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Diagnosis USMLE 2 (802-899)

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

. Pyramidal tract

. Lower motor neuron

. Upper motor neuron

. Lower and upper motor neuron

. Cerebral cortex

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

. Esophageal carcinoma

. Bronchogenic carcinoma with invasion of the esophagus

. Benign esophageal polyp

. leiomyoma

Lymphoma

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

. Factitious diarrhea

. Irritable bowel syndrome

. Celiac disease

. Infectious diarrhea

. Non-Hodgkin's lymphoma

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

. Pulmonary fibrosis

. Pulmonary vascular lesions

. Aspiration pneumonia

. Bronchogenic carcinoma

. Restriction of chest movement

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

Fibrocystic disease

Fibroadenomas

Intraductal papilloma

Breast cancer

Engorgement attributable to increased prolactin

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

. Myelolipoma

. Cushing disease

. Adrenocortical carcinoma

. Pheochromocytoma

. Carcinoid

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

. Postoperative bleeding

. Diabetic ketoacidosis

. Intra-abdominal abscess

. Intestinal obstruction

. Adrenal insufficiency

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

. AML with maturation

. Acute promyelocytic leukemia

. Acute lymphoblastic leukemia

. Acute erythroleukemia

. Acute monocytic leukemia

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

. Goiter

. Bradykinesia

. Intention tremor

. "Clasp knife" phenomenon

. Babinski sign

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

. Heart failure

Pneumonia

. Drug-induced lupus

. Pulmonary embolism

. Hypoalbuminemia

A 47-year-old smoker presents to the emergency room with a three-day history of shortness of breath and cough. His past medical history is significant for tuberculosis ten years ago, treated with six months of a multidrug regimen. On exam today, his blood pressure is 140/90 mmHg and his heart rate is 110/min. Breath sounds are decreased over the right lung base. Over the same area there is dullness to file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-2Diagnosis/C-2Diagnos... 161 of 316 12/19/2016 2:59 PM percussion and increased fremitus. The patient also has trace ankle edema. Which of the following most likely accounts for these findings?

. Pneumothorax

. Pleural effusion

. Emphysema

. Consolidation

Asthma

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

Glucagonoma

. Stress ulcer

. Parathyroid adenoma

. Vitamin-D toxicity

. Metastatic gastric carcinoma

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

. Delusional disorder

. Schizoaffective disorder

. Schizophrenia, paranoid type

. Schizophreniform disorder

. Major depression with psychotic features

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

. Colloid carcinoma

. Comedocarcinoma

. Infiltrating ductal carcinoma

. Infiltrating lobular carcinoma

. Lobular carcinoma in situ

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

. Diverticulitis

. Infectious gastroenteritis

. Inflammatory bowel disease

. Carcinoid syndrome

. Irritable bowel syndrome

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

. Niemann-Pick disease, type A

. Infantile Gaucher disease

. Tay-Sachs disease

. Krabbe disease

. Fabry disease

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

. Aortic stenosis

. Coarctation of the aorta

. Patent ductus arteriosus

. Tetralogy of Fallot

. Ventricular septal defect

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

. Contact dermatitis

. Scabies

. Exfoliative dermatitis

. Atopic dermatitis

. Seborrheic dermatitis

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

. Abdominal ultrasound

. Careful clinical examination with palpation of an epigastric mass

. UGI contrast study

. Surgical exploration

. endoscopy

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

Acute mastoiditis

Barotitis media

Chronic otitis media

Meniere disease

Secretory otitis media

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

Abetalipoproteinemia

Fabry disease

Gaucher disease

Niemann-Pick disease

Tangier disease

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

Retinoblastoma

Orbital cellulitis

Periorbital cellulitis

Neuroblastoma

Hyphema

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

Membranoproliferative glomerulonephritis

Membranous glomerulopathy

Minimal change disease

Postinfectious acute glomerulonephritis

Systemic lupus erythematosus

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

. Medullary thyroid cancer

. Pheochromocytoma

. Primary hyperparathyroidism

Neuromas

. Marfanoid habitus

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

. Alpert's syndrome

. Acute interstitial nephritis

. Acute post infectious glomerulonephritis

. Mixed essential cryoglobulinemia

. Benign recurrent hematuria

A 50-year-old man comes to the physician for a routine check-up. He has no present complaints. He has diabetes mellitus, type 2, stable angina, and gout. He takes glyburide and atenolol. He smokes two packs a day and, occasionally, consumes alcohol. His father had an early myocardial infarction; his brother has diabetes mellitus. His blood pressure is 140/90 mm Hg and heart rate is 65/min. Physical examination shows no abnormalities. There is concern about end organ damage in this patient due to diabetes mellitus. Which of the file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-2Diagnosis/C-2Diagnos... 169 of 316 12/19/2016 2:59 PM following is the earliest renal abnormality that could be seen in this patient?

. Nodular sclerosis

. Glomerular basement membrane (GBM) thickening

. Mesangial expansion

. Immune deposits

. Glomerular hyperfiltration

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

. Celiac disease

. Tropical sprue

. Crohn's disease

. Whipple's disease

. Cystic fibrosis

A 50-year-old woman presents to the physician’s office for evaluation of a right neck mass. The mass has been present for 3 years file:///D:/DES_Entry_2016MCQs/3C_USMLE/C-2Diagnosis/C-2Diagnos... 171 of 316 12/19/2016 2:59 PM and is painless. On examination, a nontender, firm, 2.5-cm mass is noted slightly below and posterior to the angle of the mandible on the right. Which one is the most likely diagnosis?

. Carotid artery aneurysm

. Mixed parotid tumor (pleomorphic adenoma)

. Laryngeal carcinoma

. Parathyroid adenoma

. Branchial cleft cyst

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