Frence

A 2-week-old neonate is brought to the office due to poor feeding and persistent vomiting. He had an episode of jerky movements of his limbs this morning. He was delivered at term with no complications and weighed 2.7kg (6 Ib) at birth. He appears lethargic, irritable and jaundiced. On examination, he weighs 2.2kg (5 Ib). His liver and spleen are enlarged. Bilateral cataracts are evident. Which of the following is most consistent with these findings?

A 16-year-old boy is brought into the emergency department by his friends. He is semicomatose, with a pulse of 60/min and respirations of 6-8/min. His pupils are constricted. Which of the following will most likely be revealed on a urine toxicology screen?

) A 16-year-old girl presents with a history of primary amenorrhea. On examination, short stature and a short neck with a low posterior hairline are noted. Chromosomal analysis most likely would reveal which of the following?

A 2-year-old boy is rushed to the emergency department by his 21 -year-old white mother because he had a sudden-onset nosebleed which has now subsided. He never had any previous episodes. He is "sickly" and suffers from a productive cough and diarrhea that "refuses to go." His stools are greasy and foul-smelling. His appetite is normal, although his diet consists mainly of milk. His mother's boyfriend lives with them and is a chronic alcoholic. He was delivered vaginally without any complications. His weight is at the 25th percentile for his age. Physical examination reveals dry skin and dried blood at the nasal turbinates. What is the most likely cause of this child's failure to thrive

A 22-year-old Caucasian female who has received no prenatal care experiences a stillbirth. This is her first pregnancy. The baby has multiple fractures, blue sclerae and short, bent extremities. Her past medical history is significant for a seizure disorder. She has been taking phenytoin regularly and had no seizure episodes during the pregnancy. She admits to eating poorly and occasionally drinking alcohol during the first trimester. She lives with her boyfriend who abuses her physically. She recalls several episodes of abuse during the pregnancy. Which of the following is most likely responsible for fetal abnormalities?

A 22-year-old female presents to the emergency room with a nosebleed. A quick review of her records reveals that she presented with the same problem yesterday, at which time the bleeding was stopped with prolonged local pressure. On review of systems, the patient also reports easy bruising for the past several months. On physical examination, her heart and lungs appear normal. The liver span is 8 cm and the spleen is not palpable. There are scattered ecchymoses over her arms and legs. Laboratory findings include the following: Hematocrit 45%, Platelet count 9,000/mm3, Leukocyte count 5,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%, Fibrinogen 250 mg/dL, Prothrombin time 13 sec. Which of the following is the most likely cause of this patient's condition?

A 25-year-old African American woman presents with a photo distributed skin rash and arthralgias. She is found to have low-range proteinuria and abnormal urinary sediment. Renal biopsy findings are consistent with focal proliferative glomerulonephritis. Her complete blood count shows: Erythrocyte count 3.2 mln/mm3, Platelets 60,000/mm3, Leukocyte count 2,500/mm3. Which of the following is the most likely cause of these hematologic findings?

) A 25-year-old married female is brought to the emergency department by her mother for excruciating right-sided abdominal pain. A urine pregnancy test is positive and a pelvic ultrasound reveals an empty uterus. Ruptured ectopic pregnancy is suspected, and an operating room is reserved for an emergent laparotomy. The patient's medical history is unremarkable except for a psychiatric diagnosis of paranoid schizophrenia. Who should sign the informed consent paperwork for the procedure?

A 29-year-old man with HIV, on a highly active antiretroviral therapy (HAART) regimen including the protease inhibitor indinavir, presents with severe edema and a serum creatinine of 2.0 mg/dL. He has had bone pain for 5 years and takes large amounts of acetaminophen with codeine, aspirin, and ibuprofen. He is on prophylactic trimethoprim-sulfamethoxazole. Blood pressure is 170/110 mm Hg; urinalysis shows 4+ protein, 5 to 10 RBC, 0 WBC; 24-hour urine protein is 6.2 g. The serum albumin is 1.9 g/L (normal above 3.7). Which of the following is the most likely cause of his renal disease?

