USMLE_Diagnosis VIII

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USMLE Diagnosis Challenge

Test your medical knowledge with our engaging USMLE Diagnosis Challenge! This quiz features 30 carefully crafted questions covering a range of clinical scenarios, aimed at both medical professionals and students. Challenge yourself and see how well you understand these critical concepts.

Key features of the quiz include:

Comprehensive coverage of diverse medical cases
Multiple-choice format for effective learning
Immediate feedback on your answers

100 Questions25 MinutesCreated by DiagnosingDoctor42

A 45-year-old male presents to your office because his "hands are getting thick and swollen." He is also having difficulty with wearing shoes because his feet have become large. His blood pressure is 150/90 mmHg. On examination, he has enlarged, swollen hands and feet. He has coarse facial features, with prominent frontal bones and jaws. While you are discussing the most likely diagnosis, he appears worried and asks about the complications and risk of death associated with his condition. What is the most common cause of death in patients with this condition?

A 45-year-old man comes to the office for the evaluation of excessive wasting of his extremity muscles, which is more apparent on the extensor side. The weakness began distally and asymmetrically. He recently started to have difficulties with swallowing, chewing, and speaking. He feels some movements in his face and tongue. He also has muscle stiffness. His bowel, bladder, cognitive, and sensory functions are intact. The physical examination reveals excessive wasting of his muscles, which is more prominent in the lower extremities. Fasciculation and hyperreflexia of all extremities are noted. His bulbar reflexes are decreased. What neural pathway is most likely damaged?

A 45-year-old man is brought to the office due a sudden onset of skin lesions and fever. He is unable to eat or drink due to the pain in his mouth and throat. His wife says that he was complaining of a headache, malaise, and joint pain prior to developing the skin lesions. Generally, he has been in good health, other than an episode of sinusitis, for which he was prescribed trimethoprim-sulfamethoxazole 5 days ago. His pulse is 92/min, blood pressure is 110/80 mmHg, respirations are 14/min, and temperature is 36.8°C (98.4°F). On examination, both conjunctivae are inflamed. There is erythema, blistering and ulceration over the oral mucosa. There is an erythematous rash over the trunk and cutaneous lesions over the hands, arms and feet. Some of the lesions are shown in the picture below. What is the most likely diagnosis?

A 45-year-old man presents to the physician’s office complaining of dysphagia and retrosternal pressure and pain of 2-year duration. The symptoms have worsened over the last 3 months. He has a 30 pack-year smoking history and drinks beer on weekends. Vital signs include a BP of 150/90 mmHg, pulse rate of 90/min, and respiratory rate of 12/min, with a normal temperature. Examination reveals a thin man with a normal heart, lung, and abdomen examination. An esophagogram reveals a 6-cm, smooth, concave defect in the midesophagus with sharp borders. Esophagoscopy reveals intact overlying mucosa and a mobile tumor. Which of the following is the most likely diagnosis?

A 45-year-old man presents to the physician’s office for evaluation of a posterior neck mass. The mass has been present for years, but has slowly enlarged over the last 2 years. Examination reveals a subcutaneous mass that is soft, nontender, and movable. Which one is the most likely diagnosis?

A 45-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 6-12. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most likely diagnosis?

A 45-year-old man with a chronic psychotic disorder is interviewed after being admitted to a psychiatric unit. He mimics the examiner’s body posture and movements during the interview. Which of the following terms best characterizes this patient’s symptom?

A 45-year-old man with a long history of alcohol intake comes into the emergency room with upper gastrointestinal (UGI) bleeding. Urgent endoscopy reveals the following findings. Which of the following is the most likely diagnosis?

A 45-year-old man with Parkinson disease has macular areas of erythema and scaling behind the ears and on the scalp, eyebrows, glabella, nasolabial folds, and central chest. Which of the following is the most likely diagnosis?

A 45-year-old mildly overweight male recovering from an anterior wall myocardial infarction develops sudden onset of left-sided chest pain. He appears agitated and restless. Two minutes later, he is unresponsive. His pulse is not palpable and ECG monitor shows sinus tachycardia at the rate of 130/min. He presented five days earlier with substernal chest pain and diaphoresis. He has had no dyspnea, extremity swelling or palpitations since admission. His past medical history is significant for diabetes mellitus type 2. Which of the following is the most likely diagnosis?

A 45-year-old mildly overweight male recovering from an anterior wall myocardial infarction develops sudden onset of sharp pain in the left side of his chest. He presented five days earlier with substernal chest pain and diaphoresis. He has had no dyspnea, extremity swelling or palpitations since admission. His past medical history is significant for diabetes mellitus type 2. He seems mildly restless, especially in the supine position. The pain improves when sitting up and leaning forward. His breathing is fast and shallow due to the pain. His lungs are clear on auscultation. His blood pressure is 120/78 mmHg and his heart rate is 60/min There is no change in blood pressure upon deep inspiration. ECG shows sinus rhythm with new diffuse ST segment elevation. Which of the following is the most likely diagnosis?

A 45-year-old mildly overweight smoker presents with occasional episodes of nocturnal substernal chest pain that wakes her up from sleep. The episodes last 15-20 minutes and resolve spontaneously. She denies any illicit drug use. She leads a sedentary lifestyle but states that she can climb two flights of stairs without any discomfort. Her pulse is 78/min and regular, blood pressure is 130/70 mmHg and respirations are 13/min. Auscultation of her heart and lungs is unremarkable. Extended ambulatory ECG monitoring reveals transient ST segment elevations in leads V4-V6 during the pain attack. The pathophysiology of this patient's condition is most similar to that of which of the following?

