National Physical Therapy Examination (NPTE) Quiz: Patient History And Systems Review
20 questions · exam conditions
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Patient History And Systems ReviewQuestion 1 of 20

A 30-year-old female post-knee surgery reports numbness around incision and increasing calf swelling; which finding is most concerning?

Small area of numbness near incision that is stable since surgery
Increasing unilateral calf swelling with tenderness and warmth
Mild pain with end-range knee flexion during heel slides
Quadriceps inhibition noted during straight leg raise attempts
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National Physical Therapy Examination (NPTE) Quiz

National Physical Therapy Examination (NPTE) Quiz: Patient History And Systems Review

Practice Patient History And Systems Review in National Physical Therapy Examination (NPTE) with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Patient History And Systems Review, giving you a quick way to practice the rules, question types, and explanations that matter most for National Physical Therapy Examination (NPTE).

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

A 30-year-old female post-knee surgery reports numbness around incision and increasing calf swelling; which finding is most concerning?

  1. Small area of numbness near incision that is stable since surgery
  2. Increasing unilateral calf swelling with tenderness and warmth (correct answer)
  3. Mild pain with end-range knee flexion during heel slides
  4. Quadriceps inhibition noted during straight leg raise attempts
Explanation: This question tests the ability to collect and interpret patient history and systems review data relevant to physical therapy examination. Understanding the patient's history and conducting a thorough systems review is critical in identifying the most pressing clinical concerns and formulating an effective treatment plan. In the given scenario, the patient's numbness and calf swelling post-knee surgery highlight DVT risk. The correct answer is justified by the alignment with the patient's primary complaint and the clinical importance of vascular signs. A common distractor may focus on irrelevant systems or misinterpret the significance of the symptoms, such as expected numbness, leading to ineffective prioritization. To assist students: Emphasize the importance of correlating patient history with current clinical presentation, and practice identifying which systems are most pertinent to specific symptoms. Encourage frequent review of patient goals and outcomes in clinical decision-making processes.

Question 2

A 30-year-old female 6 weeks post-meniscus repair reports incision itching only; which systems review finding is most concerning?

  1. Localized itching with intact skin and no drainage
  2. New spreading redness with increasing pain and fever (correct answer)
  3. Mild stiffness after sitting that improves with movement
  4. Soreness in quadriceps after stationary bike use
Explanation: This question tests the ability to collect and interpret patient history and systems review data relevant to physical therapy examination. Understanding the patient's history and conducting a thorough systems review is critical in identifying the most pressing clinical concerns and formulating an effective treatment plan. In the given scenario, the patient's incision itching post-meniscus repair is benign, but spreading redness with fever indicates infection. The correct answer is justified by the alignment with the patient's primary complaint and the clinical importance of infection signs. A common distractor may focus on irrelevant systems or misinterpret the significance of the symptoms, such as mild stiffness, leading to ineffective prioritization. To assist students: Emphasize the importance of correlating patient history with current clinical presentation, and practice identifying which systems are most pertinent to specific symptoms. Encourage frequent review of patient goals and outcomes in clinical decision-making processes.

Question 3

A 35-year-old female presents with neck pain and headaches. During the systems review, she reports episodes of dizziness, diplopia, and difficulty swallowing. She also mentions occasional numbness in her face and feeling unsteady on her feet, as if she might fall. These neurological symptoms are intermittent and sometimes brought on by turning her head quickly. She has a history of a motor vehicle accident 3 months ago with a whiplash injury.

The patient's constellation of symptoms reported in the systems review is MOST concerning for which condition?

  1. Cervicogenic headaches
  2. Benign paroxysmal positional vertigo (BPPV)
  3. Vertebrobasilar insufficiency (VBI) (correct answer)
  4. Post-concussion syndrome
Explanation: The correct answer is C. The patient is reporting the classic '5 D's and 3 N's' of vertebrobasilar insufficiency: Dizziness, Diplopia, Dysphagia, Drop attacks, Dysarthria, and Nausea, Numbness, Nystagmus. The history of trauma (whiplash) is a significant risk factor for vertebral artery dissection or injury. These symptoms indicate upper cervical ligamentous instability or VBI and represent red flags requiring immediate cessation of examination and urgent medical referral. A is incorrect because cervicogenic headaches would not explain the cranial nerve signs (diplopia, dysphagia) or ataxia. B is incorrect as BPPV causes brief episodes of vertigo with position changes but does not involve the other neurological symptoms. D is incorrect because while some symptoms overlap, the specific pattern of cranial nerve and cerebellar signs triggered by neck movement is more specific to VBI.

