Part8(1957-2000)......(1785-2039)6breetpit

An 84-year-old man is brought to the emergency department because of 1 hour of severe back pain. He also had syncope that lasted <1 minute. Before arriving at the hospital, he had an episode of gross hematuria, which he has never had before. He also complains of some shortness of breath. He denies chest pain, cough, nausea, vomiting, headache, and neck pain. His blood pressure is 72/55 mm Hg and pulse is 112/min and regular. His pulse oximetry shows 92% on room air. His ECG shows sinus tachycardia with prominent horizontal ST segment depression in the anterior chest leads. Which of the following is the most likely diagnosis?

A 54-year-old man comes to the physician because of edema of his right ankle. He reports heaviness and cramping in the same leg that is worse after a long day at work. The swelling is usually reduced significantly when he wakes up in the morning and worsens progressively throughout the day. He denies any other symptoms. He has no significant medical problems except hypertension, for which he takes atenolol. His temperature is 36.7° C (98° F), blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 16/min. JVP is normaL Lungs are clear to auscultation. There are no murmurs. There is no hepatosplenomegaly. Examination shows edema of the right ankle. Doppler examination of the leg shows no evidence of thrombosis. Which of the following is the most likely cause of his edema?

A 68-year-old man presents to the physician’s office complaining of progressive dysphagia over the last 3 months associated with mild chest discomfort. He reports a 15-lb weight loss, a 30 pack-year smoking history, and occasional alcohol intake. The physical examination, including vital signs, is unremarkable. A chest x-ray was normal, and a barium esophagogram shows an irregular filling defect in the distal third of the esophagus with distortion and narrowing of the lumen. Which of the following is the most likely diagnosis?

A 29-year-old man presents with a 2-day history of severe left-sided scrotal pain and swelling. He is sexually active and has had "many" sexual partners. His temperature is 38.2 C (100.8 F), blood pressure is 120/70 mm Hg, and pulse is 80/min. Examination shows unilateral intrascrotal tenderness and swelling. Testicular support makes the pain less intense. Which of the following is the most likely diagnosis?

A 24-year-old man comes to the physician because of 1 week of abdominal pain. It is localized in the right lower quadrant and somewhat exacerbated by motion. Over the past 2 days, it has radiated to the back. He initially had two episodes of vomiting but now just has decreased appetite. He had one episode of diarrhea 1 day ago. He denies urinary frequency. His other medical problems include mild intermittent asthma and gastroesophageal reflux disease. He traveled to Mexico for 5 days 1 month ago and did not have any gastrointestinal symptoms during his stay there. His mother was diagnosed with colon cancer at the age of 49 years. His temperature is 38.2°C (100.8°F), blood pressure is 122/77 mm Hg, and pulse is 109/min and regular. Physical examination reveals prominent tenderness in the right lower quadrant, without rebound. Flexion of the right hip against resistance elicits significant abdominal pain. Laboratory results show:WBC count 16,000/mmHemoglobin 14.2 g/dlPlatelet count 620,000/mmPotassium 4.5 mEq/LCreatinine 1.0 mg/dlWhich of the following is the most likely diagnosis?

A 35-year-old woman is involved in a motor vehicle crash, sustaining a severe pelvic fracture, with disruption of the pelvic ring. In the trauma resuscitation room, she is confused and tachypneic, with a blood pressure of 90 mmHg systolic and a heart rate of 130/min. Laboratory investigations include serum electrolyte analysis, revealing a sodium of 139, a chloride of 103, and a bicarbonate of 14 meq/L. This patient demonstrates which of the following?

A 43-year-old man develops excruciating abdominal pain at 8:23 PM (he looked at his watch when the pain "hit him"). When seen in the emergency department about 30 minutes later, he has a rigid abdomen, lies motionless on the examination table, has no bowel sounds, and is obviously in great pain, which he describes as constant and encompassing the entire abdomen. There is very severe pain when deep palpation of the abdomen is attempted in any of the four quadrants. However, the examining hand cannot make much of an indentation because of the impressive muscle guarding. When the attempt is aborted, he manifests severe rebound tenderness. X-ray films show free air under both diaphragms. Which of the following does this man most likely have?

