exam2 Flashcards
(260 cards)
1
Q
Mrs. Alden is a 29-year-old pregnant patient in her third trimester. She tells you that her vision has been a little blurred, and she thinks she needs to get new contact lenses. You should
advise her to
a. get new lenses as soon as possible to avoid complications.
b. wait until several weeks after delivery to get new lenses.
c. go to the nearest emergency department for evaluation.
d. change her diet to include more yellow vegetables.
A
b. wait until several weeks after delivery to get new lenses.
Because of the increased level of lysozyme in the tears during pregnancy, a blurred sensation may occur but will subside several weeks after pregnancy. The blurred vision is a normal occurrence during pregnancy. It is not an emergency, nor is it diet-dependent
2
Q
A condition that typically develops by the age of 45 years is
a. presbyopia.
b. hyperopia.
c. myopia.
d. astigmatism.
A
a. presbyopia.
By 45 years of age, a condition known as presbyopia develops; presbyopia involves a weakening of accommodation. Hyperopia occurs in early infancy. Myopia and astigmatism
can occur at any time
3
Q
Which finding, when seen in the infant, is ominous?
a. Difficulty tracking objects with the eyes
b. Appearing to have better peripheral than central vision
c. Blinking when bright light is directed at the face
d. White pupils on photographs
A
ANS: D
The absence of a red reflex, determined by physical examination or the appearance of white
pupils on a photograph, is indicative of retinoblastoma, a serious retinal tumor.
d. White pupils on photographs
4
Q
Mr. C’s visual acuity is 20/50. This means that he
a. can see 50% of what the average person sees at 20 feet.
b. has perfect vision when tested at 50 feet.
c. can see 20% of the letters on the chart’s 20/50 line.
d. can read letters while standing 20 feet from the chart that the average person could read at 50 feet
A
d. can read letters while standing 20 feet from the chart that the average person could read at 50 feet
5
Q
The criterion for determining the adequacy of a patient’s visual field is
a. the ability to discriminate primary colors.
b. the ability to discriminate details.
c. correspondence with the visual field of the examiner.
d. distance vision equal to that of an average person.
A
c. correspondence with the visual field of the examiner.
The examiner compares his or her own peripheral vision to that of the patient while performing the confrontation test, so unless the examiner is aware of a problem with his or her own vision, the examiner could assume that the fields are full if they match.
6
Q
. Mrs. S. is a 69-year-old woman who presents for a physical examination. On inspection of her eyes, you note that the left upper eyelid droops, covering more of the iris than does the right.
This is recorded as
a. exophthalmos on the right.
b. ptosis on the left.
c. nystagmus on the left.
d. astigmatism on the right.
A
ANS: B
Ptosis is when one of the upper eyelids covers more of the iris than the other lid, possibly extending over the pupil
7
Q
A condition in which the eyelids do not completely meet to cover the globe is called
a. glaucoma.
b. lagophthalmos.
c. exophthalmos.
d. hordeolum.
A
ANS: B
Lagophthalmos is a term used to describe the condition in which eyelids do not completely
meet when closing. Glaucoma involves elevated pressure in the eye. Exophthalmus involves
bulging eyes. A hordeolum is better known as a stye
8
Q
Mr. Morris is a 38-year-old patient who presents to the clinic with complaints of allergies. An allergy can cause the conjunctiva to have a
a. cobblestone pattern.
b. dry surface.
c. subconjunctival hemorrhage.
d. rust-colored pigment.
A
ANS: A
A red or cobblestone pattern, especially to the upper conjunctiva, indicates allergic
conjunctivitis. Allergies also cause itchy, watery eyes rather than dry surfaces, hemorrhage, or rust-colored pigment
9
Q
A pterygium is more common in people heavily exposed to
a. high altitudes.
b. tuberculosis.
c. ultraviolet light.
d. cigarette smoke.
A
ANS: C
Persons heavily exposed to ultraviolet light are more susceptible to the development of a pterygium.
10
Q
Mr. Brown was admitted from the emergency department, and you are completing his physical examination. His pupils are 2 mm bilaterally, and you notice that they fail to dilate when the penlight is moved away. This is characteristic in patients who are or have been
a. in a coma.
b. taking sympathomimetic drugs (cocaine).
c. taking opioid drugs (morphine).
d. treated for head trauma.
A
ANS: C
Pupil constriction to less than 2 mm is called miosis. With miosis, the pupils fail to dilate in the dark, a common result of opioid ingestion or the use of drops for glaucoma. Pupils are usually dilated greater than 6 mm in a patient described in the other choices.
11
Q
When testing corneal sensitivity controlled by cranial nerve V, you should expect the patient to respond with
a. brisk blinking.
b. copious tearing.
c. pupil dilation.
d. reflex smiling
A
ANS: A
Brisk blinking is an expected response to corneal sensitivity testing, which involves gently touching the cornea with a piece of cotton
12
Q
You observe pupillary response as the patient looks at a distant object and then at an object held 10 cm from the bridge of the nose. You are assessing for
a. confrontation reaction.
b. accommodation.
c. pupillary light reflex.
d. nystagmus
A
ANS: B
Testing for accommodation involves asking the patient to look at an object at a distance (pupils dilate) and then to look at another, much closer object (pupils constrict).
13
Q
When inspecting the region of the lacrimal gland, palpate
a. the lower orbital rim, near the inner canthus.
b. in the area between the arch of the eyebrow and upper lid.
c. beneath the lower lid, adjacent to the inner canthus.
d. adjacent to the lateral aspect of the eye, just beneath the upper lid.
A
ANS: A
The lacrimal gland is located at the lower orbital rim near the inner canthus of the eye
14
Q
Examination to assess for extraocular muscle imbalance is conducted by
a. comparing pupillary responses to different shapes.
b. having the patient follow your finger through planes.
c. inspecting slightly closed lids for fasciculations.
d. transilluminating the cornea with tangential light.
A
ANS: B
The test for extraocular muscle function is to have the patient follow an object as you move it through planes of vision while observing for nystagmus.
15
Q
Mr. Older is a 40-year-old patient who presents to the office for a follow-up eye examination after the diagnosis of myopia. To see retinal details in a myopic patient, you will need to
a. adjust your ophthalmoscope into the plus lens.
b. move your ophthalmoscope backward.
c. move your hand farther forward.
d. turn your ophthalmoscope to a minus lens.
A
ANS: D
The myopic patient (nearsighted) has longer eyeballs, so that light rays focus in front of the retina. To see the retina, use the minus (red) numbers by moving the diopter wheel counterclockwise; to assess a hyperopic patient, use a plus lens.
16
Q
Ask the patient to look directly at the light of the ophthalmoscope when you are ready to examine the
a. retina.
b. optic disc.
c. retinal vessels.
d. macula.
A
ANS: D
The macula is the site of central vision and is observed when the patient looks directly at the ophthalmoscope light.
17
Q
Opacities of the red reflex may indicate the presence of
a. hypertension.
b. hydrocephalus.
c. cataracts.
d. myopia.
A
ANS: C
Opacities or dark spots of the red reflex may indicate the presence of congenital cataracts in the newborn.
18
Q
If a patient has early papilledema, using an ophthalmoscope, the examiner will be able to detect
a. dilated retinal veins.
b. retinal vein pulsations.
c. sharply defined optic discs.
d. visual defects.
A
ANS: A
Papilledema is caused by increased intracranial pressure along the optic nerve, pushing the vessels forward (cup protrudes forward) and dilating the retinal veins. Retinal vein pulsations and visual defects are not visible with an ophthalmoscope. On examination, papilledema is characterized by loss of definition of the optic disc.
19
Q
Cupping of the optic disc may be a result of
a. migraine headaches.
b. diabetes.
c. glaucoma.
d. dehydration
A
ANS: C
Cupping is seen with causes of increased intraocular pressure, such as glaucoma. Migraine headaches, diabetes, and dehydration do not cause cupping of the optic disc. Diabetes results in cotton wool patches and hemorrhages.
20
Q
When drusen bodies are noted to be increasing in number or in intensity of color, the patient should be further evaluated with a(n)
a. Amsler grid.
b. Snellen E chart.
c. litmus test.
d. confrontation test
A
ANS: A
Drusen bodies, when they increase in number or intensity of color, may indicate a precursor state of macular degeneration. When this happens, the patient’s central vision should be
assessed using the Amsler grid. The Snellen E chart measures visual acuity, the litmus test is used for testing pH, and a confrontation test examines peripheral vision.
21
Q
Cotton wool spots are most closely associated with
a. glaucoma.
b. normal aging processes.
c. hypertension.
d. eye trauma
A
ANS: C
Cotton wool spots actually represent infarcts of the retina and are associated with hypertension or diabetes.
22
Q
Which may be suggestive of Down syndrome?
a. Drusen bodies
b. Papilledema
c. Narrow palpebral fissures
d. Prominent epicanthal folds
A
ANS: D
Prominent epicanthal folds, or slanting of the eyes, may be normal in Asian infants, but in other ethnic groups it may indicate Down syndrome.
23
Q
To differentiate between infants who have strabismus and those who have pseudostrabismus, use the
a. confrontation test.
b. corneal light reflex.
c. E chart.
d. Amsler grid
A
ANS: B
The corneal light reflex is used with infants to differentiate between strabismus and
pseudostrabismus by noting an asymmetric versus symmetric light reflex.
24
Q
You are attempting to examine the eyes of a newborn. To facilitate eye opening, you would first
a. dim the room lights.
b. elicit pain.
c. place him in the supine position.
d. shine the penlight in his or her eyes.
A
ANS: A
The best way to assess the eyes of a newborn is to start by dimming the lights because it encourages infants to open their eyes.
25
Dot hemorrhages, or microaneurysms, in the retina and the presence of hard and soft exudates are most commonly seen in those with
a. Down syndrome.
b. diabetic retinopathy.
c. systemic lupus.
d. glaucoma.
ANS: B
Dot hemorrhages or tiny aneurysms are characteristics of background retinopathy. A trapping of lipids within incompetent capillaries causes the hemorrhages.
26
Which maneuver can be done to reduce the systemic absorption of cycloplegic and mydriatic agents when examining a pregnant woman if the examination is mandatory?
a. Have the woman keep her eyes closed for several minutes.
b. Instill half the usual dosage.
c. Keep the patient supine, with her head turned and flexed.
d. Use nasolacrimal occlusion after instillation
ANS: D
To reduce absorption systemically, the examiner may use nasolacrimal occlusion after applying, which involves pinching the upper bridge of the nose.
27
Changes seen in proliferative diabetic retinopathy are the result of
a. anoxic stimulation.
b. macular damage.
c. papilledema.
d. minute hemorrhages.
ANS: A
New vessels are a characteristic seen in proliferative retinopathy resulting from anoxic stimulation. An insufficient blood supply from failing capillaries causes new vessel growth
28
Which are the signs and symptoms of infant retinoblastoma? (Select all that apply.)
a. White reflex
b. Red reflex
c. Corneal light reflex
d. Absence of a blink reflex
e. Autosomal dominant trait
f. Drainage from the affected eye
g. Visual acuity of 20/500
ANS: A, E
Retinoblastoma in an infant is marked by a characteristic white reflex, also called cat’s eye reflex or leukocoria. Red reflex and corneal light reflex are expected findings. Absence of the blink reflex is not associated with retinoblastoma
29
Contraction or relaxation of the ciliary body:
a. allows voluntary blinking.
b. changes lens thickness.
c. regulates peripheral vision.
d. sends light impulses to the brain.
e. regulates tear production.
