Medpage675-713

133) A 56-year-old white male comes to the office for a health maintenance visit. He feels healthy, and is "enjoying life as much as possible in a stressed environment." He smokes 2-3 packs of cigarettes daily and drinks socially. His temperature is 37°C (98.6°F), blood pressure is 160/94 mm Hg, pulse is 78/min, and respirations are 14/min. Physical examination reveals plethora of the face and moderate splenomegaly. Blood tests show the following: WBC 15,600/mm3, Hemoglobin 17 gm/dl, Hematocrit 52%, Platelets 550,000mm3, RBC count 7.5 million, Sodium 141 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 22 mEq/L, Blood urea nitrogen 16 mg/dl, Creatinine 0.6 mg/dl, Glucose 95 mg/dl. The erythrocyte indices are all within normal range. What is the most probable diagnosis?
. Idiopathic hypertension
Cushing syndrome
. Polycythemia vera
. Congestive heart failure
. Primary hyperaldosteronism
134) A 49-year-old woman comes to the office and complains of a "strange, itchy rash" on her left areola which has been present for the last month. She tried applying various lotions and creams, but the lesion did not resolve. She denies having other skin conditions, except for a poison ivy rash 2 months ago. She does not take any medications and feels "goofy" when she takes penicillin. Physical examination reveals an eczemoid lesion on the left nipple. No abnormality is visible on the mammogram. Biopsy demonstrates large cells surrounded by halo-like areas which invade the epidermis. What is the most likely diagnosis?
. Adenoma of nipple
Paget's disease
. Scirrhous carcinoma
. Phyllodes tumor
. Lymphocytic carcinoma of breast
135) A 41-year-old fire-fighter comes to your office and requests for prostate cancer screening. He is concerned because his elder brother was recently diagnosed with prostate cancer, and he read in the paper that "cancers run in families." He requests to be screened urgently, as he "cannot even think of life with such a deadly disease." He has no medical complaints. He has been your patient for the past 6 years, and has no other medical history. He is on a very balanced diet, and adds that he eats a lot of garlic "so that cholesterol remains in check." He takes a low-dose aspirin daily. He does not smoke, and is only a social drinker. He admits using marijuana "once in a while” What is the best next step to address this patient's concerns?
Transurethral ultrasonogram
Bone scan
. T ransrectal ultrasonogram
. Perform digital rectal examination
Needle biopsy
136) A 27-year-old male presents with dyspnea and fatigue. He has no family history of asthma, heart disease or any blood disorder. His vital signs are stable, and he is afebrile. The only significant findings on examination are pallor and splenomegaly. Lab studies show: Hematocrit 20%, WBC count 4,000/micro-L, Platelet count 85,000/miro-L, Bilirubin 7 mg/dl, Direct bilirubin 1.2 mg/dl, Serum LDH 500 U/L (normal value is 80-280 U/L), Serum haptoglobin 20mg/dl (normal value is 30-220 mg/dl). Peripheral blood smear shows microcytic hypochromic cells. Serum ferritin is low while total iron binding capacity (TIBC) is elevated. Reticulocyte count is 5 %. Urine dipstick testing is positive for hematuria and microscopy of urine shows 1 RBC/HPF. Repeated G6PD assays are normal. Coomb's and micro-Coomb's tests are negative. Bone marrow examination shows hypocellular marrow. Based on these findings, what is the most likely diagnosis?
. Aplastic anemia
G6PD deficiency
. Hereditary spherocytosis
. Autoimmune hemolytic anemia
Paroxysmal nocturnal hemoglobinuria
137) A 44-year-old man who comes to the office because he has had several episodes of hemoptysis for the past two months. He admits to smoking 2-3 packs of cigarettes daily for the last 24 years. Physical examination and chest x-ray are very suggestive of a lung malignancy. Chest CT and bronchoscopy with biopsy are done, and the patient goes on vacation in Aruba. The patient returns to the office after one week, and you are now holding the biopsy result in your hands. It reads, "The tumor has spread to the hilar and mediastinal lymph nodes with bony extension." Which of the following is the most appropriate opening statement?
. "How much would you like to know about your condition?"
"I am sorry to tell you that you have lung cancer and it is fairly advanced."
. "What do you think of your symptoms?"
. "Unfortunately, the situation is more serious than what I earlier thought."
"Would you like to have someone else with you as I don't have good news for you?"
138) A 25-year-old male presents to his physician with dyspnea and fatigue for the last few weeks. He is a non-smoker. He denies any family history of asthma or blood disorders. He does not take any medications. Examination shows pallor, scleral icterus and splenomegaly. Lab tests show the following: Hematocrit 20%, WBC count 10,000/micro-L, Platelet count 180,000/miro-L, Total Bilirubin 7 mg/dl, Direct bilirubin 1 A mg/dl, BUN 10 mg/dl, Serum creatinine 0.7 mg/dl, Serum LDH 400 U/L (normal value is 80-280 U/L), Serum haptoglobin 160mg/dl (normal value is 30-220 mg/dl ), Reticulocyte count 8 %. Peripheral blood smear shows spherocytes with central pallor. Osmotic fragility and direct Coombs' tests are positive Based on these findings, what is the most likely diagnosis?
Hereditary spherocytosis
Autoimmune hemolytic anemia
. Paroxysmal nocturnal hemoglobinuria
Sickle cell anemia
G6PD deficiency
139) A 10-year-old white boy is brought to the office by his foster parents for the evaluation of severe pain in his left knee for the last few days. His left knee has been hurting so bad that he is now unable to play with his peers. The pain is continuous and non-radiating. His knee appears swollen, but he denies any history of trauma. His family history is unknown. His vital signs are stable. Physical examination reveals a pale young boy. The left knee is tender, erythematous and swollen. Blood tests reveal: WBC 12,600/mm3, Hemoglobin 9.3 g/dl, Hematocrit 29%, Platelets 201,000/mm3, ESR 40. X-ray of the knee reveals that the lower end of the femur has a central lytic lesion, onion skinning and a moth-eaten appearance with some extension into the soft tissue. What is the most likely diagnosis?
. Osteomylitis
. Ewings sarcoma
Chondrosarcoma
Glomus tumor
. Fibrosarcoma
140) A 56-year-old woman is complaining of cough for the past 4 months. The cough was dry initially, but only yesterday she was scared-to-death to see phlegm with blood. She is not feeling well and thinks that she has lost "a lot of weight" recently, despite no apparent change in her diet. She swears that she has never smoked a cigarette in her life. There is no history of night sweats nor contact with any person with similar complaints. She is a housewife who rarely drinks, and can't think of using recreational drugs. She is completely faithful to her husband. Her husband is also a "religious non-smoker". Her vitals are stable and lung examination reveals no significant findings. Her chest x-ray shows 1.5cm lesion in the right peripheral lung field and no evidence of any hilar or mediastinal lymph node enlargement. What is the most probable diagnosis?
. Tuberculosis
. Sarcoidosis
. Small cell carcinoma of lung
Squamous cell carcinoma of lung
Adenocarcinoma of lung
141) A 74-year-old immigrant from Colombia comes to the office and complains of having "all sorts of problems of old age." He has pain all over his body. He often has headaches and feels dizzy. He has visual problems, and finds it difficult to walk. For the last several weeks, he has been feeling weak and numb in his feet. He lives with his son, and is not happy with the way his son treats him; however, he denies receiving any form of physical abuse. His past medical history is unremarkable. His mother had "some blood disease." His vital signs are stable. Physical examination reveals multiple bruises on his body, and sensory deficits in his feet. Other significant findings include lymphadenopathy and hepatosplenomegaly. Ophthalmoscopy shows dilated, segmented, and tortuous retinal veins. Laboratory studies show: WBC 10,200 /mm3, Hemoglobin 9.6 g/dl, Hematocrit 29%, Platelets 94,000 /mm3, Sodium 141 mEq/L, Potassium 3.6 mEq/L, Blood urea nitrogen 18 mg/dl, Creatinine 0.8 mg/dl, Glucose 115 mg/dl. Serum protein electrophoresis reveals an lgM spike. Which of the following is the most likely diagnosis in this patient?
. Multiple myeloma
Waldenstrom's macroglobulinemia
. Monoclonal gammopathy of undetermined significance
Elderly abuse
. Heavy chain disease
142) A 25-year-old white female presents to the clinic with persisting pain in her wrists and ankles for the last 3 months. The pain is 3/10 in intensity, and partially relieved by ibuprofen. She also has a rash on her face. She denies smoking, and drinks alcohol occasionally. Her temperature is 37.3°C (99.2°F), blood pressure is 120/80 mm Hg, pulse is 79/min, and respirations are 18/min. Physical examination reveals swollen joints of the hands and ankle, as well as erythema over the bridge of the nose and the upper cheeks. There is no muscle weakness. Labs show: Hemoglobin 11.0 g/dL, Hematocrit 33%, Platelets 240,000/mm3, WBC 13,600/mm3. Leukocyte distribution:Segmented neutrophils 76%, Lymphocytes 20%, Bands 2%, Monocytes 2%. RF, ANA, and antibodies to double stranded-DNA are positive in high titers. What is the most likely diagnosis?
. Scleroderma
. Systemic lupus erythematosus
. Dermatomyositis
. Polymyositis
. Mixed connective tissue disease
143) A 23-year-old man presents to the emergency room complaining of severe abdominal pain. He has also suffered from nausea and vomiting for several hours. His past medical history is insignificant, but his brother has had similar problems. He denies risky sexual behavior and intravenous drug use. On exam, his temperature is 38.8°C (101.8°F), heart rate is 102/min, and respirations are 14/min. There is tenderness in the right upper quadrant exacerbated by deep inspiration. The liver span is 7 cm. His spleen is palpated 2 cm below the left costal margin. There are no peritoneal signs. Which of the following is the most likely diagnosis?
