Bates’ Guide to Physical Examination and History Taking 12th Edition – Test Bank

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Bates’ Guide to Physical Examination and History Taking, 12th Edition

 

 

Chapter 3: Interviewing and the Health History

 

 

 

 

Multiple Choice

 

 

 

 

1. You are running late after your quarterly quality improvement meeting at the hospital and have just gotten paged from the nurses’ station because a family member of one of your patients wants to talk with you about that patient’sYou have clinic this afternoon and are

double-booked for the first appointment time; three other patients also have arrived and are sitting in the waiting room. Which of the following demeanors is a behavior consistent with skilled interviewing when you walk into the examination room to speak with your first clinic patient?

1. Irritability
2. Impatience
3. Boredom
4. Calm

 

Ans:    D Chapter:     03

 

Feedback:     The appearance of calmness and patience, even when time is limited, is the hallmark of a skilled interviewer.

 

 

 

 

2. Suzanne, a 25 year old, comes to your clinic to establish You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient–provider interview?
3. Establish the agenda, negotiate a plan, establish rapport, and invite the patient’s
4. Invite the patient’s story, negotiate a plan, establish the agenda, and establish
5. Greet the patient, establish rapport, invite the patient’s story, establish the agenda, expand and clarify the patient’s story, and negotiate a
6. Negotiate a plan, establish an agenda, invite the patient’s story, and establish

 

Ans:    C Chapter:      03

 

Feedback:     This is the most productive sequence for the interview. Greeting patients and establishing rapport allows them to feel more comfortable before “inviting” them to relate their story. After hearing the patient’s story, together you establish the agenda regarding the most important items to expand upon. At the end, together you negotiate the plan of diagnosis and treatment.

 

 

 

 

3. Alexandra is a 28-year-old editor who presents to the clinic with abdominal The pain is a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and it seems to be worse a couple of hours after eating. She has noticed that it starts after eating greasy foods, so she has cut down on these as much as she can. Initially it occurred once a week, but now it is occurring every other day. Nothing makes it better. From this description, which of the seven attributes of a symptom has been omitted?
4. Setting in which the symptom occurs
5. Associated manifestations
6. Quality
7. Timing

 

Ans:    B Chapter:      03

 

Feedback:     The interviewer has not recorded whether or not the pain has been accompanied by nausea, vomiting, fever, chills, weight loss, and so on. Associated manifestations are additional symptoms that may accompany the initial chief complaint and that help the examiner to start refining his or her differential diagnosis.

 

 

 

 

4. Jason is a 41-year-old electrician who presents to the clinic for evaluation of shortness of The shortness of breath occurs with exertion and improves with rest. It has been going on for several months and initially occurred only a couple of times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than a dozen times per day. The shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea.

Which of the following symptom attributes was not addressed in this description?

1. Severity
2. Setting in which the symptom occurs
3. Timing
4. Associated manifestations Ans: A

 

Chapter:     03

 

Feedback:     The severity of the symptom was not recorded by the interviewer, so we have no understanding as to how bad the symptom is for this patient.  The patient could have been asked to rate his pain on a 0 to 10 scale or used one of the other standardized pain scales available.

This allows the comparison of pain intensity before and after an intervention.

 

 

 

 

5. You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary Which of the following techniques is not a component of adaptive questioning?
6. Directed questioning: starting with the general and proceeding to the specific in a manner that does not make the patient give a yes/no answer
7. Reassuring the patient that the urinary symptoms are benign and that she doesn’t need to worry about it being a sign of cancer
8. Offering the patient multiple choices in order to clarify the character of the urinary symptoms that she is experiencing
9. Asking her to tell you exactly what she means when she states that she has a urinary tract infection

 

Ans:    B Chapter:      03

 

Feedback:     Reassurance is not part of clarifying the patient’s story; it is part of establishing rapport and empathizing with the patient.

 

 

 

 

6. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to be checked out for the symptom of chest pain. As you listen to him describe his symptom in more detail, you say “Go on,” and later, “Mm-hmmm.” This is an example of which of the following skilled interviewing techniques?
7. Echoing
8. Nonverbal communication
9. Facilitation
10. Empathic response

 

Ans:    C Chapter:      03

 

Feedback:     This is an example of facilitation. Facilitation can be posture, actions, or words that encourage the patient to say more.

 

 

 

 

7. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and doesn’t say anything in response to your question. This is an example of which type of challenging patient?
8. Talkative patient
9. Angry patient
10. Silent patient
11. Hearing-impaired patient

 

Ans:    C Chapter:      03

 

Feedback:     This is one example of a silent patient. There are many possibilities for this patient’s silence: depression, dementia, the manner in which you asked the question, and so on.

