Difficulty USMLE

A 45-year-old man presents to the emergency room with a two-day history of fever, dyspnea, abdominal pain, and diarrhea. He has no chest pain, but complains of dry cough. His past medical history is significant for bone marrow transplantation for acute myeloid leukemia (AML) three months ago. His temperature is 39°C (102.2°F), blood pressure is 122/80 mm Hg, pulse is 98/min, and respirations are 22/min. Exam of the oropharynx reveals thrush. Lungs exam demonstrates bilateral diffuse rales. Heart sounds are regular. Nonspecific abdominal tenderness is present. The chest radiograph shows multifocal, diffuse patchy infiltrates. Which of the following is the most likely cause of this patient's current condition?

A 56-year-old male complains of occasional dizziness. He gets a brief spinning sensation while getting out of bed. He sometimes feels dizzy while turning in bed or looking up. He denies any nausea, diaphoresis, chest pain or tinnitus. His past medical history is significant for long-standing hypertension, which is being treated with hydrochlorothiazide, and hyperlipidemia, which is being treated with simvastatin. His father died of a stroke at the age of 62 years. His blood pressure is 130/80 mmHg while supine, and 135/85 mmHg while standing. His heart rate is 77/min. A grade II/VI ejection murmur is heard over the aortic area. ECG reveals left ventricular hypertrophy and premature ventricular contractions. Which of the following is the most likely cause of this patient's complaints?

A 27-year-old woman, who has recently returned from holiday in Africa, presents to accident and emergency with a 7-day history of fevers, sweats, headache, malaise and lethargy. On examination, her temperature is 39°C. Cardiorespiratory and gastrointestinal examinations are unremarkable. What is the most likely differential diagnosis?

On observation, a patient has a left facial droop. On closer examination his nasolabial fold is flattened. When asked to smile, the left corner of his mouth droops. He is unable to keep his cheeks puffed out. Eye closure is only slightly weaker compared to the right and his forehead wrinkles when he is asked to look up high. What is the diagnosis?

A 70-year-old woman presents with hip pain following a fall. The fall appears to have been related to alcohol ingestion and, whilst the history is vague, she denies loss of consciousness and does not seem grossly confused, nor is there evidence of infection. She is a smoker and has a history of ischaemic heart disease and depression. A hip fracture is ruled out and she is admitted for rehabilitation purposes. On day 3, however, the nurses report that she is increasingly sleepy and muddled. On examination, observations are stable, she is apyrexial, her Glasgow Coma Score (GCS) is 12, and on neurological examination, she appears to have some mild left arm and leg weakness with normal or brisk reflexes. There is no hemianopia or other neurological deficit. Which of the following is most likely to explain the changes?

A 75-year-old man presents to your clinic with a dark lump on his forehead which has been increasing in size over the last 6 weeks. He first noticed the lump, which initially appeared as a small pinkish-red patch of skin, over a month ago. On examination you observe a 1 x 2 cm hyperpigmented nodule with everted edges and a centrally, deep, ulcerated red base. Which one of the following is the most likely diagnosis?

A 53-year-old severely distressed and confused woman presents to accident and emergency with her husband. A collateral history reveals she has been suffering increasingly severe tremors, sweating and weight loss during the week. Since yesterday she has started to suffer from palpitations and increasing confusion. Blood pressure is 157 /93 mmHg and there is an irregularly irregular pulse. The most likely diagnosis is:

A 43-year-old man presents to his GP with a 3-month history of recurrent nose bleeds, mucosa! bleeding, haemoptysis and recurrent sinusitis. Besides that, he also noticed that he has increasingly become short of breath. On examination, he had a nasal deformity and chest auscultation revealed crackles in the left lower zone. A urine dipstick test showed microscopic haematuria. Which of the following is the most likely diagnosis?

A 36-year-old woman presents to clinic with neurological symptoms. On examination, she is able to stand with her feet together. Upon closing her eyes, however, she is unable to keep her balance. What is the diagnosis?

A 36-year-old man is seen because of palpitations. He admits to precordial discomfort, weakness, and anxiety. His pulse is 150/min, and his blood pressure is 124/70 mmHg. Heart sounds are normal. Carotid sinus pressure gradually changes the rate to 75/min, but when released, the pulse rate returns to 150/min. Which of the following is the most likely diagnosis?

A 44-year-old white male presents with a long history of joint pains in several joints. He has seen a physician before but no diagnosis was made. He has been taking ibuprofen with partial relief. He has now developed fever, diarrhea and weight loss. He denies any genitourinary or eye symptoms. He does not use tobacco, alcohol or drugs. He is a farmer. On examination, he has generalized lymphadenopathy and non-deforming arthritis. Small intestinal biopsy reveals periodic Acid-Schiff (PAS)-positive macrophages. Which of the following is the most likely diagnosis?

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 63-year-old accountant is brought to the emergency department after suddenly collapsing at his desk at work. He is unconscious upon arrival but regains consciousness within several minutes. His medical history is significant for stable angina, hypertension, and hypercholesterolemia. He has had no surgeries. His medications include atenolol, simvastatin, aspirin, and a multivitamin. Physical examination is remarkable for paralysis of the upper and lower extremities on the right side. Vibration and position sense are absent on the right side. When the flat of the right foot is stroked with a pen, the right great toe is up going and the other toes fan out. The patient's tongue deviates to the left upon protrusion. Given these findings, a lesion in which region of the brain is most likely?

A 60-year-old male complains of recent onset gait imbalance and visual illusion of to-and-fro environmental motion. The symptoms are constant. He has no associated nausea or vomiting. His past medical history includes diabetes, hypertension, and chronic renal failure, and recent enterococcal endocarditis for which he is taking ampicillin and gentamicin. On physical examination, his temperature is 36.7°C (98°F), blood pressure is 120/76 mm Hg, pulse is 80/min, and respirations are 16/min. Neurologic examination shows 5/5 power and 2+ reflexes in all four extremities. Cranial nerve examination is normal. There is no nystagmus. Which of the following is the most likely cause of his current condition?

A 35-year-old male presents with complaints of weakness and fatigue of one year's duration. He is anorexic and has lost interest in all his activities. He also complains of cold intolerance and constipation. His blood pressure is 98/72 mmHg, temperature is 37.1°C (99°F), respirations are 14/min, and pulse is 50/min. His skin is dry and rough, nails are brittle, and hair is thin. There is no hyperpigmentation of the skin. Delayed deep tendon reflexes are noted on neurological examination. Lab studies show: Hemoglobin 10.2 g/dL, WBC count 5,000/micro-L, Neutrophils 45%, Monocytes 5%, Eosinophils 10%, Basophils 1%, Lymphocytes 40%, Serum sodium 135 mEq/L, Serum potassium 4.0 mEq/L. Which of the following is most consistent with this patient's findings?

A 16-year old girl has recently been referred to your family practice. She is a recent immigrant from Southeast Asia, and has been taking isoniazid (INH) and rifampin for uncomplicated tuberculosis. Routine blood tests are unremarkable, except for an elevated direct bilirubin. Other liver enzymes and function tests are completely normal. Which of the following is the most likely diagnosis?

A 37-year-old male prisoner has been complaining of fever, chills and abdominal pain over the last week. He vomited once before reaching the emergency room. On physical examination, his blood pressure is 112/63 mmHg and his heart rate is 115/min. Breath sounds are diminished at the left lung base and there is marked left upper quadrant tenderness. Laboratory values are given below:WBC count 23,500/mm3, Neutrophils 65%, Bands 11%, Hemoglobin 12.5 mg/dL, Platelets 250,000/mm3, Total bilirubin 3.1 mg/dL, AST 46 units/L, AL T 70 units/L, Alkaline phosphatase 120 units/L. CT scan of the abdomen reveals a fluid collection within the spleen. Which of the following is the most likely diagnosis?

224. A 67-year-old male is brought to the ER because of increasing abdominal pain and nausea for the past few hours. He has multiple medical problems including type-2 diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular accident, peripheral vascular disease, ischemic cardiomyopathy and atrial 􀃒brillation. He has not been on anticoagulation because of recurrent bleeding peptic ulcer disease. He has had a cholecystectomy. He takes multiple medications at prescribed doses and lives at home with his family. He quit smoking 10 years ago and does not use alcohol or drugs. His temperature is 37.8°C (100.0°F), blood pressure is 150/90 mm Hg, pulse is 110/min and respirations are 22/min. Physical examination shows an elderly male in acute distress. Lungs have few crackles at the bases. Heart rate is irregular. Bowel sounds are decreased and di􀃗use tenderness is present. There is no peripheral edema. Initial laboratory studies show the following: Serum sodium 140 mEq/L, Chloride 103 mEq/L, Bicarbonate 14 mEq/L, Blood urea nitrogen (BUN) 20 mg/dl, Serum creatinine 0.8 mg/dl, Blood glucose 198 mg/dl, Amylase 255 U/L. Which of the following is the most likely diagnosis in this patient?

A 64-year-old male presents to the ER with shortness of breath. The symptoms started one week ago with a dry cough and mild fever. His past medical history includes hypertension and exertional angina. He was hospitalized six months ago for pneumonia. He has a 35 pack-year smoking history. His blood pressure is 140/90 mmHg and heart rate is 90 and regular. On examination, the patient is in mild respiratory distress. He uses some accessory respiratory muscles for breathing, but he can speak in full sentences. Chest auscultation reveals bilateral wheezes and crackles at the left lung base. His ABG shows: pH 7.36, pO2 72mmHg, pCO2 51mmHg. Which of the following is the most likely cause of this patient's current symptoms?

A 43-year-old Caucasian female presents to your o􀃕ce complaining of joint pain and swelling in her hand. On history, she endorses easy fatigability and loss of energy that has been worsening insidiously. It is especially di􀃕cult for her to do daily activities in the morning due to prolonged sti􀃗ness. She also describes frequent knee pain accompanied by a low-grade fever. She takes ibuprofen and naproxen to relieve her symptoms. Her hematocrit is 33%. The patient is at the greatest risk of which of the following?

A 65-year-old man comes to the physician's o􀃕ce because of frequent falls. For the past 2 months, he has been having increasing di􀃕culty in maintaining balance when walking or standing. He tends to lose his balance on the left side, and feels that his "left body has become weak." He also complains of occasional headaches and nausea for the past 3 months. His other medical problems include hypertension, diabetes mellitus-type 2 and a myocardial infarction 10 years ago. He denies the use of tobacco, alcohol, or drugs. His medications include glyburide, aspirin and enalapril. His vital signs are within normal limits. When asked to get up from the chair and stand with his feet together, he tends to sway to the left, even with his eyes open. When asked to walk a few steps, he walks cautiously and lurches to the left. There is decreased resistance to passive 􀃓exion. Which of the following is the most likely diagnosis?

