Exam 4 Flashcards
A 72-year-old retired saleswoman comes to your office, complaining of a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The patient denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetric, with no skin changes. You are able to express bloody discharge from her left nipple. You feel no discrete masses, but her left axilla has a hard, 1-cm fixed node. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable.
What cause of nipple discharge is the most likely in her circumstance?
A) Benign breast abnormality
B) Breast cancer
C) Galactorrhea
Ans: B
Chapter: 10
Page and Header: 392, The Health History
Feedback: Nipple discharge in breast cancer is usually unilateral and can be clear or bloody. Although a breast mass is not palpated, in this case a fixed lymph node is palpated. Other forms of breast cancer can present as a chronic rash on the breast.
A 44-year-old female comes to your clinic, complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. On examination you find a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath you palpate a nontender 2-cm mass. The axilla contains only soft, moveable nodes. The left breast and axilla examination findings are unremarkable.
What visible skin change of the breast does she have?
A) Nipple retraction
B) Paget’s disease
C) Peau d’orange sign
Ans: B
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: This uncommon form of breast cancer starts as an eczema-like, scaly skin change around the areola. The lesion may weep, crust, or erode. It can be associated with an underlying mass, but the skin change can also be found alone. Any eczema-like area around the nipple that does not respond to topical treatment needs to be evaluated for breast cancer.
A 56-year-old female comes to your clinic, complaining of her left breast looking unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-examinations, so she doesn’t know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On examination you find a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels thickened. Lateral to the areola you palpate a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast and axilla examinations are unremarkable.
What visible skin change of the breast does she have?
A) Nipple retraction
B) Paget’s disease
C) Peau d’orange sign
Ans: A
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: A retracted nipple is flattened or pulled inward or toward the medial, lateral, anterior, or posterior side of the breast. The surrounding skin can be thickened. This is a relatively late finding in breast cancer.
A 19-year-old female comes to your office, complaining of a clear discharge from her right breast for 2 months. She states that she noticed it when she and her boyfriend were “messing around” and he squeezed her nipple. She continues to have this discharge anytime she squeezes that nipple. She denies any trauma to her breasts. Her past medical history is unremarkable. She denies any pregnancies. Both of her parents are healthy. She denies using tobacco or illegal drugs and drinks three to four beers a week. On examination her breasts are symmetric with no skin changes. You are able to express clear discharge from her right nipple. You feel no discrete masses and her axillae are normal. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. A urine pregnancy test is negative.
What cause of nipple discharge is the most likely in her circumstance?
A) Benign breast abnormality
B) Breast cancer
C) Nonpuerperal galactorrhea
Ans: A
Chapter: 10
Page and Header: 392, The Health History
Feedback: Nipple discharge in benign breast abnormalities tends to be clear and unilateral. The discharge is usually not spontaneous. This patient needs to be told to stop compressing her nipple. If the problem still persists after the patient has stopped compressing the nipple, further workup is warranted.
A 23-year-old computer programmer comes to your office for an annual examination. She has recently become sexually active and wants to be placed on birth control. Her only complaint is that the skin in her armpits has become darker. She states it looks like dirt, and she scrubs her skin nightly with soap and water but the color stays. Her past medical symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high blood pressure. The patient denies using tobacco but has four to five drinks on Friday and Saturday nights. She denies any illegal drug use. On examination you see a mildly obese female who is breathing comfortably. Her vital signs are unremarkable. Looking under her axilla, you see dark, velvet-like skin. Her annual examination is otherwise unremarkable.
What disorder of the breast or axilla is she most likely to have?
A) Peau d’orange
B) Acanthosis nigricans
C) Hidradenitis suppurativa
Ans: B
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: Acanthosis nigricans can be associated with an internal malignancy, but in most cases it is a benign dermatologic condition associated with polycystic ovarian syndrome, consisting of acne, hirsutism, obesity, irregular periods, infertility, ovarian cysts, and early onset type 2 diabetes. It is also known to correlate with insulin resistance.
A 43-year-old store clerk comes to your office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago), and until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The patient does not smoke, drink, or use illegal drugs. Her father is in good health. On examination you see a tense female appearing her stated age. On visual inspection of her left axilla you see a tense red area. There is no scarring around the axilla. Palpating this area, you feel a 2-cm tender, movable lymph node underlying hot skin. Other shotty nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examining her left arm, you see a scabbed-over superficial laceration over her left hand. Upon your questioning, she remembers she cut her hand gardening last week.
What disorder of the axilla is most likely responsible for her symptoms?
A) Breast cancer
B) Lymphadenopathy of infectious origin
C) Hidradenitis suppurativa
Ans: B
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: A lymph node enlarged because of infection is generally hot, tender, and red. Close examination of the skin that drains to that lymph node region is advised. Often there will be a cut or scratch over the involved arm that has an infectious agent. An example is cat scratch disease.
