USMLE_Diagnosis XII

A 68-year-old man is brought to the emergency department following a high-speed automobile accident. He is alert and complains of chest pain and mild back pain. His blood pressure is 80/60 mm Hg. Chest x-ray shows a widened mediastinum, tracheal deviation, bronchial displacement, and loss of the aortic knob. Which of the following is the most likely diagnosis?

A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8 cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. Which of the following is the most likely diagnosis?

A 68-year-old man presents to the physician’s office complaining of progressive dysphagia over the last 3 months associated with mild chest discomfort. He reports a 15-lb weight loss, a 30 pack-year smoking history, and occasional alcohol intake. The physical examination, including vital signs, is unremarkable. A chest x-ray was normal, and a barium esophagogram shows an irregular filling defect in the distal third of the esophagus with distortion and narrowing of the lumen. Which of the following is the most likely diagnosis?

A 68-year-old man with hypertension, hyperlipidemia, and diabetes is hospitalized for an acute myocardial infarction. It is complicated by pulmonary edema and he undergoes angiography of the left anterior descending artery. On post-operative day 3, he complains of abdominal pain and discoloration of his toes. His vital signs are stable. Examination shows bluish discoloration of his right great toe and of all the toes on his left foot. The skin over the toes is cold and clammy. Bilateral pedal pulses are present and full. His abdomen is soft and mildly tender at the center. Chest auscultation is clear. Laboratory studies show a rise in creatinine to 2.3 g/dl from his baseline of 1.2 g/dl. An EKG shows sinus rhythm and Q waves in anterior leads. Which of the following is the most likely cause of his toe discoloration?

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

A 68-year-old woman comes to the office due to the inability to move the right half of her face for the past 24 hours. Her blood pressure is 135/90 mm Hg and heart rate is 76/min. The physical examination is performed. Which of the following signs will exclude the diagnosis of central facial paresis?

A 69-year-old male presents to the emergency department with severe pain in the back of his chest that began suddenly 6 hours ago, and 2 hours of difficulty walking due to leg weakness. He has never had such symptoms before. His past medical history is significant for hypertension, bleeding peptic ulcers, and deep vein thrombosis requiring inferior vena cava filter placement. He drinks 6-8 cans of beer each weekend and does not smoke cigarettes or use illicit drugs. Blood pressure taken from his right arm is 210/120 mmHg. His heart rate is 120/min and regular. Chest x-ray reveals a right-sided pleural effusion. EKG shows sinus tachycardia. What is the most likely diagnosis?

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 69-year-old man is evaluated after undergoing an elective repair of a rapidly expanding abdominal aortic aneurysm. The surgical procedure was complicated by a significant amount of blood loss and required multiple transfusions. In the postoperative recovery room, he had weakness in both lower extremities and developed urinary retention. Neurologic examination shows spastic paraplegia and loss of pain sensation over the lower extremities; vibratory sensation is intact. Upper extremity examination shows no abnormalities. Which of the following is the most likely pathophysiologic mechanism of the neurologic dysfunction?

A 69-year-old man presents to the emergency department with a severe occipital headache, nausea and vomiting for several hours. His medical history is significant for poorly controlled essential hypertension for the last 7 years. The neurologic examination shows ataxia, right-sided facial weakness and deviation of the eyes to the left side. His CT scan is consistent with a hemorrhagic stroke. Which of the following is the most likely diagnosis?

A 69-year-old white male presents to your office complaining of progressive bilateral loss of vision over the past several months. He only has problems with his central vision. His peripheral field and navigational vision are not affected. He denies smoking and alcohol intake. He does not have any history of diabetes or hypertension Two years ago, he had cataracts removed from both eyes. What is the most likely diagnosis?

A 69-year-old woman with diabetes mellitus complains of urinary incontinence. Her diabetes is well controlled with oral hypoglycemic agents. She has no complaints other than the wetness. Which of the following tests is most likely to demonstrate the cause?

A 7 -year-old boy is brought to the emergency department after falling on his outstretched hand. On examination, there is minimal swelling at the right elbow. The skin on the right forearm appears tense, and severe pain is present. The brachial pulses are good bilaterally, and sensations are intact in both upper limbs. X-rays of the right upper limb show a displaced anterior fat pad. Which of the following statements is true about this condition?