A 57-year-old man presents to the emergency department complaining of right arm weakness. He says that he 􀃒rst noticed the weakness two hours ago when he was unable to grip a pen. He is now unable to shake hands and walks with a mild limp. His past medical history is signi􀃒cant for hypertension, diabetes mellitus, and mild headaches over the past several days. He does not smoke or consume alcohol. His blood pressure is 180/100 mmHg, heart rate is 80/min and regular. There is mild asymmetry of the lower face, decreased muscle strength in the right arm, and an extensor plantar re􀃓ex on the right side. Sensory examination is normal. Blood glucose level is 210mg/dL. ECG shows sinus rhythm with occasional ventricular premature beats. His urine is negative for ketones and protein. Non- contrast CT scan of the head does not reveal any abnormalities. Which of the following is the most likely cause of this patient's symptoms?

A 42-year-old white male presents to your o􀃕ce complaining of periodic breathing di􀃕culty and wheezing. He visited an otolaryngologist for persistent nasal blockage recently. His past medical history is signi􀃒cant for unstable angina experienced 􀃒ve months ago. His current treatment includes aspirin, diltiazem, and pravastatin. He does not use tobacco, alcohol, or drugs. His vital signs are within limits. What is the most probable cause of this patient's respiratory complaints?

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

A 25-year-old immigrant from Eastern Europe is being evaluated for right shoulder pain and swelling. He also complains of heel pain while walking. Palpation over the heels, iliac crests and tibial tuberosities elicits tenderness. Which of the following additional findings is most likely in this patient?

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

A 40-year-old Caucasian man comes to the emergency department because of fever, dry cough, and shortness of breath. Symptoms started 24 hours ago. He denies hemoptysis. He was recently discharged from the hospital after a second cycle of chemotherapy for acute myeloid leukemia. He does not use tobacco, alcohol, or drugs. His temperature is 38.9°C (102.0°F), blood pressure is 120/70 mmHg, pulse is 112/min and respirations are 28/min. The patient's pulse oximetry showed 86% at room air. Examination shows diffuse crackles all over the lung fields. His chest x-ray shows diffuse interstitial infiltrates. Which of the following is the most likely cause of his condition?

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 signi􀃒cant 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 64-year-old man presents to the ER with back pain and frequent falls. He also describes di􀃕culty initiating urination. The symptoms started one week ago and have progressed gradually. He was diagnosed with prostate cancer one year ago and treated with radiation therapy. Physical examination reveals weakness of knee and hip extension that is more pronounced on the right. Knee and ankle re􀃓exes are absent bilaterally. Babinski sign is negative. Perianal skin is insensitive to touch but sensation in the anterolateral thigh is preserved. Which of the following is the most likely lesion location in this patient?

A 63-year-old painter complains of severe right shoulder pain. The pain is located posteriorly over the scapula. These symptoms began after he fell from a ladder 2 weeks ago. The pain is especially bad at night and makes it di􀃕cult for him to sleep. In addition, he has had some pain in the right upper arm. Treatment with acetaminophen and ibuprofen has been unsuccessful in controlling his pain. On examination the patient appears uncomfortable. The right shoulder has full range of motion. Movement of the shoulder is not painful. There is no tenderness to palpation of the scapula. What is the most likely diagnosis?

A 42-year-old male from El Salvador complains of several months of dyspnea on exertion. Physical examination reveals an elevated jugular venous pressure, clear lungs, a third heart sound, a pulsatile liver, ascites, and dependent edema. Chest radiography reveals no cardiomegaly and clear lung fields. An echocardiogram demonstrates normal to mildly decreased left ventricular systolic function. The initial diagnostic workup should include all the following except?

A 52-year-old woman presents to the GP with intermittent palpitations and breathlessness that has occurred over the last few weeks. She denies chest pain. Her electrocardiogram (ECG) shows sinus tachycardia and she does not appear to be anaemic. Which blood test would be of most use in confirming the diagnosis?

A 33-year-old woman presents to accident and emergency with severe right flank pain. The pain started 3 hours ago and is not constant, occasionally moving towards her right iliac fossa. The patient also feels nauseous and has a low-grade fever. The most appropriate investigation is:

A 28-year-old man presents to the ED complaining of constant vague, diffuse epigastric pain. He describes having a poor appetite and feeling nauseated ever since eating sushi last night. His BP is 125/75 mm Hg, HR is 96 beats per minute, temperature is 100.5°F, and his RR is 16 breaths per minute. On examination, his abdomen is soft and moderately tender in the right lower quadrant (RLQ). Laboratory results reveal a WBC of 12,000/ μL. Urinalysis shows 1+ leukocyte esterase. The patient is convinced that this is food poisoning from the sushi and asks for some antacid. Which of the following is the most appropriate next step in management?

A 19-year-old woman presents with an acute episode of feeling unwell. While in the middle of moving to a new house, she experienced an extremely severe pain near the back of her bead. She denies any recent travelling, fever or neck stiffness. The most defmitive investigation is:

A 32-year-old woman attends her GP for a routine medical examination and is noted to have a mid-diastolic murmur with an opening snap. Her blood pressure is 118/71 mmHg and the pulse is regular at 66 beats per minute. She is entirely asymptomatic and chest x-ray and ECG are normal. What would be the most appropriate investigation at this point?

A 58-year-old postmenopausal female presents to your office on suggestion from a urologist. She has passed 3 kidney stones within the past 3 years. She is taking no medications. Her basic laboratory work shows the following: Na: 139 mEq/L, K: 4.2 mEq/L, HCO3: 25 mEq/L, Cl: 101 mEq/L, BUN: 19 mg/dL, Creatinine: 1.1 mg/dL, Ca: 11.2 mg/dL. A repeat calcium level is 11.4 mg/dL; PO4 is 2.3 mmol/L (normal above 2.5). Which of the following tests will confirm the most likely diagnosis?

A 72-year-old man with a history of myocardial infarction 10 years ago and angina presents with complaints of recurrent chest pain, which he has been experiencing over the past 4 months. This pain is retrosternal, is brought on by exertion, and is relieved by rest. The patient has been taking aspirin, long acting diltiazem, simvastatin, atenolol, and isosorbide dinitrate at maximal doses. His blood pressure is 130/80 mm Hg; pulse, 62 beats/min; and respirations, 16 breaths/min. Physical examination is normal. ECG shows normal sinus rhythm, with left bundle branch block. Which of the following tests would be most useful in the evaluation of this patient's angina?

A 38-year-old woman presents to her GP with a 2-week history of dysuria, haematuria and shortness of breath. She suffers from chronic headaches and has been taking ibuprofen in order to treat them. She has a history of cardiovascular disease in the family and a friend recommended she use aspirin to keep healthy. The most appropriate investigation is:

You are asked by your registrar to request an imaging investigation for a 49-year- old woman with jaundice and abdominal pain. She has a past medical history of gallstones and you suspect this is a recurrence of the same problem. The most appropriate imaging investigation is:

A 58-year-old man presents with breathlessness, he reports feeling unwell over the last three months with nausea, vomiting and difficulty breathing. You notice his ankles are swollen and he has bruises on his arms. The patient mentions he has not been urinating as often as normal. The most appropriate investigation is:

A 65-year-old Asian male presents to the physician with a four-week history of weakness and vague postprandial epigastric pain. His past medical history is insignificant. He does not take any medications. He smokes 1½packs of cigarettes daily and drinks alcohol occasionally. The fecal occult blood test is positive. Gastroduodenoscopy shows an antral ulcer. Four of seven biopsies taken from the margins of the ulcer are consistent with adenocarcinoma. Which of the following is the most appropriate next step in management?

A 42-year-old man presents with a 2-day history of severe chest pain. The patient reports a sudden ripping sensation at the front of the chest that occasionally radiates to the back. The patient has tried paracetamol and ibuprofen to alleviate the pain, but has had no success. The patient suffers from poorly controlled hypertension and at the last GP appointment his blood pressure was 167/95 mmHg. The most definitive investigation is:

A 26-year-old man presents with a 1-week history of intermittent, crampy, lower abdominal pain accompanied by rectal urgency, bloody diarrhea, nausea and vomiting. His symptoms have become more severe over the past 24 hours. His past medical history is unremarkable. He denies any recent travel or antibiotic use. His temperature is 38.5°C (102.0°F), blood pressure is 120/80 mmHg, pulse is 95/min, and respirations are 15/min. Abdominal examination reveals distension and tenderness to palpation without rebound or guarding. The bowel sounds are decreased. Rectal examination shows marked rectal tenderness and mucus mixed with blood in the vault. An x-ray film of the abdomen shows distended colon filled with gas. Laboratory studies show: Hb 10.8 g/dl, WBC 19,600/cmm, Platelet count 459,000/cmm, ESR 54/hr. Which of the following is the most appropriate next step in management?

A 23-year-old man reports a 3-day history of a constant left-sided chest pain, which worsens with inspiration and activity. His symptoms were preceded by several days of fatigue, rhinorrhea, and cough. He is worried that he has broken a rib from coughing. He reports no other symptoms and has no risk factors for cardiovascular disease. On examination, he is comfortable. Other findings on physical examination are as follows: blood pressure, 120/70 mm Hg; pulse, 94 beats/min; respiratory rate, 12 breaths/min; temperature, 100.2° F (37.9° C). His lungs are clear. Cardiovascular examination shows tachycardia, but otherwise the results are normal. Which of the following should be the appropriate step to take next in this patient's workup?

A 32-year-old Caucasian female presents to your o􀃕ce 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 􀃒ne 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 in􀃒ltrates and left upper lobe 􀃒brosis. The ECG reveals non-speci􀃒c ST segment and T wave changes. What is the best next step in the management of this patient?

A 45-year-old man presents with two days of bilateral hand pain that is most severe in his wrists. Physical examination reveals bilateral wrist tenderness, thickening of the distal fingers, and convex nail beds. There is nicotine staining of the right index and middle fingers. He states that he has been smoking 2 packs of cigarettes a day for the past 25 years. Chest examination reveals decreased breath sounds and a prolonged expiratory phase. The patient relates the pain's onset to a data entry job he recently started. He notes that his boss believes he is fabricating his pain to get off work. His job records reveal numerous sick leaves. Which of the following is the most appropriate course of action?

