MIDTERM 634 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 (Answer) Which is the proper sequence of examination for the abdomen? A) Auscultation, inspection, palpation, percussion B) Inspection, percussion, palpation, auscultation C) Inspection, auscultation, percussion, palpation D) Auscultation, percussion, inspection, palpation 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 Which of the following is a clinical identifier of metabolic syndrome? A) Waist circumference of 38 inches for a male B) Waist circumference of 34 inches for a female C) BP of 134/88 for a male D) BP of 128/84 for a female Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or more at a time and has started recently. Which of the following should be considered? A) Peptic ulcer B) Pancreatitis C) Myocardial ischemia D) All of the above A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior chest pain radiating to her back. She describes it as if someone is “ripping out her heart.” It began less than an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain better or worse. Her medical history consists of difficult-to-control hypertension and coronary artery disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger brother who has had bypass surgery. On examination you see an elderly female in a great deal of distress. She is lying on the table, curled up, holding her left and right arms against her chest and is restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and 130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital’s ER for further evaluation. What disorder of the chest best describes her symptoms? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true? A) She obtains a 20% correct score at 100 feet. B) She can accurately name 20% of the letters at 20 feet. C) She can see at 2.

1. MIDTERM 634
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 (Answer)
Which is the proper sequence of examination for the abdomen?
A) Auscultation, inspection, palpation, percussion
B) Inspection, percussion, palpation, auscultation
C) Inspection, auscultation, percussion, palpation
D) Auscultation, percussion, inspection, palpation
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
Which of the following is a clinical identifier of metabolic
syndrome?
A) Waist circumference of 38 inches for a male
B) Waist circumference of 34 inches for a female
C) BP of 134/88 for a male
D) BP of 128/84 for a female
Bill, a 55-year-old man, presents with pain in his epigastrium

2. which lasts for 30 minutes or more at a time and has started
recently. Which of the following should be considered?
A) Peptic ulcer
B) Pancreatitis
C) Myocardial ischemia
D) All of the above
A 75-year-old retired teacher presents to your clinic,
complaining of severe, unrelenting anterior chest pain radiating
to her back. She describes it as if someone is “ripping out her
heart.” It began less than an hour ago. She states she is feeling
very nauseated and may pass out. She denies any trauma or
recent illnesses. She states she has never had pain like this
before. Nothing seems to make the pain better or worse. Her
medical history consists of difficult-to-control hypertension and
coronary artery disease requiring two stents in the past. She is a
widow. She denies any alcohol, tobacco, or illegal drug use. Her
mother died of a stroke and her father died of a heart attack.
She has one younger brother who has had bypass surgery. On
examination you see an elderly female in a great deal of
distress. She is lying on the table, curled up, holding her left
and right arms against her chest and is restless, trying to find a
comfortable position. Her blood pressure is 180/110 in the right
arm and 130/60 in the left arm, and her pulse is 120. Her right
carotid pulse is bounding but the left carotid pulse is weak. She
is afebrile but her respirations are 24 times a minute. On
auscultation her lungs are clear and her cardiac examination is
unremarkable. You call EMS and have her taken to the
hospital’s ER for further evaluation.
What disorder of the chest best describes her symptoms?
A) Angina pectoris
B) Pericarditis
C) Dissecting aortic aneurysm

3. D) Pleural pain
A patient is assigned a visual acuity of 20/100 in her left eye.
Which of the following is true?
A) She obtains a 20% correct score at 100 feet.
B) She can accurately name 20% of the letters at 20 feet.
C) She can see at 20 feet what a normal person could see at 100
feet.
D) She can see at 100 feet what a normal person could see at 20
feet.
A 46-year-old former salesman presents to the ER, complaining
of black stools for the past few weeks. His past medical history
is significant for cirrhosis. He has gained weight recently,
especially around his abdomen. He has smoked two packs of
cigarettes a day for 30 years and has drunk approximately 10
alcoholic beverages a day for 25 years. He has used IV heroin
and smoked crack in the past. He denies any recent use. He is
currently unemployed and has never been married. On
examination you find a man appearing older than his stated age.
His skin has a yellowish tint and he is thin, with a prominent
abdomen. You note multiple “spider angiomas” at the base of
his neck. Otherwise, his heart and lung examinations are
normal. On inspection he has dilated veins around his
umbilicus. Increased bowel sounds are heard during
auscultation. Palpation reveals diffuse tenderness that is more
severe in the epigastric area. His liver is small and hard to
palpation and he has a positive fluid wave. He is positive for
occult blood on his rectal examination.
What cause of black stools most likely describes his symptoms
and signs?
A) Infectious diarrhea
B) Mallory-Weiss tear

