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.376) A 26-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling of her hands and feet. Her previous prenatal check-up was normal. Blood pressure is 150/95 mmHg, and five minutes later following lateral rest her blood pressure is 140/95 mmHg. Physical examination shows 2+ pitting edema of the legs and a macular eruption on the cheekbones. Optic fundi show no abnormalities. Laboratory studies are as follows: Urinalysis: 4+ protein, RBC casts, Urine protein: 8 g/24hr, Uric acid: 5 mg/dl, BUN: 28 mg/dl, Serum creatinine: 2.1 mg/dl, Serum electrolytes, liver function tests and coagulation studies are within normal limits. A serum antinuclear antibody (ANA) test is positive in high titers Which of the following is the most likely diagnosis?

.377) A 26-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling of her hands and feet. Her previous prenatal check-up was normal. Blood pressure is 150/95 mmHg, and five minutes later following lateral rest her blood pressure is 140/95 mmHg. Physical examination shows 2+ pitting edema of the legs and a macular eruption on the cheekbones. Optic fundi show no abnormalities. Laboratory studies are as follows: Urinalysis: 4+ protein, RBC casts, Urine protein: 8 g/24hr, Uric acid: 5 mg/dl, BUN: 28 mg/dl, Serum creatinine: 2.1 mg/dl, Serum electrolytes, liver function tests and coagulation studies are within normal limits. A serum antinuclear antibody (ANA) test is positive in high titers. Which of the following is the most likely diagnosis?

.378) A 26-year-old primigravid woman at 42 weeks' gestation comes to the labor and delivery ward for induction of labor. The prenatal course was significant for a positive group B Streptococcus culture performed at 35 weeks. Antenatal testing over the past 2 weeks has been unremarkable. The patient is started on lactated Ringer's IV solution. Sterile vaginal examination shows that the patient's cervix is long, thick, and closed. Prostaglandin (PGE2) gel is placed into the vagina, and electronic fetal heart rate monitoring is continued. In approximately 60 minutes, the fetal heart rate falls to the 90s, as the tocodynamometer shows the uterus to be contracting every 1 minute with essentially no rest in between contractions. Which of the following was most likely the cause of the uterine hyperstimulation?

.380) A 26-year-old woman comes to the physician's office for evaluation of a vulvar ulcer that she noticed two days ago. Initially she had a small painless papule that later became ulcerated. Upon further questioning she reluctantly admits to using sex to obtain drugs. She also reports using oral contraceptives to prevent pregnancy. On vulvar examination there is a 2-cm ulcer with a non-exudative base and a raised, indurated margin. Painless bilateral inguinal lymphadenopathy is present. Which of the following is the most likely diagnosis?

.382) A 26-year-old woman complains of a vaginal discharge causing burning and itching of the perineum. The pH of the discharge is 4.5. Which of the following is the most likely cause of her discharge?

.383) A 26-year-old woman develops acute lower abdominal pain and vaginal bleeding. While in the bathroom she passes a cast of tissue composed of clot material and then collapses. She is brought to the hospital, where a physical examination reveals a soft, tender mass in right adnexa and pouch of Douglas. Histologic examination of the tissue passed in the bathroom reveals blood clots and decidualized tissue. No chorionic villi or trophoblastic tissue are present. Which of the following conditions is most likely present in this individual?

.384) A 26-year-old woman in the third trimester of her first pregnancy develops persistent headaches and swelling of her legs and face. Early during her pregnancy, a physical examination was unremarkable; however, now her blood pressure is 170/105 mmHg and urinalysis reveals slight proteinuria. Which of the following is the most likely diagnosis?

.386) A 26-year-old woman presents to her physician because of pain in her breast. She gave birth 3 months ago and is breast-feeding. Soon after she began lactating she developed cracks in the nipples, and for the past 5 days her left breast has become progressively more tender. On physical examination, her affected breast is red, hot, swollen, and painful to palpation. Her temperature is 38.3 C (101 F), and her white cell count is 13,000/mm3. Which of the following is the most likely diagnosis?

.387) A 26-year-old woman presents to your office complaining of fatigue. Her past medical history is insignificant. She was adopted in Greece and came to the United States when she was three years old. Her menstrual periods are regular and bleeding lasts three days. She does not use tobacco, alcohol, or illicit drugs. She takes no medication. Laboratory studies show: Complete blood count: Hemoglobin 10.1 g/L, MCHC 28%, MCV 70 fL, Platelets 200,000/mm3, Leukocyte count 7,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%. Fecal occult blood test is negative. Iron therapy is initiated. When the patient returns four weeks later, her lab findings are essentially the same. This patient most likely suffers from:

.389) A 26-year-old woman with panic disorder notes that during the middle of one of her attacks she feels as if she is disconnected from the world, as though it were unreal or distant. Which of the following terms best describes this symptom?

