USMLE diagnosis 2

4) A 42-year-old man found vomiting in the street is brought to the ED by emergency medical services (EMS). He has a known history of alcohol abuse with multiple presentations for intoxication. Today, the patient complains of acute onset, persistent chest pain associated with dysphagia, and pain upon flexing his neck. His BP is 115/70 mmHg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 97% on room air. As you listen to his heart, you hear a crunching sound. His abdomen is soft with mild epigastric tenderness. The ECG is sinus tachycardia without ST-T–wave abnormalities. On chest radiograph, you note lateral displacement of the left mediastinal pleura. What is the most likely diagnosis?

5) A 65-year-old man with a history of chronic hypertension presents to the ED with sudden-onset tearing chest pain that radiates to his jaw. His BP is 205/110 mmHg, HR is 90 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. He appears apprehensive. On cardiac examination you hear a diastolic murmur at the right sternal border. A chest x-ray reveals a widened mediastinum. Which of the following is the preferred study of choice to diagnose this patient’s condition?

6) A 36-year-old man is seen because of palpitations. He admits to precordial discomfort, weakness, and anxiety. His pulse is 150/min, and his blood pressure is 124/70 mmHg. Heart sounds are normal. Carotid sinus pressure gradually changes the rate to 75/min, but when released, the pulse rate returns to 150/min. Which of the following is the most likely diagnosis?

7) A 25-year-old man complains of left precordial chest pain that radiates to the left shoulder but not down the left arm. The pain is accentuated by inspiration and relieved by sitting up. The pain is accompanied by fever and chills. His blood pressure is 105/75 mmHg, pulse 110/min and regular, and temperature 37.5°C. Aside from the tachycardia, there are no abnormal physical findings in the heart or lungs. The ECG shows STsegment elevation in all leads except aVR and VI. On the third hospital day, the patient’s blood pressure falls, JVP rises, and he goes into CHF. Which of the following is the most likely diagnosis?

9) A 42-year-old female with acute pericarditis develops jugular venous distention and hypotension. The ECG shows electrical alternans. Which of the following is the most likely additional physical finding?

10) A 36-year-old man presents to the clinic with complaints of a genital sore. The patient is a sexually active heterosexual involved with three partners and practices unprotected intercourse. Four days ago he noted a painless sore on his penis. He is afebrile, with a heart rate of 80/min and blood pressure of 120/77 mmHg. Physical examination reveals a solitary ulcerated lesion located on the lateral aspect of his penis. The lesion is nontender and associated with bilateral inguinal lymphadenopathy. Physical examination is otherwise normal. If left untreated, this man is at increased risk for which of the following?

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?