A 45-year-old nurse practitioner presents to the emergency department due to painful abdominal cramps and watery diarrhea. She has about 10 to 20 bowel movements a day. She also has nocturnal bowel movements. She has had multiple hospitalizations in the past for similar problems without a definite diagnosis. A lower GI endoscopy during a previous hospitalization showed dark brown discoloration of the colon with lymph follicles shining through as pale patches. Which of the following is the most likely diagnosis?

A 45-year-old policeman presents to your office complaining of tiredness and sleepiness. He says that his job seems tiring to him recently. It is difficult for him to get up in the morning and go to work. He goes to bed early because he feels tired and sleepy. Two months ago, he was investigating a case of massive murder. He slipped on the blood on the floor, fell and hit his head. He also describes recent abdominal pain that is constant and gnawing, interfering with his sleep. His appetite is poor, and he lost 15 pounds over the last month. Physical examination is significant only for tenderness and fullness in the epigastrium. Which of the following is the most likely diagnosis?

A 45-year-old policeman presents to your office complaining of tiredness and sleepiness. He says that his job seems tiring to him recently. It is difficult for him to get up in the morning and go to work. He goes to bed early because he feels tired and sleepy. Two months ago, he was investigating a case of mass murder. He slipped on the blood on the floor, fell and hit his head. He also describes recent abdominal pain that is constant and gnawing, interfering with his sleep. His appetite is poor, and he lost 15 pounds over the last month. Physical examination is significant only for tenderness and fullness in the epigastrium. Which of the following is the most likely diagnosis?

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?

A 45-year-old tennis player comes to your office with a complaint of pain over the lateral side of the right elbow. He has been a professional tennis player for 15 years but has never had this kind of pain before. Range of motion at both elbows is normal. There is point tenderness over the lateral side of the distal end of right humerus. Pain is exacerbated by extension of wrist against resistance. The rest of the physical examination is normal. Which of the following is the most likely diagnosis in this patient?

A 45-year-old white male comes to your office for evaluation of diarrhea of 8-months duration. He says that he has lost almost 15 lbs during the past 8 months. He denies any blood in the stools. 24-hour stool collection reveals fecal fat of 10 gm/day. Stool microscopy reveals no pathogens and no leucocytes. D-xylose test was performed which shows that less than 2 grams of D-xylose is excreted in urine in 5 hours. D-xylose test was re-performed after 4-week treatment with antibiotics but excretion is still less than 2 grams in 5 hours. Based on these findings, what is the most likely diagnosis in this patient?

A 45-year-old white male presents with a 4-month history of headaches. The headache is generalized, dull, constant, and worsened by bending, coughing and sneezing. It is unresponsive to simple analgesics, and associated with nausea and vomiting. His wife says he has been acting strangely for the last few months, and she has noted a personality change. The neurological examination is non-focal. Fundoscopy reveals papilledema. His CT scan is shown below. Which of the following is the most likely diagnosis?

A 45-year-old woman comes to her physician for help with her insomnia. She states “ever since my husband died, I just can’t sleep.” The patient states her 57-year-old husband died suddenly of a heart attack 9 weeks ago. Since that time, the patient has had a very depressed mood, had been crying, has lost interest in activities, is fatigued, and has insomnia. Which of the following symptoms, if present, should make the physician think this patient has a major depression instead of bereavement?

. The patient feels that she would be better off dead

. The patient has marked functional impairment

. The patient has lots of guilt about not recognizing that the chest pain her husband was having was the start of a heart attack

. The patient has mild psychomotor retardation

. The patient reports hearing the voice of her dead husband calling her name twice

A 45-year-old woman comes to the office for the evaluation of reddened areas over her face (flushed skin). These areas worsen every time she drinks something hot or goes out in hot, sunny weather. Her vital signs are stable. On examination, there is evident erythema over her nose, cheeks, forehead and chin with telangiectasias, pustules and papules. What is the most likely diagnosis?

A 45-year-old woman comes to your office with a three-month history of fatigue, exertional dyspnea, and non-productive cough. She has also been having difficulty swallowing. Her only other medical problems are Raynaud's phenomenon, heartburn, and high blood pressure. On examination, diffuse thickening of the skin with telangiectasia is noted. Her current medications include amlodipine, enalapril, and ranitidine. What is the most probable pathologic mechanism of her pulmonary complaints?

A 45-year-old woman complains to her primary care physician of nervousness, sweating, tremulousness, and weight loss. The thyroid scan shown here exhibits a pattern that is most consistent with which of the following disorders?

A 45-year-old woman has bilateral breast pain that is most severe premenstrually. On palpation, there is excessive nodularity, tenderness, and cystic areas that diminish in size after menses. Which of the following is the most likely diagnosis?

A 45-year-old woman has severe symptoms of epigastric and abdominal pain after eating. A trial of acid suppression therapy with proton pump inhibitors (PPI) only partially improved her symptoms. She undergoes elective outpatient upper endoscopy, which is positive for a small duodenal ulcer. Two hours later, she is short of breath and complaining of severe anterior chest pain, which is made worse with deep inspiration. On examination, she looks unwell, blood pressure is 150/90 mm Hg, pulse 110/min, and lungs are clear. Heart sounds are normal but an “extra crunching” type sound is intermittently heard. CXR demonstrates air surrounding the heart. Which of the following is the most likely diagnosis?

A 45-year-old woman presents with hypertension, development of facial hair, and a 7-cm suprarenal mass. Which of the following is the most likely diagnosis?

A 45-year-old woman underwent elective surgery for an inguinal hernia. In the postoperative recovery room, she developed nausea, vomiting, and acute abdominal pain. She has a history of systemic lupus erythematosus, pernicious anemia, type 1 diabetes, chronic low back pain, and uterine fibroids. Her preoperative medications include monthly vitamin B-12 injections, insulin, prednisone, hydroxychloroquine, and acetaminophen. Her blood pressure is 70/40 mm Hg and heart rate is 110/min. Initial laboratory studies show blood glucose of 50 mg/dl. Which of the following is the most likely cause of her condition?

