DES 2016. Final (Part 22)

78) A 62-year-old male is brought to the ER after passing out at work. He reports having had difficulty walking over the past couple of days due to an infected wound on his right foot. His past medical history is significant for diabetes mellitus. On physical examination, his blood pressure is 80/40 mm Hg and his heart rate is 120/min, regular. His skin is cold and clammy. Right heart catheterization is performed, and the following readings are obtained: Right atrial pressure 18 mmHg, Pulmonary artery pressure 40/20 mmHg, Pulmonary capillary wedge pressure 9 mmHg. Which of the following is the most likely diagnosis?

79) You are asked to evaluate four different patients, all who have presented with cough and progressive dyspnea. Each has a chest x-ray showing diffuse pulmonary infiltrates. In which of the following patients would bronchoscopy with bronchoalveolar lavage be most likely to yield a diagnosis?

81) A 54-year-old man is being evaluated for shortness of breath. Examination shows dullness to percussion and increased breath sounds, particularly during expiration, in the right lower lobe. Cardiac examination reveals regular rate and rhythm with normal S1 and S2. There is no murmur. Moderate peripheral edema is present. Which of the following is the most likely cause of his shortness of breath?

82) A 15-year-old male comes to your office with a one-week history of fever, non-productive cough, sore throat and headaches. Today he noticed a skin rash. His temperature is 38.5°C (101.3°F), pulse is 90/min, blood pressure is 115/78 mm Hg and respirations are 16/min. His throat is hyperemic, but there is no cervical lymphadenopathy. Chest auscultation and percussion reveal no abnormalities. You note dusky red, target shaped skin lesions over all four extremities. Chest x-ray reveals interstitial infiltrates in the left lower lobe. Sputum gram stain reveals polymorphonuclear cells but no organisms. Which of the following organisms is most likely responsible for this presentation?

83) A 53-year-old man presents with two episodes of hemoptysis over the last week. He describes a preceding two-year history of morning cough productive of approximately one tablespoon of yellowish sputum. During the last week his morning cough was accompanied by a small amount of blood on two occasions. He denies any dyspnea, fever, chest pain, or weight loss. He has been smoking for 30 years but has tried to cut down recently. He works in construction. His only medication is ranitidine for occasional heartburn. Which of the following is the most likely cause of his hemoptysis?

84) A 60-year-old Caucasian man comes to the physician because of a productive cough and dyspnea on exertion. He denies hemoptysis, chest pain, and leg swelling. He has smoked one-and-a-half packs of cigarettes daily for 40 years and drinks 2-ounces of alcohol daily. He has worked in a shipyard for 10 years. His temperature is 37.2°C (99°F), blood pressure is 140/80 mmHg, pulse is 80/min, and respirations are 20/min. His chest x-ray shows prominent bronchovascular markings and mild diaphragmatic flattening. His pulmonary function testing shows decreased FEV1/FVC ratio and normal DLCO. Which of the following is the most likely diagnosis?

85) A 47-year-old smoker presents to the emergency room with a three-day history of shortness of breath and cough. His past medical history is significant for tuberculosis ten years ago, treated with six months of a multidrug regimen. On exam today, his blood pressure is 140/90 mmHg and his heart rate is 110/min. Breath sounds are decreased over the right lung base. Over the same area there is dullness to percussion and increased fremitus. The patient also has trace ankle edema. Which of the following most likely accounts for these findings?

86) A 51-year-old man develops acute respiratory distress syndrome (ARDS) while hospitalized for acute pancreatitis. On his third day in the intensive care unit, he is sedated, intubated, and ventilated with a PEEP (positive end-expiratory pressure) of 15 cm water and Fi0 2 of 0.6 (60%). Suddenly his pulse increases from 100 to 140/min, systolic blood pressure drops from 120 to 90 mm Hg, and central venous pressure increases from 10 to 15 cm water. On chest auscultation, breath sounds are absent on the left side. Which of the following is the most likely explanation for this sudden deterioration?

87) A 27-year-old male presents to you with complaints of cough, chest discomfort and dyspnea on exertion. He says that he has lost 10 pounds over the past 2 months. He has been smoking 1 pack per day for the past 10 years. He drinks 2 beers every weekend. He denies illegal drug use and has not had multiple sexual partners. Physical examination is unremarkable. Chest x-ray reveals a large anterior mediastinal mass. Blood work reveals that he has elevated levels of HCG and alpha-fetoprotein (AFP). What is the most likely diagnosis?

89) A 42-year-old man presents to his primary care physician complaining of daytime sleepiness. He says that he often falls asleep during meetings, watching TV, and even while driving his car. He does not feel refreshed after his daytime naps, and has not experienced vivid hallucinations when falling asleep or upon awakening. He has occasional morning headaches and his wife complains that he sometimes keeps her up at night. Physical exam reveals a body mass index (BMI) of 31.3 kg/m2. An arterial blood gas is normal. What is this patient's most likely diagnosis?

90) A 34-year-old male is rushed to the emergency room with severe respiratory distress. He is agitated and gasping for breath. He has been seen in the ER several times before for difficulty breathing, food intolerances and skin allergies. Physical examination is notable for excessive accessory respiratory muscle use, retraction of the subclavicular fossae during inspiration, and scattered urticaria over the upper body. What is the most likely diagnosis?

91) A healthy 36-year-old Caucasian woman comes to the physician because of dyspnea on exertion. She has no other medical problems. She does not use tobacco, alcohol, or drugs. Her father has prostate cancer and her mother had a stroke. She takes no medication and has no known drug allergies. Her temperature is 36.7°C (98°F), blood pressure is 140/90 mmHg, pulse is 84/min, and respirations are 22/min. Examination shows clear lung fields. Her chest x-ray shows prominent pulmonary arteries and an enlarged right heart border. EKG shows right axis deviation. Which of the following is the most likely diagnosis?

92) A 65-year-old male comes to the physician because of fever, chills, and productive cough. The symptoms started four days ago. He also complains of chest pain, which increases with inspiration. He has smoked one pack of cigarettes daily for 45 years. He drinks 3-4 ounces of alcohol daily. His chest x-ray showed an infiltrate in the right upper lobe. The sputum examination of the patient reveals capsulated gram-negative bacilli. Sputum culture is growing mucoid colonies. Which of the following is the most likely causative organism in this patient?