A 63-year-old nurse comes to your office, upset because she has found an enlarged lymph node under her right arm. She states she found it last week while taking a shower. She isn’t sure if she has any breast lumps because she doesn’t know how to do self-exams. She states her last mammogram was 5 years ago and it was normal. Her past medical history is significant for high blood pressure and chronic obstructive pulmonary disease. She quit smoking 2 years ago after a 55-packs/year history. She denies using any illegal drugs and drinks alcohol rarely. Her mother died of a heart attack and her father died of a stroke. She has no children. On examination you see an older female appearing her stated age. On visual inspection of her right axilla you see nothing unusual. Palpating this area, you feel a 2-cm hard, fixed lymph node. She denies any tenderness. Visualization of both breasts is normal. Palpation of her left axilla and breast is unremarkable. On palpation of her right breast you feel a nontender 1-cm lump in the tail of Spence.
What disorder of the axilla is most likely responsible for her symptoms?
A) Breast cancer
B) Lymphadenopathy of infectious origin
C) Hidradenitis suppurativa
Ans: A
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: Metastatic lymph nodes tend to be hard, nontender, and fixed, often to the rib cage. Although the patient has no family history of breast cancer, she is at a slightly increased risk due to her never having had children.
A 40-year-old mother of two presents to your office for consultation. She is interested in knowing what her relative risks are for developing breast cancer. She is concerned because her sister had unilateral breast cancer 6 years ago at age 38. The patient reports on her history that she began having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco, alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable.
Which risk factor of her personal and family history most puts her in danger of getting breast cancer?
A) First-degree relative with premenopausal breast cancer
B) Age at menarche of less than 12
C) First live birth between the ages of 25 and 29
D) First-degree relative with postmenopausal breast cancer
Ans: A
Chapter: 10
Page and Header: 393, Health Promotion and Counseling
Feedback: Having a first-degree relative with cancer before menopause gives a relative risk of 3.1.
A 51-year-old cook comes to your office for consultation. She recently found out that her 44-year-old sister with premenopausal breast cancer is positive for the BRCA1 gene. Your patient has been doing research on the Internet and saw that her chance of having also inherited the BRCA1 gene is 50%. She is interested in knowing what her risk of developing breast cancer would be if she were positive for the gene. She denies any lumps in her breasts and has had normal mammograms. She has had no weight loss, fever, or night sweats. Her mother is healthy and her father has prostate cancer. Two of her paternal aunts died of breast cancer. She is married. She denies using tobacco or illegal drugs and rarely drinks alcohol. Her breast and axilla examinations are unremarkable.
At her age, what is her risk of getting breast cancer if she has the BRCA1 gene?
A) 10%
B) 50%
C) 80%
Ans: B
Chapter: 10
Page and Header: 393, Health Promotion and Counseling
Feedback: At the age of 50, the risk of breast cancer for someone with the BRCA1 gene is 50%.
A 14-year-old junior high school student is brought in by his mother and father because he seems to be developing breasts. The mother is upset because she read on the Internet that smoking marijuana leads to breast enlargement in males. The young man adamantly denies using any tobacco, alcohol, or drugs. He has recently noticed changes in his penis, testicles, and pubic hair pattern. Otherwise, his past medical history is unremarkable. His parents are both in good health. He has two older brothers who never had this problem. On examination you see a mildly overweight teenager with enlarged breast tissue that is slightly tender on both sides. Otherwise his examination is normal. He is agreeable to taking a drug test.
What is the most likely cause of his gynecomastia?
A) Breast cancer
B) Imbalance of hormones of puberty
C) Drug use
Ans: B
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: Approximately one third of teenage boys develop gynecomastia during puberty. It is not surprising that the two older brothers did not have this.
A patient is concerned about a dark skin lesion on her anterolateral abdomen. It has not changed, and there is no discharge or bleeding. On examination there is a medium brown circular lesion on the anterolateral wall of the abdomen. It is soft, has regular borders, is evenly pigmented, and is about 7 mm in diameter. What is this lesion?
A) Melanoma
B) Dysplastic nevus
C) Supernumerary nipple
D) Dermatofibroma
Ans: C
Chapter: 10
Page and Header: 389, Anatomy and Physiology
Feedback: This represents a supernumerary nipple. These occur along the “milk line” and do not exhibit features of more concerning lesions.
A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no diagnosis of breast cancer in his first-degree relatives. What is the most likely diagnosis?
A) Breast tissue
B) Fibrocystic disease
C) Breast cancer
D) Lymph node
Ans: A
Chapter: 10
Page and Header: 389, Anatomy and Physiology
Feedback: Approximately one third of adult men will have palpable breast tissue under the areola. While males can have breast cancer, this is much less common. There are no lymph nodes in this area.
Which of the following lymph node groups is most commonly involved in breast cancer?
A) Lateral
B) Subscapular
C) Pectoral
D) Central
Ans: D
Chapter: 10
Page and Header: 389, Anatomy and Physiology
Feedback: The central nodes at the apex of the axilla are most commonly involved in breast cancer. The axilla can be viewed roughly as a four-sided pyramid. An examination covering all sides and the apex is unlikely to miss a significant node.
When should a woman conduct breast self-examination with respect to her menses?