.392) A 27-year-old female at 30 weeks gestation complains of difficulty hearing, especially on the right side. She denies any ear pain or discharge. Her pregnancy was complicated by acute pyelonephritis at 22 weeks gestation, which was treated with antibiotics. She does not smoke or consume alcohol, and she eats a balanced diet. She has no preexisting medical problems and takes no medications aside from a multivitamin. Her blood pressure is 160/100 mmHg and heart rate is 75/min. Cardiac and pulmonary examinations are unremarkable. No focal abnormalities are found on neurologic examination. When a tuning fork is placed on the right mastoid process, she appreciates the tone louder than when it is held near the external auditory meatus. Audiometry shows right low-frequency hearing loss. Which of the following is the most likely cause of this patient's complaints?

.395) A 27-year-old has just had an ectopic pregnancy. Which of the following events would be most likely to predispose to ectopic pregnancy?

.397) A 27-year-old male presents to clinic complaining of "marital problems." He says that for the past year that he has been married, he and his wife have not successfully had sexual intercourse on even one occasion. He strongly feels that she either finds him physically unattractive or is having an affair with another man. He adds that he is extremely frustrated with his wife "contracting herself," which prevents any kind of vaginal penetration. After several failed attempts, his wife now avoids any sexual intimacy with him. Which of the following is the most likely diagnosis?

398) A 27-year-old male presents to the physician's office because of pain on the medial side of the tibia just below the knee. The pain does not radiate and is continuous. He relates the onset of his pain to falling on the ground while playing football two weeks ago. He denies fever, malaise and weight loss. His past medical history is not significant. On examination, a well-defined area of tenderness is present on the upper tibia below the medial knee joint. There is no redness, warmth or swelling. His gait is normal. A valgus stress test has no effect on his pain. X-ray of the knee and tibia shows no abnormalities. Which of the following is the most likely cause of his current symptoms?

.399) A 27-year-old male presents to you with complaints of cough, chest discomfort and dyspnea on exertion. He says that he has lost 10 pounds over the past 2 months. He has been smoking 1 pack per day for the past 10 years. He drinks 2 beers every weekend. He denies illegal drug use and has not had multiple sexual partners. Physical examination is unremarkable. Chest x-ray reveals a large anterior mediastinal mass. Blood work reveals that he has elevated levels of HCG and alpha-fetoprotein (AFP). What is the most likely diagnosis?

400) A 27-year-old male presents with a history of intermittent abdominal distention, flatulence and greasy stools. He also complains of fatigue. He has no other medical problems. His family history is unremarkable. He does not use tobacco, alcohol or smoking. His vital signs are within normal limits. Physical examination shows a pruritic, papulovesicular rash over the extensor surfaces of the extremities and over the trunk, scalp and neck. His abdomen is soft, nontender and non-distended. Stool for occult blood testing is negative. Lab studies show: Hemoglobin 10.0 g/L, MCV 75 fl, Platelets 340,000/mm3, Leukocyte count 4,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%. Which of the following is the most likely diagnosis of his skin condition?

.401) A 27-year-old male presents with dyspnea and fatigue. He has no family history of asthma, heart disease or any blood disorder. His vital signs are stable, and he is afebrile. The only significant findings on examination are pallor and splenomegaly. Lab studies show: Hematocrit 20%, WBC count 4,000/micro-L, Platelet count 85,000/miro-L, Bilirubin 7 mg/dl, Direct bilirubin 1.2 mg/dl, Serum LDH 500 U/L (normal value is 80-280 U/L), Serum haptoglobin 20mg/dl (normal value is 30-220 mg/dl). Peripheral blood smear shows microcytic hypochromic cells. Serum ferritin is low while total iron binding capacity (TIBC) is elevated. Reticulocyte count is 5 %. Urine dipstick testing is positive for hematuria and microscopy of urine shows 1 RBC/HPF. Repeated G6PD assays are normal. Coomb's and micro- Coomb's tests are negative. Bone marrow examination shows hypocellular marrow. Based on these findings, what is the most likely diagnosis?

