Part 4 (765-865) (765-1019) NR 1

A 55-year-old Caucasian man comes to the emergency department because of fever and productive cough, with foul-smelling sputum. He also complains of shortness of breath. His other medical problems include hypertension and hypercholesterolemia. In the past three months, he was admitted in the hospital two times for pneumonia. He has smoked one pack of cigarettes daily for 28 years and drinks 5-6 beers daily. Family history is not significant. His medications include hydrochlorothiazide and simvastatin. His temperature is 38.9°C (102°F), blood pressure is 120/70 mmHg, pulse is 112/min, and respirations are 24/min. The patient's pulse oximetry showed 89% at room air. Examination shows crackles at the right lung base. His chest x-ray shows right, lower lobe infiltrate. A CT scan of the chest shows no mass or obstruction. Which of the following is most likely responsible for this patient's symptoms?

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

A 60-year-old male with a history of hypertension, diabetes, coronary artery disease, asthma, and cigarette smoking undergoes emergent laparotomy for a perforated peptic ulcer. He receives 4 liters of intravenous normal saline intraoperatively. Following the procedure, he is extubated without complication, but subsequently develops respiratory distress. Immediate arterial blood gas analysis on room air shows: PaO2 60mmHg, pH 7.46, PaCO2 37mmHg, HCO3 22mmHg. His temperature is 37.2°C (98.9°F) and blood pressure is 126/76 mm Hg. Lung auscultation reveals bilateral rales. His arterial blood gas fails to improve with administration of 100% oxygen. What is the most likely cause of his respiratory distress?

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

A 62-year-old Caucasian male presents to your office because of a non-productive cough that is 'quite disturbing.' The cough has been present for several weeks. He visited your office two times before for poorly controlled hypertension, and was started on lisinopril. He usually takes aspirin, amlodipine, and metoprolol. He does not smoke or consume alcohol. His blood pressure is 130/90 mmHg and heart rate is 60/min. Physical examination reveals a bruit over the right carotid artery, but is otherwise normal. Which of the following is the most likely cause of this patient's complaint?

A 26-year-old white female comes to the Emergency Room with severe shortness of breath. She has a long history of asthma with periodic exacerbations. She is taking an inhaled albuterol, inhaled steroid, salmeterol and cromolyn. Her temperature is 37.2°C (99°F), blood pressure is 150/90 mmHg, pulse is 110/min, and respirations are 24/min. On examination, she has moderate respiratory distress, prolonged expiratory phase, and significant wheezing all over the lung fields. Patient is admitted and is given nebulized albuterol, intravenous methyl prednisone, and oxygen. The next day her respiratory status improved. Her vital signs did not change much, except normalization of respiratory rate. Still scattered bilateral wheezes are heard on lung auscultation. The next day her laboratory values are: Hemoglobin 14 g/dL, MCV 95 fL, Leukocyte count 19,000/cmm, Segmented Neutrophils 80%, Bands 5%, Lymphocytes 13%, Eosinophils 0%, Basophils 0%, Monocytes 2%. Chest x-ray obtained at the time of admission is normal, except for hyperinflated lung fields. What is the most probable cause of the abnormal lab findings in this patient?

A 32-year-old male presents to your office complaining of daytime sleepiness and frequent night-time awakenings. He says that his sleep gets disrupted by a choking sensation, sometimes accompanied by cough and dyspnea. After such episodes he typically has trouble falling back to sleep. The patient notes that his symptoms are somewhat improved when he sleeps with multiple pillows. Physical examination is unremarkable except for a BMI of 29 Kg/m2. What is the most likely diagnosis?

A 20-year-old African American woman presents with mild dyspnea on exertion and joint discomfort in her knees, wrists, and ankles. She also has a fever and red tender rash on her shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, corneal opacities, and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy. Transbronchial biopsy reveals noncaseating granulomas. Which of the following is the most likely cause for the eye lesion?

A 74-year-old man with a history of smoking notices blood in his chronic daily sputum production. He has no fever or chills, but has lost 10 lb in the past 6 months. On examination, he has bilateral expiratory wheezes, and his fingers are clubbed. There are no lymph nodes and the remaining examination is normal. CXR reveals a left hilar mass. Which of the following suggests that the tumor is a small cell lung cancer?

A 35-year-old HIV-positive man (CD4+ cell count 150/mm³) is seen in the emergency department with right-sided chest pain. The patient has become progressively dyspneic over the past few days. Suddenly, 30 minutes ago he noticed a sharp pain in his chest associated with shortness of breath. His temperature is 37.7°C (99.9°F), blood pressure is 128/84 mm Hg, pulse is 102/min and regular, respiratory rate is 25/min, and oxygen saturation is 90% on room air. Physical examination reveals diminished right-sided breath sounds and hyperresonance. Jugular venous distention is 5 cm and there is no tracheal deviation. ECG shows sinus tachycardia. X-ray of the chest shows a right-sided pneumothorax occupying approximately 10% of the right thoracic cavity. Which of the following most likely caused this patient’s presentation?

