A 42-year-old realtor comes to your clinic, complaining of "growths" in her vulvar area. She is currently undergoing a divorce and is convinced she has a sexually transmitted disease. She denies any vaginal discharge or pain with urination. She has had no fever, malaise, or night sweats. Her past medical history consists of depression and hypothyroidism. She has had two spontaneous vaginal deliveries and one cesarean section. She has had no other surgeries. She denies smoking or drug use. She has two to three drinks weekly. Her mother also has hypothyroidism and her father has high blood pressure and hypercholesterolemia. On examination you see a woman who is anxious but appears otherwise healthy. Her blood pressure, pulse, and temperature are unremarkable. On visualization of the perineum you see two 2- to 3- mm, round, yellow nodules on the left labia. On palpation they are nontender and quite firm. What diagnosis best fits this description of her examination?

Correct Answer: D

Rationale: The correct answer is D: Epidermoid cyst. The key features in the clinical scenario that point towards an epidermoid cyst are the presence of painless, firm, non-tender, round, yellow nodules on the labia. These cysts are common in the vulvar area and often arise from blocked hair follicles. The absence of symptoms suggestive of a sexually transmitted infection (STI) such as vaginal discharge, pain with urination, fever, malaise, or night sweats, along with the patient's history of anxiety and the appearance of the nodules being consistent with an epidermoid cyst support this diagnosis. Choice A: Genital herpes typically presents with painful vesicles or ulcers, which are not described in this case. Choice B: Condylomata acuminata (genital warts) would present as soft, pink, or flesh-colored growths and are associated with HPV infection, which is not suggested in this scenario. Choice C: Sy

Correct Answer: D

Rationale: The correct answer is D: Nocturia. Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland, leading to urinary symptoms such as frequent urination at night (nocturia). This occurs due to the prostate pressing against the urethra, causing urinary flow issues. Weight loss (A) is not typically associated with BPH. Bone pain (B) is more indicative of conditions like prostate cancer or metastasis. Fever (C) is not a common symptom of BPH. Therefore, D is the most appropriate sign of BPH.

Correct Answer: C

Rationale: The correct answer is C: Mechanical low back pain. This is the most likely cause as the patient's pain is aching, located in the lumbosacral region, intermittent for years, with no radiation, numbness, tingling, or incontinence. The physical exam findings of muscle spasm, normal reflexes, and muscle strength support this diagnosis. Mechanical low back pain is common and often related to muscle strain or overuse, as seen in this construction worker who was moving furniture. Choice A (Herniated disc) is incorrect as the patient does not have radiation of pain or neurological symptoms. Choice B (Compression fracture) is unlikely without a history of trauma or injury. Choice D (Ankylosing spondylitis) is less likely given the lack of inflammatory symptoms and typical age of onset.

Correct Answer: A

Rationale: The correct answer is A: Articular joint pain. Pain, swelling, loss of motion, locking, and deformity are indicative of articular joint involvement. Articular joints are where two or more bones meet and allow movement. This type of pain is often associated with conditions like osteoarthritis, rheumatoid arthritis, or joint injuries. Bursitis (choice B) typically presents with localized pain and swelling around a joint. Muscular injury (choice C) usually results in pain and limited motion but does not typically involve locking or deformity. Nerve damage (choice D) may cause pain and numbness, but it does not typically lead to joint locking or deformity.