.402) A 27-year-old male returning home after a three-month visit to Puerto Rico presents with diarrhea for the past 6 weeks. Other accompanying symptoms include cramps, gas, fatigue and progressive weight loss. Abdominal auscultation shows hyperactive bowel sounds, and borborygmi. The family history is unremarkable for intestinal disease. Laboratory studies show anemia with a hematocrit of 25% and MCV of 105fl; stool examination for ova and parasites is negative. Small intestinal mucosal biopsy shows blunting of villi with infiltration of chronic inflammatory cells, including lymphocytes, plasma cells, and eosinophils. Which of the following is the most likely diagnosis?

.403) A 27-year-old man comes into the emergency department because of a 2-week history of hemoptysis, breathing difficulty, ankle edema, and dark urine. His past medical history is insignificant. He is not taking any medication. He does not use tobacco, alcohol, or drugs. Laboratory studies show: Hb 10.5 g/dl, Serum Na 135 mEq/L, Serum K 4.8 mEq/L, BUN 36 mg/dl, Serum creatinine 2.8 mg/dl. Urinalysis shows numerous dysmorphic red blood cells/HPF, moderate proteinuria, and red cell casts. Chest x-ray reveals bilateral alveolar infiltrates. Diagnosis of which of the following pulmonary-renal syndromes require emergency plasmapheresis?

.405) A 27-year-old man comes to the physician because of red urine. He has had no pain or burning on urination. He has infiltrative pulmonary tuberculosis (diagnosed recently). He takes isoniazid, rifampin, and pyrazinamide. He smokes two packs a day and consumes alcohol occasionally. Vital signs are stable Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

.406) A 27-year-old man is shot point blank with a .22-caliber revolver. The entrance wound is in the anterior chest wall, just to the left of the sternal border, at the level of the 4th intercostal space. There is no exit wound. He is diaphoretic, cold, shivering, and anxious, and is asking for a blanket and a drink of water. His blood pressure is 65/40 mm Hg, and his pulse is 145/min and barely perceptible. He has large, distended veins in his neck and forehead. He is breathing adequately and has bilateral breath sounds. He is neurologically intact. Which of the following is the most likely diagnosis?

.408) 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?

.409) A 27-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding and cramping lower abdominal pain. She continues to have cramping in the ER. Her temperature is 37.0 C (98.7 F), blood pressure is 100/76 mmHg, pulse is 84/min and respirations are 14/min. Physical examination shows an effaced and dilated cervix. Gestational tissue is visualized through the internal cervical os. Bimanual examination shows the uterus is soft and enlarged, and vaginal bleeding is seen. Which of the following is the most likely diagnosis?

.413) A 27-year-old woman, gravida 2, para 2, comes to the physician to have her staples removed after an elective repeat cesarean delivery. Her pregnancy course was uncomplicated. She states that she is doing well except that since the delivery she has noticed some episodes of sadness and tearfulness. She is eating and sleeping normally and has no strange thoughts or thoughts of hurting herself or others. Physical examination is within normal limits for a patient who is status post cesarean delivery. Which of the following is the most likely diagnosis?

.414) A 28-month-old female has been living with her mother in a shelter for homeless women and children. She is brought to the Emergency Department in status epilepticus, which is stopped with intravenous lorazepam. She is placed on a cardiac monitor and a wide complex tachycardia is noted. The ventricular tachycardia reverts to sinus tachycardia after defibrillation is performed. Her temperature is 38.5 C (101.3 F), blood pressure is 120/80 mm Hg, pulse is 195, and respirations are 26. Physical examination reveals a lethargic, pale toddler with dilated and reactive pupils, dry mucous membranes, shallow respirations, diaphoresis and brisk deep tendon reflexes. A urine toxicology screen is most likely to detect which of the following substances?

.415) A 28-year-old African American female complains of recurrent nasal discharge and increasing nasal congestion. She has a constant sensation of dripping in the back of her throat, and states that food has tasted bland to her recently. She is known to have sickle cell trait. She came to the emergency department for severe wheezing after taking naproxen for menstrual cramping one year ago. She has no history of head trauma. She does not smoke cigarettes, but she admits to smoking marijuana occasionally. Which of the following is the most likely diagnosis?

.416) A 28-year-old business executive sees her physician because she is having difficulty in her new position, as it requires her to do frequent public speaking. She states that she is terrified she will do or say something that will cause her extreme embarrassment. The patient says that when she must speak in public, she becomes extremely anxious and her heart beats uncontrollably. Based on this clinical picture, which of the following is the most likely diagnosis?

