The temporal pattern of a disease or condition is more significant for distinguishing which classification of headaches?
a. post concussion headaches
b. chronic headaches
c. eye strain headaches
d. sinus and orofascial pain syndromes
b. chronic headaches
The “temporal patter” refers to the time course and presentation of signs and symptoms during the development of a condition. It is a significant characteristic in the diagnosis of all diseases, but it becomes more significant in conditions that do not have a clear mechanism of injury or causative etiology. By definition, the chronic headaches are diagnosed according to International Headache Criteria, which involve excluding other significant options and identifying the temporal pattern of symptoms.
Many disease processes have premonitory symptoms that help identify the disease by the clinical pattern. Which of the following disease processes often presents with premonitory symptoms?
a. concussion, cord contusion, disc herniation
b. migraine, epilepsy, syncope
c. whiplash, compression fracture, facet syndrome
d. stroke, vertebrobasiliar ischemia, transient ischemic attack
b. migraine, epilepsy, syncope
Antecedent transient visual symptoms before migraine, preepileptic euphoria or depression, and the progressive “grey-out” of a faint are common warning signs of the associated eminent crisis.
A patient states that he recently had a benign mass removed from his upper neck and that a nerve was damaged during the surgery. His formerly deep voice has become very “raspy” and he is having difficulty swallowing. Which nerve was most likely damaged?
a. fascial
b. trigeminal
c. hypoglossal
d. vagus
d. vagus
The vagus nerve is the correct answer because it is the motor supply for the muscles of the pharynx (swallowing) and the larynx (voice). Some may become confused because of the similarity of names of “hypoglossal” (cranial nerve XII, control of the tongue) and “glossopharyngeal” (cranial nerve IX, whose functions are paired with those of the vagus nerve). This is an actual patient case.
A 41-year-old woman presents with sudden onset of numbness and drooping of the left side of her face and pain directly behind her left ear. Further questioning and a general assessment of the patient revealed asymmetrical facial expression lateralizing to the right side, mild slurring of speech, dysgeusia, hyperacusis, and difficulty drinking noted as the “dribbling” of a beverage. She was recently diagnosed with a viral URI three days ago and treatment consisted of rest and fluids. Ms. Ryan denies a traumatic episode, headache, vertigo, lightheadedness, tinnitus, use of oral contraceptives, and smoking of cigarettes. What is the most likely diagnosis?
a. Guillain-Barré syndrome
b. Bell’s Palsy
c. Lyme disease
d. stroke
b. Bell’s Palsy
Bell’s palsy is a disease process affecting the seventh cranial nerve leading to abrupt facial paralysis/weakness as well as the symptoms presented in the case study, which is usually unilateral and self-remitting within a few months to a year. Several possible causes have been linked to the onset or recurrence of the disease process, one of which is a recent viral infection. Obvious physical examination findings involve those structures innervated by the seventh cranial nerve. Other areas of the body are not affected with Bell’s palsy, as would be evident with Lyme disease, Guillian-Barré syndrome, and stroke. In stroke, the patient is able to wrinkle the forehead.
A thin, pale, and distraught 53-year-old man presents to the office with a chief complaint of progressive dysphagia to solids and unintentional weight loss of 25 pounds within the past month. Further questioning of the patient revealed recent hoarseness of his voice and fatigue. Lymphadenopathy of the supraclavicular regions was evident on physical examination. Which of the following is the most likely diagnosis?
a. gastroesophageal reflux disease
b. adenocarcinoma of esophagus
c. scleroderma
d. diffuse esophageal spasm
b. adenocarcinoma of esophagus
Chronic GERD may lead to hoarseness of the nice due to irritation of the larynx and is the most common predisposing factor for adenocarcinoma of the esophagus.
Chronic heartburn and dysphagia to liquids and solids are common symptoms associated with scleroderma.
Chest pain and intermittent dysphagia to solids and liquids are common symptoms of diffuse esophageal spasm.
The part of the case history describing the circumstances surrounding the patient’s primary reason for the visit is called the:
a. family history
b. history of present illness
c. personal and social history
d. past medical history
b. history of the present illness
The history of present illness is the part of the case history where the interviewer follows a step-by-step process detailing the circumstances of the patient’s chief complaint that prompted the visit.
When conducting a case history, what is the most risky type of question that the interviewer can ask?
a. open-ended question
b. direct question
c. clarifying question
d. leading question
d. leading question
Leading questions are the most risky to ask because by their format they limit the response of the patient to what he or she thinks the interviewer wants to know and does not allow the patient to elaborate, giving more detail.
Which of the following is the preferred way of inquiring about precipitating factors of a patient’s chest pain?
a. “What brings on your chest pain?”
b. “What types of activities cause your chest pain?”
c. “Is your chest pain caused by walking rapidly?”
d. “Does your chest pain occur with activity or when you are upset?”
a. “What brings on your chest pain?”
Open-ended questions are always preferable to leading questions. Asking about activities, or walking, makes the assumption that these are precipitating factors. Because patients are often eager to please the physician, leading questions may cause a patient to give an answer that is inaccurate.
A patient with joint pain tells you that his father was diagnosed with gout 20 years ago. This information is part of what type of information?
a. history of the present complaint
b. review of systems
c. past medical history
d. family history
d. family history
The information provided by the patient is about his father. The history of the present illness, review of systems, and past medical history refer to the patient.
Which of the following best describes objectivity when interviewing a patient?
a. multiple interviewers would obtain a reasonable similar history
b. the physician accurately understands and interprets the patient’s history
c. the interviewer sets aside preconceived conclusions about the patient
d. the physician is able to determine the diagnosis from the history
c. the interviewer sets aside preconceived conclusions about the patient
* Objectivity* is the physician’s skill at allowing the patient to speak without making hasty value judgments about the patient or to reach preconceived conclusions about what is wrong with the patient; the physician allows the evidence (what the patient says and how the patient behaves) to speak for itself as much as possible.
Choice “a” is an example of reliability, and “b” is an example of precision.
Which of the following is the definition of respect during a patient interview?
a. the physician behaves naturally, that is, “being herself”
b. the physician accepts the patient as he is without judgment
c. the physician understands the patient’s complaint
d. the physician feels sorry for the patient’s suffering
b. the physician accepts the patient as he is without judgment
* Respect* is generally defined as accepting people as they are, even if the patient’s values and world views differ from those of the physician.
Choice “a” is the definition of genuineness, “c” is the definition of empathy, and “d” defines sympathy.
