DES C_ParaClinic (1) Prepared : CHILLY

A 1-day-old normal-appearing infant develops tetany and convulsions. He was born at 34 weeks’ gestation with Apgar scores of 2 and 4 (at 1 and 5 minutes, respectively) to a woman whose pregnancy was complicated by diabetes mellitus and pregnancy-induced hypertension. Which of the following serum chemistry values is likely to be the explanation for his condition?

A 1-month-old male infant is brought to the emergency department by his mother due to a 3-day history of projectile vomiting. He has been formula- fed since birth, and his bowel movements are normal. He has never been ill before. His parents and 4-year-old sister are all healthy. One of his maternal uncles is mentally retarded. He weighs 3.1 kg (7 Ib). Physical examination reveals fair hair and skin, blue eyes, eczematous rash, and mild signs of dehydration. His urine has a mousy odor. What is the most appropriate screening test for this patient's early diagnosis and treatment?

A 1-year-old boy is brought to the pediatrician for a routine visit. While talking to his mother, she reports that they moved into an old house several months ago and are in the process of renovating. The child eats table food and drinks whole milk. His height, weight, and head circumference are all at the 50th percentile for his age. Physical examination is normal. The results of a fingerstick blood test are shown below: Hemoglobin 10.5 g/dL, Hematocrit 30.0%, Lead level 12 μg/dL (Normal < 10 μg/dL). Which of the following is the most appropriate next step in management?

A 10-month-old baby boy, recently adopted from Guyana, has a 5-hour history of crying, with intermittent drawing up of his knees to his chest. On the way to the emergency room he passes a loose, bloody stool. He has had no vomiting and has refused his bottle since the crying began. Physical examination is noteworthy for an irritable infant whose abdomen is very difficult to examine because of constant crying. His temperature is 38.8C (101.8F). The rectal ampulla is empty, but there is some gross blood on the examining finger. Which of the following studies would be most helpful in the immediate management of this patient?

A 10-month-old infant has poor weight gain, a persistent cough, and a history of several bouts of pneumonitis. The mother describes the child as having very large, foul-smelling stools for months. Which of the following diagnostic maneuvers is likely to result in the correct diagnosis of this child?

A 10-year-old boy has a long history of recurrent infections. These have included pneumonia, suppurative lymphadenitis, persistent rhinitis, dermatitis, diarrhea, and perianal abscesses. Involved organisms have included Staphylococcus aureus, Serratia, Escherichia coli, and Pseudomonas. Biopsy of skin and lymph nodes have demonstrated granulomatous lesions, even though the only species isolated were those noted above. Immunoglobulin levels are higher than normal. Which of the following findings would be most helpful in establishing the diagnosis?

A 10-year-old child arrives with the complaint of new-onset bed-wetting. He has had no fever, his urine culture is negative, and he has had no new stresses in his life. He is well above the 95th percentile for weight as is much of his family. Which of the following is most helpful in making a diagnosis?

A 10-year-old patient with sickle cell disease comes to the physician for a routine visit. The patient has a history of multiple pain crises and pneumonias. He was started on hydroxyurea one year ago and has not had any further pain crises since then. He has had no recent illnesses or hospitalizations. His physical examination is unremarkable. The patient's laboratory results are shown below. Complete blood count: Hemoglobin 9.0 g/L, Erythrocyte count 2.2 mln/mm3, MCHC 32%, MCV 105 fl, Reticulocytes 2.0%, Platelets 212,000/mm3, Leukocyte count 9500/mm3, Neutrophils 56%, Eosinophils 3%, Lymphocytes 36%, Monocytes 5%. Which of the following best describes the role of hydroxyurea in the treatment of patients with sickle cell disease?

A 12-year-old boy is in a motor vehicle collision in which the car caught fire. He sustains significant inhalation injury and a circumferential burn without fractures or other soft tissue trauma to his left lower extremity during extrication from the burning vehicle. He is intubated and aggressively resuscitated in the intensive care unit. Which of the following is the most appropriate method of assessing for compartment syndrome of the left lower extremity?

A 12-year-old girl has a solitary thyroid nodule found on routine examination; she has no symptoms. Which of the following is the most appropriate next step for this patient?

A 12-year-old male child comes to the office after being referred for a medical evaluation. His schoolteacher says that he has a problem concentrating during class. He stares in space for a few seconds several times a day, and appears totally absorbed in his thoughts. He is not disruptive in class, but appears forgetful. There is no history of trauma, infection or problem at birth. On examination, the child is alert with stable vital signs. There is no loss of motor or sensory perceptioin. Which of the following can confirm the patient’s diagnosis?

A 12-year-old male child comes to the office after being referred for a medical evaluation. His schoolteacher says that he has a problem concentrating during class. He stares in space for a few seconds several times a day, and appears totally absorbed in his thoughts. He is not disruptive in class, but appears forgetful. There is no history of trauma, infection or problems at birth. On examination, the child is alert with stable vital signs. There is no loss of motor or sensory perception. Which of the following can confirm the patient's diagnosis?

A 12-year-old, previously healthy girl presents to her physician with a chief complaint of early morning headaches. She states that these headaches wake her up from sleep 2-3 days a week. She also complains of some vomiting associated with the headaches. The headaches have been getting progressively worse for the past 2 months. She denies any photophobia, dizziness, or blurred vision. There is no history of a recent respiratory infection, runny nose, or cough. There is no history of recent trauma. In the office, her vital signs are within normal limits. Her examination shows pupils that are equal, round, and reactive, with no maxillary or frontal sinus tenderness. Her tympanic membranes are clear and intact. Her neck is supple with full range of motion. Neurologic examination shows a positive Romberg sign. Which of the following tests would most likely confirm the diagnosis?

