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TEST BANK Bates’ Guide to Physical Examination and History Taking 12th Edition Bickley

Bates’ Guide to Physical Examination and History Taking, 12th Edition
Chapter 1: Overview: Physical Examination and History Taking
Multiple Choice
1. For which of the following patients would a comprehensive health history be appropriate?
A) A new patient with the chief complaint of “I sprained my ankle”
B) An established patient with the chief complaint of “I have an upper respiratory infection”
C) A new patient with the chief complaint of “I am here to establish care”
D) A new patient with the chief complaint of “I cut my hand”
Ans: C
Chapter: 01
Page and Header: 4, Patient Assessment: Comprehensive or Focused
Feedback: This patient is here to establish care, and because she is new to you, a comprehensive
health history is appropriate.
2. The components of the health history include all of the following except which one?
A) Review of systems
B) Thorax and lungs
C) Present illness
D) Personal and social items
Ans: B
Chapter: 01
Page and Header: 4, Patient Assessment: Comprehensive or Focused
Feedback: The thorax and lungs are part of the physical examination, not part of the health
history. The others answers are all part of a complete health history.
3. Is the following information subjective or objective?
Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity
and relieved by rest.
A) Subjective
B) Objective
Ans: A
Chapter: 01
Page and Header: 6, Differences Between Subjective and Objective Data
Feedback: This is information given by the patient about the circumstances of his chief
complaint. It does not represent an objective observation by the examiner.
4. Is the following information subjective or objective?
Mr. M. has a respiratory rate of 32 and a pulse rate of 120.
A) Subjective
B) Objective
Ans: B
Chapter: 01
Page and Header: 6, Differences Between Subjective and Objective Data
Feedback: This is a measurement obtained by the examiner, so it is considered objective data.
The patient is unlikely to be able to give this information to the examiner.
5. The following information is recorded in the health history: “The patient has had abdominal
pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9
on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the midepigastric
area.”
Which of these categories does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: B
Chapter: 01
Page and Header: 6, The Comprehensive Adult Health History
Feedback: This information describes the problem of abdominal pain, which is the present
illness. The interviewer has obtained the location, timing, severity, and associated manifestations
of the pain. The interviewer will still need to obtain information concerning the quality of the
pain, the setting in which it occurred, and the factors that aggravate and alleviate the pain. You
will notice that it does include portions of the pertinent review of systems, but because it relates
directly to the complaint, it is included in the history of present illness.
6. The following information is recorded in the health history: “The patient completed 8th grade.
He currently lives with his wife and two children. He works on old cars on the weekend. He
works in a glass factory during the week.”
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: C
Chapter: 01
Page and Header: 6, The Comprehensive Adult Health History
Feedback: Personal and social history information includes educational level, family of origin,
current household status, personal interests, employment, religious beliefs, military history, and
lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and sexual
preferences and history). All of this information is documented in this example.
7. The following information is recorded in the health history: “I feel really tired.”
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: A
Chapter: 01
Page and Header: 6, The Comprehensive Adult Health History
Feedback: The chief complaint is an attempt to quote the patient’s own words, as long as they
are suitable to print. It is brief, like a headline, and further details should be sought in the present
illness section. The above information is a chief complaint.
8. The following information is recorded in the health history: “Patient denies chest pain,
palpitations, orthopnea, and paroxysmal nocturnal dyspnea.”
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Ans: D
Chapter: 01
Page and Header: 6, The Comprehensive Adult Health History
Feedback: Review of systems documents the presence or absence of common symptoms related
to each major body system. The absence of cardiac symptoms is listed in the above example.
9. The following information is best placed in which category?
“The patient has had three cesarean sections.”
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: B
Chapter: 01
Page and Header: 9, Past History
Feedback: A cesarean section is a surgical procedure. Approximate dates or the age of the patient
at the time of the surgery should also be recorded.
10. The following information is best placed in which category?
“The patient had a stent placed in the left anterior descending artery (LAD) in 1999.”
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A
Chapter: 01
Page and Header: 9, Past History
Feedback: The adult illnesses category is reserved for chronic illnesses, significant
hospitalizations, significant injuries, and significant procedures. A stent is a major procedure but
does not involve a surgeon.
11. The following information is best placed in which category?
“The patient was treated for an asthma exacerbation in the hospital last year; the patient has
never been intubated.”
A) Adult illnesses
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A
Chapter: 01
Page and Header: 9, Past History
Feedback: This is information about a significant hospitalization and should be placed in the
adult illnesses section. If the patient is being seen for an asthma exacerbation, you may consider
placing this information in the present illness section, because it relates to the chief complaint at
that visit.
Bates’ Guide to Physical Examination and History Taking, 12th Edition
Chapter 2: Clinical Reasoning, Assessment, and Recording Your Findings
Multiple Choice
1. A patient presents for evaluation of a sharp, aching chest pain which increases with breathing.
Which anatomic area would you localize the symptom to?
A) Musculoskeletal
B) Reproductive
C) Urinary
D) Endocrine
Ans: A
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: Chest pain may be due to a musculoskeletal condition, such as costochondritis or
intercostal muscle cramp. This would be worsened by motion of the chest wall. Pleuritic chest
pain is also a sharp chest pain which increases with a deep breath. This type of pain can occur
with inflammation of the pleura from pneumonia or other conditions and pulmonary embolus.
2. A patient comes to the emergency room for evaluation of shortness of breath. To which
anatomic region would you assign the symptom?
A) Reproductive
B) Urinary
C) Cardiac
D) Hematologic
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: Cardiac disorders such as congestive heart failure are the most likely on this list to
result in shortness of breath. There are cases within the other categories which may also result in
shortness of breath, such as anemia in the hematologic category, pregnancy in the reproductive
category, or sepsis with UTI in the urinary category. This demonstrates the “tension” in clinical
reasoning between making sure all possibilities are covered, while still being able to pick the
most likely cause.
3. A patient presents for evaluation of a cough. Which of the following anatomic regions can be
responsible for a cough?
A) Ophthalmologic
B) Auditory
C) Cardiac
D) Endocrine
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: The cardiac system can cause a cough if the patient has congestive heart failure. This
results in fluid buildup in the lungs, which in turn can cause a cough that produces pink, frothy
sputum. A foreign body in the ear may also cause a cough by stimulating Arnold’s branch of the
vagus nerve, but this is less likely to be seen clinically than heart failure.
4. A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new,
located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash;
she also denies recent travel or camping activities. She has a family history significant for
rheumatoid arthritis. Based on this information, which of the following pathologic processes
would be the most correct?
