USS DES Test 13B (Start from page1964 to 1991 & 2298 to 2299)

82) A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness.

P1965 Q82

83) A 63-year-old man is seen because of facial swelling and cyanosis, especially when he bends over. There are large, dilated subcutaneous veins on his upper chest. His jugular veins are prominent even while he is upright. Which of the following conditions is the most likely cause of these findings?

84) A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Which of the following is the most likely diagnosis?

85) A 65-year-old woman has had pain in her right shoulder and has been treated with analgesics without relief. The CXR reveals a mass in the apex of the right chest. A transthoracic needle biopsy documents carcinoma. Superior pulmonary sulcus carcinomas (Pancoast tumors) are bronchogenic carcinomas that typically produce which of the following clinical features?

86) A 45-year-old woman presents with hypertension, development of facial hair, and a 7-cm suprarenal mass. Which of the following is the most likely diagnosis?

89) A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full-blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. Which of the following is the most likely diagnosis?

90) A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Which of the following would help confirm the diagnosis? 90) A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Which of the following would help confirm the diagnosis? . Transscrotal needle biopsy . Transscrotal aspiration of the hydrocele for cytology . Radical orchiectomy through an inguinal incision . Transscrotal exploration and orchiectomy . Laparotomy with pelvic and retroperitoneal node dissection

92) The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Shortly after admission, he develops a blood pressure of 80/50 mm Hg, a pulse rate of 110/min, and a venous pressure of zero. He becomes pale, cold, and clammy, but the rest of his physical examination and x-ray films of the chest and pelvis are unremarkable. A sonogram of the abdomen done in the emergency department is likewise negative. Which of the following is the most likely reason for the low blood pressure?

93) A 24-year-old patient with known neurofibromatosis type 2 undergoes an MRI for ringing in his ears. The MRI demonstrates lesions in bilateral auditory canals. Which of the following is the most likely diagnosis?

94) A40-year-old man with a history of alcohol abuse presents after an episode of binge drinking. He is complaining of epigastric pain, radiating to the back, associated with nausea and vomiting. On examination, he has marked tenderness in the epigastrium, with guarding, decreased bowel sounds, and moderate abdominal distention. Laboratory findings include leukocytosis and increased serum amylase and lipase. Abdominal roentgenograms demonstrate several dilated bowel loops in the upper abdomen. Select the most likely diagnosis?

95) A 65-year-old man presents with a 4-day history of worsening lower abdominal pain and constipation. On examination, he is febrile (38.5°C) and has lower abdominal tenderness that is most intense in the midline and left lower quadrant associated with a palpable fullness. Laboratory findings demonstrate a moderate leukocytosis and abdominal roentgenograms show an ileus pattern. Select the most likely diagnosis?

96) A 65-year-old man presents to the physician’s office with complaints of abdominal discomfort and jaundice for the past 3 weeks. Past history is pertinent for 30 pack-year smoking history, occasional alcohol intake, and a 5.5-mm ulcerating melanoma removed from his back 21/ 2 years ago. Examination reveals a mildly jaundiced patient with normal vital signs and a slightly distended abdomen with mild right upper quadrant tenderness and significant hepatomegaly. Which one is the most likely diagnosis?

97) A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most likely diagnosis?

98) A 15-year-old otherwise healthy female high school student begins to notice galactorrhea. A pregnancy test is negative. Which of the following is a frequently associated physical finding?

99) A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable.

P1972 Q99

100) A 76-year-old man is undergoing an abdominoperineal resection for rectal cancer. During the surgery, unexpected severe bleeding is encountered, and the patient is hypotensive on and off for almost an hour. The anesthesiologist notes ST depression and T-wave flattening on the ECG monitor. Which of the following are the most likely diagnosis and the expected mortality?

101) A 72-year-old woman has a red, swollen breast. She states that the condition has been present for at least several weeks, perhaps a month or two. She has no pain or fever. The skin over the area looks like orange peel. The area is not warm to the touch, but on physical examination there is fullness to the entire breast, with no discrete mass. Which of the following is the most likely diagnosis?

