USMLE medecine interne

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?

A 64-year-old white woman presents to her primary care physician complaining of difficulty and pain with swallowing, as well as occasional chest pain. She has a history of breast cancer treated with lumpectomy and radiation, hyper- tension, high cholesterol, and ovarian polyps. She indicates that her current problem started with liquids, but has progressed to solids, and that the food “just gets stuck in my throat.” The chest pain was once so bad that she took one of her husband’s nitroglycerin pills and the pain subsided, but it has since occurred many times. The physician orders an x-ray of the chest, but it is not diagnostic. Manometry is conducted, and it shows uncoordinated contractions. Which of the following is the most likely diagnosis?

A 22-year-old woman presents with chronic diarrhea. She has no abdominal discomfort, feels well, and reports no weight loss or systemic symptoms. Physical examination reveals a healthy young woman who is 5’7” tall and weighs 150 lb. The complete physical examination is normal. Which of the following is the most likely cause of a secretory diarrhea in this young woman?

A full-term 5-day-old African-American girl is taken to the pediatrician because her “eyes look yellow.” She is being exclusively formula- fed with an iron-rich formula. She has six wet diapers a day and stools twice a day. The pregnancy was uncomplicated and she was delivered by spontaneous vaginal delivery. Her Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. Her temperature is 37°C (98.6°F), her head circumference is in the 50th percentile, and her weight is 3420 g (3 g below her birth weight). Her sclerae are icteric. There is no hepatomegaly or splenomegaly. Her total bilirubin is 9 mg/dL and her conjugated bilirubin is 0.2 mg/dL. Hemoglobin is 15 g/dL. Which of the following is the most likely diagnosis?`

A 20-year-old man presents to the ED with fever and severe right lower quadrant (RLQ) pain for 1 day. Prior to this episode, he reports 2 months of crampy abdominal pain, generalized malaise, a 10-lb weight loss, and occasional bloody diarrhea. On examination, his HR is 115 beats per minute, BP is 125/70 mm Hg, RR is 18 breaths per minute, and temperature is 100.8°F. His only significant past medical history is recurrent perirectal abscesses. On physical examination, the patient appears uncomfortable and has a tender mass in the RLQ, without guarding or rebound. Rectal examination is positive for trace heme-positive stool. An abdominal computed tomographic (CT) scan reveals no periappendiceal fat stranding. There is inflammation of the distal ileum and several areas of the colon. There are no rectal inflammatory changes. Which of the following is the most likely diagnosis?

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

A 64-year-old woman develops sudden-onset abdominal discomfort after eating a large meal. The pain is constant, localizes to the epigastric area with radiation to her right scapula. She also has nausea and vomiting. It eventual subsides 1 hour later. An ultrasound of the abdomen reveals a dilated common bile duct secondary to stones. Which of the following statements regarding common bile duct stones is most likely true?

A 30-year-old man complains of chronic diarrhea for the past 6 months. There is no weight loss, fever, or abdominal pain. He takes no medications and feels fine. His physical examination is completely normal. Further history reveals that this man does not take laxatives; however, in an effort to stay slim he eats a lot of sugar-free gum and sugarless candy. Which of the following explanations is the most likely cause of his diarrhea?

A 16-year-old girl is referred to the office because of chronic diarrhea and weight loss. She is experiencing large-volume watery diarrhea that is painless. The symptoms persist even when she is fasting, and there is no relationship to foods or liquids. She is not on any medications, and there is no travel history or other constitutional symptoms. Her physical examination is normal. Which of the following is the most likely diagnosis?

A 52-year-old man has suffered with chronic diarrhea for several years, but has refused to see a doctor. He finally comes because he is having trouble driving at night, because of difficulty seeing. Physical examination reveals a slender, pale, unwell-looking man. He has a microcytic anemia, low calcium, and albumin levels. Which of the following is the most likely cause for his diarrhea?

The physician on call is paged to the well-baby nursery because a full-term, 3-hour-old boy has had green emesis twice, once after each of his feedings. He is being breast-fed. He was born by spontaneous vaginal delivery following a pregnancy complicated by polyhydramnios. His Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. His temperature is 37°C (98.6°F), blood pressure is 70/50 mm Hg, pulse is 150/min, and respiratory rate is 24/ min. His upper abdomen is distended, soft, and without palpable masses. Air is visualized in the duodenum and the stomach on x-ray. Which of the following is the most likely diagnosis?

A 50-year-old woman undergoes screening colonoscopy at her primary care physician’s recommendation. She has no family history of colorectal cancer. A single lesion is removed during the procedure and sent for pathologic examination. Which of the following findings carries the greatest risk of malignancy?

A 24-year-old woman presents to her primary care provider because of bloody diarrhea for several months and uveitis. Complete blood cell count shows mild anemia but a normal WBC count. The erythrocyte sedimentation rate and the C-reactive protein level are not elevated. Which of the following is the most likely diagnosis?

A 66-year-old woman presents to her physician because of recurrent painless bleeding on defecation over the past month. She has regular, soft bowel movements and no history of constipation or diarrhea. A recent diagnosis of aortic stenosis was an incidental finding on echocardiogram. She takes calcium and vitamin D supplements daily. Her last colonoscopy (at age 60) was normal. Heart rate is 82/min, blood pressure is 133/72 mm Hg, respiratory rate is 12/min, and temperature is 36.6°C (97.8°F). Physical examination reveals her conjunctivae are pink and mucosa is moist. She has no abdominal tenderness or palpable masses and no hemorrhoids or fissures. Stool is hemoccult positive. Colonoscopy shows a spider-like lesion in the ascending colon. Which of the following is the most likely diagnosis?

A 61-year-old woman is brought to the emergency department drowsy and disoriented, able only to follow simple commands. On examination her abdomen is distended and nontender, her skin has a yellow hue, and there are multiple spider nevi on her chest. In her purse, the physician finds prescriptions for peginterferon and ribavirin. When asked to raise her hands, the physician notices a coarse tremor. Laboratory tests show: Blood urea nitrogen: 17 mg/dL Creatinine kinase: 1.1 mg/dL Aspartate aminotransferase: 89 U/L Alanine aminotransferase: 93 U/L Total bilirubin: 3.1 mg/dL Ammonia: 124 μg/dL Which of the following is the most likely diagnosis?

A 51-year-old man describes 1 week of gradually worsening scrotal pain and dysuria. He is sexually active with his wife. His temperature is 100.1°F, HR 81 beats per minute, BP 140/75 mm Hg, and oxygen saturation is 99% on room air. On physical examination, his scrotal skin is warm and erythematous. A cremasteric reflex is present. The posterior left testicle is swollen and tender to touch. Color Doppler ultrasonography demonstrates increased testicular blood flow. Urinalysis is positive for leukocyte esterase. What is the most likely diagnosis?

