3st Basic USMLE 100Q

A 52-year-old woman presents with hypertension, obesity, and new skin striae. You are concerned about possible Cushing syndrome. Which of the following is the most common cause of Cushing syndrome?

A 53-year-old Caucasian man comes to the emergency department at 2 am because of severe pain in his right great toe for the past 2 hours. He complains that the pain began suddenly as a dull, aching pain, and has worsened over time to a severe throbbing pain, not relieved by acetaminophen. His other medical problems include hypertension, diabetes mellitus-type 2, hypercholesterolemia, and peptic ulcer disease. He has smoked 2 packs of cigarettes daily for 30 years. He drinks 5-6 ounces of alcohol daily. He eats a lot of junk food and exercises infrequently. Both his father and mother have diabetes and hypertension. His older brother died of a myocardial infarction 2 years ago. His medications include glyburide, lisinopril, atenolol, simvastatin and famotidine. His temperature is 37.8°C (100°F), blood pressure is 160/90 mm Hg, pulse is 88/min and respirations are 16/min. On examination, the right great toe appears markedly swollen, red, and is warm to touch. Aspiration of the joint fluid reveals negatively birefringent needle shaped crystals. Apart from prescribing oral indomethacin, what other intervention would be most important to prevent the development of further attacks?

A 53-year-old female presents to the clinic with an erythematous lesion on the dorsum of her right hand. The lesion has been present for the past 7 months and has not responded to corticosteroid treatment. She is concerned because the lesion occasionally bleeds and has grown in size during the past few months. On physical examination you notice an 11-mm erythematous plaque with a small central ulceration. The skin is also indurated with mild crusting on the surface. Which of the following is true about this process?

A 53-year-old homosexual man comes to the ER with shortness of breath and dry cough over the past week. You note that he was hospitalized for Candida esophagitis one month ago, but left against medical advice. On physical examination, his blood pressure is 120/70 mmHg, heart rate is 120/min and regular, oxygen saturation is 89% on 2L/min of oxygen by nasal cannula, and temperature is 38.3°C (101°F). There are extensive white plaques over the oral mucosa and there is a soft 2/6 systolic murmur over the cardiac apex. Lung auscultation is remarkable for faint bilateral crackles. Which of the following is most likely responsible?

A 53-year-old male presents to your office with a two-day history of right calf pain and swelling. He describes the pain as constant and states that it is exacerbated by knee flexion. He has a history of past IV drug abuse, endocarditis, and stroke. He is currently wheelchair-bound secondary to stroke-related left-sided hemiparesis. On physical examination, his blood pressure is 140/90 mmHg and his heart rate is 100/min. There is no jugular venous distention or hepato-jugular reflux. His chest is clear to auscultation but his abdomen is enlarged with shifting dullness and a fluid wave, suggestive of ascites. His liver is palpable 3 cm below the right costal margin. His spleen is also palpable. On examination of his lower extremities, you note right-sided calf swelling and tenderness. Which of the following is the most likely cause of this patient's ascites?

A 53-year-old man comes to the office because of difficulty reading fine print over the last year. He now has to hold books, menus, and magazines at an arm’s length in order to read them. He has never had visual problems before. Which of the following is most likely abnormal in this patient?

A 53-year-old man presents to the emergency room with squeezing chest pain that started two hours ago. He also complains of shortness of breath that is worse when lying down. He has never had pain like this before. He has no significant past medical history and he takes no medications. A routine health maintenance visit two weeks ago was normal. On physical examination in the ER, his blood pressure is 140/90 mmHg and his heart rate is 100/min. Chest auscultation reveals a grade II/VI blowing systolic murmur at the cardiac apex and bibasilar crackles in the lungs. ECG shows ST segment elevations in leads I, aVL, and v1-v3. Which of the following is most likely increased in this patient?

A 53-year-old man presents to your office complaining of weakness and exertional dyspnea over the last week. He denies chest pain and palpitations. He has no other past medical history. His father died of a myocardial infarction at age 55. On exam, his heart rate is 100/min and blood pressure is 90/60 mmHg. Internal jugular venous pulsation is observed 7 cm above the sternal angle. Lungs are clear to auscultation. Heart sounds are muffled. Which of the following is the most likely cause of this patient's complaints?

A 53-year-old woman has been intubated for several days after sustaining a right pulmonary contusion after a motor vehicle collision as well as multiple rib fractures. Which of the following is a reasonable indication to attempt extubation?

A 53-year-old woman presents to your office with right-sided abdominal pain that started two days ago. She describes the pain as constant and burning in nature. There is no associated nausea, vomiting or diarrhea. The patient reports taking over-the-counter antacids and ibuprofen, which brought no relief. Her medical history is significant for breast cancer diagnosed one year ago, for which she underwent a modified radical mastectomy and is receiving chemotherapy, the last course of which was completed two months ago. On physical examination, her temperature is 36.7°C (98°F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 16/min. Her lung fields are clear to auscultation and her abdomen is soft and non-distended. The liver span is 10 cm and the spleen is not palpable. Lightly touching the skin to the right of the umbilicus elicits intense pain. In one week the patient is most likely to develop:

A 54 year-old male comes to the physician because of abdominal distention. He thinks his big belly is making it hard for him to breathe. He received radiation therapy for Hodgkin lymphoma several years ago and was told that he is cured. He drinks alcohol on a regular basis. His temperature is 36.7°C (98°F), blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 20/min. Examination shows a jugular venous pressure 7 cm above the sternal angle. Dullness to percussion and decreased breath sounds are noted in the right lung base. The abdomen is quite distended with an obvious fluid wave. Mild hepatomegaly is present. Extremities have 2+ lower extremity edema. Initial laboratory studies are shown below: Serum creatinine 0.8 mg/dL, Alburnin 4.0 mg/dL, Total bihrubin 1.0 mg/dl, Prothrombin time 11 sec. Urinalysis is within normal limits. Which of the following is the most likely cause of his condition?