ANS: B
The lens is circularly supported by a framework of fibers from the ciliary body, and contraction or relaxation of this structure results in a change in the thickness of the lens, allowing for accommodation as needed. Voluntary blinking, peripheral vision, tear production, and impulses to the brain are not controlled by the ciliary body.
30
Term infants have a visual acuity of about:
a. 20/20.
b. 20/100.
c. 20/200.
d. 20/300.
e. 20/400
ANS: E
Term infants are hyperopic, with a visual acuity of less than 20/400.
31
At what age does an infant usually develop the ability to distinguish color?
a. At birth
b. 2 months
c. 6 months
d. 12 months
e. 16 months
ANS: C
By 6 months of age, vision has developed so that colors can be differentiated.
32
After focusing on a blood vessel in the retina with your ophthalmoscope, you attempt to locate the optic disc. You should:
a. follow the vessel as it branches out.
b. have the patient move his or her eye laterally.
c. have the patient move his or her eye up.
d. have the patient move his or her eye down.
e. follow the vessel as it converges into larger vessles
ANS: E
When you locate a vessel, follow it in the direction of the optic disc. Vessels nearer the disc are directionally toward the nose, are larger, and have less branching.
33
An allergy can cause the conjunctiva to have a:
a. cobblestone pattern.
b. dry surface.
c. subconjunctival hemorrhage.
d. rust-colored pigment.
e. pale appearance.
ANS: A
A red or cobblestone pattern, especially to the upper conjunctiva, indicates an allergic conjunctivitis. Allergies also cause itchy, watery eyes rather than dry surfaces, hemorrhage, or rust-colored pigment.
34
Bone spicule pigmentation is a hallmark of:
a. chorioretinal pigmentosa.
b. cytomegalovirus infection.
c. lipemia retinalis.
d. retinitis pigmentosa.
e. choroidal nevus.
ANS: D
Retinitis pigmentosa is inherited night blindness, characterized by the hallmark pigmentation of the peripheral fields or bone spicules.
35
Drusen bodies are most commonly a consequence of:
a. glaucoma.
b. aging.
c. presbyopia.
d. papilledema.
e. hypertension.
ANS: B
Drusen bodies, or lesions or spots on the retina, are part of the aging process. Glaucoma, presbyopia, and papilledema do not present with spots on the retina. Retinal hemorrhages and cotton wool spots are associated with hypertensive retinopathy.
36
Entropion implies that the eyelid is:
a. drooping.
b. everted.
c. edematous.
d. turned inward.
e. inflamed.
ANS: D
Entropion of the lower eyelid does not imply drooping, eversion, inflammation, or edema but is a slight inward turn of the lower eyelid.
37
Episcleritis may indicate:
a. lipid abnormalities.
b. an autoimmune disorder.
c. an anaphylactoid reaction.
d. severe anemia.
e. thyroid disease.
ANS: B
Episcleritis is an inflammation of the sclera, involves purplish bumps, and is commonly associated with autoimmune disorder. Lipid abnormalities, anaphylactoid reactions, anemia, and thyroid disease are not associated with these symptoms..
38
Horner syndrome is manifested by:
a. proptosis and contralateral mydriasis.
b. excessive watering of the eyes.
c. blurring of vision when glucose levels fall.
d. ipsilateral miosis and mild ptosis.
e. band keratopathy and miosis.
ANS: D
Horner syndrome is characterized by mild pupil constriction and drooping of the upper eyelid of the same eye. Horner syndrome is a result of a break in the sympathetic nerve supply to that eye. Mydriasis involves enlarged pupils. Watering of the eyes and blurred vision are not affected by a disruption in the sympathetic nervous system. Band keratopathy is a result of chronic corneal disease and is not associated with Horner syndrome.
39
An increased level of lysozyme in the tears will occur normally during which life stage?
a. Adolescence
b. Childhood
c. Infancy
d. Pregnancy
e. Older adults
ANS: D
Because of rising hormonal levels, lysozyme is present in an increased amount in the tears during pregnancy. Tears are not affected by increased lysozyme at any other stage in life.
40
Mydriasis accompanies:
a. coma.
b. diabetes.
c. hyperopia.
d. astigmatism.
e. morphine administration.
ANS: A
Coma patients always have mydriasis, which occurs when the pupils are dilated more than 6 mm. Diabetes may cause a coma but not mydriasis. Hyperopia is a condition of infants, describing their visual acuity as at or worse than 20/400. Astigmatism affects the shape of the lens, not the pupils. Opiates cause miosis
41
Periorbital edema is:
a. an abnormal sign.
b. expected with aging.
c. more common in males.
d. present in children.
e. an abnormality of lipid metabolism.
ANS: A
A clinical finding of periorbital edema should always be regarded as an abnormal finding until ruled otherwise
42
Peripheral vision can be estimated by means of which test?
a. Confrontation
b. Pupillary reaction
c. Accommodation
d. Snellen E chart
e. Swinging flashligh
ANS: A
The confrontation test measures peripheral vision. The examiner sits or stands across from the patient and asks the patient to close one eye while the examiner closes the opposite eye. The examiner then proceeds to wave the fingers while moving the extended arms from a lateral to a central position along both the temporal and the nasal fields. The pupillary reaction test is done by observing the pupil's response to light. The accommodation test deals with pupil reaction to light, and the Snellen E chart measures visual acuity. The swinging flashlight test evaluates the health of the optic nerve by looking for an afferent pupillary defect
43
A pterygium is more common in people heavily exposed to:
a. high altitudes.
b. tuberculosis.
c. ultraviolet light.
d. cigarette smoke.
e. lead.
ANS: C
Persons heavily exposed to ultraviolet light are more susceptible to pterygium developments. High altitudes, tuberculosis, lead, and cigarette smoke do not cause an overgrowth of the conjunctiva.
44
Ptosis may be secondary to:
a. blepharitis.
b. hyperthyroidism.
c. psoriasis.
d. paresis of a branch of cranial nerve III.
e. entropion.
ANS: D
Ptosis is caused by a congenital defect of the muscle around the eye controlled by cranial nerve III. Hyperthyroidism causes exophthalmos, psoriasis is a skin condition, and blepharitis is a crusting of the eyelashes. Entropion is an inversion of the lower eyelid
45
Retinal hemorrhages in an infant require investigation for:
a. retinoblastoma.
b. retrolental fibroplasia.
c. pituitary tumor.
d. child abuse.
e. strabismus.
ANS: D
Beyond newborn age, any hemorrhages to the retina indicate infection, allergy, or trauma and should be further investigated. Retinoblastoma, retrolental fibroplasia, pituitary tumors, and strabismus are not associated with retinal hemorrhages.
46
To see retinal details in a patient with myopia, the examiner will need to:
a. adjust the ophthalmoscope into the plus lenses.
b. move the ophthalmoscope backward.
c. move the hand farther forward.
d. examine the patient in a well-lighted room.
e. turn the ophthalmoscope to a minus lens
ANS: E
A patient with myopia (nearsighted) has longer eyeballs, so light rays focus in front of the retina. To see the retina, the examiner should use the minus (red) numbers by moving the diopter wheel counterclockwise; to assess a patient with hyperopia, a plus lens should be used
47
The unit of measurement in describing lesion size and location on the fundus is the:
a. disc diameter.
b. macular diameter.
c. pupillary diameter.
d. centimeter.
e. diopter.
ANS: A
When examining the eye and the fundus comes into focus, the branching of blood vessels becomes apparent. These always branch away from the optic disc and can be used as landmarks to locate the optic disc. The disc itself measures about 1.5 mm in diameter and the disc diameter is therefore the unit of measurement used to describe lesion size and location on the fundus.
48
What is the common cause of a hordeolum?
a. Error in lipid metabolism
b. Increased intraocular pressure
c. Prolonged exposure to ultraviolet light
d. Infection due to Staphylococcus aureus
ANS: D. Infection due to Staphylococcus aureus
49
When inspecting the region of the lacrimal gland, palpate:
a. the lower orbital rim near the inner canthus.
b. in the area between the arch of the eyebrow and the upper eyelid.
c. beneath the lower eyelid adjacent to the inner canthus.
d. adjacent to the lateral aspect of the eye, just beneath the upper eyelid.
e. medially above the eyebrow.
ANS: A
The lacrimal gland is located in the area between the arch of the eyebrow and the upper lid. The lacrimal sac is located in the corner of the eye closest to the nose near the inner canthus.
50
Which condition of the eye is associated with impaired vision?
a. Anisocoria
b. Blepharitis
c. Arcus senilis
d. Corneal scar
ANS: D. Corneal scar
51
Which finding during an ophthalmoscopic examination suggests the patient has hypertension?
a. Narrowed retinal arteries
b. Presence of the red reflex
c. Crossing of arterioles and venules
d. Absence of cones and rods in the optic disc
ANS: A. Narrowed retinal arteries
52
Which instruction is given to a patient for the Snellen test?
a. Each eye is tested separately and then with both eyes.
b. Testing will be done with and without the corrective lens.
c. The patient advances to the next row if 75% of the letters are correct.
d. Apply slight pressure on the covered eye to assist vision in eye being tested.
ANS: B. Testing will be done with and without the corrective lens.
53
Which of the following is a genetic eye disorder that should be included in the history and physical examination, under family history, for all members of the affected family?
a. Constrictive iritis
b. Retinoblastoma
c. Oval pupils
d. Retinal hemorrhages
e. Maculates
ANS: B
Retinal cancer, or retinoblastoma, is a tumor originating from the retina and often occurs during the first 24 months of life. It has been found to be caused by an autosomal trait or a mutation of the chromosomes. Constrictive iritis, maculates, oval pupils, and retinal hemorrhages are not autosomal dominant disorders.
54
Which of the following is a relatively benign condition that may occur during pregnancy or labor?
a. Macular degeneration
b. Papilledema
c. Subconjunctival hemorrhage
d. Cupping of the optic disc
e. Presbyopia
ANS: C
Because of falling intraocular pressure during the late stages of pregnancy, hemorrhages may occur in the conjunctiva and resolve spontaneously. Papilledema is never a benign condition, and presbyopia, macular degeneration, and cupping of the optic disc occur in older adults.
55
Which patient concern suggests the development of a cataract?
a. Poor night vision
b. Inability to focus close up
c. Having blind spots in vision
d. Gradual loss of peripheral vision
ANS: A. Poor night vision
56
Which test assesses a patient's peripheral vision?
a. Cover test
b. Confrontation test
c. Reading from a Jaeger card
d. Reading from a Snellen chart
ANS: B. Confrontation test
57
White specks scattered in a linear pattern around the entire circumference of the iris are called:
a. drusen bodies.
b. cotton wool spots.
c. rust spots.
d. Brushfield spots.
e. band keratopathy.
ANS: D
Brushfield spots strongly suggest Down syndrome or mental retardation and are characterized by white specks that align perfectly around the circumference of the iris. Drusen bodies, cotton wool spots, band keratopathy, and rust spots are not associated with mental retardation.
58
Xanthelasma may suggest that the patient has an abnormality of:
a. lipid metabolism.
b. cognitive function.
c. renal metabolism.
d. bone marrow function.
e. thyroid disease.
ANS: A
Small, odd-shaped, yellow-colored plaques around the eyes are actually lipid deposits and are characteristics of a lipid metabolism problem. The other conditions are not associated with eye plaques.
59
You observe a pupillary response as the patient looks at a distant object and then at an object held 10 cm from the bridge of the nose. You are assessing for:
a. confrontation reaction.
b. accommodation.
c. pupillary light reflex.
d. nystagmus.
e. corneal arcus senilis.
