USMLE_Diagnosis VII

A 4-month-old child presents with a 2-day history of vomiting and intermittent irritability. On examination, “currant jelly” stool is noted in the diaper, and a sausage-shaped mass is palpated in the right upper quadrant of the abdomen. Which of the following conditions is most likely to cause this?

A 4-month-old infant is evaluated by a dermatologist because of thick, erythematous skin with fine scaling, principally involving his face. The mother reports that the infant is "always scratching his face." An older brother and a maternal uncle had a similar condition. Screening hematologic studies show the following: Erythrocyte count 5.1 million/mm3, Leukocyte count 12,000/mm3, Segmented neutrophils 80%, Bands 5%, Eosinophils 3%, Basophils 1%, Lymphocytes 5%, Monocytes 6%, Platelet count 35,000/mm3 , with the comment that the platelets are smaller than normal. Serum immunoglobulin studies demonstrate the following: IgA 120 mg/dL, IgE 2300 IU/mL, IgG 900 mg/dL, IgM 15 mg/dL. Patients with this condition have a significantly increased incidence of which of the following?

A 4-month-old male infant is brought to the office by his parents due to progressive lethargy, poor feeding, fatigue and increasing pallor for the past four weeks. His antenatal and birth histories are unremarkable. His diet consists mainly of breast milk. His immunizations are up-to-date. His mother's blood type is 0 +. Physical examination reveals a webbed neck, cleft lip, shielded chest, triphalangeal thumbs, and pale mucous membranes and conjunctivae. Cardiac auscultation reveals mild tachycardia and a systolic ejection murmur over the left upper sternal border. The initial investigations reveal the following: Hb 8 g/dl, Ht 26%, WBCs 7,000/mm3, Platelets 300,000 /mm3, Reticulocytes 04%, MCV 104 fl, Blood type A -, Bilirubin direct 0.1 mg/dl, Bilirubin total 1.0 mg/dl. What is the most likely diagnosis?

A 4-year-old boy and his family have recently visited a local amusement park. Several of the family members developed “gastroenteritis” with fever and diarrhea, but the 4-year-old’s stool was slightly different, as it contained blood. His mother reports that in the past 24 hours he developed pallor and lethargy; she relates that his face looks swollen and that he has been urinating very little. Laboratory evaluation reveals a hematocrit of 28% and a platelet count of 72,000/μL. He has blood and protein in the urine. Which of the following diagnoses is most likely to explain these symptoms?

A 4-year-old boy is being evaluated for short stature. He has a history of multiple bone fractures in the past. He requires a wheelchair to ambulate and has hearing difficulty. On physical examination, his height is below the 5th percentile. His sclerae are blue in color. There is marked deformity of his lower extremities. Which of the following is the most likely diagnosis?

A 4-year-old boy is brought by his mother to a Medical Camp for the Uninsured for the evaluation of his inflamed right eye. He has had a nasal discharge for the past 10 days. His brother has similar symptoms. His vital signs are stable. There are follicles and inflammatory changes in the conjunctiva of his right eye. The cornea shows neovascularization. What is the most likely diagnosis?

A 4-year-old boy is brought to his pediatrician by his mother for "multiple fainting spells." Although physical examination reveals no abnormalities, the boy is admitted to the hospital for an extensive diagnostic workup. Laboratory evaluation reveals no abnormalities except for low serum glucose, high serum insulin, and low levels of serum C-peptide. The test results are revealed to the boy's mother, who works as a nurse in the hospital. Which of the following is the most likely diagnosis?

A 4-year-old boy is brought to the office because his school teacher thinks that his dusky blue appearance may have something to do with his inability to participate in regular school activities. His mother says that he has always appeared slightly out of breath. He has no history of any trauma, past surgery or medical conditions. His birth history is unremarkable. Physical examination reveals perioral cyanosis and a systolic murmur along the left sternal border. When the child squats, the murmur disappears and the cyanosis slightly improves. What is the most likely diagnosis of this patient?

