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21) A 48-year-old woman presents to her primary care physician because of 2 weeks of neck pain. The pain is constant and sharp (rated at 10 of 10) and is felt in the anterior portion of her neck. She also notes several weeks of loose stools and fatigue. Past medical history is significant for a viral upper respiratory infection about 1 month ago. She has a temperature of 37.9°C (100.2°F), heart rate of 96/min, and blood pressure of 136/82 mmHg. On neck examination there is diffuse enlargement of the thyroid and it is exquisitely tender to even mild palpation. Laboratory tests show a total tri-iodothyronine level of 280 ng/dL, total thyroxine of 25 μg/dL, and thyroid-stimulating hormone of 2 μU/mL (normal: 0.4–4 μU/L).Which of the following is the most likely diagnosis?

22) A 74-year-old woman is brought to the emergency department by her daughter. The daughter states that her mother lives alone and has no significant medical problems. She says that she last saw her mother a month prior, before she left on an extended business trip. When she returned, she found her mother appeared restless and very nervous. She also appeared to have lost a noticeable amount of weight. The patient told her daughter that she had been having increased frequency of bowel movements, and felt like her heart was beating fast and funny, and that she felt like she might be coming down with a cold. Initial evaluation in the emergency department reveals sinus tachycardia and a painful, enlarged thyroid. Which of the following is the most likely etiology of her symptoms?

23) A 32-year-old woman undergoes a cesarean section because of failure of labor to progress, and delivers a healthy baby boy. The procedure is complicated by significant intraoperative blood loss and hypotension, but the patient is successfully resuscitated. Postoperatively she experiences dull, aching, non-localized abdominal pain and nausea, but denies headache, visual changes, or abnormal edema. On postoperative day three she is passing flatus and remains afebrile, but becomes hypotensive to 90–100 mm Hg systolic and 40–50 mm Hg diastolic. She has not begun lactating despite her attempts to breast-feed her infant. Laboratory values indicate that she is hyponatremic and mildly hyperkalemic. Urinalysis and liver enzymes are normal. Which of the following is the most likely cause of her symptoms?

24) A 24-year-old white male presents with a persistent headache for the past few months. The headache has been gradually worsening and not responding to over-the-counter medicines. He reports trouble with his peripheral vision which he noticed while driving. He takes no medications. He denies illicit drug use but has smoked one pack of cigarettes per day since the age of 18. Past history is significant for an episode of kidney stones last year. He tells you no treatment was needed as he passed the stones, and he was told to increase his fluid intake. Family history is positive for diabetes in his mother and a brother (age 20) who has had kidney stones from too much calcium and a “low sugar problem.” His father died of some type of tumor at age 40. Physical examination reveals a deficit in temporal fields of vision and a few subcutaneous lipomas. Laboratory results are as follows: Calcium: 11.8 mg/dL (normal 8.5-10.5), Cr: 1.1 mg/dL, Bun: 17 mg/dL, Glucose: 70 mg/dL, Prolactin: 220 μg/L (normal 0-20), Intact parathormone: 90 pg/mL (normal 8-51). You suspect a pituitary tumor and order an MRI which reveals a 0.7 cm pituitary mass. Based on this patient’s presentation, which of the following is the most probable diagnosis?

25) A 26-year-old man with a history of kidney stones presents with 1 week of severe burning epigastric pain. He also notes several days of diarrhea and nausea but denies emesis or fever. His family history is remarkable for a paternal uncle with pancreatic cancer. His temperature is 37°C (98.6°F), heart rate is 88/min, respiratory rate is 16/min, and blood pressure is 125/85 mm Hg. Abdominal examination is significant for tenderness in the mid-epigastrium. Upper endoscopy reveals a 1-cm ulceration in the first part of the duodenum. This is the third episode of confirmed peptic ulcers in this patient. Laboratory studies show: Na+: 140 mEq/L, K+: 4.9 mEq/L , Cl−: 105 mEq/L, HCO −: 25 mEq/L, Ca2+: 12.0 mg/dL, PO4: 1.4 mg/dL, Mg2+: 2.0 mg/dL, Blood urea nitrogen: 10 mg/dL Creatinine: 1.0 mg/dL , Glucose: 87 mg/dL. Which of the following is most likely to be found in this patient?