A 74-year-old man presents to his primary care physician complaining of dyspnea and cough with blood-tinged sputum for the past several weeks. He has diabetes and elevated cholesterol. Medications include a sulfonylurea and a statin. The patient has a 50-pack-year smoking history and a family history of hypertension. His vital signs are within normal limits. Physical examination reveals abdominal striae and moon facies, along with a truncal fat distribution. X-ray of the chest reveals a single central nodule, and follow-up CT again demonstrates the nodule and multiple solid hepatic masses. Which of the following is the most likely diagnosis?

A 5-month-old infant has failed to gain weight despite a good appetite. The child’s mother reports that the baby has up to eight bulky, foul-smelling, oily stools per day. A sweat chloride test reveals a chloride level of 78 mEq/L (normal: <60 mEq/L). Which of the following sequelae is most likely to occur as a result of this patient’s disease?

A 33-year-old farmer complains of recurrent episodes of wheezing after working in a barn where hay is stored. On auscultation, there are bibasilar crackles and heart sounds are normal. His laboratory work is normal with no increase in eosinophils and the chest x-ray (CXR) reveals patchy lower lobe infiltrates. Which of the following is the most likely diagnosis?

A 53-year-old man presents to the clinic with complaints of increasing shortness of breath, a nagging cough, and weight loss over several months. He reports no history of cigarette smoking but has worked underground in the New York City subway system for the past 20 years. Spirometry demonstrates an FEV1: FVC ratio of 0.7 and an FEV1 value that is 60% of expected. The FEV1 improves to 70% of expected with bronchodilator treatment. Which of the following is the most likely diagnosis?

A 78-year-old woman is seen in the emergency department for difficulty breathing and cough over the past 4 hours. She has a history of congestive heart failure for which she takes hydrochlorothiazide, metoprolol, and enalapril. Her oxygen saturation is 92% on room air. On examination there is a high-pitched systolic crescendodecrescendo murmur best heard at the right upper sternal border with radiation to the carotids, and rales are present in both lung fields on inspiration. There is 2+ symmetrical pitting edema bilaterally in the lower extremities. X-ray of the chest shows an enlarged heart and prominent pulmonary vasculature. Which of the following is the most likely cause of the patient’s pulmonary edema?

A 56-year-old man is evaluated for chronic cough. It is present most of the time and is progressively getting worse over the past 3 years. With the cough he usually has white to yellow sputum that he has to expectorate. There is no history of wheezing, asthma, congestive heart failure (CHF), or acid reflux disease. He currently smokes one pack a day for the past 25 years. On examination, his chest is clear. CXR is normal and his forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) on spirometry are normal. Which of the following is the most likely diagnosis?

A 35-year-old man is evaluated for symptoms of shortness of breath. He reports no other lung or heart disease. He smokes half pack a day for the past 10 years. On examination, his JVP is 2 cm, heart sounds normal, and lungs are clear. A CXR shows hyperinflation and increased lucency of the lung fields. A chest CT reveals bullae and emphysematous changes, while pulmonary function tests show an FEV1/FVC ratio of <70%. Evaluation of his family reveals other affected individuals. Which of the following is the most likely diagnosis?

A 23-year-old man notices a gradual but progressive increase in breathing difficulty. He has a long history of back pain with prolonged morning stiffness. He has also had an episode of iritis in the past. On examination, there is reduced range of motion in the lumbar spine with forward flexion and pain on palpation of the sacroiliac joint and surrounding soft tissue. X-rays of the pelvis show erosions and sclerosis of the sacroiliac joint. Which of the following is the most likely pulmonary complication of this condition?

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

A 44-year-old woman has been complaining of a 4-year history of increasing dyspnea and fatigue. Physical examination reveals increased JVP and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and right-sided S3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests show a slight restrictive pattern. A diagnosis of primary pulmonary hypertension is made. Which of the following is the most likely cause of death in this condition?

After an uncomplicated pregnancy and cesarean section for breech presentation, twins are born at 32 weeks’ gestation to a 24-year-old primigravida mother. Twin A weighs 1610 g (3.5 lb) and has Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Twin B weighs 1600 g (3.5 lb) and has Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Within minutes of birth, twin B becomes mildly cyanotic and tachypneic with subcostal retractions, expiratory grunting, and nasal flaring. Twin B’s blood pressure is 58/39 mm Hg, heart rate is 130/min, respiratory rate is 100/min, and temperature is 37.0°C (98.6°F). Twin B is intubated and given 70% fraction of inspired oxygen. Compared to twin A, what is twin B at greater risk of developing?

A 32-year-old white man with HIV and a re- cent CD4+ cell count of 400/mm³ presents to the emergency department with a 3-day history of fever, anorexia, cough, and night sweats. He recently returned from a camping vacation in Arizona, approximately 1 month prior to presentation. He also describes diffuse joint pains. His temperature is 38.9°C (102°F), oxygen saturation is 99% on room air, and there is a rash on his arms and hands. There is dullness to percussion at the right lung base. X-ray of the chest reveals a small right-sided infiltrate and hilar lymphadenopathy. Sputum analysis does not reveal any organisms. He reportedly had a negative purified protein derivative test 2 months ago. Which of the following is the most likely diagnosis?