A) Infectious
B) Inflammatory
C) Hematologic
D) Traumatic
Ans: B
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: The description is most consistent with an inflammatory process, although all the
other etiologies should be considered. Lyme disease is an infection which commonly causes
arthritis, hemophilia is a hematologic condition which can cause bleeding in the joints, and
trauma can obviously cause joint pain. Your clinical reasoning skills are important for sorting
through all of the data to arrive at the most likely conclusion.
5. A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for
several years. He normally takes over-the-counter medications to ease the pain, but this time they
haven’t worked as well, and he still has discomfort. He recently wallpapered the entire second
floor in his house, which caused him great discomfort. The pain resolved with rest. He denies
fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this
description, what is the most likely pathologic process?
A) Infectious
B) Neoplastic
C) Degenerative
D) Traumatic
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: The description is most consistent with degenerative arthritis in the neck. The patient
has had intermittent symptoms and the questions asked to elicit pertinent negative and positive
findings are negative for infectious, traumatic, or neoplastic disease.
6. A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history
of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which
is the most likely pathologic process?
A) Infection
B) Inflammation
C) Allergic
D) Vascular
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: This description is most consistent with allergic rhinitis.
7. A 19-year-old-college student presents to the emergency room with fever, headache, and neck
pain/stiffness. She is concerned about the possibility of meningococcal meningitis. Several of
her dorm mates have been vaccinated, but she hasn’t been. Which of the following physical
examination descriptions is most consistent with meningitis?
A) Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range of
motion
B) Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle
spasm and limited range of motion to the right
C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to
palpation, unable to perform range of motion
D) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full
range of motion
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: Blurred disc margins are consistent with papilledema, and neck tenderness and lack
of range of motion are consistent with neck stiffness, which in this scenario is likely to be caused
by meningeal inflammation. Later, you will learn about Kernig’s and Brudzinski’s signs, which
are helpful in testing for meningeal irritation on examination.
8. A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The
pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods.
Which one of the following physical examination descriptions would be most consistent with the
diagnosis of cholecystitis?
A) Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses.
B) Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or
guarding.
C) Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the
point of stopping inspiration, and there is no rebound or guarding.
D) Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or
guarding.
Ans: C
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: In cholecystitis, the pain, which originates from the gallbladder, is located in the right
upper quadrant. Severity of pain with inspiration that is sufficient to stop further inhalation is
also known as Murphy’s sign, which, if present, is further indicative of inflammation of the
gallbladder.
9. A 55-year-old data entry operator comes to the clinic to establish care. She has the following
symptoms: headache, neck pain, sinus congestion, sore throat, ringing in ears, sharp brief chest
pains at rest, burning abdominal pain with spicy foods, constipation, urinary frequency that is
worse with coughing and sneezing, and swelling in legs. This cluster of symptoms is explained
by:
A) One disease process
B) More than one disease process
Ans: B
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: The patient appears to have several possible conditions: allergic rhinitis, arthritis,
conductive hearing loss, pleuritic chest pains, heartburn, stress urinary incontinence, and venous
stasis, among other conditions. Although we always try, it is very difficult to assign all of these
symptoms to one cohesive diagnosis.
10. A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever,
headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of
symptoms is best explained by:
A) One disease process
B) More than one disease process
Ans: A
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: This cluster of symptoms is most consistent with sinusitis. The chance that all of
these symptoms are caused by multiple synchronous conditions in the same patient is much less
than the possibility of having one problem which accounts for all of them.
11. Steve has just seen a 5-year-old girl who wheezes when exposed to cats. The patient’s
family history is positive for asthma. You think the child most likely has asthma. What have you
just accomplished?
A) You have tested your hypothesis.
B) You have developed a plan.
C) You have established a working diagnosis.
D) You have created a hypothesis.
Ans: D
Chapter: 02
Page and Header: 27, Assessment and Plan: The Process of Clinical Reasoning
Feedback: As you go through a history and examination, you will start to generate ideas to
explain the patient’s symptoms. It is best to keep an open mind and make as many hypotheses as
you can, to avoid missing a possibility. A common mistake is to latch onto one idea too early.
Once you have committed your mind to a diagnosis, it is difficult to change to another. To think
about looking for wheezes on examination would be an example of testing your new hypothesis.
Starting a patient on an inhaled medicine would be a plan. It is too early to commit to a working
diagnosis, given the amount of information you have gathered.
12. Ms. Washington is a 67-year-old who had a heart attack last month. Now she complains of
shortness of breath and not being able to sleep in a flat position (orthopnea). On examination
you note increased jugular venous pressure, an S3 gallop, crackles low in the lung fields, and
swollen ankles (edema). This is an example of a:
A) Pathophysiologic problem
B) Psychopathologic problem
Ans: A
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: This is an example of a pathophysiologic problem because Ms. Washington’s
symptoms are consistent with a pathophysiologic process. The heart attack reduced the ability of
her heart to handle her volume status and subsequently produced the many features of congestive
heart failure.
13. On the way to see your next patient, you glance at the calendar and make a mental note to
buy a Mother’s Day card. Your patient is Ms. Hernandez, a 76-year-old widow who lost her
husband in May, two years ago. She comes in today with a headaches, abdominal pain, and
general malaise. This happened once before, about a year ago, according to your detailed office
notes. You have done a thorough evaluation but are unable to arrive at a consistent picture to tie
these symptoms together. This is an example of a:
A) Pathophysiologic problem
B) Psychopathologic problem
Ans: B
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: It is not uncommon for patients to experience psychopathologic symptoms around the
anniversary of a traumatic event. The time of year and the lack of an obvious connection
between Ms. Hernandez’s symptoms would make you consider this as a possibility. You will
note that although this might have been an early consideration in your hypothesis generation, it is
key to convince yourself that there is not a physiologic explanation for these symptoms, by
performing a careful history and examination.
14. Mr. Larson is a 42-year-old widowed father of two children, ages 4 and 11. He works in a
sales office to support his family. Recently he has injured his back and you are thinking he
would benefit from physical therapy, three times a week, for an hour per session. What would be
your next step?
A) Write the physical therapy prescription.
B) Have your office staff explain directions to the physical therapy center.
C) Discuss the plan with Mr. Larson.
D) Tell Mr. Larson that he will be going to physical therapy three times a week.
Ans: C
Chapter: 02
Page and Header: 30, Develop a Plan Agreeable to the Patient
Feedback: You should discuss your proposed plan with the patient before implementing it. In
this case, you and Mr. Larson will need to weigh the benefit of physical therapy against the
ability to provide for his family. You may need to consider other ways of helping the patient,
perhaps through prescribed back exercises he can do at home. It is a common mistake to
implement a plan without coming to an agreement with the patient first.
