USLME medecine interne

A 33-year-old male was involved in a motor vehicle accident with numerous rib fractures. His course in the hospital was complicated by difficulty with deep breathing and later developed pneumonia. The chest x-ray later confirmed that the patient had developed a parapneumonic effusion. Which one of the following laboratory tests on the pleural fluid is currently thought to be most helpful in determining the need for chest tube placement in parapneumonic effusion?

A 24-year-old Caucasian man is brought to the emergency room with acute asthma exacerbation. His current medications include inhaled fluticasone and salmeterol. The attack started 10 hours ago and did not respond to numerous albuterol inhalations and systemic steroids. His blood pressure is 120/70 mmHg and heart rate is 110/min. The patient is tachypneic and speaks with difficulty. Lung auscultation reveals decreased breath sounds, prolonged expiration, and bilateral wheezing. Pulse oximetry showed 86% at room air. ABG at room air are: pH 7.43, Po2 68 mmHg, PCO2 40mmHg. The chest x-ray demonstrates hyperinflated lungs. Which of the following findings indicates that the patient is getting worse?

A 26-year-old Caucasian male comes to the physician because of severe productive cough for the past two months. He also complains of occasional blood in sputum, and dyspnea for the last three weeks. His past medical history is significant for otitis media, two episodes of pneumonia, and sinusitis. He and his wife were recently worked up for infertility. Physical examination shows crackles in the left upper lobe. Chest x-ray shows dilated and thickened airways and irregular peripheral opacities in the left upper lobe. Which of the following is the most appropriate test to make the diagnosis of his condition?

A 31-year-old woman presents to the emergency department complaining of shortness of breath. She denies associated chest pain or palpitations. She tells you that she recently returned from a trip to Thailand. She smokes one pack of cigarettes per day and drinks alcohol occasionally. She is married and uses oral contraceptives. She has no significant past medical history. On physical examination, her blood pressure is 110/70 mmHg and her heart rate is 120/min. A negative result on which of the following tests would best exclude pulmonary venous thromboembolism in this patient?

A 32-year-old Caucasian female presents to your office with persistent cough and shortness of breath. She has had three episodes of pneumonia over the last year. She had severe sinusitis one year ago, and an episode of bloody diarrhea that required hospitalization and IV antibiotic therapy six months ago. She does not smoke or consume alcohol. She denies any illicit drug use. She is currently not taking any medications. All her immunizations are up-to-date. Her blood pressure is 130/80 mmHg and heart rate is 90/min. Physical examination reveals fine crackles over the right lower lung lobe. No lower extremity edema is present. Neck palpation does not reveal any lymph node enlargement. The chest x-ray shows right lower lobe infiltrates and left upper lobe fibrosis. The ECG reveals non-specific ST segment and T wave changes. What is the best next step in the management of this patient?

A 25-year-old male presents with progressive shortness of breath over the past 6 months. His past medical history is significant only for neonatal hepatitis that resolved spontaneously when he was 6 months of age. The man has never smoked. On lung auscultation today, there are decreased breath sounds over both lower lobes. Chest x-ray demonstrates emphysematous changes in the bilateral lower lobes. Routine blood work is normal. Which of the following analyses would be most helpful in establishing this patient's diagnosis?

A 55-year-old man presents to your office with a six-month history of non-productive cough, especially at night. He denies postnasal drip, chest pain, difficulty breathing, or wheezing. His only other complaint is water brash. His past medical history is insignificant, and he is not taking any medications. He does not smoke or consume alcohol. Physical examination is insignificant. Chest x-ray and pulmonary function testing are normal. Esophagoscopy is also normal. What is the next best step in the management of this patient?

A 65-year-old Caucasian male comes to the physician because of shortness of breath, fever, and a productive cough for the last four days. He is a chronic smoker and alcoholic. He quit smoking two years ago. His medical problems include hypertension, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, and coronary artery disease. He is taking daily-inhaled ipratropium bromide, albuterol, metformin, metoprolol, warfarin, and diltiazem. His temperature is 38.9°C (102°F), blood pressure is 140/88 mmHg, pulse is 110/min, and respirations are 28/min. Pulse oximetry showed 88% on room air. Examination shows decreased breath sounds and crackles over the right lower lobe of the lung. Which of the following is the most appropriate next step in his management?