A 56-year-old woman presents for evaluation of a murmur suggestive of mitral stenosis and is noted on echocardiography to have a lesion attached to the fossa ovalis of the left atrial septum. The mass is causing obstruction of the mitral valve. Which of the following is the most likely diagnosis?

A 54-year-old man presents to the emergency department on transfer from another hospital at the request of the family. He was admitted to the outside hospital 2 weeks ago with abdominal pain, nausea, vomiting, and fever. He was treated with antibiotics, NG tube decompression, and TPN without significant improvement. He developed jaundice 2 days ago. His past history is pertinent for a 40 pack-year smoking history, chronic alcohol abuse, and diabetes. Examination reveals a mildly jaundiced patient with vital signs of temperature 100°F, pulse rate 95/min, and BP 110/60 mmHg. Cardiac examination is unremarkable, lung examination reveals decreased breath sounds at the bases bilaterally, and abdominal examination reveals fullness in the epigastrium with tenderness and voluntary guarding. Which one is the most likely diagnosis?

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 fontanelle and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Which of the following is the most likely diagnosis?

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?

An older, overweight man complains of disabling, sharp heel pain every time his foot strikes the ground. The pain is worse in the mornings, preventing him from putting any weight on the heel. X-ray films show a bony spur matching the location of his pain, and physical examination shows exquisite tenderness to direct palpation right over that heel spur. Furthermore, when the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation. Which of the following is the most likely diagnosis?

A 63-year-old man is seen because of facial swelling and cyanosis, especially when he bends over. There are large, dilated subcutaneous veins on his upper chest. His jugular veins are prominent even while he is upright. Which of the following conditions is the most likely cause of these findings?

A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Which of the following is the most likely diagnosis?

A 65-year-old woman has had pain in her right shoulder and has been treated with analgesics without relief. The CXR reveals a mass in the apex of the right chest. A transthoracic needle biopsy documents carcinoma. Superior pulmonary sulcus carcinomas (Pancoast tumors) are bronchogenic carcinomas that typically produce which of the following clinical features?

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?

A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full-blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. Which of the following is the most likely diagnosis?

A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Which of the following would help confirm the diagnosis?

The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Shortly after admission, he develops a blood pressure of 80/50 mm Hg, a pulse rate of 110/min, and a venous pressure of zero. He becomes pale, cold, and clammy, but the rest of his physical examination and x-ray films of the chest and pelvis are unremarkable. A sonogram of the abdomen done in the emergency department is likewise negative. Which of the following is the most likely reason for the low blood pressure?

A 24-year-old patient with known neurofibromatosis type 2 undergoes an MRI for ringing in his ears. The MRI demonstrates lesions in bilateral auditory canals. Which of the following is the most likely diagnosis?

A40-year-old man with a history of alcohol abuse presents after an episode of binge drinking. He is complaining of epigastric pain, radiating to the back, associated with nausea and vomiting. On examination, he has marked tenderness in the epigastrium, with guarding, decreased bowel sounds, and moderate abdominal distention. Laboratory findings include leukocytosis and increased serum amylase and lipase. Abdominal roentgenograms demonstrate several dilated bowel loops in the upper abdomen. Select the most likely diagnosis?

A 65-year-old man presents with a 4-day history of worsening lower abdominal pain and constipation. On examination, he is febrile (38.5°C) and has lower abdominal tenderness that is most intense in the midline and left lower quadrant associated with a palpable fullness. Laboratory findings demonstrate a moderate leukocytosis and abdominal roentgenograms show an ileus pattern. Select the most likely diagnosis?

A 65-year-old man presents to the physician’s office with complaints of abdominal discomfort and jaundice for the past 3 weeks. Past history is pertinent for 30 pack-year smoking history, occasional alcohol intake, and a 5.5-mm ulcerating melanoma removed from his back 21/ 2 years ago. Examination reveals a mildly jaundiced patient with normal vital signs and a slightly distended abdomen with mild right upper quadrant tenderness and significant hepatomegaly. Which one is the most likely diagnosis?

A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most likely diagnosis?

A 15-year-old otherwise healthy female high school student begins to notice galactorrhea. A pregnancy test is negative. Which of the following is a frequently associated physical finding?