4. C) Esophageal varices
Mrs. Hill is a 28-year-old African-American with a history of
SLE (systemic lupus erythematosus). She has noticed a raised,
dark red rash on her legs. When you press on the rash, it doesn’t
blanch. What would you tell her regarding her rash?
A) It is likely to be related to her lupus.
B) It is likely to be related to an exposure to a chemical.
C) It is likely to be related to an allergic reaction.
D) It should not cause any problems.
A 21-year-old receptionist comes to your clinic, complaining of
frequent diarrhea. She states that the stools are very loose and
there is some cramping beforehand. She states this has occurred
on and off since she was in high school. She denies any nausea,
vomiting, or blood in her stool. Occasionally she has periods of
constipation, but that is rare. She thinks the diarrhea is much
worse when she is nervous. Her past medical history is not
significant. She is single and a junior in college majoring in
accounting. She smokes when she drinks alcohol but denies
using any illegal drugs. Both of her parents are healthy. Her
entire physical examination is unremarkable.
What is most likely the etiology of her diarrhea?
A) Secretory infections
B) Inflammatory infections
C) Irritable bowel syndrome
D) Malabsorption syndrome
A 27-year-old policewoman comes to your clinic, complaining
of severe left-sided back pain radiating down into her groin. It
began in the middle of the night and woke her up suddenly. It
hurts in her bladder to urinate but she has no burning on the
outside. She has had no frequency or urgency with urination but

5. she has seen blood in her urine. She has had nausea with the
pain but no vomiting or fever. She denies any other recent
illness or injuries. Her past medical history is unremarkable.
She denies tobacco or drug use and drinks alcohol rarely. Her
mother has high blood pressure and her father is healthy. On
examination she looks her stated age and is in obvious pain. She
is lying on her left side trying to remain very still. Her cardiac,
pulmonary, and abdominal examinations are unremarkable. She
has tenderness just inferior to the left costovertebral angle. Her
urine pregnancy test is negative and her urine analysis shows
red blood cells.
What type of urinary tract pain is she most likely to have?
A) Kidney pain (from pyelonephritis)
B) Ureteral pain (from a kidney stone) (Answer)
C) Musculoskeletal pain
D) Ischemic bowel pain
Chris is a 20-year-old college student who has had abdominal
pain for 3 days. It started at his umbilicus and was associated
with nausea and vomiting. He was unable to find a comfortable
position. Yesterday, the pain became more severe and constant.
Now, he hesitates to walk, because any motion makes the pain
much worse. It is localized just medial and inferior to his iliac
crest on the right. Which of the following is most likely?
A) Peptic ulcer
B) Cholecystitis
C) Pancreatitis
D) Appendicitis
A 68-year-old retired farmer comes to your office for evaluation
of a skin lesion. On the right temporal area of the forehead, you
see a flattened papule the same color as his skin, covered by a
dry scale that is round and feels hard. He has several more of
these scattered on the forehead, arms, and legs. Based on this