A 30-year-old G3P3 is postoperative day 4 after a repeat cesarean delivery. During the surgery she received 2 units of packed red blood cells for a hemorrhage related to uterine atony. She is to be discharged home today. She complains of some yellowish drainage from her incision and redness that just started earlier in the day. She states that she feels feverish. She is breast-feeding. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. Her vital signs are temperature 37.8C (100.1F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Breast, lung, and cardiac examinations are normal. Her midline vertical skin incision is erythematous and has a foul-smelling purulent discharge from the lower segment of the wound. It is tender to touch. The uterine fundus is not tender. Which of the following is not a risk factor for her condition?

A 32-year-old male complains of progressive weakness and exertional dyspnea. His past medical history is significant for a knife injury to the right thigh two months ago. He has been arrested several times for robbery. He consumes alcohol regularly, and smokes crack occasionally. His younger brother died of cystic fibrosis. His blood pressure is 160/60 mmHg, and heart rate is 100/min. His extremities are warm and flushed. Carotid upstroke is brisk. The point of maximal impulse is displaced to the left, and a soft, holosystolic murmur is heard over the cardiac apex. The murmur does not change with the Valsalva maneuver. Which of the following is the most likely cause of this patient's symptoms?

) A 34-year-old man rushes into the ER complaining of severe substernal chest pain that began abruptly 30 minutes ago. He says that he also feels as though his heart 'is racing,' but denies any shortness of breath, cough or fever. He has never experienced pain like this before. His past medical history is significant for an appendectomy one year ago. The patient reports that his father died at age 64 due to "some heart problem" and his mother died of ovarian cancer. On physical examination, the patient is agitated and sweating profusely. His pulse is 110/min, blood pressure is160/100 mmHg, and respirations are 14/min. Physical examination is normal except for dilated pupils and a small amount of blood at the external nares. EKG shows ST elevations in leads v1-v4. What is the most likely explanation for his symptoms?

A 34-year-old obese Caucasian female complains of periodic visual obscurations. She has episodes during which she "goes blind" for several seconds when standing up or stooping forward abruptly. She also describes frequent morning headaches over the last two months for which she has had to take ibuprofen or aspirin almost every morning. She takes no other medications. Past medical history is insignificant aside from one uncomplicated vaginal delivery. She denies use of alcohol, tobacco, or illicit drugs. She is afebrile with a blood pressure of 138/88 mmHg and pulse of 93/min. Visual field testing shows enlarged blind spots. There are no other significant findings on neurologic examination. Which of the following is the most likely cause of this patient's symptoms?

A 4-week-old boy is brought to clinic by his mother because of a 1 day history of labored breathing. His birth was uneventful and immunizations have been up to date. His mother reports that the patient developed conjunctivitis on the fourth day of life. On physical examination, he is breathing rapidly at 40 breaths per minute and is afebrile. His chest reveals bilateral inspiratory crackles and a slight wheeze. On chest x-ray, bilateral pneumonia is evident. The leukocyte count is elevated at 15,000 with 40% eosinophils. Which of the following is the most likely pathogen causing the patient's symptoms?

A 44-year-old woman presents with increased shortness of breath, cough, and sputum production. She has had asthma since childhood and uses her medications as directed. Recently, she noticed that her peak flow readings were decreasing after the symptoms started. On examination, she is in moderate respiratory distress, respirations 25/min, there are bilateral wheezes and oxygen saturation is 90% on room air. On her blood gas, the PCO2 is 50 mm Hg. Which of the following is the most likely mechanism for her carbon dioxide retention?

A 52-year-old female presents with a rash over her face for the past few weeks. She also complains of recent-onset difficulty with rising from a seated position and climbing stairs. On examination, you notice a dusky malar rash and a violaceous periorbital edema. Her vital signs are within normal limits. Examination shows symmetric proximal muscle weakness in legs. This patient's condition is most often associated with which of the following

A 52-year-old man with a family history of multiple endocrine neoplasia type 1 (MEN1) has an elevated gastrin level and is suspected to have a gastrinoma. Which of the following is the most likely location for his tumor?