 

 

 

 

8. T. comes for her regular visit to the clinic. She is on your schedule because her regular provider is on vacation and she wanted to be seen. You have heard about her many times from your colleague and are aware that she is a very talkative person. Which of the following is a helpful technique to improve the quality of the interview for both the provider and the patient?
9. Allow the patient to speak uninterrupted for the duration of the
10. Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told
11. Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the
12. Allow your impatience to show so that the patient picks up on your nonverbal cue that the appointment needs to

 

Ans:    B Chapter:      03

 

Feedback:     You can also say, “I want to make sure I take good care of this problem because it is very important.          We may need to talk about the others at the next appointment.                                                                   Is that okay with you?”         This is a technique that can help you to change the subject but, at the same time, validate the patient’s concerns; it also can provide more structure to the interview.

 

 

 

 

9. H. comes to your clinic, wanting antibiotics for a sinus infection. When you enter the room, she appears to be very angry. She has a raised tone of voice and states that she has been

 

waiting for the past hour and has to get back to work. She states that she is unimpressed by the reception staff, the nurse, and the clinic in general and wants to know why the office wouldn’t call in an antibiotic for her. Which of the following techniques is not useful in helping to calm this patient?

1. Avoiding admission that you had a part in provoking her anger because you were late
2. Accepting angry feelings from the patient and trying not to get angry in return
3. Staying calm
4. Keeping your posture relaxed

 

Ans:    A Chapter:     03

 

Feedback:     In this scenario, the provider was 1 hour late in seeing the patient. The provider should acknowledge that he was late and apologize for this, no matter the reason for being late. It often helps to acknowledge that a patient’s anger with you is understandable and that you might be angry in a similar situation.

 

 

 

 

10. A 23-year-old graduate student comes to your clinic for evaluation of a urethral As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information?
11. Are you sexually active?
12. When was the last time you had intimate physical contact with someone, and did that contact include sexual intercourse?
13. Do you have sex with men, women, or both?
14. How many sexual partners have you had in the last 6 months?

 

Ans:    A Chapter:     03

 

Feedback:     This is inappropriate because it is too vague. Given the complaint, you should probably assume that he is sexually active. Sometimes patients may respond to this question with the phrase “No, I just lie there.”     A specific sexual history will help you to assess this patient’s risk for other sexually transmitted infections.

 

 

 

 

11. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has come to the office many times in the past with a variety of injuries, and you suspect that he has a problem with alcohol. Which one of the following questions will be most helpful in diagnosing this problem?
12. You are an alcoholic, aren’t you?
13. When was your last drink?

 

1. Do you drink 2 to 3 beers every weekend?
2. Do you drink alcohol when you are supposed to be working?

 

Ans:    B Chapter:      03

 

Feedback:     This is a good opening question that is general and neutral in tone; depending on the timing, you will be able to ask for more specific information related to the patient’s last drink.

The others will tend to stifle the conversation because they are closed-ended questions.      Answer D implies negative behavior and may also keep the person from sharing freely with you.

 

 

 

 

12. On a very busy day in the office, Donelan, who is 81 years old, comes for her usual visit for her blood pressure. She is on a low-dose diuretic chronically and denies any side effects.           Her blood pressure is 118/78 today, which is well-controlled.     As you are writing her script, she mentions that it is hard not having her husband Bill around anymore. What would you do next?
13. Hand her the script and make sure she has a 3-month follow-up
14. Make sure she understands the
15. Ask why Bill is not
16. Explain that you will have more time at the next visit to discuss

 

Ans:    C Chapter:      03

 

Feedback:     Sometimes, the patient’s greatest need is for support and empathy.     It would be inappropriate to ignore this comment today.                    She may have relied heavily upon Bill for care and may be in danger.           She may be depressed and even suicidal, but you will not know unless you discuss this with her.       Most importantly, you should empathize with her by saying something like “It must be very difficult not to have him at home” and allow a pause for her to answer.

You may also ask “What did you rely on him to do for you?” Only a life-threatening crisis with another patient should take you out of her room at this point, and you may need to adjust your office schedule to allow adequate time for her today.

 

 

 

 

13. A patient is describing a very personal part of her history very quickly and in great How should you react to this?
14. Write down as much as you can, as quickly as
15. Ask her to repeat key phrases or to pause at regular intervals, so you can get almost every
16. Tell her that she can go over the notes later to make sure they are
17. Push away from the keyboard or put down your pen and

 

 

Ans:    D Chapter:     03

 

Feedback:     This is a common event in clinical practice. It is much more important to listen actively with good eye contact at this time than to document the story verbatim.                    You want to minimize interruption (e.g., answer B).     It is usually not appropriate to ask a patient to go over the written notes, but it would be a good idea to repeat the main ideas back to her. You should be certain she has completed her story before doing this.                                      By putting down your pen or pushing away from the keyboard, you let the patient know that her story is the most important thing to you at this moment.