ANS: B
Testing for accommodation involves asking the patient to look at an object at a distance (pupils dilate) and then look at another object much closer (pupils constrict). The other choices do not test for accommodation.
60
Diplopia is the perception of two images, and may be monocular or binocular. Monocular diplopia is an ______ problem; binocular diplopia is an _______ problem.
Monocular diplopia is an optical problem; binocular diplopia is an alignment problem.
61
Lesions most likely to produce _____ abnormalities include stroke, retinal detachment, optic neuropathy, pituitary tumor compression at the optic chiasm, and central retinal vascular occlusion.
confrontation
62
periorbital edema is always abnormal; the significance varies directly with the amount. It may represent the presence of what 4 things
thyroid eye disease
allergies
nephrotic syndrome
congestive heart failure
63
An acute suppurative inflammation of the follicle of an eyelash can cause an erythematous or yellow lump.
generally caused by a staphylococcal infection
hordeolum, or stye,
64
Crusting along the eyelashes may represent ______ caused by bacterial infection, seborrhea, psoriasis, a manifestation of rosacea, or an allergic response
blepharitis
64
An erythematous or cobblestone appearance, especially on the tarsal conjunctiva, may indicate an _____ or ______conjunctivitis
allergic or infectious conjunctivitis
65
If the closed lids do not completely cover the globe, a condition called ______ the cornea may become dried and be at increased risk of infection.
## Footnote
Thyroid eye disease, seventh nerve palsy (Bell palsy), and overaggressive ptosis or blepharoplasty surgical repair are common causes.
lagophthalmos,
66
Bright red blood in a sharply defined area surrounded by healthy-appearing conjunctiva indicates __________
subconjunctival hemorrhage
67
is an abnormal growth of conjunctiva that extends over the cornea from the limbus.
## Footnote
It occurs more commonly on the nasal side but may arise temporally as well. more common in people heavily exposed to ultraviolet light.
pterygium
68
is often associated with diabetes, herpes simplex and herpes zoster viral infections, or is a sequela of trigeminal neuralgia or ocular surgery.
Decreased corneal sensation
69
pupillary constriction; usually less than 2 mm in diameter
can be caused by miotic eye drops, opioid abuse
Miosis
70
(pupillary dilation; usually more than 6 mm in diameter)
caused by
mydriatic or cycloplegic drops, midbrain lesions or hypoxia, oculomotor damage, acute-angle glaucoma, stimulant abuse
Mydriasis
71
irregularly shaped pupils that fail to constrict with light but retain constriction with convergence; pupils may or may not be equal in size; commonly caused by neurosyphilis or lesions in midbrain where afferent pupillary fibers synapse
Argyll Robertson pupil
72
(unequal size of pupils)
caused by: Congenital (approximately 20% of healthy people have minor or noticeable differences in pupil size, but reflexes are normal) or caused by local eye medications (constrictors or dilators), or unilateral sympathetic or parasympathetic pupillary pathway destruction (Note: Examiner should test whether pupils react equally to light; if response is unequal, examiner should note whether larger or smaller eye reacts more slowly [or not at all], because either pupil could represent the abnormal size.)
Anisocoria
73
unilateral; constriction of pupil accompanied by pain and reddened eye, especially adjacent to the iris
Iritis (anterior uveitis) constrictive response
74
Pupil dilated and fixed; eye deviated laterally and downward; ptosis
Oculomotor nerve (CN III) damage
75
Affected pupil dilated and reacts slowly or fails to react to light; responds to convergence; caused by impairment of postganglionic parasympathetic innervation to sphincter pupillae muscle or ciliary malfunction; often accompanied by diminished tendon reflexes (as with diabetic neuropathy or alcoholism)
Adie pupil (tonic pupil)
76
If your patient is myopic, you will need to use a ____ (red) lens; if the patient is hyperopic or lacks a lens (aphakic), you will need a ____ lens
. If your patient is myopic, you will need to use a minus (red) lens; if the patient is hyperopic or lacks a lens (aphakic), you will need a plus lens
77
Characteristics found on ophthalmologic examination in a patient with ________ include narrowing of vessels, increased vascular tortuosity, copper wiring (diffuse red-brown reflex), arteriovenous nicking, and retinal hemorrhages (
hypertension
78
A hemorrhage at the disc margin often indicates poorly controlled or undiagnosed
glaucoma
79
may actually represent microaneurysms, which are common in diabetic retinopathy.
Dot hemorrhages
80
Loss of definition of optic disc margin initially occurs superiorly and inferiorly, then nasally and temporally central vessels are pushed forward, and veins are markedly dilated.
Venous pulsations are not visible and cannot be induced by pressure applied to the globe.
Venous hemorrhages may occur.
Severe papilledema
81
White area with soft, ill-defined peripheral margins usually continuous with the optic disc
Myelinated retinal nerve fibers
82
Physiologic disc margins are raised with a lowered central area.
Blood vessels may disappear over the edge of the physiologic disc and may be seen again deep within the disc.
Result of increased intraocular pressure with loss of nerve fibers and death of ganglion cells.
Glaucomatous optic nerve head cupping
83
Ill-defined, yellow areas caused by infarction of nerve layer of the retina.
Vascular disease secondary to hypertension or diabetes mellitus is a common cause
Cotton wool spot
84
Inflammation of the superficial layers of the sclera anterior to the insertion of the rectus muscles
Episcleritis
85
Uses light for
magnification
of eye
* Thin slit allows
for visualization
of cornea, iris,
and lens.
© Fitzgerald Health Education Associates, Inc. 26
Lens
Iris
Cornea
Using a Slit Lam
86
Uses light for magnification of eye
* Thin slit allows for visualization of cornea, iris, and lens.
slit lamp
87
Normal tonometry pressure __–__ mm Hg
Normal pressure 10–20 mm Hg
88
DO NOT attempt intraocular pressure measurement if _______ is suspected.
globe rupture
89
Do NOT dilate under what 3 circumstances
–Narrow angle
–Globe rupture
–Head injury (at risk for herniation)
90
* Detect corneal lacerations
flouriscene eye stain
91
normal aqueous production but the iris leaflet bows outward blocking the chamber angle and prohibiting flow causing increased intraocular pressure (IOP).
Acute Angle-closure Glaucoma
92
clinical presentaion
Abrupt onset
● Pain in affected eye
● Visual impairment
● Frontal or supraorbital headache
● Blurred vision
● Nausea and vomiting
Acute Angle-closure Glaucoma
93
clinical findings
Fixed, midposition pupil
* Hazy, cloudy cornea
* Conjunctival injection
* Rock hard eye
* Elevated IOP with tonometry
– May be as high as 80 mm Hg
Acute Angle-closure Glaucoma
94
Oil gland blockage causing inflammation of the eyelid
* Acute or chronic
* Painless bump in lid or lid margin
* May be accompanied with localized erythema
Chalazion
95
Inflammation of eyelash follicles along lash-line of eyelid
* Overgrowth of S. epidermitis releases a toxin causing an inflammatory reaction
* Associated with
– Seborrheic and atopic dermatitis, lice
infestation, or infection (S. aureus
Blepharitis
96
watery, red, itchy eyes
* Clinical findings
– Swollen erythematous eyelids
– Injected and edematous conjunctiva with papillae on inferior conjunctival fornix
Allergic Conjunctivitis
97
* Cool compresses QID
* Artificial tears
* Topical antihistamine/decongestant ophthalmic drops
* Topical corticosteroids **not** recommended
Allergic Conjunctivitis
98
The most common type of eye disorder is:
A. Refractive errors
B. Macular conditions
C. Neurological conditions
D. Astigmatisms
ANS: A
The most common forms of visual impairment are refractive errors. In fact, over 150 million Americans are reported to use corrective lenses for refractive errors.
99
Which of the following findings should trigger an urgent referral to a cardiologist or neurologist?
A. History of bright flash of light followed by significantly blurred vision
B. History of transient and painless monocular loss of vision
C. History of monocular severe eye pain, blurred vision, and ciliary flush
D. All of the above
ANS: B
Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist
100
The first assessment to complete related to the eyes is:
A. Eye lids
B. Visual acuity
C. Extraocular movements
D. Peripheral vision
ANS: B
The eye examination begins with determination of the patient’s visual acuity. Next, the examiner typically inspects the external and accessory structures before concentrating inward to include the
eye.
101
It is important to not dilate the eye if is suspected.
A. Cataract
B. Macular degeneration
C. Acute closed-angle glaucoma
D. Chronic open-angle glaucoma
ANS: C
If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute closed-angle glaucoma is present because dilating the eye may increase the intraocular pressure.
102
Which of the following is true concerning adjustment of diopters during funduscopic exam?
A. Moving towards more positive diopters shifts examiner’s focus posteriorly
B. Moving towards more negative diopters shifts examiner’s focus anteriorly
C. Moving towards more positive diopters broadens the examiner’s field of view
D. Moving towards more negative diopters broadens the examiner’s field of view
ANS: B
As the dial on the ophthalmoscope is moved counterclockwise, the diopters shift from positive to negative. Because the more negative diopters direct the focus posteriorly, by moving from the
positive to negative diopters, your focus will shift from the anterior eye to the posterior eye, retina, and optic disk.
103
A clinician can assess the alignment of the eyes by all except:
A. Checking for a symmetric light reflex
B. Observing eye movements
C. Performing cover/uncover exam
D. Measuring the palpebral gap
ANS: D
Alignment is evaluated by observing eye motion, performing the cover/uncover test, and assessing the light reflex.
104
The fundoscopic examination allows the clinician to directly observe:
A. Cranial nerve I
B. Cranial nerve II
C. Cranial nerve III
D. Cranial nerve IV
B
The optic nerve (CN II) is directly observed during the fundoscopic examination
105
Shining a light directly on one pupil should make the other pupil constrict. This is called the:
A. Accommodation response
B. Red reflex
C. Corneal light reflex
D. Consensual pupil response
ANS: D
The pupillary reflex is elicited by holding the light source in front of the patient so that it is directed toward one eye. At this point, observe both pupils, noting the direct response of the eye
receiving the direct light and the consensual response in the opposite eye
106
Your patient describes blurry vision as well as halos and glares in response to bright lights or when driving in the dark. There is no pain. These are symptoms of:
A. Glaucoma
B. Macular degeneration
C. Cataracts
D. Diabetic retinopathy
ANS: C
Patients with cataracts generally describe progressive and painless decreased visual acuity. The altered vision includes general blurring, dimming, and haziness of vision as well as the
development of halos and glares in response to bright lights or when driving in the dark. The opacities may be visible as gray or whitening areas over the pupil.
107
While assessing visual acuity, you notice that the patient is turning his head “side-to-side” for an oblique, or peripheral, view of the Snellen chart, raising your suspicion that the patient may suffer
from:
A. Glaucoma
B. Cataract
C. Macular degeneration
D. Amaurosis fugax
ANS: C
Visual loss associated with macular degeneration can be progressive, unilateral or bilateral, and starts centrally.
108
When examining the six cardinal fields of gaze, the clinician is assessing function of:
A. CN III
B. CN IV
C. CN VI
D. All of the above
ANS: D
The six cardinal fields of gaze are testing the extraocular muscles, which are innervated by the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI).
109
Your patient has been treated for glaucoma for 5 years. Which of the following will provide indication of the level of progression during the funduscopic examination for this patient?
A. Checking the macula
B. Estimating cup-to-disk ratio
C. Verifying a red reflex
D. Extraocular movements
ANS: B
In glaucoma, inspection may identify cup/disk ratio change; late afferent effect is possible.
