Test Bank For Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition

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Chapter 1 Clinical Reasoning, Differential Diagnosis, Evidence-Based Practice, and Symptom AnalysisMultiple ChoiceIdentify the choice that best completes the statement or answers the question.____1.Which type of clinical decision-making is most reliable?AIntuitiveBAnalyticalCExperientialDAugenblick____2.Which of the following is false? To obtain adequate history, health-care providers must be:AMethodical and systematicBCDAttentive to the patient’s verbal and nonverbal language Able toaccurately interpret the patient’s responses Adept at reading into thepatient’s statements____3.Essential parts of a health history include all of the following except:AChief complaintBHistory of the present illnessC.Current vital signsDAll of the above are essential history components____4.Which of the following is false?While performing the physical examination, the examiner must be able to:ADifferentiate between normal and abnormal findingsBCRecall knowledge of a range of conditions and their associated signs and symptoms Recognize howcertain conditions affect the response to other conditionsDForesee unpredictable findings____5.The following is the least reliable source of information for diagnostic statistics:AEvidence-based investigationsBPrimary reports of researchCEstimation based on a provider’s experienceDPublished meta-analyses____6.AThe following can be used to assist in sound clinical decision-making: Algorithmpublished in a peer-reviewed journal articleBClinical practice guidelinesCEvidence-based researchDAll of the above____7. If a diagnostic study has high sensitivity, this indicates a:ABCHigh percentage of persons with the given condition will have an abnormal resultLow percentage of persons with the given condition will have an abnormal result Low likelihoodof normal result in persons without a given conditionDNone of the above____8. If a diagnostic study has high specificity, this indicates a:ALow percentage of healthy individuals will show a normal result

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BCDHigh percentage of healthy individuals will show a normal resultHigh percentage of individuals with a disorder will show a normal resultLow percentage of individuals with a disorder will show an abnormal result____9.ABCDA likelihood ratio above 1 indicates that a diagnostic test showing a:Positive result is strongly associated with thediseaseNegative result is strongly associated with absence of the diseasePositive result is weakly associated with the diseaseNegative result is weakly associated with absence of the disease____10.Which of the following clinical reasoning tools is defined as evidence-based resource based onmathematicalmodeling to express the likelihood of a condition in select situations, settings, and/or patients?ABClinical practice guidelineClinical decision ruleCClinical algorithmAnswer SectionMULTIPLE CHOICE1.ANS:BCroskerry (2009) describes two major types of clinical diagnostic decision-making: intuitive and analytical.Intuitivedecision-making (similar to Augenblink decision-making) is based on the experience and intuitionof the clinician and isless reliable and paired with fairly common errors. In contrast, analytical decision-making is based on careful considerationand has greater reliability with rare errors.2.ANS:DTo obtain adequate history, providers must be well organized, attentive to the patient’s verbal and nonverballanguage, and able to accurately interpret the patient’s responses to questions. Rather than reading into the patient’sstatements, they clarify any areas of uncertainty.3.ANS:CVital signs are part of the physical examination portion of patient assessment, not part of the health history.4.ANS:DWhile performing the physical examination, the examiner must be able to differentiate between normal andabnormalfindings, recall knowledge of a range of conditions, including their associated signs andsymptoms, recognize how certainconditions affect the response to other conditions, and distinguish therelevance of varied abnormal findings.5.ANS:CSources for diagnostic statistics include textbooks, primary reports of research, and published meta-analyses. Another sourceof statistics, the one that has been most widely used and available for applicationto the reasoning process, is the estimationbased on a provider’s experience, although these are rarelyaccurate. Over the past decade, the availability of evidence onwhich to base clinical reasoning is improving,and there is an increasing expectation that clinical reasoning be based onscientific evidence. Evidence-based statistics are also increasingly being used to develop resources to facilitate clinicaldecision-making.6.ANS:DTo assist in clinical decision-making, a number of evidence-based resources have been developed to assist the clinician.Resources, such as algorithms and clinical practice guidelines, assist in clinical reasoning when properly applied.7.ANS:A

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The sensitivity of a diagnostic study is the percentage of individuals with the target condition who show anabnormal, or positive, result. A high sensitivity indicates that a greater percentage of persons with the givencondition will have an abnormal result.8.ANS:BThe specificity of a diagnostic study is the percentage of normal, healthy individuals who havea normal result. Thegreater the specificity, the greater the percentage of individuals who willhave negative, or normal, results if they donot have the target condition.9.ANS:AThe likelihood ratio is the probability that a positive test result will be associated with a personwho has the targetcondition and a negative result will be associated with a healthy person. Alikelihood ratio above 1 indicates that apositive result is associated with the disease; a likelihoodratio less than 1 indicates that a negative result isassociated with an absence of the disease.10.ANS:BClinical decision (or prediction) rules provide another support for clinical reasoning. Clinical decision rules areevidence-based resources that provide probabilistic statements regarding the likelihood that a condition exists ifcertain variables are met with regard to the prognosis of patients with specific findings. Decision rules usemathematical models and are specific to certain situations, settings, and/or patient characteristics.