15. You are seeing an elderly man with multiple complaints. He has chronic arthritis, pain from
an old war injury, and headaches. Today he complains of these pains, as well as dull chest pain
under his sternum. What would the order of priority be for your problem list?
A) Arthritis, war injury pain, headaches, chest pain
B) War injury pain, arthritis, headaches, chest pain
C) Headaches, arthritis, war injury pain, chest pain
D) Chest pain, headaches, arthritis, war injury pain
Ans: D
Chapter: 02
Page and Header: 37, Generating the Problem List
Feedback: The problem list should have the most active and serious problem first. This new
complaint of chest pain is almost certainly a higher priority than his other, more chronic
problems.
16. You are excited about a positive test finding you have just noticed on physical examination
of your patient. You go on to do more examination, laboratory work, and diagnostic tests, only
to find that there is no sign of the disease you thought would correlate with the finding. This
same experience happens several times. What should you conclude?
A) Consider not doing this test routinely.
B) Use this test when you have a higher suspicion for a certain correlating condition.
C) Continue using the test, perhaps doing less laboratory work and diagnostics.
D) Omit this test from future examinations.
Ans: C
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: This is an example of a sensitive physical finding that lacks specificity. This does not
make this a useless test, because the purpose of a screening physical is to find disease. This
finding made you consider the associated condition as one of your hypotheses, and this in itself
has value. Other possibilities are that you may be doing the maneuver incorrectly or using it on
the wrong population. It is important to ask for hands-on help from your instructor when you
have a question about a maneuver. Make sure that your information about the maneuver comes
from a reliable source as well. All of this information also applies to history questions.
17. You are growing fatigued of performing a maneuver on examination because you have never
found a positive and are usually pressed for time. How should you next approach this
maneuver?
A) Use this test when you have a higher suspicion for a certain correlating condition.
B) Omit this test from future examinations.
C) Continue doing the test, but rely more heavily on laboratory work and diagnostics.
D) Continue performing it on all future examinations.
Ans: A
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: This is an example of a specific test that lacks sensitivity. With this scenario, when
you finally find a positive, you might be very certain that a given condition is present. We
generally develop our examinations to fit our clinical experiences. Sensitive tests are performed
routinely on the screening examination, while specific tests are usually saved for the detailed or
“branched” examinations. Branched examinations are further maneuvers we can perform to
investigate positive findings on our screening examinations. Save this type of maneuver to
confirm your hypothesis. All of this information also applies to history questions.
18. You have recently returned from a medical missions trip to sub-Saharan Africa, where you
learned a great deal about malaria. You decide to use some of the same questions and maneuvers
in your “routine” when examining patients in the midwestern United States. You are
disappointed to find that despite getting some positive answers and findings, on further workup,
none of your patients has malaria except one, who recently emigrated from Ghana. How should
you next approach these questions and maneuvers?
A) Continue asking these questions in a more selective way.
B) Stop asking these questions, because they are low yield.
C) Question the validity of the questions.
D) Ask these questions of all your patients.
Ans: A
Chapter: 02
Page and Header: 38, The Challenges of Clinical Data
Feedback: The predictive value of a positive finding depends upon the prevalence of a given
disease in a population. The prevalence of malaria in the Midwest is almost zero, except in
people immigrating from areas of high prevalence. You will waste time and resources applying
these questions and maneuvers to all patients. It would be wise to continue applying what you
learned to those who are from areas of high prevalence of a given disease. Likewise, physicians
from Ghana should not ask about signs or symptoms of multiple sclerosis, as it is found almost
exclusively in northern latitudes. You will learn to tailor your examination to the population you
are serving.
Bates’ Guide to Physical Examination and History Taking, 12th Edition
Chapter 3: Interviewing and the Health History
Multiple Choice
1. You are running late after your quarterly quality improvement meeting at the hospital and
have just gotten paged from the nurses’ station because a family member of one of your patients
wants to talk with you about that patient’s care. You have clinic this afternoon and are doublebooked
for the first appointment time; three other patients also have arrived and are sitting in the
waiting room. Which of the following demeanors is a behavior consistent with skilled
interviewing when you walk into the examination room to speak with your first clinic patient?
A) Irritability
B) Impatience
C) Boredom
D) Calm
Ans: D
Chapter: 03
Page and Header: 58, Getting Ready: The Approach to the Interview
Feedback: The appearance of calmness and patience, even when time is limited, is the hallmark
of a skilled interviewer.
2. Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to
go into the examination room to interview her. Which of the following is the most logical
sequence for the patient–provider interview?
A) Establish the agenda, negotiate a plan, establish rapport, and invite the patient’s story.
B) Invite the patient’s story, negotiate a plan, establish the agenda, and establish rapport.
C) Greet the patient, establish rapport, invite the patient’s story, establish the agenda, expand and
clarify the patient’s story, and negotiate a plan.
D) Negotiate a plan, establish an agenda, invite the patient’s story, and establish rapport.
Ans: C
Chapter: 03
Page and Header: 60, Learning About the Patient: The Sequence of the Interview
Feedback: This is the most productive sequence for the interview. Greeting patients and
establishing rapport allows them to feel more comfortable before “inviting” them to relate their
story. After hearing the patient’s story, together you establish the agenda regarding the most
important items to expand upon. At the end, together you negotiate the plan of diagnosis and
treatment.
3. Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The pain is
a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the
worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and
it seems to be worse a couple of hours after eating. She has noticed that it starts after eating
greasy foods, so she has cut down on these as much as she can. Initially it occurred once a week,
but now it is occurring every other day. Nothing makes it better. From this description, which of
the seven attributes of a symptom has been omitted?
A) Setting in which the symptom occurs
B) Associated manifestations
C) Quality
D) Timing
Ans: B
Chapter: 03
Page and Header: 65, The Seven Attributes of a Symptom
Feedback: The interviewer has not recorded whether or not the pain has been accompanied by
nausea, vomiting, fever, chills, weight loss, and so on. Associated manifestations are additional
symptoms that may accompany the initial chief complaint and that help the examiner to start
refining his or her differential diagnosis.
4. Jason is a 41-year-old electrician who presents to the clinic for evaluation of shortness of
breath. The shortness of breath occurs with exertion and improves with rest. It has been going on
for several months and initially occurred only a couple of times a day with strenuous exertion;
however, it has started to occur with minimal exertion and is happening more than a dozen times
per day. The shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest
pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal
dyspnea.
Which of the following symptom attributes was not addressed in this description?
A) Severity
B) Setting in which the symptom occurs
C) Timing
D) Associated manifestations
Ans: A
Chapter: 03
Page and Header: 65, The Seven Attributes of a Symptom
Feedback: The severity of the symptom was not recorded by the interviewer, so we have no
understanding as to how bad the symptom is for this patient. The patient could have been asked
to rate his pain on a 0 to 10 scale or used one of the other standardized pain scales available.
