Part 3 "510-764" NaIII (595-638)

14) A boy is delivered at 37 weeks gestation via spontaneous vaginal delivery. He is the product of a normal pregnancy and was delivered without complications. Prenatally the mother was blood type B and was rubella immune and negative for Rh antibody, group B streptococci, rapid plasma reagin, hepatitis B surface antigen, gonorrhea, and chlamydia. The patient appears cyanotic. He is breathing at a rate of 60/min and his heart rate is 130/min. He has a normal S1 and S2. There is a harsh holosystolic murmur that is loudest at the left lower sternal border. His examination reveals palpable nonbounding peripheral pulses bilaterally. Which of the following is the most likely diagnosis?

15) A 75-year-old man comes into the emergency department with a 10-minute history of crushing substernal chest pain radiating to his left arm. This man is well known to the staff due to his long history of chest pain. His creatine phosphokinase level is elevated and his troponin T level is 0.4 ng/mL. Which of the following is the most likely diagnosis?

16) A 55-year-old man with hypertension and a one-pack-per-day smoking history presents to the ED complaining of three episodes of severe heavy chest pain this morning that radiated to his left shoulder. In the past, he experienced chest discomfort after walking 20 minutes that resolved with rest. The episodes of chest pain this morning occurred while he was reading the newspaper. His BP is 155/80 mmHg, HR 76 beats per minute, and RR 15 breaths per minute. He does not have chest pain in the ED. An ECG reveals sinus rhythm with a rate of 72. A troponin I is negative. Which of the following best describes this patient’s diagnosis?

20) A 38-year-old woman presents to the emergency room complaining of chest pain for the past several hours. She describes it as sharp, centrally located and non-radiation. The pain worsens somewhat with inspiration and movement. The patient denies having fevers, chills, dyspnea, swelling, or difficulty breathing at night. She says she first noticed the pain while exercising three weeks ago, but has experienced it at rest as well. She says that she has been exercising heavily in an attempt to lose weight. Her BMI is currently 34kg/m2. Her father had a myocardial infarction at age 60. Her medical history is significant for two normal vaginal deliveries. She smokes a half-pack of cigarettes daily. On physical examination, her blood pressure is 112/69 mmHg and her heat rate is 72/min. Cardiac exam reveals a regular S1 and S2 without extra sounds or murmurs. There is tenderness to palpation over the sternum. What is the most likely cause of her chest pain?

21) A 12-year-old white male wants to participate in sports at school. He has been growing normally since birth. His immunizations are up-to-date and he is not suffering from any known medical conditions. Which of the following measures should be taken to screen him for underlying heart disease that could cause sudden cardiac death?

25) An 18-year-old girl comes to the emergency department for sudden-onset redness and swelling of her skin over exposed areas. She had just spent 1 hour at the beach when she began to experience a burning sensation, followed by redness and swelling of those areas. Her face has a few inflammatory nodules as well as open and closed comedones, and she was recently prescribed "some medication for the past month or so" for her facial lesions. Her pulse is 82/min, blood pressure is 120/80 mmHg, respirations are 14/min and temperature is 37.2°C (99°F). On examination, you notice erythema, edema and vesicles on her face, neck, dorsal hands and upper chest. She has no mucosal lesions. Which of the following best explains her condition?

27) A 55-year-old man comes to the office due to a sudden onset of blisters all over his body. He complains of pain in the involved areas. He first noticed the lesions in his mouth a few days ago. His pulse is 82/min, blood pressure is 140/90 mmHg, respirations are 14/min, and temperature is 36.8°C (98.4°F). On examination, there are crops of flaccid bullae over normal-appearing skin, and large erosions at sites where the bullae had ruptured. The oral mucosa shows erosions and ulcerations. Slight rubbing of the uninvolved skin causes easy separation of the epidermis. Immunofluorescence microscopy shows deposits of IgG inter cellularly in the epidermis. What is the most likely diagnosis?

28) A 45-year-old woman comes to the office for the evaluation of reddened areas over her face (flushed skin). These areas worsen every time she drinks something hot or goes out in hot, sunny weather. Her vital signs are stable. On examination, there is evident erythema over her nose, cheeks, forehead and chin with telangiectasias, pustules and papules. What is the most likely diagnosis?

30) A 28-year-old Caucasian woman presents to the primary care physician with complaints of painless blistering on the backs of her hands, accompanied by an increased fragility of the surrounding skin. She first noted the blisters one week ago, after spending some time gardening outdoors. She denies ever having similar symptoms, but suspects that her mother may occasionally have had a similar presentation that eventually resolved without treatment. Her past medical history is significant for chronic infection with Hepatitis C virus. Current medications include oral contraceptives, which were begun last month. Physical examination reveals mild hyperpigmentation of the face. Which of the following is the most likely diagnosis?

31) A 36-year-old male presents to clinic complaining of a pruritic eruption on his forearms. He denies fever, chills and malaise. Physical examination reveals an erythematous rash with occasional vesicles affecting both forearms. No lymphadenopathy is appreciated. Vesicular fluid grows coagulase-negative staphylococci. His only relevant history is recent work in the woods behind his home chopping and transporting firewood. Which of the following is the most likely diagnosis?