A) Five to seven days following her menses
B) Midcycle
C) Immediately prior to menses
D) During her menses
Ans: A
Chapter: 10
Page and Header: 392, The Health History
Feedback: The breast examination should be conducted during the time with the least estrogen stimulation of the breast tissue. This corresponds to five to seven days following menses.
Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass. Without any other information, what is the risk of this mass being cancerous?
A) About 10%
B) About 20%
C) About 30%
D) About 40%
Ans: A
Chapter: 10
Page and Header: 393, Health Promotion and Counseling
Feedback: Eleven percent of women presenting with a breast mass will have breast cancer. This statistic can be reassuring to a patient, but the importance of further studies must be emphasized.
How often, according to American Cancer Society recommendations, should a woman undergo a screening breast examination by a skilled clinician?
A) Every year
B) Every 2 years
C) Every 3 years
D) Every 4 years
Ans: C
Chapter: 10
Page and Header: 393, Health Promotion and Counseling
Feedback: The current recommendation for screening by breast examination is every 3 years.
Which of the following is most likely benign on breast examination?
A) Dimpling of the skin resembling that of an orange
B) One breast larger than the other
C) One nipple inverted
D) One breast with dimple when the patient leans forward
Ans: B
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: Asymmetry in size of the breasts is a common benign finding. The others are concerning for underlying malignancy.
Which is the most effective pattern of palpation for breast cancer?
A) Beginning at the nipple, make an ever-enlarging spiral.
B) Divide the breast into quadrants and inspect each systematically.
C) Examine in lines resembling the back and forth pattern of mowing a lawn.
D) Beginning at the nipple, palpate outward in a stripe pattern.
Ans: C
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: The vertical strip pattern has been shown to be the most effective pattern for palpation of the breast. The most important aspect, however, is to be systematic. The tail of Spence, located on the upper anterior chest, is an area commonly missed on examination.
Which is true of women who have had a unilateral mastectomy?
A) They no longer require breast examination.
B) They should be examined carefully along the surgical scar for masses.
C) Lymphedema of the ipsilateral arm usually suggests recurrence of breast cancer.
D) Women with breast reconstruction over their mastectomy site no longer require examination.
Ans: B
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: A woman who has had breast cancer remains at high risk for recurrence, especially in the contralateral breast. The mastectomy site should be carefully examined for local recurrence as well. Lymphedema or swelling of the ipsilateral arm following mastectomy is common and does not usually indicate recurrence. Women with breast reconstruction must also undergo careful examination.
Which of the following is true regarding breast self-examination?
A) It has been shown to reduce mortality from breast cancer.
B) It is recommended unanimously by organizations making screening recommendations.
C) A high proportion of breast masses are detected by breast self-examination.
D) The undue fear caused by finding a mass justifies omitting instruction in breast self-examination.
Ans: C
Chapter: 10
Page and Header: 402, Techniques of Examination
Feedback: Although self-examination has not been shown to reduce mortality and is not recommended by all groups making screening recommendations, many choose to teach women a systematic method in which to examine their breasts. A high proportion of breast masses are detected by breast self-examination.
A 28-year-old musician comes to your clinic, complaining of a “spot” on his penis. He states his partner noticed it 2 days ago and it hasn’t gone away. He says it doesn’t hurt. He has had no burning with urination and no pain during intercourse. He has had several partners in the last year and uses condoms occasionally. His past medical history consists of nongonococcal urethritis from Chlamydia and prostatitis. He denies any surgeries. He smokes two packs of cigarettes a day, drinks a case of beer a week, and smokes marijuana and occasionally crack. He has injected IV drugs before but not in the last few years. He is single and currently unemployed. His mother has rheumatoid arthritis and he doesn’t know anything about his father. On examination you see a young man appearing deconditioned but pleasant. His vital signs are unremarkable. On visualization of his penis there is a 6-mm red, oval ulcer with an indurated base just proximal to the corona. There is no prepuce because of neonatal circumcision. On palpation the ulcer is nontender. In the inguinal region there is nontender lymphadenopathy.
What disorder of the penis is most likely the diagnosis?
A) Condylomata acuminata
B) Genital herpes
C) Syphilitic chancre
D) Penile carcinoma
Ans: C
Chapter: 13
Page and Header: 516, Table 13–2
Feedback: Primary syphilis causes a larger ulcer that is firm and painless. Syphilis is fairly uncommon but does occur in the highly promiscuous population, especially when coupled with illegal drug use. You should consider further questions and workup regarding HIV status.
A 20-year-old part-time college student comes to your clinic, complaining of growths on his penile shaft. They have been there for about 6 weeks and haven’t gone away. In fact, he thinks there may be more now. He denies any pain with intercourse or urination. He has had three former partners and has been with his current girlfriend for 6 months. He says that because she is on the pill they don’t use condoms. He denies any fever, weight loss, or night sweats. His past medical history is unremarkable. In addition to college, he works part-time for his father in construction. He is engaged to be married and has no children. His father is healthy and his mother has hypothyroidism. On examination the young man appears healthy. His vital signs are unremarkable. On visualization of his penis you see several moist papules along all sides of his penile shaft and even two on the corona. He has been circumcised. On palpation of his inguinal region there is no inguinal lymphadenopathy.