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____Chapter 2 Evidence-Based Health ScreeningMultiple ChoiceIdentify the choice that best completes the statement or answers the question.1.The first step in the genomic assessment of a patient is obtaining information regarding:AFamily historyBCDEnvironmental exposuresLifestyle and behaviorsCurrent medications____2.An affected individual who manifests symptoms of a particular condition through whom a familywith a genetic disorder is ascertained is called a(n):AConsultandBCConsulbandIndex patientDProband____3.An autosomal dominant disorder involves the:AX chromosomeBY chromosomeCDMitochondrial DNA Non-sex chromosomes____4.To illustrate a union between two second cousin family members in a pedigree, draw:AArrows pointing to the male and femaleBBrackets around the male and femaleCDouble horizontal lines between the male and femaleDCircles around the male and female____5.ATo illustrate two family members in an adoptive relationship in a pedigree: Arrows aredrawn pointing to the male and femaleBBrackets are drawn around the male and femaleCDouble horizontal lines are drawn between the male and femaleDCircles are drawn around the male and female____6.When analyzing the pedigree for autosomal dominant disorders, it is common to see:ASeveral generations of affected membersBMany consanguineous relationshipsCDMore members of the maternal lineage affected than paternal Moremembers of the paternal lineage affected than maternal____7.AIn autosomal recessive (AR) disorders, individuals need:Only one mutated gene on the sex chromosomes to acquire the diseaseBOnly one mutated gene to acquire the diseaseCTwo mutated genes to acquire the diseaseDTwo mutated genes to become carriers

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____8.In autosomal recessive disorders, carriers have:ABCDTwo mutated genes; one from each parent that cause diseaseA mutation on a sex chromosome that causes a diseaseA single gene mutation that causes the diseaseOne copy of a gene mutation but not the disease____9.With an autosomal recessive disorder, it is important that parents understand that if theyboth carry amutation, the following are the risks to each of their offspring (each pregnancy):A 50% chance that offspring will carry the diseaseBCD10% chance of offspring affected by disease25%chance children will carry the disease10% chancechildren will be disease free____10.A woman with an X-linked dominant disorder will:ANot be affected by the disorder herselfBTransmit the disorder to 50 % of her offspring (male or female)CNot transmit the disorder to her daughtersDTransmit the disorder to only her daughters____11.In creating your female patient’s pedigree, you note that she and both of her sisters were affected by thesame geneticdisorder. Although neither of her parents had indications of the disorder, her paternalgrandmother and her paternalgrandmother’s two sisters were affected by the same condition. This patternsuggests:A Autosomal dominant disorderBChromosomal disorderCDMitochondrial DNA disorderX-linked dominant disorder____12.A woman affected with an X-linked recessive disorder:ABCDHas one X chromosome affected by the mutationWill transmit the disorder to all of her childrenWill transmit the disorder to all of her sonsWill not transmit the mutation to any of her daughters____13.Which of the following are found in an individual with aneuploidy?AAn abnormal number of chromosomesBAn X-linked disorderCSelect cells containing abnormal-appearing chromosomesDAn autosomal recessive disorder____14.The pedigree of a family with a mitochondrial DNA disorder is unique in that:ABCNone of the female offspring will have the diseaseAll offspring from an affected female will have diseaseNone of the offspring of an affected female will have the diseaseDAll the offspring from an affected male will havedisease____15.Which population is at highest risk for the occurrence of aneuploidy in offspring?