. Acute viral hepatitis
. Acute pancreatitis
. Gaucher's disease
. Hodgkin's lymphoma
. Hereditary spherocytosis
144) A 60-year-old Vietnam war veteran comes for his annual examination. He does not have any complaints, other than getting tired very quickly. Physical examination reveals pallor and an enlarged spleen. CBC reveals: WBC 14,000/cmm, Hemoglobin 9.9 g/dL, Hematocrit 30%, Platelets 100,000/cmm. The lymphocytes have fine, irregular cytoplasmic projections. Cytochemical testing reveals a strong acid phosphatase reaction, which is not inhibited by tartaric acid. What is the most probable diagnosis?
Lymphoblastic leukemia
. Hairy cell leukemia
. Chronic lymphocytic leukemia
. Chronic myeloid leukemia
. Hodgkin's disease
145) A 47-year-old woman comes to the office and complains of burning abdominal pain which has been present for the past 3 months, is grade 6/10 in severity, continuous, and relieved by taking antacids. She also complains of some constipation. Her father has a history of "ulcers in his belly." She works as a floor secretary in a surgical ward, and is not happy with her new boss. She denies any weight loss or decreased appetite. Her temperature is 37.1°C (98.8°F), blood pressure is 130/85 mm Hg, heart rate is 78/min, and respirations are 14/min. She is awake, alert, and oriented. The abdominal examination reveals normoactive bowel sounds and tenderness in the epigastric region, but no palpable mass. Her stools are occult blood positive. ECG reveals increased PR and shortened QT intervals. The laboratory results reveal the following: Sodium 137 mEq/dL, Potassium 4.2 mEq/dL, Chloride 101 mEq/dL, Bicarbonate 27 mEq/dL, Calcium 12.0 mg/dl, Phosphorus 2.2 mg/dl, BUN 37 mg/dl, Creatinine 1.8 mg/dl. Which of the following is the most likely diagnosis?
. Glucagonoma
Stress ulcer
. Parathyroid adenoma
. Vitamin-D toxicity
. Metastatic gastric carcinoma
146) A 21-year-old Caucasian man bumped into a table in his living room two days ago and now presents to the emergency department with a swollen and tender right thigh. Pulsation is decreased over the right popliteal artery. His uncle suffered from a "blood clotting disease". This patient's history is most likely to reveal which of the following episodes in his past?
. Occasional tarry stools
. Spontaneous bruises
. Joint swelling
. Cola-colored urine
. Red papules over his trunk and lips
147) A 7-year-old Caucasian boy is brought to your office for a routine check-up. He underwent splenectomy one year ago for persistent anemia and jaundice. He has received pneumococcal vaccination and takes penicillin prophylaxis. His uncle underwent splenectomy for "some blood disorder" in his childhood. His blood hemoglobin level is 11.5 mg/dL and MCV is 90 fl. Blood smear demonstrates occasional red blood cells with single, round, blue inclusions on Wright stain. The latter finding is most likely related to?
. Hemoglobin precipitation
. Low reticulocyte count
. Penicillin therapy
. Mechanical RBC damage
. Splenectomy
148) A 25-year-old white female presents with a 5-day history of sore throat, extreme fatigue, and headaches. She has just returned from a spring break in Jamaica where she had "the time of her life." She smokes 2-3 cigarettes daily and occasionally drinks alcohol. Her vital signs are stable. She is afebrile. Physical examination reveals posterior cervical lymphadenopathy, mild splenomegaly, and exudative pharyngitis. Palatal petechiae are present. CBC shows: WBC 16,000/cmm with 55% lymphocytes, Hemoglobin 13 .5gm/dl, Hematocrit 4 1%, Platelets 216,000/cmm. Many variant forms of lymphocytes are seen, including cells with convoluted nuclei and highly vacuolated cytoplasm. Rapid streptococcal throat test, urinalysis, and heterophilic antibody test are all negative. What is the most likely diagnosis?
. Acute myeloid leukemia
. Chronic myeloid leukemia
. Acute lymphoblastic leukemia
Chronic lymphocytic leukemia
. Infectious mononucleosis
149) A 2-year-old boy is brought by his mother to the emergency department because of a high-grade fever which "does not go away" with acetaminophen. For the last four days, the child has been very irritable and is crying a lot. He is also pulling his ear and not eating well. He has been generally well, other than the occasional sore throat this season. His temperature is 38.8°C (102.2°F), blood pressure is 90/60 mm Hg, pulse is 119/min, and respirations are 24/min. He appears well nourished, but is irritable. Physical examination reveals enlarged cervical lymph nodes and splenomegaly. The tympanic membranes are inflamed. CBC shows: WBC 81,100 /mm3, Hemoglobin 8.0 g/dL, Hematocrit 25%, Platelets 16,000 /mm3, Blast forms 80%, Prolymphocytes 10%, Lymphocytes 10%. The blast cells have condensed nuclear chromatin, small nucleoli and scant agranular cytoplasm. Subsequent histochemical staining reveals strongly positive periodic acid Schiff (PAS) reaction. No Auer rods were seen. Which of the following is the most likely diagnosis?
. Burkitt lymphoma
. Acute myelocytic leukemia
. Prolymphocytic leukemia
. Acute lymphoblastic leukemia
. Myelodysplastic syndrome
150) A 34-year-old woman comes to the office for her annual examination. She has been your patient for the last 4 years. She eats a lot of meat, but does not like fruits and vegetables. Her menstrual period began at age 12. She has two children, who are ages 13 and 11. She is in a monogamous relationship with her husband, and uses oral contraceptive pills. She smokes 1/2 pack of cigarettes daily, and drinks alcohol socially. Her mother had breast disease and had an operation, but died 1 month after the surgery due to a heart attack. She has read in "US Health News" that breast cancer is the leading culprit for cancer death among non-smoking women. She now asks you, "What is the most important risk factor for breast cancer?" What is the correct response to this patient's question?
. Parity of the woman
. Age of menarche
. Age of woman
. Use of oral contraceptive pills
. Family history of breast cancer
151) A 54-year-old male had undergone an emergency colonic resection following an extensive ischemic colitis. The surgery was uneventful. The patient has been on peperacillin and tazobactam (Zosyn) for the past five days. He was NPO (nothing by mouth) for the past five days. He has a significant alcoholic history. On postoperative day six, he developed bleeding from the venipuncture site. His temperature is 36.7° C (98° F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Lab results are: Hb 11.5g/dL, MCV 88 fl, Platelet count 160,000/cmm, Leukocyte count 7,500/cmm, Segmented neutrophils 68%, Bands 1%, Eosinophils 1%, Lymphocytes 24%, Monocytes 6%, Prothrombin time 20 sec (INR=1.9), Partial thromboplastin time 45 sec. His family history is insignificant. Which of the following is the most likely cause of his condition?
. Thrombotic thrombocytopenic purpura
. Hemolytic uremic syndrome
. Idiopathic thrombocytopenic purpura
. Vitamin deficiency
Medication effect
152) A 16-year-old boy is brought to the office by his basketball coach because, "he is unable to work out with other boys." For the past several weeks, the boy has been complaining of left knee pain which is dull and worsens with running, especially on the court. In addition, he thinks he has lost some weight. He does not smoke or drink alcohol. He is sexually active with many partners, and does not use condoms. His vital signs are stable. On examination, his left knee is swollen and tender. X-ray reveals a sclerotic lesion in the distal femur with periosteum lifted and a "sun burst appearance”. What is the most likely diagnosis?
. Ewings sarcoma
. Growing pains
Osteosarcoma
. Septic arthritis
. Giant cell tumor
153) A 54-year-old female with megaloblastic anemia and ataxia is given radiolabeled cobalamin by mouth followed by an intramuscular injection of unlabeled cobalamin. The urine radioactivity level measured afterwards is determined to be normal. Which of the following is the most likely cause of this patient's symptoms?
. Dietary cobalamin deficiency
. Atrophic gastritis
. Nontropical sprue
. Fish tapeworm infestation
. Chronic low-volume Gl bleeding
154) An 18-year-old boy comes to clinic to discuss an embarrassing problem. For the last 6 weeks he has noticed a painless mass in his right testis. This is not bothering him at all, but it is becoming larger. He is afraid that his girlfriend may notice it and find out about his other partners. He has multiple partners, and does not use condoms. He has no fever and no other medical complaints. His cousin has SLE but otherwise family history is unremarkable. On ultrasound you suspect testicular cancer and order a few tests. Results are as follows: Alpha-fetoprotein (AFP) Increased, Beta subunit of the human chorionic gonadotropin (hCG) Normal, Placental Alkaline phosphate (PLAP) Normal, Carcinoembryonic antigen (CEA) Slightly Increased, Lactate Dehydrogenase (LDH) Increased. What could be the most likely diagnosis?
. Seminoma
. Embryonal carcinoma
. Choriocarcinoma
. Teratoma
Sertoli cell tumor
155) Elizabeth, a 13-year-old girl, comes with complaints of new onset seizures. She has morning headaches that go away after vomiting. She also has history of colonic polyps, for which she is undergoing work-up. Her family history is significant for her mother having problems with polyps. (She underwent proctocolectomy.) Initial non-contrast T1-weighted MRI shows a large, heterogeneous, hypointense mass in the white matter of the right temporal lobe and extending into the parietal and occipital lobes. The lower signal area within the mass suggests tissue necrosis. What is the most likely diagnosis in this patient?