110
A patient describes a brief episode of visual impairment where it was as if a dark shade was gradually coming down over one eye. The vision returned a moment later. This is most commonly
described in which condition?
A. Glaucoma
B. Cataracts
C. Amaurosis fugax
D. Macular degeneration
ANS: C
In amaurosis fugax, the patient often describes an episode as if a shade had been pulled over one eye in a descending fashion and then, a short time later, the shade was raised and vision restored.
111
A Marcus-Gunn effect involves:
A. Abnormal pupillary responses
B. Abnormal visual acuity
C. Abnormal funduscopic findings
D. All of the above
ANS: A
Note whether the pupil response is a slight constriction, slightly more pronounced with direct light, which is normal, or the pupil slightly relaxes so that the response is slightly less pronounced with direct light, which is an abnormal, Marcus-Gunn effect.
112
In the following condition, patients often describe a sudden, large flash of light with gradual loss of vision in one eye.
A. Amaurosis fugax
B. Acute glaucoma
C. Temporal arteritis
D. Retinal detachment
D. Retinal detachment
With retinal detachment, the patient usually provides a history of a contributing condition or trauma, followed by a sudden visual disturbance, such as flashing light, floaters, or scotoma. The
visual defect may advance or progress as the retinal detachment enlarges, but central vision will be retained unless the macula is involved
113
Macular degeneration is a visual disturbance due to:
A. Sudden head trauma
B. Ischemia of the central retinal artery
C. Elevated intraocular pressure
D. Physiological aging
ANS: D
Most commonly, macular degeneration is associated with aging and results either from atrophy of the macula or exudation and hemorrhage of the vessels in the macular region
114
. An Amsler grid is used to evaluate which of the following conditions?
A. Optic neuritis
B. Macular degeneration
C. Amaurosis fugax
D. Retinal detachment
ANS: B
With macular degeneration, a commonly used test, the Amsler grid, assesses the patient’s ability to accurately see a set of grids.
115
The most common cause of eye redness is:
A. Conjunctivitis
B. Acute glaucoma
C. Head trauma
D. Corneal abrasion
. ANS: A
The most common cause of eye redness is conjunctivitis (see Plate 38), which involves an inflammation of one or more areas of the conjunctiva. It is important to discriminate between
allergic, viral, bacterial, and other causes of conjunctivitis in order to provide definitive treatment. Infectious conjunctivitis is usually caused by viral organisms, although bacterial infections are also
common and can be secondary to viral infections. Allergies are the most frequent cause of noninfectious conjunctivitis. Other causes include chemical reactions.
116
A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely with:
A. Bacterial conjunctivitis
B. Allergic conjunctivitis
C. Chemical conjunctivitis
D. Viral conjunctivitis
ANS: D
Preauricular nodes are nonpalpable and nontender in allergic conjunctivitis, usually nonpalpable in bacterial conjunctivitis, and palpable in viral conjunctivitis.
117
Your patient with Crohn’s Disease complains of eye pain and photophobia. This is likely related to:
A. Symptoms of temporal arteritis
B. Altered pupil response due to uveitis
C. Blurry vision due to bilateral cataracts
D. Subconjunctival hemorrhage
ANS: B
Uveitis involves inflammation of the uveal tract, including the iris. The inflammation may be caused either by infection or as part of a reaction associated with a systemic disorder. For instance,
an increased incidence of uveitis is associated with autoimmune disorders, such as Crohn’s disease, ankylosing spondylitis, and HIV infection. The vision changes associated with uveitis stem from
altered responsiveness of the pupil and lens. Patients commonly experience both photophobia and eye pain. There is a ciliary flush and, usually, a constricted pupil.
118
Your patient is suffering from herpes zoster along the trigeminal nerve distribution of the face. You should carefully assess for the presence of:
A. Keratitis
B. Uveitis
C. Scleritis
D. Conjunctivitis
A. Keratitis
Keratitis is inflammation of the cornea that can lead to blindness in the affected eye. Keratitis is commonly caused by herpetic and other infections, ischemia, chemical exposures, foreign bodies,
or corneal abrasions. Keratitis is noteworthy because it can lead to ulcerations, opacities, and blindness of the affected eye; thus, patients suspected of this disorder should be immediately
referred to an ophthalmologist
119
A 4-day-old newborn presents with redness and tearing of one eye. Slight pressure over the lacrimal sac produces white discharge. The clinician should be aware that the following condition is common in newborns:
A. Conjunctivitis
B. Sinus infection
C. Dacryocystitis
D. Herpes infection
ANS: C
Dacryocystitis is an infection of the lacrimal sac and is most common in infants, secondary to congenital stenosis of the lacrimal duct. If the duct is occluded, constant tearing may occur. The lacrimal sac may be edematous, red, and tender. Pressure over the sac produces purulent discharge.
120
Ptosis is commonly the first sign of:
A. Stevens-Johnson syndrome
B. Hyperthyroidism
C. Temporal arteritis
D. Myasthenia gravis
ANS: D
Ptosis, or drooping of an eyelid, can be related to simple aging, with natural loss of elasticity and lid drooping, or it can result from a variety of other causes. The causes of ptosis are often
categorized as congenital and acquired. Causes occurring after birth include trauma, conditions adding mass to the eyelid, and conditions that affect the nerves or muscles controlling the lid’s
position. In 75% of the cases, the first manifestation of myasthenia gravis is ptosis.
121
A 9-month-old patient presents with fever and large areas of redness and bullae over the trunk, palms, legs, and sole of the feet. There is redness and swelling of the conjunctiva and lips. The
clinician should recognize this condition as:
A. Giant cell arteritis
B. Stevens-Johnson syndrome
C. Botulism
D. Myasthenia gravis
ANS: B
Stevens-Johnson syndrome, also called erythema multiforme, involves inflammation of the mucous membranes and skin. It is often related to an infection or can be due to almost any
medication. Often, no specific cause is identified. The condition can be fatal. It is important to immediately recognize and treat. The patient appears acutely ill and has systemic symptoms,
including malaise, fever, and arthralgias, so that the eye findings are not isolated. Conjunctival bullae and ulcerations may develop. Patients develop erythematous lesions and bullae over the skin
and hemorrhagic lesions of the mucous membranes. In addition to the eye tissue, the palms, soles, anus, vagina, nose, and mouth are commonly affected.
122
In assessing the eyes, which of the following is considered a “red flag” finding when associated with eye redness?
A. History of prior red-eye episodes
B. Grossly visible corneal defect
C. Exophthalmos
D. Photophobia
ANS: B
Red flag warnings for eye redness include pain (not discomfort or irritation), decreased vision, profuse discharge, and corneal defect grossly visible.
123
Mr. Sprat is a 21-year-old patient who complains of nasal congestion. He admits to using recreational drugs. On examination, you have noted a septal perforation. Which of the
following recreational drugs is commonly associated with nasal septum perforation?
a. Heroin
b. Cocaine
c. PCP
d. Ecstasy
ANS: B
Long-term cocaine snorting causes ischemic necrosis of the septal cartilage and leads to perforation of the nasal septum
124
A 5-year-old child presents with nasal congestion and a headache. To assess for sinus tenderness, you should palpate over the
a. sphenoid and frontal sinuses.
b. maxillary and frontal sinuses.
c. maxillary sinuses only.
d. sphenoid sinuses only
ANS: C
Only the maxillary and the frontal sinuses are accessible for physical examination; however,the young child does not develop frontal sinuses until 7 to 8 years of age.
125
Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear drainage. When examining an infant’s middle ear, the nurse should use one hand to stabilize
the otoscope against the head while using the other hand to
a. pull the auricle down and back.
b. hold the speculum in the canal.
c. distract the infant.
d. stabilize the chest.
ANS: A
The nurse should use the other hand to pull the auricle down and back in an effort to straighten the upward curvature of the canal.
126
Mrs. Donaldson is a 31-year-old patient who is pregnant. In providing Mrs. Donaldson with healthcare information, you will explain that she can expect to experience
a. more nasal stuffiness.
b. a sensitive sense of smell.
c. drooling.
d. enhanced hearing
ANS: A
Physiologic changes of pregnancy include nasal stuffiness, a decreased sense of smell, impaired hearing, epistaxis, and a sense of fullness in the ears.
127
You are performing hearing screening tests. Who would be expected to find difficulty in hearing the highest frequencies?
a. A 7-year-old
b. An 18-year-old
c. A 30-year-old
d. A 50-year-old
ANS: D
Sensorineural hearing loss begins after 50 years of age, initially with losses of high-frequency sounds and then progressing to tones of lower frequency.
128
Mr. Spencer presents with the complaint of hearing loss. You specifically inquire about current medications. Which medications, if listed, are likely to contribute to his hearing loss?
a. Chlorothiazide
b. Acetaminophen
c. Salicylates
d. Cephalosporins
ANS: C
Ototoxic medications include aminoglycoside, salicylates, furosemide, streptomycin, quinine, ethacrynic acid, and cisplatin
129
To approximate vocal frequencies, which tuning fork should be used to assess hearing?
a. 100 to 300 Hz
b. 200 to 400 Hz
c. 500 to 1000 Hz
d. 1500 to 2000 Hz
ANS: C
Use of a 500- to 1000-Hz tuning fork approximates vocal frequencies
130
You are using a pneumatic attachment on the otoscope while assessing tympanic membrane movement. You gently squeeze the bulb but see no movement of the membrane. Your next
action should be to
a. remove all cerumen from the canal
b. change to a larger speculum.
c. squeeze the bulb with more force.
d. insert the speculum to a depth of 2 cm
B
To see tympanic movement when using the pneumatic attachment, there should be a seal
around the speculum to block outside air. In this manner, the normal tympanic membrane
moves as a result of pressure changes from the insufflator bulb. A soft rubber speculum is
recommended to establish the seal
131
When conducting an adult otoscopic examination, you should
a. position the patient’s head leaning toward you.
b. grasp the handle of the otoscope as you would a baseball bat.
c. select the largest speculum that will fit in the canal.
d. ask the patient to keep his or her eyes closed
ANS: C
When conducting an adult otoscopic examination, select the largest speculum that will comfortably fit in the patient’s ear. When you are conducting an adult otoscopic examination, the patient’s head should be positioned toward the opposite shoulder. Hold the handle of the otoscope between the thumb and index finger, supporting it on the middle finger. There is no reason for the patient to keep her or his eyes shut.
132
Bulging of an amber tympanic membrane without mobility is usually associated with
a. middle ear effusion.
b. healed tympanic membrane perforation.
c. impacted cerumen in the canal.
d. repeated and prolonged crying cycles.
ANS: A
An amber color, with bulging of the tympanic membrane and without mobility or redness, usually indicates the presence of fluid in the middle ear.
133
When hearing is evaluated, which cranial nerve is being tested?
a. III
b. IV
c. VIII
d. XII
ANS: C
Cranial nerve VIII, the vestibulocochlear nerve, is associated with hearing.
134
Speech with a monotonous tone and erratic volume may indicate
a. otitis externa.
b. hearing loss.
c. serous otitis media.
d. sinusitis.
ANS: B
Speech with a monotonous tone and erratic volume may indicate hearing loss
135
You are performing Weber and Rinne hearing tests. For the Weber test, the sound lateralized to the unaffected ear; for the Rinne test, air conduction-to-bone conduction ratio is less than
2:1. You interpret these findings as suggestive of
a. a defect in the inner ear.
b. a defect in the middle ear.
c. otitis externa.
d. impacted cerumen.
ANS: A
These results are consistent with a sensorineural hearing loss, a defect in the inner ear. Otitis externa and impacted cerumen are conditions of the external ear that can cause conductive
hearing problems.
