DES C_Diagnosis (9) Prepared : CHILLY

A 54-year-old man is brought to the emergency department 1 0 minutes after being involved in a motor vehicle collision. On arrival, he is breathing spontaneously, is non-cyanotic and has no signs of external injury. His temperature is 37C (98.6F), blood pressure is 104/50 mm Hg, pulse is 122/min and respirations are 16/min. Examination shows bilateral round and reactive pupils of 4 mm. He is making some incomprehensible sounds. He responds to his name by opening his eyes and on applying supraorbital pressure he extends his left extremity and grasps your hand with his right hand. What is the Glasgow coma scale (GCS) in this patient?

A 54-year-old man is brought to the ER three hours after the onset of severe, 10/10, tearing, substernal chest pain radiating to his back. He still complains of pain and dizziness at the time of arrival. Physical examination demonstrates a pale thin male who is anxious and diaphoretic. His blood pressure is 90/60 mmHg in the right arm and 70/40 mmHg in the left arm. There is an 18 mmHg difference in systolic blood pressure between inspiration and expiration. His jugular veins are distended while sitting. Bedside echocardiogram demonstrates a moderate amount of pericardial fluid. Which of the following is the most likely diagnosis?

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

A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns, and blinks excessively. Which of the following disorders is most likely in this patient?

A 54-year-old overweight man wakes up in the middle of the night with substernal discomfort that he describes as a burning sensation. He also complains of left-sided neck pain and feels sweaty and short of breath. He has never had similar pain before. Prior to going to bed he had eaten a big meal. His past medical history is significant for diabetes and hypertension. Which of the following physical findings is most consistent with this patient's clinical presentation?

A 54-year-old retired schoolteacher comes to the physician's office because of worsening low back pain. The pain started three weeks ago. It is continuous and is worse at night. He has had little relief with over-the-counter nonsteroidal analgesics. He has no other symptoms. He had a surgical resection of a lung tumor one year ago for non-small cell carcinoma of the lung. Preoperative positron emission tomography (PET) scanning did not reveal any evidence of metastasis. His vital signs are within normal limits. Examination shows local spinal tenderness at the L4-L5 level. What is the most likely cause of his back pain?

A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nulliparity, and early age at menarche. She takes no other medications. Examination is within normal limits. Which of the following is this patient most likely to develop while taking tamoxifen?

A 54-year-old woman is brought to the emergency department after a head-on automobile accident. On arrival, she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-ray films show multiple rib fractures on both sides, but the lung parenchyma is clear, and both lungs are expanded. Two days later she is in respiratory distress, and her lungs "white out" on repeat chest x-ray films. Which of the following is the most likely diagnosis?

A 55-year-old Caucasian man comes to the emergency department because of fever and productive cough, with foul-smelling sputum. He also complains of shortness of breath. His other medical problems include hypertension and hypercholesterolemia. In the past three months, he was admitted in the hospital two times for pneumonia. He has smoked one pack of cigarettes daily for 28 years and drinks 5-6 beers daily. Family history is not significant. His medications include hydrochlorothiazide and simvastatin. His temperature is 38.9°C (102°F), blood pressure is 120/70 mmHg, pulse is 112/min, and respirations are 24/min. The patient's pulse oximetry showed 89% at room air. Examination shows crackles at the right lung base. His chest x-ray shows right, lower lobe infiltrate. A CT scan of the chest shows no mass or obstruction. Which of the following is most likely responsible for this patient's symptoms?

A 55-year-old male Asian immigrant presents to the physician because of recent-onset neck swelling. He also notes having several episodes of epistaxis lately. He has not sustained any trauma to the neck or nose. His past medical history is significant for syphilis and recurrent bacterial sinusitis. He drinks 2 beers daily and has a 30-pack year smoking history. He takes daily multivitamins with antioxidants. On physical examination, you note a mass in the posterior nasal cavity. Biopsy shows undifferentiated carcinoma. Which of the following is a risk factor for this cancer?

A 55-year-old male comes to the physician with a history of diarrhea, weight loss, bloating, and excessive flatulence. His symptoms began soon after having "stomach surgery" two years ago. He has a history of gastric ulcers. Physical examination shows scarring associated with past surgery, and abdominal distention with identifiable succussion splash. Laboratory studies show anemia with MCV of 100fl. Which of the following is the most likely diagnosis?

A 55-year-old male comes to the physician's office because of chronic pain in his buttock, hip and thigh muscles. The aching pain is present in both legs and usually is associated with walking. He has multiple medical problems and takes several medications. He has a 30 pack year smoking history. His temperature is 36.7C (98F), blood pressure is 150/88 mm Hg, pulse is 80/min and respirations are 16/min. Examination shows decreased femoral, popliteal and dorsalis pedis pulses in both legs. Which of the following additional complaints is most likely in this patient?