A 54-year-old female complains of muscle weakness. She describes difficulty getting up from a chair and combing her hair. She does not use tobacco, alcohol or drugs. She takes no medication. Her vital signs are within normal limits. Physical examination reveals bilateral ptosis. Which of the following is the most likely cause of this patient's complaints?

A 54-year-old male with a history of chronic alcoholism is admitted to the hospital with hematemesis and abdominal distension. Upper gastrointestinal endoscopy reveals the presence of esophageal varices. Continued workup of his condition results in a diagnosis of cirrhosis of the liver. He is treated appropriately and strongly counseled about the need to abstain from alcohol. He is then discharged home. After discharge, he begins to work as a full-time volunteer for a non-profit organization that assists patients with alcoholic cirrhosis. Which of the following defense mechanisms is this man using?

A 54-year-old man complains of burning epigastric pain that usually improves after a meal, and is occasionally relieved with antacids. On examination, he appears well and besides some epigastric tenderness on palpation, the rest of the examination is normal. Upper endoscopy confirms a duodenal ulcer. Which of the following statements concerning PUD is most likely correct?

A 54-year-old man with a 20-year history of chronic obstructive lung disease has a heave that is palpable at the lower left sternal border at the third, fourth, and fifth intercostal spaces. Which of the following best explains the etiology of the heave?

A 54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the correct stage of this patient’s colon cancer?

A 54-year-old woman presents to your office complaining of difficulty walking. She describes severe weakness and occasional pain in her thigh muscles. She has stumbled and fallen several times over the last week. Her past medical history is significant for hypertension treated with hydrochlorothiazide and metoprolol. She consumes two to three cans of beer on weekends. Her younger brother died of a neurological disease when he was 20 years old. Her mother suffers from hypertension and diabetes mellitus. Her heart rate is 90/min and blood pressure is 170/100 mmHg. Chest examination is within normal limits. A bruit is heard over the left carotid artery. Neurologic examination reveals hyporeflexia and decreased strength in all muscle groups. Her ESR is 12 mm/hr. ECG shows flat and broad T waves with occasional premature ventricular contractions. Which of the following is the most likely cause of this patient's current complaints?

A 55-year-old Asian man with mitral stenosis secondary to rheumatic heart disease undergoes dental surgery for caries. Postoperatively, he does well and is discharged home. Two weeks later, he presents with fever, chills, fatigue, and feels "sick." Four out of four blood culture bottles are positive for gram-positive cocci. An echocardiogram is performed and shows mitral valve vegetations. Which of the following is the most likely causative organism of this patient's condition?

A 55-year-old Caucasian male presents to the office for a routine check-up. He has no present complaints. His past medical history is significant for a long history of hypertension. He does not smoke or consume alcohol. His current medications are enalapril and hydrochlorothiazide. His blood pressure is 140/90 mmHg and heart rate is 80/min. Physical examination reveals a moderately overweight man (BMI = 27 kg/m2) with a waist circumference of 41 inches. The laboratory studies show: Fasting blood glucose 112 mg/dl, Total cholesterol 220 mg/dl, LDL cholesterol 140 mg/dl, Triglycerides 240 mg/dl. Which of the following is the most important pathogenic factor for this patient's condition?

A 55-year-old Caucasian male presents to your office with muscle pain of recent onset. His past medical history is significant for hypertension and an acute myocardial infarction experienced 2 months ago. His current medications include metoprolol captopril, aspirin and simvastatin. His blood pressure is 130/80 mmHg and heat rate is 60/min. Liver function tests are slightly abnormal. Serum creatine kinase level is elevated. You suspect a drug-induced reaction. Which of the following is the most possible mechanism of drug-induced reaction in this patient?

A 55-year-old homeless man presents to the emergency room complaining of muscle cramps and perioral numbing. The patient looks malnourished. He says that he consumed a lot of alcohol recently. His past medical history is significant for chronic and recurrent abdominal pain for which he was advised to quit drinking alcohol. His temperature is 36.7°C (98°F), blood pressure is 110/65 mmHg, pulse is 80/min, and respirations are 18/min. The laboratory values are: Hemoglobin 7.2 g/dl, MCV 105 fl, Leukocyte count 9,000/cmm, Platelets 200,000/cmm, ESR 20 mm/hr, Serum sodium 145 mEq/L, Serum potassium 4.0 mEq/L, Serum calcium 6.8 mg/dl, Serum phosphorus 2.5 mg/dl. What is the most probable cause of hypocalcemia observed in this patient?

A 55-year-old man presents to the ED with chest pain and shortness of breath. His BP is 170/80 mmHg, HR is 89 beats per minute, and oxygen saturation is 90% on room air. Physical examination reveals crackles midway up both lung fields and a new holosystolic murmur that is loudest at the apex and radiates to the left axilla. ECG reveals ST elevations in the inferior leads. Chest radiograph shows pulmonary edema with a normal sized cardiac silhouette. Which of the following is the most likely cause of the cardiac murmur?

A 55-year-old man presents with worsening cirrhosis. After evaluation by a hepatologist, he presents for evaluation for hepatic transplantation. He is informed that prioritization for transplantation is based on the Model of End-stage Liver Disease (MELD) score, and that patients with higher MELD scores have a greater benefit from transplantation. Which of the following contributes to the MELD score?