A 55-year-old man was admitted to the hospital 2 weeks ago for rapid onset of cough, fatigue, and pleuritic chest pain. He has worked as a sandblaster for the past year. When first seen in the hospital, he denied hemoptysis and smoking. Currently, the patient is intubated and on assist-control ventilation. His temperature is 36.7°C (98°F), pulse is 96/min, blood pressure is 138/85 mm Hg, and respiratory rate is 18/ min. A recent arterial blood gas study showed a pH 7.42, arterial carbon dioxide pressure of 36 mm Hg, and arterial oxygen pressure of 110 mm Hg while on 100% oxygen. Physical examination is significant for diffuse crackles throughout both lung fields, a loud pulmonic component of the second heart sound, and jugular venous distention of 9 cm with a prominent A wave, a left parasternal heave, and symmetric 3+ lower extremity pitting edema. Which of the following is the most likely diagnosis?

A 30-year-old woman presents to her physician’s office because of 3 months of nonproductive cough, exertional dyspnea, fatigue, malaise, and blurred vision. She denies weight loss, fever, chills, sweats, recent travel, or sick contacts. She works on the assembly line of an electronics plant. Vital signs are unremarkable. Physical examination reveals she has tender red papules over her shins. The patient said she first noticed the bumps when she changed oral contraceptive pills (her only medication), but assumed they would disappear. X-ray of the chest shows bilateral hilar lymphadenopathy with pulmonary infiltrates. Laboratory findings are: WBC count: 5600/mm3, Hemoglobin: 14.3 g/dL, Platelet count: 300,000/mm3, Na+: 140 mEq/L, K+: 4.2 mEq/L, Cl−: 108 mEq/L, Ca2+: 16 mg/dL, CO2: 24 mmol/L, Blood urea nitrogen: 10 mg/dL, Creatinine: 1.0 mg/dL. Culture of bronchoalveolar lavage fluid is neg- ative. Which of the following is the most likely diagnosis?

A 58-year-old man presents to the emergency department complaining of fever and chills. The fever started last night and has not subsided, even though he took acetaminophen. He had a successful appendectomy 3 days ago and was discharged from the hospital 2 days ago. His only medication is ibuprofen, which is adequately controlling his pain. He is a 30-pack-year smoker with a chronic cough productive of white sputum. He has noticed increased sputum production, which has become yellowish-green. He denies dysuria, urgency, or frequency. His temperature is 38.4°C (101.1°F), heart rate is 88/min, respiratory rate is 16/min, and blood pressure is 126/74 mm Hg. On examination he appears to be tired but not in acute distress. Pulmonary examination is limited because deep inhalation causes coughing and slight abdominal pain. There is no tactile fremitus or dullness to percussion. He has a slightly erythematous, appropriately tender healing incision in the right lower quadrant without exudates and normal active bowel sounds. Extremities are warm and well perfused without erythema or edema. Pulses are intact. Which of the following most likely could have prevented this condition?

A 23-year-old man is experiencing a flare of his asthma. He is using his salbutamol inhaler more frequently than usual and despite increasing his inhaled steroids he is still short of breath. Previously his asthma was considered mild with no severe exacerbations requiring oral steroids or hospitalization. With his flare, he has recurrent episodes of bronchial obstruction, fever, malaise, and expectoration of brownish mucous plugs. On examination, there is bilateral wheezing. The heart, abdomen, neurologic, and skin exams are normal. CXR reveals upper lobe pulmonary infiltrates; the eosinophil count is 3000/mL, and serum precipitating antibodies to Aspergillus are positive. Which of the following is the most likely diagnosis?

A 55-year-old woman presents with coughing up blood and sputum. She gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is worse on lying down and in the morning. On physical examination, she appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is a recognized precursor to this patient’s condition?

A 50-year-old man presents with excessive day- time sleepiness and a history of snoring. One week ago, he fell asleep while driving his car and got into a minor accident. On examination, he is obese (body mass index [BMI] >30) and his blood pressure is 160/90 mm Hg. His lungs are clear and heart sounds are distant. Which of the following is the most likely explanation for the symptoms associated with this condition?

A 23-year-old man presents with coughing up blood and sputum. He gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is worse when lying down and in the morning. On physical examination, he appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. There are no hepatosplenomegaly or any palpable lymph nodes. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is sometimes seen in this condition?

A 34-year-old woman is complaining of progressive and worsening shortness of breath. Her symptoms first started 3 years ago, and she now gets dyspneic and fatigued while doing her activities of daily living. Her past medical history is not significant and she not taking any medications. Physical examination reveals increased JVP and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and right-sided S3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests are normal. Which of the following is the most likely diagnosis?