A 53-year-old female presents to the clinic with an erythematous lesion on the dorsum of her right hand. The lesion has been present for the past 7 months and has not responded to corticosteroid treatment. She is concerned because the lesion occasionally bleeds and has grown in size during the past few months. On physical examination you notice an 11-mm erythematous plaque with a small central ulceration. The skin is also indurated with mild crusting on the surface. Which of the following is true about this process?

A 64-year-old man complains of palpitations and progressive shortness of breath over the past several hours. He says that he also develops a choking sensation every time he tries to lie down. His medical history is significant for hypertension for the past 20 years and medication non-compliance. He also has a 35-year smoking history. He reports that his father died of a heart attack at age 70 and his mother suffered from asthma. On physical examination, his blood pressure is 170/100 mmHg and his heat rate is 130/min and irregularly irregular. Lung exam reveals bibasilar crackles. There is 2+ pitting edema of the lower extremities. Bedside echocardiography shows a left ventricular ejection fraction of 55%. Which of the following is most likely responsible for his symptoms?

A 65-year-old male has been having a non-productive, hacking cough for over a week. He takes an over-the-counter medication containing guaifenesin and diphenhydramine in an effort to improve his symptoms. The next day, he complains of lower abdominal discomfort and difficulty voiding. Which of the following most likely accounts for this patient's new complain

A 68-year-old Caucasian man is admitted with a diagnosis of left lower lobe pneumonia, and is started on gatifloxacin. He has a long history of diabetes, hypothyroidism, hypercholesterolemia, and hypertension. He also has diabetic retinopathy, peripheral neuropathy, and nephropathy. He has an arterio-venous fistula placed for a possible dialysis. His medications are insulin, furosemide, atorvastatin, metoprolol and levothyroxine. After having his blood drawn for some laboratory studies today, he bleeds persistently. Laboratory studies show: Hb 11.5 g/dl, Platelets 160,000/cmm, Blood glucose 178 mg/dl, BUN 56 mg/dl, Serum creatinine 3.5 mg/dl. His baseline creatinine level is between 3.2-3.5 mg/dl. Which of the following is the most likely cause of his bleeding?

A 7-year-old girl is brought to the office by her mother. The mother is worried because she noticed some axillary hair development in her daughter. The girl appears calm, and denies the presence of headaches, visual disturbances or abdominal pain. There has been no change in her behavior. Her medical history is unremarkable. Her older sister's pubertal changes began at age 11. Physical examination reveals scarce and dark axillary hair, absent breast development and absent pubic hair. The rest of the examination is unremarkable. Activation of which of the following structures is most likely responsible for this patient's symptomatology?

A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies?

A previously healthy 4-year-old child is brought to the physician for a school physical for kindergarten. His mother has brought in his immunization record and reports that received all his immunizations prior to age 2. He has received only a yearly influenza vaccine since age 2. His physical examination is unremarkable. Which of the following immunizations should he be given during this visit?

A 14-year-old boy is brought to the psychiatrist because for the past 15 months he has been irritable and depressed almost constantly. The boy notes that he has difficulty concentrating, and he has lost 5 lb during that time period without trying. He states that he feels as if he has always been depressed, and he feels hopeless about ever feeling better. He denies suicidal ideation or hallucinations. He is sleeping well and doing well in school, though his teachers have noticed that he does not seem to be able to concentrate as well as he had previously. Which of the following is the most likely diagnosis?

A 14-year-old boy presents with decreased exercise tolerance. He is noted to have a grade III/VI systolic ejection murmur best heard at the left upper sternal border and a grade II/VI mid-diastolic murmur at the lower left sternal border. The first heart sound is normal. The second heart sound is widely split and fixed. A right ventricular impulse is palpated. On a chest roentgenogram, the pulmonary artery segment is enlarged, and pulmonary vascular markings are increased. An ECG shows right axis deviation. Which of the following congenital heart diseases does this boy most likely have?