Question 4

A 72-year-old female is referred to physical therapy for generalized weakness and balance deficits after a recent hospitalization for pneumonia. Her past medical history is significant for heart failure with preserved ejection fraction (HFpEF), hypertension, and type 2 diabetes. Her medication list includes lisinopril, furosemide, metoprolol, and metformin. During the subjective interview, she reports feeling unusually fatigued and notes a new, persistent, dry cough that started about a week ago. She denies fever, chills, or productive sputum. The systems review is otherwise unremarkable.

Based on this patient's history, which of the following is the MOST critical initial action for the physical therapist?

  1. Contact the referring physician to discuss the potential for an ACE inhibitor-induced cough and its impact on therapy. (correct answer)
  2. Proceed with the examination, focusing on pulmonary function tests to establish a baseline due to the recent pneumonia.
  3. Postpone the examination and advise the patient to monitor the cough, as it is a common residual effect of pneumonia.
  4. Initiate a low-intensity exercise program, carefully monitoring for signs of exertional intolerance secondary to deconditioning.
Explanation: The correct answer is A. The patient is taking lisinopril, an ACE inhibitor, which is known to cause a persistent, dry cough as a side effect in up to 20% of patients. Given her history of heart failure and recent pneumonia, it is critical to differentiate between a medication side effect, a sign of worsening heart failure, or a residual pulmonary issue. The new onset and non-productive nature, without other signs of infection, make the ACE inhibitor a primary suspect. Contacting the physician is the most appropriate action to facilitate medical management, which may involve changing the medication, and ensures safe and effective physical therapy. B is incorrect because while pulmonary function is important, the potential adverse drug reaction is a more immediate concern that needs to be addressed with the medical team. C is incorrect because dismissing the cough as a residual effect of pneumonia without considering other causes, particularly a known medication side effect or worsening heart failure, is unsafe. D is incorrect as initiating exercise without addressing the potential underlying cause of the new cough is inappropriate and could be unsafe if the cough is indicative of a worsening medical condition.

Question 5

A 55-year-old female is being seen for left-sided neck and arm pain. Her history reveals she works as an accountant and spends long hours at her computer. She reports the pain is burning and tingling, extending from her neck down to her fourth and fifth digits. During the systems review, she mentions occasional clumsiness in her left hand, such as difficulty buttoning her shirt. When asked about general health, she casually notes that for the past month she has felt her legs are 'heavy' and she has stumbled a few times when walking on uneven ground. She denies any bowel or bladder changes.

Based on the constellation of symptoms reported in the history and systems review, the physical therapist's examination should be prioritized to investigate which condition?

  1. Thoracic outlet syndrome involving the lower trunk of the brachial plexus.
  2. Cervical radiculopathy affecting the C8-T1 nerve roots.
  3. Carpal tunnel syndrome with proximal referral of symptoms.
  4. Cervical myelopathy secondary to spinal cord compression. (correct answer)
Explanation: The correct answer is D. The patient's presentation includes symptoms of both upper and lower motor neuron involvement, which is a hallmark of cervical myelopathy. The neck and arm pain with paresthesias in a C8-T1 distribution are consistent with lower motor neuron signs at the level of compression. However, the report of leg heaviness, stumbling, and gait disturbance are classic upper motor neuron signs, indicating that the spinal cord itself is compromised. Hand clumsiness is another key finding in myelopathy. A and B are plausible diagnoses for the arm symptoms alone, but they do not explain the bilateral leg symptoms and gait disturbance. C is incorrect as carpal tunnel syndrome affects the median nerve distribution (digits 1-3 and half of 4) and would not cause neck pain or lower extremity symptoms. The presence of both upper and lower extremity signs makes cervical myelopathy the most critical condition to screen for, as it may require urgent surgical intervention.