A 45-year-old woman has severe symptoms of epigastric and abdominal pain after eating. A trial of acid suppression therapy with proton pump inhibitors (PPI) only partially improved her symptoms. She undergoes elective outpatient upper endoscopy, which is positive for a small duodenal ulcer. Two hours later, she is short of breath and complaining of severe anterior chest pain, which is made worse with deep inspiration. On examination, she looks unwell, blood pressure is 150/90 mm Hg, pulse 110/min, and lungs are clear. Heart sounds are normal but an “extra crunching” type sound is intermittently heard. CXR demonstrates air surrounding the heart. Which of the following is the most likely diagnosis?

A 31-year-old G4P3 woman gave birth via repeat cesarean section to a full-term, 3700-gm (8.2-lb) baby girl. There were no complications during the pregnancy or delivery. Two hours after the birth the resident is called to evaluate the baby girl. She is afebrile but is breathing rapidly with mild subcostal retractions. Breath sounds are equal and clear bilaterally. S1 and S2 are normal and the point of maximal intensity is not displaced. X-ray of the chest reveals flattened diaphragms, prominent vascular markings, and fluid lines in the fissures. Which of the following is the most likely diagnosis?

A 67-year-old man presents to his primary care physician with complaints of dyspnea on exertion over the past 6 months that has progressively worsened to dyspnea at rest. He denies cough and wheezing and has had no fevers, night sweats, or unintentional weight loss. The man has never smoked and worked as a ship-builder for >30 years. Which of the following findings on x-ray of the chest would confirm the most likely diagnosis?

A 16-year-old girl is brought to clinic by her mother, who complains that the girl is "difficult to get along with lately." The mother says her daughter can no longer concentrate for prolonged periods and is easily fatigued. She has found her tossing in her sleep at night. She says that her daughter is generally considered by friends and family to be "high strung." Upon inquiry, the girl admits to feeling extremely apprehensive when taking tests at school. She feels this stems from her naturally competitive nature and her desire to be class valedictorian. She worries about being accepted to a good university and then business school. She says that she is unable to control her thoughts and sometimes takes a day off from school to "escape all the stress that comes with it” Which of the following is the most likely diagnosis?

A 30-year-old man presents to his primary care physician and describes a sense of generalized fatigue. He reports having been very energetic and healthy during his college days but says that "everything has seemed to be go wrong" for at least the last 6 years. He eats poorly and has lost 8 pounds over the last three years. He sleeps 12 hours per night and says that he has difficulty concentrating on most tasks. His past medical history is otherwise unremarkable, and he does not abuse drugs or alcohol. The patient says that he is not suicidal and still enjoys watching baseball with his friends. Based on the above presentation, what is the most likely diagnosis?

A single mother brings her 10-year-old son to see the pediatrician. The mother says that she is "absolutely fed up" with her son's behavior and is unable to control him. The boy frequently gets into fights with his siblings, neighbors, and classmates at school. When asked to help with household chores, he refuses. He is very short-tempered and argues frequently with his parents and teachers. A few days ago, he got into an argument with the elderly woman who lives next door, and in a fit of anger he "grabbed a marker and wrote an obscenity on her front door." What is the most likely diagnosis?

A middle-aged, divorced woman brings her 18-year-old daughter to the physician with the complaint that her daughter "seems abnormal." She is concerned because her daughter has no close friends, does not date, and shows no interest in the activities that are popular with young adults. The girl prefers solitude and keeps to her room for most of the day. When she does go out, she hikes in the woods alone for hours at a time. She attends a local university where she studies engineering and performs well academically. During the office visit, the daughter avoids eye contact. In response to questioning about her reasons for being aloof, she replies, "I just don't enjoy being in the company of others. People do not interest me much and I would rather keep to myself." Her thought process appears devoid of delusions or hallucinations. Which of the following personality disorders is demonstrated by her behavior?

A middle-aged, divorced mother brings her 19-year -old daughter in for an evaluation. She says that her daughter has "a serious problem." The woman is concerned because her daughter always keeps to herself, does not date, has no close friends, and refuses to participate in activities popular with women of her age. The daughter is extremely fascinated by witchcraft, spending countless hours in her room gazing into a crystal ball and muttering under her breath. When confronted about her behavior, she says, "I have some supernatural powers that I am not willing to discuss." She attends college regularly and earns good grades. Which one of the following is the most likely diagnosis?

A Hispanic married couple brings in their 17-year-old son because his behavior has been abnormal for the past two weeks. Normally, the boy is polite and soft spoken but he has recently become irritable and rude. His parents dismissed his behavior as a "phase" with the expectation that he would grow out of it, but they became very concerned upon discovering that he had been spending large sums of money from his college fund without their consent. When questioned by his father about his strange behavior, the boy responded, "I'm on a secret mission. The king of Norway has sent me here to spy on the U.S. government." His vital signs include temperature of 36.6°C (98.0°F), blood pressure of 132/94 mm Hg, pulse of 105/min, and respirations of 18/min. On physical examination, the boy appears to be in no distress. His pupils are dilated. Which of the following is the most likely diagnosis?