A 55-year-old male comes to you with complaint of fatigue for the past month. He also complains of occasional heartburn. His past medical history is significant for hepatomegaly, secondary to fatty liver. He has been drinking 3-4 shots of alcohol per day for the past 30 years. He denies smoking. His physical examination reveals pallor of skin and mucous membranes, and mild hepatomegaly. His laboratory report shows: Hb 8.5 g/dl, WBC 8,000/cmm, MCV 110 fl, Platelets 150,000/cmm, Blood glucose 118 mg/dl, BUN 16 mg/dl, Serum creatinine 1.0 mg/dl. What is the most likely cause of anemia in this patient?

A 55-year-old male presents to the emergency room with right-sided weakness that has persisted for the past several hours. He also complains of severe central chest pain that is "ripping" in quality and radiates to his back. He has had hypertension for the past seven years and has not been taking any anti-hypertensive medication. He has been smoking one pack of cigarettes per day for the past 25 years. His father died of coronary artery disease at age 44 years. His temperature is 37.1°C (98.6°F), pulse is 78/min, blood pressure is 180/120 mm Hg in the right arm and 110/70 mm Hg in the left arm, and respirations are 16/min. He is diaphoretic and confuse. His neurological examination is significant for decreased power and tone in the right upper and right lower extremities. The rest of his physical examination is unremarkable ECG shows left axis-deviation and a chest x ray is normal. Based on these findings, what is the most likely diagnosis?

A 55-year-old man comes to the office due to a sudden onset of blisters all over his body. He complains of pain in the involved areas. He first noticed the lesions in his mouth a few days ago. His pulse is 82/min, blood pressure is 140/90 mmHg, respirations are 14/min, and temperature is 36.8°C (98.4°F). On examination, there are crops of flaccid bullae over normal-appearing skin, and large erosions at sites where the bullae had ruptured. The oral mucosa shows erosions and ulcerations. Slight rubbing of the uninvolved skin causes easy separation of the epidermis. Immunofluorescence microscopy shows deposits of IgG inter cellularly in the epidermis. What is the most likely diagnosis?

A 55-year-old man comes to the physician because of a 4-month history of an ulcer on the sole of his right foot. He has had no trauma and does not remember how he got the ulcer. He states the ulcer has been difficult to heal and readily gets infected. He does not use tobacco, alcohol or drugs. Examination shows the ulcer is located on the sole of his foot just below the head of the first metatarsal bone. His foot is warm and dry and appears slightly deformed. Dorsalis pedis pulses are present. Which of the following is the most likely cause of his condition?

A 55-year-old man comes to the physician because of a 4-month history of an ulcer on the sole of his right foot. He has had no trauma and does not remember how he got the ulcer. He states the ulcer has been difficult to heal and readily gets infected. He has multiple medical problems. He does not use tobacco, alcohol or drugs. Examination shows the ulcer is located on the sole of his foot just below the head of the first metatarsal bone. His foot is warm and dry and appears slightly deformed. Dorsalis pedis pulses are present. Which of the following is the most likely cause of his condition?

A 55-year-old man is diagnosed with benign prostatic hyperplasia. The patient declines pharmacologic treatment and elects to undergo transurethral resection of the prostate (TURP). Which of the following is the most common complication of this procedure?

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

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

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

A 55-year-old man was admitted to the hospital 2 weeks ago for rapid onset of cough, fatigue, and pleuritic chest pain. He has worked as a sandblaster for the past year. When first seen in the hospital, he denied hemoptysis and smoking. Currently, the patient is intubated and on assist-control ventilation. His temperature is 36.7°C (98°F), pulse is 96/min, blood pressure is 138/85 mm Hg, and respiratory rate is 18/ min. A recent arterial blood gas study showed a pH 7.42, arterial carbon dioxide pressure of 36 mm Hg, and arterial oxygen pressure of 110 mm Hg while on 100% oxygen. Physical examination is significant for diffuse crackles throughout both lung fields, a loud pulmonic component of the second heart sound, and jugular venous distention of 9 cm with a prominent A wave, a left parasternal heave, and symmetric 3+ lower extremity pitting edema. Which of the following is the most likely diagnosis?

A 55-year-old man with hypertension and a one-pack-per-day smoking history presents to the ED complaining of three episodes of severe heavy chest pain this morning that radiated to his left shoulder. In the past, he experienced chest discomfort after walking 20 minutes that resolved with rest. The episodes of chest pain this morning occurred while he was reading the newspaper. His BP is 155/80 mmHg, HR 76 beats per minute, and RR 15 breaths per minute. He does not have chest pain in the ED. An ECG reveals sinus rhythm with a rate of 72. A troponin I is negative. Which of the following best describes this patient’s diagnosis?

