Final Exam Week 8: NR 509/ NR509 (Latest 2025/ 2026 Update) Advanced Physical Assessment | Questions & Answers | Grade A| 100% Correct (Verified Solutions) - Chamberlain

Final Exam Week 8: NR 509/ NR509 (Latest 2025/ 2026 Update) Advanced Physical Assessment | Questions & Answers | Grade A| 100% Correct (Verified Solutions) - Chamberlain Question: CHAPTER 19: Abdomen An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last periterm-12od was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis? Answer: Ruptured tubal (or ectopic) pregnancy Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β-hCG, and findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured ectopic pregnancy with significant intra-abdominal bleeding leading to peritoneal signs. This case is emergent and requires immediate treatment of her hypotension and presumed blood loss as well as gynecological consult for emergent surgery. Ruptured ectopic pregnancies can lead to life-threatening intra-abdominal bleeding. Although acute cholecystitis, ruptured appendix, bowel wall perforation, and ruptured ovarian cyst are all possibilities, the positive β-hCG testing and her unstable vital signs make ruptured ectopic pregnancy more likely. Question: CHAPTER 19: Abdomen A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly? Answer: Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would be considered normal on inspiration when the liver is pushed down into the abdominal cavity on inspiration, but is abnormal on expiration. Findings to support hepatomegaly would be more convincing if, by percussion, the liver span was >12 cm at the midclavicular line. For patients with obstructive lung disease, air trapping in the lungs may displace the liver downwards into the abdominal cavity. The liver span and dullness to percussion refer to the same measurement. Measurements of 6-12 cm at the mid-clavicular line and 4-8 cm at the midsternal line are considered normal. Question: CHAPTER 19: Abdomen A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA? Answer: History of smoking Rationale: History of smoking is her most significant risk factor for an AAA. Male gender, not female gender, is considered as risk factor. Underweight is not a risk factor for AAA. Family history of ruptured aneurysm is vague and could be a cerebral aneurysm. Further, her family history is in a first-degree cousin not a first-degree relative (biologic parents, siblings, and children). Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based on one elevated blood pressure reading. Question: CHAPTER 19: Abdomen A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient? Answer: Do not screen routinely Rationale: The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and benefits with the patient. Annual FOBT screening may continue until age 80-85 years if benefits to doing so outweigh risks for the individual patient; however, screening should not be routinely continued. In general, a life expectancy >7 years is necessary for screening to be potentially beneficial. There is no indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option, but again screening is not routinely recommended for patients age >75 years. Question: CHAPTER 19: Abdomen An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? Answer: Functional change in bowel movement Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea predominant, constipation predominant, or mixed. Other functional causes for her constipation should be excluded prior to making this diagnosis. A large firm fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that increasing fiber helps her constipation. Spasm of the external sphincter is associated with painful anal lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known diagnosis that would increase suspicion of neurological impairment. Question: CHAPTER 19: Abdomen A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam? Answer: Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant Rationale: Situs inversus is a rare condition in which organs are reversed and is associated with Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on the left. A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is likely constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left upper quadrant with organ reversal. Findings given in the remaining answer choices are both associated with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis. Question: CHAPTER 19: Abdomen An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis? Answer: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over several examinations describes rigidity. Abdominal pain that increases with hip flexion is not suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal peritoneum. They often walk bent forward at the hips for this reason. Localized pain over McBurney point is certainly suggestive of appendicitis, but not suggestive of peritonitis. Similarly pain with internal rotation of the right hip, or a positive obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but not peritonitis. Question: CHAPTER 19: Abdomen A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis? Answer: Fibrosis of the pancreas Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency and diabetes mellitus. H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually associated with diarrhea. Inflammation of the colonic diverticulum is diverticulitis and typically causes left-lower-quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an acute disease. Reduced blood supply to the bowel characterizes mesenteric ischemia. It can be acute or chronic in presentation and causes diffuse abdominal pain, vomiting, diarrhea, or constipation. It is associated with older age and vascular risk factors such as coronary artery disease. Question: CHAPTER 19: Abdomen A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic? Answer: Associated right shoulder pain Rationale: Pain with biliary colic can produced referred pain to the right shoulder or scapula due to irritation of the right hemidiaphragm. Alcohol is not an exacerbating factor for biliary colic. Positive McBurney point tenderness is associated with acute appendicitis. The Murphy sign is associated with acute cholecystitis. Poorly localized periumbilical pain is associated with early stages of acute appendicitis. Vomiting bile is associated with small