A 68-year-old male was intubated in the emergency room because of pulmonary edema. Stat echocardiogram reveals an ejection fraction of 45% and severe mitral regurgitation. In spite of aggressive diuresis with furosemide, the patient continues to require mechanical ventilation secondary to pulmonary edema. What is the best next step in treating this patient?

A 35-year-old woman with systemic lupus erythematosus (SLE) is brought to the ED by her brother after he found her febrile and confused. Physical examination reveals fever, tachycardia, a waxing and waning mental status, petechiae over her oral mucosa, pallor, and mildly hemepositive stool. Her urinalysis is positive for blood, red cell casts, and proteinuria. Laboratory results reveal blood urea nitrogen (BUN) of 40 mg/dL and creatinine of 2 mg/dL. Her bilirubin is elevated (unconjugated > conjugated) and her international normalized ratio (INR) is 0.98. Her complete blood count reveals WBC 12,000/μL, hematocrit 29%, and platelet count 17,000/μL with schistocytes on the peripheral smear. Which of the following is the most appropriate next step in management?

A 72-year-old diabetic man is admitted to AE with a 40 minute history of central, crushing chest pain. The pain eases after an hour with bedrest, oxygen and morphine. ECG shows mild anterior ST flattening. The troponin T level is slightly raised. What would be the optimal management of the underlying cause of his chest pain be besides usual medical measures?

A 20-year-old man presents to the ED with multiple stab wounds to his chest. His BP is 85/50 mmHg and HR is 123 beats per minute. Two large-bore IVs (intravenous) are established and running wide open. On examination, the patient is mumbling incomprehensibly, has good air entry on lung examination, and you notice jugular venous distension (JVD). As you are listening to his heart, the nurse calls out that the patient has lost his pulse and that she cannot get a BP reading. Which of the following is the most appropriate next step in management?

A 34-year-old construction worker is brought to the ED by EMS after falling 30 ft from a scaffold. His vital signs are HR 124 beats per minute, BP 80/40 mmHg, and oxygen saturation 93% on 100% oxygen. He has obvious head trauma with a scalp laceration overlying a skull fracture on his occiput. He does not speak when asked his name, his respirations are poor, and you hear gurgling with each attempted breath. Auscultation of the chest reveals diminished breath sounds on the right. There is no JVD or anterior chest wall crepitus. His pelvis is unstable with movement laterally to medially and you note blood at the urethral meatus. His right leg is grossly deformed at the knee and there is an obvious fracture of his left arm. Which of the following is the most appropriate next step in management?

A 62-year-old male presents with palpitations, which are shown on ECG to be atrial fibrillation with a ventricular rate of approximately 130/minute. He has mild central chest discomfort but is not acutely distressed. He first noticed these about 3 hours before coming to hospital. As far as is known this is his first episode of this kind. Which of the following would you pref er as first-line therapy?

A 70-year-old man with a history of constipation has been experiencing intermittent left-sided abdominal pain and fevers for 2 days. He came to the emergency department immediately after he noticed blood in his toilet this morning. His heart rate is 110/min, blood pressure is 90/50 mm Hg, respiratory rate is 18/ min, and oxygen saturation is 95% on room air. On physical examination the physician notes copious amounts of bright red blood per rectum. The physician immediately places two large bore intravenous lines, administers fluid, and sends blood for type and screen. Which of the following is the best next step in management?

An 81-year-old man is brought to the hospital due to complaints of very severe pain in his back and thighs. Seven months ago, he was diagnosed with stage IV prostate cancer which reached the spine. He has had palliative radiotherapy of his spine, and is now taking leuprolide. He is restless and very irritable, even after the nursing home staff gave him ibuprofen. He has never received any narcotics. What is the best next step in this patient's pain management?

An 84-year-old woman with coronary artery disease, congestive heart failure, peripheral vascular disease, and atrial fibrillation presents to the emergency department with dizziness, weakness, and sudden-onset crampy periumbilical pain. The pain is associated with one episode of diarrhea and one episode of emesis. The patient notes she has been having similar pain after meals for “several months” but never this severe. Her temperature is 37.2°C (98.9°F), heart rate is 135/min, blood pressure is 96/60 mm Hg, and respiratory rate is 16/min. Physical examination is notable for a slightly distended abdomen that is extremely tender to palpation with diminished bowel sounds. There is no rigidity or rebound tenderness noted on the abdominal examination. In addition, the patient has heme positive stool. Her WBC count is 19,500/mm³, hemoglobin is 10.9 g/dL, and platelet count is 159,000/mm³. Liver function testing results are normal. After stabilizing the patient, what is the best next step in management?

A 37-year-old white female with myasthenia gravis presents to the office with a fever and cough productive of yellow-green sputum. She has been on pyridostigmine for the past few months. She refuses to have a thymectomy. Her pulse is 90/min, blood pressure is 120/76 mm Hg, respirations are 18/min, and temperature is 38.9°C (102°F). Her respiratory effort is weak. Pulse oximetry reveals 86% oxygen saturation on room air. There is a consistent decline on serial measurement of vital capacity. Which of the following is the most appropriate next step in management?

A 62-year-old woman presents to the ED with general weakness, shortness of breath, and substernal chest pain that radiates to her left shoulder. Her BP is 155/80 mmHg, HR is 92 beats per minute, and RR is 16 breaths per minute. You suspect that she is having an acute MI. Which of the following therapeutic agents has been shown to independently reduce mortality in the setting of an acute MI?

A 60-year-old man is brought to the emergency department due to syncope. He has had similar episodes a few times during the past few weeks. These episodes usually occur after he exerts himself. He does not feel confused or tired after these episodes. He denies any chest pain or palpitation. His wife reports that when he collapses, he seems to lose consciousness for a few seconds, but then is back to being alert right away. She denies any jerking movement. His past medical history is significant diverticulosis, for which he takes fiber supplements. He is not on any other medication. His temperature is 37.1°C (98.8°F), blood pressure is 110/98 mm Hg, pulse is 88/min, and respirations are 14/min. On examination, he has a fourth heart sound and harsh 3/6 systolic murmur, best heard over the right sternal border. The murmur is accentuated on expiration. The lung fields are clear to auscultation. After performing an echocardiograph to confirm the diagnosis, which of the following management options is most appropriate?

A 40-year-old male presents with six months of worsening dyspnea. His symptoms have progressed to the point that walking even one block causes him to become shot of breath. He has a history of cigarette smoking, but quit 10 years ago. He drinks approximately one alcoholic drink daily. His medical history is significant for peptic ulcer disease for which he takes antacids. On physical examination, he is afebrile. His pulse is 86/min, blood pressure is 140/56 mmHg, and respiratory rate is 14/min. While examining his heat you note a high-pitched blowing, early diastolic, decrescendo murmur, which is heard best in the left third intercostal space and is intensified by handgrip. There is prominent cardiomegaly on chest x-ray. Which of the following medications would improve both this patient’s symptoms and cardiomegaly?

A 55-year-old patient presents to you after a 3-day hospital stay for gradually increasing shortness of breath and leg swelling while away on a business trip. He was told that he had congestive heart failure, but is asymptomatic now, with normal vital signs and physical examination. An echocardiogram shows an estimated ejection fraction of 38%. The patient likes to keep medications to a minimum. He is currently on aspirin and simvastatin. Which would be the most appropriate additional treatment?

A 54-year-old male with a past medical history of type 2 diabetes mellitus comes to the emergency department complaining of shortness of breath. His blood pressure is 146/92 mmHg, respiratory rate is 26/min, and oxygen saturation is 87% on room air. Cardiac auscultation over the apex shown S3. Based on the physical findings, which of the following is the best initial therapy for this patient?

An 81-year-old retired farmer presents with a 1.5 cm raised lesion on his left temple that has slowly grown over the past year and occasionally bleeds. He has had a basal cell carcinoma removed from his right temple previously, and he has had cryotherapy for actinic keratoses on his temples and head several times at his GP surgery. On examination, the lesion has a rolled edge and is translucent with telangiectasia. Which of the following treatment options is NOT recommended for this lesion?

A 60-year-old man who works for an oil company presents with a lesion on the temple that is bothering him as it is growing. It bled once when he knocked it. On examination, the lesion is 8 mm in diameter and is a flat, mildly erythematous patch with a few scales and a larger keratotic horn in the centre. There are no other lesions on inspection of his skin and no personal or family history of skin cancer. Which of the following is the most appropriate management plan?

A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable angina. She is started on appropriate medication to reduce her cardiac risk. She is hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial fibrillation. What is the most appropriate treatment?

A 54-year-old woman presents for a routine physical. She has no complaints. She has no history of hypertension, diabetes, hypercholesterolemia, or heart disease, and she does not use tobacco, alcohol or drugs. On physical examination, her pulse is irregular. There are no murmurs. Her lungs are clear to auscultation and her legs are free of edema. An EKG shows atrial fibrillation with a heart rate of 72 beats per minute. An echocardiogram is unremarkable except for evidence of atrial fibrillation. What is the most appropriate management of this patient?

A 76-year-old man presents to your office with progressively worsening fatigue over the past several months. He denies associated chest pain, dyspnea, nausea, cough, or ankle swelling. He has smoked a pack of cigarettes per day for the past 30 years. His past medical history is significant for hypertension for which he takes hydrochlorothiazide and type 2 diabetes mellitus controlled with metformin. He had a medical check-up five months ago which did not uncover any new abnormalities or medical issues. On physical examination today, his blood pressure is 130/80 mmHg and his heart rate is 110 and irregularly irregular. His lab values are: Hematocrit 41%, WBC count 4,700/mm3, Platelets 200,000/mm3, Sodium 137 mEq/L, Potassium 4.1 mEq/L, Creatinine 0.8 mg/dl, Fasting glucose 85 mg/dl. Which of the following is the best treatment for this patient?

A 70-year-old male with a history of coronary artery disease presents to the emergency department with 2 hours of substernal chest pressure, diaphoresis, and nausea. He reports difficulty “catching his breath.” An electrocardiogram shows septal T-wave inversion. The patient is given 325-mg aspirin and sublingual nitroglycerin while awaiting the results of his blood work. His troponin I is 0.65 ng/mL (normal < 0.04 ng/mL). The physician in the emergency department starts the patient on low-molecular-weight heparin. His pain is 3/10. Blood pressure is currently 154/78 mmHg and heart rate is 72. You are asked to assume care of this patient. What is the best next step in management?