A 76-year-old man is undergoing an abdominoperineal resection for rectal cancer. During the surgery, unexpected severe bleeding is encountered, and the patient is hypotensive on and off for almost an hour. The anesthesiologist notes ST depression and T-wave flattening on the ECG monitor. Which of the following are the most likely diagnosis and the expected mortality?

A 72-year-old woman has a red, swollen breast. She states that the condition has been present for at least several weeks, perhaps a month or two. She has no pain or fever. The skin over the area looks like orange peel. The area is not warm to the touch, but on physical examination there is fullness to the entire breast, with no discrete mass. Which of the following is the most likely diagnosis?

An 18-year-old football player is seen in the emergency ward with severe knee pain incurred after being hit by a tackler while running. Which of the following findings on physical examination is most sensitive for an anterior cruciate ligament injury?

A 30-year-old man presents with sudden onset of severe epigastric pain 6 hours ago. Examination reveals a low-grade fever, tender abdomen throughout, with rigidity of the abdominal usculature. Abdominal roentgenograms show pneumoperitoneum. Select the most likely diagnosis?

A 40-year-old woman presents to the emergency room with a 3-day history of worsening abdominal pain, with nausea and vomiting. Examination reveals a low-grade fever and abdominal tenderness in the right upper quadrant with guarding, especially during inspiration. Laboratory findings include a mild leukocytosis and a slightly elevated bilirubin. Select the most likely diagnosis?

A 3-year-old boy presents to the physician’s office with an asymptomatic neck mass located in the midline, just below the level of the thyroid cartilage. The mass moves with deglutition and on protrusion of the tongue. Which one is the most likely diagnosis?

A 60-year-old otherwise healthy woman presents to her physician with a 3-week history of severe headaches. A contrast CT scan reveals a small, circular, hypodense lesion with ringlike contrast enhancement. Which of the following is the most likely diagnosis?

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 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?

A 35-year-old woman presents to the physician’s office for evaluation of a left neck mass discovered 1 month ago on a routine physical examination. On examination, the mass measures 2 cm and is located anterolateral to the larynx and trachea. It is nontender and moves with swallowing. Past history is pertinent for a 15 pack-year smoking history and occasional alcohol intake. Which one is the most likely diagnosis?

A 55-year-old man presents to the physician’s office with complaints of hoarseness and left neck fullness for the past month. On examination, a firm, movable, left submandibular mass is noted. Past history is pertinent for a 30 packyear smoking history with occasional alcohol intake. Which one is the most likely diagnosis?

A 50-year-old man presents to the emergency department for increasing abdominal distention and jaundice over the last 4–6 weeks. Examination reveals mild jaundice, spider angiomas, and ascites. Enlarged veins are noted around the umbilicus. Which one is the most likely diagnosis?

A 75-year-old man is brought to the emergency department by his family for evaluation of jaundice. He complains of pruritus of 2 weeks’ duration and a recent 10-lb weight loss. On examination, he is deeply jaundiced and has a nontender, globular mass in the right upper quadrant of the abdomen that moves with respiration. Which one is the most likely diagnosis?

A 75-year-old woman is brought to the emergency department from the nursing home for jaundice and mental confusion. The nursing home notes state that she has become less responsive and has developed jaundice over the last 2 weeks. Past history is pertinent for hypertension, diabetes, and prior colon resection for cancer at age 55. Examination reveals mild jaundice with vital signs of temperature 101.5°F, pulse rate 110/min, and BP 100/60 mmHg. She does not respond to verbal commands, but withdraws to pain. Abdominal examination reveals tenderness in the epigastrium and right upper quadrant. Which one is the most likely diagnosis?

An 18-year-old man is admitted to the ER following a motorcycle accident. He is alert and fully oriented, but witnesses to the accident report an interval of unresponsiveness following the injury. Skull films disclose a fracture of the left temporal bone. Following x-ray, the patient suddenly loses consciousness and dilation of the left pupil is noted. Which of the following is the most likely diagnosis?

A trauma patient with a closed-head injury is being monitored in the neurosurgical intensive care unit (ICU). His ICP measurement is seen to rise precipitously. An acute increase in ICP is characterized by which of the following clinical findings?

A 45-year-old man presents to the physician’s office for evaluation of a posterior neck mass. The mass has been present for years, but has slowly enlarged over the last 2 years. Examination reveals a subcutaneous mass that is soft, nontender, and movable. Which one is the most likely diagnosis?