. Multiple hamartoma syndrome
. Gardner's Syndrome
. Turcot's Syndrome
. Peutz-Jeghers syndrome
Cronkhite-Canada syndrome
156) A 72-year-old Caucasian man presents to your office complaining of severe fatigue. He says that five months ago he was able to climb four flights of stairs without shortness of breath, but now he has to rest after two. His appetite has decreased, but he denies any abdominal discomfort or black stool. Physical examination reveals firm, enlarged cervical and supraclavicular lymph nodes. A soft I/VI grade systolic murmur is heard along the left sternal border. Abdomen is soft and non-tender. His liver span is 10 cm and the spleen is palpated 4 cm below the left costal margin. His blood hemoglobin level is 7.5 mg/dl. Which of the following is the most likely cause of this patient's anemia?
. Iron deficiency
. Folate deficiency
Bone marrow infiltration
. Glucose-6-phosphate dehydrogenase deficiency
Red blood cell membrane defect
157) A 54-year-old male comes to the physician's office because of chronic cough and recent bloody sputum. He used to smoke 2 packs of cigarettes daily for 22 years, but he quit last month. His other symptoms are weight loss, anorexia, constipation, increased thirst, and easy fatigability. He thinks that he is depressed because his wife died 4 months ago and "life never felt the same after that." On examination, he is a slim man who appears pale. His vital signs are stable, although he appears a little irritable and short of breath. Laboratory and radiologic studies reveal: Sodium 144 mEq/dL, Potassium 4.3 mEq/dL, Chloride 98 mEq/dL, Bicarbonate 21 mEq/dL, Calcium 11.5 mg/dl, BUN 28 mg/dl, Creatinine 0.8 mg/dl. Chest x-ray hilar mass in the left lung. Biopsy of the mass would most likely reveal?
. Tuberculosis
Squamous cell carcinoma of the lung
Oat cell carcinoma of the lung
Sarcoidosis
Adenocarcinoma of the lung
158) A 24-year-old man from Long Island, New York, presents with fever, drenching sweats, and malaise for the past week. For the last few days, he has noted jaundice and dark-colored urine. He recalls being bitten by a tick two weeks ago. His surgical history includes splenectomy after a car accident 10 years ago. He does not use tobacco, alcohol, or illicit drugs. His temperature is 39.5°C (103°F), pulse is 106/min, and blood pressure is 110/70 mm Hg. Systemic examination is unremarkable, except for jaundice. Based on these findings, what is the most likely diagnosis?
. Malaria
Babesiosis
. Ehrlichiosis
. Q fever
. Lyme disease
159) A 55-year-old pig farmer is brought to the emergency department (ED) after having a seizure two hours ago. During his transit to the ED, he has another seizure. On arrival, he is unconscious, pulseless, and not breathing. Resuscitation is successful and the patient is stabilized; however, he does not do well over the next several days and is eventually declared dead. His wife says that he had been healthy most of his life, except for the past few weeks, when he was complaining of headaches. Autopsy shows multiple fluid-filled cysts in the brain parenchyma. Which of the following is the most likely diagnosis of this patient?
. Neurocysticercosis
. Lymphoma
. Metastatic brain tumor
Creutzfeldt-Jacob disease
Glioblastoma multiforme
160) A 34-year-old recently migrated African American male presents with severe headache and high-grade fever with chills for the last two days. He also complains of severe malaise, myalgia and vomiting. He adds that the present episode started with feeling of intense cold and chills with shivering followed by high-grade fever. He had two similar episodes in the past, when he was in Africa. His vitals are: T° 38.9°C (102°F), RR 20/min, PR 110/min and BP100/60 mm Hg. He has pallor with mild splenomegaly but rest of his physical examination is normal. What is the most likely diagnosis in this patient?
. Sickle cell crisis
. Babesiosis
. Falciparum malaria
. Meningitis
Typhoid fever
161) A 22-year-old man comes to the urgent care clinic with a one-week history of fever, sore throat, and malaise. He has tried several over-the-counter products with partial relief. His temperature is 38.8°C (102°F), pulse is 110/min, respirations are 18/min, and blood pressure is 130/70 mm Hg. Oropharyngeal examination reveals palatal petechiae with streaky hemorrhages and blotchy, red macules. The tonsils are enlarged and covered with whitish exudate. Mild jaundice is present. Enlarged lymph nodes are palpable posterior to the sternocleidomastoid muscle bilaterally. Axillary lymphadenopathy is also present. Abdominal examination reveals normal bowel sounds and mild hepatosplenomegaly. His complete blood count is shown below: Hemoglobin 14.0 g/L, MCV 88 f l, Platelets 140,000/mm3, Leukocyte count 14,500/mm3, Neutrophils 33%, Lymphocytes 66%, Eosinophils 1%. Which of the following is commonly associated with this patient's condition?
. Bronchopneumonia
Autoimmune hemolytic anemia
Splenic infarction
. Hepatocellular carcinoma
. Dilated cardiomyopathy
162) A 36-year-old man from Ohio presents with fever, malaise, fatigue, and skin lesions on his right forearm. His fever is low-grade, without any rigors or chills. His temperature is 38.4°C (101°F), pulse is 87/min, and blood pressure is 124/74mm Hg. Examination shows 1-2cm warty, heaped-up skin lesions with a violaceous hue and sharply demarcated border. Some of these lesions are crusted. Wet preparation of purulent material from skin lesions shows yeast Based on these findings, what is the most likely diagnosis?
. Histoplasmosis
. Blastomycosis
. Coccidioidomycosis
. Aspergillosis
Sporotrichosis
163) A 34-year-old male comes to the physician's office due to a severely pruritic lesions on his hands. He denies any trauma but recalls using his hands to change the sand of his children's sandbox when they went to Miami Beach three days ago. He later developed pruritic, erythematous papules over his arm. These papules progressed to serpiginous, reddish brown, elevated lesions, which are evident bilaterally on the upper extremities on exam. What is the most likely diagnosis?
. Cat scratch disease
. Sporotrichosis
. Cutaneous larva migrans
Brown recluse spider bite
. Scabies
164) A 64-year-old male recovering from an upper respiratory infection develops malaise and productive cough. Two days later he presents to the emergency department with confusion and severe dyspnea. He reports coughing up copious amounts of yellowish sputum streaked with blood today. On physical examination, his temperature is 40°C (104°F), blood pressure is 150/90 mm Hg, pulse is 110/min, and respirations are 24/min. Chest x-ray reveals infiltrates in the lung midfields bilaterally as well as multiple thinwalled cavities. What is the most likely cause of this patient's condition?
. Legionnaires disease
. Pulmonary thromboembolism
Tuberculosis
. Bronchiectasis
. Staphylococcus infection
165) A 35-year-old man presents to the office with a two-week history of low-grade fever and progressive weakness. He has "a heart murmur detected a long time ago." He denies illicit drug use. Physical examination reveals splinter hemorrhages, small petechiae on the palatal mucosa, and an audible murmur. His ESR is 60/min. Urinalysis reveals microscopic hematuria and 1 +proteinuria. Which of the following valvular dysfunctions is most likely to be detected?
Aortic regurgitation
. Mitral regurgitation
. Tricuspid regurgitation
. Pulmonic stenosis
. Mitral stenosis
166) A 22-year-old female presents with a two-day history of inability to close her right eye, a low-grade fever, and a rash on her trunk. There is no burning or itching associated with the rash. She denies headache, confusion, neck stiffness, numbness, and tingling. She went on a camping trip in Vermont four weeks ago but cannot recall any exposure to ticks. She was treated for chlamydia! Urethritis infection in the past. She has been using over-the-counter acetaminophen for fever; she noticed the rash after beginning the acetaminophen. Physical examination reveals several erythematous lesions around her waistline. Neurological examination shows right-sided facial nerve palsy. Based on these findings, what is the most likely diagnosis?
. Bell's palsy
. Lyme disease
. Secondary syphilis
. Botulism
. Atypical Guillain-Barre syndrome
167) A 22-year-old male student presents with an acute onset of fever, double vision, and painful swelling around his eyes. He also has significant muscle pain in his neck and jaw muscles. A week earlier, he experienced a period of abdominal pain, nausea, vomiting, and diarrhea, all of which resolved spontaneously. He has a history of intravenous drug abuse but has recently completed of a drug rehabilitation program. He is febrile. Physical examination shows "splinter" hemorrhages, periorbital edema, and chemosis. Chest is clear to auscultation. Cardiac exam reveals no murmur. Abdomen is soft and nontender with no organomegaly. His complete blood count is shown below: Hemoglobin 13.0 g/L, MCV 85 fl, Platelets 228,000/mm3, Leukocyte count 10,500/mm3, Neutrophils 56%, Eosinophils 21%, Lymphocytes 23%. Based on these findings, what is the most likely diagnosis?
. Trichinellosis
. Botulism
Infective endocarditis
. Guillain-Barre syndrome
. Angioedema
168) A 19-year-old woman comes to the physician because of fever, joint pain, and rash. The rash started on her face and is spreading down her body. She has pain in her fingers, wrists, and knees. She denies any neck stiffness, nausea, or vomiting. She has been sexually active with multiple partners. Her vaccination status is unknown. Her pulse is 86/min, blood pressure is 125/75 mm Hg, and temperature is 37.7°C (99.8°F). Physical examination reveals a maculopapular rash on her face and chest. Posterior auricular, cervical, and suboccipital lymphadenopathy is present. She has mild conjunctivitis. Oropharynx is clear. Chest is clearto auscultation. What is the most likely diagnosis?