A 4-year-old boy is brought to the office for a routine exam. He has a small face, upslanting palpebral fissures, a speckled iris, and a simian crease. Auscultation reveals a loud P2. His mother informs you that he has trisomy. What is the most likely congenital heart disorder in this patient?

A 4-year-old boy is seen in the office for a general check-up. The child appears well nourished and has normal developmental milestones. His temperature is 36.6 C (98 F), pulse rate is 80/min, and blood pressure is 110/70 mmHg. On abdominal palpation, there is a lobular right-sided flank mass, and the kidneys are palpable bilaterally. What is the most likely cause of the flank mass in this child?

A 4-year-old boy presents to the emergency department with generalized tonic-clonic seizures. On physical examination, the child is noted to be lethargic. His temperature is 37.4 C (99.3 F), blood pressure is 100/60 mm Hg, pulse is 72/min, and respirations are 16/min. His oral mucosa is moist, and there is no peripheral edema. Laboratory tests show: Blood: Sodium 120 mEq/L, Potassium 4.2 mEq/L, Chloride 96 mEq/L, Bicarbonate 20 mEq/L, Blood urea nitrogen 9.6 mg/dL, Creatinine 0.4 mg/dL, Glucose 88 mg/dL, Urine: Sodium 55 mEq/L, Potassium 16 mEq/L, Osmolality 530 mOsmol/kg. Which of the following is the most likely diagnosis?

A 4-year-old boy presents with severe pains in both of his legs. On physical examination, his temperature is 37.7 C (99.8 F), blood pressure is 108/68 mm Hg, pulse is 96/min, and respirations are 17/min. He is noted to have marked pallor on his lips and palpebral conjunctiva. Numerous purpura and petechiae are noted on his skin. His spleen is palpable 3 cm below his left costal margin. Laboratory evaluation reveals a white blood cell count of 1600/mm3; hemoglobin, 6.1 g/dL; and platelets, 36,000/mm3. Which of the following diagnoses is most consistent with these findings?

A 4-year-old boy, whose past medical history is positive for three urinary tract infections, presents with a blood pressure of 135/90 mm Hg. He is likely to exhibit which of the following symptoms or signs?

A 4-year-old Caucasian boy is brought to his physician's office for a health maintenance exam. He will be starting preschool soon, and his parents want to make sure that he is in optimal health. The child has no complaints, and is generally happy. His medical history is significant for pneumonia as a newborn, and three episodes of otitis media since birth. He does not take any medications on a regular basis. His newborn screening test results are normal. His developmental milestones are at par with his age. He lives with his parents in a middle-class, suburban house built in 1981. Which of the following is the most appropriate next step for this child's primary care?

A 4-year-old child presents with an enlarged submandibular node that is 4 cm in diameter, nontender, and not fluctuant. The node has been enlarged for about 4 weeks, and there is no history of fever or contact with any person who was ill. A CBC is normal, and a Mantoux test with 5 tuberculin units of PPD shows 6 mm of induration. Which of the following is the most likely diagnosis?

A 4-year-old child was brought in for evaluation of sleep problems. He cried and screamed within an hour of falling asleep. He seemed disoriented and confused; he did not seem aware of his parents’ presence. They were unable to arouse him to comfort him. This resolved spontaneously, and he had no recollection of the event the next morning. You informed the parents that he was most likely experiencing which of the following?

A 4-year-old girl is brought to the office by her parents due to a red rash and blisters. Yesterday, she had a fever and was irritable. Today, she developed the rash with blisters. Her pulse is 90/min, blood pressure is 90/60 mmHg, respirations are 14/min, and temperature is 39°C (102°F). On examination, there are superficial flaccid bullae and an erythematous rash diffusely distributed over her body. Nikolsky's sign is positive. Her face is edematous, and there is crusting around the mouth area. Her skin is warm and tender with exfoliation. What is the most likely diagnosis?