26) A 52-year-old man presents to the primary care clinic for the first time. He states that he has been in good health throughout his life and takes no medications. He was once athletic but has noted a dramatic decrease in his muscle strength and exercise tolerance over the past year. On examination the patient is moderately hypertensive, with a tanned, round, plethoric face; large supraclavicular fat pads; and significant truncal obesity. He has no focal cardiovascular, pulmonary, or neurologic findings. His fasting blood sugar is 200 mg/dL. Which of the following is the most common etiology of this condition?

27) A 3-year-old girl is brought to the pediatrician’s office because of an abdominal mass. Physical examination reveals short stature, coarse facial features, a protruding tongue, and an easily reducible umbilical hernia. The girl has difficulty walking and knows six words, although she is unable to form a sentence. Her mother reports no health problems and an uncomplicated pregnancy. What is the most likely cause of the patient’s condition?

28) A moderately overweight 34-year-old woman presents to the emergency department with excessive sweating, flushing, tachycardia, and nervousness. Presuming that she might be suffering from thyrotoxicosis, the physician checks her blood levels of thyroid hormones, and finds that her free thyroxine and triiodothyronine levels are elevated, while her thyroid-stimulating hormone is decreased. Her radioactive iodine uptake test shows a complete absence of iodine uptake. Which of the following is the most likely diagnosis?

29) A 28-year-old Caucasian male presents to the emergency department complaining of neck pain for the past two days. He states that a chicken bone scratched the back of his throat a week ago. Two weeks ago, he was in Arizona visiting his friends. He is otherwise healthy and has never been hospitalized. His temperature is 39°C (102.2°F), blood pressure is 125/85 mmHg, and heart rate is 120/min. On examination, he refuses to fully open his mouth. Neck movements, especially neck extension, are restricted secondary to pain. Which of the following is the most likely diagnosis?

30) A 7-year-old boy with a 6-day history of nasal discharge presents with a swollen and painful left eye. His blood pressure is 100/70 mmHg, pulse is 92/min, respirations are 18/min, and temperature is 39.4°C (103°F). Examination of the left eye reveals swollen and erythematous eyelids, mild protrusion of the eyeball, and pain with eye movements. The affected eye is tender and his visual acuity is decreased. Funduscopic examination is normal. Which of the following is the most likely diagnosis?

31) A 32-year-old male complains of difficulty hearing in his left ear for the past month. He denies any headaches, fever, chills, weight loss, or ear discharge. He is HIV positive, and is currently being treated with highly active antiretroviral therapy (HAART). He also takes trimethoprim/sulfamethoxazole daily. His most recent CD4 count was 425/mm3. Examination of the affected ear shows a dull, hypomobile tympanic membrane. What is the most likely cause of hearing loss in this patient?

32) A 36-year-old woman presents to your office with complaints of worsening throat pain for the past six days. She also has pain in her ears and neck as well as difficulty swallowing. On examination, she has excessive salivation and difficulty opening her mouth. Her temperature is 39°C (102.2°F), blood pressure is 130/80 mmHg, pulse is 100/min, and respiratory rate is 18/min. Which of the following neck space infections carries the highest risk of mediastinal involvement?

33) A 23-year-old male comes to your office with a 10-day history of severe headaches. He states that they are sharp in character and are mostly right-sided involving the frontal area. The headaches interfere with his sleep, and he also complains of double vision, nausea, and malaise. His blood pressure is 120/80 mmHg, pulse is 103/min, respirations are 14/min, and temperature is 38.0°C (100.5°F). Examination reveals bilateral periorbital edema. There is subtle right-sided lateral gaze palsy. Which of the following is the most likely diagnosis?

34) A 24-year-old Caucasian female complains of recurrent painful ulcers in her mouth and occasional abdominal pain. She has also unintentionally lost 5 pounds over the last six months. She is not sexually active, and denies use of tobacco, alcohol, or drugs. Past medical history is noncontributory and she takes no regular medications. Her mother suffers from asthma and her father has prostate cancer. She is afebrile with a blood pressure of 118/69 mmHg and pulse of 71/min. Physical examination reveals mild abdominal tenderness primarily in the lower abdomen without guarding or rebound. Several shallow ulcers are seen on the buccal mucosa. A biopsy of one of the ulcers demonstrates granulomatous inflammation. Her hematocrit is 42%. Which of the following is the most likely cause of this patient's complaints?

