A 29-year-old married computer programmer comes to your clinic, complaining of "something strange" going on in his scrotum. Last month while he was doing his testicular self- examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable. What disorder of the testes is most likely the diagnosis?

Correct Answer: B

Rationale: The most likely diagnosis in this case is a scrotal hernia. The patient's history of a previous groin surgery as a baby is a key clue, as it increases the risk for developing a hernia. The lump in the left testis with aching, along with the inability to palpate above the mass through the left inguinal ring, suggests that the lump may be a hernia protruding through the inguinal canal into the scrotum. The presence of a scar in the right inguinal region also supports the likelihood of a hernia. The normal prostate on rectal examination rules out any involvement of the prostate in the presentation. Scrotal hernias may present as painless masses in the scrotum, often increasing in size with activities that increase intra-abdominal pressure, such as straining or coughing. Surgical repair is often necessary to prevent complications such as incarceration or strangulation

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: The symptom described - sharp, aching chest pain that increases with breathing - is typically associated with musculoskeletal issues. The pain worsening with breathing suggests a connection to the movements of the chest wall, which could involve the muscles, bones, or joints in that area. Conditions such as costochondritis (inflammation of the cartilage that connects a rib to the breastbone) or muscle strains in the chest wall are common causes of chest pain that worsens with breathing. This localization to the musculoskeletal system is based on the characteristics of the pain and how it is affected by breathing, helping to narrow down the differential diagnosis.

Correct Answer: B

Rationale: In an elderly woman with a history of coronary bypass surgery presenting with severe, diffuse abdominal pain that is not worsened by abdominal palpation, neuropathy should be suspected. Neuropathy refers to nerve damage, which can result in abnormal sensations of pain, often described as burning, shooting, or stabbing. Abdominal neuropathy can be caused by various conditions such as diabetes, alcohol abuse, vitamin deficiencies, or certain medications. The absence of worsening pain upon palpation makes organic abdominal pathology less likely, suggesting a neuropathic etiology. In this case, further evaluation and testing for neuropathy would be warranted.

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: B

Rationale: The patient's presentation with an enlarged chest diameter, decreased breath sounds throughout all lobes, and the presence of rhonchi over all lung fields is suggestive of a chronic condition that affects the entire respiratory system. These findings are classic for COPD, a progressive lung disease characterized by airflow limitation. The breath sounds are decreased due to airflow obstruction, and the presence of rhonchi indicates mucus production and airway inflammation commonly seen in COPD. In contrast, a spontaneous pneumothorax would typically present with sudden chest pain and shortness of breath, often in a younger patient with risk factors such as smoking. Asthma would present with wheezing, shortness of breath, and possibly a history of atopy or allergies. Pneumonia would typically present with fever, cough, and focal findings on chest examination, such as crackles or bronchial breath sounds over a consolidated area. In

Correct Answer: B

Rationale: Urge incontinence, also known as overactive bladder, is characterized by a sudden and strong urge to urinate which is difficult to control. In this case, Mrs. LaFarge is unable to get to the bathroom quickly enough when she senses the need to urinate, which indicates a lack of control over the urge to urinate. This is typically caused by involuntary contractions of the bladder muscle. Stress incontinence, on the other hand, is leakage of urine during activities that increase intra-abdominal pressure, such as coughing or exercising. Overflow incontinence is characterized by urinary retention and constant dribbling of urine due to the bladder being unable to empty properly. Functional incontinence occurs when a person has normal bladder control but is unable to reach the bathroom in time due to physical or cognitive impairments. Since Mrs. LaFarge is experiencing a sudden and strong urge to urinate that she cannot

Correct Answer: A

Rationale: A sudden, painless unilateral vision loss may be caused by a retinal detachment. Retinal detachment occurs when the retina, which is the light-sensitive tissue lining the back of the eye, pulls away from its normal position. This can lead to visual disturbances, including sudden loss of vision in one eye. Retinal detachment can be a medical emergency and requires prompt evaluation and treatment to prevent permanent vision loss. Other conditions mentioned in the choices, such as corneal ulcer, acute glaucoma, and uveitis, may also cause vision problems but are less likely to present with a sudden and painless unilateral vision loss as a primary symptom.

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.