USMLE_Basic III

A 38-year-old Caucasian female presents to your office complaining of a small amount of vaginal discharge that appears following sexual intercourse. There is no associated abdominal pain or urinary symptoms. Her menstrual cycles occur with regular 28-day cycles; her last menstrual period was 2 weeks ago. She has never been pregnant. Menarche occurred at age 10, and she has been sexually active with 10 different partners over the last 20 years. She smokes two packs of cigarettes per day and consumes alcohol regularly. She admits that her diet is poor in vegetables and fruit. Her mother died of breast cancer at age 54, and her father, who is living, has hypertension. Cervical biopsy reveals cervical intraepithelial neoplasia III (CIN III). Which of the following is the strongest risk factor for this condition?

A 38-year-old female comes to your office complaining of occasional palpitations. She describes feeling a fast and irregular heartbeat. Over the past two months, she has had three such episodes, each lasting about two hours. She denies any associated chest pain, shortness of breath cough or ankle swelling. She drinks alcohol on social occasions and does not smoke cigarettes. She has no other medical problems and is not taking any medications. On physical examination, her temperature is 37.1°C (98.9°F), pulse is 80/min, blood pressure is 130/70mmHg, and respirations are 14/min. On auscultation of her heat the apical impulse is displaced and there is an S3. You also hear a pansystolic murmur, which is loudest at the apex and radiates to the axilla. Which of the following is the most likely cause of her symptoms?

A 38-year-old G3P3 begins to breast-feed her 5-day-old infant. The baby latches on appropriately and begins to suckle. In the mother, which of the following is a response to suckling?

A 38-year-old G4P3 at 33 weeks gestation is noted to have a fundal height of 29 cm on routine obstetrical visit. An ultrasound is performed by the maternal-fetal medicine specialist. The estimated fetal weight is determined to be in the fifth percentile for the estimated gestational age. The biparietal diameter and abdominal circumference are concordant in size. Which of the following is associated with symmetric growth restriction?

A 38-year-old male with steroid-dependent sarcoidosis presents to the physician's office because of progressive right hip pain. He localizes thepain to right groin and states that the pain is present on weight bearing and at rest. His temperature is 37.2°C (98.9°F) and blood pressure is 156/86 mm Hg. Examination shows decreased range of motion due to pain. He also has a round face and fullness in supraclavicular area. Purple striae are present on skin. Muscle power is slightly decreased in the proximal thigh muscles in both legs. Reflexes are 2+, and there are no sensory deficits. Plain films of the right hip show no significant abnormalities ESR is 10 mm/hr. Which of the following is the most likely cause of his hip pain?

A 38-year-old man is being seen in his physician’s office after being involved in a car accident. He has a vague pain along his right sternal border, where he crashed into the steering wheel. His temperature is 36.6°C (97.8°F), pulse is 80/min, blood pressure is 123/75 mm Hg, respiratory rate is 14/min, and oxygen saturation is 99% on room air. Physical examination is significant for point tenderness over the right sternal border. X-ray of the chest shows no broken ribs but a single, well-circumscribed pulmonary nodule, 1.5 cm in diameter, located in the left lower lung field. A search through the patient’s electronic medical file reveals that he had an x-ray of the chest taken 2 years ago. The radiology report from that time reveals that the nodule was only 0.75 cm in diameter. To characterize the lesion, CT of the chest is performed and shows dense, flocculated calcification within the lesion. Which of the following risk factors most increases the chances of malignancy in this patient?

A 38-year-old Mexican male presents to the emergency department with a history of weight loss, fever, cough with sputum, nausea, abdominal pain, and postural dizziness for the last three months. Adrenal insufficiency is suspected, and cosyntropin (synthetic ACTH) stimulation test is performed. The rise of serum cortisol following an injection of cosyntropin is grossly subnormal. CT scan of the abdomen shows calcification of both adrenal glands. What is the most likely cause of this patient's adrenocortical insufficiency?

A 38-year-old woman who underwent total thyroidectomy for multinodular goiter 6 months ago presents with persistent hoarseness. Which of the following nerves was most likely injured during her operation?

A 39-year-old G3P3 presents for her postpartum examination and desires a long-term contraceptive method, but is unsure if she wants sterilization. She has been happily married for 15 years and denies any sexually transmitted diseases. Her past medical history is significant for mild hypertension, for which she takes a low-dose diuretic. She is considering an intrauterine device and wants to know how it works. Which of the following is the best explanation for the mechanism of the action of the intrauterine device (IUD)?

A 39-year-old patient is contemplating discontinuing birth control pills in order to conceive. She is concerned about her fertility at this age, and inquires about when she can anticipate resumption of normal menses. You counsel her that by 3 months after discontinuation of birth control pills, what proportion of patients will resume normal menses?

A 39-year-old woman presents to the physician’s office for evaluation of a palpable nodule in the neck of 2 years’ duration. Her past history is pertinent for Hashimoto’s disease diagnosed 5 years ago, for which she takes thyroid hormone. She has a history of low-dose chest irradiation for an enlarged thymus gland during infancy. On examination, a 2.5-cm nodule is palpable in the left lobe of the thyroid and is firm and nontender. Which of the following portions of her history increases the risk for thyroid cancer?

A 39-year-old woman presents with generalized malaise and lymphadenopathy. Biopsy of a supraclavicular lymph node reveals non-Hodgkin lymphoma. Fortyeight hours after initiation of chemotherapy, she develops a high-grade fever and her laboratory studies demonstrate hyperkalemia, hyperphosphatemia, and hypocalcemia. Which of the following cells mediate this syndrome?

A 39-year-old woman presents with increasing abdominal distention and pelvic pain. A CT scan finds a slight amount of fluid in the pleural cavity and also a 3.5cm tumor of the right ovary. The tumor is resected and histologic sections reveal the tumor to be composed of spindle-shaped cells. These cells did not stain with an oil red O special stain. Which of the following types of ovarian tumor is most likely to produce this constellation of findings?

A 4-day-old boy is brought to the physician for an outpatient follow-up visit. His mother's pregnancy and delivery were uncomplicated. The patient weighed 3.4 kg (7.5 lb) and was 48.2 cm (1'7") long at birth. He did well in the newborn nursery and was discharged from the hospital on day 2 of life. His mother reports that he is now exclusively breastfed and nurses for 10 minutes on each breast every 3 hours. He has two wet diapers/day and has not had a bowel movement for 2 days. He weighs 2.95 kg (6.5 lb) and is 48.2 cm (1'7'') long. He appears jaundiced on the face and chest. The remainder of the physical examination shows no abnormalities. Laboratory studies reveal: Total bilirubin 15 mg/dl, direct bilirubin 1 mg/dl, Infant's blood type 0 positive, Mother's blood type A positive. Which of the following is the most likely cause of this infant's hyperbilirubinemia?

A 4-day-old infant is brought to the physician for an outpatient follow-up visit. The mother's pregnancy and delivery were uncomplicated. The infant weighed 3.4kg (7 .5 lb) and was 19 in (48.2 cm) long at birth. He did well in the newborn nursery and was discharged from the hospital on day 2 of life. Today his mother reports that he is exclusively breastfed, and nurses for 10 minutes every 3 hours. He has 3-4 wet diapers a day, and has not had a bowel movement for two days. On examination, he weighs 2.95 kg (6.5 lb) and is 19 in (48.2 cm) long. He appears jaundiced on the face and chest. The remainder of the physical examination is unremarkable. Laboratory values are shown below. Total bilirubin 15 mg/dl, direct bilirubin 1 mg/dl, Infant's blood type O positive, Mother's blood type A positive. Which of the following is the most likely cause of this infant's hyperbilirubinemia?

A 4-month-old baby is in for a well-child check and routine immunizations. The baby had a fever of 39°C the day he received his 2-month immunizations. The parents have read about the vaccine on the Internet and express their concerns. Which of the following is an absolute contraindication to giving the diphtheria and tetanus toxoids and acellular pertussis (DTaP)?

A 4-month-old infant boy has gained only 10 ounces since birth. He has failed to gain weight with multiple formula preparations. His stools have been loose and fatty. An older sister had similar symptoms and has been repeatedly hospitalized for failure to thrive and recurrent pulmonary infections. Which of the following is the most likely cause of this patient's gastrointestinal 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 4-year-old boy is sent to the emergency room because of clinical suspicion of meningitis. He has been ill for 2 days with fever and lethargy. On examination, he is febrile, the neck is stiff, and papilledema is present. There is no rash, the lungs are clear, and heart sounds normal. Which of the following is the most likely causative organism?

