A 77-year-old retired nurse has an ulcer on a lower extremity that you are asked to evaluate when you do your weekly rounds at a local long-term care facility. All of the following are responsible for causing ulcers in the lower extremities except for which condition?

Correct Answer: D

Rationale: Hypertension, or high blood pressure, is not typically associated with causing ulcers in the lower extremities. The most common causes of lower extremity ulcers are arterial insufficiency, venous insufficiency, and diminished sensation in pressure points. Arterial insufficiency leads to decreased blood flow to the lower extremities, causing tissue damage and ulcers. Venous insufficiency results in poor circulation and increased pressure in the veins, leading to ulcers. Diminished sensation in pressure points, often seen in conditions like diabetes, can cause ulcers due to lack of feeling and increased risk of trauma. So, hypertension is not directly related to the development of lower extremity ulcers.

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: C

Rationale: Peyronie's disease is a condition characterized by the formation of fibrous scar tissue in the penis, leading to the development of plaques or indurations along the shaft of the penis, typically on the ventral surface. These plaques can cause penile curvature, pain, and erectile dysfunction. Urethral stricture, testicular carcinoma, and epidermoid cysts are not typically associated with indurations along the ventral surface of the penis.

Correct Answer: C

Rationale: The patient's history of frequent loose stools with cramping, occurring since high school and worsening during periods of nervousness, along with occasional constipation, is characteristic of irritable bowel syndrome (IBS). IBS is a functional gastrointestinal disorder that presents with symptoms such as abdominal pain or discomfort, bloating, and altered bowel habits (diarrhea, constipation, or both) without any evidence of organic disease. The absence of systemic symptoms like fever, weight loss, or blood in the stool, as well as normal physical examination findings, also support the diagnosis of IBS in this case. This condition is often triggered or exacerbated by stress or anxiety. Monitoring stress levels, dietary modifications, and possibly prescription medications may help manage IBS symptoms in this patient.

Correct Answer: C

Rationale: The obturator sign is a physical examination maneuver used to assess for irritation of the obturator muscle due to an inflamed appendix that is in close proximity. This pain is typically felt in the right lower quadrant or hypogastric region. The sign is elicited by passively flexing the hip and knee of the patient, then internally rotating the hip. An alternative method is to position the patient on her left side and ask her to raise her right thigh against resistance while the examiner provides counterpressure. Pain experienced by the patient with these maneuvers is consistent with obturator sign, indicating possible appendicitis. Hence, option C is the correct answer.

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: D

Rationale: Hypertension, or high blood pressure, is not typically associated with causing ulcers in the lower extremities. The most common causes of lower extremity ulcers are arterial insufficiency, venous insufficiency, and diminished sensation in pressure points. Arterial insufficiency leads to decreased blood flow to the lower extremities, causing tissue damage and ulcers. Venous insufficiency results in poor circulation and increased pressure in the veins, leading to ulcers. Diminished sensation in pressure points, often seen in conditions like diabetes, can cause ulcers due to lack of feeling and increased risk of trauma. So, hypertension is not directly related to the development of lower extremity ulcers.

Correct Answer: A

Rationale: Anisocoria refers to a condition where the pupils are of unequal size. Pathologic causes of anisocoria can include conditions such as Horner's syndrome. Horner's syndrome is a rare disorder caused by damage to the sympathetic nerves of the face and eye. Symptoms can include a constricted pupil (miosis), drooping of the upper eyelid (ptosis), and decreased sweating in the affected area. This results in anisocoria, where the affected pupil is smaller than the unaffected pupil. Other options listed (B-D) do not typically lead to pathologic anisocoria.

Correct Answer: D

Rationale: Weight loss can have a significant impact on the health problems associated with obesity. Even a modest weight loss of around 10% can lead to noticeable improvements in conditions such as diabetes, hypertension, osteoarthritis, and obstructive sleep apnea. Encouraging Mr. Curtiss to focus on achieving a meaningful but achievable goal, such as a 10% weight loss, can help him experience positive changes in his health and overall wellbeing, even if his ultimate goal weight seems far away. This approach can also help to boost his motivation and confidence in his ability to make progress towards better health.