3RD Para USMLE 100Q

A 30-year-old female complains of palpitations, fatigue, and insomnia. On physical examination, her extremities are warm and she is tachycardic. There is diffuse thyroid gland enlargement and proptosis. There is thickening of the skin in the pretibial area. Mild clubbing of digits is present. Which of the following laboratory values would you expect in this patient?

A 30-year-old male presents with right upper quadrant pain. He has been well except for an episode of diarrhea that occurred 4 months ago, just after he returned from a missionary trip to Mexico. He has lost 7 pounds. He is not having diarrhea. His blood pressure is 140/70, pulse 80, and temperature 37.5°C (99.5°F). On physical examination there is right upper-quadrant tenderness without rebound. There is some radiation of the pain to the shoulder. The liver is percussed at 14 cm. There is no lower-quadrant tenderness. Bowel sounds are normal and active. Which of the following is the most appropriate next step in evaluation of the patient?

A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most appropriate next diagnostic test?

A 30-year-old woman comes to the office due to the recent onset of fever, chills, and dysuria. Her temperature is 38.3°C (101.0°F), blood pressure is 110/70mm Hg, pulse is 68/min, and respirations are 15/min. Examination shows tenderness at the right costovertebral angle. Laboratory studies show WBC count of 16,000/microl with left shift. Urinalysis shows bacteriuria and pyuria. Her urine and blood is collected for culture and sensitivity. She is prescribed oral ciprofloxacin and sent home. After three days, she returns for a follow-up visit. She is still febrile, and the physical examination is unchanged. The blood cultures have no growth after 72 hours of incubation. Results of the urine culture show. Which of the following is the most appropriate next step in management?

A 31-year-old pregnant woman 6–7 weeks from her last menses comes to the emergency department of your hospital complaining of lower abdominal pain for 3 hours. The pain is diffused in the lower abdomen but worse on the right side. Her serum human chorionic gonadotropin (hCG) concentration is 9600 mIU/mL. Which of the following is the strongest evidence that she has a tubal ectopic pregnancy?

A 31-year-old woman comes to the clinic for a preoperative evaluation. She is undergoing an infertility workup and a laparoscopy is planned. She and her husband have been trying to have a child for the last 5 years, but have not had any success. Over that time period, this woman has suffered three miscarriages. Her past medical history is remarkable for anemia, a history of depression, and a deep venous thrombus suffered during her first pregnancy. Her review of systems reveals diffuse arthralgias, but is otherwise unremarkable. She is currently not taking any medications, though she does report having a drug reaction to prenatal vitamins. Early in pregnancy, she had a red facial rash across her face that spared her nasolabial folds. Physical examination today is unremarkable. Laboratory studies, with the exception of a prothrombin time elevated to two times greater than normal, are unremarkable. Which of the following studies will most likely explain this patient’s laboratory abnormality?

A 32-year-old Caucasian female comes to the physician because of a one-week history of fatigue, progressive worsening of shortness of breath and swelling of feet. She denies any chest pain. She has no other medical problems except a recent cold two weeks ago. She is not taking any medication. Her temperature is 36.7°C (98°F), blood pressure is 110/65 mmHg, pulse is 90/min, and respirations are 20/min. Bilateral basal crackles, elevated jugular venous pressure, and 2+ bilateral pitting edema of the ankles are noted. Complete blood count is unremarkable. Transthoracic echocardiogram of her heat will most likely show?

A 32-year-old man is intubated and mechanically ventilated after an opioid drug overdose. The ventilator triggers 12 breaths per minute, each delivering 500 ml of tidal volume at a flow rate of 60 L/min. You perform an inspiratory hold for 2 seconds following delivery of the tidal volume, and the airway pressure is measured to be 30 cm H2O. The measured pressure reflects which of the following?

