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Diagnosis USMLE 3 (905-998)

A 51-year-old Caucasian female complains of low-back pain radiating to the buttocks. She also complains of persistent muscle pain that gets worse with exercise. Physical examination reveals normal muscle strength. Her joints are not swollen, but palpation over the outer upper quadrants of the buttocks and the medial aspect of the knees elicits tenderness. Her ESR is 12mm/hr. Which of the following is the most likely diagnosis?

. Seronegative spondyloarthropathy

. Polymyalgia rheumatica

. Polymyositis

. Rheumatoid arthritis

. Fibromyalgia

A 51-year-old male with a history of alcoholic pancreatitis presented to the hospital because of sudden onset severe retrosternal and upper abdominal pain. He has been vomiting for the past few hours after consuming alcohol. His temperature is 38.1C (100.9F), blood pressure is 140/90 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows palpable crepitus in the suprasternal notch. Lungs are clear to auscultation. The abdomen is tender to palpation mostly in the epigastrium. Which of the following is the most likely cause of his current condition?

. Spontaneous pneumothorax

. Acute pancreatitis

. Perforated duodenal ulcer

. Esophageal perforation

. Mallory-Weiss tear

A 51-year-old man develops acute respiratory distress syndrome (ARDS) while hospitalized for acute pancreatitis. On his third day in the intensive care unit, he is sedated, intubated, and ventilated with a PEEP (positive end-expiratory pressure) of 15 cm water and FiO2 of 0.6 (60%). Suddenly his pulse increases from 100 to 140/min, systolic blood pressure drops from 120 to 90 mm Hg, and central venous pressure increases from 10 to 15 cm water. On chest auscultation, breath sounds are absent on the left side. Which of the following is the most likely explanation for this sudden deterioration?

. Endotracheal tube shift into the right main bronchus

. Pulmonary thromboembolism

. Myocardial infarction

. Tension pneumothorax

. Mucous plugging and atelectasis

A 51-year-old man is undergoing abdominal surgery and becomes hypotensive while under general anesthesia. The patient had been doing well during most of the procedure but now has a blood pressure of 80/40 mm Hg. His past medical history is significant for coronary artery disease and diabetes mellitus. A pulmonary artery catheter placed prior to the procedure gives the following data: Central venous pressure 10 mmHg, Pulmonary artery pressure 60/30 mmHg, Pulmonary capillary occlusion 24 mm Hgpressure Cardiac output 2.3 L/min. Which of the following is the most likely diagnosis?

Acute left heart failure

Acute mitral regurgitation

Acute right heart failure

Hypoxic pulmonary vasoconstriction

Sepsis syndrome

A 52-year-old man presents to the primary care clinic for the first time. He states that he has been in good health throughout his life and takes no medications. He was once athletic but has noted a dramatic decrease in his muscle strength and exercise tolerance over the past year. On examination the patient is moderately hypertensive, with a tanned, round, plethoric face; large supraclavicular fat pads; and significant truncal obesity. He has no focal cardiovascular, pulmonary, or neurologic findings. His fasting blood sugar is 200 mg/dL. Which of the following is the most common etiology of this condition?

ACTH-secreting pituitary adenoma

Adrenal tumor

Ectopic ACTH-secreting tumor

Primary adrenal hyperplasia

Small cell lung cancer

A 53-year-old Caucasian female is admitted to the ER with hypotension. Her condition is considered very serious, and invasive hemodynamic monitoring is established. Blood pressure measured by intra-arterial method is 72/46 mmHg. Her heart rate is 120/min, regular. Pulmonary capillary wedge pressure (PCWP) estimated using Swan-Ganz catheter is 6 mmHg. Mixed venous oxygen concentration (MVo2) is 16 vol% (Normal = 15.5 vol%). Which of the following is the most likely cause of this patient's condition?

. Cardiogenic shock

. Volume depletion

. Septic shock

. Hemorrhagic shock

. Neurogenic shock

A 53-year-old male is brought to the emergency room after a high-speed motor vehicle accident. He was an unrestrained driver and admits to consuming a moderate amount of alcohol before driving. In the ER, he complains of bilateral chest pain and left leg pain. His past medical history is significant for emphysema, diabetes mellitus and remote drug abuse. A traumatic fracture of the left femur is evident on physical examination. His initial arterial blood gas analysis shows a pH of 7.45, p02 of 81 mmHg and pC02 of 32 mmHg. His pulmonary capillary wedge pressure is 1OmmHg. After a 2000 ml IV fluid challenge, his p02 is 76 mmHg and his pulmonary capillary wedge pressure is 12 mmHg. Chest x-ray shows alveolar opacities over the right and left lower lobes. Hours after the accident, he complains of continued chest pain and shortness of breath. Which of the following diagnoses is most likely responsible for his shortness of breath?

