.    “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”

B.    “Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant”

C.     “Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant”

D.    “Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant”

E.     “Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple”

A. “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”

Rationale: Breast findings can be described by quadrant or by position on a clock face, with 12 o’clock at the superior edge of the breast and the nipple at the center of the clock. The 10:30 position meets this patient’s description of a mass in the right breast that is proximal and to the left of the nipple. “Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant” is incorrect. Though description by quadrant is common, this mass would be found in the upper outer quadrant. “Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant” is incorrect as above. “Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant” is incorrect. This mass is in the right, not left, breast—just a reminder that precision is key in record keeping. “Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple” is incorrect. The 1:30 position describes a mass that is 3 cm proximal and 3 cm to the right of the nipple, rather than 3 cm proximal and 3 cm to the left to the nipple.

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?

A.    Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of mammograms.

B.    Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause.

C.     Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules.

D.    Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous sources over the lifetime.

E.     Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited for that reason.

C. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules

Rationale: Glandular tissue of the breast atrophies with menopause, primarily due to a decrease in the number of lobules. The consequent decrease in breast density makes mammograms ever more useful during the age when breast cancer incidence starts to rise markedly. This concept underpins many controversies in breast cancer screening: Prior to menopause, dense breasts obscure, underestimate, and overestimate disease in a lower-prevalence population; after menopause, less-dense breasts increase the utility of mammography in a higher-prevalence population. This has lead a number of agencies to recommend against frequent screening of women in their 40s because of high rates of false positives. Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of mammograms is incorrect. As above, the reverse is true: The transformation to primarily fatty tissue with menopause increases the utility of mammograms. Estrogen in HRT has no effect on breast density after menopause is incorrect. Though the exact role of estrogen from exogenous sources is unclear, estrogen from HRT likely plays a role in maintaining dense breasts past menopause and contributing to breast cancer risk. Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous sources over the lifetime is incorrect. Breast density is affected by a number of factors, among which is a genetic contribution. Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited for that reason is incorrect. Mammography performs most accurately in menopausal and postmenopausal women and should be primarily used in that group.

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?

A. Ruptured tubal (or ectopic) pregnancy

B. Acute cholecystitis

C. Ruptured appendix

D. Ruptured ovarian cyst

a. Ruptured tubal (or ectopic) pregnancy

Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β-hCG, and findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured ectopic pregnancy with significant intra-abdominal bleeding leading to peritoneal signs. This case is emergent and requires immediate treatment of her hypotension and presumed blood loss as well as gynecological consult for emergent surgery. Ruptured ectopic pregnancies can lead to life-threatening intra-abdominal bleeding. Although acute cholecystitis, ruptured appendix, bowel wall perforation, and ruptured ovarian cyst are all possibilities, the positive β-hCG testing and her unstable vital signs make ruptured ectopic pregnancy more likely.

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?

A.    Liver span 11cm at the midclavicular line

B.    Liver span of 8cm at the midclavicular line

C.     Dullness to percussion over a span of 11cm at the midclavicular line

D.    Dullness to percussion over a span of 8cm at the midsternal line

E.     Liver palpable 3cm below the right costal margin, mid clavicular line, on expiration

e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration

Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would be considered normal on inspiration when the liver is pushed down into the abdominal cavity on inspiration, but is abnormal on expiration. Findings to support hepatomegaly would be more convincing if, by percussion, the liver span was >12 cm at the midclavicular line. For patients with obstructive lung disease, air trapping in the lungs may displace the liver downwards into the abdominal cavity. The liver span and dullness to percussion refer to the same measurement. Measurements of 6–12 cm at the mid-clavicular line and 4–8 cm at the midsternal line are considered normal.

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?

A. Female gender

B. Hx of smoking

C. Underweight

D. Family history of ruptured aneurysm

E. Hypertension

b. History of smoking

Rationale: History of smoking is her most significant risk factor for an AAA. Male gender, not female gender, is considered as risk factor. Underweight is not a risk factor for AAA. Family history of ruptured aneurysm is vague and could be a cerebral aneurysm. Further, her family history is in a first-degree cousin not a first-degree relative (biologic parents, siblings, and children). Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based on one elevated blood pressure reading.

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?

A. Do not screen routinely

B. Continue annual FOBT screening until age 80 years

C. Continue annual FOBT until age 85 years

D. Repeat colonoscopy this year

E. Sigmoidoscopy every 5 years with FOBT every 3 years

a. Do not screen routinely

Rationale: The USPSTF recommends not screening routinely. For most adults ages 76–85 years, the gain in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and benefits with the patient. Annual FOBT screening may continue until age 80–85 years if benefits to doing so outweigh risks for the individual patient; however, screening should not be routinely continued. In general, a life expectancy >7 years is necessary for screening to be potentially beneficial. There is no indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option, but again screening is not routinely recommended for patients age >75 years.

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?

A. A large, firm fecal mass in the rectum

B. Decreased fecal bulk

C. Functional change in bowel movement

D. Spasm of the external sphincter

E. Impairment of autonomic innervations

c. Functional change in bowel movement

Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea predominant, constipation predominant, or mixed. Other functional causes for her constipation should be excluded prior to making this diagnosis. A large firm fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that increasing fiber helps her constipation. Spasm of the external sphincter is associated with painful anal lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known diagnosis that would increase suspicion of neurological impairment.

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?

A. Tympany to percussion in the RUQ, dullness to percussion of the LUQ

B. Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation

C. Liver dullness in the RUQ that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease

D. Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line

E. A change in percussion from the tympany to dullness in the left lower anterior chest wall on inspiration

a. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant

Rationale: Situs inversus is a rare condition in which organs are reversed and is associated with Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on the left. A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is likely constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left upper quadrant with organ reversal. Findings given in the remaining answer choices are both associated with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis.

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?

A. Voluntary contractions of the abdominal wall that persists over several examinations

B. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain

C. Abdominal pain that increases with hip flexion

D. Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus

E. Pain with internal rotation of the right hip

b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain

Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over several examinations describes rigidity. Abdominal pain that increases with hip flexion is not suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal peritoneum. They often walk bent forward at the hips for this reason. Localized pain over McBurney point is certainly suggestive of appendicitis, but not suggestive of peritonitis. Similarly pain with internal rotation of the right hip, or a positive obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but not peritonitis.

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?

A. Helicobacter pylori infection

B. Inflammation of the gallbladder

C. Inflammation of colonic diverticulum

D. Reduced blood supply to the bowel

E. Fibrosis of the pancreas

e. Fibrosis of the pancreas

Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency and diabetes mellitus. H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually associated with diarrhea. Inflammation of the colonic diverticulum is diverticulitis and typically causes left-lower- quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an acute disease. Reduced blood supply to the bowel characterizes mesenteric ischemia. It can be acute or chronic in presentation and causes diffuse abdominal pain, vomiting, diarrhea, or constipation. It is associated with older age and vascular risk factors such as coronary artery disease.

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?

A. Exacerbating factor includes alcohol intake

B. Positive McBurney point tenderness

C. Poorly localized periumbilical pain

D. Vomiting of bile

E. Associated right shoulder pain

e. Associated right shoulder pain

Rationale: Pain with biliary colic can produced referred pain to the right shoulder or scapula due to irritation of the right hemidiaphragm. Alcohol is not an exacerbating factor for biliary colic. Positive McBurney point tenderness is associated with acute appendicitis. The Murphy sign is associated with acute cholecystitis. Poorly localized periumbilical pain is associated with early stages of acute appendicitis. Vomiting bile is associated with small bowel obstruction.

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?

A. Corpora cavernosa

B. Ejaculatory duct

C. Epididymis

D. Seminal vesicle

E. Vas deferens

A- Corpora cavernosa

Rationale: The corpora cavernosa are two structures within the shaft of the penis that become engorged with venous blood during erection. Patients with a history of cardiovascular disease such as hypertension and other diseases, such as diabetes, that cause limitations of blood flow are common causes of ED. Ejaculatory duct is incorrect. It is a conduit for seminal fluid from the seminal vesicle and terminal vas deferens to the urethra and is not involved in the process of an erection. Epididymis is incorrect. It is a structure on top of each of the testicles that provides a reservoir for storage, saturation, and transport of sperm from the testes and is also not involved in the process of an erection. Seminal vesicle is incorrect. It produces secretions that contribute to the seminal fluid and is also not involved in the process of an erection. Vas deferens is incorrect. It is a cord-like structure that transports sperm from the tail of the epididymis to the urethra and also is not involved in the process of an erection.

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?

A. Androgen insufficiency

B. Endocrine dysfunction

C. Peyronie disease

D. Psychogenic

E. Sexually transmitted infection (STI)

D- Psychogenic

Rationale: Lack of orgasm with ejaculation is usually not a physiological or structural issue, rather psychogenic in nature. It is fairly uncommon but does occur, and clinicians should be aware of the problem and take a thorough history to ascertain the roots of this disorder. Androgen insufficiency is incorrect as it is more likely to cause a decrease in libido and problems with erectile dysfunction (ED) rather than lack of orgasm. Endocrine dysfunction is incorrect as it may also cause ED and decreased libido as well as reduced or absent ejaculation among others; however, it should not cause the symptoms described above. Peyronie disease is incorrect as it is the development of fibrous scar tissue within the penis that causes disfigured and painful erections. STI is incorrect. STIs can cause a constellation of symptoms such as urethral discharge, fever, and pain to name a few; however, they should not cause the symptoms described above.

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?

A. Follicle stimulating hormone (FSH)

B. Gonadotropin releasing hormone (GRH)

C. Luteinizing hormone (LH)

D. Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP)

E. Testosterone

D- Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP)

Rationale: NO and cGMP are powerful vasodilators that are crucial in the process of an erection. Both allow venous blood to accumulate within the corpora cavernosa and corpus spongiosum making the penis rigid. FSH is incorrect as it is secreted from the pituitary and regulate sperm production in the testes. GRH is incorrect as it is secreted from the hypothalamus and stimulates pituitary secretion of LH and FSH. LH is incorrect as it is secreted from the pituitary gland and stimulates the synthesis of testosterone. Testosterone is incorrect as it is synthesized by Leydig cells in the testes and is responsible for multiple other processes such as pubertal growth of male genitalia, secondary sex characteristics, and muscular growth, to name a few.

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?

A. 6-9 months

B. 1-3 years

C. 5-7 years

D. 9-21 years

E. 30-50 years

D- 9-21 years

Rationale: The current recommendation for HPV vaccination for males starts at age 9 years and continues until age 26 years when males are most likely to be exposed to the virus. HPV can cause genital warts in both males and females, cervical cancer in females, and has also been linked to other types of cancers such as oropharyngeal cancers. Current literature suggests that age groups other than 9–21 years do not have any significant benefit or need for the HPV vaccination.

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?

A. Direct hernia

B. Indirect hernia

C. Spermatocele

D. Testicular tumor

E. Varicocele

C- Spermatocele

Rationale: A spermatocele is a benign, typically painless, movable cystic mass just above the testis that will typically transilluminate with a strong light source. Direct hernia and indirect hernia are incorrect as they will typically contain abdominal contents such as bowel that do not transilluminate. A direct hernia does not produce a mass in the scrotum. Testicular tumor is incorrect. A testicular tumor is a solid mass that will not transilluminate. A varicocele is incorrect as it is a dilatation or varicosities of veins of the spermatic cord that are filled with blood and therefore will not transilluminate.

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?

A. Acute epididymitis

B. Hydrocele

C. Primary syphilis

D. Spermatocele

E. Testicular cancer

A- Acute epididymitis

Rationale: Acute epididymitis typically results from a bacterial infection such as chlamydia and presents with scrotal swelling and pain. Given this patient’s history of recent unprotected sexual intercourse with multiple partners, he is at higher risk of sexually transmitted infections (STIs). Hydrocele is incorrect as it is a nontender, fluid filled mass within the tunica vaginalis surrounding the testicle. Hydroceles are usually a congenital defect in which peritoneal fluid travels down in between the testicle and tunica vaginalis from a patent communication that normally closes. Primary syphilis is incorrect as it is typically presents as a small red papule that becomes a chancre or painless erosion on the penis. Spermatocele is incorrect as it is benign, typically painless, movable cystic mass just above the testis. Testicular cancer is incorrect as it will typically present as a painless nodule on the testis, not usually causing significant pain or scrotal swelling.

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?

A. Dihydrotesterone

B. Reductase

C. Follicle stimulating hormone (FSH)

D. Luteinizing hormone (LH)

E. Thyroid stimulating hormone (TSH)

C- Follicle stimulating hormone (FSH)

Rationale: FSH is secreted from the pituitary gland and is responsible for regulation of sperm production in the germ cells and Sertoli cells of the tubules in the testicles. 5α-Reductase is incorrect as it is an enzyme that converts testosterone to 5α-dihydrotestosterone. 5α-Dihydrotestosterone is incorrect. It is a hormone that triggers pubertal growth of the male genitalia, prostate, seminal vesicles, and secondary sex characteristics. LH is incorrect as it is secreted from the pituitary gland and acts on the Leydig cells in the testicles to produce testosterone. TSH is incorrect as it is released from the pituitary and has many functions; however, should not have a significant effect on male fertility. Recent studies show disturbances of thyroid hormones adversely affect spermatogenesis and male fertility.

