Spring 2011 Quiz 1 1.

You are seeing a 28 year old male overweight patient in your clinic and obtain the following blood pressure readings on two consecutive visits: 125/85 and 135/80. You tell him that he has: A. Normal blood pressure: Initiate exercise and follow up on weight on next visit. B. Pre-hypertension: limit salt in the diet and initiate exercise C. Stage I hypertension. Limit salt, initiate exercise, and start 1 medication D. Stage II hypertension. Limit salt, initiate exercise, and start 2 medications Answer Key: B

2. Which answer is true about temperature measurement: A. The oral temperature is the best approximation of core temperature. B. Cerumen impaction can result in overestimation of temperature when ear temperature gauge is used. C. An elderly patient with sepsis may present with sub-normal temperatures. D. Rectal temperatures tend to overestimate core temperature determination. Answer Key: C 3. You see a 63 year-old patient who complains of weight loss, fatigue, and headaches. During the history and physical, you may choose to focus on all of the following except: A. check for a prominent temporal artery B. check for scalp tenderness C. ask about calf pain when walking D. ask about pain in the jaw when chewing Answer Key: C 4. You see a 58 yo hypertensive man with a headache in your primary care clerkship with a pressure of 210/115. You are concerned he may have hypertensive emergency and therefore, check his fundus for signs of increased intercranial pressure. Which of the following is true: A. Photophobia, or the lack of papillary constriction to light, can be an indication of increased intercranial pressure B. A blurred lateral optic disc margin can indicate increased intercranial pressure. C. A/V nicking can be an indication of elevated intercranial pressures

D. Cotton wool spots are often associated with acutely elevated intercranial pressure Answer Key: B 5. You are performing a cervical lymph node exam on a 23 year old patient who has developed weight loss, fevers, and fatigue. Which features on the lymph node exam are suggestive of malignancy? A. Fixed nodes B. Tender nodes C. Size of nodes has been stable for a year D. Soft and rubbery in consistency

Answer Key: A

Quiz week 2:

1. A 19 year old college student presents to the emergency room for sudden onset of dyspnea. The general survey reveals that she is 6‟1” tall and weighs 135 pounds. She denies fever, chills, cough, or sore throat. She is a non-smoker. You suspect that she has pneumothorax. What findings would you expect with percussion of the thorax? (A) * (B) (C) (D) Decreased resonance on the affected side Increased resonance on the affected side Increased resonance on the nonaffected side Dullness bilaterally

2. A 75 year old retired publisher presents to the Emergency Department for shortness of breath. He has a history of class III congestive heart failure, hypertension, and hyperlipidemia. His symptoms began after he ran out of his diuretic a week ago. On examination of his cardiovascular system, what would you expect to find? (A) (B) (C) * (D) PMI in the fifth interspace, midclavicular line, 8 cm lateral to the midsternal line PMI in the fifth interspace, left parasternal location PMI in the third interspace, midclavicular line PMI in the seventh interspace, lateral to the midclavicular line

3. A 42 year-old female store clerk presents to your office with shortness of breath. She has had a fever and a cough productive of green sputum for 3 days. On exam, you hear

crackles in left lower posterior lung field. You also percuss her chest wall and check tactile fremitus. You suspect a pneunomia and send her for a chest radiograph. Your impression is supported by the radiograph, which shows an infiltrate in the left lower lobe. On exam, tactile fremitus in the left lower posterior thorax (compared to the right) was most likely: (A) * (B) (C) (D) Decreased Increased Unchanged from normal Displaced

4. In the case above, percussion of the left lower thorax (compared to the right side) was most likely: * (A) (B) (C) (D) Dull Resonant High pitched Hyper-resonant

5. You are evaluating a 44 year old man with a history of viral myocarditis. You are concerned that he may have a persistent dilated cardiomyopathy. What position should you place the patient in order to best hear an s3 gallop? (A) (B) * (C) (D) Sitting up and leaning forward Standing next to the bed Left lateral decubitus position Lying supine with the head elevated 30 degrees

Quiz week 3 1. A 43 year old man presents with this chronic pruritic rash. This rash is most consistent with: (A) (B) * (C) (D) Atopic dermatitis Seborrheic dermatitis Psoriasis Squamous cell carcinoma

2. What is the preferred order for examination of the abdomen? * (A) (B) (C) (D) Inspection, auscultation, percussion, palpation Percussion, auscultation, palpation, inspection Auscultation, inspection, palpation, percussion Inspection, palpation, auscultation, percussion

3. You are in the Emergency Department assessing a patient with abdominal pain and fever. You are performing an abdominal examination to assess for peritoneal signs. Which one of the following is not a peritoneal sign? (A) (B) * (C) (D) Rebound tenderness Involuntary guarding Voluntary guarding Rigidity of the abdomen

4. A 22 year old woman presents to the clinic for evaluation of flank pain, nausea and fever over the past 36 hours. She has also been having urinary frequency and discomfort. Urine pregnancy test is negative. Which finding would increase your suspicion for pyelonephritis? (A) * (B) (C) (D) Psoas sign CVA tenderness Rovsing‟s sign Murphy‟s sign

5. A 6 month old boy is found to have the following is 4 x 2 cm flat, hyperpigmented lesion on his left upper flank. You would describe the finding as a: (A) (B) * (C) (D) Macule Plaque Patch Papule

Quiz week 4 1. You are admitting a 76 year old woman who fell at home. On exam you find that she is able to raise her left leg off the bed and is able to push her leg against the force of the examiner‟s hand. On examination of the right leg you note that she is able to move the leg in the plane of the bed, but is not able to raise her leg off the bed. How do you describe the degree of muscular strength in the right leg? (A) * (B) (C) (D) I/V II/V III/V V/V

2. A 21 year old man comes into your office with a complaint of new onset facial asymmetry. Which of the following is consistent with a right-sided upper motor-neuron facial nerve lesion?