bowel obstruction. Question: CHAPTER 22: Anus, Rectum, and Prostate A 49-year-old male nurse experiences fecal incontinence after a motor vehicle accident that left him paralyzed below the waist. He asks his rehabilitation physician about the control of this function in a person without his injuries. Which of the following is true regarding the muscle control of the anal sphincter? Answer: The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Rationale: The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Together, these two muscles hold the anal sphincter closed until the individual is ready to defecate. The internal anal sphincter is under voluntary control, whereas the external anal sphincter is under involuntary control; both internal and external anal sphincter are under voluntary control; and both internal and external anal sphincter are under involuntary control are incorrect because, as above, the internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Control of the anal sphincters is variable between individuals is incorrect because this anatomic and neurological arrangement is not typically variable between individuals, although these pathways may be interrupted by derangements of normal physiology such as spinal cord injuries. Question: CHAPTER 18: Breasts and Axillae A 42-year-old female website developer presents for an annual preventive examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer. Which of the following is true about MRI as a screening modality for breast cancer in the general population? Answer: Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. Increased sensitivity (in this case, higher-resolution imaging to pick up subtler disease) is often traded for reduced specificity (in the form of discovering many small items of no pathological significance). This is a core concept in designing screening tests—very sensitive tests often pick up false positives, while very specific tests often rule out disease effectively by missing many actual cases. Balance must be sought between these two when setting thresholds for positive and negative screens. Breast cancer screening by MRI has been well studied in the general population is incorrect. This screening modality has only been studied in high-risk populations. This patient is an ideal candidate for screening via breast MRI based on current evidence is incorrect. This patient meets no known criteria for screening with breast MRI (known BRCA mutation, history of chest radiation, etc.). Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI is incorrect. Only women at high lifetime risk (>20%) are current recommended to utilize breast MRI as a screening tool. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI is incorrect. The BRCA1 or BRCA2 mutation confers a risk >20% of breast cancer over a lifetime, which is considered sufficient criteria for screening with MRI rather than mammogram. Question: CHAPTER 18: Breasts and Axillae A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This discharge started several weeks ago and has occurred at irregular intervals since that time. She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irregular periods over the last few months. On examination, she is able to express a small amount of discharge, which is sent to the laboratory and found to be consistent with breast milk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis? Answer: Prolactinoma Rationale: Prolactinomas are pituitary tumors that secrete prolactin, which causes the production of breast milk and can suppress menstruation. Mastitis is incorrect. Mastitis is a breast infection that is typically painful and characterized by a focal area of redness and tenderness in one breast. Ductal carcinoma in situ is incorrect. While nipple discharge should raise suspicion for breast cancer, in this case the discharge is neither bloody nor purulent, and it is notably bilateral. A prudent provider may still order a mammogram and/or ultrasound, but the answer is unlikely to be breast cancer. Paget disease of the breast is incorrect. This condition may present with nipple discharge, but it is usually bloody. Occult pregnancy is incorrect. This patient has a negative HCG test, which is the standard hormonal laboratory examination used to determine pregnancy in both urine and serum tests. Question: CHAPTER 18: Breasts and Axillae A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on breast self-examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self-detection of breast cancer? Answer: a. Most masses that women find at home and bring to a provider's attention turn out to be malignant. Rationale: This patient is more likely to find a fibroadenoma than a cancer on self-examination. In this patient's age range (15-25 years), palpable masses are most likely to be benign fibroadenomas. Most masses that women find at home and bring to a provider's attention turn out to be malignant is incorrect. About 11% of complaints of breast masses turn out to be malignant, leaving the vast majority (89%) noncancerous. The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying mastitis is incorrect. This patient has neither the symptoms of mastitis (localized swelling/erythema/tenderness with generalized fever) nor the risk factors for this condition (pregnancy and/or breastfeeding), making mastitis a very unlikely diagnosis. Because of this patient's age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low is incorrect. Though the risk of cancer in this patient is low, the consequence of missing a cancer diagnosis is quite high; for that reason, definitive diagnosis should be pursued for almost all breast masses. Because of this patient's age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low is incorrect. BSE suffers from notoriously low sensitivity and specificity, making it a very controversial recommendation as it tends to overestimate disease in healthy breasts and miss cancer in breasts with subtle disease. Question: CHAPTER 18: Breasts and Axillae A 48-year-old female psychologist presents to clinic with concerns about her breast cancer risk after an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father's side in as many years to be diagnosed with breast cancer, including the patient's own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires further information about whether this would