94) A 59-year-old male is brought to the emergency department with severe dyspnea and left-sided chest discomfort. He says that he was driving to work when he began to feel suddenly weak and short of breath. He has a long history of chronic obstructive pulmonary disease, esophageal reflux and chronic pyelonephritis. He smokes one pack of cigarettes per day. His current medications include ranitidine and inhaled ipratropium and albuterol as needed. Physical examination reveals trace ankle edema, decreased breath sounds over the left chest and scattered wheezes over the right chest. ECG shows sinus tachycardia. Arterial blood gas analysis is given below: pH 7.42, pO2 59 mmHg, pCO2 41 mmHg. Which of the following most likely underlies this patient's current condition?

95) A 32-year-old man with a known history of recreational drug abuse is found by a friend on the floor of his apartment. There is a pool of urine around him. He is confused, not oriented to time or place, and does not recall recent events. His blood pressure is 110/70 mmHg and his heart rate is 120/min. He talks and moves all his extremities. His laboratory findings are the following: Hemoglobin 15.2 mg/dl, WBC 12,500/mm3, Platelets 160,000/mm3, Sodium 136 mEq/L, Potassium 5.1 mEq/L, Creatinine 1.1 mg/dl, AST 35 units/L, AL T 40 units/L, Alkaline phosphatase 70 units/L, CPK 26,000 units/L. His urine toxicology screen is positive for cocaine and cannabinoids. The patient is at the greatest risk of which of the following?

96) A 52-year-old nursing home worker presents with a four-week history of non-productive cough and night-time sweating. She also reports having unintentionally lost five pounds over the last month. Her medical history is significant for a mastectomy for left-sided breast cancer five years ago and hepatitis C for which she does not take treatment. She says she was last tested for HIV 6 months ago and the test was negative. She takes no medications currently. She emigrated from Mexico two years ago. She smokes one pack of cigarettes daily and consumes two bottles of beer every weekend. Chest x-ray shows a right upper lobe cavity with surrounding infiltration. Which of the following is the most important epidemiologic clue to the etiology of this patient's disease?

97) A 44-year-old obese Asian immigrant presents to the ER complaining of a persistent cough for about 3 months. He denies any fever, chills, runny nose or sputum production. He does complain of dyspnea on exertion, which also has been of a short duration. He says that over the last year, he has become progressively short of breath and is unable to sleep lying down. He denies any chest pain or diaphoresis, but has had palpitations in the past. He does not smoke or drink alcohol. On examination, he is alert and in mild distress. He has a BP of 110/70 mmHg, pulse 100/min and is afebrile. Auscultation is difficult. The chest-x ray reveals an enlarged cardiac silhouette. It appears that the left main stem bronchus is elevated. There is no other lung pathology visible. The ECG shows irregularly irregular rhythm. The pathophysiology of this condition is related to which of the following?

98) A 72-year-old white male with a past medical history of hypertension, hypothyroidism, and coronary artery disease presented to the physician's office because of fever, malaise, nonproductive cough, and shortness of breath. His temperature was 38.3°C (101°F). His chest x-ray showed a patchy right lower lobe infiltrate. He was sent home on oral amoxicillin. Four days later, the patient was brought to the emergency room because he was having continuous fevers, headache, pleuritic chest pain, and abdominal pain. He appears confused. His blood pressure is 120/70 mmHg, pulse rate is 100 per minute, respiratory rate is 24 per minute, and temperature is 38.9°C (102°F). His chest x-ray showed consolidation of the right lower lobe. Which of the following is the most likely cause of this patient's pneumonia?

100) A 56-year-old woman is brought to the emergency room with shortness of breath, which she says began suddenly two hours ago while she was enjoying her favorite television show. She also reports the simultaneous onset of sharp, left-sided chest pain. Her previous medical history includes diabetes mellitus for the past 10 years and hypertension for the past 6 years. Her family history is significant for heart disease in her father, who died at age 40. Her medications include enteric-coated aspirin, captopril and glipizide. She has a 30 pack-year smoking history, but does not smoke currently. On physical examination, she is in acute distress and is sweating profusely. Her temperature is 38.0°C (100.5°F), pulse is 140/min and irregular, respiratory rate is 30/min, and blood pressure is 110/60 mm Hg. Her oxygen saturation is 84% on room air by pulse oximetry. Jugular venous pressure is within normal limits and her lungs are clear to auscultation. Serum analysis reveals the following: Hematocrit 40%, WBC count 11,600/mm3, Platelet count 190,000/mm3. Chest x-ray is unremarkable. ECG reveals irregular RR intervals, with no definite P waves and narrow QRS complexes. Which of the following is the most likely cause of her current symptoms?

101) A 42-year-old white male presents to your office complaining of periodic breathing difficulty and wheezing. He visited an otolaryngologist for persistent nasal blockage recently. His past medical history is significant for unstable angina experienced five months ago. His current treatment includes aspirin, diltiazem, and pravastatin. He does not use tobacco, alcohol, or drugs. His vital signs are within limits. What is the most probable cause of this patient's respiratory complaints?

103) A 43-year-old moderately overweight woman presents to the emergency department complaining of two days of shortness of breath. Today, while climbing stairs, she had an episode of severe lightheadedness and near syncope. Her medical history is significant for a right calf deep venous thrombosis one year ago. She takes no medications currently. On physical examination, her blood pressure is 90/50 mmHg and her heart rate is 120/min and regular Imaging studies are most likely to reveal which of the following?

104) A healthy 33-year-old man comes for a pre-employment examination. He has no complaints and has no medical problems. He does not use tobacco, alcohol, or drugs and takes no medications. He has no occupational exposures and has lived his entire life in suburban Mississippi. His temperature is 36.7°C (98.0°F), blood pressure is 120/80 mmHg, pulse is 78/min, and respirations are 16/min. Examination shows no abnormalities. His chest x-ray shows a 1 .5 cm nodule in his right mid-lung field. Other labs are unremarkable. Which of the following is the most likely diagnosis?

