The NP certification exams are a test of a broad-based knowledge base needed for practice. Since appropriate assessment is an important component of NP practice, a significant portion of the certification exams reflects this content. You might be tempted to think of studying for the assessment portion by memorizing findings found in certain common clinical conditions. However, understanding disease process as it is manifested in the physical examination will not only enhance your exam performance but also help you in your practice. (Correct response in italics.)

When examining a 24 year-old woman with mitral valve prolapse, you expect to find a murmur in:

A. Early to mid systole
B. Throughout systole
C. Diastole
D. Middle to late systole

Additional findings in mitral valve prolapse usually include a(n):

A. Opening snap
B. Midsystolic click
C. Paradoxical splitting of the second heart sound
D. S4 heart sound

Mitral valve prolapse is likely the most common valvular heart problem, present in about 10% of the population. The majority of people with mitral valve prolapse have a benign condition where one valve leaflet is unusually long and buckles or prolapses into the left atrium when the valve closes.  This results in a mid systolic click followed by a short mid to late systolic murmur caused by regurgitation of blood into the left atrium.

Expected findings during an acute asthma exacerbation include:

A. Prolonged inspiration phase
B. Inspiratory crackles
C. Increase in tactile fremitus
D. Hyperresonance on thoracic percussion

Asthma is predominantly a disease of inflammation with superimposed bronchospasm, leading to air trapping. As such, the normally resonant thorax becomes hyperresonant, reflecting the less dense quality of the air- filled thoracic tissue, and tactile fremitus is diminished. Additional asthma findings include prolonged expiration phase and hyperinflation reported on the chest x-ray. Prolonged inspiration phase of respiration is usually found in upper airway obstruction such as epiglottis or tonsillar abscess.  Tactile fremitus is typically increased when there is increased lung tissue density in conditions including pneumonia with consolidation.

Physical examination findings in Graves disease likely include:

A. Muscle tenderness
B. Coarse, dry skin
C. Lid retraction
D. Constipation

Clinical presentation in hypothyroidism includes:

A.   Tremor
B.   Smooth, silky skin
C.   Delayed return in the patellar reflex
D.   Frequent small volume loose stools

Thyroid hormone is essential to normal body function as it assists cells in energy-releasing activities. As a result, when assessing the person with thyroid dysfunction, look for signs of excessive cellular energy release in hyperthyroidism such as heat intolerance, hyperreflexia, anxiety, tremor, and diarrhea. Graves’ disease includes this as well as goiter and an infiltrative ophthalmia, usually leading to lid retraction. In hypothyroidism, there is decreased cellular energy release. As a result, its clinical presentation includes cold intolerance, constipation, depression and delayed return of the deep tendon reflexes.

Funduscopic exam findings in angle-closure glaucoma usually include:

A.   Excessive optic disc cupping
B.   Arteriovenous nicking        
C.   Papilledema
D.   Pinpoint hemorrhages

Glaucoma, whether open-angle or angle-closure, is primarily a problem of increased intraocular pressure, or pressure in front of the optic disc and physiologic cup.  As a result, the optic disc and physiologic cup are compressed, creating the classic finding of glaucomatous cupping. Angle-closure glaucoma is an acute ophthalmologic emergency, usually presenting with eye pain, redness and visual changes. Open-angle glaucoma is usually without symptoms until advanced, when the patient reports peripheral vision loss. Increased risk for open-angle glaucoma includes people of African ancestry and diabetes.

Papilledema, where the optic disc bulges and its margins are blurred, is seen when there is excessive pressure behind the eye, as in increased intracranial pressure.  Arteriovenous nicking is seen in hypertensive retinopathy.

As part of the evaluation of the person with osteoarthritis, the NP anticipates finding:

A.  Anemia of chronic disease
B.   Elevated C-reactive protein
C.  Narrowing of the joint space on x-ray
D. Elevated antinuclear antibody titer

Osteoarthritis (OA) is the most common joint disease in the United States, affecting more than 20 million Americans and is a degenerative disease without systemic manifestation or inflammation.  The most problematic joint involvement is in larger, weight-bearing joints such as the hip and knee.  Worst symptoms are reported with use, and in contrast with rheumatoid arthritis, there is minimum morning stiffness.

In OA, the articular cartilage is roughened and wears away. Bone spurs may form and the synovial membrane thickens. As a result, the joint space narrows. As OA is not an inflammatory disease, sedimentation rate and C-reactive protein, both markers of inflammation, are normal. Unlike rheumatoid arthritis and systemic lupus erythematosus, antinuclear antibodies are absent from the serum.

Learning the reason for assessment findings will not only help you successfully achieve certification but also guide your clinical practice.

References

Fitzgerald, M.A. (2005) Nurse Practitioner Certification Examination and Practice Preparation, 2nd Edition, Philadelphia: F. A. Davis.

Mangione, S. (2007) Physical Diagnosis Secrets, 2nd Edition, St. Louis: Elsevier Health Sciences.

Revised 12.27.07

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This article originally appeared in my quarterly certification column in Advance for Nurse Practitioners and is made available here by the courtesy of Advance. For other articles of interest to Nurse Practitioners, be sure to subscribe to this outstanding journal.