5th Para USMLE 100Q

A 5-week-old bottle-fed boy presents with persistent and worsening projectile vomiting, poor weight gain, and hypochloremic metabolic alkalosis. Of the following diagnostic modalities, which would most likely reveal the 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. Electrolytes and a urinalysis are evaluated. Which of the following laboratory findings are most likely to be seen in this patient?

A 5-year-old boy develops a headache, cough, myalgia and a fever. He has been a healthy child with all immunizations up to date. He is given a decongestant and an aspirin for his symptoms with some relief. However, 4 days later, he is brought back by his parents because of persistent vomiting and irritability. On physical examination, he is found to be semicomatose, becoming combative on stimulation. Which of the following levels should be measured to aid in the diagnosis of this patient?

A 5-year-old boy is brought to clinic with increasing right lower foot pain. He stepped on a nail several days ago. At that time, the family had sought medical attention. The child was given a tetanus shot, and the wound was extensively irrigated. On examination, the foot is tender, swollen, warm, and erythematous. Osteomyelitis is suspected. Which of the following is the most appropriate next step in diagnosis?

A 5-year-old boy is brought to the clinic by his mother because he was sent home by the school nurse. The nurse claims to have heard a murmur in his chest. The child has always been healthy, and has never had any shortness of breath, chest pain, dizziness or any other illnesses. On examination, the child appears alert, and his vital signs are stable. Auscultation of the chest reveals a grade-2 systolic ejection murmur at the left sternal border, but no other extra sounds. The murmur changes with position. What is the best next step in the management of this patient?

A 5-year-old boy presents to the emergency department with 2-day history of fever, anorexia, loose stools, and yellow skin color. He attends a large daycare center. On physical examination, his temperature is 38.1 C (100.7 F), blood pressure is 88/56 mm Hg, pulse is 74/min, and respirations are 15/min. Initial laboratory evaluation reveals a total bilirubin of 1.8 mg/dL and alanine aminotransferase of 764 U/L. Which of the following is the most appropriate diagnostic test?

A 50-year-old G4P4 presents for her well-woman examination. She had one cesarean delivery followed by three vaginal deliveries. Her menses stopped 1 year ago and she occasionally still has a hot flash. She tells you that about 10 years ago she was treated with a laser conization for carcinoma in situ of her cervix. Since that time, all of her Pap tests have been normal. What recommendation should you make regarding how frequently she should undergo Pap smear testing?

A 50-year-old male presents to his physician complaining of daytime somnolence. He reports that yesterday, he fell asleep while stopped at a red light. His wife adds that he is a habitual snorer, and sometimes seems to stop breathing for seconds at a time while sleeping. His past medical history is significant for hypertension, a 25 pack-year smoking history, and a two beer per day drinking habit. Physical examination reveals an obese, middle-aged man in no apparent distress. His pulse is 88/min, blood pressure is 160/100 mm Hg, and respirations are 14/min. The remainder of the physical examination, including chest auscultation, is within normal limits. Which of the following is the most appropriate next step in the management of this patient?

A 50-year-old man comes in for his annual check-up. There is a swelling on his left eyelid, which he casually acknowledges by saying that it has appeared "on-and-off for the past 2 years." It initially starts as a painful lesion which regresses with hot compresses, but then eventually reappears. On examination of his left eye, you note a nodular, painless, rubbery lesion on the eyelid without any discharge, redness or other abnormalities. What is the best next step in the management of his eye lesion?

A 50-year-old man comes to the physician because of a 2-day history of constipation and not passing flatus. For the last 3 days he has been having intermittent, but worsening, right lower quadrant (RLQ) pain. He has vomited several times today and feels nauseated. Examination shows a distended abdomen with tenderness in the RLQ; there is no rebound; there are no masses or hernias; bowel sounds are absent. Rectal examination shows an enlarged prostate. An upright x-ray film of the abdomen shows gas distributed throughout the small and large bowel, and some fluid levels. After nasogastric tube placement and hydration, his temperature is 36.50C (97.60F), blood pressure is 140/80 mm Hg, pulse is 57/min, and respirations are 12/min. Laboratory studies show: RBC count 4.5 million, WBC 7,400, Na 140, K 3.5, Cl 100, BUN 15 mg/dl, Creatinine 1.0 mg/dl, Urine pH 5.5, Urine sediment: 2 W BC and 15 RBC/high power field, and needle-shaped crystals are present. Which of the following is the most appropriate next step in management?