32) A 64-year-old female presents with complaints of lesions over her breasts and thighs. She had been experiencing severe pain in those areas prior to developing redness and blisters. Her past medical history is significant for valvular heart disease with atrial fibrillation, ulcerative colitis diagnosed 20 years ago, and a resection of part of her colon. She is a known patient of yours, and four days ago, you started her on treatment for atrial fibrillation with antiarrhythmics and oral anticoagulants. Her pulse is 82/min, blood pressure is 140/90 mmHg, respirations are 14/min, and temperature is 36.8°C (98.4°F). On examination, you notice well-demarcated lesions with bullae and necrotic changes over her thighs and breasts. What is the most likely diagnosis?

33) A mother brings her 6-month-old infant to your office for evaluation of scaly, erythematous lesions around his eyebrows and sides of his nose. She also notes a scaly scalp that improves with baby shampoo. Which of the following is the most likely diagnosis?

36) An 83-year-old man is brought to the office by his wife because he has had frequent falls for the past 3 months. The wife says that, "He's not his usual self these days. He needs help with everything, even everyday things." The patient has mask-like facies. He speaks very softly with a poorly modulated voice, and he has a fine tremor in both hands. The resting tremor in his hands disappears with voluntary movements. The other pertinent findings include a shuffling gait with short steps, stooped posture, tendency to fall and rigidity of both upper limbs. What skin condition is associated with this patient's neurologic diagnosis?

37) A 43-year-old woman comes to the office because she has "finally decided to see a doctor." For the past four months, she has suffered from itching all over her body. She is tired of using over-the-counter products with no relief. Over the past two months, she has had loose stools, which "take forever to flush." Physical examination reveals jaundice, hepatomegaly and splenomegaly. The results of her blood work are as follows: Alkaline phosphatase 200 u/dL, Bilirubin 3.3 mg/dL, Anti-mitochondrial antibodies positive. Which of the following benign lesions of the eye is frequently associated with this patient's condition?

38) A 25-year-old male comes to the office due to severe itching and burning of the skin lesions on his knees, elbows and back of his neck. He gives a history of loose stools, flatulence, weight loss of more than 10 lbs, and fatigue for the past 6 months. His vital signs are stable. On examination, there are papules and vesicles over the extensor aspect of his elbows, knees, posterior neck and scalp. The laboratory studies reveal the presence of anti-endomysial antibodies. Which of the following is the most likely diagnosis?

39) A 36-year-old male comes to the office for the evaluation of a skin lesion. For the past two months, he noticed darkening and thickening of the skin over his neck and groin area. These areas occasionally feel itchy. His pulse is 82/min, blood pressure is 130/80 mmHg, respirations are 14/min, and temperature is 36.8°C (98.4°F). Physical examination reveals symmetrical, hyperpigmented, velvety plaques on the axilla, groin and posterior neck. This patient's condition should alert the physician to check for which of the following?

41) A 17-year-old man presents with a non-pruritic rash in his periumbilical area. The rash consists of firm, dome-shaped, flesh-colored papules with central umbilication. This patient's rash is most commonly associated with which of the following conditions?

42) An 8-year-old boy is brought to the office due to itchy rashes with blisters over his face, trunk and legs for the past 2 days. His vital signs are normal, except for a temperature of 37.7°C (100°F). On examination, you notice macules, pustules, vesicles, and honey-colored crusts around his mouth, nose, legs, buttocks and trunk area. What is the most likely diagnosis?

43) An 18-year-old white female is brought to the emergency department due to severe vomiting, fever and rashes. She was fine until today, when she developed a fever, flu-like symptoms and dizziness. She has a history of asthma and allergic rhinitis. She denies taking drugs or alcohol, or being exposed to other sick individuals. She had her period yesterday, but did not place a tampon until today, 6 hours prior to becoming ill. Her last menstrual period was 6 weeks ago. She appears alert but listless. Her temperature is 38.8°C, pulse is 120/min, respirations are 23/min, and blood pressures are 100/66 mmHg, supine and 66/30 mmHg, standing. On examination, there are erythematous flat and raised rashes on her trunk and extremities. What is the most likely diagnosis?

44) An 18-month-old Caucasian boy is brought to the emergency department due to a 3-day history of fever and facial rash. His past medical history is significant for atopic dermatitis, which was diagnosed 1 week ago and treated with topical steroids. Examination reveals numerous umbilicated vesicles over erythematous skin of both cheeks. Submandibular adenopathy is present. What is the most probable diagnosis?

46) A 28-year-old Caucasian male presents to the office with a rash on his trunk. He complains of constant itching over the area. He has no other medical problems. He denies any family history of diabetes. He currently has two sexual partners, and he does not use condoms. His pulse is 84/min, blood pressure is 120/80 mmHg, respirations are 14/min, and temperature is 37°C (98.4°F). On his trunk, there are 4 circular patches with central clearing and scaly borders, measuring approximately 3-8cms in diameter. What is the most likely diagnosis?

47) A 30-year-old, Caucasian male comes to the office for the evaluation of some pale patches in a mottled distribution over his trunk area. He just returned from a 2-week summer vacation in the Bahamas, where he first noticed these lesions. His skin is generally well-tanned. Located over his central upper trunk area are multiple, velvety pink, pale macules, measuring approximately 4-5 mm in diameter. These lesions scale on scraping. What is the most likely diagnosis?

48) A 48-year-old Caucasian female presents to your office due to a small swelling on her left lower eyelid. She has worked outdoors her whole life. This swelling has been present for the past 6 months. Recently, she noticed a loss of eyelashes on her lower eyelid. On examination, there is a small nodular lesion on the lower eyelid margin. It is firm, painless, pearly and indurated. Loss of lashes on the left lower eyelid is confirmed. Which of the following is the most likely diagnosis?

