Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?

Correct Answer: D

Rationale: The presentation is highly suggestive of appendicitis, especially given the migration of pain from the periumbilical region to the right lower quadrant (just medial and inferior to the iliac crest). The worsening of pain with motion, along with associated symptoms such as nausea, vomiting, anorexia, and fever, are typical features of appendicitis. The classic presentation of appendicitis is pain starting around the umbilicus (due to visceral innervation) and then shifting to the right lower quadrant (due to irritation of the parietal peritoneum). Surgical intervention is usually required promptly to prevent complications like perforation, which can lead to peritonitis and sepsis.

Correct Answer: A

Rationale: In order to listen carefully for S splitting, one should use the diaphragm with light pressure over the 2nd right intercostal space. S splitting refers to a split of the second heart sound (S2) into its two components - A2 and P2. The A2 component is normally heard as the main heart sound when the aortic valve closes, and the P2 component is heard when the pulmonic valve closes. By placing the diaphragm lightly over the 2nd right intercostal space, one can best auscultate the aortic area and listen for the timing and splitting of the S2 components. Using the bell or applying firm pressure may not allow for optimal detection of S splitting in this specific case.

Correct Answer: D

Rationale: Audiometric testing is a very sensitive method for detecting hearing loss. It involves a series of tests that measure a person's ability to hear sounds at various frequencies and volumes. These tests can detect even subtle changes in hearing ability and provide detailed information on the type and degree of hearing loss. The whisper test and finger rub test are basic screening tests and are not as sensitive or comprehensive as audiometric testing. The tuning fork test is also used in evaluating hearing loss, but it is not as accurate or sensitive as audiometric testing. Overall, audiometric testing is considered the gold standard for diagnosing hearing loss due to its high sensitivity and ability to provide detailed information on the individual's hearing capabilities.

Correct Answer: D

Rationale: The group of lymph nodes that lie just behind the sternocleidomastoid muscles bilaterally are known as the posterior cervical lymph nodes. These lymph nodes are part of the superficial cervical lymph node chain, which is involved in draining lymph from the head and neck region. In the case described, the presence of sore throat, fever, and enlarged tonsils with exudates suggests a likely upper respiratory tract infection or tonsillitis, leading to the enlargement of the nearby lymph nodes. The posterior cervical lymph nodes are commonly examined in cases of upper respiratory infections and tonsillitis due to their proximity to the area of infection and inflammation.

Correct Answer: D

Rationale: The patient's presentation of new onset tremors, slow movements with shuffling steps (bradykinesia), decreased facial mobility, and blunt expression are characteristic features of Parkinson's disease. Parkinson's disease is a neurodegenerative disorder that affects movement, typically presenting with tremors, rigidity, and bradykinesia. The presence of these symptoms in this patient, along with the absence of any other medical conditions or medication use, points toward a diagnosis of Parkinson's disease. Other conditions like Cushing's syndrome, nephrotic syndrome, and myxedema are unlikely based on the patient's clinical presentation.

Correct Answer: C

Rationale: The symptoms described, such as sneezing, itchy watery eyes, clear nasal discharge, ear pain, and nonproductive cough, are classic signs of allergic rhinitis, commonly known as seasonal allergies. Allergic rhinitis is an inflammatory response triggered by allergens in the environment such as pollen, dust mites, or pet dander. The immune system overreacts to these allergens, releasing histamine and other chemicals that cause the symptoms experienced by the patient. In this case, the most likely pathologic process underlying the symptoms is an allergic response rather than infection, inflammation, or vascular issues.

Correct Answer: A

Rationale: The raised, dark red rash that does not blanch when pressed on, typically known as erythema nodosum, is a common skin manifestation of systemic lupus erythematosus (SLE). Given Mrs. Hill's history of SLE, it is likely that her rash is related to her autoimmune condition rather than an exposure to a chemical or an allergic reaction. It is important for her to discuss this new symptom with her healthcare provider to ensure appropriate management and monitoring of her lupus.

Correct Answer: D

Rationale: A rectal polyp is a growth that originates from the inner lining of the rectum and protrudes into the rectal canal. It may present as a soft, smooth, nontender mass on digital rectal examination. Rectal polyps are usually benign, but some may have the potential to become cancerous if left untreated. Therefore, it is important to evaluate and remove polyps to prevent complications. In this case, the description of a pedunculated mass on the posterior wall of the rectum is most suggestive of a rectal polyp.

Correct Answer: B

Rationale: The dullness in the last intercostal space in the anterior axillary line on the left side with a deep breath is suggestive of splenomegaly. However, this finding alone is not definitive for an enlarged spleen. The size of the spleen can vary, and further examination is required to confirm if the spleen is indeed enlarged. Therefore, Option B is the most appropriate choice as it indicates that the spleen is possibly enlarged, and close attention should be paid to further examination to confirm its status. Further workup, such as imaging studies or blood tests, may be necessary to evaluate the size and function of the spleen in this case.