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 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 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. 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 36-year-old married bank teller comes to your office, complaining of pain with defecation and occasional blood on the toilet paper. She states that last week she had food poisoning with nausea, vomiting, and diarrhea. She had runny stools but no black or bloody stools. Ever since her illness, she has continued to have severe pain with bowel movements. She now tries to put off defecation as long as possible. Although she is having constipation she denies any further diarrhea or leakage of stool. She has a past medical history of hypothyroidism and two spontaneous vaginal deliveries. She has had no other chronic illnesses or surgeries. She does not smoke and rarely drinks. She has two children. There is no family history of breast or colon cancer. She has had no weight gain, weight loss, fever, or night sweats. On examination she is afebrile, with a blood pressure of 115/70 and a pulse of 80. On abdominal examination she has active bowel sounds, is nontender in all quadrants, and has no hepatosplenomegaly. Inspection of the anus reveals inflammation on the posterior side with erythema. Digital rectal examination is painful for the patient but no abnormalities are palpated. Anoscopic examination reveals no inflammation or bleeding. What is the anal disorder that best describes her symptoms? A 42-year-old house painter comes to your clinic, complaining of pain with defecation and profuse bleeding in the toilet after a bowel movement. He was in his usual state of health until 2 weeks ago, when he was injured in a car accident. After the accident he began taking prescription narcotics for the pain in his shoulder. Since then he has had very few bowel movements. His stool is hard and pebble-like. He states he has always been "regular" in the past, with easy bowel movements. His diet has not changed but he states that he is exercising less since the accident. His past medical history includes hypertension and he is on a low-dose diuretic. He has had no other chronic illnesses or surgeries. He has a family history of hypertension, coronary heart disease, and diabetes but no cancer. He is divorced and has three children. He smokes two packs of cigarettes per day and quit drinking more than 10 years ago. He has had no recent weight loss, weight gain, fever, or night sweats. On examination he appears muscular and healthy; he is afebrile. His blood pressure is 135/90 with a pulse of 80. His cardiac, lung, and abdominal examinations are normal. He is wearing a sling on his left arm. On observation of his anus you find a swollen bluish ovoid mass that appears to contain a blood clot. Digital rectal examination is extremely painful for the patient. No other mass is palpated within the anus or rectum.
What disorder of the anus is this patient likely to have?
A 75-year-old retired construction worker comes to your clinic, complaining of bright red blood in the toilet for the last several months. He has no pain with defecation but has occasional constipation. He states he eats a healthy diet with fruits and vegetables and walks 2 miles a day. He has had a 10-pound weight loss over the last 3 months. He denies fever or night sweats. His medical history includes high blood pressure, coronary artery disease, and arthritis. He has also had an appendectomy. He smoked for 40 years, two packs a day, but quit 15 years ago. He used to drink alcohol but doesn't now. His father died in his 60s of a heart attack and his mother had breast cancer in her 70s. On examination he appears his stated age and sits comfortably on the examining table. His blood pressure is 150/85 and his pulse is 88. He is afebrile. His cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no erythema, masses, or inflammation. Digital rectal examination elicits an irregular, firm mass on the posterior side of the rectum. After you remove your finger you notice frank blood on your glove.
What anal or rectal disorder is this patient most likely to have?
A 60-year-old coach comes to your clinic, complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s and his father is currently in his 80s with high blood pressure and arthritis. On examination you see a mildly obese male who is alert and cooperative. His blood pressure is 130/70 with a heart rate of 80. He is afebrile and his cardiac, lung, and abdominal examinations are normal. On visualization of the anus you see no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove or on guaiac testing. An analysis of the urine shows no red blood cells, white blood cells, or bacteria.
What disorder of the anus, rectum, or prostate is this most likely to be?
A 45-year-old African-American minister comes to your clinic for a general physical examination. He has not been feeling very well for about 3 months, including night sweats and a chronic low-grade fever of 100 to 101 degrees. He denies any upper respiratory symptoms, chest pain, nausea, constipation, diarrhea, blood in his stool, or urinary tract symptoms. He has had some lower back pain. He has a past history of difficult-to-control high blood pressure and high cholesterol. He has had no surgeries in the past. His mother has diabetes and high blood pressure. He knows very little about his father because his parents divorced when he was young. He knows his father died in his 50s, but he is unsure of the exact cause. The patient denies smoking, drinking, or drug use. He is married and has three children. On examination he appears his stated age and is generally fit. His temperature is 99.9 degrees and his blood pressure is 160/90. His head, ears, nose, throat, and neck examinations are normal. His cardiac, lung, and abdominal examinations are also normal. On visualization of the anus there is no inflammation, masses, or fissures. Digital rectal examination elicits an irregular, asymmetric, hard nodule on the otherwise normal posterior surface of the prostate. Examination of the scrotum and penis are normal. Laboratory results are pending.
What disorder of the anus, rectum, or prostate is mostly likely in this case?
A 55-year-old retired property manager comes to your clinic, concerned that she may have a tumor in her rectum. When asked why, she states that after straining at a bowel movement she felt a mass around her rectum. She denies any blood in her stool, black stools, or pain with defecation. She admits to having had chronic constipation for 30 years. She often uses laxatives to be able to have a bowel movement. She denies any recent weight gain, weight loss, fever, or night sweats. Her past medical history consists of hypothyroidism, and she has had two spontaneous vaginal deliveries. Her mother died recently of colon cancer and her father has high blood pressure but is otherwise healthy. She denies any smoking and only occasionally drinks alcohol. On examination she seems nervous. Her blood pressure is 140/90 and her pulse is 100. Her cardiac, lung, and abdominal examinations are normal. On visualization of her anus, no inflammation, masses, or fissures are noted. When she is asked to bear down, you see a rosette of red mucosa prolapsing from the anus. On digital rectal examination there are no masses and no blood is found on the glove.
What disorder of the anus or rectum is this likely to be?
A 50-year-old truck driver comes to your clinic for a work physical. He has had no upper respiratory, cardiac, pulmonary, gastrointestinal, urinary, or musculoskeletal system complaints. His past medical history is significant for mild arthritis and prior knee surgery in college. He is married and just changed jobs, working for a different trucking company. He smokes one pack of cigarettes a day, drinks less than six beers a week, and denies using any illegal drugs. His mother has high blood pressure and arthritis and his father died of lung cancer in his 60s. On examination, his blood pressure is 130/80 and his pulse is 80. His cardiac, lung, and abdominal examinations are normal. He has no inguinal hernia, but on his digital rectal examination you palpate a soft, smooth, nontender pedunculated mass on the posterior wall of the rectum.
What anal, rectal, or prostate disorder best fits his presentation?