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Chapter 3. Skin Multiple Choice Identify the choice that best completes the statement or answers the question. ____1.When a patient presents with a skin-related complaint, it is important to firs... t: A. Fully inspect all skin lesions before asking the patient how the lesion in question developed B. Obtain a full history about the development of the skin lesion prior to the physical examination C. Complete a full physical examination of the body prior to inspecting the skin lesion D. Examine the skin lesion without hearing a health history in order to not prejudice the diagnosis ____2.Jaundice is a state of high bilirubin in the bloodstream. It is most commonly seen first in the: A. Sclera B. Nailbeds C. Palms of the hands D. Unexposed skin areas ____3.Skin turgor is best assessed by pinching skin over the: A. Forehead B. Forearm C. Knees D. Dorsum of the hand ____4.What kind of lesions are caused by the herpes simplex virus? A. Scales B. Vesicles C. Plaques D. Urticaria ____5.A patient presents with vesicles on a reddened base in a symmetrical pattern on the lower neck and upper back, stating that he had noticed discomfort prior to the onset of the “rash.” Which of the following should be considered in your differential diagnosis? A. Dermatitis herpetiformis B. Herpes zoster C. Dishydrosis D. Contact dermatitis ____6.Herpetic whitlow is commonly located on: A. The eyelid B. The scalp C. A finger D. Lip ____7.Which type of lesion is referred to as resembling “a dew drop on a rose petal?” A. Varicella zoster B. Measles C. Rubella D. Tinea ____8.Which lesions are typically located along the distribution of dermatome? A. Scabies B. Herpes zoster C. Tinea D. Dishydrosis ____9.Folliculitis is most commonly due to: A. Contact dermatitis B. Varicella zoster C. Dermatophytes D. Staphylococcal infection ____10.A patient presents with polymorphous lesions consisting of small, red papules and vesicles, with a few eroded and crusted lesions. Your differential diagnosis should include all except which of the following? A. Herpes simplex B. Varicella C. Bacterial folliculitis D. Contactdermatitis ____11.The following has been associated with cervical and anal cancer: A. Secondary syphilis B. Human papilloma virus C. Herpes simplex D. Epstein-Barr virus ____12.During a routine exam, you notice a 5 mm lesion on the right medial cheek. The border is raised and pearlescent in color and the area is crusted. The patient admits that it has been present for several months and has only recently become tender with the development of the crusting. This is most likely: A. Squamous cell carcinoma B. Epidermoid cyst C. Basal cell carcinoma D. Actinic keratosis ____13.A patient has a tender, firm, nodular cystic lesion on his scalp that produces cheesy discharge with foul odor. This is most likely a: A. Bacterial folliculitis B. Basal cell carcinoma C. Bullous impetigo D. Epidermoid cyst ____14.Which of the following is not associated with development of erythema multiforme? A. Herpes virus B. Mycoplasms C. Medications D. Trauma ____15.Your patient complains of a progressive loss of pigment in various patches on the body. Affected skin surfaces are otherwise normal (e.g. no scaling, vesicles, elevation, or other changes). The most likely cause is: A. Vitiligo B. Acanthosis nigricans C. Psoriasis D. Pityriasis alba ____16.A patient has an irregularly shaped, brown to black lesion on the upper arm that has changed color recently. The widest diameter is 6 mm. You should: A. Measure and record the dimensions and schedule follow-up to repeat measurement in 2 weeks B. Biopsy the lesion C. Obtain skin scraping for dermatophytes D. All of the above ____17.Which of the following skin disorders is associated with diabetes? A. Acanthosis nigricans B. Vitiligo C. Impetigo D. Folliculitis ____18.Which of the following disorders often presents in patients with café-au-lait spots ? A. Diabetes B. Malignancy C. Neurofibromatosis D. Autoimmune disease ____19.Patient presents with complaint of a “swollen node” under his arm. The area is tender and the node has progressed in size over the past few days. Which of the following should be included in your differential diagnosis? A. Hidradenitis suppurativa B. Epidermoid cyst C. Furuncle D. Both A and C ____20.Which of the following skin conditions frequently heralds an anaphylactic reaction? A. Contact dermatitis B. Eczema C. Urticaria D. Erythema multiforme ____21.A patient with sarcoidosis has firm, tender, reddened nodules, along the anterior aspect of the leg. These lesions are called: A. Erythema multiforme B. Erythema nodosum C. A discoid rash D. Lichen planus ____22.A patient suffered a laceration of the shin three days ago, and today presents with a painful, warm, red swollen region around the area. The laceration has a purulent exudate. The clinician should recognize that the infected region is called: A. Contact dermatitis B. Folliculitis C. Hidradenitis suppurative D. Cellulitis ____23.A woman complains of malaise and arthralgias. You note a butterfly-shaped, macular, erythematous rash across her cheeks and nose. These conditions are common in: A. Psoriasis B. Lichen planus C. Systemic lupus erythematosus D. Erythema nodosum ____24.Which of the following characteristics is not helpful in differentiating between psoriasis and atopic dermatitis? A. Distribution B. Family history C. Lesion morphology D. Chronicity ____25.A patient presents complaining of recent onset of aching and malaise followed by the development of a generalized rash. He denies previous rash although he does admit that about a month ago he had an open sore on his right hand that was nonpainful. The exam reveals a maculopapular rash and lymphadenopathy. This presentation is most consistent with: A. Pityriasis rosea B. Secondary syphilis C. Herpetic whitlow D. Pyogenic granuloma Chapter 14. Musculoskeletal System Multiple Choice Identify the choice