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ABCMothers younger than 18Fathers younger than 18Mothers over age 35DFathers over age 35____16.ABCDApproximately what percentage of cancers is due to a single-gene mutation?50% to 70%30% to 40%20% to 25%5% to 10%____17.According to the Genetic Information Nondiscrimination Act (GINA):ABCNPs should keep all genetic information of patients confidentialNPs must obtain informed consent prior to genetic testing of all patientsEmployerscannot inquire about an employee’s genetic informationDAll of the above____18.The leading causes of death in the United States are due to:AB.Multifactorial inheritanceSingle gene mutationsC.X-linked disordersDAneuploidy____19.Whichof the following would be considered a “red flag” that requires more investigation in a patientassessment?AColon cancer in family member at age70BCDBreast cancer in family member at age 75Myocardialinfarction in family member at age 35All of the above____20.When patients express variable forms of the same hereditary disorder, this is due to:APenetranceBAneuploidyCDDe novo mutationSporadic inheritance____21.Your2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures,singletransversepalmar crease, and a low nasal bridge. These are referred to as:ABVariable expressivity related to inherited diseaseDysmorphic features related to genetic diseaseCDe novo mutations of genetic diseaseDDifferent penetrant signs of genetic disease____22.In order to provide a comprehensive genetic history of a patient, the NP should:ABCAsk patients to complete a family history worksheetSeek out pathology reports related to the patient’s disorderInterviewfamily members regarding genetic disordersDAll of the above

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Answer SectionMULTIPLE CHOICE1.ANS:AA critical first step in genomic assessment, including assessment of risk, is the use of familyhistory. Family historyis consideredthe first genetic screen (Berry & Shooner 2004) and is acritical component of care because it reflectsshared geneticsusceptibilities, shared environment,and common behaviors (Yoon, Scheuner, & Khoury 2003).2.ANS:DA proband is defined as the affected individual who manifests symptoms of a particular condition through whom afamily with a genetic disorder is ascertained (Pagon et al. 1993–2013). The proband is the affected individualthat brings the family to medical attention.3.ANS:DAutosomal dominant (AD) inheritance is a result of a gene mutation in one of the 22 autosomes.4.ANS:CA consanguineous family is related by descent from a common ancestry and is defined as a“union between two individuals who are related as second cousins or closer” (Hamamy 2012). Consanguinity, ifpresent in the family history, is portrayed using two horizontal lines to establish the relationship between themale and female partners.5.ANS:BFor adopted members of the family, use brackets as the appropriate standardized pedigreesymbol ([e.g.,brackets]).6.ANS:APedigrees associated with autosomal dominant (AD) disorders typically reveal multiple affected family memberswith the diseaseor syndrome. When analyzing the pedigree for AD disorders or syndromes, it is common to see a“vertical” pattern denoting several generations of affected members.7.ANS:CIn autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copyof the genemutation from each of the parents. Autosomal recessive disorders must be inheritedthrough both parents (Nussbaumet al. 2007). Individuals who have an AR disorder have twomutated genes, one on each locus of the chromosome.Parents of an affected person are calledcarriers because each carries one copy of the mutation on one chromosomeand a normal gene onthe other chromosome. Carrierstypically are not affected by the disease.8.ANS:DIndividuals who have an AR disorder have two mutated genes, one on each allele of thechromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutationon one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease.In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutationis on an autosome.9.ANS:AIt is important that parents understand that if they both carry a mutation, the risk to each of their offspring (eachpregnancy) is an independent event: 25% disease free, 25% affected, and 50% carrier.

