Part 24 (148-294)

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?

178) A 27-year-old male presents to clinic complaining of "marital problems." He says that for the past year that he has been married, he and his wife have not successfully had sexual intercourse on even one occasion. He strongly feels that she either finds him physically unattractive or is having an affair with another man. He adds that he is extremely frustrated with his wife "contracting herself," which prevents any kind of vaginal penetration. After several failed attempts, his wife now avoids any sexual intimacy with him. Which of the following is the most likely diagnosis?

179) A 19-year-old student is referred to the university health center for inability to complete his assignments. He has always been a good student, and was valedictorian of his high school class. However, since starting college, he has found it difficult to keep up with all the work. He audio-records every class, playing the tapes back later in the day to transcribe each entire lecture word for word. He admits to sometimes needing to go over certain sections multiple times to be sure he has heard correctly. He also takes a long time to complete assignments, as he always checks his work multiple times prior to handing it in. Because of this, he has had to ask for many extensions on his assignments. He is sure to complete all his assignments, even after they have been reviewed in class and even though they are not graded. He spends all his time doing his classwork, and is not involved in social activities. What is the most likely diagnosis?

180) A 46-year-old man with a history of medication-controlled hypertension sees his doctor for a routine check-up. His blood pressure is 115/80 mm Hg and an electrocardiogram shows a normal sinus rhythm. The doctor notes that the man seems more down than usual. The man admits that he has been "stressed out" for the past two weeks, as a few people at work recently quit and he has had to take on more work while management finds replacements. He has been sleeping poorly at night, feels tired during the day, and states that he hates his job right now, but has no other choice. He continues to get his work done and enjoys social activities, remarking that he "can still golf on the weekends." What isthe patient's most likely diagnosis?

181) An anxious mother brings her 4-year-old son to clinic for a new patient visit. She says that her son was progressing well developmentally and meeting all milestones until three months ago. Since then, she and her husband have noticed a marked restriction in the boy's activities. He keeps to himself, refuses to play with his siblings, speaks only when spoken to, and appears indifferent to the presence of others. Attempts to engage the child in conversation are unsuccessful. He seems disinterested and refuses to make eye contact. While in the examination room, he starts banging his head against the wall. Given this clinical presentation, which of the following is the most likely diagnosis?

182) A 59-year-old Caucasian female presents to the emergency department with sudden onset paralysis of her bilateral lower extremities. She has no other symptoms. Physical examination reveals normal tone, normal deep tendon reflexes, and no Babinski sign. Her motor strength is 3/5 in both lower extremities. The remainder of her examination is unremarkable. The patient dramatically improves after she is injected with sodium amytal. What is the most likely diagnosis?

183) A mother brings in her 3-year-old son to the pediatrician because she is concerned about his "poor development." She says that she thinks her son's behavior is "very different from that of other children his age." She says that ever since he was a toddler, he has seemed indifferent to her presence. She previously attributed this to her son being "unique" compared to his two older sisters. However, she is increasingly worried about her son because he does not play with his siblings or the neighborhood children who come to visit, and she suspects that his speech development is limited. Upon examination, the child is spinning continuously in a circle. When questions are asked of him, he makes no eye contact and responds with "A house for the mouse." His physical appearance is otherwise normal. Which of the following is the most likely diagnosis?

184) A 36-year-old known patient of yours presents for a routine annual examination. Toward the end of the visit, she glumly mentions that she intends to file for a divorce from her husband. She says that he is always in an irritable or depressed mood, and that she is "sick and tired of him spending huge sums of money on gambling." Although she was aware of his placing the occasional bet before they got married, she says his passion for gambling has increased significantly since his mother's death two months ago. He was recently fired from his job as an insurance agent after he was caught forging signatures in an attempt to finance some gambling trips to Las Vegas. She has confronted him about his behavior on many occasions in the past, but he has always denied that it was a problem. Now he admits that he finds it hard to control himself and that he is in debt to several creditors. Although he has lost a considerable amount of money, he is convinced that he could win it all back if he could just borrow enough from friends. Which of the following is the most likely diagnosis?

185) An anxious mother brings in her 12-year-old daughter to your clinic for "severe hair loss". On examination, you find several alopecic patches on her head. While taking a detailed history, you find out that the young girl has been pulling out her hair when stressed. Although she has been indulging in this behavior periodically since childhood, she finds a recent increase in the same. She reveals to you that she is "really nervous" about her upcoming exams, and has disturbed sleep. She also adds that she feels so stressed that she has been avoiding going out with her friends and keeps to her books all the time. She denies any alterations in weight, but does admit to a decreased appetite. What do you think is the underlying diagnosis in this case?

186) A 21-year-old woman presents to the physician at her mother's urging because she has been experiencing significant sleep disturbances. Three months ago, she was the victim of a sexual assault in the parking lot of her workplace. Since then, she has had recurrent nightmares about the assault, and dreads falling asleep at night. During the day, she has flashbacks about the assault. She has become very withdrawn, quit her job, and avoids other people. The woman is very distressed about the flashbacks and says that they "dominate her life." She has difficulty concentrating and startles easily when others speak to her. Which of the following is the most likely diagnosis?

187) A 32-year-old married woman presents with lower back pain that has persisted for the past week. She says she developed the pain after lifting some heavy furniture. She denies any other symptoms. A thorough physical examination reveals mild paraspinal muscle spasm. There is no significant pain with a straight leg raise on either side. Multiple bruises on her abdomen, back, and chest are also evident. When the topic of the bruises is raised, the woman becomes tearful and begins to cry. Which of the following is the most appropriate response?

188) A 31-year-old Caucasian female with a chronic history of schizophrenia presents for a prescription refill at her local mental health clinic. She has been treated with olanzapine for the last six months. The psychiatrist notes at this visit that the woman appears less agitated and complains of fewer auditory hallucinations. When asked questions, the woman gives detailed but irrelevant responses. Her answers drift away from the subject but eventually return. Which of the following is she demonstrating?

