Test 25 b

125) 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?

 

127) A 16-year-old girl is referred to the office because of chronic diarrhea and weight loss. She is experiencing large-volume watery diarrhea that is painless. The symptoms persist even when she is fasting, and there is no relationship to foods or liquids. She is not on any medications, and there is no travel history or other constitutional symptoms. Her physical examination is normal. Which of the following is the most likely diagnosis?

 

128) A 16-year-old girl presents for evaluation of acne, which has been getting progressively worse over the past 2 weeks. Her medical history is significant for systemic lupus erythematosus (SLE) for which she has been taking prednisone for a recent exacerbation. Hydroxychloroquine is her only other medicine. She does not use tobacco, alcohol or drugs and her menstrual cycle is regular. On physical examination, her blood pressure is 110/76 mmHg and her pulse is 72/min. Her BMI is 22 kg/m2. Distributed over the face, arms and trunk are monomorphous erythematous papules. There are no open or closed comedones. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of her acne?

 

129) A 16-year-old girl presents to the emergency department complaining of fever, chills, abdominal pain, and vaginal bleeding. She gives a history of unprotected sexual activity with her 17-year-old boyfriend over the past several months. Her last menstrual period was 8 weeks ago. She reports having a dilatation and curettage procedure at an unlicensed abortion clinic recently to try to abort the pregnancy. Her temperature is 38.7C (101.7F), heart rate is 120/min, and blood pressure is 100/70 mmHg. Pelvic examination reveals cervical motion tenderness, tissue in the internal os, and foul-smelling vaginal discharge. Urine is positive for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis?

 

130) A 16-year-old girl presents with lower abdominal pain and fever. On physical examination, a tender adnexal mass is felt. Further questioning in private reveals the following: she has a new sexual partner; her periods are irregular; she has a vaginal discharge. Which of the following is the most likely diagnosis?

 

131) A 17-year-old African American man comes to the physician after an episode of gross hematuria that resolved spontaneously. He has no other complaints. His past medical history is insignificant. He takes no medications. He smokes occasionally. He does not use drugs or alcohol. His temperature is 36.7°C (98°F), blood pressure is 120/70 mm Hg, pulse is 70/min, and respirations are 14/min. Physical examination shows no abnormalities. Urinalysis shows many unchanged red blood cells/HPF, but is otherwise normal. Laboratory studies show a creatinine level of 0.9 mg/dl. Which of the following is the most likely diagnosis?

 

134) A 17-year-old female comes to the physician because she has not yet had a menstrual period. She also complains of a lack of breast development. Past medical history is significant for anosmia and color blindness. Past surgical history is significant for a cleft palate that was repaired in childhood. She takes no medications and has no allergies to medications. Examination is significant for absent breast development, and a hypoestrogenic vulva and vagina. Urine hCG is negative. Which of the following is the most likely diagnosis?

 

135) A 17-year-old female presents with a pruritic rash localized to the wrist. Papules and vesicles are noted in a band like pattern, with slight oozing from some lesions. Which of the following is the most likely cause of the rash?

 

136) A 17-year-old G1P1001 is now 5 weeks postpartum after a routine vaginal delivery. She calls your office to report a 3-week history of difficulty sleeping and “feeling blue.” On further questioning, she reports difficulty concentrating, very poor appetite, occasional wishes that she had never become pregnant, and feelings of guilt about those wishes. She has not left her home in more than a week because she “just can’t find the energy to go anywhere.” This patient’s symptoms are most consistent with:

 

137) A 17-year-old girl comes to the clinic with several weeks of joint pain and rash. The joint pain is most prominent in the hands. She states that the pain is most severe in the morning and tends to improve over the day. She has noted some swelling of her fingers. She has also had a rash on her face that becomes more prominent when she is outdoors. She states that sunlight tends to bother her eyes. On further questioning, she states that she has not felt well for several months. She has had intermittent fever, has been more tired than usual, and has lost weight although she has not been restricting her diet. On physical examination, she looks tired. She has lost 5 lbs since her last visit 1 year ago. She has an erythematous rash on her cheeks. She has several shallow ulcers in her mouth. She has fusiform swelling of her fingers and pain with movement of her fingers. Which of the following is the most likely diagnosis?

 

138) A 17-year-old girl is brought to the ER 30 minutes after an episode where she lost consciousness. She is accompanied by her father who witnessed the event. He says that the patient recently broke up with her boyfriend and has been under a lot of stress. Her sleep has been poor. She has had three similar episodes over the last month. On exam, her heart rate is 90/min, respirations are 13/min, and blood pressure is 120/70 mmHg. She seems sleepy but can be aroused easily. She gives her correct name but is disoriented to time and place. Pupils are symmetric and reactive to light. Blood glucose level is 100 mg/dl. Which of the following findings would you most expect in this patient? 