A 55-year-old man with hypertension and end-stage renal disease requiring hemodialysis presents with 2 days of painless hematochezia. He reports similar episodes of bleeding in the past, which were attributed to angiodysplasia. He denies abdominal pain, nausea, vomiting, diarrhea, and fever. His vitals include HR of 90 beats per minute, BP of 145/95 mm Hg, RR of 18 breaths per minute, and temperature of 98°F. His abdomen is soft and nontender and his stool is grossly positive for blood. Which of the following statements are true regarding angiodysplasia?

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?

A 55-year-old postmenopausal woman shows evidence of temporal balding, clitoromegaly, and increased facial hair that began 6 months ago and had a rapid onset. She is noted to have a 5 cm unilateral, solid pelvic mass. Family history is negative for these findings. Which of the following is the most likely diagnosis?

A 55-year-old white woman has had recurrent episodes of alcoholinduced pancreatitis. Despite abstinence, the patient develops postprandial abdominal pain, bloating, weight loss despite good appetite, and bulky, foul-smelling stools. KUB shows pancreatic calcifications. In this patient, you should expect to find which of the following?

A 55-year-old white woman with a history of iron deficiency anemia has had intermittent trouble swallowing solids for the past few years. She denies alcohol or tobacco use. Her vital signs are stable. Her iron level is 40μg/dL and total iron binding capacity is 500 μg/dL. Other laboratory tests are within normal limits. Which of the following is the most likely diagnosis?

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?

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

A 55-year-old woman presents to your office for consultation regarding her symptoms of menopause. She stopped having periods 8 months ago and is having severe hot flushes. The hot flushes are causing her considerable stress. What should you tell her regarding the psychological symptoms of the climacteric?

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

A 55-year-old woman presents with coughing up blood and sputum. She gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is worse on lying down and in the morning. On physical examination, she appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is a recognized precursor to this patient’s condition?

A 55-year-old woman requires an abdominoperineal operation for rectal cancer. She has a history of stable angina. Which of the following clinical markers is most likely to predict a cardiac event during her noncardiac surgery and should prompt further cardiac workup prior to her operation?

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 with long-standing rheumatoid arthritis is on prednisone 5 mg daily and etanercept (Enbrel) 50 mg subcutaneously once a week. Her arthritis is well-controlled. However, she complains of a 2-day history of headaches, chills, and spiking fevers to 39.4°C (103°F). You suspect which of the following?

A 55-year-old, HIV-positive man has a fungating mass growing out of the anus. He can feel it when he wipes himself after having a bowel movement, but it is not painful. For the past 6 months, he has noticed blood on the toilet paper, and from time to time there has also been blood coating the outside of the stools. He has lost weight, and he looks emaciated and ill. On physical examination, the mass is easily visible. It measures 3.5 cm in diameter, is fixed to surrounding tissues, and appears to grow out of the anal canal. He also has rock-hard, enlarged lymph nodes on both groins, some of them as large as 2 cm in diameter. Which of the following is the most likely diagnosis?

A 56-year-old Caucasian male complains of chronic exertional dyspnea for the past several years that has progressively worsened. He cannot remember the last time that he saw a doctor, and does not take any medications regularly. It is difficult for him to climb two flights of stairs without having to rest. His dyspnea has gotten so bad that it has severely limited his activity level, and he now spends most of his time on the couch. He also describes recurrent episodes of nocturnal dyspnea, during which he wakes up at around 2:00 AM with difficulty breathing, coughing, and wheezing that improve when he sits up. He usually coughs up some yellowish sputum before being able to go back to sleep. He has had no fever, chills, or chest pain. Which of the following is the most likely cause of this patient's complaints?

A 56-year-old female is admitted with a diagnosis of chronic renal failure from systemic lupus erythematosus and non-steroidal anti-inflammatory drug use. She has a history of recurrent kidney stones. Laboratory studies show the following: Serum calcium 10.6 mg/dL, Serum albumin 3.9 g/L, PTH 140 pg/mL, Serum phosphorus 3.0 mg/dL. Her baseline serum creatinine level ranges from 1.6 to 1.8 mg/dL. Her bone mineral density is measured by DXA scan, revealing a T score of-2.5 at the lumbar spine, which is consistent with osteoporosis. What is the most likely cause of this patient's hypercalcemia?