(A) * (B) (C) (D)

Deepening of right-sided naso-labial fold Sparing of right frontalis muscle Weakness of right frontalis muscle Weakness of left frontalis muscle

3. Which finding would you expect with a lower motor neuron lesion? (A) Hyperreflexia *(B) Fasciculations (C) Spasticity (D) Increased tone

4. A 64 year old man with hypothyroidism complains of pain and parasthesias in his right hand. You perform a Phalen test which reproduces the pain and parasthesias. The likely diagnosis is: (A) (B) (C) * (D) Medial epicondylitis Lateral epicondylitis Ulnar nerve pathology Median nerve pathology

5. Which finding supports a diagnosis of rotator cuff tendinopathy? (A) * (B) (C) (D) Pain radiating down arm Painful arc test Positive Tinel test Reduced deep tendon responses in affected upper extremity

Quiz week 5

1. While testing the cranial nerves of a patient that has had a carotid artery dissection you find that on tongue protrusion, the tongue deviates to the patient‟s left side. This suggests: (A) * (B) (C) (D) Right glossopharyngeal nerve injury Left glossopharyngeal nerve injury Right hypoglossal nerve injury Left hypoglossal nerve injury

2. A 54 year old man is found to have a large 12 cm x 4 cm confluent region of scalp with a raised scaly dermatosis with a erythematous base. How would you characterize the rash:

(A) (B) * (C) (D)

Macule Plaque Patch Papule

3. A 32 year old female patient with uncontrolled diabetes has right sided ear pain and purulent ear discharge. What finding would be consistent with otitis externa? (A) (B) * (C) (D) Bulging tympanic membrane Immobile tympanic membrane on pneumatic insufflation Tug test Weber test lateralizes to unaffected ear

4. You see a 68 year-old man in the Urgi-care clinic who has a long-standing history of hypertension who presents with a 1 day history of constant chest pain. He feels as if something is „tearing‟ in his mid-chest and mid-upper back, with a 7/10 pain intensity. He

cannot identify alleviating or aggravating factors. Which finding would make you most concerned for an aortic dissection and result in transfer to the Emergency Department? (A) * (B) (C) (D) New aortic stenosis murmur Pulse amplitude differential between the left and right upper extremities Fixed split S2 New S3 gallop

5. Each of the following is a test of cerebellar function except: (A) * (B) (C) (D) Finger-Nose-Finger Joint position sense Fingertap Heel-to-Shin

Quiz 6 This week‟s quiz is based on the contents of last week‟s lectures. Review the lecture videos posted on sakai under Recordings for guidance if you didn‟t make it to the lecture. We want you to practice looking things up. This is a key habit in clinical work and is part of your training in this course. You can use sources such as uptodate.com or Harrisons online for instance (both available through Columbia computers/library). 1. You examine a 72 year old man with diabetes who comes in with a bilateral inguinal rash. On inspection you determine that the patient has tinea cruris and prescribe him an anti-fungal cream. On inspection of his genitalia, you find that he has a small opening at the distal midline ventral aspect of his penis. On subsequent history, you learn that the patient has had this all of his life and that he leaks urine from this os when urinating. What is your most likely diagnosis? a. Horseshoe kidney * b. Distal hypospadias c. Polycystic kidney disease d. Urethral stricture

2. A 54 year-old man comes to your clinic complaining of swelling of the scrotum. You consider several possible etiologies of the condition. Which of the following is true: a. Ability to transilluminate a scrotal fluid collection may help diagnose epiditymitis b. A direct hernia will result in testicular swelling

c. Testicular torsion may result in acute swelling, pain, and redness, and is typical found in this age range. * d. A varicocele is more likely found on the left side and can be described on the physical exam as a “bag of worms”.

3. A 72 year old woman comes to your clinic complaining of vaginal burning and pruritis (pruritis=itching). Which findings on exam may lead you to suspect vaginal atrophy (atrophic vaginitis)? a. Erythematous and lichenified vaginal epithelium. * b. Pale dry vaginal epithelium that is smooth and shiny. c. Copius vaginal discharge on examination. d. Increased rugation of vaginal epithelium.

4. What finding on pelvic examination is consistent with a trichomonas vaginalis infection? * a. Purulent malodorous thin discharge b. Cervical erythema with a notable lack of discharge c. May be associated with uterine prolapse d. Copious serous and sanguinous cervical secretions

5. Which of the following statements regarding the Write-Up is not true? a. The first sentence of the HPI should list only diagnoses that are pertinent or too big to ignore, in the order of importance for this particular admission. b. The assessment should contain the differential diagnosis and should explore your clinical reasoning for why you think certain diagnoses are less likely and why others are more likely. * c. The HPI should be presented as a list of events, either as bullet points or enumerated. d. Any part of the history (PMH, PSxH, Meds, All, SH, FH, ROS) that is pertinent to the current presentation should be presented in the HPI.

Quiz 7

1. You see a 62 year-old man in your clinic that ran out of medications 10 days prior to this visit. On exam, he has a blood pressure of 210/105 bilaterally. Which of the following history and physical exam characteristics will require an ED referral? a. Shortness of breath with new bi-basilar rales b. Complaint of headache and a finding of lethargy on physical exam c. Complaint of new onset chest pain d. Blurred lateral optic disc margin * e. All of the above 2. You see a 76 year-old woman with chronic joint pain that affects numerous joints, including her hands. This hand inspection is consistent with: * (A) (B) (C) (D) Osteoarthritis Rhematoid arthritis Systemic lupus erythematosis Scleroderma

3. Which of the following are valid reasons for using patient-centered, open-ended questions with minimal interruptions during the first 10% of the interview? a. It helps the interviewer understand how the patient frames the current problem (helps to access the patient‟s illness narrative). b. It alerts the interviewer to more immediate concerns that need to be addressed (pain, discomfort, or other distressing emotions). c. It helps the patient feel heard and supported during a stressful time. Thus the interviewer attends to his/her role as healer. * d. All of the above