Rubella
. Chicken pox
. Disseminated gonococcal infection
Infectious mononucleosis
. Secondary syphilis
169) An elderly bedridden patient in the hospital develops cough, fever, and shortness of breath. On examination, the JVP is 4 cm, heart sounds are normal, and there are crackles on inspiration in the right lower lobe. A CXR reveals a new right lower lobe infiltrate and his WBC is 15,000/mL. He was admitted to the hospital 7 days ago for the treatment of congestive heart failure. Which of the following is the most likely diagnosis?
Hospital-acquired pneumonia
Atelectasis
Pulmonary embolism
Community-acquired pneumonia
Asymmetric congestive heart failure
170) A 35-year-old male complains of inability to close his right eye. Examination shows facial nerve weakness of the upper and lower halves of the face. There are no other cranial nerve abnormalities, and the rest of the neurological examination is normal. Examination of the heart, chest, abdomen, and skin show no additional abnormalities. There is no lymphadenopathy. About one month ago the patient was seen by a dermatologist for a bull’s-eye skin rash. The patient lives in upstate New York and returned from a camping trip a few weeks before noting the rash. Which of the following is the most likely diagnosis?
. Sarcoidosis
. Idiopathic Bell palsy
. Lyme disease
. Syphilis
. Lacunar infarct
171) An 18-year-old woman presents with headache, anorexia, chilly sensations, and discomfort on both sides of her jaw. She has also noticed discomfort in both lower abdominal quadrants. Physical examination reveals bilateral enlarged parotid glands that are doughy, elastic, and slightly tender; with a reddened orifice of Stensen’s duct. Her abdomen is soft with bilateral lower quadrant abdominal tenderness; a temperature of 38.5°C; and a pulse rate of 92/min. Laboratory data show hemoglobin 13 g/dL; hematocrit 40%; white blood cells (WBC) 9000/mL, with 35% segmented neutrophils, 7% monocytes, and 58% lymphocytes. Which of the following is the most likely cause for her abdominal pain and tenderness?
Mesenteric lymphadenitis
Oophoritis
Gonorrhea
Peritoneal metastases
Intestinal hyperperistalsis
172) A 20-year-old woman presents with headache, fever, and neck stiffness. On examination, her blood pressure is 100/70 mm Hg, pulse 100/min, temperature 38.6°C, and the neck is stiff and painful to flex and extend. The ears, throat, and sinuses are normal, there are no focal neurologic signs, and the remaining examination is normal. There are no reported similar cases in the community. Which of the following is the most likely source of her infection?
An infected heart valve
Nasopharynx
Skin
Oral ingestion
Bowel
173) A 32-year-old woman acutely develops high fever, hypotension, and rash. This is followed by vomiting, diarrhea, confusion, and abdominal pain. In the hospital, evidence of multiorgan failure develops. Desquamation of the skin occurs 1 week after the acute illness. On further history, the illness started 3 days after the onset of menstruation. Which of the following is the most likely diagnosis?
S. Aureus toxic shock syndrome (TSS)
Streptococcal infection (scarlet fever)
Clostridial infection
RMSF
Staphylococcal scaled skin syndrome
175) A 22-year-old man is an avid spelunker (cave explorer) and has recently been exploring several caves. A routine CXR taken for a new job reveals hilar adenopathy and two patches of pneumonitis. His physical examination is completely normal. Careful questioning reveals he has just gotten over a cold with mild fever, cough, and malaise. Which of the following is the most likely diagnosis?
Tuberculosis (TB)
Sarcoidosis
Candidiasis
Histoplasmosis
Coccidioidomycosis
176) A 53-year-old man with alcoholic cirrhosis presents with increasing jaundice and abdominal discomfort. He reports no fevers or chills. On examination, his blood pressure is 100/60 mm Hg, pulse 100/min, temperature 38.1°C. He has a distended abdomen, peripheral edema, and shifting dullness. The abdomen is tender and bowel sounds are present. A diagnostic paracentesis is performed; the total cell count is 940/mL with polymorphonuclear neutrophils (PMNs) equal to 550/mL, Gram stain is negative, and cultures are pending. Which of the following is the most likely diagnosis?
Pancreatic ascites
Malignant ascites
Spontaneous bacterial peritonitis (SBP)
Secondary peritonitis
Tuberculous ascites
177) A 20-year-old woman presents with headache, anorexia, chilly sensations, pain, and drawing sensations in both sides of her jaw. She has also noticed discomfort in both lower abdominal quadrants. Physical examination reveals bilateral enlarged parotid glands that are doughy, elastic, and slightly tender; with a reddened orifice of Stensen’s duct. Her abdomen is soft with bilateral lower quadrant abdominal tenderness, a temperature of 38.5°C, and a pulse rate of 92/min. Laboratory data show hemoglobin 13 g/dL; hematocrit 40%; WBC 9000/mL, with 35% segmented neutrophils, 7% monocytes, and 58% lymphocytes. Which of the following is the most likely diagnosis?
Cervical lymphadenitis
Mikulicz’s syndrome
Parotid gland tumor
Uveoparotid fever
Mumps
178) An 18-year-old woman visits her physician because of 3 weeks of malaise, 2 weeks of fever, and a sore throat. Physical examination shows pharyngeal infection with enlarged tonsils and a patchy, white exudate; enlarged, palpable anterior and posterior cervical, axillary, and inguinal lymph nodes; tenderness in the right upper quadrant; and minimal splenomegaly. Laboratory data show hemoglobin 14 g/dL; hematocrit 42%; platelets 380,000/mL; WBC 8500/mL, with 35% segmented neutrophils, 1% eosinophils, and 64% lymphocytes, of which 36% were atypical. Which of the following is the most likely diagnosis?
Infectious hepatitis
Lymphocytic leukemia
Infectious mononucleosis
Hodgkin’s disease
Cat-scratch fever
179) A 43-year-old man developed a cough shortly after returning from a 1-month hiking trip in California. While there, he was hiking in the central California valleys. During his trip, he had developed a flu-like‖ illness consisting of fever, cough, and muscle pains, which resolved spontaneously. A CXR shows a thin-walled cavity in the right upper lobe, and the sputum reveals fungal elements. Which of the following is the most likely causative organism?
Ringworm
Cryptococcus neoformans
Candida albicans
Mycobacteria
Coccidioidomycosis
180) A 34-year-old man presents with diarrhea 3 weeks after returning from a trip to rural South America. Over the past few days, he has gradually developed lower abdominal pain and diarrhea. Now the symptoms are much worse with eight stools a day consisting mostly of mucus and blood. He is afebrile, the abdomen is tender in left lower quadrant, and the remaining examination is normal. His stool is mostly comprised of blood and mucus, and stools tests show trophozoites of Entamoeba hitolytica. Which of the following is the most likely site of extra intestinal involvement?
Genitals
Pleura
Pericardium
Liver
Cerebral cortex
181) A 40-year-old man develops erythema nodosum, conjunctivitis, and a pleural effusion. Over several weeks, pulmonary lesions lead to cavitation and a large, thin-walled cavity. He was traveling in Arizona before becoming ill. Sputum samples reveal mature spherules. Which of the following is the most likely diagnosis?
Streptococcus
Coccidioidomycosis
Candidiasis
Staphylococcus
Pneumocystis carinii
183) A 7-year-old child, unvaccinated because of his parents’ religious beliefs, develops malaise, cough, coryza, and conjunctivitis with a high fever. Examination of his mouth reveals blue white spots on a red base beside his second molars. The next day he develops an erythematous, nonpruritic, maculopapular rash at his hairline and behind his ears, which spreads over his body. Which of the following is the most likely diagnosis?
Hand-foot-and-mouth disease (coxsackievirus)
Measles (rubeola)
Rubella (German measles)
Mumps
Pertussis
184) A 51-year-old man is admitted to the hospital because of renal failure. His past medical history is significant for recurrent episodes of bilateral flank pain over the past several years as well as nocturia 2 to 3 times per night for the past 10 years. He has no weight loss. On physical examination, his blood pressure is 160/100 mm Hg. His mucous membranes are pale. There is a palpable mass located at the right flank. Which of the following is the most likely diagnosis?
. Horseshoe kidney
. Nephrolithiasis
. Papillary necrosis
Polycystic kidney disease
Renal cell carcinoma
185) A 30-year-old African American man comes to the physician because of a two-week history of fatigue and ankle edema. He is HIV-positive. He takes no medications. He does not use tobacco, alcohol, or drugs. His temperature is 36.7°C (98°F), blood pressure is 140/86 mm Hg and respirations are 16/min. Physical examination shows mild ankle edema. Laboratory studies show: Hb 12.5 g/dl, WBC 6,000/cmm, Platelets 140,000/cmm, Serum Na 135 mEq/L, Serum K 5.0 mEq/L, BUN 28 mg/dl, Serum creatinine 2.4 mg/dl. Urinalysis revealed 2+ proteinuria but otherwise shows no abnormalities. CD4 count taken three weeks ago was 550. Which of the following is the most probable form of kidney disease in this patient?
Membranous glomerulonephritis
. Mesangioproliferative glomerulonephritis
. Collapsing focal and segmental glomerulosclerosis
. Diffuse proliferative glomerulonephritis
. Acute interstitial nephritis
186) A 43-year-old man complains of occasional red urine. He denies fever, edema, flank pain or weight loss. Specifically, he says that each urine stream starts out transparent, but turns red by the end of the stream. At times he has noticed small clots in his urine. Physical examination is within normal limits. What is the most likely cause of his complaints?