A 55-year-old woman has been hospitalized because of recurrent pancreatitis, ARDS, prolonged ileus, and need for parenteral nutrition. She demonstrates weakness, lassitude, orthostatic hypotension, nausea, and fever. Which of the following abnormalities is most likely to explain these symptoms?

A 55-year-old woman is in the intensive care unit on a ventilator for hypoxemia following “flash” pulmonary edema. Her PO2 on the blood gas prior to intubation was 44 mm Hg, and now while breathing 100% oxygen on the ventilator her repeat blood gas reveals a PO2 of 80 mm Hg. Hypoxemia while receiving 100% oxygen indicates which of the following problems?

A 55-year-old woman presents with a three-week history of low-grade fever, weight loss of 4.5kg (10 lb), and malaise. She is known to have mitral valve prolapse, but is otherwise healthy. She underwent a tooth extraction one month ago. She denies alcohol, tobacco, and illicit drug use. Her temperature is 38.5°C (101.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 145/76 mm Hg. Her chest is clear to auscultation and percussion. Cardiac examination reveals a III/IV holosystolic murmur at the apex that radiates to the axilla. Chest x-ray is normal. Urinalysis is unremarkable. Blood cultures are drawn and empiric antibiotics are started. Echocardiogram shows mitral regurgitation with vegetation on the mitral valve. Which of the following organisms is the most likely cause of this patient's condition?

A 55-year-old woman who has end-stage liver disease is referred to a hepatologist for evaluation. Which of the following would prevent her from being a transplantation candidate?

A 55-year-old-woman of Asian descent goes to the emergency department because of vomiting and severe abdominal cramping of 3 days' duration. Her pain is centered on the umbilicus. She denies being exposed to a viral or bacterial illness. Her medical history includes a previous cholecystectomy and an appendectomy after which she developed an infection. Her abdomen is not tender, but hyperactive, high-pitched peristalsis with rushes coincides with palpable bowel cramping. Abdominal x-ray films taken in the supine and upright positions demonstrate a ladder-like series of distended small bowel loops. Which of the following is the most likely explanation for these findings?

A 56-year-old male complains of occasional dizziness. He gets a brief spinning sensation while getting out of bed. He sometimes feels dizzy while turning in bed or looking up. He denies any nausea, diaphoresis, chest pain or tinnitus. His past medical history is significant for long-standing hypertension, which is being treated with hydrochlorothiazide, and hyperlipidemia, which is being treated with simvastatin. His father died of a stroke at the age of 62 years. His blood pressure is 130/80 mmHg while supine, and 135/85 mmHg while standing. His heart rate is 77/min. A grade II/VI ejection murmur is heard over the aortic area. ECG reveals left ventricular hypertrophy and premature ventricular contractions. Which of the following is the most likely cause of this patient's complaints?

A 56-year-old male presents with progressively worsening dyspnea over a 4 month period. He denies fever, chest pain, cough or ankle swelling and does not use tobacco, alcohol or drugs. He works for a home insulation and plumbing company. He has never been abroad and does not own any pets. His only medications are hydrochlorothiazide and metoprolol for blood pressure control. On physical examination, his temperature is 36.8°C (98.2°F), pulse is 76/min, blood pressure is 130/78 mmHg, and respirations are 15/min. Examination shows digital clubbing and fine bibasilar end-inspiratory crackles. Jugular venous pressure is 7 cm and there is no peripheral edema. Which of the following additional findings is most likely in this patient?

A 56-year-old male with a long history of diabetes mellitus complains of nocturnal urinary frequency, occasional dribbling and difficulty completing his stream. His past medical history is significant for a myocardial infarction two years ago and moderately decreased visual acuity. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 70/min. There is a carotid bruit auscultated on the left side as well as trace ankle edema. Post-void bladder catheterization yields 60 ml of urine. Dipstick urinalysis reveals 2+ protein and 3-4 WBC/hpf. The patient's serum creatinine level is 2.4 mg/dl. Which of the following is the most likely cause of his renal dysfunction?

A 56-year-old man is having intermittent fevers and malaise for the past 2 weeks. He has no other localizing symptoms. Two months ago, he had valve replacement surgery for a bicuspid aortic valve. A mechanical valve was inserted and his postoperative course was uncomplicated. On examination, his temperature is 38°C, blood pressure 124/80 mm Hg, pulse 72/min, and head and neck are normal. There is a 3/6 systolic ejection murmur, the second heart sound is mechanical, and a 2/6 early diastolic murmur is heard. The lungs are clear and the skin examination is normal. Three sets of blood cultures are drawn and an urgent echocardiogram is ordered. Which of the following is the most likely causative organism?

A 56-year-old woman becomes the chief financial officer of a large company and, several months thereafter, develops upper abdominal pain that she ascribes to stress. She takes an over-the-counter antacid with temporary benefit. She uses no other medications. One night she awakens with nausea and vomits a large volume of coffee grounds-like material; she becomes weak and diaphoretic. Upon hospitalization, she is found to have an actively bleeding duodenal ulcer. Which of the following statements is true?

A 56-year-old woman is undergoing chemotherapy. She presents today with complaints of burning on urination and bloody urine. Which of the following agents causes hemorrhagic cystitis?

A 56-year-old woman presents to the clinic for routine health screening. Her concern is the development of breast cancer. She has no current breast-related complaints. Past history is pertinent for fibrocystic changes with atypical ductal hyperplasia and a single fibroadenoma, both diagnosed by open biopsy 5 years ago. She smokes one pack per day and drinks one can of beer daily. Family history is positive for breast cancer in her mother, diagnosed at the age of 85. Current medications include a cholesterol-lowering agent, an antihypertensive, and HRT, which she has taken for 5 years. Physical examination is unremarkable. Mammograms show dense breasts, decreasing the accuracy of the study, but no suspicious findings were noted. Which of the following is the most common risk factor in evaluating women for breast cancer?