4. A 22 year-old woman presents to the clinic for evaluation of flank pain, nausea and fever over the past 36 hours. She has also been having urinary frequency and discomfort. Urine pregnancy test is negative. Which finding would increase your suspicion for pyelonephritis? (A) * (B) (C) (D) Psoas sign CVA (costovertebral angle) tenderness Rovsing‟s sign Murphy‟s sign

5. You are in the Emergency Department assessing a patient with abdominal pain and fever. You are performing an abdominal examination to assess for peritoneal signs. Which one of the following is not a peritoneal sign? (A) (B) *(C) (D) Quiz 8 1. The following is true regarding the History of Present Illness: A. The narrative should unfold chronologically B. It should contain all elements of history (meds, allergies, PMH, PSxH, SH, FH, ROS) that you deem pertinent to the current admission. C. It should contain a thorough exploration of the dimensions of the illness (ex: OLDCARTS), followed by a pertinent negative review of systems (ROS). D. ** All of the above. 2. A 64 year old man with hypothyroidism complains of pain and parasthesias in his right hand. You perform a Tinel‟s test and are able to reproduce the pain and parasthesias which radiate to the tips of the palmar aspect of the thumb and the second and third digit. The likely diagnosis is: a. Medial epicondylitis b. Lateral epicondylitis c. ** Median nerve pathology d. Ulnar nerve pathology 3. A 68 year-old male patient with regular medical follow-up and who has no significant past medical history comes in preoperative evaluation before eye surgery. His vitals signs are all normal. On cardiac auscultation you hear a lowpitched sound that comes right before S1 in the apex. It does not change with respiration. What does this most likely represent? a. Left ventricular hypertrophy from long-standing undiagnosed hypertension Rebound tenderness Involuntary guarding Voluntary guarding Rigidity of the abdomen

b. ** S4 can sometimes be heard in older patients as the ventricle stiffens c. physiologic split S2 d. dilated cardiomyopathy -- the patient will require echocardiography 4. Mrs. B is a 44 year old obese woman with HTN, type 2 DM and dyslipidemia who presents to clinic as a walk-in reporting right upper quadrant pain that radiates to her right shoulder, nausea/vomiting and fever. You recall that you should check for a positive Murphy‟s sign on physical exam, which of the following describes that? a. CVA tenderness b. Dilated superficial abdominal veins (caput medusa) c. **Increased RUQ tenderness and inspiratory arrest with deep breath during palpation of R subcostal region d. Rebound tenderness on deep palpation of the abdomen 5. You are called to the ER to examine a patient with the following findings. How would you document these 0.4 cm lesions in your medical write-up?

a. b. c. d. Quiz 9

Papules Pustules **Vesicles Bulla

1. All of the following are tests of cerebellar function except: (A) * (B) (C) (D) Finger-Nose-Finger Romberg Fingertap Heel-to-Shin

2. A 14 year old female is seen in the ER complaining of a sore throat and difficulty swallowing. On exam, you detect an erythematous pharynx with tonsillar exudates. Which lymph nodes would you expect to be involved?

* (A) (B) (C) (D)

Anterior Cervical lymph node Occipital lymph node Inguinal lymph nodes Cubital lymph nodes

3. Which finding would you expect with a lower motor neuron lesion? (A) Hyperreflexia * (B) Fasciculations (C) Spasticity (D) Increased tone

4. A 73 year old man presents with the following skin lesion on his face.

This finding is most consistent with: (A) (B) (C) Atopic dermatitis Seborrheic dermatitis Psoriasis

* (D) Squamous cell carcinoma

5. For proper blood pressure measurement: (A) The doctor should not support the arm, since not doing so will artificially lower blood pressure readings (B) The doctor should listen in the lateral part of the antecubital fossa for Korotkoff sounds (C) Cuff bladder length should be equal to the circumference of the arm *(D) Cuff bladder width should be approximately 40% of the arm circumference

Quiz 10 1. A 53 year old man takes up racketball. Three weeks later, he begins having discomfort that you diagnose as “tennis elbow”. Where did you elicit tenderness on exam to make this diagnosis? a. insertion of the long head of the biceps tendon b. medial epicondyle * c. lateral epicondyle d. over the olecranon

2. You examine a 32 year old patient with a family history of hypercoagulability and with progressive shortness of breath. What finding on the cardiac exam might cause concern for chronic pulmonary emboli? a. Pericardial friction rub b. S3 gallop * c. Prominent P2 d. Bradycardia

3. You examine an 48 year old obese woman who is has been hospitalized for 2 weeks s/p MI, CABG, and post-up tachyarrythmias. Over the past two days, she has been developing increased shortness of breath. What maneuvers can you do to assess whether the patient is retaining extravascular fluid? a. check for non-pitting edema over the tibia

b. transilluminate abdomen for ascites c. check for strength of dorsalis pedis and posterior tibial pulses * d. check for pitting edema over sacrum

4. You perform an exam on a 56 year old man with urinary hesitancy. Which finding would be most concerning for prostate cancer? a. Penile discharge b. Exquisitely tender prostate on digital rectal exam c. Firm, diffuse, nontender enlargement on digital rectal exam * d. Focal induration of the prostate on digital rectal exam

5. A 23 year old man is seen in his primary care clinic for 2 months of fatigue. Which findings on examination may suggest infectious mononucleosis? * a. posterior cervical lymphadenopathy b. proptosis c. signs of portal hypertension d. petechiae

Fall 2011 Quiz 1 1. A 35 year old woman presents to the ER with altered mental status. Although she is breathing spontaneously, she can only be awakened with painful stimuli. The chart may describe her level of consciousness as: (A) *(B) (C) (D) Not oriented to time, place, or situation Obtunded Flat affect Tangential

The correct answer is B. Level of consciousness is an important dimension of the neurological assessment. Answer A refers to orientation, which is not a description of level of consciousness. C refers to affect, which again is not a parameter of level of

consciousness. D, „tangential‟ refers to thought process, which does not reflect level of consciousness. B, “obtunded” is the correct answer. We wanted to expose you to the word because you is a term that you might see used from time to time to describe a level of consciousness that is reduced. However, note that it suggests lowered level of consciousness, but it is not very specific. To be more specific, we encourage you to be descriptive in your assessment. Examples may be “opens eyes to only to painful stimuli and briefly able to follow simple commands before closing eyes again” or “Pt is lethargic: pt opens eyes and awakens to voice and is able to remain awake and follow simple commands for few minutes but falls easily back to reduced consciousness and eyes closes in absence of verbal stimuli.”