A 4-year-old boy, who has a ventriculoperitoneal shunt for congenital hydrocephalus, develops fever, headache, irritability, lethargy, photophobia, and vomiting. His temperature is 39.6 C (103.2 F). He is noted to have nuchal rigidity, with the presence of both Kernig's and Brudzinski's signs. The shunt tract is erythematous on the surface. A lumbar puncture is performed and shows a WBC of 40,000/mm3 with 85% neutrophils, a glucose concentration of 48 mg/dL, and a protein concentration of 169 mg/dL. Which of the following is the most likely pathogen?

A 4-year-old child comes in for a health maintenance visit. His mother is concerned that he is not doing some things that other kids in his preschool do. Which of the following skills would be expected of a 4-year-old?

A 4-year-old child presents in the clinic with an illness notable for swelling in front of and in back of the ear on the affected side, as well as altered taste sensation. Correct statements about this condition include which of the following?

A 4-year-old girl is brought to the physician because of a crusted honey-colored erythema resulting from rupture of tiny vesicles and pustules. Her temperature is 37.7 C (102 F). Skin lesions are distributed over the face and extremities. Physical examination reveals enlargement of lymph nodes in the cervical and axillary regions. Which of the following is the most frequent pathogen of this skin infection?

A 4-year-old male is brought to the physician with fever and headache. His symptoms began two days ago with low-grade fever, cough, and congestion. Last night, he developed a temperature of 102 F (38.9 C) and became fussy and less active. Today, he is crying and complaining of a headache. His parents report that he has vomited twice today. In the office, his temperature is 102.5 F (39 C), pulse is 110/min, and respiratory rate is 20/min. On examination, he is irritable and shows signs of photophobia. His oropharynx is erythematous. Nuchal rigidity is present and when the neck is flexed, the patient flexes his lower extremities. The remainder of the physical examination is normal. Lumbar puncture is performed and the results are shown below. CSF: Glucose 60 mg/dL, Protein 80 mg/dL, RBC 10/mm3, WBC 100/mm3, Neutrophils 10%, Lymphocytes 70%, Monocytes 20%, Gram stain negative. Which of the following organisms is most likely responsible for this patient's presentation?

A 4-year-old previously well African American boy is brought to the office by his aunt. She reports that he developed pallor, dark urine, and jaundice over the past few days. He stays with her, has not traveled, and has not been exposed to a jaundiced person, but he is taking trimethoprim sulfamethoxazole for otitis media. The CBC in the office shows a low hemoglobin and hematocrit, while his “stat” serum electrolytes, blood urea nitrogen (BUN), and chemistries are remarkable only for an elevation of his bilirubin levels. His aunt seems to recall his 8-year-old brother having had an “allergic reaction” to aspirin, which also caused a short-lived period of anemia and jaundice. Which of the following is the most likely cause of this patient’s symptoms?

A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale = 15/ 15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the right lower medial leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?

A 40-year-old female presents with altered mental status and confusion. Last year, she was diagnosed with rheumatoid arthritis, for which she is currently using indomethacin and methotrexate. Her temperature is 37°C (98.6°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 15/min. She is disoriented and irritable. Mucus membranes are moist. There is no jugular venous distention. Lungs are clear to auscultation. Abdomen is soft, nontender and not distended. There is no peripheral edema. Serum chemistry reveals: Sodium 122 mEq/L, Potassium 3.7 mEq/L, Bicarbonate 22 mEq/L, Blood glucose 90 mg/dL, BUN 9.0 mg/dL, Uric acid 3.0 mg/dL. Serum osmolality is 265mOsm/kg, while urine osmolality is 500 mOsm/kg. What is the most likely cause of this patient's hyponatremia?

A 40-year-old G2P1001 presents to your office for a routine OB visit at 30 weeks gestational age. Her first pregnancy was delivered 10 years ago and was uncomplicated. She had a normal vaginal delivery at 40 weeks and the baby weighed 7 lb. During this present pregnancy, she has not had any complications, and she reports no significant medical history. She is a nonsmoker and has gained about 25 lb to date. Despite being of advanced maternal age, she declined any screening or diagnostic testing for Down syndrome. Her blood pressure range has been 100 to 120/60 to 70. During her examination, you note that her fundal height measures only 25 cm. Which of the following is a likely explanation for this patient’s decreased fundal height?

A 40-year-old male patient presents with a thyroid nodule. His other complaints are episodes of palpitations, anxiety and sweating. He denies heat intolerance. His weight and appetite are normal. He has a family history of thyroid cancer. His pulse is 80/min, and blood pressure is 160/100 mmHg. Examination of the neck shows a 4-cm, hard, non-tender thyroid nodule. The urinalysis, serum sodium, serum potassium, serum calcium, serum creatinine, serum PTH, TSH, T3 and T 4 levels, and the EKG are all normal. The serum calcitonin level is elevated. The urinary levels of metanephrine and norepinephrine are increased as well. FNA biopsy of the thyroid nodule shows malignant cells. Genetic testing shows a mutation in the RETproto oncogene. Which of the following abnormalities is also present in most patients suffering from this disorder?

A 40-year-old man comes to the physician because of a two-week history of fatigue, lower extremity edema and dark urine. He has no history of serious illnesses. He takes no medications. He does not use tobacco, alcohol, or drugs. His blood pressure is 130/80 mm Hg and pulse is 80/min. Physical examination shows symmetric pitting edema of lower extremities. Laboratory studies show a serum creatinine level of 1.1 mg/dl. Urinalysis shows 4+ proteinuria and microhematuria. Light microscopy of the specimen obtained from kidney biopsy shows dense deposits within glomerular basement membrane that stain for C3, not immunoglobulins. Which of the following is the most likely pathophysiologic mechanism that explains this patient's condition?

A 40-year-old man comes to the physician because of increasing urinary frequency and urgency. He has had these symptoms in the past, but they are more troublesome now. He has also had urinary hesitancy and interruption of flow. His temperature is 37°C (98.6°F), blood pressure is 130/75mm Hg, pulse is 76/min, and respirations are 15/min. Physical examination shows no abnormalities except increased tone of the anal sphincter and mild periprostatic tenderness. Urinalysis and urine culture shows no abnormalities and expressed prostatic secretions show a leukocyte count of four WBCs/HPF (normal is less than 10 WBCs/HPF). Serum prostate-specific antigen is 2 ng/ml (normal value is less than 4ng/ml). Which of the following is the most likely diagnosis?

A 41-year-old woman undergoes exploratory laparotomy for a persistent adnexal mass. Frozen section diagnosis is serous carcinoma. Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in this malignancy?

A 41-year-old woman who is 32-weeks pregnant presents to the emergency department in labor. Her pregnancy has been complicated by gestational hypertension. Her medical history is otherwise unremarkable. She does not abuse alcohol, tobacco, or illicit drugs. Despite medical interventions, her preterm labor cannot be arrested, and she delivers a 2 kg (41b, 5oz) female infant. Both she and the child do well after delivery. Which of the following is true regarding immunizations for this infant?

A 4196 g (9 lb 4 oz) infant is delivered via vaginal delivery to a 31-year-old mother with gestational diabetes. The delivery was complicated by shoulder dystocia. He is taken to the newborn nursery where his initial plasma glucose level is 20 mg/dL. The initial spun hematocrit is 65%. Which of the following congenital anomalies is this baby most likely to have?

A 42-year-old morbidly obese man is being evaluated for poor sleep. He complains of frequent awakenings due to a choking sensation and says that the resulting tiredness severely limits his physical activity. He also complains of chronic leg swelling. He denies cigarette, alcohol, or drug use. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 110/min. Which of the following additional findings is most likely to be present in this patient?

A 42-year-old woman is evaluated for chronic abdominal pain and fatigue. Her pain is epigastric, crampy, and sometimes awakens her from sleep. She denies any recent weight loss, nausea, or vomiting. Her diet consists mainly of fruits and vegetables. She also complains of a "strange appetite" for paper and ice that she has never had before. Upper gastrointestinal endoscopy reveals an ulcer located on the anterior wall of the duodenal bulb. Her unusual appetite is most directly related to:

A 42-year-old woman is evaluated for depression, mood swings and poor. She also complains of mild headaches and muscle weakness. She has had two ER visits for kidney stones over the past year. She denies any illicit drug use. Her blood pressure is 160/105 mmHg and her heat rate is 85/min. Her laboratory findings are shown below: Sodium 140mEq/L, Potassium 3.6 mEq/L, Chloride 101 mEq/L, Bicarbonate 24 mEq/L, BUN 13 mEq/L, Creatinine 0.9 mEq/L, Glucose 98 mEq/L, Calcium 11.7 mg/dL. Which of the following is the most likely cause of this patient's hypertension?