A 56-year-old woman presents to your office for her routine wellwoman examination. She had a hysterectomy at age 44 for symptomatic uterine fibroids. She entered menopause at age 54 based on menopausal symptoms and an elevated FSH level. She started taking estrogen replacement therapy at that time for relief of her symptoms. She is fasting and would like to have her lipid panel checked while she is in the office today. You counsel the patient on the effects of estrogen therapy on her lipid panel. She should expect which of the following?

A 57-year-old Caucasian female is diagnosed with deep venous thrombosis of the right leg that was confirmed with Doppler ultrasonography. She was diagnosed with pneumonia and empyema one week earlier, and treated with chest tube, antibiotics and bed rest. On her 6th day of anticoagulation therapy, she develops right hemiparesis and slight motor aphasia. The laboratory findings are: Red blood cells 4.3 million/mm3, Hemoglobin 14.00 g/dL, White blood cells 7,000/cmm, Platelets 50,000/cmm, APTT 60 sec (N < 25-40 sec), Fibrin degradation products negative. The emergency head CT scan does not reveal blood in the subarachnoid space or brain parenchyma. Which of the following is the most probable cause of this patient's condition?

A 57-year-old Caucasian woman presents for a follow-up visit regarding her lower back pain. She originally presented with this complaint last month and was advised to limit activity and use ibuprofen as needed. When her pain persisted, she was scheduled for an MRI of her back. The MRI report returned today and describes the presence of metastatic deposits in her spine. The source of the primary neoplasm remains undetermined. The patient has not yet been told about the findings and will need to be informed today. Which of the following is the best means of initiating a conversation about her condition?

A 57-year-old female with a history of type 2 diabetes mellitus complains of fatigue, urinary frequency, increasingly blurred vision and worsening leg cramps over the past week. She reports that the symptoms all began following an upper respiratory infection 7 or 8 days ago. She does not take any medications, but adheres to a diet low in saturated fat and simple carbohydrates to manage her diabetes. On physical examination, her blood pressure is 160/90 mmHg and her heart rate is 90/min. Her mucous membranes are dry. Her urine is positive for glucose but negative for ketones. Which of the following is the most likely cause of this patient's vision impairment?

A 57-year-old male is hospitalized for hyponatremia. Physical examination reveals no signs of fluid overload. Serum analysis reveals a sodium concentration of 125mEq/l, glucose level of 12mg/dl, BUN of 8mg/dl, and creatinine of 0.7mg/dl. The urine osmolarity is 330mOsm/l and urine sodium concentration is 45mEq/l. After a 2L normal saline infusion, the serum sodium is 126mEq/l and the urine sodium excretion is increased to 90 mEq/l. Which of the following is the most likely cause of this patient's hyponatremia?

A 57-year-old male presents to your office with a two week history of fever, chills, and generalized weakness. His medical history is significant for a hospitalization for pyelonephritis requiring IV antibiotics six months ago. He also recently underwent cystoscopy for evaluation of persistent dysuria. His past medical history is also significant for an episode of rheumatic fever as a child and Hodgkin's lymphoma treated with chemotherapy 10 years ago. On examination, his temperature is 37.8°C (100°F), blood pressure is 150/86 mmHg, pulse is 98/min and regular, and respirations are 16/min. The patient appears slightly diaphoretic. You note a new II/VI systolic murmur and tender erythematous lesions affecting several fingertips. The remainder of the physical examination is unremarkable. Which of the following bacteria is most likely responsible for his present illness?

A 57-year-old man has end-stage heart failure due to atherosclerosis. His cardiologist refers him for evaluation for heart transplantation. Which of the following is an absolute contraindication for heart transplantation?

A 57-year-old man with a 40-pack-per-year history of smoking experiences symptoms of shortness of breath on exertion. He has bilateral wheezes on expiration and increased resonance to percussion of the chest. Pulmonary function tests confirm the diagnosis of chronic obstructive lung disease (COPD). Which of the following is the best definition of this condition?

A 58-year-old Caucasian woman comes in to your office for advice regarding her risk factors for developing osteoporosis. She is 5ft 1 in tall and weighs 195 lb. She stopped having periods at age 49. She is healthy but smokes one pack of cigarettes per day. She does not take any medications. She has never taken hormone replacement for menopause. Her mother died at age 71 after she suffered a spontaneous hip fracture. Which of the following will have the least effect on this patient’s risk for developing osteoporosis?

A 58-year-old man presents with a one-year history of diarrhea. The stools are watery and accompanied by abdominal cramps. He denies any fever, blood per rectum, or foul-smelling stools. He has also experienced frequent episodes of dizziness, flushing, wheezing, and a feeling of warmth. He has taken herbal medicines, which failed to relieve his symptoms. He is depressed about his illness, and feels hopeless about diagnosis and treatment. He appears ill. Auscultation of the chest shows a 2/6 systolic murmur over the left lower sternal border. Abdominal examination shows hepatomegaly 3cm below the right costal margin, mild shifting dullness, and no abdominal tenderness. Laboratory studies show: Hb 13.0gm/dl, MCV 90fl, WBC 6,100/cmm, Platelets 210,000/cmm, AST101 U/L, ALT 99 U/L, Alkaline phosphatase 400 mg/dl. This patient is at risk of developing a deficiency of which vitamin or mineral?

