Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has come to the office many times in the past with a variety of injuries, and you suspect that he has a problem with alcohol. Which one of the following questions will be most helpful in diagnosing this problem?

Correct Answer: B

Rationale: Asking Mr. Q. when his last drink was is an open-ended question that can provide valuable information regarding his alcohol consumption patterns. This question allows Mr. Q. to disclose whether he has been drinking recently and can help determine the frequency and quantity of his alcohol consumption. It avoids leading or judgmental language, which can help build rapport and facilitate a more honest conversation about his alcohol use. By knowing when his last drink was, you can better assess the potential impact of alcohol on his current symptoms of fatigue and further explore any potential issues related to alcohol abuse.

Correct Answer: B

Rationale: The scenario described suggests that Ray experiences pain only when actively lifting his arm over his head, which indicates the issue is likely originating from structures outside of the joint itself. When the shoulder is moved passively (moved by an external force), there is full range of motion without pain, suggesting that the limitation and pain occur due to muscles, tendons, or ligaments surrounding the joint rather than within the joint itself. In this case, the joint disease is likely to be extra-articular, involving structures such as muscles or tendons rather than being articular in nature.

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: 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: 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: 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: C

Rationale: Shortness of breath is commonly associated with issues related to the heart and cardiovascular system. Conditions such as heart failure, coronary artery disease, or arrhythmias can lead to symptoms like shortness of breath. Therefore, the symptom of shortness of breath would be assigned to the cardiac anatomic region.

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: A

Rationale: In a 30-year-old man with a firm, 2-cm mass under his areola and no other symptoms, the most likely diagnosis is breast tissue. Gynecomastia is a common condition in males where there is proliferation of breast tissue. It typically presents as a firm subareolar mass and can occur due to hormonal imbalances, medication use, or underlying medical conditions. Given the lack of family history of breast cancer, absence of other symptoms, and the age of the patient, breast tissue is the most probable diagnosis in this case. Breast cancer is less likely in this scenario, especially without any additional concerning findings or family history. Fibrocystic disease and lymph node involvement are also less likely given the presentation of a firm mass under the areola.