) A 15-year-old girl presents to a pediatric cardiology clinic with a complaint of chest pain. She states the pain has come and gone over the past year, but has increased in frequency over the past few weeks. She describes it as a sharp pain over her left chest. Physical examination reveals a healthy-appearing 15-year-old girl. Her temperature is 37.2 C (99 F), pulse is 90/min, and respiratory rate is 20/min. Lung examination is normal. Cardiac examination reveals a late systolic murmur preceded by a click at the apex. No heave or rub is present. An electrocardiogram and chest x-ray film are unremarkable. Which of the following is the most likely diagnosis?

A 2 and a half-year-old child is brought to the office for the evaluation of easy bruising, nosebleeds, and decreased activity over the past week. He had an upper respiratory infection that was treated with an antibiotic 2 weeks ago. On examination, he is well-developed, seems well-nourished, anicteric, and pale. Pertinent findings include some small palpable posterior cervical lymph nodes, sinus tachycardia, a grade I/VI systolic ejection murmur, ecchymoses on his left shoulder and both lower extremities, and petechiae over his extremities and groin. There is no hepatosplenomegaly. The laboratory findings are as follows: Hemoglobin 7.9 g/dl, Hematocrit 24%, Platelet count 12, 000/mm3, WBC 3,000/mm3, Reticulocyte count 0.5%. A bone marrow biopsy reveal a markedly hypocellular marrow with decreased megakaryocytes and precursors of the erythroid and myeloid cell lines. What is the most likely diagnosis?

A 2-hour-old male neonate has developed worsening cyanosis over the past few minutes. The infant was vaginally delivered (assisted with forceps) at full term and weighed 4.1 kg (9 lb). The Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Oxygen is administered by mask but does not relieve the cyanosis. Further examination reveals tachypnea, subcostal retractions, a normal first heart sound, a single and loud second heart sound (S2), and no murmur. Which of the following is the most likely cause of the infant's cyanosis?

A 2-month-old infant is evaluated by a pediatric cardiologist. The infant was noted at birth to have an upper left sternal border ejection murmur. The infant at that time was not cyanotic, but slowly developed cyanosis over the next two months. At the time of the pediatric cardiologist's examination, an ECG showed right axis deviation and right ventricular hypertrophy. A chest x-ray film showed a small heart with a concave main pulmonary artery segment and diminished pulmonary blood flow. Which of the following is the most likely diagnosis?

) A 2-year-old child is brought to the physician for a routine visit. He is growing and developing appropriately. He eats a variety of foods including meat, vegetables, and fruits, and 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 is unremarkable. Routine laboratory studies show the following: Hemoglobin 9.5 g/dl, RDW 14%, MCV 65 fl, Reticulocyte count 3.0%, Platelet count 212,000/mm3, Leukocyte count 6,500/mm3, TIBC 300 mcg/dl (240-450 mcg/dl), Ferritin 100 ng/ml (7 -140 ng/ml). What is the most likely cause for this child's anemia?

A 20-year-old white female presents with chest pain for the past few weeks. She describes the pain as sharp, located to the left of the sternum, and lasting 5-10 seconds at a time. There is no associated fever, cough, breathlessness, palpitations, or syncope. She does not smoke or drink alcohol. On cardiac examination, there is a short systolic murmur at the apex that disappears with squatting. Which of the following is the most likely diagnosi

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?

A 26-year-old woman presents to your office complaining of fatigue. Her past medical history is insignificant. She was adopted in Greece and came to the United States when she was three years old. Her menstrual periods are regular and bleeding lasts three days. She does not use tobacco, alcohol, or illicit drugs. She takes no medication. Laboratory studies show: Complete blood count: Hemoglobin 10.1 g/L, MCHC 28%, MCV 70 fL, Platelets 200,000/mm3, Leukocyte count 7,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%. Fecal occult blood test is negative. Iron therapy is initiated. When the patient returns four weeks later, her lab findings are essentially the same. This patient most likely suffers from:

A 27-year-old woman, gravida 2, para 2, comes to the physician to have her staples removed after an elective repeat cesarean delivery. Her pregnancy course was uncomplicated. She states that she is doing well except that since the delivery she has noticed some episodes of sadness and tearfulness. She is eating and sleeping normally and has no strange thoughts or thoughts of hurting herself or others. Physical examination is within normal limits for a patient who is status post cesarean delivery. Which of the following is the most likely diagnosis?