189) A 27-year-old female is brought to the emergency department by her husband after she fainted at home. The patient admits that she has been fasting and exercising vigorously for the past two days to compensate for the excessive amount of food she ate three days ago. She admits to a similar pattern of eating large amounts of food followed by a period of fasting since she lost her job a few months ago. She is very distressed by these "uncontrollable eating episodes" because she feels awful afterward. Periodically, she breaks down in tears while telling her story. Review of systems is otherwise unremarkable. Her menstrual periods are regular. Vital signs are temperature 37°C (98.6°F), blood pressure 98/62 mmHg, pulse 96/min, and respiratory rate 14/min. Her height is 5'4" (163 cm) and weight is 120 lbs (54 kg). Physical examination is unremarkable. What is the most likely diagnosis?

190) A 42-year-old man comes to the emergency room with the chief complaint that “the men are following me.” He also complains of hearing a voice telling him to hurt others. He tells the examiner that the news anchorman gives him special messages about the state of the world every night through the TV. Which of the following psychiatric findings best describes this last belief of the patient?

191) A 32-year-old woman is seen in an outpatient psychiatric clinic for the chief complaint of a depressed mood for 4 months. During the interview, she gives very long, complicated explanations and many unnecessary details before finally answering the original questions. Which of the following psychiatric findings best describes this style of train of thought?

192) An 18-year-old man is seen by a psychiatrist in the emergency room. During the history, the patient is asked to describe his mood. He answers the following, “My mood is flextitating, I am up and down.” The patient is exhibiting which of the following thought disorders

193) A 56-year-old man has been hospitalized for a myocardial infarction. Two days after admission, he awakens in the middle of the night and screams that there is a man standing by the window in his room. When the nurse enters the room and turns on a light, the patient is relieved to learn that the “man” was actually a drape by the window. This misperception of reality is best described by which of the following psychiatric terms?

194) A 22-year-old woman is seen by a psychiatrist in the emergency room after she is found walking in the middle of a busy street with no shoes on. During her interview she is asked to count backwards from 100 by 7’s. Which of the following best describes the cognitive functions being tested by this request?

195) A 72-year-old woman is admitted to the burn unit with second- and third-degree burns covering 35% of her body, which she received in a house fire. At 8 pm on the fourth day of her hospital stay, she pulls out her IV and begins screaming that people are trying to hurt her. Several hours later she is found to be difficult to arouse and disoriented. Which of the following is the most likely diagnosis?

196) A psychiatric resident is called to consult on the case of a 75-year-old woman who had undergone a hip replacement 2 days before. On examination, the resident notes that the patient states the date as 1956, and she thinks she is at her son’s house. These impairments best illustrate which aspect of the mental status examination

197) A 52-year-old man is sent to see a psychiatrist after he is disciplined at his job because he consistently turns in his assignments late. He insists that he is not about to turn in anything until it is “perfect, unlike all of my colleagues.” He has few friends because he annoys them with his demands for “precise timeliness” and because of his lack of emotional warmth. This has been a lifelong pattern for the patient, though he refuses to believe the problems have anything to do with his personal behavior. Which of the following is the most likely diagnosis for this patient?

198) A 23-year-old woman comes to the psychiatrist because she “cannot get out of the shower.” She tells the psychiatrist that she has been unable to go to her job as a secretary for the past 3 weeks because it takes her at least 4 hours to shower. She describes an elaborate ritual in which she must make sure that each part of her body has been scrubbed three times, in exactly the same order each time. She notes that her hands are raw and bloody from all the scrubbing. She states that she hates what she is doing to herself but becomes unbearably anxious each time she tries to stop. She notes that she has always taken long showers, but the problem has been worsening steadily for the past 5 months. She denies problems with friends or at work, other than the problems that currently are keeping her from going to work. Which of the following is the most likely diagnosis?

199) A 23-year-old woman comes to the emergency room with the chief complaint that she has been hearing voices for 7 months. Besides the hallucinations, she has the idea that the radio is giving her special messages. When asked the meaning of the proverb “People in glass houses should not throw stones,” the patient replies, “Because the windows would break.” Which of the following mental status findings does this patient display?

200) A 69-year-old man is brought to see his physician by his wife. She notes that over the past year he has experienced a slow, stepwise decline in his cognitive functioning. One year ago she felt his thinking was “as good as it always had been,” but now he gets lost around the house and can’t remember simple directions. The patient insists that he feels fine, though he is depressed about his loss of memory. He is eating and sleeping well. Which of the following is the most likely diagnosis?

201) A psychiatrist is seeing a patient in his outpatient practice. The patient treats the psychiatrist as if he were unreliable and punitive, though he had not been either. The patient’s father was an alcoholic who often did not show up to pick her up from school and frequently hit her. The psychiatrist begins to feel as if he must overprotect the patient and treat her gingerly. Which of the following psychological mechanisms best describes the psychiatrist’s behavior?

202) A patient is able to appreciate subtle nuances in thinking and can use metaphors and understand them. This patient’s thinking can be best defined by which of the following terms?

203) A 65-year-old man, who had been hospitalized for an acute pneumonia 3 days previously, begins screaming for his nurse, stating that “there are people in the room out to get me.” He then gets out of bed and begins pulling out his IV line. On examination, he alternates between agitation and somnolence. He is not oriented to time or place. His vital signs are as follows: pulse, 126 beats per minute; respiration, 32 breaths per minute; blood pressure (BP), 80/58; temperature, 39.2°C (102.5°F). Which of the following diagnoses best fits this patient’s clinical picture?

204) A 59-year-old man goes to a psychiatrist for a 3-month history of panic attacks. He notes for the past 3 months he has experienced “out of the blue,” extreme episodes of fearfulness that last about 20 minutes. During that time he experiences palpitations, sweating, shortness of breath, and trembling. He denies any substance abuse, and has never had symptoms like this before these past 3 months. Which of the following signs or symptoms would likely lead the physicians to expect a diagnosis of anxiety secondary to a general medical condition in this case?

205) A 19-year-old woman presents to the emergency room with the chief complaint of a depressed mood for 2 weeks. She notes that since her therapist went on vacation she has experienced suicidal ideation, crying spells, and an increased appetite. She states that she has left 40 messages on the therapist’s answering machine telling him that she is going to kill herself and that it would serve him right for leaving her. Physical examination reveals multiple well-healed scars and cigarette burns on the anterior aspect of both forearms. Which of the following diagnoses best fits this patient’s clinical presentation?

