A 36-year-old security officer comes to your clinic, complaining of a painless mass in his scrotum. He found it 3 days ago during a testicular self-examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. His past medical history is notable for high blood pressure. He is married and has three healthy children. He denies using illegal drugs, smokes two to three cigars a week, and drinks six to eight alcoholic beverages per week. His mother is in good health and his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis, he is circumcised and has no lesions. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft cystic-like lesion measuring 2 cm over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight bearing there are no bulges. His prostate examination is unremarkable. What disorder of the scrotum does he most likely have?

Correct Answer: A

Rationale: The patient most likely has a hydrocele based on the presentation of a painless, soft cystic-like lesion measuring 2 cm over his right testicle. A hydrocele is a collection of fluid surrounding the testicle within the tunica vaginalis, resulting in a painless scrotal swelling. It is common and can occur at any age but is more common in older individuals. A key feature of a hydrocele is that the swelling is not reducible, meaning it cannot be pushed back into the abdomen. In this patient, there was no difficulty getting a gloved finger through either inguinal ring, ruling out a scrotal hernia. Testicular tumors typically present as painless testicular masses but are usually solid rather than cystic. Varicoceles are enlarged veins within the scrotum and have a characteristic "bag of worms" appearance on palpation, which is not described in this case.

Correct Answer: D

Rationale: In this situation, it is important to prioritize active listening over taking detailed notes. By pushing away from the keyboard or putting down your pen, you are signaling to the patient that you are fully present and engaged in listening to their story. This will help foster trust and encourage the patient to continue sharing their personal history. Taking notes can be done later, but the immediate focus should be on providing a supportive and attentive environment for the patient to share their experiences.

Correct Answer: A

Rationale: When examining a newborn and noting that the right testicle is not in the scrotum, it is important to refer the newborn to a pediatric urologist for further evaluation and management. This condition could be a case of undescended testis (cryptorchidism), where the testicle fails to descend into the scrotum. Early intervention is crucial as the undescended testis may lead to complications such as infertility, testicular cancer, and inguinal hernia. Urology specialists can determine the best course of action to bring down the testis and ensure proper testicular development. Waiting or attempting manual descent without expertise could lead to complications, so it is best to involve a urologist for proper assessment and management.

Correct Answer: A

Rationale: When a patient presents with epistaxis (nosebleed), other causes such as intracranial hemorrhage should be considered. Intracranial hemorrhage refers to bleeding within the skull, which can sometimes manifest as epistaxis. Common symptoms of intracranial hemorrhage include severe headache, altered mental status, focal neurological deficits, and sometimes, epistaxis. It is essential to assess for signs of increased intracranial pressure or neurological deficits if a patient with epistaxis has a history of trauma or other risk factors for intracranial bleeding. Immediate medical evaluation and imaging studies may be necessary to rule out intracranial hemorrhage in such cases to prevent serious consequences.

Correct Answer: C

Rationale: The described clinical presentation is consistent with internal hemorrhoids. The typical symptoms of internal hemorrhoids include painless rectal bleeding, protrusion from the anus during straining, and a feeling of incomplete evacuation. In this case, the protrusion is observed to be red, moist, and enlarges with bearing down, all indicative of internal hemorrhoids. The enlarged tender area felt on digital rectal examination supports the diagnosis. Additionally, the presence of blood on the glove after the examination is also suggestive of internal hemorrhoids causing bleeding. Anal fissures typically present with sharp pain during defecation and may have visible tears in the anal mucosa. External hemorrhoids are usually more painful and can be felt as a lump around the anus. Anorectal fistulas have different signs and symptoms, including discharge of pus and recurrent infections.

Correct Answer: C

Rationale: Beau's lines are transverse grooves or depressions in the nails that occur from a temporary disruption in nail growth. These lines can be caused by a variety of factors, including systemic diseases, medication use, trauma, or environmental stressors. However, one of the most common causes of Beau's lines is a significant physiological stress such as a severe illness or major surgery that occurred about 3 months prior to the appearance of the lines. Therefore, looking for information from family and records regarding any problems that occurred around 3 months ago is the most appropriate next step to understand the underlying cause of Beau's lines in this unconscious patient. This information can provide crucial insights into the patient's medical history and potential underlying health issues that may need to be addressed.

Correct Answer: B

Rationale: The information provided about Mr. M's shortness of breath being present for the past 10 days, worsening with activity, and relieved by rest are all objective findings. These are measurable and observable facts that can be documented by healthcare professionals through physical examination, assessment, and potentially diagnostic tests. Subjective information would involve Mr. M's personal feelings or descriptions of his symptoms, which are not included in the given information.

Correct Answer: A

Rationale: The patient most likely has a hydrocele based on the presentation of a painless, soft cystic-like lesion measuring 2 cm over his right testicle. A hydrocele is a collection of fluid surrounding the testicle within the tunica vaginalis, resulting in a painless scrotal swelling. It is common and can occur at any age but is more common in older individuals. A key feature of a hydrocele is that the swelling is not reducible, meaning it cannot be pushed back into the abdomen. In this patient, there was no difficulty getting a gloved finger through either inguinal ring, ruling out a scrotal hernia. Testicular tumors typically present as painless testicular masses but are usually solid rather than cystic. Varicoceles are enlarged veins within the scrotum and have a characteristic "bag of worms" appearance on palpation, which is not described in this case.

Correct Answer: B

Rationale: Peripheral arterial disease (PAD) is considered a coronary heart disease risk equivalent, meaning it confers a similar risk as having a history of coronary heart disease itself. Individuals with PAD have a significantly increased risk of cardiovascular events such as heart attack and stroke. Therefore, when assessing the 10-year coronary heart disease risk of the 40-year-old banker, having peripheral arterial disease would be a crucial factor to consider in addition to other risk factors like hypertension, exercise habits, and smoking history.