A 56-year-old Hispanic male presents with right-sided arm weakness and speech difficulty. He expresses words slowly and with difficulty. His speech is agrammatic and the melody of speech is abnormal. He is able to comprehend words spoken to him. Which of the following is the most likely site of lesion in the above patient?

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?

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?

A 56-year-old male presents in the emergency department with severe nausea, vomiting, polyuria, polydipsia, and constipation. His past medical history is significant for hypertension and type 2 diabetes mellitus. His home medications include metformin, atenolol, and hydrochlorothiazide. He has a 26-pack-year history of smoking. He drinks alcohol occasionally. He denies the use of recreational drugs. His father also has diabetes mellitus type 2. His blood pressure is 110/70 mmHg, pulse is 102/min, temperature is 36.7°C (98°F) and respirations are 16/min. His mucus membranes are dry. His lung examination reveals decreased breath sounds over the right base. The rest of the physical examination is unremarkable. The patient is subsequently admitted. Laboratory studies (obtained in the emergency department) are as follows: Serum calcium 14.8 mg/dl, Albumin 4.0 g/dl, PTH 9 pg/ml (normal 10-60 pg/ml), Serum creatinine 1.9 mg/dl, BUN 54 mg/dl, Blood glucose 180 mg/dl, 25-hydroxyvitamin D 30 ng/ml (normal 20 to 60 ng/ml), 1,25-dihydroxyvitamin D 30 pg/ml (normal 15 to 65 pg/ml). What is the most likely cause of this patient's hypercalcemia?

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?

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

A 56-year-old man has been having bloody bowel movements on and off for the past several weeks. He reports that the blood is bright red, it coats the outside of the stools, and he can see it in the toilet bowl even before he wipes himself. When he does so, there is also blood on the toilet paper. After further questioning, it is ascertained that he has been constipated for the past 2 months and that the caliber of the stools has changed. They are now pencil thin, rather the usual diameter of an inch or so that was customary for him. He has no pain. Which of the following is the most likely diagnosis?

A 56-year-old man has been hospitalized for a myocardial infarction. Two days after admission, he awakens in the middle of the night and screams that there is a man standing by the window in his room. When the nurse enters the room and turns on a light, the patient is relieved to learn that the “man” was actually a drape by the window. This misperception of reality is best described by which of the following psychiatric terms?

A 56-year-old man is brought to the physician’s office by his wife because she has noted a personality change during the past 3 months. While the patient is being interviewed, he answers every question with the same three words. Which of the following symptoms best fits this patient’s behavior?

A 56-year-old man is evaluated for chronic cough. It is present most of the time and is progressively getting worse over the past 3 years. With the cough he usually has white to yellow sputum that he has to expectorate. There is no history of wheezing, asthma, congestive heart failure (CHF), or acid reflux disease. He currently smokes one pack a day for the past 25 years. On examination, his chest is clear. CXR is normal and his forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) on spirometry are normal. Which of the following is the most likely diagnosis?

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?

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

A 56-year-old woman is brought to the emergency room with shortness of breath, which she says began suddenly two hours ago while she was enjoying her favorite television show. She also reports the simultaneous onset of sharp, left-sided chest pain. Her previous medical history includes diabetes mellitus for the past 10 years and hypertension for the past 6 years. Her family history is significant for heart disease in her father, who died at age 40. Her medications include enteric-coated aspirin, captopril and glipizide. She has a 30 pack-year smoking history, but does not smoke currently. On physical examination, she is in acute distress and is sweating profusely. Her temperature is 38.0°C (100.5°F), pulse is 140/min and irregular, respiratory rate is 30/min, and blood pressure is 110/60 mm Hg. Her oxygen saturation is 84% on room air by pulse oximetry. Jugular venous pressure is within normal limits and her lungs are clear to auscultation. Serum analysis reveals the following: Hematocrit 40%, WBC count 11,600/mm3, Platelet count 190,000/mm3. Chest x-ray is unremarkable. ECG reveals irregular RR intervals, with no definite P waves and narrow QRS complexes. Which of the following is the most likely cause of her current symptoms?

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?

A 56-year-old woman is referred to you about 3 months after a colostomy subsequent to a sigmoid resection for cancer. She complains that her stoma is not functioning properly. Which of the following is the most common serious complication of an end colostomy?

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

A 56-year-old woman presents to the clinic with a 7-month history of headache and visual disturbance. Her past medical history is unremarkable. She is currently not taking any medications. She admits to smoking a pack of cigarettes daily for the last 15-years, and does not drink. On visual field examination, there is a small field defect noted in both eyes. MRI scan shows a pituitary tumor. Which of the following is the most common type of pituitary tumor?