be appropriate for her. Which of the following is true about this patient's indications for BRCA testing? Answer: This patient carries several risk factors that together justify BRCA testing. Rationale: This patient has both a first-degree male relative with breast cancer and several relatives in the same lineage with breast cancer. Both of these suggest risk for the BRCA genes, but the BRCAPRO calculator can further refine the numerical risk and help decide if screening might be helpful. Her familial lineage is irrelevant to her risk of BRCA genes, and should be discounted in assessing her risk for these genes is incorrect. Ashkenazi-Jewish heritage is a risk factor for carrying the BRCA genes, and for obvious reasons, historical events in the last century obscured the family history of many Jewish families from Europe. Though this patient does not overtly describe Jewish heritage, her family's story certainly raises concern that she may carry some genetic lineage that is at risk for this mutation. Breast cancer in a male relative does not significant weight to the decision to test for the BRCA genes in this patient is incorrect. Breast cancer is quite rare in men, and any case of it should raise concerns for the presence of the BRCA genes. The BRCAPRO calculator does not add any further clinical information to this patient's risk for carrying the BRCA gene is incorrect. The BRCAPRO calculator offers a numerical estimation of the patient's risk of carrying a BRCA gene based on risk factors. It does not, however, analyze risk of developing breast cancer based on those risks. Even if this patient is BRCA positive, no changes in screening or treatment are recommended for patients with this genetic mutation, so the test is not recommended is incorrect. BRCA positive individuals may undergo prophylactic mastectomy, oophorectomy, and increased screening with magnetic resonance imaging instead of mammography to find early cases of brea Question: CHAPTER 18: Breasts and Axillae A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient? Answer: Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts). Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in health breasts). Sensitivity and specificity of screening test are almost always trade-offs; that is, a test that picks up more true cases is also very likely to then pick up more false positives, and vice versa. With breast MRI, the pick-up rate of true disease is almost double that of mammograms, but at the expense of double the false positives. No agency recommends breast MRI for a patient such as this one, who has moderately but not extraordinary risk factors for breast cancer is incorrect. This patient presents with an extraordinary risk profile, including strong family history of breast cancer (suggestive of BRCA linkage to disease but without clear diagnosis), history of chest radiation, and dense breasts requiring prior biopsies to rule out malignancy. She meets the American Cancer Society (ACS) criteria for annual breast MRI, though the USPSTF does not agree that the evidence exists to support this recommendation. The USPSTF recommends against screening with MRI for patients with such risk factors is incorrect. The USPSTF, recognizing the limited data available on this screening test, states that there is insufficient evidence to state one way or another whether this test is appropriate for high-risk patients. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs over mammograms in patients such as this individual is incorrect. Breast density is both a risk factor for breast cancer and a factor that hampers effective screening wit Question: CHAPTER 18: Breasts and Axillae A 66-year-old female museum curator presents for a routine annual examination. On examination, a notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy? Answer: Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. Though axillary lymphadenopathy should be evaluated with age-appropriate imaging to rule out breast cancer, cells that are metastasizing from the breasts can pass directly to the infraclavicular, then supraclavicular nodes. Lack of axillary adenopathy should not be considered grounds to exclude a breast cancer diagnosis. Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla is incorrect for reasons noted above. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up is incorrect. Supraclavicular lymph nodes are uniformly considered malignant until proven otherwise. The differential diagnosis for these malignancies is wide but includes cancers of the breast, lung, head, and neck, esophagus, pancreas, etc. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck is incorrect. This describes the location of the posterior cervical chain of lymph nodes. Supraclavicular nodes are found deep in the angle formed by the clavicle and the sternocleidomastoid muscle. Firm, rubbery lymph nodes are generally considered to be benign is incorrect. Firm or fixed lymph nodes are of concern for malignancy; tender nodes suggest inflammation. Question: CHAPTER 18: Breasts and Axillae A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery, mobile, nontender mass is palpated in the right breast as described by the patient, which is consistent with a firbroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal to and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to report this finding? Answer: "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple" Breast findings can be described by quadrant or by position on a clock face, with 12 o'clock at the superior edge of the breast and the nipple at the center of the clock. The 10:30 position meets this patient's description of a mass in the right breast that is proximal and to the left of the nipple. "Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant" is incorrect. Though description by quadrant is common, this mass would be found in the upper outer quadrant. "Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant" is incorrect as above. "Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant" is incorrect. This mass is in the right, not left, breast—just a reminder that precision is key in record keeping. "Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple" is incorrect. The 1:30 position describes a mass that is 3 cm proximal and 3 cm to the right of the nipple, rather than 3 cm proximal