35) A 70-year-old man comes to your office with complaints of difficulty hearing. His wife says that he has been raising the television volume much louder recently. The patient claims that he can hear well when he talks to his family members at home, but he has significant difficulty hearing in restaurants or during other family gatherings, which is why he prefers to stay at home most of the time. He worked in a shipbuilding yard for 30 years, and retired five years ago. He has no history of significant noise exposure. What is the most likely diagnosis?

36) A 12-year-old girl comes to the office complaining of a small amount of left-sided ear discharge that has persisted for the last three weeks. She has completed two courses of antibiotics that were prescribed during her previous visits. She also complains of hearing loss on the left side. On examination, she is afebrile. Otoscopy reveals an intact left tympanic membrane with peripheral granulation and some skin debris. The patient should be evaluated for which of the following?

37) A 33-year-old Caucasian female has suffered from recurrent episodes of dizziness over the last six months. She describes the episodes as a sensation of severe spinning that last one to two hours and are accompanied by intense nausea. She also feels unsteady during the episode, and has to lie down with her eyes closed for relief. There is no particular factor that precipitates the episodes. She denies any headaches, but complains of fullness in her right ear. She has no ear pain or ear discharge. She has used some over-the-counter ear drops with minimal relief of the fullness sensation. She prefers holding her cell phone on the left side. Which of the following is the most likely cause of this patient's condition?

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

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

40) A 26-year-old man comes to your office with a one-week history of right-sided ear pain. The pain often wakes him up at night, and increases in severity when he chews food. He cannot recall any recent episodes of pharyngitis. He denies having any ear discharge, sinus tenderness, or skin rash. He exercises by swimming frequently at a local club. He is sexually active and uses condoms "quite regularly." He lives with his brother, who often comments on his habit of grinding his teeth at night. On examination, his ears are normal with a mild amount of wax. Pain is not elicited by pulling on the pinna. There are no hearing deficits appreciated. Mobility of the tympanic membrane is normal, and the Weber and Rinne test results are within normal limits. What is the most likely diagnosis?

42) A 45-year-old nurse practitioner presents to the emergency department due to painful abdominal cramps and watery diarrhea. She has about 10 to 20 bowel movements a day. She also has nocturnal bowel movements. She has had multiple hospitalizations in the past for similar problems without a definite diagnosis. A lower GI endoscopy during a previous hospitalization showed dark brown discoloration of the colon with lymph follicles shining through as pale patches. Which of the following is the most likely diagnosis?

44) A 65-year-old man comes to the physician's office with a 2-month history of dysphagia. He initially had difficulty swallowing solids, but now this includes liquids. He has occasional heartburn, which usually responds well to antacids. He has lost 20 lbs of weight in the past 2 months. He has a 40 pack- year history of smoking. He has been a chronic alcoholic for 20 years. His temperature is 36.7°C (98°F), blood pressure is 110/80 mmHg, pulse is 66/min, and respirations are 14/min. Physical examination shows no abnormalities. Barium studies show a minimally dilated esophagus with beak-shaped narrowing. Manometry shows increased lower esophageal sphincter tone. Which of the following is the most likely diagnosis?

45) Ms. Lee, a 62-year-old Chinese woman, comes with yellowness in her eyes for the past 6 weeks. She is generally feeling tired, has lost some weight, and occasionally had some nausea. She denies any altered bowel habits. She is a non-smoker but drinks 2-3 beers each night. Her dad is suffering from high cholesterol and also has had stroke. She had a dilatation and curettage for an abnormal pap smear 15 years ago. Her vitals are stable and she is afebrile. She has marked scleral icterus. An abdominal examination reveals normal bowel sounds and no organomegaly. Her stools were occult blood negative. Her liver function tests and enzymes were ordered and the results are: Total protein 6.1 g/dl, Albumin 39 g/dl, AST 67U/L, ALT 52U/L, Alkaline phosphatase 290 U/L, Total bilirubin 96 mg/dl, Direct bilirubin 89 mg/dl, Serum lipase is 46 U/L, Anti-mitochondrial antibodies negative. Which of the following is the most likely cause of these findings?