105) A 30-year-old African American female presents with a two month history of shortness of breath and nonproductive cough. She has never had symptoms like these before. Her past medical history is significant for an episode of uveitis six months ago. She does not take any medications. She works as a secretary in a local office building. She does not use tobacco and drinks alcohol only on special occasions. She has no pets and has been monogamous with a single partner for the last three years. On physical examination, her temperature is 37.2°C (98.9°F), blood pressure is 126/76 mm Hg, pulse is 76/min and respirations are 16/min. Lung auscultation reveals patchy rales. The remainder of her examination is unremarkable. Chest x-ray shows diffuse interstitial infiltrates. Which of the following is the most likely cause of her shortness of breath?

106) A 63-year-old male complains of cough and nocturnal wheezing. The cough is mostly non-productive but can sometimes relieve chest tightness if a small amount of yellow sputum is produced. His past medical history is significant for a hospitalization for a 'chest infection' two years ago. His appetite is good but he lost 5 pounds over the last several months. He has smoked one pack of cigarettes per day for the past 40 years. He drinks 2-3 cans of beer per day on the weekends. His mother suffered from diabetes mellitus and his father died of a stroke. On physical examination, his blood pressure is 140/80 mmHg and his heart rate is 80/min. There is chest hyperinflation and scattered expiratory wheezes on auscultation. The patient expires through pursed lips. His fingers demonstrate prominent clubbing. This patient's clubbing is most likely related to:

107) A 40-year-old Caucasian man comes to the emergency department because of fever, dry cough, and shortness of breath. Symptoms started 24 hours ago. He denies hemoptysis. He was recently discharged from the hospital after a second cycle of chemotherapy for acute myeloid leukemia. He does not use tobacco, alcohol, or drugs. His temperature is 38.9°C (102.0°F), blood pressure is 120/70 mmHg, pulse is 112/min and respirations are 28/min. The patient's pulse oximetry showed 86% at room air. Examination shows diffuse crackles all over the lung fields. His chest x-ray shows diffuse interstitial infiltrates. Which of the following is the most likely cause of his condition?

108) A 45-year-old woman comes to your office with a three-month history of fatigue, exertional dyspnea, and non-productive cough. She has also been having difficulty swallowing. Her only other medical problems are Raynaud's phenomenon, heartburn, and high blood pressure. On examination, diffuse thickening of the skin with telangiectasia is noted. Her current medications include amlodipine, enalapril, and ranitidine. What is the most probable pathologic mechanism of her pulmonary complaints?

109) A 65-year-old man with chronic obstructive pulmonary disease, chronic atrial fibrillation, hypertension, and diabetes mellitus presents with a three-day history of shortness of breath. His condition began with runny nose, itchy eyes, and sore throat, but his symptoms progressed to productive cough, wheeze, and dyspnea. Physical examination reveals a mildly overweight man in moderate respiratory distress. His blood pressure is 150/90 mmHg and his heart rate is 110/min and irregular. On chest auscultation, expirations are prolonged and there are bilateral wheezes. You administer bronchodilators, facial mask oxygen, and lorazepam for agitation. Thirty minutes later, he is lethargic and confused. While you discuss the case with your attending, the patient experiences a generalized tonic-clonic seizure. Which of the following most likely underlies his neurologic symptoms?

110) A 56-year-old Caucasian male complains of chronic exertional dyspnea for the past several years that has progressively worsened. He cannot remember the last time that he saw a doctor, and does not take any medications regularly. It is difficult for him to climb two flights of stairs without having to rest. His dyspnea has gotten so bad that it has severely limited his activity level, and he now spends most of his time on the couch. He also describes recurrent episodes of nocturnal dyspnea, during which he wakes up at around 2:00 AM with difficulty breathing, coughing, and wheezing that improve when he sits up. He usually coughs up some yellowish sputum before being able to go back to sleep. He has had no fever, chills, or chest pain. Which of the following is the most likely cause of this patient's complaints?

111) A 62-year-old man presents to his primary care physician's office with progressive exertional dyspnea. His past medical history is significant for hypertension treated with hydrochlorothiazide and diabetes mellitus treated with metformin. He was an industrial worker for 30 years and retired one year ago. He smokes one pack of cigarettes per day and consumes alcohol occasionally. His blood pressure is 150/100 mmHg and his heart rate is 80/min. His BMI is 31 kg/m2. Chest x-ray reveals pleural calcifications. Pulmonary function studies show the following: FEV1 70% of predicted, FVC 65% of predicted, Residual volume 70% of predicted, DLCO decreased. Which of the following is the most likely cause of this patient's symptoms?

112) A 47-year-old African American woman presents with two days of shortness of breath and left-sided chest pain. Her past medical history is significant for a mastectomy six months ago for breast cancer, for which she also received adjuvant chemotherapy. Her mobility has been limited recently due to progressive back pain. Her current medications include tamoxifen. On chest x-ray, there is an infiltrate obscuring the right heart border as well as a right-sided pleural effusion. Pleural fluid analysis reveals the following: pH 5.75, Nucleated cells 10,050/mm3, RBC 1,500/mm3, Protein 3.9 g/dl, LDH 620 units/L, Glucose 38 mg/dl. Her serum chemistries are notable for an LDH of 310 units/L and protein of 6.1 g/dl. Which of the following is the most likely cause of her effusion?

113) A 64-year-old male presents to the ER with shortness of breath. The symptoms started one week ago with a dry cough and mild fever. His past medical history includes hypertension and exertional angina. He was hospitalized six months ago for pneumonia. He has a 35 pack-year smoking history. His blood pressure is 140/90 mmHg and heart rate is 90 and regular. On examination, the patient is in mild respiratory distress. He uses some accessory respiratory muscles for breathing, but he can speak in full sentences. Chest auscultation reveals bilateral wheezes and crackles at the left lung base. His ABG shows: pH 7.36, pO2 72mmHg, pCO2 51mmHg. Which of the following is the most likely cause of this patient's current symptoms?

114) A 37-year-old female with a long history of multiple sclerosis presents to her primary care physician complaining of dyspnea. She denies cough and fever but admits to right-sided chest pain. Her medical history is significant for an episode of atrial fibrillation diagnosed in the emergency department two weeks ago, which resolved spontaneously without intervention. She is wheelchair-bound due to spastic paraparesis and has saccadic speech. Her only allergy is to penicillin. On physical examination, her blood pressure is 120/70 mmHg and her heart rate is 110/min and regular. Chest x-ray demonstrates a right-sided pleural effusion. Therapeutic thoracocentesis is performed, and pleural fluid analysis reveals the following: Protein 3.1 g/L, RBC count 230/mm3, WBC count 150/mm3, LDH 220 IU/L, Glucose 100 mg/dl. Which of the following is the most likely cause of this patient's pleural effusion?