A 32-year-old woman is brought in to clinic by her husband of four years because she has been "restless and hyperactive" for the past two weeks. The husband describes her as unusually talkative, and says she speaks so quickly that others have difficulty understanding her. She has spent large sums of money on new clothing, makeup, and perfumes. When asked about her purchases, she says that she needs to look elegant since she is "a member of the royal family." She stays up very late each night to thoroughly clean the house, often sleeping only an hour or two. The husband has never observed these symptoms before in his wife. Physical examination of her is unremarkable. Which of the following is this woman most likely suffering from?

A 74-year-old woman is brought to the clinic by her daughter-in-law. The woman is a regular patient and has a long history of hypertension and ischemic heart disease. She lives with her son and daughter in-law, who are concerned that she has become increasingly forgetful over the past year. Initially, they attributed her forgetfulness to normal aging but her memory impairment has progressively worsened over the past several months. Of late, she has also developed some difficulty with speech and now is no longer able to perform the activities of daily living. Which one of the following is the most likely diagnosis?

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

An 18-year-old college freshman is brought to the emergency department by his friends. They say that he is normally happy and good-natured, but became unusually withdrawn and aloof a few hours after a football game. He complains of a dry mouth. Physical examination reveals injected conjunctivae and tachycardia. Which of the following is most consistent with this patient's presentation?

A 34-year-old male presents to the emergency department complaining of severe lower back pain. He rates the pain as 10/10 in severity and describes it as non-radiating, sudden in onset, and aggravated by movement. He refuses to be examined, insisting that any examination will worsen his pain. He denies any history of trauma or lifting of heavy weights. He says, "Doc, the only thing that can relieve my pain is morphine ... You've got to have mercy on me." The patient has a long history of opioid dependence and has been admitted to the hospital multiple times while intoxicated. His last admission was two weeks ago and he was referred to a drug rehabilitation program upon discharge. Given the clinical presentation, what is the most likely diagnosis?

A young Caucasian mother brings her 5-year-old daughter to the pediatrician two months after the girl first began attending kindergarten. She says that earlier this week, her daughter's teacher called to say that the girl persistently refuses to answer questions or to speak to others in class. The teacher added that the girl also does not smile at, play with, or otherwise engage her fellow students. The mother finds this very surprising because her daughter is very verbal and talkative at home, plays happily with her siblings, and is an affectionate child. Further questioning reveals that the girl is "a little shy" at social gatherings. Which of the following is the most likely diagnosis?

A 12-year-old boy is accused of setting his neighbor's house on fire. His parents describe him as a hyperactive, talkative child. He earns excellent grades in school but frequently gets into fights with schoolmates and siblings. Two years ago, he was caught setting the interior of his father's car on fire. He has also been linked to several suspicious fires in the neighborhood, though no criminal charges were brought against him Based on this information, what is the most likely diagnosis?

A 39-year-old agitated female with an unknown medical history is brought to the emergency department by police after she was found assaulting an innocent pedestrian on the street. She tells the attending physician that she has unusual powers and has been sent on a special mission by God. She is proud of frequently communicating with God, both telepathically and verbally, and says that he assists her in "punishing all of the wicked people in the world” Which of the following is most demonstrated in her thought content?

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

A 10-year old girl is brought to the office by her mother for the evaluation of recent changes in behavior. She has been sleeping poorly at night and has started wetting her bed. Her school grades have dropped significantly, and she has become irritable and cranky. She refuses to sleep at night until her father returns home and goes to bed. Her father works as a taxi driver, and is an alcoholic. Her mother is a close friend of yours, and appears very concerned. Prior to this office visit, you have known this girl to be cheerful and lively; however, as you attempt to talk to the young girl in the office, she suddenly bursts into tears. Which of the following should you consider at this point?

A 19-year-old woman makes an appointment to see her primary care physician about a "personal concern." When she comes in for her visit, she says that she has been "deeply depressed" for the past several months because of her "enormous nose." She proceeds to describe in detail the numerous cosmetic aspects of her nose that prove troubling. She says that she is now so embarrassed that she is unwilling to go out with friends because "everyone just stares at my nose." She finds it difficult to concentrate on her studies because she is preoccupied with thoughts about undergoing corrective surgery. On examination, her nose appears completely normal. She pleads for a referral to a good plastic surgeon. Which of the following is the most likely diagnosis?

You are an internist making your rounds at a local nursing home. While you are reviewing a medical chart, one of the nurses approaches you to complain about a 62-year-old male patient who frequently masturbates in front of the staff and other nursing home residents. He has been taking olanzapine for years for schizophrenia. Upon interviewing him, you find the patient's thought processes to be devoid of hallucinations or delusions. There are several times when he laughs inappropriately during the interview. His speech is rambling and unpredictably shifts from one topic to another. Based on his clinical presentation, how should his illness be classified?