This allows the comparison of pain intensity before and after an intervention.
5. You are interviewing an elderly woman in the ambulatory setting and trying to get more
information about her urinary symptoms. Which of the following techniques is not a component
of adaptive questioning?
A) Directed questioning: starting with the general and proceeding to the specific in a manner
that does not make the patient give a yes/no answer
B) Reassuring the patient that the urinary symptoms are benign and that she doesn’t need to
worry about it being a sign of cancer
C) Offering the patient multiple choices in order to clarify the character of the urinary symptoms
that she is experiencing
D) Asking her to tell you exactly what she means when she states that she has a urinary tract
infection
Ans: B
Chapter: 03
Page and Header: 68, Building a Therapeutic Relationship: The Techniques of Skilled
Interviewing
Feedback: Reassurance is not part of clarifying the patient’s story; it is part of establishing
rapport and empathizing with the patient.
6. Mr. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to be
checked out for the symptom of chest pain. As you listen to him describe his symptom in more
detail, you say “Go on,” and later, “Mm-hmmm.” This is an example of which of the following
skilled interviewing techniques?
A) Echoing
B) Nonverbal communication
C) Facilitation
D) Empathic response
Ans: C
Chapter: 03
Page and Header: 68, Building a Therapeutic Relationship: The Techniques of Skilled
Interviewing
Feedback: This is an example of facilitation. Facilitation can be posture, actions, or words that
encourage the patient to say more.
7. Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her
daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and
doesn’t say anything in response to your question. This is an example of which type of
challenging patient?
A) Talkative patient
B) Angry patient
C) Silent patient
D) Hearing-impaired patient
Ans: C
Chapter: 03
Page and Header: 75, Adapting Your Interview to Specific Situations
Feedback: This is one example of a silent patient. There are many possibilities for this patient’s
silence: depression, dementia, the manner in which you asked the question, and so on.
8. Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular
provider is on vacation and she wanted to be seen. You have heard about her many times from
your colleague and are aware that she is a very talkative person. Which of the following is a
helpful technique to improve the quality of the interview for both the provider and the patient?
A) Allow the patient to speak uninterrupted for the duration of the appointment.
B) Briefly summarize what you heard from the patient in the first 5 minutes and then try
to have her focus on one aspect of what she told you.
C) Set the time limit at the beginning of the interview and stick with it, no matter what occurs in
the course of the interview.
D) Allow your impatience to show so that the patient picks up on your nonverbal cue that the
appointment needs to end.
Ans: B
Chapter: 03
Page and Header: 75, Adapting Your Interview to Specific Situations
Feedback: You can also say, “I want to make sure I take good care of this problem because it is
very important. We may need to talk about the others at the next appointment. Is that okay with
you?” This is a technique that can help you to change the subject but, at the same time, validate
the patient’s concerns; it also can provide more structure to the interview.
9. Mrs. H. comes to your clinic, wanting antibiotics for a sinus infection. When you enter the
room, she appears to be very angry. She has a raised tone of voice and states that she has been
waiting for the past hour and has to get back to work. She states that she is unimpressed by the
reception staff, the nurse, and the clinic in general and wants to know why the office wouldn’t
call in an antibiotic for her. Which of the following techniques is not useful in helping to calm
this patient?
A) Avoiding admission that you had a part in provoking her anger because you were late
B) Accepting angry feelings from the patient and trying not to get angry in return
C) Staying calm
D) Keeping your posture relaxed
Ans: A
Chapter: 03
Page and Header: 75, Adapting Your Interview to Specific Situations
Feedback: In this scenario, the provider was 1 hour late in seeing the patient. The provider
should acknowledge that he was late and apologize for this, no matter the reason for being late.
It often helps to acknowledge that a patient’s anger with you is understandable and that you
might be angry in a similar situation.
10. A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge.
As the provider, you need to get a sexual history. Which one of the following questions is
inappropriate for eliciting the information?
A) Are you sexually active?
B) When was the last time you had intimate physical contact with someone, and did that contact
include sexual intercourse?
C) Do you have sex with men, women, or both?
D) How many sexual partners have you had in the last 6 months?
Ans: A
Chapter: 03
Page and Header: 81, Sensitive Topics That Call For Specific Approaches
Feedback: This is inappropriate because it is too vague. Given the complaint, you should
probably assume that he is sexually active. Sometimes patients may respond to this question with
the phrase “No, I just lie there.” A specific sexual history will help you to assess this patient’s
risk for other sexually transmitted infections.
11. Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has
come to the office many times in the past with a variety of injuries, and you suspect that he has a
problem with alcohol. Which one of the following questions will be most helpful in diagnosing
this problem?
A) You are an alcoholic, aren’t you?
B) When was your last drink?
C) Do you drink 2 to 3 beers every weekend?
D) Do you drink alcohol when you are supposed to be working?
Ans: B
Chapter: 03
Page and Header: 81, Sensitive Topics That Call for Specific Approaches
Feedback: This is a good opening question that is general and neutral in tone; depending on the
timing, you will be able to ask for more specific information related to the patient’s last drink.
The others will tend to stifle the conversation because they are closed-ended questions. Answer
D implies negative behavior and may also keep the person from sharing freely with you.
12. On a very busy day in the office, Mrs. Donelan, who is 81 years old, comes for her usual
visit for her blood pressure. She is on a low-dose diuretic chronically and denies any side
effects. Her blood pressure is 118/78 today, which is well-controlled. As you are writing her
script, she mentions that it is hard not having her husband Bill around anymore. What would you
do next?
A) Hand her the script and make sure she has a 3-month follow-up appointment.
B) Make sure she understands the script.
C) Ask why Bill is not there.
D) Explain that you will have more time at the next visit to discuss this.
Ans: C
Chapter: 03
Page and Header: 81, Sensitive Topics That Call for Specific Approaches
Feedback: Sometimes, the patient’s greatest need is for support and empathy. It would be
inappropriate to ignore this comment today. She may have relied heavily upon Bill for care and
may be in danger. She may be depressed and even suicidal, but you will not know unless you
discuss this with her. Most importantly, you should empathize with her by saying something like
“It must be very difficult not to have him at home” and allow a pause for her to answer. You may
also ask “What did you rely on him to do for you?” Only a life-threatening crisis with another
patient should take you out of her room at this point, and you may need to adjust your office
schedule to allow adequate time for her today.
13. A patient is describing a very personal part of her history very quickly and in great detail.
How should you react to this?
A) Write down as much as you can, as quickly as possible.
B) Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every
word.
C) Tell her that she can go over the notes later to make sure they are accurate.