206) A 29-year-old man is brought to the emergency room by his wife after he woke up with paralysis of his right arm. The patient reports that the day before, he had gotten into a verbal altercation with his mother over her intrusiveness in his life. The patient notes that he has always had mixed feelings about his mother, but that people should always respect their mothers above all else. Which of the following diagnoses best fits this patient’s clinical picture?

207) A 28-year-old business executive sees her physician because she is having difficulty in her new position, as it requires her to do frequent public speaking. She states that she is terrified she will do or say something that will cause her extreme embarrassment. The patient says that when she must speak in public, she becomes extremely anxious and her heart beats uncontrollably. Based on this clinical picture, which of the following is the most likely diagnosis?

208) A 56-year-old man is brought to the physician’s office by his wife because she has noted a personality change during the past 3 months. While the patient is being interviewed, he answers every question with the same three words. Which of the following symptoms best fits this patient’s behavior?

209) A 32-year-old patient is being interviewed in his physician’s office. He eventually answers each question, but he gives long answers with a great deal of tedious and unnecessary detail before doing so. Which of the following symptoms best describes this patient’s presentation?

210) An 18-year-old man is brought to the emergency room by the police after he is found walking along the edge of a high building. In the emergency room, he mumbles to himself and appears to be responding to internal stimuli. When asked open-ended questions, he suddenly stops his answer in the middle of a sentence, as if he has forgotten what to say. Which of the following symptoms best describes this last behavior?

211) A 26-year-old woman with panic disorder notes that during the middle of one of her attacks she feels as if she is disconnected from the world, as though it were unreal or distant. Which of the following terms best describes this symptom?

212) A patient with a chronic psychotic disorder is convinced that she has caused a recent earthquake because she was bored and wishing for something exciting to occur. Which of the following symptoms most closely describes this patient’s thoughts?

213) A 45-year-old man with a chronic psychotic disorder is interviewed after being admitted to a psychiatric unit. He mimics the examiner’s body posture and movements during the interview. Which of the following terms best characterizes this patient’s symptom?

214) A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns, and blinks excessively. Which of the following disorders is most likely in this patient?

215) A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk. She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder?

216) A 24-year-old woman comes to the emergency room with the chief complaint that “my stomach is rotting out from the inside.” She states that for the last 6 months she has been crying on a daily basis and that she has decreased concentration, energy, and interest in her usual hobbies. She has lost 25 lb during that time. She cannot get to sleep, and when she does, she wakes up early in the morning. For the past 3 weeks, she has become convinced that she is dying of cancer and is rotting on the inside of her body. Also, in the past 2 weeks she has been hearing a voice calling her name when no one is around. Which of the following is the most likely diagnosis?

217) A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the Mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans because “they are into everything––I can’t be too careful.” He is convinced that the Mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. His roommate states that for the past 2 months the patient has been increasingly withdrawn and suspicious. Which of the following is the most likely diagnosis?

218) A 36-year-old woman is brought to the psychiatrist by her husband because for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors’ leaving their garbage cans out on the street to try to trip her, parking their cars in their driveways so they can hide behind them and spy on her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be “better if they would leave me alone.” She denies hearing the neighbors or anyone else talks to her, but is sure that they are out to “cause her death and mayhem.” Which of the following is the most likely diagnosis?

219) A 35-year-old woman has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering softly to herself, or looking at her reflection in a small mirror. She needs help with dressing and showering, and she often giggles and laughs for no apparent reason. Which of the following is the most likely diagnosis?

220) A 20-year-old woman is brought to the emergency room by her family because they have been unable to get her to eat or drink anything for the past 2 days. The patient, although awake, is completely unresponsive both vocally and nonverbally. She actively resists any attempt to be moved. Her family reports that during the previous 7 months she became increasingly withdrawn, socially isolated, and bizarre; often speaking to people no one else could see. Which of the following is the most likely diagnosis?

221) A 21-year-old man is brought to the emergency room by his parents because he has not slept, bathed, or eaten in the past 3 days. The parents report that for the past 6 months their son has been acting strangely and “not himself.” They state that he has been locking himself in his room, talking to himself, and writing on the walls. Six weeks prior to the emergency room visit, their son became convinced that a fellow student was stealing his thoughts and making him unable to learn his school material. In the past 2 weeks, they have noticed that their son has become depressed and has stopped taking care of himself, including bathing, eating, and getting dressed. On examination, the patient is dirty, disheveled, and crying. He complains of not being able to concentrate, a low energy level, and feeling suicidal. Which of the following is the most likely diagnosis for this patient?

222) A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her. Which of the following is the most appropriate diagnosis for this patient?

223) A 40-year-old woman is arrested by the police after she is found crawling through the window of a movie star’s home. She states that the movie star invited her into his home because the two are secretly married and “it just wouldn’t be good for his career if everyone knew.” The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life. Which of the following is the most likely diagnosis?

224) A 26-year-old woman is brought to the emergency room by her husband after she begins screaming that her children are calling to her and becomes hysterical. The husband states that 2 weeks previously, the couple’s two children were killed in a car accident, and since that time the patient has been agitated, disorganized, and incoherent. He states that she will not eat because she believes he has been poisoning her food, and she has not slept for the past 2 days. The patient believes that the nurses in the emergency room are going to cause her harm as well. The patient is sedated and later sent home. One week later, all her symptoms remit spontaneously. Which of the following is the most likely diagnosis for this patient?

225) A 25-year-old woman is diagnosed with schizophrenia when, after the sudden death of her mother, she begins complaining about hearing the voice of the devil and is suddenly afraid that other people are out to hurt her. Her history indicates that she has also experienced a 3-year period of slowly worsening social withdrawal, apathy, and bizarre behavior. Her family history includes major depression in her father. Which of the following details of her history leads the physician to suspect that her outcome may be poor?

226) A 22-year-old man is brought to the emergency room after he became exceedingly anxious in his college dormitory room, stating that he was sure the college administration was sending a “hit squad” to kill him. He also notes that he can see “visions” of men dressed in black who are carrying guns and stalking him. His thought process is relatively intact, without thought blocking or loose associations. His urine toxicology screen is positive for one of the following drugs. Which drug is the most likely cause of these symptoms?