A 13-year-old patient with sickle-cell anemia presents with respiratory distress; she has an infiltrate on chest radiograph. The laboratory workup of the patient reveals the following: hemoglobin 5 g/dL; hematocrit 16%; white blood cell count 30,000/μL; and arterial blood (room air) pH 7.1, PO2: 35 mm Hg, and PaCO2: 28 mm Hg. These values indicate which of the following?

A 14-year-old African-American girl presents to the ER with a mild fever and severe right-sided thigh pain. She is agitated and requests quick pain relief. Her heart rate is 120/min and blood pressure is 120/70 mmHg. She says that she had a similar episode one year ago and was placed in the hospital for intravenous pain management. Her brother had similar episodes and died of an infection at 10 years of age. Which of the following would you most expect to see on this patient's peripheral blood smear?

A 14-year-old boy comes to the office because he has been feeling a mass under his right nipple for the last three weeks. The physical examination reveals clinical findings suggestive of right gynecomastia with very mild tenderness. The left breast and the rest of the physical exam is unremarkable. His testis is 2 cm in length and has 3 ml volume. What is the most appropriate next step in the management of this patient?

A 14-year-old boy comes to the physician because of a 2-day history of fever and nasal discharge. He has also had malaise, fatigue and myalgia. His temperature is 38.8°C (101.9°F), blood pressure is 130/70mm Hg, pulse is 90/min, and respirations are 15/min. Examination shows no abnormalities. Urine dipstick testing shows proteinuria but there is no hematuria or pyuria; urinalysis otherwise shows no abnormalities. Which of the following is the most appropriate next step in management?

A 14-year-old boy is brought to your office by his mother because of a two-week history of generalized edema, fatigue, and abdominal pain. His past medical history is insignificant, and the boy is not taking any medications. His BP is 110/70 mmHg and heart rate is 80/min. Urinalysis reveals proteinuria 4+, but urine sediment findings are within normal limits. Which of the following light microscopy finding would you expect in this patient's kidney biopsy?

A 14-year-old boy slides down a banister and crashes into a large ornamental knob at its base, thereby injuring his scrotal contents. He presents in the emergency department with acute testicular pain and a scrotal hematoma the size of a grapefruit. He is able to void normally, and his urine does not contain blood. A rectal examination is unremarkable. Findings from which of the following tests will most likely determine further therapy?

A 14-year-old girl comes to the physician for an annual examination. She has no complaints. She became sexually active during the past year and uses condoms occasionally for contraception. She has asthma, for which she occasionally takes an albuterol inhaler. She had an appendectomy at age 9. Physical examination is unremarkable including a normal pelvic examination. When should this patient begin having Pap testing?

A 14-year-old girl is being evaluated for short stature. She has not yet had any menstrual periods. She is not sexually active. She is at 6th percentile for height and 20th percentile for weight. Blood pressure is elevated in the upper extremities and low in the lower extremities. Lungs are clear to auscultation. If measured, which of the following is most likely to be present in this patient?

A 14-year-old girl is brought to the office by her mother for the evaluation of leg muscle fatigability while climbing the stairs. She has occasional headaches. She was diagnosed (via karyotyping) with Turner's syndrome two years ago. Her blood pressure is 165/95 mm Hg on the right arm, and 161/95 mm Hg on the left arm. Her heart rate is 85/min. The physical examination reveals no secondary sexual characteristics. Her chest is broad. The point of maximal apical impulse is displaced to the left and increased in intensity. A mild, continuous murmur is heard all over the chest. The lungs are clear. What is the most probable finding on her chest radiograph?

A 14-year-old male presents with a complaint of soreness, and weakness in his legs for the past day that has slowly spread from his calves to his thighs. He now complains of weakness in his trunk and arms. On examination he appears tired and lays on the examining table. His temperature is 37 C (98.6 F), pulse is 48/min, and respirations are 22/min. Both of his legs are diffusely tender. Deep tendon reflexes are absent in the lower extremities, and sensation is greatly diminished. Which of the following studies is essential for this patient's diagnosis?

A 15-year-old African-American girl has a facial rash and vague joint pains. Her temperature is 37.2C (99F). On examination, a malar erythematous rash is noted. Her laboratory evaluation is significant for anemia, leukopenia, and a normal platelet count. Her antinuclear antibody and Rapid Plasma Reagin (RPR) tests are positive. Which of the following tests is confirmatory for this patient's condition?

A 15-year-old boy has been immobilized in a double hip spica cast for 6 weeks after having fractured his femur in a skiing accident. He has become depressed and listless during the past few days and has complained of nausea and constipation. He is found to have microscopic hematuria and a blood pressure of 150/100 mm Hg. Which of the following is the most appropriate course of action?

A 15-year-old boy with tall stature presents with decreased exercise tolerance over the past 2 months. He states that he used to play two games of basketball with no problem, but he now can play only one game. On physical examination, his weight is at the 25th percentile, and his height higher than the 95th percentile. He is thin and has a gangly body habitus. His fingers are long and thin. There is pectus deformity in his chest. His joints are hyperextensible. An ophthalmologic examination reveals mild subluxation of the lens. Which of the following is the most likely finding on an echocardiogram?

A 15-year-old Caucasian female comes to your office because her menses have not yet started. Her breast development is Tanner stage 2 and there is scant pubic hair. Physical examination is also significant for decreased femoral pulses. Which of the following is the best next step in evaluating her condition?

A 15-year-old girl is being evaluated for primary amenorrhea. Her previous medical history is unremarkable and she denies taking any medications. Examination reveals absent breasts as well as pubic and axillary hair. Vaginal examination could not be performed. Olfactory exam reveals an inability to identify different odors. Ultrasound shows a uterus and two ovaries; serum FSH level is 2 U/L (Normal is 4-30). Which of the following is the most likely karyotype to be found in this patient?

