MEDICINE Dally Test Day 04

101. An infant can move his head from side to side while following a moving object, can lift his head from a prone position 45 degrees off the examining table, smiles when encouraged, and makes cooing sounds. He cannot maintain a seated position. The most likely age of the infant is

102. A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family had similar symptoms. Four hours ago, the patient’s cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flaring, hyperexpansion of the chest, and easily audible wheezing without rales. The most likely diagnosis is

103. A 5-year-old boy comes to the emergency department at midnight with a complaint of severe scrotal pain since 7 P.M. There is no history of trauma. Your first step is to

104. The Coronary Drug Project was a randomized trial to evaluate the efficacy of several lipid-lowering drugs. The 5-year mortality of the men who adhered to the regimen of clofibrate (i.e., took 80% of their medicine or more) was 15%; among those assigned to the clofibrate group who were less compliant, it was 24.6%. The result was highly statistically significant (P < 0.0001). From this, one can conclude that

105. A 64-year-old man from Calicut afflicted with severe emphysema, who receives oxygen therapy at home, is admitted to the hospital because of upper gastrointestinal bleeding. The bleeding ceases soon after admission, and the patient becomes agitated and then disoriented; he is given 5 mg intramuscular diazepam . Twenty minutes later he is unresponsive. Physical examination reveals a stuporous but arousable man who has papilledema and asterixis. Arterial blood gases are pH, 7.17; PO2, 42 kPa; PCO2, 95 kPa. The best immediate therapy is to

106. A 2-wk-old female infant is noted to have a thin membrane adhering together the upper portion of labia minora. The most appropriate course of action for these labial adhesions is to

107. A 55-year-old man who is extremely obese reports weakness, sweating, tachycardia, confusion, and headache whenever he fasts for more than a few hours. He has prompt relief of symptoms when he eats. These symptoms are most suggestive of which of the following disorders?

108. A 35-year-old man stumbles into the ER. His pulse is 100 beats/min, his blood pressure is 170/95 mm Hg, and he is diaphoretic. He is tremulous and has difficulty relating a history. He does admit to insomnia the past two nights and states that he sees spiders walking on the walls. He has been a drinker since age 19, but has not had a drink in 3 days. The most likely diagnosis is

109. A 68 year old woman was admitted to hospital with evidence of biventricular cardiac failure. On examination her pulse was 100 beats per minute (sinus rhythm), and her blood pressure was 140/60 mmHg. She had haemorrhages in both fundi. Her condition improved after intravenous diuretics. Investigations revealed: Haemoglobin 5.6 g/dl (11.5 – 16.5); Haematocrit 0.19 (0.36 – 0.47); MCV 118 fl (80 – 96); MCH 33.0 pg (28 – 32); WCC 3.4 x 109/L (4 – 11); platelet count 95 x 109/L (150 – 400); What is the next most appropriate step in management?

110. A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family had similar symptoms. Four hours ago, the patient’s cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flaring, hyperexpansion of the chest, and easily audible wheezing without rales. The most likely agent responsible for the infant’s condition in the previous question is

111. A 30-year-old woman in the last trimester of pregnancy suddenly develops massive swelling of the left lower extremity from the inguinal ligament to the ankle. The correct sequence of workup and treatment should be

112. A 16-year-old boy complains of several months of swelling but no pain just above his left testicle. He is sexually active but states that he uses condoms. On physical examination, he has a mass along the spermatic cord that feels like a “bag of worms.” Which of the following is appropriate for this condition?

113. A 75-year-old man with angina has been increasingly moody and irritable for 5 wk. He has lost interest in sex and his favorite leisure activities and nothing seems to cheer him up. He has difficulty falling asleep at night and his appetite is decreased, although he has not lost any weight. His heart medications have not been changed for the past year. There have been no changes or stressful events in his life during the past 6 mo. What is the most likely diagnosis?

114. A 6-year-old child presents with flesh-colored papules on the hand that are not pruritic. Examination reveals lesions that are approximately 4 mm in diameter with central umbilication. A halo is seen around those lesions undergoing regression. Which of the following is the most likely diagnosis?