227) A 72-year-old woman is brought to the emergency room by her daughter after she found her mother rummaging in the garbage cans outside her home. The daughter states that the patient has never had any behavior like this previously. On interview, the patient states she sees “martians hiding around her home, and on occasion, hears them too.” She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patient’s behavior except one. Which symptom is common in patients with a psychiatric cause for their behavior (ie, not a medical cause)?

228) A 62-year-old man with chronic schizophrenia is brought to the emergency room after he is found wandering around his halfway house, confused and disoriented. His serum sodium concentration is 123 meq/L and urine sodium concentration is 5 meq/L. The patient has been treated with risperidone 4 mg/day for the past 3 years with good symptom control. His roommate reports that the patient often complains of feeling thirsty. Which of the following is the most likely cause of this patient’s symptoms?

229) A 75-year-old man is being cared for in a hospice setting. He has widely spread prostatic carcinoma and is considered terminal. Which of the following psychiatric symptoms are seen in 90% of all terminal patients?

230) A 52-year-old man is seen by a psychiatrist in the emergency room because he is complaining about hearing and seeing miniature people who tell him to kill everyone in sight. He states that these symptoms developed suddenly during the past 48 hours, but that he has had them “on and off” for years. He states that he has never previously sought treatment for the symptoms, but that this episode is particularly bad. He denies the use of any illicit substances. The patient is alert and oriented to person, place, and time. His mental status examination is normal except for his auditory and visual hallucinations. His thought process is normal. His drug toxicology screen is positive for marijuana. He is quite insistent that he needs to be “put away” in the hospital for the symptoms he is experiencing. Which of the following is the most likely diagnosis?

231) A 25-year-old man is brought to the physician after complaining about a visual hallucination of a transparent phantom of his own body. Which of the following specific syndromes is this patient most likely to be displaying?

232) A 26-year-old man comes to the physician with the chief complaint of a depressed mood for the past 5 weeks. He has been feeling down, with decreased concentration, energy, and interest in his usual hobbies. Six weeks prior to this office visit, he had been to the emergency room for an acute asthma attack and was started on prednisone. Which of the following is the most likely diagnosis?

233) A 24-year-old woman, 5 days after delivery of a normal, full-term infant, is brought to the obstetrician because she is so tearful. She states that her mood is quite labile, often changing within minutes. She has trouble sleeping, both falling asleep and awakening early. She notes anhedonia, stating she doesn’t enjoy “much of anything” right now. Which of this patient’s symptoms point preferentially to a postpartum depression?

234) A 28-year-old woman sees her physician with the chief complaint of a depressed mood. She also notes that she is sleeping more than usual––up to 14 hours per night––but does not feel rested and that she feels tired and fatigued all the time. She has gained 14 lb in the last month, something that she is very unhappy about, but she says that she seems to have such a craving for sweets that the weight gain seemed inevitable. Which of the following is the most likely diagnosis?

235) A 27-year-old woman has been feeling blue for the past 2 weeks. She has little energy and has trouble concentrating. She states that 6 weeks ago she had been feeling very good, with lots of energy and no need for sleep. She says that this pattern has been occurring for at least the past 3 years, though the episodes have never been so severe that she couldn’t work. Which of the following is the most likely diagnosis?

236) A 19-year-old woman comes to the psychiatrist for a history of anger and irritability, which occurs on monthly on an average. During this time the patient also reports feeling anxious and “about to explode,” which alternates rapidly with crying spells and angry outbursts. The patient notes during this time she can’t concentrate and sleeps much more than she usually needs to do. During the several days these symptoms last, the patient must skip most of her classes because she cannot function. Which of the following is the most likely diagnosis?

237) A 64-year-old man is admitted to the psychiatric unit after an unsuccessful suicide attempt. Following admission, he attempts to cut his wrists three times in the next 24 hours and refuses to eat or drink anything. He is scheduled to have electroconvulsive therapy (ECT) because he is so severely depressed that an antidepressant is deemed too slow acting. Which of the following side effects should the patient be informed is most common after ECT?

238) A 14-year-old boy is brought to the psychiatrist because for the past 15 months he has been irritable and depressed almost constantly. The boy notes that he has difficulty concentrating, and he has lost 5 lb during that time period without trying. He states that he feels as if he has always been depressed, and he feels hopeless about ever feeling better. He denies suicidal ideation or hallucinations. He is sleeping well and doing well in school, though his teachers have noticed that he does not seem to be able to concentrate as well as he had previously. Which of the following is the most likely diagnosis?

239) A 45-year-old woman comes to her physician for help with her insomnia. She states “ever since my husband died, I just can’t sleep.” The patient states her 57-year-old husband died suddenly of a heart attack 9 weeks ago. Since that time, the patient has had a very depressed mood, had been crying, has lost interest in activities, is fatigued, and has insomnia. Which of the following symptoms, if present, should make the physician think this patient has a major depression instead of bereavement?

240) A 32-year-old man is being treated for a severe major depression. Which of the following symptoms, if present, is one of the most accurate indicators of long-term suicidal risk?

241) A 44-year-old white male presents with a long history of joint pains in several joints. He has seen a physician before but no diagnosis was made. He has been taking ibuprofen with partial relief. He has now developed fever, diarrhea and weight loss. He denies any genitourinary or eye symptoms. He does not use tobacco, alcohol or drugs. He is a farmer. On examination, he has generalized lymphadenopathy and non-deforming arthritis. Small intestinal biopsy reveals periodic Acid-Schiff (PAS)-positive macrophages. Which of the following is the most likely diagnosis?

242) A 33-year-old tennis player comes to you with a complaint of pain in his right shoulder. He says that the pain is absent at rest but present when he lifts his arm over his head. The pain is compromising his play. On examination, active motion at right shoulder is limited due to pain. Pain is most severe on passive internal rotation and flexion at the right shoulder. No atrophy of the shoulder muscle is seen. Which of the following is the most likely diagnosis in this patient?