A 15-year-old girl is brought to the physician by her mother because she has not begun menstruating. She is otherwise healthy and has no medical problems. Vitals signs are within normal limits. Physical examination shows absence of breast development and no pubic hair is seen. Examination shows no other abnormalities. Ultrasound confirms the presence of a uterus. Which of the following is the most appropriate next step in management?

A 15-year-old girl presents with diplopia after prolonged reading and ptosis that worsens in the afternoon. On examination, she is noted to have bilateral ptosis, impaired extraocular muscle movements, facial weakness, and generalized hypotonia and weakness increasing with repetition. Which of the following is the best diagnostic test for this disorder?

A 15-year-old male presents to your office on the advice of his football coach. The patient started playing football this year and suffered a syncopal episode at practice yesterday. He reports that he was sprinting with the rest of the team and became lightheaded. He lost consciousness and fell to the ground, regaining consciousness within one or two minutes. He suffered no trauma during the event. He has no prior history of head injury or recent illness. He has had no prior episodes of syncope. The patient is adopted and family history unavailable. Physical examination is unremarkable. What is the best course of action regarding this patient’s syncopal episode?

A 15-year-old otherwise healthy boy presents with a complaint of intermittent abdominal distention, crampy abdominal pain, and excessive flatulence. He first started noticing these symptoms when he moved into his father’s house, and his stepmother insisted on milk at dinner every night. He has normal growth, has not lost weight, and has no travel history. Which of the following is the most appropriate study to diagnose his condition?

A 15-year-old woman presents to your office for her first well-woman examination. She has a history of asthma, for which she uses an inhaler as needed. She denies any prior surgeries. Her menses started at the age of 13 and are regular. She has recently become sexually active with her 17-year-old boyfriend. She states that they use condoms for contraception, but she is interested in something more effective. Which of the following is the most appropriate instrument to use when performing the Pap smear test in this patient?

A 16-month-old girl is brought to medical attention because of irritability, poor feeding, and temperatures up to 39.4 C (103 F). Careful history and physical examination fail to disclose any identifiable cause of her fever. There is some degree of abdominal tenderness on palpation. Which of the following is the most appropriate next step in diagnosis?

A 16-year-old boy was brought to the emergency department because of left shoulder and left hand pain after falling on his outstretched hand while playing soccer. He heard a crunching sound and had intense pain in his left shoulder area following the injury. Examination shows bruising around the clavicle area. He is holding his left arm with his right hand. There is a palpable gap in the middle of the clavicle. Auscultation shows a loud bruit just beneath the clavicle. An x-ray film of the left shoulder and chest shows the middle of the clavicle is fractured and displaced. Which of the following is the most appropriate next step in management?

A 16-year-old female presents to the office with her mother and complains of changes in her physical appearance over the past year. She first noted the appearance of dark hair on the cheeks, upper lips, around the nipples and umbilicus. Her menstrual cycles have always been irregular since her menarche at age 14. Her medical history is otherwise unremarkable. She denies taking any medications. She has a boyfriend, but claims that she is still not sexually active. Her blood pressure is 115/65 mmHg, pulse is 80/min, respirations are 16/min, and temperature is 37°C (98°F). Pelvic examination could not be performed, and abdominal examination is normal. Ultrasound is normal. Results of the initial work-up are as follows: Serum Na+ 140mEq/L, Serum K+ 4.0mEq/L, Serum Cl- 98 mEq/L, Bicarbonate 25 mEq/L, 1,7-alpha-hydroxyprogesterone elevated. According to these findings, which of the following hormone deficiencies does this patient most likely have?

A 16-year-old girl comes to the emergency department because of abdominal pain and vaginal bleeding. She has been sexually active with her boyfriend for the past year; they occasionally use condoms. This is their only means of contraception. Her last menstrual period was eight weeks ago. Previous menses occurred at regular 28-day intervals. She has had two episodes of pelvic inflammatory disease in the past year. Which of the following is the most appropriate next step in management?

A 16-year-old girl is brought to your office by her mother for evaluation of primary amenorrhea. Her older sister had her first period at age 13. Vitals signs are within normal limits. Physical examination shows absence of breast development and external genitalia at Tanner stage 1. Examination shows no other abnormalities. Which of the following is the most appropriate next step in management?

A 16-year-old obese Hispanic girl presents to her physician’s office complaining of ugly skin around my neck and having to wear turtlenecks. On examination the physician notes darkening and thickening of the skin, which has a velvety appearance. Which of the following is the most appropriate course of action?

A 17-year-old G1P1 presents to your office for her yearly wellwoman examination. She had an uncomplicated vaginal delivery last year. She has been sexually active for the past 4 years and has had six different sexual partners. Her menses occurs every 28 days and lasts for 4 days. She denies any intermenstrual spotting, postcoital bleeding, or vaginal discharge. She denies tobacco, alcohol, or illicit drug use. Which of the following are appropriate screening tests for this patient?

A 17-year-old girl is brought to the office by her mother due to weakness of her hands and legs. The weakness has been progressively worsening over the past 24 hours, and she now feels that the weakness is affecting her hips. Her mother says she was a bit unwell a couple of weeks ago, but otherwise her past medical history is unremarkable. The physical examination reveals 1/5 power in ankle and knee flexion/extension and 2/5 power in hip flexion. Reflexes are absent in her lower extremities bilaterally. She is admitted to the hospital. Spinal fluid analysis shows albumino-cytologic dissociation. Which of the following tests is the most appropriate for monitoring her respiratory function?