.417) A 28-year-old Caucasian female comes to the office due to fever for the past 3 days. She also complains of pain and swelling in her right breast for the past 4 days. She exclusively breastfeeds her 3-month-old baby. On examination, she is febrile. Her right breast is engorged, red and tender, without any area of fluctuation. She wants to know if she can continue to breastfeed. Which of the following is a contraindication to breastfeeding?

.421) A 28-year-old Caucasian woman presents to the primary care physician with complaints of painless blistering on the backs of her hands, accompanied by an increased fragility of the surrounding skin. She first noted the blisters one week ago, after spending some time gardening outdoors. She denies ever having similar symptoms, but suspects that her mother may occasionally have had a similar presentation that eventually resolved without treatment. Her past medical history is significant for chronic infection with Hepatitis C virus. Current medications include oral contraceptives, which were begun last month. Physical examination reveals mild hyperpigmentation of the face. Which of the following is the most likely diagnosis?

.422) A 28-year-old female presents to her family doctor with her mother, who complains that her daughter has been behaving eccentrically and has been socially withdrawn for the past year. The mother says that her daughter used to be very lively and friendly, but that she abruptly quit her job as a data analyst one year ago and now prefers to stay home in her bedroom most of the time. The patient is thoroughly evaluated by a psychiatrist. During that interview, she reveals to the psychiatrist that she constantly hears "so many voices" in her head. The voices tell her various things of a critical and suspicious nature. She also adds that she feels very sad and has had numerous severe crying spells after her pet dog's death four months ago. She prefers to be alone and does not enjoy interacting with others. She has poor sleep and little appetite. Which of the following is the most likely diagnosis in this woman?

.423) A 28-year-old G1 presents to your office at 8 weeks gestation. She has a history of diabetes since the age of 14. She uses insulin and denies any complications related to her diabetes. Which of the following is the most common birth defect associated with diabetes?

425) A 28-year-old G1P0 presents to your office at 18 weeks gestational age for an unscheduled visit secondary to right-sided groin pain. She describes the pain as sharp and occurring with movement and exercise. She denies any change in urinary or bowel habits. She also denies any fever or chills. The application of a heating pad helps alleviate the discomfort. As her obstetrician, what should you tell this patient is the most likely etiology of this pain?

427) A 28-year-old male comes for evaluation of infertility. He has been healthy and otherwise has no complaints. He says the he eats a high protein diet and exercises daily in order to be muscular. He weighs 85 kg (187 1b) and is 175cm (70 in) tall. His temperature is 37.2 C (98.9 F), and his blood pressure is 130/82 mmHg. Physical examination shows small testes. The remainder of the examination is unremarkable. Initial laboratory studies show: Hemoglobin: 16.0 g/L, Platelets: 200,000/mm3, Leukocyte count: 4,500/mm3, Serum creatinine: 1.4 mg/dl, Serum LH: low, Serum testosterone: low. Which of the following is the most likely cause of his infertility?

.428) A 28-year-old man presents with symptoms of frequent bowel movements, crampy abdominal pain, and the passage of mucus. There is no history of any bloody diarrhea, but recently, he developed joint discomfort in his hands, knees, and back. On examination he is thin, and his abdomen is soft with voluntary guarding in the left lower quadrant. His joints are not actively inflamed and there is an asymmetric distribution. Which of the following is the most likely diagnosis?

.429) 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?

.430) A 28-year-old nulligravid woman is found on routine annual examination to have an asymptomatic, mobile, nontender, 6 cm unilateral pelvic mass. On sonogram, the mass is partially solid and partially cystic, with foci of calcifications. She is sexually active with her husband of 5 years. She has used combination oral contraceptives for the past 3 years. Which of the following is the most likely diagnosis?

.431) A 28-year-old primigravid woman at 34 weeks gestation is brought to the emergency department following a motor vehicle accident. She had intense abdominal pain and became agitated and restless in the ambulance. She has mild vaginal bleeding and diffuse abdominal pain. She is on continuous fetal heart monitoring. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her blood pressure is 110/60mmHg, pulse is 110/min and respirations are 32/min. Physical examination shows hyperventilation, cold extremities and a distended abdomen with irregular contours. Fetal heart monitoring shows repetitive late decelerations and a long-term variability of 2 cycles/min. Which of the following is the most likely diagnosis?

.432) A 28-year-old primigravid woman comes to the physician for a follow-up prenatal visit. According to prenatal records, ultrasound at 16 weeks gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. She is now at 40 weeks gestation. Examination shows a fundal height consistent with dates and the cervix is not favorable. Fetal heart tracing is reassuring. She wishes to continue the pregnancy for two more weeks rather than undergoing induction. She should be closely monitored for which of the following?

