P 551 to 571 q 150 to 35

151) A 28-year-old woman is brought to see a psychiatrist by her mother. The patient insists that nothing is wrong with her, but the mother notes that the patient has been slowly but progressively isolating herself from everyone. She now rarely leaves the house. The mother says she can hear the patient talking to “people who aren’t there” while she’s in her room. On examination, the patient is noted to have auditory hallucinations and the delusional belief that her mother is going to kick her out of the house so that it can be turned into a theme park. Which of the following is the lifetime prevalence for this disorder?

.152) A 32-year-old man is admitted to the psychiatric unit after his wife brought him to the emergency room in a severe major depression. The patient signs himself in voluntarily because he “didn’t think he is safe” at home. Which of the following factors most increases a patient’s risk of suicide while on the inpatient unit?

.154) A 50-year-old man presents to your office complaining of pain and swelling of the right knee. He bumped his right knee into a pole 2 days ago while working. He had one episode of similar pain two years ago that resolved with over-the-counter analgesics. He denies any illicit drug use. He has no other medical problems and does not take any medications. His temperature is 37.2°C (98.9°F), and blood pressure is 126/76 mmHg. Examination reveals swelling, warmth and decreased range of motion of the right knee. All other joints are within normal limits. Synovial fluid analysis shows positive birefringent crystals and negative Gram stain. These crystals are most likely composed of?

.155) A 53-year-old Caucasian man comes to the emergency department at 2 am because of severe pain in his right great toe for the past 2 hours. He complains that the pain began suddenly as a dull, aching pain, and has worsened over time to a severe throbbing pain, not relieved by acetaminophen. His other medical problems include hypertension, diabetes mellitus-type 2, hypercholesterolemia, and peptic ulcer disease. He has smoked 2 packs of cigarettes daily for 30 years. He drinks 5-6 ounces of alcohol daily. He eats a lot of junk food and exercises infrequently. Both his father and mother have diabetes and hypertension. His older brother died of a myocardial infarction 2 years ago. His medications include glyburide, lisinopril, atenolol, simvastatin and famotidine. His temperature is 37.8°C (100°F), blood pressure is 160/90 mm Hg, pulse is 88/min and respirations are 16/min. On examination, the right great toe appears markedly swollen, red, and is warm to touch. Aspiration of the joint fluid reveals negatively birefringent needle shaped crystals. Apart from prescribing oral indomethacin, what other intervention would be most important to prevent the development of further attacks?

.160) A 38-year-old male with steroid-dependent sarcoidosis presents to the physician's office because of progressive right hip pain. He localizes the pain to right groin and states that the pain is present on weight bearing and at rest. His temperature is 37.2°C (98.9°F) and blood pressure is 156/86 mm Hg. Examination shows decreased range of motion due to pain. He also has a round face and fullness in supraclavicular area. Purple striae are present on skin. Muscle power is slightly decreased in the proximal thigh muscles in both legs. Reflexes are 2+, and there are no sensory deficits. Plain films of the right hip show no significant abnormalities ESR is 10 mm/hr. Which of the following is the most likely cause of his hip pain?

.161) A 65-year-old man comes to the emergency room complaining of 2 days of severe pain and swelling of his right knee. He denies any recent respiratory illness, diarrhea or urinary symptoms. He has a history of severe degenerative joint disease and underwent total knee replacement four years ago. He drinks one can of beer every night and does not use tobacco or illicit drugs. His temperature is 40°C (104°F), blood pressure is 120/60 mmHg, and pulse is 110/min. Examination shows warmth, swelling, and tenderness over the knee. His range of motion is restricted. Synovial fluid white blood cell count is 98,000/microl. Which of the following is the most likely cause of his current condition?

.162) A 24-year-old woman comes to the physician complaining of a skin rash and pain in her wrists, ankles and elbows over the past 4 days. She has also had a fever and sweats, but denies headache, nausea or vomiting. She has no significant past medical history and does not take any medications. She recently took a vacation with her new boyfriend. She denies any previous sexually transmitted diseases but acknowledges having unprotected sex with her new boyfriend. She does not use tobacco, alcohol or illicit drugs. Her temperature is 38.5°C (101.3°F) and her pulse is 98/min. Her oropharynx is clear and there is no thrush or lymphadenopathy. Her abdomen is benign and the pelvic examination is within normal limits. She has pain along the tendon sheaths with active and passive hand movement. A photo of her skin rash is shown below. Which of the following is the most likely cause of her symptoms?