and 3 cm to the left to the nipple. Question: CHAPTER 18: Breasts and Axillae A 54-year-old female dietician presents for a routine annual examination. On review of systems, she reports that she has had many breast findings over several years, including one biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changes in the breasts with menopause? Answer: Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules. Rationale: Glandular tissue of the breast atrophies with menopause, primarily due to a decrease in the number of lobules. The consequent decrease in breast density makes mammograms ever more useful during the age when breast cancer incidence starts to rise markedly. This concept underpins many controversies in breast cancer screening: Prior to menopause, dense breasts obscure, underestimate, and overestimate disease in a lower-prevalence population; after menopause, less-dense breasts increase the utility of mammography in a higher-prevalence population. This has lead a number of agencies to recommend against frequent screening of women in their 40s because of high rates of false positives. Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of mammograms is incorrect. As above, the reverse is true: The transformation to primarily fatty tissue with menopause increases the utility of mammograms. Estrogen in HRT has no effect on breast density after menopause is incorrect. Though the exact role of estrogen from exogenous sources is unclear, estrogen from HRT likely plays a role in maintaining dense breasts past menopause and contributing to breast cancer risk. Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous sources over the lifetime is incorrect. Breast density is affected by a number of factors, among which is a genetic contribution. Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited for that reason is incorrect. Mammography performs most accurately in menopausal and postmenopausal women and should be primarily used in that group. Question: CHAPTER 18: Breasts and Axillae A 44-year-old female mathematician presents to clinic with a complaint of a mass in the right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self-examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening test at age 43 years after a brief discussion with her primary care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group? Answer: c. This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint. This patient was in compliance with the USPSTF recommendations for her age group and risk factors prior to her current complaint. The USPSTF recommends that women age <50 years discuss risks and benefits with their provider and decide on appropriate screening for their individual preferences and needs. These recommendations are controversial and likely to change again over time, but they are underpinned by one key issue: Mammograms have low sensitivity and specificity in younger women with higher levels of estrogen, which keeps breast tissue dense and obscures lesions. This patient should be reassured that her decision not to screen further was well reasoned and did not lead to morbidity in her case. BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced is incorrect. BSE is also extremely controversial and may lead to high rates of invasive testing for finding that are not malignant. Recommending agencies disagree greatly on this particular screening modality. CBE is superior to self breast examination and should be a routine part of annual examinations starting at age 30 years is incorrect. CBE is also fraught with variable sensitivity and specificity and may lead to invasive interventions for nonmalignant lesions. Recommending agencies also disagree greatly on this particular screening modality. Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to image accurately is incorrect. The reverse is true: Mammography suffers low sensitivity and specificity when high estrogen levels feed dense tissue that obscures lesions; the test becomes much more accur Question: CHAPTER 20: Male Genitalia A 67-year-old electronics technician with a history of hypertension and type 2 diabetes presents for his yearly physical examination and complains of progressively worsening erectile dysfunction (ED). While counseling him, the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most affected by vascular deficiencies related to his preexisting medical conditions and is likely contributing to his symptoms? Answer: Corpora cavernosa Rationale: The corpora cavernosa are two structures within the shaft of the penis that become engorged with venous blood during erection. Patients with a history of cardiovascular disease such as hypertension and other diseases, such as diabetes, that cause limitations of blood flow are common causes of ED. Ejaculatory duct is incorrect. It is a conduit for seminal fluid from the seminal vesicle and terminal vas deferens to the urethra and is not involved in the process of an erection. Epididymis is incorrect. It is a structure on top of each of the testicles that provides a reservoir for storage, saturation, and transport of sperm from the testes and is also not involved in the process of an erection. Seminal vesicle is incorrect. It produces secretions that contribute to the seminal fluid and is also not involved in the process of an erection. Vas deferens is incorrect. It is a cord-like structure that transports sperm from the tail of the epididymis to the urethra and also is not involved in the process of an erection. Question: CHAPTER 20: Male Genitalia A 29-year-old graduate student states that he is able to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medications. What is the most likely cause of his problem? Answer: Psychogenic Rationale: Lack of orgasm with ejaculation is usually not a physiological or structural issue, rather psychogenic in nature. It is fairly uncommon but does occur, and clinicians should be aware of the problem and take a thorough history to ascertain the roots of this disorder. Androgen insufficiency is incorrect as it is more likely to cause a decrease in libido and problems with erectile dysfunction (ED) rather than lack of orgasm. Endocrine dysfunction is incorrect as it may also cause ED and decreased libido as well as reduced or absent ejaculation among others; however, it should not cause the symptoms described above. Peyronie