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

A 19-year-old student is referred to the university health center for inability to complete his assignments. He has always been a good student, and was valedictorian of his high school class. However, since starting college, he has found it difficult to keep up with all the work. He audio-records every class, playing the tapes back later in the day to transcribe each entire lecture word for word. He admits to sometimes needing to go over certain sections multiple times to be sure he has heard correctly. He also takes a long time to complete assignments, as he always checks his work multiple times prior to handing it in. Because of this, he has had to ask for many extensions on his assignments. He is sure to complete all his assignments, even after they have been reviewed in class and even though they are not graded. He spends all his time doing his classwork, and is not involved in social activities. What is the most likely diagnosis?

A 46-year-old man with a history of medication-controlled hypertension sees his doctor for a routine check-up. His blood pressure is 115/80 mm Hg and an electrocardiogram shows a normal sinus rhythm. The doctor notes that the man seems more down than usual. The man admits that he has been "stressed out" for the past two weeks, as a few people at work recently quit and he has had to take on more work while management finds replacements. He has been sleeping poorly at night, feels tired during the day, and states that he hates his job right now, but has no other choice. He continues to get his work done and enjoys social activities, remarking that he "can still golf on the weekends." What is the patient's most likely diagnosis?

An anxious mother brings her 4-year-old son to clinic for a new patient visit. She says that her son was progressing well developmentally and meeting all milestones until three months ago. Since then, she and her husband have noticed a marked restriction in the boy's activities. He keeps to himself, refuses to play with his siblings, speaks only when spoken to, and appears indifferent to the presence of others. Attempts to engage the child in conversation are unsuccessful. He seems disinterested and refuses to make eye contact. While in the examination room, he starts banging his head against the wall. Given this clinical presentation, which of the following is the most likely diagnosis?

A 59-year-old Caucasian female presents to the emergency department with sudden onset paralysis of her bilateral lower extremities. She has no other symptoms. Physical examination reveals normal tone, normal deep tendon reflexes, and no Babinski sign. Her motor strength is 3/5 in both lower extremities. The remainder of her examination is unremarkable. The patient dramatically improves after she is injected with sodium amytal. What is the most likely diagnosis?

A mother brings in her 3-year-old son to the pediatrician because she is concerned about his "poor development." She says that she thinks her son's behavior is "very different from that of other children his age." She says that ever since he was a toddler, he has seemed indifferent to her presence. She previously attributed this to her son being "unique" compared to his two older sisters. However, she is increasingly worried about her son because he does not play with his siblings or the neighborhood children who come to visit, and she suspects that his speech development is limited. Upon examination, the child is spinning continuously in a circle. When questions are asked of him, he makes no eye contact and responds with "A house for the mouse." His physical appearance is otherwise normal. Which of the following is the most likely diagnosis?

A 36-year-old known patient of yours presents for a routine annual examination. Toward the end of the visit, she glumly mentions that she intends to file for a divorce from her husband. She says that he is always in an irritable or depressed mood, and that she is "sick and tired of him spending huge sums of money on gambling." Although she was aware of his placing the occasional bet before they got married, she says his passion for gambling has increased significantly since his mother's death two months ago. He was recently fired from his job as an insurance agent after he was caught forging signatures in an attempt to finance some gambling trips to Las Vegas. She has confronted him about his behavior on many occasions in the past, but he has always denied that it was a problem. Now he admits that he finds it hard to control himself and that he is in debt to several creditors. Although he has lost a considerable amount of money, he is convinced that he could win it all back if he could just borrow enough from friends. Which of the following is the most likely diagnosis?

An anxious mother brings in her 12-year-old daughter to your clinic for "severe hair loss". On examination, you find several alopecic patches on her head. While taking a detailed history, you find out that the young girl has been pulling out her hair when stressed. Although she has been indulging in this behavior periodically since childhood, she finds a recent increase in the same. She reveals to you that she is "really nervous" about her upcoming exams, and has disturbed sleep. She also adds that she feels so stressed that she has been avoiding going out with her friends and keeps to her books all the time. She denies any alterations in weight, but does admit to a decreased appetite. What do you think is the underlying diagnosis in this case?

A 21-year-old woman presents to the physician at her mother's urging because she has been experiencing significant sleep disturbances. Three months ago, she was the victim of a sexual assault in the parking lot of her workplace. Since then, she has had recurrent nightmares about the assault, and dreads falling asleep at night. During the day, she has flashbacks about the assault. She has become very withdrawn, quit her job, and avoids other people. The woman is very distressed about the flashbacks and says that they "dominate her life." She has difficulty concentrating and startles easily when others speak to her. Which of the following is the most likely diagnosis?

A 32-year-old married woman presents with lower back pain that has persisted for the past week. She says she developed the pain after lifting some heavy furniture. She denies any other symptoms. A thorough physical examination reveals mild paraspinal muscle spasm. There is no significant pain with a straight leg raise on either side. Multiple bruises on her abdomen, back, and chest are also evident. When the topic of the bruises is raised, the woman becomes tearful and begins to cry. Which of the following is the most appropriate response?