A 7 -year-old girl is brought to the clinic by her mother due to a persistent postnasal drip and repeated episodes of a runny nose. In the winter, she experiences several episodes of upper respiratory tract infections, which last for two to three weeks at a time. She snores, and is unable to smell her favorite food. Her immunizations are up-to-date. On examination, she is mildly underweight for her age. She has a runny nose, and her nasal drainage is colorless and stringy. Nasal inspection reveals bilateral nasal polyps, and auscultation of the chest reveals coarse rales. What is the one condition that you would like to rule out in this child?

A 7 -year-old girl is brought to the physician's office by her mother due to recurrent, prolonged episodes of nausea and severe vomiting for the past 4 days. According to the mother, the vomiting starts in the early morning and recur 7 to 8 times daily. The child denies any headache, abdominal pain, diarrhea, chest pain or respiratory distress. She has had two similar episodes of vomiting and nausea in the past year, which resolved spontaneously. The mother has a history of migraines. On examination, the child is afebrile and has pallor with signs of mild dehydration. The abdomen is soft and non-tender to palpation. What is the most likely cause of this child's symptoms?

A 7-day-old boy is admitted to a hospital for evaluation of vomiting and dehydration. Physical examination is otherwise normal except for minimal hyperpigmentation of the nipples. Serum sodium and potassium concentrations are 120 mEq/L and 9 mEq/L (without hemolysis), respectively; serum glucose is 40 mg/dL. Which of the following is the most likely diagnosis?

A 7-month-old baby presents with a history of constipation for 1 month. He has one hard stool every week. He has been well otherwise. His physical examination is normal. Which of the following is the most likely cause of his problem?

A 7-month-old patient presents with a history of 3 days of fever to 104°F, which resolved the same day that an exanthem erupted. The exanthem is prominent on the neck and trunk. It is macular, with discrete lesions 3–5 mm in diameter. Which of the following is the most likely diagnosis?

A 7-year-old boy arrives at the emergency room in acute distress. Over the past 3 to 4 days he has become progressively ill with generalized fatigue and mild, mid-abdominal pain that have become steadily worse. On physical examination he has a maculopapular rash on his thighs and feet with some spread of the rash to his buttocks. The rash does not blanch and the some lesions near the ankles look petechial or bruised. His temperature is 39.0 C (102.2 F) and he is drawing his knees to his chest for relief of his stomach pains. He is nauseated and vomited once before coming to the hospital. He has semi-soft dark stool, which is guaiac-positive. The boy has not voided since early morning and cannot provide a urine sample. The doctor determines that he is 10% dehydrated and asks the nurse to start intravenous fluids. Which of the following is the most likely diagnosis?

A 7-year-old boy is brought to the clinic by his mother, who states that he has been complaining of abdominal pain for 2-3 days. He has been afebrile, with no vomiting or diarrhea. His mother states she brought him to the office today because she noticed a rash on his legs that is getting worse, and he is now complaining of knee pain. On examination, there are palpable purpuric lesions on both legs and buttocks. He has pain around his ankle and knee joints with minimal swelling, and no warmth or erythema. Which of the following is the most likely diagnosis?

A 7-year-old boy is brought to the physician because of a persistent mucopurulent nasal discharge for 2 weeks following a common cold. The mother also reports that the child has had frequent cough during the day and occasional temperatures up to 38.0 C (100.5 F). The child does not appear critically ill, but he complains of mild pain in the maxillary region and nasal obstruction. Rhinoscopic examination reveals a rivulet of purulent fluid coming from the inferior meatus. The rest of the physical examination is normal. Which of the following is the most likely diagnosis?

A 7-year-old boy is brought to the physician because of recurrent headaches. The child feels nauseated before and during each attack, and derives some relief from lying down in a dark room. Noises, bright light, and fatigue seem to trigger the episodes. The child frequently complains of headaches at school, and his mother has been occasionally compelled to take him home. The mother is worried about the possibility of a serious illness. She reports that the child's father has similar headaches. The child's growth is normal, and a neurologic examination fails to reveal any abnormality. Which of the following is the most likely diagnosis?

A 7-year-old boy is referred by his school for psychiatric evaluation. The teachers have noticed that, in the past year, he has been unable to sustain attention in class, and has been fidgeting and talking to his peers during class. He seems unable to wait for others to finish speaking and keeps interrupting and blurting out answers before questions are completed. At home, his parents state that he is forgetful and losses things easily. Which of the following is the most likely diagnosis?