Question 6

A 60-year-old female presents with neck pain and headaches. Her past medical history includes hypertension, hyperlipidemia, and a 40-pack-year smoking history. During the systems review, while discussing her headaches, she describes a recent, sudden-onset 'thunderclap' headache that was the 'worst headache of her life,' which lasted for about an hour and then subsided. She also reports some neck stiffness and photophobia during the episode but has felt relatively normal since. She did not seek medical attention at the time.

The patient's description of her recent headache during the systems review represents a critical red flag that requires what immediate action by the physical therapist?

  1. Perform an upper cervical ligamentous integrity screen before proceeding with any manual therapy.
  2. Initiate treatment for cervicogenic headache, as the neck stiffness is a primary component.
  3. Educate the patient on posture and ergonomics to prevent future headache episodes.
  4. Cease the evaluation and facilitate an immediate referral to the emergency department. (correct answer)
Explanation: The correct answer is D. A 'thunderclap' headache, described as a sudden, severe headache that peaks within seconds to a minute, is a medical emergency until proven otherwise. It is the hallmark symptom of a subarachnoid hemorrhage (SAH), often from a ruptured cerebral aneurysm. The associated neck stiffness (meningismus) and photophobia further support this concern. Even though the headache has resolved, the risk of a re-bleed is high and carries significant morbidity and mortality. This history constitutes a major red flag that supersedes any musculoskeletal examination or treatment. The physical therapist's primary responsibility is to ensure the patient receives immediate medical evaluation. A, B, and C are all inappropriate actions that delay critical medical care and fail to recognize the gravity of the reported history.

Question 7

A 50-year-old man presents with a 2-month history of right upper quadrant (RUQ) abdominal pain and right-sided, mid-thoracic back pain. He states the pain is a dull ache that can become sharp, especially after eating a heavy or fatty meal. He has a history of hyperlipidemia. During the systems review, he notes that his skin has seemed slightly yellow (jaundiced) at times and his stools have been lighter in color than usual. He denies fever or recent trauma.

The patient's history and systems review findings are MOST suggestive of pain referral from which organ system?

  1. Renal system, likely a kidney stone.
  2. Gastric system, likely a peptic ulcer.
  3. Hepatic and biliary system, likely cholecystitis or cholelithiasis. (correct answer)
  4. Pulmonary system, likely irritation of the right hemidiaphragm.
Explanation: The correct answer is C. This patient's clinical presentation points strongly to a hepatobiliary source. The location of pain (RUQ and referred mid-thoracic/scapular pain), the trigger (worsening after fatty meals), and the associated signs of jaundice and light-colored stools are classic for gallbladder disease (cholelithiasis/cholecystitis) or other biliary obstruction. The fatty meal intolerance is due to the gallbladder's role in releasing bile to digest fats. The jaundice and light stools suggest a blockage of bile flow. A (renal pain) is typically flank pain radiating to the groin and is not related to meals. B (peptic ulcer) usually causes epigastric pain, which may be relieved or worsened by food, but is not associated with jaundice. D (diaphragmatic irritation) can refer to the shoulder (phrenic nerve), not typically the mid-thoracic region, and lacks the GI-specific triggers and signs.

Question 8

A 34-year-old male presents with a primary complaint of low back pain that began after he started a new, more intensive weightlifting program two months ago. He describes the pain as a deep ache in the lumbosacral area, worse with lumbar extension activities like overhead presses. He denies radiating pain, numbness, or tingling. During the systems review, the therapist inquires about gastrointestinal function. The patient reports no changes in bowel habits but mentions that he has been experiencing intermittent, crampy abdominal pain and bloating for the past few months, which he attributes to stress and dietary changes for his new workout regimen.

Given the patient's report of both mechanical low back pain and concomitant gastrointestinal symptoms, which of the following is the MOST important line of inquiry for the physical therapist to pursue?

