Deck 16: Nonspecific Complaints

Question 1

A 67-year-old male with a smoking history of 120-pack years complains of fatigue with exertion, shortness of breath, chronic cough, and wheezing. On physical examination, the patient shows barrel-shaped chest, prolonged exhalation, circumoral cyanosis, and wheezing throughout both lung fields. His heart has a regular rate and rhythm of 80 beats/min. The abdomen is obese and nontender. Extremities show no significant findings. No neurological deficits. Arterial blood gases reveal acidosis. These signs and symptoms are characteristic of:

A) Congestive heart failure
B) Chronic obstructive pulmonary disease
C) Asthma
D) Lung cancer

Answer 1

Chronic obstructive pulmonary disease

Question 2

A 45-year-old female complains of feeling extremely anxious, fatigued, and has a loss of enjoyment of previously engaging activities. She has a difficult time arising from bed in the morning to go to work. She has lost her appetite, cannot sleep, and has trouble "thinking straight." On physical examination, there are no significant findings. These signs and symptoms are characteristic of:

A) The presence of a malignancy
B) Clinical depression
C) Hypothyroidism
D) Adrenal insufficiency

Answer 2

Clinical depression

Question 3

A 44-year-old female comes in for a physical examination. She complains of having trouble losing weight, excessive fatigue, sluggishness, and loss of excessive blood with menses. On physical examination, there are no significant findings, except her body mass index of 28 is in the overweight category. What other question(s) would assist in the diagnosis?

A) Is there a history of thyroid disorders in the family?
B) Do you feel excessively cold or hot when others are not?
C) Have you had a recent upper respiratory infection?
D) A and B

Answer 3

A and B

Question 4

A 23-year-old female complains of episodes of blurry vision, and numbness and tingling in the left foot. When the foot falls asleep, the patient feels imbalanced and a gait disturbance develops, making the patient fall. The patient has a medical-surgical history of appendectomy at age 10. Otherwise, the patient has no history of illness and takes no medications. She denies use of tobacco or alcohol. On physical examination, vital signs are: temperature 98°F, respirations 18 breaths/min, pulse 66 beats/min, and blood pressure 110/60. Vision: 20/20 os, 20/20 od, and 20/20 ou. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities: skin is pink, cool to touch, and intact bilaterally. Left and right quadriceps muscle strength 5/5. Deep tendon reflexes left and right are positive 2/4. No clonus. Negative Homan's and Babinski's signs. Sensation to pinprick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally. No neurological deficits. The following disorder(s) should be considered in the diagnosis:

A) Multiple sclerosis
B) Peripheral vascular disease
C) Restless legs syndrome
D) None of the above

Question 5

To evaluate pain, the following objective scales are used:

A) Visual analog scale
B) Verbal rating scale
C) McGill questionnaire
D) All of the above

Question 6

A 45-year-old female complains of recent weight gain, amenorrhea for 3 months, and bruising. No current medications. Medical and surgical history positive for cholecystectomy at age 41. On review of systems, the patient reveals hair growth on face, acne, and easy bruisability. Vital signs are: afebrile, pulse 80 beats/min, respirations 12 breaths/min, blood pressure 148/92. Physical examination shows abdominal obesity and striae over abdomen. Which of the following questions is most helpful toward a differential diagnosis?

A) Have you used corticosteroids in the last month?
B) How much weight have you gained in the last 3 months?
C) Have you had any bleeding episodes, such as nosebleeds or gums bleeding?
D) Is cancer in the family history?

Question 7

A 54-year-old male complains of loss of appetite, weakness, fatigue, and unintentional weight loss of 10 pounds over the last month. His wife recommended that he get a physical examination. On physical examination, you do not find significant signs of a specific disorder. The complete blood count with differential shows anemia. A serum metabolic panel has all normal findings. Which diagnostic test(s) would you recommend to obtain more information?

A) Cystoscopy
B) Digital rectal exam
C) Colonoscopy
D) B and C

Question 8

A 28-year-old male complains of fever of 101°F to 103°F for the last week. He reports fatigue, no appetite, sore throat, 7-pound weight loss in the last week, and two episodes of nosebleeds. The patient reports no medical problems and no current medications. Surgical history is tonsillectomy at 5 years old. Paternal family history of hypertension and diabetes; father alive at age 50. Maternal history: no significant disorders. Denies use of tobacco; occasional alcohol use on weekends. Denies unsafe sex. No recent travel. On review of systems, night sweats and dyspnea on exertion are noted. Which of the following should be considered in the differential diagnosis?