A 50-year-old man presents with intractable peptic ulcer disease, severe esophagitis, and abdominal pain. Which of the following is most consistent with the diagnosis of Zollinger-Ellison syndrome?

A 50-year-old man with a history of alcohol and tobacco abuse has complained of difficulty swallowing solid food for the past 2 months. More recently, swallowing fluids has also become a problem. He has noted black, tarry stools on occasion. The patient has lost 10 lb. Which of the following statements is correct?

A 50-year-old pale man comes to the office and says, "For the past year, I've been feeling very weak. I get tired early, and I feel that I've lost my sense of humor. I find it difficult to remember things now." When asked about his social history, he says, "I'm jobless and am living on social security benefits. I don't drink or smoke anymore, but I was charged with driving under the influence three times before." His parents died of old age. He shares his room with four friends. His vital signs are normal. CBC reveals: WBC 5,500 /mm3, Hemoglobin 7.0 mg/dl, Hematocrit 22%, Platelets 196,000/mm3, RBC count 1.7 million, MCV 119 fl, MCH 36, MCHC 28%, Reticulocyte count 04%. Peripheral smear shows anisocytosis, poikilocytosis, and basophilic stippling. What is the best next step in the management of this patient?

A 50-year-old salesman is on a yacht with a client when he has a severe vomiting and retching spell punctuated by a sharp substernal pain. He arrives in your emergency room 4 hours later and has a chest film in which the left descending aorta is outlined by air density. Which of the following is the most appropriate next step in his workup?

A 50-year-old white male presents with complaints of bitter taste and central chest pain. He further describes he pain as moderate-to-severe, occurring during or after meals, non-radiating, and burning. The pain is relieved with antacids, and worsened by lying supine. He has lost 10 lbs (4.5kg) over the past 5-months (unintentional). He has smoked 2 packs of cigarettes daily for 20 years. His vital signs are stable, and he is afebrile. The physical examination is unremarkable. Chest x-ray and EKG show no abnormalities. Which of the following is the most appropriate next step in management?

A 50-year-old woman comes to the office and complains of right shoulder pain which radiates to her hand. She has had cough for many weeks, and feels "more tired than the usual." In addition, her fingers are always swollen, and she now finds it difficult to walk because her knees give way. She has had rheumatoid arthritis for the past 10 years and is used to having pain in her joints; however, she believes that this pain is not due to her arthritis. She takes celecoxib for rheumatoid arthritis. She admits to smoking one pack of cigarettes daily for the past 25 years and to drinking one odd beer every night. All her family members have crippling rheumatoid arthritis. Her vital signs are stable. She is afebrile. Physical examination reveals drooping of the right eyelid and miosis. What is the best next step in the management of this patient?

A 51-year-old man comes to the office for his annual examination. He is apparently healthy, and does not have any complaints. His diet is normal, and he exercises regularly. He experiences some stress at work, but says that he is "strong and can fight it out." His father died of a heart attack 4 years ago, and his mother has Alzheimer's disease. His brother has recently been diagnosed with colonic polyps. His vital signs are stable. Hematology and chemistries are within normal limits, but the fecal occult blood test (FOBT) is positive. What is the best next step in the management of this patient?

A 52-year-old Caucasian male presents complaining of diminished energy for the past three months. He appears very sad and moves slowly. He says that he has been feeling terrible after his wife died in a car accident three months ago. He is filled with thoughts of guilt because he was driving the car when the accident took place. Since then, he has been suffering from disturbed sleep and finds himself unable to focus on his favorite activities, like coin collecting or fishing. He reports being disturbed by repeated flashbacks of the event. He keeps himself aloof and isolated from others because he "just doesn't feel like socializing anymore." He adds that he has a poor appetite and has gained 20 lbs (9.1 kg). He admits to wanting to "end my life in order to escape the memories of that nightmarish day." He is able to contract for safety. What is the most appropriate next step?