Which abnormality of the penis does this patient most likely have?
A) Condylomata acuminata
B) Genital herpes
C) Syphilitic chancre
D) Penile carcinoma
Ans: A
Chapter: 13
Page and Header: 516, Table 13–2
Feedback: Warts are generally painless papules along the shaft and corona. They are likely to spread and are caused by the human papilloma virus, transmitted through sexual contact. You should discuss prevention of STIs with him. Although his girlfriend’s contraceptive pill protects her from pregnancy, he and she are unprotected from sharing STIs. She should receive regular Pap examinations and consider the HPV vaccine.
A 29-year-old married computer programmer comes to your clinic, complaining of “something strange” going on in his scrotum. Last month while he was doing his testicular self-examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable.
What disorder of the testes is most likely the diagnosis?
A) Hydrocele
B) Scrotal hernia
C) Scrotal edema
D) Varicocele
Ans: B
Chapter: 13
Page and Header: 519, Table 13–5
Feedback: Scrotal hernias occur when the small intestine passes through a weak spot of the inguinal ring. The examiner cannot get a finger above the hernia into the ring. Hernias are often caused by increased abdominal pressure, such as in weight lifting. Patients who have a hernia on one side often have another hernia on the opposite side. In this patient’s case, a right-sided hernia was repaired as an infant.
A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn’t change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He is a married hospital administrator with two children. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On examination you see a young man appearing his stated age with unremarkable vital signs. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down, you feel no bulges. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate examination is unremarkable.
What abnormality of the scrotum does he most likely have?
A) Hydrocele
B) Scrotal hernia
C) Scrotal edema
D) Varicocele
Ans: D
Chapter: 13
Page and Header: 518, Table 13–4
Feedback: Varicoceles are varicose veins surrounding the spermatic cord, coming through the inguinal ring. These veins feel like spaghetti and are often referred to as a “bag of worms.” The increased number of veins affects the temperature of the testes, often causing infertility problems. Like most varicose veins in any area, varicoceles can cause a nonspecific aching. Although usually benign, a unilateral varicocele on the right or a varicocele which does not resolve in the supine position deserves further workup.
A 48-year-old policeman comes to your clinic, complaining of a swollen scrotum. He states it began a couple of weeks ago and has steadily worsened. He says the longer he stands up the worse it gets, but when he lies down it improves. He denies any pain with urination. Because he is impotent he doesn’t know if intercourse would hurt. He states he has become more tired lately and has also gained 10 pounds in the last month. He denies any fever or weight loss. He has had some shortness of breath with exertion. His past medical history consists of type 2 diabetes for 20 years, high blood pressure, and coronary artery disease. He is on insulin, three high blood pressure pills, and a water pill. He has had his gallbladder removed. He is married and has five children. He is currently on disability because of his health problems. Both of his parents died of complications of diabetes. On examination you see a pleasant male appearing chronically ill. He is afebrile but his blood pressure is 160/100 and his pulse is 90. His head, eyes, ears, nose, throat, and neck examinations are normal. There are some crackles in the bases of each lung. During his cardiac examination there is an extra heart sound. Visualization of his penis shows an uncircumcised prepuce but no lesions or masses. Palpation of his scrotum shows generalized swelling, with no discrete masses. A gloved finger is placed through each inguinal ring, and with bearing down there are no bulges. The prostate is smooth and nontender.
What abnormality of the scrotum is most likely the diagnosis?
A) Hydrocele
B) Scrotal hernia
C) Scrotal edema
D) Varicocele
Ans: C
Chapter: 13
Page and Header: 515, Table 13–1
Feedback: Scrotal edema is a generalized swelling of the scrotum due to a systemic illness. No discrete masses are palpated. In this case, with the history of diabetes, hypertension, and coronary artery disease, the symptom of weight gain, and the signs of crackles in the lungs and an extra heart sound, the patient is probably suffering from congestive heart failure. This is also seen in patients with edema from hypoalbuminemia.
A 36-year-old security officer comes to your clinic, complaining of a painless mass in his scrotum. He found it 3 days ago during a testicular self-examination. He has had no burning with urination and no pain during sexual intercourse. He denies any weight loss, weight gain, fever, or night sweats. His past medical history is notable for high blood pressure. He is married and has three healthy children. He denies using illegal drugs, smokes two to three cigars a week, and drinks six to eight alcoholic beverages per week. His mother is in good health and his father had high blood pressure and coronary artery disease. On physical examination he appears anxious but in no pain. His vital signs are unremarkable. On visualization of his penis, he is circumcised and has no lesions. His inguinal region has no lymphadenopathy. Palpation of his scrotum shows a soft cystic-like lesion measuring 2 cm over his right testicle. There is no difficulty getting a gloved finger through either inguinal ring. With weight bearing there are no bulges. His prostate examination is unremarkable.
What disorder of the scrotum does he most likely have?