136
Nasal symptoms that imply an allergic response include
a. purulent nasal drainage.
b. bluish gray turbinates.
c. small, atrophied nasal membranes.
d. firm consistency of turbinates.
ANS: B
Nasal symptoms that imply an allergic response include bluish gray or pale pink nasal turbinates that are swollen and boggy and a transverse crease at the junction between the
cartilage and bone of the nose.
137
You are interviewing a parent whose child has a fever, is pulling at her right ear, and is irritable. You ask the parent about the child’s appetite and find that the child has a decreased appetite. This additional finding is more suggestive of
a. acute otitis media.
b. otitis externa.
c. serous otitis media.
d. middle ear effusion.
ANS: A
Anorexia is an initial symptom of acute otitis media.
138
A hairy tongue with yellowish brown to black elongated papillae on the dorsum
a. is indicative of oral cancer.
b. is sometimes seen following antibiotic therapy.
c. usually indicates vitamin deficiency.
d. usually indicates anemia.
ANS: B
Recent antibiotic use can turn the tongue yellow-brown to black and make it appear hairy. Oral cancer involves lesions. A smooth red tongue with a slick appearance may indicate a
niacin or vitamin B12 deficiency. Pallor usually indicates anemia.
139
To inspect the lateral borders of the tongue, you should
a. ask the patient to extend the tongue outward.
b. insert the tongue blade obliquely against the tongue.
c. lift the tongue upward with gloved fingers.
d. pull the gauze-wrapped tongue to each side
ANS: D
To inspect the lateral borders of the tongue, you should wrap the tongue with a piece of gauze and then pull the tongue to each side for inspection.
140
For best results, an otoscopic and oral examination in a child should be
a. conducted at the beginning of the assessment.
b. done after inspection.
c. performed at the end of the examination.
d. performed before palpation.
ANS: C
Because young children often resist an otoscopic and oral examination, it may be wise to postpone these procedures until the end, after you have gained some trust
141
Mr. Akins is a 78-year-old patient who presents to the clinic with complaints of hearing loss. Which are changes in hearing that occur in older adults? (Select all that apply.)
a. Results from cranial nerve VII
b. Slow progression
c. Loss of high frequency
d. Bone conduction heard longer than air conduction
e. Sounds may be garbled, difficult to localize
f. Unable to hear in a crowded room
ANS: C, E, F
Age-related hearing loss is associated with degeneration of hair cells in the organ of Corti, loss of cortical and organ of Corti auditory neurons, degeneration of the cochlear conductive
membrane, and decreased vascularity in the cochlea. Sensorineural hearing loss first occurs with high-frequency sounds and then progresses to tones of lower frequency. Loss of
high-frequency sounds usually interferes with the understanding of speech and localization of sound. Conductive hearing loss may result from an excess deposition of bone cells along the
ossicle chain, causing fixation of the stapes in the oval window, cerumen impaction, or a sclerotic tympanic membrane.
142
Which signs and symptoms occur with a sensorineural hearing loss? (Select all that apply.)
a. Air conduction shorter than bone conduction
b. Lateralization to the affected ear
c. Loss of high-frequency sounds
d. Speaks more loudly
e. Disorder of the inner ear
f. Air conduction longer than bone conduction
ANS: C, D, E, F
The signs and symptoms of sensorineural hearing loss include loss of high-frequency sounds, speaks more loudly, disorder of the inner ear, air conduction longer than bone conduction, and
lateralization to the unaffected ear
143
A 44-year-old male patient who complains of a cough has presented to the emergency department. He admits to smoking one pack per day. During your inspection of his chest, the
most appropriate lighting source to highlight chest movement is
a. bright tangential lighting.
b. daylight from a window.
c. flashlight in a dark room.
d. fluorescent ceiling lights
ANS: A
Bright tangential light is best for visualizing chest movements
144
When auscultating the apex of the lung, you should listen at a point
a. even with the second rib.
b. 4 cm above the first rib.
c. higher on the right side.
d. on the convex diaphragm surface.
ANS: B
The apex of the lung is 4 cm above the first rib.
145
To count the ribs and the intercostal spaces, you begin by palpating the reference point of the
a. distal point of the xiphoid.
b. manubriosternal junction.
c. suprasternal notch.
d. acromion process.
ANS: B
The angle of Louis, the junction of the manubrium and the sternum, corresponds to the second rib, the reference point for counting ribs and intercostal spaces.
146
Mr. Curtis is a 44-year-old patient who has presented to the emergency department with shortness of breath. During the history, the patient describes shortness of breath that gets
worse when he sits up. To document this, you will use the term
a. platypnea.
b. orthopnea.
c. tachypnea.
d. bradypnea.
**ANS: A
Dyspnea that increases in the upright posture is called platypnea. Orthopnea is dyspnea that worsens when the person lies down. Tachypnea is an increased respiratory rate. Bradypnea is a decreased respiratory rate.
147
Which finding suggests a minor structural variation?
a. Barrel chest
b. Clubbed fingers
c. Pectus carinatum
d. Chest wall retractions
ANS: C
Pectus carinatum (pigeon chest) is a minor structural variation. Barrel chest, clubbing of the fingers, and chest wall retractions result from compromised respirations
148
Ms. Rudman, age 74 years, has no known health problems or diseases. You are doing a preventive healthcare history and examination. Which symptom is associated with
intrathoracic infection?
a. Barrel chest
b. Cor pulmonale
c. Funnel chest
d. Malodorous breath
ANS: D
Intrathoracic infections may make the breath malodorous
149
The best time to observe and count respirations is while
a. the patient is answering questions.
b. weighing the patient.
c. palpating the pulse.
d. the patient is sleeping.
ANS: C
Counting respirations while you palpate the pulse does not make the patient self-conscious because the patient expects you to be counting the pulse. Respiratory patterns change as the
patient speaks. Attempting to count during weighing would make the patient self-conscious and affect the respiratory rate. Respiratory patterns change as the patient sleeps
150
As you take vital signs on Mr. Barrow, age 78 years, you note that his respirations are 40 breaths/min. He has been resting, and his mucosa is pink. In regard to Mr. Barrow’s
respirations, you would
a. document his rate as normal
b. do nothing because his color is pink.
c. note that his rate is below normal.
d. report that he has an above-average rate.
ANS: D
151
In which patient situation would you expect to assess tachypnea?
a. Patient who is depressed
b. Patient who abuses narcotics
c. Patient with metabolic acidosis
d. Patient with myasthenia gravis
ANS: C
In metabolic acidosis, the body compensates by increasing the respiratory rate to blow off the excess carbon dioxide. A patient who is depressed, abuses narcotics, or has myasthenia gravis
would have respiratory depression.
152
Which site of chest wall retractions indicates a more severe obstruction in the asthmatic patient?
a. Lower chest
b. Along the anterior axillary line
c. Above the clavicles
d. At the nipple line
ANS: C
Asthma usually causes retractions of the lower chest. The more severe the obstruction, the greater the negative pressure produced in the chest during inspiration, and retractions are
manifested in the upper thorax
153
You would expect to document the presence of a pleural friction rub for a patient being treated for
a. pneumonia.
b. atelectasis.
c. pleurisy.
d. emphysema.
ANS: C
A pleural friction rub is caused by inflammation of the pleural surfaces and would be expected to be auscultated with pleurisy.
154
Which type of apnea requires immediate action?
a. Primary apnea
b. Secondary apnea
c. Sleep apnea
d. Periodic apnea of the newborn
ANS: B
Secondary apnea is a grave condition, and unless resuscitative measures are instituted immediately, breathing will not resume spontaneously. Primary apnea is self-limiting. Sleep apnea should be evaluated but does not require immediate action. Periodic apnea of the newborn is a normal condition.
155
With consolidation in the lung tissue, the breath sounds are louder and easier to hear, whereas healthy lung tissue produces softer sounds. This is because
a. consolidation echoes in the chest.
b. consolidation is a poor conductor of sound.
c. air-filled lung sounds are from smaller spaces.
d. air-filled lung tissue is an insulator of sound.
ANS: D
Air is a poor conductor of sound. Denser consolidation promotes louder sounds and is a better conductor of sound. Consolidation is a better conductor of sound than air. Breath sounds are
easier to hear when the lungs are consolidated; the mass surrounding the tube of the respiratory tree promotes sound transmission better than air-filled alveoli.
156
Which lung sounds are associated with atelectasis? (Select all that apply.)
a. Wheezes
b. Ronchi
c. Crackles
d. Crepitus
e. Rales
ANS: A, B, C
Wheezes, rhonchi, and crackles in varying amounts are associated with atelectasis
157
Upon physical examination of a 1-year-old patient, you note abnormal placement of the ears, hypertelorism, and strabismus. These are often signs of:
A. Genetic conditions
B. Deafness
C. Birth injury
D. Physical abuse
ANS: A
Facial dysmorphism often indicates a genetic disorder. These features include microcephaly,brachycephaly, hypertelorism, upslanting palpebral fissures, strabismus, broad nasal bridge, wide
anterior fontanalle, anteverted nares, high arched palate, microretrognathia, low-set dysmorphic ears, and short neck
158
An 86-year-old patient who wears a hearing aid complains of poor hearing in the affected ear. In addition to possible hearing aid malfunction, this condition is often due to:
A. Acoustic neuroma
B. Cerumen impaction
C. Otitis media
D. Ménière’s disease
ANS: B
Elderly clients frequently present with complaints of hardened cerumen and decreased hearing resulting from cerumen impaction aggravated by hearing aid wear.
159
A patient presents to the emergency department due to head trauma related to a motorcycle accident. On physical examination, you note clear, serous discharge from the ear. This is
commonly a sign of:
A. Basilar skull fracture
B. Injury of the auricle
C. Otitis discharge
D. Tympanic membrane perforation
ANS: A
In cases of head trauma, there are signs of skull fracture. These signs include cerebrospinal fluid otorrhea, rhinorrhea, and raccoon eyes
160
A pneumatic otoscopic examination is used to assess:
A. Inner ear conditions
B. Otitis externa
C. Cerumen impaction
D. Tympanic membrane mobility
ANS: D
Pneumatic otoscopy is an examination that allows determination of the mobility of a patient’s tympanic membrane (TM). The normal tympanic membrane moves in response to a puff of air
pressure from the otoscope. Immobility may be due to fluid in the middle ear, a perforation, or tympanosclerosis, among other reasons. The detection of middle ear effusion by pneumatic
otoscopy is key in establishing the diagnosis of otitis media with effusion. The inner ear is not visible with an otoscope. Cerumen impaction will impede function of the pneumatic otoscope.
Otitis externa is an external ear infection that is diagnosed without the use of an otoscope
161
In examination of the nose, the clinician observes gray, pale mucous membranes with clear, serous discharge. This is most likely indicative of:
A. Bacterial sinusitis
B. Allergic rhinitis
C. Drug abuse
D. Skull fracture
ANS: B
When examining the nose, assess the mucosa for integrity, color, moistness, and edema/lesions and the nasal septum for patency. The turbinates should be assessed for color and size. Pale, boggy
turbinates suggest allergies; erythematous, swollen turbinates are often seen with infection. Any discharge should be noted. Clear, profuse discharge is often associated with allergies.
162
With inspection of the mouth and buccal mucosa, Stensen’s duct can be seen on the:
A. Underside of the tongue
B. Buccal mucosa opposite the lower molars
C. Buccal mucosa opposite the upper molars
D. Soft palate
C
In examination of the mouth, use a tongue depressor to displace the lips and cheeks. Inspect areas of the buccal mucosa that are not otherwise visible, including the sites of the Stensen’s and
Wharton’s ducts. Stenson’s duct of the parotid gland, which releases saliva, is located on the upper buccal mucosa opposite the molars.