A 6-year-old boy presents to the emergency department with a cough, sore throat, and malaise of 4 days’ duration. Examination reveals a temperature of 101.5°F, erythematous pharynx, and a tender right neck mass with overlying erythema. Which one is the most likely diagnosis?

An 18-month-old girl is brought to the physician’s office for evaluation of left neck mass. Examination reveals a 2-cm soft, nontender, fluctuant mass in the left lateral neck. This is located at the anterior border of the sternomastoid, midway between the mastoid and clavicle. Which one is the most likely diagnosis?

A 6-year-old boy is brought into the emergency room by his mother for walking with a limp for several weeks. On examination, the patient has tenderness over his right thigh without evidence of external trauma. An x-ray of the pelvis shows a right femoral head that is small and denser than normal. Which of the following is the most likely diagnosis?

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?

During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24-year-old man, was inhaling at that moment. Which of the following most likely caused this patient's death?

A 42-year-old man presents with a solitary lung lesion. At the time of operation on this patient, a firm, rubbery lesion in the periphery of the lung is discovered. It is sectioned in the operating room to reveal tissue that looks like cartilage and smooth muscle. Which of the following is the most likely diagnosis?

A 55-year-old man presents with fever and pain in the perineal region. Upon further questioning he also complains of frequency, urgency, dysuria, and a decreased urinary stream. On physical examination his abdomen is soft, nondistended, and nontender. Digital rectal examination demonstrates exquisite tenderness on the anterior aspect. Laboratory examination reveals leukocytosis and findings on urinalysis are consistent with a bacterial infection. Which of the following is the most likely diagnosis?

A previously healthy 45-year-old man presents with a 9-month history of a slow-growing, painless right neck mass. He is a nonsmoker and has no significant past medical history. On examination, there is a nontender, discrete, 3-cm mass over the angle of the right mandible. Facial muscle function and sensation are normal. An oropharyngeal examination is normal. Which of the following is the most likely diagnosis?

A young mother complains of pain along the radial side of the wrist and the first dorsal compartment. She relates that the pain is often caused by the position of wrist flexion and simultaneous thumb extension that she assumes to carry the head of her baby. On physical examination, the pain is reproduced by asking her to hold her thumb inside her closed fist, and then forcing the wrist into ulnar deviation. Which of the following is the most likely diagnosis?

A 67-year-old man has had an indolent, unhealing ulcer at the heel of the right foot for several weeks. The patient began wearing a new pair of shoes shortly before the ulcer started and noticed a blister as the first anomaly at the site where the ulcer eventually developed. He indicates that neither the blister nor the ulcer ever gave him any pain. The ulcer is 3.5 cm in diameter, the ulcer base looks dirty, and there is hardly any granulation tissue. The skin around the ulcer looks normal. The patient has no sensation to pin prick anywhere in that foot. Peripheral pulses are weak but palpable. He is obese and has varicose veins, high cholesterol, and poorly controlled type 2 diabetes mellitus. Which of the following most accurately characterizes the ulcer?

A 40-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most likely diagnosis?

A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Which of the following is the most likely diagnosis?

A 21-year-old previously healthy woman presents with abdominal pain of 48-hour duration. The pain was initially periumbilical and on progression became localized in the right lower quadrant. The woman had nausea and an appetite. She denied dysuria. Her last menstrual period was 2 weeks earlier. On examination, she was febrile (temperature 38.2°C), and was found to have localized tenderness in the right lower quadrant with guarding. Rectal examination was normal. Laboratory examination demonstrated mild leukocytosis. Select the most likely diagnosis?

A 25-year-old woman presents to the emergency room complaining of redness and pain in her right foot up to the level of the midcalf. She reports that her right lower extremity has been swollen for at least 15 years, but her left leg has been normal. On physical examination, she has a temperature of 39°C (102.2°F) and the right lower extremity is nontender with nonpitting edema from the groin down to the foot. There is cellulitis of the right foot without ulcers or skin discoloration. The left leg is normal. Which of the following is the most likely underlying problem?