A 40-year-old woman presents to the ED complaining of fever and 1 day of increasingly severe pain in her RUQ. She denies nausea or vomiting and has no history of fatty food intolerance. The patient returned from a trip to Mexico 6 months ago. About 2 weeks ago she experienced intermittent diarrhea with blood-streaked mucus. Her BP is 130/80 mm Hg, HR is 107 beats per minute, temperature is 102°F, and RR is 17 breaths per minute. Physical examination reveals decreased breath sounds over the right lung base. Abdominal examination shows tenderness to percussion over the RUQ and normal active bowel sounds. There is no Murphy sign. Her WBC is 20,500/μL. Chest radiograph reveals a small right-pleural effusion. Which of the following is the most likely diagnosis?

A 20-year-old man presents with several weeks of painful rectal bleeding. He denies fever, nausea, or vomiting. He is sexually active with women only and usually uses condoms. He denies any history of CD, UC, or malignancy. He states that the pain is most severe during and immediately after defecating. Bleeding is bright red and only enough to stain the toilet paper. Which of the following is the most common etiology of painful rectal bleeding?

A premature newborn is being treated in the neonatal intensive care unit. On the sixth day of life he is noted to be lethargic and in mild respiratory distress. His heart rate is 162/min, blood pressure is 55/38 mm Hg, and respiratory rate is 56/min. In addition to a distended abdomen, he has guaiac-positive stools. X-ray of the abdomen shows gas bubbles within the bowel wall. From what potentially life-threatening condition is this patient most likely suffering?

A 65-year-old man comes to the emergency department complaining of left lower abdominal pain that began the prior morning. He became concerned when he developed bloody diarrhea overnight. He has experienced similar pain, although to a lesser degree, over the past 2 months, especially after eating. The pain usually resolved within 1–2 hours, and he never had bloody diarrhea. His past medical history is significant for coronary artery disease and hypertension. He has smoked one pack of cigarettes per day for the past 30 years. On physical examination he is afebrile, heart rate is 90/min, and blood pressure is 135/85 mm Hg. He is visibly uncomfortable but in no apparent distress. His abdominal examination is significant for left lower quadrant tenderness but no guarding or rebound. Which of the following is the most likely diagnosis?

A 25-year-old previously healthy man experiences fatigue and malaise. One week ago he had a “viral” type illness consisting of a sore throat, fever, and myalgias. He now appears jaundiced, but the rest of the physical examination is normal. His investigations reveal a total bilirubin of 4 mg/dL (0.1–1.0 mg/dL) and a direct bilirubin of 0.3 mg/dL (0.0–0.3 mg/dL). Which of the following is the most likely diagnosis?

A 49-year-old man is brought to the ED by EMS stating that he vomited approximately three cups of blood over the last 2 hours. He also complains of epigastric pain. While examining the patient, he has another episode of hematemesis. You decide to place an NG tube. You insert the tube, confirm its placement, and attach it to suction. You retrieve 200 mL of coffee-ground blood. What is the most common etiology of an upper GI bleed?

A 63-year-old woman with cirrhosis caused by chronic hepatitis C is hospitalized because of confusion. She has guaiac-positive stools and a low-grade fever. She has received lorazepam for sleep disturbance. On physical examination, the patient is confused. She has no meningeal signs and no focal neurologic findings. There is hyperreflexia and a nonrhythmic flapping tremor of the wrists. Which of the following is the most likely explanation for this patient’s mental status change?

A 40-year-old white male complains of weakness, weight loss, and abdominal pain. On examination, the patient has diffuse hyperpigmentation and a palpable liver edge. Polyarthritis of the wrists and hips is also noted. Fasting blood sugar is 185 mg/dL. Which of the following is the most likely diagnosis?

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

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

A 62-year-old Caucasian man presents to your office with occasional ear pain and a lump in his neck. His past medical history is significant for hypertension treated with hydrochlorothiazide and diabetes mellitus treated with metformin. He smokes two packs of cigarettes per day and consumes alcohol occasionally. He is not sexually active. Physical examination reveals a hard, non-tender submandibular mass that is 3 cm in diameter. Chest examination is unremarkable. Abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. His extremities have no cyanosis, clubbing, or edema. Complete blood count is within normal limits. Which of the following is the most likely cause of this patient's complaint?

A 67-year-old woman comes to her physician because she is feeling tired, all the time. She thinks that it is due to multiple surgeries she had over the past several years. She had two caesarian sections at the age of 22 and 26. She also had a thyroid surgery for Graves’s disease, 30 years ago. 12 years ago she was diagnosed with colon cancer and had undergone left hemicolectomy. She denies smoking or alcohol use. Her vitals are Temperature 36.7°C (98.2°F); BP 138/86 mm Hg; PR 77/min; RR 12/min. She looks markedly pale and has weakness in all four extremities. There is some sensory loss in lower limbs. The test for occult blood was negative. Labs came back as: Sodium 144 mEq/L, Potassium 4.2 mEq/L, Bicarbonate 24mEq/L, Blood urea nitrogen 18mg/dl, Creatinine 1.0 mg/dl, Glucose 82 mg/dl, WBC 8,600/cmm, Hemoglobin 7.9, Hematocrit 25%, Platelets 176,000/cmm. The physician decides to further investigate anemia and order RBC indices and peripheral blood smear. The results are: MCV 120 fl, MCH 36 pg, MCHC 28%, Reticulocyte count 04%. Peripheral smear showed anisocytosis, poikilocytosis, 4+ macrocytes, polychromatophilia and basophilic stippling. A whole new bunch of tests are ordered and the following report is seen on the computer. Vitamin B12 106 pg/ml (N=210-911 pg/ml), Serum Folate 16.4 ng/ml (N=2.8-17.8 ng/ml), Serum Bilirubin 1.8 mg/dl, Serum LDH 2500 U/L. Gastric analysis demonstrated an absence of hydrochloric acid. What is the most probable cause of her anemia?

A 34-year-old Caucasian man presents to your office with easy fatigability, difficulty concentrating, insomnia, and occasional muscle pain. He also complains of right hand clumsiness and some memory loss. He does not smoke and drinks one to two cans of beer on the weekends. Physical examination reveals extensor weakness of the right hand. Ankle reflexes are symmetric and there is no Babinski reflex. Laboratory studies show: Hemoglobin 8.5 g/dl, MCV 81 fl, AST 18 U/L, ALT 16 U/L, Bilirubin 0.8 mg/dl, Creatinine 2.1 mg/dl. Which of the following is most important in revealing the cause of this patient's condition?

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:

An 8-month-old pale child is referred by a nurse practitioner due to "pale mucous membranes, irritability, and listlessness." The stool examination is negative for occult blood, ova and parasites. Laboratory studies reveal: Hemoglobin 6.0 g/L, MCHC 25%, MCH 16.5 pg, MCV 68 fl, Reticulocytes 0.6%, Platelets 230,000/mm3, Leukocyte count 5,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%, Serum Iron 40 mg/dL, TIBC 460 mg/dL (normal 300-350 mg/dL), Percent saturation of transferrin 8.7%, Total serum bilirubin 0.9 mg/dL. The peripheral blood smear shows marked anisocytosis, microcytosis, hypochromia, and poikilocytosis. Which of the following is the most likely diagnosis?