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10.ANS:BEveryone born with an X-linked dominant disorder will be affected with the disease.Transmission of thedisorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all heroffspring (male or female).11.ANS:DA man with an X-linked dominant disorder will transmit the mutation to 100% of his daughters(they receive his X chromosome) and none of his sons (they receive his Y chromosome). Thepedigree of a family with an X-linked dominant disorder would reveal all the daughters and noneof the sons affected with the disorder if the father has an X-linked disorder.12.ANS:CAn X-linked recessive disorder means that in a woman, both X chromosomes must have themutation if she is to be affected. Because males have only one copy of the X chromosome, theywill be affected if their X chromosome carries the mutation.13.ANS:AAn individual with an abnormal number of chromosomes has a condition called aneuploidy,which is frequently associated with mental problems or physical problems or both (Jorde, Carey,& Bamshad 2010; Nussbaum et al. 2007).14.ANS:BMitochondrial DNA is inherited from the ovum and, therefore, from the mother. The pedigree ofa family with a mitochondrial DNA disorder is unique in that all offspring (regardless of gender)of an affected female will have the disease, and none of the offspring from an affected male willhave the disease.15.ANS:CSome individuals or couples have unique identifiable risks that should be discussed prior toconception wheneverpossible. For example, women who will be 35 years of age or older at delivery (advanced maternal age) are atincreased risk for aneuploidy.16.ANS:DThe majority of cancers are sporadic or multifactorial due to a combination of genetic andenvironmental factors;however, approximately 5% to 10% of all cancers are due to a single-gene mutation (Garber & Offit 2005).17.ANS:DOn May 21, 2008, President George W. Bush signed the Genetic Information NondiscriminationAct (GINA) to protect Americans against discrimination based upon their genetic informationwhen it comes to health insurance and employment, paving the way for patient personalizedgenetic medicine without fear of discrimination (National Human Genome Research Institute2012).18.ANS:AMost disease-causing conditions are not due to a single-gene disorder but are due to multifactorialinheritance, a result of genomics and environmental or behavioral influences. In fact, the leadingcauses of mortality in the United States—heart disease,cerebrovascular disease, diabetes, and cancer—are allmultifactorial. Most congenital malformation, hypertension, arthritis, asthma, obesity, epilepsy, Alzheimer’s, and mentalhealth disorders are also multifactorial.19.ANS:CEarly onset cancer syndromes, heart disease, or dementia are red flags that warrant furtherinvestigation regardinghereditary disorders.20.ANS:ASome disorders have a range of expression from mild to severe. This variability is referred to asthe penetrance of genetic disease.For example, patients with neurofibromatosis (NF1), an AD disorder of thenervous system, may manifest with many forms of the disease. For instance, some patients with NF1 may have mildsymptoms, like café-au-lait spots or freckling on the axillary or

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skin, while others may have life-threatening spinal cord tumors or malignancy (Jorde, Carey, & Bamshad 2010;Nussbaum et al. 2007).21.ANS:BAssessing for dysmorphic features may enable identification of certain syndromes or geneticorchromosomaldisorders(Jorde,Carey,&Bamshad2010;Prichard&Korf2008).Dysmorphology is defined as “thestudy of abnormal physical development” (Jorde, Carey, &Bamshad 2010, 302).22.ANS:DAsking the patient to complete a family history worksheet prior to the appointment saves timein the visit whileoffering the patient an opportunity to contribute to the collection of anaccurate family history. Reviewing thefamily information can also help establish familyrapport while verifying medical conditions in individual familymembers. If a hereditarycondition is being considered but family medical information is unclear or unknown,requestingmedical records and pathology or autopsy reports may be warranted.

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Chapter 3 Abdominal PainMultiple ChoiceIdentify the choice that best completes the statement or answersthe question.____1. When performing abdominal assessment, the clinician should perform examination techniques in the following order:AInspection, palpation, percussion, and auscultationB.Inspection, percussion, palpation, and auscultationC.Inspection, auscultation, percussion, and palpationDAuscultation, palpation, percussion, and inspection____2. The clinician should auscultate the abdomen to listen for possible bruits of the:AAortaB.Renal arteryC.Iliac arteryDAll of the above____3. On abdominal examination, which of the following is assessed using percussion?ALiverB.KidneysC.PancreasDEsophagus____4. In abdominal assessment, a digital rectal examination is performed to assess for:AHemorrhoidsB.Prostate sizeC.Blood in stoolDUreteral stenosis____5. Rebound tenderness of the abdomen is a sign of:AConstipationB.Peritoneal inflammationC.Elevated venous pressureDPeritoneal edema____6. While assessing the abdomen, the clinician deeply palpates the left lower quadrant of the abdomen, and thiscauses pain in the patient’s right lower abdomen. This is most commonly indicative of:AConstipationB.DiverticulitisC.AppendicitisDHepatitis____7. Your patient complains of severe right lower quadrant abdominal pain. To assess the patient forperitoneal inflammation, the examiner should:A.Percuss the right lower quadrant of the abdomenB.Deeply palpate the right lower quadrant of the abdomenC.Auscultate the right lower quadrant for hyperactive bowel soundsD.Strike the plantar surface of the patient’s heel while the patient is supine