A 4-year-old girl is brought to the office due to easy bruising and a rash for the past 3 days. She had an upper respiratory infection approximately two weeks ago. She has never had palpable bruises, hemarthroses, or deep muscle bleeding in the past. She has 2 older brothers, neither of which has had bleeding symptoms before. Her family history is negative for any bleeding disorders. Her vital signs are normal. Physical examination reveals a diffuse petechial rash on her neck, trunk, extremities and groin. There is no hepatosplenomegaly. Nonpalpable ecchymoses of varying ages are present on the shins and arms. The laboratory findings are as follows: Hemoglobin 12 .8 g/dl, Hematocrit 38.5%, WBC 6,000/mm3, Platelets 5,000/mm3, PT 12.0 sec, PTT 30 sec. Peripheral smear shows normal morphology of the red and white blood cell lines. The platelets are reduced in number, and majority of them are increased in size. What is the most likely diagnosis?

A 4-year-old girl is brought to the office due to seizures that occurred 2 hours ago. This is her first episode. Her parents are also concerned because she is not able to carry on activities that children of her age are expected to do. On examination, there is a red flat lesion covering the left eye area and adjacent facial skin, which does not blanch on pressure, and which the parents say has been present since birth. Other pertinent findings are hemianopia, hemiparesis, and hemisensory disturbances. An x-ray of the skull shows tramline intra-cranial calcifications. What is the most likely diagnosis?

A 4-year-old girl is brought to the physician by her mother who is concerned because her child has a vaginal discharge. Starting 2 days ago, the child began scratching her vulva and complaining of burning with urination. The child is otherwise healthy and has never had a similar problem. Examination reveals normal structural anatomy for a 4-year-old girl. There is no evidence of atrophy. There is an inflammatory erythema on the medial aspects of the labia majora and excoriations. There is a mucous discharge with a few flecks of blood intermixed. Which of the following is the most likely cause of a vaginal discharge in this patient?

A 4-year-old girl is brought to your office by her mother for recent onset of fever and rash. For the past 4 days, she has had headaches, fever, and sore throat. She was apparently normal 4 days ago, and upon presentation of the symptoms, her mother thought that she was having a simple viral fever which would go away with time; however, she then developed a pale pink maculo-papular rash, first on the face and neck, and then it rapidly spread onto the trunk and limbs. On examination, the child is afebrile and doesn't appear ill, but there are few palpable suboccipital and posterior auricular lymph nodes. What is the most likely cause of this patient's condition?

A 4-year-old immigrant boy is brought by his mother to a Medical Camp for the Uninsured for the evaluation of his inflamed right eye. He has had a nasal discharge for the past 10 days. His brother has similar symptoms. His vital signs are stable. There are follicles and inflammatory changes in the conjunctiva of his right eye. The cornea shows neovascularization. What is the most likely diagnosis?

A 4-year-old previously healthy but unimmunized boy presents with sudden onset of high fever, inspiratory stridor, and refusal to drink. Of the following causes of inspiratory stridor, which best fits this clinical scenario?

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?

A 4-year-old, apparently healthy child is examined by a pediatrician. The pediatrician hears a loud systolic ejection murmur with a prominent systolic ejection click. He also hears a soft, early diastolic murmur. Both murmurs are heard best at the upper right sternal border. ECG shows left ventricular hypertrophy. Which of the following is the most likely diagnosis?

A 40-year-old Caucasian man comes to the emergency department because of fever, dry cough, and shortness of breath. Symptoms started 24 hours ago. He denies hemoptysis. He was recently discharged from the hospital after a second cycle of chemotherapy for acute myeloid leukemia. He does not use tobacco, alcohol, or drugs. His temperature is 38.9°C (102.0°F), blood pressure is 120/70 mmHg, pulse is 112/min and respirations are 28/min. The patient's pulse oximetry showed 86% at room air. Examination shows diffuse crackles all over the lung fields. His chest x-ray shows diffuse interstitial infiltrates. Which of the following is the most likely cause of his condition?