A 32-year-old woman comes to the emergency department complaining of sudden onset shortness of breath accompanied by a non-productive cough and left-sided chest discomfort that increases on inspiration. She denies subjective fever, coughing up blood, wheezing, palpitations, leg pain, and swelling of the lower extremities or any recent travel. Past medical history is significant for an appendectomy at age 15. Her medications include birth control pills and over- the-counter vitamins. She is a known carrier of sickle cell trait. Her father, age 65, has had diabetes for 20 years; mother, age 58, has coronary artery disease. She has never been pregnant, drinks alcohol socially and does not smoke. Her temperature is 99°F (38°C), blood pressure is 110/70 mmHg, pulse 130/min and respirations are 33/min. Pulse oximetry shows an oxygen saturation of 85% on 6 liters of oxygen. Her BMI is 30 kg/m2. She is alert and cooperative without cyanosis or jaundice. Her lungs are clear to auscultation. Her abdomen is soft, nondistended and non-tender. Which of the following is the best test to confirm this patient's diagnosis?

A 53-year-old male presents with progressively worsening dyspnea over a 4-month period. He also complains of decreased appetite, weight loss, and nagging epigastric discomfort. His past medical history is significant for a chronic duodenal ulcer for which he takes ranitidine on and off. He does not use tobacco, alcohol or illicit drugs. He has worked as a plumber for the past 30 years. On physical examination, his temperature is 36.9°C (98.4°F), blood pressure is 140/86 mm Hg, pulse is 80/min, and respirations are 15/min. Physical exam reveals fingernail clubbing and bibasilar end-inspiratory crackles on lung auscultation. Chest x-ray demonstrates ground glass opacities of the lower lung fields, multiple pleural plaques, and one 3x3 cm mass in the right lung periphery. CT guided biopsy of the mass is planned. Biopsy is most likely to show which of the following?

A 50-year-old male presents to his physician complaining of daytime somnolence. He reports that yesterday, he fell asleep while stopped at a red light. His wife adds that he is a habitual snorer, and sometimes seems to stop breathing for seconds at a time while sleeping. His past medical history is significant for hypertension, a 25 pack-year smoking history, and a two beer per day drinking habit. Physical examination reveals an obese, middle-aged man in no apparent distress. His pulse is 88/min, blood pressure is 160/100 mm Hg, and respirations are 14/min. The remainder of the physical examination, including chest auscultation, is within normal limits. Which of the following is the most appropriate next step in the management of this patient?

A 37-year-old male is being evaluated after a motor vehicle accident. He complains of right sided chest pain. Physical examination reveals mild bruising over the right chest wall, and is otherwise unremarkable. Chest x-ray shows no rib fractures but a solitary round lesion is seen in the right upper lobe of the lung. Upon further questioning the patient denies recent weight loss or appetite change. He has never smoked cigarettes. Which of the following is the most appropriate next step in the management of his lung lesion?

A 25-year-old female presents to the emergency department with sudden-onset severe shortness of breath and wheezing. She has a history of asthma. On examination, she is unable to speak in full sentences and is using accessory muscles of respiration. She is intubated, mechanically ventilated and treated with continuous albuterol nebulization and intravenous methylprednisolone. Within six hours, her condition is improved. She is extubated and treated with hourly nebulizer treatments. The next morning, she complains of muscle weakness. On physical examination, she has difficulty lifting her arms over her head and mild hand tremors. Her vital signs are stable What should be the immediate next step in her management?

A 40-year-old black male presents with dyspnea and tachypnea of sudden onset. He says that he was diagnosed with deep venous thrombosis (DVT) of the lower extremities three times before. Ventilation/perfusion scan reveals mismatched perfusion defect. Venous ultrasonography is positive for DVT. You suspect that inherited predisposition to hypercoagulation may be present. Which of the following is the most common form of such a predisposition?

A 45-year-old male immigrant from Haiti complains of cough and tenacious mucopurulent sputum for several months. He denies fever or chest pain, but notes shortness of breath and occasional blood-tinged sputum. He has received antibiotic treatment for similar symptoms twice in the past year. He has smoked 1 pack of cigarettes daily for the past 20 years. On physical examination, his temperature is 37.2°C (98.9°F), blood pressure is 120/68 mm Hg, pulse is 80/min, and respirations are 14/min. On lung auscultation there are coarse crepitations at the bilateral bases. Chest x-ray reveals prominent bronchioles in the lower lobes but is otherwise unremarkable. What is the most appropriate next step in the management of this patient?