115) A 35-year-old male from Wisconsin presents to his physician complaining of fever, night sweats, productive cough, and an unintentional 17-lb weight loss over the past 3 months. Several days ago, he also began to notice multiple skin lesions. He has no known medical problems and does not take any medications, nor does he use tobacco, alcohol or illicit drugs. He works outdoors in wood cutting and construction. Physical examination reveals a man of medium build in no apparent distress. His temperature is 38.4°C (101.1°F), blood pressure is 120/68 mm Hg, pulse is 86/min, and respirations are 14/min. Skin examination reveals multiple, well-circumscribed, verrucous, crusted lesions. Chest x-ray shows left upper lobe consolidation and two lytic lesions in the anterior ribs. Which of the following is the most likely cause of his current symptoms?

117) A 25-year-old man presents to the emergency room with shortness of breath and cough productive of blood tinged sputum for the past few days. He denies associated fever, arthralgias or weight loss. He has never had these symptoms before, and is extremely concerned. He has no history of recent travel or sick contacts. He smokes half a pack of cigarettes daily, and has had two sexual partners in the past six months. On physical examination, his temperature is 37.2°C (98.9°F), blood pressure is 120/70 mm Hg, pulse is 102/min, and respirations are 22/min. Lung auscultation reveals patchy bilateral rales. Chest x-ray demonstrates bilateral pulmonary infiltrates. His serum creatinine is 2.6 mg/dl and urinalysis shows dysmorphic red cells. Which of the following is the most likely cause of his current condition?

118) A 32-year-old female complains of a 'nagging' dry cough over the last 4 weeks. She says that the cough is present during the day and also wakes her from sleep at night. There is no associated shortness of breath, chest pain or wheezing. Her past medical history is significant for chronic rhinorrhea and an occasional itching skin rash. She takes no medications. Chest x-ray shows no abnormalities. One week of treatment with chlorpheniramine significantly improves her symptoms. Decrease in which of the following is most likely responsible her symptom relief?

119) A 66-year-old male presents to the emergency room with shortness of breath. The symptoms started one week ago with a dry cough and exertional dyspnea. His past medical history includes hypertension and recent stenting for double-vessel coronary artery disease. He was hospitalized six months ago for pneumonia. He has a 35 pack-year smoking history. His temperature is 37.2°C (98.9°F), blood pressure is 160/90 mmHg, and heart rate is 90 and regular. On examination, the patient is in mild respiratory distress, but he can speak in full sentences. Chest auscultation reveals decreased breath sounds at the lung bases, bilateral crackles and occasional wheezes. His ABG shows: pH 7.46, pO2 73mmHg, pCO2 31mmHg. Which of the following is the most likely explanation for this patient's symptoms?

120) A 55-year-old Caucasian man comes to the emergency department because of fever and productive cough, with foul-smelling sputum. He also complains of shortness of breath. His other medical problems include hypertension and hypercholesterolemia. In the past three months, he was admitted in the hospital two times for pneumonia. He has smoked one pack of cigarettes daily for 28 years and drinks 5-6 beers daily. Family history is not significant. His medications include hydrochlorothiazide and simvastatin. His temperature is 38.9°C (102°F), blood pressure is 120/70 mmHg, pulse is 112/min, and respirations are 24/min. The patient's pulse oximetry showed 89% at room air. Examination shows crackles at the right lung base. His chest x-ray shows right, lower lobe infiltrate. A CT scan of the chest shows no mass or obstruction. Which of the following is most likely responsible for this patient's symptoms?

121) A 45-year-old female presents to the emergency department because of increasing somnolence and shortness of breath. Her past medical history is significant for hyperlipidemia, hypertension and type2 diabetes. She has never smoked and does not use drugs or alcohol. Her temperature is 36.7°C (98°F), blood pressure is 160/80 mm Hg, pulse is 80/min, and respirations are 16/min. Her BMI is 55 kg/m2. On physical examination, she is drowsy but able to respond to commands. Jugular venous distention is difficult to visualize due to a thick neck. Lungs are clear to auscultation. Heart sounds are distant. Abdomen is obese and non-tender. Lower extremities have edema bilaterally. There are no obvious focal deficits on neurologic examination. Chest x-ray is poor in quality but no obvious abnormalities are noted. EKG shows low voltage QRS complexes but no significant ST-segment or T-wave abnormalities. Laboratory studies show: Complete blood count: Hemoglobin 16.0 g/L, Hematocrit 48%, Mean corpuscular volume 85 fl, Platelet count 224,000/mm3, Leukocyte count 6,600/mm3. Arterial blood gas: pH 7.30, pO2 60mmHg, pCO2 69mm Hg. Which of the following is the most likely cause of her condition?

122) A 60-year-old male with a history of hypertension, diabetes, coronary artery disease, asthma, and cigarette smoking undergoes emergent laparotomy for a perforated peptic ulcer. He receives 4 liters of intravenous normal saline intraoperatively. Following the procedure, he is extubated without complication, but subsequently develops respiratory distress. Immediate arterial blood gas analysis on room air shows: PaO2 60mmHg, pH 7.46, PaCO2 37mmHg, HCO3 22mmHg. His temperature is 37.2°C (98.9°F) and blood pressure is 126/76 mm Hg. Lung auscultation reveals bilateral rales. His arterial blood gas fails to improve with administration of 100% oxygen. What is the most likely cause of his respiratory distress?

123) A 40-year-old man presents to the emergency room with shortness of breath, cough and hemoptysis for the past two days. He says he has never had symptoms like these before. His medical history is significant for a non-healing leg ulcer and chronic purulent nasal discharge. He has smoked a pack of cigarettes daily for the past 20 years. On physical examination, his temperature is 37.6°C (99.7°F), blood pressure is 130/90 mm Hg, pulse is 94/min and respiratory rate is 18/min. Lung auscultation reveals patchy rales bilaterally. Heart sounds are regular. A 2x3cm ulcer with rolled, undermined borders is noted on the right lower leg. Which of the following is the most likely explanation for his hemoptysis?