A 59-year-old female is hospitalized due to lower gastrointestinal bleeding. Her past medical history includes diabetes mellitus, hypertension, chronic obstructive pulmonary disease, cor pulmonale and recurrent urinary tract infections. Her condition initially stabilized with fluid resuscitation and blood transfusions, but she subsequently developed an acute renal failure. Her urine output has been between 300 and 400 ml per day for the last couple of days. On the 10th day of her hospitalization she is lethargic. Serum analysis reveals: Hemoglobin 10.2 g/dl, Hematocrit 30%, WBC 14,300/mm3, Blood glucose 93 mg/dl, BUN 141 mg/dl, Creatinine 4.1 mg/dl, Sodium 133 mEq/L, Potassium 5.0 mEq/L, pH 7.15, pO2 90 mmHg, pCO2 60 mmHg, HCO3 18 mEq/L. Which of the following is the most likely cause of her lethargy?

A 59-year-old male presents to the ER with diplopia that started several hours ago. He has no other complaints. His past medical history is significant for long-standing diabetes with poor glycemic control, right knee osteoarthritis, and peptic ulcer disease. Physical examination reveals right-sided ptosis with the right eye looking down and out. Pupils are equal and reactive to light. This patient's condition is most likely due to which of the following?

A 59-year-old man comes to the physician because of dysuria, urinary urgency, and frequency. He also complains of hematuria, nocturia, decreased force of stream, and a feeling of incomplete voiding. These symptoms have been present for more than a month. For the past few days he has been experiencing dull, non-radiating suprapubic pain. He has also been having low-grade fever and malaise for the past couple of days. He has been taking analgesics for osteoarthritis of his right knee for more than 10 years. He has a 40-pack-years history of cigarette smoking and does not use alcohol or drugs. Rectal examination shows a smooth, firm enlargement of the prostate without induration or asymmetry. Neurological examination shows no abnormalities. Urinalysis shows hematuria with isomorphic red blood cells. Laboratory studies show a serum creatinine of 1.5 mg/dl, and a PSA of 2 ng/ml. Which of the following is the most likely explanation for this patient's symptoms?

A 6-day-old female neonate is admitted to the hospital for the evaluation of jaundice. She was born to a 17-year-old German mother at 39 weeks gestation. Her mother's blood type is B+, and was treated for newborn jaundice due to presumed ABO incompatibility. Her other family members also had neonatal jaundice. The infant's vital signs are normal. On examination, she is visibly jaundiced, and her spleen tip is palpable. Her total bilirubin level is 25mg/dl and direct bilirubin level is 0.4mg/dl. Her hemoglobin was initially 15.7g/dl, but is now 10.7g/dl. Her reticulocyte count is 4% and platelet count is 230,000/mm3. The peripheral smear shows moderate schistocytes with burr cells and moderate spherocytes. Her blood type is B+ and Coombs' test is negative. Her stools are negative for occult blood. Her mother's incubated red cell osmotic fragility study is abnormal. What is the most likely cause of this neonate's symptoms?

A 6-month-old male is brought to the office due to fussiness and tugging at his right ear for the past 2 days. He has had a fever of 39.4 C (103 F) for the past 2 days. His past medical history is significant for recurrent ear and lung infections, oral candidiasis, and persistent diarrhea by rotavirus. His temperature is 39.4 C (103F), pulse rate is 150/min, respirations are 28/min, and blood pressure is 80/60mm Hg. Physical examination reveals an erythematous, bulging right tympanic membrane with poor mobility on pneumatic otoscopy. His lymph nodes are not palpable, and his tonsils are not visualized. His B and T lymphocyte levels are markedly reduced. The chest x-ray reveals an absent thymic shadow. What is the most likely etiology of this patient's condition?

A 6-week-old male infant, who was born at 32 weeks' gestation with a birth weight of 1500 g, has had an average weight gain of 8 g/day since birth. He takes an iron-fortified formula that is 24kcal/oz. His calorie intake is about 125kcal/day. It is noted that his stool is poorly formed and bulky. Which of the following dietary modifications will most likely result in decreased steatorrhea and improved weight gain?

A 6-year-old African-American child is brought in by his father for complaints of easy fatigability and pallor. These symptoms occurred after the son was treated with "some medication" for a recent diarrhea. Physical examination is normal except for pallor and multiple petechiae. Laboratory values are as follows: Hb 8.0 g/dL, WBC 12,000/cmm, Platelets 50,000/cmm, Blood glucose 118 mg/dL, Serum Na 135 mEq/L, Serum K 5.3 mEq/L, Chloride 110 mEq/L, Bicarbonate 18 mEq/L, BUN 38 mg/dL, Serum creatinine 2.5 mg/dL, Total bilirubin 3 mg/dL, Direct bilirubin 0.5 mg/dL, PT 12 seconds, APTT 30 seconds, LDH 900 IU/L, Reticulocyte count 6%. A peripheral blood smear reveals giant platelets and multiple schistocytes. What is the most likely underlying pathophysiology for this boy's pallor?

A 6-year-old Asian boy is brought by his parents to the office due to high-grade fever and rash for the last 9 days. A brick-red, maculopapular rash first appeared on his face and subsequently spread to his trunk and extremities. Prior to the outbreak of the rash, he had a non-productive cough, tearing of eyes, runny nose, sneezing, and intermittent nasal obstruction. Laboratory findings are as follows: Hct 46%, WBC 2,000/mm3, Platelets 160,000/mm3. Which of the following has been shown to reduce the morbidity and mortality rates of patients with this kind of infection?

A 6-year-old boy had been in his normal state of good health until a few hours prior to presentation to the ER room. His mother reports that he began to have difficulty walking, and she noticed that he was falling and unable to maintain his balance. Which of the following is the most likely cause for his condition?