A 40-year-old female is brought to the emergency department following a motor vehicle accident in which she was the front seat passenger. She reports hitting her head against the windshield and hurting her right leg. She appears completely alert and oriented. Glasgow Coma Scale =15/15. Her pupils are equal and reactive to light. There is a bruise over the right forehead, but no tenderness is present on palpation of the cranial bones. Examination of the right leg reveals a hematoma over the thigh. Knee extension on the right is markedly reduced when compared to the left. Sensory examination reveals decreased sensory perception to both sharp and dull stimuli over the medial side of the right lower thigh and leg. All other dermatomes are intact. What nerve injury is most likely present in this patient?

A 40-year-old female presents with a 12-month history of episodes of chest pain and dysphagia. The episodes last from a few seconds to a few minutes. She has not had weight loss, fevers or chills. Chest-x ray, ECG and barium swallow show no abnormalities. Manometric studies show simultaneous high amplitude contractions with normal relaxation of the lower esophageal sphincter. Which of the following is the most likely diagnosis?

A 40-year-old G3P2 obese patient at 37 weeks presents for her routine OB visit. She has gestational diabetes that is controlled with diet. She reports that her fasting and postprandial sugars have all been within the normal range. Her fetus has an estimated fetal weight of 6.5 lb by Leopold maneuvers. Which of the following is the best next step in her management?

A 40-year-old G3P3 comes to your office for a routine annual GYN examination. She tells you that she gets up several times during the night to void. On further questioning, she admits to you that during the day she sometimes gets the urge to void, but sometimes cannot quite make it to the bathroom. She attributes this to getting older and is not extremely concerned, although she often wears a pad when she goes out in case she loses some urine. This patient is very healthy otherwise and does not take any medication on a regular basis. She still has regular, monthly menstrual periods. She has had three normal spontaneous vaginal deliveries of infants weighing between 7 and 8 lb. An office dipstick of her urine does not indicate any blood, bacteria, WBCs, or protein. Her urine culture is negative. Based on her office presentation and history, which of the following is the most likely diagnosis?

A 40-year-old male presents to the Emergency Room with a two-month history of occasional severe headache and blurring of vision. His past medical history is significant for hypertension controlled with hydrochlorothiazide for two years. His family history is significant for hypertension and diabetes. He smokes two packs a day and occasionally consumes alcohol. His blood pressure is 200/140 mmHg and heart rate is 75/min. Which of the following is most consistent with a diagnosis of malignant hypertension in this patient?

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 40-year-old man is brought to the emergency room because of altered mental status and gait instability. He has had two falls in the last two days. He drinks one pint of vodka daily and smokes one pack of cigarettes daily. His temperature is 35.0°C (95.0°F), blood pressure is 100/70 mm Hg, pulse is 90/min, and respirations are 14/min. He is disoriented, but not in acute distress. You note prominent horizontal nystagmus and conjugate gaze palsy in both eyes and absent ankle reflexes in both legs. His chest is clear to auscultation. Which of the following is the most likely cause of his symptoms?

A 40-year-old man presents to the emergency room with shortness of breath, cough and hemoptysis for the past two days. He says he has never had symptoms like these before. His medical history is significant for a non-healing leg ulcer and chronic purulent nasal discharge. He has smoked a pack of cigarettes daily for the past 20 years. On physical examination, his temperature is 37.6°C (99.7°F), blood pressure is 130/90 mm Hg, pulse is 94/min and respiratory rate is 18/min. Lung auscultation reveals patchy rales bilaterally. Heart sounds are regular. A 2x3cm ulcer with rolled, undermined borders is noted on the right lower leg. Which of the following is the most likely explanation for his hemoptysis?

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?

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 40-year-old woman is arrested by the police after she is found crawling through the window of a movie star’s home. She states that the movie star invited her into his home because the two are secretly married and “it just wouldn’t be good for his career if everyone knew.” The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life. Which of the following 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 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?

