Surgery shakora

46) A 78-year-old man comes to the physician because of a bloody urethral discharge for 3 days. He has had increasing frequency of urination and hesitancy for the past 2 years, but these symptoms have never been severe enough to require medical attention. Digital rectal examination reveals a slightly enlarged and firm prostate. Expressed prostatic secretions are negative for bacteria and leukocytes. Collection of clean-catch urine in separate aliquots reveals initial hematuria, with blood present in the first 5 mL. Which of the following is the most likely diagnosis?

47) A 19-year-old man sustains severe lower-extremity trauma, including a femur fracture and a crush injury to his foot. He requires vascular reconstruction of the popliteal artery. On the day after surgery, he becomes dyspneic and hypoxemic and requires intubation and mechanical ventilation. Which of the following is the most likely etiology of his decompensation?

48) An 18-year-old gang member is stabbed in the back, just to the right of the midline. Physical examination shows paralysis and loss of proprioception distal to the injury on the right side, and loss of pain perception distal to the injury on the left side. Which of the following is the most likely diagnosis?

49) A 14-year-old girl has a firm, movable, rubbery mass in her left breast. The mass was first noticed 6 months ago and has since grown to about 6 cm in diameter. Which of the following is the most likely diagnosis?

50) A 3-week-old infant is brought in because of 2 days of protracted bilious vomiting. He looks acutely ill, and plain x-rays show two large air fluid levels in the upper abdomen, the larger one on the left side and a smaller one on the right side. The radiologist describes the finding as a "double bubble sign." He also reports that there is intraluminal gas distal to those two air fluid levels, but that it is sparse and does not outline distended loops. Which of the following is the most likely tentative clinical diagnosis?

51) A 16-year-old boy is persuaded by his older brother to accompany him and his friends on a beer-drinking binge. This is the first such experience for the boy, and it leads to the development of severe colicky left flank pain. When rescued by his parents, he is diaphoretic and doubled up in pain. He relates that he began to urinate frequently and profusely after the third or fourth beer and that the pain seized him shortly thereafter. He is tender to fist percussion over the left costovertebral angle but is afebrile. Which of the following is the most likely diagnosis?

52) A 53-year-old man is brought to the emergency department by his wife because of headache and visual changes. Approximately 3 hours ago, he had the acute onset of an extremely severe posterior headache that was non-radiating but was associated with nausea and vomiting. This headache subsided, but over the past hour he has developed mild neck stiffness and pain on flexion of his neck. The patient is not cooperative, so no additional history is known; however, his wife states that he was feeling well until recently and has no allergies. The patient appears moderately uncomfortable and is complaining of the worst headache he has ever experienced. Which of the following is the most likely cause for his symptoms?

54) 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?

55) A patient involved in a car accident sustains burst fractures of several thoracic vertebral bodies. At the time of admission, he has no neurologic function at all below the level of the injury and he has flaccid sphincters. After a few days, there is partial recovery of function; the remaining deficits are loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, with preservation of vibratory and positional senses. Which of the following is the most likely diagnosis?

56) A 51-year-old man is undergoing abdominal surgery and becomes hypotensive while under general anesthesia. The patient had been doing well during most of the procedure but now has a blood pressure of 80/40 mm Hg. His past medical history is significant for coronary artery disease and diabetes mellitus. A pulmonary artery catheter placed prior to the procedure gives the following data: Central venous pressure 10 mmHg, Pulmonary artery pressure 60/30 mmHg, Pulmonary capillary occlusion 24 mm Hgpressure Cardiac output 2.3 L/min. Which of the following is the most likely diagnosis?

57) A 62-year-old man complains of perineal discomfort and reports that there are streaks of fecal soiling in his underwear. Four months ago, he had a perirectal abscess drained surgically. Physical examination shows a perineal opening in the skin lateral to the anus, and a cord-like tract can be palpated going from the opening toward the inside of the anal canal. Brownish purulent discharge can be expressed from the tract. Which of the following is the most likely diagnosis?

58) A 50-year-old woman with a history of essential hypertension presents to the emergency department with sudden onset of a severe headache, nausea and vomiting, and photophobia. On examination, her BP is 160/100 mmHg. She is mildly confused and has nuchal rigidity, without focal neurologic signs. Which of the following is the most likely diagnosis?

59) A 72-year-old man of Norwegian ancestry has a contracted hand that can no longer be extended and placed flat on a table. The problem developed gradually, over many years. He complains of no pain or neurologic abnormalities and, to the extent that the deformity allows, can move his fingers at will. Physical examination demonstrates the deformity described and in addition shows the presence of palpable fascial nodules. Which of the following is the most likely diagnosis?

60) A previously healthy 28-year-old woman develops significant postpartum hemorrhage, with a rapid drop in hematocrit to 18%. Despite aggressive IV fluid resuscitation, the patient has a persistent tachycardia, labile systolic blood pressure, and poor urine output. Ongoing resuscitation includes emergency transfusion with 2 units of O-negative packed red blood cells. During transfusion of the second unit, the patient develops chills, fever, vomiting, and hypertension. These symptoms are most likely the result of which of the following?

61) A 45-year-old woman underwent elective surgery for an inguinal hernia. In the postoperative recovery room, she developed nausea, vomiting, and acute abdominal pain. She has a history of systemic lupus erythematosus, pernicious anemia, type 1 diabetes, chronic low back pain, and uterine fibroids. Her preoperative medications include monthly vitamin B-12 injections, insulin, prednisone, hydroxychloroquine, and acetaminophen. Her blood pressure is 70/40 mm Hg and heart rate is 110/min. Initial laboratory studies show blood glucose of 50 mg/dl. Which of the following is the most likely cause of her condition?

62) A 45-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation. Which of the following is the most likely diagnosis?

63) A 45-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 6-12. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most likely diagnosis?

64) 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?

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

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

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

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

69) A 65-year-old woman presents to the physician’s office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure 6-13. A chest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most likely diagnosis?