104) An 18-year-old football player is seen in the emergency ward with severe knee pain incurred after being hit by a tackler while running. Which of the following findings on physical examination is most sensitive for an anterior cruciate ligament injury?

105) A 30-year-old man presents with sudden onset of severe epigastric pain 6 hours ago. Examination reveals a low-grade fever, tender abdomen throughout, with rigidity of the abdominal usculature. Abdominal roentgenograms show pneumoperitoneum. Select the most likely diagnosis?

106) A 40-year-old woman presents to the emergency room with a 3-day history of worsening abdominal pain, with nausea and vomiting. Examination reveals a low-grade fever and abdominal tenderness in the right upper quadrant with guarding, especially during inspiration. Laboratory findings include a mild leukocytosis and a slightly elevated bilirubin. Select the most likely diagnosis?

107) A 3-year-old boy presents to the physician’s office with an asymptomatic neck mass located in the midline, just below the level of the thyroid cartilage. The mass moves with deglutition and on protrusion of the tongue. Which one is the most likely diagnosis?

108) A 60-year-old otherwise healthy woman presents to her physician with a 3-week history of severe headaches. A contrast CT scan reveals a small, circular, hypodense lesion with ringlike contrast enhancement. Which of the following is the most likely diagnosis?

110) A 50-year-old woman presents to the physician’s office for evaluation of a right neck mass. The mass has been present for 3 years and is painless. On examination, a nontender, firm, 2.5-cm mass is noted slightly below and posterior to the angle of the mandible on the right. Which one is the most likely diagnosis?

111) A 35-year-old woman presents to the physician’s office for evaluation of a left neck mass discovered 1 month ago on a routine physical examination. On examination, the mass measures 2 cm and is located anterolateral to the larynx and trachea. It is nontender and moves with swallowing. Past history is pertinent for a 15 pack-year smoking history and occasional alcohol intake. Which one is the most likely diagnosis?

112) A 55-year-old man presents to the physician’s office with complaints of hoarseness and left neck fullness for the past month. On examination, a firm, movable, left submandibular mass is noted. Past history is pertinent for a 30 packyear smoking history with occasional alcohol intake. Which one is the most likely diagnosis?

114) A 50-year-old man presents to the emergency department for increasing abdominal distention and jaundice over the last 4–6 weeks. Examination reveals mild jaundice, spider angiomas, and ascites. Enlarged veins are noted around the umbilicus. Which one is the most likely diagnosis?

115) A 75-year-old man is brought to the emergency department by his family for evaluation of jaundice. He complains of pruritus of 2 weeks’ duration and a recent 10-lb weight loss. On examination, he is deeply jaundiced and has a nontender, globular mass in the right upper quadrant of the abdomen that moves with respiration. Which one is the most likely diagnosis?

116) A 75-year-old woman is brought to the emergency department from the nursing home for jaundice and mental confusion. The nursing home notes state that she has become less responsive and has developed jaundice over the last 2 weeks. Past history is pertinent for hypertension, diabetes, and prior colon resection for cancer at age 55. Examination reveals mild jaundice with vital signs of temperature 101.5°F, pulse rate 110/min, and BP 100/60 mmHg. She does not respond to verbal commands, but withdraws to pain. Abdominal examination reveals tenderness in the epigastrium and right upper quadrant. Which one is the most likely diagnosis?

117) An 18-year-old man is admitted to the ER following a motorcycle accident. He is alert and fully oriented, but witnesses to the accident report an interval of unresponsiveness following the injury. Skull films disclose a fracture of the left temporal bone. Following x-ray, the patient suddenly loses consciousness and dilation of the left pupil is noted. Which of the following is the most likely diagnosis?

118) A trauma patient with a closed-head injury is being monitored in the neurosurgical intensive care unit (ICU). His ICP measurement is seen to rise precipitously. An acute increase in ICP is characterized by which of the following clinical findings?

120) A 45-year-old man presents to the physician’s office for evaluation of a posterior neck mass. The mass has been present for years, but has slowly enlarged over the last 2 years. Examination reveals a subcutaneous mass that is soft, nontender, and movable. Which one is the most likely diagnosis?