A 32-year-old woman comes to the emergency department complaining of sudden onset shortness of breath accompanied by a non-productive cough and left-sided chest discomfort that increases on inspiration. She denies subjective fever, coughing up blood, wheezing, palpitations, leg pain, and swelling of the lower extremities or any recent travel. Past medical history is significant for an appendectomy at age 15. Her medications include birth control pills and over- the-counter vitamins. She is a known carrier of sickle cell trait. Her father, age 65, has had diabetes for 20 years; mother, age 58, has coronary artery disease. She has never been pregnant, drinks alcohol socially and does not smoke. Her temperature is 99°F (38°C), blood pressure is 110/70 mmHg, pulse 130/min and respirations are 33/min. Pulse oximetry shows an oxygen saturation of 85% on 6 liters of oxygen. Her BMI is 30 kg/m2. She is alert and cooperative without cyanosis or jaundice. Her lungs are clear to auscultation. Her abdomen is soft, nondistended and non-tender. Which of the following is the best test to confirm this patient's diagnosis?

A 32-year-old woman presents to the ED with a persistent fever of 101°F over the last 3 days. The patient states that she used to work as a convenience store clerk but was fired 2 weeks ago. Since then, she has been using drugs intravenously daily. Cardiac examination reveals a heart murmur. Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal white blood cells (WBC) 14,000/μL with 91% neutrophils, hematocrit 33%, and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart block. Which of the following is the most appropriate next step in management?

A 33-year-old African-American woman presents with one week of painful skin lesions on her legs. She has no cough, shortness of breath or bowel symptoms, and denies any recent illness or travel. She has no other significant past medical history and does not take any medication. She smokes one pack of cigarettes and drinks one glass of wine daily. She denies a history of sexually transmitted diseases and has been married to a monogamous partner for the past eight years. Her mother was diagnosed with ovarian cancer at age 65. Her temperature is 37.2°C (98.9°F), and blood pressure is 126/76 mmHg. On examination, she has multiple tender pink to reddish nodules noted below the knee on the extensor surface, as shown below. Which of the following is the most appropriate next step in her management?

A 33-year-old woman comes to the emergency department due to a 4-day history of left-sided flank pain, nausea, vomiting, fevers and chills. Her temperature is 39°C (102°F) and blood pressure is 100/60 mm Hg. Examination shows significant left costovertebral angle tenderness. Urinalysis shows positive nitrites, many WBC and bacteria. Laboratory studies show a WBC count of 17,000/cmm with 8% bands. Which of the following is the most appropriate next step in management?

A 34-year-old Caucasian man presents to your office with a several day history of difficulty walking. He also describes some "funny" sensations in his feet. He denies any recent skin rash, diarrhea, or joint pain. His past medical history is significant only for a recent mild respiratory infection. He visited his friends in Connecticut one month ago. He smokes one pack of cigarettes a day and admits to occasional IV drug use. He is not sexually active. His temperature is 36°C (98°F), heart rate is 90/min, respirations are 20/min, and blood pressure is 160/100 mmHg. Chest examination is unremarkable. Abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Cranial nerves II-XII are intact. Muscle strength is reduced in the lower extremities but well preserved in the upper extremities. Lower extremity sensation is decreased. Stroking the soles of the feet elicits extension of the great toe. Which of the following is most likely to diagnose this patient's condition?

A 34-year-old woman comes to your office to establish primary care. While she has no current complaints and reports herself to be “fairly healthy,” she wishes to see a doctor regularly for preventive medicine. She does regular breast examinations on herself, has a good diet and exercise, and has no family history of malignancy or chronic disease. While all of her other habits are healthy, she reluctantly admits to smoking a pack of cigarettes a day. She had a “cervical smear” in her twenties, which she says was normal, and has never had a mammogram or ultrasound of her breasts. She reports being sexually active, and that she practices safe sex. Physical examination reveals a young woman in no apparent distress, with unremarkable vital signs. Her examination, including a breast and genitourinary exam, is normal. Which of the following is the most appropriate screening exam at this time?