A 7-year-old boy presents with a rash. His mother states that he was well until 3 days ago when he developed fever and malaise. The next day, the rash started as papules on the trunk, which rapidly changed to vesicles. The lesions have spread all over the body. On physical examination, he has no fever and seems well. You note numerous vesicles all over the body, some of which have crusted over. Which of the following is the most likely diagnosis?

A 7-year-old boy who has had pain in his right leg for 4 months is being evaluated. The pain is worse at night and is unrelenting, but it can usually be relieved with ibuprofen. On physical examination, there is localized tenderness over the anterior aspect of the right thigh. There is also mild atrophy of the affected limb. A radiograph of the femur reveals a radiolucent nidus with surrounding reactive sclerotic bone. Which of the following is the most likely diagnosis?

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?

A 7-year-old Caucasian boy is brought to the clinic because of poor performance in school. His mother says that his teachers have been complaining about his poor attention in the classroom for the past 8 months. They have also complained that he is out of his seat often, fidgets, and talks excessively, gets distracted easily, and interrupts class and other students. His mother has noticed that he often loses his things, and she is having more and more difficulty disciplining him at home. His antenatal and postnatal history is insignificant. His parents never had any similar problems with his 10-year-old sister. What is your clinical diagnosis?

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

A 7-year-old child is brought to the emergency department after being involved in a highway motor vehicle collision. He had blunt trauma to his abdomen. Vital signs are stable, except for a respiratory rate of 30 per minute. Physical examination shows bruising of the upper abdomen, abdominal distention, and tenderness. He is in moderate respiratory distress; breath sounds are decreased on the left side. Chest tube placement shows no blood or air in the pleural cavity. An x-ray film of the chest shows an elevated left hemidiaphragm. Laboratory studies show hemoglobin and hematocrit within normal limits. Which of the following is the most likely diagnosis?

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

A 7-year-old girl is brought to the office by her mother due to a rash all over her body. She was apparently in good health until 4 days ago, when she developed fever, cough and eye pain. This morning, she developed a rash on her face, which later spread all over her entire body. Her pulse is 86/min, respirations are 14/min, blood pressure is 110/70 mmHg, and temperature is 37.2°C (99°F). On examination, there is an erythematous maculopapular rash covering her entire body. There are small red spots with bluish specks on her buccal mucosa. What is the most likely diagnosis?

A 7-year-old girl is brought to the physician because of an exanthematous rash associated with malaise and headache for 2 days. On examination, the child shows a fiery red facial rash with a characteristic "slapped cheek" pattern and pallor around the mouth. There is no fever. In immunocompromised patients, the pathogen that causes this condition may result in which of the following manifestations?

A 7-year-old girl is brought to your office by her parents after they noticed the development of axillary and pubic hair 3 months ago. The girl has also experienced a significant growth spurt over the past year. There has been no change in her behavior or school performance. The girl denies headaches, vomiting or visual disturbances. Her personal and family medical histories are unremarkable. On examination, you note the presence of axillary hair, pubic hair at Tanner stage 2, and breast development at Tanner stage 3. Abdominal, genital and neurologic examinations reveal nothing abnormal. Her bone age is more than two standard deviations above normal. Serum FSH and LH levels are elevated. MRI of the brain is normal. Which of the following is the most likely cause of her symptoms?

A 70-year-old Caucasian male comes to your office four weeks after experiencing an ischemic stroke. His past medical history is significant for a long history of hypertension, diabetes, coronary artery disease, congestive heart failure, and atrial fibrillation. You noticed that the patient has shaved only the right side of his face. When you ask him to raise his left arm, he raises his right arm. You ask him to fill in the numbers of a clock, and he puts numbers only on the right side. Which of the following areas is most likely affected by the stroke in this patient?

A 70-year-old Caucasian male is brought to the emergency department due to a sudden onset of right-sided weakness and urinary incontinence about ten hours ago. His past medical history is significant for type 2 diabetes for the last 20 years and hypertension for the last 28 years. On examination, there is 3/5 power in the right upper extremity and 1/5 power in the right lower extremity. Babinski's sign is positive on the right side. The sensations are decreased on the right side of the body, more so in the right lower limb than the right upper limb. Which of the following is the most likely diagnosis?