A 31-year-old Caucasian female with a chronic history of schizophrenia presents for a prescription refill at her local mental health clinic. She has been treated with olanzapine for the last six months. The psychiatrist notes at this visit that the woman appears less agitated and complains of fewer auditory hallucinations. When asked questions, the woman gives detailed but irrelevant responses. Her answers drift away from the subject but eventually return. Which of the following is she demonstrating?

A 27-year-old female is brought to the emergency department by her husband after she fainted at home. The patient admits that she has been fasting and exercising vigorously for the past two days to compensate for the excessive amount of food she ate three days ago. She admits to a similar pattern of eating large amounts of food followed by a period of fasting since she lost her job a few months ago. She is very distressed by these "uncontrollable eating episodes" because she feels awful afterward. Periodically, she breaks down in tears while telling her story. Review of systems is otherwise unremarkable. Her menstrual periods are regular. Vital signs are temperature 37°C (98.6°F), blood pressure 98/62 mmHg, pulse 96/min, and respiratory rate 14/min. Her height is 5'4" (163 cm) and weight is 120 lbs (54 kg). Physical examination is unremarkable. What is the most likely diagnosis?

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

A 32-year-old woman is seen in an outpatient psychiatric clinic for the chief complaint of a depressed mood for 4 months. During the interview, she gives very long, complicated explanations and many unnecessary details before finally answering the original questions. Which of the following psychiatric findings best describes this style of train of thought?

An 18-year-old man is seen by a psychiatrist in the emergency room. During the history, the patient is asked to describe his mood. He answers the following, “My mood is flextitating, I am up and down.” The patient is exhibiting which of the following thought disorders?

A 56-year-old man has been hospitalized for a myocardial infarction. Two days after admission, he awakens in the middle of the night and screams that there is a man standing by the window in his room. When the nurse enters the room and turns on a light, the patient is relieved to learn that the “man” was actually a drape by the window. This misperception of reality is best described by which of the following psychiatric terms?

A 22-year-old woman is seen by a psychiatrist in the emergency room after she is found walking in the middle of a busy street with no shoes on. During her interview she is asked to count backwards from 100 by 7’s. Which of the following best describes the cognitive functions being tested by this request?

A 72-year-old woman is admitted to the burn unit with second- and third-degree burns covering 35% of her body, which she received in a house fire. At 8 pm on the fourth day of her hospital stay, she pulls out her IV and begins screaming that people are trying to hurt her. Several hours later she is found to be difficult to arouse and disoriented. Which of the following is the most likely diagnosis?

A psychiatric resident is called to consult on the case of a 75-year-old woman who had undergone a hip replacement 2 days before. On examination, the resident notes that the patient states the date as 1956, and she thinks she is at her son’s house. These impairments best illustrate which aspect of the mental status examination?

A 52-year-old man is sent to see a psychiatrist after he is disciplined at his job because he consistently turns in his assignments late. He insists that he is not about to turn in anything until it is “perfect, unlike all of my colleagues.” He has few friends because he annoys them with his demands for “precise timeliness” and because of his lack of emotional warmth. This has been a lifelong pattern for the patient, though he refuses to believe the problems have anything to do with his personal behavior. Which of the following is the most likely diagnosis for this patient?

A 23-year-old woman comes to the psychiatrist because she “cannot get out of the shower.” She tells the psychiatrist that she has been unable to go to her job as a secretary for the past 3 weeks because it takes her at least 4 hours to shower. She describes an elaborate ritual in which she must make sure that each part of her body has been scrubbed three times, in exactly the same order each time. She notes that her hands are raw and bloody from all the scrubbing. She states that she hates what she is doing to herself but becomes unbearably anxious each time she tries to stop. She notes that she has always taken long showers, but the problem has been worsening steadily for the past 5 months. She denies problems with friends or at work, other than the problems that currently are keeping her from going to work. Which of the following is the most likely diagnosis?

A 23-year-old woman comes to the emergency room with the chief complaint that she has been hearing voices for 7 months. Besides the hallucinations, she has the idea that the radio is giving her special messages. When asked the meaning of the proverb “People in glass houses should not throw stones,” the patient replies, “Because the windows would break.” Which of the following mental status findings does this patient display?

A 69-year-old man is brought to see his physician by his wife. She notes that over the past year he has experienced a slow, stepwise decline in his cognitive functioning. One year ago she felt his thinking was “as good as it always had been,” but now he gets lost around the house and can’t remember simple directions. The patient insists that he feels fine, though he is depressed about his loss of memory. He is eating and sleeping well. Which of the following is the most likely diagnosis?

A psychiatrist is seeing a patient in his outpatient practice. The patient treats the psychiatrist as if he were unreliable and punitive, though he had not been either. The patient’s father was an alcoholic who often did not show up to pick her up from school and frequently hit her. The psychiatrist begins to feel as if he must overprotect the patient and treat her gingerly. Which of the following psychological mechanisms best describes the psychiatrist’s behavior?