115. An 18-year-old woman develops urticaria and wheezing after an injection of penicillin. Her blood pressure is 120/60 mm Hg, her heart rate is 155 beats/min, and her respiratory rate is 30 breaths/min. Immediate therapy should include

116. A 35-year-old man stumbles into the ER. His pulse is 100 beats/min, his blood pressure is 170/95 mm Hg, and he is diaphoretic. He is tremulous and has difficulty relating a history. He does admit to insomnia the past two nights and states that he sees spiders walking on the walls. He has been a drinker since age 19, but has not had a drink in 3 days. Initial treatment usually includes

117. A 70-year-old patient with long-standing Type 2 diabetes mellitus presents with complaints of pain in the left ear with purulent drainage. On physical exam, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The peripheral white blood cell count is normal. The organism most likely to grow from the purulent drainage is

118. A 4-year-old boy is seen 1 h after ingestion of a lye drain cleaner. No oropharyngeal burns are noted, but the patient’s voice is hoarse. Chest x-ray is normal. Of the following, which is the most appropriate therapy?

119. A 56-year-old woman has been treated for 3 years for wheezing on exertion, which was diagnosed as asthma. The chest radiograph shown below is obtained and reveals a midline mass compressing the trachea. The most likely diagnosis is

120. An 18-year-old man has been seen in clinic for urethral discharge. He was treated with ceftriaxone, but the discharge has not resolved and the culture has returned as no growth. The most likely etiologic agent to cause this infection is

A teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room, he is awake and alert and appears frightened but in no distress. The chest radiograph suggests an airfluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest. The best next step in management is

122. A 48-year-old woman develops pain in her right lower quadrant while playing tennis. The pain progresses and she presents to the emergency room (ER) later that day with a low-grade fever, a white blood count of 13,000, and complaints of anorexia and nausea as well as persistent, sharp pain of the right lower quadrant. On examination she is tender in the right lower quadrant with muscular spasm and there is a suggestion of a mass effect. An ultrasound is ordered and shows an apparent mass in the abdominal wall. Which of the following is the most likely diagnosis?

123. A 64-year-old woman is found to have a left-sided pleural effusion on chest x-ray. Analysis of the pleural fluid reveals a ratio of concentration of total protein in pleural fluid to serum of 0.38, a lactate dehydrogenase (LDH) level of 125 IU, and a ratio of LDH concentration in pleural fluid to serum of 0.46. Which of the following disorders is most likely in this patient?

124. A 31-year-old man is brought to the emergency room following an automobile accident in which his chest struck the steering wheel. Examination reveals stable vital signs, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax, but a large pulmonary contusion is developing. Proper treatment consists of which of the following?

125. A 45-year-old woman with Crohn’s disease and a small intestina fistula develops tetany during the second week of parenteral nutrition. The laboratory findings include Ca 8.2 meq/L; Na 135 meq/L; K 3.2 meq/L; Cl 103 meq/L; PO4 2.4 meq/L; albumin 2.4; pH 7.48; 38 kPa; P 84 kPa; bicarbonate 25 meq/L. The most likely cause of the tetany is

126. A 30-year-old immigrant farmer from rural Bihar consults with symptoms of night sweats, low-grade fever, cough, and fatigue. He does not smoke. He has a history of asthma. The chest x-ray required for immigration was normal 5 mo ago. He received the BCG vaccine as a child. The skin test for tuberculosis is positive at 15 mm. The most likely diagnosis is

127. You are a physician in charge of the patients who reside in a nursing home. Several of the patients have developed influenza-like symptoms, and the community is in the midst of an influenza A outbreak. None of the nursing home residents have received the influenza vaccine. What course of action is most appropriate?

128. A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystectomy. A transfusion of fresh frozen plasma is planned to minimize the risk of bleeding due to surgery. The optimal timing of this transfusion is

129. A 62-year-old woman complains of limb discomfort and trouble getting off the toilet. She is unable to climb stairs and has noticed a rash on her face about her eyes. On examination she is found to have weakness about the hip and shoulder girdle. Not only does she have a purplish-red discoloration of the skin about the eyes, but she also has erythematous discoloration over the finger joints and purplish nodules over the elbows and knees. Which of the following is the most probable diagnosis?