  1. Assess for a psoas major muscle strain, as it can refer pain to the low back and is associated with abdominal guarding.
  2. Investigate for spondylolysis, as the mechanism of pain (worse with extension) is highly suggestive of this condition in a weightlifter.
  3. Screen for potential inflammatory bowel disease, such as Crohn's disease, which can present with both GI symptoms and sacroiliitis.
  4. Explore the patient's use of nonsteroidal anti-inflammatory drugs (NSAIDs) for his back pain, as they can cause gastrointestinal distress. (correct answer)
Explanation: The correct answer is D. While C is a plausible consideration for a systemic cause, the MOST important and common link between new-onset mechanical back pain and new-onset GI distress in an athletic individual is the use of NSAIDs. Patients often initiate over-the-counter NSAID use for activity-related pain, and these medications are a very common cause of gastritis, abdominal pain, and bloating. This is a direct, iatrogenic link that must be screened for. A and B are musculoskeletal diagnoses that fit the back pain presentation but do not directly explain the GI symptoms. C is a possibility (ankylosing spondylitis is also in this family), but it is a less common diagnosis, and the GI symptoms are not specific. Ruling out a common medication side effect is the most critical and parsimonious first step in interpreting this combination of findings before considering a more complex systemic disease.

Question 9

A 44-year-old female presents with a 4-month history of right-sided chest wall and mid-back pain. The pain is sharp, intermittent, and seems to wrap around her side. It is aggravated by deep breathing, coughing, and trunk rotation. She has no history of trauma. Her primary care physician diagnosed her with costochondritis, but rest and anti-inflammatories have not helped. During the systems review, she mentions that about 5 months ago, she had a strange, painful rash on that same side of her trunk, which has since resolved but left some areas of sensitive skin.

Based on the additional information from the systems review, the patient's current pain is MOST likely attributable to which of the following?

  1. Intercostal neuralgia secondary to thoracic disc herniation.
  2. Post-herpetic neuralgia. (correct answer)
  3. Slipping rib syndrome.
  4. Pleural irritation from an undiagnosed pulmonary condition.
Explanation: The correct answer is B. The key historical finding is the report of a painful rash preceding the onset of the persistent nerve-like pain in the same dermatomal distribution. This is a classic history for herpes zoster (shingles), and the lingering pain after the rash resolves is termed post-herpetic neuralgia (PHN). The character (sharp, intermittent), location (dermatomal), and triggers (movement, deep breathing) are all consistent with intercostal nerve irritation from PHN. A is less likely as thoracic disc herniations are rare and the history of the rash is too specific to ignore. C is a mechanical condition that does not involve a prior rash. D is a red flag consideration, but again, the history of the antecedent rash provides a much more direct and likely explanation for her specific neuropathic symptoms.

Question 10

A 29-year-old male who is an avid cyclist presents with left lateral knee pain, which has been diagnosed by his physician as iliotibial band syndrome. He has completed 4 weeks of physical therapy elsewhere with minimal improvement. During a detailed history intake, he reports that in addition to the knee pain, he has been experiencing recurrent, painful sores in his mouth and on his genitals for the past year. In the systems review, he also mentions intermittent left eye redness and pain. He denies any known family history of autoimmune disease.

The patient's multisystem complaints should prompt the physical therapist to consider that the knee pain may be an arthritic manifestation of what underlying systemic condition?

  1. Reactive arthritis.
  2. Behçet's disease. (correct answer)
  3. Ankylosing spondylitis.
  4. Psoriatic arthritis.
Explanation: The correct answer is B. Behçet's disease is a rare systemic vasculitis characterized by a classic triad of recurrent oral aphthous ulcers, genital ulcers, and uveitis (eye inflammation). Arthritis is also a common feature, often affecting the knees. The patient's history includes all key components of this syndrome. Recognizing this pattern is critical because the knee pain is not a simple mechanical issue but a manifestation of a serious systemic disease requiring rheumatological management. A (Reactive arthritis) classically presents with the triad of arthritis, urethritis, and conjunctivitis, often following an infection, which does not fit this patient's presentation of oral/genital ulcers. C often involves the spine and sacroiliac joints. D is associated with psoriasis, which the patient does not report.