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

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

72) A 1-day-old infant with Down syndrome, feeding intolerance, bilious vomiting, and a double bubble on plain radiographs (Figure 6-18). Which one is the most likely diagnostic?

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

74) 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?

75) 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?

76) A 65-year-old male cigarette smoker reports onset of claudication of his right lower extremity approximately 3 weeks previously. He can walk 3 blocks before the onset of claudication. Physical examination reveals palpable pulses in the entire left lower extremity, but no pulses are palpable below the right groin level. Non-invasive flow studies are obtained and are pictured here. What is the level of the occlusive process in this patient?

77) A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanelle and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Which of the following is the most likely diagnosis?

78) A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanels and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. The diagnosis is best confirmed by which of the following?

79) An 80-year-old man is found to have an asymptomatic pulsatile abdominal mass. An arteriogram is obtained (shown below). Which of the following is the most frequent and lethal complication of this condition?

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

81) A 65-year-old woman presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in Figure 6-8. Which of the following is the most likely diagnosis?

82) A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness. Plain abdominal x-rays reveal dilated loops of bowel, and a barium enema is obtained and shown in Figure 6-9. Which of the following is the most likely diagnosis?

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

84) 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?

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

86) A 45-year-old woman presents with hypertension, development of facial hair, and a 7-cm suprarenal mass. Which of the following is the most likely diagnosis?

87) An 85-year-old man presents to the emergency room with an acute onset of midepigastric pain, nausea, vomiting, and hiccups starting 2 days ago. He is unable to keep any food down. Past history is pertinent for a long-standing hiatal hernia, hypertension, and diet-controlled diabetes. Examination reveals vital signs of pulse rate 82/min, BP 100/52 mmHg, respiratory rate 16/min, and temperature 97.2°F. The patient is in no acute distress, but has epigastric tenderness without guarding. Laboratory analysis revealed a hematocrit of 46 and a normal white blood cell (WBC) count. A chest x-ray is shown in Figure 6-5a. A fluoroscopically guided NG tube was placed using contrast, and his stomach was decompressed. After adequate fluid and electrolyte resuscitation, an upper gastrointestinal (UGI) contrast study was obtained and is shown in 6-5b. Which of the following is the most likely diagnosis?

88) An 83-year-old woman presents to a mammographic facility for a screening mammogram. The technician notices a mass in the lateral right breast. The patient denies any breast pain, nipple discharge, skin changes, or breast trauma. A right breast CC view is shown in Figure 6-7. Which of the following is the most likely diagnosis?

89) 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?

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

91) A 45-year-old woman complains to her primary care physician of nervousness, sweating, tremulousness, and weight loss. The thyroid scan shown here exhibits a pattern that is most consistent with which of the following disorders?

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

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

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

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

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

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

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

99) A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable. An MLO view of the right breast is shown in Figure 6-6a along with a magnification view of the craniocaudal (CC) film (Figure 6-6b). Which of the following is the most likely diagnosis?

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

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

102) A 14-year-old black girl has her right breast removed because of a large mass. The tumor weighs 1400 g and has a bulging, very firm, lobulated surface with a whorl-like pattern, as illustrated here. Which of the following is the most likely diagnosis?

103) A 51-year-old woman presents to the physician’s office with a 2-month history of a right breast blood tinged nipple discharge. Past history is unremarkable. Family history is positive for postmenopausal breast cancer in a maternal grandmother. Examination reveals no palpable masses or regional adenopathy, but a serous discharge is easily elicited from a single duct in the right breast. Bilateral mammograms show no abnormalities. Cytology from the discharge was not diagnostic. A ductogram was ordered, and the results are shown: Which of the following is the most likely diagnosis?

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

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

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

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

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

109) A 39-year-old man presents to his physician with the complaint of loss of peripheral vision. Which of the following findings are demonstrated by the subsequent magnetic resonance imaging (MRI) scan, shown here?

110) A 50-year-old woman presents to the physician’s office for evaluation of a right neck mass. The mass has been present for 3 years and is painless. On examination, a nontender, firm, 2.5-cm mass is noted slightly below and posterior to the angle of the mandible on the right. Which one is the most likely diagnosis?

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

112) 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?

113) A 76-year-old woman presents with acute onset of persistent back pain and hypotension. A CT scan is obtained (shown below), and the patient is taken emergently to the operating room. Three days after surgery she complains of abdominal pain and bloody mucus per rectum. Which of the following is the most likely diagnosis?

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

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

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

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

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

119) A term infant is born at a small community hospital by caesarean section for failure to progress. The infant is noted to have the following abnormality at birth. Which of the following is the most likely diagnosis?

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

121) 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?

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

123) A 55-year-old-woman presents to the physician’s office for evaluation of mammographic findings on a screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for insulin-dependent diabetes. Family history is positive for postmenopausal breast cancer in her mother. She has a normal breast examination and no axillary adenopathy. A mediolateral oblique (MLO) view of the right breast is shown: Which of the following is the most likely diagnosis?

124) 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?

125) A 45-year-old man presents to the physician’s office complaining of dysphagia and retrosternal pressure and pain of 2-year duration. The symptoms have worsened over the last 3 months. He has a 30 pack-year smoking history and drinks beer on weekends. Vital signs include a BP of 150/90 mmHg, pulse rate of 90/min, and respiratory rate of 12/min, with a normal temperature. Examination reveals a thin man with a normal heart, lung, and abdomen examination. An esophagogram reveals a 6-cm, smooth, concave defect in the midesophagus with sharp borders. Esophagoscopy reveals intact overlying mucosa and a mobile tumor. Which of the following is the most likely diagnosis?

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

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

128) 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?

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

130) A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. His abdomen is soft and nondistended, with fullness to palpation in the right upper quadrant. The child passed another stool in the emergency department (see Figure 6-14). Which of the following is the most likely diagnosis?

131) In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure 6-19. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most likely diagnosis?

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

133) A 10-day-old infant presenting with bilious vomiting, paucity of gas on plain radiographs, and duodenal obstruction on UGI contrast study (Figures 6-15 and 6-16). Which one is the most likely diagnostic?