6. description, what is your most likely diagnosis?
A) Actinic keratosis
B) Seborrheic keratosis
C) Basal cell carcinoma
D) Squamous cell carcinoma
Jim is a 60-year-old man who presents with vomiting. He denies
seeing any blood with emesis, which has been occurring for 2
days. He does note a dark, granular substance resembling the
coffee left in the filter after brewing. What do you suspect?
A) Bleeding from a diverticulum
B) Bleeding from a peptic ulcer
C) Bleeding from a colon cancer
D) Bleeding from cholecystitis
A 76-year-old retired farmer comes to your office complaining
of abdominal pain, constipation, and a low-grade fever for about
3 days. He denies any nausea, vomiting, or diarrhea. The only
unusual thing he remembers eating is two bags of popcorn at the
movies with his grandson, 3 days before his symptoms began.
He denies any other recent illnesses. His past medical history is
significant for coronary artery disease and high blood pressure.
He has been married for over 50 years. He denies any tobacco,
alcohol, or drug use. His mother died of colon cancer and his
father had a stroke. On examination he appears his stated age
and is in no acute distress. His temperature is 100.9 degrees and
his other vital signs are unremarkable. His head, cardiac, and
pulmonary examinations are normal. He has normal bowel
sounds and is tender over the left lower quadrant. He has no
rebound or guarding. His rectal examination is unremarkable
and his fecal occult blood test is negative. His prostate is
slightly enlarged but his testicular, penile, and inguinal
examinations are all normal. Blood work is pending.
What diagnosis for abdominal pain best describes his symptoms
and signs?

7. A) Acute diverticulitis (Answer)
B) Acute cholecystitis
C) Acute appendicitis
D) Mesenteric ischemia
You are obtaining an arterial blood gas in the radial artery on a
retired cab driver who has been hospitalized in the intensive
care unit for a stroke. You are concerned about the possibility
of arterial insufficiency. You perform the Allen test. This means
that you:
A) Checked for patency of the radial artery
B) Checked for patency of the brachial artery
C) Checked for patency of the ulnar artery
D) Checked for patency of the femoral artery
You are a student in the vascular surgery clinic. You are asked
to perform a physical examination on a patient with known
peripheral vascular disease in the legs. Which of the following
aspects is important to note when you perform your
examination?
A) Size, symmetry, and skin color
B) Muscle bulk and tone
C) Nodules in joints
D) Lower extremity strength
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

8. 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.
A 28-year-old patient comes to the office for evaluation of a
rash. At first there was only one large patch, but then more
lesions erupted suddenly on the back and torso; the lesions itch.
On physical examination, you note that the pattern of eruption
is like a Christmas tree and that there are a variety of
erythematous papules and macules on the cleavage lines of the
back. Based on this description, what is the most likely
diagnosis?
A) Pityriasis rosea
B) Tinea versicolor
C) Psoriasis
D) Atopic eczema
A 58-year-old gardener comes to your office for evaluation of a
new lesion on her upper chest. The lesion appears to be “stuck
on” and is oval, brown, and slightly elevated with a flat surface.
It has a rough, wartlike texture on palpation. Based on this
description, what is your most likely diagnosis?
A) Actinic keratosis
B) Seborrheic keratosis
C) Basal cell carcinoma
D) Squamous cell carcinoma
A middle-aged man comes in because he has noticed multiple
small, blood-red, raised lesions over his anterior chest and
abdomen for the past several months. They are not painful and
he has not noted any bleeding or bruising. He is concerned this
may be consistent with a dangerous condition. What should you
do?
A) Reassure him that there is nothing to worry about.
B) Do laboratory work to check for platelet problems.

9. C) Obtain an extensive history regarding blood problems and
bleeding disorders.
D) Do a skin biopsy in the office.
You are assessing a patient for peripheral vascular disease in
the arms, secondary to a complaint of increased weakness and a
history of coronary artery disease and diabetes. You assess the
brachial and radial pulses and note that they are bounding. What
does that translate to on a scale of 0 to 3?
A) 0
B) 3+
C) 2+
D) 1+
You are speaking to an 8th grade class about health prevention
and are preparing to discuss the ABCDEs of melanoma. Which
of the following descriptions correctly defines the ABCDEs?
A) A = actinic; B = basal cell; C = color changes, especially
blue; D = diameter >6 mm; E = evolution
B) A = asymmetry; B = irregular borders; C = color changes,
especially blue; D = diameter >6 mm; E = evolution
C) A = actinic; B = irregular borders; C = keratoses; D =
dystrophic nails; E = evolution
D) A = asymmetry; B = regular borders; C = color changes,
especially orange; D = diameter >6 mm; E = evolution
Which of the following changes are expected in vision as part of
the normal aging process?
A) Cataracts
B) Glaucoma
C) Macular degeneration
D) Blurring of near vision
A light is pointed at a patient’s pupil, which contracts. It is
also noted that the other pupil contracts as well, though it is not