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 41-year-old intravenous drug abuser presents with shortness of breath and pleuritic chest pain. He is febrile with a temperature of 103.5°F. He has no skin lesions and funduscopic exam is negative. He has jugular venous distension that increases with compression of the liver. The liver is pulsatile. The jugular venous pulse shows a prominent v wave. The patient has splenomegaly. Heart auscultation reveals a holosystolic murmur heard best at the left lower sternal border. The murmur increases with inspiration (Müller maneuver). Which of the following is the most likely diagnosis?

A 41-year-old woman, gravida 3, para 3, comes to the physician because of a 2-year history of dysmenorrhea and menorrhagia that has been increasing in intensity. She has no dyspareunia or any other symptoms. She has a history of chronic hypertension. She had a cesarean section in her 3rd pregnancy followed by surgical sterilization. Vital signs are normal. Bimanual examination shows a symmetrically enlarged and tender uterus with soft consistency and free adnexae. Which of the following is the most likely diagnosis?

A 42-year-old female with acute pericarditis develops jugular venous distention and hypotension. The ECG shows electrical alternans. Which of the following is the most likely additional physical finding?

A 42-year-old male comes to the physician's office for evaluation of skin rash and hair loss. He has a long history of Crohn's disease and has had extensive small bowel resection resulting in short bowel syndrome. He is currently receiving total parenteral nutrition. When he does try to eat, he complains that the food does not taste good. His vital signs are stable. Examination shows alopecia and bullous, pustular lesions around the perioral and periorbital areas. Which of the following is the most likely cause of his current symptoms?

A 42-year-old male presents to your office complaining of back pain that started two days ago after carrying heavy packages. He denies any weakness or sensory changes in his legs. His past medical history is insignificant. He is not taking any medications and denies drug abuse. His temperature is 36.7°C (98°F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals paravertebral tenderness. Lower extremity power is 5/5 and the deep tendon reflexes are 2+. Babinski's sign is negative. Straight-leg raising test is negative at 90 degrees. What is the most probable diagnosis in this patient?

A 42-year-old man comes to the emergency room with the chief complaint that “the men are following me.” He also complains of hearing a voice telling him to hurt others. He tells the examiner that the news anchorman gives him special messages about the state of the world every night through the TV. Which of the following psychiatric findings best describes this last belief of the patient?

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?

A 42-year-old man found vomiting in the street is brought to the ED by emergency medical services (EMS). He has a known history of alcohol abuse with multiple presentations for intoxication. Today, the patient complains of acute onset, persistent chest pain associated with dysphagia, and pain upon flexing his neck. His BP is 115/70 mmHg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 97% on room air. As you listen to his heart, you hear a crunching sound. His abdomen is soft with mild epigastric tenderness. The ECG is sinus tachycardia without ST-T–wave abnormalities. On chest radiograph, you note lateral displacement of the left mediastinal pleura. What is the most likely diagnosis?

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?

A 42-year-old man has had a rocky course for the 3 days following a bowel resection for intestinal perforation due to inflammatory bowel disease. His CVP had been 12 to 14 but is now 6, in the face of diminished blood pressure and oliguria. Which of the following is the most likely etiology of his hypotension?

A 42-year-old man is undergoing chemotherapy after resection of a cecal adenocarcinoma with positive lymph nodes. You are asked to see him regarding a potential surgical complication. Which of the following potentially operable complications is a common occurrence among patients receiving systemic chemotherapy?

A 42-year-old man presents to his primary care physician complaining of daytime sleepiness. He says that he often falls asleep during meetings, watching TV, and even while driving his car. He does not feel refreshed after his daytime naps, and has not experienced vivid hallucinations when falling asleep or upon awakening. He has occasional morning headaches and his wife complains that he sometimes keeps her up at night. Physical exam reveals a body mass index (BMI) of 31.3 kg/m2. An arterial blood gas is normal. What is this patient's most likely diagnosis?