134) A neonate with bile-stained vomiting, abdominal distention, dilated loops of bowel on plain radiographs, and a small-caliber colon on contrast enema (Figure 6-17). Which one is the most likely diagnosis?

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

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

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

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

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

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

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

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

143) A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most likely diagnosis?

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

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

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

2) 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?

3) 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?

4) A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. A barium xray is obtained, and one view is shown in Figure 6-11. Which of the following is the most likely diagnosis?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

22) 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?

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

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

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

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

27) A 72-year-old man comes in complaining of persistent and nagging low back pain that he has had for several weeks. The pain seems to be increasing in intensity, is worse at night, is unrelieved by rest or positional changes, and is not exacerbated by coughing, sneezing, or straining to have a bowel movement. He is a chronic smoker, and for the past 3 months has had persistent cough with occasional bloody streaked sputum, as well as a 20-pound weight loss. On physical examination, he is distinctly tender to palpation at a particular spot over his lower thoracic spine. Which of the following is the most likely diagnosis?

28) The unrestrained front-seat passenger in a car that crashed at high speed arrives at the emergency department with signs of moderate respiratory distress. Physical examination shows no breath sounds at all on the left hemithorax. Percussion is unremarkable, and his vital signs are normal. A chest x-ray film shows a collapsed left lung and multiple air-fluid levels filling the left pleural cavity. A nasogastric tube that had been placed prior to taking the film shows the tube reaching the upper abdomen and then curling up into the left chest. Which of the following is the most likely diagnosis?

29) A 67-year-old man shows up in the emergency department because he has not been able to void for the past 12 hours. He feels the need to, but he cannot do it. He gives a history that, for several years now, he has been getting up four or five times a night to urinate. It would take him a considerable time to get the urinary stream going, and the stream lacked force and often ended in a dribble. Because of a cold, 2 days ago he began taking an antihistamine, taking a decongestant, and drinking plenty of fluids. Physical examination shows a palpable, smooth, round mass arising from the pubis and reaching about half way toward the umbilicus. The mass is dull to percussion, and pushing on it accentuates the feeling of needing to void. Rectal examination reveals a large, boggy, non-tender prostate gland without nodules. This a classic presentation for which of the following acute conditions?

30) Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Which of the following is most appropriate to provide diagnostic confirmation of the nature of the problem and eventual therapy?

31) 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?

32) A 33-year-old woman is involved in a high-speed automobile collision. She arrives at the emergency department gasping for breath. Her lips are cyanotic and she has flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple rib fractures. Her blood pressure is 60/45 mm Hg, pulse is 160/min and feeble and central venous pressure is 25 cm H2O. Her neck and forehead veins are distended. She is diaphoretic and has a hint of subcutaneous emphysema in the lower neck and upper chest. Her left hemithorax has no breath sounds and is hyper resonant to percussion. The trachea is deviated to the right, as are the heart sounds. Which of the following is the most likely diagnosis?

33) A 32-year-old male is rushed to the emergency room after a motor vehicle accident. He was driving 55 mph when he suddenly lost control of his vehicle and hit a tree. He was wearing a seat belt. On physical examination, the patient appears scared and complains of moderate chest and abdominal discomfort. His voice is soft. His blood pressure is 190/ 100 mmHg and his heart rate is 100/min. The pupils are symmetric and reactive to light and the trachea is midline. You note bruising over the chest and upper abdomen. No penetrating injuries are evident. Which of the following injuries is most likely in this patient?

34) A 23-year-old male is brought to the emergency department following a motor vehicle accident (MVA) where he was the unrestrained driver. The patient was found unresponsive at the scene and was intubated by paramedics. He receives 2.5L of normal saline over the 20 minutes before he reaches the ED. His blood pressure there is 70/30 mmHg and his heart rate is 120/min. On physical examination, he responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. There are multiple bruises over the anterior chest and upper abdomen. His neck veins are flat, trachea is midline and extremities are cold. Cardiac monitoring shows sinus tachycardia. Which of the following is the most likely cause of this patient's current condition?

35) A 33-year-old male falls while riding his bicycle in the park, and presents to the emergency department. Physical examination reveals upper abdominal bruises. His abdomen is non-distended, soft, and mildly tender in the epigastrium. Abdominal CT scan does not reveal any abnormalities. The patient is sent home with analgesic medications. He returns one week later with fever, shaking chills, poor appetite and deep abdominal pain Which of the following is most likely related to this patient's symptoms?

36) A 36-year-old woman presents to the emergency department with severe epigastric pain and right shoulder pain of about two hours duration. She also reports having one episode of emesis. When asked about her diet, she explains that she unintentionally fasted yesterday and had a large meal two hours ago. Her past medical history is significant for frequent heartburn for which she takes ranitidine. Several hours after presenting, the patient's pain resolves completely. Which of the following best explains this episode?

37) A 74-year-old male is undergoing elective abdominal aortic aneurysm repair. He is given two units of packed red blood cells during the surgery. He develops fever and chills one hour after finishing the surgery and transfusion. He received one dose of prophylactic antibiotics before surgery. He had coronary bypass grafting two months ago. His temperature is 38.5C (101.3F), blood pressure is 130/76 mm Hg, pulse is 90/min and respirations are 16/min. Physical examination shows a mildly tender wound; there is no redness. The lungs are clearto auscultation. He has a Foley catheter and right subclavian central venous access, each placed at the time of surgery. Which of the following is the most likely cause of his fever?

38) 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?

39) A 23-year-old male is brought to the emergency department after a motor vehicle accident. He was an unrestrained driver. He was found unresponsive at the scene of the accident, and was intubated by the paramedics. He has received 2L of normal saline over the last 20 minutes. His blood pressure is 80/40 mmHg, and heart rate is 120/min. He responds to strong vocal and tactile stimuli by opening his eyes. His pupils are equal and reactive to light. His neck veins are distended. There are multiple bruises involving the anterior chest and upper abdomen. His chest x-ray shows a small, left-sided pleural effusion and normal cardiac contours. Which of the following is the most likely diagnosis?