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?

A. External inguinal ring

B. Internal inguinal ring

c. Pubic tubercle

D. Anterior superior iliac spine

E. Direct inguinal hernia

B- Indirect inguinal ring

Rationale: The internal inguinal ring is typically not palpable through the abdominal wall. The internal inguinal ring is the opening through which the spermatic cord passes from the abdominal cavity into the inguinal canal. It is sometimes palpable if the external inguinal ring is large enough and may be found by invaginating the scrotum, angling toward the inguinal canal. The external inguinal ring is incorrect as it is usually palpable through the abdominal wall; however, it is better evaluated from a transscrotal approach. The pubic tubercle is incorrect as it is easily palpable in most circumstances from an external approach. Anterior superior iliac spine is incorrect as it is also palpable externally and is the location for the proximal attachment of the inguinal ligament. Direct inguinal hernias is incorrect. It typically presents as a bulge near the external inguinal ring and may be palpable from an external approach.

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?

A. Early withdrawal

B. Male condoms

C. Spermicides

D. Diaphragms

E. Cervical caps

B- Male condoms

Rationale: The correct use of male condoms is highly effective in preventing the transmission of multiple sexually transmitted infections including HIV, human papillomavirus, chlamydia, gonorrhea, and others. Key instructions should include using a new condom with each sex act, applying the condom before any sexual contact occurs, adding only water-based lubricants, and holding the condom during withdrawal to keep it from slipping off. Although, the most effective way to prevent STIs is abstinence, for the individuals who choose to have an active sexual life, proper usage of condom provides the best protection against most STIs. Early withdrawal, spermicides, diaphragms, and cervical caps are incorrect as they do not provide any significant barriers to prevent the transmission of most STIs. Prolonged use of spermicides may cause localized erosions of genital tissue, which may increase risk of STIs.

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?

A. Large colonic stool

B. Ovarian mass

C. Fibroids

D. 4-Month pregnancy

E. Bartholin gland enlargement

c. Fibroids

Rationale: Fibroids, also known as myomas, are very common benign uterine tumors that can become quite enlarged. Large colonic stool is incorrect. Stool cannot be easily palpated in the abdomen except in a very thin person. Ovarian mass is incorrect. The mass palpated is in the midline and ovarian masses will generally be in the adnexal area. In this case, the adnexal area had no palpable mass. Four-month pregnancy is incorrect. This patient’s husband has had a vasectomy, and this patient had menses last week. Bartholin gland enlargement is incorrect. An enlarged Bartholin gland is noted in the labial area and not in the abdomen.

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?

A. Prior pelvic inflammatory disease (PID)

B. Prior Bartholin gland infection

C. Prior herpes infection

D. Metabolic disorder with subsequent hormonal irregularities leading to anovulation

E. Secondary amenorrhea

a. Prior pelvic inflammatory disease (PID)

Rationale: PID is a genital infection caused by gonorrhea, chlamydia, and other organisms. If not treated early enough it can lead to tubal pregnancies or infertility. Prior Bartholin gland infection is incorrect. Although Bartholin cyst infections can be from sexually transmitted infections, they are only located on the labia and do not lead to fertility issues. Prior herpes infection is incorrect. Herpes generally only affects the labial tissues, vagina, and cervix. Although a baby delivered through an outbreak can suffer complications from maternal herpes, it does not affect fertility. Metabolic disorder with subsequent hormonal irregularities leading to anovulation is incorrect. Although metabolic disorder does lead to anovulation and infertility problems, this patient relates being regular all of her life so most likely has no hormonal abnormalities. Secondary amenorrhea is incorrect. Secondary amenorrhea occurs when a woman having periods stops having them for some reason. This woman has not had an absence of her menses.

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?

A. Zona reticularis

B. Transformation zone

C. Squamous zone

D. Columnar zone

E. Linea nigra

b. Transformation zone

Rationale: The transformation zone is where cancerous cells are most likely to develop and is thus the most important area to sample in a Pap test. Zona reticularis is incorrect. This is actually a part of the adrenal glands that produces hormones. Squamous zone and columnar zone are incorrect. Although each of these can be affected by the human papillomavirus, the transformation zone where these two meet (and columnar cells become squamous cells) is the area of most pathological activity and thus the area that is most important to sample during a Pap smear. Linea nigra is incorrect. The linea nigra is actually the pigmented line often seen in the midline with pregnant women.

A 35-year-old grade school teacher presents for her annual exam. Her last Pap smear was 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?

A. No cervical motion tenderness

B. No pus from the os

C. The mass dents with digital pressure

D. Both adnexa are nontender

E. The perineum has no lesions

c. The mass dents with digital pressure

Rationale: Stool in the rectum simulates a rectovaginal mass. Unlike a malignant mass it is dented by digital pressure reassuring the examiner. A rectovaginal exam will confirm the distinction. No cervical motion tenderness is incorrect. This reassures the examiner that there is no pelvic inflammatory disease (PID), ectopic pregnancy, or appendicitis. No pus from the os is incorrect. No pus reassures the examiner that there is no PID or cervicitis. Both adnexa are nontender is incorrect. The adnexa being nontender is reassuring that there is no tubo-ovarian infection or ovarian artery torsion. The perineum has no lesions is incorrect. No lesions would indicate there is no active human papillomavirus warts or herpes infection.

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?

A. Several shallow ulcers with a red base

B. Translucent nodules

C. Raised friable or lobed lesions

D. Bright red, soft lesion arising from the cervical canal

E. Strawberry cervix (small red granular spots or petechiae)

c. Raised friable or lobed lesions

Rationale: Warts or condylomata are raised lesions that are often lobed in appearance. With addition of acetic acid, they will often turn white. Several shallow ulcers with a red base is incorrect. These are associated with herpetic infections. Translucent nodules is incorrect. This is a description of retention cysts or nabothian cysts. Bright red, soft lesion arising from the cervical canal is incorrect. This is a description of a cervical polyp. Strawberry cervix (small red granular spots or petechiae) is incorrect. This is a common description of the cervix with a Trichomonas infection.

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?

A. She is on her menses.

B. She has only one current partner and does not need STI testing.

C. She had a normal Pap smear within the last 3 years.

D. She should not be sexually active.

E. She has been using condoms.

a. She is on her menses.

Rationale: For best results with either a Pap smear or STI testing it is best to not have the patient menstruating. On conventional Pap smears, blood masks the cytology. For STI testing, the vaginal sample results are not always valid. Some practices do use urine STI testing but this is not yet universally available. She has only one current partner and does not need STI testing is incorrect. Until the age of 25 years, high-risk individuals with a history of several partners are still tested yearly. She had a normal Pap smear within the last 3 years is incorrect. Although she does not need a Pap smear at this time, she still needs STI testing. She should not be sexually active is incorrect. This is a personal judgment of the provider and should not be involved in decision making for the patient’s care. She has been using condoms is incorrect. As long as a patient has not used a condom for the last 48 hours, there is no need to postpone a speculum exam due to general condom usage.

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?

A. Cervical os

B. Posterior fornix

C. Anterior fornix

D. Skene gland opening

E. Bartholin gland opening

a. Cervical os

Rationale: An infection in the uterus, tubes, and ovaries would drain through the cervix and out of the os. Posterior fornix is incorrect. Any discharge in the fornix may be from the cervix, or it may be from a vaginal infection. Anterior fornix is incorrect. Again any discharge in the fornix may be from the cervix, or it could be from a vaginal infection. Skene gland opening is incorrect. This gland is within the labia minor and surrounds the urethral opening. Discharge from PID comes from the uterus so would be coming from the os within the introitus. Bartholin gland opening is incorrect. This opening is just within the introitus near the 4 and 8 o’clock positions of the labia minora. Discharge from PID would be from the os within the introitus and not from just inside the introitus.

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?

A. Replace the speculum with a larger one (large Graves).

B. Withdraw the speculum and do a bimanual exam to find the cervix.

C. Withdraw the speculum slightly and reposition it on a different slope.

D. Replace the speculum with a plastic one with a better light source.

E. Discontinue the speculum exam and treat empirically.

c. Withdraw the speculum slightly and reposition it on a different slope.

Rationale: The first maneuver when the cervix is not easily within view is to switch the angle of how the speculum is being inserted. Replace the speculum with a larger one (large Graves) is incorrect. In some patients, this could be done after repositioning the original speculum. In this patient, a thin G0, a larger speculum would not be helpful. Withdraw the speculum and do a bimanual exam to find the cervix is incorrect. Although this can be helpful to find a cervix, it is not the next maneuver that would be done. Replace the speculum with a plastic one with a better light source is incorrect. Although this can also be done as a later maneuver it is not the next one done to visualize the cervix. Discontinue the speculum exam and treat empirically is incorrect. The clinician would not stop trying to visualize the cervix after one failed attempt. In this case, also it is unknown if this discharge is bacterial vaginosis, Trichomonas, a yeast infection, or some other sexually transmitted infection.

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?

A. Sitting
B. Supine
C. Prone
D. Trendelenburg

E. Lithotomy

e. Lithotomy

Rationale: Lithotomy or dorsal lithotomy position describes a patient lying on an exam table supine but with the legs abducted with the feet in the stirrups. This was named lithotomy because it is how doctors used to access the urethra in both men and women to be able to remove stones with instruments. This is the easiest position to visualize the cervix and do the bimanual exam. Sitting is incorrect. Obviously the vagina and perineum cannot be accessed in the sitting position. Supine is incorrect. A purely supine position lying on the back with the legs adducted closed would provide no exposure to the female genitalia. Prone is incorrect. In the prone position, the patient is laying on the stomach, and the genitalia are not accessible. Trendelenburg is incorrect. In the Trendelenburg position, the patient is supine and the legs are elevated higher than the level of the head. A reverse Trendelenburg has the patient supine with the head higher than the level of the feet.

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?

A. Levatori ani

B. Anal sphincter

C. Pubis symphysis

D. Ischiocavernosus muscle

E. Bulbocavernosus muscle

a. Levatori ani

Rationale: The levatori ani muscle group consisting of the pubococcygeus muscle and the iliococcygeus muscle is responsible for the support of the pelvic floor. Weakening can cause prolapse of the pelvic organs. Weakness of the anal sphincter is incorrect. Weakness of this muscle can lead to anal incontinence of stool. Weakness of the pubis symphysis is incorrect. Although there can be slight separation of the pubis symphysis following childbirth, it usually returns to its normal state afterward and does not lead to weakening of the pelvic musculature. Weakness of the ischiocavernosus or bulbocavernosus muscles is incorrect. Weakness of these muscles can lead to urinary incontinence.

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?

A. Stop the examination immediately

B. Have him return to see another provider

C. Explain this is a normal response and finish the examination

D. Tell him the examination cannot proceed until the erection subsides

E. Assume that he is malingering

C- Explain this is a normal response and finish the examination

Rationale: Explain that erection is a normal response. When performing an examination on the male genitalia, it is important to explain each step of the examination so that the patient knows what to expect. Having an assistant in the room is appropriate for both male and female providers. If the patient refuses to be examined, his wishes should be respected. Stop the examination immediately is incorrect and would be inappropriate without any explanation or further examination. Given his report of a lesion and history of multiple sexual partners, this patient requires a thorough examination and having him return to see another provider at a later time is incorrect and may lead to further morbidity if a sexually transmitted infection is not recognized and treated promptly. Tell him the examination cannot proceed until the erection subsides is incorrect. It is not necessary if the patient is willing to continue. Assume that he is malingering is incorrect based on his reported history. Again, it is important to have an escort in the room if there is any question.

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?

A. The internal anal sphincter is under voluntary control, whereas the external anal sphincter is under involuntary control

B. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control

C. Both internal and external anal sphincter are under involuntary control

D. Control of the anal sphincters is variable between individuals

b. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control.

Rationale: The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Together, these two muscles hold the anal sphincter closed until the individual is ready to defecate. The internal anal sphincter is under voluntary control, whereas the external anal sphincter is under involuntary control; both internal and external anal sphincter are under voluntary control; and both internal and external anal sphincter are under involuntary control are incorrect because, as above, the internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Control of the anal sphincters is variable between individuals is incorrect because this anatomic and neurological arrangement is not typically variable between individuals, although these pathways may be interrupted by derangements of normal physiology such as spinal cord injuries.

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?

A. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the rectum the most likely source of this patients discomfort

B. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the anus the most likely source of this patients discomfort

C. Proximal to the dentate line, the lower gastrointestinal tract is innervated primarily by somatosensory nerves, making the proximal reach of the examination the most likely site of this patients pain

D. The anal canal has a rich somatosensory innervation, making poorly directed examinations painful in this area

E. The dentate or pectinate line does not differentiate any neurological input, making the area either proximal or distal to the line equally responsible for this patients discomfort

d. The anal canal has a rich somatosensory innervation, making poorly directed examinations painful in this area.

Rationale: The anal canal is characterized by somatosensory innervation, whereas the rectum has little such nerve supply. Thus, the patient’s discomfort likely occurred due to the stretch of the anal canal rather than disruption of the more proximal rectal mucosa. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the rectum the most likely source of this patient’s discomfort is incorrect because the anal canal is more richly innervated with somatosensory nerves than the rectum. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the anus the most likely source of this patient’s discomfort is incorrect because, although the anal canal is the most likely site of the patient’s discomfort, the anal canal (not the rectum) contains a greater concentration of somatosensory nerves. Proximal to the dentate line, the lower gastrointestinal tract is innervated primarily by somatosensory nerves, making the proximal reach of the examination the most likely site of this patient’s pain is incorrect because the reverse is true: somatosensory innervation is greater in the anal canal than the rectum. The dentate or pectinate line does not differentiate any neurological input, making the area either proximal or distal to the line equally responsible for this patient’s discomfort is incorrect because the dentate or pectinate line forms the anorectal junction. Little somatosensory innervation occurs proximal to this line, making the rectal area a less likely source of a patient’s discomfort during anorectal examinations.

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?

A. All three lobes of the prostate are palpable on DRE

B. The seminal vesicles are palpable distal to the prostate of DRE

C. The median lobe of the prostate is located anterior to the urethra and is not palpable on DRE

D. The median sulcus divides the lateral lobes from the median lobe and is palpable on DRE

E. A prostate of 5cm diameter without palpable nodes or masses represents a normal prostate examination

c. The median lobe of the prostate is located anterior to the urethra and is not palpable on DRE.

Rationale: Due to its location at the anterior aspect of the urethra, the median lobe of the prostate is not palpable on DRE, nor are small tumors in this area. All three lobes of the prostate are palpable on DRE is incorrect because the median lobe of the prostate is not palpable on DRE, although the two lateral lobes are palpable. The seminal vesicles are palpable distal to the prostate on DRE is incorrect because the seminal vesicles are proximal (not distal) to the prostate. They are generally not palpable on DRE. The median sulcus divides the lateral lobes from the median lobe and is palpable on DRE is incorrect because the median sulcus divides the lateral lobes from each other; it is palpable on examination. A prostate of 5 cm diameter without palpable nodes or masses represents a normal prostate examination is incorrect because, although a lack of nodes and masses is normal, a 5-cm prostate is larger than normal (which is closer to 2.5 cm diameter).

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?

A. Sacrum

B. Pectinate line

C. Uterine fundus

D. Prostate

E. Cervix

e. Cervix

Rationale: The cervix is often palpable through the anterior rectal wall on DRE of female patients. Sacrum is incorrect because it lies posterior (not anterior) to the rectum. Pectinate line is incorrect because it lies circumferentially in the rectum. It is visible on proctoscopic examination but is not palpable on digital rectal examination. Uterine fundus is incorrect because, although the cervix is palpable through the anterior rectal wall on digital examination, the fundus of the uterus is generally too proximal to palpable. Prostate is incorrect because this patient is female, making the presence of a prostate notably unlikely.

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?

A. Long term history of hemorrhoids

B. Recent history of black, tarry stools

C. Remote history of anal pruritus

D. New onset anal fissures

E. Recent onset of small caliber stools

e. Recent onset of small-caliber stools

Rationale: Small-caliber stools may be caused by narrowing of the colon due to a mass. Colonoscopy should be performed to rule out such pathology, especially in a patient with such a notable family history. Long-term history of hemorrhoids is incorrect because hemorrhoids are not directly associated with colon cancer. However, bleeding from hemorrhoids should be evaluated carefully in high-risk patients, as bleeding attributed to hemorrhoids is virtually indistinguishable from fresh blood from the lower gastrointestinal (GI) tract. A low threshold for ordering colonoscopy should be maintained in patients with risk factors for colon cancer, including age >50 years and strong family history. Recent history of black, tarry stools is incorrect because black, tarry stools (“melena”) generally represent blood in the GI tract, whereas melanotic stools usually have a source in the upper tract, not the colon. Although this should be thoroughly investigated, it is not likely to have colon cancer as a source. Remote history of anal pruritus is incorrect because it may be due to hemorrhoids, proctitis, receptive anal intercourse, pinworms, and a variety of other sources. Anal pruritus is not typically associated with colon cancer. New-onset anal fissures is incorrect because anal fissures may be associated with constipation and Crohn disease, but they are not generally indicative of colon cancer.

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?

A. The patient should begin screening for colon cancer 10 years prior to the age of onset of his fathers prostate cancer

B. The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer

C. The patient is due for routine age based colon cancer screening by colonoscopy regardless of his risk factors

D. The patient has a reassuring family history and thus needs no colon cancer screening until at least age 60 years

E. The patients condition puts him at a high risk of bowl perforation during colonoscopy, thus colon cancer screening should be deferred indefinitely.

b. The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer.

Rationale: The two forms of IBD (UC and Crohn disease) increase the risk of colon cancer and do warrant increased screening at shortened intervals. The patient should begin screening for colon cancer 10 years prior to the age of onset of his father’s prostate cancer is incorrect because family history of breast, ovarian, or colon cancer increases an individual’s risk of colon cancer, whereas family history of prostate cancer alone does not increase an individual’s risk of colon cancer and thus does not indicate increased screening. (Of note, prostate cancer may rarely be a manifestation of the BRCA genetic mutation that would put this patient at higher risk for many types cancer, but this would usually be accompanied by a family history of many cancers, especially breast and ovarian cancer in the female line.) The patient is due for routine age-based colon cancer screening by colonoscopy regardless of his risk factors is incorrect because routine age- based screening by colonoscopy begins at age 50 years. Younger patients may require colonoscopy for diagnosis of symptomatic disease or for screening due to high-risk histories. The patient has a reassuring family history and thus needs no colon cancer screening until at least age 60 years is incorrect because even with a benign family history, routine colon cancer screening by colonoscopy, sigmoidoscopy, and/or fecal occult blood testing is recommended at age 50 years, not at age 60 years. The patient’s condition puts him at a high risk of bowel perforation during colonoscopy, thus colon cancer screening should be deferred indefinitely is incorrect. Although risks and benefits should always be considered before any procedure, this patient’s risks for colon cancer (and thus benefit from screening) outweigh his risks of a major adverse event from colonoscopy.

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?

A. Pathological constriction of the anal canal

B. Normal anatomy of the mucosal surface

C. Carcinoma

D. Valve of Houston

E. External anal sphincter

b. Normal anatomy of the mucosal surface

Rationale: The circumferential border between the anal canal and rectum is visible on proctoscopic examination but is not palpable on DRE. This demarcation is known as the dentate or pectinate line. Pathological constriction of the anal canal is incorrect because the patient has no complaints regarding defecation, and this change in tissue between the anal canal and rectum is a normal finding. Carcinoma is incorrect because neoplastic tissue is unlikely to present as a regular, circumferential demarcation between tissues. Valve of Houston is incorrect because the valves of Houston are three inward foldings of the rectal wall; although they are palpable on deep DRE, they do not appear as distinct types of tissue on proctoscopic examination. External anal sphincter is incorrect because the internal and external anal sphincters are distal to the pectinate line and are not superficially visible on internal examination of the anal canal and rectum.

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?

A. Inflammatory bowel disease

B. Lymphogranuloma venereum

C. Human Papillomavirus

D. Gonorrhea cervicitis

E. Primary syphilis

a. Inflammatory bowel disease (IBD)

Rationale: Anal fissures are associated with the underlying condition of Crohn disease, which is one of the two IBDs (the other is ulcerative colitis). Anal fissures may have no underlying cause, although constipation is a common and benign condition that may lead to this problem. Lymphogranuloma venereum is incorrect because it is a sexually transmitted infection (STI) that may cause proctitis, but rarely anal fissures. HPV is incorrect because HPV strains contribute to cervical cancer, genital warts, and papillomatosus (an overabundance of genital warts in the anogenital area). Gonorrhea cervicitis is incorrect because although this STI may cause vaginal discharge, itching, and ascending infections in the uterus, it is unlikely to cause anal fissures. Primary syphilis is incorrect because the chancre of primary syphilis may cause proctitis, but it is unlikely to cause anal fissures.

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?

A. The incidence of prostate cancer does not rise until age >65 years, thus this patient needs no screening at this time

B. Prostate cancer is always an aggressive neoplasm, thus the risks of overdiagnosis with screening is outweighed by the benefits of early case finding

C. This patient is at an elevated risk of prostate cancer due to his family history, thus screening modalities should be discussed between the patient and provider

D. The patients race is a protective factor for prostate cancer, thus reassurance is the only intervention necessary

E. The patients family history in the female line is irrelevant to his own risk and can be safely ignored in discussion of his risk for prostate cancer

c. This patient is at an elevated risk of prostate cancer due to his family history, thus screening modalities should be discussed between the patient and provider.

Rationale: This patient has a number of obvious risks: family history of prostate cancer (a first-degree relative with prostate cancer doubles or triples the risk of this disease in an individual), African American race, and an unusual family history of cancers that may be associated with the BRCA genetic mutation. Although prostate cancer screening techniques are controversial due to limited sensitivity and specificity, in this case, the risk of over- or underdiagnosis may be outweighed by the benefits of screening. The incidence of prostate cancer does not rise until age >65 years, thus this patient needs no screening at this time is incorrect. The incidence of prostate cancer rises sharply with each decade after age 50 years. Prostate cancer is always an aggressive neoplasm, thus the risks of overdiagnosis with screening is outweighed by the benefits of early case- finding is incorrect. Prostate cancer is very often an indolent disease, with many men dying of other age-related disorders before prostate cancer can evolve far enough to cause mortality. This patient’s race is a protective factor for prostate cancer, thus reassurance is the only intervention necessary is incorrect. This patient’s race (African American) puts him at increased (rather than decreased) risk for prostate cancer. As such, screening should be discussed, although the risks and benefits of screening for prostate are somewhat ambiguous as discussed above. The patient’s family history in the female line is irrelevant to his own risks and can be safely ignored in discussion of his risk for prostate cancer is incorrect. Although prostate cancer alone in the family history is not a red flag for a serious genetic variation, this patient’s family history in the female line is suspicious for the BRCA gene that is associated with a variety of cancers. Although the BRCA gene is not all that common in African American populations, this issue should still be addressed with appropriate screening recommended for both prostate cancer and the BRCA gene itself.

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?

A. Regardless of sensitivity and specificity of testing modalities, screening for prostate cancer should always be ordered due to the malignant nature of the disease

B. The prostate-specific antigen effectively differentiates aggressively malignant prostate tumors from indolent cases

C. The prostate specific antigen cut off of 4.0ng/ml is virtually 100% specific for aggressive prostate cancer

D. Setting normal cut offs for prostate specific antigen testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis

E. Most prostate cancers are palpable and symptomatic by the time they are biopsied, reducing the need for screening as patients can report symptoms

d. Setting normal cut-offs for prostate-specific antigen (PSA) testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis.

Rationale: Setting normal cut-offs for PSA testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis is a very common theme among screening tests: If the norms of a given test are set too tightly, chances are that true cases of the disease will be missed (loss of sensitivity). Conversely, setting looser norms captures more true positives but also captures more patients with normal variant results near the ends of the bell curve (loss of specificity). This problem is increased in screening tests in which there are numerous normal conditions that cause the target result; PSA testing for prostate cancer is notorious for this complication, as is the CA-125 tumor marker for ovarian cancer. Screening tests without clear norms are very problematic in the interpretation of results—a particularly frustrating factor in ovarian cancer screening in which most patients with the disease present at an advanced stage and the need for a good early screening test is clear. Regardless of sensitivity and specificity of testing modalities, screening for prostate cancer should always be ordered due to the malignant nature of the disease is incorrect because the decision to screen should be undertaken on a case-by-case basis with each individual patient. The PSA effectively differentiates aggressively malignant prostate tumors from indolent cases is incorrect because PSA has almost no role in differentiating indolent from aggressive prostate tumors—in fact, PSA can be elevated in conditions that are not cancerous at all, such as benign prostatic hyperplasia, urinary retention, and recent ejaculation. The PSA cut-off of 4.0 ng/ml is virtually 100% specific for aggressive prostate cancer is incorrect because, as above, the PSA is neither particularly sensitive nor specific for prostate cancer of any kind. Most prostate cancers are palpable and symptomatic by the time they are biopsied, reducing the need for screening as patients can report symptoms is incorrect because most prostate cancers identified via biopsy are nonpalpable and asymptomatic. Of note, screening for diseases that are symptomatic in early stages is rarely necessary, as patients can easily report symptoms before the disease becomes dangerous. Unfortunately, a large number of malignant diseases are asymptomatic until local spread or distant metastases have occurred—making effective screening techniques for asymptomatic patients important to long-term survival rates. In the case of prostate cancer, a test that effectively separates indolent from aggressive lesions is ideal but not yet forthcoming.