130. A 75-year-old man has complained of malaise and slowly progressive weight loss for the better part of 3 mo. Laboratory tests reveal a hematocrit of 32%, an erythrocyte sedimentation rate (ESR) of 97 mm/h, and a white blood cell count of 10,700/ìL. Serum creatine kinase (CK) and thyroxine (T4) levels are normal. Which of the following is most likely the explanation for the patient’s complaints?

131. A 60-year-old man complains of pain in both knees gradually worsening over the past 2 years. The pain is relieved by rest and worsened by movement. There is bony enlargement of the knees with mild inflammation. Crepitation is noted on motion of the knee joint. The only other finding is bony enlargement at the distal interphalangeal joint. The patient is 5 ft, 9 in. Tall and weighs 190 lbs. The best way to prevent disease progression is

132. A 25-year-old woman with blonde hair and a fair complexion complains of a “mole.” The lesion is on the upper back. The lesion is 6 mm, darkly pigmented, and asymmetric with a very irregular border. The next step in management is to

133. 75 year-old man with a history of anterior MI is taking amiodarone 400mg/day for history of VT. He has a prolonged QT interval on his ECG. What is the most appropriate management?

134. A 75-year-old man with a history of recent memory impairment is admitted with a headache, confusion, and a left homonymous hemianopsia. He has recently experienced two episodes of brief unresponsiveness. There is no history of hypertension. CT scan shows a right occipital lobe hemorrhage with some subarachnoid extension of the blood. MRI scan with gradient echo sequences reveals foci of hemosiderin in the right temporal and left frontal cortex. The likely cause of the patient’s symptoms and signs is

135. A preterm male infant is found to be jaundiced 12 h after birth. At 36 h of age, his serum bilirubin is 18 mg/dL, hemoglobin concentration is 12.5 g/dL, and reticulocyte count is 9%. Many nucleated red cells and some spherocytes are seen in the peripheral blood smear. The differential diagnosis should include which of the following?

136. The patient illustrated on the chest x-ray film and contrast study on the following page was hospitalized after a car collision in which he suffered blunt trauma to the abdomen. He sustained several left rib fractures, but was hemodynamically stable. True statements about the injury demonstrated in the films include

137. Paroxysmal nocturnal dyspnea usually occurs after

138. A 50-year-old man complains of low back pain and stiffness that becomes worse on bending and is relieved by lying down. There are no symptoms of fever, chills, weight loss, or urinary problems. The patient had similar pain several years ago. On exam there is paraspinal tenderness and spasm of the lower lumbar back. There are no sensory deficits, and reflexes are normal. The next step in management is

139. A 13-year-old girl grunts and clears her throat several times an hour, and her conversation is often interrupted by random shouting. She also performs idiosyncratic, complex motor activities such as turning her head to the right while she shuts her eyes and opens her mouth. She can prevent these movements for brief periods of time, with effort. The most appropriate treatment for this disorder is

140. A 14-year-old boy is seen in the emergency room because of a 3-wk history of fever between 38.3C and 38.9C (101F and 102F), lethargy, and a 6-lb weight loss. Physical examination reveals marked cervical and inguinal adenopathy, enlarged tonsils with exudate, small hemorrhages on the soft palate, aWBC differential that has 50% lymphocytes (10% atypical), and a palpable spleen 2 cm below the left costal margin. Which of the following conditions is the likely diagnosis?

141. A 60-year-old asymptomatic man is found to have a leukocytosis when a routine complete blood count (CBC) is obtained. Physical exam shows no abnormalities. The spleen is normal size. Lab data includes: Hemoglobin: 9 g/dL (normal: 14 to 18 g/dL) Leukocyte count: 40,000/ìL (normal: 4,300 to 10,800/ìL) Peripheral blood smear shows a differential that includes 97% small lymphocytes. The most likely diagnosis is

142. A 28-year-old man is brought to the emergency room of a local hospital by the police, who found him wandering without a coat in subzero weather, muttering about being persecuted by a secret organization. During the evaluation he is disorganized and distractible and from time to time dozes off in the middle of a sentence. Family members deny previous psychiatric or substance abuse history, but they add that lately the patient has complained of fatigue and increased thirst. Toxic screen is negative and glucose level is 450 mg/dL. Choose the most likely diagnosis.