A 45-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. Which of the following is the most likely diagnosis?

A 46-year-old bank executive is referred to the clinic by her dentist. For the past 6 weeks, she has had swollen, bleeding gums. She appears pale and feels weak. She smokes half a pack of cigarettes daily and drinks alcohol socially. Her family history is not significant. Her vital signs are stable. She is afebrile. WBC 44,100 mm3, Hemoglobin 9.0 g/dL, Hematocrit 27%, Platelets 16,000/mm3. Leukocyte distribution: Blast forms 79%, Promonocytes 12%, Monocytes 8%, Lymphocytes 1%. Cytochemical analysis:Sudan black: slightly positive, Alpha-naphthyl esterase: positive, PAS reaction: negative. Which of the following is the most likely diagnosis?

A 46-year-old female complains of a "sandy" sensation in her eyes. Review of systems is notable for a 6 pound weight loss over the last month. A picture of her eyes is shown on the slide below. Which of the following most likely underlies this finding?

. High circulating thyroxine level

. Periorbital lymphocytic infiltration

. Bilateral facial nerve compression

. Increased intraocular pressure

. Increased intracranial pressure

A 46-year-old homeless man is being evaluated for frequent falls and a broad-based gait. A single tap on his patellar tendon elicits several to-and-fro leg movements. There is also nystagmus on physical examination. Which of the following additional findings would you expect most in this patient?

A 46-year-old male is brought to the emergency department after falling on his head and back during a downhill bike race and losing consciousness for 1 minute. He has severe back and abdominal pain. AP and lateral skull films show no abnormalities. Lumbar films show anterior compression wedge fractures of the bodies of L1 and L2. A brace is placed. CT scan of the abdomen shows a mild retroperitoneal bleed and splenic laceration. During the hospitalization he was treated conservatively with analgesics and supportive measures. On hospital day 3, he started to have abdominal distention, pain and nausea. His last bowel movement was 4 days ago and he is not passing gas. His abdomen is distended, tympanic and mildly tender without rebound or guarding. Bowel sounds are absent. An x-ray film of the abdomen is shown below: Which of the following is the most likely diagnosis?

A 46-year-old man is brought to the emergency department after a fall during a downhill bike race. He lost consciousness for approximately 1 minute after the fall. He complains of severe back and abdominal pain. He has no other medical problems. Head computed tomography (CT) scan shows no intracranial bleeding. Lumbar films suggest a compression wedge fracture of the body of L2 vertebra, and a brace is placed. Abdominal CT scan shows a small retroperitoneal bleed and splenic laceration. He is conservatively treated with analgesics and supportive measures. On hospital day three, he complains of abdominal pain and nausea. His abdomen is distended, tympanic, and mildly tender, without rebound or guarding. Bowel sounds are absent. X-ray of the abdomen reveals. Which is the most likely diagnosis?

A 46-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unresponsive and his injuries include a basilar skull fracture, brain contusion, fractures of ribs 7-10, hemopneumothorax on the right, and a pelvic fracture. After placement of a chest tube and pelvis fixation, his condition stabilizes. On the fifth day of his hospital stay, he is still unresponsive with a Glasgow Coma Scale of 8 and spontaneous respirations. Examination shows an abnormal facial reaction with palpation of the right upper quadrant of the abdomen and diminished bowel sounds. Rectal examination shows no abnormalities. Nasogastric tube aspiration shows retention of gastric contents. An abdominal CT scan shows gaseous distention of the small and large bowels without air-fluid levels. The gall bladder is distended with pericholecystic fluid but no gallstones. Which of the following is the most likely diagnosis for this patient's abdominal findings?

A 46-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unresponsive. His injuries include a basilar skull fracture, brain contusion, fractures of ribs 7-10, hemopneumothorax on the right and a pelvic fracture. After placement of a chest tube and pelvis fixation, his condition stabilized. On the fifth day of his hospital stay, he is still unresponsive with a Glasgow Coma Scale of 8. He is breathing spontaneously. Examination shows an abnormal facial reaction to abdominal palpation. Pain appears to be elicited by palpation in right upper quadrant. Bowel sounds are diminished. Rectal examination shows no abnormalities. Nasogastric tube aspiration shows retention of gastric contents. An abdominal CT scan shows gaseous distention of the small and large bowels without airfluid levels. The gall bladder is distended and pericholecystic fluid is present. Stones are not seen. Which of the following is the most likely diagnosis?

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?

A 46-year-old man with a history of medication-controlled hypertension sees his doctor for a routine check-up. His blood pressure is 115/80 mm Hg and an electrocardiogram shows a normal sinus rhythm. The doctor notes that the man seems more down than usual. The man admits that he has been "stressed out" for the past two weeks, as a few people at work recently quit and he has had to take on more work while management finds replacements. He has been sleeping poorly at night, feels tired during the day, and states that he hates his job right now, but has no other choice. He continues to get his work done and enjoys social activities, remarking that he "can still golf on the weekends." What is the patient's most likely diagnosis?

A 46-year-old woman presents with a 4-month history of a discharge from the nipple. An excisional biopsy of the nipple area reveals infiltration of the nipple by large cells with clear cytoplasm. These cells are found both singly and in small clusters in the epidermis and are PAS-positive and diastase resistant. Which of the following is the most likely diagnosis?