A 17-year-old man presents with new symptoms of fatigue, malaise, fever, and a sore throat. He has no significant past medical history and is not on any medications. Physical examination is entirely normal except for enlarged, palpable cervical, lymph nodes. He reports no weight loss or night sweats. Laboratory investigations include a normal chest x-ray, negative throat swab, but abnormal blood film with atypical lymphocytes. The hemoglobin is 15.5 g/dL; hematocrit 42%; platelets 290,000/mL; WBC 10500/mL, with 45% segmented neutrophils, 1% eosinophils, and 54% lymphocytes, of which 36% were atypical. Which of the following is the most appropriate initial diagnostic test?

A 17-year-old primipara at 41 weeks wants an immediate cesarean section. She is being followed with biophysical profile (BPP) testing. Which of the following is correct information to share with the patient?

A 17-year-old teenage girl presents to your office with a 10-month history of lower abdominal pain that radiates to the upper thighs and back. The pain is colicky in nature and usually starts a few hours prior to menses, lasting 3-4 days. Menses have occurred at regular 28-day intervals over the past 2 years. She has no inter-menstrual bleeding. She became sexually active 6-months ago and does not use contraception. Physical examination shows healthy genitalia and well-developed secondary sexual characteristics; the uterus is normal in size and freely mobile. Examination shows no other abnormalities. Which of the following is the most likely cause of her pelvic pathology?

A 17-year-old woman presents with peripheral and periorbital edema. She has previously been healthy and takes no medications. Her blood pressure is 146/92 mm Hg; she is afebrile. The patient has mild basilar dullness on lung examination; her cardiac examination is normal. She has periorbital edema and soft, doughy 3+ edema in her legs. Her serum creatinine is 0.6 mg/dL and her serum albumin is 2.1 g/L. Urinalysis shows 3+ protein, no RBC or WBC, and some oval fat bodies. What is the next best step to take in evaluating this patient?

A 19-year-old G1P0 presents to her obstetrician’s office for a routine OB visit at 32 weeks gestation. Her pregnancy has been complicated by gestational diabetes requiring insulin for control. She has been noncompliant with diet and insulin therapy. She has had two prior normal ultrasounds at 20 and 28 weeks gestation. She has no other significant past medical or surgical history. During the visit, her fundal height measures 38 cm. Which of the following is the most likely explanation for the discrepancy between the fundal height and the gestational age?

A 19-year-old male presents with a 1-week history of malaise and anorexia followed by fever and sore throat. On physical examination, the throat is inflamed without exudate. There are a few palatal petechiae. Cervical adenopathy is present. The liver span is 12 cm and the spleen is palpable. Throat culture: negative for group A streptococci, Hgb: 12.5, Hct: 38%, Reticulocytes: 4%, WBC: 14, 000/μL, Segmented: 30%, Lymphocytes: 60%, Monocytes: 10%, Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2), Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220), Aspartate aminotransferase (AST): 40 U/L (normal 8 to 20 U/L), Alanine aminotransferase (ALT): 35 U/L (normal 8 to 20 U/L), Alkaline phosphatase: 40 IU/L (normal 35 to 125). Which of the following is the most important initial test combination to order?

A 19-year-old man is involved in a motorcycle accident in which he sustains a closed fracture of his right femur and a pelvic fracture. In addition to the obvious deformity in his leg, physical examination is remarkable for the presence of a scrotal hematoma and blood at the meatus. There is no blood in the rectal exam, but the prostate cannot be felt. The patient states that he feels the need to void, but cannot do it. Which of the following is the most appropriate next step in diagnosis?

A 19-year-old man presents to your office with a one-week history of fever, fatigue, and sore throat. He denies diarrhea or rash. He has no significant past medical history. His brother died of cystic fibrosis at 14 years of age. He admits to occasional cigarette use and alcohol consumption. He has smoked marijuana several times but has never used injectable drugs. He is sexually active with one partner and uses condoms occasionally. Physical examination reveals enlarged tonsils with a whitish exudate and enlarged, slightly tender lymph nodes deep to the sternocleidomastoid muscle bilaterally. The exam is otherwise unremarkable. Which of the following is the best initial test in this patient?

A 19-year-old man presents with malaise, nausea, and decreased urine output. He was previously well, and his physical examination is normal except for an elevated jugular venous pressure (JVP) and a pericardial rub. His electrolytes reveal acute renal failure (ARF). Which of the following findings on the urinalysis is most likely in keeping with acute glomerulonephritis (GN)?

A 19-year-old man with insulin-dependent diabetes mellitus is taking 30 units of NPH insulin each morning and 15 units at night. Because of persistent morning glycosuria with some ketonuria, the evening dose is increased to 20 units. This worsens the morning glycosuria, and now moderate ketones are noted in urine. The patient complains of sweats and headaches at night. Which of the following is the most appropriate next step in management?

A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The primary care physician suspects that the boy has Hirschsprung disease. Which of the following findings on workup is diagnostic?

A 2-month-old infant is brought to the emergency department with irritability and lethargy. The parents state that he was well until he rolled off the couch on to the floor yesterday. On examination, he is inconsolable and afebrile. The fontanels are full and tense. He has a generalized tonic-clonic seizure. Which of the following is the most important initial diagnostic study to order?

A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following should be performed as part of the preoperative workup and management of this child’s disorder?

A 2-year-old boy has been doing well despite his diagnosis of tetralogy of Fallot. He presented to an outside ER a few days ago with a complaint of an acute febrile illness for which he was started on a “pink antibiotic.” His mother reports that for the past 12 hours or so he has had a headache and is more lethargic than normal. On your examination he seems to have a severe headache, nystagmus, and ataxia. Which of the following would be the most appropriate first test to order?