140) A 17-year-old girl presents to the clinic because she has not yet menstruated and does not have significant breast development. Family history is significant only for some cousins who are color blind. The patient denies ethanol, tobacco, and illicit drug use and sexual activity. Physical examination reveals a normal-appearing girl in no acute distress with minimal breast development and a lack of pubic hair. She is 168 cm (5'6") tall and weighs 61.2 kg (135 lb). Cardiac examination reveals no murmurs, rubs, or gallops, with point of maximal impulse at the left mid-clavicular line between the third and fourth intercostal space. Gynecologic examination reveals a vagina without rugae and a cervix that is easily visualized. There is no discharge. A urine test is negative for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis?

141) A 17-year-old girl presents with a 4-week history of intermittent fever, increasing fatigue, generalized myalgia, and swelling of both her knees and ankles. There is a fine erythematous rash on her back, and she has swollen knees and ankles; the remainder of her physical examination is unremarkable. Initial laboratory evaluation shows: Leukocytes 11,400 cells/mm3, Hemoglobin 8.8 g/dL, Blood urea nitrogen 4 mg/dL, Creatinine 1.4 mg/dL, Glucose 98 mg/dL, C3 complement 36 mg/dL (normal >80 mg/dL), Antinuclear antibody titer 1:3200, Anti-double-stranded DNA titer 1:640, Antineutrophil cytoplasmic antibodies: Negative, Urinalysis Moderate hematuria (50 RBC/hpf), Moderate proteinuria (400 mg/dL). Which of the following is the most likely diagnosis?

142) A 17-year-old man is brought to the emergency room with confusion and incoordination. He is uncooperative and refuses to provide further history. Physical examination reveals an RR of 30; the vital signs are otherwise normal as is the general physical examination. Laboratory values are as follows: Na: 135 mEq/L, K: 2.7 mEq/L, HCO3: 15 mEq/L, Cl: 110 mEq/L. Arterial blood gases: PO2 92, PCO2 30, pH 7.28 Urine: pH 7.5, glucose—negative, Ca: 9.7 mg/dL, PO4: 4.0 mg/dL. Which of the following is the most likely cause of the acid base disorder?

143) A 17-year-old man presents with a non-pruritic rash in his periumbilical area. The rash consists of firm, dome-shaped, flesh-colored papules with central umbilication. This patient's rash is most commonly associated with which of the following conditions? 

144) A 17-year-old teenage girl presents to your office after having problems during sex with her boyfriend. She also states that she has been developing facial hair, which she has constantly been removing. She started her menstruations at the age of 13 and her cycles have always been regular. On examination she is obese but appears a little masculine and has an enlarged clitoris. Initial lab values are as follows: Serum LH 20 IU/L, Serum FSH 10 IU/L, 17 -hydroxyprogesterone 600ng/ml (Normal is 15ng/ml), Serum testosterone Normal, Serum DHEA 4.0ng/ml (Normal is 4.2ng/ml). What is the most likely diagnosis? 

126) A 16-year-old girl is brought to the office due to abdominal pain and bloody diarrhea for the past two days. Her immunizations are up to date. Her past medical history is unremarkable. On examination, she appears lethargic and weak. Her skin turgor is poor, face and extremities are swollen, and skin appears yellow. Abdominal examination shows moderate non-localized, abdominal pain. Laboratory studies show: Hb 64 g/dl, Hct 26.9%, Platelets 45,000/mm3, Creatinine 2.3 mg/dl, Total bilirubin 5.0 mg/dl. What is the most common complication of the patient's condition?

 

146) A 17-year-old white female comes to the office for the evaluation of fatigue which has been present for the past 4 months. Her past medical history is insignificant. She denies the use of any drugs. Her pulse is 74/min, blood pressure is 110/70 mmHg, and temperature is 36.7°C (98.0°F). Physical examination shows scars on the dorsum of her hands and dental erosions. Laboratory studies show: Plasma sodium 139 mEq/L, Serum potassium 2.3 mEq/L, Bicarbonate 40 mEq/L. Urine chloride concentration is 15 mEq/L (Normal = 80-250 mEq/L). Based on these findings, what is the most likely diagnosis?

147) A 19-year-old female comes to the physician because she has not had a menstrual period. She experienced normal breast development through puberty but has yet to have a period. She has no other complaints. She has no medical problems. Examination shows the patient to be tall with long arms and big hands. The breasts are normal-appearing except that the nipples are immature and the areolae are pale. Pelvic examination shows scant pubic hair with a blind-ended vaginal pouch. Which of the following is the most likely diagnosis? 

148) A 19-year-old G0 woman presents to her family physician complaining of dysmenorrhea for the past year. She reports severe right-sided pain that coincides with days 1–5 of her menstrual cycle. Her menses occur regularly every 28 days, and she requires three to four pads per day for the first 2 days of her bleeding and one to two pads per day for the remainder. She has never had surgery. She is not sexually active and does not smoke. Her last menstrual period was 1 week ago. Her temperature is 36.7C (98.1F), blood pressure is 121/74 mmHg, heart rate is 80/min, and respiratory rate is 14/min. Physical examination reveals a thin, healthy-appearing young woman. Pelvic examination reveals a normal sized uterus and no cervical motion tenderness. Which of the following is the most likely diagnosis?

149) 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? .