A blond, blue-eyed, 69-year-old sailor has a non-healing, indolent, 1.5-cm ulcer on the lower lip, arising from the vermilion border. The ulcer has been present and growing for the past 8 months. He is a pipe smoker, but has no history of alcohol or drug abuse. Physical examination shows "weather-beaten" facial skin, but no other ulcers. There are no enlarged lymph nodes in his neck. Which of the following is the most likely diagnosis?

A 30-year-old woman presents with hypertension, weakness, bone pain, and a serum calcium level of 15.2 mg/dL. Hand films below show osteitis fibrosa cystica. Which of the following is the most likely cause of these findings?

A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung fields. Which of the following is the preferred modality in establishing the diagnosis?

An elderly man is involved in a rear end automobile collision in which he hyperextends his neck. He develops paralysis and burning pain of both upper extremities, while maintaining good motor function in his legs. Which of the following is the most likely diagnosis?

A 53-year-old woman presents with weight loss and a persistent rash to her lower abdomen and perineum. She is diagnosed with necrolytic migrating erythema and additional workup demonstrates diabetes mellitus, anemia and a large mass in the tail of the pancreas. Which of the following is the most likely diagnosis?

A 25-year-old previously healthy man is scheduled for elective inguinal hernia repair under general anesthesia. After induction of anesthesia and initial inguinal incision, the patient develops tachycardia, muscle rigidity, fever of 38.5°C, and elevated end-tidal carbon dioxide. Which of the following is the most likely diagnosis?

A 55-year-old man presents to the emergency department with left lower quadrant abdominal pain. The pain has been present for 1 week, but has increased in intensity over the last 2 days associated with nausea, constipation, and dysuria. Past history is unremarkable. Examination reveals a temperature of 101°F, pulse rate of 95/min, BP of 130/70 mmHg, and normal heart and lung examinations. Abdominal examination reveals fullness and marked tenderness in the left lower quadrant, with voluntary guarding and decreased bowel sounds. Laboratory tests reveal a WBC count of 18,000 with a left shift and 20–50 WBCs in the urinalysis. A CT scan of the abdomen reveals a thickened sigmoid colon with pericolonic inflammation. He is admitted to the hospital for treatment. Which of the following is the most likely diagnosis?

A 56-year-old woman has been treated for 3 years for wheezing on exertion, which was diagnosed as asthma. Chest radiograph, shown here, reveals a midline mass compressing the trachea. Which of the following is the most likely diagnosis?

A 25-year-old man was admitted to the ICU with severe head injury with a basal skull fracture. Eighteen hours after the injury, he developed polyuria. Urine osmolality was 150 mOsm/Land serum osmolality was 350 mOsm/L. IV fluids were stopped, and 1 hour later urine output and urine osmolality remained unchanged. Five units of vasopressin were administered intravenously, and urine osmolality increased to 300mOsm/L. Select the most likely diagnosis of the patients with polyuria?

A 70-year-old man was admitted to the ICU with severe pancreatitis. During his ICU course, he underwent several CT scans with IV contrast and was also treated with an aminoglycoside for a urinary tract infection. The patient required a prolonged course of TPN, and developed Candida sepsis treated with amphotericin. He subsequently developed polyuria with urine osmolality of 250mOsm/L and serum osmolality of 350 mOsm/L. After receiving 5 units of vasopressin intravenously, there is no change in urine osmolality or urine output. Select the most likely diagnosis of the patients with polyuria?

A 42-year-old man describes intermittent episodes of severe, crushing chest pain that extends to the back and the jaw and last anywhere from a few seconds to several minutes. Many times the pain is accompanied by dysphagia and triggered by the ingestion of very cold or very hot liquids. However, sometimes the pain occurs for no apparent reason. There is no history of regurgitation, and, although the problem has been present for many years, there has been no progression of the symptoms. Repeated ECGs and cardiac enzymes have always been negative. Barium swallow shows an area of "corkscrew" appearance. Manometry shows that about one half of wet swallows produce repetitive simultaneous esophageal contractions of the esophageal body, and that the lower esophageal sphincter has normal pressures and exhibits normal relaxation. Which of the following is the most likely diagnosis?