124) A 62-year-old Caucasian male presents to your office because of a non-productive cough that is 'quite disturbing.' The cough has been present for several weeks. He visited your office two times before for poorly controlled hypertension, and was started on lisinopril. He usually takes aspirin, amlodipine, and metoprolol. He does not smoke or consume alcohol. His blood pressure is 130/90 mmHg and heart rate is 60/min. Physical examination reveals a bruit over the right carotid artery, but is otherwise normal. Which of the following is the most likely cause of this patient's complaint?

125) A 26-year-old white female comes to the Emergency Room with severe shortness of breath. She has a long history of asthma with periodic exacerbations. She is taking an inhaled albuterol, inhaled steroid, salmeterol and cromolyn. Her temperature is 37.2°C (99°F), blood pressure is 150/90 mmHg, pulse is 110/min, and respirations are 24/min. On examination, she has moderate respiratory distress, prolonged expiratory phase, and significant wheezing all over the lung fields. Patient is admitted and is given nebulized albuterol, intravenous methyl prednisone, and oxygen. The next day her respiratory status improved. Her vital signs did not change much, except normalization of respiratory rate. Still scattered bilateral wheezes are heard on lung auscultation. The next day her laboratory values are: Hemoglobin 14 g/dL, MCV 95 fL, Leukocyte count 19,000/cmm, Segmented Neutrophils 80%, Bands 5%, Lymphocytes 13%, Eosinophils 0%, Basophils 0%, Monocytes 2%. Chest x-ray obtained at the time of admission is normal, except for hyperinflated lung fields. What is the most probable cause of the abnormal lab findings in this patient?

126) A 32-year-old male presents to your office complaining of daytime sleepiness and frequent night-time awakenings. He says that his sleep gets disrupted by a choking sensation, sometimes accompanied by cough and dyspnea. After such episodes he typically has trouble falling back to sleep. The patient notes that his symptoms are somewhat improved when he sleeps with multiple pillows. Physical examination is unremarkable except for a BMI of 29 Kg/m2. What is the most likely diagnosis?

127) A 20-year-old African American woman presents with mild dyspnea on exertion and joint discomfort in her knees, wrists, and ankles. She also has a fever and red tender rash on her shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, corneal opacities, and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy. Transbronchial biopsy reveals noncaseating granulomas. Which of the following is the most likely cause for the eye lesion?

128) A 74-year-old man with a history of smoking notices blood in his chronic daily sputum production. He has no fever or chills, but has lost 10 lb in the past 6 months. On examination, he has bilateral expiratory wheezes, and his fingers are clubbed. There are no lymph nodes and the remaining examination is normal. CXR reveals a left hilar mass. Which of the following suggests that the tumor is a small cell lung cancer?

129) A 35-year-old HIV-positive man (CD4+ cell count 150/mm³) is seen in the emergency department with right-sided chest pain. The patient has become progressively dyspneic over the past few days. Suddenly, 30 minutes ago he noticed a sharp pain in his chest associated with shortness of breath. His temperature is 37.7°C (99.9°F), blood pressure is 128/84 mm Hg, pulse is 102/min and regular, respiratory rate is 25/min, and oxygen saturation is 90% on room air. Physical examination reveals diminished right-sided breath sounds and hyperresonance. Jugular venous distention is 5 cm and there is no tracheal deviation. ECG shows sinus tachycardia. X-ray of the chest shows a right-sided pneumothorax occupying approximately 10% of the right thoracic cavity. Which of the following most likely caused this patient’s presentation?

130) A 74-year-old man presents to his primary care physician complaining of dyspnea and cough with blood-tinged sputum for the past several weeks. He has diabetes and elevated cholesterol. Medications include a sulfonylurea and a statin. The patient has a 50-pack-year smoking history and a family history of hypertension. His vital signs are within normal limits. Physical examination reveals abdominal striae and moon facies, along with a truncal fat distribution. X-ray of the chest reveals a single central nodule, and follow-up CT again demonstrates the nodule and multiple solid hepatic masses. Which of the following is the most likely diagnosis?

131) A 5-month-old infant has failed to gain weight despite a good appetite. The child’s mother reports that the baby has up to eight bulky, foul-smelling, oily stools per day. A sweat chloride test reveals a chloride level of 78 mEq/L (normal: <60 mEq/L). Which of the following sequelae is most likely to occur as a result of this patient’s disease?

132) A 33-year-old farmer complains of recurrent episodes of wheezing after working in a barn where hay is stored. On auscultation, there are bibasilar crackles and heart sounds are normal. His laboratory work is normal with no increase in eosinophils and the chest x-ray (CXR) reveals patchy lower lobe infiltrates. Which of the following is the most likely diagnosis?

134) A 53-year-old man presents to the clinic with complaints of increasing shortness of breath, a nagging cough, and weight loss over several months. He reports no history of cigarette smoking but has worked underground in the New York City subway system for the past 20 years. Spirometry demonstrates an FEV1: FVC ratio of 0.7 and an FEV1 value that is 60% of expected. The FEV1 improves to 70% of expected with bronchodilator treatment. Which of the following is the most likely diagnosis?

135) A 78-year-old woman is seen in the emergency department for difficulty breathing and cough over the past 4 hours. She has a history of congestive heart failure for which she takes hydrochlorothiazide, metoprolol, and enalapril. Her oxygen saturation is 92% on room air. On examination there is a high-pitched systolic crescendodecrescendo murmur best heard at the right upper sternal border with radiation to the carotids, and rales are present in both lung fields on inspiration. There is 2+ symmetrical pitting edema bilaterally in the lower extremities. X-ray of the chest shows an enlarged heart and prominent pulmonary vasculature. Which of the following is the most likely cause of the patient’s pulmonary edema?

136) A 56-year-old man is evaluated for chronic cough. It is present most of the time and is progressively getting worse over the past 3 years. With the cough he usually has white to yellow sputum that he has to expectorate. There is no history of wheezing, asthma, congestive heart failure (CHF), or acid reflux disease. He currently smokes one pack a day for the past 25 years. On examination, his chest is clear. CXR is normal and his forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) on spirometry are normal. Which of the following is the most likely diagnosis?