A 47-year-old African American woman presents with two days of shortness of breath and left-sided chest pain. Her past medical history is significant for a mastectomy six months ago for breast cancer, for which she also received adjuvant chemotherapy. Her mobility has been limited recently due to progressive back pain. Her current medications include tamoxifen. On chest x-ray, there is an infiltrate obscuring the right heart border as well as a right-sided pleural effusion. Pleural fluid analysis reveals the following: pH 5.75, Nucleated cells 10,050/mm3, RBC 1,500/mm3, Protein 3.9 g/dl, LDH 620 units/L, Glucose 38 mg/dl. Her serum chemistries are notable for an LDH of 310 units/L and protein of 6.1 g/dl. Which of the following is the most likely cause of her effusion?

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?

. Acute respiratory distress syndrome

. Hospital acquired pneumonia

. Iatrogenic volume overload

. Congestive heart failure from myocardial infarction

. Alcoholic cardiomyopathy

A 47-year-old obese female comes to the office for the evaluation of recent episodes of mood instability. Her mood varies between sad and irritable. She denies any other symptoms, except for some mild forgetfulness. She tearfully shares that she is convinced that she is going to die, as her father also developed similar symptoms around the same age and died subsequently. On physical examination, writhing movements of the extremities are prominent. This patient's clinical presentation is most consistent with:

A 47-year-old smoker presents to the emergency room with a three-day history of shortness of breath and cough. His past medical history is significant for tuberculosis ten years ago, treated with six months of a multidrug regimen. On exam today, his blood pressure is 140/90 mmHg and his heart rate is 110/min. Breath sounds are decreased over the right lung base. Over the same area there is dullness to percussion and increased fremitus. The patient also has trace ankle edema. Which of the following most likely accounts for these findings?

A 47-year-old woman comes to the office and complains of burning abdominal pain which has been present for the past 3 months, is grade 6/10 in severity, continuous, and relieved by taking antacids. She also complains of some constipation. Her father has a history of "ulcers in his belly." She works as a floor secretary in a surgical ward, and is not happy with her new boss. She denies any weight loss or decreased appetite. Her temperature is 37.1°C (98.8°F), blood pressure is 130/85 mm Hg, heart rate is 78/min, and respirations are 14/min. She is awake, alert, and oriented. The abdominal examination reveals normoactive bowel sounds and tenderness in the epigastric region, but no palpable mass. Her stools are occult blood positive. ECG reveals increased PR and shortened QT intervals. The laboratory results reveal the following: Sodium 137 mEq/dL, Potassium 4.2 mEq/dL, Chloride 101 mEq/dL, Bicarbonate 27 mEq/dL, Calcium 12.0 mg/dl, Phosphorus 2.2 mg/dl, BUN 37 mg/dl, Creatinine 1.8 mg/dl. Which of the following is the most likely diagnosis?

A 47-year-old woman develops accelerated hypertension (blood pressure 210/105 mmHg) but no clinical symptoms except frequent headaches. Which of the following findings are most likely on examination of the fundii?

A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her. Which of the following is the most appropriate diagnosis for this patient?

A 47-year-old woman presents to your office with complaints of lower abdominal pain, nocturia, urinary urgency and frequency relieved with urination. She states the symptoms have been worsening this past month and she recently experienced dyspareunia. She is sexually active with her husband, but this is causing her a great amount of pain. She has four children and had uncomplicated pregnancies. She denies fevers or chills. On examination, she has diffuse lower abdominal pain with no rebound or guarding. Her external genitalia appear normal. On bimanual examination, palpation of the anterior vaginal wall elicits extreme pain. No cervical motion tenderness is present. No other abnormalities are noted. A urinalysis is negative. The most likely diagnosis is:

A 48-year-old Caucasian female presents to your office due to a small swelling on her left lower eyelid. She has worked outdoors her whole life. This swelling has been present for the past 6 months. Recently, she noticed a loss of eyelashes on her lower eyelid. On examination, there is a small nodular lesion on the lower eyelid margin. It is firm, painless, pearly and indurated. Loss of lashes on the left lower eyelid is confirmed. Which of the following is the most likely diagnosis?

A 48-year-old G5P5 woman has genuine stress incontinence (GSI). Kegel exercises have not helped, and her incontinence is gradually worsening. Her urethrovesical junction (UVJ) is prolapsed into the vagina, and her urethral closure pressure is normal. Which of the following procedures will most likely cure her incontinence?

A 48-year-old white male comes to the emergency department with complaints of severe pain and swelling in his left leg. He sustained an injury to his left leg while playing tennis five days ago. The pain worsened over the past 2-3 days, and is now unbearable. He also complains of flu-like symptoms. His temperature is 39 °C (102°F), pulse is 104/min, blood pressure is 110/80 mmHg, and respirations are 18/min. Physical examination reveals an edematous limb with purplish discoloration of the injured area, along with bullae and a serosanguineous discharge. The leg is extremely tender to touch. A scalpel incision of the skin reveals yellowish green necrotic tissues. What is the most likely diagnosis?

A 48-year-old woman develops pain in the right lower quadrant while playing tennis. The pain progresses and the patient presents to the emergency room later that day with a low-grade fever, a WBC count of 13,000/mm3 and complaints of anorexia and nausea as well as persistent, sharp pain of the right lower quadrant. On examination, she is tender in the right lower quadrant with muscular spasm, and there is a suggestion of a mass effect. An ultrasound is ordered and shows an apparent mass in the abdominal wall. Which of the following is the most likely diagnosis?

A 48-year-old woman has been married for 8 years and desperately wants to have a child of her own before it is too late. She consults a new obstetrician for help because she has experienced multiple early secondtrimester losses due to painless cervical dilation leading to expulsion of immature stillborn fetuses. She reports that she was exposed in utero to diethylstilbestrol (DES), explaining that when her mother was pregnant with her she experienced early pregnancy bleeding and, as a consequence, was treated with DES to prevent the pregnancy from being terminated. At this time, this patient is most likely to demonstrate which of the following conditions on physical examination?