A 42-year-old man presents to the emergency department complaining of two weeks of weakness, low-grade fevers, and exertional shortness of breath. He also notes fingertip pain and urine that has been dark and cloudy recently. On physical examination, several of his proximal inter phalangeal joints are swollen. Which of the following diagnoses is most consistent with his presentation?

A 42-year-old man presents to the emergency department with a complaint of increasing shortness of breath when walking to get his newspaper, difficulty breathing while lying flat, and a 4.5-kg (10-lb) weight gain over the past month. He is afebrile, his pulse is 75/min, and his blood pressure is 98/50 mmHg. On examination he smells of alcohol and has 2+ pitting edema in the lower extremities and a third heart sound. X-ray of the chest reveals cardiomegaly. What additional findings must be present to confirm this man’s underlying diagnosis?

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?

A 42-year-old man with known valvular heart disease develops a fever for 1 week. He appears unwell; findings include a pansystolic murmur at the apex that radiates to the axilla and a soft S1 sound. He has petechiae on his conjunctival sac, linear hemorrhages under a few fingernails, and painful, tender, and erythematous nodules on some of the distal fingertips. Which of the following is the most responsible mechanism for these physical findings?

A 42-year-old white male presents to your office complaining of periodic breathing difficulty and wheezing. He visited an otolaryngologist for persistent nasal blockage recently. His past medical history is significant for unstable angina experienced five months ago. His current treatment includes aspirin, diltiazem, and pravastatin. He does not use tobacco, alcohol, or drugs. His vital signs are within limits. What is the most probable cause of this patient's respiratory complaints?

A 42-year-old woman comes to the physician because of vaginal itch and discharge, dysuria, and dyspareunia. These symptoms have been steadily worsening over the past 3 days. Pelvic examination reveals an erythematous vagina and a thin, green, frothy vaginal discharge with a pH of 6. Microscopic examination of the discharge demonstrates the presence of a pear-shaped, motile organism. Which of the following is the most likely pathogen?

A 43-year-old Caucasian female presents to your office complaining of joint pain and swelling in her hand. On history, she endorses easy fatigability and loss of energy that has been worsening insidiously. It is especially difficult for her to do daily activities in the morning due to prolonged stiffness. She also describes frequent knee pain accompanied by a low-grade fever. She takes ibuprofen and naproxen to relieve her symptoms. Her hematocrit is 33%. The patient is at the greatest risk of which of the following?

A 43-year-old female presents to the physician's office with muscle cramps, polydipsia and polyuria. She has no other medical problems, and does not take any medications. She does not use tobacco, alcohol or drugs. Her father died from alcoholic liver disease at age 50. Her pulse is 75/min, respirations are 13/min, blood pressure is 160/100 mmHg, and temperature is 37°C (98.6°F). Laboratory studies show: Blood glucose 115 mg/dL, Serum sodium 142 mEq/L, Serum potassium 2.7 mEq/L. Plasma renin activity is low. What is the most likely diagnosis?

A 43-year-old G2P2 comes to your office complaining of an intermittent right nipple discharge that is bloody. She reports that the discharge is spontaneous and not associated with any nipple pruritus, burning, or discomfort. On physical examination, you do not detect any dominant breast masses or adenopathy. There are no skin changes noted. Which of the following conditions is the most likely cause of this patient’s problem?

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?

A 43-year-old male complains of right shoulder pain and weakness after falling on his outstretched hands two days ago. He denies shoulder deformity. The physician passively abducts both his arms above his head and then asks 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?

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 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 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?

A 43-year-old man is evaluated for a one-year history of chronic abdominal pain. He describes episodes of epigastric and left upper quadrant pain that last for hours and are not relieved by antacids. Certain foods can precipitate the pain. He also complains of occasional diarrhea. The patient has lost 10 pounds over the last 6 months. Four years ago he was hospitalized for three days with acute abdominal pain. He smokes one pack of cigarettes a day and consumes alcohol regularly. His family history is significant for diabetes mellitus in his mother and prostate cancer in his father. Which of the following is most likely to diagnose this patient's condition?