A 42-year-old, right-handed man has had a history of progressive speech difficulties and right hemiparesis for 5 months. He has had progressively severe headaches for the past 2 months, which are worse in the mornings. At the time of admission, he is confused and vomiting, and has blurred vision, papilledema, and diplopia. Shortly thereafter, his blood pressure increases to 190/110 mm Hg, and he develops bradycardia. Which of the following is most likely the significance of the hypertension and the bradycardia?

A 43-year-old Caucasian female has a long history of polyarthritis. She also complains of fatigue, low-grade fever, weakness and recent weight loss. Her current medications are methotrexate, naproxen and ranitidine. Physical examination reveals deformed hand joints and a soft, tender mass palpated in the right popliteal fossa. The latter finding is best explained by:

A 43-year-old HIV-positive male presents to your office with several exophytic purple skin masses on his lower abdomen. Physical examination reveals tender hepatomegaly and an abdominal CT scan shows nodular, contrast-enhanced intrahepatic lesions of variable size. Liver biopsy is attempted but severe hemorrhage results. Which of the following is the most likely cause of this patient's condition?

A 43-year-old man feels vaguely unwell. Physical examination is unremarkable except for evidence of scleral icterus. The skin appears normal. Which of the following is the most likely explanation for why early jaundice is visible in the eyes but not the skin?

A 43-year-old man is being evaluated for one month of blurred vision, frontal headaches and occasional falls. He reports that the blurry vision is worse when he leans forward. He relates his symptoms to a recent break-up with his girlfriend. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 60/min. Which of the following is most likely responsible?

A 43-year-old man presents to your office with low energy and increased fatigability. He also complains of daytime sleepiness and occasional headaches. He drinks two to three glasses of wine daily but does not smoke. He sleeps in a separate room from his wife because she finds his constant snoring annoying. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 80/min. His BMI is 31.5 kg/m2. His abdomen is soft and non-tender. The liver span is 10 cm and the spleen is not palpable. Laboratory findings are: Hematocrit 60%, WBC count 9,000/mm3, Platelets 190,000/mm3. Which of the following is most likely responsible for this patient's increased hematocrit?

A 43-year-old man with a gangrenous gallbladder and gram-negative sepsis agrees to participate in a research study. An assay of tumor necrosis factor (TNF) is performed. Which of the following is the origin of this peptide?

A 43-year-old trauma patient develops acute respiratory distress syndrome (ARDS) and has difficulty oxygenating despite increased concentrations of inspired O2. After the positive end-expiratory pressure (PEEP) is increased, the patient’s oxygenation improves. What is the mechanism by which this occurs?

A 43-year-old woman with congestive heart failure, rheumatoid arthritis and chronic hepatitis C complains of abdominal discomfort and difficulty breathing. Physical examination shows dullness to percussion at the right lung base. Chest x-ray reveals a large right-sided pleural effusion. Thoracentesis yields pleural fluid with a glucose content of 30 mg/dl and an LDH of 192units/L. Which of the following explains the pleural fluid glucose concentration?

A 44-year-old G6P3215 presents for her well-woman examination. She tells you that all of her deliveries were vaginal and that her largest child weighed 2900 g at birth. How many full-term pregnancies did this patient have?

A 44-year-old male who has had an extensive small bowel resection for Crohn's disease has been on total parenteral nutrition for two years. He presented to the hospital with epigastric and right upper quadrant pain. He has been taking azathioprine. His vital signs are within normal limits. Physical examination shows mild right upper quadrant tenderness. An ultrasonogram shows several gallstones; an ultrasonogram performed two years ago did not demonstrate gall stones. Which of the following is the most likely cause of his gallstones?

A 44-year-old obese female undergoes an open cholecystectomy for a complicated acute cholecystitis. On her third post-operative day, her temperature is 36.7°C (98.2°F), blood pressure is 110/80 mm Hg and pulse is 92/min. Her arterial blood gas shows the following: Blood pH 7.28, PaO2 62 mmHg, PaCO2 54 mmHg, HCO3- 30 mEq/L. What is the most likely cause of acidosis in this patient?

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 44-year-old woman, gravida 4, para 3, at 8 weeks' gestation comes to the physician for her first prenatal visit. She has mild nausea and vomiting but no other complaints. Her obstetric history is significant for three full-term, normal vaginal deliveries of normal infants. She has no medical or surgical history and takes no medications. Physical examination reveals an 8-week-sized uterus, but is otherwise unremarkable. She wishes to have chromosomal testing of the fetus and wants to have chorionic villus sampling performed, as she did with her last pregnancy. Compared with amniocentesis, chorionic villus sampling may place the patient at greater risk for which of the following?

A 45-year-old Asian male complains of a progressively worsening sore throat and difficulty swallowing for the past 24 hours. You notice that his voice is muffled and he is drooling. He also has a harsh shrill associated with respiration. His temperature is 39.3°C (103°F), blood pressure is 120/80 mmHg, pulse is 106/min, and respiratory rate is 22/min. On examination, a few cervical lymph nodes are palpable and there is tenderness to palpation over his larynx. Which of the following are the two most common organisms that cause this condition?

A 45-year-old Asian man presents to your office complaining of easy fatigability. He denies abdominal pain, distention, nausea, vomiting, or significant weight loss. His past medical history includes a gastrectomy for a non-healing gastric ulcer. He is not currently taking any medications. He quit smoking several years ago and does not use alcohol or illicit drugs. His vital signs are within normal limits. Physical examination reveals a shiny tongue and pale palmar creases. No lymphadenopathy, hepatomegaly, or splenomegaly is present. His blood hemoglobin level is 7.5 mg/dL and W8C count is 3,800/mm3. Stool tests for occult blood are repeatedly negative. This patient's condition involves which of the following pathophysiologic mechanisms?

A 45-year-old Caucasian male presents with a 2-year history of progressive heartburn which is most severe while supine. Over-the-counter antacids have not relieved his symptoms. Endoscopy shows a hiatal hernia. The patient is reluctant to accept any treatment. Which of the following is he at risk for if his condition is left untreated?

A 45-year-old female presents complaining of constipation and abdominal pain for the past two weeks. She also complains of urinary frequency and constant thirst. Her past medical history is significant for obesity. She tells you that she has been trying very hard to lose weight, and over the past six months has even attempted various fad diets. She assures you that she supplements her intake with numerous over-the-counter vitamins and minerals. She has managed to lose 20 lbs during this time. Her medical history is also significant for atrial fibrillation for the past 4 years, for which she takes diltiazem. On physical examination, her temperature is 36.8°C (98.2°F), blood pressure is 120/70 mmHg, pulse is 90/min, and respirations are 13/min. Her mucous membranes are dry, and her abdomen is soft and non-tender without rebound or rigidity. Bowel sounds are present. Urinalysis is within normal limits. Which of the following is most likely responsible for her current symptoms?

A 45-year-old male comes to the physician with a 6-month history of periodic abdominal pain. He tried several over-the-counter medications including H2 blockers and proton pump inhibitors with moderate success. Workup, including an upper GI series and endoscopy, showed multiple duodenal ulcers and a single jejunal ulcer. Test of the stool for occult blood is positive. Test of the stool for fat is positive. Which of the following is the best explanation for this patient's impaired fat absorption?

A 45-year-old man comes to the office and complains of intermittent, bloody diarrhea and abdominal pain for the past month. During this time period, he has lost six pounds. He was diagnosed with HIV infection in the past, but has refused antiretroviral therapy. Laboratory results show a CD4 count of 50cells/μL. The stool examination is negative. Colonoscopy with biopsy shows multiple colonic ulcerations and mucosal erosions. The biopsy shows large cells containing eosinophilic intranuclear and basophilic intracytoplasmic inclusions. What is the most likely cause of this patient's diarrhea?

A 45-year-old man is examined for a yearly executive physical. A mass is palpated in the rectum, and a biopsy suggests carcinoid. Which of the following findings is most likely to be associated with the carcinoid syndrome?

A 45-year-old man presents to the emergency department because of dyspnea, fatigue, poor appetite and weight gain over the past several weeks. He says that about four weeks ago he began to develop worsening shortness of breath with exertion and more recently has been waking at night with breathlessness. He also notes that it is sometimes difficult for him to open his eyes in the morning due to facial edema. He has no significant past medical history and he takes no medications. On physical examination, his blood pressure is 200/120 mmHg and his heart rate is 100/min. You note generalized bodily edema and distention of his jugular veins while he is sitting upright. On lung auscultation you hear bibasilar rales. Urinalysis shows trace protein, no nitrites, trace leukocyte esterase, 50+ red blood cells and occasional neutrophils. Which of the following is the most likely cause of this patient's edema?