46) A 64-year-old white male with a history of severe stable angina and peripheral vascular disease undergoes coronary artery bypass surgery. His post-operative course is complicated by hypotension, which is treated successfully; however, a few hours later, he experiences abdominal pain followed by bloody diarrhea. His temperature is 37.8°C (100°F), blood pressure is 110/60 mmHg, pulse is 110/min, and respirations are 20/min. Abdominal examination is benign. Laboratory studies show a WBC count of 15,000/cmm with 7% bands. The lactic acid level is elevated. A CT scan is ordered. Which of the following areas of the colon will most likely show abnormal findings?

47) A 52-year-old man presents to your office after passing a black stool. He also describes occasional abdominal discomfort and nausea but denies hematemesis. He says that food seems to help his abdominal pain, so he eats frequently during the day and keeps some snacks on his night stand. As a consequence, he has gained 5 pounds over the last year. He admits that his diet is lacking in vegetables and fruit. He drinks one to two cans of beer nightly, but does not smoke or use illicit drugs. He says that his father died of colon cancer and his mother died from a stroke. Physical examination reveals a right-sided carotid bruit. The fecal occult blood test is positive. Which of the following is the most likely cause of his condition?

48) A 35-year-old Caucasian female presents to your office with several months history of heartburn. She also describes a periodic 'sticking sensation' in her throat during the meal. Her past medical history is significant for asthma that is controlled with inhaled steroids, and acoustic neuroma that was removed 2 years ago. She does not smoke or consume alcohol. She denies any recreational drug use. She is not allergic to any medications. She works as a secretary at a private firm, and considers her work moderately stressful. Her family history is significant for breast cancer in her mother and prostate cancer in her father. Endoscopic evaluation shows mild hyperemia in the distal esophagus. Esophageal manometry reveals absent peristaltic waves in the lower two-thirds of the esophagus and a significant decrease in lower esophageal sphincter tone. Which of the following is the most likely cause of this patient's complaints?

49) 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?

50) 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?

53) 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?

54) A 50-year-old woman comes to clinic due to several episodes of severe watery diarrhea for the past 15 days. There is 4/10 pain all over her abdomen but she has not noticed any blood in her stools. She has normal diet and has not travelled anywhere recently. She denies any one around her having similar complaints. She also had occasional cramps in her leg muscles and feels dehydrated. She smokes one to two cigarettes a day and drinks socially. Her temperature is 36.8°C (98.1°F), blood pressure is 108/64 mmHg, pulse is 118/min, and respirations are 18/min. On examination her abdomen is slightly tender. Laboratory results are as follows. WBC 5600mm3, Hemoglobin 13.6, Hematocrit: 41%, Platelets 209,000mm3, Sodium 138mEq/L, Potassium: 2.1mEq/L, Bicarbonate: 35mEq/L, Blood urea nitrogen: 16 mg/dl, Creatinine: 0.8 mg/dl, Glucose 106 mg/dl. A CT abdomen is ordered which shows a mass in the head of pancreas. What is the most probable diagnosis?

55) An 83-year-old woman presents with a 1-year history of progressively severe crampy abdominal pain after eating. She has started avoiding food because of the pain. The pain is often associated with bloating, nausea, and occasional diarrhea. She has had a 15 kg (33 lb) weight loss over the past year. Her other medical problems include hypertension, diabetes mellitus-type 2, hypercholesterolemia, peripheral vascular disease, coronary artery disease and myocardial infarction. Social history is not significant. Abdomen is soft, nontender and non-distended. Abdominal x-ray and CT scan are unremarkable. Which of the following is the most likely diagnosis?

56) A 65-year-old woman presents with painless intermittent rectal bleeding. The bleeding is bright red in color. She does not have abdominal pain, nausea, or vomiting. She has a history of hypertension, diabetes mellitus, and hypercholesterolemia. Her temperature is 36.7°C (98° F), blood pressure is 140/80 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination shows a systolic ejection murmur in the right second intercostal space; examination is otherwise unremarkable. Sigmoidoscopy shows no abnormalities. Which of the following is the most likely diagnosis?