A 60-year-old male patient is receiving aspirin, an angiotensin-converting enzyme inhibitor, nitrates, and a beta-blocker for chronic stable angina. He presents to the ER with an episode of more severe and long-lasting angina chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. Which of the following is the best course of action?

A 58-year-old man is admitted to the coronary care unit for telemetric monitoring after an episode of bradycardia. While in the unit, he suddenly loses consciousness. His pulse is undetectable and his blood pressure drops to 40 mmHg. His airway is clear and patent, and he is still breathing on his own. An ECG shows electrical activity. Chest compressions are started and he is quickly given a bolus of intravenous sodium bicarbonate and atropine. When his tracing does not improve, the boluses are repeated twice, and finally his tracing returns to normal sinus rhythm. Moments later, when he regains consciousness, he complains of a dry mouth, blurred vision, and feeling flushed. What is the most appropriate next step in the management of this patient?

A 77-year-old woman presents with 2 hours of chest pain, which varies in intensity from mild to severe. Her pain is described as ''pressure'' felt over the left chest, with radiation to the left arm. It occurred at rest and is worsened by any activity. She has nausea without vomiting. Her medical history is remarkable for an inferior MI 5 years ago, diabetes, and hypertension. Her medications include lisinopril and metformin. Physical examination reveals a moderately obese woman in apparent discomfort. Vital signs include pulse, 84 beats/min; BP, 130/80 mm Hg; respiratory rate, 16; oxygen saturation, 96% on room air. Cardiac and lung examinations are normal. Her ECG shows Q waves in ID and a VF; 2 m V ST segment depression in leads V3 to V 6; and 1 m V ST segment elevation in Vl. She is treated initially with oxygen, sub lingual nitroglycerin, aspirin, metoprolol, and morphine, and her symptoms improve. She still rates her pain as moderate, and repeat ECG is unchanged. Which of the following would NOT be an appropriate intervention for this patient?

A 65-year-old male with oxygen-dependent chronic obstructive pulmonary disease, chronic atrial fibrillation, and depression comes into the Emergency Room, with symptoms of increased dyspnea and worsening cough pattern. His recent history had been significant for a gradual worsening of his baseline lung disease over the past month, which had been treated by his outpatient doctor with increased frequency of inhaled beta-agonist and azithromycin. This morning he had a severe shortness of breath that was unresponsive to "stacked" home nebulizer treatments. The ER physician notes that the patient is in moderate severe respiratory distress. His temperature is 37.2°C (99°F), blood pressure is 150/90 mmHg, pulse is 110/min, and respirations are 28/min. Accessory muscle use was noted. Lung exam shows diffuse rhonchi and wheezing. A pulse oximetry revealed an oxygen saturation of 80% on room air. His chest x-ray showed no new infiltrates. His WBC count is 7,000/cmm with normal differential. The ER physician had given nebulization, and the patient is on 5-liters of oxygen. Which of the following should also be considered in this patient?

A 45-year-old patient presents in shock complaining of sudden-onset generalized upper abdominal pain radiating to the right iliac f ossa and the tip of his right shoulder. He reports one episode of vomiting, but none since. He has no past medical problems. On examination, his abdomen is rigid and bowel sounds are absent. The diagnosis is?

An 84-year-old man is brought to the emergency department because of 1 hour of severe back pain. He also had syncope that lasted < 1 minute. Before arriving at the hospital, he had an episode of gross hematuria, which he has never had before. He also complains of some shortness of breath. He denies chest pain, cough, nausea, vomiting, headache, and neck pain. His blood pressure is 72/55 mm Hg and pulse is 112/min and regular. His pulse oximetry shows 92% on room air. His ECG shows sinus tachycardia with prominent horizontal ST segment depression in the anterior chest leads. Which of the following is the most likely diagnosis?

A 24-year-old man sustains a twisting injury to his knee, with his body turning outwards (the tibia rotates inwards) as he falls while climbing a mountain. His binding fails to release and he feels a crack in his knee. Nothing seems to be out of place, but it swells immediately and he has to be brought down off the mountain on a stretcher. He has a positive Lachman's test. What is the most likely diagnosis?

An 18-year-old man was traveling at a high speed when his car slammed into a wall. He is brought into the emergency department by ambulance. His blood pressure is 60/40 mmHg, pulse is 115/min and weak, respirations are 18/min, and central venous pressure is 2 cmH2O. He is responsive only to painful stimuli. Breath sounds are equal bilaterally, and cardiac auscultation reveals only tachycardia. The abdomen is soft, nondistended, and nontender with active bowel sounds. A chest x-ray film shows a widened mediastinum. Which of the following is the most likely diagnosis?

A 42-year-old man is brought to the emergency department after a motor vehicle accident. He was a restrained driver and hit a car from behind on a highway. He drank one glass of wine before driving. He occasionally uses cocaine. His medical problems include mild intermittent asthma and peptic ulcer disease. On initial evaluation, his blood pressure is 112/92 mm Hg and pulse is 96/min. His pulse oximetry shows 95% on room air. Examination shows bruises on the anterior chest wall and abdominal wall. X-rays reveal a fracture of the eighth left rib but no pneumothorax or pleural effusion. Cervical C-spine series are negative. An ultrasound does not show free intraperitoneal fluid. An ECG shows normal sinus rhythm with no ST-segment or T-wave changes. He is treated with intravenous fluids and analgesics. Eight hours later, he complains of epigastric discomfort, left shoulder pain, and mild nausea. His blood pressure is 97/62 mm Hg and pulse is 112/min. His pulse oximetry shows 96% on room air. Which of the following is most likely to diagnose this patient's current condition?

A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 50% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 65% right coronary artery stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day. Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort. He appears to be diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The groin site for arterial puncture is mildly tender, without subcutaneous hematoma. He receives 1000 ml of normal saline, with symptomatic improvement. His blood pressure is 96/60 mm Hg and pulse is 85/min. His ECG seems to be unchanged. Which of the following is the most appropriate next step in managing this patient?

A 69-year-old man is admitted, complaining of right upper quadrant pain and fever. A correct diagnosis of acute cholecystitis is made and antibiotics prescribed. The option of immediate surgery is discussed, but the patient opts to wait for 6 weeks. Ten days later the patient phones to ask advice; his pain has not improved and his fevers have returned following completion of the antibiotics, with rigors and night sweats now a problem. In addition, he is concerned regarding itching the previous day, which he ascribed to his antibiotics. The most appropriate advice for this patient is?

A 57-year-old lady is post total thyroidectomy for thyromegaly with retrosternal extension. During the transfer of the patient from theatre to recovery, she develops shortness of breath. The patient is alert and speaking in complete sentences. Her respiratory rate is 20 breaths per minute, pulse is 90 beats per minute and blood pressure is 115/75 mmHg. Oxygen saturations have decreased from 98 % on 2 litres of oxygen per minute to 92 % . On examination of the chest, there is decreased expansion of the right hemithorax and ipsilateral reduced air entry and hyper-resonance. From the list below, choose the most appropriate step to take in this patient's management?

A 71-year-old woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of right upper quadrant abdominal pain. She did not want to eat and "took to her bed sick." The daughter recalls that she complained of chills, nausea, and some vomiting. Physical examination reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in the right upper quadrant, along with muscle guarding and rebound. Her temperature is 40C (104F), and laboratory analysis shows a white cell count of 22,000/mm3 with multiple immature forms, a bilirubin of 5 mg/dL and alkaline phosphatase of 840 U/L. The serum amylase is normal. An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?

In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management?

On the 5th postoperative day after abdominal surgery, a patient has been draining copious amounts of clear pink fluid from his midline laparotomy wound. A medical student removes the dressing, confirms that it is soaked, and sees a normal-appearing fresh wound with a row of skin staples in place. The student asks the patient to sit up so he can get out of bed and be helped to the treatment room for a more thorough examination. When the patient complies, the wound opens widely, and a handful of small bowel suddenly rushes out. Which of the following is the most appropriate management at this time?

A 26-year-old previously healthy man was pinned under a crane at a construction site. After a prolonged extrication, he was brought to the emergency department, immobilized on a back board and receiving 100% oxygen by mask. He is alert and complaining of chest pain with respiratory effort. On examination, he is found to have an oxygen saturation of 90% by pulse oximetry, shallow respirations at a respiratory rate of 35/min, heart rate of 120 beats/min, and a blood pressure of 85/60 mmHg. The trachea is deviated to the right. There is tenderness and crepitation over the left chest wall, asymmetric chest wall movement, and decreased air entry over the left lung field. Which of the following is the most appropriate next step in the initial evaluation and management of this patient?

A 4-week-old male infant presents with projectile, nonbilious emesis. Ultrasound of the abdomen reveals a pyloric muscle thickness of 8 mm (normal 3-4 mm). Which of the following is the best initial management of this patient?

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 29-year-old G3P2 black woman in the thirty-third week of gestation is admitted to the emergency room because of acute abdominal pain that has been increasing during the past 24 hours. The pain is severe and is radiating from the epigastrium to the back. The patient has vomited a few times and has not eaten or had a bowel movement since the pain started. On examination, you observe an acutely ill patient lying on the bed with her knees drawn up. Her blood pressure is 100/70 mm Hg, her pulse is 110 beats per minute, and her temperature is 38.8C (101.8F). On palpation, the abdomen is somewhat distended and tender, mainly in the epigastric area, and the uterine fundus reaches 31 cm above the symphysis. Hypotonic bowel sounds are noted. Fetal monitoring reveals a normal pattern of fetal heart rate (FHR) without uterine contractions. On ultrasonography, the fetus is in vertex presentation and appropriate in size for gestational age; fetal breathing and trunk movements are noted, and the volume of amniotic fluid is normal. The placenta is located on the anterior uterine wall and no previa is seen. Laboratory values show mild leukocytosis (12,000 cells per mL); a hematocrit of 43; mildly elevated serum glutamicoxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), and bilirubin; and serum amylase of 180 U/dL. Urinalysis is normal. Which of the following is the most likely diagnosis?