243) A 75-year-old white male comes to the physician's office for his routine health maintenance examination. He has no symptoms. He has a past medical history significant for hypertension and hyperlipidemia. He takes aspirin, hydrochlorothiazide and simvastatin. He does not smoke and consumes 1-2 beers on weekends. He walks 2 miles every morning and eats a balanced diet. His vital signs are within normal limits. His chest is clear to auscultation, and his abdomen is soft and nontender. Rectal examination shows a diffusely enlarged, firm prostate without nodules. Stool for occult blood is negative. The distal interphalangeal joints are enlarged, and his gait is normal. His labs are as follows: Total bilirubin 1.0 mg/dl, Alkaline phosphatase 420 U/L, Aspartate aminotransferase (SGOT) 20 U/L, Alanine aminotransferase (SGPT) 25 U/L, Serum creatinine 0.8 mg/dl, Calcium 8.8 mg/dl, Serum PSA 2.1 ng/ml. Which of the following is the most likely cause of the elevated alkaline phosphatase in this patient?

244) A 21-year-old Caucasian female presents with a one-week history of low-grade fever and joint pain. She describes symmetric swelling of the small hand joints. Her rheumatoid factor tests positive, and antinuclear antibodies are weakly positive at a 1:40 dilution. She is treated with NSAIDs. Four weeks later, the patient reports not taking the prescribed drugs since she feels no pain. Which of the following is the most likely diagnosis?

245) A 64-year-old male comes to the physician's office because of increasing pain in his right groin for the past several months. The pain increases with activity and is relieved with rest. He also has difficulty moving after a period of rest. He denies any trauma or falls. He has no fever, weight loss or loss of appetite. He has had lumbar disk herniation in the past but denies any current back pain. He has no other active medical problems. His vital signs are within normal limits. He weighs 95 kg (210 lb) and is 168 cm (66 in) tall. Examination shows pain on passive internal rotation of right hip joint. Direct pressure over the groin did not increase the pain. His reflexes are 2+, and there are no sensory deficits. Muscle bulk, tone and power are within normal limits. Pulses are 2+ in both legs. Which of the following is the most likely cause of his hip pain?

246) A 36-year-old female who is currently having regular menstrual periods comes to the emergency room because of malaise and a high-grade fever with chills. She also complains of pain in multiple joints. She always uses highly absorbent tampons during her menses. She uses intravenous heroin and cocaine and works as a prostitute. Her temperature is 39.3°C (103.4°F), pulse is 102/min, blood pressure is 120/80mmHg and respirations are 14/min. Examination shows multiple pustules on the extensor surfaces of her forearms. Joint examination does not show redness, swelling or tenderness. Three sets of blood cultures are negative Based on these findings, which of the following is the most likely diagnosis in this patient?

247) A 54-year-old retired schoolteacher comes to the physician's office because of worsening low back pain. The pain started three weeks ago. It is continuous and is worse at night. He has had little relief with over-the-counter nonsteroidal analgesics. He has no other symptoms. He had a surgical resection of a lung tumor one year ago for non-small cell carcinoma of the lung. Preoperative positron emission tomography (PET) scanning did not reveal any evidence of metastasis. His vital signs are within normal limits. Examination shows local spinal tenderness at the L4-L5 level. What is the most likely cause of his back pain?

248) A 60-year-old man presents to the emergency department after being awoken from sleep by severe pain in his right great toe. He reports that his toe is suddenly swollen and very tender to touch. On review of systems, the patient also describes occasional headaches and pruritus that can be "unbearable" after a hot bath. He does not smoke or drink alcohol. On physical examination, his lungs are normal. The liver span is 10 cm and the spleen is palpable 2 cm below the costal margin. Aspiration of the affected toe joint reveals negatively birefringent crystals. Which of the following is most likely responsible for this patient's symptoms?

249) A 29-year-old woman presents to your office complaining of easy fatigability over the last several months. She tires easily after walking short distances. She also has difficulties combing her hair due to an inability to hold her hands over her head for a long time. She reports a weight loss of two or three pounds over the last two months. She denies fever or loss of appetite. She does not smoke or consume alcohol. On family history, her father died of a stroke when he was 54 years old and her mother has diabetes mellitus. On examination, she is afebrile with a pulse of 105/min. Cardiac exam reveals regular rhythm with no murmur. Her gait is normal but, when asked to sit down slowly, she drops into the chair. A fine finger tremor is evident when she extends her arms. Her muscles are non-tender to palpation. She appears to have decreased muscle mass in her shoulders. Deep tendon reflexes are normal. Which of the following is the most likely cause of this patient's symptoms?

250) A 62-year-old male treated for hypertension and hyperlipidemia complains of nagging right knee pain that is worse in the evening. The pain has been present for several months and it seems to limit his physical activities. His blood pressure is 160/100 mmHg and his heart rate is 70/min. His BMI is 32 kg/m2, and palpation of the knee reveals a cool joint with bony tenderness. His blood cholesterol level is 200 mg/dl and his serum uric acid level is 9.0 mg/dl. Which of the following additional findings is likely on further examination of the right knee?

251) A 34-year-old man complains of back tightness and persistent low back pain. The pain has a dull and aching quality. It is worse during the night and in the morning but improves gradually during the day. He has no significant past medical history. He does not use tobacco, alcohol, or illicit drugs. He is married and lives with his wife. His pulse is 80/min, respirations are 14/min, and blood pressure is 120/76 mmHg. Which of the following most likely accounts for this patient's symptoms?

252) A 34-year-old woman with a skin rash, joint pains, and oral ulcers is diagnosed with systemic lupus erythematosus. She has no renal or central nervous system involvement, and her past medical history and review of systems are otherwise negative. Therapy with hydroxychloroquine is started. Which of the following screening tests is most important in this patient?

253) A 68-year-old man with hypertension, hyperlipidemia, and diabetes is hospitalized for an acute myocardial infarction. It is complicated by pulmonary edema and he undergoes angiography of the left anterior descending artery. On post-operative day 3, he complains of abdominal pain and discoloration of his toes. His vital signs are stable. Examination shows bluish discoloration of his right great toe and of all the toes on his left foot. The skin over the toes is cold and clammy. Bilateral pedal pulses are present and full. His abdomen is soft and mildly tender at the center. Chest auscultation is clear. Laboratory studies show a rise in creatinine to 2.3 g/dl from his baseline of 1.2 g/dl. An EKG shows sinus rhythm and Q waves in anterior leads. Which of the following is the most likely cause of his toe discoloration?