143. A 35-year-old woman undergoes her first screening mammogram. Which of the following mammographic findings would require a breast biopsy?

144. A patient with low-grade fever and weight loss has poor excursion on the right side of the chest with decreased fremitus, flatness to percussion, and decreased breath sounds, all on the right. The trachea is deviated to the left. Likely diagnosis is

145. A 60-year-old woman with a history of urinary tract infection, steroid-dependent chronic obstructive lung disease, and asthma presents with bilateral infiltrates and an eosinophil count of 15%. The least likely diagnosis is

146. A 62-year-old man who was diagnosed with schizophrenia in his early twenties is found wandering around his halfway house confused and disoriented. He is rushed to a local emergency room, where his serum sodium concentration is found to be 123 meq/L. His urine sodium concentration is 5 meq/L. The patient has been treated with risperidone 4 mg a day for the past 3 years with good symptoms control.His roommate reports that the patient makes many trips to the water cooler and often complains of being thirsty. What is the most likely cause of this patient’s metabolic unbalance?

147. You are a public health physician working at a city health department. You receive a report of a case of hepatitis A virus (HAV) infection in a 32-year-old man who lives with his wife and 1-year-old twins. He is a self-employed contractor who often eats on the run. His wife works part-time at a book store and his children attend day care. He has no history of travel, eating raw fish, or known contact with other cases of HAV infection. The first step in investigating this case is to confirm the diagnosis of HAV with

148. A 25-year-old woman presents to the delivery room in labor. She has had no prenatal care. The female newborn weighs 4.5 lb and has episodes of seizures shortly after birth. Irritability and hypertonicity are also noted. The most likely cause for these findings in the newborn is

149. During endoscopic biopsy of a distal esophageal cancer, perforation of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. You would recommend

150. A 68-year-old man is admitted to the coronary care unit with an acute myocardial infarction. His postinfarction course is marked by congestive heart failure and intermittent hypotension. On the fourth hospital day, he develops severe midabdominal pain. On physical examination, blood pressure is 90/60 mm Hg and pulse is 110 beats/min and regular; the abdomen is soft with mild generalized tenderness and distension. Bowel sounds are hypoactive; stool hematest is positive. The next step in this patient’s management should be which of the following?

151. A 65-year-old woman who has a 12-year history of symmetrical polyarthritis is admitted to the hospital. Physical examination reveals splenomegaly, ulcerations over the lateral malleoli, and synovitis of the wrists, shoulders, and knees. There is no hepatomegaly. Laboratory values demonstrate a white blood cell count of 2500/ìL and a rheumatoid factor titer of 1:4096. This patient’s white blood cell differential count is likely to reveal

152. A large explosion occurs at a construction site during excavation. None of the workers appear injured. Some were exposed to sound pressure levels of 190 dB. Which of the following is the most likely outcome for these workers?

153. A 14-year-old black girl has her right breast removed because of a large mass. The tumor weighs 1400 g and is found to have a bulging, very firm, lobulated surface with a whorl-like pattern, as illustrated below. This neoplasm is most likely

154. A full-term infant is born after a normal pregnancy; delivery, however, is complicated by marginal placental separation. At 12 h of age the child, although appearing to be in good health, passes a bloody meconium stool. Which of the following diagnostic procedures should be performed first to determine the cause of the bleeding?

155. A previously healthy 18-month old has been in a separate room from his family. The family notices the sudden onset of coughing, which resolves over a few minutes. Subsequently, the patient appears to be normal except for increased amounts of drooling and refusal to take foods orally. The most likely explanation for this toddler’s condition is

156. A 16-year-old high school student presents with the sudden onset of sharp right-sided chest pain associated with shortness of breath. He denies any history of trauma. On physical examination, the patient is afebrile with a respiratory rate of 28 breaths/min. His blood pressure is 100/70 mm Hg and his heart rate is 120 beats/min. Neck examination reveals no tracheal deviation. On lung auscultation, the patient has decreased fremitus, hyperresonance, and diminished breath sounds over the right posterior hemithorax. Which of the following is the most likely diagnosis?