10. exposed to bright light. Which of the following terms describes
this latter phenomenon?
A) Direct reaction
B) Consensual reaction
C) Near reaction
D) Accommodation
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?
A 55–year-old smoker complains of chest pain and gestures
with a closed fist over her sternum to describe it. Which of the
following diagnoses should you consider because of her
gesture?
A) Bronchitis
B) Costochondritis
C) Pericarditis
D) Angina pectoris (Answer)
A 77-year-old retired bus driver comes to your clinic for a
physical examination at his wife’s request. He has recently been
losing weight and has felt very fatigued. He has had no chest
pain, shortness of breath, nausea, vomiting, or fever. His past
medical history includes colon cancer, for which he had
surgery, and arthritis. He has been married for over 40 years.
He denies any tobacco or drug use and has not drunk alcohol in
over 40 years. His parents both died of cancer in their 60s. On
examination his vital signs are normal. His head, cardiac, and
pulmonary examinations are unremarkable. On abdominal
examination you hear normal bowel sounds, but when you

11. palpate his liver it is abnormal. His rectal examination is
positive for occult blood.
What further abnormality of the liver was likely found on
examination?
A) Smooth, large, nontender liver
B) Irregular, large liver
C) Smooth, large, tender liver
An elderly woman with a history of coronary bypass comes in
with severe, diffuse, abdominal pain. Strangely, during your
examination, the pain is not made worse by pressing on the
abdomen. What do you suspect?
A) Malingering
B) Neuropathy
C) Ischemia
D) Physical abuse
A 58-year-old teacher presents to your clinic with a complaint
of breathlessness with activity. The patient has no chronic
conditions and does not take any medications, herbs, or
supplements. Which of the following symptoms is appropriate
to ask about in the cardiovascular review of systems?
A) Abdominal pain
B) Orthopnea
C) Hematochezia
D) Tenesmus
You are screening people at the mall as part of a health fair.
The first person who comes for screening has a blood pressure
of 132/85. How would you categorize this?
A) Normal
B) Prehypertension

12. C) Stage 1 hypertension
D) Stage 2 hypertension
Jacob, a 33-year-old construction worker, complains of a “lump
on his back” over his scapula. It has been there for about a year
and is getting larger. He says his wife has been able to squeeze
out a cheesy-textured substance on occasion. He worries this
may be cancer. When gently pinched from the side, a prominent
dimple forms in the middle of the mass. What is most likely?
A) An enlarged lymph node
B) A sebaceous cyst
C) An actinic keratosis
D) A malignant lesion
A 72-year-old teacher comes to a skilled nursing facility for
rehabilitation after being in the hospital for 6 weeks. She was
treated for sepsis and respiratory failure and had to be on the
ventilator for 3 weeks. You are completing your initial
assessment and are evaluating her skin condition. On her sacrum
there is full-thickness skin loss that is 5 cm in diameter, with
damage to the subcutaneous tissue. The underlying muscle is
not affected. You diagnose this as a pressure ulcer. What is the
stage of this ulcer?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Mr. Maxwell has noticed that he is gaining weight and has
increasing girth. Which of the following would argue for the
presence of ascites?
A) Bilateral flank tympany
B) Dullness which remains despite change in position