A 45-year-old man presents to the emergency room with a two-day history of fever, dyspnea, abdominal pain, and diarrhea. He has no chest pain, but complains of dry cough. His past medical history is significant for bone marrow transplantation for acute myeloid leukemia (AML) three months ago. His temperature is 39°C (102.2°F), blood pressure is 122/80 mm Hg, pulse is 98/min, and respirations are 22/min. Exam of the oropharynx reveals thrush. Lungs exam demonstrates bilateral diffuse rales. Heart sounds are regular. Nonspecific abdominal tenderness is present. The chest radiograph shows multifocal, diffuse patchy infiltrates. Which of the following is the most likely cause of this patient's current condition?

A 45-year-old man was an unhelmeted motorcyclist involved in a high-speed collision. He was ejected from the motorcycle and was noted to be apneic at the scene. After being intubated, he was brought to the ER, where he is noted to have a left dilated pupil that responds only sluggishly. What is the pathophysiology of his dilated pupil?

A 45-year-old white female has undergone a right mastectomy for a node-negative, estrogen and progesterone receptor-positive tumor. She is scheduled to begin adjuvant therapy with tamoxifen. Her menstrual cycles are regular and her last menstrual period was 15 days ago. She has many concerns about tamoxifen therapy and would like to know its risks and benefits. Which of the following is she at risk for?

A 45-year-old woman is seen with wasting of the intrinsic muscles of the hand, weakness, and pain in the wrist. Which of the following nerves has most likely been injured?

A 45-year-old woman with breast cancer undergoes a modified radical mastectomy with lymph node dissection. Six weeks later, she returns complaining of decreased mobility of her shoulder. On physical examination, the scapula protrudes from the body when pressing her outstretched arm on the wall. Which of the following nerves was most likely injured during the operation?

A 45-year-old woman with Crohn disease and a small intestinal fistula develops tetany during the second week of parenteral nutrition. The laboratory findings include: Na: 135 mEq/LK: 3.2 mEq/LCl: 103 mEq/LHCO3: 25 mEq/LCa: 8.2 mEq/LMg: 1.2 mEq/LPO4: 2.4 mEq/LAlbumin: 2.4An arterial blood gas sample reveals a pH of 7.42, PCO2 of 38 mm Hg, and PO2 of 84 mm Hg. Which of the following is the most likely cause of the patient’s tetany?

A 45-year-old woman with long-standing, well-controlled rheumatoid arthritis develops severe pain and swelling in the left elbow over 2 days. She is not sexually active. Arthrocentesis reveals cloudy fluid. Synovial fluid analysis reveals >100,000 cells/mL; 98% of these are PMNs. What is the most likely organism to cause this scenario?

A 46-year -old alcoholic man comes to the emergency department because of several episodes of vomiting. The last episode of emesis contained blood. Five hours ago, he had a fatty meal and several alcoholic drinks. Two days ago, he had an upper GI tract endoscopy and abdominal ultrasound for the evaluation of dyspepsia. The endoscopy was unremarkable, and the ultrasound showed a hyperechogenic enlarged liver and stones in the gallbladder. His temperature is 36.6°C (97.9°F), blood pressure is 120/70 mm Hg, pulse is 95/min, and respirations are 15/min. Laboratory studies show: Hb 12.8 g/dl, WBC 5,400/cmm, BUN 26 mg/dl, Creatinine 1.1 mg/dl, AST 100 U/L, ALT 45 U/L, Bilirubin 0.7 mg/dl. Nasogastric suction shows normal stomach contents mixed with bright red blood. The rectal examination shows no melena. Which of the following is the most likely explanation for this patient's bloody vomiting?

A 46-year-old farmer comes to the physician because of pain and swelling of his right heel. He accidentally stepped on a rusty nail while working 2 weeks ago. Although he applied over the-counter antibiotic cream locally and took acetaminophen orally, he continued to have pain at the site of the injury. He has no other medical problems and takes no medication. He has no known drug allergies. He smokes 2-3 cigarettes a day and drinks alcohol occasionally. His temperature is 38.3°C (101°F), blood pressure is 140/90 mm Hg, pulse is 84/min and respirations are 14/min. On examination, the right heel is swollen, red, and warm and tender to touch. A small puncture wound is visible. Laboratory reports show mild leukocytosis. X-ray of the right foot shows features suggestive of osteomyelitis. The most likely cause of the patient's symptoms is infection with which of the following?

A 46-year-old male presents with swelling of his face that is especially prominent in the periorbital area. He also complains of bilateral ankle swelling. He denies shortness of breath, fever and discoloration of urine. He is a non-smoker and non-alcoholic. His past medical history is not significant. He is currently not taking any medication. His pulse is 78/min, blood pressure is 130/70mmHg, respirations are 14/min and temperature is 37.1°C (99.0°F). Examination shows bilateral pitting ankle edema. Auscultation reveals clear lungs, normal heart sounds, and no murmurs. Dipstick urinalysis is positive for protein. 24-hour urine collection shows proteinuria of 4.6 g/day. Lab studies show: Total serum calcium 7.5 mg/dL, Albumin 2.2 g/dL, Phosphorus 3.5 mg/dL, Magnesium 2.2 mg/dL, Creatinine 0.8 mg/dL. Which of the following is the most likely cause of his low serum calcium level?

A 46-year-old man complains of exertional dyspnea and dry cough. He also describes occasional episodes of a suffocating night-time cough that is relieved only when he stands up. His medical history is significant for a myocardial infarction six months ago. His current medications are metoprolol, aspirin and simvastatin. He does not use tobacco but drinks alcohol on social occasions. His father died of a stroke and his mother suffers from diabetes mellitus. His blood pressure is 150/100 mmHg and his heart rate is 60/min. Chest examination reveals bibasilar rales. His cardiac apex is palpated in the sixth intercostal space. The liver span is 12 cm. Bilateral pitting leg edema is also present. Which of the following most likely contributes to his edema?

A 46-year-old man complains of right flank discomfort. He describes decreased urination over the last week with occasional episodes of high urine output and weakness. He is otherwise healthy. There is no family history of renal disease. On physical examination, his blood pressure is 140/90 mmHg and his heart rate is 80/min. The serum creatinine level is 2.1 mg/dl. Urinalysis shows few red blood cells, white blood cells, trace protein, and no casts. Which of the following is the most likely cause of his complaints?

A 46-year-old woman is hospitalized for agitation, restlessness and poor sleep. She has been complaining of headaches recently and has gained 14 pounds over the past three months. She denies any illicit drug use. Her blood pressure is 160/110 mmHg and her heart rate is 90/min. Her laboratory findings are shown below: Sodium 142 mEq/L, Potassium 3.2 mEq/L, Chloride 98 mEq/L, Bicarbonate 26 mEq/L, BUN 12 mg/dl, Creatinine 0.9 mg/dl, Glucose 205 mg/dl, Calcium 9.4 mg/dl. Which of the following is the most likely cause of this patient's hypertension?

A 46-year-old woman undergoes an abdominal hysterectomy for a “fibroid” uterus. The surgeon requests a frozen section on the tumor, which is deferred because of the lesion’s degree of cellularity. Which of the following histologic criteria will be used by the pathologist to determine if this tumor is benign or malignant?

A 47-year-old male presents to your office with a two-month history of lethargy and decreased libido. His medical records reveal that he has been treated for joint pain and swelling over the last six months and was diagnosed with diabetes mellitus one year ago. Physical examination reveals hepatomegaly and testicular atrophy. Which of the following cardiac abnormalities is most likely to also be present in this patient?

A 47-year-old male was brought to the emergency room with chest pain of acute onset. The pain was associated with nausea, vomiting, and diaphoresis. He has a history of diabetes, hypertension, and hyperlipidemia. ECG reveals ST segment elevation in the anterolateral leads and ventricular premature beats (VPBs). The patient dies within the first hour after the arrival to emergency room. What is the most likely pathophysiologic mechanism responsible for this patient's death?

A 47-year-old man is found to have edema, ascites, and hepatosplenomegaly. The examination of his neck veins reveals elevated venous pressure with a deep y descent. Heart size on x-ray is normal. Which of the following etiologies is not a possible explanation for this syndrome?