A 57-year-old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit for 1 week, where he required chest tubes for pleural effusions and was on a respirator for several days. Eventually, he improved sufficiently to be transferred to the floor. Three days after leaving the unit, and about 2 weeks after the onset of the disease, he spikes a fever and develops leukocytosis. Which of the following developments do these recent findings most likely suggest?

A 57-year-old male presents to the emergency department with recent-onset dyspnea and cough. He reports that his symptoms began earlier this morning while he was jogging, when he suddenly started feeling short of breath and very weak. In the emergency department, laboratory analysis reveals a markedly elevated serum b-type natriuretic peptide level. Which of the following clinical signs best correlates with this finding?

A 57-year-old man presents to the emergency department complaining of right arm weakness. He says that he first noticed the weakness two hours ago when he was unable to grip a pen. He is now unable to shake hands and walks with a mild limp. His past medical history is significant for hypertension, diabetes mellitus, and mild headaches over the past several days. He does not smoke or consume alcohol. His blood pressure is 180/100 mmHg, heart rate is 80/min and regular. There is mild asymmetry of the lower face, decreased muscle strength in the right arm, and an extensor plantar reflex on the right side. Sensory examination is normal. Blood glucose level is 210mg/dL. ECG shows sinus rhythm with occasional ventricular premature beats. His urine is negative for ketones and protein. Non-contrast CT scan of the head does not reveal any abnormalities. Which of the following is the most likely cause of this patient's symptoms?

A 58-year-old G6P4Ab2 diabetic woman who weighs 122.6 kg (270 lb) has her first episode of vaginal bleeding in 5 years. Her physician performs an outpatient operative hysteroscopy and dilatation and curettage (D&C). Which of the following is an indication for the procedure and the most likely diagnosis?

A 58-year-old man presents to the emergency department complaining of fever and chills. The fever started last night and has not subsided, even though he took acetaminophen. He had a successful appendectomy 3 days ago and was discharged from the hospital 2 days ago. His only medication is ibuprofen, which is adequately controlling his pain. He is a 30-pack-year smoker with a chronic cough productive of white sputum. He has noticed increased sputum production, which has become yellowish-green. He denies dysuria, urgency, or frequency. His temperature is 38.4°C (101.1°F), heart rate is 88/min, respiratory rate is 16/min, and blood pressure is 126/74 mm Hg. On examination he appears to be tired but not in acute distress. Pulmonary examination is limited because deep inhalation causes coughing and slight abdominal pain. There is no tactile fremitus or dullness to percussion. He has a slightly erythematous, appropriately tender healing incision in the right lower quadrant without exudates and normal active bowel sounds. Extremities are warm and well perfused without erythema or edema. Pulses are intact. Which of the following most likely could have prevented this condition?

A 58-year-old man presents with pain in the left leg after walking more than one block that is relieved with rest. On physical examination, distal pulses are not palpable in the left foot and there is dry gangrene on the tip of his left fifth toe. An ankle-brachial index on the same side is 0.5. Which of the patient’s symptoms or signs of arterial insufficiency qualifies him for reconstructive arterial surgery of the left lower extremity?

A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk. She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder?

A 58-year-old woman with stage II epithelial ovarian cancer undergoes successful surgical debulking followed by chemotherapy with carboplatin and radiation therapy. Subsequently, she develops non-pitting edema of both legs and pain and numbness in her legs. Which of the following is the most likely cause of her pain and numbness?

A 59-year-old Caucasian female presents to the emergency department with sudden onset paralysis of her bilateral lower extremities. She has no other symptoms. Physical examination reveals normal tone, normal deep tendon reflexes, and no Babinski sign. Her motor strength is 3/5 in both lower extremities. The remainder of her examination is unremarkable. The patient dramatically improves after she is injected with sodium amytal. What is the most likely diagnosis?

A 59-year-old G4P4 presents to your office complaining of losing urine when she coughs, sneezes, or engages in certain types of strenuous physical activity. The problem has gotten increasingly worse over the past few years, to the point where the patient finds her activities of daily living compromised secondary to fear of embarrassment. She denies any other urinary symptoms such as urgency, frequency, or hematuria. In addition, she denies any problems with her bowel movements. Her prior surgeries include tonsillectomy and appendectomy. She has adult-onset diabetes and her blood sugars are well controlled with oral Metformin. The patient has no history of any gynecologic problems in the past. She has four children who were all delivered vaginally. Their weights ranged from 8 to 9 lb. Her last delivery was forceps assisted. She had a third-degree laceration with that birth. She is currently sexually active with her partner of 25 years. She has been menopausal for 4 years and has never taken any hormone replacement therapy. Her height is 5 ft 6 in, and she weighs 190 lb. Her blood pressure is 130/80 mmHg. Based on the patient’s history, which of the following is the most likely diagnosis?

