USMLE_Diagnosis V

A 30-year-old obese woman comes to the emergency department complaining of four days of progressive pain, swelling and redness of her right leg. She has no obvious trauma or insect bites. She does not use tobacco, alcohol or illicit drugs. Her temperature is 38.7°C (103.0°F), pulse is 106/min, and blood pressure is 130/80 mmHg. Her right calf is swollen, erythematous, and extremely tender and warm to the touch over a 6 x 3 cm region. There is a tender, palpable mass in her right groin. There is no overlying crepitus and no bullae are seen. The toe webs are fissured and macerated. Laboratory studies show: Complete blood count: Hemoglobin 14.0 g/L, Platelets 222,000/mm3, Leukocyte count 14,500/mm3, Neutrophils 86%, Lymphocytes 14%, Which of the following is the most likely cause of her current leg condition?

A 30-year-old previously healthy man presents with refractory hypertension on four medications. Urinalysis is positive for metanephrines. He was adopted as an infant and therefore does not know his family history. Which of the following inherited syndromes is not associated with this disease?

A 30-year-old white male presented to your office with low back pain and stiffness. His pain is worse in the morning and is improved with activity. He has also been having bloody diarrhea for the past few days. On examination, he has painful erythematous nodules over his shins. Pain and stiffness is present in his lower back. Plain radiographs show sacroiliac joint inflammation. Stool cultures are negative. Laboratory studies show anemia and thrombocytosis. P-ANCA is positive in high titers. Which of the following is the most likely cause of his symptoms?

A 30-year-old woman comes to the physician because of a 10-month history of dysmenorrhea associated with a dull pelvic sensation. She has heavy periods but denies inter-menstrual bleeding. She is sexually active with her husband and does not use contraception because they have been trying to become pregnant for one year. She has no pain during intercourse. Physical examination shows normal external genitalia and an enlarged uterus, but is otherwise normal. Which of the following is the most likely diagnosis?

A 30-year-old woman comes to the physician because of a 2-day history of periorbital edema and abdominal distention. She has no other complaints. Her temperature is 37.1°C (98.9°F), blood pressure is 125/75 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows ascites. Urinalysis shows proteinuria; 24-hour urinary protein excretion is 4 g/day, total serum protein is 5 g/dl and serum albumin is 2.5g/dl. A diagnosis of nephrotic syndrome is made. Renal biopsy is performed. She is started on diuretics and her salt and protein intake is restricted. Her edema begins to improve. However, the patient suddenly develops severe abdominal pain, fever, and gross hematuria. Which of the following is the most likely diagnosis that will be revealed by renal biopsy?

A 30-year-old woman comes to the physician due to several weeks history of generalized edema, fatigue, and decreased appetite. She has no other medical problems. She takes no medications. She does not use tobacco, alcohol, or drugs. Her temperature is 36.7°C (98°F), blood pressure is 110/70 mm Hg, pulse is 80/min, and respirations are 18/min. Physical examination shows generalized edema. Laboratory studies show a low serum albumin level. HBsAg is positive, and liver function tests are abnormal. Urinalysis shows +4 proteinuria and microhematuria. Which of the following is the most likely diagnosis?

A 30-year-old woman in her second pregnancy presents to your office at 36 weeks gestation complaining of dull, low back pain. The pain is minimal in the morning, but increases at the end of the day. She also noticed ankle edema that appears at the end of the day. Her past medical history is insignificant. Her temperature is 36.7C (98F), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min. Urinalysis is normal. Which of the following is the most likely cause of this patient's complaints?

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: 24mmol/L, Blood urea nitrogen: 10 mg/dL, Creatinine: 1.0 mg/dL. Culture of bronchoalveolar lavage fluid is negative. Which of the following is the most likely diagnosis?

A 30-year-old woman presents with hypertension, weakness, bone pain, and a serum calcium level of 15.2 mg/dL. Hand films below show osteitis fibrosa cystica. Which of the following is the most likely cause of these findings?

A 30-year-old, Caucasian male comes to the office for the evaluation of some pale patches in a mottled distribution over his trunk area. He just returned from a 2-week summer vacation in the Bahamas, where he first noticed these lesions. His skin is generally well-tanned. Located over his central upper trunk area are multiple, velvety pink, pale macules, measuring approximately 4-5 mm in diameter. These lesions scale on scraping. What is the most likely diagnosis?

A 30-year-old, HIV-positive male, presents with left-sided paralysis of recent onset. His temperature is 37.1°C (98.9°F), pulse is 78/min, blood pressure is 130/80, and respirations are 16/min. The neurological examination reveals loss of recent memory, expressive aphasia, hyperreflexia, hypertonia, and up going plantars on the left side. His current medications include zidovudine, didanosine, indinavir and trimethoprim-sulfamethoxazole. His CD4 count is 70/dl and viral load is 90,000 copies/ml by PCR. The serology is positive for Toxoplasma. CT scan shows multiple, hypodense, non-enhancing lesions with no mass effect in the cerebral white matter. What is the most likely diagnosis?