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____8.Your patient is lying supine and you ask him to raise his leg while you place resistance against the thigh.The examineris testing the patient for:APsoas signB.Obturator signC.Rovsing’s signDMurphys’ sign____9.A patient is lying supine and the clinician deeply palpates the right upper quadrant of the abdomenwhile the patientinhales. The examiner is testing the patient for:APsoas signB.Obturator signC.Rovsing’s signDMurphys’ sign____10.Your patient has abdominal pain, and it is worsened when the examiner rotates the patient’s right hipinward with theknee bent and the obturator internus muscle is stretched. This is a sign of:ADiverticulitisB.CholecystitisC.AppendicitisDMesenteric adenitis____11.On abdominal examination as the clinician presses on the right upper quadrant to assess liver size,jugular veindistension becomes obvious. Hepatojugular reflux is indicative of:AAcute hepatitisB.Right ventricular failureC.CholecystitisDLeft ventricular failure____12.Your patient demonstrates positive shifting dullness on percussion of the abdomen. This is indicative of:ACholecystitisB.AppendicitisC.AscitesDHepatitis____13.Your 44-year-old female patient complains of right upper quadrant pain. Her skin and sclera are yellow,and she hashyperbilirubinemia and elevated liver enzymes. The clinician should suspect:AAcute pancreatitisB.Biliary duct obstructionC.Acute hepatitisDAtypical appendicitis____14.The most common cause of acute pancreatitis is:ATraumaB.Hepatitis virus AC.HyperlipidemiaDAlcohol abuse____15.Your patient with pancreatitis has a Ranson rule score of 8. The clinician should recognize that this is a risk of:

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APleural involvementB.AlcoholismC.High mortalityDBile duct obstruction____16.Your patient complains of left upper quadrant pain, fever, extreme fatigue, and spontaneous bruising.The clinicianshould recognize that these symptoms are often related to:AHematopoetic disordersB.HepatomegalyC.Esophageal varicesDPleural effusion____17.A 16-year-old patient presents with sore throat, cervical lymphadenopathy, fever, extreme fatigue, and left upperquadrantpain. The physical examination reveals splenomegaly. The clinician should recognize the probability of:ABacterial endocarditisB.Infectious mononucleosisC.Pneumonia with pleural effusionDPancreatic cancer____18.Your patient complains of lower abdominal pain, anorexia, extreme fatigue, unintentional weight loss of 10 pounds inlast 3weeks, and you find a positive hemoccult on digital rectal examination. Laboratory tests show iron deficiency anemia. Theclinician needs to consider:ADiverticulitisB.AppendicitisC.Colon cancerDPeptic ulcer disease____19.Which of the following is the most common cause of heartburn-type epigastric pain?ADecreased lower esophageal sphincter toneB.Helicobacteria pylori infection of stomachC.Esophageal spasmDExcess use of NSAIDs____20.A 22-year-old female enters the emergency room with complaints of right lower quadrant abdominal pain,which hasbeen worsening over the last 24 hours. On examination of the abdomen, there is a palpable mass andrebound tenderness over theright lower quadrant. The clinician should recognize the importance of:ADigital rectal examinationB.EndoscopyC.UltrasoundDPelvic examination____21.The major sign of ectopic pregnancy is:A.Sudden onset of severe epigastric painB.Amenorrhea with unilateral lower quadrant painC.Lower back and rectal painD.Palpable abdominal mass____22.When ruptured ectopic pregnancy is suspected, the following procedure is most important:ACuldocentesis

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B.CT scanC.Abdominal x-rayDDigital rectal examination____23.The majority of colon cancers are located in the:ATransverse colonB.CecumC.Rectosigmoid regionDAscending colon____24.The following symptom(s) in the patient’s history should raise the clinician’s suspicion of colon cancer:AAlternating constipation and diarrheaB.Narrowed caliber of stoolC.HematocheziaDAll of the above____25.A patient presents to the emergency department with nausea and severe, colicky back pain that radiatesinto the groin.When asked to locate the pain, he points to the right costovertebral angle region. His physicalexamination is unremarkable.Which of the following lab tests is most important for the diagnosis?AUrinalysisB.Serum electrolyte levelsC.Digital rectal examDLumbar x-ray____26.Your 34-year-old female patient complains of a feeling of “heaviness” in the right lower quadrant, achiness, andbloating.On pelvic examination, there is a palpable mass in the right lower quadrant. Urine and serum pregnancy tests arenegative.The diagnostic tool that would be most helpful is:ADigital rectal examB.Transvaginal ultrasoundC.Pap smearDUrinalysis____27.Your 54-year-old male patient complains of a painless “lump” in his lower left abdomen that comes andgoes for thepast couple of weeks. When examining the abdomen, you should have the patient:ALie flat and take a deep breathB.Stand and bear down against your handC.Prepare for a digital rectal examinationDLie in a left lateral recumbent position____28.A nurse practitioner reports that your patient’s abdominal x-ray demonstrates multiple air-fluid levelsin the bowel.This is a diagnostic finding found in:AAppendicitisB.CholecystitisC.Bowel obstructionDDiverticulitis