A 70-year-old male rushed to the emergency department because of bright red bleeding per rectum. He says his commode is full of blood and has never experienced any bleeding before. He has a history of constipation. He takes daily aspirin for prevention of stroke and hydrochlorothiazide for high blood pressure. His temperature is 36.50C (97.80F), blood pressure is 100/60 mm Hg, pulse is 120/min and respirations are 20/min. He is not hypoxic. Abdomen is soft, non-distended and non-tender; no masses or organomegaly are palpated; bowel sounds are normal. Rectal examination shows bright red blood and an enlarged prostate. Nasogastric tube aspirate shows non-bilious stomach contents without blood. An x-ray of the abdomen shows no abnormalities. Which of the following is the most likely cause of his bleeding?

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?

A 70-year-old man is brought to the hospital by his son because of worsening fatigue. His son states that his father does not like seeing doctors and has not seen a physician in the past 20 years. He has no medical problems. Physical examination of the prostate shows no abnormalities. Laboratory studies show: Hb 10.5 g/dl, WBC 7,400/cmm, Platelets 160,000/cmm, Serum Na 135 mEq/L, Serum K 5.0 mEq/L, BUN 50 mg/dl, Serum creatinine 3.0 mg/dl. Ultrasonogram of the abdomen shows bilateral small kidneys and no evidence of hydronephrosis. Kidney biopsy shows intimal thickening and luminal narrowing of renal arterioles with evidence of sclerosis. Which of the following is the most likely cause of this patient's findings?

A 70-year-old man presents to the emergency department with a 12-hour history of inability to void. He also complains of nocturia and problems with initiating micturition for the past few weeks. He denies fever, weakness, numbness, dysuria or hematuria. He does not use tobacco, alcohol, or drugs. Neurological examination shows no abnormalities, except absent Achilles tendon reflexes bilaterally. Straight catheterization of the bladder produces 600 ml of urine. Further evaluation will most likely show which of the following?

A 70-year-old man presents to the ER with several fractures and a ruptured spleen after falling 20 ft. Which of the following will occur in response to the injury?

A 70-year-old man was admitted to the ICU with severe pancreatitis. During his ICU course, he underwent several CT scans with IV contrast and was also treated with an aminoglycoside for a urinary tract infection. The patient required a prolonged course of TPN, and developed Candida sepsis treated with amphotericin. He subsequently developed polyuria with urine osmolality of 250mOsm/L and serum osmolality of 350 mOsm/L. After receiving 5 units of vasopressin intravenously, there is no change in urine osmolality or urine output. Select the most likely diagnosis of the patients with polyuria?

A 70-year-old retired engineer is brought to the office by his son for a routine check-up. He believes that his son is too greedy and wants all his property. He is accusing his son of "kicking him out of the house to get all of his property." He has been getting more forgetful over the past few years. His younger sibling has the same problem. He has no significant past medical history, except a history of smoking for 6 years when he was young. His blood pressure is 138/78 mm Hg, pulse is 86/min, respirations are 14/min and temperature is 37.0°C (98.6°F). He cannot remember current events, such as the name of the current American president; however, he can still remember past political history. He is unable to concentrate, but is oriented to time, place and person. The neurological examination is nonfocal. CT scan reveals mild generalized atrophy. His HIV and RPR tests are negative. The serum electrolytes and thyroid function tests are normal. What is the most likely diagnosis of this patient?

A 70-year-old woman presents for evaluation of a pruritic lesion on the vulva. Examination shows a white, friable lesion on the right labia majora that is 3 cm in diameter. No other suspicious areas are noted. Biopsy of the lesion confirms squamous cell carcinoma. In this patient, lymphatic drainage characteristically would be first to which of the following nodes?

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?

A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

A 71-year-old man is involved in a minor automobile accident on the road between Guadalajara and Lake Chapala in Mexico. The man is an American citizen who at the age of 65 years retired to a lakeside home in that area. Although he is asymptomatic, he decides to return to the United States to be "thoroughly checked." He is admitted to a veteran's hospital in south Texas, where he undergoes a CT scan of his abdomen. There are no signs of traumatic injuries, but the scan reveals the presence of four simple, thin walled cystic structures, approximately 1 cm in diameter, scattered throughout both lobes of his liver. They have no septations. There are no cysts in the kidneys or pancreas. The man is completely asymptomatic and afebrile. Liver function tests are normal, as is his white blood count and differential. Which of the following is the most likely diagnosis?