A 43-year-old man is hospitalized with chest pain, lightheadedness and nausea. He describes the pain as dull and non-radiating. He has never had chest pain before, but does report occasional episodes of dyspnea and coughing. His medical history is significant for eczema. He is not presently taking any medications. His family history is significant for prostate cancer in his father and rheumatoid arthritis in his mother. He does not smoke or consume alcohol. The patient is admitted to the hospital and is given aspirin, low-molecular weight heparin, metoprolol and captopril. On day 2 of his hospitalization he complains of shortness of breath. Physical examination reveals prolonged expirations and bilateral wheezes. There are no crackles. You estimate the jugular venous pressure to be 7 cm with the patient's head elevated at 45 degrees. Which of the following is most likely responsible for this patient's current respiratory symptoms?

A 43-year-old man presents to your office complaining of periodic involuntary head turning and head fixation to the right side. Physical examination reveals a hypertrophied right sternocleidomastoid muscle. What is the most likely diagnosis?

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?

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 had 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?

A 43-year-old moderately overweight woman presents to the emergency department complaining of two days of shortness of breath. Today, while climbing stairs, she had an episode of severe lightheadedness and near syncope. Her medical history is significant for a right calf deep venous thrombosis one year ago. She takes no medications currently. On physical examination, her blood pressure is 90/50 mmHg and her heart rate is 120/min and regular Imaging studies are most likely to reveal which of the following?

A 43-year-old woman comes to the office because she has "finally decided to see a doctor." For the past four months, she has suffered from itching all over her body. She is tired of using over-the-counter products with no relief. Over the past two months, she has had loose stools, which "take forever to flush." Physical examination reveals jaundice, hepatomegaly and splenomegaly. The results of her blood work are as follows: Alkaline phosphatase 200 u/dL, Bilirubin 3.3 mg/dL, Anti-mitochondrial antibodies positive. Which of the following benign lesions of the eye is frequently associated with this patient's condition?

A 44 year old woman delivers a 3120 g (6 lb 14 oz) newborn male. Her pregnancy was normal except that she noted decreased fetal movement compared to her previous pregnancies. She declined an amniocentesis offered by her obstetrician. Physical examination of the newborn reveals an infant with facial features suggestive of Down syndrome. The infant then has bilious vomiting. An x-ray film showing the kidneys, ureters, and bladder (KUB) is performed, which shows a "double bubble" sign. Which of the following is the most likely cause of the abdominal signs and symptoms?

A 44-year-old female complains of generalized weakness, low-grade fever and joint pain. Her daily activities are limited due to joint stiffness, especially in the morning. Her hand joints are swollen symmetrically. The inferior pole of the spleen is palpable on physical examination. Her hematocrit is 34%. Liver and renal function tests are normal. Two months after the initial visit, the patient develops painful oral ulcers. Her laboratory values are: Hematocrit 33%, AST 120 U/L, ALT 90 U/L, Alkaline phosphatase 90 U/L, Bilirubin 1.1 mg/dl, Creatinine 0.8 mg/dl, BUN 16 mg/dl. Which of the following is the most likely cause of this patient's current complaints?

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?

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?

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 44-year-old obese Asian immigrant presents to the ER complaining of a persistent cough for about 3 months. He denies any fever, chills, runny nose or sputum production. He does complain of dyspnea on exertion, which also has been of a short duration. He says that over the last year, he has become progressively short of breath and is unable to sleep lying down. He denies any chest pain or diaphoresis, but has had palpitations in the past. He does not smoke or drink alcohol. On examination, he is alert and in mild distress. He has a BP of 110/70 mmHg, pulse 100/min and is afebrile. Auscultation is difficult. The chest-x ray reveals an enlarged cardiac silhouette. It appears that the left main stem bronchus is elevated. There is no other lung pathology visible. The ECG shows irregularly irregular rhythm. The pathophysiology of this condition is related to which of the following?