Question 11

A 77-year-old male is referred for rehabilitation following a right total knee arthroplasty 3 weeks ago. His recovery is proceeding slower than expected, with persistent pain, swelling, and limited range of motion. During the history, the therapist notes the patient seems confused and is slow to respond to questions. His wife, who is present, reports that he has been increasingly lethargic over the past week and has had a poor appetite. A review of his vital signs taken at the start of the session reveals: Temperature 100.8°F (38.2°C), HR 105 bpm, RR 22 breaths/min, BP 100/60 mmHg.

The combination of the patient's post-operative status, reported symptoms, and vital signs is MOST concerning for which of the following complications?

  1. Deep vein thrombosis (DVT).
  2. Pulmonary embolism (PE).
  3. Post-operative sepsis. (correct answer)
  4. Adverse reaction to opioid analgesics.
Explanation: The correct answer is C. The patient is exhibiting classic signs and symptoms of a systemic infection, or sepsis, likely originating from the surgical site (periprosthetic joint infection). The key findings are the combination of a fever (temperature >100.4°F), tachycardia (HR >90 bpm), tachypnea (RR >20 breaths/min), and hypotension (systolic BP <100 mmHg), along with systemic signs like confusion, lethargy, and malaise in a post-operative patient. This constitutes a medical emergency requiring immediate attention. A (DVT) would present with unilateral leg swelling and pain but not typically with fever and systemic signs unless it leads to a PE. B (PE) would present with shortness of breath, chest pain, and tachycardia, but fever and confusion are less common primary signs. D (opioid reaction) could cause confusion and lethargy but would typically be associated with respiratory depression (low RR) and bradycardia, not fever and tachycardia.

Question 12

A 40-year-old female presents to physical therapy with a primary complaint of fatigue and muscle aches, particularly in her proximal muscles (shoulders and hips). She finds it difficult to climb stairs or lift her arms to brush her hair. The symptoms have been progressing over the past six months. During the systems review, she shows the therapist a distinct, purplish rash over her eyelids (heliotrope rash) and reddish papules over her knuckles (Gottron's papules). She also mentions she has had some difficulty swallowing solid foods recently.

This unique constellation of cutaneous and musculoskeletal findings from the history and systems review is pathognomonic for which condition?

  1. Systemic lupus erythematosus (SLE).
  2. Polymyalgia rheumatica (PMR).
  3. Dermatomyositis. (correct answer)
  4. Scleroderma.
Explanation: The correct answer is C. Dermatomyositis is an idiopathic inflammatory myopathy characterized by the combination of progressive, symmetrical proximal muscle weakness and characteristic skin findings. The heliotrope rash (purplish discoloration of the eyelids) and Gottron's papules (erythematous papules over the extensor aspects of the metacarpophalangeal and interphalangeal joints) are pathognomonic for the condition. Dysphagia (difficulty swallowing) is also a common and serious manifestation due to involvement of striated muscles of the pharynx. A (SLE) can have a malar ('butterfly') rash but not the specific eyelid and knuckle findings. B (PMR) causes proximal muscle pain and stiffness, primarily in older adults (>50), but not true weakness or the characteristic rash. D (Scleroderma) is characterized by skin thickening and fibrosis, not the specific rashes and primary muscle weakness seen here.

Question 13

A 66-year-old male presents with bilateral foot pain and paresthesias. His medical history is significant for poorly controlled type 2 diabetes (most recent HbA1c of 9.5%), hypertension, and hyperlipidemia for which he takes metformin, lisinopril, and atorvastatin. He describes his symptoms as a 'stocking-like' distribution of burning and numbness in both feet, which is worse at night. During the systems review, he also reports recent issues with feeling full quickly after eating (early satiety), occasional dizziness upon standing, and erectile dysfunction.

The patient's full symptom cluster, beyond his chief complaint, is MOST indicative of which of the following complications of his primary disease?