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?

A. Osteoporosis

B. Ankylosing spondylitis

C. Malignancy

D. Infection

E. Torticollis

b. Ankylosing spondylitis

Rationale: Tenderness over the sacroiliac joint is common in sacroilitis and also seen in ankylosing spondylitis. Osteoporosis is incorrect; osteoporosis may be associated with pain on percussion of the spine. Malignancy is incorrect; malignancy may be associated with pain on percussion of the spine. Infection is incorrect; infection may be associated with pain on percussion of the spine. Torticollis is incorrect; torticollis is caused by contraction of the sternocleidomastoid muscle and presents as lateral deviation and rotation of the head.

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?

A. Splenius capitis

B. Trapezius

C. Splenius cervicis

D. Sternocleidomastoid (SCM)

E. Sacrospinalis

d. Sternocleidomastoid (SCM)

Rationale: The SCM muscle flexes and rotates the neck. Splenius capitis is incorrect; the splenius capitis extends the neck. Trapezius is incorrect; the trapezius extends the neck. Splenius cervicis is incorrect; the splenius cervicis attaches to the posterior aspect of the spine and extends the neck. Sacrospinalis is incorrect; the sacrospinalis attaches to the posterior aspect of the spine. When muscles attached to the posterior aspect of the spine contract, the spine extends.

An obese 50-year-old patient presents with a long history of back trouble. What structure in the spine supports the body’s weight?

A. Vertebral arch

B. Intervertebral disk

C. Transverse process

D. Vertebral body

E. Spinous process

d. Vertebral body

Rationale: The vertebral body is a weight-bearing structure of the spine. Vertebral arch is incorrect; the vertebral arch encloses the spinal cord. Intervertebral disk is incorrect; the intervertebral disk provides a cushion between the vertebrae. Transverse process and Spinous process are incorrect; these structures serve as a site of muscle attachment.

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?

A. Torticollis

B. Spondylolisthesis

C. Osteoarthritis (OA)

D. Thoracic kyphosis

E. Ankylosing spondylitis

a. Torticollis

Rationale: The characteristic physical signs of torticollis are head rotation and lateral deviation. Spondylolisthesis is incorrect; spondylolisthesis is the slippage between vertebrae and does not present with the head rotated laterally and downward. OA is incorrect. Although it can cause a stiff and painful neck, it would not cause the head to be laterally deviated toward the shoulder and rotated. Thoracic kyphosis is incorrect; thoracic kyphosis is increased flexion of the thoracic vertebrae and occurs with aging. Ankylosing spondylitis is incorrect; ankylosing spondylitis does not present with the head rotated laterally and downward.

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?

A. Assess his ability to touch his toes

B. Assess the lateral bending movement of his neck

C. Compare the strength of his trapezia muscles

D. Assess his ability to extend his back

E. Check for listing of his trunk

c. Compare the strength of his trapezia muscles

Rationale: One cause of winged scapula is the contralateral weakness of the trapezius muscle. As this patient has had his left arm immobilized for 8 weeks, he may have muscle wasting and weakness of the left trapezius relative to his right side. Assess his ability to touch his toes is incorrect; touching toes assesses the muscles that flex the back as well as looks for scoliosis (differences in the height of scapulae). Assess the lateral bending movement of his neck is incorrect; this action assesses the function of the scalene and small intrinsic neck muscles. Assess his ability to extend his back is incorrect; this action assesses the function of the deep intrinsic muscles of the back. Check for listing of his trunk is incorrect; this sign may be present with a herniated disk.

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)?

A. Scalenes

B. Sternocleidomastoid (SCM)

C. Splenius capitis

D. Prevertebral muscles

E. Splenius cervicis

b. Sternocleidomastoid (SCM)

Rationale: The action is rotation of the neck. The muscles responsible for rotation of the neck are the SCM and the small intrinsic neck muscles. Scalenes is incorrect; the action of the scalene muscle is to flex the neck. The scalenes also laterally bend the neck. Splenius capitis is incorrect; the action of the splenius capitis muscle is to extend the neck. Prevertebral muscles is incorrect; the action of the prevertebral muscles is to flex the neck. Splenius cervicis is incorrect; the action of the splenius cervicis muscle is to extend the neck.

During a musculoskeletal examination of the spine, what is the action(s) of the erector spinae muscle group?

A. Rotation of the spine

B. Extension of the spine

C. Flexion of the spine

D. Lateral bending of the spine

E. Rotation and lateral bending of the spine

b. Extension of the spine

Rationale: The erector spinae muscle group is one of the deep intrinsic muscle groups of the back that extend the spine. Rotation of the spine is incorrect; the muscles that rotate the spine are the abdominal muscles and the intrinsic muscles of the back. Flexion of the spine is incorrect; the muscles that flex the spine are the psoas major and minor, quadratus lumborum, and the abdominal muscles. Lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back. Rotation and lateral bending of the spine is incorrect; the muscles that laterally bend the spine are the abdominal muscles and the intrinsic muscles of the back.

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?

A. Hyperreflexia of the lower limb

B. Pelvic tilt or drop

C. Thoracic kyphosis

D. Positive straight leg raise

E. Flexed forward posture with lower extremity weakness

F. Gout

G. Polymyalgia rheumatica

e. Flexed forward posture with lower extremity weakness

Rationale: The physical signs of lumbar spinal stenosis include flexed forward posture and weakness of the lower extremities. Hyperreflexia of the lower limb is incorrect; hyporeflexia of the lower extremities is consistent with lumbar spinal stenosis. Pelvic tilt or drop is incorrect; weakness of the pelvic stabilizers—the gluteus medius and minimus are not consistent with lumbar spinal stenosis. Thoracic kyphosis is incorrect; thoracic kyphosis is not associated with lumbar spinal stenosis. Positive straight leg raise is incorrect; the straight-leg test is usually negative in lumbar spinal stenosis.

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?

A. Osteoarthritis (OA)

B. Rheumatoid arthritis

C. Psoriatic arthritis

a. Osteoarthritis (OA)

Rationale: The common locations of joints involved with OA are the knees, hips, hands, wrists, neck, and lower back. RA is incorrect; the common locations of joints involved with RA are the small joints of the hands, feet, wrists, and ankles, and also the joints of the elbows and knees. This patient has involvement of the hips, which is not characteristic of RA. Psoriatic arthritis is incorrect; psoriatic arthritis is a mono/oligoarthritis—involving one to three joints. This patient has at least six joints involved. Gout is incorrect; the common locations of joints involved with acute gout are the base of the big toe, foot, ankles, knees, and elbows. The common locations of joints involved with chronic tophaceous gout are the feet, ankles, wrists, fingers, and elbows. This patient has involvement of the hips, neck, and low back which is not characteristic of gout. Polymyalgia rheumatica is incorrect; the common locations of pain in polymyalgia rheumatica are the muscles surrounding the hip and shoulder joints.

A 62-year-old patient with rheumatoid arthritis (RA) complains of increased joint stiffness. What characteristic(s) are consistent with her diagnosis of RA?

A. Stiffness follows joint activity

B. Joint distribution is asymmetrical

C. Swelling of the synovial tissue is seen in joints and tendon sheaths

D. It most frequently involves the first metatarsophalangeal joint

E. Tophi are found in the subcutaneous tissue

c. Swelling of the synovial tissue is seen in joints and tendon sheaths.

Rationale: The physical signs of RA include frequent swelling of the synovial tissue in joints or tendon sheaths. Stiffness follows joint activity is incorrect; joint stiffness is usually present after periods of inactivity in RA. Joint distribution is asymmetrical is incorrect; the distribution of involved joints is usually symmetrical in RA. It most frequently involves the first metatarsophalangeal joint is incorrect; the involvement of the first metatarsophalangeal joint is typical of acute gout. Tophi are found in the subcutaneous tissue is incorrect; tophi in the subcutaneous tissue is typical of chronic tophaceous gout.

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?

A. The headache is similar in nature to prior ones she has had for decades but more severe

B. The patient had a car accident and minor head trauma about 3 months ago

C. The patient also developed fever and night sweats and thinks she lost some weight

D. The headache comes and goes

E. The patient lost her glasses

C- The patient also developed fever and night sweats and thinks she lost some weight

Rationale: Concomitant fever, night sweats, and weight loss are concerning systemic symptoms and suggest a serious underlying cause of the headaches. The headache is similar in nature to prior ones she has had for decades but more severe is incorrect. Most headaches follow a classic pattern and even if this one is more severe, the same pattern to prior headaches makes this one likely to be benign. The patient had a car accident and minor head trauma about three months ago is incorrect. Although recent head trauma is a concerning history, trauma 3 months ago is unlikely to have produced changes that lead to a headache at this time. The headache comes and goes is incorrect. Headaches that come and go tend to be benign. For example, migraines come and go. The patient lost her glasses is incorrect. Losing glasses can cause squinting and subsequent development of headache. In any case, this is not a serious concern although she should get new glasses.

In the case of a middle-aged female with a pounding headache, what is an effective question to ask the patient?

A. Does the patient have any aura prior to the headaches ?

B. How old is the patient?

C. Is she feeling stressed?

D. Does she think she is losing her memory?

E. Has she ever seen anyone with a stroke?

A- Does the patient have an aura prior to the headaches?

Rationale: An aura or a prodrome of unusual feelings or neurological symptoms may increase the likelihood that this is a migraine. “How old is the patient?” is incorrect. Age of the patient does not produce a useful clue. “Is she feeling stressed?” is incorrect. Most patients report feeling stressed. Also, headaches themselves can stress out a patient. “Does she think she is losing her memory?” is incorrect. Losing memory may be an early symptom of dementia but is not typically linked to headaches. “Has she ever seen anyone with a stroke?” is incorrect. This is unlikely to be a stroke, and asking such a question will only increase the patient’s stress.

A 35-year-old female patient has had migraines for much of her adult life. At her 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?

A. Reassure her that this is a common pattern with migraines

B. Order studies to evaluate potential transient ischemi attacks (TIAs) because she is on OCPs

C. Take further history and perform a very careful neurologic examination

D. Treat her for sinusitis

E. Prescribe a strong medication for her migraines

C- Take a further history and perform a very careful neurological examination

Rationale: The history of nightly awakening and nausea is concerning for increased intracranial pressure from a tumor or other mass. (Brain tumor is not common in a 35-year-old.) A careful neurological examination may uncover deficits. Reassure her that this is a common pattern with migraines is incorrect. The new symptoms are not typical of migraines. Order studies to evaluate potential TIAs because she is on OCPs is incorrect. Despite her being on OCPs, the new symptoms are not typical of TIAs or strokes. Treat her for sinusitis is incorrect. Headaches from sinusitis are typically frontal, worse when leaning forward, and do not typically cause such nighttime nausea. Prescribe a strong medication for her migraines is incorrect. Treatment without further workup is not prudent, particularly since these symptoms are not typical of migraines.

An 82-year-old grandmother presents to the Emergency Department in the care of he 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?

A. Dysponia with expressive deficit

B. Dysarthia

C. Wernicke aphasia

D. Global aphasia

E. Broca aphasia

4. C- Wernicke aphasia

Rationale: The combination of both receptive and expressive aphasia is a characteristic of Wernicke aphasia, which is usually due to a lesion of the posterior superior temporal lobe. Dysphonia with expressive deficit is incorrect because it is an impairment of the voice due to dysfunction of vocal cords and related structures but does not affect the ability to understand or express oneself. Dysarthria is incorrect because it is an impairment of the voice due to dysfunction of the muscles that allow speech but does not affect the ability to understand or express oneself. Global aphasia is incorrect because it is a condition in which all communicative capacity is impaired, resulting in a complete inability to communicate with others. Broca aphasia (usually due to a lesion in the posterior inferior frontal lobe) is incorrect because it results in verbose, meaningless verbal expression but with sparing of language interpretation.

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?

A. Atrial fibrillation is not a risk factor for ischemic stroke in individuals age >75

B. Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke

C. Obesity with normal glucose tolerance is not a risk factor for stroke

D. Transient ischemic attacks (TIAs) that resolve in 1 hour confer a 5% risk factor from stroke within the next 12 months

E. Due to increasing public awareness, the median time for arrival to care for suspected stroke is <3 hours

B- Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke

Rationale: Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke. Although many risk factors for stroke have been recognized, hypertension remains the greatest risk after smoking, high cholesterol, diabetes, elevated weight, and low exercise levels. Atrial fibrillation is not a risk factor for ischemic stroke in individuals age ≥75 years is incorrect because atrial fibrillation that is not recognized or not treated with anticoagulation confers a significant risk of stroke. Obesity with normal glucose tolerance is not a risk factor for stroke is incorrect because obesity doubles the risk of stroke even without associated glucose intolerance. TIAs that resolve within in 1 hour confer a 5% risk of death from stroke within the next 12 months is incorrect because TIAs are a significant predictor for risk of stroke, with 1-year mortality of ~12% associated with them, regardless of the time it takes a TIA to resolve. Due to increasing public awareness, the median time for arrival to care for suspected stroke is <3 hours is incorrect because, unfortunately, most patients present after the third hour of symptoms with a median time for arrival of 3–6 hours. This is often outside of the window for intervention with thrombolytic therapy.