A 29-year-old man presents to the ER with persistent vomiting and abdominal pain for the last 24 hours. The pain is crampy, diffuse, and has been getting worse. He had a normal bowel movement two days ago and denies diarrhea. The emesis appears green without blood or coffee grounds. He has not eaten since the onset of the pain due to nausea. On exam, his temperature is 36.8° C (98.2° F}, pulse is 91/min, and blood pressure is 116/75 mmHg while sitting and 94/65 mmHg while standing. His abdomen is distended with hyperactive bowel sounds. Percussion reveals tympany and he is diffusely tender to palpation. There is no rebound tenderness or guarding. Laboratory studies reveal:WBC count 9,600/mm3Hematocrit 45%Sodium 147 mEq/LPotassium 3.1 mEq/LCreatinine 1.0 mg/dLAST 20 U/LALT 12 U/LBilirubin 0.8 mg/dLWhich of the following historical findings would you most expect in this patient?

A 63-year-old obese female undergoes an elective cholecystectomy after two episodes of acute calculous cholecystitis. Three days after surgery, her blood pressure is 150/100 mmHg, her heart rate is 90/min, and her arterial oxygen saturation is 91 % on room air. She is afebrile. Which of the following would most likely increase her functional residual lung capacity?

A 62-year-old woman had an abdominal hysterectomy and salpingo-oophorectomy 3 days ago. She had an indwelling bladder catheter during the procedure, which was removed in the recovery room. She has been voiding at will since then. She also had compression pneumatic stockings on both lower extremities during the operation. She began ambulation on the 1st postoperative day, and has been as active as possible under the circumstances, including faithful adherence to a prescribed program of incentive spirometry. On the evening of the 3rd postoperative day, she spikes a fever, with a temperature to 39.4C (103F). Which of the following is the most likely source of the fever?

A 44-year-old male is found unresponsive and hypotensive at the scene of a high-speed motor vehicle accident. He is intubated and immediately rushed to the emergency department. The passenger in his car is pronounced dead at the scene. Physical examination in the ED shows large bruises over the entire chest wall and collapsed neck veins bilaterally. Lung exam reveals decreased breath sounds on the left side. Chest x-ray shows a large left hemothorax and a widened, rightward deviating mediastinum. The most likely diagnosis is?

An 85-year-old male is placed on mechanical ventilation after a complicated elective hernia repair. After five days of endotracheal intubation with mechanical ventilation, the ratio of the rate of carbon dioxide produced to the rate of oxygen uptake is 1.05. What is the best explanation for these findings?

A 75-year-old woman is admitted to the hospital from a nursing home for abdominal pain and pneumonia. She was noted to be short of breath with increasing cough for 2 days before admission. Treatment, consisting of supplemental oxygen, IV antibiotics, and pulmonary toilet, is instituted, with improvement within 2 days. On the third hospital day, her abdominal pain worsens. Examination reveals a mildly distended abdomen with bowel sounds but no signs of peritonitis. Remainder of examination reveals a tender bulge in the medial left thigh below the inguinal ligament. Gentle pressure causes more pain but does not change the size or shape of the bulge. Abdominal films show a nonspecific bowel gas pattern. Laboratory analysis shows a WBC of 13,000, decreased from 18,000 at the time of admission. Which of the following is the most likely diagnosis?

A 66-year-old woman picks up a bag of groceries out of the supermarket cart to place it in the trunk of her car. As she does so, she feels sharp, sudden pain in the middle of her arm, and her humerus suddenly breaks. She arrives at the emergency department cradling her arm; the deformity leaves no doubt that the bone is broken. Which of the following is the most likely reason for the fracture?

An 18-year-old male comes to the physician's office because of dull aching and fullness of the scrotum. Examination shows soft left-sided scrotal swelling; transillumination testing is negative. The scrotal swelling increases when the patient performs the Valsalva maneuver. The physical examination is otherwise unremarkable. Which of the following is the most likely cause of his condition?

A 72-year-old man underwent surgical repair of an aneurysm of the infrarenal aorta. He received perioperative prophylaxis with a second-generation cephalosporin antibiotic. On the first postoperative day he complains of progressive abdominal pain and bloody diarrhea. His temperature is 38.5° C (101° F), blood pressure is 110/65 mm Hg, pulse is 110/min and respirations are 22/min. His abdomen is mildly distended and tender to palpation. The tenderness is mostly in the left lower quadrant without rebound. Femoral pulses are full and symmetric. His white blood cell count is 12,000/mm3. Which of the following is the most likely diagnosis?