  1. Adverse effects from polypharmacy, particularly the statin and antihypertensive medications.
  2. Diabetic peripheral neuropathy combined with autonomic neuropathy. (correct answer)
  3. Peripheral arterial disease leading to ischemic neuropathy.
  4. Vitamin B12 deficiency neuropathy secondary to long-term metformin use.
Explanation: The correct answer is B. The patient's 'stocking-glove' sensory disturbance is a classic presentation of diabetic peripheral neuropathy. However, the critical thinking step is to recognize that the other symptoms reported in the systems review—early satiety (gastroparesis), orthostatic dizziness, and erectile dysfunction—are all classic manifestations of diabetic autonomic neuropathy. This indicates widespread nerve damage affecting both the peripheral sensory and autonomic nervous systems, which is common in poorly controlled diabetes. A is less likely as this specific cluster of symptoms is not typical for the listed medications. C is possible given his risk factors, but ischemic pain is typically exertional (claudication) rather than a constant nocturnal burning, and it doesn't explain the autonomic symptoms. D is a valid consideration, as metformin can cause B12 deficiency, but the autonomic features make widespread diabetic neuropathy the most comprehensive explanation for the entire clinical picture.

Question 14

A 31-year-old female presents with low back pain and right buttock pain that started six weeks ago without a known cause. She is an office worker and sits for most of the day. The pain is worse with sitting and forward bending. During the systems review, she reports increased urinary frequency and urgency over the past month. She also notes new pain with intercourse (dyspareunia). She denies fever, radiating leg pain, or true weakness. Her menstrual cycles are regular but have become more painful recently.

Given the combination of musculoskeletal and pelvic symptoms in the history, the physical therapist should consider a referral to a specialist to rule out which of the following non-musculoskeletal conditions?

  1. Interstitial cystitis.
  2. Sacroiliac joint dysfunction.
  3. Endometriosis. (correct answer)
  4. Cauda equina syndrome.
Explanation: The correct answer is C. This patient presents with mechanical-sounding low back pain, but the concomitant systems review findings of urinary urgency/frequency, dyspareunia, and increased dysmenorrhea are red flags for a gynecological origin. Endometriosis, the presence of endometrial tissue outside the uterus, can cause cyclical or chronic inflammation, leading to low back, pelvic, and buttock pain that can mimic musculoskeletal conditions. The combination of these symptoms makes it a primary consideration. A (Interstitial cystitis) primarily involves bladder pain and urinary symptoms, but wouldn't typically explain the increased dysmenorrhea. B is a musculoskeletal diagnosis that doesn't account for the pelvic and urinary symptoms. D is incorrect as the patient denies the cardinal signs of cauda equina syndrome, such as saddle anesthesia, severe or progressive neurologic deficits, or changes in bowel/bladder retention.

Question 15

A 28-year-old female presents for physical therapy with diffuse joint pain, fatigue, and a recent diagnosis of Ehlers-Danlos Syndrome, hypermobile type (hEDS). During the subjective history, she reports that in addition to her joint pain, she frequently feels lightheaded or has near-syncopal episodes upon standing up from a seated or lying position. She also reports frequent palpitations, 'brain fog,' and chronic fatigue that seems out of proportion to her activity level. Her symptoms are worse in warm environments, such as a hot shower.

The patient's report of orthostatic intolerance, palpitations, and fatigue should prompt the physical therapist to screen for which common comorbidity of hEDS?

  1. Chiari malformation.
  2. Postural Orthostatic Tachycardia Syndrome (POTS). (correct answer)
  3. Fibromyalgia.
  4. Mast Cell Activation Syndrome (MCAS).
Explanation: The correct answer is B. There is a very high prevalence of autonomic dysfunction, specifically POTS, in the hEDS population. POTS is characterized by orthostatic intolerance with a significant increase in heart rate upon standing (>30 bpm increase, or >120 bpm total) without a significant drop in blood pressure. The patient's description of lightheadedness on standing, palpitations, brain fog, and worsening symptoms in the heat are all classic features of POTS. Recognizing this comorbidity is crucial as it significantly impacts exercise tolerance and prescription. A (Chiari malformation) can be associated with EDS but typically presents with headache and brainstem signs. C (Fibromyalgia) is also common but does not specifically explain the orthostatic symptoms. D (MCAS) is another common comorbidity, but it typically presents with allergic-type symptoms (hives, flushing, GI distress), not primarily orthostatic intolerance.