A 48-year-old woman presents to her primary care physician because of 2 weeks of neck pain. The pain is constant and sharp (rated at 10 of 10) and is felt in the anterior portion of her neck. She also notes several weeks of loose stools and fatigue. Past medical history is significant for a viral upper respiratory infection about 1 month ago. She has a temperature of 37.9°C (100.2°F), heart rate of 96/min, and blood pressure of 136/82 mmHg. On neck examination there is diffuse enlargement of the thyroid and it is exquisitely tender to even mild palpation. Laboratory tests show a total tri-iodothyronine level of 280 ng/dL, total thyroxine of 25 μg/dL, and thyroidstimulating hormone of 2 μU/mL (normal: 0.4–4 μU/L).Which of the following is the most likely diagnosis?

A 48-year-old woman presents with a 1.5-cm firm mass in the upper outer quadrant of her left breast. A biopsy from this mass reveals many of the ducts to be filled with atypical cells. In the center of these ducts there is extensive necrosis. No invasion into the surrounding fibrous tissue is seen. Which of the following is the most likely diagnosis?

A 48-year-old woman with five children complains of urinary incontinence with coughing and stair climbing. She likely has genuine stress urinary incontinence if which of the following is true?

Loss of urine is secondary to involuntary bladder contractions.

Loss of urine is associated with a strong desire to void immediately.

Loss of urine occurs in relation to anxiety or depression.

Loss of urine occurs when intravesical pressure exceeds maximal urethral pressure.

Loss of urine is due to increased intravesical pressure associated with bladder distention.

A 49-year-old G4P4 presents to your office complaining of a 2-month history of leakage of urine every time she exercises. She has had to limit her physical activities because of the loss of urine. She has had burning with urination and some blood in her urine for the past few days. Which of the following is the best next step in the evaluation and management of this patient?

A 49-year-old man is brought to the ED by EMS stating that he vomited approximately three cups of blood over the last 2 hours. He also complains of epigastric pain. While examining the patient, he has another episode of hematemesis. You decide to place an NG tube. You insert the tube, confirm its placement, and attach it to suction. You retrieve 200 mL of coffee-ground blood. What is the most common etiology of an upper GI bleed?

A 49-year-old woman comes to the office and complains of a "strange, itchy rash" on her left areola which has been present for the last month. She tried applying various lotions and creams, but the lesion did not resolve. She denies having other skin conditions, except for a poison ivy rash 2 months ago. She does not take any medications and feels "goofy" when she takes penicillin. Physical examination reveals an eczemoid lesion on the left nipple. No abnormality is visible on the mammogram. Biopsy demonstrates large cells surrounded by halo-like areas which invade the epidermis. What is the most likely diagnosis?

A 49-year-old woman presents with a two-week history of lower abdominal pain and severe diarrhea. The stools are watery without blood or mucus. The abdominal pain is mild and unrelated to her stools. She has had recent episodes of flushing. She has not had fever. There is no history of travel. She does not smoke or drink alcohol. Her past surgical history includes a fracture repair of her right leg 3 years ago. Her temperature is 36.6°C (97.8°F), blood pressure is 106/68 mm Hg, pulse is 103/min, and respirations are 20/min. Oxygen saturation is 99% on room air. Physical examination shows facial flushing, a prominent jugular venous pulse and expiratory wheezes. Which of the following is the most likely diagnosis?

A 5-day-old male premature infant in the NICU develops a decreased level of consciousness, hypotonia and decreased spontaneous movements. He was delivered vaginally at 32 weeks of gestation, and his birth weight was 1800g. Examination reveals a lethargic infant with a weak and high-pitched cry, prominent scalp veins, tense fontanels, and eyes directed downward, poor suckling, hypotonia. CT scan reveals dilation of the entire ventricular system, with distinct enlargement of the subarachnoid space over the cerebral cortex. What is the most likely cause of the patient's condition?

A 5-day-old male term neonate has been passing maroon-colored stools for the past three days, along with frequent episodes of vomiting. He is being breastfed by his mother, who is an asthmatic. His vital signs are within normal limits. The physical examination is unremarkable. Stool examination is positive for RBCs and eosinophils. What is the most likely cause of this patient's findings?

A 5-month-old boy is brought to the office for a mass in his left groin area. The infant is on the examination table, quietly sucking on his pacifier. On examination, there is a fluid-filled sac that does not reach the inguinal ring and transilluminates well. Which of the following is the most likely diagnosis?

A 5-month-old child was normal at birth, but the family reports that the child does not seem to look at them any longer. They also report the child seems to “startle” more easily than he had before. Testing of his white blood cells (WBCs) identifies the absence of β-hexosaminidase A activity, confirming the diagnosis of which of the following?

A 5-month-old child with poor growth presents to the ER with generalized tonic-clonic seizure activity of about 30-minute duration that stops upon the administration of lorazepam. Which of the following historical bits of information gathered from the mother is most likely to lead to the correct diagnosis in this patient?

The child has had congestion without fever for the past 3 days

The child is developmentally normal, as are his siblings

The mother has been diluting the infant’s formula to make it last longer

The mother reports there are two dogs and one cat at home.

The mother previously worked as an attorney in an energy-trading firm

A 5-month-old girl is brought to the office by her mother, who states that the girl had an episode following feeding during which she began to breathe deeply, became blue, and then lost consciousness. The mother states that she picked her up and held her, and the infant regained her usual color and became alert. Physical examination reveals a harsh systolic murmur. Which of the following is the most likely diagnosis?