.164) A 45-year-old woman with long-standing, well-controlled rheumatoid arthritis develops severe pain and swelling in the left elbow over 2 days. She is not sexually active. Arthrocentesis reveals cloudy fluid. Synovial fluid analysis reveals >100,000 cells/mL; 98% of these are PMNs. What is the most likely organism to cause this scenario?

2) A 45-year-old recently immigrated Mexican farmer comes to your office complaining of dyspnea, fatigue and abdominal distention for the past two months. On physical exam, his temperature is 37°C (98°F), blood pressure is 126/80 mmHg, pulse is 80/min, and respirations are16/min. You note pedal edema, elevated jugular venous pressure with positive Kussmaul's sign, and increased abdominal girth with free fluid. Chest auscultation reveals decreased heart sound intensity at the apex and an early heart sound following S2. The jugular venous pressure tracing shows prominent 'x’ and 'y' descents. Which of the following is the most likely cause of this patient's symptoms

.5) A 63-year-old Caucasian female presents to the emergency room with a recent onset of left-sided Weakness. She has been experiencing increased fatigability, low-grade fevers and occasional palpitations over the past two months. She has lost seven pounds during the same period. Her temperature is 37°C (98.6°F), pulse is 80/min (regular), blood pressure is 120/76mmHg and respirations are 14/min. Her lungs are clear. Cardiac auscultation reveals normal first and second heat sounds and a mid-diastolic rumble at the apex. Echocardiography shows a mass in the left atrium. Which of the following is the most likely diagnosis?

.6) A 56-year-old male presents with progressively worsening dyspnea and ankle edema. He denies chest pain syncope or palpitations. He does not smoke or drink alcohol. He denies diabetes mellitus, hypertension, or hyperlipidemia. His temperature is 37.1°C (98.7°F), pulse is 70/min, blood pressure is 136/70mmHg, and respirations are 15/min. Examination shows elevated jugular venous pressure, bilateral ankle edema, and tender hepatomegaly. Chest auscultation shows bibasilar rales. His heat sounds are distant and there is no murmur. Chest x-ray shows mild cardiomegaly and a right-sided pleural effusion. ECG shows low voltage QRS complexes and nonspecific ST-T wave changes. Echocardiography shows normal left ventricular volume with symmetrical thickening of the left ventricular walls and slightly reduced systolic function. Which of the following would represent a potentially reversible cause of this patient’s heat disease?

.7) A 55-year-old male presents to the emergency room with right-sided weakness that has persisted for the past several hours. He also complains of severe central chest pain that is "ripping" in quality and radiates to his back. He has had hypertension for the past seven years and has not been taking any anti-hypertensive medication. He has been smoking one pack of cigarettes per day for the past 25 years. His father died of coronary artery disease at age 44 years. His temperature is 37.1°C (98.6°F), pulse is 78/min, blood pressure is 180/120 mm Hg in the right arm and 110/70 mm Hg in the left arm, and respirations are 16/min. He is diaphoretic and confuse. His neurological examination is significant for decreased power and tone in the right upper and right lower extremities. The rest of his physical examination is unremarkable ECG shows left axis-deviation and a chest x ray is normal. Based on these findings, what is the most likely diagnosis?

.9) A 22-year-old male presents to you with feelings of general malaise. He is always tired and has noticed that he has frequent headaches. Exam reveals an elevated arm blood pressure with a radial to femoral delay. ECG shows left ventricular hypertrophy and the chest-x ray is shown below. Close examination of the x-ray reveals a "3" sign. What is the most likely diagnosis in this patient? 

.12) A 63-year-old female presents to your clinic complaining of palpitations. For the past 3 weeks, she has noticed pounding of her heart that comes and goes. Her symptoms are more frequent at night. Her only medicine is insulin for diabetes mellitus. On physical examination, she is alert and oriented, and in no distress. Her EKG is shown below. Which of the following best accounts for this patient's symptoms?

.14) A 60-year-old female comes to your office for progressive exertional dyspnea and new-onset ankle swelling. She has been recently worked up for proteinuria and easy bruisability. Otherwise her past medical history is insignificant. She has a ten pack-year history of smoking and she drinks two to three glasses of wine every day. Her temperature is 37.1°C (98.8°F), blood pressure is 130/70 mmHg, pulse is 80/min and respirations are 14/min. There is mild jugular venous distention on physical examination. Chest auscultation shows scattered bibasilar crackles. Echocardiography reveals symmetrical thickening of the ventricular walls, normal ventricular dimensions and a slightly reduced systolic function. Which of the following is the most likely diagnosis?