A 54-year-old Caucasian man presents to his family physician's office complaining of several months of increased fatigability. He eats meat occasionally and drinks two to three cans of beer on weekends. Physical examination reveals pale conjunctivae and hyperdynamic carotid pulses. His blood hemoglobin level is 7.7 mg/dl, WBC count is 4,500/mm3, and platelet count is 170,000/mm3 Folic acid therapy is initiated. Four weeks later the patient's hemoglobin level is 9.1 mg/dl, but he complains of new tingling in his toes. Which of the following is a likely cause of this patient's current symptoms?

A 46-year-old bank executive is referred to the clinic by her dentist. For the past 6 weeks, she has had swollen, bleeding gums. She appears pale and feels weak. She smokes half a pack of cigarettes daily and drinks alcohol socially. Her family history is not significant. Her vital signs are stable. She is afebrile. WBC 44,100 mm3, Hemoglobin 9.0 g/dL, Hematocrit 27%, Platelets 16,000/mm3. Leukocyte distribution: Blast forms 79%, Promonocytes 12%, Monocytes 8%, Lymphocytes 1%. Cytochemical analysis:Sudan black: slightly positive, Alpha-naphthyl esterase: positive, PAS reaction: negative. Which of the following is the most likely diagnosis?

A 65-year-old woman is being evaluated for "generalized depression." She has felt weak and fatigued ever since her husband died 4 months ago. She does not have any suicidal thoughts, but is losing interest in her daily activities. She quit smoking 24 years ago, and drinks 1-2 beers weekly. Physical examination reveals pallor and cervical lymphadenopathy. Blood work reveals: Hemoglobin 12.0 g/L, MCV 85 fl, Platelets 224,000/mm3, Leukocyte count 54,500/mm3, Neutrophils 16%, Lymphocytes 75%, Monocytes 9%. Some variants of lymphocytes and smudge cells are present. Which of the following is the most likely diagnosis?

A 54-year-old male is brought to the emergency department because of severe abdominal pain and diarrhea for the past 24 hours. He is confused and crying out in pain. His temperature is 38.6°C (101.6°F), blood pressure is 82/58 mm Hg, pulse is 118/min, and respirations are 24/min. Physical examination reveals extensive abdominal distention. There is fresh blood in his stools. Intravenous administration of normal saline is started after drawing blood for the necessary laboratory tests. The results of these tests are: Sodium 136 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 18 mEq/L, Blood urea nitrogen 32 mg/dL, Creatinine 1.3 mg/dL, Glucose 86 mg/dL, WBC 35,000/mm3, Hemoglobin 13.0 g/dL, Hematocrit 36%, Platelets 460,000/mm3. Leukocyte distribution:Promyelocyte 2%, Myelocytes 7%, Metamyelocytes 18%, Bands 32%, Segmented neutrophils 24%, Lymphocytes 15%. The patient's temperature continues to remain elevated during the night of admission. A broad-spectrum antibiotic is added to the IV infusion. Repeat CBC on the following morning shows a WBC count of 118,000/mm3 with essentially the same differential distribution of leukocytes. His leukocyte alkaline phosphatase score is elevated. What is the most probable diagnosis of this patient?

A 25-year-old African American man presents to your office complaining of nocturia over the past several months. He reports having to wake to urinate 2 to 3 times per night despite restricting his fluid intake. He denies any back pain, fever, dysuria, or urinary urgency. His past medical history is significant for recurrent otitis media in childhood and hepatitis A infection two years ago. He is sexually active with one partner and does not use condoms. His brother died of a "blood disease" at age 10. The man's hematocrit is 49%. Urinalysis reveals no proteinuria or sediment abnormalities. His nocturia is most likely related to:

A 25-year-old African American male comes to the office with sudden-onset back pain, dark urine and an one day history of fatigue. Two days ago, he was started on trimethoprim-sulfamethoxazole for his sinusitis. Otherwise, his past medical history is unremarkable. Physical examination reveals significant pallor. His laboratory report shows: Hb 7.5 g/dl, Total bilirubin 3.5 mg/dl, Direct bilirubin 0.8 mg/dl, Haptoglobin decreased, LDH increased. The peripheral smear shows bite cells. His G6PD level is normal. Which of the following is the most likely cause of his hemolysis?

A 75-year-old Caucasian male comes to the office for his routine medical check-up. He complains of fatigue for the past month. His previous medical history is significant for calcified aortic valves and hypertension. His vital signs are stable; except for a blood pressure of 150/90 mm Hg. Physical examination reveals pallor and a 4+ ejection systolic murmur in the aortic area. Lab reports show: Hb 9 g/dl, MCV 75 fl, Reticulocyte count increased, Serum LDH increased, Haptoglobin decreased, Peripheral smear fragmented RBC. Which of the following is the most likely cause of this patient's anemia?

A 68-year-old unconscious man is brought to the emergency department by a hospice nurse. He had seizures 2 hours ago, after which he lost consciousness. The hospice staff responded by securing his airway and giving him 2L of oxygen. He is in hospice for terminal care for stage IV esophageal carcinoma. He also had a part of his finger removed 1.5 years ago due to a skin cancer. His pulse oximetry reading is 91%. His temperature is 37.9°C (100.2°F), respirations are 23/min, pulse is 96/min, and blood pressure is 140/85 mmHg. He does not respond to painful stimuli. Rectal examination reveals a hard, irregular surface of an enlarged prostate. His recent prostate specific antigen level is 40. MRI shows an intracranial lesion with bleeding inside, and these findings are consistent with metastasis. What is the most likely diagnosis?

A 44-year-old woman comes to the office with complaints of weight loss and blood in her stools for the last year. Her mother is on chemotherapy for colon carcinoma. Her maternal uncle also had colon cancer, as did her first cousin who died of colon cancer at the age of 46. She is very worried that she might have the same cancer. Based on her history, she falls within the criteria for Lynch syndrome (also known as HNPCC/ Hereditary Nonpolyposis Colorectal Cancer). Apart from the complete work-up for colon cancer, this patient should be evaluated for which of the following condition?