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?

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

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

A 72-year-old man comes in complaining of persistent and nagging low back pain that he has had for several weeks. The pain seems to be increasing in intensity, is worse at night, is unrelieved by rest or positional changes, and is not exacerbated by coughing, sneezing, or straining to have a bowel movement. He is a chronic smoker, and for the past 3 months has had persistent cough with occasional bloody streaked sputum, as well as a 20-pound weight loss. On physical examination, he is distinctly tender to palpation at a particular spot over his lower thoracic spine. Which of the following is the most likely diagnosis?

A 72-year-old man has a 4-cm hard mass in the left supraclavicular area. The mass is movable and nontender and has been present and steadily growing for the past 3 months. On direct questioning the only additional findings include a 20-pound weight loss and a vague feeling of epigastric discomfort over the past 2 months. Physical examination shows evidence of the weight loss but no other significant findings in the abdominal examination. The supraclavicular mass are obvious, but no other masses can be felt anywhere else in the neck, axillas, or groins. There is occult blood in the stool, and his hemoglobin is 10.5 g/dL. Which of the following would a biopsy of the supraclavicular mass most likely reveal?

A 72-year-old man of Norwegian ancestry has a contracted hand that can no longer be extended and placed flat on a table. The problem developed gradually, over many years. He complains of no pain or neurologic abnormalities and, to the extent that the deformity allows, can move his fingers at will. Physical examination demonstrates the deformity described and in addition shows the presence of palpable fascial nodules. Which of the following is the most likely diagnosis?

A 72-year-old man presents with shortness of breath and increased home oxygen requirement. The patient has coronary artery disease, he has had two previous myocardial infarctions, and he has a history of chronic obstructive pulmonary disease requiring 2 L of continuous home oxygen. The patient has a 45-pack-year history of smoking. He is unable to walk more than a block and the swelling in his legs has worsened. The physician suggests measuring a brain natriuretic peptide (BNP) level to distinguish a cardiac from a pulmonary cause of his symptoms. Which of the following statements regarding BNP is true?

A 72-year-old man undergoes a subtotal colectomy for a cecal perforation due to a sigmoid colon obstruction. He has had a prolonged recovery and has been on total parenteral nutrition (TPN) for 2 weeks postoperatively. After regaining bowel function, he experienced significant diarrhea. Examination of his abdominal wound demonstrates minimal granulation tissue. He complains that he has lost his taste for food. He also has increased hair loss and a new perioral pustular rash. Which of the following deficiencies does he most likely have?

A 72-year-old man underwent surgical repair of an aneurysm of the infrarenal aorta. He received perioperative prophylaxis with a second-generation cephalosporin antibiotic. On the first postoperative day he complains of progressive abdominal pain and bloody diarrhea. His temperature is 38.5° C (101° F), blood pressure is 110/65 mm Hg, pulse is 110/min and respirations are 22/min. His abdomen is mildly distended and tender to palpation. The tenderness is mostly in the left lower quadrant without rebound. Femoral pulses are full and symmetric. His white blood cell count is 12,000/mm3. Which of the following is the most likely diagnosis?

A 72-year-old man underwent surgical repair of an aneurysm of the infrarenal aorta. He received perioperative prophylaxis with a second-generation cephalosporin antibiotic. On the first postoperative day he complains of progressive abdominal pain and bloody diarrhea. His temperature is 38.5C (101F), blood pressure is 110/65 mm Hg, pulse is 110/min and respirations are 22/min. His abdomen is mildly distended and tender to palpation. The tenderness is mostly in the left lower quadrant without rebound. Femoral pulses are full and symmetric. His white blood cell count is 12,000/mm3. Which of the following is the most likely diagnosis?

A 72-year-old white male with a past medical history of hypertension, hypothyroidism, and coronary artery disease presented to the physician's office because of fever, malaise, nonproductive cough, and shortness of breath. His temperature was 38.3°C (101°F). His chest x-ray showed a patchy right lower lobe infiltrate. He was sent home on oral amoxicillin. Four days later, the patient was brought to the emergency room because he was having continuous fevers, headache, pleuritic chest pain, and abdominal pain. He appears confused. His blood pressure is 120/70 mmHg, pulse rate is 100 per minute, respiratory rate is 24 per minute, and temperature is 38.9°C (102°F). His chest x-ray showed consolidation of the right lower lobe. Which of the following is the most likely cause of this patient's pneumonia?