2. You would see this retinal field when examining: (A) *(B) (C) The Right eye The Left eye Either eye, depending on whether you assume a medial or lateral approach to the exam. (D) Either eye depending on whether the patient is looking straight ahead or at the ophthalmoscope.

Answer is B. When performing the fundoscopic exam, it is important for the examiner to be aware of normal landmarks so that he/she is aware of what to look for where. The optic disc and the radiating veins and arteries are located medially (nasally). The fovea (the darker circle seen on the right side of this image) is visualized when the examiner asks the patient to look directly into the light. Since the optic disc/cup are located on the left side of this retinal image, this represents the left eye grounds. B and C are incorrect because the angle of fundoscopic approach or direction of patient gaze will not affect the overall relative positions of anatomic structures on exam.

3. A 64 year old man with hypothyroidism complains of long-standing pain and parasthesias in his right hand. You suspect carpal tunnel syndrome. Which finding is consistent with classic severe carpal tunnel syndrome? (A) (B) (C) *(D) Pain and parasthesias radiating to entire palm and dorsum of hand Pain affecting the first three digits of dorsum of the hand, while sparing the palm Sensory and motor symptoms affecting the ulnar nerve distribution of the hand Atrophy of the thenar eminence

Answer is D. A is wrong because the symptoms of CTS are classicallyl localized to the distribution of the median nerve. Though atypical presentations can involve the entire hand, the classic case will be limited to the median nerve distribution. B is wrong because the palmar surface is typically affected. C is wrong because CTS is a median nerve problem. With severe and long-standing carpal tunnel syndrome (median nerve compression), you may see atrophy of muscles that are innervated by the median nerve. Thenar muscle atrophy can be seen in cases of severe and longstanding CTS. These same patients may experience weakness in handgrip and may have an inability to perform even simple activities requiring the use of the hand (opening jar).

4. You are on the surgical service taking care of a patient post-op from a left sided carotid endarterectomy (CEA). On exam, you note a new slurred speech. You are concerned about a possible stroke versus another common problem after such a procedure: injury to the hypoglossal nerve. What finding would you see if the patient did indeed have a hypoglossal nerve injury? A. Lessening of the nasolabial fold on the left side of the face B. Loss of sensation on the left side of the face * C. On tongue protrusion, tongue deviation to the left. D. On mouth opening, weakness in elevation of the soft palate on left side The correct answer is C. Decrease in prominence of the nasolabial fold suggests injury to the facial nerve. Loss of facial sensation suggests trigeminal nerve (CN V) injury. Dysfunction of elevation of the soft palate suggests injury to the vagus nerve (CN X, and often coupled with injury to glossopharyngeal nerve CN IX). Answer is C. Injury to the hypoglossal nerve results in tongue deviation to the side of injury. It may be identified after a CEA. Injury to this nerve may result from inadvertent retraction or, rarely, transection. 5. You are assessing a 75 year-old man with progressive cognitive impairment and gait disturbance. Which of the following features is not consistent with a diagnosis of Parkinson‟s Disease? A. Bradykinesia which can affect both the upper and lower extremities. B. Rigidity on exam that can be characterized as “cogwheel” in nature C. Postural instability that usually presents late in the disease.

* D. A “pill rolling” tremor that gets worse when engaged in a purposeful activity. The correct answer is D. Bradykinesia is indeed one of the major causes of disability in patients with Parkinson‟s Disease. It manifests as overall slowness and can impair basic activities of daily living such as buttoning clothes or eating. It can also result in gait disturbance that results in a shuffling gait. Cogwheel rigidity is a characteristic feature of Parkinson‟s Disease. It manifests as a ratcheting, alternating resistance and relaxation when testing for tone. Postural instability does affect the patient with Parkinson‟s Disease late in the disease. A physical examination that might pick up on this a bit earlier is an abnormal pull test. See the SLATE video with Dr. Ford for a demonstration of this test. http://ccnmtl.columbia.edu/projects/slate/weeks/neurological_exam.html The normal patient is able to regain balance after a step or two with the pull test, whereas the PD patient may need to take numerous steps backward or may fall backwards and need the examiner to provide support. The pill rolling tremor is a resting tremor that is worst when not engaged in purposeful activity.

Quiz 2 1. You see a 74 year old Russian patient in clinic. The patient‟s daughter is concerned that he isn‟t moving his extremities well. You take a history and perform an exam with the following findings:

His left upper extremity is held in a fixed flexed position and he cannot extend his fingers fully. When you try to extend the arm, you note hypertonia of the muscles. The reflexes are increased to +3 (compared to +2 on the right). The left lower extremity, held in plantar flexion of the foot, is also hypertonic with hyperreflexia. Although he ambulates, you note that he circumducts his foot. What is your diagnosis?

1. Left-sided lower motor neuron disorder, such as peroneal paralysis 2. Extrapyramidal disorder, such as Parkinsons 3. Chronic left-sided brainstem lesion 4. Chronic right-sided upper motor neuron lesion, such as stroke

Answer: 4 This patient has findings consistent with a stroke affecting the right cerebral cortex. The contractures indicate that the stroke was not recent, but rather chronic. Injury to the lower motor neuron, for example infection with the poliovirus, results in a flaccid paralysis.