. Aspiration pneumonia

. Hemothorax

. Pulmonary contusion

. Myocardial contusion

. Aortic rupture

A 53-year-old man presents to the clinic with complaints of increasing shortness of breath, a nagging cough, and weight loss over several months. He reports no history of cigarette smoking but has worked underground in the New York City subway system for the past 20 years. Spirometry demonstrates an FEV1: FVC ratio of 0.7 and an FEV1 value that is 60% of expected. The FEV1 improves to 70% of expected with bronchodilator treatment. Which of the following is the most likely diagnosis?

Asthma

Chronic aspiration

Chronic obstructive pulmonary disease

Histoplasmosis

Tuberculosis

A 54-year-old construction worker presents to your office complaining of a "funny sensation" in his right arm. He has no significant past medical history. His diet consists of mainly fast food and he drinks one to two litters of soda per day. He does not exercise regularly. He smokes 1½ pack of cigarettes per day. His BMI is 28.5 kg/m2. You ask the patient to stretch out his arms with the palms facing up and close his eyes. Five seconds later you observe the right palm turning inward and downward. Which of the following best explains the observed findings in this patient?

. Impaired proprioception

. Tactile sensation loss

. Cerebellar dysfunction

. Parietal lobe lesion

. Upper motor neuron lesion

A 54-year-old male comes to the physician's office because of chronic cough and recent bloody sputum. He used to smoke 2 packs of cigarettes daily for 22 years, but he quit last month. His other symptoms are weight loss, anorexia, constipation, increased thirst, and easy fatigability. He thinks that he is depressed because his wife died 4 months ago and "life never felt the same after that." On examination, he is a slim man who appears pale. His vital signs are stable, although he appears a little irritable and short of breath. Laboratory and radiologic studies reveal: Sodium 144 mEq/dL, Potassium 4.3 mEq/dL, Chloride 98 mEq/dL, Bicarbonate 21 mEq/dL, Calcium 11.5 mg/dl, BUN 28 mg/dl, Creatinine 0.8 mg/dl. Chest x-ray hilar mass in the left lung. Biopsy of the mass would most likely reveal? .

. Tuberculosis

. Squamous cell carcinoma of the lung

. Oat cell carcinoma of the lung

. Sarcoidosis

. Adenocarcinoma of the lung

A 54-year-old male had undergone an emergency colonic resection following an extensive ischemic colitis. The surgery was uneventful. The patient has been on peperacillin and tazobactam (Zosyn) for the past five days. He was NPO (nothing by mouth) for the past five days. He has a significant alcoholic history. On postoperative day six, he developed bleeding from the venipuncture site. His temperature is 36.7° C (98° F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Lab results are: Hb 11.5g/dL, MCV 88 fl, Platelet count 160,000/cmm, Leukocyte count 7,500/cmm, Segmented neutrophils 68%, Bands 1%, Eosinophils 1%, Lymphocytes 24%, Monocytes 6%, Prothrombin time 20 sec (INR=1.9), Partial thromboplastin time 45 sec. His family history is insignificant. Which of the following is the most likely cause of his condition?

. Thrombotic thrombocytopenic purpura

. Hemolytic uremic syndrome

. Idiopathic thrombocytopenic purpura

. Vitamin deficiency

. Medication effect

A 54-year-old male is brought to the emergency department because of severe abdominal pain and diarrhea for the past 24 hours. He is confused and crying out in pain. His temperature is 38.6°C (101.6°F), blood pressure is 82/58 mm Hg, pulse is 118/min, and respirations are 24/min. Physical examination reveals extensive abdominal distention. There is fresh blood in his stools. Intravenous administration of normal saline is started after drawing blood for the necessary laboratory tests. The results of these tests are: Sodium 136 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 18 mEq/L, Blood urea nitrogen 32 mg/dL, Creatinine 1.3 mg/dL, Glucose 86 mg/dL, WBC 35,000/mm3, Hemoglobin 13.0 g/dL, Hematocrit 36%, Platelets 460,000/mm3. Leukocyte distribution:Promyelocyte 2%, Myelocytes 7%, Metamyelocytes 18%, Bands 32%, Segmented neutrophils 24%, Lymphocytes 15%. The patient's temperature continues to remain elevated during the night of admission. A broad-spectrum antibiotic is added to the IV infusion. Repeat CBC on the following morning shows a WBC count of 118,000/mm3 with essentially the same differential distribution of leukocytes. His leukocyte alkaline phosphatase score is elevated. What is the most probable diagnosis of this patient?