A 78-year-old man is seen in the doctor’s office for a nonproductive cough, 9-kg (20-lb) unintentional weight loss, and bilateral breast enlargement, all occurring within the past 6 months. He has smoked two packs per day for the past 40 years. His past medical history is otherwise unremarkable, and he takes no medications. His temperature is 36.7°C (98.1°F), blood pressure is 125/85 mm Hg, pulse is 68/ min and regular, respiratory rate is 15/min, and oxygen saturation is 99% on room air. There are crackles at the left lower lung field and a ridge of symmetric glandular tissue (1 cm in diameter) around the nipple-areolar complexes of both breasts. Complete blood cell count shows a WBC count of 6000/mm³ hemoglobin of 14.7 g/dL, and platelet count of 210,000/ mm³. All other laboratory results are normal. X-ray of the chest shows a focal 5-cm mass lesion in the left lower lung corroborated by CT scan. Which of the following is most likely histologic type of lung cancer present in this patient?

A 30-year-old patient with a history of mild persistent asthma (baseline peak expiratory flow rate of 85%) presents to the emergency department with shortness of breath and wheezing that has not relieved by her albuterol inhaler for the past 12 hours. She was able to tolerate pulmonary function tests and a set was performed. Which of the following is the most likely test result?

A 27-year-old woman is 7 months pregnant with her first child. Her pregnancy has been uncomplicated to date. She presents to the emergency department complaining of sudden-onset, right-sided chest pain that is exacerbated with deep breathing and shortness of breath, which began 1 hour ago. She denies leg pain and notes that her legs began swelling during the sixth month of her pregnancy but the swelling has not worsened. Her temperature is 37.9°C (100.3°F), blood pressure is 130/87 mm Hg, pulse is 107/min and regular, respiratory rate is 24/min, and oxygen saturation is 90% on room air, increasing to 98% with 4 L oxygen via nasal cannula. Physical examination is significant for crackles at the lower right lung field and a negative Homans’ sign bilaterally. X-ray of the chest appears normal. The D-dimer level is elevated. ECG shows sinus tachycardia, right-axis deviation, S wave in lead I, Q wave in lead III, and an inverted T wave in lead III. Which of the following is the most appropriate next step in diagnosis?

A 55-year-old man presents to his physician’s office with increasing dyspnea on exertion. He denies chest pain, diaphoresis, nausea, or vomiting. He has been involved in eight motor vehicle accidents in the past 3 years. Past medical history is significant for hypertension, for which he takes a diuretic. His temperature is 37.2°C (99.0°F), blood pressure is 121/82 mm Hg, pulse is 85/min, respiratory rate is 14/min, and oxygen saturation is 99% on room air. Physical examination is significant for a body mass index of 35 kg/m², a diffuse and laterally displaced point of maximal intensity, and an S3 gallop. Which of the following is the most appropriate next step in diagnosing his most likely underlying condition?

A 63-year-old woman is seen in the emergency room with acute shortness of breath. There is no history of heart or lung problems in the past. She was recently diagnosed with breast cancer and is undergoing active treatment. On examination, her blood pressure is 120/80 mm Hg, pulse 100/min, and heart and lungs are normal. There are no clinical signs of deep venous thrombosis (DVT). Which of the following investigations is most likely to rule out a pulmonary embolism (PE)?

A 40-year-old woman has been complaining of a 3-year history of increasing dyspnea and fatigue. She has no other medical illness. Physical examination reveals increased jugular venous pressure (JVP) with prominent c-v wave, and a reduced carotid pulse. Precordial examination reveals a left parasternal lift, loud P2, and right- sided S3 and S4. There are no audible murmurs. CXR reveals clear lung fields and an ECG shows evidence of right ventricular hypertrophy. Pulmonary function tests show a slight restrictive pattern. Primary pulmonary hypertension is suspected. Which of the following is the most appropriate test to confirm the diagnosis?

A 58-year-old man is recently diagnosed with bowel cancer. He now complains of vague chest discomfort and shortness of breath. On examination, he is unwell, blood pressure 90/50 mm Hg, pulse 110/min, respirations 26/min, and oxygen saturation 88%. His lungs are normal on auscultation, the JVP is 8 cm, and P2 is loud. There is no edema or leg tenderness on palpation. A quantitative (ELISA) D-dimer assay is positive, ECG reveals sinus tachycardia, and cardiac enzymes are negative. The lung scan is read as high probability for PE. Which of the following tests is most likely to help in guiding emergent therapy?