) A 28-year-old female presents to her family doctor with her mother, who complains that her daughter has been behaving eccentrically and has been socially withdrawn for the past year. The mother says that her daughter used to be very lively and friendly, but that she abruptly quit her job as a data analyst one year ago and now prefers to stay home in her bedroom most of the time. The patient is thoroughly evaluated by a psychiatrist. During that interview, she reveals to the psychiatrist that she constantly hears "so many voices" in her head. The voices tell her various things of a critical and suspicious nature. She also adds that she feels very sad and has had numerous severe crying spells after her pet dog's death four months ago. She prefers to be alone and does not enjoy interacting with others. She has poor sleep and little appetite. Which of the following is the most likely diagnosis in this woman?

A 30-year-old man presents to his primary care physician and describes a sense of generalized fatigue. He reports having been very energetic and healthy during his college days but says that "everything has seemed to be go wrong" for at least the last 6 years. He eats poorly and has lost 8 pounds over the last three years. He sleeps 12 hours per night and says that he has difficulty concentrating on most tasks. His past medical history is otherwise unremarkable, and he does not abuse drugs or alcohol. The patient says that he is not suicidal and still enjoys watching baseball with his friends. Based on the above presentation, what is the most likely diagnosis?

A 34-year-old G1P1 who delivered her first baby 5 weeks ago calls your office and asks to speak with you. She tells you that she is feeling very overwhelmed and anxious. She feels that she cannot do anything right and feels sad throughout the day. She tells you that she finds herself crying all the time and is unable to sleep at night. Which of the following is the most likely diagnosis?

A 35-week-term infant presents with cyanosis shortly after birth. His arterial oxygen saturation is only 30%. Which of the following is the most likely diagnosis?

A 35-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unconscious. His blood pressure is 100/50 mm Hg, pulse is 100/min, and respirations are 19/min. Examination shows bilaterally reactive and non-dilated pupils. He does not follow commands and makes inappropriate sounds. A CT scan of the head shows numerous minute punctuate hemorrhages with blurring of the gray-white matter interface. Which of the following is the most likely diagnosis?

A 35-year-old white male presents with fatigue, decreased appetite, weight gain, constipation and cold intolerance. He cannot recall any stressful event. He does not take any medications. He is a non-smoker and non-alcoholic. His pulse is 47/min and blood pressure is 145/91 mmHg. Physical examination reveals cool, pale skin, coarse hair, and brittle nails. There is delayed relaxation of deep tendon reflexes. The thyroid gland is normal on palpation. Laboratory studies reveal increased serum free T3 and T4 levels, and normal serum TSH level. Which of the following is the most likely diagnosis?

A 4-year-old boy is brought to the office because his school teacher thinks that his dusky blue appearance may have something to do with his inability to participate in regular school activities. His mother says that he has always appeared slightly out of breath. He has no history of any trauma, past surgery or medical conditions. His birth history is unremarkable. Physical examination reveals perioral cyanosis and a systolic murmur along the left sternal border. When the child squats, the murmur disappears and the cyanosis slightly improves. What is the most likely diagnosis of this patient?

A 4-year-old boy presents with severe pains in both of his legs. On physical examination, his temperature is 37.7 C (99.8 F), blood pressure is 108/68 mm Hg, pulse is 96/min, and respirations are 17/min. He is noted to have marked pallor on his lips and palpebral conjunctiva. Numerous purpura and petechiae are noted on his skin. His spleen is palpable 3 cm below his left costal margin. Laboratory evaluation reveals a white blood cell count of 1600/mm3; hemoglobin, 6.1 g/dL; and platelets, 36,000/mm3. Which of the following diagnoses is most consistent with these findings?

A 4-year-old, apparently healthy child is examined by a pediatrician. The pediatrician hears a loud systolic ejection murmur with a prominent systolic ejection click. He also hears a soft, early diastolic murmur. Both murmurs are heard best at the upper right sternal border. ECG shows left ventricular hypertrophy. Which of the following is the most likely diagnosis?