A 19-year-old G0 woman presents to her family physician complaining of dysmenorrhea for the past year. She reports severe right-sided pain that coincides with days 1–5 of her menstrual cycle. Her menses occur regularly every 28 days, and she requires three to four pads per day for the first 2 days of her bleeding and one to two pads per day for the remainder. She has never had surgery. She is not sexually active and does not smoke. Her last menstrual period was 1 week ago. Her temperature is 36.7C (98.1F), blood pressure is 121/74 mmHg, heart rate is 80/min, and respiratory rate is 14/min. Physical examination reveals a thin, healthy-appearing young woman. Pelvic examination reveals a normal sized uterus and no cervical motion tenderness. Which of the following is the most likely diagnosis?

A 39-year-old woman is 6 days post-partum and has come back to hospital with shortness of breath. She is struggling to breath at rest, has a respiratory rate of 28, pulse 115, BP 105/60 mmHg, temperature 37 .4 On examination she has an audible wheeze and cough. Investigations reveal a PO2 of 9.5 kPa on arterial blood gas and a PCO2 3.7 kPa, pH 7.36, base excess -3.4. A chest x-ray shows some upper lobe diversion and bilateral diffuse shadowing with an enlarged heart. Her haemoglobin is 8.9 g/dL, white blood count 11.1 x 109/L and C-reactive protein 21 mg/L. What is the most likely cause of her symptoms?

A 30-year-old French woman delivers a live female infant by spontaneous vaginal delivery at term. In the eleventh week of pregnancy she developed a flu-like illness which resolved spontaneously a week later. Her newborn child has severe hydrocephalus and chorioretinitis. Four days after birth, she develops severeconvulsions and efforts to revive her are unsuccessful. Which pathogen is most likely to be responsible?

A 35-year-old woman is seen in the assisted conception unit. She has been trying to conceive for 4 years. In this period she has been having regular intercourse. Her periods have been irregular and recently she has had no periods at all. Her BMI is 19.5 kg/m2, she has had an appendectomy and is otherwise well. Her biochemistry comes back as follows: luteinizing hormone (LH) 0.5 IU/L, follicle-stimulating hormone (FSH) 1.0 IU/L, prolactin 490 mIU/L, thyroxine (T4) 12, thyroid stimulating hormone (TSH) 4.2 mIU/L, oestradiol 60 pmol/L. What is the most likely cause of her subfertility?

A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency room complaining of a 24-hour history of increasing pelvic pain. This morning she experienced chills and a fever, although she did not take her temperature. She reports no changes in her urine or bowel habits. She has had no nausea or vomiting. She is hungry. She denies any medical problems. Her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses and denies dysmenorrhea. She is currently sexually active. She has a new sexual partner and had sexual intercourse with him just prior to her last menstrual period. She denies a history of any abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is completely normal. WBC is 18,000. Temperature is 38.8C (102F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished. Which of the following is the most likely diagnosis?

A healthy 42-year-old G2P1001 presents to labor and delivery at 30 weeks gestation complaining of a small amount of bright red blood per vagina which occurred shortly after intercourse. It started off as spotting and then progressed to a light bleeding. By the time the patient arrived at labor and delivery, the bleeding had completely resolved. The patient denies any regular uterine contractions, but admits to occasional abdominal cramping. She reports no pregnancy complications and a normal ultrasound done at 14 weeks of gestation. Her obstetrical history is significant for a previous low transverse cesarean section at term. Which of the following can be ruled out as a cause for her vaginal bleeding?

A patient is seen on the first postoperative day after a difficult abdominal hysterectomy complicated by hemorrhage from the left uterine artery pedicle. Multiple sutures were placed into this area to control bleeding. Her estimated blood loss was 500 mL. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are temperature 38.2C (100.8F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 to 9.8, her white blood cell count is 9.5, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL. What is next best step in the management of this patient?

A 29-year-old woman presents for her first prenatal visit. She is 10 weeks pregnant as determined by her last menstrual period. She does not have any medical problems and does not take any medications. She is devoutly religious and has been in a monogamous relationship with her husband since getting married 5 years ago. They live in a house built in 1983 where she works as a homemaker. Her husband is an accountant. She does not smoke cigarettes or drink alcohol. Her physical exam is within normal limits. Which of the following screening tests is indicated at this time?

A pregnant woman who is 7 weeks from her LMP comes in to the office for her first prenatal visit. Her previous pregnancy ended in a missed abortion in the first trimester. The patient therefore is very anxious about the well being of this pregnancy. Which of the following modalities will allow you to best document fetal heart action?

A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management?

A 16-year-old girl attends accident and emergency complaining of mild vaginal spotting. Her serum beta hCG is 4016 mIU/mL. She is complaining of severe left iliac fossa pain and stabbing sensations in her shoulder tip. What is the most appropriate definitive investigation?

A 35-year-old woman with systemic lupus erythematosus (SLE) is brought to the ED by her brother after he found her febrile and confused. Physical examination reveals fever, tachycardia, a waxing and waning mental status, petechiae over her oral mucosa, pallor, and mildly hemepositive stool. Her urinalysis is positive for blood, red cell casts, and proteinuria. Laboratory results reveal blood urea nitrogen (BUN) of 40 mg/dL and creatinine of 2 mg/dL. Her bilirubin is elevated (unconjugated > conjugated) and her international normalized ratio (INR) is 0.98. Her complete blood count reveals WBC 12,000/μL, hematocrit 29%, and platelet count 17,000/μL with schistocytes on the peripheral smear. Which of the following is the most appropriate next step in management?

A 53-year-old woman comes to the physician for an annual examination. She has no complaints. She has hypertension, for which she takes a thiazide diuretic, but no other medical problems. Her past gynecologic history is significant for normal annual Pap tests for many years, her last being 2 months ago. A recent mammogram was negative. Heart, lung, breast, abdomen, and pelvic examination are unremarkable. Which of the following procedures or tests should most likely be performed on this patient?

A 30-year-old woman, gravida 2, para 1, at 37 weeks gestation is brought to the emergency department because of acute onset intense uterine contractions and vaginal bleeding. She has been followed closely for pre-eclampsia since her 32nd week of gestation. Her temperature is 37.0°C (98.7°F), blood pressure is 140/86mmHg, pulse is 92/min and respirations are 18/min. Physical examination shows uterine tenderness and hyperactivity and moderate vaginal bleeding. Pelvic examination shows an effaced and 3cm dilated cervix. Ultrasonography shows a fundic placenta and a fetus in the cephalic position. Fetal heart tracing shows 140/min with good long-term and beat-to beat variability. After initial resuscitation the bleeding is stopped. Which of the following is the most appropriate next step in management?

A 46-year-old woman is returned to the ward from the recovery room following a routine vaginal hysterectomy for heavy periods and prolapse. The estimated blood loss at operation was 200 mL. Two hours later the ward sister becomes concerned that her urine output is low and calls the doctor. Her observations show: pulse 115 bpm, BP 90/62 mmHg, temperature 37.1 ° What are the most appropriate next steps in her management?

An 81-year-old woman presents to your o􀃕ce complaining that her uterus fell out 2 months ago. She has multiple medical problems, including chronic hypertension, congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair because of her health problems. Her fallen uterus causes signi􀃒cant pain. On physical examination, the patient is frail and requires assistance with getting on the examination table. She has complete procidentia of the uterus. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old woman is referred by her GP to the gynaecology clinic with increasing bloating and a raised CA 125 level. A CT scan shows an irregular, enlarged left ovary and several well-circumscribed nodular lesions in the liver and on the omentum which are highly suspicious for metastatic ovarian cancer. What is the most appropriate treatment regimen?

A 19-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are very painful and occurring every 3 to 5 minutes. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 4 to 12 minutes. The nurse states that the contractions are mild to moderate to palpation. On examination the cervix is 1 cm dilated, 60% effaced, and the vertex is at −1 station. The patient had the same cervical examination in your office last week. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. Which of the following is the most appropriate next step in the management of this patient?

An 18-year-old G1 has asymptomatic bacteriuria (ASB) at her first prenatal visit at 15 weeks gestation. Which of the following statements is true?

A 33-year-old woman comes to the clinic at 16 weeks’ gestation with no complaints. This is her second pregnancy. During the first pregnancy she delivered an 8.5 lb. infant. The patient reports hydramnios during that pregnancy. She has no prior medical history and is on no medications. On physical examination, she has a firm uterus. Which of the following is the appropriate management of this patient?

You are following a 22-year-old G2P1 at 39 weeks during her labor. She is given an epidural for pain management. Three hours after administrating the pain medication, the patient’s cervical examination is unchanged. Her contractions are now every 2 to 3 minutes, lasting 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and early decelerations. Which of the following is the best next step in management of this patient?

A 27-year-old woman (G3P2) comes to the delivery floor at 37 weeks gestation. She has had no prenatal care. She complains that, on bending down to pick up her 2-year-old child, she experienced sudden, severe back pain that now has persisted for 2 hours. Approximately 30 minutes ago she noted bright red blood coming from her vagina. By the time she arrives at the delivery floor, she is contracting strongly every 3 minutes; the uterus is quite firm even between contractions. By abdominal palpation, the fetus is vertex with the head deeply engaged. Fetal heart rate is 130 beats per minutes. The fundus is 38 cm above the symphysis. Blood for clotting is drawn, and a clot forms in 4 minutes. Clotting studies are sent to the laboratory. Which of the following actions can most likely wait until the patient is stabilized?

A 20-year-old, gravida 1, para 0, at 10 weeks gestation is brought to the emergency department because of moderate vaginal bleeding. She has a colicky suprapubic pain radiating to the back and denies the passage of tissue through her introitus. She does not use tobacco, alcohol or drugs. She has no history of trauma or serious illness. Her temperature is 37.0C (98.7 F), blood pressure is 100/65 mm of Hg, pulse is 90/min and respirations are 17/min. Physical examination shows a dilated cervix and the products of conception can be seen through it. Her blood type is AB Rh negative and her antibody titer is 1:2. Ultrasonogram shows a ruptured gestational sac with no fetal heart motion. Which of the following is the most appropriate next step in management?

A 32-year-old, gravida 3, para 2 woman at 35 weeks gestation comes to the hospital because of regular and painful uterine contractions occurring every 5 - 6 minutes. She also has continuous leakage of clear fluid from her vagina that started 10 hours earlier. She has chronic hypertension and was prescribed methyldopa throughout pregnancy but has been noncompliant. She also has a history of drug abuse and has missed two previous antenatal appointments. Her temperature is 37.0C (98.7F), blood pressure is 160/100 mmHg, pulse is 80/min and respirations are 16/min. Sterile speculum examination shows pooling of amniotic fluid in the vagina; the cervix is 80% effaced and 3cm dilated. Ultrasound shows a small for gestational age fetus in the vertex presentation with a decreased amniotic fluid index. Fetal heart monitoring shows repetitive late decelerations. Uterine contractions are now occurring every 4 minutes. Which of the following is the most appropriate next step in management?