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?

A. The patient most likely has a central upper motor neuron lesion involving cranial nerve (CN) VII (the facial nerve)

B. The patient most likely has a central process of unclear location; an acute ischemic event must be ruled out with an emergent computed tomography (CT)

C. The patient most likely has had an empolic affecting an upper motor neuron (UMN)

D. The patient most likely has an isolated peripheral lower neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve

E. The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) V, the trigeminal nerve

D- The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve

Rationale: This patient most likely has an isolated peripheral LMN lesion involving CNVII, the facial nerve. Facial paralysis is a concerning finding in any patient, and it is critical to make the clinical distinction between Bell palsy (a facial nerve weakness due to primarily benign causes) and central lesions of the contralateral motor cortex (such as stroke or tumor). A peripheral (or LMN) lesion involves the entire affected side, whereas a central (UMN) lesion spares the upper face and selectively paralyzes the lower face. The patient most likely has a central UMN lesion involving CN VII (the facial nerve); the patient most likely has a central process of unclear location; an acute ischemic event must be ruled out with an emergent CT scan; and the patient most likely has had an embolic affecting a UMN are incorrect. All of these answers include a UMN lesion, while this patient has examination findings consistent with an LMN lesion. The patient most likely has an isolated peripheral LMN lesion involving CN V, the trigeminal nerve is incorrect because this nerve supplies sensory (not motor) innervation to the face, although it does innervate muscles of mastication.

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?

A. Thalamus

B. Basal ganglia

C. Internal capsule

D. Diencephalon

E. Reticular activating system

C- Internal capsule

Rationale: The internal capsule is a white matter structure in which myelinated axons from the cerebral cortex converge and descend into the brainstem. Blood supply is provided via arterioles and, as such, is especially vulnerable to the effects of ateriolosclerosis. Thalamus and basal ganglia are incorrect because these are gray matter structures deep in the brain. Diencephalon is incorrect because this posterior part of the forebrain connects the midbrain with the cerebral hemispheres, encloses the third ventricle, and contains the thalamus and hypothalamus. As such, it contains numerous structures of both gray and white matter. The reticular activating system is incorrect because, although a complex neural network in the central core of the brainstem, it monitors the state and function of the body in such processes as arousal, sleep, attention, and muscle tone. It contains both gray and white matter.

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?  

A. CNII

B. CN III

C. CNIV

D. CNV

E. CNVI

B- CN III

Rationale: The oculomotor nerve (CN III) is a pure motor nerve controlling pupillary constriction, eye opening, and most of the extraocular movements. Injury to this nerve and its peripheral fibers, as is the case here, could result in impaired pupillary constriction, leading to a complaint of sensitivity to light. CN II is incorrect because the optic nerve is a special sensory nerve and transmits signals related to vision. CN IV is incorrect because the trochlear nerve is a motor nerve, responsible for downward and internal rotation of the eye. CN V is incorrect because the trigeminal nerve is a mixed sensorimotor nerve innervating the temporal, masseter, and lateral pterygoid muscles and supplies sensation to the face. CN VI is incorrect because the abducens nerve is a motor nerve responsible for lateral deviation of the eye.

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?

A. CN VII

B. CNIX

C. CNX

D. CNXI

E. CN XII

B- CN IX

Rationale: The glossopharyngeal nerve (CN IX) is a mixed sensorimotor nerve; it innervates the muscles of the pharynx and provides sensory fibers to portions of the tympanic membrane, auditory canal, pharynx, and the posterior third of the tongue. CN VII is incorrect because the facial nerve is a mixed sensorimotor nerve, innervates the muscles of facial expression, and supplies sensation for the anterior two thirds of the tongue. CN X is incorrect because the vagus nerve supplies sensorimotor innervation to the pharynx and larynx and motor innervation to the palate. CN XI is incorrect because the spinal accessory nerve is a motor nerve innervating the sternocleidomastoid and trapezius (upper portion) muscles. CN XII is incorrect because the hypoglossal is the motor nerve innervating the tongue.

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?

A. Right oculomotor nerve (CN III)

B. Right trochelear nerve (CN IV)

C. Right abducens nerve (CN VI)

D. Left oculomotor nerve (CN III)

E. Left trochlear nerve (CN IV)

F. Left abducens nerve (CN VI)

F- Left abducens nerve (CN VI)

Rationale: The left abducens nerve (CN VI) moves the left eye outward to the left. Paresis or weakness of this muscle will produce the inability of the baby to move the left eye out to the left. The right oculomotor nerve (CN III) is incorrect because this nerve moves the right eye inward, up and in, up and out, and down and out. The right trochlear nerve (CN IV) is incorrect because this nerve moves the right eye downward and in. The right abducens nerve (CN VI) is incorrect because this nerve moves the right eye outward to the right. The left oculomotor nerve (CN III) is incorrect because this nerve moves the left eye inward, up and in, up and out, and down and out. The left trochlear nerve (CN IV) is incorrect because this nerve moves the left eye downward and in.

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?

A. Corticospinal tract

B. Corticobulbar tract

C. Spinothalamic tract

D. Cerebellar system

E. Posterior column system

B- Corticobulbar tract

Rationale: The corticobulbar tract is a motor tract that mediates voluntary movement, including skilled, complex, and fine movements (such as what are involved in speech) in the muscles of the face, head, and neck innervated by the cranial nerves. Corticospinal tract is incorrect because this is a motor tract mediating voluntary movement in the body below the neck. Spinothalamic system is incorrect because this is a sensory pathway transmitting impulses from nerve endings registering pain and temperature in the body up to the thalamus. Cerebellar system is incorrect because this system consists of sensorimotor control pathways coordinating motor activity, equilibrium, and posture. Posterior column system is incorrect because this is an afferent sensory pathway that transmits the sensations of vibration, proprioception, kinesthesia, pressure, and light touch.

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?

A. Right plantar (Babinski)

B. Right ankle

C. Right knee

D. Left plantar (Babinski)

E. Left ankle

F. Left knee

B- Right ankle

Rationale: An ipsilateral diminished reflex indicates impaired sacral 1 function on the right and corresponds to the patient’s pattern of pain and sensory loss on examination. Right and left plantar (Babinski) are incorrect because a positive plantar response comes from a central nervous system lesion in the corticospinal pathway. Right and left knees are incorrect because the deep tendon reflex at the knee is mediated by lumbar 2, 3, 4 nerve roots and does not correspond to the spinal level of this patient’s pattern of pain and sensory loss on examination. Left ankle is incorrect because the spinal level, sacral 1, is correct but is contralateral to the symptoms, neurological findings, and lesion.

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?

A. Frontal motor area of the cerebral cortex

B. Brainstem

C. Lumbar spinal cord

D. Peripheral nerve

E. Distal muscle

D- Peripheral nerve

Rationale: Pure motor neuropathy would first affect the distal extremity farthest away from the motor neuron based simply on the length of the nerve. The symptoms are symmetrical. Support of the tall, rigid boot would help to maintain the function of the weakened foot and ankle muscles; house slippers would do the opposite. Frontal motor area of the cerebral cortex is incorrect because the symptoms are bilateral, symmetrical, and distal; most bilateral, symmetrical distal motor symptoms are not caused by cortical pathology, which would require symmetrical, bilateral brain lesions. Brainstem is incorrect. Because the brainstem is compact, filled with multiple ascending and descending motor and sensory tracts to cranial and spinal nerves, lesions affecting bilateral descending motor tracts would also impinge on other structures, causing a multitude of other symptoms and signs. Lumbar spinal cord is incorrect because a spinal lesion causing this pattern of bilateral distal motor dysfunction would also affect sensory and autonomic functions. Distal muscle is incorrect because primary muscle conditions such as myopathy or muscular dystrophy generally will affect the larger, proximal muscles first, based on bulk and strength alone.

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?

a) Begin with least invasive parts of the examination first.
b) Children age <2 years do not need to be examined.
c) Always give immunizations prior to beginning the examination.
d) Examine the child in the same order as for an adult patient.
e) Never examine a young child in the mother’s lap

a) Begin with least invasive parts of the examination first.

Rationale: The sequence of examination of a child should vary with the child's age, development, and overall comfort level. In general, perform less invasive maneuvers first and delay potentially distressing maneuvers until later in the examination. Always give immunizations prior to beginning the examination is incorrect. Administering immunizations prior to the examination will upset the child and increase the difficulty of the examination. Examine the child in the same order as for an adult patient is incorrect. The adult examination is sequenced head to toe and may be used in older children and adolescents. Examining the ears or mouth in a young child may elicit significant distress and make it challenging to conduct the rest of the examination. Children age <2 years do not need to be examined is incorrect. All children, regardless of age, need a thorough examination at regular intervals in time to assess health, growth and development. Never examine a young child in the mother's lap is incorrect. Young children may be more cooperative and comfortable in their parent's lap

In caring for children, physicians and other clinicians need to understand child development. Of the following, which is a principle of normal child development?

a) All delays in development can be explained by one or two risk factors.
b) Child development proceeds along a predictable pathway in a healthy child.
c) Regression in developmental skills is not a cause for concern.
d) There is minimal variation in when children achieve milestones.
e) A child's developmental level can be ignored in conducting an examination.

b) Child development proceeds along a predictable pathway in a healthy child.

Rationale: Development follows a predictable pathway in a healthy child across all cultures, although adverse experiences prenatally or in childhood can disrupt the trajectory. There is minimal variation in when children achieve milestones is incorrect. There is some variability in when children achieve specific developmental milestones. For example, some children walk as young as 10 months, whereas others may not walk until age 15 months. However, most children are walking by about 12 months. All delays in development can be explained by one or two risk factors is incorrect. There are a large number of risk factors that can negatively impact development including genetic risks, prenatal exposures,
maternal illness during pregnancy, chronic illness, and environmental stressors such as poverty, malnutrition, child maltreatment, and exposure to domestic violence. Regression in developmental skills is not a cause for concern is incorrect. Any regression in developmental milestones is a cause for concern. Some children may display a minor
and temporary lapse as they acquire and integrate new skills. A regression in developmental skills such as language, social interaction, or motor skills is always a cause for concern and further evaluation.
Ignoring the child's developmental level in conducting an examination is incorrect. The examination of a child will be more successful if the child is cooperative and cooperation is best elicited by considering the child's developmental capacities. For example, a toddler with significant
stranger anxiety may do best when examined in his parent's lap and if the examiner delays distressing parts of the examination until the end

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?

a) Send the child to the Emergency Department (ED).
b) Refer the parents for mental health counseling.
c) Refer the child to a developmental and behavioral pediatrician.
d) Reassure the parents that all toddlers lose skills at some point in development.
e) Reassure the parents that the child is fine as long as he has not lost skills in other domains

c) Refer the child to a developmental and behavioral pediatrician.

Rationale: Any loss of milestones of this duration and severity requires that the examiner take a thorough medical, developmental, family, and social history. Referral to either a developmental and behavioral pediatrician and/or child neurologist for diagnostic clarification is important. The child may also be referred to early intervention for services to addressthe delays. This child is likely to have autism and so timely diagnosisand intervention is important in optimizing developmental outcomes. Reassure the parents that all toddlers lose skills at some point indevelopment is incorrect. Reassuring the parents at this point will delay necessary care. Reassure the parents that the child is fine as long as he has not lost skills in other domains is incorrect. Reassuring the parents at this point will delay necessary care. Send the child to the ED is incorrect. Although the loss of milestones needs timely referral and evaluation, the child has no findings on examination that suggest a neurological emergency. Thus, referral to the ED is apt to be expensive and not fruitful. Refer the parents for mental health counseling is incorrect. The parents may benefit from mental health counseling at some point, but it is more important at this point for the child to be referred to a specialist who can make an accurate diagnosis.

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?

a) Postpone vision and hearing screening because the child may not pass.
b) Reassure the parent that the family stressors are not impacting the child's asthma.
c) Delay immunizations because of the family stressors.
d) Plan less frequent pediatric visits because the family will take too much time.
e) Develop a health promotion plan that includes more frequent visits and guidance to
assist family with stressors and improve the child's asthma symptoms.

e) Develop a health promotion plan that includes more frequent visits and guidance to assist family with stressors and improve the child's
asthma symptoms.