 

 

 

 

14. You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire rightShe cannot speak (aphasia).         You are supposed to examine her.                                        You notice that the last examiner left her socks at the bottom of the bed, and although sensitive areas are covered by a sheet, the blanket is heaped by her feet at the bottom of the bed.     What would you do next?
15. Carry out your examination, focusing on the neurologic portion, and then cover her
16. Carry out your examination and let the nurse assigned to her “put her back ”
17. Put her socks back on and cover her completely before beginning the
18. Apologize for the last examiner but let the next examiner dress and cover

 

Ans:    C Chapter:      03

 

Feedback:     It is crucial to make an effort to make a patient comfortable.     In this scenario, the patient can neither speak nor move well.           Take a moment to imagine yourself in her situation. As a matter of respect as well as comfort, you should cover the patient appropriately and consider returning a little later to do your examination if you feel she is cold. While it is her nurse’s job to keep her comfortable, it is also your responsibility, and you should do what you can.                                    It is unacceptable to leave the patient in the same state in which you found her.

 

 

 

 

15. When you enter your patient’s examination room, his wife is waiting there with Which of the following is most appropriate?
16. Ask if it’s okay to carry out the visit with both people in the
17. Carry on as you would The permission is implied because his wife is in the room with him.
18. Ask his wife to leave the room for reasons of
19. First ask his wife what she thinks is going

 

Ans:    A Chapter:     03

 

Feedback:     Even in situations involving people very familiar with each other, it is important to respect individual privacy.       There is no implicit consent merely because he has allowed his wife to be in the room with him.        On the other hand, it is inappropriate to assume that his wife should leave the room.  Remember, the patient is the focus of the visit, so it would be appropriate to allow him to control who is in the room with him and        inappropriate to address his wife first.

Although your duty is to the patient, you may get optimal information by offering to speak to both people confidentially.          This situation is analogous to an adolescent’s visit.

 

 

 

 

16. A patient complains of knee pain on your arrival in the What should your first sentence be after greeting the patient?
17. How much pain are you having?
18. Have you injured this knee in the past?
19. When did this first occur?
20. Could you please describe what happened?

 

Ans:    D Chapter:     03

 

Feedback: When looking into a complaint, it is best to start with an invitation for the patient to tell you in his or her own words.   More specific questions should be used later in the interview to fill in any gaps.

 

 

 

 

17. You have just asked a patient how he feels about his He becomes silent, folds his arms across his chest and leans back in his chair, and then replies, “It is what it is.” How should you respond?
18. “You seem bothered by this ”
19. “Next, I would like to talk with you about your smoking ”
20. “Okay, let’s move on to your other ”
21. “You have adopted a practical attitude toward your ”

 

Ans:    A Chapter:     03

 

Feedback:     You have astutely noted that the patient’s body language changed at the time you asked this question, and despite the patient’s response, you suspect there is more beneath the surface.      Maybe he is afraid of being browbeaten about his smoking, maybe a relative has recently died from this disorder, or maybe a friend told him 20 years ago that he would

 

eventually get emphysema.     Regardless, by sharing your observation and leaving a pause, he may begin to talk about some issues which are very important to him.

 

 

 

 

18. A patient tells you about her experience with prolonged therapy for her breast You comment, “That must have been a very trying time for you.”       What is this an example of?
19. Reassurance
20. Empathy
21. Summarization
22. Validation

 

Ans:    D Chapter:     03

 

Feedback:     This is an example of validation to legitimize her emotional experience.     “Now that you have had your treatment, you should not have any further troubles” is an example of reassurance.                                                     “I understand what you went through because I am a cancer survivor myself” is an example of empathy.                                                          “So, you have had a lumpectomy and multiple radiation treatments” is an example of summarization as applied to this vignette.

 

 

 

 

19. You are performing a young woman’s first pelvic You make sure to tell her verbally what is coming next and what to expect.   Then you carry out each maneuver of the examination.  You let her know at the outset that if she needs a break or wants to stop, this is possible.                                                        You ask several times during the examination, “How are you doing, Brittney?”   What are you accomplishing with these techniques?
20. Increasing the patient’s sense of control
21. Increasing the patient’s trust in you as a caregiver
22. Decreasing her sense of vulnerability
23. All of the above

 

Ans:    D Chapter:     03

 

Feedback: These techniques minimize the effects of transitions during an examination and empower the patient. Especially during a sensitive examination, it is important to give the patient as much control as possible.

 

 

 

 

20. When using an interpreter to facilitate an interview, where should the interpreter be

 

positioned?

1. Behind you, the examiner, so that the lips of the patient and the patient’s nonverbal cues can be seen
2. Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of the patient
3. Between you and the patient so all parties can make the necessary observations
4. In a corner of the room so as to provide minimal distraction to the interview Ans: B

Feedback:     Interpreters are invaluable in encounters where the examiner and patient do not speak the same language, including encounters with the deaf.       It should be noted that deaf people from different regions of the world use different sign languages.            The priority is for you to have a good view of the patient.    Remember to use short, simple phrases while speaking directly to the patient and ask the patient to repeat back what he or she understands.