that best completes the statement or answers the question. ____1.To assess muscle tone, the clinician should: A. Palpate the patient’s muscle as the muscle is passively stretched B. Examine how the patient performs active range of motion C. Palpate the muscles comparing side to side D. A and C ____2.Muscle strength is assessed by: A. Having the patient move their muscle against the clinician’s resistance B. Examining how the patient performs active range of motion C. Passively stretching the patient’s muscle D. Performing passive range of motion on the patient’s muscle ____3.Which of the following serological diagnostic tests is most specific for rheumatoid arthritis? A. C-reactive protein (CRP) B. Rheumatoid factor (RF) C. Anti-nuclear antibodies (ANA) D. Anti-citrullinated protein autoantibodies (ACPA) ____4.A 33-year-old female reports general malaise, fatigue, stiffness, and pain in multiple joints of the body. There is no history of systemic disease and no history of trauma. On physical examination, the patient has no swelling or decreased range of motion in any of the joints. She indicates specific points on the neck and shoulders that are particularly affected. She complains of tenderness upon palpation of the neck, both shoulders, hips, and medial regions of the knees. The clinician should include the following disorder in the list of potential diagnoses: A. Osteoarthritis B. Rheumatoid arthritis C. Fibromyalgia D. Polymyalgia rheumatica ____5.A 46-year-old female complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. On physical examination, you note swelling of the metacarpophalangeal joints bilaterally. These are common signs of: A. Osteoarthritis B. Rheumatoid arthritis C. Scleroderma D. Sarcoidosis ____6.Your patient is a 55-year-old male who presents with sudden, severely tender, swollen, erythematous elbow. The patient reports that he experienced similar symptoms in the past. You note the right elbow has a swollen, tender, soft 3 cm round nodule. The clinician should recognize these are signs and symptoms of: A. Gouty arthritis B. Rheumatoid arthritis C. Epicondylitis D. Reiter’s syndrome ____7.Sarcoidosis is an autoimmune disease that presents with non-specific symptoms of fatigue, fever, and arthralgias. Which of the following signs should raise suspicion of this disorder? A. Facial rash across nose and cheeks B. Bilateral hilar lymphadenopathy on chest x-ray C. Specific tender points on the body D. Swelling of metacarpophalangeal joints ____8.Which of the following infectious diseases is often the cause of a reactive arthritis? A. Gonococcus infection B. Beta-hemolytic streptococcus infection C. Chlamydia infection D. Norovirus infection ____9.A 34-year-old female presents with fever, general malaise, fatigue, arthralgias and rash for the last 2 weeks. On physical examination, you note facial erythema across the nose and cheeks. Serum diagnostic tests reveal positive antinuclear antibodies, anti-DNA antibodies, elevated C-reactive protein and erythrocyte sedimentation rate. The clinician should include the following disorder in the list of potential problems: A. Fibromyalgia B. Sarcoidosis C. Systemic lupus erythematosus D. Rheumatoid arthritis ____10.Which of the following microorganisms causes Lyme disease? A. Clostridia B. Shigella C. Borrelia D. Epstein-Barr virus ____11.A 60-year-old female patient complains of pain in the hands that is worse in the morning. On physical examination, the thumb metacarpophalangeal joint is swollen on both hands. There is swelling of the proximal and distal interphalangeal joints bilaterally. These are typical signs of: A. Osteoarthritis B. Rheumatoid arthritis C. Normal aging D. Gouty arthritis ____12.A 56-year-old male presents with complaints of right-sided neck pain with radiation down the right arm into the right index finger and thumb. He reports a recent fall from a scaffold while painting on the job. On physical examination, you note a 0/4 biceps reflex on the right compared to 2/4 on the left and 1/5 grip strength of the right hand compared to 5/5 of the left hand. Which of the following is a test that can be performed to assist in the diagnosis of cervical disk herniation? A. Spurling’s sign B. Apley’s sign C. Lhermitte’s sign D. A and C ____13.Your 66-year-old male patient has recently started treatment for metabolic syndrome and is currently taking the following medications: an ACE inhibitor and beta blocker for treatment of hypertension. He is also taking a statin medication, simvastatin for hyperlipidemia, and a biguanide, metformin, for type 2 diabetes. The patient complains of myalgias of the legs bilaterally and blood work shows elevated serum creatine kinase. Which of the medications can cause such a side effect? A. Beta blocker B. ACE inhibitor C. Statin medication D. Metformin ____14.A 75-year-old female patient complains of fatigue as well as pain and stiffness of the shoulders and neck. There is no history of trauma or exercised-induced pain. Medications include a beta blocker and ACE inhibitor. Medical history includes giant cell arteritis and Raynaud’s syndrome. Physical examination is unremarkable. There is no swelling or erythema over the temporal arteries. There is no swelling, erythema, limitation in range of motion or point tenderness over the shoulder joints. The neck has normal range of motion and no tenderness or swelling. Which of the following disorders should be included in the list of possible diagnoses? A. Rheumatoid arthritis B. Polymyalgia rheumatic C. Drug-induced myalgia D. Fibromyalgia ____15.A 20-year-old male construction worker is experiencing new onset of knee pain. He complains of right knee pain when kneeling, squatting, or walking up and down stairs. On physical examination, there is swelling and crepitus of the right knee and obvious pain with resisted range of motion of the knee. He is unable to squat due to pain. Which of the following disorders should be considered in