163
To examine if there is an intact gag reflex, ask the patient to say “ah” as you observe the:
A. Movement of the uvula to the left
B. Movement of uvula to the right
C. Tongue extension in the midline
D. Upward movement of the uvula in the midline
ANS: D
Within the oropharynx, upward movement of the uvula within the midline when the patient says “ah” is indicative of an intact gag reflex.
164
Malignant oral cancerous lesions are most frequently located on the:
A. Tongue
B. Tonsils
C. Gums
D. Hard palate
. ANS: A
There are several types of oral cancers, but around 90% are squamous cell carcinomas, originating in the tissues that line the mouth and lips. Oral or mouth cancer most commonly involves the tongue.
165
Ear pain related to tenderness over the auricle and ear canal is most commonly related to:
A. Excessive exposure to noise
B. Cerumen impaction
C. Otitis externa
D. Ménière’s disease
ANS: C
Ear pain is most often seen in children and is usually associated with bacterial or viral upper respiratory infection. Complaints of ear pain in the summer are often associated with otitis externa
(OE), owing to swimmer’s ear. Complaints of primary ear pain decline with age and, in adults, are more likely associated with secondary conditions, such as sinus infection; dental disease;
malignancy; other disorders of the head, face, and neck; and nervous and vascular symptoms.
165
Which of the following symptoms is common with acute otitis media?
A. Bulging tympanic membrane
B. Bright light reflex of tympanic membrane
C. Increased tympanic membrane mobility
D. All of the above
ANS: D
Acute otitis media (AOM) involves infection of the fluid in the middle ear space. The three bacterial organisms most often associated with AOM include streptococcal pneumoniae,
Haemophilus influenzae, and Moraxella catarrhalis. The patient often complains of unilateral ear pain, which may radiate to the neck or jaw. There is commonly a current or recent history of
symptoms consistent with an upper respiratory infection
165
A 6-year-old child presents with complaints of unilateral ear pain, fever, and sore throat. The clinician should recognize that this is most commonly due to:
A. Otitis externa
B. Inner ear infection
C. Sinusitis
D. Otitis media
ANS: D
In otitis media (middle ear infection), the tympanic membrane (TM) is typically dull, may be inflamed, and bulges so that the posterior landmarks are obscured. The light reflex is distorted or
obscured. If myringitis (inflammation of the TM) is present, the TM is reddened. Purulent or yellow fluid may be evident posterior to the TM, with diminished TM mobilit
166
Which of the following microorganisms commonly causes otitis externa?
A. Streptococcus pneumoniae
B. Pseudomonas
C. Moraxella catarrhalis
D. Haemophilus influenza
B
Otitis externa (OE) is inflammation of the ear canal and outer ear. Frequent causes include pseudomonas and fungal organisms. It is frequently associated with swimming as well as trauma.
Acute otitis media (AOM) involves infection of the fluid in the middle ear space. The three bacterial organisms most often associated with AOM include streptococcal pneumonia,
Haemophilus influenzae, and Moraxella catarrhalis. Frequently, viral organisms coexist with one of the preceding bacterial causes.
166
A 5-year-old patient with a history of chronic otitis media complains of severe unilateral ear pain that worsens at night. The pain has progressively worsened over the past 3 days. Your examination reveals tenderness, erythema, and swelling below the right ear, and diminished hearing on the
right. Which of the following is a likely diagnosis?
A. Sinus infection
B. Skull fracture
C. Mastoiditis
D. Foreign body
. ANS: C
Mastoiditis refers to infection of the mastoid bone, which is almost always a complication of acute otitis media (AOM). The patient complains of radiating ear pain and fever. The pain is persistent
(for days to weeks), severe, deep, and often worst at night. The hearing on the affected site is usually significantly diminished. As the condition progresses, there is swelling, erythema, and
tenderness over the mastoid bone.
167
Presbycusis is the hearing impairment that is associated with:
A. Physiologic aging
B. Ménière’s disease
C. Cerumen impaction
D. Herpes zoster
ANS: A
Presbycusis is an age-related cause of gradual sensorineural hearing loss and involves diminished hairy cell function within the cochlea as well as decreased elasticity of the TM. Although the
changes associated with presbycusis often start in early adulthood, the decreased hearing acuity is usually not noticed until the individual is older than 65
168
. A nonmalignant cancerous tumor affecting cranial nerve VIII that causes unilateral hearing loss, tinnitus, and vertigo is:
A. Otosclerosis
B. Acoustic neuroma
C. Cholesteatoma
D. Squamous cell carcinoma
ANS: B
With an acoustic neuroma, the onset of symptoms usually occurs after age 30. Early complaints include unilateral hearing loss, tinnitus, and vertigo. As the tumor advances, symptoms may
include headache, facial pain, ataxia, nausea/vomiting, and lethargy. The ear structures appear normal. Cholesteatoma is not a cancer; it is a destructive and expanding growth consisting of
keratinizing in the middle ear and/or mastoid process. The growth erodes the ossicles and can spread through the base of the skull into the brain. Otosclerosis involves degenerative changes to
the bony structures of the middle ear and results in gradual onset of hearing deficit as the bones lose their vibratory ability. The patient typically complains of painless, progressive changes in
hearing. Symptoms are usually bilateral, and tinnitus may be present. The physical examination is usually normal, with the exception of the hearing acuity test.
169
Epistaxis can be a symptom of:
A. Over-anticoagulation
B. Hematologic malignancy
C. Cocaine abuse
D. All of the above
ANS: D
Cocaine abuse, which is more common than might be expected, frequently causes epistaxis. Hematologic disorders likely to cause bleeding include thrombocytopenia, leukemia, aplastic
anemia, and hereditary coagulopathies. High doses of anticoagulants can cause epistaxis and
bleeding from the gums.
170
Nasal discharge of green-yellow mucus, pharyngitis, and otitis media commonly indicate:
A. Allergic rhinitis
B. Viral infection
C. Bacterial infection
D. Nasal polyps
ANS: C
Nasal discharge should be assessed for its amount and color as well as any associated symptoms. Clear, profuse discharge is allergic in nature; yellow-green purulent discharge indicates bacterial
infection.
171
. The following disorder commonly presents with vesicular or ulcerated lesions with a yellow base
on the oral mucosa and lips.
A. Aphthous ulcer
B. Herpes simplex I
C. Coxsackie viral infection
D. All of the above
ANS: A
Aphthous ulcers are painful and usually small (less than 1 cm). The ulcer is shallow, surrounded by erythema and mild edema. The base of the ulcer is pale yellow or gray. Orolabial ulcers are often
caused by herpes simplex type 1 virus. The ulcers are typically preceded by a prodromal phase of tenderness, followed by edema at the site where an individual or cluster of vesicles forms and
progresses to ulceration. The prodromal phase may also include fever. Hand-foot-and-mouth disease is caused by a coxsackievirus. Painful skin and oral lesions are often preceded by a period
of malaise and fever. The patient often presents once the lesions appear on the lips and/or oral mucosa. The lesions erupt as vesicles, which later ulcerate
172
. Hand-foot-and mouth disease often causes vesicular lesions on the palms, soles of the feet, and oral mucosa. The microorganism that causes this disease is:
A. Herpes zoster
B. Herpes simplex I
C. Coxsackie virus
D. Candida
ANS: C
Hand-foot-and-mouth disease is caused by a coxsackie virus. Outbreaks are most common in the summer and fall months. The condition is occasionally associated with meningitis. Painful skin
and oral lesions are often preceded by a period of malaise and fever. The patient often presents once the lesions appear on the lips and/or oral mucosa. The lesions erupt as vesicles, which later
ulcerate. Multiple lesions are located on the lips and oral mucosa. As the condition’s name implies, the lesions often appear on the hands and feet as well as in the mouth.
173
Thrush occurs as white patches surrounded by erythematous tissue in oral mucosa. The microorganism that causes this is:
A. Candida
B. Herpes simplex I
C. Coxsackie virus
D. Herpes zoster
ANS: A
Candidal infections of the oral mucosa take several forms. Thrush, or pseudomembranous candida, results in white patches, or plaques, overlying a very red base. Erythematous candida results in erythematous lesions and, on occasion, ulcerative lesions. Angular stomatitis results in lesions at the corners or angles of the mouth. The amount of associated pain is variable
174
A condition that presents as painless, raised white patches on the oral mucosa that predisposes to
squamous cell carcinoma is:
A. Candida
B. Lichen planus
C. Coxsackie virus
D. Leukoplakia
ANS: D
The cause of most episodes of leukoplakia is not determined. However, this condition, which results in the development of painless, raised white patches on the oral mucosa, is associated with an increased risk of oral squamous cell cancer. Risk factors for the development of leukoplakia include chronic/recurrent trauma to the affected site and the use of smokeless and smoked tobacco and alcohol
175
Your patient has been using chewing tobacco for 10 years. On physical examination, you observe a white ulceration surrounded by erythematous base on the side of his tongue. The clinician should recognize that very often this is:
A. Malignant melanoma
B. Squamous cell carcinoma
C. Aphthous ulceration
D. Behcet’s syndrome
B
Most oral malignancies are painless until quite advanced, so patients are often unaware of the lesion unless the lip or anterior portion of the tongue is involved. The patient may become aware of the lesion if it bleeds. Squamous cell cancer lesions vary in appearance, from the reddened patches of erythroplakia to areas of induration/thickening, ulceration, or necrotic lesions. Lesions of
malignant melanoma have varied pigmentation, including brown, blue, and black. Even lesions that appear flat and smooth may be nodular, indurated, or fixed to adjacent tissue on palpation.
Even though patients with squamous cell malignancies often have a history of heavy alcohol and/or tobacco use or poor dentition, these are not risk factors for malignant melanoma. In
Behcet’s syndrome, the patient complains of recurrent episodes of oral lesions that are consistent with aphthous ulcers. The number of lesions ranges from one to several; the size of the ulcers
varies from less than to greater than 1 cm. Like aphthous ulcers, the lesions are well defined, with a pale yellow or gray base surrounded by erythema. The majority of patients also develop lesions on the genitals and eyes.
176
. A patient complains of fever, fatigue, and pharyngitis. On physical examination there is pronounced cervical lymphadenopathy. Which of the following diagnostic tests should be
considered?
A. Mono spot
B. Strep test
C. Throat culture
D. All of the above
ANS: D
The physical examination for sore throat should include a comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes. Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. A CBC with differential count is helpful in determining the cause of sore
throat.
177
Rheumatic heart disease is a complication that can arise from which type of infection?
A. Epstein-Barr virus
B. Diptheria
C. Group A beta hemolytic streptococcus
D. Streptococcus pneumoniae
ANS: C
Group A beta-hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly called strep throat. Complications of GABHS pharyngitis, although rare, include
rheumatic heart disease and glomerulonephritis, and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths. Otherbacterial causes of pharyngitis include mycoplasmal pneumonia, gonorrhea, and diphtheria.
178
Which microorganism is the most common cause of tonsillitis in adolescents?
A. Epstein-Barr virus
B. Streptococcus pneumoniae
C. Mycoplasma
D. Grp A beta hemolytic streptococcus
ANS: A
Most cases of tonsillitis are diagnosed in school-aged children and adolescents. Tonsillitis involves infection of the tonsils, usually by GABHS, in very young children. However, viral tonsillitis
(often associated with EBV) is more common in adolescents. Patients can develop chronic tonsillitis and/or have frequent recurrences of the condition.