Parkinsons manifests with rigidity, usually cogwheel in nature and typically does not affect the body asymmetrically. A brainstem lesion may present with weakness and spasticity. However, you would expect to encounter cranial nerve deficits such as diplopia and dysarthria.

2. A 70-year old retired professor is brought to your office for a follow-up visit, 6 weeks after a left-sided CVA. The content of his speech is coherent, yet the speech delivery is slurred. How would you describe this condition?

1. Dysarthria 2. Dysphonia 3. Dysphasia 4. Aphasia

Answer: 1

Depending on the locus of the central lesion, speech may be affected in a number of ways. Here the patient is able to think and find the words, however he has difficulty coordinating the muscles that produce the speech. The lesion may be upper motor neuron, in the pyramidal tract or in the extrapyramidal tract. This condition is called dysarthria.

Dysphonia is a neurological disorder affecting speech caused by involuntary spasms of the musculature. Hoarseness is a common form of dysphonia.

Dysphasia and aphasia are used interchangeably and describe full or partial loss of verbal skills resulting from insults to the language center of the brain. In motor dysphasia, also called expressive dysphasia, the patient understands verbal communication but cannot respond with proper grammar, syntax or words. In sensory dysphasia, also called receptive dysphasia, the patient has no problem with producing fluent speech, however they cannot understand the meaning and context. Furthermore, they are not aware of their mistakes.

3. You are seeing a 40 year-old woman who complains of back pain and reduced strength in her left foot for two days. The pain started after she tripped on the curb while walking. Although she didn‟t fall, she noted immediate pain as she tried to balance. Of note, she had a similar pain in the lower back after a motor vehicle accident two years prior. At that time, she underwent physical therapy and it resolved.

The examination of her back shows midline lumbar tenderness. You observe her walk and note that she appears to lift her left foot higher than the right when in stride and when planting her left foot down impacts the front of the foot first instead of the heel. She also has difficulty walking on her left heel.

You diagnose radiculopathy; at what level is nerve root compression?

1. L2 2. L3 3. L4 4. L5 5. S1

Answer 4

Lower back pain is very common. During the physical exam, it is important to observe carefully for any deficits in the muscles innervated by nerves of the lower back. Compression of the nerve root may affect the patient‟s ability to perform specific movements. In this case, the patient has an L5 lesion which causes a foot drop and difficulty with toe extention and difficulty with heel walk. The iliopsoas muscle is a hip flexor and may be impaired if L2 is compressed. L3 innervates the quadriceps that extend the knee and L4 the tibialis anterior that dorsiflexes the foot. Finally, S1 innervates the gastrocnemius muscles that plantar flex the foot.

4. You see a 71 year old man with 8 months of progressive weakness in his hands, more pronounced on the left. Over the past month he has dropped three coffee cups. You ask a detailed ROS and discover that he is also coughing more when he swallows liquid beverages. He hasn‟t noticed problems with gait. Your visual inspection of the hand is pictured below. On close observation, you see fasciculations. He does not have the strength to hold digits I and V in opposition.

Which of the following is highest on your differential diagnosis?

1. polio 2. amyotrophic lateral sclerosis 3. botulism 4. multiple sclerosis

Answer: 2

In ALS, both the upper and lower motor neuron may be affected. Depending on the site of the motor neuron degeneration, the symptoms or signs manifest in the arms or legs and

may impact speech and swallow functions. In this image, there is evidence of muscular atrophy. Both atrophy and the finding of fasciculations are reflective of lower motor neuron pathology.The onset is subtle with insidious progression. The polio virus most commonly affects the spinal cord and results in an asymmetric flaccid paralysis of the legs. The infection is accompanied by atrophy of the muscles but it is not insidious as in this case. Botulism is a disorder caused by anaerobic bacteria Clostridium botulinum that produces a neurotoxin resulting in paralysis. It is most commonly found in improperly stored/canned food. Multiple sclerosis is an autoimmune disorder characterized by skip lesions of the myelin sheath that results in intermittent slowing or stopping of nerve impulses. Atrophy is not a hallmark.

5. You are seeing a new patient, a 5-year old boy, who just moved to the area. His mom says he is falling frequently and most recently has started to crawl up stairs that he used to walk one at a time. Although he always seemed a little weaker than other kids his age, it was never this bad. On examination, you note bilateral atrophy of the proximal leg muscles especially compared with the calves. When you ask the boy to stand, he uses his arms to “walk up” his thighs.

what testing might you consider in this presentation?

1. Lumbar puncture (possible meningitis)

2. MRI of the spinal cord 3. genetic testing (possible muscular dystrophy, ie Duchenne) 4. Head CT (possible neonatal anoxia)

Answer: 3

This is a presentation of Muscular Dystrophy (Duchenne), an X-linked hereditary condition. The larger-appearing calves are described as pseudohypertrophy because they represent degeneration of muscle cells, not enlargement. The proximal loss of muscle bulk is a hallmark of Duchenne dystrophy. Meningitis is a condition of acute onset accompanied by fever and neck stiffness. Antenatal and intrapartum conditions have been associated with cerebral palsy, a condition that can manifest in multiple ways: scissors gait, athetotic movements, mental impairment, unilateral or bilateral involvement; upper and/or lower extremities depending on which areas of the brain were affected by the pathologic cause (infectious, anoxia).

Quiz 3

PARTIAL SIMPLE SEIZURE

You are called to see a patient in the ER who has been noted to have “shaking”. What would you expect in a partial simple seizure?

A B C D

the patient maintains consciousness and notes shaking movements in the entire body the patient loses consciousness and notes shaking movements in one part of the body the patient maintains consciousness and experiences shaking movements in one part of the body the patient loses consciousness but no shaking movements are noted

Answer: C Both the effect on consciousness and the presence and distribution of abnormal movements (entire body or only a part) are important parameters in classifying seizures. A simple seizure does not affect consciousness while a complex seizure impairs consciousness. Partial seizures produce shaking only in part of the body; generalized seizures affect the entire body. Thus, a partial simple seizure will produce shaking only in a limited part of the body and will not impair consciousness.