A 59-year-old male is brought to the emergency department with severe dyspnea and left-sided chest discomfort. He says that he was driving to work when he began to feel suddenly weak and short of breath. He has a long history of chronic obstructive pulmonary disease, esophageal reflux and chronic pyelonephritis. He smokes one pack of cigarettes per day. His current medications include ranitidine and inhaled ipratropium and albuterol as needed. Physical examination reveals trace ankle edema, decreased breath sounds over the left chest and scattered wheezes over the right chest. ECG shows sinus tachycardia. Arterial blood gas analysis is given below: pH 7.42, pO2 59 mmHg, pCO2 41 mmHg. Which of the following most likely underlies this patient's current condition?

A 59-year-old man goes to a psychiatrist for a 3-month history of panic attacks. He notes for the past 3 months he has experienced “out of the blue,” extreme episodes of fearfulness that last about 20 minutes. During that time he experiences palpitations, sweating, shortness of breath, and trembling. He denies any substance abuse, and has never had symptoms like this before these past 3 months. Which of the following signs or symptoms would likely lead the physicians to expect a diagnosis of anxiety secondary to a general medical condition in this case?

A 59-year-old man presents to his internist for a routine visit. He has no complaints, and review of symptoms is negative. His past medical history is significant for poorly controlled hypertension for 15 years due to noncompliance with antihypertensive medications. He takes hydrochlorothiazide 25 mg orally four times a day. His family history is significant for hypertension, heart failure, and stroke. He has a 30-pack-year smoking history and drinks two beers a day. On physical examination he is a mildly obese man in no acute distress. He has a normal jugular venous pressure. He has a prominent point of maximum impulse, regular rate and rhythm, normal S1, loud S2, and audible S4 with no murmurs. His lungs are clear to auscultation bilaterally, and he has no signs of edema. His abdominal and neurologic examinations are within normal limits. His temperature is 37.0°C (98.6°F), pulse is 81/min, respiratory rate is 12/min, blood pressure is 165/96 mmHg, and oxygen saturation is 100% on room air. His ECG shows normal sinus rhythm with large amplitude of the S wave in V1 and V2 and of the R wave in V5 and V6. Also present are diffuse ST segment/T wave changes, widened bifid P waves, and prolonged QRS waveforms. Which of the following is the most likely diagnosis?

A 59-year-old obese man comes to the office "to make sure everything is okay." Yesterday after lunch, he experienced weakness in his right upper arm and right lower extremity. He was limping, and his right hand was not strong enough to hold some heavy things. His speech was "somewhat faulty”, and he had a light diffuse headache. By dinnertime, his symptoms were resolving, and when he woke up this morning, his weakness was gone. His past medical history is significant for hypertension, for which he takes atenolol. He has smoking 1 pack of cigarettes a day for the past 40 yrs. His blood pressure is 150/95 mm of Hg and heart rate is 78/min. The neurological examination is normal. There is a mild carotid bruit on his left side. What is the most likely diagnosis?

A 59-year-old woman who had been diagnosed with infiltrating ductal carcinoma 2years prior presents with pain of her right breast. The breast is swollen, tender on palpation, and is diffusely indurated with a “peau d’orange” appearance. Multiple axillary lymph nodes are palpable in the lower axilla. A skin biopsy from her breast reveals extensive invasion of dermal lymphatics. What is the best diagnosis?

A 6-day-old girl who was born at home is being evaluated for bruising and gastrointestinal bleeding. Laboratory findings include partial thromboplastin time and prothrombin time, greater than 2 minutes; serum bilirubin, 4.7 mg/dL; alanine aminotransferase, 18 mg/dL; platelet count, 330,000/mm3; and hemoglobin, 16.3 g/dL. Which of the following is the most likely cause of her bleeding?

A 6-month-old boy is found to have bilateral metaphyseal fractures of both proximal and distal ends of the tibia. The mother says that her boyfriend takes care of the infant while she is at work. Her boyfriend explains the injuries as the result of multiple falls from bed. Which of the following is the most likely diagnosis?

A 6-month-old infant has poor weight gain, vomiting, episodic fevers, and chronic constipation. Laboratory studies reveal a urinalysis with a pH of 8.0, specific gravity of 1.010, 1+ glucose, and 1+ protein. Urine anion gap is normal. Serum chemistries show a normal glucose and a normal albumin with a hyperchloremic metabolic acidosis. Serum phosphorus and calcium are low. What is the best diagnosis to explain these findings?