A 2-year-old boy is brought to the clinic because of a swelling at the base of his neck on the left side. The family indicates that since he was born, they suspected he had some kind of a mass in his left supraclavicular area and behind the sternomastoid on that same side, but the area felt soft and mushy, was not always evident, and seemed to be painless, so they did nothing about it. Two weeks ago the child had an upper respiratory infection, and within a day or two the mass became larger and quite obvious. On physical examination he indeed has a soft, mushy, ill-defined mass occupying the entire left supraclavicular area and extending into the posterior triangle of the neck. He has no enlarged lymph nodes anywhere, and his spleen and liver are not palpable. Which of the following is the most appropriate next step in the evaluation?

A 2-year-old boy is brought to the emergency department (ED) in acute respiratory distress. He is afebrile, and has a heart rate of 100/min, respiratory rate of 80/min, and Sa02 of 84% on room air. He is sitting upright, and has significant nasal flaring and intercostal retractions. He is given supplemental oxygen in the ED. Chest x-ray reveal hyperinflation of the right lung, mediastinal shift to the left, and a severely hypoinflated left lung Which of the following is the most appropriate next step in management?

A 2-year-old boy who emigrated from Eastern Europe 1 year ago is brought to the physician because of fever, cough, and night sweats for 3 weeks. The child's grandmother, who lives with him, has similar symptoms. The child's temperature is 39.2 C (102.6 F), Wood pressure is 110/65 mm Hg, pulse is 90/min, and respirations are 28/min. A Mantoux test is reactive, and a chest x-ray film shows a right middle lobe infiltrate and hilar lymphadenopathy. Which of the following is the most appropriate next step in diagnosis?

A 2-year-old boy with cough and difficulty breathing is brought to the emergency department by his mother. She says that he was well and playing with his toys until 2 hours prior to presentation. He is healthy, but his 6-year old brother has a peanut allergy. The patient's temperature is 36.7 C (98 F), blood pressure is 92/48 mmHg, pulse is 114/min, and respirations are 48/min. The patient's pulse oximetry shows 91 % on room air. Physical examination shows nasal flaring and grunting with both subcostal and intercostal retractions. Wheezing is heard in the right lung field; the left field is clear to auscultation. No rales or rhonchi are noted. The remainder of the physical examination is within normal limits. Supplementary oxygen is applied. Chest x-ray reveals mild hyperinflation of the right lung. Which of the following is the most appropriate next step in management of this child?

A 2-year-old child is brought to the physician for a routine visit. He is growing and developing appropriately. He drinks 3-4 glasses of whole milk each day. He is starting to put words together into short sentences. His mother has no concerns. Physical examination shows mild pallor. Laboratory studies show the following: Hemoglobin 9.5 g/dL, RDW 21%, MCV 70 fl, Platelet count 284,000/mm3, Leukocyte count 6,500/mm3. Which of the following additional findings is most likely in this patient?

A 2-year-old girl is brought to the emergency department with a fever, chills, poor appetite, and vomiting. On examination, she is irritable and diaphoretic. Her temperature is 39.2 C (102.5 F), blood pressure is 80/48 mm Hg, pulse is 88/min, and respirations are 17/min. She is tender at the left costovertebral angle. Initial laboratory tests show the following: Leukocyte count 16,300/mm3, Hemoglobin 12.5 g/dL, Platelet count 245,000/mm3, Blood urea nitrogen 6 mg/dL, Creatinine 0.5 mg/dl. Urinalysis is positive for leukocyte esterase and nitrite, with 150 white blood cells/hpf. After TV antibiotic administration and stabilization, what is the most appropriate diagnostic study?

A 2-year-old presents to the emergency center with several days of rectal bleeding. The mother first noticed reddish-colored stools 2 days prior to arrival and has since changed several diapers with just blood. The child is afebrile, alert, and playful, and is eating well without emesis. He is slightly tachycardic, and his abdominal examination is normal. Which of the following is the best diagnostic study to order to confirm the diagnosis?

A 20-month-old male is brought to the emergency department for evaluation of rectal bleeding after his parents discovered a substantial amount of maroon colored stool when changing his diaper. He has no history of hematochezia. The patient has been otherwise healthy and has not appeared to be in any pain. He has been eating and drinking well. His temperature is 37 C (98.6 F), blood pressure is 85/50 mmHg, pulse is 130/min, and respiratory rate is 20/min. On examination, the abdomen is soft, nondistended, and nontender. On rectal examination, there are no fissures or masses present. A fecal occult blood test is positive. The remainder of the physical examination is normal. Which of the following is the best test to confirm the diagnosis?

A 20-year old GOPO woman presents to the emergency room with complaints of vaginal bleeding and right lower quadrant pain. Her last menstrual period was approximately 5 weeks ago. She is sexually active and uses condoms occasionally. Her temperature is 37.2 C (98.9 F), blood pressure is 120/74 mm Hg, pulse is 80/min and respirations are 14/min. Examination shows mild right lower quadrant tenderness, but no rebound or guarding. There is no active vaginal bleeding and the cervical os is closed. Her initial hemoglobin is 11.0 g/dl. She is Rh positive and a quantitative β-HCG is 1000 mIU/mL. A vaginal ultrasound is done and no intrauterine or extrauterine pregnancy can be seen. Which of the following is next best step in management?

A 20-year-old female college student presents with a 5-day history of cough, low-grade fever (temperature 37.8°C [100°F]), sore throat, and coryza. On examination, there is mild conjunctivitis and pharyngitis. Tympanic membranes are inflamed, and one bullous lesion is seen. Chest examination shows a few basilar rales. Sputum Gram stain shows white blood cells without organisms. Laboratory findings are as follows: Hct: 31, WBC: 12,000/μL, Lymphocytes: 50%, Mean corpuscular volume (MCV): 94 nL, Reticulocytes: 9% of red cells, CXR: bilateral patchy lower lobe infiltrates. Which of the following is the best method for confirmation of the diagnosis?