A) Hydrocele
B) Scrotal hernia
C) Testicular tumor
D) Varicocele
Ans: A
Chapter: 13
Page and Header: 515, Table 13–1
Feedback: The hydrocele is a fluid-filled cyst originating within the tunica vaginalis. An examining finger can be placed over the mass into the inguinal ring. An outside light source can be placed beneath the scrotum. Hydroceles often transilluminate light, whereas solid tumors do not.
A 22-year-old unemployed roofer presents to your clinic, complaining of pain in his testicle and penis. He states the pain began last night and has steadily become worse. He states it hurts when he urinates and he has not attempted intercourse since the pain began. He has tried Tylenol and ibuprofen without improvement. He denies any fever or night sweats. His past medical history is unremarkable. He has had four previous sexual partners and has had a new partner for the last month. She is on oral contraceptives so he has not used condoms. His parents are both in good health. On examination you see a young man lying on his side. He appears mildly ill. His temperature is 100.2 and his blood pressure, respirations, and pulse are normal. On visualization of the penis he is circumcised, with no lesions or discharge from the meatus. Visualization of the scrotal skin appears unremarkable. Palpation of the testes shows severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells and bacteria.
What diagnosis of the male genitalia is most likely in this case?
A) Acute orchitis
B) Acute epididymitis
C) Torsion of the spermatic cord
D) Prostatitis
Ans: B
Chapter: 13
Page and Header: 518, Table 13–4
Feedback: Epididymitis is an infection of the epididymis superior to the testicle. It can often be caused by sexually transmitted disease and can cause burning with urination and scrotal pain. Palpate the spermatic cord through the scrotum by pinching medially and sliding your pinched fingers laterally. The spermatic cord, including the epididymis, will pass between your fingers and be tender if involved.
A 15-year-old high school football player is brought to your office by his mother. He is complaining of severe testicular pain since exactly 8:00 this morning. He denies any sexual activity and states that he hurts so bad he can’t even urinate. He is nauseated and is throwing up. He denies any recent illness or fever. His past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. On examination you see a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. His blood pressure is 150/100, his pulse is 110, and his respirations are 24. On visualization of the penis he is circumcised and there are no lesions and no discharge from the meatus. His scrotal skin is tense and red. Palpation of the left testicle causes severe pain and the patient begins to cry. His prostate examination is unremarkable. His cremasteric reflex is absent on the left but is normal on the right. By catheter you get a urine sample and the analysis is unremarkable. You send the boy with his mother to the emergency room for further workup.
What is the most likely diagnosis for this young man’s symptoms?
A) Acute orchitis
B) Acute epididymitis
C) Torsion of the spermatic cord
D) Prostatitis
Ans: C
Chapter: 13
Page and Header: 518, Table 13–4
Feedback: Torsion is caused by the twisting of the testicle on its spermatic cord and blood vessels, leading to severe pain. The scrotum becomes red and tense. Torsion is usually seen in adolescents and is a true surgical emergency. If not quickly surgically repaired, the testicle’s function is lost and it has to be removed. The presence of a cremasteric reflex is reassuring, but in this case a thorough evaluation must take place as soon as possible.
A 16-year-old high school junior is brought to your clinic by his father. The teenager was taught in his health class at school to do monthly testicular self-examinations. Yesterday when he felt his left testicle it was enlarged and tender. He isn't sure if he has had burning with urination and he says he has never had sexual intercourse. He has had a sore throat, cough, and runny nose for the last 3 days. His past medical history is significant for a tonsillectomy as a small child. His father has high blood pressure and his mother is healthy. On examination you see a teenager in no acute distress. His temperature is 100.8 and his blood pressure and pulse are unremarkable. On visualization of his penis, he is uncircumcised and has no lesions or discharge. His scrotum is red and tense on the left and normal appearing on the right. Palpating his left testicle reveals a mildly sore swollen testicle. The right testicle is unremarkable. An examining finger is put through both inguinal rings, and there are no bulges with bearing down. His prostate examination is unremarkable. Urine analysis is also unremarkable. What abnormality of the testes does this teenager most likely have?
A) Acute orchitis
B) Acute epididymitis
C) Torsion of the spermatic cord
D) Prostatitis
Ans: A
Chapter: 13
Page and Header: 517, Table 13–3
Feedback: Acute orchitis causes an inflamed, tender testicle. The scrotum will be red and tense. Orchitis is usually unilateral and often associated with viral infections such as mumps.
A 45-year-old electrical engineer presents to your clinic, complaining of spots on his scrotum. He first noticed the spots several months ago, and they have gotten bigger. He denies any pain with urination or with sexual intercourse. He has had no fever, night sweats, weight gain, or weight loss. His past medical history consists of a vasectomy 10 years ago and mild obesity. He is on medication for hyperlipidemia. He denies any tobacco or illegal drug use and drinks alcohol socially. His mother has Alzheimer’s disease and his father died of leukemia. On examination he appears relaxed and has unremarkable vital signs. On visualization of his penis, he is circumcised and has no lesions on his penis. Visualization of his scrotum shows three yellow nodules 2–3 millimeters in diameter. During palpation they are firm and nontender.
