Bates’ Guide To Physical Examination And History Taking 11th Edition By Lynn Bickley – Test Bank

21. Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?
A) It is a splenic rub.
B) It is a variant of bowel noise.
C) It represents borborygmi.
D) It is a vascular noise.

Ans: A
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A rough, grating noise over this area represents a splenic rub, which can accompany splenic infarction. Rubs also occur over the liver and pleura and pericardium.

22. You are palpating the abdomen and feel a small mass. Which of the following would you do next?
A) Ultrasound
B) Examination with the abdominal muscles tensed
C) Surgery referral
D) Determine size by percussion

Ans: B
Chapter: 11
Page and Header: 451, Recording Your Findings
Feedback: It is easy to determine whether the mass is actually in the abdominal wall versus in the abdomen by palpating with the abdominal wall tensed. This can be accomplished by having the patient lift her head off the bed while supine. Usually, abdominal wall masses can be observed, whereas intra-abdominal masses are more concerning.

23. Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice dullness in the last intercostal space in the anterior axillary line on his left side with a deep breath. What does this indicate?
A) His spleen is definitely enlarged and further workup is warranted.
B) His spleen is possibly enlarged and close attention should be paid to further examination.
C) His spleen is possibly enlarged and further workup is warranted.
D) His spleen is definitely normal.

Ans: B
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: This scenario is not uncommon in infectious mononucleosis. The presence of dullness with inspiration should definitely increase your attention to further examination of the spleen, although dullness can occur in normal patients too.

24. A young patient presents with a left-sided mass in her abdomen. You confirm that it is present in the left upper quadrant. Which of the following would support that this represents an enlarged kidney rather than her spleen?
A) A palpable “notch” along its edge
B) The inability to push your fingers between the mass and the costal margin
C) The presence of normal tympany over this area
D) The ability to push your fingers medial and deep to the mass

Ans: C
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A left upper quadrant mass is more likely to be a kidney if there is no palpable “notch,” you can push your fingers between the mass and the costal margin, there is normal tympany over this area, and you cannot push your fingers medial and deep to the mass. These findings are very difficult to appreciate in an obese patient.

25. Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the symphysis pubis. What does this most likely represent?
A) Sigmoid mass
B) Tumor in the abdominal wall
C) Hernia
D) Enlarged bladder

Ans: D
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: It is possible that this represents a sigmoid colon mass, but this is less likely than an enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently cause partial urinary obstruction with bladder enlargement. If the mass resolves with catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A hernia would most likely not be dull to percussion. Midline abdominal wall tumors of this size would be unusual but could be discerned by having the patient tense his abdominal muscles.

26. Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What should you do next?
A) Obtain abdominal ultrasound
B) Reassess by examination in 6 months
C) Reassess by examination in 3 months
D) Refer to a vascular surgeon

Ans: A
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 centimeters. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature.

27. Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?
A) Bilateral flank tympany
B) Dullness which remains despite change in position
C) Dullness centrally when the patient is supine
D) Tympany which changes location with patient position

Ans: D
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float so that dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany which changes location with patient position (“shifting dullness”) would support the presence of ascites. A fluid wave and edema would support this diagnosis as well.

28. Which of the following is consistent with obturator sign?
A) Pain distant from the site used to check rebound tenderness
B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated
C) Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion
D) Pain that stops inhalation in the right upper quadrant

Ans: B
Chapter: 11
Page and Header: 434, Techniques of Examination
Feedback: Obturator sign is seen in appendicitis. It is pain with the stretching of the internal obturator muscle because of inflammation. Pain distant from the site used to check rebound tenderness is Rovsing’s sign and is a reliable sign of peritonitis. Answer “C” describes psoas sign, which is also seen in appendicitis. Palpation in the right upper quadrant that causes pain severe enough to stop inhalation is consistent with inflammation of the gallbladder and is called Murphy’s sign.

29. An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect?
A) Malingering
B) Neuropathy
C) Ischemia
D) Physical abuse

Ans: C
Chapter: 11
Page and Header: 454, Table 11–1
Feedback: Ischemic pain can be severe but is not made worse with palpation. The history of bypass could be a clue that there is vascular narrowing elsewhere. Malingering is less likely, and neuropathic pain, as seen in herpes zoster, would worsen with touch. You are to be commended if you considered elder abuse, because this is frequently missed. Ordinarily, this pain would be worse with examination because of the preceding trauma.