A 20-year-old female presents to your office for a routine. She has no complaints and her past medical history is insignificant. She is not taking any medications and denies drug abuse. Her blood pressure is 125/65 mmHg and heat rate is 80/min. Cardiac auscultation reveals early diastolic murmur at the left sternal border. What is the next best step in the management of this patient?

A 20-year-old man presents with obtundation. Past medical history is unobtainable. Blood pressure is 120/70 mm Hg without orthostatic change, and he is well perfused peripherally. The neurological examination is nonfocal. His laboratory values are as follows: Na: 138 mEq/L, K: 4.2 mEq/L, HCO3: 5 mEq/L, Cl: 104 mEq/L, Creatinine: 1.0 mg/dL, BUN: 14 mg/dL, Ca: 10 mg/dL. Arterial blood gas on room air: PO2 96, PCO2 15, pH 7.02 Blood glucose: 90 mg/dL. Urinalysis: normal, without blood, protein, or crystals. Which of the following is the most likely acid-base disorder?

A 20-year-old white male is found to have an elevated calcium level on routine pre-employment screening blood tests. He denies any polyuria, polydipsia or constipation. He has no significant past medical history and does not take any medication. He does not use tobacco, alcohol or drugs. His pulse rate is 82/min, blood pressure is 110/70 mmHg, temperature is 37.0°C (99°F) and respirations are 14/min. Complete physical examination is unremarkable. Laboratory studies show the following: Serum sodium 140 mEq/L, Serum potassium 4.0 mEq/L, Chloride 103 mEq/L, Bicarbonate 24 mEq/L, Blood urea nitrogen (BUN) 18 mg/dl, Serum creatinine 0.8 mg/dl, Calcium 11.2 mg/dl, Blood glucose 98 mg/dl, Serum PTH level 55 pg/ml (normal 10-65 pg/ml), Urine calcium/creatinine clearance ratio < 0.01. Which of the following conditions is most consistent with this patient's findings?

A 20-year-old white man notes an uneven tan on his upper back and chest. On examination, he has many circular, lighter macules with a barely visible scale that coalesce into larger areas. Which test is most likely to establish the diagnosis?

A 20-year-old woman complains of headache and discomfort in both sides of her jaw. Physical examination reveals enlarged parotid glands that are slightly tender on palpation. There is reddening of the orifice of Stensen’s duct on intra oral examination; her temperature is 38.3°C, and the pulse rate is 80/min. Laboratory data show hemoglobin 14 g/dL; hematocrit 40%; WBC 11000/mL, with 33% segmented neutrophils, 7% monocytes, and 60% lymphocytes. Which of the following diagnostic tests will help to confirm the diagnosis of epidemic parotitis?

A 20-year-old woman presents complaining of bumps around her vaginal opening. The bumps have been there for several months and are getting bigger. Her boyfriend has the same type of bumps on his penis. On physical examination the patient has multiple 2- to 10-mm lesions around her introitus consistent with condyloma. Her cervix has no gross lesions. A Pap smear is done. One week later, the Pap smear returns showing atypical squamous cells of undetermined significance (ASCUS). Reflex HPV typing showed no high-risk HPV. Which of the following viral types is most likely responsible for the patient’s condyloma?

A 21-year-old female has a several month history of easy fatigability and palpitations. She also complains of excessive sweating. She follows a strict, low calorie diet in order to lose weight. Her blood pressure is 120/70 mmHg and her heart rate is 100/min. Her BMI is 19kg/m2 Thyroid function testing reveals the following findings: TSH decreased, Total T4 high, Total T3 high. Radioiodine uptake is diffusely decreased over the thyroid gland. Which of the following is the most likely pathologic finding on biopsy of this woman's thyroid gland?

A 21-year-old man presents to the clinic feeling tired and generally unwell. He has fallen several times over the past month and has developed a slight tremor in both hands. Physical examination is significant for scleral icterus, ankle edema, and a distended and tense abdomen. Laboratory studies show: Hemoglobin: 7 g/dL, Reticulocyte count: 7% Total bilirubin: 3.1 mg/dL, Aspartate aminotransferase: 84 U/L Alanine aminotransferase: 92 U/L Ceruloplasmin: 5 mg/dL (normal: 20–45 mg/dL). Results of a Coombs’ test are negative. Which of the following is an appropriate preventive management step after chelation therapy?

A 21-year-old woman G1P0 with an intrauterine pregnancy (IUP) at 8 weeks' gestation presents for her first prenatal visit. The patient states that she would like to have a termination of the pregnancy. She denies any medical history, surgical history, allergies, and taking any medications. Vital sign: BP, 115/75 mm Hg; P, 78 beats/min; R, 20 breaths/min; T, 98.6°F. Fetal movement: Negative, contractions: Negative, vaginal bleeding: Negative, leakage of fluid: Negative. What laboratory studies need to be done before consideration of this request?

A 21-year-old woman has just delivered a term infant. She has had only one visit to her obstetrician, and that was at about 6 weeks of pregnancy. She provides her laboratory results from that visit. The delivered infant is microcephalic, has cataracts, a heart murmur, and hepatosplenomegaly. Your further evaluation of the child demonstrates thrombocytopenia, mild hemolytic anemia, and, on the echocardiogram, patent ductus arteriosus and peripheral pulmonary artery stenosis. Which of the following maternal laboratory tests done at 6 weeks gestation is likely to explain the findings in this child?