Glomerular disease
. Nephrolithiasis
. Urinary tract infection
Urethral injury
. Bladder disease
187) A 74-year-old man comes to the physician because of a one-year history of increased urinary frequency and urgency. He feels that his bladder is "not emptying properly", and has a constant sensation of incomplete voiding. His only other medical problem is hypertension, for which he takes hydrochlorothiazide. He never had any surgeries. Urine culture shows no abnormality. Which of the following is true regarding this patient's disorder?
. It is best treated with oral antibiotics.
. It usually starts in the central part of the prostate.
It can be treated with continuous suprapubic catheter irrigation.
. It responds well to beta blockers.
. It usually starts in the peripheral part of the prostate.
188) A 26-year-old man comes to the emergency department because of a sudden onset of severe, colicky, leftsided flank pain that radiates to the scrotum. He also has nausea, vomiting and dark-colored urine. He has never had these symptoms before. Examination shows no abnormalities. Non-contrast helical CT shows a 5 mm radiopaque stone in the left upper ureter. His laboratory studies are as follows: Serum calcium 9.8 mg/dl, Serum creatinine 0.9 mg/dl, BUN 15 mg/dl. Urinalysis shows hematuria but no casts. Which of the following is the most likely cause of this patient's symptoms?
. Calcium oxalate stones
. Calcium phosphate stones
Uric acid stones
. Cysteine stones
. Struvite stones
189) A 36-year-old man comes to the physician because of fatigue and generalized edema. He was recently diagnosed with Hodgkin's lymphoma. Laboratory studies show: Serum sodium 145 mEq/L, Serum potassium 3.8 mEq/L, Serum albumin 2.0 g/dl, Serum globulin 7.0 g/dl, Total serum bilirubin 0.9 mg/dl, Serum creatinine 1.2 mg/dl. Urinalysis shows proteinuria 4+. Which of the following glomerulopathies is more likely to be present in this patient?
. Focal segmental glomerulosclerosis
. Membranous glomerulonephritis
. Diffuse proliferative glomerulonephritis
Minimal change disease
. Crescentic glomerulonephritis
190) A 30-year-old woman comes to the physician because of a 2-day history of periorbital edema and abdominal distention. She has no other complaints. Her temperature is 37.1°C (98.9°F), blood pressure is 125/75 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows ascites. Urinalysis shows proteinuria; 24-hour urinary protein excretion is 4 g/day, total serum protein is 5 g/dl and serum albumin is 2.5g/dl. A diagnosis of nephrotic syndrome is made. Renal biopsy is performed. She is started on diuretics and her salt and protein intake is restricted. Her edema begins to improve. However, the patient suddenly develops severe abdominal pain, fever, and gross hematuria. Which of the following is the most likely diagnosis that will be revealed by renal biopsy?
. Minimal change disease
. Systemic amyloidosis
. Focal segmental glomerulosclerosis
. Membranous glomerulonephritis
. Diabetic nephropathy
191) A 30-year-old African American man comes to the physician because of a 2-day history of periorbital edema and abdominal distention. His temperature is 37.1°C (98.7°F), blood pressure is 125/75mm Hg, pulse is 80/min, and respirations are 14/min. His height is 170cm (5'7") and weight is 104kg (2301bs). He has been in a drug rehabilitation program for the past 2-months, for a long history of IV drug abuse. Examination shows significant ascites. Urinalysis shows proteinuria; 24-hr urinary protein excretion is 4g/day. Which of the following is the most likely diagnosis?
. Minimal change disease
. Systemic amyloidosis
. Focal segmental glomerulosclerosis
. Membranous glomerulonephritis
IgA nephropathy
192) A 50-year-old man comes to the physician for a routine check-up. He has no present complaints. He has diabetes mellitus, type 2, stable angina, and gout. He takes glyburide and atenolol. He smokes two packs a day and, occasionally, consumes alcohol. His father had an early myocardial infarction; his brother has diabetes mellitus. His blood pressure is 140/90 mm Hg and heart rate is 65/min. Physical examination shows no abnormalities. There is concern about end organ damage in this patient due to diabetes mellitus. Which of the following is the earliest renal abnormality that could be seen in this patient?
Nodular sclerosis
Glomerular basement membrane (GBM) thickening
. Mesangial expansion
. Immune deposits
. Glomerular hyperfiltration
193) A 70-year-old man presents to the emergency department with a 12-hour history of inability to void. He also complains of nocturia and problems with initiating micturition for the past few weeks. He denies fever, weakness, numbness, dysuria or hematuria. He does not use tobacco, alcohol, or drugs. Neurological examination shows no abnormalities, except absent Achilles tendon reflexes bilaterally. Straight catheterization of the bladder produces 600 ml of urine. Further evaluation will most likely show which of the following?
. Urinary tract infection
. Enlarged prostate
. Carcinoma of the bladder
Multiple sclerosis
. Urinary fistula
194) A 36-year-old man comes to the emergency department because of excruciating flank pain. The pain radiates to the groin. His temperature is 36.9°C (98.5°F), blood pressure is 115/75 mm Hg, pulse is 85/min, and respirations are 14/min. Urinalysis shows six RBCs/HPF. Laboratory studies show BUN of 12mg/dl and serum creatinine of 0.9mg/dl. X-ray film of the abdomen shows nephrocalcinosis and IVP shows multiple contrast filled cysts. Ultrasonogram of the kidneys is unremarkable. Which of the following is the most likely diagnosis?
. Medullary cystic kidney
Hydronephrosis
. Autosomal dominant polycystic kidney disease
Autosomal recessive polycystic kidney disease
. Acquired cystic kidney disease
195) A 22-year-old man comes to the physician because of a 2-day history of dark urine. He has had an upper respiratory tract infection for 3 days. His temperature is 37.1° C (98.9°F), blood pressure is 145/90mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows no abnormalities. Laboratory studies show: Urinalysis: Glucose Negative, Protein 1+, Ketones Negative, Leukocyte esterase Negative, Nitrites Negative, WBC 3-6/hpf, RBC 30-50/hpf, Casts RBC. Serum chemistry: Serum Na 138 mEq/L, Serum K 4.5 mEq/L, Bicarbonate 22 mEq/L, BUN 30 mg/dL, Serum creatinine 1.8 mg/dL. Serum complement level is within normal limits. Which of the following is the most likely diagnosis?
. IgA nephropathy
. Acute interstitial nephritis
. Acute post-infectious glomerulonephritis
. Anti-glomerular basement membrane disease
. Benign recurrent hematuria
196) A 27-year-old man comes to the physician because of red urine. He has had no pain or burning on urination. He has infiltrative pulmonary tuberculosis (diagnosed recently). He takes isoniazid, rifampin, and pyrazinamide. He smokes two packs a day and consumes alcohol occasionally. Vital signs are stable Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
. Acute cystitis
Renal tuberculosis
. Drug reaction
. Nephrolithiasis
Glomerulopathy
197) An 18-year-old girl comes to the emergency department with a rash and arthralgias. She is sexually active and has had the same sexual partner for the past 4-months. Recent medical history is significant for an episode of dysuria and increased urinary frequency, both of which started 5-days ago. Her primary care physician prescribed TMP+SMX (Bactrim) for this. She developed her present symptoms 3-days after starting the medication. Her aunt has Lupus. Her temperature is 38.5°C (101.3°F), pulse is 86/min, and respirations are 16/min. Physical examination shows a disseminated maculopapular rash; there is no costovertebral tenderness or flank pain; serum creatinine is 2 mg/dL. Urinalysis shows 2-5 RBC/hpf, numerous white blood cell casts made mostly of eosinophils, and mild proteinuria. Which of the following is the most likely diagnosis?
. Disseminated gonococcemia
. Post-infectious acute glomerulonephritis
. Drug induced interstitial nephritis
. Lupus nephritis
. Pyelonephritis
198) A 26-year-old woman presents with a one-week history of dysuria and increased urinary frequency. She admits to having multiple sexual partners in the past. Her temperature is 37.1°C (98.9°F), blood pressure is 110/70 mm Hg, pulse is 68/min, and respirations are 15/min. Examination shows suprapubic tenderness. Mucopurulent discharge is observed at the urethral os. Urinalysis shows: Blood Negative, Glucose Negative, Ketones Negative, Leukocyte esterase Positive, Nitrites Negative, WBC 40-50/hpf, RBC 1-2/hpf, Bacteria None. Urine culture after 24hours < 100colonies/ml. Which of the following is the most likely diagnosis?
. Acute pyelonephritis
Acute bacterial cystitis
Chlamydial urethritis
Gonococcal urethritis
Trichomonal vaginitis
199) A 60-year-old man comes to the physician's office because of fatigue and hematuria. His past medical history is significant for fatty liver, gout, and anemia. He has smoked two packs of cigarettes daily for 40 years. He is a heavy alcohol drinker. His last visit to his physician was 1 month agoforthe 'flu'. His temperature is 37.1°C (98.9°F), blood pressure is 145/90mm Hg, pulse is 78/min, and respirations are 14/min. Examination shows no abnormalities. Dipstick testing is positive for hematuria. Laboratory studies show: Urinalysis: Glucose Negative, Ketones Negative, Leukocyte esterase Negative, Nitrites Negative, WBC 1-2/hpf, RBC 1-2/hpf, Casts Epithelial cell. Serum chemistry: Serum Na 140 mEq/L, Serum K 5.0 mEq/L, Bicarbonate 20 mEq/L, BUN 36 mg/dL, Serum creatinine 34 mg/dL. Which of the following is the most likely diagnosis?