Absence seizures

Working in the Pediatric ER, you are seeing a 5-year-old girl who was brought in by her mother. Her mom reports that she has had 'staring spells', occurring throughout the day. In fact, during the interview you witness one of the 'spells' and describe it as lasting a few seconds and associated with eyelid fluttering. You note no other change in the child's behavior during these spells and this is consistent with the mother‟s experience. The finding that is most helpful in diagnosing absence seizures is

A B C D

the presence of an aura abnormal MRI of the head normal findings on EEG an average seizure duration < 2 minutes

Answer: D The onset of absence seizures in children is between the ages of 3 to 8 years of age and is more common in girls. Affected children are normal between seizures. The long-term prognosis is good. There are two types of absence seizures: typical and atypical. Typical absence seizures last 5 minutes and cause a brief decrease in consciousness. Accordingly, an average seizure duration of less than 2 minutes is a helpful diagnostic finding. The only associated motor signs are a slight decrease in tone or mild eye fluttering, as is reported for this particular patient. Many seizures may occur during the day. Atypical absence seizures may be characterized by autonomic phenomena or simple motor autonomatisms that resemble the findings associated with complex partial seizures. Interictal electroencephalography (EEG) in absence epilepsy shows a brief burst of irregular

spike and wave activity in 30% of cases. Hyperventilation is a very strong precipitant of seizures and often produce clinical episodes in the office setting. Complex partial seizures usually are of much longer duration than absence seizures and often are accompanies by oral automatisms such as swallowing, chewing, and lipsmacking as well as writhing of the hands. There may be sensory auras prior to the spell, the most common of which is epigastric heaviness associated with fear. Gliosis of the mesial temporal lobe or small developmental tumors or cysts may be documented on magnetic resonance imaging or the findings may be normal. Localization on EEG is not always possible. Complex partial seizures typically do not recur many times daily.

Delirium vs dementia

You are called to evaluate a 55 year old lawyer who presents with altered mental status. On your way to the ER you recall that dementia and delirium are in the differential or this presentation. All of the following statements are true about delirium EXCEPT:

A B C

Delirium has an acute onset In delirium there is always a disturbed level of consciousness Orientation is fairly well maintained but becomes impaired in the later stages of illness

D May be caused by an underlying illness such as a pneumonia or heart failure with hypoxia

Answer: C The triad of the major Cognitive Disorders includes: delirium, dementia and amnesia. Delirium is characterized by sudden onset of confusion and changes in brain function caused by a physical or mental illness that include electrolyte or metabolic (for example, glucose) disturbances; hypoxia; drug or alcohol ingestion; infectious process. The treatment of delirium is to attend to the underlying cause.

Dementia is caused by damage to the structure of the brain. Common types of dementia include: vascular dementia (also known as Multi-infarct dementia or MID), Alzheimer‟s dementia or AD, dementia with Lewy bodies or DLB and Fronto-temporal dementia. This leads to progressive diminution of cognitive function.

Amnesia is a disturbance of memory; anterograde amnesia is the loss of short-term memory and retrograde amnesia is the loss of ability to remember life events and identity preceding the onset of the amnesia.

ICP

An 18-year old college freshman presents to the emergency room for evaluation of fever, headache, and neck stiffness. On physical examination, the patient is resting quietly and has a flushed face. His vital signs are: temperature: 104 F; pulse: 110 bpm; BP: 105/70 mmHG. There are no rashes. During the physical examination, you flex the patient‟s neck. His hips and knees flex in the response to your maneuver. This is an abnormal_____:

A B C D

Kernig‟s sign, indicative of cranial nerve injury Brudzinski‟s sign, indicative of meningeal inflammation Babinski‟s sign, indicative of upper motor neuron injury Lachman‟s sign, indicative of early tetanus toxin exposure

Answer: B

Irritation of the meninges through infection, inflammation or compression (for example in subarachnoid bleed) may result in positive physical exam signs, including Brudzinski‟s sign described here. This involuntary flexion of the lower extremities is a response to pain. Kernig‟s sign if another sign of meningeal irritation in which the patient‟s lower extremities are flexed at the knees and the hips; when the examiner attempts to straighten the leg at the knee, there is severe pain. Lachman‟s test is performed to evaluate the stability of the anterior cruciate ligament. Click on this link for a quick update: http://www.youtube.com/watch?v=_5WyoDY31Fc Babinski‟s sign is positive if there is an upgoing hallux in response to stimulation of the lateral side of the foot sole with a blunt instrument. This primitive reflex may be found in neonates and children until age two; with maturation of the corticalspinal tract thereafter, the hallux response is usually downgoing.

Cheyne-stokes respiration You are examining a terminally ill hospitalized patient with irregular breathing, characterized by deep and rapid breaths followed by slow shallow breaths. You also note episodes of apnea. This breathing pattern may be best described as:

A B C D

Obstructive Sleep Apnea Narcolepsy Somnambulism Cheyne-stokes respirations

Answer: D Cheyne-stokes respirations are a pattern of irregular breathing often seen in the last days of life. Breathing can be very deep and rapid, followed by periods of slow shallow breaths, or episodes of apnea, where an individual stops breathing altogether for a period of time. Obstructive sleep apnea (OSA) is characterized by repetitive pauses in breathing during sleep, despite the effort to breathe, and is usually associated with a reduction in blood O2 saturation. The pauses usually last 20-40 seconds. Obese and morbidly obese patients are at increased risk for OSA that can results in poor sleep, excessive daytime sleepiness, hypertension, and places the patient at higher risk for pulmonary hypertension. Treatments can vary, depending on the cause of the obstruction. In many patients, continuous positive pressure airflow delivered through a face mask can improve sleep and daytime performance. Narcolepsy is a chronic neurologic disorder of sleep notable for an excessive urge to sleep at inappropriate times. Narcoleptics often experience disturbed nocturnal sleep and an abnormal daytime sleep pattern. You may witness cataplexy, a sudden muscular weakness at times brought on by strong emotions. It often manifests as muscular weaknesses ranging from a barely perceptible slackening of the facial muscles to the dropping of the jaw or head, weakness at the knees, or a total collapse. Sleepwalking, also known as somnambulism, is a sleep disorder characterized by sleepwalking out of the slow wave sleep stage into a state of low consciousness. The individual participates in activities that are usually performed during a state of full consciousness. These may be as benign as sitting up in bed, going to the bathroom, and cleaning, or as hazardous as cooking and driving.