A patient is able to appreciate subtle nuances in thinking and can use metaphors and understand them. This patient’s thinking can be best defined by which of the following terms?

A 65-year-old man, who had been hospitalized for an acute pneumonia 3 days previously, begins screaming for his nurse, stating that “there are people in the room out to get me.” He then gets out of bed and begins pulling out his IV line. On examination, he alternates between agitation and somnolence. He is not oriented to time or place. His vital signs are as follows: pulse, 126 beats per minute; respiration, 32 breaths per minute; blood pressure (BP), 80/58; temperature, 39.2°C (102.5°F). Which of the following diagnoses best fits this patient’s clinical picture?

A 59-year-old man goes to a psychiatrist for a 3-month history of panic attacks. He notes for the past 3 months he has experienced “out of the blue,” extreme episodes of fearfulness that last about 20 minutes. During that time he experiences palpitations, sweating, shortness of breath, and trembling. He denies any substance abuse, and has never had symptoms like this before these past 3 months. Which of the following signs or symptoms would likely lead the physicians to expect a diagnosis of anxiety secondary to a general medical condition in this case?

A 19-year-old woman presents to the emergency room with the chief complaint of a depressed mood for 2 weeks. She notes that since her therapist went on vacation she has experienced suicidal ideation, crying spells, and an increased appetite. She states that she has left 40 messages on the therapist’s answering machine telling him that she is going to kill herself and that it would serve him right for leaving her. Physical examination reveals multiple well-healed scars and cigarette burns on the anterior aspect of both forearms. Which of the following diagnoses best fits this patient’s clinical presentation?

A 29-year-old man is brought to the emergency room by his wife after he woke up with paralysis of his right arm. The patient reports that the day before, he had gotten into a verbal altercation with his mother over her intrusiveness in his life. The patient notes that he has always had mixed feelings about his mother, but that people should always respect their mothers above all else. Which of the following diagnoses best fits this patient’s clinical picture?

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

A 56-year-old man is brought to the physician’s office by his wife because she has noted a personality change during the past 3 months. While the patient is being interviewed, he answers every question with the same three words. Which of the following symptoms best fits this patient’s behavior?

A 32-year-old patient is being interviewed in his physician’s office. He eventually answers each question, but he gives long answers with a great deal of tedious and unnecessary detail before doing so. Which of the following symptoms best describes this patient’s presentation?

An 18-year-old man is brought to the emergency room by the police after he is found walking along the edge of a high building. In the emergency room, he mumbles to himself and appears to be responding to internal stimuli. When asked open-ended questions, he suddenly stops his answer in the middle of a sentence, as if he has forgotten what to say. Which of the following symptoms best describes this last behavior?

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

A patient with a chronic psychotic disorder is convinced that she has caused a recent earthquake because she was bored and wishing for something exciting to occur. Which of the following symptoms most closely describes this patient’s thoughts?

A 45-year-old man with a chronic psychotic disorder is interviewed after being admitted to a psychiatric unit. He mimics the examiner’s body posture and movements during the interview. Which of the following terms best characterizes this patient’s symptom?

A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns, and blinks excessively. Which of the following disorders is most likely in this patient?

A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk. She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder?

A 24-year-old woman comes to the emergency room with the chief complaint that “my stomach is rotting out from the inside.” She states that for the last 6 months she has been crying on a daily basis and that she has decreased concentration, energy, and interest in her usual hobbies. She has lost 25 lb during that time. She cannot get to sleep, and when she does, she wakes up early in the morning. For the past 3 weeks, she has become convinced that she is dying of cancer and is rotting on the inside of her body. Also, in the past 2 weeks she has been hearing a voice calling her name when no one is around. Which of the following is the most likely diagnosis?

A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the Mafia was after him. He reports that he has eaten nothing for the past 6 weeks other than canned beans because “they are into everything––I can’t be too careful.” He is convinced that the Mafia has put cameras in his dormitory room and that they are watching his every move. He occasionally hears the voices of two men talking about him when no one is around. His roommate states that for the past 2 months the patient has been increasingly withdrawn and suspicious. Which of the following is the most likely diagnosis?

A 36-year-old woman is brought to the psychiatrist by her husband because for the past 8 months she has refused to go out of the house, believing that the neighbors are trying to harm her. She is afraid that if they see her they will hurt her, and she finds many small bits of evidence to support this. This evidence includes the neighbors’ leaving their garbage cans out on the street to try to trip her, parking their cars in their driveways so they can hide behind them and spy on her, and walking by her house to try to get a look into where she is hiding. She states that her mood is fine and would be “better if they would leave me alone.” She denies hearing the neighbors or anyone else talks to her, but is sure that they are out to “cause her death and mayhem.” Which of the following is the most likely diagnosis?

A 35-year-old woman has lived in a state psychiatric hospital for the past 10 years. She spends most of her day rocking, muttering softly to herself, or looking at her reflection in a small mirror. She needs help with dressing and showering, and she often giggles and laughs for no apparent reason. Which of the following is the most likely diagnosis?