A 28-year-old man presents with coughing up blood and sputum. He gives a history of recur- rent pneumonias and a chronic cough productive of foul-smelling purulent sputum. He has no other past medical history and is a lifetime nonsmoker. On physical examination, there are no oral lesions, heart sounds are normal, and wet inspiratory crackles are heard at the lung bases posteriorly. He also has clubbing of his fingers, but there is no hepatosplenomegaly or any palpable lymph nodes. CXR show fibrosis and pulmonary infiltrates in the right lower lung. Which of the following is the most appro- priate initial diagnostic test?

A 5-year old girl is brought to the emergency department in December by her mother, who complains that her daughter seems confused. The mother reports that her daughter has complained of intermittent headaches since the two of them moved into the first floor of an older apartment building 6 months ago. The mother has been at home with the daughter for the past 24 hours and the girl appears lethargic and is complaining of joint aches, nausea, and a headache. Her pulse is 120/min, blood pressure is 130/85 mm Hg, respiratory rate is 25/min, and oxygen saturation is 100% on room air. The girl’s mother also notes having a slight headache that started yesterday. Which of the following diagnostic tests should be most rapidly pursued?

A 34-year-old African American man presents with mild dyspnea on exertion and joint discomfort in his knees, wrists, and ankles. He also has a fever and red tender rash on his shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, and tender erythematous nodules on his legs. CXR shows bilateral symmetric hilar adenopathy. Which of the following laboratory findings is not characteristic of this condition?

A 21-year-old man has a nonproductive cough, shortness of breath, and chest pain, which changes with breathing. He also has pain in the left arm. On examination, there is tender- ness over the left shoulder, heart sounds are normal, and the lungs are clear. CXR reveals a lytic lesion in the left humerus and reticulonodular opacities in the upper and middles lobes. The eosinophil count is normal. Which of the following is the most appropriate initial diagnostic test?

A 33-year-old woman, otherwise perfectly well, presents with recurrent episodes of hemopty- sis. She has no fever, weight loss, cough, or sputum production. Her physical examination is entirely normal. Her CXR, biochemisty, CBC, and coagulation profile are also normal. Which of the following is the most appropriate initial diagnostic test?

A 31-year-old man with severe kyphoscoliosis due to cerebral palsy is experiencing worsening shortness of breath with exertion. On examination, he has a severe scoliosis to the left and decreased air entry to that side. His right lung is clear, JVP is 3 cm, and heart sounds are normal. Pulmonary function tests are performed. Which of the following is the most likely abnormality to be seen on the pulmonary function tests?

An 83-year-old man with Parkinson’s disease presents with low-grade fever and cough for several weeks. Lately, he has been experiencing more rigidity and difficulty with his walking. He is on a levodopa/carbidopa combination for treatment for the past 5 years. On examination, his gait is shuffling and slow. He has a tremor in his left hand at rest, and there is cogwheel rigidity of the forearm. There are crackles in the left lower lung field. CXR reveals a lung abscess in the left lower lobe. Which of the following is the most likely bacteriologic diagnosis for the lung abscess?

A 28-year-old African American woman presents with mild dyspnea on exertion. She reports no coughing, sputum production, or wheezing symptoms, but has noticed a red tender rash on her shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy. Her pulmonary function tests reveal a mild restrictive pattern. Which of the following tests will most likely make a definitive diagnosis?

A 69-year-old woman has recently returned on an overnight flight from Europe. She now complains of vague chest discomfort and shortness of breath. On examination, she is comfortable, blood pressure 130/80 mm Hg, pulse 90/min, respirations 18/min, and oxygen saturation 97%. Her heart and lungs are normal on auscultation, and there is no edema or leg tenderness on palpation. A quantitative (ELISA) D-dimer assay is positive. Which of the following statements regarding the D-dimer assay is correct?