A 31-year-old accounting student presents with a persistent headache that began approximately 4 months ago. The headache has been gradually increasing in intensity, and is worse in the mornings. Thinking that she might need new glasses, she sought help from her optometrist, who discovered that she has bilateral papilledema and sent her in for medical evaluation. On direct questioning, she admits to repeat vomiting for the past 3 weeks, with no heaving, straining, or preceding nausea. "I would just open my mouth, and the stuff would hit the wall," she explains. She denies any other neurological symptoms. Which of the following is the most likely diagnosis?

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 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 31-year-old Hispanic female presents with palpitations and weight loss. Her past medical history is insignificant. Her family history is unremarkable. She recently moved from South America. She does not smoke cigarettes or drink alcohol. She is married and has three children. Her last delivery was four years ago. Her blood pressure is 140/90 mmHg, pulse is 102/min, temperature is 36.7°C (98°F) and respirations are 20/min. Her eye examination is unremarkable. Thyroid examination reveals a 2 x 2 cm left-sided thyroid nodule. Her T3 and T 4 are elevated, and TSH is undetectable. Radioactive iodine scan shows uptake only in the left thyroid nodule. Uptake in the rest of the thyroid is markedly reduced. Which of the following is the most likely diagnosis?

A 31-year-old male is brought to the emergency department after being involved in a motor vehicle collision as an unrestrained passenger. He was given 3L of normal saline in the ambulance on his way to the hospital and has been receiving 5 L/min of oxygen by nasal cannula. He is agitated and moves all four extremities spontaneously. His blood pressure is 85/55 mmHg and his heart rate is 120/min. His respiratory rate is 30/min. His pupils are symmetric and reactive to light. His neck veins are flat and his trachea is shifted slightly to the right. Over the left hemithorax, breath sounds are absent and there is dullness to percussion. Which of the following diagnoses is most likely?

A 31-year-old male presents to your office with pain and swelling over his coccyx. He has never had symptoms like this before. His past medical history is significant for an appendectomy two years ago and acute pyelonephritis one year ago. Which of the following is the most likely diagnosis?

A 31-year-old woman comes to the physician because she has not had a menstrual period for 7 months. She previously had normal cycles. She also states that over the past year she has felt increasingly weak and tired. She notes that she always feels cold and that her hair has been thinning over the course of the year. She also complains of constipation, weight gain, and depression. Her temperature is 36.7 C (98 F), blood pressure is 100/60 mmHg, pulse is 56/minute, and respirations are 10/minute. Examination is significant for brittle hair and delayed deep tendon reflexes. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is 20 μU/mL. Prolactin is normal. Which of the following is the most likely cause of this patient's amenorrhea?

A 31-year-old woman with systemic lupus erythematosus who is 4 weeks pregnant presents to her obstetrician for her first prenatal visit. She is very concerned that the lupus will affect her baby. She was diagnosed with systemic lupus erythematosus 5 years ago and her symptoms have been well controlled with low-dose prednisone. She has baseline renal insufficiency, with a creatinine level of 1.3 mg/dL that has been stable for the past 6 months. This is her first pregnancy. For which of the following is the baby at increased risk?

A 32-year-old Caucasian male complains of inability to grip his cup of coffee and hold a pen in the morning. He says that he is 'fully functional' in the afternoon. His ESR is 45 mml hr. Which of the following is most likely to be affected by this patient's disease?

A 32-year-old construction worker is brought to the emergency room after his co-workers found him confused, disoriented, and bleeding from the nose. His past medical history is unknown. According to his friends, he had been in his normal state of health this morning when he came to work. He then spent the morning moving heavy packages under direct sunlight for several hours. Presently, his blood pressure is 130/90 mmHg, heart rate is 120/min and regular, and temperature is 42°C (108°F). His skin is warm and dry and his neck is supple with no stiffness. His pupils are symmetric, mid-size and reactive to light. Deep tendon reflexes are symmetric and Babinski reflexes are downgoing bilaterally. He moves all four extremities but is unable to speak or follow simple commands. There is active bleeding from the right nostril. Which of the following is the most likely diagnosis?

A 32-year-old female complains of a 'nagging' dry cough over the last 4 weeks. She says that the cough is present during the day and also wakes her from sleep at night. There is no associated shortness of breath, chest pain or wheezing. Her past medical history is significant for chronic rhinorrhea and an occasional itching skin rash. She takes no medications. Chest x-ray shows no abnormalities. One week of treatment with chlorpheniramine significantly improves her symptoms. Decrease in which of the following is most likely responsible her symptom relief?

A 32-year-old female presents to the emergency department with abdominal pain and vaginal bleeding. Her last menstrual period was 8 weeks ago and her pregnancy test is positive. On examination she is tachycardic and hypotensive and her abdominal examination findings reveal peritoneal signs, a bedside abdominal ultrasound shows free fluid within the abdominal cavity. The decision is made to take the patient to the operating room for emergency exploratory laparotomy. Which of the following is the most likely diagnosis?