A 72-year-old Hispanic man comes to the clinic with complaints of mild headache and lethargy for the past several days. He complains of cough for the past 12 years but, has been bothering him more lately. The cough is mucoid in nature. He has noticed blood in it once in a while. He has been smoking 1 pack/day for 29 years. His Temperature 37C (98.6F); BP 120/84 mmHg; PR 78/min; RR 24/min. On examination of the lungs, adventitious sounds are heard in all the lobes and scant basilar crackles. Laboratory studies show: WBC 7,600/mm3, Hemoglobin 13.6, Hematocrit 40%, Platelets 214,000/mm3, Sodium 131 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 18 mEq/L, Blood urea nitrogen 16 mg/dL, Creatinine 0.6 mg/dL, Glucose 95 mg/dL, Serum osmolality 260 mOsm/kg (275-295 mosm/kg H2O), Urine osmolality 310 mOsm/kg (38-1400 mosm/kg H2O). A chest x-ray shows a 2-centimeter left upper lobe nodule and mediastinal adenopathy your diagnosis is?

A 63-year-old Caucasian man reports occasional palpitations when exercising. He denies chest pain. Past medical history includes coronary artery disease status post coronary artery stenting, mitral valve replacement with mechanical valve, and diabetes mellitus. He consumes a well-balanced diet and takes one multivitamin tablet daily. His medications include warfarin, simvastatin, metoprolol, lisinopril, and metformin. Physical examination reveals conjunctival pallor and heart sounds consistent with the presence of a mechanical mitral valve. His hematocrit is 30%. The peripheral blood smear shows occasional schistocytes and his serum LDH level is elevated. His stool is negative for occult blood. Which of the following is the most likely cause of this patient's anemia?

An 80-year-old female is brought to your office, by her son, because of severe fatigue. She lives alone and is suffering from severe degenerative joint disease, which puts her in a house arrest-type state. Her son usually helps with getting grocery. Her only other medical problem is hypertension. She takes hydrochlorothiazide and acetaminophen. Her vitals are stable. On examination, she has pallor, and evidence of severe degenerative joint disease. Which of the following is the most likely cause of pallor in this patient?

A 56-year-old white male comes to the office for a health maintenance visit. He feels healthy, and is "enjoying life as much as possible in a stressed environment." He smokes 2-3 packs of cigarettes daily and drinks socially. His temperature is 37°C (98.6°F), blood pressure is 160/94 mm Hg, pulse is 78/min, and respirations are 14/min. Physical examination reveals plethora of the face and moderate splenomegaly. Blood tests show the following: WBC 15,600/mm3, Hemoglobin 17 gm/dl, Hematocrit 52%, Platelets 550,000mm3, RBC count 7.5 million, Sodium 141 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 22 mEq/L, Blood urea nitrogen 16 mg/dl, Creatinine 0.6 mg/dl, Glucose 95 mg/dl. The erythrocyte indices are all within normal range. What is the most probable diagnosis?

A 49-year-old woman comes to the office and complains of a "strange, itchy rash" on her left areola which has been present for the last month. She tried applying various lotions and creams, but the lesion did not resolve. She denies having other skin conditions, except for a poison ivy rash 2 months ago. She does not take any medications and feels "goofy" when she takes penicillin. Physical examination reveals an eczemoid lesion on the left nipple. No abnormality is visible on the mammogram. Biopsy demonstrates large cells surrounded by halo-like areas which invade the epidermis. What is the most likely diagnosis?

A 41-year-old fire-fighter comes to your office and requests for prostate cancer screening. He is concerned because his elder brother was recently diagnosed with prostate cancer, and he read in the paper that "cancers run in families." He requests to be screened urgently, as he "cannot even think of life with such a deadly disease." He has no medical complaints. He has been your patient for the past 6 years, and has no other medical history. He is on a very balanced diet, and adds that he eats a lot of garlic "so that cholesterol remains in check." He takes a low-dose aspirin daily. He does not smoke, and is only a social drinker. He admits using marijuana "once in a while” What is the best next step to address this patient's concerns?

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?

A 44-year-old man who comes to the office because he has had several episodes of hemoptysis for the past two months. He admits to smoking 2-3 packs of cigarettes daily for the last 24 years. Physical examination and chest x-ray are very suggestive of a lung malignancy. Chest CT and bronchoscopy with biopsy are done, and the patient goes on vacation in Aruba. The patient returns to the office after one week, and you are now holding the biopsy result in your hands. It reads, "The tumor has spread to the hilar and mediastinal lymph nodes with bony extension." Which of the following is the most appropriate opening statement?

A 25-year-old male presents to his physician with dyspnea and fatigue for the last few weeks. He is a non-smoker. He denies any family history of asthma or blood disorders. He does not take any medications. Examination shows pallor, scleral icterus and splenomegaly. Lab tests show the following: Hematocrit 20%, WBC count 10,000/micro-L, Platelet count 180,000/miro-L, Total Bilirubin 7 mg/dl, Direct bilirubin 1 A mg/dl, BUN 10 mg/dl, Serum creatinine 0.7 mg/dl, Serum LDH 400 U/L (normal value is 80-280 U/L), Serum haptoglobin 160mg/dl (normal value is 30-220 mg/dl ), Reticulocyte count 8 %. Peripheral blood smear shows spherocytes with central pallor. Osmotic fragility and direct Coombs' tests are positive Based on these findings, what is the most likely diagnosis?

A 10-year-old white boy is brought to the office by his foster parents for the evaluation of severe pain in his left knee for the last few days. His left knee has been hurting so bad that he is now unable to play with his peers. The pain is continuous and non-radiating. His knee appears swollen, but he denies any history of trauma. His family history is unknown. His vital signs are stable. Physical examination reveals a pale young boy. The left knee is tender, erythematous and swollen. Blood tests reveal: WBC 12,600/mm3, Hemoglobin 9.3 g/dl, Hematocrit 29%, Platelets 201,000/mm3, ESR 40. X-ray of the knee reveals that the lower end of the femur has a central lytic lesion, onion skinning and a moth-eaten appearance with some extension into the soft tissue. What is the most likely diagnosis?

A 56-year-old woman is complaining of cough for the past 4 months. The cough was dry initially, but only yesterday she was scared-to-death to see phlegm with blood. She is not feeling well and thinks that she has lost "a lot of weight" recently, despite no apparent change in her diet. She swears that she has never smoked a cigarette in her life. There is no history of night sweats nor contact with any person with similar complaints. She is a housewife who rarely drinks, and can't think of using recreational drugs. She is completely faithful to her husband. Her husband is also a "religious non-smoker". Her vitals are stable and lung examination reveals no significant findings. Her chest x-ray shows 1.5cm lesion in the right peripheral lung field and no evidence of any hilar or mediastinal lymph node enlargement. What is the most probable diagnosis?

A 74-year-old immigrant from Colombia comes to the office and complains of having "all sorts of problems of old age." He has pain all over his body. He often has headaches and feels dizzy. He has visual problems, and finds it difficult to walk. For the last several weeks, he has been feeling weak and numb in his feet. He lives with his son, and is not happy with the way his son treats him; however, he denies receiving any form of physical abuse. His past medical history is unremarkable. His mother had "some blood disease." His vital signs are stable. Physical examination reveals multiple bruises on his body, and sensory deficits in his feet. Other significant findings include lymphadenopathy and hepatosplenomegaly. Ophthalmoscopy shows dilated, segmented, and tortuous retinal veins. Laboratory studies show: WBC 10,200 /mm3, Hemoglobin 9.6 g/dl, Hematocrit 29%, Platelets 94,000 /mm3, Sodium 141 mEq/L, Potassium 3.6 mEq/L, Blood urea nitrogen 18 mg/dl, Creatinine 0.8 mg/dl, Glucose 115 mg/dl. Serum protein electrophoresis reveals an lgM spike. Which of the following is the most likely diagnosis in this patient?

