25 f2 J

325) A 24-year-old woman delivers a normal 8-lb baby boy at 40 weeks of gestation. She has no history of drug abuse, and her pregnancy was unre-markable. Examination had revealed the placenta to be located normally, but following delivery the woman fails to deliver the placenta and subsequently develops massive postpartum hemorrhage and shock. Emergency surgery is performed to stop the bleeding. Which of the following is the most likely cause of her postpartum bleeding?

326) A 24-year-old woman develops moderate, generalized abdominal pain of sudden onset and shortly thereafter faints. At the time of evaluation in the emergency department, she has regained consciousness, is pale, and has a blood pressure of 95/70 mm Hg and a faint pulse rate of 90/min. The abdomen is mildly distended and tender, with normal bowel sounds. Her hemoglobin is 7 g/dL. There is no history of trauma, but it is suspected that she might be bleeding into her abdomen, and a diagnostic peritoneal lavage is performed. The study shows that there is free blood in the peritoneal cavity. She denies the possibility of pregnancy because she has been on birth control pills since the age of 14 and has never missed taking them. Pelvic examination is normal, and a pregnancy test is negative. At laparotomy, the surgeons are likely to find which of the following?

328) A 24-year-old woman presents to her primary care provider because of bloody diarrhea for several months and uveitis. Complete blood cell count shows mild anemia but a normal WBC count. The erythrocyte sedimentation rate and the C-reactive protein level are not elevated. Which of the following is the most likely diagnosis?

330) A 24-year-old woman, gravida 2, para 1, at 36 weeks' gestation is brought to the emergency department after passing out. She is drowsy and moaning, complaining of abdominal pain. Her husband accompanies her. He states that she has not experienced any trauma, but that she experienced the sudden onset of severe abdominal pain before she passed out. She has no significant past medical history. Her pregnancy has been uncomplicated thus far. She does not use tobacco, alcohol, or drugs. She takes supplemental vitamins, but no other medications. Her temperature is 36.9 C (98.4F), blood pressure is 90/60 mm of Hg, and pulse is 130/min. Physical examination shows a cold and diaphoretic female. Examination shows a uterus consistent in size with a 36-week gestation; the cervical os is closed and no vaginal bleeding is noted. Which of the following is the most likely diagnosis?

331) A 25-year-old African American male comes to the office with sudden-onset back pain, dark urine and an one day history of fatigue. Two days ago, he was started on trimethoprim-sulfamethoxazole for his sinusitis. Otherwise, his past medical history is unremarkable. Physical examination reveals significant pallor. His laboratory report shows: Hb 7.5 g/dl, Total bilirubin 3.5 mg/dl, Direct bilirubin 0.8 mg/dl, Haptoglobin decreased, LDH increased. The peripheral smear shows bite cells. His G6PD level is normal. Which of the following is the most likely cause of his hemolysis?

332) A 25-year-old African American man presents to your office complaining of nocturia over the past several months. He reports having to wake to urinate 2 to 3 times per night despite restricting his fluid intake. He denies any back pain, fever, dysuria, or urinary urgency. His past medical history is significant for recurrent otitis media in childhood and hepatitis A infection two years ago. He is sexually active with one partner and does not use condoms. His brother died of a "blood disease" at age 10. The man's hematocrit is 49%. Urinalysis reveals no proteinuria or sediment abnormalities. His nocturia is most likely related to:

334) A 25-year-old female presents to the physician's office for evaluation of infertility. Her menstrual periods are regular. She has mild chronic pelvic pain. Her husband's semen analysis is within normal limits. She has no history of sexually transmitted diseases in the past. Her temperature is 37.2 C (98.9 F), and her blood pressure is 120/72 mmHg. Physical examination shows a normal sized uterus and enlarged left adnexae. Ultrasonography shows a homogeneous mass on the left ovary, but is otherwise normal. Which of the following is the most likely diagnosis?