. Post infectious glomerulonephritis
. Hepatorenal syndrome
Rhabdomyolysis
. Renal cell cancer
Bladder cancer
200) A 50-year-old man comes to the physician because of a skin rash, joint pains, malaise and fatigue. He has a history of intravenous drug abuse. His temperature is 37.1°C (98.9°F), blood pressure is 140/90 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows palpable purpura and hepatosplenomegaly. Urinalysis shows hematuria, red blood cell casts and proteinuria. The results of the laboratory studies are as follows: BUN 30 mg/dl, Creatinine 2.0 mg/dl, Serum complement Low, Anti-HCV Positive. Which of the following is the most likely diagnosis?
. Alpert's syndrome
. Acute interstitial nephritis
. Acute post infectious glomerulonephritis
. Mixed essential cryoglobulinemia
. Benign recurrent hematuria
201) A 27-year-old man comes to the physician because of a 2-day history of periorbital swelling. He was treated with oral dicloxacillin for a skin infection 3-weeks ago. His urine has turned darker. His temperature is 37.4°C (99.4°F), blood pressure is 150/90 mm Hg, pulse is 80/min, and respirations are 15/min. Examination shows periorbital swelling. Urinalysis shows 8 RBCs/HPF with RBC casts and a mild proteinuria. Laboratory studies show low serum C3 levels; BUN is 40 mg/dl and serum creatinine is 2 mg/dl. Which of the following is the most likely diagnosis?
. Drug-induced acute interstitial nephritis
. Acute pyelonephritis
. Post streptococcal glomerulonephritis
. Membranoproliferative glomerulonephritis
. IgA nephropathy
202) A 27-year-old man comes into the emergency department because of a 2-week history of hemoptysis, breathing difficulty, ankle edema, and dark urine. His past medical history is insignificant. He is not taking any medication. He does not use tobacco, alcohol, or drugs. Laboratory studies show: Hb 10.5 g/dl, Serum Na 135 mEq/L, Serum K 4.8 mEq/L, BUN 36 mg/dl, Serum creatinine 2.8 mg/dl. Urinalysis shows numerous dysmorphic red blood cells/HPF, moderate proteinuria, and red cell casts. Chest x-ray reveals bilateral alveolar infiltrates. Diagnosis of which of the following pulmonary-renal syndromes require emergency plasmapheresis?
. Good pasture's syndrome
. Wegener's granulomatosis
. SLE-associated nephritis
. Polyarteritis nodosa
. Idiopathic rapidly progressive glomerulonephritis (RPGN)
203) A 64-year-old man is scheduled for hemodialysis due to end stage renal disease. He has a several year history of hypertension, diabetes, coronary artery disease, hypercholesterolemia, peripheral vascular disease, gout, and diverticulosis. Six months ago, he was admitted for urosepsis. Recently, his haemoglobin has ranged between 8.5 to 9.5 g/dl. He has already been on iron therapy, and now you are considering erythropoietin injections twice weekly. Which of the following is most likely to be seen following erythropoietin therapy?
. Worsening of his hypertension
. Increase in insulin requirement
. Increased susceptibility to infections
. Deterioration in renal function
. Flare-up of gout
204) A 70-year-old man is brought to the hospital by his son because of worsening fatigue. His son states that his father does not like seeing doctors and has not seen a physician in the past 20 years. He has no medical problems. Physical examination of the prostate shows no abnormalities. Laboratory studies show: Hb 10.5 g/dl, WBC 7,400/cmm, Platelets 160,000/cmm, Serum Na 135 mEq/L, Serum K 5.0 mEq/L, BUN 50 mg/dl, Serum creatinine 3.0 mg/dl. Ultrasonogram of the abdomen shows bilateral small kidneys and no evidence of hydronephrosis. Kidney biopsy shows intimal thickening and luminal narrowing of renal arterioles with evidence of sclerosis. Which of the following is the most likely cause of this patient's findings?
. Hypertension
. Diabetes mellitus
. Multiple myeloma
. Analgesic abuse
. Renal lithiasis
205) A 35-year-old woman who recently emigrated from Russia comes to the physician because of hematuria. She has a history of frequent headaches. Extensive evaluation did not reveal the cause of her headaches. They occur almost every day, and she tried various analgesics to relieve them. Her family history is significant for hypertension and diabetes mellitus. She does not use tobacco, alcohol, or drugs. Her blood pressure is 120/70 mm Hg and heart rate is 80/min. Physical examination shows no abnormalities. Urinalysis shows numerous unchanged red blood cells/hpf. Which of the following is the most likely cause of this patient's condition?
. Malignancy
. Glomerular injury
. Papillary necrosis
. Infection
Nephrolithiasis
206) A 55-year-old woman comes to the physician for an annual physical examination. She has no new complaints, except fatigue. She has an 8-year history of chronic low back pain; severe degenerative joint disease has been documented on MRI. She had an anterior wall myocardial infarction four years ago. Her current medications include naproxen, acetaminophen, oxycodone, aspirin, atenolol, and simvastatin. Her blood pressure is 130/80 mm Hg and pulse is 72/min. Laboratory studies show: Hb 10 g/dl, WBC 6,000/cmm, Blood sugar 82 mg/dl, BUN 36 mg/dl, Serum creatinine 2.0 mg/dl. Urinalysis : Protein 2+, Glucose Absent, RBC AbsentWBC 10-15/HPF, Nitrite Negative, Esterase Negative, Sediment WBC casts. Serum protein electrophoresis is negative for monoclonal gammopathy. Two years ago, her BUN level was 22 mg/dl, and creatinine level was 1.6 mg/dl. Which of the following is the most likely pathology involved in this patient's renal failure?
. Acute tubular necrosis
. Chronic glomerulonephritis
. Tubulointerstitial nephritis
. Recurrent pyelonephritis
. Renal tuberculosis
207) A 50-year-old man comes to the physician for a routine follow-up visit. He has hypertension, diabetes mellitus, secondary hyperparathyroidism, and end-stage renal disease. He has been on hemodialysis for the past three years. He was admitted three months ago for line sepsis, which was treated with antibiotics. He had a right below-the-knee amputation two years ago following a non-healing foot ulcer. Physical examination shows a right carotid bruit. If this patient dies within the next five years, what would be the most likely cause of his death?
. Cardiovascular disease
. Stroke
Infection
. Cancer
. Withdrawal from dialysis
208) 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?
Alport's syndrome
. Acute interstitial nephritis
. Acute post infectious glomerulonephritis
. Anti-glomerular basement membrane disease
. Benign recurrent hematuria
209) A 17-year-old African American man comes to the physician after an episode of gross hematuria that resolved spontaneously. He has no other complaints. His past medical history is insignificant. He takes no medications. He smokes occasionally. He does not use drugs or alcohol. His temperature is 36.7°C (98°F), blood pressure is 120/70 mm Hg, pulse is 70/min, and respirations are 14/min. Physical examination shows no abnormalities. Urinalysis shows many unchanged red blood cells/HPF, but is otherwise normal. Laboratory studies show a creatinine level of 0.9 mg/dl. Which of the following is the most likely diagnosis?
. Acute glomerulonephritis
. Acute interstitial nephritis
. Sickle cell trait
. Coagulopathy
. Acute cystitis
210) A 30-year-old woman comes to the physician due to several weeks history of generalized edema, fatigue, and decreased appetite. She has no other medical problems. She takes no medications. She does not use tobacco, alcohol, or drugs. Her temperature is 36.7°C (98°F), blood pressure is 110/70 mm Hg, pulse is 80/min, and respirations are 18/min. Physical examination shows generalized edema. Laboratory studies show a low serum albumin level. HBsAg is positive, and liver function tests are abnormal. Urinalysis shows +4 proteinuria and microhematuria. Which of the following is the most likely diagnosis?
. Membranoproliferative glomerulonephritis
. Minimal change disease
. Focal segmental glomerulosclerosis
. Diffuse proliferative glomerulonephritis
. Membranous glomerulonephritis
212) A 64-year-old man presents with weight gain, shortness of breath, easy bruising, and leg swelling. On examination, his blood pressure is 140/80 mm Hg, pulse 100/min, JVP 4 cm, heart sounds normal, and lungs are clear. There is a 3+ pedal and some periorbital edema. Investigations include a normal chest x-ray (CXR), electrocardiogram (ECG) with low voltages, anemia, high urea and creatinine, and 4 g/day of protein in the urine. A renal biopsy, which shows nodular deposits that have an apple-green birefringence under polarized light when stained with Congo red. Which of the following is the most likely diagnosis?
Amyloidosis
Multiple myeloma
Diabetic nephropathy
Minimal change disease
Immunoglobulin A (IgA) nephropathy
213) A 25-year-old man is referred to you because of hematuria. He noticed brief reddening of the urine with a recent respiratory infection. The gross hematuria resolved, but his physician found microscopic hematuria on two subsequent first-voided morning urine specimens. The patient is otherwise healthy; he does not smoke. His blood pressure is 114/72 mm Hg and the physical examination is normal. The urinalysis shows 2+ protein and 10 to 15 RBC/hpf, with some dysmorphic erythrocytes. No WBC or casts are seen. What is the most likely cause of his hematuria?