A 6-year-old boy is brought to the clinic for the evaluation of a large, red, circular rash on his left thigh which has been present since two weeks and has been enlarging. He has a mild headache and myalgia, but is afebrile. Three weeks ago, he and his family visited relatives at a rural farm in Connecticut and went hiking in the woods. His temperature is 37.2 C (99 F) and pulse is 90/min. He is alert, active, appears non-toxic, and not in distress. On the anterior surface of his left thigh, there is a red ring that is 7 cm in diameter with central clearing, and a central brownish-red macule that is 3 mm in diameter. Which of the following measures would have prevented this condition?

A 6-year-old boy is seen in the office for evaluation of polyuria. Further questioning reveals several months of headache with occasional emesis. Your physical examination reveals a child who is less than 5% for weight. He has mild papilledema. His glucose is normal, and his first urine void specific gravity after a night without liquids is 1.005 g/mL. Which of the following might also be expected to be seen in this patient?

A 6-year-old Caucasian boy is hospitalized for acute sinusitis that was accompanied with intensive nasal bleeding. Past medical history is significant for recurrent pulmonary infections and several hospitalizations for parenteral antibiotic therapy. The sweat chloride test is positive. The blood tests reveal a prothrombin time (PT) of 20 seconds. Which of the following coagulation factors is most likely to be deficient in this patient?

A 6-year-old child has had repeated episodes of otitis media. She undergoes an uneventful surgical placement of pressure-equalization (PE) tubes. In the recovery room she develops a fever of 40C (104F), rigidity of her muscles, and metabolic and respiratory acidosis. Which of the following is the most likely explanation for her condition?

A 60-year-old Caucasian male is brought to the emergency department by his daughter due to a 2-day history of confusion and lethargy. According to his daughter, he had been complaining of fatigue, anorexia, polyuria and constipation for the last several weeks. He smokes two packs of cigarettes daily, and consumes alcohol occasionally. His blood pressure is 130/90 mmHg and heart rate is 90/min. Physical examination reveals a somnolent patient who is not oriented in time. His lab values are: Serum Na 140 mEq/L, Serum K 4.0 mEq/L, Serum chloride 100 mEq/L, Serum bicarbonate 22 mEq/L, Serum creatinine 1.6 mg/dl, Serum calcium 13.4 mg/dL, Serum phosphorus 2.2 mg/dL, Blood glucose 100 mg/dL, Alkaline phosphatase 80 U/L. Chest x-ray demonstrates a right middle lobe mass and perihilar adenopathy. What is the most probable cause of this patient's symptoms?

A 60-year-old Caucasian male presents to your office complaining of decreased hearing on the right side. He also feels that something is wrong with his head because his hat size had increased over the last two years. His past medical history is significant for hypertension and peptic ulcer disease. His current medications are hydrochlorothiazide and enalapril. He also takes ibuprofen for occasional headaches, and ranitidine for infrequent episodes of heartburn. Lab tests showed increased alkaline phosphatase levels. Which of the following is the most likely mechanism underlying this patient's condition?

A 60-year-old diabetic man undergoes incision and drainage of an infected boil on his back. The wound is left open and packed daily. Week by week, the wound grows smaller and eventually heals. Which of the following terms describes the method of wound closure by the patient?

A 60-year-old male is brought to ER by his son because he had an episode of syncope. He was watching TV in an arm-chair when suddenly lost his consciousness without any warning sign. He had several clonic jerks while unconscious. He never had such an episode before. His past medical history is significant for acute myocardial infarction six months ago and well-controlled hypertension. His current medications include captopril metoprolol hydrochlorothiazide, clopidogrel and aspirin. His blood pressure is 130/85 mmHg and heat rate is 80/min with frequent ectopic beat. Physical examination revealed mild holosystolic apical murmur radiating to the axilla. Which of the following is the most probable pathophysiologic mechanism for his syncopal episode?

A 60-year-old male presents to the emergency room with the chief complaint of progressive exertional dyspnea and fatigue. He denies any chest pain, syncope, cough, or edema. He suffered an acute anterior wall myocardial infarction one month ago. Chest auscultation reveals bilateral crackles in his lower chest. Cardiac auscultation reveals a pansystolic murmur at the apex with radiation to the axilla. ECG shows previously present unchanged Q waves and a persistent ST segment elevation in the anterior leads. Based on these findings, what is the most likely underlying cause of his symptoms?

A 60-year-old man comes to the physician because of worsening fatigue and nausea. He had a carotid angiogram for the evaluation of symptomatic carotid artery stenosis 15 days ago, and was discharged home three days after the procedure. His medical problems are hypercholesterolemia, coronary artery disease, intermittent claudication, hypertension for 18 years, and diabetes mellitus for 15 years. Physical examination shows painless, reddish-blue mottling of the skin of the extremities. Laboratory studies show: Hb 10.5 g/dl, WBC 10,000/cmm with 12% eosinophils, BUN 46 mg/dl, Serum creatinine 3.0 mg/dl, Serum C3 level Decreased. Urinalysis:pH Normal,Esterase Negative, Nitrite Negative, Protein 1+, WBC Many eosinophils, RBC 1-2/HPF. Which of the following is the most likely cause of this patient's findings?

A 60-year-old man is brought to the ER by his wife because he lost consciousness in the bathroom at night. He says that he woke up, went to the bathroom to urinate, and fainted there. He rapidly recovered his consciousness without any indication of disorientation. He has never had such an episode before. He admits' problems with urination,' including difficulty with initiating urination and frequent awakening to void at night. He does not take any medication. His past medical history is insignificant. He smokes 2 packs of cigarettes per day and does not consume alcohol. His blood pressure is 130/80 mmHg while supine, and 132/80 mmHg while standing. His heart rate is 70/min. His physical examination is within normal limits. The ECG is normal. What is the most probable cause of the syncopal episode in this patient?