A 52-year-old Caucasian male presents complaining of diminished energy for the past three months. He appears very sad and moves slowly. He says that he has been feeling terrible after his wife died in a car accident three months ago. He is filled with thoughts of guilt because he was driving the car when the accident took place. Since then, he has been suffering from disturbed sleep and finds himself unable to focus on his favorite activities, like coin collecting or fishing. He reports being disturbed by repeated flashbacks of the event. He keeps himself aloof and isolated from others because he "just doesn't feel like socializing anymore." He adds that he has a poor appetite and has gained 20 lbs (9.1 kg). He admits to wanting to "end my life in order to escape the memories of that nightmarish day." He is able to contract for safety. What is the most appropriate next step?

A 6-year-old girl is brought to the physician by her mother, who says the child has been falling behind at school. She notes that the girl did not speak until the age of 4. She is friendly at school, but is unable to complete most tasks, even when aided. She is noted to have a very short attention span and occasional temper tantrums at school and at home. Which of the following tests would be most helpful in establishing the diagnosis?

A 23-year-old man presents to the emergency room with the history of a fever up to 38°C (100.5°F) intermittently over the past 2 weeks, a persistent cough, and a 10-lb weight loss in the past month. He notes that he has also been becoming increasingly forgetful for the past month and that his thinking is “not always clear.” He has gotten lost twice recently while driving. Which of the following diagnostic tests will be most helpful with this patient?

A 29-year-old man is brought to the hospital because he was found running around on the streets with no shoes on in the middle of winter, screaming to everyone that he was going to be elected president. Upon admission to the hospital, he was stabilized on olanzapine and lithium and then discharged home. Assuming the patient is maintained on the olanzapine and the lithium, which of the following tests should be performed at least once per year?

A middle-aged woman presents with a variety of cognitive and somatic symptoms, fatigue, and memory loss. She denies feeling sad, but her family physician is aware of this patient’s lifelong inability to identify and express feelings. He suspects she is depressed. Which of the following results is most likely to confirm a diagnosis of depression?

A 40-year-old female presents to your office complaining of the pain in her right hip. She denies trauma and says that the pain began two weeks ago and gradually increased. Her past medical history is significant for systemic lupus erythematosus diagnosed seven years ago. Her current medications include prednisone, hydroxychloroquine, and lansoprazole. There is no local tenderness on physical examination and the range of motion of the right hip is normal. Hip radiograph is normal. What is the next best step in the management of this patient?

A 61-year-old man presents to your office with a two-week history of low back pain. He describes the pain as constant, dull, and aching. It is non-radiating. The pain is not affected by movement and cannot be fully relieved by lying down. He denies fever and urinary frequency or hesitancy. He has started taking sleeping pills because the pain disturbs him during the night. On physical examination, the paraspinal muscles are non-tender. Percussion over the lumbar vertebrae does not elicit tenderness. Knee reflexes are symmetric and he has 5/5 strength in the extremities bilaterally. A straight leg raise test is negative. Which of the following is the best test for this patient?

A 68-year-old Caucasian male complains of right-sided leg pain over the last year. The pain is poorly controlled with over-the-counter pain medications. He also complains of frequent headaches. His past medical history is significant for hypertension and recent hearing loss. An X-ray of the skull shows areas of bone resorption and sclerosis. Which of the following are the most likely findings on laboratory work-up? (Serum calcium, serum phosphate, alkaline phosphatase, Urinary hydroxyproline)

A 25-year-old female presents to the physician's office complaining of fatigue, joint pains, and frequent mouth ulcers over the past three months. She has no medical problems and does not take any medications. She does not use tobacco, alcohol or drugs. Her temperature is 37.5°C (99.5°F), blood pressure is 150/100 mmHg and pulse is 78/min. Examination shows erythema over the cheeks and nose. Labs reveal a serum creatinine of 2.8 mg/dl and her urinalysis shows 2+ protein and 20 RBC/HPF. Anti- double stranded antibodies (anti-dsDNA) are positive. Which of the following is the most appropriate next step in management of this patient?

A 43-year-old man was brought to the ED after he was unable to get out of his bed today due to leg weakness. He has been having constant back pain over the past several days. His past medical history is significant for poorly controlled diabetes mellitus and hypertension. His temperature is 38.3°C (101°F), pulse is 100/min, respirations are 18/min, and blood pressure is 150/100 mmHg. On examination, he smells of urine. His back is tender to palpation over L2-L5. Neurologic exam reveals 3/5 strength in the lower extremities with decreased sensation to temperature and light touch. He has an extensor plantar response bilaterally. Which of the following is the best next step in evaluating this patient?