49) 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-the-counter 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?

50) A 48-year-old white male comes to the emergency department with complaints of severe pain and swelling in his left leg. He sustained an injury to his left leg while playing tennis five days ago. The pain worsened over the past 2-3 days, and is now unbearable. He also complains of flu-like symptoms. His temperature is 39C° (102°F), pulse is 104/min, blood pressure is 110/80 mmHg, and respirations are 18/min. Physical examination reveals an edematous limb with purplish discoloration of the injured area, along with bullae and a serosanguineous discharge. The leg is extremely tender to touch. A scalpel incision of the skin reveals yellowish green necrotic tissues. What is the most likely diagnosis?

51) A 20-year-old woman presents with complaints of a rash for the past 2 days. She was in good health until 5-6 days ago, when she developed fever, malaise and headache. The rash first appeared on her face, and then rapidly spread to her trunk and extremities. Her pulse is 86/min, blood pressure is 110/70 mmHg, respirations are 14/min, and temperature is 37.2°C (99°F). On examination, there is a pink maculopapular rash involving her face, trunk and extremities. Tender lymph nodes are palpable in the posterior auricular and posterior cervical areas. Her soft palate reveals patchy erythema. What is the most likely diagnosis?

52) A 4-year-old girl is brought to the office by her parents due to a red rash and blisters. Yesterday, she had a fever and was irritable. Today, she developed the rash with blisters. Her pulse is 90/min, blood pressure is 90/60 mmHg, respirations are 14/min, and temperature is 39°C (102°F). On examination, there are superficial flaccid bullae and an erythematous rash diffusely distributed over her body. Nikolsky's sign is positive. Her face is edematous, and there is crusting around the mouth area. Her skin is warm and tender with exfoliation. What is the most likely diagnosis?

53) A 23-year-old college student comes to the office due to itching all over her body for the past 10 days. She hardly gets to sleep at night because of it. Her roommate has similar complaints. Her vital signs are stable. Physical examination reveals vesicles and pustules arranged in short, gray wavy channels on the finger webs, heels of palms, and in wrist creases. There are papules over the nipples and areola of her breasts. What is the most likely diagnosis?

54) A 7-year-old girl is brought to the office by her mother due to a rash all over her body. She was apparently in good health until 4 days ago, when she developed fever, cough and eye pain. This morning, she developed a rash on her face, which later spread all over her entire body. Her pulse is 86/min, respirations are 14/min, blood pressure is 110/70 mmHg, and temperature is 37.2°C (99°F). On examination, there is an erythematous maculopapular rash covering her entire body. There are small red spots with bluish specks on her buccal mucosa. What is the most likely diagnosis?

55) A 17-year-old female presents with a pruritic rash localized to the wrist. Papules and vesicles are noted in a band like pattern, with slight oozing from some lesions. Which of the following is the most likely cause of the rash?

57) A 15-year-old girl complains of low-grade fever, malaise, conjunctivitis, runny nose, and cough. After this prodromal phase, a rash of discrete pink macules begins on her face and extends to her hands and feet. She is noted to have small red spots on her palate. What is the most likely cause of her rash?

58) A 17-year-old girl noted a 2-cm annular pink, scaly lesion on her back. Over the next 2 weeks she develops several smaller oval pink lesions with a fine collarette of scale. They seem to run in the body folds and mainly involve the trunk, although a few occur on the upper arms and thighs. There is no adenopathy and no oral lesions. Which of the following is the most likely diagnosis?

59) A 45-year-old man with Parkinson disease has macular areas of erythema and scaling behind the ears and on the scalp, eyebrows, glabella, nasolabial folds, and central chest. Which of the following is the most likely diagnosis?

60) A 33-year-old fair-skinned woman has telangiectasias of the cheeks and nose along with red papules and occasional pustules. She also appears to have conjunctivitis with dilated scleral vessels. She reports frequent flushing and blushing. Drinking red wine produces a severe flushing of the face. There is a family history of this condition. Which of the following is the most likely diagnosis?

61) A 50-year-old male presents for the evaluation of polyuria and polydipsia of two months duration. He also complains of weakness and fatigue. He had one episode of paralysis that resolved on its own. He has a 20 pack-year history of smoking. He does not drink alcohol. His past medical and family histories are not significant His pulse is 78/min, blood pressure is 150/96 mmHg and temperature is 37°C (98.6°F). The rest of his examination, including the neurological examination, is unremarkable. Laboratory studies show: Plasma sodium 145 mEq/L, Potassium 24 mEq/L, Serum creatinine 0.8 mg/dl, Plasma renin activity low, Plasma aldosterone concentration high. Which of the following is the most likely diagnosis?

62) A 24-year-old Caucasian female comes to the outpatient clinic and complains of heat intolerance and increased appetite. Her past medical history is insignificant. She denies use of over-the-counter medications. Her pulse is 110/min and regular, temperature is 37.2°C (99°F), and respirations are 14/min. Swelling is noted in the front of her neck, which moves with deglutition. Lab studies show: Total T4 Increased, Free T4 Increased, TSH Decreased. Radioactive iodine uptake is decreased. The thyroid scan shows very low uptake of radioiodine. What is the most likely diagnosis?