179
Which microorganism is the most common cause of peritonsillar abscess?
A. Epstein-Barr virus
B. Streptococcus pneumoniae
C. Mycoplasma
D. Grp A beta hemolytic streptococcus
D
Peritonsillar abscesses may occur at any age, although most cases involve adults. Many cases evolve as a complication of tonsillitis, but others develop as peritonsillar abscess without a history
of tonsillitis. The condition involves infection of the peritonsillar space. A number of pathogens cause peritonsillar abscesses, although the most common cause is GABHS.
180
Which of the following conditions can cause upper airway obstruction?
A. Behcet’s syndrome
B. Influenza
C. Epiglottitis
D. Thrush
ANS: C
Epiglottitis is rare, but it can cause significant respiratory obstruction and death. The condition can occur at any age. The patient presents with rapidly developing sore throat, fever, cough, and difficulty swallowing. The patient’s voice is muffled, and there is drooling. Stridor and/or varying signs of respiratory distress may be evident. The patient often leans forward while sitting to maximize the airway opening. The patient has a very ill appearance, and gentle palpation over the larynx causes significant pain
181
Your patient is a 78-year-old female with a smoking history of 120-pack years. She complains of hoarseness that has developed over the last few months. It is important to exclude the possibility
of:
A. Thrush
B. Laryngeal cancer
C. Carotidynia
D. Thyroiditis
ANS: B
Hoarseness may result from squamous cell cancer of the larynx as well as from malignancies within the pulmonary tree, neck, and throat. The risk of malignancy as a cause for hoarseness is
greatest in patients with a history of cigarette smoking and/or alcohol abuse. The history usually reveals a progressive onset of hoarseness that has persisted for weeks. The physical examination
specific to a complaint of hoarseness should include the ears, nose, throat, neck, lungs, and CNs (particularly CN IX and CN X). When hoarseness is persistent or laryngeal structural disorders are considered, laryngoscopy should be performed to view any redness, edema, motion, and masses or polyps.
182
. A 26-year-old female who gave birth 1 month ago presents with sudden development of fever, neck pain, sore throat with dysphagia, and radiation of pain to the ear. Which of the following
conditions is most important to consider?
A. Diptheria
B. Epiglottitis
C. Thyroiditis
D. Otitis media
ANS: C
Painful subacute thyroiditis involves inflammation of the thyroid gland. A variant, postpartum thyroiditis occurs within 6 months of giving birth and is generally painless. Although the etiology
of painful subacute thyroiditis is not clear, it may have a viral trigger. Patients commonly complain of pain in the throat and/or neck, with radiation to an ear. Onset is described as relatively sudden,and associated symptoms include fever, malaise, and achiness. The throat pain may be associated with dysphagia.
183
A 66-year-old patient presents to the clinic complaining of dyspnea and wheezing. The patient reports a smoking history of 2 packs of cigarettes per day since age 16. This would be recorded in the chart
as:
A. 50 x 2-pack years
B. 100-pack years
C. 50-year, 2-pack history
D. 100 pack history
ANS: B
When recording the smoking history, the measure is calculated by the number of packs per day multiplied by the number of years the patient smoked. In this scenario, the patient smoked 2 packs per day for 66 – 16 years = 50 years. This is 100-pack years
184
Which of the following is characteristic of COPD?
A. Asymmetric chest expansion
B. Increased lateral diameter
C. Increased anterior-posterior
diameter
D. Pectus excavatum
ANS: C
In COPD, patients commonly develop a barrel-shaped chest due to
emphysematous changes in the lungs. A barrel shape is due to an
increased anterior-posterior (AP) diameter. In emphysema, there is a 1:1 ratio of AP to lateral diameter; AP diameter equals the lateral diameter. Normally the AP diameter is twice the lateral diameter.
185
When palpating the posterior chest, the clinician notes increased
tactile fremitus over the left lower lobe. This can be indicative of:
A. Pneumonia
B. Emphysema
C. Pneumothorax
D. Asthma
ANS: A
Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. Conversely, areas of decreased fremitus raise the suspicion of abnormal fluid- or air-filled spaces, such as occurs with pleural effusion, pneumothorax, or emphysema. In the instance of an extensive bronchial obstruction, no palpable vibration is felt in the related field.
186
During physical examination of a patient, you note resonance on
percussion in the upper lung fields. This is consistent with:
A. COPD
B. Pneumothorax
C. A normal finding
D. Pleural effusion
ANS: C
The lung fields should be percussed posteriorly, starting from the
superior-most areas and then proceeding inferiorly to the level of the diaphragm. Resonance is the normal sound on percussion.
Hyperresonance suggests air trapping, which occurs with COPD or
tension pneumothorax. Dullness to percussion is detected over the actual site of consolidated lung or pleural fluid. Dullness is also found with pneumonia, severe atelectasis, or pleural effusion.
187
Which of the following imaging studies should be considered if a
pulmonary malignancy is suspected?
A. Computed tomography (CT) scan
B. Chest xray with PA, lateral, and
lordotic views
C. Ultrasound
D. Positron emission tomography
(PET) scan
ANS: A
For pulmonary malignancy, chest films are often nondiagnostic,
although they may reveal a nodule, mass, or other abnormality. A CT scan of the chest is typically diagnostic.
188
Alpha-1 antitrypsin deficiency should be considered in patients diagnosed with:
A. Exercise-induced cough
B. Bronciectasis
C. COPD
D. Pericarditis
ANS: C
When younger patients or nonsmokers develop findings consistent with COPD, alpha-1 antitrypsin deficiency should be suspected. Currently, the American Thoracic Society (2003) recommends that all individuals with COPD or asthma with chronic obstructive changes be tested for alpha-1 antitrypsin deficiency. If alpha-1 antitrypsin deficit is suspected, a qualitative serum should be performed as a screen, followed by quantitative study, as indicated.
189
Upon assessment of respiratory excursion, the clinician notes
asymmetric expansion of the chest. One side expands greater than the other. This could be due to:
A. Pneumothorax
B. Pleural effusion
C. Pneumonia
D. Pulmonary embolism
ANS: A
The respiratory excursion, or expansion, is determined by placing
hands around the patient’s posterior rib cage with the thumbs
approximately at the level of the 10th rib between the thumbs, and then asking the patient to take a deep breath and observing the movement of the hands. The motion should be symmetrical. Less than anticipated movement occurs with advanced COPD and many restrictive processes, such as interstitial lung disease. Asymmetry of movement occurs with atelectasis, lobar collapse, pneumothorax, and several other conditions.
190
During auscultation of the chest, your exam reveals a loud grating
sound at the lower anterolateral lung fields, at full inspiration and early expiration. This finding is consistent with:
A. Pneumonia
B. Pleuritis
C. Pneumothorax
D. A and B
ANS: D
An adventitious sound, called a pleural friction rub, is a typically loud, grating sound produced when the two inflamed and roughened surfaces of the visceral and parietal pleurae rub together. A friction rub is usually noted in the late inspiratory and early expiratory phases and in the lower anterolateral lung fields. Examples of conditions that result in a pleural rub include pneumonia, pleuritis, and malignancy
191
While assessing auscultated spoken sounds, the ausculated sound is heard as “a-a-a” when he is asked to repeat “e-e-e.” This is indicative
of:
A. Asthma
B. Tumor
C. Pneumonia
D. Pleural effusion
ANS: C
Depending on the findings associated with the examination, the
examiner can decide whether to proceed with auscultated spoken
sounds: bronchophony, egophony, and/or whispered pectoriloquy. If the detected sound is heard as “A-A-A” with a nasal quality over a particular area, indicating egophony, this is an indication of pneumonia
192
A cough is described as chronic if it has been present for:
A. 2 weeks or more
B. 8 weeks or more
C. 3 months or more
D. 6 months or more
ANS: B
Cough is classified as acute (less than 3 weeks in duration), subacute (lasting 3 to 8 weeks), and chronic (8 or more weeks in duration), and these distinctions help to narrow the potential differential diagnoses.
193
# **
Which of the following medications are commonly associated with the side effect of cough?
A. Beta blocker
B. Diuretic
C. ACE inhibitor
D. Calcium antagonist
ANS: C
The medical history of a patient who complains of cough should be comprehensive, with a particular focus on the potential for asthma, COPD, chronic or acute bronchitis, heart failure, GERD, or recent upper or lower respiratory infections. The medication history should be elicited, particularly if the patient is taking an ACE inhibitor which has the potential to induce cough. The patient’s prior self-treatment or prescribed treatment of cough should be explored, including the response and tolerance of the treatment.
194
Which of the following details are NOT considered while staging
asthma?
A. Nighttime awakenings
B. Long-acting beta agonist usage
C. Frequency of symptoms
D. Spirometry findings
ANS: B
The history is an important aspect of asthma because the frequency of various symptoms, nighttime awakenings, use of a short-acting beta agonist, and interference with activities are used, along with spirometry, in staging asthma.
195
When asthma is suspected, which of the following is NOT useful in
making a diagnosis?
A. Decreased FEV1/FVC ratio
B. Decreased FEV1
C. Some reversibility with
administration of bronchodilator
D. Peak flow meter reading
ANS: D
Pulmonary function tests or spirometry provide diagnosis of asthma; diminished forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio with diminished FEV1 If they are the same, please choose one and use throughout to indicate obstructed outflow. Some degree of reversibility occurs with administration of bronchodilators. Chest films are generally within normal limits unless there is significant air trapping. Peak flow meters should not be used as diagnostic tools. They are appropriate for monitoring ongoing symptoms and determining the response to therapy, particularly once a patient’s
“personal best” is determined
196
The following criterion is considered a positive finding when
determining whether a patient with asthma can be safely monitored and treated at home:
A. Age over 40
B. Fever greater than 101
C. Tachypnea greater than 30
breaths/minute
D. Productive cough
ANS: C
Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present:
* Confusion of new onset
* BUN greater than 20mg/dL
* Respiratory rate of 30 breaths/minute
* Blood pressure is less than 90 mmHg systolic or diastolic 60 mm Hg
* Age 65 or older
Patients scoring 3 to 5 typically require hospitalization for observation
and therapy. Scores of 0 to 1 indicate likelihood that outpatient
management is appropriate. A score of 2 is inconclusive
197
The most common etiologic organism for community-acquired
pneumonia is:
A. Streptococcus pneumoniae
B. Beta hemolytic streptococcus
C. Mycoplasma
D. Methicillin resistant
staphylococcus
ANS: A
Pneumonia involves inflammation and consolidation of lung tissue.
Pneumonia is broadly categorized by whether it occurs outside of the hospital (community-acquired pneumonia) or within the hospital (nosocomial, or hospital-acquired, pneumonia). The cause is most often Streptococcus pneumoniae, Haemophilus influenzae, or Staphylococcus aureus. Atypical pneumonia involves infection of mycoplasma, legionella, or chlamydia
198
A 75-year-old patient with community-acquired pneumonia presents with temperature of 102.1, chills, productive cough, BP 90/5062, WBC 12,000, and blood urea nitrogen (BUN) 20 mg/dl. He has a history of mild dementia and his mental status is unchanged from his last visit. These findings indicate that the patient:
A. Can be treated as an outpatient
B. Requires hospitalization for
treatment
C. Requires a high dose of
parenteral antibiotic
D. Can be treated with oral
antibiotics
ANS: A
Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present:
* Confusion of new onset
* BUN is greater than 20mg/dl
* Respiratory rate of 30 breaths/minute
* Blood pressure is less than 90 mmHg systolic or diastolic 60 mm Hg
* Age 65 or older
Patients scoring 3 to 5 typically require hospitalization for observation
and therapy. Scores of 0 to 1 indicate likelihood that outpatient
management is appropriate. A score of 2 is inconclusive.