13. C) Dullness centrally when the patient is supine
D) Tympany which changes location with patient position
Ms. Whiting is a 68 year old who comes in for her usual follow-
up visit. You notice a few flat red and purple lesions, about 6
centimeters in diameter, on the ulnar aspect of her forearms but
nowhere else. She doesn’t mention them. They are tender when
you examine them. What should you do?
A) Conclude that these are lessons she has had for a long time.
B) Wait for her to mention them before asking further
questions.
C) Ask how she acquired them.
D) Conduct the visit as usual for the patient.
A 55-year-old secretary with a recent history of breast cancer,
for which she underwent surgery and radiation therapy, and a
history of hypertension comes to your office for a routine
checkup. Which of the following aspects of the physical are
important to note when assessing the patient for peripheral
vascular disease in the arms?
A) Femoral pulse, popliteal pulse
B) Dorsalis pedis pulse, posterior tibial pulse
C) Carotid pulse
D) Radial pulse, brachial pulse
A 62-year-old woman has been followed by you for 3 years and
has had recent onset of hypertension. She is still not at goal
despite three antihypertensive medicines, and you strongly
doubt nonadherence. Her father died of a heart attack at age 58.
Today her pressure is 168/94 and pressure on the other arm is
similar. What would you do next?
A) Add a fourth medicine
B) Refer to nephrology
C) Get a CT scan
D) Listen closely to her abdomen

14. Which of the following is consistent with obturator sign?
A) Pain distant from the site used to check rebound tenderness
B) Right hypogastric pain with the right hip and knee flexed and
the hip internally rotated
C) Pain with extension of the right thigh while the patient is on
her left side or while pressing her knee against your hand with
thigh flexion
D) Pain that stops inhalation in the right upper quadrant
A 17-year-old high school senior presents to your clinic in acute
respiratory distress. Between shallow breaths he states he was at
home finishing his homework when he suddenly began having
right-sided chest pain and severe shortness of breath. He denies
any recent traumas or illnesses. His past medical history is
unremarkable. He doesn’t smoke but drinks several beers on the
weekend. He has tried marijuana several times but denies any
other illegal drugs. He is an honors student and is on the
basketball team. His parents are both in good health. He denies
any recent weight gain, weight loss, fever, or night sweats. On
examination, you see a tall, thin young man in obvious distress.
He is diaphoretic and is breathing at a rate of 35 breaths per
minute. On auscultation you hear no breath sounds on the right
side of his superior chest wall. On percussion he is
hyperresonant over the right upper lobe. With palpation he has
absent fremitus over the right upper lobe.
What disorder of the thorax or lung best describes his
symptoms?
A) Spontaneous pneumothorax
B) Chronic obstructive pulmonary disease (COPD)
C) Asthma
D) Pneumonia
Monique is a 33-year-old administrative assistant who has had
intermittent lower abdominal pain approximately one week a

15. month for the past year. It is not related to her menses. She
notes relief with defecation, and a change in form and frequency
of her bowel movements with these episodes. Which of the
following is most likely?
A) Colon cancer
B) Cholecystitis
C) Inflammatory bowel disease
D) Irritable bowel syndrome
Mrs. LaFarge is a 60-year-old who presents with urinary
incontinence. She is unable to get to the bathroom quickly
enough when she senses the need to urinate. She has normal
mobility. Which of the following is most likely?
A) Stress incontinence
B) Urge incontinence
C) Overflow incontinence
D) Functional incontinence
Which of the following percussion notes would you obtain over
the gastric bubble?
A) Resonance
B) Tympany
C) Hyperresonance
D) Flatness
A 17-year-old high school senior presents to your clinic in acute
respiratory distress. Between shallow breaths he states he was at
home finishing his homework when he suddenly began having
right-sided chest pain and severe shortness of breath. He denies
any recent traumas or illnesses. His past medical history is
unremarkable. He doesn’t smoke but drinks several beers on the
weekend. He has tried marijuana several times but denies any
other illegal drugs. He is an honors student and is on the
basketball team. His parents are both in good health. He denies
any recent weight gain, weight loss, fever, or night sweats. On

16. examination you see a tall, thin young man in obvious distress.
He is diaphoretic and is breathing at a rate of 35 breaths per
minute. On auscultation you hear no breath sounds on the right
side of his superior chest wall. On percussion he is
hyperresonant over the right upper lobe. With palpation he has
absent fremitus over the right upper lobe.
What disorder of the thorax or lung best describes his
symptoms?
A) Spontaneous pneumothorax (Answer)
B) Chronic obstructive pulmonary disease (COPD)
C) Asthma
D) Pneumonia