D) Push away from the keyboard or put down your pen and listen.
Ans: D
Chapter: 03
Page and Header: 58, Getting Ready: The Approach to the Interview
Feedback: This is a common event in clinical practice. It is much more important to listen
actively with good eye contact at this time than to document the story verbatim. You want to
minimize interruption (e.g., answer B). It is usually not appropriate to ask a patient to go over
the written notes, but it would be a good idea to repeat the main ideas back to her. You should be
certain she has completed her story before doing this. By putting down your pen or pushing
away from the keyboard, you let the patient know that her story is the most important thing to
you at this moment.
14. You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire
right side. She cannot speak (aphasia). You are supposed to examine her. You notice that the
last examiner left her socks at the bottom of the bed, and although sensitive areas are covered by
a sheet, the blanket is heaped by her feet at the bottom of the bed. What would you do next?
A) Carry out your examination, focusing on the neurologic portion, and then cover her properly.
B) Carry out your examination and let the nurse assigned to her “put her back together.”
C) Put her socks back on and cover her completely before beginning the evaluation.
D) Apologize for the last examiner but let the next examiner dress and cover her.
Ans: C
Chapter: 03
Page and Header: 58, Getting Ready: The Approach to the Interview
Feedback: It is crucial to make an effort to make a patient comfortable. In this scenario, the
patient can neither speak nor move well. Take a moment to imagine yourself in her situation. As
a matter of respect as well as comfort, you should cover the patient appropriately and consider
returning a little later to do your examination if you feel she is cold. While it is her nurse’s job to
keep her comfortable, it is also your responsibility, and you should do what you can. It is
unacceptable to leave the patient in the same state in which you found her.
15. When you enter your patient’s examination room, his wife is waiting there with him. Which
of the following is most appropriate?
A) Ask if it’s okay to carry out the visit with both people in the room.
B) Carry on as you would ordinarily. The permission is implied because his wife is in the room
with him.
C) Ask his wife to leave the room for reasons of confidentiality.
D) First ask his wife what she thinks is going on.
Ans: A
Chapter: 03
Page and Header: 60, Learning About the Patient: The Sequence of the Interview
Feedback: Even in situations involving people very familiar with each other, it is important to
respect individual privacy. There is no implicit consent merely because he has allowed his wife
to be in the room with him. On the other hand, it is inappropriate to assume that his wife should
leave the room. Remember, the patient is the focus of the visit, so it would be appropriate to
allow him to control who is in the room with him and inappropriate to address his wife first.
Although your duty is to the patient, you may get optimal information by offering to speak to
both people confidentially. This situation is analogous to an adolescent’s visit.
16. A patient complains of knee pain on your arrival in the room. What should your first
sentence be after greeting the patient?
A) How much pain are you having?
B) Have you injured this knee in the past?
C) When did this first occur?
D) Could you please describe what happened?
Ans: D
Chapter: 03
Page and Header: 60, Learning About the Patient: The Sequence of the Interview
Feedback: When looking into a complaint, it is best to start with an invitation for the patient to
tell you in his or her own words. More specific questions should be used later in the interview to
fill in any gaps.
17. You have just asked a patient how he feels about his emphysema. He becomes silent, folds
his arms across his chest and leans back in his chair, and then replies, “It is what it is.” How
should you respond?
A) “You seem bothered by this question.”
B) “Next, I would like to talk with you about your smoking habit.”
C) “Okay, let’s move on to your other problems.”
D) “You have adopted a practical attitude toward your problem.”
Ans: A
Chapter: 03
Page and Header: 60, Learning About the Patient: The Sequence of the Interview
Feedback: You have astutely noted that the patient’s body language changed at the time you
asked this question, and despite the patient’s response, you suspect there is more beneath the
surface. Maybe he is afraid of being browbeaten about his smoking, maybe a relative has
recently died from this disorder, or maybe a friend told him 20 years ago that he would
eventually get emphysema. Regardless, by sharing your observation and leaving a pause, he
may begin to talk about some issues which are very important to him.
18. A patient tells you about her experience with prolonged therapy for her breast cancer. You
comment, “That must have been a very trying time for you.” What is this an example of?
A) Reassurance
B) Empathy
C) Summarization
D) Validation
Ans: D
Chapter: 03
Page and Header: 68, Building a Therapeutic Relationship: The Techniques of Skilled
Interviewing
Feedback: This is an example of validation to legitimize her emotional experience. “Now that
you have had your treatment, you should not have any further troubles” is an example of
reassurance. “I understand what you went through because I am a cancer survivor myself” is an
example of empathy. “So, you have had a lumpectomy and multiple radiation treatments” is an
example of summarization as applied to this vignette.
19. You are performing a young woman’s first pelvic examination. You make sure to tell her
verbally what is coming next and what to expect. Then you carry out each maneuver of the
examination. You let her know at the outset that if she needs a break or wants to stop, this is
possible. You ask several times during the examination, “How are you doing, Brittney?” What
are you accomplishing with these techniques?
A) Increasing the patient’s sense of control
B) Increasing the patient’s trust in you as a caregiver
C) Decreasing her sense of vulnerability
D) All of the above
Ans: D
Chapter: 03
Page and Header: 68, Building a Therapeutic Relationship: The Techniques of Skilled
Interviewing
Feedback: These techniques minimize the effects of transitions during an examination and
empower the patient. Especially during a sensitive examination, it is important to give the
patient as much control as possible.
20. When using an interpreter to facilitate an interview, where should the interpreter be
positioned?
A) Behind you, the examiner, so that the lips of the patient and the patient’s nonverbal cues can
be seen
B) Next to the patient, so the examiner can maintain eye contact and observe the
nonverbal cues of the patient
C) Between you and the patient so all parties can make the necessary observations
D) In a corner of the room so as to provide minimal distraction to the interview
Ans: B
Chapter: 03
Page and Header: 75, Adapting Your Interview to Specific Situations
Feedback: Interpreters are invaluable in encounters where the examiner and patient do not speak
the same language, including encounters with the deaf. It should be noted that deaf people from
different regions of the world use different sign languages. The priority is for you to have a good
view of the patient. Remember to use short, simple phrases while speaking directly to the patient
and ask the patient to repeat back what he or she understands.
Bates’ Guide to Physical Examination and History Taking, 12th Edition
Chapter 4: Beginning the Physical Examination: General Survey, Vital Signs, and Pain
Multiple Choice
1. A 15-year-old high school sophomore and her mother come to your clinic because the mother
is concerned about her daughter’s weight. You measure her daughter’s height and weight and
obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?
A) Refer the patient to a nutritionist and a psychologist because the patient is anorexic.