A 25-year-old white female presents to the clinic with persisting pain in her wrists and ankles for the last 3 months. The pain is 3/10 in intensity, and partially relieved by ibuprofen. She also has a rash on her face. She denies smoking, and drinks alcohol occasionally. Her temperature is 37.3°C (99.2°F), blood pressure is 120/80 mm Hg, pulse is 79/min, and respirations are 18/min. Physical examination reveals swollen joints of the hands and ankle, as well as erythema over the bridge of the nose and the upper cheeks. There is no muscle weakness. Labs show: Hemoglobin 11.0 g/dL, Hematocrit 33%, Platelets 240,000/mm3, WBC 13,600/mm3. Leukocyte distribution:Segmented neutrophils 76%, Lymphocytes 20%, Bands 2%, Monocytes 2%. RF, ANA, and antibodies to double stranded-DNA are positive in high titers. What is the most likely diagnosis?

A 23-year-old man presents to the emergency room complaining of severe abdominal pain. He has also suffered from nausea and vomiting for several hours. His past medical history is insignificant, but his brother has had similar problems. He denies risky sexual behavior and intravenous drug use. On exam, his temperature is 38.8°C (101.8°F), heart rate is 102/min, and respirations are 14/min. There is tenderness in the right upper quadrant exacerbated by deep inspiration. The liver span is 7 cm. His spleen is palpated 2 cm below the left costal margin. There are no peritoneal signs. Which of the following is the most likely diagnosis?

A 60-year-old Vietnam war veteran comes for his annual examination. He does not have any complaints, other than getting tired very quickly. Physical examination reveals pallor and an enlarged spleen. CBC reveals: WBC 14,000/cmm, Hemoglobin 9.9 g/dL, Hematocrit 30%, Platelets 100,000/cmm. The lymphocytes have fine, irregular cytoplasmic projections. Cytochemical testing reveals a strong acid phosphatase reaction, which is not inhibited by tartaric acid. What is the most probable diagnosis?

A 47-year-old woman comes to the office and complains of burning abdominal pain which has been present for the past 3 months, is grade 6/10 in severity, continuous, and relieved by taking antacids. She also complains of some constipation. Her father has a history of "ulcers in his belly." She works as a floor secretary in a surgical ward, and is not happy with her new boss. She denies any weight loss or decreased appetite. Her temperature is 37.1°C (98.8°F), blood pressure is 130/85 mm Hg, heart rate is 78/min, and respirations are 14/min. She is awake, alert, and oriented. The abdominal examination reveals normoactive bowel sounds and tenderness in the epigastric region, but no palpable mass. Her stools are occult blood positive. ECG reveals increased PR and shortened QT intervals. The laboratory results reveal the following: Sodium 137 mEq/dL, Potassium 4.2 mEq/dL, Chloride 101 mEq/dL, Bicarbonate 27 mEq/dL, Calcium 12.0 mg/dl, Phosphorus 2.2 mg/dl, BUN 37 mg/dl, Creatinine 1.8 mg/dl. Which of the following is the most likely diagnosis?

A 21-year-old Caucasian man bumped into a table in his living room two days ago and now presents to the emergency department with a swollen and tender right thigh. Pulsation is decreased over the right popliteal artery. His uncle suffered from a "blood clotting disease". This patient's history is most likely to reveal which of the following episodes in his past?

A 7-year-old Caucasian boy is brought to your office for a routine check-up. He underwent splenectomy one year ago for persistent anemia and jaundice. He has received pneumococcal vaccination and takes penicillin prophylaxis. His uncle underwent splenectomy for "some blood disorder" in his childhood. His blood hemoglobin level is 11.5 mg/dL and MCV is 90 fl. Blood smear demonstrates occasional red blood cells with single, round, blue inclusions on Wright stain. The latter finding is most likely related to?

A 25-year-old white female presents with a 5-day history of sore throat, extreme fatigue, and headaches. She has just returned from a spring break in Jamaica where she had "the time of her life." She smokes 2-3 cigarettes daily and occasionally drinks alcohol. Her vital signs are stable. She is afebrile. Physical examination reveals posterior cervical lymphadenopathy, mild splenomegaly, and exudative pharyngitis. Palatal petechiae are present. CBC shows: WBC 16,000/cmm with 55% lymphocytes, Hemoglobin 13 .5gm/dl, Hematocrit 4 1%, Platelets 216,000/cmm. Many variant forms of lymphocytes are seen, including cells with convoluted nuclei and highly vacuolated cytoplasm. Rapid streptococcal throat test, urinalysis, and heterophilic antibody test are all negative. What is the most likely diagnosis?

A 2-year-old boy is brought by his mother to the emergency department because of a high-grade fever which "does not go away" with acetaminophen. For the last four days, the child has been very irritable and is crying a lot. He is also pulling his ear and not eating well. He has been generally well, other than the occasional sore throat this season. His temperature is 38.8°C (102.2°F), blood pressure is 90/60 mm Hg, pulse is 119/min, and respirations are 24/min. He appears well nourished, but is irritable. Physical examination reveals enlarged cervical lymph nodes and splenomegaly. The tympanic membranes are inflamed. CBC shows: WBC 81,100 /mm3, Hemoglobin 8.0 g/dL, Hematocrit 25%, Platelets 16,000 /mm3, Blast forms 80%, Prolymphocytes 10%, Lymphocytes 10%. The blast cells have condensed nuclear chromatin, small nucleoli and scant agranular cytoplasm. Subsequent histochemical staining reveals strongly positive periodic acid Schiff (PAS) reaction. No Auer rods were seen. Which of the following is the most likely diagnosis?

A 34-year-old woman comes to the office for her annual examination. She has been your patient for the last 4 years. She eats a lot of meat, but does not like fruits and vegetables. Her menstrual period began at age 12. She has two children, who are ages 13 and 11. She is in a monogamous relationship with her husband, and uses oral contraceptive pills. She smokes 1/2 pack of cigarettes daily, and drinks alcohol socially. Her mother had breast disease and had an operation, but died 1 month after the surgery due to a heart attack. She has read in "US Health News" that breast cancer is the leading culprit for cancer death among non-smoking women. She now asks you, "What is the most important risk factor for breast cancer?" What is the correct response to this patient's question?