Rationale: Children with a chronic illness require more frequent health promotion and health management visits to achieve optimal outcomes. Developing a health promotion plan in partnership with the parent is likely to be more successful because the family's needs and wishes are taken into consideration. More frequent visits are also an opportunity to provide additional support to the family, especially when there are social stressors that can adversely impact the child's health, as in this vignette. Plan less frequent pediatric visits because the family will take too much time is incorrect. Although the family may appreciate having fewer medical appointments, this is counter to the child's needs for better asthma management. Delay immunizations because of the family stressors is incorrect. Delaying immunizations places the child at risk for infections that may worsen the child's asthma. Postpone vision and hearing screening because the child may not pass is incorrect. Delaying routine screening will delay appropriate intervention. The child with asthma is no more likely to have hearing and vision problems than a healthy child but is also no less likely to have issues. Reassure the parent that the family stressors are not impacting the child's asthma is incorrect. Family stressors are major stressors for children, especially when they involve family disruption (such as separation and divorce and/or separation from parents). Asthma and other chronic illnesses may get worse during this time because the parent is less attentive to the child's care but also because the elevation of stress hormones alters the child's physiology in profound ways.

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?

a) 9
b) 7
c) 3
d) 5
e) 1

a) 9

Rationale: The APGAR scoring system is used to quickly assess how well the newborn is transitioning and is measured at 1 and 5 minutes after birth. The five parameters of the APGAR score include: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The infant can achieve
a score of 0, 1, or 2 in each parameter for a maximum score of 10. An APGAR score of <8 may necessitate some intervention on the part of the
examiner. This infant scored 2 points in each parameter except for color, for which the infant received a 1. Thus, the APGAR score was 9.
The 5‐minute APGAR score is predictive of central nervous system and other organ system outcome. Thus, a score of 0-7 at 5 minutes requires
intervention. Likewise, a score of 0-4 at 1 minute requires immediate resuscitation of the infant. All other answer choices are incorrect according to the AGPAR scoring system.

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?

a) Order a chest x‐ray.
b) Suction the infant's mouth while waiting to calculate the 5‐minute APGAR score.
c) Dry the infant off and swaddle him.
d) Discuss the infant's poor appearance with the parents who are both in the room.
e) Begin neonatal resuscitation.

e) Begin neonatal resuscitation.

Rationale: This infant has an APGAR score of 2 at 1 minute and is in need of immediate resuscitation. The APGAR scoring system is used to quickly
assess how well the newborn is transitioning and is measured at 1 and 5 minutes after birth. The five parameters of the APGAR score include: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The infant can achieve a score of 0, 1, or 2 in each parameter for a maximum score of 10 at 1 and 5 minutes after birth. This infant's 1‐ minute APGAR score is 2, necessitating immediate resuscitation. This may significantly improve the infant's 5‐minute APGAR, which is more indicative of long‐term outcomes. Discuss the infant's poor appearance
with the parents who are both in the room is incorrect. Although the examiner eventually needs to explain the infant's clinical condition to the parents, the infant needs emergent intervention to survive. Suction the infant's mouth while waiting to calculate the 5‐minute APGAR score is incorrect. Suctioning the mouth will not save this infant's life. The 5‐ minute APGAR will be calculated, but resuscitation should commence immediately. Dry the infant off and swaddle him is incorrect. Drying the infant and swaddling him can occur once the infant's respiratory and circulatory systems are stabilized. Order a chest x‐ray is incorrect. A
chest x‐ray will be ordered once the infant is stabilized, but this is not the immediate intervention needed.

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?

a) Full‐term, appropriate‐for‐gestational age (AGA) infants having a high risk of long‐
term problems.
b) These two factors help to anticipate certain medical and developmental problems.
c) A SGA infant is at low risk for neonatal problems.
d) The parents should be informed of these.
e) A premature infant with a weight appropriate for gestational age has a very low risk
for neonatal problems.

b) These two factors help to anticipate certain medical and developmental problems.

Rationale: Classifying newborns according to their gestational age (or maturity) and birth weight help predict certain medical problems and their risk of
morbidity. Clinical practice guidelines exist for infants born prematurely or postterm. Both small‐ and large‐for‐gestational‐age infants, even if born full‐term, are at higher risk for complications. Informing the parents about these measures is incorrect. Although informing the parents about their child's gestational age and weight and the
implications of these factors is very important, the most important reason for the examiner to be aware of these factors is that it enables an assessment of the newborn's risk for specific complications. An SGA infant is at low risk for neonatal problems is incorrect. SGA infants are at higher risk for neonatal complications. A premature infant with a weight
appropriate for gestational age is at very low risk for neonatal problems is incorrect. Premature infants are at higher risk for neonatal complications. Full‐term AGA infants having a high risk of long‐term
problems is incorrect. Full‐term AGA infants have the lowest risk for neonatal and long‐term complications.

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?

a) State that the infant should be examined in the presence of the parents so they can
be taught about what their newborn can do.
b) Refer the parents to a good book on newborns and wheel the infant back to the
newborn nursery to conduct the examination.
c) State that it will be much more efficient to conduct the examination in the nursery.
d) Note that the infant already had an examination in the delivery room and does not
need another examination so soon.
e) Note that the lighting is better in the newborn nursery.

a) State that the infant should be examined in the presence of theparents so they can be taught about what their newborn can do.

Rationale: Newborns are making a tremendous transition from the protected world of the uterus to the outside world during the first hours and days after birth. Examining the infant several hours after birth is important to assess the newborn's adaptation. Examining the infant in the presence
of the parents is very important because it is the opportunity to teach parents about all the things their baby can already do, what the newborn can see, and how the newborn responds to the environment. The examiner can also explain the infant examination to the parents, reassuring them about what is normal as the examination progresses. It is also an opportunity to answer their questions and to demonstrate how to hold, calm, swaddle, and feed the infant. Ideally, the examiner
has the opportunity to observe breastfeeding and provide supportive guidance to the mother. State that it will be much more efficient to conduct the examination in the nursery is incorrect. Even though it may be more efficient to examine neonates in the newborn nursery, the examiner misses an important opportunity to teach the new parents about infant care. Note that the infant already had an examination in the delivery room and does not need another examination so soon is incorrect. Neonates are in a state of transition from the uterus to the
outside world, and it is important to examine them within several hours of birth to assess how this transition is going. Note that the lighting is
better in the newborn nursery is incorrect. Although the lighting may be better in the newborn nursery than in the hospital room, the examinercan accommodate for this by conducting the examination near the window or as close to the light source as possible. Moving the infant to
the nursery for the examination may cause the examiner to miss an important opportunity to teach the new parents about infant care. Refer the parents to a good book on newborns and wheel the infant back to the newborn nursery to conduct the examination is incorrect. Although it is important to refer parents to appropriate reading material
and websites for detailed information on newborn care, this does not replace the reassurance and information that parents can get from the infant's physician during this encounter several hours after birth.

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?

a) The infant lies in a symmetric position with limbs flexed when relaxed.
b) The infant's vital signs are normal.
c) The infant also has asymmetric limb movements.
d) The tremor is brief and only present when the infant is crying vigorously.
e) There is a history of benign tremor in elderly family members.

c) The infant also has asymmetric limb movements.

Rationale: Tremor is a concerning sign in a newborn infant unless it only occurs while the infant is crying vigorously and is brief and suppressible. In addition, tremor would be more concerning in an infant with
asymmetric limb movements, which by themselves are a sign of possible neurological deficits. Normal infants move their extremities symmetrically. Asymmetrical movement and tremor together are
suggestive of seizure or other concerning neurological process. A history of benign tremor in elderly family members is incorrect. Benign tremors
are common in the elderly and do not have any implications for neonates. The nurse noting that the infant's vital signs are normal is incorrect. Normal vital signs are reassuring, although the tremor still
needs further evaluation. The tremor is brief and only present when the infant is crying vigorously is incorrect. The tremor that occurs only briefly and with vigorous crying is benign. The infant lies in a symmetric position with limbs flexed when relaxed is incorrect. Infants, when relaxed or asleep, lie with their arms and legs flexed and their hands fisted. When awake they will also move their arms and legs
symmetrically in slow circular movements.

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?

a) Her child is progressing normally and does not need further evaluation.
b) Gross motor development proceeds from peripheral skills, such as finger feeding, to
central skills, such as sitting.
c) Delays in gross motor skills are usually because of lack of coordination and catch up
as the child ages.
d) As long as the child is babbling, delays in gross motor skills are not a concern.
e) The delay in his physical motor skills is concerning and warrants a more complete
developmental history and possible referral for early intervention

e) The delay in his physical motor skills is concerning and warrants a more complete developmental history and possible referral for early intervention.

Rationale: Knowing the normal sequence and range of infant development is extremely important as it alerts the examiner to the child with developmental delays. Delays in one or more developmental skills or domains, whether physical (gross motor or fine motor), cognitive, language, or social‐emotional, are an indication for further assessment. Early intervention can provide a detailed assessment of a child's development, provide services to promote development, and teach parents to stimulate skills. Her child is progressing normally and does not need further evaluation is incorrect. The child is behind in gross motor development. By age 9 months, the infant should be sitting, rolling over, and perhaps even pulling up to stand. Gross motor
development proceeds from peripheral skills, such as finger feeding, to central skills, such as sitting is incorrect. Physical motor development proceeds from central (head control and sitting) to peripheral (feeding oneself, clapping). As long as the child is babbling, delays in his gross motor skills are not of concern is incorrect. A child with significant
delays in any developmental domain should have further assessment. Delays can be isolated to one domain, such as language, or include multiple domains. Delays in gross motor skills are usually because of lack of coordination and catch up as the child ages is incorrect. Delays in gross motor skills deserve further assessment. They may catch up to
some extent depending on the underlying cause but cannot be attributed to just a lack of coordination. Reasons for gross motor delays
can include problems with the central nervous system, such as cerebral palsy, and weakness for a variety of reasons.

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?

A. Its determined by her LMP

B. It is 18 weeks and 2 days

C. It is determined by date of insemination plus two weeks

D. It is determined by the opinion of the specialist who completed the procedure

E. It is determinate due to the IUI procedure

C- it is determined by the date of insemination plus two weeks

Rationale: Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. Increased sensitivity (in this case, higher-resolution imaging to pick up subtler disease) is often traded for reduced specificity (in the form of discovering many small items of no pathological significance). This is a core concept in designing screening tests—very sensitive tests often pick up false positives, while very specific tests often rule out disease effectively by missing many actual cases. Balance must be sought between these two when setting thresholds for positive and negative screens. Breast cancer screening by MRI has been well studied in the general population is incorrect. This screening modality has only been studied in high-risk populations. This patient is an ideal candidate for screening via breast MRI based on current evidence is incorrect. This patient meets no known criteria for screening with breast MRI (known BRCA mutation, history of chest radiation, etc.). Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI is incorrect. Only women at high lifetime risk (>20%) are current recommended to utilize breast MRI as a screening tool. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI is incorrect. BRCA1 or BRCA2 mutation confers a risk >20% of breast cancer over a lifetime, which is considered sufficient criteria for screening with MRI rather than mammogram.

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?

A. A cervix with a texture firmer than the nonpregnant cervix, known as the Hegar sign

B. Hyperexcitability of the facial nerve known as a Chvostek sign

C. An internal cervical os open to the width of a finger

D. A bluish hue of cervix known as the Chadwick sign

E. A uterine fundus that is palpable just below the umbilicus

D- A bluish hue of cervix known as the Chadwick sign

Rationale: The Chadwick sign is a bluish coloration of the cervix that appears in early pregnancy and has historically been used to identify pregnancy before rapid HCG testing was available. A cervix with a texture firmer than the nonpregnant cervix, the Hegar sign, is incorrect as Hegar sign is a softening, not a firming, of the pregnant cervix. Hyperexcitability of the facial nerve known as a Chvostek sign is incorrect as this is a physical finding typically associated with hypocalcemia and is not generally found in a healthy pregnant woman. An internal cervical os open to the width of a fingertip is incorrect as the internal os should be closed, even in multiparous women. A uterine fundus that is palpable just below the umbilicus is incorrect as the fundus should be palpable at the umbilicus at 20 weeks’ gestational age, and this patient presents far before that by reliable LMP.

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?

A. Schedule a return visit in 2 weeks

B. Admit the patient to labor and delivery for monitoring

C. Perform an external version

D. Plan for induction of labor at 36 weeks

E. Order a STAT cesarean section

A- schedule a return visit in 2 weeks

Rationale: The physical findings on this patient are essentially normal for gestational age; at 32 weeks’ gestation, the fetus has sufficient room within the uterus to rotate. A 32-week fetus in transverse lie should be evaluated at routine appointments but does not require intervention such as a version or an early induction of labor (indeed, labor should never be induced when a fetus is in a transverse lie). Additionally, Leopold maneuvers are minimally accurate until gestational age 36 weeks. Fetal heart tones in the 140s with beat-to-beat variability are normal, and no intervention is needed. There is little firm evidence for optimal intervals between prenatal visits, but, between 30 and 36 weeks, biweekly visits are the norm. Admit the patient to labor and delivery for monitoring is incorrect as there are no abnormalities to monitor. Perform an external version is incorrect as, again, the fetus has several weeks to rotate into a vertex position, and this procedure does carry some risk of rupturing membranes. Plan for induction of labor at 36 weeks is incorrect as there is no abnormality at this time; labor should not be induced at 36 weeks unless there are benefits that outweigh the risks associated with pre-term birth. Order a stat cesarean section is incorrect as, again, there are no notable abnormalities on this exam except the transverse lie (which may still resolve spontaneously), and the birth of a neonate at 32 weeks’ is likely to engender complications for the neonate.