63) A 17-year-old white female comes to the office for the evaluation of fatigue which has been present for the past 4 months. Her past medical history is insignificant. She denies the use of any drugs. Her pulse is 74/min, blood pressure is 110/70 mmHg, and temperature is 36.7°C (98.0°F). Physical examination shows scars on the dorsum of her hands and dental erosions. Laboratory studies show: Plasma sodium 139 mEq/L, Serum potassium 2.3 mEq/L, Bicarbonate 40 mEq/L. Urine chloride concentration is 15 mEq/L (Normal = 80-250 mEq/L). Based on these findings, what is the most likely diagnosis?

64) A 56-year-old female is admitted with a diagnosis of chronic renal failure from systemic lupus erythematosus and non-steroidal anti-inflammatory drug use. She has a history of recurrent kidney stones. Laboratory studies show the following: Serum calcium 10.6 mg/dL, Serum albumin 3.9 g/L, PTH 140 pg/mL, Serum phosphorus 3.0 mg/dL. Her baseline serum creatinine level ranges from 1.6 to 1.8 mg/dL. Her bone mineral density is measured by DXA scan, revealing a T score of-2.5 at the lumbar spine, which is consistent with osteoporosis. What is the most likely cause of this patient's hypercalcemia?

65) A 31-year-old Hispanic female presents with palpitations and weight loss. Her past medical history is insignificant. Her family history is unremarkable. She recently moved from South America. She does not smoke cigarettes or drink alcohol. She is married and has three children. Her last delivery was four years ago. Her blood pressure is 140/90 mmHg, pulse is 102/min, temperature is 36.7°C (98°F) and respirations are 20/min. Her eye examination is unremarkable. Thyroid examination reveals a 2 x 2 cm left-sided thyroid nodule. Her T3 and T 4 are elevated, and TSH is undetectable. Radioactive iodine scan shows uptake only in the left thyroid nodule. Uptake in the rest of the thyroid is markedly reduced. Which of the following is the most likely diagnosis?

66) A 36-year-old male comes to the office for the evaluation of fatigue and weakness for the last several weeks. He denies any change in appetite, change in weight, heat or cold intolerance, nausea, vomiting and constipation. He cannot recall any recent stressful events. His past medical and family histories are unremarkable. He does not have any medications. His pulse is 76/min, blood pressure is 120/70 mmHg, respirations are 14/min, and temperature is 36.7°C (98°F). He is well-oriented to time, place and person. His neurological examination is nonfocal; the deep tendon reflexes are normal. Lab tests show: Hematocrit 43%, WBC count 6,000/microl, Platelet count 200,000/microl, Serum calcium 11 mg/dL, Serum albumin 4.5 g/dL, 24-hour urinary calcium 200 mg. Which of the following is the most likely cause of his symptoms?

1) A 63-year-old white female presents with a thyroid nodule. She denies any weight loss, change in appetite, diarrhea, heat or cold intolerance, menstrual irregularities, hoarseness and dyspnea. Her past medical history is unremarkable. There is no family history of thyroid cancer. She does not take any medications. Physical examination shows a 4-5 cm, fixed, hard, and non-tender thyroid nodule. There is cervical lymphadenopathy. Her serum TSH level is normal. Fine needle aspiration (FNA) of the thyroid shows malignant cells. Which of the following is the most likely expected pathology on FNA?

2) A 36-year-old female presents with headaches and visual problems. She also complains of palpitations, heat intolerance and weight loss. Her past medical history is unremarkable. She is currently on no medications. Her blood pressure is 130/60 mmHg, heart rate is 100/min and regular, and weight is 152 lb (weight one year ago was 170 lb). Physical examination reveals a symmetrically enlarged thyroid gland without any tenderness. Auscultation of the chest reveals tachycardia. She has bitemporal hemianopsia on confrontation. The rest of the physical examination is unremarkable. Her lab investigations show: Serum T3 222 ng/mL, Serum T4 13.9 mcg/dL, Serum TSH 7.9 IU/mL, Alpha subunit level elevated. Which of the following is the most likely diagnosis?

3) A 35-year-old male presents with complaints of weakness and fatigue of one year's duration. He is anorexic and has lost interest in all his activities. He also complains of cold intolerance and constipation. His blood pressure is 98/72 mmHg, temperature is 37.1°C (99°F), respirations are 14/min, and pulse is 50/min. His skin is dry and rough, nails are brittle, and hair is thin. There is no hyperpigmentation of the skin. Delayed deep tendon reflexes are noted on neurological examination. Lab studies show: Hemoglobin 10.2 g/dL, WBC count 5,000/micro-L, Neutrophils 45%, Monocytes 5%, Eosinophils 10%, Basophils 1%, Lymphocytes 40%, Serum sodium 135 mEq/L, Serum potassium 4.0 mEq/L. Which of the following is most consistent with this patient's findings?

4) A 60-year-old male is admitted to the hospital because of right lower lobe pneumonia. His medical history is significant for hypertension, diabetes mellitus, severe degenerative disease of the spine, and longstanding lower back pain. He is a chronic smoker with a 40-pack year smoking history. During his hospitalization, the laboratory report shows decreased serum calcium levels and increased phosphate levels. Further evaluation reveals increased serum intact parathyroid hormone levels. Which of the following medical conditions is most likely responsible for this patient's abnormal lab findings?