A 60-year-old man presents to his primary care physician for routine medical care. He has no complaints, takes no medications, and has a family history of DM. Examination is unremarkable. A screening laboratory test reveals a fasting blood glucose level of 152 mg/dL. One week later the test is repeated and a value of 144 mg/dL is obtained. Which of the following is the most likely cause of these findings?

A 60-year-old man presents with a 6-mm basal cell carcinoma on the tip of his nose. He is scheduled to undergo excision of the tumor in the operating room with repair of the defect using skin and subcutaneous tissue from his earlobe. Which of the following terms most appropriately describes this form of reconstructive surgery?

A 60-year-old man with no past medical history undergoes upper endoscopy and biopsy for an upset stomach that is worsened by eating. He is found to have inflammation predominantly in the antrum of the stomach. Which of the following is the most likely etiology of this condition?

A 60-year-old physician is admitted to the hospital for jaundice and weight loss. He denies other symptoms, including abdominal pain and alterations in bowel movements. His past medical history is noncontributory. He denies any history of significant alcohol intake but admits to a 30-pack-year smoking history. A detailed work-up eventually reveals the diagnosis of pancreatic carcinoma. Shortly after his discharge, he spends several hours per day on his laptop computer so that he can obtain the latest information on his illness. Which of the following psychological defense mechanisms is this physician most likely employing?

A 60-year-old postmenopausal woman presents with the new onset of uterine bleeding. An endometrial biopsy is diagnosed as atypical hyperplasia. Which of the following histologic changes is most characteristic of this abnormality?

A 60-year-old white male presents to the Emergency Room with sudden onset of dyspnea. He is a truck driver and just returned from a long trip. His past medical history is insignificant. He is not taking any medications. His blood pressure is 110/70 mmHg and heart rate is 110/min. Physical examination reveals a moderately overweight man with tachypnea. Lungs are clear on auscultation. ECG shows right axis deviation. You order ventilation/perfusion scanning. Which of the following findings will help you the most to confirm the diagnosis?

A 60-year-old white man comes into the Emergency Room with intensive retrosternal pain that began ten minutes ago. He has never had such pain before. His past medical history is significant for diabetes mellitus, type 2, controlled with diet. His blood pressure is 150/95 mmHg and HR is 80/min. You give him one chewable tablet of aspirin and two sublingual tablets of nitroglycerin with a 5-minute interval. After the second tablet of nitroglycerin, the pain is greatly relieved. What is the most important mechanism responsible for pain relief in this patient?

A 60-year-old woman comes to the physician because of a 3-month history of worsening fatigue and back pain. She has had diabetes mellitus for the past three years, and hypertension for the past ten years. Laboratory studies show: Hb 9.0 mg/dL, Serum calcium 11.2 mg/dL, Serum phosphorus 3.5 mg/dL, BUN 38 mg/dL, Serum creatinine 2.0 mg/dL. Which of the following is the most likely cause of this patient's renal failure?

A 60-year-old woman recently diagnosed with type 2 DM complains of daily headaches and double vision that have gradually worsened over the previous month. An MRI shows a large pituitary adenoma. Which of the following is most likely being secreted by this tumor?

A 60-year-old woman with heart failure and normal renal function is started on furosemide (Lasix) 80 mg/day. She notices a good diuretic response every time she takes the medication. A few weeks later, she is feeling unwell because of fatigue and muscle weakness, but her heart failure symptoms are better. Which of the following is the most likely explanation for her muscle weakness?

A 62-year-old male comes to your office for a routine follow-up appointment. He has smoked one pack of cigarettes per day for the past 30 years and adamantly refuses to quit. He also drinks six to ten beers each weekend. His past medical history is significant for type 2 diabetes mellitus and hypertension. His last hemoglobinA1c was 8.3%. He is overweight with a current BMI of 27.5 kg/m2. While examining him, you notice a whitish patch over the anterior floor of his mouth. The lesion appears to have a granular texture and is not removed by scraping with a tongue depressor. Which of the following is most likely cause of his oral lesion?

A 62-year-old man has progressive symptoms of dyspnea, and more recently noticed difficulty lying supine. Examination shows an elevated JVP at 8 cm, with a third heart sound, pedal edema, and bibasilar crackles on auscultation. Which one of the following may be implicated in fluid retention for this condition?

A 62-year-old man with a prosthetic aortic valve develops fevers and malaise. His valve was replaced 5 years ago because of aortic stenosis from a bicuspid valve. He has a systolic ejection murmur but no other abnormalities on examination. Blood cultures are most likely to grow which of the following?

A 62-year-old postmenopausal woman was found to have right adnexal enlargement on pelvic examination 2 weeks ago. Transabdominal and transvaginal ultrasounds revealed a 5-cm, unilocular, right ovarian mass with regular borders. There is no ascites. The patient went through menopause at age 52. She has had no postmenopausal spotting. There is no family history of ovarian or breast cancer. Her latest mammogram 2 months ago showed no abnormalities. Which of the following is the most appropriate course of action?

A 62-year-old woman presents complaining of recurrent cough productive of yellow sputum. She was seen several weeks ago for similar complaints and was effectively treated with a course of azithromycin. Today she expresses frustration that she seems to keep getting sick with the same infection. On review of systems, the patient also reports recent-onset back pain for which she has been taking acetaminophen. Her past medical history is otherwise insignificant. She has never smoked cigarettes, and drinks alcohol only on rare social occasions. Physical examination reveals conjunctival pallor, a few scattered rales in the lungs bilaterally, and tenderness over the lumbar vertebrae. Laboratory analyses reveal: Hemoglobin 8.4 g/dL, Leukocyte count 5,500/mm3, Blood urea nitrogen 34 mg/dL, Creatinine 2.0 mg/dL, Calcium 10.9 mg/dL, Albumin 3.8 g/dL, Total protein 9.5 g/dL. This patient is at increased risk for recurrent infections because of which of the following abnormalities?