A 5-month-old infant has failed to gain weight despite a good appetite. The child’s mother reports that the baby has up to eight bulky, foul-smelling, oily stools per day. A sweat chloride test reveals a chloride level of 78 mEq/L (normal: < 60 mEq/L). Which of the following sequelae is most likely to occur as a result of this patient’s disease?

Cirrhosis and subsequent hepatic failure

Dehydration, electrolyte abnormalities, and acute hypotension

Esophageal ulceration or strictures and upper gastrointestinal bleeding

Purple lines on the gums, red-brown discoloration of the urine, and renal tubular acidosis

Recurrent airway disease with eventual respiratory insufficiency associated with bronchiectasis

A 5-month-old infant is brought to the office by his mother because of a rash on his face, hands and chest. The baby is constantly scratching these areas, and his mother is having a hard time keeping his hands away from the rash. She has tried a variety of over-thecounter products and many home remedies, as advised by her mother, but has noted no improvement. On physical examination, there are erythematous lesions on his cheeks with erosion, scaling, excoriated papules and plaques. Similar lesions are also found on his trunk, scalp and forehead. The lesions are symmetrical, and the diaper area appears spared. What is the most likely diagnosis?

A 5-week-old infant is brought to the clinic for a 4-week history of noisy breathing that has not improved. She has otherwise been healthy except for a current upper respiratory infection for the past 4 days, which according to the parents, has worsened the noisy breathing. On examination, she has inspiratory stridor. The noisy breathing improves when the infant is asleep. Which of the following is the most likely diagnosis?

A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanelle and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Which of the following is the most likely diagnosis?

A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanels and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. The diagnosis is best confirmed by which of the following?

A 5-year-old boy is brought to the emergency department by his mother. One week ago, he developed a low grade fever followed by persistent bouts of coughing that last 20-30 minutes each. The coughing spells are severe, unresponsive to antitussive medications, and appear to worsen with eating and drinking cold liquids. On physical examination, there is subconjunctival hemorrhage and extensive subcutaneous emphysema over the anterior chest. What is the most likely organism responsible for this child's illness?

A 5-year-old boy is brought to the emergency department due to general malaise and a swollen scrotum. His mother noticed the swollen scrotum today, and is sure that "it was not there yesterday." He had a low-grade fever and a cough two weeks ago, and "hasn't been himself ever since." He has no significant past medical history. On examination, he looks ill and lethargic. He has palpable purpura on his buttocks and lower legs. He has a swollen right scrotum which is slightly tender to palpation, and his abdomen is moderately tender to palpation. Urinalysis reveals the presence of a small amount of blood and protein. He is subsequently admitted for observation. Which of the following adverse outcomes is he most likely to develop?

A 5-year-old boy is brought to the emergency department with high-grade fevers, irritability, dyspnea and difficulty swallowing that started just hours ago. His mother reports that he had been well before going to bed, but then awoke in the middle of the night with respiratory distress. His vaccination history is uncertain. On physical examination, his temperature is 39. 1 °C (102 .4°F), pulse is 130/min, and respirations are 46/min. He appears anxious and restless, and he is drooling. While observing his respirations, you note that inspiring causes him particular distress. There is no stridor. Sitting upright with his neck hyperextended seems to give the child some relief. Which of the following is the most likely diagnosis?

A 5-year-old boy is brought to the physician because of a malodorous discharge coming from his right nostril. His parents report that the child developed frequent sneezing and mucus discharge for one week. They thought it was a common cold. The child is afebrile and in apparent good health. There is no history of allergic diseases or recurrent infections. Examination reveals obstruction of the right nasal fossa with associated purulent discharge from the right nostril. Which of the following is the most likely diagnosis?

A 5-year-old child develops an earache, but her mother is too busy to take her to the pediatrician. Two weeks later, the child still has not improved and now has a painful, swollen, red area behind the pinna. At this point, the child is taken to the emergency department, where the physician additionally notes the presence of fever and a creamy discharge in the ear canal. Which of the following is the most likely diagnosis?

A 5-year-old child undergoes a school entrance physical examination. The pediatrician notices grey-brown pigmentation on the skin of his forehead, hands, and pretibial regions. Subconjunctival areas near the corneoscleral junction show wedge-shaped, yellow-brown discoloration (pingueculae). Enlargement of both the spleen and the liver are noted on abdominal examination. Needle biopsy of the spleen demonstrates the presence of unusually large (20- to 100-mm diameter) reticuloendothelial histiocytes with a "crumpled-silk" appearance. Bone marrow biopsy demonstrates the presence of the same type of cells. Which of the following is the most likely diagnosis?

A 5-year-old febrile child presents with swelling of the right eyelid. Proptosis and limitation of ocular movements is noted. Which of the following is the most likely diagnosis?

A 5-year-old female child is brought to the emergency department due to fever, chills and abdominal pain. She has been complaining of burning micturition and abdominal pain for the last 2 days. Her temperature is 102 F (38.9C), respirations are 20/min, pulse is 130/min, and blood pressure is 90/60 mmHg. Physical examination reveals costovertebral angle tenderness. Urine analysis shows pyuria, significant bacteriuria, WBC casts, positive nitrite, and esterase. What is the most likely cause of this condition in children?

A 5-year-old girl is being evaluated for generalized swelling. Her blood pressure is 98/60 mm Hg. Her laboratory results show: Creatinine 0.7 mg/dl, Albumin 1.6 g/dL, Cholesterol 360 mg/dL, Triglycerides 400 mg/dL, C3 complement 120 mg/dL (normal, >80 mg/dL), Antinuclear antibody Negative, Urinalysis 1 RBC/hpf, protein 400 mg/dL. Which of the following is the most likely diagnosis?

