A 58-year-old gardener comes to your office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wartlike texture on palpation. Based on this description, what is your most likely diagnosis?

Correct Answer: B

Rationale: The description of an oval, brown, slightly elevated lesion with a flat surface and rough, wartlike texture on palpation is characteristic of a seborrheic keratosis. Seborrheic keratoses are common benign skin growths that typically occur in older adults. They can vary in color, ranging from tan to dark brown, and often have a waxy or stuck-on appearance. The lesion described does not fit the typical characteristics of actinic keratosis, basal cell carcinoma, or squamous cell carcinoma.

Correct Answer: A

Rationale: A murmur heard only at the cardiac apex is most likely due to mitral valve pathology. The mitral valve is located near the apex of the heart, and murmurs related to mitral valve issues are typically best heard at the apex during auscultation. Mitral valve diseases such as mitral valve prolapse, mitral stenosis, or mitral regurgitation can lead to the development of a murmur in this location.

Correct Answer: C

Rationale: A "red flag" regarding patients presenting with a headache is their age being over 50. This is because new-onset or persistent headaches in individuals over 50 may raise concerns about underlying serious conditions such as temporal arteritis, brain tumor, or other vascular issues. It is important to thoroughly evaluate and consider these possibilities in older patients with headaches to ensure appropriate management and timely intervention.

Correct Answer: D

Rationale: Finding a bounding carotid pulse suggests a wide pulse pressure, which can be associated with aortic insufficiency. Aortic insufficiency (also known as aortic regurgitation) is characterized by the backflow of blood from the aorta into the left ventricle during diastole due to incomplete closure of the aortic valve. This results in increased stroke volume and left ventricular pressure, leading to widened pulse pressure and a bounding arterial pulse. Therefore, when a bounding carotid pulse is detected in a patient, it is important to search for signs and symptoms of aortic insufficiency, such as a diastolic murmur heard best at the left sternal border and radiating to the neck.

Correct Answer: A

Rationale: The point of maximal impulse (PMI), also known as the apical impulse, is the point where the left ventricle is closest to the chest wall. Normally, the PMI is located in the left 5th intercostal space, around 7 to 9 cm lateral to the sternum. This area corresponds to the apex of the heart. By palpating the PMI, healthcare providers can assess the size, strength, and regularity of the heart's contractions, which can provide important diagnostic information about cardiac health. Locating the PMI accurately is essential for physical examination and diagnosis of cardiac conditions.

Correct Answer: A

Rationale: The presence of a firm and immobile mass felt against the bowel wall during a rectal examination is concerning for a potential malignancy, such as colon cancer. Other conditions such as hemorrhoids or anal fissures are typically not associated with a mass that is firm and immobile. The "Valve of Houston" is a term that does not pertain to this scenario and is not a recognized medical entity. Therefore, the most likely diagnosis based on the given information is colon cancer, and further evaluation such as a colonoscopy would be warranted for definitive diagnosis and management.

Correct Answer: A

Rationale: The progression of excruciating pain starting under the lower ribs on the right side, then moving to the lateral abdomen, and finally settling in the right lower quadrant is classic for appendicitis. Appendicitis is an inflammation of the appendix, a small tube-like structure attached to the cecum (beginning of the large intestine). The pain typically starts around the umbilicus and then migrates to the right lower quadrant, where the appendix is located. Other symptoms that may accompany appendicitis include fever, nausea, vomiting, loss of appetite, and tenderness at McBurney's point (a specific area in the abdomen). It is a medical emergency that requires immediate attention to avoid complications such as perforation and peritonitis.

Correct Answer: B

Rationale: The description of an oval, brown, slightly elevated lesion with a flat surface and rough, wartlike texture on palpation is characteristic of a seborrheic keratosis. Seborrheic keratoses are common benign skin growths that typically occur in older adults. They can vary in color, ranging from tan to dark brown, and often have a waxy or stuck-on appearance. The lesion described does not fit the typical characteristics of actinic keratosis, basal cell carcinoma, or squamous cell carcinoma.

Correct Answer: A

Rationale: Acknowledging and taking responsibility for any part you may have played in provoking the patient's anger is important in effectively addressing the situation. By avoiding admission of your lateness, you may come across as dismissive of the patient's feelings and not addressing the issue at hand. It is essential to validate the patient's feelings and work towards finding a solution rather than avoiding the issue.