A 62-year-old woman presents to your office complaining of urinary frequency and burning during urination. She denies fever, chills, nausea, back pain or abdominal pain. Her past medical history is significant for a long history of diabetes mellitus and hypertension. She does not use tobacco or consume alcohol. Her blood pressure is 160/100 mmHg and her heart rate is 70/min. Her hematocrit is 43% and her WBC count is 8,500/mm3 Urinalysis reveals the following: Glucose negative, Ketones negative, Nitrates positive, Protein 2+, WBC 20-25/hpf, RBC 3-5/hpf. She is given a three-day course of levofloxacin. Urinalysis two weeks later reveals 2+ protein but no nitrates, WBCs, or RBCs. Which of the following is most likely responsible for her persistent urinalysis abnormality?

A 62-year-old woman presents with invasive ductal carcinoma of the right breast. Which of the following findings would still allow her to receive breast conservation surgery (partial mastectomy)?

A 63-year-old man presents to the ER with substernal chest pain and diaphoresis. The pain stated one hour ago and did not remit with antacids. He has a past medical history of asthma for which he uses inhaled fluticasone and peptic ulcer disease for which he takes omeprazole. His family history is significant for prostate cancer in his father and breast cancer in his mother. Physical examination reveals a blood pressure of 160/100 mmHg and a heat rate of 90/min. A bruit is heard over the right carotid artery and a mild systolic murmur is present at the cardiac apex. Sublingual nitroglycerin and aspirin are administered in the. Within minutes, the patient reports decreased pain. Which of the following most likely accounts for this improvement in his symptoms?

A 63-year-old man with a 40-pack per year smoking history undergoes a low anterior resection for rectal cancer and on postoperative day 5 develops a fever, new infiltrate on chest x-ray, and leukocytosis. He is transferred to the ICU for treatment of his pneumonia because of clinical deterioration. Which of the following is a sign of early sepsis?

A 63-year-old woman with a long history of hypertension faints after experiencing the sudden onset of severe chest pain that radiates to her back. She is rushed to the emergency room. Upon arrival she is agitated and demands quick pain relief. Her heart rate is 110/min and blood pressure is 90/50 mmHg. Jugular veins are distended. An intra-arterial catheter shows significant variation of systolic blood pressure related to the respiratory cycle. Chest x-ray reveals widening of the mediastinum. Which of the following is the most likely cause of this patient's syncope?

A 64-year-old man complains of palpitations and progressive shortness of breath over the past several hours. He says that he also develops a choking sensation every time he tries to lie down. His medical history is significant for hypertension for the past 20 years and medication non-compliance. He also has a 35-year smoking history. He reports that his father died of a heart attack at age 70 and his mother suffered from asthma. On physical examination, his blood pressure is 170/100 mmHg and his heat rate is 130/min and irregularly irregular. Lung exam reveals bibasilar crackles. There is 2+ pitting edema of the lower extremities. Bedside echocardiography shows a left ventricular ejection fraction of 55%. Which of the following is most likely responsible for his symptoms?

A 64-year-old man presents to the emergency department with progressive exertional dyspnea that worsened after he contracted an upper respiratory infection. He also complains of bilateral ankle swelling. He has a 40 pack-year history of smoking. Physical examination reveals a mildly overweight patient in mild respiratory distress. Lung auscultation reveals bilateral wheezes and a prolonged expiratory phase. His white blood cell count is 14,500/mm3 and his hemoglobin level is 16 mg/dl. Arterial blood gas analysis reveals the following: pH 7.37, pO2 65mmHg, pCO2 60mmHg. Absence of marked acidosis in this patient is best explained by which of the following?

A 64-year-old woman is admitted to the hospital with right lobar pneumonia and sepsis syndrome. She becomes progressively more short of breath and hypoxemic requiring intubation and mechanical ventilation. Her repeat CXR in the intensive care unit now shows diffuse pulmonary infiltrates and a diagnosis of acute respiratory distress syndrome (ARDS) is made. Which of the following mechanisms is the most likely cause for the early exudative phase of ARDS?

A 64-year-old woman presents to your office after falling in the grocery store earlier today. She says she was doing her usual shopping when she felt weak in her legs and fell down. She denies hitting her head, headache, or loss of consciousness, but does complain of low back pain. Her past medical history is significant for diabetes mellitus, hypertension, severe osteoporosis, chronic neck pain and congestive heart failure. She has had three transient ischemic attacks, each lasting 15-20 minutes and characterized by slurred speech, in the past. Her medications include insulin, lisinopril, carvedilol, alendronate, aspirin, and acetaminophen. Her blood pressure is 160/90 mmHg and her heart rate is 73/min. Physical exam reveals muscular weakness, increased deep tendon reflexes, and mildly decreased pinprick sensation in both lower extremities. Which of the following is most likely responsible?

A 65-year-old bedridden woman is brought in with complaints of weight loss, weakness and malaise. Her past medical history includes chronic obstructive pulmonary disease (diagnosed fifteen years ago) and hypertension of ten years' duration. She quit smoking two years ago, but previously smoked three packs of cigarettes daily since she was 20 years of age. Her vital signs are stable. Her physical examination reveals severe weakness in her proximal muscles, and loss of deep tendon reflexes. Chest x-ray shows a right upper lung mass with mediastinal lymphadenopathy. Which of the following is the most likely cause of her weakness?