40) A 65-year-old male comes to the ER because of sudden onset severe pain in his right leg. He says he has never previously had pain in his leg and denies any recent trauma, fever or chills. He recently suffered an acute anterior wall myocardial infarction that resulted in cardiogenic shock and is currently undergoing cardiac rehabilitation. His other medical problems include hypertension, diabetes and hyperlipidemia. His temperature is 36.7C (98F), blood pressure is 110/70 mm Hg, pulse is 90/min (regular) and respirations are 16/min. His lungs are clear to auscultation. His heart rate is regular with no murmurs. Below the knee the right leg is cool to touch and appears pale. The dorsalis pedis pulse is not palpable while the popliteal pulses are full. Pulses are normal in the contralateral extremity. Neurologic examination shows numbness over the dorsum of the leg and foot. Which of the following is the most likely cause of his symptoms?

41) An 88-year-old male complains of severe right calf pain several hours after undergoing a right femoral artery embolectomy. He also complains of a burning sensation in his posterior right leg. He has a long history of atrial fibrillation and hypertension. His past medical history also includes stroke, bleeding duodenal ulcer, diabetes mellitus and diabetic nephropathy. On physical examination, his blood pressure is 160/70 mm Hg and his heart rate is 100 per minute and irregular. His right calf is swollen, tense and exquisitely tender; the pain is worsened by passive extension of the right knee. Dorsalis pedis and posterior tibial pulses are palpable in the bilateral lower extremities. Which of the following is the most likely cause of this patient's symptoms?

42) A 62-year-old man is brought to the emergency department after being involved in a motor vehicle collision where he suffered serious burns. On physical examination there are second degree burns covering both upper extremities and third degree burns over the anterior aspects of both lower extremities. On day three of his hospitalization, the patient develops tachycardia and decreased urine output. His blood pressure is 90/60 mmHg, pulse is 120/min, temperature is 95°F (35°C), and respirations are 26/min. Laboratory analysis reveals: Blood glucose 230 mg/dL, WBC 16,000/mm3, Platelets 80,000/mm3. Which of the following is the best explanation for this patient's current condition?

43) A 36-year-old male presents with firm, non-tender swelling of his right cheek. He tells you that he had similar swelling at that site two years ago and was diagnosed with a tumor, which was subsequently removed without complication. Examination reveals fullness of the parapharyngeal space on the right side. Repeat surgery in this patient is most likely to result in which of the following complications?

44) A 43-year-old male complains of right shoulder pain and weakness after falling on his outstretched hands two days ago. He denies any swelling or shoulder deformity. You passively abduct both his arms above his head and then ask him to bring his arms down slowly in an adducting motion. The right arm drops rapidly at the midpoint of its descent. What is the most likely diagnosis?

45) A 32-year-old female presents with intermittent blood staining of her bra from her left breast. She has not felt any lumps on either breast. Physical examination shows no breast mass or axillary lymphadenopathy. Ultrasonogram of the breast is within normal limits. Which of the following is the most likely diagnosis?

46) A 31-year-old male presents to your office with pain and swelling over his coccyx. He has never had symptoms like this before. His past medical history is significant for an appendectomy two years ago and acute pyelonephritis one year ago. Which of the following is the most likely diagnosis?

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

48) A 12-year-old boy is brought to the emergency department after being involved in a motor vehicle collision. He is in no distress and is admitted for observation. Two hours after admission, he develops tachypnea and tachycardia. His temperature is 36.7C (98F), blood pressure is 110/66 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows bruises on the right side of the chest, but palpation of the ribs does not elicit pain or suspicion for rib fractures. Breath sounds are decreased on the right side. ABG on 6 liters of oxygen shows PO2 of 60 mm Hg, PCO2 of 32 mm Hg, and pH of 7.42. An x-ray film of the chest shows a patchy irregular alveolar infiltrate in the right middle and lower lobes. Which of the following is the most likely diagnosis?

49) A 31-year-old male is brought to the emergency department after being involved in a motor vehicle collision as an unrestrained passenger. He was given 3L of normal saline in the ambulance on his way to the hospital and has been receiving 5 L/min of oxygen by nasal cannula. He is agitated and moves all four extremities spontaneously. His blood pressure is 85/55 mmHg and his heart rate is 120/min. His respiratory rate is 30/min. His pupils are symmetric and reactive to light. His neck veins are flat and his trachea is shifted slightly to the right. Over the left hemithorax, breath sounds are absent and there is dullness to percussion. Which of the following diagnoses is most likely?

50) A 45-year-old policeman presents to your office complaining of tiredness and sleepiness. He says that his job seems tiring to him recently. It is difficult for him to get up in the morning and go to work. He goes to bed early because he feels tired and sleepy. Two months ago, he was investigating a case of massive murder. He slipped on the blood on the floor, fell and hit his head. He also describes recent abdominal pain that is constant and gnawing, interfering with his sleep. His appetite is poor, and he lost 15 pounds over the last month. Physical examination is significant only for tenderness and fullness in the epigastrium. Which of the following is the most likely diagnosis?

51) A 54-year-old female with a 30 pack-year smoking history undergoes cholecystectomy after an episode of biliary pancreatitis. On the third postoperative day, she complains of discomfort in the upper abdomen. Though she is breathing comfortably, her oxygen saturation is 90%, compared with 98% yesterday. Her blood pressure is 130/80 mmHg, heart rate is 90/min, respiratory rate is 20/min, and temperature is 98F (36C). Arterial blood gas analysis reveals the following: pH = 7.44, p02 =64 mmHg, pC02 =34 mmHg, which of the following most likely explains the observed findings?

52) A 35-year-old male presents with complaints of muscle weakness and sensory loss in his upper extremities. His medical history is significant for involvement in a motor vehicle accident seven years ago in which he sustained a whiplash cervical spine injury. Physical examination today reveals moderate wasting of the small hand muscles and impaired pain and temperature sensation in the bilateral upper extremities. Light touch, vibration, and position senses are all intact. Which of the following is the most likely diagnosis?