. CML with blast crisis

. Chronic lymphocytic leukemia

. Leukemoid reaction

. Secondary polycythemia

. Myelodysplastic syndrome

A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns, and blinks excessively. Which of the following disorders is most likely in this patient?

. Tourette syndrome

. Akathisia

. Tardive dyskinesia

. Parkinson disease

. Huntington disease

A 54-year-old overweight man wakes up in the middle of the night with substernal discomfort that he describes as a burning sensation. He also complains of left-sided neck pain and feels sweaty and short of breath. He has never had similar pain before. Prior to going to bed he had eaten a big meal. His past medical history is significant for diabetes and hypertension. Which of the following physical findings is most consistent with this patient's clinical presentation?

. Fixed splitting of S2

. Ejection-type systolic murmur

. Friction rub

. Fourth heart sound

. Pulsus paradoxus

A 54-year-old retired schoolteacher comes to the physician's office because of worsening low back pain. The pain started three weeks ago. It is continuous and is worse at night. He has had little relief with over-the-counter nonsteroidal analgesics. He has no other symptoms. He had a surgical resection of a lung tumor one year ago for non-small cell carcinoma of the lung. Preoperative positron emission tomography (PET) scanning did not reveal any evidence of metastasis. His vital signs are within normal limits. Examination shows local spinal tenderness at the L4-L5 level. What is the most likely cause of his back pain?

. Lumbar strain

. Central spinal canal stenosis

. Disc herniation

. Vertebral compression fracture

. Metastatic disease

A 54-year-old woman is brought to the emergency department after a head-on automobile accident. On arrival, she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-ray films show multiple rib fractures on both sides, but the lung parenchyma is clear, and both lungs are expanded. Two days later she is in respiratory distress, and her lungs "white out" on repeat chest x-ray films. Which of the following is the most likely diagnosis?

Flail chest

Myocardial contusion

Pulmonary contusion

Tension pneumothorax

Traumatic rupture of the aorta

A 54-year-old woman presents to the ED because of a change in behavior at home. For the past 3 years, she has end-stage renal disease requiring dialysis. Her daughter states that the patient has been increasingly tired and occasionally confused for the past 3 days and has not been eating her usual diet. On examination, the patient is alert and oriented to person only. The remainder of her examination is normal. An initial 12-lead ECG is performed as seen on the following page. Which of the following electrolyte abnormalities best explains these findings?

Hypokalemia

Hyperkalemia

Hypocalcemia

Hypercalcemia

Hyponatremia

A 55-year-old male Asian immigrant presents to the physician because of recent-onset neck swelling. He also notes having several episodes of epistaxis lately. He has not sustained any trauma to the neck or nose. His past medical history is significant for syphilis and recurrent bacterial sinusitis. He drinks 2 beers daily and has a 30-pack year smoking history. He takes daily multivitamins with antioxidants. On physical examination, you note a mass in the posterior nasal cavity. Biopsy shows undifferentiated carcinoma. Which of the following is a risk factor for this cancer?

. Alcohol use

. Spirochete infection

. Bacterial infection

. Viral infection

. Vitamin supplements

A 55-year-old male comes to you with complaint of fatigue for the past month. He also complains of occasional heartburn. His past medical history is significant for hepatomegaly, secondary to fatty liver. He has been drinking 3-4 shots of alcohol per day for the past 30 years. He denies smoking. His physical examination reveals pallor of skin and mucous membranes, and mild hepatomegaly. His laboratory report shows: Hb 8.5 g/dl, WBC 8,000/cmm, MCV 110 fl, Platelets 150,000/cmm, Blood glucose 118 mg/dl, BUN 16 mg/dl, Serum creatinine 1.0 mg/dl. What is the most likely cause of anemia in this patient?