57) A 45-year-old white male comes to your office for evaluation of diarrhea of 8-months duration. He says that he has lost almost 15 lbs during the past 8 months. He denies any blood in the stools. 24-hour stool collection reveals fecal fat of 10 gm/day. Stool microscopy reveals no pathogens and no leucocytes. D-xylose test was performed which shows that less than 2 grams of D-xylose is excreted in urine in 5 hours. D-xylose test was re-performed after 4-week treatment with antibiotics but excretion is still less than 2 grams in 5 hours. Based on these findings, what is the most likely diagnosis in this patient?

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

59) A 49-year-old woman presents with a two-week history of lower abdominal pain and severe diarrhea. The stools are watery without blood or mucus. The abdominal pain is mild and unrelated to her stools. She has had recent episodes of flushing. She has not had fever. There is no history of travel. She does not smoke or drink alcohol. Her past surgical history includes a fracture repair of her right leg 3 years ago. Her temperature is 36.6°C (97.8°F), blood pressure is 106/68 mm Hg, pulse is 103/min, and respirations are 20/min. Oxygen saturation is 99% on room air. Physical examination shows facial flushing, a prominent jugular venous pulse and expiratory wheezes. Which of the following is the most likely diagnosis?

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

61) A 50-year-old female presents with a 3-year history of abdominal pain and diarrhea. She has not been evaluated by a physician. Recently, her symptoms have been progressively worsening. Endoscopy shows multiple ulcerations of the duodenum and prominent gastric folds. Secretin stimulation test shows increased gastrin secretion. Which of the following is most likely associated with this patient's condition?

62) A 27-year-old Caucasian woman presents with abdominal pain, diarrhea and a 4.5 (2kg) weight loss for the past two months. She describes the abdominal pain as intermittent, moderate-to-severe, and located in the right lower quadrant. Over the past 48 hours, the pain has intensified. Her temperature is 37.6°C (99.6°F), blood pressure is 120/70 mm Hg, pulse is 100/min, and respirations are 14/min. Several shallow ulcers are present in her mouth. Abdominal examination shows tenderness in the right lower quadrant without rebound. Rectal examination shows mucus. Rectosigmoidoscopy is unremarkable. An x-ray film of the abdomen shows gas in the small and large bowels. Laboratory studies show: Hb 10.2 g/dL, WBC 16,500/cmm, Platelet count 530,000/cmm, ESR 48/hr. Which of the following is the most likely diagnosis?

63) A 65-year-old man treated for heart failure with enalapril and digoxin presents to the emergency department (ED) with palpitations. His blood pressure is 160/100 mmHg, and heart rate is 110/min. His rhythm is irregular. His lungs are clear on auscultation. His abdomen is soft and non-distended. Mild epigastric tenderness is elicited on deep palpation. ECG shows atrial fibrillation without acute ischemic changes. Cardiac enzyme levels are normal. Treatment with warfarin and verapamil is initiated, and the patient is eventually discharged home. After two weeks, he returns to the ED to complain of profound anorexia. Which of the following is the most likely cause of his current complaint?

64) A 52-year-old Caucasian male comes to you for a routine health check-up. You decide to do age-appropriate screening in this patient and order a colonoscopy. The colonoscopy is normal, except for a 1.5cm polyp in the left descending colon. A colonoscopic polypectomy is done and the biopsy results are pending. The patient is anxious to know the expected biopsy results and the risk of cancer. Which of the following types of polyps is considered to be most premalignant?

65) A 50-year-old white male comes to the physician's office because of diarrhea, abdominal pain and weight loss. He has bulky, foul-smelling stools, abdominal distension and flatulence. He also has arthralgias and a chronic cough. His temperature is 37.8°C (100°F), blood pressure is 120/80 mm Hg, pulse is 80/min, and respirations are 18/min. Physical examination shows generalized lymphadenopathy, skin hyperpigmentation and a diastolic murmur in the aortic area. Small bowel biopsy shows villous atrophy with numerous PAS-positive materials in the lamina propria. Which of the following is the most likely diagnosis?