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?

A. Urinary frequency and suprapubic discomfort in second and third trimesters of pregnancy is inevitably due to the fetus pushing on the maternal bladder; no evaluation is necessary

B. The hormone human placental lactogen is responsible for constipation by slowing intestinal transit

C. Pregnant women safely lose >5% of pregnancy weight due to nausea and vomiting

D. Round ligament pain presents as severe, spontaneous sudden onset abdominal pain that is not provoked or relieved by changing position and may be accompanied by vaginal bleeding

E. Iron supplementation, hormonal changes, slowed intestinal transit, physical pressure from the gravid uterus, and increased blood volume all contribute to abdominal symptoms in pregnant women

E- Iron supplementation, hormonal changes, slowed intestinal transit, physical pressure from the gravid uterus, and increased blood volume all contribute to abdominal symptoms in pregnant women

Rationale: Iron supplementation in prenatal vitamins contributes to constipation. Hormonal changes affect a variety of symptoms, including relaxation of the pubic symphysis leading to localized discomfort, relaxation of smooth muscle in the esophagus leading to gastroesophageal reflux, etc. Increased blood volume leads to urinary frequency. Physical pressure from the gravid uterus can cause round ligament pain, pressure on the bladder leading to urinary frequency, and many other intra-abdominal complaints. The hormone human placental lactogen is responsible for constipation by slowing intestinal transit is incorrect; this hormone plays a role in gestational diabetes but has no known role in causing constipation. Urinary frequency and suprapubic discomfort in second and third trimesters of pregnancy is inevitably due to the fetus pushing on the maternal bladder; no evaluation is necessary is incorrect. Urinary frequency with other signs/symptoms of a urinary tract infection (UTI) should be evaluated as UTIs can progress rapidly in pregnant women and may be associated with preterm labor. Pregnant women may safely lose >5% of prepregnancy weight due to nausea and vomiting is incorrect; >5% weight loss from prepregnancy level is associated with hyperemesis gravidarum and may require treatment to prevent further weight loss. Round ligament pain presents as a severe, spontaneous, sudden-onset abdominal pain that is not provoked or relieved by changing position and may be accompanied by vaginal bleeding is incorrect. This constellation of symptoms is classically associated with a placental abruption, and round ligament pain should never be accompanied by vaginal bleeding. A presentation of abdominal pain with bleeding should be evaluated immediately for placental abruption as this condition endangers both the pregnant woman and the fetus.

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?

A. Diastolic murmurs during pregnancy maybe due to anemia

B. A diastolic murmur during pregnancy is known as a venous hum

C. A diastolic murmur during pregnancy is likely pathological and should always be investigated

D. Cardiomyopathy is very rare during and after pregnancy due to protective effects of estrogen and progesterone; it does not need to be considered on this patients differential diagnosis

E. A leftward rotated apical impulse would confirm a diagnosis of heart failure in this patient

C- A diastolic murmur during pregnancy is likely pathological and should always be investigated

Rationale: Diastolic murmurs are rarely benign and should always be investigated, especially during pregnancy. Diastolic murmurs during pregnancy may be due to anemia is incorrect. As above, diastolic murmurs are rarely benign. Murmurs due to anemia are usually systolic. A diastolic murmur during pregnancy is known as a venous hum is incorrect; a venous hum is a sound caused by increased blood flow through normal vessels—it is not a type of murmur. Cardiomyopathy is very rare during and after pregnancy due to protective effects of estrogen and progesterone; it does not need to be considered on this patient’s differential diagnosis is incorrect. Although peripartum cardiomyopathy is not common, the causes and protective effects are unknown. In a patient with diastolic murmur, dyspnea, and lower extremity edema in late pregnancy, peripartum cardiomyopathy should be considered in the differential diagnosis. A leftward rotated apical impulse would confirm a diagnosis of heart failure in this patient is incorrect. This finding is normal with the anatomic changes due to the presence of the uterus; it neither confirms nor rules out heart failure in a pregnant woman.

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?

A. Normal size, organs and amniotic fluid for the gestational age

B. Uterine leiomyomata that is restrict fetal development

C. Extra amniotic fluid

D. Renal agenesis of the fetus resulting in intrauterine growth retardation

E. Twin pregnancy

D. Renal agenesis of the fetus resulting in intrauterine growth retardation

Rationale: After 20 weeks’ gestational age, the fundal height as measured from the pubic symphysis should equal the number of weeks in the gestational age (e.g., 34 cm at 34 weeks’ gestational age). Although these measurements are not exact, deviations >4 cm deserve evaluation for the cause of the abnormally large or small fundal height. The fetal kidneys produce urine that becomes amniotic fluid; without normal development of the kidneys (i.e., renal agenesis), fluid levels can be very low, resulting in small-for-dates measurements on exam; bilateral renal agenesis is not usually compatible with life. There are many other potential reasons a fetus may be small for dates—such as fetal anomaly or missed abortion—but none of the other explanations listed here are likely explanations. Normal size, organs, and amniotic fluid for the gestational age is incorrect; normal parameters would be unlikely for a fetus with measurements so far off from the expected norm. If the fundal height is >4 cm greater or less than expected, evaluation is warranted. Uterine leiomyomata that restrict fetal development is incorrect. Generally, uterine fibroids large enough to affect a pregnancy will cause the uterus to appear large, rather than small, on exam. Extra amniotic fluid is incorrect as that would also cause the uterus to appear larger, rather than smaller, on exam. Twin pregnancy is not correct as this would also result in a larger, rather than smaller, fundal height.

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?

A. If a pregnant woman does not show sufficient titers to rubella, measles/mumps/rubella (MMR) vaccination should be given postpartum to protect future pregnancies from the effects of congenital rubella.

B. Hepatitis B, measles/mumps/rubella (MMR), and influenza vaccines are safe during pregnancy.

C. Polio and influenza vaccinations are not safe during pregnancy and should never be utilized.

D. RhoGAM is a vaccine specific to pregnancy that should be given to all pregnant women.

E. No vaccines are safe during pregnancy, and the risks of vaccination outweigh the benefits of immunity to infectious diseases.

A- If a pregnant woman does not show sufficient titers to rubella, measles/mumps/rubella (MMR) vaccination should be given postpartum to protect future pregnancies from the effects of congenital rubella.

Rationale: If a pregnant woman does not show sufficient titers to rubella, MMR vaccination should be given postpartum to protect future pregnancies from the effects of congenital rubella. The following are incorrect: Hepatitis B, MMR, and influenza vaccines are safe during pregnancy; polio and influenza vaccinations are not safe during pregnancy; and no vaccines are safe during pregnancy, and In general, live or live attenuated vaccines are not considered to be safe during pregnancy; inactivated vaccines are considered to be safe. MMR, live polio, and varicella vaccines are not considered to be safe during pregnancy, but influenza and hepatitis B are. RhoGAM is a vaccine specific to pregnancy that should be given to all pregnant women is incorrect; RhoGAM is not a vaccine; when used, it is given to Rh-negative women only to prevent sensitization to an Rh-positive infant.

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?

A. She should gain at least 40lbs during pregnancy to account for being underweight at the time of conception

B. Immersions in hot water is safe and effective nonmedical way of coping with musculoskeletal complaints during pregnancy

C. She should increase her calorie intake to 300 calories per day or more from her prepregnancy baseline.

D. She should avoid unpasteurized dairy products and delicatessen meats due to the risk of mycobacteria, shigellosis, and brucellosis.

E. She should switch from running to weight-lifting (e.g., bench press) to maintain muscle mass while avoiding the stressors of running on the fetus

C- She should increase her calorie intake to 300 calories per day or more from her prepregnancy baseline.

Rationale: As the patient’s BMI was low-normal to begin with, she may need more than the usual 300 calorie increase to account for the growing fetus. She should gain at least 40 pounds during the pregnancy is incorrect; because her BMI was at the lower end of the normal range, she should gain between 25 and 35 pounds during pregnancy. Immersion in hot water is a safe and effective nonmedicinal way of coping with musculoskeletal complaints during pregnancy is incorrect. Although water exercises may help with musculoskeletal pain, this should occur in tepid or cool water, as hot-water immersion may have negative effects on fetal development. She should avoid unpasteurized dairy products and delicatessen meats due to the risk of mycobacteria, shigellosis, and brucellosis is incorrect. These products should be avoided due to the risk of listeria, salmonella, and toxoplasmosis. Mycobacteria is generally not transmitted in food, and, although brucellosis can be passed from mother to fetus, this is rare and usually not seen in developed nations. She should switch from running to weight-lifting such as bench presses is incorrect as exercising in the supine position while pregnant compresses the vena cava, leading to dizziness in the gravid woman and possible placental insufficiency in the fetus. There is no specific contraindication to running during pregnancy as long as the individual tolerates it well.

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?

A. Ask that she bring the partner to all appointments so that he can be included in decisions and thus feel less threatened and less likely to harm the patient again.

B. Reassure her that no matter what she reveals, all information she discloses will be kept strictly confidential.

C. Ask open-ended questions, allow her to make decisions that she feels are best for herself given the circumstance, and provide immediate or long-term referrals to domestic violence resources.

D. Reassure her that she is safe as very few pregnant women are hurt or murdered by their partners, who generally become less violent during the vulnerable period of pregnancy.

E. Demand that she leaves the partner immediately and threaten to withhold care if she does not comply.

C- Ask open-ended questions, allow her to make decisions that she feels are best for herself given the circumstance, and provide immediate or long-term referrals to domestic violence resources.

Rationale: The approach of asking open-ended questions, allowing her to make decisions that she feels are best for herself given the circumstance, and providing immediate or long-term referrals to domestic violence resources is most likely to build trust and provide the resource needed for the patient to care for herself and her children. Ask that she bring the partner to all appointments is incorrect, as abusive partners often attend medical appointments with the abused partner to maintain control and prevent the abused partner from expressing fears. Reassure her that all information she discloses will be kept strictly confidential is incorrect. Mandatory reporting laws stipulate that confidentiality must be broken to inform authorities if a minor is in an unsafe/abusive situation. Reassure her that she is safe as very few pregnant women are hurt or murdered by their partners is incorrect; rates of abuse and homicide rise during pregnancy. Demand that she leaves the partner immediately is incorrect; the patient is the best judge of how safe she may be at home, repercussions of her actions against an abusive partner, and other details that the physician is unlikely to know or be able to take into account.

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?

A. Pregnant women are not routinely screened for hepatitis C, butthis test should be added to the panel of prenatal blood tests forpatients with a history of intravenous drug use.

B. Cigarettes are a rare cause of low birth weight in the growing fetus.

C. Women can safely drink one alcoholic drink per day without risk of fetal alcohol syndrome.

D. If a pregnant patient does not intend to quit tobacco, she should not bother to cut down as there is no benefit to the pregnancy from decreased use without cessation.

E. Tobacco is only associated with low birth weight; no other negative outcomes are known from cigarette use during pregnancy

A- Pregnant women are not routinely screened for hepatitis C, but this test should be added to the panel of prenatal blood tests for patients with a history of intravenous drug use.

Rationale: The U.S. Preventive Services Task Force currently does not recommend routine screening of pregnant women for hepatitis C but does recommend screening of individuals at elevated risk of the disease. Cigarettes are a rare cause of low birth weight in the growing fetus and tobacco is only associated with low birth weight; no other negative outcomes are known from cigarette use during pregnancy are incorrect. Cigarettes account for a substantial portion of low-birth-weight babies as well as associated with other pregnancy complications such as placental abruptions. Women can safely drink one alcoholic drink per day without risk of fetal alcohol syndrome is incorrect. No safe dose of alcohol during pregnancy is known; with the lack of evidence for safety, no alcohol ingestion is routinely recommended during pregnancy. One drink per day is the current guideline for nonpregnant women. If a pregnant patient does not intend to quit tobacco, she should not bother to cut down is incorrect. Any decreased in use of tobacco is considered beneficial to the pregnancy.