A 54-year-old man presents to the emergency room with acute pain, swelling and redness of his right knee. He had one episode of gouty arthritis a year ago that resolved quickly with indomethacin. He also has type 2 diabetes, hypertension and chronic renal disease. He does not use any illicit drugs. His temperature is 38.3°C (100.9°F), blood pressure is 110/65 mmHg, and pulse is 110/min. Examination reveals a tender, erythematous effusion of the right knee with decreased range of motion. Which of the following is the most appropriate next step in management?

A 23-year-old man complains of progressive low back pain for the past several months. He has morning stiffness that lasts for one hour. He has no history of trauma to his back and denies any recent illness. He had an episode of pain, blurring, and photophobia of his right eye two years ago that required ophthalmology evaluation. His vital signs are within normal limits. Examination shows tenderness in both sacroiliac joints and reduced range of motion of the lower back. If measured, which of the following is most likely to be present in this patient?

A 65-year-old man presents with right shoulder pain and weakness after falling on his outstretched hand. The pain is worse when he tries to position his arm above the shoulder level or when he pulls or pushes. He also complains of pain when he lies on the affected shoulder. He has a 40-pack-year history of cigarette smoking. His father died of multiple myeloma. His vital signs are within normal limits. Examination shows limitation of mid arc abduction and external rotation that does not improve after lidocaine injection. There is no swelling, redness or warmth of the joint. Radial pulse is normal. Muscle tone and bulk is within normal limits. Which of the following would be most helpful in confirming the patient's diagnosis?

A 49-year-old African American female complains of progressive exertional dyspnea. She also complains of swelling and pain in her finger joints over the last 6 months. She has been treated for severe heartburn with pantoprazole and for hypertension with lisinopril and hydrochlorothiazide. Her blood pressure is 145/100 mmHg and her heart rate is 80/min. Physical examination reveals prominent jugular venous distention. Her lungs are clear to auscultation, and no murmurs are present on cardiac auscultation. Her skin is thickened and discolored over the fingertips and interphalangeal joints. There is mild pitting ankle edema. Which of the following is most likely to be positive in this patient?

A 52-year-old woman presents with gradual-onset weakness in her leg muscles. She has noted difficulty climbing stairs and raising from a chair that has been worsening for the past few years. She initially related her symptoms to simply being "out of shape." She has no problem with chewing food. She has no pain in her muscles and has no skin rash. She takes metoprolol and hydrochlorothiazide for hypertension. She does not use tobacco, alcohol or drugs. Her vital signs are within normal limits. Examination reveals mild weakness of the thigh muscles in both legs. Deep tendon reflexes and sensory examination shows no abnormalities. Babinski sign is negative. Which of the following is most likely abnormal in this patient?

A 62-year-old Caucasian female complains of difficulty swallowing solid food. She needs to take sips of water during every meal to help with swallowing. Her past medical history is significant for hypertension controlled with metoprolol. She uses some over-the-counter eye drops for eye dryness. Her blood pressure is 140/90 mmHg and heart rate is 60/min. Physical examination reveals prominent dental caries. There are bilateral firm submandibular swellings present on neck palpation. Which of the following is the best test to confirm this patient's diagnosis?

A 60-year-old male presents to the emergency room with a two-week history of low back pain and low-grade fever. His past medical history is insignificant. He tried several over-the-counter pain medications with little success. His temperature is 38.3°C (101°F), blood pressure is 120/76 mmHg, pulse is 90/min, and respirations are 16/min. Physical examination reveals percussion tenderness over the lumbar vertebrae and local paravertebral muscular spasm. Neurological examination shows 2+ deep tendon reflexes and 5/5 muscle power. The straight-leg raising test is negative at 90 degrees. Laboratory values are: Hemoglobin 12.2 g/dL, Leukocyte count 10,700/cmm, Segmented Neutrophils 63%, Bands 4%, Eosinophils 3%, Basophils 0%, Lymphocytes 23%, Monocytes 6%, Platelets 400,000/cmm, ESR 75 mm/hr. What is the next step in the management of this patient?