A 47-year-old man presents to your office complaining of occasional daytime headaches, dizziness and nausea. He has no significant past medical history. He works as a traffic controller in an underground parking lot. He does not smoke cigarettes, and consumes alcohol only on weekends. He is sexually active in a monogamous relationship with his wife and uses condoms for contraception. His cardiac exam is unremarkable. His abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Laboratory findings are: Hematocrit 59%, WBC count 7,000/mm3, Platelets 200,000/mm3. Which of the following is most likely responsible for this patient's increased hematocrit?

A 47-year-old woman has new-onset transient right arm weakness and word finding difficulty symptoms lasting 3 hours. She is also experiencing exertional dyspnea, and had a syncopal event 1 month ago. Her echocardiogram reveals a cardiac tumor in the left atrium, it is pendunculated and attached to the endocardium. Which of the following is the most likely cause of this lesion?

A 47-year-old woman loses consciousness for 2 minutes while shopping in a supermarket. In the emergency room, she recounts feeling nausea and warmth spreading over her body immediately before passing out. She has never had a similar episode before. She has not seen a doctor for several years and does not take any medications, nor does she use tobacco, alcohol or drug. Her family history is unremarkable. Which of the following most likely caused this episode?

A 47-year-old woman who is 2 weeks post triple bypass surgery presents to the emergency department with a chief complaint of sudden onset, sharp chest pain for several hours. She is fatigued and short of breath. On physical examination she has distended neck veins that grow more distended on inspiration. Muffled heart sounds are heard. Her temperature is 37.0°C (98.6°F), pulse is 133/min, blood pressure is 70/50 mmHg, respiratory rate is 30/ min, and oxygen saturation is 100% on room air. An echocardiogram shows a large pericardial effusion and chamber collapse; therefore, pericardiocentesis is performed. Although a large amount of blood is aspirated, the patient’s clinical picture acutely worsens. Her pain level increases substantially; pulse is 150/min, blood pressure is 60/41 mm Hg, respiratory rate is 30/ min, and oxygen saturation is 100%. Repeat echocardiography shows an even larger pericardial effusion with chamber collapse. Which complication of pericardiocentesis is most likely in this patient?

A 48-year-old Caucasian male presents to your office complaining of progressive exertional dyspnea. It has become especially bothersome over the past two months. Presently, he becomes short of breath after climbing one flight of stairs. He denies any significant problems in the past. He is not taking any medications and he denies smoking or drinking alcohol. His temperature is 37.2°C (98.9°F), pulse is 78/min, blood pressure is 130/75 mmHg and respirations are 14/min. Chest examination reveals a harsh systolic murmur that is best heard at the right second intercostal space with radiation along the carotid arteries. An S4 is heard at the apex. Based on these findings, what is the most likely cause of this patient's symptoms?

A 48-year-old woman develops constipation postoperatively and self-medicates with milk of magnesia. She presents to clinic, at which time her serum electrolytes are checked, and she is noted to have an elevated serum magnesium level. Which of the following represents the earliest clinical indication of hypermagnesemia?

A 48-year-old woman notices a firm, fixed mass in her right breast but chooses to ignore it. The mass is then detected on her annual physical examination eight months later. By that point, the mass has increased greatly in size. When questioned as to why she did not report the mass when she first noticed it, the woman states that she was not concerned about the mass because she does not have a family history of breast cancer This response is an example of which of the following defense mechanisms?

A 48-year-old woman presents to your office with the complaint of vaginal dryness during intercourse. She denies any medical problems or prior surgeries and does not take any medications. She still has regular menstrual cycles every 28 days. She denies any sexually transmitted diseases. She describes her sexual relationship with her husband as satisfying. Her physical examination is normal. Components of the natural lubrication produced by the female during sexual arousal and intercourse include which of the following?

A 49-year-old woman presents to her physician with dysphagia, regurgitation of undigested food eaten hours earlier, and coughing over the last 6 months. She was hospitalized 1 month ago for aspiration pneumonia and successfully treated with antibiotics. Examination reveals a thin-appearing woman with normal vital signs and unremarkable chest, heart, and abdominal examination. A UGI contrast study is performed and reveals a pharyngoesophageal (Zenker’s) diverticulum. Which of the following statements is true regarding Zenker’s diverticula?

A 5-month-old boy is brought in for a routine check-up. He was born at 37 weeks' gestation and has had persistent wheezing since shortly after birth despite inhaled bronchodilator and oral corticosteroid therapy. His diet consists of 32 ounces of iron-fortified cow's milk-based formula daily. On physical examination, the child appears well-nourished and happy. You note moderate relief of his wheezing with neck extension. Which of the following is the most likely mechanism of this infant's wheezing?

A 5-month-old infant is brought to the office for the evaluation of persistent vomiting, failure to thrive, and developmental delay. His antenatal and postnatal histories are not known to his Caucasian foster parents, who adopted him when he was 4 months old. The physical examination reveals an infant with blonde hair, fair skin and blue eyes. His urine has a peculiar musty odor. His plasma phenylalanine level is 40 mg/dl and tyrosine level is normal. His urinary phenylpyruvic and a-hydroxy phenylacetic acid levels are both increased. What is the most likely etiology of this child's symptoms?

A 5-year-old boy suffers from a condition characterized by recurrent fungal and viral infections, thymic hypoplasia, tetany, and abnormal facies. Serum levels of immunoglobulins are mildly depressed, and lymph node biopsy shows lymphocyte depletion of T-dependent areas. Which of the following is the underlying pathogenetic mechanism?

A 5-year-old pedestrian is hit by a car in a mall parking lot and he is brought to the emergency department. There was loss of consciousness for less than 1 minute. On evaluation, the child has no neurologic deficits and a CT scan of the head reveals no intracranial abnormalities and no obvious skull fractures. The parents want to know what possible long-term problems there might be. You remember that problems after head trauma may include the development of seizures and that the risk of developing posttraumatic epilepsy is increased by which of the following?

A 50-year-old man presents to the office with fatigue, malaise, and disabling joint pain in his fingers, wrists, shoulder, hips, knees, and ankles. His pain is severe and associated with a mild degree of morning stiffness for 10-15 minutes. He occasionally takes acetaminophen and ibuprofen for this pain. He has a 10-pack-year smoking history. He does not drink alcohol. Family history includes an uncle who died of liver cancer. On examination, there is grayish skin pigmentation, most prominent on the exposed parts. Abdominal examination is significant for liver enlargement 2 cm below the costal margin. Laboratory studies reveal the following: Hemoglobin 13.0 g/L, Leukocyte count 5,500/mm3, Serum creatinine 0.8 mg/dl, Blood glucose 218mg/dl, Aspartate aminotransferase (SGOT) 128 U/L, Alanine aminotransferase (SGPT) 155 U/L, Alkaline phosphatase 120 U/L , Serum iron 450 mol/L (50-170g/dL), Transferrin saturation of iron 62% (22-47%), Serum Ferritin 3000ng/L (15-200 ng/ml, males). X-ray of the joints shows narrowing of joint spaces and diffuses demineralization. This patient's condition makes him more vulnerable to which of the following infections?

A 50-year-old man presents to your office complaining of pain and swelling of the right knee. He bumped his right knee into a pole 2 days ago while working. He had one episode of similar pain two years ago that resolved with over-the-counter analgesics. He denies any illicit drug use. He has no other medical problems and does not take any medications. His temperature is 37.2°C (98.9°F), and blood pressure is 126/76 mmHg. Examination reveals swelling, warmth and decreased range of motion of the right knee. All other joints are within normal limits. Synovial fluid analysis shows positive birefringent crystals and negative Gram stain. These crystals are most likely composed of?

A 50-year-old man wants to talk to you about something, "absolutely confidential". After you assure him, he admits, "He is unable to get an erection and just can't have sex." He wants to figure it out quickly because "he simply can't live like this." He has never been diagnosed with diabetes and denies other complaints. He has a 2 pack/day history of smoking for 30 years. On examination, his BP: 158/90mm of Hg; Temperature: 37.1°C (98.8°F); RR 14/min; PR 82/min. There is upper body obesity, rounded face, increased fat around the neck, and thinning of arms and legs. You find his skin to be bruised, fragile and thin. Laboratory reveals the following results. Serum: Glucose 186 mg/dl, Sodium 142 mEq/L, Potassium 2.5 mEq/L, Bicarbonate 38 mEq/L. Chest X ray shows a large mass in left bronchus. What is the most likely cause of patient's condition?