5) A 43-year-old female presents to the physician's office with muscle cramps, polydipsia and polyuria. She has no other medical problems, and does not take any medications. She does not use tobacco, alcohol or drugs. Her father died from alcoholic liver disease at age 50. Her pulse is 75/min, respirations are 13/min, blood pressure is 160/100 mmHg, and temperature is 37°C (98.6°F). Laboratory studies show: Blood glucose 115 mg/dL, Serum sodium 142 mEq/L, Serum potassium 2.7 mEq/L. Plasma renin activity is low. What is the most likely diagnosis?

6) A 30-year-old Hispanic male presents to the office with complaints of palpitations, tremor, nervousness and headache. His past history is insignificant. His mother has type 2 diabetes, which is well-controlled with medications. His temperature is 37.0°C (98.6°F), pulse is 100/min, blood pressure is 150/80 mmHg, and respirations are 16/min. He appears anxious, sweaty and shaky. His neurological examination is non-focal, and examination of other systems is unremarkable. His fingerstick blood glucose level is 38 mg/dL. Intravenous administration of a bolus of 50% dextrose leads to the improvement of his symptoms. He is then subjected to supervise prolonged fasting. After an overnight fast, laboratory studies reveal: Blood glucose 40 mg/dl, Serum insulin 15 microU/L (normal value is < 6 microU/L with hypoglycemia), Serum pro-insulin 9 microU/L (normal value is < 20% of total immunoreactive insulin), C-peptide level 0.8 nmol/L (normal value is less than 0.2 nmol/L), Sulfonylurea Negative, IGF-II Negative. Based on the above information, what is the most likely cause of this patient's hypoglycemia?

7) A 35-year-old male presents to the family physician for bilateral gynecomastia. He observed a progressive increase in his breast size starting 6 months ago. He is sexually active and denies any drug use. Physical examination reveals bilateral gynecomastia and tenderness. The genito-urinary examination shows a 1 cm nodule in the right testis. Otherwise, the examination is within normal limits. The laboratory report shows: LH 3 U/L, FSH 2 U/L, testosterone 270 ng/dL (Normal 3-10 ng/dL), estradiol 115 pg/mL (Normal 20-60 pg/mL), beta HCG undetectable, AFP undetectable. Which is the most likely diagnosis?

8) A 39-year-old woman comes to the physician because of a "pins and needles" sensation around her mouth for the last 2-3 weeks. She gets similar sensations in her feet sometimes, along with muscle cramps, especially at the end of the day. She has no similar episodes in the past and has always been healthy. She works as a waitress and has "clean habits." Her family history is not significant. She is currently not taking any medications, and is allergic to penicillin. Her vital signs are normal. Examination is unremarkable. The patient's labs reveal: CBC: Hb 12.4 g/dl, WBC 6,000/cmm. Serum: Serum Na 140 mEq/L, Serum K 4.0 mEq/L, Chloride 100 mEq/L, Bicarbonate 24 mEq/L, BUN 10 mg/dl, Serum creatinine 0.8 mg/dl, Glucose 100 mg/dl, Calcium 6.5 mg/dl, Phosphorus, inorganic 5.8 mg/dl. Protein: Total 7.0 g/dl, Albumin 3.8 g/dl, Globulins 3.0 g/dl. Which of the following is the most likely cause of her condition?

9) A 56-year-old male presents in the emergency department with severe nausea, vomiting, polyuria, polydipsia, and constipation. His past medical history is significant for hypertension and type 2 diabetes mellitus. His home medications include metformin, atenolol, and hydrochlorothiazide. He has a 26-pack-year history of smoking. He drinks alcohol occasionally. He denies the use of recreational drugs. His father also has diabetes mellitus type 2. His blood pressure is 110/70 mmHg, pulse is 102/min, temperature is 36.7°C (98°F) and respirations are 16/min. His mucus membranes are dry. His lung examination reveals decreased breath sounds over the right base. The rest of the physical examination is unremarkable. The patient is subsequently admitted. Laboratory studies (obtained in the emergency department) are as follows: Serum calcium 14.8 mg/dl, Albumin 4.0 g/dl, PTH 9 pg/ml (normal 10-60 pg/ml), Serum creatinine 1.9 mg/dl, BUN 54 mg/dl, Blood glucose 180 mg/dl, 25-hydroxyvitamin D 30 ng/ml (normal 20 to 60 ng/ml), 1,25-dihydroxyvitamin D 30 pg/ml (normal 15 to 65 pg/ml). What is the most likely cause of this patient's hypercalcemia?

10) A 63-year-old otherwise healthy male presents with a thyroid nodule. He denies any symptoms of anxiety, heat or cold intolerance, and recent changes in appetite or weight. He has hypertension, which is being treated with a beta-blocker. He does not have any other medical problems. He denies any family history of thyroid disease. His pulse is 79/min and blood pressure is 130/76 mmHg. Neck examination shows a hard, fixed, non-tender, 4 cm thyroid nodule in the right thyroid lobe. His serum TSH level is normal. Fine needle aspiration biopsy (FNAB) shows follicular cells. Follicular carcinoma is suspected. Which of the following is necessary to make a diagnosis of follicular thyroid cancer?

11) A 38-year-old Caucasian female presents to the office complaining of lethargy, weight gain and fatigue. She denies headaches, pruritus or urine discoloration. She just gave birth 2 months ago via vaginal delivery; her baby is in good health and receives formula nutrition. Her delivery was complicated by vaginal bleeding that required blood transfusion, and postpartum endometritis that rapidly responded to antibiotics. She has not had any menstrual periods following delivery. Physical examination shows sparse pubic hair, dry skin and delayed tendon reflexes. Urinalysis shows no glucose or ketones. Which of the following is most likely to be responsible for this patient's condition?