What abnormality of the male genitalia is this most likely to be?
A) Condylomata acuminata
B) Syphilitic chancre
C) Peyronie’s disease
D) Epidermoid cysts
Ans: D
Chapter: 13
Page and Header: 508, Techniques of Examination
Feedback: Epidermoid cysts are firm, yellowish, painless cysts on the scrotal skin. They are very common and are benign.
Jim is a 47-year-old man who is having difficulties with sexual function. He is recently separated from his wife of 20 years. He notes that he has early morning erections but otherwise cannot function. Which of the following is a likely cause for his problem?
A) Decreased testosterone levels
B) Psychological issues
C) Abnormal hypogastric arterial circulation
D) Impaired neural innervation
Ans: B
Chapter: 13
Page and Header: 504, The Health History
Feedback: The fact that he has an early morning erection is indicative of normal physiologic function. You may consider looking further into psychological issues, perhaps related to his marital difficulties. If the patient is unsure of whether early morning erections are occurring, some recommend the postage stamp test in which a ring of postage stamps or other perforated stickers is placed around the penis while in the flaccid state. If the perforations are broken, it is likely an erection has occurred. Do not perform this test without perforations in the stickers, or the ring may function as a tourniquet.
Which of the following conditions involves a tight prepuce which, once retracted, cannot be returned?
A) Phimosis
B) Paraphimosis
C) Balanitis
D) Balanoposthitis
Ans: B
Chapter: 13
Page and Header: 508, Techniques of Examination
Feedback: This describes paraphimosis. Phimosis describes a foreskin which cannot be retracted. Balanitis involves an inflammation of the glans, whereas balanoposthitis involves inflammation of both the glans and the prepuce.
Induration along the ventral surface of the penis suggests which of the following?
A) Urethral stricture
B) Testicular carcinoma
C) Peyronie’s disease
D) Epidermoid cysts
Ans: A
Chapter: 13
Page and Header: 508, Techniques of Examination
Feedback: Urethral stricture may cause induration of the ventral surface of the penis. It more rarely represents a local carcinoma. A testicular carcinoma would be much more likely to occur in the scrotum. Peyronie’s disease often causes induration on the dorsal proximal penis, and epidermoid cysts are benign findings on the scrotum.
A tender, painful swelling of the scrotum should suggest which of the following?
A) Acute epididymitis
B) Strangulated inguinal hernia
C) Torsion of the spermatic cord
D) All of the above
Ans: D
Chapter: 13
Page and Header: 508, Techniques of Examination
Feedback: A tender, painful swelling of the scrotum can be a medical emergency. All of these conditions should be considered, as well as acute orchitis.
A young man feels something in his scrotum and comes to you for clarification. On your examination, you note what feels like a “bag of worms” in the left scrotum, superior to the testicles. Which of the following is most likely?
A) Hydrocele of the spermatic cord
B) Varicocele
C) Testicular carcinoma
D) A normal vas deferens
Ans: B
Chapter: 13
Page and Header: 508, Techniques of Examination
Feedback: Varicoceles are common in normal men. They are often found in the left scrotum or bilaterally and should normally resolve in the supine position. This is because they represent varicosities within the scrotum. These require further investigation if they occur only on the right side or do not resolve in the supine position. They can contribute to infertility because the testicles are unable to achieve a cool enough temperature for sperm production, due to increased blood flow from the varicocele. A hydrocele would be a painless mass on the spermatic cord and the vas deferens is palpated as part of the spermatic cord. You should lightly pinch the scrotum medially and move laterally until you feel the spermatic cord pass between your fingers.
Which of the following would lead you to suspect a hydrocele versus other causes of scrotal swelling?
A) The presence of bowel sounds in the scrotum
B) Being unable to palpate superior to the mass
C) A positive transillumination test
D) Normal thickness of the skin of the scrotum
Ans: C
Chapter: 13
Page and Header: 515, Table 13–1
Feedback: A cystic structure will often transilluminate well. While a transilluminator head for your battery handle is ideal, it is possible to use an otoscope to transilluminate the scrotum. You should be able to get above the mass on palpation and bowel sounds should not be present. If they are, it should lead you to consider an inguinal hernia. Scrotal edema involves thickened skin which can be measured by gently pinching a section of the scrotum itself.
You are examining a newborn and note that the right testicle is not in the scrotum. What should you do next?
A) Refer to urology
B) Recheck in 6 months
C) Tell the parent the testicle is absent but that this should not affect fertility
D) Attempt to bring down the testis from the inguinal canal
Ans: D
Chapter: 13
Page and Header: 517, Table 13–3
Feedback: This is not an uncommon finding, and the testis must often be “milked” into the scrotum from the inguinal canal. Six months is too long to wait, but urology referral is unnecessary unless the testicle cannot be brought into the scrotum. An intra-abdominal testis is at much higher risk for testicular cancer.
Francis is a middle-aged man who noted right-sided lower abdominal pain after straining with yard work. Which of the following would make a hernia more likely?