disease is incorrect as it is the development of fibrous scar tissue within the penis that causes disfigured and painful erections. STI is incorrect. STIs can cause a constellation of symptoms such as urethral discharge, fever, and pain to name a few; however, they should not cause the symptoms described above. Question: CHAPTER 20: Male Genitalia Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from higher brain centers to the T11-L2 levels of the spinal cord and parasympathetic outflow from S2 to S4 reflex arcs. Local vasodilatation within the penis erectile tissue results from increased levels of which of the following? Answer: Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) Rationale: NO and cGMP are powerful vasodilators that are crucial in the process of an erection. Both allow venous blood to accumulate within the corpora cavernosa and corpus spongiosum making the penis rigid. FSH is incorrect as it is secreted from the pituitary and regulate sperm production in the testes. GRH is incorrect as it is secreted from the hypothalamus and stimulates pituitary secretion of LH and FSH. LH is incorrect as it is secreted from the pituitary gland and stimulates the synthesis of testosterone. Testosterone is incorrect as it is synthesized by Leydig cells in the testes and is responsible for multiple other processes such as pubertal growth of male genitalia, secondary sex characteristics, and muscular growth, to name a few. Question: CHAPTER 20: Male Genitalia The human papillomavirus (HPV) can cause genital warts in males and females as well as cervical cancer in females. Vaccination against HPV is available and should be offered to males between what ages? Answer: 9-21 years Rationale: The current recommendation for HPV vaccination for males starts at age 9 years and continues until age 26 years when males are most likely to be exposed to the virus. HPV can cause genital warts in both males and females, cervical cancer in females, and has also been linked to other types of cancers such as oropharyngeal cancers. Current literature suggests that age groups other than 9-21 years do not have any significant benefit or need for the HPV vaccination. Question: CHAPTER 20: Male Genitalia A 32-year-old male complains of a painless, cystic mass just above his left testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in question and transillumination is noted. What is the most likely diagnosis? Answer: Spermatocele Rationale: A spermatocele is a benign, typically painless, movable cystic mass just above the testis that will typically transilluminate with a strong light source. Direct hernia and indirect hernia are incorrect as they will typically contain abdominal contents such as bowel that do not transilluminate. A direct hernia does not produce a mass in the scrotum. Testicular tumor is incorrect. A testicular tumor is a solid mass that will not transilluminate. A varicocele is incorrect as it is a dilatation or varicosities of veins of the spermatic cord that are filled with blood and therefore will not transilluminate. Question: CHAPTER 20: Male Genitalia A 25-year-old graduate student presents to the clinic complaining of scrotal pain, which has been increasing over the past 2 days. He is sexually active and has had unprotected intercourse with multiple partners in the past couple of weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpation of the right testicle are notes. What is the most likely diagnosis? Answer: Acute epididymitis Rationale: Acute epididymitis typically results from a bacterial infection such as chlamydia and presents with scrotal swelling and pain. Given this patient's history of recent unprotected sexual intercourse with multiple partners, he is at higher risk of sexually transmitted infections (STIs). Hydrocele is incorrect as it is a nontender, fluid filled mass within the tunica vaginalis surrounding the testicle. Hydroceles are usually a congenital defect in which peritoneal fluid travels down in between the testicle and tunica vaginalis from a patent communication that normally closes. Primary syphilis is incorrect as it is typically presents as a small red papule that becomes a chancre or painless erosion on the penis. Spermatocele is incorrect as it is benign, typically painless, movable cystic mass just above the testis. Testicular cancer is incorrect as it will typically present as a painless nodule on the testis, not usually causing significant pain or scrotal swelling. Question: CHAPTER 20: Male Genitalia A 32-year-old elementary teacher requests a workup for infertility. He and his wife have been trying to conceive for the last 2 years. He reports that his wife has been evaluated and does not appear to have any infertility issues. The overall examination does not reveal any significant abnormalities. He is of average height and weight and has normal secondary sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility? Answer: Follicle-stimulating hormone (FSH) Rationale: FSH is secreted from the pituitary gland and is responsible for regulation of sperm production in the germ cells and Sertoli cells of the tubules in the testicles. 5α-Reductase is incorrect as it is an enzyme that converts testosterone to 5α-dihydrotestosterone. 5α-Dihydrotestosterone is incorrect. It is a hormone that triggers pubertal growth of the male genitalia, prostate, seminal vesicles, and secondary sex characteristics. LH is incorrect as it is secreted from the pituitary gland and acts on the Leydig cells in the testicles to produce testosterone. TSH is incorrect as it is released from the pituitary and has many functions; however, should not have a significant effect on male fertility. Recent studies show disturbances of thyroid hormones adversely affect spermatogenesis and male fertility. Question: CHAPTER 20: Male Genitalia While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to the inguinal canal and related hernias. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region? Answer: Internal inguinal ring Rationale: The internal inguinal ring is typically not palpable through the abdominal wall. The internal inguinal ring is the opening through which the spermatic cord passes from the abdominal cavity into the inguinal canal. It is sometimes palpable if the external inguinal ring is large enough and may be found by invaginating the scrotum, angling toward the inguinal canal. The external inguinal ring is incorrect as it is usually palpable through the abdominal wall; however, it is better evaluated from a transscrotal approach. The pubic tubercle is incorrect as it is easily palpable in most circumstances from an external approach. Anterior superior iliac spine is incorrect as it is also palpable externally and is the location for the proximal attachment of the inguinal ligament. Direct inguinal hernias is incorrect. It typically presents as a bulge near the external inguinal ring and may be palpable from an external approach. Question: CHAPTER 20: Male Genitalia A 20-year-old college student presents for his annual physical examination. He recently became sexually active and is inquiring about the best means of preventing sexually transmitted infections (STIs). Of the following, which would be the most effective means of prevention? Answer: Male condoms Rationale: The correct use of male condoms is highly effective in preventing the transmission of multiple sexually transmitted infections including HIV, human papillomavirus, chlamydia, gonorrhea, and others. Key instructions should include using a new condom with each sex act, applying the condom before any sexual contact occurs, adding only water-based lubricants, and holding the condom during withdrawal to keep it from slipping off. Although, the most effective way to prevent STIs is abstinence, for the individuals who choose to have an active sexual life, proper usage of condom provides the best protection against most STIs. Early withdrawal, spermicides, diaphragms, and cervical caps are incorrect as they do not provide any significant barriers to prevent the transmission of most STIs. Prolonged use of spermicides may cause localized erosions of genital tissue, which may increase risk of STIs. Question: CHAPTER 20: Male Genitalia A 21-year-old college student presents to the student health clinic for a full physical examination. He is generally healthy; however, he reports that he has had sexual intercourse with multiple partners in the past couple of months. He noticed a small lesion on the shaft of his penis a few days ago. While performing the examination, he unwillingly achieves an erection. How should the clinician proceed at this point? Answer: Explain this is a normal response and finish the examination. Rationale: Explain that erection is a normal response. When performing an examination on the male genitalia, it is important to explain each step of the examination so that the patient knows what to expect. Having an assistant in the room is appropriate for both male and female providers. If the patient refuses to be examined, his wishes should be respected. Stop the examination immediately is incorrect and would be inappropriate without any explanation or further examination. Given his report of a lesion and history of multiple sexual partners, this patient requires a thorough examination and having him return to see another provider at a later time is incorrect and may lead to further morbidity if a sexually transmitted infection is not recognized and treated promptly. Tell him the examination cannot proceed until the erection subsides is incorrect. It is not necessary if the patient is willing to continue. Assume that he is malingering is incorrect based on his reported history. Again, it is important to have an escort in the room if there is any question. Question: CHAPTER 21: Female Genitalia A 45-year-old driver's education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding? Answer: Fibroids Rationale: Fibroids, also known as myomas, are very common benign uterine tumors that can become quite enlarged. Large colonic stool is incorrect. Stool cannot be easily palpated in the abdomen except in a very thin person. Ovarian mass is incorrect. The mass palpated is in the midline and ovarian masses will generally be in the adnexal area. In this case, the adnexal area had no palpable mass. Four-month pregnancy is incorrect. This patient's husband has had a vasectomy, and this patient had menses last week. Bartholin gland enlargement is incorrect. An enlarged Bartholin gland is noted in the labial area and not in the abdomen. Question: CHAPTER 21: Female Genitalia A 32-year-old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever since. She began oral contraceptive pills from when she got married until last year, when she began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient's history, what is the best explanation for her infertility? Answer: Prior pelvic inflammatory disease (PID) Rationale: PID is a genital infection caused by gonorrhea, chlamydia, and other organisms. If not treated early enough it can lead to tubal pregnancies or infertility. Prior Bartholin gland infection is incorrect. Although Bartholin cyst infections can be from sexually transmitted infections, they are only located on the labia and do not lead to fertility issues. Prior herpes infection is incorrect. Herpes generally only affects the labial tissues, vagina, and cervix. Although a baby delivered through an outbreak can suffer complications from maternal herpes, it does not affect fertility. Metabolic disorder with subsequent hormonal irregularities leading to anovulation is incorrect. Although metabolic disorder does lead to anovulation and infertility problems, this patient relates being regular all of her life so most likely has no hormonal abnormalities. Secondary amenorrhea is incorrect. Secondary amenorrhea occurs when a woman having periods stops having them for some reason. This woman has not had an absence of her menses. Question: CHAPTER 21: Female Genitalia A 24-year-old retail clerk presents to the clinic for an annual exam. Her last Pap was 3 years ago and was normal. She is a G0 and is currently not sexually active although she has had two lifetime partners. She is on oral contraceptive pills for cycle control and has no medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and places the speculum. There are two layers of cells, squamous and columnar. Where is the most important area to obtain cells for a Pap smear? Answer: Transformation zone Rationale: The transformation zone is where cancerous cells are most likely to develop and is thus the most important area to sample in a Pap test. Zona reticularis is incorrect. This is actually a part