the differential diagnosis? A. Joint infection B. Chondromalacia patella C. Prepatellar bursitis D. All of the above ____16.A 17-year-old male complains of severe right knee pain. He was playing football when he heard a “pop” at the moment of being tackled and his knee “gave away” from under him. On physical examination, there is right knee swelling and decreased range of motion. There is a positive anterior drawer sign. These findings indicate: A. Knee ligament injury B. Osgood-Schlatter disease C. Prepatellar bursitis D. Chondromalacia patella ____17.A 55-year-old patient complains of lower back pain due to heavy lifting at work yesterday. He reports weakness of the left leg and paresthesias in the left foot. On physical examination, the patient has diminished ability to dorsiflex the left ankle. Which of the following symptoms should prompt the clinician to make immediate referral to a neurosurgeon? A. Straight leg raising sign B. Lumbar herniated disc on x-ray C. Loss of left sided patellar reflex D. Urinary incontinence ____18.Your patient is 40-year-old baseball player who needs his yearly physical exam. He reports a 5-year history of chronic lower back pain due to spinal stenosis. Which of the following findings indicate spinal stenosis? A. Lumbar x-ray demonstrates vertebral osteophytes B. Positive straight leg raising sign upon physical exam C. Lumbar MRI shows decreased intervertebral space D. A and C ____19.Which of the following disorders has a strong genetic component and causes loss of spinal mobility and progressive erosion of the sacroiliac joint? A. Syringomyelia B. Spinal stenosis C. Ankylosing spondylitis D. None of the above ____20.Whenever a patient presents with acute non-traumatic shoulder pain, the clinician should make sure to exclude a: A. Cardiac origin of symptoms B. Gastrointestinal condition C. Cervical spine disorder D. All of the above ____21.A 34-year-old baseball pitcher complains of pain in the left shoulder, particularly with raising the left arm when attempting to pitch. Which of the following is a test used to diagnose rotator cuff injury? A. Apley’s test B. Trousseau test C. Hawkin’s test D. A and C ____22.Which of the following is a sign of glenohumeral instability? A. Positive Lachman test B. Negative Spurling’s sign C. Positive apprehension test D. Negative Lhermitte sign ____23.Your patient is a 43-year-old female golfer who complains of arm pain. On physical examination, there is point tenderness on the elbow and pain when the patient is asked to flex the wrist against the clinician’s resistance. These are typical signs of: A. Carpal tunnel syndrome B. Osteoarthritis of the wrist C. Epicondylitis D. Cervical osteoarthritis ____24.A 3-year-old male toddler complains of sudden arm pain. The mother indicated that pain occurred suddenly while his 9-year-old sister was helping him get dressed. The child presents with the arm flexed while protecting his elbow. On physical examination, there is tenderness along the radius with no swelling or evidence of trauma. This is a typical history of: A. Nursemaid’s elbow B. Epicondylitis C. Smith fracture D. Nursery pseudo-fracture ____25.A 46-year-old administrative assistant complains of pain in the wrist that radiates into the palm and into the fingers. The clinician can test the patient for carpal tunnel syndrome by eliciting which of the following signs? A. Tinel’s sign B. Apley’s sign C. Finkelstein sign D. Lhermitte’s sign ____26.Which of the following describes the pathology of De Quervain’s tenosynovitis? A. Irritation of a tendon located on the radial side of the wrist, near the thumb. B. Impingement of the median nerve, causing pain in the palm and fingers C. Fluid-filled cyst that typically develops adjacent to a tendon sheath in the wrist D. Ulnar nerve compression at the olecranon process ____27.What is the most common cause of hip pain in older adults? A. Osteoporosis B. Osteoarthritis C. Trauma due to fall D. Trochanteric bursitis ____28.A 33-year-old male marathon runner presents with knee pain. Which of the following tests is positive if the meniscus of the knee is torn? A. McMurray’s test B. Straight leg raising sign C. Anterior drawer sign D. Lachman test ____29.A 23-year-old female presents with ankle pain due to a fall while walking on ice 1 hour ago. You watch her limp as she walks into the emergency room. On physical examination, the ankle is erythematous, swollen, and tender to touch. The patient cannot stand on the affected ankle. Range of motion is severely limited on inversion of the ankle. On palpation, there is no pain with pressure on the medial or lateral malleolus. Should this patient be sent for ankle x-rays according to the Ottawa ankle rules? A. No, the ankle shows no tenderness over the medial or lateral malleolus B. Yes, the patient is unable to bear weight on the ankle C. Yes, ankle range of motion is limited D. No, range of motion of the ankle is not limited in all planes ____30.A 43-year-old female was in a bicycling accident and complains of severe pain of the right foot. The patient limps into the emergency room. On physical examination, there is no point tenderness over the medial or lateral ankle malleolus. There is no foot tenderness except at the base of the fifth metatarsal bone. According to the Ottawa foot rules, should an x-ray of the feet be ordered? A. Yes, there is tenderness over the fifth metatarsal B. No, there is not tenderness over the navicular bone C. Yes, the patient cannot bear weight on the foot D. A and C ____31.A 36-year-old female patient complains of foot pain when she wears high heels. There is no history of trauma or arthritis. On physical examination, there is tenderness at the space between the third and fourth metatarsal bones. Foot x-ray shows no evidence of stress fracture. This history is typical of: A. Plantar fasciitis B. Morton’s neuroma C. Achilles tendonitis D. None of the above Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 6 The Skin, Hair, and Nails 1. A 35-year-old archaeologist comes to your office (located in Phoenix, Arizona) for a regular skin check-up. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has manyfreckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this patient? A) Age B) Hair color C) Actinic lentigines D) Heavy sun exposure Chapter:06 Feedback: The risk for melanoma is increased in people over the age of 50; our patient is 35 years old. The other answers represent known risk factors for melanoma. Especially with a family history of melanoma, she should be instructed to keep her skin covered when in the sun and use strong sunscreen on exposed areas. 2. 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 Chapter:06 Feedback:This is the correct description for the mnemonic. 3. You are beginning the examination of the skin on a 25-year-old teacher. You have previously elicited that she came to the office for evaluation of fatigue, weight gain, and hair loss. You strongly suspect that she has hypothyroidism. What is the expected moisture and texture of the skin of a patient with hypothyroidism? A) Moist and smooth B) Moist and rough C) Dry and smooth D) Dry and rough Chapter:06 Feedback:A patient with hypothyroidism is expected to have skin that is dry as well as rough. This is a good example of how the skin can give clues to systemic diseases. 4. 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 Chapter:06 Feedback:This is a classic description of pityriasis rosea. The description of a large single or “herald” patch preceding the eruption is a good way to distinguish this rash from other conditions. 5. A 19-year-old construction worker presents for evaluation of a rash. He notes that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He does sweat more than before because being outdoors is part of his job. On physical examination, you note dark tan patches with a reddish cast that has sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is your most likely diagnosis? A) Pityriasis rosea B) Tinea versicolor C) Psoriasis D) Atopic eczema Chapter:06 Feedback:This is a typical description of tinea versicolor. The information that the patient is sweating more also helps support this diagnosis, because tinea is a fungal infection and is promoted by moisture. 6. 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 description, what is your most likely diagnosis? A) Actinic keratosis B) Seborrheic keratosis C) Basal cell carcinoma D) Squamous cell carcinoma Chapter:06 Feedback:This is a typical description of actinic keratosis. Actinic keratosis may be easier to feel than to see. If left untreated, approximately 1% of cases can develop into squamous cell carcinoma. 7. 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 Chapter:06 Feedback:This is a typical description for seborrheic keratosis. The “stuck on” appearance and the rough, wartlike texture are key features for the diagnosis. They often produce a greasy scale when scratched with a fingernail, which further helps to distinguish them from other lesions. Frequently, these benign lesions actually meet several of the ABCDEs of melanoma, so it is important to distinguish these lesions to prevent unnecessary biopsy.It is important to consider biopsy whenever there is any doubt, though. 8. 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 Chapter:06 Feedback:A stage 3 ulcer is a full-thickness skin loss with damage to or necrosis of subcutaneous tissue that may extend to, but not through, the underlying muscle. 9. An 8-year-old girl comes with her mother for evaluation of hair loss. She denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her hair in braids. On physical examination, you note a clearly demarcated, round patch of hair loss without visible scaling or inflammation. There are no hair shafts visible. Based on this description, what is your most likely diagnosis? A) Alopecia areata B) Trichotillomania C) Tinea capitis D) Traction alopecia Chapter:06 Feedback:This is a typical description for alopecia areata. There are no risk factors for trichotillomania or for traction alopecia. The physical examination is not consistent with tinea capitis because the skin is intact. 10. A mother brings her 11 month old to you because her mother-in-law and others have told her that her baby is jaundiced.She is eating and growing well and performing the developmental milestones she should for her age.On examination you indeed notice a yellow tone to her skin from head to toe.Her sclerae are white.To which area should your next questions be related? A) Food the child’s eating B) Family history of liver diseases C) Family history of blood diseases D) Ethnicity of the child Chapter:06 Feedback:The lack of jaundice in the sclerae is an important clue.Typically, this is the first place where one sees jaundice.This examination should also be carried out in natural light (sunlight) as opposed to fluorescent lighting, which can alter perceived colors.Many infants this age have a large proportion of carrots, tomatoes, and yellow squash, which are rich in carotene.Liver and blood diseases can cause jaundice, but this should involve the sclerae. The ethnicity of the child should not cause a perceived change from her usual skin tone. 11. A new mother is concerned that her child occasionally “turns blue.” On further questioning, she mentions that this is at her hands and feet.She does not remember the child's lips turning blue. She is otherwise eating and growing well.What would you do now? A) Reassure her that this is normal B) Obtain an echocardiogram to check for structural heart disease and consult cardiology C) Admit the child to the hospital for further observation D) Question the validity of her story Chapter:06 Feedback:This is an example of peripheral cyanosis.This is a very common and benign condition which typically occurs when the child is slightly cold and his peripheral circulation is adjusting to keep his core warm.Without other problems, there is no need for further workup. If the lips or other central locations are involved, you must consider other etiologies. 