A 35-year-old bank executive is brought to the emergency department after the sudden onset of a severe (10/10) headache, followed by a brief period of unconsciousness. His headache started while he was at a meeting and shortly thereafter, he vomited and lost consciousness. He regained consciousness soon afterwards, but was quite confused and irritable. His blood pressure is 160/100 mm Hg, pulse is 90/min, temperature is 37.2°C (99°F), and respirations are 16/min. The physical examination reveals a normal pupil size, no congestion or inflammation of the eye, and no focal neurological deficits. The ECG reveals nonspecific ST and T wave changes. The CT scan shows a subarachnoid hemorrhage. What is the most likely expected electrolyte abnormality with the patient's disease?

A 35-year-old Caucasian male presents with weakness, fatigue, and weight loss over the past year. He is anorexic and has lost interest in all his activities. His temperature is 37.1°C (99°F), pulse is 84/min, blood pressure is 101/72 mmHg, and respirations are 14/min. On physical examination, he does not appear to be in acute distress. Dark brown pigmentation is present on his skin creases and oral cavity mucous membranes. Laboratory studies show: Hemoglobin 10.3 g/dL, WBC count 3,000/micro-L, Neutrophils 60%, Monocytes 5%,Eosinophils 10%, Basophils 1%, Lymphocytes 24%, Serum sodium 130 meq/L, Serum potassium 5.5 meq/L. Chest x-ray and PPD tests are normal. What is the most appropriate next step in the management of this patient?

A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. How should you classify or stage this patient’s disease?

A 35-year-old male is brought to the emergency room with headaches and confusion for the past 2 days. He denies any focal weakness or sensory symptoms. His past medical history is significant for HIV and hepatitis C infections for which he is not receiving therapy. The remainder of his medical history is unobtainable due to his mental status. On physical exam, he has a temperature of 37.9°C (100.2°F), a blood pressure of 140/86 mm Hg, a pulse of 96/min, and respirations of 16/min. Mild icterus is present. The patient's oropharynx is clear and his neck is supple and without rigidity. Examination of his chest and abdomen are unremarkable. Neurologic examination reveals no focal deficits. Laboratory studies show: Complete blood count:Hemoglobin 7.6 g/L, MCV 85 fl, Reticulocytes 8.1%, Platelet count 80,000/mm3, Leukocyte count 3,500/mm3. Chemistry panel: Blood urea nitrogen (BUN) 30 mg/dL, Serum creatinine 2.2 mg/dL, Serum calcium 10.0 mg/dL, Blood glucose 98 mg/dL. Liver studies:Total bilirubin 3.6 mg/dL, Direct bilirubin 1.0 mg/dL, Alkaline phosphatase 120 U/L, Aspartate aminotransferase (SGOT) 178 U/L, Alanine aminotransferase (SGPT) 255 U/L. Which of the following is the most appropriate next step in the management of this patient?

A 35-year-old male with severe persistent bronchial asthma requiring multiple medications presents complaining of weight gain over the past several months despite no changes in appetite, diet, or activity level. He denies alcohol, tobacco, and drug use and has no other significant past medical history. On physical examination, he has a blood pressure of 143/92 mm Hg, a heart rate of 65/min, a temperature of 98.7°F, and a respiratory rate of 16/min. There is moderate supraclavicular fullness, and his skin is thin with areas of bruising and acne. Neurologic exam reveals decreased proximal muscle strength. Which of the following findings is most likely to also be present in this patient?

A 35-year-old man presents with gastrointestinal complaints for the last 4 months. He currently has fever, bloody diarrhea, nausea, and severe abdominal cramps. He has lost 20 lb (9kg), and has also been feeling fatigued and anorexic. His temperature is 37.3°C (99.1° F), blood pressure is 110/74 mm Hg, pulse is 98/min, and respirations are 22/min. Physical examination reveals tenderness in the right lower quadrant. Digital rectal examination is positive for occult blood. His blood work shows: WBC 11,600 /mm3, Hemoglobin 9.6 g/dl, Hematocrit 30%, Platelets 214,000 /mm3. Flexible sigmoidoscopy reveals larger areas of ulceration within the colon. What is the best next step in the management of this patient?