157. A 47-year-old secretary has lost her job because, due to her perfectionism and excessive attention to trivial details, she could never finish an assignment on time. She writes innumerable lists of things to be done and follows rules scrupulously. She consistently annoys friends and family members with her lack of flexibility and her pedantic remarks. Her diagnosis is likely to be

158. An investigator wishes to perform a randomized clinical trial to evaluate a new beta blocker as a treatment for hypertension. To be eligible for the study, subjects must have a resting diastolic blood pressure of at least 90 mm Hg. One hundred patients seen at the screening clinic with this level of hypertension are recruited for the study and make appointments with the study nurse. When the nurse obtains the patients’ blood pressure 2 wk later, only 65 of them have diastolic blood pressures of 90 mm Hg or more. The most likely explanation for this is

159. A mother brings her 1-year old child because she is concerned about potential exposure to lead. Renovations are being made in their older home, and the mother is now considering moving to another house until the work is completed. You want to check the child’s blood lead level. Which of the following is the most accurate method of screening for lead poisoning?

160. A 35-year-old woman complains of aching all over. She sleeps poorly and all her joints hurt. Symptoms have progressed over several years. Physical exam shows multiple points of tenderness over the neck, shoulders, elbows, and wrists. There is no joint swelling or deformity. Complete blood count and erythrocyte sedimentation rate are normal. Rheumatoid factor is negative. There is no tenderness over the median third of the clavicle, the medial malleolus, or the forehead. The best therapeutic option in this patient is

161. A 6-mo-old infant has eatena diet with the following content and intake for the past 5 mo: protein, 4% of calories; fat, 50% of calories; carbohydrates, 46% of calories; 105 calories per kilogram of body weight per day. The patient’s disturbance is

162. A 2950-g baby boy is born at home at term. On arrival at the hospital, he appears pale, but the physical examination is otherwise normal. Laboratory studies reveal the following: mother’s blood type A, Rh-positive; baby’s blood type O, Rh-positive; hematocrit 38; reticulocyte count 5%. Which of the following is the most likely cause of the anemia?

163. A 24-year-old woman is chronically sleepy and fatigued. Her sleep is constantly interrupted because, as soon as she begins to fall asleep, an uncomfortable, “crawling” feeling in her calves forces her to walk or move her legs. A condition often associated with this disorder is

164. A 70-year-old woman with mild dementia complains of hip pain. There is some limitation of motion in her right hip. The first step in evaluation is

165. A chromophobe adenoma of the pituitary would be expected in which of the following

166. Glycosylated hemoglobin (hemoglobin A1C) is often used as an indicator of control in patients with diabetes mellitus. Its level usually reflects the blood concentration of glucose over the preceding

167. A middle-aged man is chronically preoccupied with his health. For many years he feared that his irregular bowel functions meant he had cancer. Now he is very preoccupied about having a serious heart disease, despite his physician’s assurance that the occasional “extra beats” he detects when he checks his pulse are completely benign. What is the most likely diagnosis?

168. An 18-year-old high school football player is kicked in the left flank. Three hours later he develops hematuria. His vital signs are stable. Initial diagnostic tests in the emergency room should include which of the following?

169. A 7-year-old girl is brought to your office by her mother because of a rash that appeared 3 days ago. Her temperature is 37.2C (99F) and her face has an intense rash with a “slapped-cheek” appearance. The most likely etiologic agent is

170. A 16-year-old girl with complex partial seizures and mild mental retardation has an area of deep red discoloration (port wine nevus) extending over her forehead and left upper eyelid. A computed tomography (CT) scan of her brain would be likely to reveal

171. A 27-year-old man presents with hoarseness for 6 mo. He has no other symptoms or complaints. He has no past medical history, takes no medications, and does not smoke cigarettes or drink alcohol. He uses no illicit drugs. He has been employed as a telephone operator for the last 8 mo. Which of the following is the most likely diagnosis?