254) A 32-year-old man presents to the clinic with one week of escalating lower back pain. He describes the pain as dull and aching. It increases with motion and it is not completely relieved by rest. He has no significant past medical history. He smokes one pack of cigarettes per day and consumes alcohol occasionally. He admits to being "under a lot of stress" and has recently used injectable drugs. His family history is significant for prostate cancer in his father. His temperature is 36.7°C (98°F), pulse is 90/min, respirations are 16/min, and blood pressure is 120/80 mmHg. Gentle percussion over the lumbar vertebrae elicits pain. A full neurologic exam including straight leg raise is normal. Laboratory results are shown below: Complete blood count: Leukocyte count 6,500/mm3, Hematocrit 46%, Platelets 400,000/mm3. Which of the following is the most likely diagnosis?

255) A 35-year-old African-American woman comes to the physician's office complaining of blurred vision, cough and shortness of breath. For the past few days she has had mild fevers, malaise and easy fatigability. She has never had these symptoms before and is anxious to uncover a diagnosis. She was recently incarcerated for two months. She practices unprotected sex with her new boyfriend. Her temperature is 37.2°C (98.9°F) and her blood pressure is 116/80 mmHg. On exam, her right eye is red and slit lamp examination shows leukocytes in the anterior chamber. Lungs have patchy rales. Chest x-ray shows bilateral reticulonodular infiltrates and hilar adenopathy. Which of the following is the most likely diagnosis in this patient?

257) A 67-year-old male hospitalized after elective hernia repair complains of severe right knee pain. Physical examination reveals redness and swelling of the right knee with limited motion due to pain. His temperature is 38.9°C (102°F), blood pressure is 160/110 mm Hg, pulse is 80/min, and respirations are 16/min. Synovial fluid analysis reveals the following findings: WBC count 30,000mm3, Neutrophils 90%, Crystals rhomboid-shaped, positively birefringent, Gram stain negative. Which of the following is most likely associated with this patient's current condition?

258) A 43-year-old Caucasian female presents to your office complaining of joint pain and swelling in her hand. On history, she endorses easy fatigability and loss of energy that has been worsening insidiously. It is especially difficult for her to do daily activities in the morning due to prolonged stiffness. She also describes frequent knee pain accompanied by a low-grade fever. She takes ibuprofen and naproxen to relieve her symptoms. Her hematocrit is 33%. The patient is at the greatest risk of which of the following?

259) A 32-year-old Caucasian male complains of inability to grip his cup of coffee and hold a pen in the morning. He says that he is 'fully functional' in the afternoon. His ESR is 45 mml hr. Which of the following is most likely to be affected by this patient's disease?

260) A 21-year-old woman presents with 4 months of slowly progressive low back pain. Her back pain is associated with early morning stiffness that improves as the day progresses. She has no fever or gastrointestinal complains. She denies any recent illness. On examination, there is limited range of motion of her back. Other examination is unremarkable. Plain X-ray films show bilateral sacroiliitis. Which of the following conditions is this patient at greatest risk of developing?

261) A 30-year-old female comes to your office with a complaint of pain over the lateral side of her wrist for the last four days. She is two months postpartum and notes that her pain is most severe when she lifts her infant from a crib. On examination, there is tenderness over the radial side of wrist and first dorsal compartment. Passive stretching of the thumb tendons over the radial styloid while the thumb is held in flexion aggravates the pain. She denies any recent trauma over the tender area. Which of the following is the most likely diagnosis in this patient?

262) A 44-year-old female complains of generalized weakness, low-grade fever and joint pain. Her daily activities are limited due to joint stiffness, especially in the morning. Her hand joints are swollen symmetrically. The inferior pole of the spleen is palpable on physical examination. Her hematocrit is 34%. Liver and renal function tests are normal. Two months after the initial visit, the patient develops painful oral ulcers. Her laboratory values are: Hematocrit 33%, AST 120 U/L, ALT 90 U/L, Alkaline phosphatase 90 U/L, Bilirubin 1.1 mg/dl, Creatinine 0.8 mg/dl, BUN 16 mg/dl. Which of the following is the most likely cause of this patient's current complaints?

263) A 35-year-old woman presents with complaints of aching pain and stiffness over her entire body for the past 3 months. She also reports, easy fatigability, poor sleep and frequent headaches. She has been using over the counter pain medications with no relief. While examining her, she complains of extreme pain to gentle palpation over her neck, shoulders and back. Her vital signs are stable. What is your diagnosis?

264) A 25-year-old immigrant from Eastern Europe is being evaluated for right shoulder pain and swelling. He also complains of heel pain while walking. Palpation over the heels, iliac crests and tibial tuberosities elicits tenderness. Which of the following additional findings is most likely in this patient?

265) A 9-year-old Caucasian male complains of fever, sore throat and difficulty swallowing. Small tender lymph nodes are palpated in the cervical region. The symptoms subside quickly on penicillin therapy. Ten days later, the patient presents again with fever, skin rash and fleeting joint pain in the lower extremities. Physical examination reveals scattered urticaria and palpable lymph nodes in the cervical, axillary and inguinal regions. Which of the following is the most likely cause of this patient's current complaints?

266) A 66-year-old man comes to the physician's office complaining of progressive lower back pain. Over-the-counter ibuprofen has provided him with moderate relief. The back pain is associated with bilateral leg pain that is precipitated by walking. The pain improves upon lying down or sitting. He has no pain at night, and no problems with bowel and bladder function. He underwent coronary artery bypass grafting (CABG) 6 years ago for a 3-vessel coronary artery disease. His medications include aspirin, enalapril, atenolol, and lovastatin. Physical examination shows normal strength, reflexes and sensation in his legs. A straight leg raise test fails to reproduce pain. His femoral, popliteal and pedal pulses are full bilaterally and he has no bruits. Plain films of the lumbosacral spine show degenerative changes of the vertebrae. Ankle brachial index measurement is within normal limits. Which of the following is most likely responsible for his current condition?