A 2950-g (6.5-lb) black baby boy is born at home at term. On arrival at the hospital, he appears pale, but the physical examination is otherwise normal. Laboratory studies reveal the following: mother’s blood type A, Rh-positive; baby’s blood type O, Rh-positive; hematocrit 38%; and reticulocyte count 5%. Which of the following is the most likely cause of the anemia?

An 18-month-old male is brought to the hospital because of fever, dyspnea, and productive cough of two days duration. His mother reports that he just recovered from prolonged diarrhea due to Giardia infection. His past medical history is also significant for pneumonia and recurrent ear infections since 6 months of age. On physical examination, his temperature is 38.7°C (101.7°F), pulse is 140/min, and respirations are 40/min. Examination reveals a young child in mild respiratory distress and bronchial breath sounds in the right lower lung lobe. Which of the following is the most likely cause of his recurrent infections?

A 3-month-old Jewish infant is brought to the emergency department because of a generalized seizure 1 hour ago. He is lethargic, weighs 2.7kg (61b), and has a doll-like face with fat cheeks, relatively thin extremities, and a protuberant abdomen. His liver is felt 5cm (2in) below the right costal margin. His kidneys are enlarged. His blood sugar level is 40mg/dl. His serum uric acid, total cholesterol, triglycerides and lactic acid levels are elevated. The levels of his liver transaminases are normal. What is the most likely cause of this infant's symptoms?

A 6-year-old African-American child is brought in by his father for complaints of easy fatigability and pallor. These symptoms occurred after the son was treated with "some medication" for a recent diarrhea. Physical examination is normal except for pallor and multiple petechiae. Laboratory values are as follows: Hb 8.0 g/dL, WBC 12,000/cmm, Platelets 50,000/cmm, Blood glucose 118 mg/dL, Serum Na 135 mEq/L, Serum K 5.3 mEq/L, Chloride 110 mEq/L, Bicarbonate 18 mEq/L, BUN 38 mg/dL, Serum creatinine 2.5 mg/dL, Total bilirubin 3 mg/dL, Direct bilirubin 0.5 mg/dL, PT 12 seconds, APTT 30 seconds, LDH 900 IU/L, Reticulocyte count 6%. A peripheral blood smear reveals giant platelets and multiple schistocytes. What is the most likely underlying pathophysiology for this boy's pallor?

A 2-week-old neonate is brought to the office due to poor feeding and persistent vomiting. He had an episode of jerky movements of his limbs this morning. He was delivered at term with no complications and weighed 2.7kg (6 Ib) at birth. He appears lethargic, irritable and jaundiced. On examination, he weighs 2.2kg (5 Ib). His liver and spleen are enlarged. Bilateral cataracts are evident. Which of the following is most consistent with these findings?

A 3-year-old boy is brought by his father to the Emergency Department with fever, headache and neck pain that developed over the past several hours. The father states he is not the birth father, and that he and his wife adopted the boy at 18 months of age after his birth mother abandoned him. Physical examination reveals a lethargic male with a temperature of 39.7 C (103.5 F). There is photophobia, and mildly injected conjunctiva are appreciated. Pupils are equal and reactive and funduscopic examination is unremarkable. The patient has neck stiffness with a positive Kernig's sign. A complete blood count reveals a leukocyte count of 24,000/mm3 with 64 segmented neutrophils and 25 bands. A lumbar puncture is performed that reveals elevated CSF pressure, decreased glucose, and elevated protein. A Gram's stain shows gram-negative pleomorphic rods. There is no growth on blood agar. Growth on chocolate agar reveals white colonies. Which of the following is the most likely pathogen?

A pregnant woman has premature rupture of membranes. Her baby is born 3 days later, at 37 weeks' gestation. The 5-minute APGAR score is 4. Lung sounds are reduced, and the infant appears to be in respiratory distress. Peripheral blood smear with differential counts demonstrates a neutrophil count of 30,000/mL, with toxic granules evident in many neutrophils. Gram stain of buffy coat demonstrates small gram-positive cocci in chains. Which of the following is the most likely causative organism?

A 10-year-old boy is admitted to the hospital because of bleeding. Pertinent laboratory findings include a platelet count of 50,000/μL, prothrombin time (PT) of 15 seconds (control 11.5 seconds), activated partial thromboplastin time (aPTT) of 51 seconds (control 36 seconds), thrombin time (TT) of 13.7 seconds (control 10.5 seconds), and factor VIII level of 14% (normal 38%-178%). Which of the following is the most likely cause of his bleeding?

A previously healthy 6-year-old girl is brought to the office due to a 10-day history of persistent, thick, nasal discharge, nasal congestion, cough, and intermittent low-grade fever. She has had no vomiting, headache, earache, or rash. Her temperature is 37.2 C (98.9 F), blood pressure is 88/50 mmHg, pulse is 90/min, and respirations are 15/min. Physical examination shows clear tympanic membranes, congested posterior nasopharynx with thick, yellow and purulent mucus, and red, swollen nasal turbinates. Transillumination of the sinuses is equivocal. Palpation of the maxillary sinuses shows mild tenderness. Lungs are clearto auscultation. Which of the following organisms is the most common etiologic agent of this condition?

A 12-year-old African American boy is brought to the office due to a 2-day history of high-grade fever and chills. He was apparently well before the onset of fever. He has no bone pain. He has sickle cell disease and has had 4 hospitalizations for painful crises and one episode of osteomyelitis. His blood pressure is 90/60 mm Hg, pulse is 100/min, respirations are 22/min and temperature is 38.9 C (102F). He appears drowsy. His laboratory report shows a total WBC count of 16,000/mm3 with 12% bands and Hb of 9.0 g/dl. Which of the following is the most likely cause of this patient's condition?

Otitis media occurring during the first 8 weeks of life deserves special consideration, because the bacteria responsible for infections during this time may be different from those that affect older infants and children. Which of the following organisms is the most likely to cause otitis media in these infants?

A newborn infant has respiratory distress and trouble feeding in the nursery. The mother has no significant medical history, but the pregnancy was complicated by decreased fetal movement. On physical examination, you note that aside from shallow respirations and some twitching of the fingers and toes, the infant is not moving, and is very hypotonic. In the mouth there is pooled saliva and you note tongue fasciculations. Deep tendon reflexes are absent. Spinal fluid is normal. Appropriate statements about this condition include which of the following statements?

A 4-year-old male is brought to the physician with fever and headache. His symptoms began two days ago with low-grade fever, cough, and congestion. Last night, he developed a temperature of 102 F (38.9 C) and became fussy and less active. Today, he is crying and complaining of a headache. His parents report that he has vomited twice today. In the office, his temperature is 102.5 F (39 C), pulse is 110/min, and respiratory rate is 20/min. On examination, he is irritable and shows signs of photophobia. His oropharynx is erythematous. Nuchal rigidity is present and when the neck is flexed, the patient flexes his lower extremities. The remainder of the physical examination is normal. Lumbar puncture is performed and the results are shown below. CSF: Glucose 60 mg/dL, Protein 80 mg/dL, RBC 10/mm3, WBC 100/mm3, Neutrophils 10%, Lymphocytes 70%, Monocytes 20%, Gram stain negative. Which of the following organisms is most likely responsible for this patient's presentation?

A 2-week-old infant presents with hepatosplenomegaly and a thick, purulent, bloody nasal discharge. Coppery, oval, maculopapular skin lesions are present in an acral distribution. The neurologic examination is normal, including head circumference. Which of the following is the most likely cause of this congenital infection?

A 6-year-old boy is brought to the physician by his mother with complaints of "inattentivity." His school teacher frequently complains about him, saying that he, "cannot sit still and just does not listen." He rarely completes his classroom assignments in time. When asked to run errands at home, he appears not to listen and continues to do whatever he is engaged in. He makes poor eye contact and has limited language skills compared to his peers. He usually prefers to play by himself. Which of these is the most likely diagnosis in this case?

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?

An infant is delivered by cesarean section at 34 weeks' gestation because of preterm labor. There is no history of ruptured membranes, maternal fever, or abnormalities in fetal heart rate monitoring. The infant requires assisted ventilation with a bag-mask device and 100% oxygen in the delivery room. His Apgar scores are 5 and 7 at 1 and 5 minutes, respectively. An umbilical cord arterial pH is 7 .23 and base deficit is 3 mmol/L. He is admitted to the newborn nursery, but transferred to the neonatal intensive care unit (NICU) within 1 hour for respiratory distress manifested by tachypnea and grunting. His arterial blood gas results (obtained on room air) upon admission to the NICU are: pH, 7.20; Pco2, 70 mm Hg; Po2, 50 mm Hg, and base deficit 10 mmol/L. Of the following, the MOST common cause for this infant's respiratory distress is

A 2-year-old boy presents to the emergency department with fever, irritability, and a skin rash 5 days after the onset of an upper respiratory infection. On examination, his temperature is 39.8 C (103.6 F), and his pulse is 94/min. There is an erythematous skin rash that involves his face, chest, back, and upper extremities. His skin is very tender to touch. Rubbing the skin causes separation of the epidermal layer. Which of the following is the most likely diagnosis?

A 2 year old was seen in accident and emergency by the senior house officer with a short history of fever, malaise and now vomiting. She had a blanching rash on her arms and abdomen. She looked unwell but had no clear focus for her fever. She was tachypnoeic but her chest was clear. A urine sample was requested which showed a trace of leukocytes and two plus of ketones. Forty-five minutes later the paediatric registrar came to review the child who appears lethargic with a capillary refill centrally of 6 seconds and the rash on her abdomen is now non-blanching. What is the most likely diagnosis?

A 15-year-old girl is admitted to the hospital with a 6-kg weight loss, bloody diarrhea, and fever that have occurred intermittently over the previous 6 months. She reports cramping abdominal pain with bowel movements. She also reports secondary amenorrhea during this time. Stool cultures in her physician’s office have shown only normal intestinal flora. A urine pregnancy test was negative, while an erythrocyte sedimentation rate (ESR) was elevated. Her examination is significant for the lack of oral mucosal ulcerations and a normal perianal examination. Anti-Saccharomyces cerevisiae antibodies (ASCA) are negative, while anti-neutrophil cytoplasm antibodies (p-ANCA) are positive. You confirm your presumptive diagnosis with a rectal biopsy. In counseling her about her disease, which of the following statements would be true?