of the adrenal glands that produces hormones. Squamous zone and columnar zone are incorrect. Although each of these can be affected by the human papillomavirus, the transformation zone where these two meet (and columnar cells become squamous cells) is the area of most pathological activity and thus the area that is most important to sample during a Pap smear. Linea nigra is incorrect. The linea nigra is actually the pigmented line often seen in the midline with pregnant women. Question: CHAPTER 21: Female Genitalia A 35-year-old grade school teacher presents for her annual exam. Her last Pap smear was 4 years ago and normal. She is a G1P1 with a 6-year-old child. She has had four lifetime partners but only one partner in the last 12 years. Otherwise she has no complaints. A speculum exam is done followed by a bimanual examination during which a rectovaginal mass is palpated. Which of the following exam findings would be most reassuring that this is not a colonic mass? Answer: The mass dents with digital pressure Rationale: Stool in the rectum simulates a rectovaginal mass. Unlike a malignant mass it is dented by digital pressure reassuring the examiner. A rectovaginal exam will confirm the distinction. No cervical motion tenderness is incorrect. This reassures the examiner that there is no pelvic inflammatory disease (PID), ectopic pregnancy, or appendicitis. No pus from the os is incorrect. No pus reassures the examiner that there is no PID or cervicitis. Both adnexa are nontender is incorrect. The adnexa being nontender is reassuring that there is no tubo-ovarian infection or ovarian artery torsion. The perineum has no lesions is incorrect. No lesions would indicate there is no active human papillomavirus warts or herpes infection. Question: CHAPTER 21: Female Genitalia A 21-year-old college student presents for her first annual exam. She has been sexually active for 1 year and has had two partners. She is not aware of having had any sexually transmitted diseases (STIs). She is using condoms for birth control and STI prevention but admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description for these lesions? Answer: Raised friable or lobed lesions Warts or condylomata are raised lesions that are often lobed in appearance. With addition of acetic acid, they will often turn white. Several shallow ulcers with a red base is incorrect. These are associated with herpetic infections. Translucent nodules is incorrect. This is a description of retention cysts or nabothian cysts. Bright red, soft lesion arising from the cervical canal is incorrect. This is a description of a cervical polyp. Strawberry cervix (small red granular spots or petechiae) is incorrect. This is a common description of the cervix with a Trichomonas infection. Question: CHAPTER 21: Female Genitalia A 23-year-old female comes to the clinic to discuss her birth control options. Although she has been sexually active since age 16 years, she has been with one partner for the last year. She has decided to discontinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam? Answer: She is on her menses. Rationale: For best results with either a Pap smear or STI testing it is best to not have the patient menstruating. On conventional Pap smears, blood masks the cytology. For STI testing, the vaginal sample results are not always valid. Some practices do use urine STI testing but this is not yet universally available. She has only one current partner and does not need STI testing is incorrect. Until the age of 25 years, high-risk individuals with a history of several partners are still tested yearly. She had a normal Pap smear within the last 3 years is incorrect. Although she does not need a Pap smear at this time, she still needs STI testing. She should not be sexually active is incorrect. This is a personal judgment of the provider and should not be involved in decision making for the patient's care. She has been using condoms is incorrect. As long as a patient has not used a condom for the last 48 hours, there is no need to postpone a speculum exam due to general condom usage. Question: CHAPTER 21: Female Genitalia An 18-year-old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID? Answer: Cervical os Rationale: An infection in the uterus, tubes, and ovaries would drain through the cervix and out of the os. Posterior fornix is incorrect. Any discharge in the fornix may be from the cervix, or it may be from a vaginal infection. Anterior fornix is incorrect. Again any discharge in the fornix may be from the cervix, or it could be from a vaginal infection. Skene gland opening is incorrect. This gland is within the labia minor and surrounds the urethral opening. Discharge from PID comes from the uterus so would be coming from the os within the introitus. Bartholin gland opening is incorrect. This opening is just within the introitus near the 4 and 8 o'clock positions of the labia minora. Discharge from PID would be from the os within the introitus and not from just inside the introitus. Question: CHAPTER 21: Female Genitalia A 27-year-old G0 bus driver presents to the clinic complaining of an itchy vaginal discharge for the last week. She reached menarche at age 12 years, became sexually active at age 18 years, and has had a total of five sexual partners. She has been with her current partner for 1 month. She is on oral contraceptive pills and does not use condoms as she is allergic to latex. Her last menstrual period was 3 weeks ago. She is not having any pelvic pain, fever, nausea, or vomiting. Her vitals are normal with a body mass index of 22. The clinician places the metal medium Graves speculum in the vagina but cannot find the cervix. What is the best next maneuver to visualize the cervix? Answer: Withdraw the speculum slightly and reposition it on a different slope. Rationale: The first maneuver when the cervix is not easily within view is to switch the angle of how the speculum is being inserted. Replace the speculum with a larger one (large Graves) is incorrect. In some patients, this could be done after repositioning the original speculum. In this patient, a thin G0, a larger speculum would not be helpful. Withdraw the speculum and do a bimanual exam to find the cervix is incorrect. Although this can be helpful to find a cervix, it is not the next maneuver that would be done. Replace the speculum