.435) A 28-year-old woman at 39 weeks gestation is admitted to the hospital. She has regular uterine contractions. Her blood pressure is 120/70mmHg, pulse is 80/min and respirations are 18/min. Fetal heart monitoring is placed and shows a baseline rate of 130 beats/min, without any associated abnormalities. Pelvic examination shows the cervix is 50% effaced and 3cm dilated. Amniotomy is performed and a bloody show is noted. Immediately after the rupture of membranes, the baseline fetal heart rate increases to 160 beats/min and then drops to 70 beats/min. As labor progresses, repetitive late decelerations are noted, as well as an increase in vaginal bleeding. Repeat vital signs of the patient shows a blood pressure of 130/70mmHg, pulse of 80/min and respirations of 18/min. Which of the following is the most likely cause of the current condition?

.436) A 28-year-old woman is admitted for delivery. She began experiencing regular, painful uterine contractions three hours ago and her water broke en route to the hospital. The cervix is 5 cm dilated and 80% effaced. The fetal presentation is vertex and the baby's head is at -1 station. After placing a fetal heart monitor and external tocometer, repetitive decreases in fetal heart rate are noted which begin at the same time as the contractions and end before the contractions have ceased. Which of the following is most likely responsible for the fetal heart pattern?

.438) A 28-year-old woman presents with a recent episode of coughing up some blood, frequent nosebleeds, and now decreased urine output. A nasal mucosa ulcer was seen on inspection. Her urinalysis is positive for protein and red cells consistent with a GN. The CXR shows two cavitary lesions and her serology is positive for antineutrophil cytoplasmic antibodies (ANCA). Which of the following is the most likely diagnosis?

.440) A 28-year-old woman who is 15 weeks pregnant has new onset of nausea, vomiting, and right sided abdominal pain. She has been free of nausea since early in her first trimester. The pain has become worse over the past 6 hours. Which of the following is the most common non-obstetric surgical disease of the abdomen during pregnancy?

.441) A 28-year-old, G2 P1 woman presented to the hospital at 34weeks gestation because of midepigastric and right upper quadrant pain associated with nausea and vomiting. She has been closely followed for mild hypertension and mild proteinuria (250 mg/24hr) on an outpatient basis since the 28th week of gestation. Her previous pregnancy was without incident. Her temperature is 37.2 C (98.9 F), blood pressure is 160/94 mmHg and pulse is 80/min. Physical examination shows epigastric and right upper quadrant tenderness; her bowel sounds are slightly reduced. The extremities have 2+ edema. Fetal heart sounds are audible on Doppler. Laboratory studies show: Hb: 8.2g/dl, Platelets: 96,000/mm3, Prothrombin time: 12.4 sec, Partial thromboplastin time: 23.6 sec, Serum creatinine: 1.1 mg/dl, Total bilirubin: 2.6 mg/dl, Direct bilirubin: 0.8 mg/dl, Alkaline phosphatase: 120 U/L, Aspartate aminotransferase: 308 U/L, Alanine aminotransferase: 265 U/L, Lipase: 53 U/L. Peripheral blood smear shows numerous red blood cell fragments. Which of the following is the most likely diagnosis?

.442) A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. Which of the following is the most likely diagnosis?

444) A 29-year-old G3P2 black woman in the thirty-third week of gestation is admitted to the emergency room because of acute abdominal pain that has been increasing during the past 24 hours. The pain is severe and is radiating from the epigastrium to the back. The patient has vomited a few times and has not eaten or had a bowel movement since the pain started. On examination, you observe an acutely ill patient lying on the bed with her knees drawn up. Her blood pressure is 100/70 mm Hg, her pulse is 110 beats per minute, and her temperature is 38.8C (101.8F). On palpation, the abdomen is somewhat distended and tender, mainly in the epigastric area, and the uterine fundus reaches 31 cm above the symphysis. Hypotonic bowel sounds are noted. Fetal monitoring reveals a normal pattern of fetal heart rate (FHR) without uterine contractions. On ultrasonography, the fetus is in vertex presentation and appropriate in size for gestational age; fetal breathing and trunk movements are noted, and the volume of amniotic fluid is normal. The placenta is located on the anterior uterine wall and no previa is seen. Laboratory values show mild leukocytosis (12,000 cells per mL); a hematocrit of 43; mildly elevated serum glutamicoxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), and bilirubin; and serum amylase of 180 U/dL. Urinalysis is normal. Which of the following is the most likely diagnosis?