Membranoproliferative glomerulonephritis

Membranous glomerulopathy

Minimal change disease

Postinfectious acute glomerulonephritis

Systemic lupus erythematosus

A 5-year-old girl is brought to the physician with low grade fever and rhinorrhea. Her symptoms began ten days ago. She has also had persistent purulent rhinorrhea, nasal congestion, and a dry cough during the day that worsens at night. Her symptoms do not seem to be improving. On examination, the child has erythema and swelling of the nasal turbinates with purulent nasal drainage. She has evidence of drainage in the posterior pharynx as well. The remainder of her examination is unremarkable. Computed topography of her face is shown below. Which of the following is the most common predisposing factor for her condition?

A 5-year-old girl is brought to the physician's office for a follow-up visit after recovering from an episode of acute bacterial meningitis. Five weeks ago, she developed pneumococcal meningitis, and was admitted to the hospital, where she underwent lumbar puncture, CT scan of the head, and ceftriaxone therapy. She was discharged in a stable condition. According to the mother, the child has not been performing well in school since her illness. She also noticed that the child has forgotten how to copy figures such as triangles and squares, and is unable to identify colours accurately. What is the most likely cause for the regression of milestones in this patient?

A 5-year-old girl presents to the emergency department with acute onset of muscle weakness. The mother carried the girl to the examination room and states that the muscle weakness started in her daughter's legs yesterday. The weakness became worse today and progressed to the trunk and both arms. She was also complaining difficulty of breathing earlier today. She has been otherwise healthy but had a common cold about 10 days ago. On examination, her respirations are 26/min and shallow. She has profound muscle weakness in her lower extremities, and moderate weakness in her upper extremities. Her deep tendon reflexes are absent. A lumbar puncture is performed, which shows increased protein concentration but no pleocytosis. Which of the following is the most likely diagnosis?

A 5-year-old girl presents with a 3-day history of fever, dyspnea, and intermittent joint pain. She has a history of sore throat about 1 month ago. On physical examination, her temperature is 39.6 C (103.2 F), blood pressure is 94/60 mm Hg, pulse is 114/min, and respirations are 22/min. Her knees and elbow joints are swollen and tender to palpation. There is a grade III/VI diastolic murmur best heard at the apex. Multiple fine, pink macules are noted on her trunk. These macules are blanching in the middle. Which of the following is the most likely diagnosis?

A 50-year-old construction worker continues to have elevated blood pressure of 160/95 mmHg even after a third agent is added to his antihypertensive regimen. Physical examination is normal, electrolytes are normal, and the patient is taking no over-the-counter medications. Which of the following is the best next step for this patient?

. Check pill count

. Evaluate for Cushing syndrome

. Check chest x-ray for coarctation of the aorta

. Obtain a renal angiogram

. Obtain an adrenal CT scan

A 50-year-old female presents with a 3-year history of abdominal pain and diarrhea. She has not been evaluated by a physician. Recently, her symptoms have been progressively worsening. Endoscopy shows multiple ulcerations of the duodenum and prominent gastric folds. Secretin stimulation test shows increased gastrin secretion. Which of the following is most likely associated with this patient's condition?

A 50-year-old male presents for the evaluation of polyuria and polydipsia of two months duration. He also complains of weakness and fatigue. He had one episode of paralysis that resolved on its own. He has a 20 pack-year history of smoking. He does not drink alcohol. His past medical and family histories are not significant His pulse is 78/min, blood pressure is 150/96 mmHg and temperature is 37°C (98.6°F). The rest of his examination, including the neurological examination, is unremarkable. Laboratory studies show: Plasma sodium 145 mEq/L, Potassium 24 mEq/L, Serum creatinine 0.8 mg/dl, Plasma renin activity low, Plasma aldosterone concentration high. Which of the following is the most likely diagnosis?

A 50-year-old man comes to the clinic seeking help for a skin condition he has had for the last 6 months. He has developed hyperpigmented, “velvety” lesions in his axilla, neck, and groin, and particularly prominent lesions on the soles of his feet and palms of his hands. Additionally, he has developed small skin tags on his neck. Since immigrating 10 years ago, he reports being in excellent health, watching his diet, and exercising regularly. Review of systems reveals some mild dyspepsia but is otherwise unremarkable. Family history includes an aunt with breast cancer but no diabetes or heart disease. He does not smoke cigarettes and only rarely drinks. Vital signs are within normal limits. The patient is a thin Japanese man in no apparent distress. Physical examination confirms the lesions about which the patient was complaining. Additionally, a firm, 3-cm left supraclavicular lymph node is palpable. Which of the following is the most likely underlying condition?

A 50-year-old man comes to the physician because of a skin rash, joint pains, malaise and fatigue. He has a history of intravenous drug abuse. His temperature is 37.1°C (98.9°F), blood pressure is 140/90 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows palpable purpura and hepatosplenomegaly. Urinalysis shows hematuria, red blood cell casts and proteinuria. The results of the laboratory studies are as follows: BUN 30 mg/dl, Creatinine 2.0 mg/dl, Serum complement Low, Anti-HCV Positive. Which of the following is the most likely diagnosis?

. Alpert's syndrome

. Acute interstitial nephritis

. Acute post infectious glomerulonephritis

. Mixed essential cryoglobulinemia

. Benign recurrent hematuria

A 50-year-old man comes to the physician for a routine check-up. He has no present complaints. He has diabetes mellitus, type 2, stable angina, and gout. He takes glyburide and atenolol. He smokes two packs a day and, occasionally, consumes alcohol. His father had an early myocardial infarction; his brother has diabetes mellitus. His blood pressure is 140/90 mm Hg and heart rate is 65/min. Physical examination shows no abnormalities. There is concern about end organ damage in this patient due to diabetes mellitus. Which of the following is the earliest renal abnormality that could be seen in this patient?