12) A 56-year-old woman presents to the clinic with a 7-month history of headache and visual disturbance. Her past medical history is unremarkable. She is currently not taking any medications. She admits to smoking a pack of cigarettes daily for the last 15-years, and does not drink. On visual field examination, there is a small field defect noted in both eyes. MRI scan shows a pituitary tumor. Which of the following is the most common type of pituitary tumor?

13) A 65-year-old Hispanic male comes to the office for a routine medical check-up. He has a history of diabetes for the past twenty years, and hypertension for the past ten years. His daily medications include insulin and ramipril. He was diagnosed with nonproliferative diabetic retinopathy at his last ophthalmologic visit. Reports from his previous laboratory studies show microalbuminuria. A detailed neurological examination is performed to check for any neuropathy. Which of the following is the most common type of neuropathy found in diabetics?

14) A 65-year-old man presents with a 1-day history of hematuria and sharp flank pain (rated 10 of 10) radiating toward the groin on the right side. Past medical history is significant for three prior episodes of nephrolithiasis over the past 5 years, all of which presented with a similar clinical picture. He is not taking any medication. There is no family history of renal calculi, renal disease, or endocrine disorders. His temperature is 36.9°C (98.5°F), heart rate is 125/min, and blood pressure is 132/86 mmHg. He is in obvious distress and cannot sit still on the bed. Physical examination is significant for a soft, nontender abdomen and extreme costovertebral angle tenderness on the right. Laboratory values show: Na+: 142 mEq/L, K+: 4.8 mEq/L , Cl−: 104 mEq/L, HCO −: 24 mEq/L , Ca2+: 11.0 mg/dL , PO4: 1.4 mg/dL , Mg2+: 2.0 mg/dL , Blood urea nitrogen: 12 mg/dL, Creatinine: 1.0 mg/dL, Glucose: 118 mg/dL, Intact parathyroid hormone: 300 pg/mL. Which of the following is the most likely diagnosis?

15) A 90-year-old male complains of hip and back pain. He has also developed headaches, hearing loss, and tinnitus. On physical examination the skull appears enlarged, with prominent superficial veins. There is marked kyphosis, and the bones of the leg appear deformed. Serum alkaline phosphatase is elevated. Calcium and phosphorus levels are normal. Skull x-ray shows sharply demarcated lucencies in the frontal, parietal, and occipital bones. X-rays of the hip show thickening of the pelvic brim. Which of the following is the most likely diagnosis?

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

17) A 65-year-old diabetic male with acute myocardial infarction complicated by cardiogenic shock is admitted in the coronary care unit. His hospital course was complicated by acute renal failure and lower GI bleeding from anticoagulation therapy. His thyroid hormone studies are abnormal. He does not have any previous history of thyroid disease. Physical examination of the thyroid gland is normal. Labs show: Triiodothyronine (T3), serum 1.4 nmol/L (normal 1.8-29 nmol/L), Thyroxine (T 4), serum 6.0 micro-g/dL (normal 5-12 micro-g/dL), Thyroid-stimulating hormone, serum 2.0 micro-U/mL. Which of the following is the most likely diagnosis?

18) A 45-year-old male presents to your office because his "hands are getting thick and swollen." He is also having difficulty with wearing shoes because his feet have become large. His blood pressure is 150/90 mmHg. On examination, he has enlarged, swollen hands and feet. He has coarse facial features, with prominent frontal bones and jaws. While you are discussing the most likely diagnosis, he appears worried and asks about the complications and risk of death associated with his condition. What is the most common cause of death in patients with this condition?

19) A 17-year-old girl presents to the clinic because she has not yet menstruated and does not have significant breast development. Family history is significant only for some cousins who are color blind. The patient denies ethanol, tobacco, and illicit drug use and sexual activity. Physical examination reveals a normal-appearing girl in no acute distress with minimal breast development and a lack of pubic hair. She is 168 cm (5'6") tall and weighs 61.2 kg (135 lb). Cardiac examination reveals no murmurs, rubs, or gallops, with point of maximal impulse at the left mid-clavicular line between the third and fourth intercostal space. Gynecologic examination reveals a vagina without rugae and a cervix that is easily visualized. There is no discharge. A urine test is negative for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis?

20) A 26-year-old man presents with increased thirst, urinary frequency, and nocturia over the past several months. Physical examination is unremarkable. Twenty-four-hour urine osmolarity is < 300 mOsm/L. A fluid deprivation test does not result in an increased urine osmolarity. Administration of 0.03 μg/kg of desmopressin results in a urine osmolarity of 450 mOsm/L after 2 hours. Which of the following is the most likely diagnosis?

21) A 48-year-old woman presents to her primary care physician because of 2 weeks of neck pain. The pain is constant and sharp (rated at 10 of 10) and is felt in the anterior portion of her neck. She also notes several weeks of loose stools and fatigue. Past medical history is significant for a viral upper respiratory infection about 1 month ago. She has a temperature of 37.9°C (100.2°F), heart rate of 96/min, and blood pressure of 136/82 mmHg. On neck examination there is diffuse enlargement of the thyroid and it is exquisitely tender to even mild palpation. Laboratory tests show a total tri-iodothyronine level of 280 ng/dL, total thyroxine of 25 μg/dL, and thyroid-stimulating hormone of 2 μU/mL (normal: 0.4–4 μU/L).Which of the following is the most likely diagnosis?