A 17-year-old boy is brought to the emergency department by his parents with the complaint of coughing up blood. He is stabilized, and his hemoglobin and hematocrit levels are 11 mg/dL and 33%, respectively. During his hospitalization, he is noted to have systolic blood pressure persistently greater than 130 mm Hg and diastolic blood pressure greater than 90 mm Hg. His urinalysis is remarkable for hematuria and proteinuria. You are suspicious the patient has which of the following?

A 12-hour-old baby on the post-natal ward has just had a seizure lasting 2 minutes. It resolved spontaneously and was generalized in nature. Her mother had gestational diabetes and poor glucose control in pregnancy. The baby's birth weight was 5 kg. There were no abnormalities noted on antenatal US scans or maternal serology. On examination she has no dysmorphic features and handles well. What initial blood tests would you do for the baby?

A 3-year-old is brought into accident and emergency on a Monday morning because she has developed several bruises on her buttocks, left leg and right arm. She is seen with her nanny who reports finding the bruises when she was getting her dressed this morning. Recently the girl has not been herself. She has had several colds over the past 2 months and has been more lethargic lately. The nanny is worried she is losing weight. On examination she appears withdrawn, pale and has a bruise on the left buttock which is 5 cm x 8 cm. She has three other bruises on her left leg and right arm which are of varying colours. She also has some fine petechiae on her neck and cheeks. She has a runny nose and a cough but the chest is clear. What is the most likely diagnosis?

A newborn female has a cardiac murmur. Before the cardiologist arrives to evaluate her, she has a seizure. Results of laboratory testing include a serum calcium concentration of 5.0 mg/dL (1.25 mmol/L). Subsequently, echocardiography reveals an aortic arch anomaly. Of the following, the MOST appropriate test to obtain to aid in the diagnosis of this infant is

An 18-month-old girl is brought to your clinic because her mother feels she is pale. She has no relevant findings on past medical history and eats a regular diet. She is alert and interactive but has significant pallor. The remainder of the physical examination results are normal. A complete blood count reveals a normal white blood cell count and platelet count. The hemoglobin concentration is 4.5 g/dL (45 g/L) and mean cell volume is 74 fL. Of the following, the MOST likely diagnosis is

Two weeks ago, a 5-year-old boy developed diarrhea, which has persisted to the present time despite dietary management. His stools have been watery, pale, and frothy. He has been afebrile. Microscopic examination of his stools is likely to show which of the following?

A 4-year-old boy is brought to accident and emergency with a limp for 1 day. He was unhappy to weight bear on his right leg. He had been with his grandparents all day and his mother brought him to hospital when she returned from work that evening. He was af ebrile with a heart rate of llObpm but had had a cold last week. Mum reports no history of trauma. What is the most important diagnosis to exclude?

A 15-year-old girl who is hirsute has had menses six times in the past year. She is overweight (body mass index of 35 kg/M2) and has a blood pressure of 110/75 mm Hg. Her cholesterol concentration is 170 mg/dL ( 4.4 mmol/L), with a high-density lipoprotein cholesterol concentration of 55 mg/dL (1.4 mmol/L) and fasting triglyceride value of 74 mg/dL (0.84 mmol/L). Her fasting blood glucose value is 108 mg/dL (6.0 mmol/L), and a 2-hour post-oral glucose blood glucose value is 115 mg/dL (6.4 mmol/L). Of the following, the MOST likely diagnosis for this patient is

You are seeing a 6-year-old boy for a health supervision visit. He was born with trisomy 21 and an atrioventricular septal defect for which he underwent complete surgical repair at 2 months of age with an excellent result. His mother reports that he has not been sleeping well, that he snores loudly, and that she believes that he fatigues easily with play. On physical examination, he appears in no distress, his respiratory rate is 24 breaths/min, his heart rate is 100 beats/min, and his blood pressure is 110/70 mm Hg. His precordial impulse is prominent, and there is a loud second heart sound and a 2/6 holosystolic murmur at the cardiac apex with radiation to the left axilla. There is mild hepatomegaly and jugular venous congestion. Of the following, the MOST likely cause of this patient's findings is

A 2-month-old infant is brought to the clinic for the evaluation of poor feeding. He was born at 32 weeks of gestation with a birth weight of 1200 g. The pertinent physical findings are pallor, tachypnea, tachycardia, and flow murmurs. The laboratory studies are as follows: Hb 7 g/dl, WBC 7,000/mm3, Platelets 230,000/mm3, Reticulocytes Low. The peripheral smear shows normocytic normochromic RBC. What is the most likely diagnosis?

A 4-year-old boy is seen in the office for a general check-up. The child appears well nourished and has normal developmental milestones. His temperature is 36.6 C (98 F), pulse rate is 80/min, and blood pressure is 110/70 mmHg. On abdominal palpation, there is a lobular right-sided flank mass, and the kidneys are palpable bilaterally. What is the most likely cause of the flank mass in this child?

A 3-year-old child is taken to a pediatrician because he develops burning pain, erythema, and swelling minutes after being exposed to the sun. Physical examination demonstrates erythema with swelling of the hands and arms. The skin is thickened on the backs of the hands but does not show blistering or scarring. Which of the following is the most likely diagnosis?

A 9-month-old boy presented to his GP with lethargy and a prominent forehead. He is pale on examination and has yellow sclerae. He is the first child of his non-consanguineous parents. His haemoglobin is 6.5g/dL, wee 5.0 x109/L, platelets 300 x 109/L. His blood film shows evidence of haemolysis, no spherocytes, no sickle cells and a good reticulocyte count. Direct antiglobulin test (DAT) is negative. What is the most likely diagnosis?

A 14-month-old infant suddenly develops a fever of 40.2C (104.4F). Physical examination shows an alert, active infant who drinks milk eagerly. No physical abnormalities are noted. The WBC count is 22,000/μL with 78% polymorphonuclear leukocytes, 18% of which are band forms. Which of the following is the most likely diagnosis?

A 20-month-old boy has been referred due to delayed walking. On further questioning you establish he has no difficulty feeding, had head control at 3 months of age, and sat up by 8 months. He has been crawling for the last 8 months, but he does not pull to stand or walk with support. He has no dysmorphic features. There is no known family history of muscle problems. His mother has no myotonia. His mother is very concerned and asks you what is wrong. What is the most likely diagnosis?

A 6-year-old girl is taken to see her GP because she is complaining of knee and elbow pains frequently. Her mother thinks it is worst after her ballet classes and when she gets home from school. She denies stiffness or pain in the mornings. Her mother has been administrating paracetamol several times a week and is worried that this is too much to be giving a child. On examination, the child looks well and has full range of movement of her joints with evidence of hyperextension. There are no swollen joints or effusions present and she is non-tender on examination. What is the most likely diagnosis?

A 14-month-old male infant presents to the emergency room with a chief complaint of high grade fever with no response to antipyretic therapy. This illness started suddenly with the abrupt onset of fever early yesterday morning. He then developed a severe cough and increased work of breathing. The mother reports that he is frequently ill. He was hospitalized 2 months ago for pneumococcal pneumonia. On examination: PR: 145/min; RR: 55/min; BP 100/60mm Hg; oxygen saturation 91%; weight 7 kg (154 lbs). He is listless, tired, and small for age. Both ear canals contain purulent drainage. An immunologic work-up is done and found to have markedly elevated IgM, undetectable IgG and IgA with diminished total B-lymphocytes and neutrophils. Which of the following is the most likely diagnosis?

A 10-year-old girl with sickle cell disease presents to her GP on Monday morning complaining of weakness in her right leg. She says she collapsed on Saturday afternoon and has not felt right since. What is the most likely diagnosis?

A 7-year-old girl is hospitalized after the acute onset of fever, rapid development of hypotension, diffuse erythema of the skin, rapidly accelerating renal failure, and multisystem organ involvement. Toxic shock syndrome (TSS) is diagnosed. Of the following, the MOST likely finding associated with TSS caused by toxin-producing Streptococcus pyogenes is

A 30-minute-old male newborn is noted to have central cyanosis. He was born to a 16-year-old white female at 28 weeks gestation. His respirations are rapid and shallow at 70/min. His other vital signs are stable. On examination, there is audible grunting, intercostal and subcostal retractions, nasal flaring, and duskiness. On auscultation, fine rales are heard over the lung bases. Nasal oxygenation does not improve his cyanosis. A chest roentgenogram shows fine reticular granularity, predominantly in the lower lobes. Arterial blood gas analysis shows evidence of hypoxemia and metabolic acidosis. What is the most likely diagnosis of this patient?

A couple who are known to both be carriers of cystic fibrosis ask to see you. They had genetic counselling but declined antenatal diagnostic testing and their baby has now been born and is ready to be discharged home. The parents are now keen to get the baby tested so that if treatment is required it can be initiated early on. What initial test do you suggest for the baby?

A 17-year-old boy comes to medical attention because of recurrent sinusitis and pneumonia, and persistent watery diarrhea due to Giardia lamblia. His parents and a sister are in excellent health. Physical examination reveals enlarged lymph nodes in cervical, axillary and inguinal regions. A lymph node biopsy shows hyperplastic follicles with an absence of plasma cells. Laboratory investigations show: Hematocrit44%, Leukocyte count9, 800/mm3, Neutrophils55%, Lymphocytes30%, Monocytes5%, CD4 T-cell count1000 cells/mm3, Proteins, serum6.2 g/dL, Albumin5.0 g/dL, Globulin1.2 g/dL. Additional studies demonstrate severely depressed levels of serum IgG, with slightly below-normal levels of IgM and IgA. Which of the following is the most likely diagnosis?

You see a 7-day-old baby boy the day that his newborn screening test is reported to show a low thyroxine concentration of 7.8 mcg/dL (100.4 nmol/L) and a thyroid-stimulating hormone concentration of 25 mcU/mL. The baby had a birthweight of 3,000 g and now weighs 3,100 g and is 48.3 cm long. He looks healthy, and the thyroid is not palpable. The mother reports that she isbreastf eeding, and the baby seems to be feeding well. He is her first child. The mother tells you that she takes thyroid hormone for an underactive thyroid and has needed to take calcium and vitamin D since she was a small child ''to keep her calcium up.'' You look at her more closely and realize that she is plump, quite short (perhaps 4 ft 10 in), has a round face, and has short stubby fingers. She says that her mother also had short stature and similar problems. She has one brother who has similar problems and a sister who is 5 ft 6 in and does not have a problem with her calcium. Of the following, this baby and his mother MOST likely have

A 6-year-old Caucasian boy is brought to the emergency room by his mother with hemiplegia of acute onset. She states that she found the boy unconscious in his room where she had left him playing several minutes ago; and, he slowly gained consciousness, but could not move his right arm and leg. His past medical history is insignificant. Physical examination reveals right hemiparesis with little sensory abnormalities. No meningeal signs are present. The motor function restored spontaneously during 24-hour observation in the hospital. A CT scan of the head is normal. What is the most probable cause of this patient's problem?