A 50-year-old man comes to the physician for a routine follow-up visit. He has hypertension, diabetes mellitus, secondary hyperparathyroidism, and end-stage renal disease. He has been on hemodialysis for the past three years. He was admitted three months ago for line sepsis, which was treated with antibiotics. He had a right below-the-knee amputation two years ago following a non-healing foot ulcer. Physical examination shows a right carotid bruit. If this patient dies within the next five years, what would be the most likely cause of his death?

A 50-year-old man is brought to the ED by ambulance with significant hematemesis. In the ambulance, paramedics placed two large-bore IVs and began infusing normal saline. In the ED, his HR is 127 beats per minute, BP is 79/45 mm Hg, temperature is 97.9°F, RR is 24 breaths per minute, and oxygen saturation is 96%. On physical examination, his abdomen is nontender, but you note spider angiomata, palmar erythema, and gynecomastia. Laboratory results reveal WBC 9000/μL, hematocrit 28%, platelets 40/μL, aspartate transaminase (AST) 675 U/L, alanine transaminase (ALT) 325 U/L, alkaline phosphatase 95 U/L, total bilirubin 14.4 mg/dL, conjugated bilirubin 12.9 mg/dL, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 26 mEq/L, blood urea nitrogen (BUN) 20 mg/dL, creatinine 1.1 mg/dL, and glucose 150 mg/dL. Which of the following is the most likely diagnosis?

A 50-year-old man presents to the emergency department for increasing abdominal distention and jaundice over the last 4–6 weeks. Examination reveals mild jaundice, spider angiomas, and ascites. Enlarged veins are noted around the umbilicus. Which one is the most likely diagnosis?

A 50-year-old man presents with excessive day- time sleepiness and a history of snoring. One week ago, he fell asleep while driving his car and got into a minor accident. On examination, he is obese (body mass index [BMI] >30) and his blood pressure is 160/90 mm Hg. His lungs are clear and heart sounds are distant. Which of the following is the most likely explanation for the symptoms associated with this condition?

A 50-year-old white male comes to the physician's office because of diarrhea, abdominal pain and weight loss. He has bulky, foul-smelling stools, abdominal distension and flatulence. He also has arthralgias and a chronic cough. His temperature is 37.8°C (100°F), blood pressure is 120/80 mm Hg, pulse is 80/min, and respirations are 18/min. Physical examination shows generalized lymphadenopathy, skin hyperpigmentation and a diastolic murmur in the aortic area. Small bowel biopsy shows villous atrophy with numerous PAS-positive materials in the lamina propria. Which of the following is the most likely diagnosis?

A 50-year-old white woman presents with aching and stiffness in the trunk, hip, and shoulders. There is widespread muscle pain after mild exertion. Symptoms are worse in the morning and improve during the day. They are also worsened by stress. The patient is always tired and exhausted. She has trouble sleeping at night. On examination, joints are normal. ESR is normal, and Lyme antibody and HIV test are negative. A diagnosis is best made by which of the following?

A 50-year-old woman comes to clinic due to several episodes of severe watery diarrhea for the past 15 days. There is 4/10 pain all over her abdomen but she has not noticed any blood in her stools. She has normal diet and has not travelled anywhere recently. She denies any one around her having similar complaints. She also had occasional cramps in her leg muscles and feels dehydrated. She smokes one to two cigarettes a day and drinks socially. Her temperature is 36.8°C (98.1°F), blood pressure is 108/64 mmHg, pulse is 118/min, and respirations are 18/min. On examination her abdomen is slightly tender. Laboratory results are as follows. WBC 5600mm3, Hemoglobin 13.6, Hematocrit: 41%, Platelets 209,000mm3, Sodium 138mEq/L, Potassium: 2.1mEq/L, Bicarbonate: 35mEq/L, Blood urea nitrogen: 16 mg/dl, Creatinine: 0.8 mg/dl, Glucose 106 mg/dl. A CT abdomen is ordered which shows a mass in the head of pancreas. What is the most probable diagnosis?

A 50-year-old woman complains of leakage of urine. After genuine stress urinary incontinence, which of the following is the most common cause of urinary leakage?

A 50-year-old woman develops pink macules and papules on her hands and forearms in association with a sore throat. The lesions are target like, with the centers a dusky violet. What causes of this disorder are most likely in this patient?

. Tampons and superficial skin infections

. Drugs and herpesvirus infections

. Rickettsial and fungal infections

. Anxiety and emotional stress

. Harsh soaps and drying agents

A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

A 50-year-old woman presents to the physician’s office for evaluation of a right neck mass. The mass has been present for 3 years and is painless. On examination, a nontender, firm, 2.5-cm mass is noted slightly below and posterior to the angle of the mandible on the right. Which one is the most likely diagnosis?

A 50-year-old woman presents to your office complaining of severe insomnia, hot flashes, and mood swings. She also states that her mother had a hip fracture at 65 years of age. She is afraid of developing osteoporosis and having a similar incident. Her last menstrual period was six months ago. Her past medical history is significant for hypothyroidism diagnosed seven years ago. She takes L-thyroxine and the dose of the hormone has been stable for the last several years. Her blood pressure is 120/70 mmHg and her heart rate is 75/min. Serum TSH level is normal. You consider estrogen replacement therapy for this patient. Which of the following is most likely concerning estrogen replacement therapy in this patient?

. The level of total thyroid hormones would decrease

. The metabolism of thyroid hormones would decrease

. The requirement for L-thyroxine would increase

. The volume of distribution of thyroxine would decrease

. The level of TSH would decrease

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