A 32-year-old female presents to your office complaining of a small amount of vaginal discharge. Wet mount preparation of the discharge shows few leukocytes. Application of KOH solution to the discharge yields a strong fishy odor. The most likely diagnosis is:

A 32-year-old female presents with intermittent blood staining of her bra from her left breast. She has not felt any lumps on either breast. Physical examination shows no breast mass or axillary lymphadenopathy. Ultrasonogram of the breast is within normal limits. Which of the following is the most likely diagnosis?

A 32-year-old female with a history of amenorrhea develops white nipple discharge. She eats a balanced diet and exercises regularly. She is not sexually active. Her family history is significant for her mother dying of breast cancer at age 50. The most likely diagnosis in this patient is:

A 32-year-old G1 at 10 weeks gestation presents for her routine OB visit. She is worried about her pregnancy because she has a history of insulin-requiring diabetes since the age of 18. Prior to becoming pregnant, her endocrinologist diagnosed her with microalbuminuria. She has had photo laser ablation of retinopathy in the past. Which diabetic complication is most likely to be worsened by pregnancy?

A 32-year-old G1P0 reports to your office for a routine OB visit at 14 weeks gestational age. Labs drawn at her first prenatal visit 4 weeks ago reveal a platelet count of 60,000, a normal PT, PTT and bleeding time. All her other labs were within normal limits. During the present visit, the patient has a blood pressure of 120/70 mm Hg. Her urine dip reveals the presence of trace protein. The patient denies any complaints. The only medication she is currently taking is a prenatal vitamin. On taking a more in-depth history you learn that, prior to pregnancy, your patient had a history of occasional nose and gum bleeds, but no serious bleeding episodes. She has considered herself to be a person who just bruises easily. Which of the following is the most likely diagnosis?

A 32-year-old G2P1 at 28 weeks gestation presents to labor and delivery with the complaint of vaginal bleeding. Her vital signs are: blood pressure 115/67 mm Hg, pulse 87 beats per minute, temperature 37.0C, respiratory rate 18 breaths per minute. She denies any contraction and states that the baby is moving normally. On ultrasound the placenta is anteriorly located and completely covers the internal cervical os. Which of the following would most increase her risk for hysterectomy?

A 32-year-old G2P1 at 41 weeks is undergoing an induction of oligohydramnios. During the course of her labor, the fetal heart rate tracing demonstrates severe variable decelerations that do not respond to oxygen, fluid, or amnioinfusion. The patient’s cervix is dilated to 4 cm. A low-transverse cesarean delivery is performed for nonreassuring fetal heart tones. After delivery of the fetus you send a cord gas, which comes back with the following arterial blood values: pH 7.29, Pco2: 50, and Po2: 20. What condition does the cord blood gas indicate?

A 32-year-old G3P2 woman at 38 weeks gestation is admitted to the hospital for labor pains. Her prenatal course, prenatal tests, and fetal growth have been normal. Ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. In her second pregnancy, she underwent a cesarean section. The woman is admitted to the delivery room and fetal heart and uterine contraction monitoring is started. Her blood pressure is 100/60 mm Hg, pulse is 115/min, and respirations are 26/min. Pelvic examination shows that the cervix is 60% effaced and 6 cm dilated. Uterine contractions are regular and occur every 4 minutes. Fetal heart tracing shows no abnormalities. The patient suddenly complains of intense lower abdominal pain. She is restless and vaginal bleeding is noted. Fetal heart monitoring shows repetitive variable decelerations, and the fetus has shifted from 0 to -2 station. Which of the following is the most likely diagnosis?

A 32-year-old G5 delivers a stillborn fetus at 34 weeks. The placenta is noted to be much larger than normal. The fetus appeared hydropic and had petechiae over much of the skin. What is the most likely causative agent?

A 32-year-old G5P1 presents for her first prenatal visit. A complete obstetrical, gynecological, and medical history and physical examination is done. Which of the following would be an indication for elective cerclage placement?

A 32-year-old infertile, obese nulligravida complains of secondary dysmenorrhea as well as pain with intercourse and bowel movements. She is sexually active but has never used any contraceptive methods. Bimanual pelvic examination reveals a 7 cm right adnexal mass. On rectovaginal examination, she is found to have uterosacral ligament nodularity and a fixed retroverted uterus. Which of the following is the most likely diagnosis?

A 32-year-old Japanese woman has a long history of recurrent aphthous oral ulcers. In the last 2 months she has had recurrent genital ulcers. She now presents with a red painful eye that was diagnosed as anterior uveitis. What is the most likely diagnosis?

A 32-year-old male comes to the emergency department because of a 3 day history of increasing lower abdominal pain, mild diarrhea and rectal pain on defecation. Ten days ago he had right lower quadrant (RLQ) pain for about 24 hours that resolved spontaneously. Since then, he has had malaise and low-grade fever. His temperature is 38.7°C (101.6°F), blood pressure is 150/90 mm Hg, pulse is 11 0/min and respirations are 15/min. Examination shows lower abdominal tenderness without rebound. No masses are palpable, and bowel sounds are decreased. Rectal examination shows a very tender, boggy and fluctuant bulging mass on palpation with the tip of the finger anteriorly. Laboratory studies show:Complete blood count Hemoglobin14.0 g/LPlatelets270,000/mm3Leukocyte count15,500/mm3His current condition is most likely a complication of?