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

67) A 37-year-old male prisoner has been complaining of fever, chills and abdominal pain over the last week. He vomited once before reaching the emergency room. On physical examination, his blood pressure is 112/63 mmHg and his heart rate is 115/min. Breath sounds are diminished at the left lung base and there is marked left upper quadrant tenderness. Laboratory values are given below:WBC count 23,500/mm3, Neutrophils 65%, Bands 11%, Hemoglobin 12.5 mg/dL, Platelets 250,000/mm3, Total bilirubin 3.1 mg/dL, AST 46 units/L, AL T 70 units/L, Alkaline phosphatase 120 units/L. CT scan of the abdomen reveals a fluid collection within the spleen. Which of the following is the most likely diagnosis?

68) 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?

69) A 29-year-old man presents to the ED complaining of RLQ pain for 24 hours. He states that the pain first began as a dull feeling around his umbilicus and slowly migrated to his right side. He has no appetite, is nauseated, and vomited twice. His BP is 130/75 mm Hg, HR is 95 beats per minute, temperature is 100.9°F, and his RR is 16 breaths per minute. His WBC is 14,000/μL. As you palpate the LLQ of the patient’s abdomen, he states that his RLQ is painful. What is the name of this sign?

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

71) A 70-year-old woman presents to the ED with dark stool for 3 weeks. She occasionally notes bright red blood mixed with the stool. Review of systems is positive for decreased appetite, constipation, and a 10-lb weight loss over 2 months. She denies abdominal pain, nausea, vomiting, and fever, but feels increased weakness and fatigue. She also describes a raspy cough with white sputum production over the previous 2 weeks. Examination reveals she is pale, with a supine BP of 115/60 mm Hg and HR of 90 beats per minute. Standing BP is 100/50 mm Hg, with a pulse of 105 beats per minute. Which of the following is the most likely diagnosis?

72) A 52-year-old man has episodes of severe chest pain associated with dysphagia. He has been seen twice in the emergency room, and both times the symptoms responded to sub-lingual nitroglycerin. He then had a full cardiac evaluation including electrocardiogram (ECG), cardiac biomarkers, and an exercise stress test, which were all normal. Which of the following is the most likely diagnosis?

73) A 16-year old girl has recently been referred to your family practice. She is a recent immigrant from Southeast Asia, and has been taking isoniazid (INH) and rifampin for uncomplicated tuberculosis. Routine blood tests are unremarkable, except for an elevated direct bilirubin. Other liver enzymes and function tests are completely normal. Which of the following is the most likely diagnosis?

74) A 78-year-old woman is brought to the ED by EMS complaining of vomiting and abdominal pain that began during the night. EMS reports that her BP is 90/50 mm Hg, HR is 110 beats per minute, temperature is 101.2°F, and RR is 18 breaths per minute. After giving her a 500 mL bolus of NS, her BP is 115/70 mm Hg. During the examination, you notice that her face and chest appear jaundiced. Her lungs are clear to auscultation and you do not appreciate a murmur on cardiac examination. She winces when you palpate her RUQ. An ultrasound reveals dilation of the common bile duct and stones in the gallbladder. What is the most likely diagnosis?

75) A 62-year-old man with a history of hypertension presents to the ED with severe constant mid-epigastric pain for the past hour. Over the last several months, he has had intermittent pain shortly after eating, but never this severe. He states he now has generalized abdominal pain that began suddenly about 15 minutes ago. He has no history of trauma, has never had surgery, and takes no medications. His vitals include HR of 115 beats per minute lying supine, increasing to 135 when sitting up, BP of 170/105 mm Hg supine, falling to 145/85 mm Hg when sitting up. He appears pale. His abdomen is rigid and diffusely tender with guarding and rebound. Bowel sounds are absent and stool hemoccult is positive. The white blood cell (WBC) count is 8500/μL, hemoglobin 8.5 mg/dL, hematocrit 27%, and platelets 255/μL. Which of the following is the most likely diagnosis?