267) A 35-year-old female presents with a complaint of oral ulcers that are extremely painful. She had a similar presentation three months ago and the ulcers healed without any scarring. Her medical history includes a recent visit to the ophthalmologist with complaints of blurred vision and she is now being treated for anterior uveitis. She has also had recurrent painful ulcers in her genital area for which she has regular follow-up with her gynecologist. On examination, you notice many hyper-pigmented areas over her extremities and few painful, nodular lesions. What is the most likely diagnosis?

270) A 30-year-old white male presented to your office with low back pain and stiffness. His pain is worse in the morning and is improved with activity. He has also been having bloody diarrhea for the past few days. On examination, he has painful erythematous nodules over his shins. Pain and stiffness is present in his lower back. Plain radiographs show sacroiliac joint inflammation. Stool cultures are negative. Laboratory studies show anemia and thrombocytosis. P-ANCA is positive in high titers. Which of the following is the most likely cause of his symptoms?

271) A 42-year-old male presents to your office complaining of back pain that started two days ago after carrying heavy packages. He denies any weakness or sensory changes in his legs. His past medical history is insignificant. He is not taking any medications and denies drug abuse. His temperature is 36.7°C (98°F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals paravertebral tenderness. Lower extremity power is 5/5 and the deep tendon reflexes are 2+. Babinski's sign is negative. Straight-leg raising test is negative at 90 degrees. What is the most probable diagnosis in this patient?

272) A 30-year-old obese woman comes to the emergency department complaining of four days of progressive pain, swelling and redness of her right leg. She has no obvious trauma or insect bites. She does not use tobacco, alcohol or illicit drugs. Her temperature is 38.7°C (103.0°F), pulse is 106/min, and blood pressure is 130/80 mmHg. Her right calf is swollen, erythematous, and extremely tender and warm to the touch over a 6 x 3 cm region. There is a tender, palpable mass in her right groin. There is no overlying crepitus and no bullae are seen. The toe webs are fissured and macerated. Laboratory studies show: Complete blood count: Hemoglobin 14.0 g/L, Platelets 222,000/mm3, Leukocyte count 14,500/mm3, Neutrophils 86%, Lymphocytes 14%, Which of the following is the most likely cause of her current leg condition?

273) A 27-year-old African-American woman presents with several complaints. She has had pain and swelling of her hands and wrists for the past few days. She also complains of easy fatigability and frequent mouth ulcers. She has no significant past medical history and does not take any medications. Her temperature is 37.1°C (98.9°F), blood pressure is 140/90mmHg, and pulse is 76/min. Examination reveals swollen, tender metacarpophalangeal and proximal interphalangeal joints. There are superficial ulcers on her buccal mucosa. X-ray of hands and wrists shows no bony erosions. Laboratory studies show: Hemoglobin 11.0 g/L, Platelets 90,000/mm3, Leukocyte count 4,500/mm3. Urinalysis shows 2+ protein and red blood cell casts. Which of the following is the most likely cause of her joint pains?

274) A 63-year-old painter presents with pain in his right shoulder for the past few weeks. He experiences pain when he tries to reach for objects and he is unable to lift his arm above his head. He denies trauma to the shoulder, fevers, chills and weight loss. Vital signs are within normal limits. On exam, the physician raises the patient's arm while asking him to relax the shoulder. At 60 degrees, the patient begins to shrug his shoulder and complain of pain. In spite of the pain, his range of motion is normal. A lidocaine injection into the shoulder leads to a significant decrease in pain upon lifting the arm. Which of the following is most likely responsible for his current condition?

275) A 22-year-old Caucasian female comes to your office complaining of difficulty swallowing. She says that solid food sticks in the middle of her chest, and that's why she prefers liquids. She has lost 10 pounds over the last 3 months. She also complains of recent severe heartburn that does not respond well to over-the-counter antacids. On review of systems, she denies cough, shortness of breath and palpitations. She has noticed occasional swelling and pain in her small finger joints. Her fingers turn blue upon cold exposure, and she always wears gloves to keep them warm. She does not smoke or drink alcohol. She denies illegal drug use. Which of the following is the most likely diagnosis?

276) A 28-year-old woman presents to her physician's office because of pain in her left knee joint. She reports having mild discomfort and pain in right wrist 4 days ago and left ankle pain two days ago. She denies any recent respiratory illness, diarrhea, or urinary symptoms. She has no vaginal discharge. She has no previous medical problems and does not take any medications. She drinks half a pint of vodka daily but denies intravenous drug abuse. She is single and sexually active. Her last menstrual period was one week ago. Her temperature is 38.5°C (101.3°F), blood pressure is 120/80 mmHg, pulse is 98/min, and respirations are 15/min. Examination of the knee reveals warmth, tenderness, decreased range of motion, and an effusion. No skin lesions are present and her pelvic examination is unremarkable. Synovial fluid analysis shows a white blood cell count of 75,000/microl. Which of the following is the most likely cause of her symptoms?

277) A 45-year-old tennis player comes to your office with a complaint of pain over the lateral side of the right elbow. He has been a professional tennis player for 15 years but has never had this kind of pain before. Range of motion at both elbows is normal. There is point tenderness over the lateral side of the distal end of right humerus. Pain is exacerbated by extension of wrist against resistance. The rest of the physical examination is normal. Which of the following is the most likely diagnosis in this patient?

278) A 65-year-old man complains of periodic back pain radiating to his thigh and buttock. The pain is related to walking or climbing the stairs but is promptly relieved by leaning forward. He also has noticed tingling and numbness in both lower extremities. He has a history of hypertension and takes hydrochlorothiazide. He does not use tobacco, alcohol, or illicit drugs. His pulse is 76/min, respirations are 14/min, and blood pressure is 140/80 mmHg. Lumbar extension reproduces the pain and tingling, while lumbar flexion relieves the symptoms. Which of the following is the most likely cause of this patient's condition?

279) A 51-year-old Caucasian female complains of low-back pain radiating to the buttocks. She also complains of persistent muscle pain that gets worse with exercise. Physical examination reveals normal muscle strength. Her joints are not swollen, but palpation over the outer upper quadrants of the buttocks and the medial aspect of the knees elicits tenderness. Her ESR is 12mm/hr. Which of the following is the most likely diagnosis?