A 32-year-old male comes to the emergency department because of a 3 day history of increasing lower abdominal pain, mild diarrhea and rectal pain on defecation. Ten days ago he had right lower quadrant (RLQ) pain for about 24 hours that resolved spontaneously. Since then, he has had malaise and low-grade fever. His temperature is 38.70C (101.60F), blood pressure is 150/90 mm Hg, pulse is 110/min and respirations are 15/min. Examination shows lower abdominal tenderness without rebound. No masses are palpable, and bowel sounds are decreased. Rectal examination shows a very tender, boggy and fluctuant bulging on palpation with the tip of the finger anteriorly. Laboratory studies show: Complete blood count: Hemoglobin 14.0 g/L, Platelets 270,000/mm3, Leukocyte count 15,500/mm3, His current condition is most likely a complication of?

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

A 32-year-old male construction worker presents with complaints of pain, watering, and redness in his left eye for the past 2 days. He reports having similar symptoms in the same eye a few months ago. Examination of his left eye reveals vesicles and dendritic ulcers in the cornea. His vital signs are stable. What is the most likely diagnosis?

A 32-year-old male is rushed to the emergency room after a motor vehicle accident. He was driving 55 mph when he suddenly lost control of his vehicle and hit a tree. He was wearing a seat belt. On physical examination, the patient appears scared and complains of moderate chest and abdominal discomfort. His voice is soft. His blood pressure is 190/ 100 mmHg and his heart rate is 100/min. The pupils are symmetric and reactive to light and the trachea is midline. You note bruising over the chest and upper abdomen. No penetrating injuries are evident. Which of the following injuries is most likely 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 32-year-old man comes to the emergency room (ER) because of acute onset left flank pain, hematuria and vomiting. His pain is relieved with analgesics in the ER. He has a history of abdominal pain due to Crohn disease, but that pain was always in the right lower quadrant and was never this severe. His temperature is 36.8°C (98.2°F), blood pressure is 120/65 mm Hg, pulse is 110/min and respirations are 16/min. Chest auscultation is clear. Abdomen is soft and mildly tender over the left flank. He has no rebound or rigidity. Bowel sounds are decreased. A laparotomy scar is present in right lower quadrant. Which of the following is the most likely cause of his symptoms?

A 32-year-old man comes to the emergency room (ER) because of acute onset left flank pain, hematuria and vomiting. His pain is relieved with ketorolac in the ER. He has a history of abdominal pain due to Crohn disease, but that pain was always in the rightlower quadrant and was never this severe. His temperature is 36.8C (98.2F), blood pressure is 120/65 mm Hg, pulse is 110/min and respirations are 16/min. Chest auscultation is clear. Abdomen is soft and mildly tender over the left flank. He has no rebound or rigidity. Bowel sounds are decreased. A laparotomy scar is present in right lower quadrant. Which of the following is the most likely cause of his symptoms?

A 32-year-old man develops severe nausea and vomiting after returning from a party. He also complains of chest pain that is more intense than any pain he has previously experienced. His past medical history is significant for HIV infection, alcohol abuse, and alcoholic hepatitis. He admits to using cocaine regularly. His temperature is 37.8°C (100°F), pulse is 120/min, respirations are 24/min, and blood pressure is 100/60 mmHg. Examination reveals injected conjunctivae and bilateral dilated pupils. Chest X-ray demonstrates a widened mediastinum and left-sided pleural effusion. EKG is unremarkable. The pleural fluid is found to have an elevated amylase content. Which of the following is the most likely diagnosis in this patient?

A 32-year-old man is being treated for a severe major depression. Which of the following symptoms, if present, is one of the most accurate indicators of long-term suicidal risk?

A 32-year-old man presents to the clinic with one week of escalating lower back pain. He describes the pain as dull and aching. It increases with motion and it is not completely relieved by rest. He has no significant past medical history. He smokes one pack of cigarettes per day and consumes alcohol occasionally. He admits to being "under a lot of stress" and has recently used injectable drugs. His family history is significant for prostate cancer in his father. His temperature is 36.7°C (98°F), pulse is 90/min, respirations are 16/min, and blood pressure is 120/80 mmHg. Gentle percussion over the lumbar vertebrae elicits pain. A full neurologic exam including straight leg raise is normal. Laboratory results are shown below: Complete blood count: Leukocyte count 6,500/mm3, Hematocrit 46%, Platelets 400,000/mm3. Which of the following is the most likely diagnosis?

A 32-year-old man presents to the emergency department with a three-day history of fever, cough and weakness. His blood pressure is 120/80mmHg and his heart rate is 110/min. Physical examination reveals multiple needle tracks on his arms. ECG shows sinus tachycardia but is otherwise normal. Chest X-ray shows scattered round lesions in the peripheral lung fields bilaterally. Urinalysis is positive for 2+ protein. Which of the following accompanying findings is most likely in this patient?