A 72-year-old woman complains of difficulty "finding the right word" when she is speaking. Her daughter notes that she also frequently complains that her neighbor is stealing her newspapers when this is not the case in actuality. Recently, the patient has been having difficulty balancing her check book as well. On physical examination, her blood pressure is 160/100 mmHg and her heart rate is 90/min. The exam is otherwise unremarkable. Over the course of the next three years, the patient develops a severe memory deficit, and suffers from poor sleep, slowness of movement, shuffling gait and urinary incontinence. Which of the following is the most likely diagnosis?

A 72-year-old woman has a red, swollen breast. She states that the condition has been present for at least several weeks, perhaps a month or two. She has no pain or fever. The skin over the area looks like orange peel. The area is not warm to the touch, but on physical examination there is fullness to the entire breast, with no discrete mass. Which of the following is the most likely diagnosis?

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 72-year-old woman is brought to the emergency room by her daughter after she found her mother rummaging in the garbage cans outside her home. The daughter states that the patient has never had any behavior like this previously. On interview, the patient states she sees “martians hiding around her home, and on occasion, hears them too.” She also demonstrates a constructional apraxia, with difficulty drawing a clock and intersecting pentagons. All of these symptoms point to a medical cause for this patient’s behavior except one. Which symptom is common in patients with a psychiatric cause for their behavior (ie, not a medical cause)?

A 73-year-old man comes to the physician because of right anterior thigh pain that is worse with walking. He has a history of stable angina, hypertension, hypercholesterolemia, and COPD with periodic exacerbations. He takes ipratropium, aspirin, metoprolol and pravastatin. He smokes 2 packs a day and drinks alcohol occasionally. Physical examination shows a small pulsatile mass in the right groin area. Which of the following is the most likely diagnosis?

A 73-year-old man undergoes abdominal aortic aneurysm repair. The patient develops hypotension to 80/50 mm Hg for approximately 20 minutes during the procedure according to the anesthesia record. He received 4 units of packed red blood cells. Postoperatively, his blood pressure is 110/70 mm Hg, heart rate is 110, surgical wound is clean, and a Foley catheter is in place. Over the next 2 days his urine output slowly decreases. His creatinine on post-op day 3 is 3.5 mg/dL (baseline 1.2). His sodium is 140 mEq/L, K 4.6 mEq/L, and BUN 50 mg/dL. Hemoglobin and hematocrit are stable. Urinalysis shows occasional granular casts but otherwise is normal. Urine sodium is 50 mEq/L, urine osmolality is 290 mosmol/L, and urine creatinine is 35 mg/dL. The FENa (fractional excretion of sodium) based on these data is 3.5. What is the most likely cause of this patient’s acute renal failure?

A 73-year-old woman with arthritis presents with confusion. Neurologic examination is nonfocal, and CT of the head is normal. Laboratory data include: Na: 140 mEq/L, K: 3.0 mEq/L, Cl: 107 mEq/L, HCO3: 12 mEq/L. Arterial blood gases: PO2 62, PCO2 24, pH 7.40. What is the acid-base disturbance?

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

A 74-year-old male is undergoing elective abdominal aortic aneurysm repair. He is given two units of packed red blood cells during the surgery. He develops fever and chills one hour after finishing the surgery and transfusion. He received one dose of prophylactic antibiotics before surgery. He had coronary bypass grafting two months ago. His temperature is 38.5C (101.3F), blood pressure is 130/76 mm Hg, pulse is 90/min and respirations are 16/min. Physical examination shows a mildly tender wound; there is no redness. The lungs are clearto auscultation. He has a Foley catheter and right subclavian central venous access, each placed at the time of surgery. Which of the following is the most likely cause of his fever?

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

A 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 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 74-year-old woman comes to your office with her husband for a routine check-up. Her husband complains that she often forgets to take her blood pressure pills. He feels that her speech has changed because she occasionally struggles to find appropriate words. Two days ago, she drove to the nearby grocery store and did not find her way back. She has difficulty falling asleep and she always wakes up early in the morning. Her appetite is good. Which of the following is the best indicator of dementia in this patient?