53) A 45-year-old male presents to his physician with persistent nausea and vomiting of partially digested food for the past month. He has also lost 5 lbs of weight during this period of time. His appetite is good but he feels full after a few bites. His past medical history is significant for a one-year history of type 2 diabetes and a suicide attempt 6 months ago in which he ingested acid. He drinks alcohol and smokes one pack of cigarettes daily. His temperature is 36.80C (98.20 F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 16/min. Mucous membranes are dry. Examination shows succussion splash on the epigastrium. Which of the following is the most likely diagnosis?

54) A 34-year-old male undergoes successful laparotomy for a gun-shot wound. He received 5 units of packed red blood cells during the surgery. He has been receiving incentive spirometry and ampicillin/sulbactam. However, he developed a fever of 38.7C (101.7F) on the sixth postoperative day. His blood pressure is 120/76 mm Hg, pulse is 97/min and respirations are 14/min. Examination shows an alert, pleasant male in no acute distress. The oropharynx is clear. The lungs and heart are clear to auscultation. The abdomen is soft and non-tender, and the wound has no discharge. He has a right femoral triple lumen catheter and Foley catheter in place. Extremities have no swelling or redness. Two days later, four bottles of blood cultures grew coagulase negative Staphylococcus. Which of the following is the most likely cause of his fever?

55) An overweight 12-year-old boy presents with left knee pain that has been going on intermittently for the past three months. Physical activity, especially stair climbing, exacerbates the pain. The boy's mother also points out that he has been limping recently. On physical examination, his anterior left hip is moderately tender to palpation, and when he is asked to stand on his left leg, the right half of his pelvis tilts downward. Which of the following best explains this finding?

56) A 23-year-old woman comes to the physician because of a 4-week history of a whistling noise during respiration. She underwent a difficult rhinoplasty a few months ago. The noise is getting louder and is annoying. Which of the following is the most likely diagnosis?

57) A 46-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unresponsive. His injuries include a basilar skull fracture, brain contusion, fractures of ribs 7-10, hemopneumothorax on the right and a pelvic fracture. After placement of a chest tube and pelvis fixation, his condition stabilized. On the fifth day of his hospital stay, he is still unresponsive with a Glasgow Coma Scale of 8. He is breathing spontaneously. Examination shows an abnormal facial reaction to abdominal palpation. Pain appears to be elicited by palpation in right upper quadrant. Bowel sounds are diminished. Rectal examination shows no abnormalities. Nasogastric tube aspiration shows retention of gastric contents. An abdominal CT scan shows gaseous distention of the small and large bowels without airfluid levels. The gall bladder is distended and pericholecystic fluid is present. Stones are not seen. Which of the following is the most likely diagnosis?

58) A 77-year-old woman is brought to the emergency department because of sudden-onset intense diffuse abdominal pain followed by vomiting. Her past medical history is significant for chronic uncontrolled hypertension, cerebrovascular accident, diabetes and hyperlipidemia. She takes multiple medications. She does not use tobacco, alcohol or drugs. Her temperature is 38.30 C (1010 F), blood pressure is 180/100 mm Hg, pulse is 110/min and irregular and her respirations are 22/min. She is in severe distress. Lungs are clear to auscultation. Abdominal examination shows severe pain to palpation and nearly absent bowel sounds. There is rigidity and rebound. Rectal examination shows heme-positive stools. EKG shows absent P waves, irregular rhythm and inverted T waves. There are no previous EKGs for comparison. An x-ray film of the chest shows cardiomegaly. Laboratory studies show: Hematocrit 49%, Leukocyte count 77,500/mm3, Troponin I normal. What is the most likely diagnosis?

59) A 35-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unconscious. His blood pressure is 100/50 mm Hg, pulse is 100/min, and respirations are 19/min. Examination shows bilaterally reactive and non-dilated pupils. He does not follow commands and makes inappropriate sounds. A CT scan of the head shows numerous minute punctuate hemorrhages with blurring of the gray-white matter interface. Which of the following is the most likely diagnosis?

60) A 65-year-old man with cervical spondylosis secondary to degenerative changes in the cervical spine was admitted after being involved in a motor vehicle accident. He regained consciousness after 5 minutes. After regaining consciousness, he had complete weakness in both upper extremities but was able to move his lower extremities. Vital signs are stable. Plain x-ray films of the cervical spine show no abnormalities except those consistent with mild degenerative changes. Which of the following is the most likely diagnosis?

61) A 54-year-old alcoholic man comes to the emergency department because of dysphagia, drooling and a fever. He has been sick for two days and has not been able to eat. His mouth is swollen and feels hot. Examination shows a pale, febrile man who is drooling. There is redness around the entire mouth extending into the floor of the mouth. A tender, symmetric and indurated swelling with palpable crepitus is present in the submandibular area. Laboratory study shows an elevated W BC count. Which of the following is the most likely source of the oral cavity infection?

62) A 69-year-old man is evaluated after undergoing an elective repair of a rapidly expanding abdominal aortic aneurysm. The surgical procedure was complicated by a significant amount of blood loss and required multiple transfusions. In the postoperative recovery room, he had weakness in both lower extremities and developed urinary retention. Neurologic examination shows spastic paraplegia and loss of pain sensation over the lower extremities; vibratory sensation is intact. Upper extremity examination shows no abnormalities. Which of the following is the most likely pathophysiologic mechanism of the neurologic dysfunction?

63) A 24-year-old woman comes to the physician because of a one-week history of increasing pain in the right leg. She is an active dancer and practices 4-5 hours a day. One week ago, she felt a dull aching pain in the right middle leg; the pain has been increasing since and is particularly bad when she dances. The pain is interfering with her dancing sessions. She is afebrile and her other vital signs are within normal limits. Examination shows point tenderness over the midpoint of the right leg; there are no abnormalities of the skin overlying the tender point. Knee and ankle examinations show no abnormalities. An x-ray of the lower leg shows no abnormalities. ESR is within normal limits. Which of the following is the most likely cause of her pain?