A) Absence of pain with straining
B) Absence of bowel sounds in the scrotum
C) Absence of a varicocele
D) Absence of symmetry of the inguinal areas with straining
Ans: D
Chapter: 13
Page and Header: 519, Table 13–5
Feedback: Even in the presence of a hernia, absolute symmetry to inspection may be preserved. The action of straining and increasing intra-abdominal pressure causes the hernia to protrude. Hernias will not necessarily be present on CT scans either unless this maneuver is undertaken. Pain with straining and bowel sounds heard in the scrotum further support the diagnosis of indirect hernia.
Frank is a 24-year-old man who presents with multiple burning erosions on the shaft of his penis and some tender inguinal adenopathy. Which of the following is most likely?
A) Primary syphilis
B) Herpes simplex
C) Chancroid
D) Gonorrhea
Ans: B
Chapter: 13
Page and Header: 516, Table 13–2
Feedback: The multiplicity of lesions as well as the burning quality of the pain would lead one to suspect herpes simplex. Syphilis usually presents with a single chancre which is generally painless. Chancroid forms a single, jagged, deep ulcer and gonorrhea usually results in a burning discharge without skin lesions.
A 22-year-old architecture major comes to your office, complaining of severe burning with urination, a fever of 101 degrees, and aching all over. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of severe acne. She is currently on an oral contraceptive. She has had no pregnancies or surgeries. She reports one new partner within the last month. She does not smoke but does drink occasionally. Her parents are both in good health. On examination you see a young woman appearing slightly ill. Her temperature is 100.3 and her pulse and blood pressure are unremarkable. Her head, ears, eyes, nose, throat, cardiac, pulmonary, and abdominal examinations are unremarkable. Palpation of the inguinal nodes shows lymphadenopathy bilaterally. On visualization of the perineum there are more than 10 shallow ulcers along each side of the vulva. Speculum and bimanual examination are unremarkable for findings, although she is very tender at the introitus. Urine analysis has some white blood cells but no red blood cells or bacteria. Her urine pregnancy test is negative.
Which disorder of the vulva is most likely in this case?
A) Genital herpes
B) Condylomata acuminata
C) Syphilitic chancre
D) Epidermoid cyst
Ans: A
Chapter: 14
Page and Header: 546, Table 14-1
Feedback: Genital herpes consists of small, shallow, painful ulcers. Primary infections are often associated with fever, malaise, and regional lymphadenopathy. The outbreak occurs generally between 1 and 3 weeks after exposure. Herpes is contagious and the majority of transmission occurs without the presence of obvious lesions. Transmission during passage through the birth canal can cause serious illness in affected newborns.
A 42-year-old realtor comes to your clinic, complaining of “growths” in her vulvar area. She is currently undergoing a divorce and is convinced she has a sexually transmitted disease. She denies any vaginal discharge or pain with urination. She has had no fever, malaise, or night sweats. Her past medical history consists of depression and hypothyroidism. She has had two spontaneous vaginal deliveries and one cesarean section. She has had no other surgeries. She denies smoking or drug use. She has two to three drinks weekly. Her mother also has hypothyroidism and her father has high blood pressure and hypercholesterolemia. On examination you see a woman who is anxious but appears otherwise healthy. Her blood pressure, pulse, and temperature are unremarkable. On visualization of the perineum you see two 2- to 3-mm, round, yellow nodules on the left labia. On palpation they are nontender and quite firm.
What diagnosis best fits this description of her examination?
A) Genital herpes
B) Condylomata acuminata
C) Syphilitic chancre
D) Epidermoid cyst
Ans: D
Chapter: 14
Page and Header: 546, Table 14-1
Feedback: These cysts are small, firm, round cystic nodules in the labia that are nonpainful. These do not represent a sexually transmitted infection, but rather a blocked sebaceous gland.
A 30-year-old paralegal analyst comes to your clinic, complaining of a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. She tried douching but it did not help. She has had no pain with urination or with sexual intercourse. She has noticed the smell increased after intercourse and during her period last week. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of one spontaneous vaginal delivery. She is married and has one child. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died from a heart disease. On examination she appears healthy and has unremarkable vital signs. On examination of the perineum there are no lesions noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5 and there is a fishy odor when potassium hydroxide (KOH) is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells).
What type of vaginitis best describes her findings?
A) Trichomonas vaginitis
B) Candida vaginitis
C) Bacterial vaginosis
D) Atrophic vaginitis
Ans: C
Chapter: 14
Page and Header: 550, Table 14-6
Feedback: Bacterial vaginosis generally has a homogenous, grayish-white, thin discharge. The pH will be over 4.5 and the KOH wet prep releases a strong fishy odor, known as a “positive whiff test.” Any basic pH fluid (semen or blood) will cause the fish-like odor to occur, often after intercourse, as with this patient. The wet prep will show clue cells, which are epithelial cells with borders stippled by bacteria.