with a plastic one with a better light source is incorrect. Although this can also be done as a later maneuver it is not the next one done to visualize the cervix. Discontinue the speculum exam and treat empirically is incorrect. The clinician would not stop trying to visualize the cervix after one failed attempt. In this case, also it is unknown if this discharge is bacterial vaginosis, Trichomonas, a yeast infection, or some other sexually transmitted infection. Question: CHAPTER 21: Female Genitalia A 63-year-old office worker comes to the clinic for her women's health exam. Her last Pap smear was 5 years ago and was normal. She is married and has been with the same sexual partner for the last 35 years. After performing the majority of the exam, the clinician decides to do a speculum exam to collect cytology for Pap smear. What is the correct position to have the patient in for her speculum exam? Answer: Lithotomy Rationale: Lithotomy or dorsal lithotomy position describes a patient lying on an exam table supine but with the legs abducted with the feet in the stirrups. This was named lithotomy because it is how doctors used to access the urethra in both men and women to be able to remove stones with instruments. This is the easiest position to visualize the cervix and do the bimanual exam. Sitting is incorrect. Obviously the vagina and perineum cannot be accessed in the sitting position. Supine is incorrect. A purely supine position lying on the back with the legs adducted closed would provide no exposure to the female genitalia. Prone is incorrect. In the prone position, the patient is laying on the stomach, and the genitalia are not accessible. Trendelenburg is incorrect. In the Trendelenburg position, the patient is supine and the legs are elevated higher than the level of the head. A reverse Trendelenburg has the patient supine with the head higher than the level of the feet. Question: CHAPTER 21: Female Genitalia A 68-year-old retired patient presents to the clinic complaining about feeling like something is falling out of her vagina. She is a G6P6007 and had all her children vaginally, even the twins. She went through menopause at age 55 years, and, for the last few months, she has felt this falling sensation. On exam, an anterior bulge in the vaginal wall is apparent when she bears down. Weakness in which muscle would best account for the anterior bulge in the vaginal wall? Answer: Levatori ani Rationale: The levatori ani muscle group consisting of the pubococcygeus muscle and the iliococcygeus muscle is responsible for the support of the pelvic floor. Weakening can cause prolapse of the pelvic organs. Weakness of the anal sphincter is incorrect. Weakness of this muscle can lead to anal incontinence of stool. Weakness of the pubis symphysis is incorrect. Although there can be slight separation of the pubis symphysis following childbirth, it usually returns to its normal state afterward and does not lead to weakening of the pelvic musculature. Weakness of the ischiocavernosus or bulbocavernosus muscles is incorrect. Weakness of these muscles can lead to urinary incontinence. Question: CHAPTER 22: Anus, Rectum, and Prostate A 62-year-old male who is undergoing evaluation for possible prostate cancer strongly declines a rectal examination, stating that, "Some trainee once did that and it hurt badly." Which of the following is true about the innervation of the anus and rectum that may explain this patient's experience of discomfort? Answer: The anal canal has a rich somatosensory innervation, making poorly directed examinations painful in this area. Rationale: The anal canal is characterized by somatosensory innervation, whereas the rectum has little such nerve supply. Thus, the patient's discomfort likely occurred due to the stretch of the anal canal rather than disruption of the more proximal rectal mucosa. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the rectum the most likely source of this patient's discomfort is incorrect because the anal canal is more richly innervated with somatosensory nerves than the rectum. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the anus the most likely source of this patient's discomfort is incorrect because, although the anal canal is the most likely site of the patient's discomfort, the anal canal (not the rectum) contains a greater concentration of somatosensory nerves. Proximal to the dentate line, the lower gastrointestinal tract is innervated primarily by somatosensory nerves, making the proximal reach of the examination the most likely site of this patient's pain is incorrect because the reverse is true: somatosensory innervation is greater in the anal canal than the rectum. The dentate or pectinate line does not differentiate any neurological input, making the area either proximal or distal to the line equally responsible for this patient's discomfort is incorrect because the dentate or pectinate line forms the anorectal junction. Little somatosensory innervation occurs proximal to this line, making the rectal area a less likely source of a patient's discomfort during anorectal examinations. Question: CHAPTER 22: Anus, Rectum, and Prostate A 54-year-old male with a strong family history of breast and prostate cancer presents to his primary care provider to discuss prostate screening. His father died at age 73 years from prostate cancer that was not detected on routine digital rectal examinations (DREs), and he would like to minimize his chance of a similar occurrence. Which of the following is true regarding the anatomy and screening of the prostate by DRE? Answer: The median lobe of the prostate is located anterior to the urethra and is not palpable on DRE. Rationale: Due to its location at the anterior aspect of the urethra, the median lobe of the prostate is not palpable on DRE, nor are small tumors in this area. All three lobes of the prostate are palpable on DRE is incorrect because the median lobe of the prostate is not palpable on DRE, although the two lateral lobes are palpable. The seminal vesicles are palpable distal to the prostate on DRE is incorrect because the seminal vesicles are proximal (not distal) to the prostate. They are generally not palpable on DRE. The median sulcus divides the lateral lobes from the median lobe and is palpable on DRE is incorrect because the median sulcus divides the la