137) A 35-year-old man is evaluated for symptoms of shortness of breath. He reports no other lung or heart disease. He smokes half pack a day for the past 10 years. On examination, his JVP is 2 cm, heart sounds normal, and lungs are clear. A CXR shows hyperinflation and increased lucency of the lung fields. A chest CT reveals bullae and emphysematous changes, while pulmonary function tests show an FEV1/FVC ratio of <70%. Evaluation of his family reveals other affected individuals. Which of the following is the most likely diagnosis?

138) A 23-year-old man notices a gradual but progressive increase in breathing difficulty. He has a long history of back pain with prolonged morning stiffness. He has also had an episode of iritis in the past. On examination, there is reduced range of motion in the lumbar spine with forward flexion and pain on palpation of the sacroiliac joint and surrounding soft tissue. X-rays of the pelvis show erosions and sclerosis of the sacroiliac joint. Which of the following is the most likely pulmonary complication of this condition?

139) A 45-year-old Haitian immigrant presents to the emergency department with a chief complaint of productive, blood-tinged cough for 2 months. He has been in the United States for 1 month. His temperature is 40.1°C (104.2°F) and heart rate is 105/min. On physical examination he appears cachectic, and pulmonary rales are heard throughout his lung fields. X-ray of the chest reveals multiple bilateral upper lobe cavitary lesions with associated intrathoracic adenopathy. Results of sputum culture are pending. Which of the following tuberculosis medications can potentially cause optic neuritis?

140) A 44-year-old woman has been complaining of a 4-year history of increasing dyspnea and fatigue. Physical examination reveals increased JVP and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and right-sided S3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests show a slight restrictive pattern. A diagnosis of primary pulmonary hypertension is made. Which of the following is the most likely cause of death in this condition?

141) After an uncomplicated pregnancy and cesarean section for breech presentation, twins are born at 32 weeks’ gestation to a 24-year-old primigravida mother. Twin A weighs 1610 g (3.5 lb) and has Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Twin B weighs 1600 g (3.5 lb) and has Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Within minutes of birth, twin B becomes mildly cyanotic and tachypneic with subcostal retractions, expiratory grunting, and nasal flaring. Twin B’s blood pressure is 58/39 mm Hg, heart rate is 130/min, respiratory rate is 100/min, and temperature is 37.0°C (98.6°F). Twin B is intubated and given 70% fraction of inspired oxygen. Compared to twin A, what is twin B at greater risk of developing?

142) A 32-year-old white man with HIV and a re- cent CD4+ cell count of 400/mm³ presents to the emergency department with a 3-day history of fever, anorexia, cough, and night sweats. He recently returned from a camping vacation in Arizona, approximately 1 month prior to presentation. He also describes diffuse joint pains. His temperature is 38.9°C (102°F), oxygen saturation is 99% on room air, and there is a rash on his arms and hands. There is dullness to percussion at the right lung base. X-ray of the chest reveals a small right-sided infiltrate and hilar lymphadenopathy. Sputum analysis does not reveal any organisms. He reportedly had a negative purified protein derivative test 2 months ago. Which of the following is the most likely diagnosis?

143) A 55-year-old man was admitted to the hospital 2 weeks ago for rapid onset of cough, fatigue, and pleuritic chest pain. He has worked as a sandblaster for the past year. When first seen in the hospital, he denied hemoptysis and smoking. Currently, the patient is intubated and on assist-control ventilation. His temperature is 36.7°C (98°F), pulse is 96/min, blood pressure is 138/85 mm Hg, and respiratory rate is 18/ min. A recent arterial blood gas study showed a pH 7.42, arterial carbon dioxide pressure of 36 mm Hg, and arterial oxygen pressure of 110 mm Hg while on 100% oxygen. Physical examination is significant for diffuse crackles throughout both lung fields, a loud pulmonic component of the second heart sound, and jugular venous distention of 9 cm with a prominent A wave, a left parasternal heave, and symmetric 3+ lower extremity pitting edema. Which of the following is the most likely diagnosis?

144) A 30-year-old woman presents to her physician’s office because of 3 months of nonproductive cough, exertional dyspnea, fatigue, malaise, and blurred vision. She denies weight loss, fever, chills, sweats, recent travel, or sick contacts. She works on the assembly line of an electronics plant. Vital signs are unremarkable. Physical examination reveals she has tender red papules over her shins. The patient said she first noticed the bumps when she changed oral contraceptive pills (her only medication), but assumed they would disappear. X-ray of the chest shows bilateral hilar lymphadenopathy with pulmonary infiltrates. Laboratory findings are: WBC count: 5600/mm3, Hemoglobin: 14.3 g/dL, Platelet count: 300,000/mm3, Na+: 140 mEq/L, K+: 4.2 mEq/L, Cl−: 108 mEq/L, Ca2+: 16 mg/dL, CO2: 24 mmol/L, Blood urea nitrogen: 10 mg/dL, Creatinine: 1.0 mg/dL. Culture of bronchoalveolar lavage fluid is neg- ative. Which of the following is the most likely diagnosis?

145) A 58-year-old man presents to the emergency department complaining of fever and chills. The fever started last night and has not subsided, even though he took acetaminophen. He had a successful appendectomy 3 days ago and was discharged from the hospital 2 days ago. His only medication is ibuprofen, which is adequately controlling his pain. He is a 30-pack-year smoker with a chronic cough productive of white sputum. He has noticed increased sputum production, which has become yellowish-green. He denies dysuria, urgency, or frequency. His temperature is 38.4°C (101.1°F), heart rate is 88/min, respiratory rate is 16/min, and blood pressure is 126/74 mm Hg. On examination he appears to be tired but not in acute distress. Pulmonary examination is limited because deep inhalation causes coughing and slight abdominal pain. There is no tactile fremitus or dullness to percussion. He has a slightly erythematous, appropriately tender healing incision in the right lower quadrant without exudates and normal active bowel sounds. Extremities are warm and well perfused without erythema or edema. Pulses are intact. Which of the following most likely could have prevented this condition?