64) A 32-year-old male comes to the emergency department because of a 3 day history of increasing lower abdominal pain, mild diarrhea and rectal pain on defecation. Ten days ago he had right lower quadrant (RLQ) pain for about 24 hours that resolved spontaneously. Since then, he has had malaise and low-grade fever. His temperature is 38.70C (101.60F), blood pressure is 150/90 mm Hg, pulse is 110/min and respirations are 15/min. Examination shows lower abdominal tenderness without rebound. No masses are palpable, and bowel sounds are decreased. Rectal examination shows a very tender, boggy and fluctuant bulging on palpation with the tip of the finger anteriorly. Laboratory studies show: Complete blood count: Hemoglobin 14.0 g/L, Platelets 270,000/mm3, Leukocyte count 15,500/mm3, His current condition is most likely a complication of?

65) A 70-year-old male rushed to the emergency department because of bright red bleeding per rectum. He says his commode is full of blood and has never experienced any bleeding before. He has a history of constipation. He takes daily aspirin for prevention of stroke and hydrochlorothiazide for high blood pressure. His temperature is 36.50C (97.80F), blood pressure is 100/60 mm Hg, pulse is 120/min and respirations are 20/min. He is not hypoxic. Abdomen is soft, non-distended and non-tender; no masses or organomegaly are palpated; bowel sounds are normal. Rectal examination shows bright red blood and an enlarged prostate. Nasogastric tube aspirate shows non-bilious stomach contents without blood. An x-ray of the abdomen shows no abnormalities. Which of the following is the most likely cause of his bleeding?

66) An 11-year-old boy is brought to the emergency department for evaluation of an injury from jumping off a 10 ft wall, 2 days ago. He had some pain in his feet immediately following the jump, but was able to walk. The past 2 days, he has had increasing pain in his right foot with walking. He has no pain at rest. He has some "crunching" in the right foot. Physical examination shows the foot appears normal with the exception of suffusion on the plantar surface. Passive motion of the second toe and passive dorsiflexion of the foot produces pain in the middle of the foot. Which of the following is the most likely diagnosis?

67) An 18-year-old woman at 9 weeks' gestation is brought to the emergency department because of an open fracture of the tibia and fibula. She is hemodynamically stabilized and referred to the orthopedic department. She is scheduled for internal fixation of the tibia for the following day. However, before the surgery she develops severe dyspnea and confusion. Her temperature is 37.70C (99.90F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows numerous non-palpable petechiae in the upper part of the body. Which of the following is the most likely diagnosis?

68) 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?

69) A 7-year-old child is brought to the emergency department after being involved in a highway motor vehicle collision. He had blunt trauma to his abdomen. Vital signs are stable, except for a respiratory rate of 30 per minute. Physical examination shows bruising of the upper abdomen, abdominal distention, and tenderness. He is in moderate respiratory distress; breath sounds are decreased on the left side. Chest tube placement shows no blood or air in the pleural cavity. An x-ray film of the chest shows an elevated left hemidiaphragm. Laboratory studies show hemoglobin and hematocrit within normal limits. Which of the following is the most likely diagnosis?

70) A 25-year-old motorcyclist is brought to the emergency department after being involved in a collision with an automobile. On arrival he is in obvious pain. He expresses an urge to void, but is unable to do so. Genital examination shows blood at the urethral meatus and a scrotal hematoma. Rectal examination reveals a high riding prostate. Abdominal examination is suggestive of a distended bladder. Which of the following is the most likely diagnosis?

71) A 43-year-old mildly overweight female complains of periodic right knee swelling and pain with physical activity for the past three months. She says that this problem started while on a hiking trip three months ago, at which point she experienced a 'popping' sensation in her right knee. She recalls that her knee was swollen the next day, and responded to over-the-counter pain killers. Recently, she has been having to limit her physical activities due to knee pain. On physical examination, there is tenderness of the anterior and medial right knee joint. Which of the following is the most likely diagnosis?

72) A 35-year-old black man is brought to the emergency department after a motorcycle accident. He hit the street with the side of his head. He was found unconscious when the emergency medical team arrived. However, on the way to the emergency department he regains consciousness. Upon arrival he is confused and complains of a headache. His temperature is 36.9C (98.5F), blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows a dilated pupil on the right side, with some weakness of the left arm and leg. CT scan of the head shows a biconvex hematoma on the right side of the head. Which of the following is the most likely diagnosis?

73) 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?

74) A four-year-old boy is brought to the physician because of discomfort in the left hip and left knee that is causing him to limp. Examination shows normal knee joints bilaterally, but there is marked limitation of internal rotation and abduction of the left hip. His temperature is 37.1 C (98.6F), blood pressure is 90/60 mm Hg, pulse is 80/min and respirations are 16/min. Laboratory studies including complete blood count and basic metabolic profile show no abnormalities. Which of the following is the most likely diagnosis?

75) A 65-year-old male is being evaluated for hip pain. The pain has been present for several months and is constant. He denies any weight loss or loss of appetite. His past medical history is significant only for high blood pressure. His temperature is 37.2 C (98.9 F), blood pressure is 150/88 mm Hg, pulse is 80/min and respirations are 12/min. Physical examination is unremarkable. Laboratory studies show: Alkaline phosphatase Elevated, Gamma glutamyl, transferase Normal, Serum calcium Normal, 2,5 (OH)2 vitamin D Normal. Bone scan shows increased uptake in several spots. This patient is at high risk of developing?

76) A 78-year-old diabetic man has undergone surgical repair of a large abdominal aortic aneurysm. Postoperatively, he develops left lower quadrant abdominal pain followed by bloody diarrhea. He has a history of prostate cancer and received radiation therapy several years ago. He eats a low fiber diet. He quit smoking recently. Vital signs show a low grade fever. Examination shows tenderness in the left lower quadrant and rectal examination reveals blood in the stool. CT scan of the abdomen demonstrates thickening of the colon at the rectosigmoid junction. On colonoscopy, ulcerations are seen in the same area while the colon above and below the lesions is completely normal. Which of the following is the most likely cause of his symptoms?