B) Reassure the mother that this is a normal body weight.
C) Give the patient information about exercise because the patient is obese.
D) Give the patient information concerning reduction of fat and cholesterol in her diet because
she is obese.
Ans: B
Chapter: 04
Page and Header: 104, Health Promotion and Counseling
Feedback: The patient has a normal BMI; the range for a normal BMI is 18.5 to 24.9 kg/m2.
You may be able to give the patient and her mother the lower limit of normal in pounds for her
daughter’s height, or instruct her in how to use a BMI table.
2. A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0
kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel
for the patient during the visit?
A) Refer the patient to a nutritionist because he is anorexic.
B) Reassure the patient that he has a normal body weight.
C) Give the patient information about reduction of fat, cholesterol, and calories because he is
overweight.
D) Give the patient information about reduction of fat and cholesterol because he is obese.
Ans: C
Chapter: 04
Page and Header: 104, Health Promotion and Counseling
Feedback: The patient has a BMI in the overweight range, which is 25.0 to 29.9 kg/m2. It is
prudent to give him information about reducing calories, fat, and cholesterol in his diet to help
prevent further weight gain.
3. A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30.0 kg/m2.
What is the most appropriate amount for a weekly weight reduction goal?
A) .5 to 1 pound per week
B) 1 to 2.5 pounds per week
C) 2.5 to 3.5 pounds per week
D) 3.5 to 4.5 pounds per week
Ans: A
Chapter: 04
Page and Header: 104, Health Promotion and Counseling
Feedback: Based on the NIH Obesity Guidelines, this is the weekly weight loss goal to strive for
to maintain long-term control of weight. More rapid weight loss than this does not result in a
better outcome at one year.
4. A 67-year-old retired janitor comes to the clinic with his wife. She brought him in because she
is concerned about his weight loss. He has a history of smoking 3 packs of cigarettes a day for 30
years, for a total of 90 pack-years. He has noticed a daily cough for the past several years, which
he states is productive of sputum. He came into the clinic approximately 1 year ago, and at that
time his weight was 140 pounds. Today, his weight is 110 pounds.
Which one of the following questions would be the most important to ask if you suspect that he
has lung cancer?
A) Have you tried to force yourself to vomit after eating a meal?
B) Do you have heartburn/indigestion and diarrhea?
C) Do you have enough food to eat?
D) Have you tried to lose weight?
Ans: D
Chapter: 04
Page and Header: 102, The Health History
Feedback: This is important: If the patient hasn’t tried to lose weight, then this weight loss is
inadvertent and poses concern for a neoplastic process, especially given his smoking history.
5. Common or concerning symptoms to inquire about in the General Survey and vital signs
include all of the following except:
A) Changes in weight
B) Fatigue and weakness
C) Cough
D) Fever and chills
Ans: C
Chapter: 04
Page and Header: 102, The Health History
Feedback: This symptom is more appropriate to the respiratory review of systems.
6. You are beginning the examination of a patient. All of the following areas are important to
observe as part of the General Survey except:
A) Level of consciousness
B) Signs of distress
C) Dress, grooming, and personal hygiene
D) Blood pressure
Ans: D
Chapter: 04
Page and Header: 109, The General Survey
Feedback: Blood pressure is a vital sign, not part of the General Survey.
7. A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous
visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior
elevated readings and her family history is negative for hypertension. You measure her blood
pressure in your office today. Which of the following factors can result in a false high reading?
A) Blood pressure cuff is tightly fitted.
B) Patient is seated quietly for 10 minutes prior to measurement.
C) Blood pressure is measured on a bare arm.
D) Patient’s arm is resting, supported by your arm at her mid-chest level as you stand to measure
the blood pressure.
Ans: A
Chapter: 04
Page and Header: 114, The Vital Signs
Feedback: A blood pressure cuff that is too tightly fitted can result in a false high reading. The
other answers are important to observe to obtain an accurate blood pressure reading. JNC-7 also
mentions the importance of having the back supported when obtaining blood pressure in the
sitting position.
8. A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling
in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are
the student assigned to do the patient’s complete history and physical examination. When you
palpate the pulse, what do you expect to feel?
A) Large amplitude, forceful
B) Small amplitude, weak
C) Normal
D) Bigeminal
Ans: B
Chapter: 04
Page and Header: 114, The Vital Signs
Feedback: Congestive heart failure is characterized by decreased stroke volume or increased
peripheral vascular resistance, which would result in a small-amplitude, weak pulse. Subtle
differences in amplitude are usually best detected in large arteries close to the heart, like the
carotid pulse. You may not be able to notice these in other locations.
9. An 18-year-old college freshman presents to the clinic for evaluation of gastroenteritis. You
measure the patient’s temperature and it is 104 degrees Fahrenheit. What type of pulse would you
expect to feel during his initial examination?
A) Large amplitude, forceful
B) Small amplitude, weak
C) Normal
D) Bigeminal
Ans: A
Chapter: 04
Page and Header: 114, The Vital Signs
Feedback: Fever results in an increased stroke volume, which results in a large-amplitude,
forceful pulse. Later in the course of the illness, if dehydration and shock result, you may expect
small amplitude and weak pulses.
10. A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath
and states that his blood sugar was 605 at home. You diagnose the patient with diabetic
ketoacidosis. What is the expected pattern of breathing?
A) Normal
B) Rapid and shallow
C) Rapid and deep
D) Slow
Ans: C
Chapter: 04
Page and Header: 114, The Vital Signs
Feedback: This is the expected rate and depth in diabetic ketoacidosis. The body is trying to rid
itself of carbon dioxide to compensate for the acidosis. This is known as Kussmaul’s breathing
and is seen in other causes of acidosis as well.
11. Mrs. Lenzo weighs herself every day with a very accurate balance-type scale. She has
noticed that over the past 2 days she has gained 4 pounds. How would you best explain this?
A) Attribute this to some overeating at the holidays.
B) Attribute this to wearing different clothing.
C) Attribute this to body fluid.
D) Attribute this to instrument inaccuracy.
Ans: C
Chapter: 04
Page and Header: 102, The Health History
Feedback: This amount of weight over a short period should make one think of body fluid
changes. You may consider a kidney problem or heart failure in your differential. The other
reasons should be considered as well, but this amount of weight gain over a short period usually
indicates causes other than excessive caloric intake. A rule of thumb for dieters is that an energy
excess of 3500 calories will cause a 1-pound weight gain, if the increase is to be attributed to
food intake.
12. Mr. Curtiss has a history of obesity, diabetes, osteoarthritis of the knees, HTN, and
obstructive sleep apnea. His BMI is 43 and he has been discouraged by his difficulty in losing
weight. He is also discouraged that his goal weight is 158 pounds away. What would you tell
him?
