Dia_Dif_S_V

A 69-year-old man is brought to see his physician by his wife. She notes that over the past year he has experienced a slow, stepwise decline in his cognitive functioning. One year ago she felt his thinking was “as good as it always had been,” but now he gets lost around the house and can’t remember simple directions. The patient insists that he feels fine, though he is depressed about his loss of memory. He is eating and sleeping well. Which of the following is the most likely diagnosis?

A 70-year-old retired engineer is brought to the office by his son for a routine check-up. He believes that his son is too greedy and wants all his property. He is accusing his son of "kicking him out of the house to get all of his property." He has been getting more forgetful over the past few years. His younger sibling has the same problem. He has no significant past medical history, except a history of smoking for 6 years when he was young. His blood pressure is 138/78 mm Hg, pulse is 86/min, respirations are 14/min and temperature is 37.0°C (98.6°F). He cannot remember current events, such as the name of the current American president; however, he can still remember past political history. He is unable to concentrate, but is oriented to time, place and person. The neurological examination is nonfocal. CT scan reveals mild generalized atrophy. His HIV and RPR tests are negative. The serum electrolytes and thyroid function tests are normal. What is the most likely diagnosis of this patient?

A 65-year-old, obese, white female comes to the office for the evaluation of her progressively worsening memory. She considers herself "very independent," and lives alone; however, the development of her new symptoms is causing her some distress, as she often forgets to pay her bills. A detailed review of systems reveals no other symptoms, except for mild urinary incontinence. She has hypertension controlled with a beta-blocker and type 2 diabetes mellitus controlled with diet. She does not use tobacco, alcohol or drugs. Her blood pressure is 130/90 mmHg, pulse is 72/min, temperature is 36.7°C (98°F) and respirations are 14/min. Lungs are clear to auscultation and percussion. A grade 2/6, systolic ejection murmur is heard. Abdominal examination shows no tenderness or masses. Neurological examination shows broad-based, shuffling gait and a right-sided carotid bruit. Complete blood count and serum chemistry panel are within normal limits MRI shows enlarged ventricles. What is the most likely diagnosis?

A 59-year-old man is brought to the office by his family due to attitude problems over the last year. He has a history of memory loss and word-finding problems. He has lost interest in golf, which used to be one of his favorite sports. Recently, he has become promiscuous and has started using "dirty language," which he has never used before. He is a non-smoker. He has no significant past medical or surgical history. His uncle had similar features, for which he was admitted into a nursing home, but died soon after admission. The physical examination reveals intact visuospatial functions, intact cranial nerves, and prominent snout and grasp reflexes. What is the most likely diagnosis?

A 60-year-old white male is brought to the physician's office for the evaluation of worsening confusion and memory loss for the past three weeks. His other complaints are muscle twitching and gait problems. He denies any fever, headache or urinary problems. He does not drink nor smoke. His pulse is 82/min, blood pressure is 130/76 mm Hg, and temperature is 37.1°C (98.7°F). He displays poor grooming and is disoriented. The pertinent physical findings are nystagmus and positive extensor plantar response bilaterally. The laboratory studies are as follows: Hematocrit 40%, WBC 6,000/microl, Platelets 160,000/microl. A non-contrast head CT scan is normal. The EEG shows periodic sharp waves. What is the most likely diagnosis of this patient?

A 66-year-old male presents to the emergency room with shortness of breath. The symptoms started one week ago with a dry cough and exertional dyspnea. His past medical history includes hypertension and recent stenting for double-vessel coronary artery disease. He was hospitalized six months ago for pneumonia. He has a 35 pack-year smoking history. His temperature is 37.2°C (98.9°F), blood pressure is 160/90 mmHg, and heart rate is 90 and regular. On examination, the patient is in mild respiratory distress, but he can speak in full sentences. Chest auscultation reveals decreased breath sounds at the lung bases, bilateral crackles and occasional wheezes. His ABG shows: pH 7.46, pO2 73mmHg, pCO2 31mmHg. Which of the following is the most likely explanation for this patient's symptoms?