. Kidney stone
. Renal cell carcinoma
. Acute poststreptococcal glomerulonephritis
. Chronic prostatitis
. IgA nephropathy (Berger disease)
214) A 17-year-old man is brought to the emergency room with confusion and incoordination. He is uncooperative and refuses to provide further history. Physical examination reveals an RR of 30; the vital signs are otherwise normal as is the general physical examination. Laboratory values are as follows: Na: 135 mEq/L, K: 2.7 mEq/L, HCO3: 15 mEq/L, Cl: 110 mEq/L. Arterial blood gases: PO2 92, PCO2 30, pH 7.28 Urine: pH 7.5, glucose—negative, Ca: 9.7 mg/dL, PO4: 4.0 mg/dL. Which of the following is the most likely cause of the acid base disorder?
. GI loss owing to diarrhea
Proximal renal tubular acidosis
. Disorder of the renin-angiotensin system
. Distal renal tubular acidosis
. Respiratory acidosis
215) A 28-year-old woman presents with a recent episode of coughing up some blood, frequent nosebleeds, and now decreased urine output. A nasal mucosa ulcer was seen on inspection. Her urinalysis is positive for protein and red cells consistent with a GN. The CXR shows two cavitary lesions and her serology is positive for antineutrophil cytoplasmic antibodies (ANCA). Which of the following is the most likely diagnosis?
Wegener’s granulomatosis
Bacterial endocarditis
Goodpasture’s syndrome
Lupus erythematosus
Poststreptococcal disease
216) A 74-year-old woman develops acute sepsis from pneumonia and is admitted to the intensive care unit because of hypotension. She is started on antibiotics, and her blood pressure is supported with intravenous normal saline. Despite this she remains oliguric and develops ARF. Her urinalysis has heme-granular casts and the urine sodium is 56 mEq/L. Which of the following is the most likely cause of her ARF?
Nephrotoxic antibiotics
Acute infectious GN
Acute tubular necrosis (ATN)
Contrast nephropathy
Cholesterol emboli
217) A 76-year-old man presents to the emergency room. He had influenza and now presents with diffuse muscle pain and weakness. His past medical history is remarkable for osteoarthritis for which he takes ibuprofen, and hypercholesterolemia for which he takes lovastatin. Physical examination reveals blood pressure of 130/90 mm Hg with no orthostatic change. The only other finding is diffuse muscle tenderness. Laboratory data include: BUN: 30 mg/dL, Creatinine: 6 mg/dL, K: 6.0 mEq/L, Uric acid: 18 mg/dL Ca: 6.5 mg/dL, PO4: 7.5 mg/dL, UA: large blood, 2+ protein. Microscopic study shows muddy brown casts and 0 to 2 rbc/hpf (red blood cells/high power field).Which of the following is the most likely diagnosis?
Nonsteroidal anti-inflammatory drug-induced acute kidney injury (AKI)
. Volume depletion
. Rhabdomyolysis-induced acute kidney injury
. Urinary tract obstruction
. Hypertensive nephrosclerosis
218) A 73-year-old man undergoes abdominal aortic aneurysm repair. The patient develops hypotension to 80/50 mm Hg for approximately 20 minutes during the procedure according to the anesthesia record. He received 4 units of packed red blood cells. Postoperatively, his blood pressure is 110/70 mm Hg, heart rate is 110, surgical wound is clean, and a Foley catheter is in place. Over the next 2 days his urine output slowly decreases. His creatinine on post-op day 3 is 3.5 mg/dL (baseline 1.2). His sodium is 140 mEq/L, K 4.6 mEq/L, and BUN 50 mg/dL. Hemoglobin and hematocrit are stable. Urinalysis shows occasional granular casts but otherwise is normal. Urine sodium is 50 mEq/L, urine osmolality is 290 mosmol/L, and urine creatinine is 35 mg/dL. The FENa (fractional excretion of sodium) based on these data is 3.5. What is the most likely cause of this patient’s acute renal failure?
. Acute interstitial nephritis
. Acute glomerulonephritis
. Acute tubular necrosis
. Prerenal azotemia
. Contrast induced nephropathy
219) A 73-year-old woman with arthritis presents with confusion. Neurologic examination is nonfocal, and CT of the head is normal. Laboratory data include: Na: 140 mEq/L, K: 3.0 mEq/L, Cl: 107 mEq/L, HCO3: 12 mEq/L. Arterial blood gases: PO2 62, PCO2 24, pH 7.40. What is the acid-base disturbance?
Respiratory alkalosis with appropriate metabolic compensation
High anion-gap metabolic acidosis with appropriate respiratory compensation
Combined metabolic acidosis and respiratory alkalosis
. No acid-base disorder
. Hyperchloremic (normal anion gap) metabolic acidosis with appropriate respiratory compensation
220) A 63-year-old man alcoholic with a 50-pack-year history of smoking presents to the emergency room with fatigue and confusion. Physical examination reveals a blood pressure of 110/70 mm Hg with no orthostatic change. Heart, lung, and abdominal examinations are normal and there is no pedal edema. Laboratory data are as follows: Na: 110 mEq/L, K: 3.7 mEq/L, Cl: 82 mEq/L, HCO3: 20 mEq/L, Glucose : 100 mg/dL, BUN : 5 mg/dL, Creatinine: 0.7 mg/dL Urinalysis: normal Specific gravity: 1.016. Which of the following is the most likely diagnosis?
. Volume depletion
. Inappropriate secretion of antidiuretic hormone
Psychogenic polydipsia
Cirrhosis
. Congestive heart failure
221) A 65-year-old white female comes to the ER because of persistent vomiting and epigastric pain. She has been suffering from left knee osteoarthritis for the past 6 years, and has been taking ibuprofen for the past year. She also has a history of chronic obstructive pulmonary disease but is well controlled on her current medications. She quit smoking a few years ago. Her laboratory results are given below: ABG: pH 7.55, PCO2 46 mm Hg. Chemistry panel: Serum sodium 132 mEq/L, Serum potassium 3.0 mEq/L, Chloride 88 mEq/L, Bicarbonate 38 mEq/L, Serum creatinine 0.8 mg/dl. Which of the following would describe her primary acid-base status?
Normal profile
Metabolic acidosis
. Metabolic alkalosis
. Respiratory acidosis
Respiratory alkalosis
222) A 36-year-old male is brought to the emergency department due to confusion, nausea and decreased arousal. He is unable to answer questions and no other history is available. His temperature is 36.7ׄ°C (98.2°F), respirations are 22/min and pulse is 86/min. His ABG and serum electrolyte levels are shown below: pH 7.21, PaO2 96 mmHg, PaCO2 28 mmHg, Serum sodium 140 mEq/L, Serum potassium 3.6 mEq/L, Chloride 90 mEq/L, Bicarbonate 12 mEq/L, Blood urea nitrogen (BUN) 30 mg/dl, Serum creatinine 1.2 mg/dl. What is the most likely primary acid-base disorder in this patient?
. Non-anion gap metabolic acidosis
Anion gap metabolic acidosis
. Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
223) A 56-year-old male comes to the emergency room because of a 2-day history of fever, chills, shortness of breath and productive cough. He also threw up once in the emergency room. He has been smoking for several years and occasionally drinks alcohol. On admission, his BP was 90/60, but with one liter of normal saline it improved to 120/80 mm Hg. His temperature is 38.8°C (102°F). His arterial blood gas (ABG) analysis is as follows: Blood pH 7.53, PaO2 70 mmHg, PaCO2 30 mmHg, HCO3- 22 mEq/L. Which of the following best describes his primary acid-base status?
. Respiratory acidosis
Respiratory alkalosis
. Metabolic acidosis
. Metabolic alkalosis
. Normal acid base status
224) A 67-year-old male is brought to the ER because of increasing abdominal pain and nausea for the past few hours. He has multiple medical problems including type-2 diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular accident, peripheral vascular disease, ischemic cardiomyopathy and atrial fibrillation. He has not been on anticoagulation because of recurrent bleeding peptic ulcer disease. He has had a cholecystectomy. He takes multiple medications at prescribed doses and lives at home with his family. He quit smoking 10 years ago and does not use alcohol or drugs. His temperature is 37.8°C (100.0°F), blood pressure is 150/90 mm Hg, pulse is 110/min and respirations are 22/min. Physical examination shows an elderly male in acute distress. Lungs have few crackles at the bases. Heart rate is irregular. Bowel sounds are decreased and diffuse tenderness is present. There is no peripheral edema. Initial laboratory studies show the following: Serum sodium 140 mEq/L, Chloride 103 mEq/L, Bicarbonate 14 mEq/L, Blood urea nitrogen (BUN) 20 mg/dl, Serum creatinine 0.8 mg/dl, Blood glucose 198 mg/dl, Amylase 255 U/L. Which of the following is the most likely diagnosis in this patient?
Diabetic ketoacidosis
. Bowel ischemia
. Acute pancreatitis
. Acute appendicitis
Peptic ulcer perforation
225) A 56-year-old male with a history of type-2 diabetes presents for a routine office visit. His blood work from two months ago showed hyperkalemia, and at that time his physician discontinued lisinopril. His repeat blood work done today is shown below: Chemistry panel: Serum sodium 136 mEq/L, Serum potassium 5.6 mEq/L, Chloride 110 mEq/L,Bicarbonate 18 mEq/L, Blood urea nitrogen (BUN) 26 mg/dl, Serum creatinine 1.9 mg/dl. He currently takes glipizide, furosemide, nifedipine and aspirin. His blood pressure is 150/90 mmHg. Examination is unremarkable. Which of the following is the most likely cause of his low bicarbonate and elevated potassium?