A 6-month-old infant is taken to the emergency department because he had a seizure. Physical examination demonstrates premature closure of cranial sutures and markedly bowed legs. Laboratory studies demonstrate low serum phosphate levels, with normal vitamin D and parathyroid hormone levels. Urinalysis shows high phosphate levels, but no increased excretion of glucose, amino acids, or protein. The child's maternal grandfather had crippling bone disease, and his mother has mild bowing of the legs. Which of the following is most likely diagnosis?

A 6-month-old infant presents to the emergency department with the new onset of weak cry, decreased activity, and poor feeding. The mother also states that the infant has been constipated for the past 2 days. On physical examination, the infant has a very weak cry, poor muscle tone, and absent deep tendon reflexes. Which of the following is the most likely diagnosis?

A 6-month-old previously health child is brought to the doctor's office because of sudden onset of lethargy, constipation, generalized weakness and poor feeding. He has been meeting all development milestones and his immunization schedule is up to date. On further questioning, his parents mention that his diet was recently advanced to a homemade formula of evaporated milk and honey. On physical examination, he has stable vital signs, clear lungs, normal skin turgor and full fontanelles. Which of the following is the most likely explanation for the patient's presentation?

A 6-week-old boy is brought to the physician because of a rash involving the diaper area. On examination, there are erythematous, slightly scaly patches covering the buttocks and the lower abdomen. Skin creases appear spared. The baby is otherwise healthy. Physical examination reveals no lymphadenopathy, fever, or other signs of organic illness. Which of the following is the most common cause of this condition?

A 6-year-old boy has insidious development of limping with decreased motion in one hip. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Examination of the knee is normal, but passive motion of the hip is guarded. The child is afebrile, and the parents indicate that his gait and level of activity were completely normal all his life until this recent problem. He has not had a recent febrile illness. Which of the following is the most likely diagnosis?

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

A 6-year-old boy is brought to the emergency department (ED) by the paramedics due to nausea, vomiting, diarrhea and abdominal pain over the past hour. His mother found an open multivitamin supplement bottle and some pills scattered on the kitchen floor. After his admission to the ED, he starts hyperventilating and experiences hematemesis. His blood pressure is 90/60 mmHg, pulse is 130/min, respirations are 50/min and temperature is 37.2 C (99F). Abdominal plain x-ray reveals several small opacities in the stomach and duodenum. Lab results are: Hb 13.5 g/dL, Ht 42%, WBC 10,000/mm3, Platelets 300,000/mm3, Blood Glucose 118 mg/dL, Serum Na 135 mEq/L, Serum K 34 mEq/L, Chloride 102 mEq/L, Bicarbonate 16 mEq/L, BUN 16 mg/dL, Serum Creatinine 1.0 mg/dL, pH 7.30, P02: 90 mm Hg, PC02: 29 mm Hg. What is the most likely diagnosis?

A 6-year-old boy is brought to the emergency department because of the acute onset of headache, nausea, and vomiting. On arrival, physical examination reveals marked nuchal rigidity and funduscopic evidence of papilledema. A head CT scan reveals a solid tumor in the posterior fossa, centered in the cerebellar vermis and extending to the fourth ventricle. An emergency craniotomy is performed, during which a small sample of the tumor is sent to the pathologist for a frozen section consultation. Which of the following is the most likely diagnosis?

A 6-year-old boy is brought to the ER with a two-day history of difficulty walking. He is dragging his right leg and seems to have weakness in his right arm. He also complains of headaches. The family just emigrated from Eastern Europe. According to his parents, the child suffers from delayed growth compared to his peers and does not like to engage in active play. His lips and fingers turn blue when he cries. His vital signs today are a blood pressure of 100/70 mmHg, pulse of 90/min, temperature of 38.3 0C (102.0 0F), and respiratory rate of 22/min. Which of the following is most likely responsible for his current complaints?

A 6-year-old boy is brought to the office by his mother due to a decreased appetite and irritability for the past three days. He also had an episode of diarrhea yesterday. Lately, he has been sitting close to the television with the volume turned up very loudly. His temperature is 38.1°C (100.5°F), blood pressure is 110/60 mmHg, and heart rate is 110/min. On examination, there is left-sided yellowish ear discharge. His nasal mucosa appears boggy and postnasal drip is present. What is the most likely diagnosis?

A 6-year-old boy is brought to the physician by his mother with complaints of "inattentivity." His school teacher frequently complains about him, saying that he, "cannot sit still and just does not listen." He rarely completes his classroom assignments in time. When asked to run errands at home, he appears not to listen and continues to do whatever he is engaged in. He makes poor eye contact and has limited language skills compared to his peers. He usually prefers to play by himself. Which of these is the most likely diagnosis in this case?

