You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?

Correct Answer: C

Rationale: The correct answer is C: Mitral valve defect. This is because the mitral valve is best heard in the left lateral decubitus position. In this position, the heart rotates, bringing the mitral valve closer to the chest wall, making it easier to auscultate any abnormalities such as murmurs. Aortic (A), pulmonic (B), and tricuspid (D) valve defects are not typically better heard in the left lateral decubitus position, so they are incorrect choices.

Correct Answer: C

Rationale: The correct answer is C: Pulmonic stenosis. This valve lesion typically produces a murmur of equal intensity throughout systole due to the obstruction of blood flow during both systole and diastole. Pulmonic stenosis results in turbulent blood flow across the pulmonary valve, creating a consistent murmur throughout the cardiac cycle. Rationale for incorrect choices: A: Aortic stenosis - Produces a crescendo-decrescendo murmur that peaks in mid-systole. B: Mitral insufficiency - Causes a holosystolic murmur that is loudest at the apex. D: Aortic insufficiency - Results in a diastolic murmur heard best at the left sternal border. In summary, pulmonic stenosis is the correct answer as it uniquely presents with a murmur of equal intensity throughout systole, distinguishing it from the other valve lesions.

Correct Answer: B

Rationale: The correct answer is B. Dividing the breast into quadrants and inspecting each systematically is the most effective pattern of palpation for breast cancer because it ensures thorough coverage of the entire breast, making it easier to detect any abnormalities. This method allows for a structured approach, reducing the likelihood of missing any potential signs of cancer. A: Beginning at the nipple and making an ever-enlarging spiral may not cover all areas of the breast equally, potentially leading to missed abnormalities. C: Examining in lines resembling mowing a lawn may also result in uneven coverage and potentially missing crucial areas. D: Beginning at the nipple and palpating outward in a stripe pattern may not provide comprehensive coverage of the entire breast, increasing the risk of overlooking abnormalities.

Correct Answer: D

Rationale: The correct answer is D: Irritable bowel syndrome (IBS). Monique's symptoms of lower abdominal pain relieved by defecation, change in bowel movements' form and frequency, and absence of menses-related pain align with IBS criteria. IBS is a functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits. It is a diagnosis of exclusion, meaning other conditions must be ruled out. Choice A: Colon cancer is less likely due to Monique's age, absence of alarming symptoms like weight loss or blood in stool, and the intermittent nature of her symptoms. Choice B: Cholecystitis typically presents with right upper quadrant pain, nausea, and vomiting, which do not match Monique's symptoms. Choice C: Inflammatory bowel disease (IBD) usually presents with persistent symptoms, blood in stool, and systemic signs, which are not seen in Monique's case.

Correct Answer: D

Rationale: Rationale for D (Enlarged bladder): The presentation of a smooth lower abdominal mass that is minimally tender and associated with dullness to percussion above the symphysis pubis suggests an enlarged bladder. This is a common finding in elderly individuals due to various reasons such as urinary retention or bladder outlet obstruction. The location and characteristics of the mass align with an enlarged bladder. Summary of other choices: A: Sigmoid mass - Unlikely as sigmoid mass typically presents with different characteristics such as irregular shape and may not cause dullness to percussion above the symphysis pubis. B: Tumor in the abdominal wall - Less likely as tumors in the abdominal wall would have a different presentation and wouldn't be associated with urinary symptoms. C: Hernia - Less likely as hernias typically manifest with a bulge that can be reduced and may not cause dullness to percussion above the symphysis pubis.