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?

a) Decreased level of thyroid hormone
b) Mild cognitive impairment
c) Decreased adipose‐to‐muscle ratio
d) Age‐related cognitive decline
e) Persistent urinary incontinence

d) Age‐related cognitive decline

Rationale: Age‐related cognitive decline is a normal finding and includes mild forgetfulness, difficulty remembering names, and mildly reduced concentration that are sporadic and do not affect function. Mild cognitive impairment is incorrect. This is characterized by evidence of memory impairment; this condition progresses to Alzheimer disease at a rate of 12%-15% per year. Decreased level of thyroid hormone is incorrect. This is an easily correctable condition that is not a part of
normal aging. Persistent urinary incontinence is incorrect. This is a pathological condition that is often treatable and can impair the ability to continue independent living if not appropriately addressed. Decreased adipose‐to‐muscle ratio is incorrect. Normal aging is associated with a mild tendency toward the opposite—increased fat as
compared to muscle mass. However, a preponderance of fat over muscle tissue ("sarcopenia") is associated with poor outcomes such as falls.

Which of the following best describes the role of the health practitioner in caring for the aging American population?

a) Prepare all persons age ≥65 years for the eventuality that they will become frail.
b) Assure that all elders complete an annual physical examination.
c) Employ the same disease models used to treat younger patients with chronic disease.
d) Evaluate geriatric conditions in terms of functionality and quality of life rather than
via traditional disease models.
e) Understand that the older population is generally homogenous with little variation in
needs.

d) Evaluate geriatric conditions in terms of functionality and quality of life rather than via traditional disease models.

Rationale: Many diseases of older patients are not curable (such as diabetes or dementia) but can be managed for maximal quality of life. This requires
a shift from traditional modes of thinking of disease as an entity that is addressed and cured. Prepare all persons age ≥65 years for the eventuality that they will become frail is incorrect. There is great
heterogeneity among individuals in this age group, and only 4% require care in institutional facilities. Understand that the older population is generally homogenous with little variation in needs is incorrect. Care of older patients requires increased adaptation to individual needs. Employ the same disease models used to treat younger patients with chronic disease is incorrect. As above, maximizing quality of life and minimizing comorbidities may be the primary goal rather than cure, which is often
the goal in younger patients. Assure that all elders complete an annual physical examination is incorrect. Little evidence exists for the utility of
annual physical exams in achieving superior health outcomes, although specific screening and preventive interventions do have variable
evidence.

Which of the following is true about hair in the aging adult?

a) Women may experience the development of sparse coarse facial hair in their mid‐50s.
b) Age‐related hair changes are the same for all individuals regardless of ethnicity or
race.
c) Age‐related hair loss in males is normal only after age 50 years.
d) Although hair loss occurs in both sexes, hair on the head, trunk, legs, and pubic hair
is invariably spared any age‐related changes.
e) Age‐related hair loss on the scalp is abnormal in women and should be evaluated to
rule out underlying pathology

a) Women may experience the development of sparse coarse facial hair in their mid‐50s.

Rationale: The development of coarse, sparse facial hair occurs to varying degrees in postmenopausal women as part of the normal aging process. Age‐
related hair loss in males is normal only after age 50 years is incorrect. Hair loss may begin as early as the 20s in normal males and is strongly driven by genetics. Age‐related hair loss on the scalp is abnormal in women and should be evaluated to rule out underlying pathology is incorrect. Although less pronounced than in men, most women experience some degree of hair loss with aging. This usually does not represent underlying pathology unless it is very marked or occurs in a patchy distribution. Although hair loss occurs in both sexes, hair on the
head, trunk, legs, and pubic hair is invariably spared any age‐related changes is incorrect. Body hair also demonstrates loss with aging. Age‐related hair changes are the same for all individuals regardless of ethnicity or race is incorrect. Hair patterns should be evaluated along the lines of norms unique to the individual's race and ethnicity. Great
individual variation also exists.

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?

a) An unchanged pulse pressure with equal increases in both systolic and diastolic
pressures
b) A widened pulse pressure with increased systolic pressure (up to 140) and decreased
diastolic pressure
c) A narrowed pulse pressure with increased systolic and diastolic components
d) An isolated increase in systolic blood pressure to >150 mm Hg
e) A drop in systolic pressure of 25 mm Hg when rising from a supine to standing
position

b) A widened pulse pressure with increased systolic pressure (up to 140) and decreased diastolic pressure

Rationale: With aging, systemic vascular resistance increases but diastolic pressure decreases, resulting in a net increase in pulse pressure (the difference between the two). However, pulse pressure >60 is considered a risk factor for cardiovascular and cerebrovascular disease. A narrowed pulse pressure with increased systolic and diastolic components and an unchanged pulse pressure with equal increases in both systolic and
diastolic pressures are incorrect. The pulse pressure narrows as above, with an increase in the systolic pressure and decrease in the diastolic
pressure. A drop in systolic pressure of 25 mm Hg when rising from a supine to standing position is incorrect. A drop in pressure this dramatic when moving from supine to standing position is, by definition, orthostatic hypotension. It is associated with falls. An isolated increase in systolic blood pressure to >150 mm Hg is incorrect. An isolated rise in systolic blood pressure to this extent after age 50 years is an independent risk factor for cardiovascular disease.

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?

a) Any hearing impairment that causes functional decline warrants formal testing and
evaluation.
b) Early age‐related hearing loss initially affects lower‐pitched sounds.
c) Decreased hearing acuity associated with aging is formally known as hypoacusis.
d) Age‐related declines in hearing does not begin until age ≥75 years.
e) His experience is consistent with the normal aging process.

a) Any hearing impairment that causes functional decline warrants formal testing and evaluation.

Rationale: Hearing impairment can be socially, financially, and functionally debilitating, so referral for formal evaluation should be offered to patients of any age who present with hearing loss that impairs their functional ability. Certainly a patient who has left a job due to hearing loss is also at risk for social isolation and other negative outcomes. His
experience is consistent with the normal aging process is incorrect. Although age‐related hearing loss is common, this patient's hearing loss has impaired his daily function and is thus not a normal part of aging—especially at the relatively young age of 65 years. Early age‐related hearing loss initially affects lower pitched sounds is incorrect. Early
hearing loss usually first affects high‐pitched sounds outside the range of voices, then moves down through the range of pitches commonly
needed to follow conversation. Decreased hearing acuity associated with aging is formally known as hypoacusis is incorrect. The correct term is presbycusis. Age‐related declines in hearing does not begin until after age ≥75 years is incorrect. Age‐related hearing decline usually starts in the 20s but does not become evident functionally or clinically until the 50s.

Medications carry both risks and benefits for older patients. Although the risks of polypharmacy (the use of many medications at once) are very well known, many older patients take many medications for a variety of conditions. Which of the following best describes medication prescribing and utilization in the older adult population?

a) Only half of all older patients take at least one drug daily.
b) Older patients rarely take or have adverse effects from sleep medications.
c) Individuals age >65 years account for 30% of all prescribed drugs.
d) Although older patients take more medications than younger adults, their rate of
hospitalization for drug‐related adverse reactions is the same.
e) Medications prescribed for known indications are not considered to be a modifiable
risk factor for adverse events.

c) Individuals age >65 years account for 30% of all prescribed drugs.

Rationale: Older patients receive a disproportionately large number of the medications that are prescribed. Although this is partly due to increase comorbidities with age, it is also alarming because of the risks of adverse events with both increasing age and increasing polypharmacy.
Although older patients take more medications than younger adults, their rate of hospitalization for drug‐related adverse reactions is the same is incorrect. Older adults account for more than half of all adverse drug event‐related hospitalizations. Older patients rarely take or have adverse effects from sleep medications in incorrect. Sleep medications
are frequently prescribed to older patients and cause a wide variety of side effects. Only half of all older patients take at least one drug daily is
incorrect. Eighty percent of all older adults take at least one medication. Medications prescribed for known indications are not considered to be a modifiable risk factor for adverse events is incorrect. Medications are considered to be a primary risk factor for falls and a variety of other adverse events. Medications should be reviewed at
every opportunity with an eye toward minimizing the number and doses of each that are needed to achieve the goals that each are prescribed
for.

Which of the following is true about the presentation of pain in the older adult?

a) Older patients are more likely to report pain symptoms than younger patients.
b) The prevalence of pain is greater in community‐dwelling older adults compared to
those living in nursing homes.
c) Pain is often overtreated in the aging population due to overreporting and
exaggeration of symptoms.
d) The majority of pain complaints in this population are due to cardiac or
gastrointestinal (GI) syndromes.
e) The American Geriatrics Society (AGS) prefers the term "persistent pain" over the
term "chronic pain."

e) The American Geriatrics Society (AGS) prefers the term "persistent pain" over the term "chronic pain."

Rationale: Because of the negative connotations associated with the phrase "chronic pain," "persistent pain" is preferred by the AGS as a means of removing stigma from a serious condition. Older patients are more likely to report pain symptoms than younger patients is incorrect. Older
patients are often reluctant to report pain, although studies show that they are reliable in reporting their pain once identified as having a painful condition. The prevalence of pain is greater in community‐
dwelling older adults compared to those living in nursing homes is incorrect. The reverse is true: Up to 80% of nursing home patients report pain, while up to 50% of community‐dwelling older patients report pain. Pain is often overtreated in the aging population due to overreporting and exaggeration of symptoms is incorrect. The reverse is true here also: Pain tends to go underrecognized as well as undertreated. The majority of pain complaints in this population are due to cardiac or GI syndromes is incorrect. The majority of complaints are musculoskeletal in nature, although other common sources of pain include headache, neuropathy, and cancer.

Concerning alcohol consumption in older adults, which of the following is true?

a) The CAGE screening for alcohol abuse retains the same sensitivity and specificity it
has for younger populations.
b) Alcohol alone does not cause cognitive impairment in older patients.
c) Symptoms and signs of alcohol abuse are more overt and easier to notice during
outpatient encounters in older patients than in younger patients.
d) Alcohol consumption is responsible for 10% of all hospitalizations in patients age >65
years.
e) The detection of alcohol abuse is higher in older patients than younger patients due
to more frequent ambulatory interactions with health care providers.

a) The CAGE screening for alcohol abuse retains the same sensitivity and specificity it has for younger populations.

Rationale: This screening tool retains its strong predictive value for detecting alcohol use in older patients. Only two of four questions must return a
"yes" answer for the screening to be positive. (The CAGE questions ask about Cutting down, Annoyance when criticized for drinking, Guilty
feelings about drinking, and needing Eye openers to start the day.) The detection of alcohol abuse is higher in older patients than younger patients due to more frequent ambulatory interactions with health care providers is incorrect. Despite the prevalence of alcohol abuse and risks of overlapping alcohol with prescription medications, detection of alcohol abuse in older patients remains low. Symptoms and signs of alcohol abuse are more overt and easier to notice during outpatient
encounters in older patients than in younger patients is incorrect. Signs and symptoms of alcohol abuse may be subtle, underreported, or
confused with other age‐related changes such as dementia. Alcohol alone does not cause cognitive impairment in older patients is incorrect. Alcohol alone can cause short‐term and long‐term impairment of cognition and functional status in older adults. Alcohol consumption is responsible for 10% of all hospitalizations in patients age >65 years is incorrect. Only 1% of hospitalizations in patients in this age group are for alcohol‐related causes. This low percentage may be accounted for by
the large number of hospitalizations for other issues, not a markedly low prevalence of alcohol in older patients.

An 80-year-old woman who lives alone at home presents with concerns about maintaining her independent living status. She continues to drive and care for herself and her pet dog but reports two falls over the past 4 months. During one fall, she struck her head, causing a bruise over the right eye. She attributes these episodes to environmental factors: Once she tripped over a rug, and once she misjudged the depth of the curb while crossing the street. Which of the following would be the best approach to this patient?

a) Order a computed tomography (CT) scan of the head to rule out cerebellar pathology.
b) Advise her that falls are associated with aging and that no preventive measures have
proven effective.
c) Perform a comprehensive assessment of fall risk and plan preventive interventions.
d) Advise the patient to be more careful and attentive to her surroundings and provide
reassurance that two episodes is not a cause for concern.
e) Advise her that she may require a walker or a cane to provide better balance.

c) Perform a comprehensive assessment of fall risk and plan preventive interventions.

Rationale: Falls are the leading cause of fatal and nonfatal injuries in patients age >65 years. This patient meets high‐risk criteria with two falls in the last year and as such should undergo a comprehensive evaluation and multi‐modal intervention to prevent future falls. Advise the patient to be more careful and attentive to her surroundings and provide reassurance that two episodes is not a cause for concern is incorrect. Although modification of the home environment may help prevent falls, a thorough investigation is required to identify and reduce the key risks. Advise her that she may require a walker or a cane to provide better balance is incorrect. There is no evidence yet that her risks are not, for example, cardiac rather than musculoskeletal in nature. As with all diagnoses in medicine, an evaluation must be conducted prior to formulating a plan. Advise her that falls are associated with aging and that no preventive measures have proven effective is incorrect. A comprehensive plan for fall prevention can help stave off future falls and the morbidity and mortality they can bring. Order a CT scan of the
head to rule out cerebellar pathology is incorrect. As above, an evaluation must be conducted prior to formulating a plan