A 21-year-old woman presents to the emergency room in active labor. She has had no prenatal care, but her last menstrual period was approximately 9 months prior. Her membranes are artificially ruptured, yielding no amniotic fluid. She delivers an 1800-g (4-lb) term infant who develops significant respiratory distress immediately at birth. The first chest radiograph on this infant demonstrates hypoplastic lungs. After this infant is stabilized, which of the following is the most appropriate next step for this infant?

A 22-year-old football player comes to the physician because of difficulty in extending his right knee. This started one month ago after he twisted his knee while playing. There was mild swelling immediately; he took pain relievers which relieved both the pain and swelling. However, now the knee motion is limited and this is significantly restricting his physical activities. Physical examination shows no swelling of the knee. While passively flexed and extended, a popping sensation is noted under the examiner's finger (which is placed at the right knee). Which of the following is the most appropriate next step in management?

A 22-year-old G1P0 presents to your clinic for follow-up of evacuation of a complete hydatidiform mole. She is asymptomatic and her examination is normal. Which of the following would be an indication to start single-agent chemotherapy?

A 22-year-old white male comes to the office and complains of a noise in his right ear. The noise has been intermittently present for several months, but recently became "very annoying." He also complains of decreased hearing on his right side while using the telephone. His past medical history is insignificant. The physical examination reveals numerous cafe-au-lait spots. What is the best next step in the management of this patient?

A 22-year-old woman (G2POA1) is being followed by her family physician for pregnancy. She is currently at 28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual intercourse during her pregnancy. Her first prenatal exam at 12 weeks' gestation showed a negative HIV, Chlamydia, gonorrhea, and urine cultures. Her blood type is A negative and Rh (D) negative. She has not communicated with the father of the child during the pregnancy but is excited to raise the child with the help of her mother. She is unable to recall or confirm her immunization status for a number of vaccines. Which of the following measures is warranted at this time?

A 22-year-old woman comes to the physician for an annual examination. She has normal periods every month and has no complaints. She has no medical problems but does smoke one pack of cigarettes per day. She has intercourse with more than one partner. Examination is unremarkable, including a normal pelvic examination. A Papanicolaou smear shows a high-grade squamous intraepithelial lesion. Which of the following is the most appropriate next step in management?

A 22-year-old woman comes to your office at 10 weeks gestation for her first prenatal visit. Her obstetrical history is significant for a spontaneous abortion at 12 weeks gestation one year ago. She states that her mother has hypothyroidism, and she asks you to order thyroid function tests for her. She denies any symptoms, and her physical examination is unremarkable. Ultrasound reveals an intrauterine gestation with normal fetal cardiac activity. Which of the following results is most likely to be expected in this patient?

A 22-year-old woman is being followed by her family physician during her first pregnancy. She is currently at 28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual intercourse for the past 15 weeks. Her first prenatal exam was at 12 weeks' gestation, at which time her HIV, chlamydia, gonorrhea, Rh(D)-antibody, and urine cultures were negative. Her blood type is A negative. She does not know who the father of the child is but is excited to raise the child with the help of her mother. She is unable to recall or confirm her immunization status for a number of vaccines. Which of the following measures is warranted at this time?

A 22-year-old woman presents for her first Pap smear. She has been sexually active with only one boyfriend since age 19. Her physical examination is completely normal. However, 2 weeks later her Pap smear results return showing HGSIL. There were no endocervical cells seen on the smear. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old woman presents with complaints of vaginal discharge and severe vulvar pruritus. She is otherwise healthy. Physical examination reveals a thin, malodorous vaginal discharge and marked vulvar and vaginal erythema. The pH of the vaginal discharge is 5.5. Microscopic examination of the discharge is most likely to reveal which of the following?

A 22-year-old woman, gravida 2, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician with bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the patient today is unremarkable. She declines to have a cerclage placed. When should this patient begin having regular cervical examinations?

A 23-year-old female comes to the physician complaining of a 3-day history of intermittent lower abdominal pain and vaginal spotting. The pain is of mild to moderate intensity. Her last menstrual period was 6 weeks ago. A pregnancy test is performed, and the result is positive. Her temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, pulse is 80/min, and respirations are 18/min. Physical examination shows unilateral adnexal tenderness. Transabdominal ultrasonogram does not reveal an intrauterine gestation. Quantitative beta-HCG is 1500 IU/L. Which of the following is the most appropriate next step in management?

A 23-year-old G1PO female presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepitheliallesions (HSIL) is seen at cytology. A test for HPV discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no site of abnormalities. At this time the next best step is?

A 23-year-old G1POfemale presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepithelial lesions (HSIL) is seen at cytology. A test for HPV discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no site of abnormalities. At this time the next best step is?

A 23-year-old man arrives in the ER after a motor vehicle collision. Examination reveals an unstable pelvis and blood at the urethral meatus. Which of the following studies would most accurately identify a urethral injury?

A 23-year-old man comes to the emergency department because of a painful swollen left knee. The pain began after he twisted his leg while playing football. Examination shows a swollen left knee with marked tenderness of the medial side of the knee. When compared to the right knee, on valgus stressing the left knee shows exaggerated laxity at the joint line. Which of the following is the most appropriate next step to confirm the diagnosis?

A 23-year-old man complains of progressive low back pain for the past several months. He has morning stiffness that lasts for one hour. He has no history of trauma to his back and denies any recent illness. He had an episode of pain, blurring, and photophobia of his right eye two years ago that required ophthalmology evaluation. His vital signs are within normal limits. Examination shows tenderness in both sacroiliac joints and reduced range of motion of the lower back. If measured, which of the following is most likely to be present in this patient?