A 32-year-old man presents to your office with blurred vision in his right eye. He denies any pain, ocular discharge, or gritting sensation. Physical examination findings include anisocoria, right-sided ciliary injection, mild ptosis, and impaired right eye adduction. Fluorescein examination reveals a large geographic corneal staining defect. Dysfunction of which of the following nerves is most likely responsible for this patient's impaired corneal sensation?

A 32-year-old man with a known history of recreational drug abuse is found by a friend on the floor of his apartment. There is a pool of urine around him. He is confused, not oriented to time or place, and does not recall recent events. His blood pressure is 110/70 mmHg and his heart rate is 120/min. He talks and moves all his extremities. His laboratory findings are the following: Hemoglobin 15.2 mg/dl, WBC 12,500/mm3, Platelets 160,000/mm3, Sodium 136 mEq/L, Potassium 5.1 mEq/L, Creatinine 1.1 mg/dl, AST 35 units/L, AL T 40 units/L, Alkaline phosphatase 70 units/L, CPK 26,000 units/L. His urine toxicology screen is positive for cocaine and cannabinoids. The patient is at the greatest risk of which of the following?

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 32-year-old morbidly obese diabetic woman presents to your office complaining of prolonged vaginal bleeding. She has never been pregnant. Her periods were regular, monthly, and light until 2 years ago. At that time, she started having periods every 3 to 6 months. Her last normal period was 5 months ago. She started having vaginal bleeding again 3 weeks ago, light at first. For the past week she has been bleeding heavily and passing large clots. On pelvic examination, the external genitalia is normal. The vagina is filled with large clots. A large clot is seen protruding through the cervix. The uterus is in the upper limit of normal size. The ovaries are normal to palpation. Her urine pregnancy test is negative. Which of the following is the most likely diagnosis?

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?

A 32-year-old white man with HIV and a recent 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 32-year-old woman acutely develops high fever, hypotension, and rash. This is followed by vomiting, diarrhea, confusion, and abdominal pain. In the hospital, evidence of multiorgan failure develops. Desquamation of the skin occurs 1 week after the acute illness. On further history, the illness started 3 days after the onset of menstruation. Which of the following is the most likely diagnosis?

A 32-year-old woman comes to the office distraught because "the colors look washed out I" She has had this vision impairment since yesterday. She also complains of pain on eye movements. Her vital signs are stable, and she is afebrile. Examination reveals decreased visual acuity, sluggish afferent pupillary response to light, and changes in color perception. Fundoscopy reveals a swollen disc. What is the most likely diagnosis?

A 32-year-old woman comes to your office for re-evaluation of her birth control method. She wants her intrauterine device (IUD) removed because it is causing her pelvic pain. She wants to be placed on oral contraceptive pills (OCPs). She has had hypertension for the past five years controlled with hydrochlorothiazide and atenolol. She has a family history of diabetes mellitus and ovarian carcinoma. Her body mass index (BMI) is 34 kg/m2. Physical examination is unremarkable. If she starts taking oral contraceptive pills, which of the following statement is most correct?

A 32-year-old woman describes five episodes of intractable vomiting over the last year. The episodes last several hours and are associated with a sensation that the room is spinning or tilting. At these times, it is difficult for her to walk because she loses her balance. She cannot relate the timing of the episodes to any particular inciting event. Physical examination reveals stability in the Romberg position and during tandem walk. Proprioception is intact. Dysfunction of which of the following structures best explains this patient's symptoms?

A 32-year-old woman has an episode of upper gastrointestinal bleeding after a night of heavy alcoholic intake followed by ingestion of multiple aspirin tablets for the hangover. There was no prior vomiting until the time when she felt nauseated, went to the bathroom, and "filled the wash basin with vomiting of bright red bloody fluid." When she arrives in the emergency department, an upper gastrointestinal endoscopy is promptly performed, which confirms a diagnosis of acute erosive gastritis. She has no duodenal ulcer and no esophageal varices. Gastric lavage with ice-cold saline is performed and the bleeding stops. Laser photocoagulation or electrocautery are not used, neither is pitressin infused. She remains hemodynamically stable throughout the procedure, and she has normal hemoglobin. She is sent home 2 hours later. Four hours after discharge, she returns complaining of severe, constant chest pain. She is in acute distress, has a temperature of 39.0C (102.2F), is having chills, and looks quite ill. Physical examination is remarkable for the presence of crepitation to palpation in the upper chest and lower neck, and chest x-rays confirm the presence of air in the mediastinum and the subcutaneous tissues. 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 32-year-old woman is brought to the emergency department with excruciating chest and neck pain. She is 6'2" and has long extremities. Her hand joints show significant extensibility. Which of the following additional findings is also likely in this patient?

