A 28-year-old married clothing sales clerk comes to your clinic for her annual examination. She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal deliveries. Her past six Pap smears have all been normal. She is married and has two children. Her mother is in good health and her father has high blood pressure. On examination you see a young woman appearing healthy and relaxed. Her vital signs are unremarkable and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness and both ovaries are palpated and nontender. What is the most likely diagnosis for the abnormality of her cervix?

Correct Answer: C

Rationale: Given the patient's history and presentation, the most likely diagnosis for the abnormality seen on examination is a cervical polyp. Cervical polyps are benign growths that arise from the mucosal surface of the cervix. They are typically red or purple in color and can bleed easily, especially when touched, as in this case with the Pap smear causing bleeding. Cervical polyps are usually asymptomatic but can present with painless bleeding, particularly after intercourse. In this patient, the visualization of a red mass at the os during speculum examination and the finding of bleeding with manipulation support the diagnosis of a cervical polyp. Additionally, the absence of other significant findings on examination and the patient's overall healthy appearance further support this benign diagnosis. Further evaluation with possible removal of the polyp may be warranted for confirmation and to alleviate the bleeding symptoms.

Correct Answer: B

Rationale: The repeated scenario of finding a positive test result that does not correlate with the suspected disease indicates a lack of specificity for the test in question. In such cases, it is important to use the test when there is a higher suspicion for a specific condition that is known to correlate with the finding. By using the test selectively in situations where it is more likely to provide accurate information, its utility can be maximized and unnecessary further workup can be avoided. This approach allows for a more targeted and efficient use of resources in the diagnostic process.

Correct Answer: A

Rationale: The area of the arm that drains to the epitrochlear nodes includes the ulnar surface of the forearm and hand, little and ring fingers, and the ulnar side of the middle finger. The epitrochlear nodes are located in the medial aspect of the arm above the elbow, close to the insertion of the biceps brachii muscle. These nodes receive lymphatic drainage from the above-mentioned areas and play a role in the immune response against infections in these regions.

Correct Answer: A

Rationale: A tender, painful swelling of the scrotum is a common symptom of acute epididymitis, which is the inflammation of the epididymis. The epididymis is a tube located at the back of the testicle that stores and transports sperm. In acute epididymitis, the swelling is usually accompanied by pain, tenderness, redness, and warmth in the affected area. Other symptoms may include fever, chills, and discharge from the penis. Prompt medical evaluation and treatment are necessary to prevent complications such as abscess formation or chronic epididymitis. Strangulated inguinal hernia and torsion of the spermatic cord may present with severe pain and swelling in the scrotum, but they have distinct mechanisms and require different management approaches.

Correct Answer: C

Rationale: The most likely diagnosis in this case is prostatitis. Prostatitis is the inflammation or infection of the prostate gland, which can cause symptoms such as discomfort between the scrotum and anus (perineum), fevers, and dysuria (painful urination). The tenderness anteriorly during rectal examination is consistent with prostatitis as the prostate gland is located in front of the rectum and can be tender to touch when inflamed. Prostate cancer typically presents with symptoms such as urinary frequency, nocturia, hematuria, or bone pain, and is less likely to cause the symptoms described in this scenario. Colon cancer and colonic polyps are less likely as they would not typically cause discomfort in the perineal area or dysuria.

Correct Answer: B

Rationale: While it is important to ask about recent sexual activity and whether it included sexual intercourse, using the term "intimate physical contact" is not specific enough. This question could potentially lead to misinterpretation or confusion regarding what types of activities are being referred to. It is more appropriate to directly ask about sexual intercourse when obtaining a sexual history. The other options are all appropriate questions to elicit information about the patient's sexual history.

Correct Answer: A

Rationale: Retinoblastoma typically presents with a white reflex, known as leukocoria or a cat's eye reflex, instead of the normal red reflex seen during ophthalmoscopy. The presence of red reflexes bilaterally in this case essentially rules out retinoblastoma as a differential diagnosis.

Correct Answer: B

Rationale: Orthopnea is a symptom characterized by difficulty breathing while lying flat that improves when sitting or standing upright. This symptom is specifically related to cardiovascular conditions, such as heart failure, in which fluid accumulates in the lungs when lying down. Considering the patient's complaint of breathlessness with activity and the need to assess for cardiovascular issues, asking about orthopnea would be most appropriate to gain insights into potential heart-related causes of the symptoms. Abdominal pain (A), hematochezia (C), and tenesmus (D) are not typically associated with cardiovascular conditions and are less relevant to the patient's presentation.

Correct Answer: C

Rationale: Leaving the plexor finger on the pleximeter after each strike is consistent with good percussion technique. This helps to maintain stability and precision during percussion by providing a consistent point of contact for accurate assessment of the underlying structures. This technique also helps to control the force and angle of the percussive strike, ensuring accurate interpretation of the resulting sounds produced. Maintaining this contact can enhance the effectiveness of percussion as a diagnostic tool in physical examinations.