172. A 39-year-old woman experiences diplopia several times a day for 6 wk. She consults a physician when the double vision becomes unremitting and also complains of dull pain behind her right eye. When a red glass is placed over the patient’s right eye and she is askedto look at a flashlight off to her left, she reports seeing a white light and a red light. The red light appears to her to be more to the left than the white light. The patient’s right pupil is more dilated than her left pupil and responds less briskly to a bright light directed at it than does the left pupil. Before any further investigations can be performed, the patient develops the worst headache of her life and becomes stuporous. Her physician discovers that she has marked neck stiffness and photophobia. The physician performs a transfemoral angiogram. This radiologic study is expected to reveal that the patient has

173. A 20-year-old woman presents with the sudden onset of severe lower abdominal pain that radiates to her left shoulder. She has some vaginal bleeding now, but her last menstrual period was 6 wk ago. She has no history of sexually transmitted diseases and has never been pregnant. She uses condoms inconsistently about 50% of the time with her partner of 18 mo. She denies dysuria or frequency. On physical examination, blood pressure is 100/70 mm Hg, heart rate is 100 beats/min, and temperature is normal. Abdominal exam reveals tenderness and rebound in the left lower quadrant. Adler sign is positive. Pelvic examination reveals a boggy and poorly delineated mass in the left adnexa. The patient’s abdominal pain worsens upon slight movement of the cervix. Which of the following is the most likely diagnosis?

174. A 21-year-old man presents with a sore throat. He also complains of dysphagia, odynophagia, and otalgia. His temperature is 102.5F. The patient speaks with a “hot potato” voice and is drooling. Examination of the throat reveals a hypertrophied right tonsil that appears to be displaced inferiorly and medially. There is contralateral deflection of the uvula. The patient has trismus and cervical lymphadenopathy. Which of the following is the most likely diagnosis?

175. A 62-year-old black man presents with hypertension, a decreased urine stream, and low back pain. Physical examination shows a hard, nodular left prostatic lobe and percussion tenderness in the lumbar vertebral bodies and left seventh rib. The next step in evaluation is

176. A 40-year-old woman is found to have a 1- to 2-cm, slightly tender cystic mass in her breast; she has no perceptible axillary adenopathy. What course would you follow? Reassurance and reexamination in the immediate postmenstrual period

177. A 60-year-old woman complains of dry mouth and a gritty sensation in her eyes. She sometimes finds it difficult to speak for more than a few minutes. There is no history of diabetes mellitus and no history of neurologic disease. The patient is on no medications. On exam the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. The next step in evaluation is

178. You are advised by the obstetrician that the mother of a baby he has delivered is a carrier of hepatitis B surface antigen (HBsAg). The most appropriate action in managing this infant is to

179. A 20 year old female patient is refered with primary amenorrhoea. Investigations reveal a 46 XY karyotype. Which of the following concerning the condition is true?

180. An octogenarian from Chandigarh who has never before been hospitalized is admitted with signs and symptoms typical of a small bowel obstruction. Which of the following clinical findings would most help in ascertaining the diagnosis?

181. A 49-year-old man with multiple myeloma presents with glucosuria, hypophosphatemia, hypokalemia, hypouricemia, aminoaciduria, and proteinuria. Further analysis of the electrolytes reveals that the patient has a metabolic acidosis. The urine pH is <5.5. Which of the following is the most likely diagnosis?

182. A 34-year-old black woman presents to your office with symptoms of cough, dyspnea, and lymphadenopathy. Physical exam shows cervical adenopathy and hepatomegaly. The patient’s chest radiograph shows symmetrical hilar lymphadenopathy. How would you pursue diagnosis?

183. A 53-year-old woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. While being evaluated, she becomes somewhat lethargic. Laboratory studies include a normal chest x-ray; serum albumin, 3.2 mg/dL; serum calcium, 14 mg/dL; serum phosphorus, 2.6 mg/dL; serum chloride, 108 mg/dL; BUN of 32 mg/dL; creatinine of 2.0 mg/dL. Appropriate initial management includes

184. The parents of an 8-year-old boy with a normal IQ are concerned because he is a very slow reader and does not appear to understand what he reads. When the boy reads aloud, he misses words and changes the sequence of the letters. Choose the correct statement about this disorder.

185. A 22-year-old man presents with a 6-mo history of a red, nonpruritic rash over his trunk, scalp, elbows, and knees. These eruptions are more likely to occur during stressful periods and have occurred at sites of skin injury. On exam, sharply demarcated plaques with a thick scale are seen. Which of the following statements is correct?