A 32-year-old woman is brought to the operating room for diagnostic laparoscopy because of chronic pelvic pain and chronic right upper quadrant pain. She has had these pains for the past 2 years. Her bowel and bladder function are normal. Past medical history is significant for two episodes of gonorrhea. She drinks one beer per day. Laboratory studies show: Urine hCG: negative, Haematocrit: 39%, leukocyte count: 8,000/mm3, platelet count: 200,000/mm3, AST: 12U/L, ALT:14U/L. Intraoperatively, the patient is noted to have dense adhesions involving her fallopian tubes, ovaries, and uterus. The fallopian tubes themselves appear clubbed and occluded. A survey of her upper abdomen is remarkable for perihepatic adhesions extending from the liver surface to the diaphragm. The liver otherwise appears unremarkable. Which of the following is the most likely diagnosis for her right upper quadrant pain?

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?

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

A 32-year-old woman, gravida 1, is in active labor. Lumbar epidural anesthesia is being used for pain control. She is having contractions every two to three minutes. The cervix is 4cm dilated. Fetal heart rate is reassuring. Her blood pressure is 90/55 mmHg and heart rate is 120/min. What is the most probable cause of her hypotension?

A 32-year-old woman, gravida 3, para 2, at 38 weeks gestation is admitted to the hospital for labor pains. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. In her second pregnancy, she had to undergo cesarean section. The woman is admitted to the delivery room and fetal heart and uterine contraction monitoring is started. Her blood pressure is 100/60mmHg, pulse is 115/min and respirations are 26/min. Pelvic examination shows the cervix is 60% effaced and 6cm dilated. Uterine contractions are regular and occurring every 4 minutes. Fetal heart tracing shows no abnormalities. Suddenly, the patient starts complaining of an intense lower abdominal pain. She is restless and vaginal bleeding is noted. Fetal heart monitoring shows variable decelerations, and the fetus has shifted to the ‘-2' station from '0' station Which of the following is the most likely diagnosis?

A 33-year-old Canadian female presents to the office with severe, bilateral, lightning-like pain on her face. The pain is burning and sharp in nature, occurs 20-30 times a day, and each episode lasts a few seconds. She is completely incapacitated by this pain. Prior to this event, she had weakness in her left arm, which gradually improved. She denies any history of trauma or drug use. She has no other medical problems. She does not use tobacco, alcohol or drugs. Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7°C (98°F) and respirations are 14/min. Complete neurologic examination shows no focal deficits. This type of disorder is most commonly seen in which of the following?

A 33-year-old Caucasian female comes to the office and complains of occasional diplopia and ptosis. These symptoms become especially prominent when she looks above her head for some time. She also complains of fatigue in her hands and leg muscles after exercising, such as swimming. Her muscle strength and double vision returns to normal after resting for some time. On examination, lid lag is observed after she is asked to look above her head for some time. No pupillary involvement is seen. The rest of the examination is normal. What is the level of the lesion in the disease that is being described?

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

A 33-year-old fair-skinned woman has telangiectasias of the cheeks and nose along with red papules and occasional pustules. She also appears to have conjunctivitis with dilated scleral vessels. She reports frequent flushing and blushing. Drinking red wine produces a severe flushing of the face. There is a family history of this condition. Which of the following is the most likely diagnosis?

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 33-year-old female presents to the office for the evaluation of a one-week history of lightning-like pain on the left side of her face. The pain is very sharp and feels like a burn. An episode lasts for 10 seconds, occurs 10-20 times a day, and keeps her from sleeping, eating, or working. She denies any history of trauma; medication use or recent surgery Vital signs are within normal limits. What is the most likely diagnosis?

A 33-year-old male falls while riding his bicycle in the park, and presents to the emergency department. Physical examination reveals upper abdominal bruises. His abdomen is non-distended, soft, and mildly tender in the epigastrium. Abdominal CT scan does not reveal any abnormalities. The patient is sent home with analgesic medications. He returns one week later with fever, shaking chills, poor appetite and deep abdominal pain Which of the following is most likely related to this patient's symptoms?

A 33-year-old Russian male reports concern over recurrent episodes of a "pounding" and "racing" heart over the last several months. He says his symptoms are worst while lying supine and while lying on his left side. On physical examination, his blood pressure is 150/55 mmHg and heart rate is 73/min. Which of the following is most likely responsible for his symptoms?

A 33-year-old tennis player comes to you with a complaint of pain in his right shoulder. He says that the pain is absent at rest but present when he lifts his arm over his head. The pain is compromising his play. On examination, active motion at right shoulder is limited due to pain. Pain is most severe on passive internal rotation and flexion at the right shoulder. No atrophy of the shoulder muscle is seen. Which of the following is the most likely diagnosis in this patient?

A 33-year-old white man with a 9-year-history of progressive-relapsing multiple sclerosis is brought to the emergency department (ED) due to a severe flare-up. He has had several attacks before, and has recovered every time with some residual damage. The last physical examination in his medical records revealed cerebellar symptomatology, a visual defect, and central hemiparesis on the right side. MRI showed multiple, bright, signal abnormalities in the white matter supratentorially on the left side, in the cerebellum, and the left optic nerve. CSF examination revealed an increased synthesis of oligoclonal bands. In the ED, the physical examination reveals paraplegia, bladder and fecal incontinency, and absent sensation from the nipples down. What is the most likely location of this patient's new plaque?