22) A 74-year-old woman is brought to the emergency department by her daughter. The daughter states that her mother lives alone and has no significant medical problems. She says that she last saw her mother a month prior, before she left on an extended business trip. When she returned, she found her mother appeared restless and very nervous. She also appeared to have lost a noticeable amount of weight. The patient told her daughter that she had been having increased frequency of bowel movements, and felt like her heart was beating fast and funny, and that she felt like she might be coming down with a cold. Initial evaluation in the emergency department reveals sinus tachycardia and a painful, enlarged thyroid. Which of the following is the most likely etiology of her symptoms?

23) A 32-year-old woman undergoes a cesarean section because of failure of labor to progress, and delivers a healthy baby boy. The procedure is complicated by significant intraoperative blood loss and hypotension, but the patient is successfully resuscitated. Postoperatively she experiences dull, aching, non-localized abdominal pain and nausea, but denies headache, visual changes, or abnormal edema. On postoperative day three she is passing flatus and remains afebrile, but becomes hypotensive to 90–100 mm Hg systolic and 40–50 mm Hg diastolic. She has not begun lactating despite her attempts to breast-feed her infant. Laboratory values indicate that she is hyponatremic and mildly hyperkalemic. Urinalysis and liver enzymes are normal. Which of the following is the most likely cause of her symptoms?

24) A 24-year-old white male presents with a persistent headache for the past few months. The headache has been gradually worsening and not responding to over-the-counter medicines. He reports trouble with his peripheral vision which he noticed while driving. He takes no medications. He denies illicit drug use but has smoked one pack of cigarettes per day since the age of 18. Past history is significant for an episode of kidney stones last year. He tells you no treatment was needed as he passed the stones, and he was told to increase his fluid intake. Family history is positive for diabetes in his mother and a brother (age 20) who has had kidney stones from too much calcium and a “low sugar problem.” His father died of some type of tumor at age 40. Physical examination reveals a deficit in temporal fields of vision and a few subcutaneous lipomas. Laboratory results are as follows: Calcium: 11.8 mg/dL (normal 8.5-10.5), Cr: 1.1 mg/dL, Bun: 17 mg/dL, Glucose: 70 mg/dL, Prolactin: 220 μg/L (normal 0-20), Intact parathormone: 90 pg/mL (normal 8-51). You suspect a pituitary tumor and order an MRI which reveals a 0.7 cm pituitary mass. Based on this patient’s presentation, which of the following is the most probable diagnosis?

25) A 26-year-old man with a history of kidney stones presents with 1 week of severe burning epigastric pain. He also notes several days of diarrhea and nausea but denies emesis or fever. His family history is remarkable for a paternal uncle with pancreatic cancer. His temperature is 37°C (98.6°F), heart rate is 88/min, respiratory rate is 16/min, and blood pressure is 125/85 mm Hg. Abdominal examination is significant for tenderness in the mid-epigastrium. Upper endoscopy reveals a 1-cm ulceration in the first part of the duodenum. This is the third episode of confirmed peptic ulcers in this patient. Laboratory studies show: Na+: 140 mEq/L, K+: 4.9 mEq/L , Cl−: 105 mEq/L, HCO −: 25 mEq/L, Ca2+: 12.0 mg/dL, PO4: 1.4 mg/dL, Mg2+: 2.0 mg/dL, Blood urea nitrogen: 10 mg/dL Creatinine: 1.0 mg/dL , Glucose: 87 mg/dL. Which of the following is most likely to be found in this patient?

26) A 52-year-old man presents to the primary care clinic for the first time. He states that he has been in good health throughout his life and takes no medications. He was once athletic but has noted a dramatic decrease in his muscle strength and exercise tolerance over the past year. On examination the patient is moderately hypertensive, with a tanned, round, plethoric face; large supraclavicular fat pads; and significant truncal obesity. He has no focal cardiovascular, pulmonary, or neurologic findings. His fasting blood sugar is 200 mg/dL. Which of the following is the most common etiology of this condition?

27) A 3-year-old girl is brought to the pediatrician’s office because of an abdominal mass. Physical examination reveals short stature, coarse facial features, a protruding tongue, and an easily reducible umbilical hernia. The girl has difficulty walking and knows six words, although she is unable to form a sentence. Her mother reports no health problems and an uncomplicated pregnancy. What is the most likely cause of the patient’s condition?

28) A moderately overweight 34-year-old woman presents to the emergency department with excessive sweating, flushing, tachycardia, and nervousness. Presuming that she might be suffering from thyrotoxicosis, the physician checks her blood levels of thyroid hormones, and finds that her free thyroxine and triiodothyronine levels are elevated, while her thyroid-stimulating hormone is decreased. Her radioactive iodine uptake test shows a complete absence of iodine uptake. Which of the following is the most likely diagnosis?

29) A 28-year-old Caucasian male presents to the emergency department complaining of neck pain for the past two days. He states that a chicken bone scratched the back of his throat a week ago. Two weeks ago, he was in Arizona visiting his friends. He is otherwise healthy and has never been hospitalized. His temperature is 39°C (102.2°F), blood pressure is 125/85 mmHg, and heart rate is 120/min. On examination, he refuses to fully open his mouth. Neck movements, especially neck extension, are restricted secondary to pain. Which of the following is the most likely diagnosis?