77) A 34-year-old man comes to the physician after being involved in a street fight. He has a painful and swollen left arm. Neurovascular examination shows no abnormalities. An x-ray film of the arm shows a fracture of the midshaft of the humerus. Closed reduction of the facture is done and the arm is kept in a hanging cast. One hour later he has numbness of the left wrist and marked limitation of extension at the wrist. Which of the following is the most likely diagnosis?

78) A 35-year-old man is brought to the emergency department after he jumped from the fourth floor of a burning building. His temperature is 36.9C (98.5F), blood pressure is 90/40, pulse is 90/min, and respirations are 20/min. Examination shows a fracture of the right tibia. He is conscious and his pupils are bilaterally equal and reactive to light and accommodation. His neurological examination shows paraplegia, with loss of pain and temperature in both legs but normal proprioception. Upper extremities do not show any neurological deficits. Passive straight leg raising test is negative. A CT scan of the spine shows a burst fracture at the level of the fourth thoracic vertebra. Which of the following is the most likely diagnosis?

79) A 32-year-old man comes to the emergency room (ER) because of acute onset left flank pain, hematuria and vomiting. His pain is relieved with ketorolac in the ER. He has a history of abdominal pain due to Crohn disease, but that pain was always in the rightlower quadrant and was never this severe. His temperature is 36.8C (98.2F), blood pressure is 120/65 mm Hg, pulse is 110/min and respirations are 16/min. Chest auscultation is clear. Abdomen is soft and mildly tender over the left flank. He has no rebound or rigidity. Bowel sounds are decreased. A laparotomy scar is present in right lower quadrant. Which of the following is the most likely cause of his symptoms?

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

81) A 30-year-old man comes to the physician because of a 2-week history of swelling and pain in the right knee. He first experienced pain when he twisted his leg while playing football 15 days ago. He felt something 'popping' in the knee at that time but ignored it. The pain and swelling has been increasing since, and he feels sudden pain with extension of his leg. Examination shows the right knee is swollen and tender along the medial side. Full extension of the right knee is not possible due to sudden pain during terminal extension. Snapping can be felt in the right knee on tibial torsion with the knee flexed at 90 degrees. An x-ray film of the knee joint shows no abnormalities. Which of the following is the most likely diagnosis?

82) A 46-year-old male is brought to the emergency department after falling on his head and back during a downhill bike race and losing consciousness for 1 minute. He has severe back and abdominal pain. AP and lateral skull films show no abnormalities. Lumbar films show anterior compression wedge fractures of the bodies of L1 and L2. A brace is placed. CT scan of the abdomen shows a mild retroperitoneal bleed and splenic laceration. During the hospitalization he was treated conservatively with analgesics and supportive measures. On hospital day 3, he started to have abdominal distention, pain and nausea. His last bowel movement was 4 days ago and he is not passing gas. His abdomen is distended, tympanic and mildly tender without rebound or guarding. Bowel sounds are absent. An x-ray film of the abdomen is shown below: Which of the following is the most likely diagnosis?

83) 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?

84) A 12-year-old boy is brought to the emergency department after falling from a tree. Examination shows tenderness and swelling over the left lower arm. An x-ray film of the arm shows a fracture of the distal end of the humerus with proximal and posterior displacement of the distal fracture segment. Closed reduction of the fracture is performed. However, postoperatively the patient complains of increasing pain in the left arm and forearm. Twelve hours postoperatively his forearm is pale and cold. There is marked pain on passive extension of the fingers. Which of the following is the potential dreaded complication of this condition?

85) A 7-year-old boy has been complaining of left hip pain for the past 8 months. Over recent weeks, he has developed a limp. When you examine his gait, you note that he takes short steps with his left leg. On physical examination, his left hip has significantly limited range of motion, and there is atrophy of the left proximal thigh muscle. X-ray of the patient's pelvis is shown below: W hich of the following is most likely responsible for this patient's condition?

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

88) A 51-year-old male with a history of alcoholic pancreatitis presented to the hospital because of sudden onset severe retrosternal and upper abdominal pain. He has been vomiting for the past few hours after consuming alcohol. His temperature is 38.1C (100.9F), blood pressure is 140/90 mm Hg, pulse is 120/min and respirations are 30/min. Examination shows palpable crepitus in the suprasternal notch. Lungs are clear to auscultation. The abdomen is tender to palpation mostly in the epigastrium. Which of the following is the most likely cause of his current condition?

89) A 53-year-old male comes to the emergency department complaining of sudden onset intense, stabbing epigastric pain. He also vomited once and a dull, aching pain then spread through his entire abdomen. He has had nonspecific epigastric pain for several months and saw a physician one month ago. He also has a history of constipation, type II diabetes mellitus and hyperlipidemia. He has smoked one and a half packs of cigarettes daily for 26 years. He drinks 4 oz of alcohol daily. His temperature is 38.3C (100.4F), blood pressure is 160/95 mm Hg, pulse is 100/min and respirations are 26/min. The entire abdomen is tender to palpation with rebound, but there is no guarding. No masses are palpable, and Murphy's sign elicits mild pain. Rectal examination shows no abnormalities. Abdominal ultrasound performed 2 weeks ago showed stones in the gall bladder. Upright chest x-ray is shown below: Which of the following is the most likely diagnosis in this patient?

90) ) A 39-year-old paleontologist complains of right-sided hip pain that makes it very difficult for him to lay on his right side while sleeping. He localizes the pain to the outer surface of his thigh. Which of the following is the most likely cause of his pain?

91) A 34-year-old male is involved in a high-speed highway motor vehicle collision. He is intubated by rescue workers at the accident scene. In the emergency department, the patient has decreased breath sounds on the right side, normal breath sounds on the left, and hypotension. A right-sided chest tube is placed. Physical examination reveals multiple bruises over the entire chest wall as well as subcutaneous emphysema. A few hours later, his chest x-ray shows an accumulation of air in the pleural space as well as pneumomediastinum. Which of the following is the most likely diagnosis?