12. You are examining an unconscious patient from another region and notice Beau's lines, a transverse groove across all of her nails, about 1 cm from the proximal nail fold. What would you do next? A) Conclude this is caused by a cultural practice. B) Conclude this finding is most likely secondary to trauma. C) Look for information from family and records regarding any problems which occurred 3 months ago. D) Ask about dietary intake. Chapter:06 Feedback:These lines can provide valuable information about previous significant illnesses, some of which are forgotten or are not able to be reported by the patient.Because the fingernails grow at about 0.1 mm per day, you would ask about an illness 100 days ago.This patient may have been hospitalized for endocarditis or may have had another significant illness which should be sought.Trauma to all 10 nails in the same location is unlikely.Dietary intake at this time would not be related to this finding.Do not assume a finding is necessarily related to a patient's culture unless you have good knowledge of that culture. 13. Dakota is a 14-year-old boy who just noticed a rash at his ankles.There is no history of exposure to ill people or other agents in the environment.He has a slight fever in the office. The rash consists of small, bright red marks.When they are pressed, the red color remains. What should you do? A) Prescribe a steroid cream to decrease inflammation. B) Consider admitting the patient to the hospital. C) Reassure the parents and the patient that this should resolve within a week. D) Tell him not to scratch them, and follow up in 3 days. Chapter:06 Feedback:Although this may not be an impressive rash, the fact that they do not “blanch” with pressure is very concerning.This generally means that there is pinpoint bleeding under the skin, and while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia.You should always report this feature of a rash immediately to a supervisor or teacher. 14. 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. Chapter:06 Feedback:A “palpable purpura” is usually associated with a vasculitis.This is an inflammatory condition of the blood vessels often associated with systemic rheumatic disease. It can cut off circulation to any portion of the body and can mimic many other diseases in this manner.While allergic and chemical exposures may be a possible cause of the rash, this patient's SLE should make you consider vasculitis. 15. 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 Chapter:06 Feedback:This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland.The fact that any lesion is enlarging is worrisome, but the other descriptors are so distinctive that cancer is highly unlikely.This would be an unusual location for a lymph node, and these do not usually drain to the skin. 16. A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several years.It seems to be worse in the winter and improves with some sun exposure.On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small “pits” in his nails.What would account for these findings? A) Eczema B) Pityriasis rosea C) Psoriasis D) Tinea infection Chapter:06 Feedback:This is a classic presentation of plaque psoriasis.Eczema is usually over the flexor surfaces and does not scale, whereas psoriasis affects the extensor surfaces.Pityriasis usually is limited to the trunk and proximal extremities.Tinea has a much finer scale associated with it, almost like powder, and is found in dark and moist areas. 17. Mrs. Anderson presents with an itchy rash which is raised and appears and disappearsin various locations.Each lesion lasts for many minutes.What most likely accounts for this rash? A) Insect bites B) Urticaria, or hives C) Psoriasis D) Purpura Chapter:06 Feedback:This is a typical case of urticaria.The most unusual aspect of this condition is that the lesions “move” from place to place.This would be distinctly unusual for the other causes listed. 18. 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 lesions 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. Chapter:06 Feedback:These are consistent with ecchymoses, or bruises.It is important to ask about antiplatelet medications such as aspirin, trauma history, and history of blood disorders in the patient and her family.Because of the different ages of the bruises and the isolation of them to the ulnar forearms, these may be a result of abuse or other violence.It is your duty to investigate the cause of these lesions. 19. 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. C) Obtain an extensive history regarding blood problems and bleeding disorders. D) Do a skin biopsy in the office. Chapter:06 Feedback:These represent cherry angiomas, which are very common, benign lesions.Further workup such as laboratory work, skin biopsy, or even further questions are not necessary at this time.It would be wise to ask the patient to report any changes in any of his skin lesions, and tell him that you would need to see him at that time. Bates’ Guide to Physical Examination and History Taking, 12th Edition Chapter 16 The Musculoskeletal System Multiple Choice 1. You are assessing a patient with joint pain and are trying to decide whether it is inflammatory or noninflammatory in nature. Which one of the following symptoms is consistent with an inflammatory process? A) Tenderness B) Cool temperature C) Ecchymosis D) Nodules Chapter:16 Feedback:Tenderness implies an inflammatory process along with increased temperature and tenderness. 2. You are assessing a patient with diffuse joint pains and want to make sure that only the joints are the problem, and that the pain is not related to other diseases. Which of the following is a systemic cause of joint pain? A) Gout B) Osteoarthritis C) Lupus D) Spondylosis Chapter:16 Feedback:Lupus is a systemic disease, one symptom of which may be joint pain.It is important to consider the presence of a systemic illness when a patient presents with arthritis. 