A 35-year-old woman comes to the clinic because of a left breast “thickness.” She noted this 5months ago and it has not receded. She has no family history of breast cancer. There is no drainage. She denies any pain. She has no other medical issues. She takes no birth control pills or any other medication. Examination shows a palpable mass in the left breast at 9 o’clock. A mammogram is nondiagnostic. Which of the following is the appropriate course of action?

A 36-year-old female complains of inability to lose weight despite low-calorie diet and daily exercise. She has also noticed that she is cold intolerant. She is wearing a jacket even though it is summer. She also reports constipation and hair loss. These symptoms have been worsening over the past 2 to 3 months. An elevated TSH and low total and free T4 confirm your suspicion of hypothyroidism. You suspect the etiology of this patient’s hypothyroidism to be autoimmune thyroiditis. What is the best test to confirm the diagnosis of autoimmune thyroiditis?

A 36-year-old G3P2002 with an IUP at 38 weeks presents for shortness of breath. Shortness of breath has been gradually getting worse for the past 2 weeks. The patient states that she now needs to sleep with three pillows to feel like she can breathe. Vital sign: BP, 135/80 mm Hg; P, 78 beats/min; R, 26 breaths/min; T, 98.6°F. She said: chest pain: Negative, cough: Negative, hemoptysis: Negative, fever: Negative, edema: Positive, fetal movement: Positive, contractions: Negative, vaginal bleeding: Negative, leakage of fluid: Negative. Physical Exam: cardiovascular system (CVS): S1S2 +Regular Rate and Rhythm (RRR) no murmurs, lungs: + Crackles bilaterally, Abdominal: gravid, Extremities: 2+ edema bilaterally. What is the next best step in the management of this patient?

A 36-year-old male comes to the emergency department because of worsening right lower quadrant (RLQ) abdominal pain. One week ago he was started on cephalexin for furunculosis. He has had type I diabetes mellitus for 1Oyears and is on insulin. His temperature is 38.83°C (101.9°F). Examination shows multiple furuncles on the inner side of both thighs; most of them are in regression. Abdominal examination shows tenderness on deep palpation in RLQ without rebound or guarding; no masses are palpated; psoas sign is positive; bowel sounds are present. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.0 g/L, Leukocyte count 17,500/mm3. Which of the following is the most appropriate next step in management?

A 36-year-old white female comes to the office due to swelling in front of her neck. She denies any hoarseness, dysphagia, fever, chills, diarrhea, constipation, heat or cold intolerance, and changes in appetite or weight. Her menstrual cycles are regular. She does not have any history of head and neck irradiation. Her family history is negative for thyroid problems. Her blood pressure is 130/80 mmHg, pulse is 80/min, respirations are 16/min, and temperature is 36.7°C (98.0°F). Examination of the neck shows a 2 x 2 cm, discrete, non-tender, firm, mobile nodule in the left thyroid lobe. There is no cervical lymphadenopathy. The rest of the examination is normal. Which of the following is the most appropriate next step in the evaluation of this patient?

A 36-year-old woman presents to the ED with sudden onset of left-sided chest pain and mild shortness of breath that began the night before. She was able to fall asleep without difficulty but woke up in the morning with persistent pain that is worsened upon taking a deep breath. She walked up the stairs at home and became very short of breath, which made her come to the ED. Two weeks ago, she took a 7-hour flight from Europe and since then has left-sided calf pain and swelling. What is the most common ECG finding for this patient’s presentation?

A 37-year-old pregnant woman with type 2 diabetes mellitus and chronic hypertension is 35 weeks’ pregnant. Which of the following is the best test to screen for fetal well-being?