A 6-year-old boy is brought to the physician for evaluation of behavior problems. His parents report he is "hyperactive all the time." They cannot get him to sit still. When he does sit, he fidgets and tries to get out of his seat. He is easily distracted and frequently changes from one activity to another. He does not seem to listen when his parents talk to him, and often forgets to do his chores. He talks excessively and often interrupts other people. His parents state that he has been like this for a few years, but they had originally assumed his behavior was normal for his age. His physical examination is unremarkable. Which of the following will be of most help in establishing the diagnosis?

A 6-year-old boy is brought to your practice by his paternal grandmother for his first visit. She has recently received custody of him after his mother entered the penal system in another state; she does not have much information about him. You note that the child is short for his age, has downslanting palpebral fissures, ptosis, low-set and malformed ears, a broad and webbed neck, shield chest, and cryptorchidism. You hear a systolic ejection murmur in the pulmonic region. His grandmother reports that he does well in regular classes, but has been diagnosed with learning disabilities and receives speech therapy for language delay. His constellation of symptoms is suggestive of which of the following?

A 6-year-old boy presents in clinic for a routine visit. Examination reveals coarse, dark pubic hair, an enlarged penis and testes, and acne of the face and upper back. His mother notes that he has a body odor similar to that of her teenage son after playing sports. The child is in file 99th percentile of height for his age group. Which of the following is the most likely diagnosis?

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

A 6-year-old Caucasian male is brought to your office with a two-week history of right shoulder pain. Physical examination reveals localized swelling below the shoulder joint, and x-ray shows a single lytic lesion in the right humeral head. Laboratory analyses show mild hypercalcemia but are otherwise within normal limits. Which of the following is the most likely diagnosis?

A 6-year-old female is brought to the physician with a rash and joint pains. Her mother reports that she has been previously healthy except for a sore throat a few weeks ago. One week ago, the patient developed pain in her knees. The knee pain resolved after a few days, but now her ankles and wrists are tender. She has also developed a pink rash on her trunk that is non-pruritic. Vital signs are temperature 38.3°C (101°F), pulse 85/min, and respiratory rate 20/min. On examination, there is pain and stiffness during manipulation of the wrists and ankles. A faint, erythematous, centrifugal rash on her trunk and proximal limbs is present. Laboratory studies show: Complete blood count: Hemoglobin 12.5 g/dL, MCHC 32%, MCV 85 fl, Reticulocyte count 0.1%, Platelet count 200,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%, C-reactive protein 3.5 mg/dL, Erythrocyte sedimentation rate 38 mm/hr. Which of the following is the most likely diagnosis?

A 6-year-old female with Down syndrome is brought to the physician for behavioral changes. Over the past few weeks, she has begun refusing to do her usual activities. Her parents also report that she seems dizzy and state that she has developed urinary incontinence. On examination, she is hypotonic but hyperreflexic with a positive Babinski reflex. Her gait is ataxic. Which of the following is the most likely diagnosis?

A 6-year-old girl has a low-grade fever, headache, and nasal congestion. She has a flushed face and has developed a lacy reticular rash on the trunk and extensor surface of her arms and legs. Palms and soles are spared. Her mother has been ill with a low-grade fever and some joint stiffness and pain. Which of the following is the most likely diagnosis?

A 6-year-old girl states that she has had vaginal bleeding for the past 3 days. She is brought to the office by her worried mother. The mother states that the child has no medical problems and is not on any medications. She denies headache or visual changes. General physical examination is consistent with a normal 6-year-old female without breast budding. External genitalia are unremarkable with no pubic hair. Which of the following is the most likely diagnosis?

A 6-year-old girl with acute lymphocytic leukemia (ALL) is admitted to the hospital with a generalized vesicular rash and high fever. She has no previous history of chickenpox and has never received immunization for varicella. Her 4-year-old sister recently recovered from chickenpox that started about 10 days ago. On admission, her temperature is 38.4 C (101.1 F), blood pressure is 94/58 mm Hg, pulse is 80/min, and respirations are 20/min. Which of the following is the most serious complication of varicella that might occur in this patient?

A 6-year-old male presents to the physician with eyelid swelling. His mother noted an insect bite on his left cheek yesterday, and states that this morning his left eyelid was completely swollen shut and painful. He has not had a fever, fatigue, headache, or rhinorrhea. On examination, he is afebrile. The left eyelid is erythematous, tender to palpation, and swollen shut. When trying to clinically distinguish between preseptal and orbital cellulitis, which of the following findings is most likely to be seen with preseptal cellulitis?