A 54-year-old male had undergone an emergency colonic resection following an extensive ischemic colitis. The surgery was uneventful. The patient has been on peperacillin and tazobactam (Zosyn) for the past five days. He was NPO (nothing by mouth) for the past five days. He has a significant alcoholic history. On postoperative day six, he developed bleeding from the venipuncture site. His temperature is 36.7° C (98° F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Lab results are: Hb 11.5g/dL, MCV 88 fl, Platelet count 160,000/cmm, Leukocyte count 7,500/cmm, Segmented neutrophils 68%, Bands 1%, Eosinophils 1%, Lymphocytes 24%, Monocytes 6%, Prothrombin time 20 sec (INR=1.9), Partial thromboplastin time 45 sec. His family history is insignificant. Which of the following is the most likely cause of his condition?

A 16-year-old boy is brought to the office by his basketball coach because, "he is unable to work out with other boys." For the past several weeks, the boy has been complaining of left knee pain which is dull and worsens with running, especially on the court. In addition, he thinks he has lost some weight. He does not smoke or drink alcohol. He is sexually active with many partners, and does not use condoms. His vital signs are stable. On examination, his left knee is swollen and tender. X-ray reveals a sclerotic lesion in the distal femur with periosteum lifted and a "sun burst appearance”. What is the most likely diagnosis?

A 54-year-old female with megaloblastic anemia and ataxia is given radiolabeled cobalamin by mouth followed by an intramuscular injection of unlabeled cobalamin. The urine radioactivity level measured afterwards is determined to be normal. Which of the following is the most likely cause of this patient's symptoms?

An 18-year-old boy comes to clinic to discuss an embarrassing problem. For the last 6 weeks he has noticed a painless mass in his right testis. This is not bothering him at all, but it is becoming larger. He is afraid that his girlfriend may notice it and find out about his other partners. He has multiple partners, and does not use condoms. He has no fever and no other medical complaints. His cousin has SLE but otherwise family history is unremarkable. On ultrasound you suspect testicular cancer and order a few tests. Results are as follows: Alpha-fetoprotein (AFP) Increased, Beta subunit of the human chorionic gonadotropin (hCG) Normal, Placental Alkaline phosphate (PLAP) Normal, Carcinoembryonic antigen (CEA) Slightly Increased, Lactate Dehydrogenase (LDH) Increased. What could be the most likely diagnosis?

Elizabeth, a 13-year-old girl, comes with complaints of new onset seizures. She has morning headaches that go away after vomiting. She also has history of colonic polyps, for which she is undergoing work-up. Her family history is significant for her mother having problems with polyps. (She underwent proctocolectomy.) Initial non-contrast T1-weighted MRI shows a large, heterogeneous, hypointense mass in the white matter of the right temporal lobe and extending into the parietal and occipital lobes. The lower signal area within the mass suggests tissue necrosis. What is the most likely diagnosis in this patient?

A 72-year-old Caucasian man presents to your office complaining of severe fatigue. He says that five months ago he was able to climb four flights of stairs without shortness of breath, but now he has to rest after two. His appetite has decreased, but he denies any abdominal discomfort or black stool. Physical examination reveals firm, enlarged cervical and supraclavicular lymph nodes. A soft I/VI grade systolic murmur is heard along the left sternal border. Abdomen is soft and non-tender. His liver span is 10 cm and the spleen is palpated 4 cm below the left costal margin. His blood hemoglobin level is 7.5 mg/dl. Which of the following is the most likely cause of this patient's anemia?

A 54-year-old male comes to the physician's office because of chronic cough and recent bloody sputum. He used to smoke 2 packs of cigarettes daily for 22 years, but he quit last month. His other symptoms are weight loss, anorexia, constipation, increased thirst, and easy fatigability. He thinks that he is depressed because his wife died 4 months ago and "life never felt the same after that." On examination, he is a slim man who appears pale. His vital signs are stable, although he appears a little irritable and short of breath. Laboratory and radiologic studies reveal: Sodium 144 mEq/dL, Potassium 4.3 mEq/dL, Chloride 98 mEq/dL, Bicarbonate 21 mEq/dL, Calcium 11.5 mg/dl, BUN 28 mg/dl, Creatinine 0.8 mg/dl. Chest x-ray hilar mass in the left lung. Biopsy of the mass would most likely reveal?

A 24-year-old man from Long Island, New York, presents with fever, drenching sweats, and malaise for the past week. For the last few days, he has noted jaundice and dark-colored urine. He recalls being bitten by a tick two weeks ago. His surgical history includes splenectomy after a car accident 10 years ago. He does not use tobacco, alcohol, or illicit drugs. His temperature is 39.5°C (103°F), pulse is 106/min, and blood pressure is 110/70 mm Hg. Systemic examination is unremarkable, except for jaundice. Based on these findings, what is the most likely diagnosis?

A 55-year-old pig farmer is brought to the emergency department (ED) after having a seizure two hours ago. During his transit to the ED, he has another seizure. On arrival, he is unconscious, pulseless, and not breathing. Resuscitation is successful and the patient is stabilized; however, he does not do well over the next several days and is eventually declared dead. His wife says that he had been healthy most of his life, except for the past few weeks, when he was complaining of headaches. Autopsy shows multiple fluid-filled cysts in the brain parenchyma. Which of the following is the most likely diagnosis of this patient?

A 34-year-old recently migrated African American male presents with severe headache and high-grade fever with chills for the last two days. He also complains of severe malaise, myalgia and vomiting. He adds that the present episode started with feeling of intense cold and chills with shivering followed by high-grade fever. He had two similar episodes in the past, when he was in Africa. His vitals are: T° 38.9°C (102°F), RR 20/min, PR 110/min and BP100/60 mm Hg. He has pallor with mild splenomegaly but rest of his physical examination is normal. What is the most likely diagnosis in this patient?

A 22-year-old man comes to the urgent care clinic with a one-week history of fever, sore throat, and malaise. He has tried several over-the-counter products with partial relief. His temperature is 38.8°C (102°F), pulse is 110/min, respirations are 18/min, and blood pressure is 130/70 mm Hg. Oropharyngeal examination reveals palatal petechiae with streaky hemorrhages and blotchy, red macules. The tonsils are enlarged and covered with whitish exudate. Mild jaundice is present. Enlarged lymph nodes are palpable posterior to the sternocleidomastoid muscle bilaterally. Axillary lymphadenopathy is also present. Abdominal examination reveals normal bowel sounds and mild hepatosplenomegaly. His complete blood count is shown below: Hemoglobin 14.0 g/L, MCV 88 f l, Platelets 140,000/mm3, Leukocyte count 14,500/mm3, Neutrophils 33%, Lymphocytes 66%, Eosinophils 1%. Which of the following is commonly associated with this patient's condition?