A 32-year-old male comes to the emergency department because of a 3 day history of increasing lower abdominal pain, mild diarrhea and rectal pain on defecation. Ten days ago he had right lower quadrant (RLQ) pain for about 24 hours that resolved spontaneously. Since then, he has had malaise and low-grade fever. His temperature is 38.7°C (101.6°F), blood pressure is 150/90 mm Hg, pulse is 11 0/min and respirations are 15/min. Examination shows lower abdominal tenderness without rebound. No masses are palpable, and bowel sounds are decreased. Rectal examination shows a very tender, boggy and fluctuant bulging mass on palpation with the tip of the finger anteriorly. Laboratory studies show:Complete blood count Hemoglobin14.0 g/LPlatelets270,000/mm3Leukocyte count15,500/mm3His current condition is most likely a complication of?

A 44-year-old man complains of vague right upper abdominal discomfort that he has had for about 1 month. He describes no other symptoms, and, except for enucleation of one eye at age 21 "for a tumor," he has been in excellent health all his life. He exercises regularly and neither smoke nor drinks. The only findings on physical examination include the artificial eye and a tender, enlarged, and nodular liver. CT scan of the upper abdomen demonstrates multiple masses within the liver. Which of the following will most likely be found on biopsy of these masses?

A previously healthy, intoxicated, 19-year-old man is driving a car without using a seat belt. He crashes the car into the back of a parked truck. In the process he slams his abdomen into the steering wheel and ruptures his spleen. Which of the following is the most important problem associated with this type of injury?

A 27-year-old immigrant from El Salvador has a 14 × 12 × 9 cm mass in her left breast. It has been present for 7 years and has slowly grown to its present size. The mass is firm, nontender, rubbery, and completely movable, and it is not attached to the overlying skin or the chest wall. There are no palpable axillary nodes or skin ulceration. Which of the following is the most likely diagnosis?

A 63-year-old man, who weighs 65 kg, is in his 2nd postoperative day after an abdominoperineal resection for cancer of the rectum. An indwelling Foley catheter was left in place after surgery. The nurses are concerned because, even though his vital signs have been stable, his urinary output in the past 2 hours has been zero. In the preceding 3 hours, they had collected 56 mL, 73 mL, and 61 mL. Which of the following is the most likely diagnosis?

A 55-year-old woman falls in the shower and hurts her right shoulder. She shows up in the emergency department with her arm held close to her body, but the forearm rotated outward as if she were going to shake hands. She is in pain and will not move the arm from that position. Her shoulder looks "square" in comparison with the rounded unhurt opposite side, and there is numbness in a small area of her shoulder over the deltoid muscle. Which of the following is the most likely diagnosis?

A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8 cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. Which of the following is the most likely diagnosis?

An out-of-shape, recently divorced, 42-year-old man is trying to impress a young woman by challenging her to a game of tennis. In the middle of the game, a loud "pop" (like a gunshot) is heard, and the man falls to the ground clutching his ankle. He limps off the court with pain and swelling in the back of the lower leg. Although he can still weakly plantar-flex his foot, he seeks medical help the next day because of persistent pain, swelling, and limping. He can put weight on that foot with no exacerbation of the pain, but the motion of taking a step is painful. Which of the following would be the most likely finding on physical examination?

A 27-year-old man sustained penetrating injuries of the chest and abdomen when he was repeatedly stabbed with a long ice-pick. At the time of admission, he had a right pneumothorax, for which a chest tube was placed prior to undergoing a general anesthetic for exploratory laparotomy. The operation revealed no intraabdominal injuries and was terminated sooner than had been anticipated. The patient remained intubated, waiting for the anesthetic to wear off. Because he was not moving enough air, he was placed on a respirator. Then, he suddenly went into cardiac arrest and died. All through this time he had been hemodynamically stable, and never had any signs of hypotension or arrhythmias. Which of the following was the most likely cause of the cardiac arrest?

A 13-year-old, obese boy complains of persistent knee pain for several weeks. The family brings him in because he has been limping. He sits in the examining table with the sole of the foot on the affected side pointing to the other leg. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and cannot be rotated internally. Which of the following is the most likely diagnosis?