3. A 19-year-old college sophomore comes to the clinic for evaluation of joint pains. The student has been back from spring break for 2 weeks; during her holiday, she went camping. She notes that she had a red spot, shaped like a target, but then it started spreading, and then the joint pains started. She used insect repellant but was in an area known to have ticks. She has never been sick and takes no medications routinely; she has never been sexually active. What is the most likely cause of her joint pain? A) Trauma B) Gonococcal arthritis C) Psoriatic arthritis D) Lyme disease Chapter:16 Feedback:Lyme disease is characterized by a target-shaped red spot at the site of the bite, which disappears, then reappears and starts spreading (erythema migrans). Lyme disease can also result in joint pain as well as cardiac and neurologic manifestations. 4. An 85-year-old retired housewife comes with her daughter to establish care. Her daughter is concerned because her mother has started to fall more. As part of her physical examination, you ask her to walk across the examination room. Which of the following is not part of the stance phase of gait? A) Foot arched B) Heel strike C) Mid-stance D) Push-off Chapter:16 Feedback:The foot when it is flat is part of the stance phase of gait, not the foot when it is arched. 5. A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a set of boxes that were heavier than usual. He also states that he has numbness and tingling in the left leg. He wants to know if he needs to be off of work. What test should you perform to assess for a herniated disc? A) Leg-length test B) Straight-leg raise C) Tinel's test D) Phalen's test Chapter:16 Feedback:The straight-leg raise involves having the patient lie supine with the examiner raising the leg. If the patient experiences a sharp pain radiating from the back down the leg in an L5 or S1 distribution, that suggests the presence of a herniated disc. 6. A 33-year-old construction worker comes for evaluation and treatment of acute onset of low back pain. He notes that the pain is an aching located in the lumbosacral area. It has been present intermittently for several years; there is no known trauma or injury. He points to the left lower back. The pain does not radiate and there is no numbness or tingling in the legs or incontinence. He was moving furniture for a friend over the weekend. On physical examination, you note muscle spasm, with normal deep tendon reflexes and muscle strength. What is the most likely cause of this patient's low back pain? A) Herniated disc B) Compression fracture C) Mechanical low back pain D) Ankylosing spondylitis Chapter:16 Feedback:The case is an example of mechanical low back pain; in a large percentage of cases there is no known underlying cause. The pain is often precipitated by moving, lifting, or twisting motions and relieved by rest. 7. A 50-year-old realtor comes to your office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she didn't think that she needed to go to the emergency room at that time. Now, she has severe pain and stiffness in her neck. On physical examination, you note pain and spasm over the paraspinous muscles on the left side of the neck, and pain when you make the patient do active range of motion of the cervical spine. What is the most likely cause of this neck pain? A) Simple stiff neck B) Aching neck C) Cervical sprain D) Cervical herniated disc Chapter:16 Feedback: The patient most likely has an acute whiplash injury secondary to the collision. The features of the physical examination, local tenderness and pain on movement, are consistent with cervical sprain. 8. A 28-year-old graduate student comes to your clinic for evaluation of pain “all over.” With further questioning, she is able to relate that the pain is worse in the neck, shoulders, hands, low back, and knees. She denies swelling in her joints; she states that the pain is worse in the morning; there is no limitation in her range of motion. On physical examination, she has several points on the muscles of the neck, shoulders, and back that are tender to palpation; muscle strength and range of motion are normal. Which of the following is likely the cause of her pain? A) Rheumatoid arthritis B) Osteoarthritis C) Fibromyalgia D) Polymyalgia rheumatica Chapter:16 Feedback:The patient has pain in specific trigger point areas on the muscles, with normal strength and range of motion. This is an indication for fibromyalgia. 9. A 68-year-old retired banker comes to your clinic for evaluation of left shoulder pain. He swims for 30 minutes daily, early in the morning. He notes a sharp, catching pain and a sensation of something grating when he tries overhead movements of his arm. On physical examination, you note tenderness just below the tip of the acromion in the area of the tendon insertions. The drop arm test is negative, and there is no limitation with shoulder shrug. The patient is not holding his arm close to his side, and there is no tenderness to palpation in the bicipital groove when the arm is at the patient's side, flexed to 90 degrees, and then supinated against resistance. Based on this description, what is the most likely cause of his shoulder pain? A) Rotator cuff tendinitis B) Rotator cuff tear C) Calcific tendinitis D) Bicipital tendinitis Chapter:16 = Feedback:Rotator cuff tendinitis is typically precipitated by repetitive motions, such as occurs with throwing or swimming. Crepitus/grating is noted in the shoulder with range of motion. 