A 52-year-old man presents with 24 hours of pain and swelling of his right knee. He also reports having constipation, excessive urination, and fatigue for the past several months. He denies fevers, chills, and trauma to the knee. He does not use tobacco, alcohol or drugs. His temperature is 37.2°C (98.9°F), and blood pressure is 130/76 mmHg. Examination shows tenderness, erythema, and swelling of the right knee. His lab values are: Serum sodium 138 mEq/L, Serum potassium 4.0 mEq/L, Serum creatinine 1.1 mg/dl, Serum calcium 11.9 mg/dl, Serum phosphorous 1.9 mg/dl, Blood glucose 98 mg/dl. Which of the following would synovial fluid analysis from the knee most likely reveal?

A 24-year-old Caucasian male undergoes pulmonary function testing. The following values are obtained: FEV 80% of predicted, FEV1/FVC 85%, FRC 110% of predicted. He has no current complaints except for occasional low back pain treated with naproxen. He smokes one pack per day and drinks a six-pack of beer each weekend. His ESR is 47 mm/hr. Which of the following best explains the pulmonary function test findings in this patient?

A 58-year-old woman has had bilateral hip and knee pain for the past several months. The pain is worse with activity and better with rest. Recently she has noticed swelling of the right knee. She reports morning stiffness of about 10-15minutes duration. She denies fever or weight loss. Her past medical history is significant for hypertension, type 2 diabetes, gastroesophageal reflux disease, and obstructive sleep apnea. She takes hydrochlorothiazide, lisinopril, omeprazole, insulin and aspirin. She does not use tobacco, alcohol or drugs. Her temperature is 37.2°C (98.9°F), and blood pressure is 146/86 mmHg. Examination shows a mild effusion, tenderness, and decreased range of motion of the right knee. Synovial fluid analysis reveals the following: Cell count 1100/ml, Gram stain negative, Crystals absent. Plain films of her knee joint would most likely reveal?

A 23-year-old white woman presents complaining of 6 months of progressive low back pain. She complains of morning stiffness that lasts one hour, and says her symptoms improve with physical activity. She denies rash, eye pain, urinary problems, and diarrhea. Her past medical history is significant only for an appendectomy at the age of 16 years. She has been taking birth control pills for the past two years. She is afebrile with normal weight and height. Examination reveals reduced forward flexion of the lumbar spine and tenderness over the sacroiliac joints. The remainder of the physical examination is normal. Which of the following is the most appropriate next step in the management of this patient?

A 60-year-old male presents to your office complaining of right-sided neck pain and numbness over the posterior surface of the forearm. He had several such episodes over the last two years that responded to NSAIDs and physical therapy. Physical examination reveals limited neck rotation and lateral bending. There is decreased pinprick sensation on the posterior aspect of the right forearm, but no muscle weakness is present. Triceps reflex is normal. Which of the following is the most likely finding on the neck radiography of this patient?

A 40-year-old school teacher comes to the physician's office complaining of joint pain. Her symptoms began 10 days ago and consist of pain in the metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints, wrists, knees and ankles, bilaterally. She describes joint stiffness lasting 10 to 15 minutes after a prolonged rest. She denies fever, malaise, weight loss and skin rash. Her past medical history is insignificant. She does not take any medications. On examination, there is no evidence of swelling, redness or tenderness of the involved joints. The remainder of the physical examination is unremarkable. Which of the following is most likely elevated in this patient?

A 40-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several months of fatigue. After a period of rest, resistance to movement is more striking. On examination, the metacarpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities. There is no alopecia, photosensitivity, kidney disease, or rash. Which of the following is correct?

A 70-year-old man complains of fever and pain in his left knee. Several days previously, he suffered an abrasion of his knee while working in his garage. The knee is red, warm, and swollen. An arthocentesis is performed, which shows 200,000 leukocytes/μL and a glucose of 20 mg/dL. No crystals are noted. Which of the following is the most important next step?

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

A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. What is the best diagnostic test?

A 65-year-old man develops the onset of severe knee pain over 24 hours. The knee is red, swollen, and tender. He has a history of diabetes mellitus and cardiomyopathy. An x-ray of the knee shows linear calcification. Definitive diagnosis is best made by which of the following?

Over the last six weeks a 45-year-old nurse has developed progressive difficulty getting out of chairs and climbing stairs. She can no longer get in and out of the bathtub. She has no muscle pain and takes no regular medications. She does not use alcohol and does not smoke cigarettes. On examination she has a purplish rash that involves both eyelids (see figure). There is weakness of the proximal leg muscles. What is the best next diagnostic test?