121) A 6-year-old boy presents to the emergency department with a cough, sore throat, and malaise of 4 days’ duration. Examination reveals a temperature of 101.5°F, erythematous pharynx, and a tender right neck mass with overlying erythema. Which one is the most likely diagnosis?

122) An 18-month-old girl is brought to the physician’s office for evaluation of left neck mass. Examination reveals a 2-cm soft, nontender, fluctuant mass in the left lateral neck. This is located at the anterior border of the sternomastoid, midway between the mastoid and clavicle. Which one is the most likely diagnosis?

124) A 6-year-old boy is brought into the emergency room by his mother for walking with a limp for several weeks. On examination, the patient has tenderness over his right thigh without evidence of external trauma. An x-ray of the pelvis shows a right femoral head that is small and denser than normal. Which of the following is the most likely diagnosis?

125) A 45-year-old man presents to the physician’s office complaining of dysphagia and retrosternal pressure and pain of 2-year duration. The symptoms have worsened over the last 3 months. He has a 30 pack-year smoking history and drinks beer on weekends. Vital signs include a BP of 150/90 mmHg, pulse rate of 90/min, and respiratory rate of 12/min, with a normal temperature. Examination reveals a thin man with a normal heart, lung, and abdomen examination. An esophagogram reveals a 6-cm, smooth, concave defect in the midesophagus with sharp borders. Esophagoscopy reveals intact overlying mucosa and a mobile tumor. Which of the following is the most likely diagnosis?

126) During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24-year-old man, was inhaling at that moment. Which of the following most likely caused this patient's death?

127) A 42-year-old man presents with a solitary lung lesion. At the time of operation on this patient, a firm, rubbery lesion in the periphery of the lung is discovered. It is sectioned in the operating room to reveal tissue that looks like cartilage and smooth muscle. Which of the following is the most likely diagnosis?

128) A 55-year-old man presents with fever and pain in the perineal region. Upon further questioning he also complains of frequency, urgency, dysuria, and a decreased urinary stream. On physical examination his abdomen is soft, nondistended, and nontender. Digital rectal examination demonstrates exquisite tenderness on the anterior aspect. Laboratory examination reveals leukocytosis and findings on urinalysis are consistent with a bacterial infection. Which of the following is the most likely diagnosis?

129) A previously healthy 45-year-old man presents with a 9-month history of a slow-growing, painless right neck mass. He is a nonsmoker and has no significant past medical history. On examination, there is a nontender, discrete, 3-cm mass over the angle of the right mandible. Facial muscle function and sensation are normal. An oropharyngeal examination is normal. Which of the following is the most likely diagnosis?

130) A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. ?

P1984 Q130

131) In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most likely diagnosis?

132) A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination, the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. Which of the following is the most likely diagnosis?

135) A 67-year-old man has had an indolent, unhealing ulcer at the heel of the right foot for several weeks. The patient began wearing a new pair of shoes shortly before the ulcer started and noticed a blister as the first anomaly at the site where the ulcer eventually developed. He indicates that neither the blister nor the ulcer ever gave him any pain. The ulcer is 3.5 cm in diameter, the ulcer base looks dirty, and there is hardly any granulation tissue. The skin around the ulcer looks normal. The patient has no sensation to pin prick anywhere in that foot. Peripheral pulses are weak but palpable. He is obese and has varicose veins, high cholesterol, and poorly controlled type 2 diabetes mellitus. Which of the following most accurately characterizes the ulcer?

136) A 40-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most likely diagnosis?

137) A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Which of the following is the most likely diagnosis?

138) A 21-year-old previously healthy woman presents with abdominal pain of 48-hour duration. The pain was initially periumbilical and on progression became localized in the right lower quadrant. The woman had nausea and an appetite. She denied dysuria. Her last menstrual period was 2 weeks earlier. On examination, she was febrile (temperature 38.2°C), and was found to have localized tenderness in the right lower quadrant with guarding. Rectal examination was normal. Laboratory examination demonstrated mild leukocytosis. Select the most likely diagnosis?