A 33-year-old woman is brought to the emergency room because of altered mental status. En route to the ER, she suffers a generalized tonic clonic seizure, and once at the hospital she is confused and no further history can be obtained. You know only that she has a history of schizophrenia. On physical examination, her temperature is 36.7°C (98°F), blood pressure is 130/76 mm Hg, pulse is 80/min, and respirations are 14/min. Examination shows normal pupils. Her chest is clear to auscultation and her heart sounds are normal. Her abdomen is soft and nontender. Extremities have no edema. Laboratory studies show: Serum sodium 118 mEq/L, Serum creatinine 0.8 mg/dL, Serum calcium 8.4 mg/dL, Serum glucose 98 mg/dL, Urine osmolality 100 mosm/kg, Urine specific gravity 1.002. Which of the following is the most likely cause of her symptoms?

A 33-year-old woman is involved in a high-speed automobile collision. She arrives at the emergency department gasping for breath. Her lips are cyanotic and she has flaring nostrils. There are bruises over both sides of the chest, and tenderness suggestive of multiple rib fractures. Her blood pressure is 60/45 mm Hg, pulse is 160/min and feeble and central venous pressure is 25 cm H2O. Her neck and forehead veins are distended. She is diaphoretic and has a hint of subcutaneous emphysema in the lower neck and upper chest. Her left hemithorax has no breath sounds and is hyper resonant to percussion. The trachea is deviated to the right, as are the heart sounds. Which of the following is the most likely diagnosis?

A 33-year-old woman presents to the physician because of a malodorous vaginal discharge that has been present for the past 3 days. She has no vaginal or vulvar irritation, and has no urinary complaints. Pelvic examination demonstrates a copious, gray discharge with a pH of 5.0. When 1 drop of potassium hydroxide (KOH) is added to a sample of the discharge there is an intense amine odor. A normal saline wet preparation is performed that demonstrates epithelial cells whose borders and nuclei are obscured by the presence of bacteria. Which of the following is the most likely pathogen?

A 33-year-old, white woman, gravida 3, para 2, at 37 weeks' gestation comes to the emergency department because of painful uterine contractions and heavy vaginal bleeding that started after she used intranasal cocaine. The patient's prenatal course was significant because she conceived while on the oral contraceptive pill, she occasionally used cocaine and heroin during the pregnancy, and she was found to be positive for group B Streptococcus colonization at 35 weeks. Fetal monitoring is not reassuring. The patient undergoes cesarean section, at which the uterus has a bluish hue. On inspection, the placenta is noted to have an adherent, retroplacental clot on 50% of its surface. Which of the following is the most likely initiating factor for this patient's presentation?

A 34-year-old Caucasian man presents to your office with easy fatigability, difficulty concentrating, insomnia, and occasional muscle pain. He also complains of right hand clumsiness and some memory loss. He does not smoke and drinks one to two cans of beer on the weekends. Physical examination reveals extensor weakness of the right hand. Ankle reflexes are symmetric and there is no Babinski reflex. Laboratory studies show: Hemoglobin 8.5 g/dl, MCV 81 fl, AST 18 U/L, ALT 16 U/L, Bilirubin 0.8 mg/dl, Creatinine 2.1 mg/dl. Which of the following is most important in revealing the cause of this patient's condition?

A 34-year-old Caucasian woman presents to your office with dyspnea and severe chest pain after returning from a trip to Central Asia. The pain is localized on the left side and increases with inspiration. She also had one episode of hemoptysis. She does not smoke or consume alcohol. She is sexually active with one partner and uses oral contraceptives. Her father died of a myocardial infarction at 52 years of age. Her temperature is 36.7°C (98°F), pulse is 100/min, respirations are 28/min, and blood pressure is 110/66 mmHg. Which of the following most likely accounts for this patient's chest pain?

A 34-year-old G1P1 who delivered her first baby 5 weeks ago calls your office and asks to speak with you. She tells you that she is feeling very overwhelmed and anxious. She feels that she cannot do anything right and feels sad throughout the day. She tells you that she finds herself crying all the time and is unable to sleep at night. Which of the following is the most likely diagnosis?

A 34-year-old G2 at 36 weeks delivers a growth-restricted infant with cataracts, anemia, patent ductus arteriosus, and sensorineural deafness. She has a history of chronic hypertension, which was well controlled with methyldopa during pregnancy. She had a viral syndrome with rash in early pregnancy. What is the most likely causative agent?

A 34-year-old G3P2 delivers a baby by spontaneous vaginal delivery. She had scant prenatal care and no ultrasound, so she is anxious to know the sex of the baby. At first glance you notice female genitalia, but on closer examination the genitalia are ambiguous. Which of the following is the best next step in the evaluation of this infant?

A 34-year-old male comes to the physician's office due to a severely pruritic lesions on his hands. He denies any trauma but recalls using his hands to change the sand of his children's sandbox when they went to Miami Beach three days ago. He later developed pruritic, erythematous papules over his arm. These papules progressed to serpiginous, reddish brown, elevated lesions, which are evident bilaterally on the upper extremities on exam. What is the most likely diagnosis?