A 74-year-old woman develops acute sepsis from pneumonia and is admitted to the intensive care unit because of hypotension. She is started on antibiotics, and her blood pressure is supported with intravenous normal saline. Despite this she remains oliguric and develops ARF. Her urinalysis has heme-granular casts and the urine sodium is 56 mEq/L. Which of the following is the most likely cause of her ARF?

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 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?

A 74-year-old woman presents to your office for well-woman examination. Her last Pap smear and mammogram were 3 years ago. She has hypertension, high cholesterol, and osteoarthritis. She stopped smoking 15 years ago, and denies alcohol use. Based on this patient’s history which of the following medical conditions should be this patient’s biggest concern?

A 75-year-old African American man comes to your office for his annual check-up. He is a known diabetic and hypertensive. His medications include lisinopril and atenolol. His vital signs are normal. Examination of his fundus reveals cupping of the optic disc. Visual field examination reveals constricted peripheral vision. What is the most likely diagnosis?

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

A 75-year-old female comes to the emergency room with acute onset of severe back pain. The pain started while lifting a turkey from the freezer. She had no obvious trauma preceding the pain. She denies weakness or sensory loss in the legs. Her past medical history is significant for temporal arteritis diagnosed several months ago and has been taking prednisone. She does not smoke or consume alcohol. Her temperature is 36.7°C (98°F), blood pressure is 140/70 mmHg, pulse is 80/min, and respirations are 16/min. Physical examination reveals local tenderness of the lumbar spine area. Bilateral ankle reflex is absent. Knee reflex is 2+ in both legs. Babinski's sign is absent bilaterally. Muscle power is 5/5 in both legs. Bilateral straight-leg raising to 90 degrees does not increase the pain What is the most probable diagnosis in this patient?

A 75-year-old man comes into the emergency department with a 10-minute history of crushing substernal chest pain radiating to his left arm. This man is well known to the staff due to his long history of chest pain. His creatine phosphokinase level is elevated and his troponin T level is 0.4 ng/mL. Which of the following is the most likely diagnosis?

A 75-year-old man is being cared for in a hospice setting. He has widely spread prostatic carcinoma and is considered terminal. Which of the following psychiatric symptoms are seen in 90% of all terminal patients?

A 75-year-old man is brought to the emergency department by his family for evaluation of jaundice. He complains of pruritus of 2 weeks’ duration and a recent 10-lb weight loss. On examination, he is deeply jaundiced and has a nontender, globular mass in the right upper quadrant of the abdomen that moves with respiration. Which one is the most likely diagnosis?

A 75-year-old patient presents to the ER after a syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and shortness of breath on exertion. His blood pressure is 110/80 mmHg and lungs have a few bibasilar rales. Which auscultatory finding would best explain his findings?

A 75-year-old white male comes to the physician's office for his routine health maintenance examination. He has no symptoms. He has a past medical history significant for hypertension and hyperlipidemia. He takes aspirin, hydrochlorothiazide and simvastatin. He does not smoke and consumes 1-2 beers on weekends. He walks 2 miles every morning and eats a balanced diet. His vital signs are within normal limits. His chest is clear to auscultation, and his abdomen is soft and nontender. Rectal examination shows a diffusely enlarged, firm prostate without nodules. Stool for occult blood is negative. The distal interphalangeal joints are enlarged, and his gait is normal. His labs are as follows: Total bilirubin 1.0 mg/dl, Alkaline phosphatase 420 U/L, Aspartate aminotransferase (SGOT) 20 U/L, Alanine aminotransferase (SGPT) 25 U/L, Serum creatinine 0.8 mg/dl, Calcium 8.8 mg/dl, Serum PSA 2.1 ng/ml. Which of the following is the most likely cause of the elevated alkaline phosphatase in this patient?

A 75-year-old woman comes to the physician because of abdominal distension. She states that she always feels bloated and that she gets full quickly when eating. She has hypertension, for which she takes an angiotensin converting enzyme (ACE) inhibitor, and no other medical problems. Examination shows abdominal distension and a positive fluid wave. Pelvic examination reveals a large, nontender right adnexal mass. Abdominal CT scan demonstrates masses on both ovaries, ascites, and omental caking. CA-125 level is significantly elevated. Serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) are negative. Which of the following is the most likely diagnosis?