Question 16

A 69-year-old female is evaluated for a recent decline in mobility and a new onset of falls. Her past medical history is significant for a remote CVA with mild residual left-sided weakness. During the history intake, her daughter reports that over the past two months, the patient has developed a shuffling gait with difficulty initiating steps, has had two episodes of urinary incontinence which is new for her, and seems more forgetful and apathetic. The daughter states, 'It's like her feet are glued to the floor.'

This classic triad of symptoms described in the patient's recent history is MOST suggestive of which of the following neurological conditions?

  1. Progression of post-stroke deficits.
  2. Parkinson's disease.
  3. Normal Pressure Hydrocephalus (NPH). (correct answer)
  4. Multi-infarct dementia.
Explanation: The correct answer is C. The patient's history presents the classic clinical triad of Normal Pressure Hydrocephalus (NPH): gait disturbance (magnetic, shuffling gait), cognitive decline (forgetfulness, apathy), and urinary incontinence. The descriptive phrase 'feet are glued to the floor' is very typical for the gait apraxia seen in NPH. It is critical for a therapist to recognize this triad because NPH is a potentially reversible cause of dementia and gait impairment, often treated with a CSF shunt. A is less likely because post-stroke progression is not typically characterized by this specific triad. B (Parkinson's) involves a shuffling gait but is also characterized by resting tremor and rigidity, which were not reported, and incontinence/cognitive issues are typically later-stage findings. D (Multi-infarct dementia) presents with a more step-wise cognitive decline and focal neurological signs corresponding to infarct locations, not usually this specific triad.

Question 17

A 45-year-old male is referred to physical therapy for chronic ankle instability. His history is significant for type 1 diabetes, diagnosed in childhood. During the systems review, he mentions that the top of his left foot has become swollen, red, and warm over the past few weeks, but he denies any specific injury, pain, fever, or chills. He reports continuing to walk on it because it doesn't hurt very much. Examination of his feet reveals diminished sensation to light touch and vibration bilaterally.

Given the patient's medical history and the description of his foot, the physical therapist should have a high index of suspicion for which of the following conditions?

  1. Charcot neuroarthropathy. (correct answer)
  2. Gout.
  3. Cellulitis.
  4. Complex Regional Pain Syndrome (CRPS).
Explanation: The correct answer is C. Charcot neuroarthropathy is a serious complication of peripheral neuropathy, most commonly from diabetes. It is a progressive condition characterized by joint dislocations, pathologic fractures, and severe deformities. The acute phase presents with a warm, erythematous, and swollen foot, often with minimal to no pain due to the underlying neuropathy. This painless, 'hot swollen foot' in a patient with long-standing diabetes and sensory loss is the classic presentation. It is a medical emergency requiring immediate offloading to prevent further destruction. A (Cellulitis) would typically be very painful and often accompanied by systemic signs of infection like fever. B (Gout) is extremely painful and involves an acute inflammatory arthritis. D (CRPS) is characterized by severe pain that is out of proportion to any injury, the opposite of this patient's painless presentation.

Question 18

A 68-year-old male with a history of coronary artery disease (post-stent 3 years ago), hypertension, and peripheral vascular disease is referred to physical therapy for intermittent claudication. During the intake, he reports the expected cramping in his calves after walking approximately 200 feet, which is relieved by rest. As part of the systems review, he also reports a new onset of pain in his low back and buttocks that also occurs with walking. He states this new pain is not relieved by sitting down and resting, but rather seems to improve only when he leans forward on his shopping cart. He denies any change in the quality of his calf pain.

The patient's description of his low back and buttock pain during the history should prompt the therapist to prioritize examination techniques to differentiate between vascular claudication and which other condition?