A 34-year-old male is involved in a high-speed highway motor vehicle collision. He is intubated by rescue workers at the accident scene. In the emergency department, the patient has decreased breath sounds on the right side, normal breath sounds on the left, and hypotension. A right-sided chest tube is placed. Physical examination reveals multiple bruises over the entire chest wall as well as subcutaneous emphysema. A few hours later, his chest x-ray shows an accumulation of air in the pleural space as well as pneumomediastinum. Which of the following is the most likely diagnosis?

A 34-year-old male is rushed to the emergency room with severe respiratory distress. He is agitated and gasping for breath. He has been seen in the ER several times before for difficulty breathing, food intolerances and skin allergies. Physical examination is notable for excessive accessory respiratory muscle use, retraction of the subclavicular fossae during inspiration, and scattered urticaria over the upper body. What is the most likely diagnosis?

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 34-year-old male undergoes successful laparotomy for a gun-shot wound. He received 5 units of packed red blood cells during the surgery. He has been receiving incentive spirometry and ampicillin/sulbactam. However, he developed a fever of 38.7C (101.7F) on the sixth postoperative day. His blood pressure is 120/76 mm Hg, pulse is 97/min and respirations are 14/min. Examination shows an alert, pleasant male in no acute distress. The oropharynx is clear. The lungs and heart are clear to auscultation. The abdomen is soft and non-tender, and the wound has no discharge. He has a right femoral triple lumen catheter and Foley catheter in place. Extremities have no swelling or redness. Two days later, four bottles of blood cultures grew coagulase negative Staphylococcus. Which of the following is the most likely cause of his fever?

A 34-year-old man comes to the physician after being involved in a street fight. He has a painful and swollen left arm. Neurovascular examination shows no abnormalities. An x-ray film of the arm shows a fracture of the midshaft of the humerus. Closed reduction of the facture is done and the arm is kept in a hanging cast. One hour later he has numbness of the left wrist and marked limitation of extension at the wrist. Which of the following is the most likely diagnosis?

A 34-year-old man complains of back tightness and persistent low back pain. The pain has a dull and aching quality. It is worse during the night and in the morning but improves gradually during the day. He has no significant past medical history. He does not use tobacco, alcohol, or illicit drugs. He is married and lives with his wife. His pulse is 80/min, respirations are 14/min, and blood pressure is 120/76 mmHg. Which of the following most likely accounts for this patient's symptoms?

A 34-year-old man presents with diarrhea 3 weeks after returning from a trip to rural South America. Over the past few days, he has gradually developed lower abdominal pain and diarrhea. Now the symptoms are much worse with eight stools a day consisting mostly of mucus and blood. He is afebrile, the abdomen is tender in left lower quadrant, and the remaining examination is normal. His stool is mostly comprised of blood and mucus, and stools tests show trophozoites of Entamoeba hitolytica. Which of the following is the most likely site of extra intestinal involvement?

A 34-year-old primigravida develops severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells. Her pregnancy was complicated by mild hypertension and trace proteinuria that was treated with low-dose methyldopa. Her mother suffered from premature menopause and severe osteoporosis. Seven days after giving birth, she has failed to lactate. Her urinalysis is insignificant and her blood pressure has ranged from 95 to110 mmHg systolic and 69 to 75 mmHg diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in this patient?

A 34-year-old recently migrated African American male presents with severe headache and high-grade fever with chills for the last two days. He also complains of severe malaise, myalgia and vomiting. He adds that the present episode started with feeling of intense cold and chills with shivering followed by high-grade fever. He had two similar episodes in the past, when he was in Africa. His vitals are: T° 38.9°C (102°F), RR 20/min, PR 110/min and BP100/60 mm Hg. He has pallor with mild splenomegaly but rest of his physical examination is normal. What is the most likely diagnosis in this patient?

A 34-year-old sexually active female comes to your office because of urinary frequency and dysuria for two days. She has had two such episodes in the past, each treated with oral antibiotics. Physical examination reveals suprapubic tenderness and her urinalysis is positive for nitrite, leukocyte esterase, many WBC, and a moderate amount of bacteria. Which of the following is the most common reason for the higher incidence of urinary tract infections in females than in males?

A 34-year-old woman comes to the office for her annual examination. She has been your patient for the last 4 years. She eats a lot of meat, but does not like fruits and vegetables. Her menstrual period began at age 12. She has two children, who are ages 13 and 11. She is in a monogamous relationship with her husband, and uses oral contraceptive pills. She smokes 1/2 pack of cigarettes daily, and drinks alcohol socially. Her mother had breast disease and had an operation, but died 1 month after the surgery due to a heart attack. She has read in "US Health News" that breast cancer is the leading culprit for cancer death among non-smoking women. She now asks you, "What is the most important risk factor for breast cancer?" What is the correct response to this patient's question?

A 34-year-old woman comes to the physician for evaluation of vulvar lesions. Examination reveals multiple small teardrop shaped growths at the vestibule of the vulva. Application of trichloroacetic acid results incomplete resolution of the lesions. Which of the following is the most likely cause of her lesions?