Quiz 4

1. You are seeing a 65 year old man with Hep C cirrhosis. Which of the following findings is not consistent with chronic liver disease? a. palmar erythema b. asterixis c. spider angiomata *d. conjunctival injection There are many physical exam findings that are typically found in patients with end stage liver cirrhosis. This includes palmar erythema, which is a diffuse redness found on the palmar surface of the hands. Asterixis, can be found in patients with hepatic encephalopathy, but can also be seen in uremia. It consists of hand tremor or “flapping” when the patient is asked to extend his/her arms and dorsiflex the hands as if “stopping traffic”. Spider angioma are superficial small vessel dilations that are can be seen in patients with cirrhosis. They can be found on the chest/trunk or extremities. They blanch and are painless. The primary ocular finding in patients with end stage liver disease is jaundice, or scleral icterus, usually not conjunctival injection. 2. A 34 year old woman with hypertension, atrial fibrillation on coumadin and alcoholism presents to the Emergency Department with upper abdominal pain radiating to the back. Which diagnosis is not consistent with this presentation? a. pancreatitis b. duodenal ulcer c. aortic dissection *d. alcoholic hepatitis Pancreatitis can present as abdominal (epigastric) pain which radiates to the back and is often caused by heavy alcohol use. Duodenal ulcers can also present as epigastric pain that radiates to the back. Aortic dissection can also present as abdominal pain radiating to the back. Alcoholic hepatitis presents as RUQ pain and typically does not radiate to the back. 3. A 60 year old woman with chronic atrial fibrillation who is non-adherent with anticoagulation arrives to the urgicare center with acute abdominal pain. Which of the following findings raises your concern for a thrombotic embolism to the gut (acute mesenteric ischemia)? a. The patient describes her pain as “burning” in nature. * b. The patient complains of severe abdominal pain, but not much abdominal tenderness is appreciated on exam. c. The patient has ascites on exam

d. The patient has flank ecchymoses on exam Burning abdominal discomfort is often associated with esophageal reflux, though this finding is not always specific for this disorder. Mesenteric ischemia is not associated with ascites. Flank ecchymoses are classically associated with retroperitoneal hemorrhage and can be seen in severe, hemorrhagic pancreatitis, a sign called Grey Turner‟s sign. A typical presentation for acute mesenteric ischemia is a patient who is in a lot of discomfort, but with a relatively unimpressive exam. The clinician must have a higher index of suspicion for this diagnosis in a patient with sudden abdominal pain and a classic predisposing condition such as atrial fibrillation. 4. You see a 23 year old man with severe abdominal pain. Which finding increases your concern for a ruptured appendix with peritoneal inflammation? *a. When you press on the left lower quadrant, the patient localizes pain to the right lower abdomen. b. The patient presents with fever, jaundice, and right upper quadrant abdominal pain. c. The patient has rebound tenderness: there is more pain when you press down on the abdomen than when you release. d. You see superficial dilation of abdominal veins. Rovsing‟s sign is when pressure on the left lower quadrant results in discomfort in the right lower quadrant, and is associated with appendicitis. Fever, jaundice, and RUQ pain is the classic triad associated with ascending cholangitis. Rebound tenderness is indeed a “peritoneal sign”, but is associated with more tenderness when the examiner releases pressure rather than when she presses down. Dilation of abdominal vessels is associated with portal hypertension, a condition not associated with pancreatitis. 5. Which statement is true regarding bowel sounds? a. Even in the healthy patient without abdominal symptoms it is important to listen to bowel sounds for 10 seconds in each abdominal quadrant b. Bowel sounds are often increased in patients who have had abdominal surgery *c. One may hear increased higher frequency bowel sounds an area of early partial small bowel obstruction d. Always do light palpation before listening to the abdomen to optimize auscultation. For the healthy patient, there is not much gained by listening extensively to bowel sounds. Once you hear and characterize bowel sounds, you can move on. Patients who have had abdominal surgery often develop post-operative ileus, which is characterized by decreased bowel sounds and decreased gut motility. Partial small bowl obstruction indeed may be accompanied by increased high pitched sounds in the area of obstruction. Always listen before you touch (please get this right on the final:).