10. A high school soccer player “blew out his knee” when the opposing goalie's head and shoulder struck his flexed knee while the goalie was diving for the ball.All of the following structures were involved in some way in his injury, but which of the following is actually an extra-articular structure? A) Synovium B) Joint capsule C) Juxta-articular bone D) Tendons Chapter:16 Feedback:Extra-articular structures include the periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin.The articular structures include the joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone. 11. Ray works a physical job and notes pain when he attempts to lift his arm over his head. When you move the shoulder passively, he has full range of motion without pain and there is no gross swelling or tenderness.What type of joint disease does this most likely represent? A) Articular B) Extra-articular C) Neither D) Both Chapter:16 Feedback:This description fits extra-articular disease.Articular disease typically involves swelling and tenderness of the entire joint and limits both active and passive range of motion. This is most likely extra-articular because it affects a certain portion of the range of motion, is not painful with passive range of motion, and is not associated with gross swelling or tenderness 12. Mark is a contractor who recently injured his back. He was told he had a “bulging disc” to account for the burning pain down his right leg and slight foot drop.The vertebral bodies of the spine involve which type of joint? A) Synovial B) Cartilaginous C) Fibrous D) Synostosis E) Feedback:The vertebral bodies of the spine are connected by cartilaginous joints involving the discs.The elbow would be an example of a synovial joint, and the sutures of the skull are an example of a fibrous joint. 13. Which of the following synovial joints would be an example of a condylar joint? A) Hip B) Interphalangeal joints of the hand C) Temporomandibular joint D) Intervertebral joint Chapter:16 Feedback:The TMJ is an example of a condylar joint because it involves the movement of two surfaces which are not dissociable.The hip would be an example of a spheroidal joint and the interphalangeal joints of the hand are hinge joints.The intervertebral joints are not synovial joints at all, but rather cartilaginous joints. 14. A 58-year-old man comes to your office complaining of bilateral back pain that now awakens him at night.This has been steadily increasing for the past 2 months.Which one of the following is the most reassuring in this patient with back pain? A) Age over 50 B) Pain at night C) Pain lasting more than 1 month or not responding to therapy D) Pain that is bilateral Chapter:16 Feedback:While bilateral pain can be associated with serious illness, it is not one of the “red flags” of back pain.Red flags should make one suspicious for serious underlying systemic disease such as cancer, infection, or others.This list includes: age over 50, history of cancer, unexplained weight loss, pain lasting more than 1 month or not responding to treatment, pain at night or increased by rest, history of intravenous drug use, or presence of infection.The presence of one of these with low back pain indicates a 10% probability of a serious systemic disease. 15. Marion presents to your office with back pain associated with constipation and urinary retention.Which of the following is most likely? A) Sciatica B) Epidural abscess C) Cauda equina D) Idiopathic low back pain Chapter:16 Feedback:The presence of bowel and bladder symptoms associated with back pain is worrisome and should suggest impingement of nerve roots S2–S4.For this reason idiopathic low back pain is unlikely.Epidural abscess may present with midline pain which can be increased with percussion over the spinous processes.Sciatica is associated with pain which radiates into the buttocks and/or down the posterior leg in the S1 distribution. 16. Louise, a 60-year-old, complains of left knee pain associated with tenderness throughout, redness, and warmth over the joint. Which of the following is least helpful in determining if a joint problem is inflammatory? A) Tenderness B) Pain C) Warmth D) Redness Chapter:16 Feedback:Pain is present in both inflammatory and noninflammatory conditions.Warmth, redness, and tenderness to palpation should lead one to consider an inflammatory etiology for the pain. 17. Pain, swelling, loss of both active and passive motion, locking, and deformity would be consistent with which of the following? A) Articular joint pain B) Bursitis C) Muscular injury D) Nerve damage Chapter:16 Feedback:These features are consistent with articular joint pain, whereas the other problems are associated with extra-articular structures. 18. You are working in a college health clinic and seeing a young woman with a red, painful, swollen DIP joint on the left index finger.There are also a few papules, pustules, and vesicles on reddened bases, located on the distal extremities.This would be consistent with which of the following? A) Lyme disease B) Systemic lupus erythematosus C) Hives (urticaria) D) Gonococcal arthritis Chapter:16 Feedback:The presentation of a monoarthritis in this age group should lead one to think of gonococcal disease.Skin findings are often seen in conjunction with arthritis.Lyme disease is associated with an expanding erythematous patch.Lupus is associated with a “butterfly” rash on the cheeks, while serum sickness and drug reactions can be associated with hives. 19. An obese 55-year-old woman went through menarche at age 16 and menopause 2 years ago.She is concerned because an aunt had severe osteoporosis.Which of the following is a risk factor for osteoporosis? A) Obesity B) Late menopause C) Having an aunt with osteoporosis D) Delayed menarche Chapter:16 Feedback:Obesity and late menopause are not associated with osteoporosis.Having a first-degree relative with osteoporosis is a risk factor, but an aunt is a second-degree relative. Delayed menarche is the only choice which is a known risk factor for osteoporosis. 