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____29.A76-year-oldpatient presents to the emergency department with severe left lower quadrant abdominal pain,diarrhea, and fever. On physical examination, you note the patient has a positive heel strike, and left lowerabdominal rebound tenderness. These are typical signs and symptoms of which of the following conditions?ADiverticulitisB.SalpingitisC.Inflammatory bowel diseaseDIrritable bowel syndrome____30. Which of the following conditions is the most common cause of nausea, vomiting, and diarrhea?AViral gastroenteritisB.Staphylococcal food poisoningC.Acute hepatitis ADE.coli gastroenteritis____31.A patient presents to the emergency department with complaints of vomiting and abdominal pain. You note that the emesiscontains bile. On physical examination, there is diffuse tenderness, abdominal distension, and rushing, high-pitched bowelsounds. Which of the following diagnoses would be most likely?AGastric outlet obstructionB.C.Small bowel obstructionDistal intestinal blockageDColonic obstruction____32.Your 5-year-old female patient presents to the emergency department with sore throat, vomiting, ear ache, 103 degree fever,photophobia, and nuchal rigidity. She has an episode of projectile vomiting while you are examining her. The clinician shouldrecognize that the following should be done:AAbdominal x-rayB.Fundoscopic examinationC.Lumbar punctureDAnalysis of vomitus____33.A 9-year-old boy accompanied by his mother reports that since he came home from summer camp, he has had fever,nausea, vomiting, severe abdominal cramps and watery stools that contain blood and mucus. The clinician should recognizethe importance of:A.Stool for ova and parasitesB.Abdominal x-rayC.Stool for clostridiumD.Fecal occult blood test____34.A 56-year-old male complains of anorexia, changes in bowel habits, extreme fatigue, and unintentional weight loss. Attimes he is constipated and other times he has episodes of diarrhea. His physical examination is unremarkable. It is important forthe clinician to recognize the importance of:ACBC with differentialB.Stool culture and sensitivityC.Abdominal x-rayDColonoscopy____35.A 20-year-old engineering student complains of episodes of abdominal discomfort, bloating, and episodes of diarrhea. Thesymptoms usually occur after eating, and pain is frequently relieved with bowel movement. She is on a “celiac diet” and theepisodic symptoms persist. Physical examination and diagnostic tests are negative. Colonoscopy is negative for anyabnormalities. This is a history and physical consistent with:AInflammatory bowel disease

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B.Irritable bowel syndromeC.Laxative abuseDNorovirus gastroenteritis____36.A 78-year-old female patient is suffering from heart failure, GERD, diabetes, and depression. Shepresents with complaints of frequent episodes of constipation. Her last bowel movement was 1 week ago. Uponexamination, you palpate a hard mass is the left lower quadrant of the abdomen. You review her list ofmedications. Which of the following of her medications cause constipation?ADigitalis (Lanoxin)B.Amlodipine (Norvasc)C.Sertraline (Zoloft)DMetformin (Glucophage)____37.You are examining a 55-year-old female patient with a history of alcohol abuse. She complains ofanorexia, nausea, pruritus, and weight loss over the last month. On physical examination, you note yellow hue ofthe skin and sclera. Which of the following physical examination techniques is most important?AScratch testB.Heel strikeC.Digital rectal examinationDPelvic examination____38.You observe Charcot’s triad of sign and symptoms in a patient under your care. This is commonly seen inwhich of the following disorders?ACirrhosisB.PancreatitisC.CholangitisDPortal hypertension____39.A 59-year-old patient with history of alcohol abuse is admitted for hematemesis. On physicalexamination, you note ascites and caput medusa. A likely cause for the hematemesis is:APeptic ulcer diseaseB.Barrett’s esophagusC.PancreatitisDEsophageal varices____40.A 16-year-old female with anorexia and bulimia is admitted for hematemesis. She admits to inducing vomiting often. Onphysical examination, you note pallor, BMI less than 15, and hypotension. A likely reason for hematemesis is:AMallory-Weiss tearB.CirrhosisC.Peptic ulcer diseaseDEsophageal varies____41.An 82-year-old female presents to the emergency department with epigastric pain and weakness. Sheadmits to having dark, tarry stools for the last few days. She reports a long history of pain due to osteoarthritis. Sheself-medicates daily with ibuprofen, naprosyn, and aspirin for joint pain. On physical examination, she hasorthostatic hypotension and pallor. Fecal occult blood test is positive. A likely etiology of the patient’s problem is:AMallory-Weiss tearB.Esophageal varices

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