Quiz 5

1. A patient with untreated and uncontrolled diabetes and hypertention presents to the emergency room with progressive shortness of breath. Each of the following is a classic manifestation of renal failure which may require dialysis except: a. Decreased level of consciousness b. pulmonary edema * c. fever d. asterixis Renal failure can result in mental status changes which may manifest as depressed levels of consciousness, or uremia. This neurologic instability can also manifest as asterixis, or hand flapping, when the hands are dorsiflexed. Inability to eliminate free water in the patient with renal failure may result in pulmonary edema. Fever is not a classic presentation of renal failure. However, bacteremia and sepsis is a common complication amongst patients who are undergoing chronic hemodialysis. 2. You are caring for a severely alcoholic patient with chronic pancreatitis and resultant fat malabsorption. What historical or physical finding may suggest vitamin D deficiency and resultant hypocalcemia? a. hypertention *b. contraction of ipsilateral facial muscles when tapping the facial nerve just anterior to ear. c. constipation d. increased urination Vitamin D is a fat soluable vitamin and deficiency may be found in several patient groups, including those with poor absorption, intake, or limited exposure to ultraviolet light. Vitamin D is involved in calcium hemostasis and low levels of vitamin D can result in hypocalcemia. This is classically manifested on physical exam with Chvostek‟s sign – or neuromuscular irritability as described in the correct answer B. Hypertension is not a typical manifestation of low levels of vitamin D. Constipation, increased urination (osmotic diuresis) can be seen in hypercalcemia (not hypocalcemia) and will not be found in vitamin D deficiency. 3. You are seeing a patient in the emergency room and notice that the abdomen appears protuberant. Each of the following may be causally related to the development of a protuberant abdomen except: a. longstanding and severe intersitial lung disease b. chronic viral hepatitis C infection and resultant cirrhosis c. small bowel obstruction *d. diverticulosis Both answers A and B relate to the development of ascites, which can be associated with a clinical finding of a protuberant abdomen. Longstanding and severe ILD or other causes of chronic hypoxia can result in pulmonary hypertension, which can then produce

increased right-sided cardiac pressures and eventual right sided heart failure. Longstanding right-sided failure can then result in hepatic congestion and central venous hypertension, resulting in ascites. Small bowel obstruction can also be associated with a physical exam finding of a protuberant abdomen. Diverticulosis is not associated with a protuberant abdomen. 4. When taking a substance use history, the interviewer should do all of the following except: a. Ensure confidentiality b. Be sure to quantify the use of the substance – when start? How often? c. Determine how it is affecting the patient‟s functioning *d. Report any illegal substance use to the police The interviewer should indeed ensure confidentiality and attempt to quantify use as well as determine how the use affects the patient‟s life. There is no mandatory reporting law for physicians who discover their patients are using illegal substances. 5. You are seeing a patient in the emergency room with respiratory difficulty. Which physical exam findings support your concern for complications related to heroin use? *a. rales on pulmonary exam b. rapid, shallow breathing c. dilated pupils d. tremor There are numerous complications of heroin overdose. Respiratory drive is suppressed, and thus the patient may present with abnormally slow breathing (not fast) or respiratory failure with respiratory acidosis on ABG. Pupils will be constricted on exam with opiate overdose. Tremor is associated with alcohol or benzodiazepine withdrawal, not opiate toxicity. Rales on exam may indeed be consistent with opiate overdose, either as a consequence of an aspiration pneumonia (classically right middle lobe) or from heroin overdose related pulmonary edema.

Quiz 6 1. The formulation section of the write up should include: a. An interpretation of the pertinent findings b. A description of the pertinent data (history, pe, labs, images), listed in order of importance. c. Should contain the pertinent as well as other data and should be as comprehensive as possible. d. * A description of the pertinent data but should always be listed in the following order: (history, pe, labs, images) The formulation is not an interpretation of findings. Rather, it lists pertinent (and not comprehensive) data as answer D suggests. It is not necessarily listed in order of importance.

2. The following statements are true regarding the assessment portion of the write except: a. It should list the differential diagnosis, and then provide evidence to support certain diagnoses and to argue against other diagnoses. b. It should not contain any new historical, physical exam, or lab/imaging data that has not already been provided in the rest of the write up. *c. The clinician should steer away from making an argument for any particular diagnosis since it is always best to keep an open mind and let the team come to a decision on the best final diagnosis. d. It represents the section of the write-up attendings look to most to get a sense of your clinical reasoning development (the other being the HPI). The assessment should be a place where you explore the ddx and provide evidence for and against diagnosis. It is the culmination of the entire write-up and is the right place to make an argument for what you think is going on. D is true.

3. The following is true regarding the HPI portion of the write-up except: *a. The HPI should contain pertinent information from all other parts of the history and physical exam. b. The HPI cannot be written until you understand the whole case. c. The HPI should contain a negative review of systems, which should be grouped according to diagnoses you are exploring. d. The diagnoses listed in the first sentence should be sequenced in order of importance for this given presentation. C, and D are true. B is true because only when you understand the case can you write the HPI, which is also part of your argument that a particular disease(s) process is likely. A is not true because the HPI should not contain any information regarding your physical exam. It should, however, draw from all other parts of the history (PMH, all, meds, SH, etc..) that you feel are pertinent to this case.

4. The following is true regarding the oral case presentation except: a. It should last about 7-10 minutes for an in-patient medicine admission presentation. *b. It should be comprehensive and should contain all the information that is found in the written H&P.

c. The presentation will be most effective if the presenter considers the mechanics of delivery, including rate of speech, how audible the discussion is, and whether the presenter enunciates clearly. d. Medical student oral case presentations can assist and facilitate the team‟s delivery of medical care when done well. A, C, and D are true. If kept succinct, pertinent, and delivered effectively, the oral case presentation can indeed facilitate good patient care. B is not true because the oral case presentation is not a comprehensive delivery of information. A more comprehensive document of the H&P will be the write-up. The oral case presentation will take the highlights (most pertinent elements) of the write up and present those to the team.

5. The following statements are true regarding the follow-up SOAP note except: *a. “S” in SOAP note refers to “systemic”. The clinician describes the systems affected in an orderly fashion. b. This SOAP structure can be used to organize both the follow-up note as well as the follow-up presentation. c. SOAP note will be considerably shorter than the initial admission H&P note. d. It is important to update the “s” section of the write-up on a daily basis. This is one important way that we track and communicate the patient‟s progress. B, C, and D are all true. A is not true because S stands for Subjective (not systemic). This is the section that details the main complaints and any other major events the patient has had since your last note. For instance for a patient that was admitted with an MI, you would comment on presence or absence of chest pain (which is subjective). If the patient went for cath since your note yesterday, you would mention that as well (major event) and could go ahead and report the main findings in this section (or could wait to put the results in the O section).

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