30) A 7-year-old boy with a 6-day history of nasal discharge presents with a swollen and painful left eye. His blood pressure is 100/70 mmHg, pulse is 92/min, respirations are 18/min, and temperature is 39.4°C (103°F). Examination of the left eye reveals swollen and erythematous eyelids, mild protrusion of the eyeball, and pain with eye movements. The affected eye is tender and his visual acuity is decreased. Funduscopic examination is normal. Which of the following is the most likely diagnosis?

31) A 32-year-old male complains of difficulty hearing in his left ear for the past month. He denies any headaches, fever, chills, weight loss, or ear discharge. He is HIV positive, and is currently being treated with highly active antiretroviral therapy (HAART). He also takes trimethoprim/sulfamethoxazole daily. His most recent CD4 count was 425/mm3. Examination of the affected ear shows a dull, hypomobile tympanic membrane. What is the most likely cause of hearing loss in this patient?

32) A 36-year-old woman presents to your office with complaints of worsening throat pain for the past six days. She also has pain in her ears and neck as well as difficulty swallowing. On examination, she has excessive salivation and difficulty opening her mouth. Her temperature is 39°C (102.2°F), blood pressure is 130/80 mmHg, pulse is 100/min, and respiratory rate is 18/min. Which of the following neck space infections carries the highest risk of mediastinal involvement?

33) A 23-year-old male comes to your office with a 10-day history of severe headaches. He states that they are sharp in character and are mostly right-sided involving the frontal area. The headaches interfere with his sleep, and he also complains of double vision, nausea, and malaise. His blood pressure is 120/80 mmHg, pulse is 103/min, respirations are 14/min, and temperature is 38.0°C (100.5°F). Examination reveals bilateral periorbital edema. There is subtle right-sided lateral gaze palsy. Which of the following is the most likely diagnosis?

34) A 24-year-old Caucasian female complains of recurrent painful ulcers in her mouth and occasional abdominal pain. She has also unintentionally lost 5 pounds over the last six months. She is not sexually active, and denies use of tobacco, alcohol, or drugs. Past medical history is noncontributory and she takes no regular medications. Her mother suffers from asthma and her father has prostate cancer. She is afebrile with a blood pressure of 118/69 mmHg and pulse of 71/min. Physical examination reveals mild abdominal tenderness primarily in the lower abdomen without guarding or rebound. Several shallow ulcers are seen on the buccal mucosa. A biopsy of one of the ulcers demonstrates granulomatous inflammation. Her hematocrit is 42%. Which of the following is the most likely cause of this patient's complaints?

35) A 70-year-old man comes to your office with complaints of difficulty hearing. His wife says that he has been raising the television volume much louder recently. The patient claims that he can hear well when he talks to his family members at home, but he has significant difficulty hearing in restaurants or during other family gatherings, which is why he prefers to stay at home most of the time. He worked in a shipbuilding yard for 30 years, and retired five years ago. He has no history of significant noise exposure. What is the most likely diagnosis?

36) A 12-year-old girl comes to the office complaining of a small amount of left-sided ear discharge that has persisted for the last three weeks. She has completed two courses of antibiotics that were prescribed during her previous visits. She also complains of hearing loss on the left side. On examination, she is afebrile. Otoscopy reveals an intact left tympanic membrane with peripheral granulation and some skin debris. The patient should be evaluated for which of the following?

37) A 33-year-old Caucasian female has suffered from recurrent episodes of dizziness over the last six months. She describes the episodes as a sensation of severe spinning that last one to two hours and are accompanied by intense nausea. She also feels unsteady during the episode, and has to lie down with her eyes closed for relief. There is no particular factor that precipitates the episodes. She denies any headaches, but complains of fullness in her right ear. She has no ear pain or ear discharge. She has used some over-the-counter ear drops with minimal relief of the fullness sensation. She prefers holding her cell phone on the left side. Which of the following is the most likely cause of this patient's condition? .

38) A 6-year-old boy is brought to the office by his mother due to a decreased appetite and irritability for the past three days. He also had an episode of diarrhea yesterday. Lately, he has been sitting close to the television with the volume turned up very loudly. His temperature is 38.1°C (100.5°F), blood pressure is 110/60 mmHg, and heart rate is 110/min. On examination, there is left-sided yellowish ear discharge. His nasal mucosa appears boggy and postnasal drip is present. What is the most likely diagnosis?

39) A 28-year-old African American female complains of recurrent nasal discharge and increasing nasal congestion. She has a constant sensation of dripping in the back of her throat, and states that food has tasted bland to her recently. She is known to have sickle cell trait. She came to the emergency department for severe wheezing after taking naproxen for menstrual cramping one year ago. She has no history of head trauma. She does not smoke cigarettes, but she admits to smoking marijuana occasionally. Which of the following is the most likely diagnosis?

40) A 26-year-old man comes to your office with a one-week history of right-sided ear pain. The pain often wakes him up at night, and increases in severity when he chews food. He cannot recall any recent episodes of pharyngitis. He denies having any ear discharge, sinus tenderness, or skin rash. He exercises by swimming frequently at a local club. He is sexually active and uses condoms "quite regularly." He lives with his brother, who often comments on his habit of grinding his teeth at night. On examination, his ears are normal with a mild amount of wax. Pain is not elicited by pulling on the pinna. There are no hearing deficits appreciated. Mobility of the tympanic membrane is normal, and the Weber and Rinne test results are within normal limits. What is the most likely diagnosis?

42) A 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?