A 44-year-old white male presents with a long history of joint pains in several joints. He has seen a physician before but no diagnosis was made. He has been taking ibuprofen with partial relief. He has now developed fever, diarrhea and weight loss. He denies any genitourinary or eye symptoms. He does not use tobacco, alcohol or drugs. He is a farmer. On examination, he has generalized lymphadenopathy and non-deforming arthritis. Small intestinal biopsy reveals periodic Acid-Schiff (PAS)-positive macrophages. Which of the following 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 44-year-old woman has been complaining of a 4-year history of increasing dyspnea and fatigue. Physical examination reveals increased JVP and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and right-sided S3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests show a slight restrictive pattern. A diagnosis of primary pulmonary hypertension is made. Which of the following is the most likely cause of death in this condition?

A 45-year-old female presents to the emergency department because of increasing somnolence and shortness of breath. Her past medical history is significant for hyperlipidemia, hypertension and type2 diabetes. She has never smoked and does not use drugs or alcohol. Her temperature is 36.7°C (98°F), blood pressure is 160/80 mm Hg, pulse is 80/min, and respirations are 16/min. Her BMI is 55 kg/m2. On physical examination, she is drowsy but able to respond to commands. Jugular venous distention is difficult to visualize due to a thick neck. Lungs are clear to auscultation. Heart sounds are distant. Abdomen is obese and non-tender. Lower extremities have edema bilaterally. There are no obvious focal deficits on neurologic examination. Chest x-ray is poor in quality but no obvious abnormalities are noted. EKG shows low voltage QRS complexes but no significant ST-segment or T-wave abnormalities. Laboratory studies show: Complete blood count: Hemoglobin 16.0 g/L, Hematocrit 48%, Mean corpuscular volume 85 fl, Platelet count 224,000/mm3, Leukocyte count 6,600/mm3. Arterial blood gas: pH 7.30, pO2 60mmHg, pCO2 69mm Hg. Which of the following is the most likely cause of her condition?

A 45-year-old Haitian immigrant presents to the emergency department with a chief complaint of productive, blood-tinged cough for 2 months. He has been in the United States for 1 month. His temperature is 40.1°C (104.2°F) and heart rate is 105/min. On physical examination he appears cachectic, and pulmonary rales are heard throughout his lung fields. X-ray of the chest reveals multiple bilateral upper lobe cavitary lesions with associated intrathoracic adenopathy. Results of sputum culture are pending. Which of the following tuberculosis medications can potentially cause optic neuritis?

A 45-year-old Hispanic male comes to the emergency department because of a two-day history of intermittent abdominal pain and bloody diarrhea. He has had four similar episodes in the past year. He is subsequently admitted to the floor. Radiographic and endoscopic evaluations show extensive disease from the terminal ileum to the rectum with multiple ulcerations and pseudopolyps. Biopsy of the lesion shows noncaseating granulomas and crypt abscess. Which of the following is the most characteristic feature which favors the diagnosis of Crohn's disease against that of ulcerative colitis?

A 45-year-old male is brought to the emergency department in a stuporous state. He appears agitated and disoriented. His temperature is 37.2°C (99°F), respirations are 22/min, pulse is 90/min and blood pressure is 110/70 mm of Hg. His lab findings are as follows: Blood pH 7.21, PaO2 100 mmHg, PaCO2 30 mmHg, HCO3- 13 mEq/L, Serum osmolarity 350 mOsm/L, Blood glucose 90 mg/dl, Na+ 141 mEq/L, K+ 4.6 mEq/L, Cl- 100 mEq/L, BUN 28mg/dl, Creatinine 2.5 mg/dl. His urine shows the presence of rectangular, envelope-shaped crystals. His creatinine three months ago was 1.2 mg/dl. What is the most likely cause of this lab abnormality in this patient?

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?