A 75-year-old woman is admitted to the hospital from a nursing home for abdominal pain and pneumonia. She was noted to be short of breath with increasing cough for 2 days before admission. Treatment, consisting of supplemental oxygen, IV antibiotics, and pulmonary toilet, is instituted, with improvement within 2 days. On the third hospital day, her abdominal pain worsens. Examination reveals a mildly distended abdomen with bowel sounds but no signs of peritonitis. Remainder of examination reveals a tender bulge in the medial left thigh below the inguinal ligament. Gentle pressure causes more pain but does not change the size or shape of the bulge. Abdominal films show a nonspecific bowel gas pattern. Laboratory analysis shows a WBC of 13,000, decreased from 18,000 at the time of admission. Which of the following is the most likely diagnosis?

A 75-year-old woman is brought to the emergency department from the nursing home for jaundice and mental confusion. The nursing home notes state that she has become less responsive and has developed jaundice over the last 2 weeks. Past history is pertinent for hypertension, diabetes, and prior colon resection for cancer at age 55. Examination reveals mild jaundice with vital signs of temperature 101.5°F, pulse rate 110/min, and BP 100/60 mmHg. She does not respond to verbal commands, but withdraws to pain. Abdominal examination reveals tenderness in the epigastrium and right upper quadrant. Which one is the most likely diagnosis?

A 75-year-old woman presents with a pruritic vulvar lesion. Physical examination reveals an irregular white, rough area involving her vulva. Biopsies from this area reveal a combination of squamous hyperplasia of the epidermis (acanthosis) with hyperkeratosis and mild dermal inflammation. No atrophy or dysplasia of the epidermis is seen. What is the best diagnosis?

A 76-year-old man is undergoing an abdominoperineal resection for rectal cancer. During the surgery, unexpected severe bleeding is encountered, and the patient is hypotensive on and off for almost an hour. The anesthesiologist notes ST depression and T-wave flattening on the ECG monitor. Which of the following are the most likely diagnosis and the expected mortality?

A 76-year-old man presents to the emergency room. He had influenza and now presents with diffuse muscle pain and weakness. His past medical history is remarkable for osteoarthritis for which he takes ibuprofen, and hypercholesterolemia for which he takes lovastatin. Physical examination reveals blood pressure of 130/90 mm Hg with no orthostatic change. The only other finding is diffuse muscle tenderness. Laboratory data include: BUN: 30 mg/dL, Creatinine: 6 mg/dL, K: 6.0 mEq/L, Uric acid: 18 mg/dL Ca: 6.5 mg/dL, PO4: 7.5 mg/dL, UA: large blood, 2+ protein. Microscopic study shows muddy brown casts and 0 to 2 rbc/hpf (red blood cells/high power field).Which of the following is the most likely diagnosis?

A 76-year-old man was operated on for a strangulated inguinal hernia and had approximately 40 cm of small bowel resected. On the morning of his third post-operative day, he falls while getting out of bed. Immediately after the fall, he is responsive but his speech is slurred and he cannot explain what happened. His pulse is 122/min, blood pressure is 96/50 mmHg, and respirations are 23/min. Lungs are clear to auscultation and his heart has a regular rate and rhythm. His neck veins are distended. An ECG is remarkable for a new onset right bundle branch block (RBBB). Immediate resuscitation is started with wide open intravenous fluids, but he becomes unresponsive. Shortly thereafter, his pupils start to dilate and his heart rate drops to 45/min. He eventually dies despite resuscitative efforts. What is the most likely cause of his death?

A 76-year-old woman presents for a routine medical check-up. Her medical history is significant for hypertension, type 2 diabetes mellitus, and hypothyroidism that are controlled with oral agents. She had a stroke one year ago and has mild residual right arm weakness. Otherwise she has no physical complaints. She is widowed and lives alone. Regarding her memory, she sometimes forgets to return phone calls and take her blood pressure pills. Occasionally during conversations, she has difficulties finding the right word. She drives herself to the grocery market weekly to do her shopping, and has no difficulty managing her finances. She describes her mood as good. She visits her close friends on occasion and often has difficulty falling asleep. Her blood pressure is 135/76 mmHg and her heart rate is 65/min. Finger stick glucose and TSH levels are normal. Which of the following is the most likely diagnosis in this patient?