186. The crude death rate in the Country A is 150 per 100,000. The crude death rate in a smaller, developing country is 75 per 100,000. Based on these data, which one of the following statements best explains this data?

187. Which of the following is correct concerning Nitric Oxide:

188. A 54-year-old obese woman presents with the chief complaint of hemoptysis. She states that over the last day she has coughed up approximately 10 cc of blood-streaked sputum. She denies any fever, chills, chest pain, or shortness of breath. She does admit to a recent upper respiratory tract infection with cough and a copious amount of sputum production. She remembers similar episodes of cough with bloody sputum occurring after colds for the last several years. She has smoked 1 pack of cigarettes per day since high school. Examinations of the pharynx and lungs are normal. Which of the following is the most likely diagnosis?

189. A 41-year-old woman with no previous medical problems presents with the chief complaint of generalized weakness. The patient states that she has been irritable lately and finds it difficult to concentrate at work. She has been amenorrheic for 12 mo and feels her symptoms might be related to early menopause. On physical examination, blood pressure is 160/90 mm Hg. The patient has a “moon face” and a “buffalo hump.” She is hirsute. Abdominal examination reveals purple striae. Her extremities appear to be atrophied. Her fingerstick glucose is 210 mg/dL. Which of the following is the most likely diagnosis?

190. A 2-year-old boy presents with progressive clumsiness and difficulty walking. On physical examination, the child has large calves. He has difficulty walking on his toes and has a waddling gait. Gower maneuver is positive. Which of the following is the most likely diagnosis?

191. After several years of successful antiparkinsonian treatment, a patient abruptly develops acute episodes of profound bradykinesia and rigidity. Remission of these signs occurs as abruptly as the onset. This patient probably suffers from

192. A 9-year-old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at age 7 and adrenarche at age 8. The most common cause of this condition in girls is

193. A 42-year-old man presents to your office for a checkup. He has been in excellent health except for a recent diagnosis of mild hypertension and bilateral carpal tunnel syndrome. On physical examination, the patient is tall with large and doughy hands. His facial features are coarse and he has a prominent mandible with wide-spaced teeth. His voice is deep and he has macroglossia. Heart examination reveals the point of maximum impulse (PMI) to be displaced 2 cm laterally. Which of the following is the most likely diagnosis?

194. Incisional biopsy of a breast mass in a 35-year-old woman demonstrates a hypercellular fibroadenoma (cystosarcoma phylloides) at the time of frozen section. Appropriate management of this lesion could include

195. What is the most important reason for early identification of HIV infection in pregnant women?

196. A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. The most useful test to make a definitive diagnosis would be

197. A 42-year-old woman of Italian descent presents for a preemployment physical examination. She has no past medical problems and takes no medications. Her physical examination is normal except for pale conjunctiva. FOBT is negative. CBC is remarkable for a hemoglobin of 11.4 g/dL, a MCV of 60 fL, and a reticulocyte count of 0.6%. White blood cell count and plate-lets are normal. Peripheral smear reveals microcytosis, hypochromia, acanthocytes (cells with irregularly spaced projections), and occasional target cells. Which of the following is the most likely diagnosis?

198. A 65-year-old man undergoes a technically difficult abdominoperineal resection for a rectal cancer, during which he receives 3 units of packed red blood cells. Four hours later, in the intensive care unit, he is bleeding heavily from his perineal wound. Emergency coagulation studies reveal normal prothrombin, partial thromboplastin, and bleeding times. The fibrin degradation products are not elevated, but the serum fibrinogen content is depressed and the platelet count is 70,000/ìL. The most likely cause of the bleeding is

199. A 45-year-old quarry worker presents with a history of progressive nonproductive cough and dyspnea. He has no fever or weight loss. Complete blood count is normal. Chest x-ray is suggestive of Pnuemoconiosis. The most likely diagnosis is

200. A 25-year-old woman with a history of epilepsy presents to the emergency room with impaired attention and unsteadiness of gait. Her phenytoin level is 37. Examination of the eyes is most likely to show which of the following?