. Vitamin B- 12 deficiency

. Folate deficiency

. Chronic blood loss from peptic ulcer

. Anemia of chronic disease

. Thiamine deficiency

A 55-year-old man comes to the office due to a sudden onset of blisters all over his body. He complains of pain in the involved areas. He first noticed the lesions in his mouth a few days ago. His pulse is 82/min, blood pressure is 140/90 mmHg, respirations are 14/min, and temperature is 36.8°C (98.4°F). On examination, there are crops of flaccid bullae over normal-appearing skin, and large erosions at sites where the bullae had ruptured. The oral mucosa shows erosions and ulcerations. Slight rubbing of the uninvolved skin causes easy separation of the epidermis. Immunofluorescence microscopy shows deposits of IgG inter cellularly in the epidermis. What is the most likely diagnosis?

. Bullous pemphigoid

. Bullous impetigo

. Pemphigus vulgaris

. Erythema multiforme

. Dermatitis herpetiformis

A 55-year-old woman comes to the physician for an annual physical examination. She has no new complaints, except fatigue. She has an 8-year history of chronic low back pain; severe degenerative joint disease has been documented on MRI. She had an anterior wall myocardial infarction four years ago. Her current medications include naproxen, acetaminophen, oxycodone, aspirin, atenolol, and simvastatin. Her blood pressure is 130/80 mm Hg and pulse is 72/min. Laboratory studies show: Hb 10 g/dl, WBC 6,000/cmm, Blood sugar 82 mg/dl, BUN 36 mg/dl, Serum creatinine 2.0 mg/dl. Urinalysis : Protein 2+, Glucose Absent, RBC AbsentWBC 10-15/HPF, Nitrite Negative, Esterase Negative, Sediment WBC casts. Serum protein electrophoresis is negative for monoclonal gammopathy. Two years ago, her BUN level was 22 mg/dl, and creatinine level was 1.6 mg/dl. Which of the following is the most likely pathology involved in this patient's renal failure?

. Acute tubular necrosis

. Chronic glomerulonephritis

. Tubulointerstitial nephritis

. Recurrent pyelonephritis

. Renal tuberculosis

A 55-year-old woman presents with coughing up blood and sputum. She gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is worse on lying down and in the morning. On physical examination, she appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is a recognized precursor to this patient’s condition?

Bronchial asthma

Cigarette smoking

Lung infection and impairment of drainage

Lung cancer

Silicosis

A 55-year-old woman with long-standing rheumatoid arthritis is on prednisone 5 mg daily and etanercept (Enbrel) 50 mg subcutaneously once a week. Her arthritis is well-controlled. However, she complains of a 2-day history of headaches, chills, and spiking fevers to 39.4°C (103°F). You suspect which of the following?

. An allergic febrile reaction to etanercept

. Fever related to her underlying autoimmune disease

. A serious infection

. A viral syndrome

. An occult malignancy

A 56-year-old Caucasian male complains of chronic exertional dyspnea for the past several years that has progressively worsened. He cannot remember the last time that he saw a doctor, and does not take any medications regularly. It is difficult for him to climb two flights of stairs without having to rest. His dyspnea has gotten so bad that it has severely limited his activity level, and he now spends most of his time on the couch. He also describes recurrent episodes of nocturnal dyspnea, during which he wakes up at around 2:00 AM with difficulty breathing, coughing, and wheezing that improve when he sits up. He usually coughs up some yellowish sputum before being able to go back to sleep. He has had no fever, chills, or chest pain. Which of the following is the most likely cause of this patient's complaints?

. Left ventricular failure

. Bronchial asthma

. Chronic bronchitis

. Pulmonary thromboembolism

. Pulmonary fibrosis

A 56-year-old female is admitted with a diagnosis of chronic renal failure from systemic lupus erythematosus and non-steroidal anti-inflammatory drug use. She has a history of recurrent kidney stones. Laboratory studies show the following: Serum calcium 10.6 mg/dL, Serum albumin 3.9 g/L, PTH 140 pg/mL, Serum phosphorus 3.0 mg/dL. Her baseline serum creatinine level ranges from 1.6 to 1.8 mg/dL. Her bone mineral density is measured by DXA scan, revealing a T score of-2.5 at the lumbar spine, which is consistent with osteoporosis. What is the most likely cause of this patient's hypercalcemia?

. Hypercalcemia of malignancy

. Milk-alkali syndrome

. Chronic renal failure

. Sarcoidosis

. Primary hyperparathyroidism

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