.17) A 47-year-old female, who is a chronic alcoholic, is admitted to the hospital with epigastric pain, nausea, and vomiting. Her serum amylase and lipase levels are significantly elevated and the diagnosis of acute pancreatitis is made. She is maintained nothing by mouth (NPO), and receives intravenous hydration and narcotic analgesics. On the second day of hospitalization she develops progressive shortness of breath. Her temperature is 37.2°C (98.9°F), blood pressure is 110/66 mm Hg, pulse is 110/min, and respirations are 24/min. Her oxygenation is measured at 84% on 100% non-rebreather mask and the decision is made to intubate. Since the time of admission, she has received 5 liters of normal saline and has produced 3 liters of urine output. On examination, there is no evidence of jugular venous distention. Chest auscultation reveals diffuse bilateral crackles. Auscultation of the heart reveals normal heart sounds with no murmurs. A chest x-ray from the time of admission and one from the time of intubation are shown below. Based on these findings, what is the most likely diagnosis in this patient?

.22) You are performing medical screening of new military recruits when an 18-year-old male reports several episodes of palpitation and syncope over the past several years. Physical examination is unremarkable. An ECG is obtained with excerpts shown below. What is the most likely diagnosis?

.24) A 34-year-old Caucasian woman presents to your office with dyspnea and severe chest pain after returning from a trip to Central Asia. The pain is localized on the left side and increases with inspiration. She also had one episode of hemoptysis. She does not smoke or consume alcohol. She is sexually active with one partner and uses oral contraceptives. Her father died of a myocardial infarction at 52 years of age. Her temperature is 36.7°C (98°F), pulse is 100/min, respirations are 28/min, and blood pressure is 110/66 mmHg. Which of the following most likely accounts for this patient's chest pain?

.25) A 32-year-old man develops severe nausea and vomiting after returning from a party. He also complains of chest pain that is more intense than any pain he has previously experienced. His past medical history is significant for HIV infection, alcohol abuse, and alcoholic hepatitis. He admits to using cocaine regularly. His temperature is 37.8°C (100°F), pulse is 120/min, respirations are 24/min, and blood pressure is 100/60 mmHg. Examination reveals injected conjunctivae and bilateral dilated pupils. Chest X-ray demonstrates a widened mediastinum and left-sided pleural effusion. EKG is unremarkable. The pleural fluid is found to have an elevated amylase content. Which of the following is the most likely diagnosis in this patient?

.26) A 56-year-old diabetic female comes to the clinic with complaints of dizziness which has been going on for 3 weeks. She denies any dyspnea or diaphoresis. She says her blood glucose is well controlled and denies any allergy. Her BP is 155/90 mmHg. Her chest-x ray is unremarkable and her blood work is normal. The ECG is recorded below. What is the most likely diagnosis?

.30) A 46-year-old man presents to the emergency department with difficulty breathing and chest discomfort. His pain worsens with inspiration but does not radiate. He says that he has never had symptoms like this before. His past medical history is unremarkable. He works as a long-haul truck driver. On physical examination, his blood pressure is 110/70 mmHg, his heart rate is 110/min, his respiratory rate is 31/min, and his temperature is 36.7°C (98°F). ECG reveals sinus tachycardia but no ischemic ST-segment or T-wave changes. His chest X-ray is shown below. What is the most likely diagnosis in this patient?

35 A 24-year-old military recruit is brought to the emergency room after suddenly collapsing while at training camp. Witnesses say he lost consciousness, and in the ER he appears confused. He had apparently been in his usual state of good health until this incident. His medical history includes allergic rhinitis for which he takes chlorpheniramine. On physical examination, his temperature is 4 1°C (106°F), blood pressure is 90/60 mmHg, respiratory rate is 22/min, and pulse is 130/min and regular. He appears restless. His pupils are 4mm in size, symmetric, and reactive to light. Lung exam reveals a few rales at both lung bases. His abdomen is soft, non-tender and bowel sounds are present. There is no neck stiffness. His skin is dry and hot. He has 2+ symmetric reflexes in the upper and lower extremities. Muscle tone and bulk are normal. Initial laboratory studies show: Hemoglobin 16.0 g/L, Platelets 120,000/mm3, Leukocyte count 18,500/mm3, Blood urea nitrogen (BUN) 40 mg/dL, Prothrombin time 17 sec, Partial thromboplastin time 40 sec. Which of the following is the most likely cause of his current condition?