Mr. Edwards complains of cramps and difficulties with walking. The cramps occur in his calves consistently after walking about 100 yards. After a period of rest, he can start to walk again, but after 100 yards these same symptoms recur. Which of the following would suggest spinal stenosis as a cause of this pain?

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: 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: C

Rationale: The young woman in this scenario is exhibiting characteristics of histrionic personality disorder. Individuals with histrionic personality disorder tend to be overly dramatic, attention-seeking, and have a tendency to be excessively emotional in their reactions. The young woman's exaggerated response to a minor cut on her finger, along with her dramatic declaration that her career as a pianist is over, reflects the emotional and attention-seeking behaviors commonly associated with histrionic personality traits.

Correct Answer: B

Rationale: Tympany is the percussion note you would obtain over the gastric bubble. Tympany is a drum-like sound and is typically heard over air-filled structures in the body, such as the stomach, intestines, and lungs. When percussing over the gastric bubble (air-filled stomach), you would expect to hear a tympanic note due to the presence of air in the stomach creating resonance. Resonance (choice A) is a low-pitched, hollow sound heard over normal lung tissue. Hyperresonance (choice C) is an abnormally loud, booming sound heard over hyperinflated lungs, as in conditions like emphysema. Flatness (choice D) is a dull sound heard over solid organs or areas of tissue consolidation, such as over the liver or a pleural effusion.

Correct Answer: D

Rationale: Placing the patient in the left lateral decubitus position and auscultating with the bell is important to detect subtle sounds like the mitral stenosis murmur, opening snap of the mitral valve, and S3 and S4 gallops. The left lateral decubitus position helps bring the heart closer to the chest wall, allowing for better transmission of these sounds that may be missed in the supine position.

Correct Answer: A

Rationale: Rectal prolapse occurs when the rectum protrudes through the anus. It typically appears as a moist, pink mass that protrudes outside the body. The prolapse is usually painless and can be seen and felt by the patient or the examiner. It is commonly seen in elderly individuals, especially women, and those with conditions like chronic constipation, pelvic floor weakness, or dementia. On the other hand, external hemorrhoids are swollen veins located around the anus, usually painful and may cause bleeding. Perianal fistula is an abnormal tunnel-like connection between the skin near the anus and the rectum, which can cause pain and discharge. Prolapsed internal hemorrhoids are internal hemorrhoids that have descended outside the anal canal and may require manual reduction. Given the symptoms described in the scenario - a moist pink mass protruding from the anus that is nontender and soft without bleeding - the most likely diagnosis is rectal prol

Correct Answer: C

Rationale: The presence of an irregular, asymmetric, hard nodule on the posterior surface of the prostate detected during digital rectal examination raises suspicion for prostate cancer. Prostate cancer commonly presents with nodules or indurations on the prostate gland during physical examination. Other findings, such as no inflammation, masses, or fissures in the anus and normal examinations of the scrotum and penis, further support the likelihood of prostate cancer as the most probable diagnosis in this case. Additional laboratory results, including prostate-specific antigen (PSA) levels, can help confirm the diagnosis. Both benign prostatic hyperplasia (BPH) and prostatitis typically present with different symptoms than those described in the scenario, making prostate cancer the most likely disorder based on the provided information. Anorectal cancer is less likely given the absence of findings indicating involvement of the anus or rectum in this case.

Correct Answer: B

Rationale: A sudden, painful unilateral loss of vision is a medical emergency that may be caused by central retinal artery occlusion. This condition occurs when the main artery supplying blood to the retina becomes blocked, leading to a sudden and severe reduction in blood flow to the eye. The lack of blood flow can cause irreversible damage to the retina, resulting in a significant loss of vision. Patients with central retinal artery occlusion typically present with sudden, painless, and severe vision loss in one eye. Immediate medical attention is crucial to try to restore blood flow and minimize potential permanent vision loss in these cases. Vitreous hemorrhage, macular degeneration, and optic neuritis do not typically present with sudden, painful unilateral loss of vision as seen in central retinal artery occlusion.

Correct Answer: D

Rationale: The patient's presentation of tenderness in the left upper quadrant and epigastric area, along with normal bowel sounds, is suggestive of acute pancreatitis. This condition typically presents with severe, steady epigastric pain that may radiate to the back or left upper quadrant. Patients may also have tenderness on physical examination in these areas. Acute pancreatitis is commonly associated with risk factors such as gallstones or excessive alcohol consumption.