76) The physician on call is called to the well-baby nursery because a full-term, African-American boy who is 49 hours old has not passed meconium. The pregnancy was uncomplicated. The neonate’s blood pressure is 70/50 mm Hg, heart rate is 140/min, and respiratory rate is 36/ min. The neonate is crying but is easily consolable. His abdomen is markedly distended. A barium enema is ordered, which shows dilated proximal bowel and a narrowed distal segment. Which of the following would provide a definitive diagnosis in this child?

77) A pregnant 16-year-old girl with no prior pre-natal care presents to the emergency department in labor. A male infant is delivered precipitously. Prenatal laboratory test results are unknown. There is no meconium. He has a birth weight of 3 kg (6 lb 10 oz). He is pink and is crying, heart rate is 130/min, and respiratory rate is 36/min, with good respiratory effort. The emergency medicine resident notices the infant has ascites and a membrane-covered anterior abdominal mass at the base of his umbilical cord. Which of the following is the most likely diagnosis?

78) A 50-year-old man is brought to the ED by ambulance with significant hematemesis. In the ambulance, paramedics placed two large-bore IVs and began infusing normal saline. In the ED, his HR is 127 beats per minute, BP is 79/45 mm Hg, temperature is 97.9°F, RR is 24 breaths per minute, and oxygen saturation is 96%. On physical examination, his abdomen is nontender, but you note spider angiomata, palmar erythema, and gynecomastia. Laboratory results reveal WBC 9000/μL, hematocrit 28%, platelets 40/μL, aspartate transaminase (AST) 675 U/L, alanine transaminase (ALT) 325 U/L, alkaline phosphatase 95 U/L, total bilirubin 14.4 mg/dL, conjugated bilirubin 12.9 mg/dL, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 26 mEq/L, blood urea nitrogen (BUN) 20 mg/dL, creatinine 1.1 mg/dL, and glucose 150 mg/dL. Which of the following is the most likely diagnosis?

79) An 81-year-old diabetic woman with a history of atrial fibrillation is transferred to your emergency department (ED) from the local nursing home. The note from the facility states that the patient is complaining of abdominal pain, having already vomited once. Her vital signs in the ED are temperature 100.1°F, blood pressure (BP) 105/75 mm Hg, heart rate (HR) 95 beats per minute, and respiratory rate (RR) 18 breaths per minute. You examine the patient and focus on her abdomen. Considering that the patient has not stopped moaning in pain since arriving to the ED, you are surprised to find that her abdomen is soft on palpation. You decide to order an abdominal radiographic series. Which of the findings on plain abdominal film is strongly suggestive of mesenteric infarction?

80) A 71-year-old obese man is brought to the ED complaining of constant left mid quadrant (LMQ) abdominal pain with radiation into his back. His past medical history is significant for hypertension, peripheral vascular disease, peptic ulcer disease, kidney stones, and gallstones. He smokes a pack of cigarettes and consumes a pint of vodka daily. His BP is 145/80 mm Hg, HR is 90 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. Abdominal examination is unremarkable. An ECG is read as sinus rhythm with an HR of 88 beats per minute. An abdominal radiograph reveals normal loops of bowel and curvilinear calcification of the aortic wall. Which of the following is the most likely diagnosis?

84) A 23-year-old woman presents to the ED with RLQ pain for the last 1 to 2 days. The pain is associated with nausea, vomiting, diarrhea, anorexia, and a fever of 100.9°F. She also reports dysuria. The patient returned 1 month ago from a trip to Mexico. She is sexually active with one partner but does not use contraception. She denies vaginal bleeding or discharge. Her last menstrual period was approximately 1 month ago. She has a history of pyelonephritis. Based on the principles of emergency medicine, what are the three priority considerations in the diagnosis of this patient?

85) 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?

86) 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?

87) 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?

88) 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?

89) 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?

90) 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?

91) 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?

92) 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?

93) 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?

94) 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?

95) 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?

99) 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?

100) 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?

101) 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?

102) 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?

104) 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?

105) 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?

106) 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?

107) 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?

108) 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?

109) 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?

110) 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?

111) 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?

112) 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?

113) 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?

116) 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?

117) 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?

118) 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?

119) 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:

120) 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?

121) 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?

122) 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?

123) 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?

124) 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?

125) 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:

126) 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?

127) 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?

128) 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?

129) 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?

130) 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?

131) 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?

132) 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?