199
Your patient with community-acquired pneumonia shows a pleural effusion on chest x-ray, indicating the need for:
A. Immediate endotracheal intubation
B. Broad spectrum intravenousantibiotics
C. Thoracentesis to rule outempyema
D. Gram stain and culture of sputum
ANS: C
In pneumonia, chest film typically reveals an area of infiltrate. It is a
red flag if a pleural effusion is also visualized, in which case adequate follow-up to exclude development of an empyema is mandatory. This often involves prompt referral to a pulmonologist for possible thoracentesis. Cultures and Gram stains of sputum are usually not ordered for outpatients.
200
If on physical examination the clinician auscultates rhonchi, the
clinician should ask the patient to take a deep breath and cough in order to:
A. Mobilize secretions
B. Diagnose pleural effusion
C. Accurately distinguish lung sounds
D. A & C
ANS: D
Cough is the most common symptom of bronchitis and may persist for several weeks after the initial infection is resolved. During the acute phase, the cough may be productive. There may be associated symptoms, including fever, malaise, chest discomfort, chills, and headache. The chills and chest discomfort are mild in comparison to the symptoms of pneumonia. There may be wheezes and/or rhonchi on auscultation, which disappear or alter with cough effort
201
Which of the following is considered a “red flag” when diagnosing a patient with pneumonia?
A. Fever of 102
B. Infiltrates on chest x-ray
C. Pleural effusion on chest x-ray
D. Elevated white blood cell count
ANS: C
With pneumonia, the chest film typically reveals an area of infiltrate. It is a red flag if a pleural effusion is also visualized, in which case adequate follow-up to exclude development of an empyema is mandatory. This often involves prompt referral to a pulmonologist for possible thoracentesis. Cultures and Gram stains of sputum are usually not ordered for outpatients. The white blood cell count is often elevated
202
A 23-year-old patient who has had bronchiectasis since childhood is likely to have which of the following:
A. Barrel-shaped chest
B. Clubbing
C. Pectus excavatum
D. Prolonged capillary refill
ANS: B
In bronchiectasis, there is usually a history of chronic, productive
cough. Sputum is typically mucopurulent and produced in increased amounts. Other common findings include shortness of breath, wheezing, fatigue, and possibly hemoptysis. Physical examination reveals rhonchi and/or wheezing. In advanced disease, clubbing and cyanosis may be present.
203
Your patient has just returned from a 6-month missionary trip to
Southeast Asia. He reports unremitting cough, hemoptysis, and an unintentional weight loss of 10 pounds over the last month. These symptoms should prompt the clinician to suspect:
A. Legionaire’s disease
B. Malaria
C. Tuberculosis
D. Pneumonia
ANS: C
Many times, patients with active tuberculosis are essentially symptom free. Some complain of malaise and/or fevers but have no significantly disruptive complaints. When respiratory symptoms occur with tuberculosis, cough is common; the cough is nonproductive at first and is later associated with sputum production. Additionally, patients with tuberculosis may experience progressive dyspnea, night sweats, weight loss, and hemoptysis. It is important to suspect tuberculosis when the patient has travelled to a country where TB is endemic, such
as Asia.
204
A 76-year-old patient with a 200-pack year smoking history presents with complaints of chronic cough, dyspnea, fatigue, hemoptysis, and weight loss over the past 2 months. The physical exam reveals decreased breath sounds and dullness to percussion over the left lower lung field. The chest x-ray demonstrates shift of the mediastinum and trachea to the left. These are classic signs of:
A. Lung cancer
B. Tuberculosis
C. Pneumonia
D. COPD
ANS: A
Dyspnea is the most common symptom associated with pleural
effusion, but effusion may be accompanied by cough, pain, and
systemic symptoms, such as malaise and fever. Abnormal physical
findings become evident as the effusion increases in volume. These include decreased lung sounds, dullness over the effusion, decreased fremitus, egophony, and whispered pectoriloquy. With extremely large effusions, the mediastinum and trachea may shift to the opposite side. The exception involves effusion related to malignancy, in which case the mediastinum and trachea may be pulled toward the malignancy.
205
Causes of pleural effusions include:
A. Malignancy
B. Pneumonia
C. Cardiomegaly
D. All of the above
ANS: D
Effusions are usually secondary to another condition, such as
malignancy, heart failure, cirrhosis, trauma, and infections.
206
Patients with pulmonary fibrosis show decreased lung tissue
compliance and diminished forced vital capacity (FVC). Pulmonary
fibrosis is a type of:
A. Obstructive disease
B. Restrictive disease
C. Hyperreactive airway disease
D. None of the above
ANS: B
Restrictive lung diseases include pulmonary disorders, such as
pneumonitis, pulmonary fibrosis, and sarcoidosis, as well as extrinsic causes, such as kyphosis, scoliosis, or obesity. In all these disorders there is diminished lung capacity and decreased compliance of lung tissue.
207
A 24-year-old patient presents to the emergency department after sustaining multiple traumatic injuries after a motorcycle accident. Upon examination, you note tachypnea, use of intercostal muscles to breathe, asymmetric chest expansion, and no breath sounds over the left lower lobe. It is most important to suspect:
A. Pulmonary embolism
B. Pleural effusion
C. Pneumothorax
D. Fracture of ribs
ANS: C
Pneumothorax involves air in the pleural cavity. A pneumothorax can occur spontaneously in otherwise healthy individuals or be secondary to trauma or intrinsic lung disease. There is history of sudden onset of shortness of breath associated with chest pain. The patient usually presents in great distress, with tachycardia and tachypnea, and is often splinting the chest. There is decreased fremitus and increased hyperresonance on the affected side. Lung sounds are diminished or absent. The trachea may shift away from the affected side if a large pneumothorax is present
208
small, whitish uric acid crystals along the peripheral margins of the auricles—may indicate gout
Tophi
209
Tympanic Membrane Bulging with no mobility
Middle ear effusion due to acute otitis media
210
Tympanic Membrane Mobility with negative pressure only
Obstruction of eustachian tube with or without middle ear effusion
211
Tympanic Membrane Retracted with no mobility
Obstruction of eustachian tube with or without middle ear effusion
212
Tympanic Membrane Excess mobility in small areas
Healed perforation, atrophic tympanic membrane
213
Tympanic Membrane Amber or yellow
Serous fluid in middle ear (otitis media with effusion)
214
Tympanic Membrane Blue or deep red
Blood in middle ear (hemotympanum)
215
Tympanic Membrane Chalky white
Infection in middle ear (acute otitis media)
216
Tympanic Membrane Redness
Infection in middle ear (acute otitis media), prolonged crying
217
Tympanic Membrane White flecks, dense white plaques
Healed inflammation
218
Tympanic Membrane Air Bubbles
serous fluid in middle ear
219
Tympanic Membrane Dullness
Fibrosis, otitis media with effusion
220
Tympanic Membrane Bullae or Vesicles
Bullous myringitis (form of acute otitis media)
221
Initial symptoms
Itching in ear canal; typically occurs after swimming
Otitis Externa
222
Initial symptoms
Sticking or cracking sound on yawning or swallowing; no signs of dizziness
Otitis Media with Effusion
223
Initial symptoms
Abrupt onset, fever, feeling of blockage, irritability, preceding or concurrent upper respiratory symptom
Acute Otitis Media
224
Pain
Intense with movement of pinna, chewing
Otitis Externa
225
Pain
Discomfort, feeling of fullness
Otitis Media with Effusion
226
Pain
Deep-seated earache that interferes with activity or sleep, pulling at ear
Acute Otitis Media
227
Discharge
Watery, then purulent and thick, musty, foul-smelling
Otitis Externa
228
Discharge
none
Otitis Media with Effusion
229
Discharge
Only if tympanic membrane ruptures or through tympanostomy tubes; foul-smelling
Acute Otitis Media
230
Hearing
Conductive loss caused by exudate and swelling of ear canal
Otitis Externa
231
Hearing
Conductive loss as middle ear fills with fluid
Otitis Media with Effusion
232
Hearing
Conductive loss as middle ear fills with purulent material
Acute Otitis Media
233
Inspection
Canal is red, edematous; tympanic membrane obscured
Otitis Externa
234
Inspection
Tympanic membrane retracted or full, yellowish, mobility impaired; air-fluid level and/or bubbles present
Otitis Media with Effusion
235
Inspection
Tympanic membrane with distinct erythema, thickened or clouding; bulging; limited or absent movement from positive or negative pressure, air-fluid level and/or bubbles present; vesicles or bullae may be seen
Acute Otitis Media
236
Expected Findings: No lateralization, but will lateralize to ear occluded by patient
Conductive Hearing Loss: Sound heard better in affected ear unless sensorineural loss
Sensorineural Hearing Loss: Sound lateralizes to better ear unless conductive loss
weber test
237
Expected Findings: Air conduction heard longer than bone conduction by 2:1 ratio (positive)
Conductive Hearing Loss: Bone conduction heard longer than air conduction in affected ear (negative)
Sensorineural Hearing Loss: Air conduction heard longer than bone conduction in affected ear, but less than 2:1 ratio
rinne test
238
-bony overgrowth also known as surfer’s ear; may be an incidental finding until it grows large enough to obstruct canal , cause pain or decreased hearing.
Exostosis
239
5 T’s of ear pain
Tympanic membrane
Tonsils
Temporomandibular joint (TMJ)
Teeth
Thyroid
240
Inflamed nasal mucosa with edema and discharge: allergic/nonallergic
Rhinitis
241
8 physical exam points for rhinitis
VS
Eyes
Sinus tenderness
Ears
Nose
Throat
Lymph nodes
Lung sounds
242
History of asthma
Intolerance to aspirin
c/o nasal obstruction & < sense of smell
nasal polyp
243
White lace-like striae
Wickham’s striae
Erosive or Nonerosive
Lichen planus
244
productive cough for 3 months of year for 2 years in a row
chronic bronchitis:
245
A red spot on the buccal mucosa at the opening of the Stensen duct is associated with _______
parotitis (mumps).
246
type of conjunctivitis that:
Pain: itchy sensation
Discharge: Watery, thin, clear Usually bilateral
allergic conjunctivitis
247
type of conjunctivitis that:
Pain: Burning or gritty sensation
Discharge: Mucopurulent, viscous, Often unilateral, May collect at lid margins
bacterial conjunctivitis
248
type of conjunctivitis that:
Pain: Foreign body or gritty sensation
Discharge: Mucoid to watery, Often starts in one eye, may involve other
viral conjunctivitis
249
type of conjunctivitis that:
Preauricular nodes: Nonpalpable/normal
symptoms: Allergy symptoms often present; history of allergies, recurrent episodes
allergic conjunctivitis
250
type of conjunctivitis that:
Preauricular nodes: Usually nonpalpable; palpable in hyperacute cases
symptoms: May have URI symptoms
bacterial
251
type of conjunctivitis that:
Preauricular nodes: palpable
symptoms: May have URI symptoms
viral
252
Studies can include ______ of the conjunctiva or tests for atopy
viral and bacterial cultures
## Footnote
findings consistent with bacterial conjunctivitis that do not respond to treatment, consider and test for gonococcal and chlamydia infection.
253
vision changes
254
Warnings for Visual Disturbances
* Eye pain; photophobia
* Eye redness
* Sudden onset
* Headache, weakness, slurred speech
* Scalp or temple tenderness
* Flashes
* Nausea and vomiting
* History of trauma
255
table 1
256
table 2