20. A 38-year-old woman comes to you and has multiple small joints involved with pain, swelling, and stiffness.Which of the following is the most likely explanation? A) Rheumatoid arthritis B) Septic arthritis C) Gout D) Trauma Chapter:16 Feedback:Rheumatoid arthritis is a systemic disease and accounts for multiple symmetrically involved joints.Septic arthritis is usually monoarticular, as are gout and trauma-related joint pain. 21. Mrs. Fletcher comes to your office with unilateral pain during chewing, which is chronic. She does not have facial tenderness or tenderness of the scalp.Which of the following is the most likely cause of her pain? A) Trigeminal neuralgia B) Temporomandibular joint syndrome C) Temporal arteritis D) Tumor of the mandible Chapter:16 Feedback:Temporomandibular joint syndrome is a very common cause of pain with chewing. Ischemic pain with chewing, or jaw claudication, can occur with temporal arteritis, but the lack of tenderness of the scalp overlying the artery makes this less likely.Trigeminal neuralgia can be associated with extreme tenderness over the branches of the trigeminal nerve.While a tumor of the mandible is possible, is it much less likely than the other choices. 22. A man's wife is upset because when she hugs him with her hands on his left shoulder blade, “it feels creepy.”This came on gradually after a recent severe left-sided rotator cuff tear. How long does it usually take to develop muscular atrophy with increased prominence of the scapular spine following a rotator cuff tear? A) 1 week B) 2–3 weeks C) 1 month D) 2–3 months Chapter:16 Feedback:Prominence of the scapular spine occurs with generalized muscle wasting as well as with specific injuries such as a rotator cuff tear. It is easily palpable, even through indoor clothing, although the back should be exposed to make other important observations.Atrophy usually occurs several weeks following a rotator cuff tear. 23. Phil comes to your office with left “shoulder pain.”You find that the pain is markedly worse when his left arm is drawn across his chest (adduction).Which of the following would you suspect? A) Rotator cuff tear B) Subacromial bursitis C) Acromioclavicular joint involvement D) Adhesive capsulitis Chapter:16 Feedback:Adduction of the patient's arm across his chest can cause pain if the acromioclavicular joint is involved.In adhesive capsulitis, this maneuver may not be possible due to limited range of motion.Subacromial bursitis would present with tenderness inferior to the acromion.Rotator cuff injury would ordinarily not be associated with pain during this maneuver. 24. Two weeks ago, Mary started a job which requires carrying 40-pound buckets. She presents with elbow pain worse on the right.On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor.What condition does she have? A) Medial epicondylitis (golfer's elbow) B) Olecranon bursitis C) Lateral epicondylitis (tennis elbow) D) Supracondylar fracture Chapter:16 Feedback:Mary's injury probably occurred by lifting heavy buckets with her palms down (toward the bucket).This caused her chronic overuse injury at the lateral epicondyle.Medial epicondylitis has reproducible pain when palmar flexion against resistance is performed and also features tenderness over the involved epicondyle.Olecranon bursitis produces erythema and swelling over the olecranon process.A supracondylar fracture of the humerus is a major injury and would present more acutely. 25. A high school football player injured his wrist in a game.He is tender between the two tendons at the base of the thumb.Which of the following should be considered? A) DeQuervain's tenosynovitis B) Scaphoid fracture C) Wrist sprain D) Rheumatoid arthritis Chapter:16 Feedback:The “anatomic snuffbox” is found between the extensor and abductor tendons at the base of the thumb.Tenderness should make one think of a scaphoid fracture.Not only is this the most common carpal bone injury, but the poor blood supply puts the bone at risk for avascular necrosis when injured.This fracture is commonly missed on x-ray, so this is an important physical finding to support further or repeated studies. 26. Mrs. Fletcher complains of numbness of her right hand.On examination, sensation of the volar aspect of the web of the thumb and index finger and the pulp of the middle finger are normal.The pulp of the index finger has decreased sensation.Which of the following is affected? A) Median nerve B) Ulnar nerve C) Radial nerve Chapter:16 Feedback:The pulp of the index finger is innervated by the median nerve.A decrease in sensation at this area would support a diagnosis of carpal tunnel syndrome.The pulp of the fifth finger is supplied by the ulnar nerve, and the dorsal web space of the thumb and index finger is supplied by the radial nerve. 27. A 50-year-old woman presents with “left hip pain” of several weeks duration.There is marked tenderness when you press over her proximal lateral thigh.What do you think she has? A) Osteoarthritis B) Rheumatoid arthritis C) Sciatica D) Trochanteric bursitis Chapter:16 Feedback:Bursitis is usually accompanied by tenderness on examination.This location is consistent with trochanteric bursitis.Osteoarthritis would generally not be tender and would more likely have decreased range of motion.Rheumatoid arthritis and sciatica would not likely be tender over this area. 28. Sarah presents with left lateral knee pain and has some locking in full extension. There is tenderness over the medial joint line. When the knee is extended with the foot externally rotated and some valgus stress is applied, a click is noted. What is the most likely diagnosis? A) Torn anterior cruciate ligament B) Torn posterior cruciate ligament C) Torn medial meniscus D) Torn lateral meniscus Chapter:16 Feedback:This maneuver is called the McMurray test.Along with the medial joint line tenderness, you should suspect a medial meniscus injury.Cruciate ligament tears should cause an anterior or posterior “drawer sign.”Although we can't rule out a lateral meniscus tear, the tenderness along the medial joint line makes this the more likely site of injury. [Show More]

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