A) HIV infection
B) Hematological malignancy
C) Thrombocytopenia
D) Tuberculosis

Question 9

When assessing a patient who complains of muscle weakness, the clinician should assess if there is specifically:

A) Bilateral or unilateral muscle weakness
B) Proximal versus distal muscle weakness
C) Upper extremity and/or lower extremity weakness
D) All of the above

Question 10

There is a high risk of respiratory depression with administration of an opiate medication in patients with:

A) Chronic obstructive pulmonary disease
B) Congestive heart failure
C) Obstructive sleep apnea
D) A and C

Question 11

A patient with Crohn's disease complains of extreme muscle weakness, fatigue, diarrhea, bruising, 10-pound weight loss over the last few weeks, and dyspnea on exertion. On physical examination, the patient is afebrile, pulse 110 beats/min, respirations 20 breaths/min, and blood pressure 100/50. Body mass index is 15. The patient is pale and frail looking, with bilateral ankle edema and bruises noted on cachectic thighs. Which of the following diagnostic tests is most helpful in the diagnosis of intestinal malabsorption?

A) Liver enzymes
B) Vitamin B₁₂ assay
C) Stool for fat
D) International normalized ratio

Question 12

A 15-year-old male presents to the clinic with fatigue, weakness, and sore throat for 4 days. The patient has no significant medical or surgical history. On physical examination, there is fever of 102°F, erythematous pharynx and tonsillar enlargement, and prominent cervical lymphadenopathy. Heart has a regular rate and rhythm. Lungs are clear to auscultation. Abdomen examination demonstrates left upper quadrant tenderness to deep palpation and splenomegaly. Extremities show no significant findings. No neurological deficits. These signs and symptoms are characteristic of:

A) Beta-hemolytic streptococcal infection
B) Scarlet fever
C) Infectious mononucleosis
D) Human immunodeficiency viral infection

Question 13

A 66-year-old female presents with fatigue, shortness of breath with exertion, cough, and swelling of the ankles. Current medications include lipid-lowering medication for hyperlipidemia and beta blocker for hypertension. On physical examination, vital signs are: temperature 98°F, respirations18 breaths/min, pulse 56 beats/min, and blood pressure 100/60. Heart demonstrates S₃ gallop and S₄. Lungs reveal bilateral basilar crackles. Abdomen is distended with shifting dullness and hepatomegaly. Extremities show bilateral ankle edema. No neurological deficits. These signs and symptoms are characteristic of:

A) Chronic renal failure
B) Congestive heart failure
C) Metabolic syndrome
D) Liver failure

Question 14

A 33-year-old female complains of episodes of weakness of the left side of the face and double vision. Drooping of the left eyelid and weakness of the jaw muscle develops gradually throughout the day, and it is worse at night than the morning. The patient has a medical-surgical history of cholecystectomy at age 30. Otherwise, the patient has no history of illness and takes no medications. She denies use of tobacco or alcohol. On physical examination, vital signs are: temperature 98°F, respirations 18 breaths/min, pulse 66 beats/min, and blood pressure 110/60. Ptosis of the left eyelid is noted. Vision: 20/20 os, 20/20 od, and 20/20 ou. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities: skin is pink, cool to touch, and intact bilaterally. Left and right quadriceps muscle strength 5/5. Deep tendon reflexes left and right +2/4. No clonus. Negative Homan's and Babinski's signs. Sensation to pinprick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally. Eyelids: left-sided ptosis. No facial droop. Left and right cheek sensation to pinprick and cotton ball intact. Masseter muscle: 2/5 on left versus 5/5 on right. Extraocular muscles intact. Gag reflex: uvula midline gag intact. Shrug and sternocleidomastoid muscle strength 5/5 bilaterally. Tongue: midline and strength 5/5 bilaterally. The following disorder(s) should be considered in the diagnosis:

A) Bell's palsy
B) Stroke
C) Myasthenia gravis
D) Multiple sclerosis

Question 15

A 22-year-old female patient complains of excessive thirst, feeling shaky when she misses meals, and increased frequency of urination. Family history is positive for cardiovascular disease, cerebrovascular disease, and diabetes. The patient denies use of tobacco, alcohol, or other drugs. She takes no medication. Daily diet is fast food, and the patient does not exercise regularly. On physical examination, there are no significant findings except obesity, demonstrated by a body mass index of 35 and blood pressure of 145/90. The signs and symptoms are characteristic of:

A) Type 2 diabetes mellitus
B) Chronic fatigue syndrome
C) Cushing's disease
D) Clinical depression

Question 16

A 66-year-old female complains of fatigue and a burning and itching feeling in the legs. The patient reports that the leg problem occurs during sleep and awakens her during the night. Current medications include: ACE inhibitor, Wellbutrin, and Prilosec. Denies use of tobacco or alcohol. History of hypertension, gastroesophageal reflux disease, and depression. On physical examination, vital signs are: temperature 98°F, respirations 18 breaths/min, pulse 66 beats/min, and blood pressure 110/60. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities: skin is pink, cool to touch, and intact bilaterally. Positive Hallux valgus bilaterally. Left and right quadriceps muscle strength 5/5. Deep tendon reflexes left and right +3/4. No clonus. Negative Homan's and Babinski's signs. Sensation to pin prick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally. No neurological deficits. These signs and symptoms are characteristic of:

A) Peripheral vascular disease
B) Restless legs syndrome
C) Peripheral neuropathy
D) All of the above

Question 17

A 34-year-old male complains of extreme fatigue and weakness, lightheadedness, anorexia, and unintentional weight loss of 20 pounds over the last month. The patient has a history of tuberculosis as a child from age 4. Current tuberculin purified protein derivative is pending. On physical examination, the patient is afebrile, with heart rate 110 beats/min., respirations 18 breaths/min, and blood pressure 100/50. He has a tanned complexion, is thin and frail looking, and looks younger than his stated age. His heart presents with tachycardia and a regular rhythm. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities show no significant findings. No neurological deficits. Chest x-ray demonstrates an area of scar tissue. These signs and symptoms are characteristic of:

A) Congestive heart failure
B) Active tuberculosis
C) Cushing's disease
D) Addison's disease

Question 18

A 45-year-old female patient complains of nausea, vomiting, fatigue, and weakness. She admits to a history of heroin abuse for 11 years. She quit using the drug after rehabilitation last year and denies current use of the drug. Habits include use of alcohol (four to five drinks daily) and tobacco use of 60-pack years. On physical examination, she is afebrile, has a blood pressure of 148/98, pulse 78 beat/min, and respirations 16 breaths/min. The patient has periorbital edema. Lungs are clear to auscultation. Abdomen is nontender and distended with mild hepatomegaly. No neurological deficits. Laboratory testing reveals Hgb 10, BUN 60, potassium 6.1, and serum creatinine 2.9 mg/dL. These findings are characteristic of:

A) Chronic renal failure
B) Dehydration
C) Congestive heart failure
D) Liver failure

Question 19

A 32-year-old morbidly obese male complains of excessive fatigue, snoring, and awakening in the middle of the night, which prevents restorative sleep. He is sluggish during the day due to the lack of sleep and feels like he is going to fall asleep at the wheel when driving to work. Occupation: dishwasher. Medical history includes hypertension and type 2 diabetes. Current medications include ACE inhibitor and metformin. He denies use of alcohol, tobacco, or drugs. On physical examination, the patient is afebrile, pulse 88 beats/min, respirations 20 breaths/min, blood pressure 178/95. Body mass index is 45. These are signs and symptoms of:

A) Obstructive sleep apnea
B) Primary insomnia
C) Heart failure
D) All of the above

Question 20

Which of the following disorders is associated with unintentional weight loss?

A) Clinical depression
B) Hyperthyroidism
C) Diabetes
D) All of the above

Question 21

In which of the following dysrhythmias does the patient commonly complain of feelings of palpitations?

A) Supraventricular tachycardia
B) Premature ventricular contraction
C) Atrial fibrillation
D) A and B

Question 22

A 57-year-old female complains of fatigue, muscle weakness, palpitations, nervousness, and insomnia for the last few weeks. She thought she was just experiencing stress from her husband's recent stroke 1 month ago. There are no current medications. Past medical history includes cholecystectomy at age 45; D&C at age 50. On physical examination, the patient is afebrile, pulse 102 beats/min, respirations18 breaths/min, blood pressure 156/98. Physical examination reveals tremulousness and quadriceps weakness bilaterally +4/5. Which of the following diagnostic tests is a priority in the work-up?

A) ACTH challenge test
B) Thyroid-stimulating hormone
C) Atrial fibrillation
D) Fasting blood glucose

Question 23

A 77-year-old female patient presents with increasing muscle weakness and numbness in both lower legs over the last week. She presents using crutches and with her daughter for walking assistance. The patient had influenza 3 weeks ago and was treated with amantadine. The patient denies recent trauma. Current medications include a beta blocker and ACE inhibitor. She denies use of tobacco or alcohol. On physical examination, the patient is alert and oriented x 3, afebrile, pulse 66 beats/min, respirations 16 breaths/min, blood pressure 110/70. Neck: no jugular venous distention, no thyromegaly, no bruits over carotid arteries. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is nontender with no organomegaly. Extremities: skin is pink, cool to touch, and intact bilaterally. Hand grip strength: 5/5 bilaterally. Biceps deep tendon reflex +2/4 bilaterally. Left and right quadriceps muscle strength 4/5. Patella reflex 1/4 bilaterally. Achilles reflex 1/4 bilaterally. Ankle strength R +3/5 and L +3/5. Sensation to pinprick and cotton ball intact in face and upper extremities and bilaterally equal. Sensation to pinprick and cotton ball decreased in feet bilaterally. Dorsalis pedis pulses +1/4 bilaterally. Negative Homan's and Babinski's signs. The following disorder(s) should be high priority in the differential diagnosis:

A) Amyotrophic lateral sclerosis
B) Guillain-Barré syndrome
C) Polymyositis
D) Multiple sclerosis

Question 24

Which of the following assists in the diagnosis of myasthenia gravis?

A) Tensilon test
B) Tinel's sign
C) McGill questionnaire
D) ACTH challenge test