A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn't know if intercourse would hurt. He states he has become more tired lately and has also gained 10 pounds in the last month. He denies any fever or weight loss. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is married and has five children. He is currently on disability because of his health problems. Both of his parents died of complications of diabetes. On examination you see a pleasant male appearing chronically ill. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges. The prostate is smooth and nontender. What abnormality of the scrotum is most likely the diagnosis?

Correct Answer: C

Rationale: The correct answer is C: Scrotal edema. The patient's presentation of a swollen scrotum that worsens with standing and improves with lying down is consistent with scrotal edema, which is often associated with fluid accumulation due to conditions like heart failure, renal failure, or liver disease. The patient's history of high blood pressure, coronary artery disease, and shortness of breath with exertion suggest possible heart failure as the underlying cause. The absence of bulges with bearing down rules out a scrotal hernia. Hydrocele presents as a painless collection of fluid around the testicle, typically without systemic symptoms. Varicocele is a dilatation of the veins in the scrotum, usually described as a "bag of worms" sensation, and is not typically associated with the patient's symptoms.

Correct Answer: B

Rationale: The correct answer is B: Venous filling within 15 seconds. When the patient is sitting up after having his legs elevated, venous blood should quickly return to the legs due to gravity, resulting in venous filling within about 15 seconds. This is a normal physiological response. A: Significant elevational pallor is incorrect as pallor would indicate poor circulation, which is not expected in this scenario. C: No change in the coloration of the skin is incorrect as there should be a change in color due to venous filling. D: Color returning to the feet within 20 seconds of assuming a sitting position is not as specific as option B, which mentions venous filling specifically within 15 seconds.

Correct Answer: D

Rationale: The correct answer is D. Asking the patient to describe what happened provides crucial information about the onset, possible cause, and nature of the knee pain. This helps in understanding the context and determining the appropriate follow-up questions or examinations. Option A focuses solely on pain intensity, neglecting important context. Option B assumes a past injury without gathering current information. Option C asks for a specific timeframe without capturing the full picture of the pain episode.

Correct Answer: D

Rationale: The correct answer is D: Emergency database. In the case of an OxyContin overdose, an emergency database would be the most appropriate type of data collection. This is because an overdose requires immediate and urgent attention, necessitating quick and focused data collection to assess the situation and provide necessary interventions promptly. A complete database (choice A) would be too time-consuming and comprehensive for an emergency situation. A focused or problem-centered database (choice B) may not capture all relevant information in a timely manner. A follow-up database (choice C) would be more suitable for monitoring and tracking progress after the initial emergency has been addressed, rather than for the immediate response to an overdose.

Correct Answer: C

Rationale: Beginning the interview by asking open, friendly questions about school and hobbies is the correct approach to establish rapport with a 15-year-old patient. This strategy helps create a comfortable and non-threatening environment, allowing the adolescent to feel more at ease and willing to engage in the conversation. By showing genuine interest in the patient's personal life and interests, you are demonstrating respect and building trust. This approach also allows the adolescent to feel heard and valued, which can lead to more open and honest communication during the rest of the interview. It sets a positive tone for the interaction and helps establish a connection before delving into more sensitive topics related to health.