280) A 27-year-old male presents to the physician's office because of pain on the medial side of the tibia just below the knee. The pain does not radiate and is continuous. He relates the onset of his pain to falling on the ground while playing football two weeks ago. He denies fever, malaise and weight loss. His past medical history is not significant. On examination, a well-defined area of tenderness is present on the upper tibia below the medial knee joint. There is no redness, warmth or swelling. His gait is normal. A valgus stress test has no effect on his pain. X-ray of the knee and tibia shows no abnormalities. Which of the following is the most likely cause of his current symptoms?

281) A 16-year-old boy presents with a seven-month history of intermittent right knee pain and swelling. He states that his discomfort first began after a baseball injury. This injury was associated with pain, swelling, and restriction of movement in his right knee. He has had three subsequent episodes of pain and swelling in his right knee, not precipitated by trauma. The last episode occurred three days ago. He denies history of fevers or chills. There is no history of recent travel, other than a camping trip with his friends to Long Island, New York a few months ago. On physical examination, he has a marked effusion of his right knee and is unable to fully flex or extend his leg. X-ray reveals no bony abnormalities. What is the most probable diagnosis?

282) A 75-year-old female comes to the emergency room with acute onset of severe back pain. The pain started while lifting a turkey from the freezer. She had no obvious trauma preceding the pain. She denies weakness or sensory loss in the legs. Her past medical history is significant for temporal arteritis diagnosed several months ago and has been taking prednisone. She does not smoke or consume alcohol. Her temperature is 36.7°C (98°F), blood pressure is 140/70 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals local tenderness of the lumbar spine area. Bilateral ankle reflex is absent. Knee reflex is 2+ in both legs. Babinski's sign is absent bilaterally. Muscle power is 5/5 in both legs. Bilateral straight-leg raising to 90 degrees does not increase the pain What is the most probable diagnosis in this patient?

283) A 66-year-old man complains of a 1-year history of low-back and buttock pain that worsens with walking and is relieved by sitting or bending forward. He has hypertension and takes hydrochlorothiazide but has otherwise been healthy. There is no history of back trauma, fever, or weight loss. On examination, the patient has a slightly stooped posture, pain on lumbar extension, and has a slightly wide base gait. Pedal pulses are normal and there are no femoral bruits. Examination of peripheral joints and skin is normal. What is the most likely cause for this patient’s back and buttock pain?

284) A 22-year-old man develops the insidious onset of low-back pain improved with exercise and worsened by rest. There is no history of diarrhea, conjunctivitis, urethritis, rash, or nail changes. On examination, the patient has loss of mobility with respect to lumbar flexion and extension. He has a kyphotic posture. A plain film of the spine shows sclerosis of the sacroiliac joints. Calcification is noted in the anterior spinal ligament. Which of the following best characterizes this patient’s disease process?

285) A 20-year-old man complains of arthritis and eye irritation. He has a history of burning on urination. On examination, there is a joint effusion of the right knee and a rash of the glans penis. Which of the following is correct?

286) Last week a 20-year-old college student developed acute wrist pain and swelling. This resolved in four days. Yesterday, he developed pain and swelling in his left knee. Two months ago he went on a backpacking trip in Rhode Island. A week or so later he developed an enlarging circular red spot that persisted for 2 weeks and then resolved. What is the most likely diagnosis?

287) A 38-year-old man has pain and stiffness of his right knee. This began 2-weeks ago after he fell while skiing. On two occasions he had the sense that his knee was locked in a semiflexed position for a few seconds. He has noted a popping sensation when he bends his knee. On examination there is tenderness over the medial joint line of the knee. Marked flexion and extension of the knee are painful. The Lachman test (anterior displacement of the lower leg with the knee at 20°of flexion) and the anterior drawer test are negative. What is the most likely diagnosis?

288) A 63-year-old painter complains of severe right shoulder pain. The pain is located posteriorly over the scapula. These symptoms began after he fell from a ladder 2 weeks ago. The pain is especially bad at night and makes it difficult for him to sleep. In addition, he has had some pain in the right upper arm. Treatment with acetaminophen and ibuprofen has been unsuccessful in controlling his pain. On examination the patient appears uncomfortable. The right shoulder has full range of motion. Movement of the shoulder is not painful. There is no tenderness to palpation of the scapula. What is the most likely diagnosis?

289) A 50-year-old woman with rheumatoid arthritis has been treated with meloxicam (Mobic). You add hydroxychloroquine. Six weeks later her arthritis is mildly improved. The same joints are still involved but she now reports only 1-hour morning stiffness. She has, however, developed epigastric burning and melena for the past 3 days. Stool is strongly positive for occult blood. Which of the following is the most likely cause for the melena in this case?

290) A 55-year-old woman with long-standing rheumatoid arthritis is on prednisone 5 mg daily and etanercept (Enbrel) 50 mg subcutaneously once a week. Her arthritis is well-controlled. However, she complains of a 2-day history of headaches, chills, and spiking fevers to 39.4°C (103°F). You suspect which of the following?

291) A 32-year-old Japanese woman has a long history of recurrent aphthous oral ulcers. In the last 2 months she has had recurrent genital ulcers. She now presents with a red painful eye that was diagnosed as anterior uveitis. What is the most likely diagnosis?

292) A 53-year-old man presents with arthritis and bloody nasal discharge. Urinalysis reveals 4+proteinuria, RBCs, and RBC casts. ANCA is positive in a cytoplasmic pattern. Antiproteinase 3 (PR3) antibodies are present, but antimyeloperoxidase (MPO) antibodies are absent. Which of the following is the most likely diagnosis?

293) A 35-year-old right-handed construction worker presents with complaints of nocturnal numbness and pain involving the right hand. Symptoms wake him and are then relieved by shaking his hand. There is some atrophy of the thenar eminence. Tinel sign is positive. Which of the following is the most likely diagnosis?

294) A 50-year-old white woman presents with aching and stiffness in the trunk, hip, and shoulders. There is widespread muscle pain after mild exertion. Symptoms are worse in the morning and improve during the day. They are also worsened by stress. The patient is always tired and exhausted. She has trouble sleeping at night. On examination, joints are normal. ESR is normal, and Lyme antibody and HIV test are negative. A diagnosis is best made by which of the following?