A 23-year-old man known to have neurofibromatosis, type 1 (von Recklinghausen's disease), presents with a left lower quadrant abdominal mass and signs of neurologic deficits in his left leg. In the ensuing workup, it is determined that he has higher than normal values of catabolites of epinephrine and norepinephrine in a 24-hour urinary collection. He is currently normotensive. Before invasive steps are taken to biopsy and eventually remove his left lower quadrant abdominal mass, which of the following is the most appropriate next step in management?

A 23-year-old man presents to the emergency room with the history of a fever up to 38°C (100.5°F) intermittently over the past 2 weeks, a persistent cough, and a 10-lb weight loss in the past month. He notes that he has also been becoming increasingly forgetful for the past month and that his thinking is “not always clear.” He has gotten lost twice recently while driving. Which of the following diagnostic tests will be most helpful with this patient?

A 23-year-old man presents to your office complaining of occasional headaches, muscle weakness and fatigue. He also describes periodic numbness of his extremities. The symptoms started 6 months ago and have gradually progressed. His past medical history is insignificant. He is not taking any medication. His blood pressure is 165/104 mmHg and heart rate is 80/min. His physical examination is within normal limits. Which of the following laboratory findings is the most specific for the patient's condition?

A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2C (98.9 F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 11 0/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50 %, Platelets: 200,000/mm3, Serum sodium: 130 mEq/L, Serum potassium: 2.8 mEq/L, Chloride: 86 mEq/L, Bicarbonate: 30 mEq/L, Blood urea nitrogen (BUN): 30mg/dl, Serum creatinine: 1.6 mg/dl, Blood glucose: 98 mg/dl. Which of the following is the most appropriate next step in management?

A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?

A 23-year-old white man is brought to the emergency department (ED) by an ambulance due to an epileptic seizure. He fell on the sidewalk while going home from a pub, where he had two beers. A witness noted tonic-clonic movements of all four extremities for about one minute. This seizure was his first episode, and lasted 30 minutes. In the ED, he is in a state of partial confusion and disoriented to time, place and person. The physical examination does not reveal any focal neurologic pathology. His eye exam does not show any papilledema. His airway is secured, and his breathing is normal. CBC, serum electrolytes, EKG and chest x-ray are normal. Urine toxicology screen is ordered, and lorazepam is given. What is the most appropriate next step in the management of this patient?

A 23-year-old white woman presents complaining of 6 months of progressive low back pain. She complains of morning stiffness that lasts one hour, and says her symptoms improve with physical activity. She denies rash, eye pain, urinary problems, and diarrhea. Her past medical history is significant only for an appendectomy at the age of 16 years. She has been taking birth control pills for the past two years. She is afebrile with normal weight and height. Examination reveals reduced forward flexion of the lumbar spine and tenderness over the sacroiliac joints. The remainder of the physical examination is normal. Which of the following is the most appropriate next step in the management of this patient?

A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test?

A 23-year-old woman presents to the ED complaining of lower abdominal pain and vaginal spotting for 2 days. Her menstrual cycle is irregular. She has a history of ovarian cysts and is sexually active but always uses condoms. Her BP is 115/75 mm Hg, HR is 75 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. Which of the following tests should be obtained next?

A 23-year-old woman presents to the ED in moderate pain in her left lower quadrant (LLQ). She states that the pain began suddenly and is associated with nausea and vomiting. She had a bout of diarrhea yesterday. This is the second time this month that she experienced pain in this location, however, never with this severity. Her BP is 120/75 mm Hg, HR is 101 beats per minute, temperature is 99.5°F, and RR is 18 breaths per minute. She has a tender LLQ on abdominal examination and a tender adnexa on pelvic examination. Which of the following is the most appropriate diagnostic test for the patient?

A 23-year-old woman presents with a rubbery, freely movable 2-cm mass in the upper outer quadrant of the left breast. Which of the following histologic features is most likely to be seen when examining a biopsy specimen from this mass?

A 23-year-old woman presents with weight loss and chronic diarrhea. She appears unwell and cachectic. Routine laboratory tests reveal a low hemoglobin level and an increased international normalized ratio (INR) even though she is not taking any anticoagulants. The liver enzymes are normal, but the albumin and calcium levels are low, suggesting generalized malnutrition. Which of the following is the most appropriate initial diagnostic test for malabsorption?

A 23-year-old woman, gravida 1, para 0, at 25 weeks’ gestation comes to the physician because of right upper quadrant pain, nausea and vomiting, and malaise for the past 2 days. Her temperature is 37 C (98.6 F), blood pressure is 104/72 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals right upper quadrant tenderness to palpation. The cervix is long, closed, and posterior. There is generalized edema. Laboratory values are as follows: Leukocyte count 10,500/mm3, Platelet count 62,000/mm3, Hematocrit: 26%, Sodium: 140 mEq/L, Chloride: 100 mEq/L, Potassium: 4.5 mEq/L, Bicarbonate: 26 mEq/L. A peripheral blood smear reveals hemolysis. Which of the following laboratory findings would be most likely in this patient?

A 24-month-old pale child is brought to the office by his mother, who says, "Doc, I think he is under some weird spell. He acts bizarre and always seems tired. He likes to eat wooden, painted toys." The child and her mother live in a relatively poor neighborhood. CBC reveals:WBC 8,600 /mm3, Hemoglobin 7.1 g/dl, Hematocrit 25%, Platelets 166,000 /mm3. His blood lead levels are elevated. Which of the following is most likely seen in this child's peripheral blood smear?

A 17-year-old adolescent female is 6 weeks postpartum. She presents to the emergency room with the complaints of increased jaundice, abdominal pain, nausea, vomiting, and fever. Her examination is remarkable for jaundice, pain of the right upper quadrant with guarding, and a clear chest. Chest radiographs appear normal. Which of the following tests is most likely to reveal the cause of this pain?