A 57-year-old maintenance worker comes to your office for evaluation of pain in his legs. He has smoked two packs per day since the age of 16, but he is otherwise healthy. You are concerned that he may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?

Correct Answer: A

Rationale: Intermittent claudication is a common symptom of peripheral vascular disease. It is characterized by muscle pain or cramping in the legs, usually in the calves, thighs, or buttocks, that occurs during physical activity such as walking and is relieved by rest. This symptom is due to inadequate blood flow to the muscles during exercise. It is important to assess for intermittent claudication in patients with risk factors such as smoking, diabetes, and hypertension, as it may indicate underlying peripheral arterial disease. The other symptoms listed (chest pressure with exertion, shortness of breath, knee pain) are not typically associated with peripheral vascular disease.

Correct Answer: B

Rationale: Relief of the pain with bending at the waist is a key hallmark of spinal stenosis. This position helps relieve the pressure on the nerves in the spinal canal, which is often the root cause of the leg symptoms experienced by the patient. The symptoms described by Mr. Edwards, such as cramps in the calves after walking a certain distance, followed by relief with rest and recurrence upon walking again, are highly suggestive of spinal stenosis. This condition involves narrowing of the spinal canal, leading to compression of the nerves and resulting in symptoms like leg cramps, weakness, and difficulty walking, especially with prolonged activity. The relief of symptoms when bending forward (e.g., leaning on a shopping cart while walking) is a characteristic feature of neurogenic claudication associated with spinal stenosis.

Correct Answer: D

Rationale: The most likely explanation for the discrepancy between the patient's relatively normal blood pressure reading (118/92) and the presence of hypertensive changes in her retinas and mild proteinuria is that the process causing her retinopathy and kidney problems has resolved. Hypertensive changes in the retinas and proteinuria are typically signs of chronic uncontrolled hypertension, but they can also be residual manifestations of previously uncontrolled hypertension that has now been effectively treated.

Correct Answer: B

Rationale: The clinical presentation described involves a patient with pericarditis. Pericarditis is inflammation of the pericardium, the sac surrounding the heart, which can lead to characteristic findings such as a scratching noise heard on auscultation, leaning forward relieving pain, and normal lung examination findings. The presence of pericarditis can also lead to a pericardial friction rub, which is often described as a scratching or grating sound heard best at the lower left sternal border.

Correct Answer: C

Rationale: This categorization is based on the blood pressure readings. Stage 1 hypertension is defined as having a systolic blood pressure between 130-139 mmHg or a diastolic blood pressure between 80-89 mmHg. The blood pressure falls within this range, indicating mild hypertension. It is important to monitor and manage blood pressure to prevent complications associated with hypertension.

Correct Answer: D

Rationale: Following a severe rotator cuff tear, it typically takes around 2-3 months for muscular atrophy to develop with increased prominence of the scapular spine. This is due to disuse of the affected shoulder muscles leading to muscle wasting and changes in the bony structures around the shoulder blade. Over time, the lack of muscle activity causes the shoulder blade to become more prominent and noticeable, which can result in altered sensations during activities like hugging. The gradual onset of these changes aligns with the timeline provided in the question, where the wife started to feel discomfort in her husband's left shoulder blade after the recent severe rotator cuff tear.

Correct Answer: B

Rationale: The third heart sound (S3) is a low-frequency sound heard in early diastole, immediately following the second heart sound (S2). It is generated by the abrupt deceleration of the column of blood against the ventricular wall during the rapid passive filling phase (early diastole) when the ventricle is suddenly stretched by a large volume of blood. The S3 sound typically reflects decreased ventricular compliance, rather than normal compliance. An S3 sound is often considered pathological and is commonly associated with conditions such as heart failure, volume overload, and dilated cardiomyopathy. Therefore, the statement that the third heart sound reflects normal compliance of the left ventricle (Choice B) is incorrect.

Correct Answer: B

Rationale: In this scenario, with a blood pressure of 168/94 on both arms, it indicates poorly controlled hypertension. Hypertension can have various causes, including kidney-related issues. Referring the patient to nephrology would be the appropriate next step to evaluate and manage any potential underlying kidney conditions contributing to the uncontrolled blood pressure. The nephrologist can conduct further tests and assessments to determine the root cause and provide specialized care for the patient's condition. This approach ensures a comprehensive evaluation and targeted management plan for the patient's hypertension.

Correct Answer: C

Rationale: For a new patient with the chief complaint of "I am here to establish care," a comprehensive health history would be appropriate. In this scenario, since the patient is new to the healthcare provider, it is important to gather detailed information about the patient's past medical history, family history, social history, medications, allergies, and specific health concerns. This comprehensive health history will help the healthcare provider establish a baseline of the patient's overall health and identify any potential risk factors or underlying conditions that may impact future care and treatment decisions. Additionally, obtaining a thorough health history is essential in building a strong patient-provider relationship and providing patient-centered care.