139) A 25-year-old woman presents to the emergency room complaining of redness and pain in her right foot up to the level of the midcalf. She reports that her right lower extremity has been swollen for at least 15 years, but her left leg has been normal. On physical examination, she has a temperature of 39°C (102.2°F) and the right lower extremity is nontender with nonpitting edema from the groin down to the foot. There is cellulitis of the right foot without ulcers or skin discoloration. The left leg is normal. Which of the following is the most likely underlying problem?

140) A blond, blue-eyed, 69-year-old sailor has a non-healing, indolent, 1.5-cm ulcer on the lower lip, arising from the vermilion border. The ulcer has been present and growing for the past 8 months. He is a pipe smoker, but has no history of alcohol or drug abuse. Physical examination shows "weather-beaten" facial skin, but no other ulcers. There are no enlarged lymph nodes in his neck. Which of the following is the most likely diagnosis?

141) A 30-year-old woman presents with hypertension, weakness, bone pain, and a serum calcium level of 15.2 mg/dL. Hand films below show osteitis fibrosa cystica. Which of the following is the most likely cause of these findings?

142) A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung fields. Which of the following is the preferred modality in establishing the diagnosis?

143) A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most likely diagnosis?

144) An elderly man is involved in a rear end automobile collision in which he hyperextends his neck. He develops paralysis and burning pain of both upper extremities, while maintaining good motor function in his legs. Which of the following is the most likely diagnosis?

145) A 53-year-old woman presents with weight loss and a persistent rash to her lower abdomen and perineum. She is diagnosed with necrolytic migrating erythema and additional workup demonstrates diabetes mellitus, anemia and a large mass in the tail of the pancreas. Which of the following is the most likely diagnosis?

1) A 14-year-old boy comes to the office because his breasts have recently become tender and slightly swollen. He is worried that he is undergoing feminization and will grow up to become a “freak.” Upon examination a tender, 2-cm mass is found to be palpable in the subareolar region of both breasts. Which of the following describes the best course of action?

2) A 56-year-old indigent man had been sent home after undergoing an operation. However, 9 days later, he returns to the hospital’s emergency room because of severe abdominal pain that has been getting progressively worse for the past week and has now become totally unbearable. On examination, the emergency physician observes an overweight male who looks much older than his stated years. His blood pressure is 88/68 mm Hg. He has a marked tenderness in the epigastric region along with “bruising” in that area. Laboratory analyses show an elevation of serum amylase. Which of the following is the most likely cause of his symptoms?

3) A 75-year-old man was rushed to the emergency room of a local hospital after having collapsed at home. The patient’s spouse related that he had complained of sudden severe pain over the left flank. She informed the physician that he had been complaining of backache for a few years, but did not want to see a physician, as he felt that it was “no big deal.” Physical examination revealed a conscious male, in acute distress, with definite signs of hypotension, tachycardia, tachypnea, and hypothermia. He had mucosal pallor but no cyanosis. The abdomen was tender to palpation, and a pulsatile supraumbilical mass was present. Bowel sounds were diminished, and peripheral pulses were equal and moderately strong. The patient was given 100% oxygen by mask, at 10 L per minute. The cardiac monitor showed sinus tachycardia with mild ischemia. Which of the following mechanisms is most likely involved in the pathogenesis of this patient’s clinical disorder?

4) A 65-year-old woman went bicycling into the country near Lake Tahoe, California, with a few of her friends. She had not bicycled since her childhood growing up at the foothills of the Ural Mountains in Russia. The front wheel struck a pothole and she fell to the ground. While doing so, her chest struck the handlebar. She was immediately rushed to the local hospital. On arrival, she is conscious and appears to be in moderate distress. Her blood pressure is 140/95 mm Hg, pulse 96/min. Her respirations are shallow and rapid, at 22/min. Bruising over the left anterior hemithorax is observed upon examination of the chest. There is no jugular venous dilatation. The rest of her examination findings are unremarkable. Further examination would most likely yield which of the following?