A 55-year-old woman presents with a complaint of a lump in her breast. On examination, a firm, non-mobile mass is palpated in the upper outer quadrant of the left breast. What is the most appropriate next step in the management of this patient?

Correct Answer: A

Rationale: The correct answer is A: Mammography. Mammography is the initial investigation of choice for evaluating breast lumps in women over 40 years old. It helps to identify the characteristics of the mass and determine if it is suspicious for malignancy. Fine needle aspiration (B) may be used for further evaluation if mammography is inconclusive. Excisional biopsy (C) is typically reserved for definitive diagnosis after suspicious findings on mammography. Ultrasound (D) may be used as an adjunct to mammography but is not the first-line investigation in this scenario.

Correct Answer: A

Rationale: The most likely diagnosis for the 60-year-old man with difficulty swallowing, weight loss, hoarse voice, smoking, and alcohol use is esophageal cancer. This is supported by the symptoms of dysphagia, weight loss, and hoarseness, which are common in esophageal cancer. Smoking and alcohol use are risk factors for developing esophageal cancer. Achalasia presents with dysphagia without weight loss or hoarseness. Gastroesophageal reflux disease typically presents with heartburn and regurgitation, not hoarseness or weight loss. Peptic ulcer disease usually presents with epigastric pain, not difficulty swallowing or hoarseness.

Correct Answer: C

Rationale: The correct answer is C: Failure of the accommodation reflex. When the pupils constrict in response to light but do not constrict when focused on a near object, it indicates a failure of the accommodation reflex. This reflex is responsible for adjusting the shape of the lens to focus on near objects. In this scenario, the pupils are reacting to light (normal pupillary response) but not adjusting properly for near vision, ruling out A. Failure of the consensual light reflex (B) would result in both pupils failing to constrict when exposed to light. Increased intracranial pressure (D) would typically present with other neurological signs and symptoms.

Correct Answer: A

Rationale: The correct answer is A: Asthma. Wheezing on expiration is a classic finding in asthma due to airway constriction. During expiration in asthma, the narrowed airways cause turbulent airflow, leading to the characteristic high-pitched wheezing sound. Asthma is a chronic inflammatory condition of the airways that results in reversible airflow obstruction. Pneumonia (B) typically presents with crackles on auscultation, not wheezing. Pulmonary edema (C) is associated with crackles and possibly wheezing on inspiration. COPD (D) may present with wheezing on both inspiration and expiration, but it is less likely than asthma to present with wheezing on expiration alone.

Correct Answer: B

Rationale: The correct answer is B: Mitral stenosis. During diastole, the mitral valve should be closed, allowing blood to flow from the left atrium to the left ventricle. A murmur during diastole indicates turbulent blood flow across a stenotic mitral valve. Mitral stenosis causes decreased flow from the left atrium to the left ventricle during diastole, leading to increased pressure in the left atrium and the pulmonary circulation. Aortic regurgitation (A) would present with a murmur during diastole, but it is typically heard in early diastole. Tricuspid regurgitation (C) would present with a murmur during systole. Systolic heart failure (D) is not associated with a diastolic murmur.