A 52-year-old male comes to the office due to a sudden onset of photophobia, redness around the eye and pain in his right eye. He also has nausea and a terrible headache, which has not responded to ibuprofen. He denies any trauma, and has never had such an episode before. He was watching TV when the event started. The physical examination reveals a non-reactive mid-dilated pupil. The eye appears red with conjunctival flushing. What is the best diagnostic test for this patient's condition?

A 52-year-old woman in renal failure is listed as a transplant candidate. In order to assess the propriety of the transplant, which of the following combinations represents how a cross-match is performed?

A 52-year-old woman presents with gradual-onset weakness in her leg muscles. She has noted difficulty climbing stairs and raising from a chair that has been worsening for the past few years. She initially related her symptoms to simply being "out of shape." She has no problem with chewing food. She has no pain in her muscles and has no skin rash. She takes metoprolol and hydrochlorothiazide for hypertension. She does not use tobacco, alcohol or drugs. Her vital signs are within normal limits. Examination reveals mild weakness of the thigh muscles in both legs. Deep tendon reflexes and sensory examination shows no abnormalities. Babinski sign is negative. Which of the following is most likely abnormal in this patient?

A 52-year-old woman returns to the clinic for a followup appointment. She has had fatigue and anorexia for the past 6 months that, despite an extensive workup, including age-appropriate cancer screening, thyroid testing, routine blood studies, and psychiatric screening, has eluded a diagnosis. She now returns with the same complaints of fatigue and diminished appetite, but now is complaining also of lower abdominal bloating and pressure. Before these 6 months, she had been in excellent health. Her past medical history is unremarkable, though she does have an uncle who had diabetes and colon cancer, an aunt with breast cancer, and a mother who died of uterine cancer. Vital signs are within normal limits. Physical examination reveals a mildly distended, nontender abdomen that is increased in size since her last visit. Additionally, the pelvic examination reveals a possible nontender adnexal mass, though it is difficult to palpate. A CA-125 level is within normal limits. Which of the following is the most appropriate next diagnostic study?

A 52-year-old woman sees her physician with complaints of fatigue, headache, flank pain, hematuria, and abdominal pain. She undergoes a sestamibi scan that demonstrates persistent uptake in the right superior parathyroid gland at 2 hours. Which of the following laboratory values is most suggestive of her diagnosis?

A 53-year-old male presents to the emergency room complaining of chest pain localized to the left chest wall and following a linear pattern along the fifth intercostal space. His past medical history is significant for polycystic kidney disease and hypertension. His current medications are metoprolol and amlodipine. He has a ten pack-year smoking history but quit 14 years ago. He consumes alcohol occasionally. His blood pressure is 160/90 mmHg and his heart rate is 90/min. Physical examination is noncontributory. His laboratory findings are as follows: Sodium 142 mEq/L, Potassium 4.2 mEq/L, Hemoglobin 9.5 mg/dl, WBC 10,000/mm3, Creatinine 1 .9 mg/dl, BUN 28 mg/dl. Chest x-ray reveals a solitary round lesion in the left upper lung field that measures 2 cm in diameter. It does not about the pleura. Which of the following is the best next step in managing this patient?

A 53-year-old man presents with constipation and a 20-lb weight loss over the course of 6 months. Colonoscopy reveals a fungating mass in the sigmoid colon; biopsy is consistent with adenocarcinoma. His metastatic workup is negative. A CEA level is obtained and is 4-fold greater than normal. Which of the following is the appropriate use of this test?

A 53-year-old white male comes to your office with long history of cough, periodic shortness of breath, and wheezing. His family history is significant for asthma in his mother and hypertension and diabetes in his father. He is not taking any medications. He smokes two packs a day ever since he was 16 years of age and consumes alcohol occasionally. Physical examination reveals bilateral scattered expiratory wheezes. Which of the following tests can help you most in differentiating asthma from emphysema in this patient?