336) A 25-year-old G1P1 comes to see you 6 weeks after an uncomplicated vaginal delivery for a routine postpartum examination. She denies any problems and has been breast-feeding her newborn without any difficulties since leaving the hospital. During the bimanual examination, you note that her uterus is irregular, firm, nontender, and about a 15-week size. Which of the following is the most likely etiology for this enlarged uterus?

337) A 25-year-old G3 at 39 weeks delivers a small-for-gestational-age infant with chorioretinitis, intracranial calcifications, jaundice, hepatosplenomegaly, and anemia. The infant displays poor feeding and tone in the nursery. The patient denies eating any raw or undercooked meat and does not have any cats living at home with her. She works as a nurse in the pediatric intensive care unit at the local hospital. What is the most likely causative agent?

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

339) A 25-year-old male comes to the office due to severe itching and burning of the skin lesions on his knees, elbows and back of his neck. He gives a history of loose stools, flatulence, weight loss of more than 10 lbs, and fatigue for the past 6 months. His vital signs are stable. On examination, there are papules and vesicles over the extensor aspect of his elbows, knees, posterior neck and scalp. The laboratory studies reveal the presence of anti-endomysial antibodies. Which of the following is the most likely diagnosis?

340) A 25-year-old male is brought to the emergency department following a motor vehicle accident in which he was the unrestrained driver. The emergency response team's reports indicate that his breath smelled of alcohol at the scene. En route to the hospital, the patient receives 2 liters of intravenous normal saline, and in the ED his blood pressure is 100/60 mmHg, heart rate is 120/min, and respiratory rate is 34/min. His neck veins are flat. You note multiple bruises overlying his anterior chest wall and upper abdomen. On inspiration, there is inward motion of the right side of his chest wall. His abdomen is soft and non-distended. He is put on positive pressure mechanical ventilation and his chest movements become symmetric. Which of the following is the most likely diagnosis?

341) A 25-year-old male presents to his physician with dyspnea and fatigue for the last few weeks. He is a non-smoker. He denies any family history of asthma or blood disorders. He does not take any medications. Examination shows pallor, scleral icterus and splenomegaly. Lab tests show the following: Hematocrit 20%, WBC count 10,000/micro-L, Platelet count 180,000/miro-L, Total Bilirubin 7 mg/dl, Direct bilirubin 1.4 mg/dl, BUN 10 mg/dl, Serum creatinine 0.7 mg/dl, Serum LDH 400 U/L (normal value is 80-280 U/L), Serum haptoglobin 160mg/dl (normal value is 30-220 mg/dl ), Reticulocyte count 8 %. Peripheral blood smear shows spherocytes with central pallor. Osmotic fragility and direct Coombs' tests are positive Based on these findings, what is the most likely diagnosis?

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

345) A 25-year-old man is referred to you because of hematuria. He noticed brief reddening of the urine with a recent respiratory infection. The gross hematuria resolved, but his physician found microscopic hematuria on two subsequent first-voided morning urine specimens. The patient is otherwise healthy; he does not smoke. His blood pressure is 114/72 mm Hg and the physical examination is normal. The urinalysis shows 2+ protein and 10 to 15 RBC/hpf, with some dysmorphic erythrocytes. No WBC or casts are seen. What is the most likely cause of his hematuria?

347) A 25-year-old man was admitted to the ICU with severe head injury with a basal skull fracture. Eighteen hours after the injury, he developed polyuria. Urine osmolality was 150 mOsm/Land serum osmolality was 350 mOsm/L. IV fluids were stopped, and 1 hour later urine output and urine osmolality remained unchanged. Five units of vasopressin were administered intravenously, and urine osmolality increased to 300mOsm/L. Select the most likely diagnosis of the patients with polyuria?

348) A 25-year-old motorcyclist is brought to the emergency department after being involved in a collision with an automobile. On arrival he is in obvious pain. He expresses an urge to void, but is unable to do so. Genital examination shows blood at the urethral meatus and a scrotal hematoma. Rectal examination reveals a high riding prostate. Abdominal examination is suggestive of a distended bladder. Which of the following is the most likely diagnosis?