A 50-year-old obese female is taking oral hypoglycemic agents. While being treated for an upper respiratory infection, she develops lethargy and is brought to the emergency room. Neurological examination is nonfocal; she does not have neck rigidity. Laboratory results are as follows: Na: 134 mEq/L, K: 4.0 mEq/L, HCO3: 25 mEq/L, Glucose: 900 mg/dL, BUN: 84 mg/dL, Creatinine: 3.0 mg/dL, HgA1c: 6.8%, BP: 120/80 mmHg lying down, 105/65 mmHg sitting. Which of the following is the most likely cause of this patient’s coma?

A 50-year-old white male comes into your office for a routine check-up. He has no present complaints. His past medical history is significant for hypertension controlled with a low-dose thiazide diuretic. His family history reveals non-fatal myocardial infarction in his father at the age of 47. The patient does not smoke or consume alcohol. His blood pressure is 130/75 mmHg and his heart rate is 70/min. His previous records show that his HDL level is persistently low in spite of acceptable total cholesterol and LDL levels. You prescribe niacin to raise HDL level. The patient returns in a week complaining of intensive generalized pruritis and flushing. What is the most probable cause of the patient's complaint?

A 50-year-old woman presents to your office complaining of lower extremity edema that stated several weeks ago, and slowly progressed thereafter. Her past medical history is significant for hypertension, treated with metoprolol for 2 years. Amlodipine was added recently because of inadequate control of BP with metoprolol alone. She does not smoke or consume alcohol. She has no known drug allergies. Her blood pressure is 130/80mmHg and her heart rate is 64/min. The physical examination reveals bilateral symmetric 3+ pitting edema of both lower extremities, without any skin changes or varicosities. Her neck vein pulsation is normal. Other physical findings are within normal limits. Her laboratory studies reveal the following: Serum albumin 4.5 g/dL, Total serum bilirubin 0.8 mg/dL, Serum sodium 140 mEq/L, Serum potassium 4.0 mEq/L, Serum creatinine 0.8 mg/dL. Urinalysis is within normal limite. What is the most likely cause of the edema in this patient?

A 51 -year-old man complains of difficulty walking and mild right-sided foot pain for the past several weeks. His medical history is significant for type 1 diabetes mellitus, hypertension and hypercholesterolemia. Physical examination reveals a significantly deformed right foot and a mildly deformed left foot. X-rays suggest effusions in several of the tarsometatarsal joints, large osteophytes, and several extra articular bone fragments. Which of the following is the most likely cause of this patient's complaints?

A 51 -year-old obese male presents to your office complaining of difficulty swallowing solids but not liquids. His medical history is significant for GERD. Six months ago he was diagnosed with Barrett's esophagus. He reports that three months after the diagnosis of Barrett's esophagus, his heartburn resolved. Barium swallow now reveals an area of symmetric, circumferential narrowing affecting the distal esophagus. Which of the following best explains this finding?

A 51-year-old female comes to the office for a routine visit. She is apparently healthy and does not have any complaints. Physical examination reveals a thyroid nodule. She is surprised to hear about the nodule and asks, "How often does this happen? What could have caused this?" Which of the following is the most common cause of thyroid nodules?

A 51-year-old woman comes to your office for a routine health maintenance examination. She has no medical history but states that she has been having irregular menses and occasional hot flashes for the past eight months. Her husband has told her that she appears moody all the time. She has not had any surgeries in the past and currently takes no medications. She has a very stressful job and drinks two to three cups of coffee every morning. She does not smoke, but she does drink four to five twelve-ounce beers a day for the past 20 years to relieve her stress. She is a lacto-ovo vegetarian and walks two miles on a treadmill each day. Her temperature is 36.5C (97.7F), blood pressure is 120/70, heart rate is 84 beats/minute, and respirations are 12/minute. She is 5'4" and weighs 180 pounds (BMI is 30.9 kg/m2). Physical examination is unremarkable. You inform her that she is probably reaching menopause, and that she will be at an increased risk of developing osteoporosis. Which of the following is the most significant risk factor for the development of osteoporosis in this patient?

A 52-year-old African-American woman with type 2 diabetes mellitus (DM) presents to her physician’s office and states that she has been feeling lousy in the morning. She notes that she reliably checks her blood glucose levels, and is frustrated at the fact that she often has a blood sugar level in the 120s at night, followed by a level in the 170s to 180s the following morning. The patient’s primary care physician increased her nightly dose of neutral protamine Hagedorn insulin 1 month ago, but her morning glucose levels have only become more elevated. She has recently begun to limit her carbohydrate intake at night, with no effect. This patient’s morning hyperglycemia might most likely be alleviated by which of the following?

A 52-year-old alcoholic man presents to the emergency department because of anxiety and tremors. His last drink of alcohol was 2 days ago. His initial electrolyte panel is: Sodium 132 mEq/L, Potassium 2.9 mEq/L, Chloride 100 mEq/L, Bicarbonate 25 mEq/L. He is treated for alcohol withdrawal, and given aggressive intravenous and oral potassium supplementation. Three days later, his electrolyte panel is: Sodium 135 mEq/L, Potassium 3.1 mEq/L, Chloride 102 mEq/L, Bicarbonate 28 mEq/L. Which of the following explains why this patient's potassium level is so difficult to correct?

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 male is referred to the neurology clinic for the evaluation of EEG abnormalities. He presented with rapidly increasing memory impairment, and denied any history of seizures or head trauma. The physical examination revealed no abnormalities, except a myoclonus. An extensive work-up ruled out the presence of any medical illness; however, the EEG report revealed sharp, triphasic and synchronous discharges. Which of the following abnormalities is most likely in this patient?

A 52-year-old man has been impotent ever since he had an abdominoperineal resection for cancer of the rectum. The tumor was staged as T3, NO, MO. He gets no nocturnal erections, and his impotence extends to all situations, regardless of sexual partner, and includes inability to masturbate. His erectile dysfunction is most likely due to 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 52-year-old woman presents with hypertension, obesity, and new skin striae. You are concerned about possible Cushing syndrome. Which of the following is the most common cause of Cushing syndrome?

A 53-year-old Caucasian man comes to the emergency department at 2 am because of severe pain in his right great toe for the past 2 hours. He complains that the pain began suddenly as a dull, aching pain, and has worsened over time to a severe throbbing pain, not relieved by acetaminophen. His other medical problems include hypertension, diabetes mellitus-type 2, hypercholesterolemia, and peptic ulcer disease. He has smoked 2 packs of cigarettes daily for 30 years. He drinks 5-6 ounces of alcohol daily. He eats a lot of junk food and exercises infrequently. Both his father and mother have diabetes and hypertension. His older brother died of a myocardial infarction 2 years ago. His medications include glyburide, lisinopril, atenolol, simvastatin and famotidine. His temperature is 37.8°C (100°F), blood pressure is 160/90 mm Hg, pulse is 88/min and respirations are 16/min. On examination, the right great toe appears markedly swollen, red, and is warm to touch. Aspiration of the joint fluid reveals negatively birefringent needle shaped crystals. Apart from prescribing oral indomethacin, what other intervention would be most important to prevent the development of further attacks?

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 53-year-old homosexual man comes to the ER with shortness of breath and dry cough over the past week. You note that he was hospitalized for Candida esophagitis one month ago, but left against medical advice. On physical examination, his blood pressure is 120/70 mmHg, heart rate is 120/min and regular, oxygen saturation is 89% on 2L/min of oxygen by nasal cannula, and temperature is 38.3°C (101°F). There are extensive white plaques over the oral mucosa and there is a soft 2/6 systolic murmur over the cardiac apex. Lung auscultation is remarkable for faint bilateral crackles. Which of the following is most likely responsible?

A 53-year-old male presents to your office with a two-day history of right calf pain and swelling. He describes the pain as constant and states that it is exacerbated by knee flexion. He has a history of past IV drug abuse, endocarditis, and stroke. He is currently wheelchair-bound secondary to stroke-related left-sided hemiparesis. On physical examination, his blood pressure is 140/90 mmHg and his heart rate is 100/min. There is no jugular venous distention or hepato-jugular reflux. His chest is clear to auscultation but his abdomen is enlarged with shifting dullness and a fluid wave, suggestive of ascites. His liver is palpable 3 cm below the right costal margin. His spleen is also palpable. On examination of his lower extremities, you note right-sided calf swelling and tenderness. Which of the following is the most likely cause of this patient's ascites?

A 53-year-old man comes to the office because of difficulty reading fine print over the last year. He now has to hold books, menus, and magazines at an arm’s length in order to read them. He has never had visual problems before. Which of the following is most likely abnormal in this patient?