. Chronic renal failure
. Renal tubular acidosis
. Furosemide
. Glipizide
Nifedipine
226) A 33-year-old woman is brought to the emergency room because of altered mental status. En route to the ER, she suffers a generalized tonic clonic seizure, and once at the hospital she is confused and no further history can be obtained. You know only that she has a history of schizophrenia. On physical examination, her temperature is 36.7°C (98°F), blood pressure is 130/76 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows normal pupils. Her chest is clear to auscultation and her heart sounds are normal. Her abdomen is soft and nontender. Extremities have no edema. Laboratory studies show: Serum sodium 118 mEq/L, Serum creatinine 0.8 mg/dL, Serum calcium 8.4 mg/dL, Serum glucose 98 mg/dL, Urine osmolality 100 mosm/kg, Urine specific gravity 1.002. Which of the following is the most likely cause of her symptoms?
. Primary polydipsia
Drug-induced ADH resistance
. Increased ADH production
. Drug-induced water retention
Deficient ADH secretion
227) A 56-year-old male comes to the emergency room because of increasing shortness of breath for the last 3 days. He had a cold recently, and since then his symptoms have been worse. He has a mild productive cough but denies fever or chills. He has a several year history of smoking and has been diagnosed with emphysema. He also has a history of diabetes, hypertension, hyperlipidemia, and hypothyroidism. He takes glipizide, metformin, lisinopril, furosemide, aspirin, atorvastatin and levothyroxine. Physical examination shows trace bilateral lower extremity edema and a diffuse decrease in breath sounds along with wheezing. Heart sounds are distant. His arterial blood gas shows the following: Blood pH 7.23, PaO2 88mm Hg, PaCO2 40 mm Hg, HCO3- 16mEq/L. Which of the following best describes the acid-base status of this patient?
. Metabolic acidosis
Respiratory acidosis
. Mixed metabolic and respiratory acidosis
. Mixed metabolic acidosis and respiratory alkalosis
. Normal acid-base balance
228) A 45-year-old male is brought to the emergency department in a stuporous state. He appears agitated and disoriented. His temperature is 37.2°C (99°F), respirations are 22/min, pulse is 90/min and blood pressure is 110/70 mm of Hg. His lab findings are as follows: Blood pH 7.21, PaO2 100 mmHg, PaCO2 30 mmHg, HCO3- 13 mEq/L, Serum osmolarity 350 mOsm/L, Blood glucose 90 mg/dl, Na+ 141 mEq/L, K+ 4.6 mEq/L, Cl- 100 mEq/L, BUN 28mg/dl, Creatinine 2.5 mg/dl. His urine shows the presence of rectangular, envelope-shaped crystals. His creatinine three months ago was 1.2 mg/dl. What is the most likely cause of this lab abnormality in this patient?
. Aspirin ingestion
. Ethylene glycol poisoning
Methyl alcohol poisoning
. Uremic acidosis
. Lactic acidosis
229) A 21-year-old female comes to the office for the evaluation of fatigue and weakness. She first noticed these symptoms nine months ago. She says, "I can't exercise a lot anymore because I get fatigued very easily, but after resting for a while, I feel better, and my fatigue disappears." She then describes a recent episode of weakness while swimming in a pool, where she experienced double vision (especially when she did not look straight ahead), difficulty raising her eyelids, and swallowing problems. What is the most likely diagnosis?
. Amyotrophic lateral sclerosis
Myasthenia gravis
. Brain tumor
. Multiple sclerosis
Duchenne muscular dystrophy
230) A 27-year-old woman presents to the ER with severe vomiting and abdominal pain that started several hours ago. She describes her emesis as "yellowish." She has a history of alcohol and cocaine use. Her temperature is 36.7°C (98°F), pulse is 98/min, respirations are 16/min, and blood pressure is 140/86 mmHg. Physical examination reveals dryness of the oral mucosa. Her abdomen is soft, non-distended, and without hepatosplenomegaly. Mild epigastric tenderness is present on deep palpation. Bowel sounds are increased. No rebound or rigidity is noted. She is treated with intravenous normal saline and metoclopramide. Several hours later she complains of neck pain and her neck muscles are noted to be stiff and tender. Which of the following best explains this patient's current complaints?
. Meningeal irritation
. Fat necrosis
Medication side effect
Eosinophilic myositis
. Nerve root compression
231) A 55-year-old Caucasian male comes to the office because of numerous falls for the past few weeks. Yesterday, he felt so dizzy that he fell on the ground and hurt his knees. He has also noticed dry mouth, dry skin, and erectile dysfunction over this period. His past medical history is significant for the recent onset of resting tremors. He was diagnosed with diabetes six months ago, which is controlled with diet. His blood pressure is 120/80 mmHg supine, and 90/60 mmHg standing. Physical examination reveals rigidity and bradykinesia. What is the most likely diagnosis of this patient?
. Idiopathic orthostatic hypotension
. Horner's syndrome
. Familial dysautonomia (Riley-Day syndrome)
. Diabetic neuropathy
. Shy-Dragger syndrome
232) 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?
. Parkinsonism
. Normal pressure hydrocephalus
. Multi-infarct dementia
. Pick's disease
. Alzheimer's disease
233) A 12-year-old boy is brought to the clinic for a routine health maintenance exam. He has no complaints, but mentions some spots on his back, which he noticed during his physical education class. He does not know how long they have been there. He denies any allergies. He remembers having a few seizures some years ago, which have not recurred since. He does not take any medication. The physical examination reveals several white spots and nodules measuring 2x3 cm on his back. There are freckles on his face and axilla. Closer examination reveals some nodules on his iris. What is the concerning complication that this boy is prone to?
. Hemoptysis
. Pancreatitis
Tumors
. GI bleed
. Early dementia
234) A 25-year-old woman comes to the office and complains of intermittent dizziness and an unsteady gait for the last few days. Her symptoms worsen with exercise. Her past medical history is significant for tingling and numbness of her right foot that lasted 3-4 days (1 year ago), and visual loss in her right eye which spontaneously resolved (3 years ago). She is currently nursing her 2-month-old baby. Her obstetrical history was uncomplicated. Her neurological examination shows right hyperactive deep tendon reflexes. On attempted left gaze, her left eye abducts and exhibits horizontal jerk nystagmus, but her right eye remains stationary. When she attempts to look to the right, her right eye abducts and exhibits horizontal jerk nystagmus, but her left eye remains stationary. The patient is able to converge both eyes together, without any associated nystagmus. The facial muscles show no signs of weakness. Where is the most likely site of this patient's lesion?
. Optic nerve
. Optic tract
. Optic chiasma
. Optic radiations
. Medial longitudinal fasciculus
235) A 60-year-old male complains of recent onset gait imbalance and visual illusion of to-and-fro environmental motion. The symptoms are constant. He has no associated nausea or vomiting. His past medical history includes diabetes, hypertension, and chronic renal failure, and recent enterococcal endocarditis for which he is taking ampicillin and gentamicin. On physical examination, his temperature is 36.7°C (98°F), blood pressure is 120/76 mm Hg, pulse is 80/min, and respirations are 16/min. Neurologic examination shows 5/5 power and 2+ reflexes in all four extremities. Cranial nerve examination is normal. There is no nystagmus. Which of the following is the most likely cause of his current condition?
. Drug toxicity
. Vertebrobasilar insufficiency
. Hypoglycemia
. Meniere's disease
. Cerebellar infarction
{"name":"Medpage675-713", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"133) A 56-year-old white male comes to the office for a health maintenance visit. He feels healthy, and is \"enjoying life as much as possible in a stressed environment.\" He smokes 2-3 packs of cigarettes daily and drinks socially. His temperature is 37°C (98.6°F), blood pressure is 160\/94 mm Hg, pulse is 78\/min, and respirations are 14\/min. Physical examination reveals plethora of the face and moderate splenomegaly. Blood tests show the following: WBC 15,600\/mm3, Hemoglobin 17 gm\/dl, Hematocrit 52%, Platelets 550,000mm3, RBC count 7.5 million, Sodium 141 mEq\/L, Potassium 3.6 mEq\/L, Bicarbonate 22 mEq\/L, Blood urea nitrogen 16 mg\/dl, Creatinine 0.6 mg\/dl, Glucose 95 mg\/dl. The erythrocyte indices are all within normal range. What is the most probable diagnosis?, 134) A 49-year-old woman comes to the office and complains of a \"strange, itchy rash\" on her left areola which has been present for the last month. She tried applying various lotions and creams, but the lesion did not resolve. She denies having other skin conditions, except for a poison ivy rash 2 months ago. She does not take any medications and feels \"goofy\" when she takes penicillin. Physical examination reveals an eczemoid lesion on the left nipple. No abnormality is visible on the mammogram. Biopsy demonstrates large cells surrounded by halo-like areas which invade the epidermis. What is the most likely diagnosis?, 135) A 41-year-old fire-fighter comes to your office and requests for prostate cancer screening. He is concerned because his elder brother was recently diagnosed with prostate cancer, and he read in the paper that \"cancers run in families.\" He requests to be screened urgently, as he \"cannot even think of life with such a deadly disease.\" He has no medical complaints. He has been your patient for the past 6 years, and has no other medical history. He is on a very balanced diet, and adds that he eats a lot of garlic \"so that cholesterol remains in check.\" He takes a low-dose aspirin daily. He does not smoke, and is only a social drinker. He admits using marijuana \"once in a while” What is the best next step to address this patient's concerns?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
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