A 36-year-old man from Ohio presents with fever, malaise, fatigue, and skin lesions on his right forearm. His fever is low-grade, without any rigors or chills. His temperature is 38.4°C (101°F), pulse is 87/min, and blood pressure is 124/74mm Hg. Examination shows 1-2cm warty, heaped-up skin lesions with a violaceous hue and sharply demarcated border. Some of these lesions are crusted. Wet preparation of purulent material from skin lesions shows yeast Based on these findings, what is the most likely diagnosis?

A 34-year-old male comes to the physician's office due to a severely pruritic lesions on his hands. He denies any trauma but recalls using his hands to change the sand of his children's sandbox when they went to Miami Beach three days ago. He later developed pruritic, erythematous papules over his arm. These papules progressed to serpiginous, reddish brown, elevated lesions, which are evident bilaterally on the upper extremities on exam. What is the most likely diagnosis?

A 64-year-old male recovering from an upper respiratory infection develops malaise and productive cough. Two days later he presents to the emergency department with confusion and severe dyspnea. He reports coughing up copious amounts of yellowish sputum streaked with blood today. On physical examination, his temperature is 40°C (104°F), blood pressure is 150/90 mm Hg, pulse is 110/min, and respirations are 24/min. Chest x-ray reveals infiltrates in the lung midfields bilaterally as well as multiple thinwalled cavities. What is the most likely cause of this patient's condition?

A 35-year-old man presents to the office with a two-week history of low-grade fever and progressive weakness. He has "a heart murmur detected a long time ago." He denies illicit drug use. Physical examination reveals splinter hemorrhages, small petechiae on the palatal mucosa, and an audible murmur. His ESR is 60/min. Urinalysis reveals microscopic hematuria and 1 +proteinuria. Which of the following valvular dysfunctions is most likely to be detected?

A 22-year-old female presents with a two-day history of inability to close her right eye, a low-grade fever, and a rash on her trunk. There is no burning or itching associated with the rash. She denies headache, confusion, neck stiffness, numbness, and tingling. She went on a camping trip in Vermont four weeks ago but cannot recall any exposure to ticks. She was treated for chlamydia! Urethritis infection in the past. She has been using over-the-counter acetaminophen for fever; she noticed the rash after beginning the acetaminophen. Physical examination reveals several erythematous lesions around her waistline. Neurological examination shows right-sided facial nerve palsy. Based on these findings, what is the most likely diagnosis?

A 22-year-old male student presents with an acute onset of fever, double vision, and painful swelling around his eyes. He also has significant muscle pain in his neck and jaw muscles. A week earlier, he experienced a period of abdominal pain, nausea, vomiting, and diarrhea, all of which resolved spontaneously. He has a history of intravenous drug abuse but has recently completed of a drug rehabilitation program. He is febrile. Physical examination shows "splinter" hemorrhages, periorbital edema, and chemosis. Chest is clear to auscultation. Cardiac exam reveals no murmur. Abdomen is soft and nontender with no organomegaly. His complete blood count is shown below: Hemoglobin 13.0 g/L, MCV 85 fl, Platelets 228,000/mm3, Leukocyte count 10,500/mm3, Neutrophils 56%, Eosinophils 21%, Lymphocytes 23%. Based on these findings, what is the most likely diagnosis?

A 19-year-old woman comes to the physician because of fever, joint pain, and rash. The rash started on her face and is spreading down her body. She has pain in her fingers, wrists, and knees. She denies any neck stiffness, nausea, or vomiting. She has been sexually active with multiple partners. Her vaccination status is unknown. Her pulse is 86/min, blood pressure is 125/75 mm Hg, and temperature is 37.7°C (99.8°F). Physical examination reveals a maculopapular rash on her face and chest. Posterior auricular, cervical, and suboccipital lymphadenopathy is present. She has mild conjunctivitis. Oropharynx is clear. Chest is clearto auscultation. What is the most likely diagnosis?

An elderly bedridden patient in the hospital develops cough, fever, and shortness of breath. On examination, the JVP is 4 cm, heart sounds are normal, and there are crackles on inspiration in the right lower lobe. A CXR reveals a new right lower lobe infiltrate and his WBC is 15,000/mL. He was admitted to the hospital 7 days ago for the treatment of congestive heart failure. Which of the following is the most likely diagnosis?

A 35-year-old male complains of inability to close his right eye. Examination shows facial nerve weakness of the upper and lower halves of the face. There are no other cranial nerve abnormalities, and the rest of the neurological examination is normal. Examination of the heart, chest, abdomen, and skin show no additional abnormalities. There is no lymphadenopathy. About one month ago the patient was seen by a dermatologist for a bull’s-eye skin rash. The patient lives in upstate New York and returned from a camping trip a few weeks before noting the rash. Which of the following is the most likely diagnosis?

An 18-year-old woman presents with headache, anorexia, chilly sensations, and discomfort on both sides of her jaw. She has also noticed discomfort in both lower abdominal quadrants. Physical examination reveals bilateral enlarged parotid glands that are doughy, elastic, and slightly tender; with a reddened orifice of Stensen’s duct. Her abdomen is soft with bilateral lower quadrant abdominal tenderness; a temperature of 38.5°C; and a pulse rate of 92/min. Laboratory data show hemoglobin 13 g/dL; hematocrit 40%; white blood cells (WBC) 9000/mL, with 35% segmented neutrophils, 7% monocytes, and 58% lymphocytes. Which of the following is the most likely cause for her abdominal pain and tenderness?

A 20-year-old woman presents with headache, fever, and neck stiffness. On examination, her blood pressure is 100/70 mm Hg, pulse 100/min, temperature 38.6°C, and the neck is stiff and painful to flex and extend. The ears, throat, and sinuses are normal, there are no focal neurologic signs, and the remaining examination is normal. There are no reported similar cases in the community. Which of the following is the most likely source of her infection?

A 32-year-old woman acutely develops high fever, hypotension, and rash. This is followed by vomiting, diarrhea, confusion, and abdominal pain. In the hospital, evidence of multiorgan failure develops. Desquamation of the skin occurs 1 week after the acute illness. On further history, the illness started 3 days after the onset of menstruation. Which of the following is the most likely diagnosis?

A 22-year-old man is an avid spelunker (cave explorer) and has recently been exploring several caves. A routine CXR taken for a new job reveals hilar adenopathy and two patches of pneumonitis. His physical examination is completely normal. Careful questioning reveals he has just gotten over a cold with mild fever, cough, and malaise. Which of the following is the most likely diagnosis?

A 53-year-old man with alcoholic cirrhosis presents with increasing jaundice and abdominal discomfort. He reports no fevers or chills. On examination, his blood pressure is 100/60 mm Hg, pulse 100/min, temperature 38.1°C. He has a distended abdomen, peripheral edema, and shifting dullness. The abdomen is tender and bowel sounds are present. A diagnostic paracentesis is performed; the total cell count is 940/mL with polymorphonuclear neutrophils (PMNs) equal to 550/mL, Gram stain is negative, and cultures are pending. Which of the following is the most likely diagnosis?