A 53-year-old man presents to the emergency room with squeezing chest pain that started two hours ago. He also complains of shortness of breath that is worse when lying down. He has never had pain like this before. He has no significant past medical history and he takes no medications. A routine health maintenance visit two weeks ago was normal. On physical examination in the ER, his blood pressure is 140/90 mmHg and his heart rate is 100/min. Chest auscultation reveals a grade II/VI blowing systolic murmur at the cardiac apex and bibasilar crackles in the lungs. ECG shows ST segment elevations in leads I, aVL, and v1-v3. Which of the following is most likely increased in this patient?

A 53-year-old man presents to your office complaining of weakness and exertional dyspnea over the last week. He denies chest pain and palpitations. He has no other past medical history. His father died of a myocardial infarction at age 55. On exam, his heart rate is 100/min and blood pressure is 90/60 mmHg. Internal jugular venous pulsation is observed 7 cm above the sternal angle. Lungs are clear to auscultation. Heart sounds are muffled. Which of the following is the most likely cause of this patient's complaints?

A 53-year-old woman has been intubated for several days after sustaining a right pulmonary contusion after a motor vehicle collision as well as multiple rib fractures. Which of the following is a reasonable indication to attempt extubation?

VA 53-year-old woman presents to your office with right-sided abdominal pain that started two days ago. She describes the pain as constant and burning in nature. There is no associated nausea, vomiting or diarrhea. The patient reports taking over-the-counter antacids and ibuprofen, which brought no relief. Her medical history is significant for breast cancer diagnosed one year ago, for which she underwent a modified radical mastectomy and is receiving chemotherapy, the last course of which was completed two months ago. On physical examination, her temperature is 36.7°C (98°F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 16/min. Her lung fields are clear to auscultation and her abdomen is soft and non-distended. The liver span is 10 cm and the spleen is not palpable. Lightly touching the skin to the right of the umbilicus elicits intense pain. In one week the patient is most likely to develop:

A 54 year-old male comes to the physician because of abdominal distention. He thinks his big belly is making it hard for him to breathe. He received radiation therapy for Hodgkin lymphoma several years ago and was told that he is cured. He drinks alcohol on a regular basis. His temperature is 36.7°C (98°F), blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 20/min. Examination shows a jugular venous pressure 7 cm above the sternal angle. Dullness to percussion and decreased breath sounds are noted in the right lung base. The abdomen is quite distended with an obvious fluid wave. Mild hepatomegaly is present. Extremities have 2+ lower extremity edema. Initial laboratory studies are shown below: Serum creatinine 0.8 mg/dL, Alburnin 4.0 mg/dL, Total bihrubin 1.0 mg/dl, Prothrombin time 11 sec. Urinalysis is within normal limits. Which of the following is the most likely cause of his condition?

A 54-year-old female complains of muscle weakness. She describes difficulty getting up from a chair and combing her hair. She does not use tobacco, alcohol or drugs. She takes no medication. Her vital signs are within normal limits. Physical examination reveals bilateral ptosis. Which of the following is the most likely cause of this patient's complaints?

A 54-year-old male with a history of chronic alcoholism is admitted to the hospital with hematemesis and abdominal distension. Upper gastrointestinal endoscopy reveals the presence of esophageal varices. Continued workup of his condition results in a diagnosis of cirrhosis of the liver. He is treated appropriately and strongly counseled about the need to abstain from alcohol. He is then discharged home. After discharge, he begins to work as a full-time volunteer for a non-profit organization that assists patients with alcoholic cirrhosis. Which of the following defense mechanisms is this man using?

A 54-year-old man complains of burning epigastric pain that usually improves after a meal, and is occasionally relieved with antacids. On examination, he appears well and besides some epigastric tenderness on palpation, the rest of the examination is normal. Upper endoscopy confirms a duodenal ulcer. Which of the following statements concerning PUD is most likely correct?

A 54-year-old man with a 20-year history of chronic obstructive lung disease has a heave that is palpable at the lower left sternal border at the third, fourth, and fifth intercostal spaces. Which of the following best explains the etiology of the heave?

A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the correct stage of this patient’s colon cancer?

A 54-year-old woman presents to your office complaining of difficulty walking. She describes severe weakness and occasional pain in her thigh muscles. She has stumbled and fallen several times over the last week. Her past medical history is significant for hypertension treated with hydrochlorothiazide and metoprolol. She consumes two to three cans of beer on weekends. Her younger brother died of a neurological disease when he was 20 years old. Her mother suffers from hypertension and diabetes mellitus. Her heart rate is 90/min and blood pressure is 170/100 mmHg. Chest examination is within normal limits. A bruit is heard over the left carotid artery. Neurologic examination reveals hyporeflexia and decreased strength in all muscle groups. Her ESR is 12 mm/hr. ECG shows flat and broad T waves with occasional premature ventricular contractions. Which of the following is the most likely cause of this patient's current complaints?

A 55-year-old Asian man with mitral stenosis secondary to rheumatic heart disease undergoes dental surgery for caries. Postoperatively, he does well and is discharged home. Two weeks later, he presents with fever, chills, fatigue, and feels "sick." Four out of four blood culture bottles are positive for gram-positive cocci. An echocardiogram is performed and shows mitral valve vegetations. Which of the following is the most likely causative organism of this patient's condition?

A 55-year-old Caucasian male presents to the office for a routine check-up. He has no present complaints. His past medical history is significant for a long history of hypertension. He does not smoke or consume alcohol. His current medications are enalapril and hydrochlorothiazide. His blood pressure is 140/90 mmHg and heart rate is 80/min. Physical examination reveals a moderately overweight man (BMI = 27 kg/m2) with a waist circumference of 41 inches. The laboratory studies show: Fasting blood glucose 112 mg/dl, Total cholesterol 220 mg/dl, LDL cholesterol 140 mg/dl, Triglycerides 240 mg/dl. Which of the following is the most important pathogenic factor for this patient's condition?

A 55-year-old Caucasian male presents to your office with muscle pain of recent onset. His past medical history is significant for hypertension and an acute myocardial infarction experienced 2 months ago. His current medications include metoprolol captopril, aspirin and simvastatin. His blood pressure is 130/80 mmHg and heat rate is 60/min. Liver function tests are slightly abnormal. Serum creatine kinase level is elevated. You suspect a drug-induced reaction. Which of the following is the most possible mechanism of drug-induced reaction in this patient?

A 55-year-old homeless man presents to the emergency room complaining of muscle cramps and perioral numbing. The patient looks malnourished. He says that he consumed a lot of alcohol recently. His past medical history is significant for chronic and recurrent abdominal pain for which he was advised to quit drinking alcohol. His temperature is 36.7°C (98°F), blood pressure is 110/65 mmHg, pulse is 80/min, and respirations are 18/min. The laboratory values are: Hemoglobin 7.2 g/dl, MCV 105 fl, Leukocyte count 9,000/cmm, Platelets 200,000/cmm, ESR 20 mm/hr, Serum sodium 145 mEq/L, Serum potassium 4.0 mEq/L, Serum calcium 6.8 mg/dl, Serum phosphorus 2.5 mg/dl. What is the most probable cause of hypocalcemia observed in this patient?

A 55-year-old man presents to the ED with chest pain and shortness of breath. His BP is 170/80 mmHg, HR is 89 beats per minute, and oxygen saturation is 90% on room air. Physical examination reveals crackles midway up both lung fields and a new holosystolic murmur that is loudest at the apex and radiates to the left axilla. ECG reveals ST elevations in the inferior leads. Chest radiograph shows pulmonary edema with a normal sized cardiac silhouette. Which of the following is the most likely cause of the cardiac murmur?

A 55-year-old man presents with worsening cirrhosis. After evaluation by a hepatologist, he presents for evaluation for hepatic transplantation. He is informed that prioritization for transplantation is based on the Model of End-stage Liver Disease (MELD) score, and that patients with higher MELD scores have a greater benefit from transplantation. Which of the following contributes to the MELD score?

A 55-year-old woman has been hospitalized because of recurrent pancreatitis, ARDS, prolonged ileus, and need for parenteral nutrition. She demonstrates weakness, lassitude, orthostatic hypotension, nausea, and fever. Which of the following abnormalities is most likely to explain these symptoms?

A 55-year-old woman is in the intensive care unit on a ventilator for hypoxemia following “flash” pulmonary edema. Her PO2 on the blood gas prior to intubation was 44 mm Hg, and now while breathing 100% oxygen on the ventilator her repeat blood gas reveals a PO2 of 80 mm Hg. Hypoxemia while receiving 100% oxygen indicates which of the following problems?