A 60-year-old female comes to your office for progressive exertional dyspnea and new-onset ankle swelling. She has been recently worked up for proteinuria and easy bruisability. Otherwise her past medical history is insignificant. She has a ten pack-year history of smoking and she drinks two to three glasses of wine every day. Her temperature is 37.1°C (98.8°F), blood pressure is 130/70 mmHg, pulse is 80/min and respirations are 14/min. There is mild jugular venous distention on physical examination. Chest auscultation shows scattered bibasilar crackles. Echocardiography reveals symmetrical thickening of the ventricular walls, normal ventricular dimensions and a slightly reduced systolic function. Which of the following is the most likely diagnosis?

A 56-year-old male presents with progressively worsening dyspnea and ankle edema. He denies chest pain syncope or palpitations. He does not smoke or drink alcohol. He denies diabetes mellitus, hypertension, or hyperlipidemia. His temperature is 37.1°C (98.7°F), pulse is 70/min, blood pressure is 136/70mmHg, and respirations are 15/min. Examination shows elevated jugular venous pressure, bilateral ankle edema, and tender hepatomegaly. Chest auscultation shows bibasilar rales. His heat sounds are distant and there is no murmur. Chest x-ray shows mild cardiomegaly and a right-sided pleural effusion. ECG shows low voltage QRS complexes and nonspecific ST-T wave changes. Echocardiography shows normal left ventricular volume with symmetrical thickening of the left ventricular walls and slightly reduced systolic function. Which of the following would represent a potentially reversible cause of this patient’s heat disease?

A 15-year-old boy comes to the physician because of hematuria and lower abdominal pain. This is his third episode of hematuria in the past 2 years. He has a family history of renal disease. 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 mild sensorineural deafness bilaterally. Urinalysis shows hematuria and proteinuria. Laboratory studies show BUN of 50 mg/dl and serum creatinine of 3.1 mg/dL; serum complement levels are normal. Renal biopsy shows foam cells, and immunofluorescence shows no immunoglobulins or complement. Electron microscopy shows alternating areas of thinned and thickened capillary loops with splitting of GBM. Which of the following is the most likely diagnosis?

A 25-year-old woman presents with lower abdominal pain, fever, and a vaginal discharge. Pelvic examination reveals bilateral adnexal (ovarian) tenderness and pain when the cervix is manipulated. Cultures taken from the vaginal discharge grow Neisseria gonorrhoeae. Which of the following is the most likely cause of this patient’s adnexal pain?

A 25-year-old, HIV-positive male presents to the office with an altered mental status. He is disoriented, lethargic, and has loss of recent memory. These symptoms have been present for the last month. His current medications include zidovudine, didanosine, indinavir, trimethoprim-sulfamethoxazole and azithromycin. His temperature is 37.7°C (99.8°F), pulse is 78/min, blood pressure is 130/80mm Hg, and respirations are 16/min. The neurological examination is non-focal. His CD4 count is 40/microl and viral load is 25,000 copies/ml by PCR. MRI scan reveals a solitary, irregular, weakly ring-enhancing mass in the periventricular area. The serology for Toxoplasma is positive. PCR of CSF shows EBV DNA. What is the most likely diagnosis?

873) A 48-year-old woman presents to her gynecologist because of vaginal bleeding. She states that after a year of hot flashes and irregular cycles, she finally stopped menstruating 4 months ago. Two days ago she began having some vaginal bleeding that was very similar to her prior menses. She is concerned because she heard that the first sign of endometria cancer in postmenopausal women is vaginal bleeding. She is an otherwise healthy woman with no medical problems. She exercises three times a week and takes multivitamins. She had three children when she was 29–35 years old. She used oral contraceptive pills for contraception from the time she was 18 until she got married at the age of 28. Which of the following is the most appropriate next step in managing this woman’s vaginal bleeding?

997) A 56-year-old male is admitted to the ICU for the management of hepatic encephalopathy. He is a known alcoholic. He is started on oral neomycin, lactulose, and a low-protein, high-carbohydrate diet. His blood pressure is 116/78 mm Hg, pulse is 78/min, temperature is 37.5°C (99.5°F), and respirations are 18/min. His labs reveal the following: Hb 10.2 g/dl, WBC 7,400/cmm, Hct 27%, Platelets 4 2,000/mm3, PT 18 sec, INR 2.02, PTT 31 sec. He has no evidence of active bleeding. Which of the following should be administered to this patient at this time?