A 20-year-old woman presents with headache, anorexia, chilly sensations, pain, and drawing sensations in both sides of her jaw. She has also noticed discomfort in both lower abdominal quadrants. Physical examination reveals bilateral enlarged parotid glands that are doughy, elastic, and slightly tender; with a reddened orifice of Stensen’s duct. Her abdomen is soft with bilateral lower quadrant abdominal tenderness, a temperature of 38.5°C, and a pulse rate of 92/min. Laboratory data show hemoglobin 13 g/dL; hematocrit 40%; WBC 9000/mL, with 35% segmented neutrophils, 7% monocytes, and 58% lymphocytes. Which of the following is the most likely diagnosis?

An 18-year-old woman visits her physician because of 3 weeks of malaise, 2 weeks of fever, and a sore throat. Physical examination shows pharyngeal infection with enlarged tonsils and a patchy, white exudate; enlarged, palpable anterior and posterior cervical, axillary, and inguinal lymph nodes; tenderness in the right upper quadrant; and minimal splenomegaly. Laboratory data show hemoglobin 14 g/dL; hematocrit 42%; platelets 380,000/mL; WBC 8500/mL, with 35% segmented neutrophils, 1% eosinophils, and 64% lymphocytes, of which 36% were atypical. Which of the following is the most likely diagnosis?

A 43-year-old man developed a cough shortly after returning from a 1-month hiking trip in California. While there, he was hiking in the central California valleys. During his trip, he had developed a flu-like‖ illness consisting of fever, cough, and muscle pains, which resolved spontaneously. A CXR shows a thin-walled cavity in the right upper lobe, and the sputum reveals fungal elements. Which of the following is the most likely causative organism?

A 34-year-old man presents with diarrhea 3 weeks after returning from a trip to rural South America. Over the past few days, he has gradually developed lower abdominal pain and diarrhea. Now the symptoms are much worse with eight stools a day consisting mostly of mucus and blood. He is afebrile, the abdomen is tender in left lower quadrant, and the remaining examination is normal. His stool is mostly comprised of blood and mucus, and stools tests show trophozoites of Entamoeba hitolytica. Which of the following is the most likely site of extra intestinal involvement?

A 40-year-old man develops erythema nodosum, conjunctivitis, and a pleural effusion. Over several weeks, pulmonary lesions lead to cavitation and a large, thin-walled cavity. He was traveling in Arizona before becoming ill. Sputum samples reveal mature spherules. Which of the following is the most likely diagnosis?

A 7-year-old child, unvaccinated because of his parents’ religious beliefs, develops malaise, cough, coryza, and conjunctivitis with a high fever. Examination of his mouth reveals blue white spots on a red base beside his second molars. The next day he develops an erythematous, nonpruritic, maculopapular rash at his hairline and behind his ears, which spreads over his body. Which of the following is the most likely diagnosis?

A 51-year-old man is admitted to the hospital because of renal failure. His past medical history is significant for recurrent episodes of bilateral flank pain over the past several years as well as nocturia 2 to 3 times per night for the past 10 years. He has no weight loss. On physical examination, his blood pressure is 160/100 mm Hg. His mucous membranes are pale. There is a palpable mass located at the right flank. Which of the following is the most likely diagnosis?

A 30-year-old African American man comes to the physician because of a two-week history of fatigue and ankle edema. He is HIV-positive. He takes no medications. He does not use tobacco, alcohol, or drugs. His temperature is 36.7°C (98°F), blood pressure is 140/86 mm Hg and respirations are 16/min. Physical examination shows mild ankle edema. Laboratory studies show: Hb 12.5 g/dl, WBC 6,000/cmm, Platelets 140,000/cmm, Serum Na 135 mEq/L, Serum K 5.0 mEq/L, BUN 28 mg/dl, Serum creatinine 2.4 mg/dl. Urinalysis revealed 2+ proteinuria but otherwise shows no abnormalities. CD4 count taken three weeks ago was 550. Which of the following is the most probable form of kidney disease in this patient?

A 43-year-old man complains of occasional red urine. He denies fever, edema, flank pain or weight loss. Specifically, he says that each urine stream starts out transparent, but turns red by the end of the stream. At times he has noticed small clots in his urine. Physical examination is within normal limits. What is the most likely cause of his complaints?

A 74-year-old man comes to the physician because of a one-year history of increased urinary frequency and urgency. He feels that his bladder is "not emptying properly", and has a constant sensation of incomplete voiding. His only other medical problem is hypertension, for which he takes hydrochlorothiazide. He never had any surgeries. Urine culture shows no abnormality. Which of the following is true regarding this patient's disorder?

A 26-year-old man comes to the emergency department because of a sudden onset of severe, colicky, leftsided flank pain that radiates to the scrotum. He also has nausea, vomiting and dark-colored urine. He has never had these symptoms before. Examination shows no abnormalities. Non-contrast helical CT shows a 5 mm radiopaque stone in the left upper ureter. His laboratory studies are as follows: Serum calcium 9.8 mg/dl, Serum creatinine 0.9 mg/dl, BUN 15 mg/dl. Urinalysis shows hematuria but no casts. Which of the following is the most likely cause of this patient's symptoms?

A 36-year-old man comes to the physician because of fatigue and generalized edema. He was recently diagnosed with Hodgkin's lymphoma. Laboratory studies show: Serum sodium 145 mEq/L, Serum potassium 3.8 mEq/L, Serum albumin 2.0 g/dl, Serum globulin 7.0 g/dl, Total serum bilirubin 0.9 mg/dl, Serum creatinine 1.2 mg/dl. Urinalysis shows proteinuria 4+. Which of the following glomerulopathies is more likely to be present in this patient?

A 30-year-old woman comes to the physician because of a 2-day history of periorbital edema and abdominal distention. She has no other complaints. Her temperature is 37.1°C (98.9°F), blood pressure is 125/75 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows ascites. Urinalysis shows proteinuria; 24-hour urinary protein excretion is 4 g/day, total serum protein is 5 g/dl and serum albumin is 2.5g/dl. A diagnosis of nephrotic syndrome is made. Renal biopsy is performed. She is started on diuretics and her salt and protein intake is restricted. Her edema begins to improve. However, the patient suddenly develops severe abdominal pain, fever, and gross hematuria. Which of the following is the most likely diagnosis that will be revealed by renal biopsy?

A 30-year-old African American man comes to the physician because of a 2-day history of periorbital edema and abdominal distention. His temperature is 37.1°C (98.7°F), blood pressure is 125/75mm Hg, pulse is 80/min, and respirations are 14/min. His height is 170cm (5'7") and weight is 104kg (2301bs). He has been in a drug rehabilitation program for the past 2-months, for a long history of IV drug abuse. Examination shows significant ascites. Urinalysis shows proteinuria; 24-hr urinary protein excretion is 4g/day. Which of the following is the most likely diagnosis?