A 55-year-old woman presents with a three-week history of low-grade fever, weight loss of 4.5kg (10 lb), and malaise. She is known to have mitral valve prolapse, but is otherwise healthy. She underwent a tooth extraction one month ago. She denies alcohol, tobacco, and illicit drug use. Her temperature is 38.5°C (101.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 145/76 mm Hg. Her chest is clear to auscultation and percussion. Cardiac examination reveals a III/IV holosystolic murmur at the apex that radiates to the axilla. Chest x-ray is normal. Urinalysis is unremarkable. Blood cultures are drawn and empiric antibiotics are started. Echocardiogram shows mitral regurgitation with vegetation on the mitral valve. Which of the following organisms is the most likely cause of this patient's condition?

A 55-year-old woman who has end-stage liver disease is referred to a hepatologist for evaluation. Which of the following would prevent her from being a transplantation candidate?

A 55-year-old-woman of Asian descent goes to the emergency department because of vomiting and severe abdominal cramping of 3 days' duration. Her pain is centered on the umbilicus. She denies being exposed to a viral or bacterial illness. Her medical history includes a previous cholecystectomy and an appendectomy after which she developed an infection. Her abdomen is not tender, but hyperactive, high-pitched peristalsis with rushes coincides with palpable bowel cramping. Abdominal x-ray films taken in the supine and upright positions demonstrate a ladder-like series of distended small bowel loops. Which of the following is the most likely explanation for these findings?

A 56-year-old male complains of occasional dizziness. He gets a brief spinning sensation while getting out of bed. He sometimes feels dizzy while turning in bed or looking up. He denies any nausea, diaphoresis, chest pain or tinnitus. His past medical history is significant for long-standing hypertension, which is being treated with hydrochlorothiazide, and hyperlipidemia, which is being treated with simvastatin. His father died of a stroke at the age of 62 years. His blood pressure is 130/80 mmHg while supine, and 135/85 mmHg while standing. His heart rate is 77/min. A grade II/VI ejection murmur is heard over the aortic area. ECG reveals left ventricular hypertrophy and premature ventricular contractions. Which of the following is the most likely cause of this patient's complaints?

A 56-year-old male presents with progressively worsening dyspnea over a 4 month period. He denies fever, chest pain, cough or ankle swelling and does not use tobacco, alcohol or drugs. He works for a home insulation and plumbing company. He has never been abroad and does not own any pets. His only medications are hydrochlorothiazide and metoprolol for blood pressure control. On physical examination, his temperature is 36.8°C (98.2°F), pulse is 76/min, blood pressure is 130/78 mmHg, and respirations are 15/min. Examination shows digital clubbing and fine bibasilar end-inspiratory crackles. Jugular venous pressure is 7 cm and there is no peripheral edema. Which of the following additional findings is most likely in this patient?

A 56-year-old male with a long history of diabetes mellitus complains of nocturnal urinary frequency, occasional dribbling and difficulty completing his stream. His past medical history is significant for a myocardial infarction two years ago and moderately decreased visual acuity. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 70/min. There is a carotid bruit auscultated on the left side as well as trace ankle edema. Post-void bladder catheterization yields 60 ml of urine. Dipstick urinalysis reveals 2+ protein and 3-4 WBC/hpf. The patient's serum creatinine level is 2.4 mg/dl. Which of the following is the most likely cause of his renal dysfunction?

A 56-year-old man is having intermittent fevers and malaise for the past 2 weeks. He has no other localizing symptoms. Two months ago, he had valve replacement surgery for a bicuspid aortic valve. A mechanical valve was inserted and his postoperative course was uncomplicated. On examination, his temperature is 38°C, blood pressure 124/80 mm Hg, pulse 72/min, and head and neck are normal. There is a 3/6 systolic ejection murmur, the second heart sound is mechanical, and a 2/6 early diastolic murmur is heard. The lungs are clear and the skin examination is normal. Three sets of blood cultures are drawn and an urgent echocardiogram is ordered. Which of the following is the most likely causative organism?

A 56-year-old woman becomes the chief financial officer of a large company and, several months thereafter, develops upper abdominal pain that she ascribes to stress. She takes an over-the-counter antacid with temporary benefit. She uses no other medications. One night she awakens with nausea and vomits a large volume of coffee grounds-like material; she becomes weak and diaphoretic. Upon hospitalization, she is found to have an actively bleeding duodenal ulcer. Which of the following statements is true?

A 56-year-old woman is undergoing chemotherapy. She presents today with complaints of burning on urination and bloody urine. Which of the following agents causes hemorrhagic cystitis?

A 56-year-old woman presents to the clinic for routine health screening. Her concern is the development of breast cancer. She has no current breast-related complaints. Past history is pertinent for fibrocystic changes with atypical ductal hyperplasia and a single fibroadenoma, both diagnosed by open biopsy 5 years ago. She smokes one pack per day and drinks one can of beer daily. Family history is positive for breast cancer in her mother, diagnosed at the age of 85. Current medications include a cholesterol-lowering agent, an antihypertensive, and HRT, which she has taken for 5 years. Physical examination is unremarkable. Mammograms show dense breasts, decreasing the accuracy of the study, but no suspicious findings were noted. Which of the following is the most common risk factor in evaluating women for breast cancer?

A 56-year-old woman presents to your office for her routine wellwoman examination. She had a hysterectomy at age 44 for symptomatic uterine fibroids. She entered menopause at age 54 based on menopausal symptoms and an elevated FSH level. She started taking estrogen replacement therapy at that time for relief of her symptoms. She is fasting and would like to have her lipid panel checked while she is in the office today. You counsel the patient on the effects of estrogen therapy on her lipid panel. She should expect which of the following?

A 57-year-old Caucasian female is diagnosed with deep venous thrombosis of the right leg that was confirmed with Doppler ultrasonography. She was diagnosed with pneumonia and empyema one week earlier, and treated with chest tube, antibiotics and bed rest. On her 6th day of anticoagulation therapy, she develops right hemiparesis and slight motor aphasia. The laboratory findings are: Red blood cells 4.3 million/mm3, Hemoglobin 14.00 g/dL, White blood cells 7,000/cmm, Platelets 50,000/cmm, APTT 60 sec (N < 25-40 sec), Fibrin degradation products negative. The emergency head CT scan does not reveal blood in the subarachnoid space or brain parenchyma. Which of the following is the most probable cause of this patient's condition?

A 57-year-old Caucasian woman presents for a follow-up visit regarding her lower back pain. She originally presented with this complaint last month and was advised to limit activity and use ibuprofen as needed. When her pain persisted, she was scheduled for an MRI of her back. The MRI report returned today and describes the presence of metastatic deposits in her spine. The source of the primary neoplasm remains undetermined. The patient has not yet been told about the findings and will need to be informed today. Which of the following is the best means of initiating a conversation about her condition?

A 57-year-old female with a history of type 2 diabetes mellitus complains of fatigue, urinary frequency, increasingly blurred vision and worsening leg cramps over the past week. She reports that the symptoms all began following an upper respiratory infection 7 or 8 days ago. She does not take any medications, but adheres to a diet low in saturated fat and simple carbohydrates to manage her diabetes. On physical examination, her blood pressure is 160/90 mmHg and her heart rate is 90/min. Her mucous membranes are dry. Her urine is positive for glucose but negative for ketones. Which of the following is the most likely cause of this patient's vision impairment?

A 57-year-old male is hospitalized for hyponatremia. Physical examination reveals no signs of fluid overload. Serum analysis reveals a sodium concentration of 125mEq/l, glucose level of 12mg/dl, BUN of 8mg/dl, and creatinine of 0.7mg/dl. The urine osmolarity is 330mOsm/l and urine sodium concentration is 45mEq/l. After a 2L normal saline infusion, the serum sodium is 126mEq/l and the urine sodium excretion is increased to 90 mEq/l. Which of the following is the most likely cause of this patient's hyponatremia?

A 57-year-old male presents to your office with a two week history of fever, chills, and generalized weakness. His medical history is significant for a hospitalization for pyelonephritis requiring IV antibiotics six months ago. He also recently underwent cystoscopy for evaluation of persistent dysuria. His past medical history is also significant for an episode of rheumatic fever as a child and Hodgkin's lymphoma treated with chemotherapy 10 years ago. On examination, his temperature is 37.8°C (100°F), blood pressure is 150/86 mmHg, pulse is 98/min and regular, and respirations are 16/min. The patient appears slightly diaphoretic. You note a new II/VI systolic murmur and tender erythematous lesions affecting several fingertips. The remainder of the physical examination is unremarkable. Which of the following bacteria is most likely responsible for his present illness?