A) “When you get down to your goal weight, you will feel so much better.”
B) “Some people seem to be able to lose weight and others just can’t, no matter how hard they
try.”
C) “We are coming up with new medicines and methods to treat your conditions every day.”
D) “Even a weight loss of 10% can make a noticeable improvement in the problems you
mention.”
Ans: D
Chapter: 04
Page and Header: 104, Health Promotion and Counseling
Feedback: Many patients trying to change a habit are overwhelmed by how far they are from
their goal. As the proverb says: “A journey of a thousand miles begins with one step.” Many
patients find it empowering to know that they can achieve a small goal, such as a loss of 1 pound
per week. They must be reminded that this process will take time and that slow weight loss is
more successful long-term. Research has shown that significant benefits often come with even a
10% weight loss.
13. Jenny is one of your favorite patients who usually shares a joke with you and is nattily
dressed. Today she is dressed in old jeans, lacks makeup, and avoids eye contact. To what do
you attribute these changes?
A) She is lacking sleep.
B) She is fatigued from work.
C) She is running into financial difficulty.
D) She is depressed.
Ans: D
Chapter: 04
Page and Header: 109, The General Survey
Feedback: It is important to use all of your skills and memory of an individual patient to guide
your thought process. She is not described as sleepy. Work fatigue would most likely not cause
avoidance of eye contact. Financial difficulties would not necessarily deplete a nice wardrobe.
It is most likely that she is depressed or in another type of difficulty.
14. You are seeing an older patient who has not had medical care for many years. Her vital
signs taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain.
You notice that she has some hypertensive changes in her retinas and you find mild proteinuria
on a urine test in your office. You expected the BP to be higher. She is not on any medications.
What do you think is causing this BP reading, which doesn’t correlate with the other findings?
A) It is caused by an “auscultatory gap.”
B) It is caused by a cuff size error.
C) It is caused by the patient’s emotional state.
D) It is caused by resolution of the process which caused her retinopathy and kidney problems.
Ans: A
Chapter: 04
Page and Header: 114, The Vital Signs
Feedback: The blood pressure is unusual in this case in that the systolic pressure is normal while
the diastolic pressure is elevated. Especially with the retinal and urinary findings, you should
consider that the BP may be much higher and that an auscultatory gap was missed. This can be
avoided by checking for obliteration of the radial pulse while the cuff is inflated. Although a
large cuff can cause a slightly lower BP on a patient with a small arm, this does not account for
the elevated DBP. Emotional upset usually causes elevation of the BP. Although a process
which caused the retinopathy and kidney problems may have resolved, leaving these findings, it
is a dangerous assumption that this is the sole cause of the problems seen in this patient.
15. Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home
are much lower. He checks them twice a day at the same time of day and has kept a log. How do
you respond?
A) You diagnose “white coat hypertension.”
B) You assume he is quite nervous when he comes to your office.
C) You question the accuracy of his measurements.
D) You question the accuracy of your measurements.
Ans: C
Chapter: 04
Page and Header: 114, The Vital Signs
Feedback: It is not uncommon to see differences in a patient’s home measurements and your
own in the office. Presuming that this is “white coat hypertension” can be dangerous because
this condition is not usually treated. This allows for the effects of a missed diagnosis of
hypertension to go unchecked. It is also very difficult to judge if a patient is outwardly nervous.
You should always consider that your measurements are not accurate as well, but the fact that
you and your staff are well-trained and perform this procedure on hundreds of patients a week
makes this less likely. Ideally, you would ask the patient to bring in his BP equipment and take a
simultaneous reading with you to make sure that he is getting an accurate reading.
16. You are observing a patient with heart failure and notice that there are pauses in his
breathing. On closer examination, you notice that after the pauses the patient takes progressively
deeper breaths and then progressively shallower breaths, which are followed by another apneic
spell. The patient is not in any distress. You make the diagnosis of:
A) Ataxic (Biot’s) breathing
B) Cheyne-Stokes respiration
C) Kussmaul’s respiration
D) COPD with prolonged expiration
Ans: B
Chapter: 04
Page and Header: 119, Respiratory Rate and Rhythm
Feedback: Cheyne-Stokes respiration can be seen in patients with heart failure and is usually not
a sign of an immediate problem. Ataxic breathing is very irregular in rhythm and depth and is
seen with brain injury. Kussmaul’s respiration is seen in patients with a metabolic acidosis, as
they are trying to rid their bodies of carbon dioxide to compensate. Respirations in COPD are
usually regular and are not usually associated with apneic episodes.
17. Mr. Garcia comes to your office for a rash on his chest associated with a burning pain. Even
a light touch causes this burning sensation to worsen. On examination, you note a rash with
small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his
right side. What type of pain is this?
A) Idiopathic pain
B) Neuropathic pain
C) Nociceptive or somatic pain
D) Psychogenic pain
Ans: B
Chapter: 04
Page and Header: 121, Acute and Chronic Pain
Feedback: This vignette is consistent with a diagnosis of herpes zoster, or shingles. This is
caused by reemergence of dormant varicella (chickenpox) viruses from Mr. Garcia’s nerve root.
The characteristic burning quality without a history of an actual burn makes one think of
neuropathic pain. It will most likely remain for months after the rash has resolved. There is no
evidence of physical injury and this is a peculiar distribution, making nociceptive pain less likely.
There is no evidence of a psychogenic etiology for this, and the presence of a rash makes this
possibility less likely as well. Because of your astute diagnostic abilities, the pain is not
idiopathic.
18. A 50-year-old body builder is upset by a letter of denial from his life insurance company. He
is very lean but has gained 2 pounds over the past 6 months. You personally performed his
health assessment and found no problems whatsoever. He says he is classified as “high risk”
because of obesity. What should you do next?
A) Explain that even small amounts of weight gain can classify you as obese.
B) Place him on a high-protein, low-fat diet.
C) Advise him to increase his aerobic exercise for calorie burning.
D) Measure his waist.
Ans: D
Chapter: 04
Page and Header: 104, Health Promotion and Counseling
Feedback: The patient most likely had a high BMI because of increased muscle mass. In this
situation, it is important to measure his waist. It is most likely under 40 inches, which makes
obesity unlikely (even to an insurance company). It is important that you personally contact the
company and explain your reasoning. Be prepared to back your argument with data. A special
diet is unlikely to be of much use, and more aerobic exercise, while probably a good idea for
most, is redundant for this individual.
19. Ms. Wright comes to your office, complaining of palpitations. While checking her pulse you
notice an irregular rhythm. When you listen to her heart, every fourth beat sounds different. It
sounds like a triplet rather than the usual “lub dup.” How would you document your
examination?