148) A 23-year-old man is experiencing a flare of his asthma. He is using his salbutamol inhaler more frequently than usual and despite increasing his inhaled steroids he is still short of breath. Previously his asthma was considered mild with no severe exacerbations requiring oral steroids or hospitalization. With his flare, he has recurrent episodes of bronchial obstruction, fever, malaise, and expectoration of brownish mucous plugs. On examination, there is bilateral wheezing. The heart, abdomen, neurologic, and skin exams are normal. CXR reveals upper lobe pulmonary infiltrates; the eosinophil count is 3000/mL, and serum precipitating antibodies to Aspergillus are positive. Which of the following is the most likely diagnosis?

149) A 55-year-old woman presents with coughing up blood and sputum. She gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is worse on lying down and in the morning. On physical examination, she appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is a recognized precursor to this patient’s condition?

150) A 50-year-old man presents with excessive day- time sleepiness and a history of snoring. One week ago, he fell asleep while driving his car and got into a minor accident. On examination, he is obese (body mass index [BMI] >30) and his blood pressure is 160/90 mm Hg. His lungs are clear and heart sounds are distant. Which of the following is the most likely explanation for the symptoms associated with this condition?

152) A 23-year-old man presents with coughing up blood and sputum. He gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is worse when lying down and in the morning. On physical examination, he appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is sometimes seen in this condition?

156) A 34-year-old woman is complaining of progressive and worsening shortness of breath. Her symptoms first started 3 years ago, and she now gets dyspneic and fatigued while doing her activities of daily living. Her past medical history is not significant and she not taking any medications. Physical examination reveals increased JVP and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and right-sided S3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests are normal. Which of the following is the most likely diagnosis?

157) A 45-year-old woman has severe symptoms of epigastric and abdominal pain after eating. A trial of acid suppression therapy with proton pump inhibitors (PPI) only partially improved her symptoms. She undergoes elective outpatient upper endoscopy, which is positive for a small duodenal ulcer. Two hours later, she is short of breath and complaining of severe anterior chest pain, which is made worse with deep inspiration. On examination, she looks unwell, blood pressure is 150/90 mm Hg, pulse 110/min, and lungs are clear. Heart sounds are normal but an “extra crunching” type sound is intermittently heard. CXR demonstrates air surrounding the heart. Which of the following is the most likely diagnosis?

158) A 31-year-old G4P3 woman gave birth via repeat cesarean section to a full-term, 3700-gm (8.2-lb) baby girl. There were no complications during the pregnancy or delivery. Two hours after the birth the resident is called to evaluate the baby girl. She is afebrile but is breathing rapidly with mild subcostal retractions. Breath sounds are equal and clear bilaterally. S1 and S2 are normal and the point of maximal intensity is not displaced. X-ray of the chest reveals flattened diaphragms, prominent vascular markings, and fluid lines in the fissures. Which of the following is the most likely diagnosis?

159) A 67-year-old man presents to his primary care physician with complaints of dyspnea on exertion over the past 6 months that has progressively worsened to dyspnea at rest. He denies cough and wheezing and has had no fevers, night sweats, or unintentional weight loss. The man has never smoked and worked as a ship-builder for >30 years. Which of the following findings on x-ray of the chest would confirm the most likely diagnosis?

160) A 16-year-old girl is brought to clinic by her mother, who complains that the girl is "difficult to get along with lately." The mother says her daughter can no longer concentrate for prolonged periods and is easily fatigued. She has found her tossing in her sleep at night. She says that her daughter is generally considered by friends and family to be "high strung." Upon inquiry, the girl admits to feeling extremely apprehensive when taking tests at school. She feels this stems from her naturally competitive nature and her desire to be class valedictorian. She worries about being accepted to a good university and then business school. She says that she is unable to control her thoughts and sometimes takes a day off from school to "escape all the stress that comes with it” Which of the following is the most likely diagnosis?

161) A 30-year-old man presents to his primary care physician and describes a sense of generalized fatigue. He reports having been very energetic and healthy during his college days but says that "everything has seemed to be go wrong" for at least the last 6 years. He eats poorly and has lost 8 pounds over the last three years. He sleeps 12 hours per night and says that he has difficulty concentrating on most tasks. His past medical history is otherwise unremarkable, and he does not abuse drugs or alcohol. The patient says that he is not suicidal and still enjoys watching baseball with his friends. Based on the above presentation, what is the most likely diagnosis?

162) A single mother brings her 10-year-old son to see the pediatrician. The mother says that she is "absolutely fed up" with her son's behavior and is unable to control him. The boy frequently gets into fights with his siblings, neighbors, and classmates at school. When asked to help with household chores, he refuses. He is very short-tempered and argues frequently with his parents and teachers. A few days ago, he got into an argument with the elderly woman who lives next door, and in a fit of anger he "grabbed a marker and wrote an obscenity on her front door." What is the most likely diagnosis?

163) A middle-aged, divorced woman brings her 18-year-old daughter to the physician with the complaint that her daughter "seems abnormal." She is concerned because her daughter has no close friends, does not date, and shows no interest in the activities that are popular with young adults. The girl prefers solitude and keeps to her room for most of the day. When she does go out, she hikes in the woods alone for hours at a time. She attends a local university where she studies engineering and performs well academically. During the office visit, the daughter avoids eye contact. In response to questioning about her reasons for being aloof, she replies, "I just don't enjoy being in the company of others. People do not interest me much and I would rather keep to myself." Her thought process appears devoid of delusions or hallucinations. Which of the following personality disorders is demonstrated by her behavior?

164) A middle-aged, divorced mother brings her 19-year -old daughter in for an evaluation. She says that her daughter has "a serious problem." The woman is concerned because her daughter always keeps to herself, does not date, has no close friends, and refuses to participate in activities popular with women of her age. The daughter is extremely fascinated by witchcraft, spending countless hours in her room gazing into a crystal ball and muttering under her breath. When confronted about her behavior, she says, "I have some supernatural powers that I am not willing to discuss." She attends college regularly and earns good grades. Which one of the following is the most likely diagnosis?

165) A Hispanic married couple brings in their 17-year-old son because his behavior has been abnormal for the past two weeks. Normally, the boy is polite and soft spoken but he has recently become irritable and rude. His parents dismissed his behavior as a "phase" with the expectation that he would grow out of it, but they became very concerned upon discovering that he had been spending large sums of money from his college fund without their consent. When questioned by his father about his strange behavior, the boy responded, "I'm on a secret mission. The king of Norway has sent me here to spy on the U.S. government." His vital signs include temperature of 36.6°C (98.0°F), blood pressure of 132/94 mm Hg, pulse of 105/min, and respirations of 18/min. On physical examination, the boy appears to be in no distress. His pupils are dilated. Which of the following is the most likely diagnosis?