92) A 22-year-old primigravida woman at 33 weeks gestation is brought to the emergency department after a tonic clonic seizure. On arrival, she also has visual disturbances and a headache. She is given magnesium sulfate and hydralazine. She soon regains consciousness but cannot move her right arm; however, she can move her fingers. Her temperature is 37.2C (99F), blood pressure is 160/100 mm Hg, pulse is 110/min and respirations are 20/min. Examination shows her arm extended along the chest and internally rotated. There is no sensory loss on the arm, but there is an inability to externally rotate the shoulder. Deep tendon reflexes (DTR) are intact. Which of the following is the most likely cause of her inability to move her hand?

93) A 15-year-old boy is brought to the physician because of a 15-day history of painful swelling of the right knee. The swelling and redness were immediate after hitting his knee on the door, but have not subsided after 15 days of ibuprofen. He states the pain is increasing. He has no other complaints. His temperature is 37.1C (98.9F), blood pressure is 110/75 mm Hg, pulse is 80/min, and respirations are 22/min. Laboratory studies show a normal ESR and elevated serum alkaline phosphatase. Examination shows the skin is warm and non-tender. An x-ray film of the femur and the knee joint shows an osteolytic lesion of the distal femur along with periosteal inflammation. Which of the following is the most likely diagnosis?

94) A 55-year-old man comes to the physician because of chronic leg problems. He has had multiple medical problems and is unable to get good medical care due to lack of insurance. A photograph of his legs is shown below. Which of the following is the most likely cause of his condition?

95) A 35-year-old man is brought to the emergency department after he jumped from the fourth floor of a burning building. His temperature is 36.9° C (98.5° F), blood pressure is 90/40, pulse is 90/min, and respirations are 20/min. Examination shows a fracture of the right tibia. He is conscious and his pupils are bilaterally equal and reactive to light and accommodation. His neurological examination shows paraplegia, with loss of pain and temperature in both legs but normal proprioception. Upper extremities do not show any neurological deficits. Passive straight leg raising test is negative. A CT scan of the spine shows a burst fracture at the level of the fourth thoracic vertebra. Which of the following is the most likely diagnosis?

96) A 30-year-old man comes to the physician because of a 2-week history of swelling and pain in the right knee. He first experienced pain when he twisted his leg while playing football 15 days ago. He felt something popping' in the knee at that time but ignored it. The pain and swelling has been increasing since, and he feels sudden pain with extension of his leg. Examination shov1s the right knee is swollen and tender along the medial side. Full extension of the right knee is not possible due to sudden pain during terminal extension. Snapping can be felt in the right knee on tibial torsion with the knee flexed at 90 degrees. An x-ray film of the knee joint shows no abnormalities. Which of the following is the most likely diagnosis?

97) A 25-year-old male is brought to the emergency department following a motor vehicle accident in which he was the unrestrained driver. The emergency response team's reports indicate that his breath smelled of alcohol at the scene. En route to the hospital, the patient receives 2 liters of intravenous normal saline, and in the ED his blood pressure is 100/60 mmHg, heart rate is 120/min, and respiratory rate is 34/min. His neck veins are flat. You note multiple bruises overlying his anterior chest wall and upper abdomen. On inspiration, there is inward motion of the right side of his chest wall. His abdomen is soft and non-distended. He is put on positive pressure mechanical ventilation and his chest movements become symmetric. Which of the following is the most likely diagnosis?

98) 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?

99) A 22-year-old college student notices a bulge in his right groin. It is accentuated with coughing, but is easily reducible. Which of the following hernias follows the path of the spermatic cord within the cremaster muscle?

100) An 80-year-old man with history of symptomatic cholelithiasis presents with signs and symptoms of a small-bowel obstruction. Which of the following findings would provide the most help in ascertaining the diagnosis?

101) A 42-year-old man has bouts of intermittent crampy abdominal pain and rectal bleeding. Colonoscopy is performed and demonstrates multiple hamartomatous polyps. The patient is successfully treated by removing as many polyps as possible with the aid of intraoperative endoscopy and polypectomy. Which of the following is the most likely diagnosis?

102) A 35-year-old man is brought to the emergency department after a motorcycle accident. He is unconscious when the emergency medical team arrived. He regains consciousness on the way to the emergency department. Upon arrival, he is mildly confused and complains of headache and nausea. His temperature is 36.9° C (98.5° F), blood pressure is 102/60 mm Hg, pulse is 116/min, and respirations are 22/min. Pupils are equal and reactive to light. He moves all extremities on command, and deep tendon reflexes are symmetric. Head CT scan shows: Which of the following is the most likely diagnosis?

103) An 18-year-old woman at 9 weeks' gestation is brought to the emergency department because of an open fracture of the tibia and fibula. She is hemodynamically stabilized and referred to the orthopedic department. She is scheduled for internal fixation of the tibia for the following day. However, before the surgery she develops severe dyspnea and confusion. Her temperature is 37.7° C (99.9° F), blood pressure is 110/70 mmHg, pulse is 11 O/min, and respirations are 22/min. Examination shows numerous non-palpable petechiae in the upper part of the body. Which of the following is the most likely diagnosis?

104) A 46-year-old man is brought to the emergency department after a fall during a downhill bike race. He lost consciousness for approximately 1 minute after the fall. He complains of severe back and abdominal pain. He has no other medical problems. Head computed tomography (CT) scan shows no intracranial bleeding. Lumbar films suggest a compression wedge fracture of the body of L2 vertebra, and a brace is placed. Abdominal CT scan shows a small retroperitoneal bleed and splenic laceration. He is conservatively treated with analgesics and supportive measures. On hospital day three, he complains of abdominal pain and nausea. His abdomen is distended, tympanic, and mildly tender, without rebound or guarding. Bowel sounds are absent. X-ray of the abdomen reveals. Which is the most likely diagnosis?