A 48-year-old high school librarian comes to your clinic, complaining of 1 week of heavy discharge causing severe itching. She is not presently sexually active and has had no burning with urination. The symptoms started several days after her last period. She just finished a course of antibiotics for a sinus infection. Her past medical history consists of type 2 diabetes and high blood pressure. She is widowed and has three children. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died of diabetes complications. On examination you see a healthy-appearing woman. Her blood pressure is 130/80 and her pulse is 70. Her head, eyes, ears, nose, throat, cardiac, lung, and abdominal examinations are unremarkable. Palpation of the inguinal lymph nodes is unremarkable. On visualization of the vulva, a thick, white, curdy discharge is seen at the introitus. On speculum examination there is a copious amount of this discharge. The pH of the discharge is 4.1 and the KOH whiff test is negative, with no unusual smell. Wet prep shows budding hyphae.
What vaginitis does this patient most likely have?
A) Trichomonas vaginitis
B) Candida vaginitis
C) Bacterial vaginosis
D) Atrophic vaginitis
Ans: B
Chapter: 14
Page and Header: 550, Table 14-6
Feedback: Candida is associated with a thick, white, curd-like discharge that causes severe pruritus. The pH will be normal (≤4.5) and the KOH whiff test will be normal. The wet prep often shows yeast spores and budding hyphae. Candida is very common in diabetics and after recent use of antibiotics. It is not thought to be sexually transmitted.
A 55-year-old married homemaker comes to your clinic, complaining of 6 months of vaginal itching and discomfort with intercourse. She has not had a discharge and has had no pain with urination. She has not had a period in over 2 years. She has no other symptoms. Her past medical history consists of removal of her gallbladder. She denies use of tobacco, alcohol, and illegal drugs. Her mother has breast cancer and her father has coronary artery disease, high blood pressure, and Alzheimer’s disease. On examination she appears healthy and has unremarkable vital signs. There is no lymphadenopathy with palpation of the inguinal nodes. Visualization of the vulva shows dry skin but no lesions or masses. The labia are somewhat smaller than usual. Speculum examination reveals scant discharge and the vaginal walls are red, dry, and bleed easily. Bimanual examination is unremarkable. The KOH whiff test produces no unusual odor and there are no clue cells on the wet prep.
What form of vaginitis is this patient most likely to have?
A) Trichomonas vaginitis
B) Candida vaginitis
C) Bacterial vaginosis
D) Atrophic vaginitis
Ans: D
Chapter: 14
Page and Header: 524, The Health History
Feedback: The itching and pain with intercourse in atrophic vaginitis are due to the decreased amount of estrogen after menopause. There is generally scant discharge and the wet prep and KOH whiff test are unremarkable. Use of vaginal lubricants or hormonal replacement in selected patients often corrects the problem.
A 28-year-old married clothing sales clerk comes to your clinic for her annual examination. She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal deliveries. Her past six Pap smears have all been normal. She is married and has two children. Her mother is in good health and her father has high blood pressure. On examination you see a young woman appearing healthy and relaxed. Her vital signs are unremarkable and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness and both ovaries are palpated and nontender.
What is the most likely diagnosis for the abnormality of her cervix?
A) Carcinoma of the cervix
B) Mucopurulent cervicitis
C) Cervical polyp
D) Retention cyst
Ans: C
Chapter: 14
Page and Header: 548, Table 14-3
Feedback: Cervical polyps are polyps of endometrial cells arising from either the uterus or the cervix. They are benign and usually painless but can bleed during intercourse.
An 18-year-old college freshman comes to your clinic, complaining of severe left-sided lower abdominal pain and a foul yellow discharge. The pain began last night while she was having intercourse with her boyfriend. Afterward the pain became more severe and the discharge started. By this morning she had a fever of 101 degrees and walking was making the pain worse. Only lying very still makes the pain better. She has tried ibuprofen and acetaminophen without any improvement. She denies any nausea, vomiting, diarrhea, or constipation. Her past medical history is unremarkable. She has had two past sexual partners. She uses the birth control patch instead of condoms. She smokes a half pack of cigarettes a day and drinks four to five beers per weekend night. She denies any illegal drug use. Her parents are both healthy. On examination you find a young woman who appears ill. Her temperature is 102 degrees and her pulse is elevated at 110. She is tender in the left lower quadrant but has no guarding or rebound. Speculum examination reveals yellow purulent drainage from the os. On palpation there is cervical motion tenderness and the left adnexa is swollen and tender. A urine analysis is unremarkable and the urine pregnancy test is pending.
What is the best choice of diagnosis for this adnexal swelling?
A) Ovarian cyst
B) Tubal pregnancy
C) Pelvic inflammatory disease
Ans: C
Chapter: 14
Page and Header: 533, Techniques of Examination
Feedback: PID is common in young sexually active woman and is usually caused by bacteria that have been sexually transmitted. It is often associated with fever, pelvic pain, and a purulent cervical discharge. On examination there is often cervical motion tenderness and adnexal swelling and pain. A purulent discharge is often seen in the cervical os. Causes of cervical infection are gonorrhea, Chlamydia, and sometimes herpes. This woman should be made aware that barrier methods of contraception may prevent transmission of these diseases, whereas the contraceptive patch or pill will not. It would be prudent to consider further history and screening for HIV in this patient.