166) A 32-year-old woman is brought in to clinic by her husband of four years because she has been "restless and hyperactive" for the past two weeks. The husband describes her as unusually talkative, and says she speaks so quickly that others have difficulty understanding her. She has spent large sums of money on new clothing, makeup, and perfumes. When asked about her purchases, she says that she needs to look elegant since she is "a member of the royal family." She stays up very late each night to thoroughly clean the house, often sleeping only an hour or two. The husband has never observed these symptoms before in his wife. Physical examination of her is unremarkable. Which of the following is this woman most likely suffering from?

167) A 74-year-old woman is brought to the clinic by her daughter-in-law. The woman is a regular patient and has a long history of hypertension and ischemic heart disease. She lives with her son and daughter in-law, who are concerned that she has become increasingly forgetful over the past year. Initially, they attributed her forgetfulness to normal aging but her memory impairment has progressively worsened over the past several months. Of late, she has also developed some difficulty with speech and now is no longer able to perform the activities of daily living. Which one of the following is the most likely diagnosis?

168) A 4-year-old boy is brought to his pediatrician by his mother for "multiple fainting spells." Although physical examination reveals no abnormalities, the boy is admitted to the hospital for an extensive diagnostic workup. Laboratory evaluation reveals no abnormalities except for low serum glucose, high serum insulin, and low levels of serum C-peptide. The test results are revealed to the boy's mother, who works as a nurse in the hospital. Which of the following is the most likely diagnosis?

169) An 18-year-old college freshman is brought to the emergency department by his friends. They say that he is normally happy and good-natured, but became unusually withdrawn and aloof a few hours after a football game. He complains of a dry mouth. Physical examination reveals injected conjunctivae and tachycardia. Which of the following is most consistent with this patient's presentation?

170) A 34-year-old male presents to the emergency department complaining of severe lower back pain. He rates the pain as 10/10 in severity and describes it as non-radiating, sudden in onset, and aggravated by movement. He refuses to be examined, insisting that any examination will worsen his pain. He denies any history of trauma or lifting of heavy weights. He says, "Doc, the only thing that can relieve my pain is morphine ... You've got to have mercy on me." The patient has a long history of opioid dependence and has been admitted to the hospital multiple times while intoxicated. His last admission was two weeks ago and he was referred to a drug rehabilitation program upon discharge. Given the clinical presentation, what is the most likely diagnosis?

171) A young Caucasian mother brings her 5-year-old daughter to the pediatrician two months after the girl first began attending kindergarten. She says that earlier this week, her daughter's teacher called to say that the girl persistently refuses to answer questions or to speak to others in class. The teacher added that the girl also does not smile at, play with, or otherwise engage her fellow students. The mother finds this very surprising because her daughter is very verbal and talkative at home, plays happily with her siblings, and is an affectionate child. Further questioning reveals that the girl is "a little shy" at social gatherings. Which of the following is the most likely diagnosis?

172) A 12-year-old boy is accused of setting his neighbor's house on fire. His parents describe him as a hyperactive, talkative child. He earns excellent grades in school but frequently gets into fights with schoolmates and siblings. Two years ago, he was caught setting the interior of his father's car on fire. He has also been linked to several suspicious fires in the neighborhood, though no criminal charges were brought against him Based on this information, what is the most likely diagnosis?

173) A 39-year-old agitated female with an unknown medical history is brought to the emergency department by police after she was found assaulting an innocent pedestrian on the street. She tells the attending physician that she has unusual powers and has been sent on a special mission by God. She is proud of frequently communicating with God, both telepathically and verbally, and says that he assists her in "punishing all of the wicked people in the world” Which of the following is most demonstrated in her thought content?

174) A 28-year-old female presents to her family doctor with her mother, who complains that her daughter has been behaving eccentrically and has been socially withdrawn for the past year. The mother says that her daughter used to be very lively and friendly, but that she abruptly quit her job as a data analyst one year ago and now prefers to stay home in her bedroom most of the time. The patient is thoroughly evaluated by a psychiatrist. During that interview, she reveals to the psychiatrist that she constantly hears "so many voices" in her head. The voices tell her various things of a critical and suspicious nature. She also adds that she feels very sad and has had numerous severe crying spells after her pet dog's death four months ago. She prefers to be alone and does not enjoy interacting with others. She has poor sleep and little appetite. Which of the following is the most likely diagnosis in this woman?

175) A 10-year old girl is brought to the office by her mother for the evaluation of recent changes in behavior. She has been sleeping poorly at night and has started wetting her bed. Her school grades have dropped significantly, and she has become irritable and cranky. She refuses to sleep at night until her father returns home and goes to bed. Her father works as a taxi driver, and is an alcoholic. Her mother is a close friend of yours, and appears very concerned. Prior to this office visit, you have known this girl to be cheerful and lively; however, as you attempt to talk to the young girl in the office, she suddenly bursts into tears. Which of the following should you consider at this point?

176) A 19-year-old woman makes an appointment to see her primary care physician about a "personal concern." When she comes in for her visit, she says that she has been "deeply depressed" for the past several months because of her "enormous nose." She proceeds to describe in detail the numerous cosmetic aspects of her nose that prove troubling. She says that she is now so embarrassed that she is unwilling to go out with friends because "everyone just stares at my nose." She finds it difficult to concentrate on her studies because she is preoccupied with thoughts about undergoing corrective surgery. On examination, her nose appears completely normal. She pleads for a referral to a good plastic surgeon. Which of the following is the most likely diagnosis?

177) You are an internist making your rounds at a local nursing home. While you are reviewing a medical chart, one of the nurses approaches you to complain about a 62-year-old male patient who frequently masturbates in front of the staff and other nursing home residents. He has been taking olanzapine for years for schizophrenia. Upon interviewing him, you find the patient's thought processes to be devoid of hallucinations or delusions. There are several times when he laughs inappropriately during the interview. His speech is rambling and unpredictably shifts from one topic to another. Based on his clinical presentation, how should his illness be classified?