A) Regular rate and rhythm
B) Irregularly irregular rhythm
C) Regularly irregular rhythm
D) Bradycardia
Ans: C
Chapter: 04
Page and Header: 119, Heart Rate and Rhythm
Feedback: Because this unusual beat occurs every fourth set of heart sounds, it is regularly
irregular. This is most consistent with ventricular premature contractions (or VPCs). This is
generally a common and benign rhythm. An irregularly irregular rhythm is a classic finding in
atrial fibrillation. The rhythm is very random in character. Bradycardia refers to the rate, not the
rhythm.
Bates’ Guide to Physical Examination and History Taking, 12th Edition
Chapter 5: Behavior and Mental Status
Multiple Choice
1. A 19-year-old college student, Todd, is brought to your clinic by his mother. She is concerned
that there is something seriously wrong with him. She states for the past 6 months his behavior
has become peculiar and he has flunked out of college. Todd denies any recent illness or injuries.
His past medical history is remarkable only for a broken foot. His parents are both healthy. He
has a paternal uncle who had similar symptoms in college. The patient admits to smoking
cigarettes and drinking alcohol. He also admits to marijuana use but none in the last week. He
denies using any other substances. He denies any feelings of depression or anxiety. While
speaking with Todd and his mother you do a complete physical examination, which is essentially
normal. When you question him on how he is feeling, he says that he is very worried that
Microsoft has stolen his software for creating a better browser. He tells you he has seen a black
van in his neighborhood at night and he is sure that it is full of computer tech workers stealing
his work through special gamma waves. You ask him why he believes they are trying to steal his
programs. He replies that the technicians have been telepathing their intents directly into his
head. He says he hears these conversations at night so he knows this is happening. Todd’s mother
then tells you, “See, I told you . . . he’s crazy. What do I do about it?”
While arranging for a psychiatry consult, what psychotic disorder do you think Todd has?
A) Schizoaffective disorder
B) Psychotic disorder due to a medical illness
C) Substance-induced psychotic disorder
D) Schizophrenia
Ans: D
Chapter: 05
Page and Header: 162, Table 5–4
Feedback: Schizophrenia generally occurs in the late teens to early 20s. It often is seen in other
family members, as in this case. Symptoms must be present for at least 6 months and must have
at least two features of (1) delusions (e.g., Microsoft is after his programs), (2) hallucinations
(e.g., technicians sending telepathic signals), (3) disorganized speech, (4) disorganized behavior,
and (5) negative symptoms such as a flat affect.
2. A 24-year-old secretary comes to your clinic, complaining of difficulty sleeping, severe
nightmares, and irritability. She states it all began 6 months ago when she went to a fast food
restaurant at midnight. While she was waiting in her car a man entered through the passenger
door and put a gun to her head. He had her drive to a remote area, where he took her money and
threatened to kill her. When the gun jammed he panicked and ran off. Ever since this occurred
the patient has been having these symptoms. She states she jumps at every noise and refuses to
drive at night. She states her anxiety has had such a marked influence on her job performance she
is afraid she will be fired. She denies any recent illnesses or injuries. Her past medical history is
unremarkable. On examination you find a nervous woman appearing her stated age. Her physical
examination is unremarkable. You recommend medication and counseling.
What anxiety disorder to you think this young woman has?
A) Specific phobia
B) Acute stress disorder
C) Post-traumatic stress disorder
D) Generalized anxiety disorder
Ans: C
Chapter: 05
Page and Header: 161, Table 5–3
Feedback: Post-traumatic stress disorder is the fearful response (nightmares, avoidance of areas,
irritability) to an event that occurred at least 1 month prior to presentation. The patient’s fears and
reactions cause marked distress and impair social and occupational functions.
3. A 75-year-old homemaker brings her 76-year-old husband to your clinic. She states that 4
months ago he had a stroke and ever since she has been frustrated with his problems with
communication. They were at a restaurant after church one Sunday when he suddenly became
quiet. When she realized something was wrong he was taken to the hospital by EMS. He spent 2
weeks in the hospital with right-sided weakness and difficulty speaking. After hospitalization he
was in a rehab center, where he regained the ability to walk and most of the use of his right hand.
He also began to speak more, but she says that much of the time “he doesn’t make any sense.”
She gives an example that when she reminded him the car needed to be serviced he told her “I
will change the Kool-Aid out of the sink myself with the ludrip.” She says that these sayings are
becoming frustrating. She wants you to tell her what is wrong and what you can do about it.
While you write up a consult to neurology, you describe the syndrome to her.
What type of aphasia does he have?
A) Wernicke’s aphasia
B) Broca’s aphasia
C) Dysarthria
Ans: A
Chapter: 05
Page and Header: 145, Techniques of Examination
Feedback: With Wernicke’s aphasia the patient can speak effortlessly and fluently, but his words
often make no sense. Words can be malformed or completely invented. Wernicke’s area is found
on the temporal lobes.
4. A 32-year-old white female comes to your clinic, complaining of overwhelming sadness. She
says for the past 2 months she has had crying episodes, difficulty sleeping, and problems with
overeating. She says she used to go out with her friends from work but now she just wants to go
home and be by herself. She also thinks that her work productivity has been dropping because
she just is too tired to care or concentrate. She denies any feelings of guilt or any suicidal
ideation. She states that she has never felt this way in the past. She denies any recent illness or
injuries. Her past medical history consists of an appendectomy when she was a teenager;
otherwise, she has been healthy. She is single and works as a clerk in a medical office. She
denies tobacco, alcohol, or illegal drug use. Her mother has high blood pressure and her father
has had a history of mental illness. On examination you see a woman appearing her stated age
who seems quite sad. Her facial expression does not change while you talk to her and she makes
little eye contact. She speaks so softly you cannot always understand her. Her thought processes
and content seem unremarkable.
What type of mood disorder do you think she has?
A) Dysthymic disorder
B) Manic (bipolar) disorder
C) Major depressive episode
Ans: C
Chapter: 05
Page and Header: 160, Table 5–2
Feedback: Major depression occurs in a person with a previously normal state of mood. The
symptoms often consist of a combination of sadness, decreased interest, sleeping problems
(insomnia or hypersomnia), eating problems (decreased or increased appetite), feelings of guilt,
decreased energy, decreased concentration, psychomotor changes (retardation or agitation), and a
preoccupation with thoughts of death or suicide. There must be at least five symptoms for a
diagnosis of major depression. This patient has six: (1) sadness, (2) trouble sleeping, (3)
overeating, (4) fatigue, (5) difficulty with concentration, and (6) no interest in doing things.
5. A 27-year-old woman is brought to your