A 53-year-old woman comes to the physician because of a "lump" in her neck. She says that her masseuse noticed it 1 month ago. There is no associated pain, pressure, or hoarseness. She feels fine and has no other complaints. She has no history of radiation exposure. Examination reveals a palpable thyroid nodule that is approximately 3 cm. Which of the following is the most appropriate next step in diagnosis?

A 53-year-old woman comes to the physician for an annual examination. She has no complaints. She has hypertension, for which she takes a thiazide diuretic, but no other medical problems. Her past gynecologic history is significant for normal annual Pap tests for many years, her last being 2 months ago. A recent mammogram was negative. Heart, lung, breast, abdomen, and pelvic examination are unremarkable. Which of the following procedures or tests should most likely be performed on this patient?

A 53-year-old woman with a history of a vagotomy and antrectomy with Billroth II reconstruction for peptic ulcer disease presents with recurrent abdominal pain. An esophagogastroduodenoscopy (EGD) demonstrates that ulcer and serum gastrin levels are greater than 1000 pg/mL on three separate determinations (normal is 40-150). Which of the following is the best test for confirming a diagnosis of gastrinoma?

A 54-year-old African American man, with a history of smoking and drinking, describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds. Which of the following is the most appropriate first step in diagnosis?

A 54-year-old male comes to the office for follow-up care of his foot ulcer. He has no complaints regarding the ulcer, but he has recently become polyuric and polydipsic. Fasting blood work reveals elevated glucose levels. He is prescribed oral hypoglycemics, and counseled on self-monitoring at home. On his next follow-up visit, the patient proudly states that he has been "very compliant" with his medications, and that his glucose levels are "always well-controlled." Which of the following is the best way to determine whether this patient is telling the truth?

A 54-year-old man sees you because of a growth on his lower lip. He smokes tobacco, has a fair complexion, and works outdoors. The biopsy report confirms a carcinoma. Which of the following is the most common diagnosis for tumors involving the lips?

A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing a tight belt, or lying flat in bed at night. He gets symptomatic relief from over-the-counter antiacids or H2 blockers, but has never been formally studied or treated. The problem has been present for many years and seems to be progressing. Which of the following is the most appropriate next step in management?

A 54-year-old patient walks into a blood donation camp at a community hospital. His blood report shows an ELISA positive for HIV and HBsAg. He is notified of this finding, and a subsequent western blot test is also positive for HIV. Considering this new diagnosis of HIV, which of the following is indicated in this patient?

A 55-year-old G3P3 with a history of fibroids presents to you complaining of irregular vaginal bleeding. Until last month, she had not had a period in over 9 months. She thought she was in menopause, but because she started bleeding again last month she is not sure. Over the past month she has had irregular, spotty vaginal bleeding. The last time she bled was 1 week ago. She also complains of frequent hot flushes and emotional lability. She does not have any medical problems and is not taking any medications. She is a nonsmoker and denies any alcohol or drug use. Her gynecologic history is significant for cryotherapy of the cervix 10 years ago for moderate dysplasia. She has had three cesarean sections and a tubal ligation. On physical examination, her uterus is 12 weeks in size and irregularly shaped. Her ovaries are not palpable. A urine pregnancy test is negative. Which of the following is the most reasonable next step in the evaluation of this patient?

A 55-year-old male presents with face and arm swelling that he says is worst when he wakes in the morning. He also notes a 10-pound unintentional weight loss over the past three months, plus new-onset exertional dyspnea. His past medical history is significant for hypertension, for which he takes hydrochlorothiazide. He has smoked cigarettes for the past 40 years and drinks alcohol occasionally. On physical examination, he is afebrile and his vital signs are within normal limits. His face is plethoric and darkappearing. The veins on the anterior chest wall appear engorged. His abdomen is soft, non-tender, and nondistended, and there is no organomegaly. The lower extremities are non-edematous. What is the most appropriate next step in the management of this patient?