  1. Degenerative joint disease of the hip with referred pain.
  2. Lumbar spinal stenosis causing neurogenic claudication. (correct answer)
  3. Piriformis syndrome with sciatic nerve irritation.
  4. Aortoiliac occlusive disease presenting as buttock claudication.
Explanation: The correct answer is B. The patient's history presents a classic picture of two distinct conditions. His calf pain, relieved by rest alone, is typical of his known vascular claudication. However, the new low back and buttock pain that is relieved by a flexed posture (leaning on a shopping cart) but not by rest alone is the hallmark symptom of neurogenic claudication secondary to lumbar spinal stenosis. This is often referred to as the 'shopping cart sign.' The therapist must recognize this dual pathology. A is less likely as hip DJD pain is typically groin-focused and not relieved by lumbar flexion. C is a possibility, but piriformis syndrome is less commonly bilateral and not typically posture-dependent in this specific way. D is a form of vascular claudication; while it causes buttock pain, the key differentiator here is the relief with lumbar flexion, which points strongly to a neurogenic, not a vascular, source for the new symptoms.

Question 19

A 22-year-old female college student presents to direct access physical therapy with bilateral wrist and hand pain, swelling, and morning stiffness that lasts for over an hour. Symptoms began insidiously about two months ago. She reports significant fatigue that is affecting her ability to attend classes. She denies any specific trauma. During the systems review, she mentions that her eyes have felt dry and gritty lately, and she has noticed a small, non-painful lump on the back of her left elbow.

The combination of findings from the patient's history and systems review is MOST indicative of which of the following conditions, warranting an urgent referral to a physician?

  1. Fibromyalgia with associated sicca syndrome.
  2. Bilateral carpal tunnel syndrome due to repetitive typing for school.
  3. Systemic lupus erythematosus (SLE).
  4. Rheumatoid arthritis (RA). (correct answer)
Explanation: The correct answer is D. This patient's presentation is a classic example of early rheumatoid arthritis. Key features include insidious onset of bilateral, symmetrical polyarthritis affecting small joints (wrists, hands), significant morning stiffness lasting >60 minutes, and profound fatigue. The additional systems review findings of dry eyes (keratoconjunctivitis sicca, a form of secondary Sjögren's syndrome common with RA) and a nodule on the extensor surface of the elbow (a rheumatoid nodule) further solidify this suspicion. A is incorrect because while fibromyalgia involves widespread pain and fatigue, it is non-inflammatory and does not typically cause objective joint swelling or rheumatoid nodules. B is incorrect because it would not explain the systemic fatigue, morning stiffness pattern, or extra-articular manifestations. C is a possibility as SLE is also a systemic autoimmune disease, but the prominent, symmetrical small joint synovitis with morning stiffness and rheumatoid nodules is more specific to RA.

Question 20

A 62-year-old female presents with right hip and groin pain. She has a history of osteopenia and was treated for breast cancer two years ago with a lumpectomy followed by chemotherapy and an aromatase inhibitor (letrozole), which she is still taking. She reports the pain is a deep, constant ache, present at night, and has been worsening over the last month. It is now causing an antalgic gait. She denies any specific injury but notes the pain is aggravated by weight-bearing.

Given this patient's specific medication history and clinical presentation, which of the following potential diagnoses requires the MOST immediate and serious consideration?

  1. Avascular necrosis of the femoral head.
  2. Stress fracture of the femoral neck. (correct answer)
  3. Greater trochanteric pain syndrome.
  4. Osteoarthritis of the hip.
Explanation: The correct answer is B. The key to this question is integrating the patient's medication history with her symptoms. Aromatase inhibitors (like letrozole) are known to cause significant bone loss and increase fracture risk. The patient's presentation of deep, constant, weight-bearing pain with night pain and an antalgic gait is highly suspicious for a femoral neck stress fracture, which can occur with minimal or no trauma in this population. This is a potential orthopedic emergency. A (AVN) is often associated with corticosteroid use, not typically aromatase inhibitors. C is incorrect as trochanteric pain is typically lateral and not described as a deep groin ache. D is a common diagnosis, but the rapid progression, constant nature, and significant night pain in the context of medication-induced bone loss make a stress fracture a more urgent and likely consideration that must be ruled out first.