A 14-year-old girl presented to the GP with an enlarged lymph node in her neck. She first noticed it 3 weeks ago and it is increasing in size. She has also had a dry cough, fevers, night sweats and weight loss. She has had a poor appetite over the last 2 weeks, which her mother blames for her weight loss. There is no history of foreign travel or tuberculosis (TB) contacts. A chest x-ray shows a mediastinal mass. What is the most likely diagnosis?

A 9-month-old boy is taken to the emergency room because of high fever. Breath sounds are diminished in the lungs, and a chest x-ray film shows lobar pneumonia. Probable streptococcal pneumonia is demonstrated in Gram's stain of sputum and then later confirmed by culture. The child responds to antibiotic therapy. A detailed history is taken during the admission, which reveals that this is the third episode of pneumonia in this young child; the two previous episodes occurred at 6 and 7.5 months of age. One of the mother's brothers had died of infection at age 9. Immunoglobulin studies demonstrate the following: IgG 80 mg/dL [normal 723-1685 mg/dL], IgA 60 mg/dL [normal 81-463 mg/dL], IgM 20 mg/dL [normal 48-271 mg/dL]. Studies of the lymphocyte population demonstrate normal numbers of T cells and markedly decreased B cells. Which of the following is the most likely diagnosis?

A 6-year-old boy is brought to the ER with a two-day history of difficulty walking. He is dragging his right leg and seems to have weakness in his right arm. He also complains of headaches. The family just emigrated from Eastern Europe. According to his parents, the child suffers from delayed growth compared to his peers and does not like to engage in active play. His lips and fingers turn blue when he cries. His vital signs today are a blood pressure of 100/70 mmHg, pulse of 90/min, temperature of 38.3 0C (102.0 0F), and respiratory rate of 22/min. Which of the following is most likely responsible for his current complaints?

A 12-year-old child who recently emigrated from southeast Asia has beta-thalassemia for which she has required frequent transfusions. She presents today with polyuria and polydipsia. On your initial evaluation, you detect a grade II/VI systolic murmur with a gallop rhythm, palpate the liver 4 cm below the costal margin, and determine that the girl is well below the 5th percentile for height. Of the following, the MOST likely diagnosis is

The parents of a previously healthy 2-year-old child note her to be pale and bring her to your clinic for evaluation. She currently has no fever, nausea, emesis, bone pain, or other complaints. Her examination is significant for pallor, tachycardia, and a systolic ejection murmur, but she has no organomegaly. Her complete blood count (CBC) reveals a hemoglobin of 4 g/dL, normal indices for age, a WBC count of 6.5/μL, and a platelet count of 750,000/μL. Her reticulocyte count is 0%. Coombs test is negative. Her peripheral blood smear shows no blast forms and no fragments. Red blood cell (RBC) adenosine deaminase levels are normal. A bone marrow reveals markedly decreased erythroid precursors. Which of the following is this child’s likely diagnosis?

A mother brings her 12-month-old boy to you because he holds his head tilted to the right. She tells you that he periodically draws up both his legs and cries. The child has developed normally, but does not yet walk or cruise. On physical examination, he has mildly increased deep tendon reflexes in the upper and lower extremities, but other findings are normal. Of the following, the study MOST likely to establish this boy's diagnosis is

A 3-year-old boy is admitted for seizure-like activity. He has been a healthy child and has been meeting all development milestones. His immunization schedule is up-to-date. Examination is notable for an erythematous throat and fever. His convulsions require IV administration of a benzodiazepine. Serum analysis reveals a normal white cell count with mild basophilic stippling. The lumbar puncture reveals elevated CSF pressure. Head CT scan is notable for cerebral edema. Which of the following is the next diagnostic step?

A 12-month-old male infant presents for an ear re-evaluation 1 month after being treated for his fourth episode of otitis media. His parents describe a normal birth history and normal development. The child is breastfed and does not attend child care. His immunizations are up to date through 6 months of age, including three doses of the conjugated pneumococcal vaccine. There is no history of sinusitis, pneumonia, sepsis, meningitis, or urinary tract infections. After the boy's last otitis media infection, your colleague measured the child's serum immunoglobulin (lg) concentrations, and results included a low IgG of 150 mg/dL (1.5 g/L), a normal lgM of 80 mg/dL (0.8 g/L), and a normal IgA of 40 mg/dL (0.4 g/L). Of the following, the next BEST laboratory test to evaluate this infant's antibody function is

The parents of a 3-year-old patient followed in your clinic recently took their child on quickly planned 5-day trip to Africa to visit an ill grandparent. Everyone did well on the trip, but since their return about 10 days ago the boy has been having intermittent, spiking fevers associated with headache, sweating, and nausea. The parents had not been too concerned since he was relatively well, except for being tired, between the fevers. Today, however, they feel that he looks a bit pale and his eyes appear “yellow.” Which of the following is likely to reveal the source of his problem?

An otherwise healthy 17-year-old complains of swollen glands in his neck and groin for the past 6 months and an increasing cough over the previous 2 weeks. He also reports some fevers, especially at night, and possibly some weight loss. On examination, you notice that he has nontender cervical, supraclavicular, axillary, and inguinal nodes, no hepatosplenomegaly, and otherwise looks to be fairly healthy. Which of the following would be the appropriate next step?

A 10-year-old boy has a long history of recurrent infections. These have included pneumonia, suppurative lymphadenitis, persistent rhinitis, dermatitis, diarrhea, and perianal abscesses. Involved organisms have included Staphylococcus aureus, Serratia, Escherichia coli, and Pseudomonas. Biopsy of skin and lymph nodes have demonstrated granulomatous lesions, even though the only species isolated were those noted above. Immunoglobulin levels are higher than normal. Which of the following findings would be most helpful in establishing the diagnosis?

You admitted to the hospital the previous evening a 1-year-old boy who presented with cough, fever, and mild hypoxia. At the time of his admission, he had evidence of a right upper lobe consolidation on his chest radiograph. A blood culture has become positive in less than 24 hours for Staphylococcus aureus. Approximately 20 hours into his hospitalization, the nurse calls you because the child has acutely worsened over the previous few minutes, with markedly increased work in breathing, increasing oxy- gen requirement, and hypotension. As you move swiftly to the child’s hospital room, you tell the nurse to order which of the following?

A 2-year-old who has a history of repaired biliary atresia presents to your office with fatigue and intermittent dark stools. On physical examination, he is afebrile and pale but active. His heart rate is 110 beats/min, liver and spleen are both enlarged, and abdomen is distended, with prominent abdominal veins. The hematocrit is 22 % (0.22). Of the following, the MOST appropriate next step is to

An 11-year-old girl was brought to accident and emergency in December with pain in her left leg. She is known to have sickle cell disease and her baseline haemoglobin is 7 .0 g/dL. She has been admitted in the past with painful leg and chest crises. She has a cough and coryza. Today her blood results show: haemoglobin 6.8, white cell count (WCC) 12 x109/L, platelets 209 x109/L, C-reactive protein (CRP) 20 mg/L. What is not part of the appropriate initial management?

An 8-month-old male infant is brought to the emergency department (ED) by his mother due to vomiting and a decreased urine output. Three days ago, he had a fever, sore throat and ear pain. He was subsequently diagnosed with otitis media and treated with oral amoxicillin. Today, in the ED, his temperature is 40.0C(104F), pulse is 80/min, respirations are 40/min and irregular, blood pressure is 100/60 mm Hg, and weight is 8kgs ( 15 lbs). He is lethargic and arousable only to painful stimuli. His anterior fontanel is full and tense. His tympanic membranes are red and bulging. His pupils are reactive, but his eyes do not focus well on his parents. What is the most appropriate next step in the management of this patient?

You inserted an endotracheal tube into a 2-year-old child who had severe head trauma after a motor vehicle crash. Initially, she had good chest rise, with oxygen saturations of 99% on 100% inspired oxygen delivered via bag-valve mask, but 10 minutes later, she suddenly deteriorates. Her oxygen saturation now is 60%, and her heart rate is 50 beats/min and falling rapidly. You note poor breath sounds on both sides of her chest and poor chest rise. Of the following, the BEST initial management of this patient is to

A 6-year-old boy is registering with a new GP, having just moved to the area. He is in a wheelchair but is able to mobilize with a fast scissoring gait over short distances. He has increased tone in his legs and has scars from previous tendon release surgeries. His upper limbs are normal. His mother says that his school performance is good and he is writing well. She thinks he was going to have a Statement of Special Educational Needs assessment before they moved. As the GP, what is the most appropriate next step in management?

A 32-year-old woman has a CXR screening, and a 1.5-cm mass is noted in the right lower lobe. She is a nonsmoker. Bronchoscopy shows a mass in the right lower lobe orifice, covered with mucosa. Biopsy indicates this is compatible with a carcinoid tumor. Imaging suggests ipsilateral mediastinal lymph node involvement but no extrathoracic disease. Which of the following is the most appropriate treatment plan?

A 1-month-old baby attends accident and emergency with a 2-day history of fever to 38.8°C measured at the GP surgery. He has been vomiting, with no diarrhoea, rash, cough or coryza. A clean catch urine has leukocytes +++ and ketones, no nitrites, blood or protein. An urgent microscopy shows >200 cells/ μL white cells. What is the most appropriate course of action?

An infant is delivered by cesarean section at 34 weeks' gestation because of preterm labor. There is no history of ruptured membranes, maternal fever, or abnormalities in fetal heart rate monitoring. The infant requires assisted ventilation with a bag-mask device and 100% oxygen in the delivery room. His Apgar scores are 5 and 7 at 1 and 5 minutes, respectively. An umbilical cord arterial pH is 7 .23 and base deficit is 3 mmol/L. He is admitted to the newborn nursery, but transferred to the neonatal intensive care unit (NICU) within 1 hour for respiratory distress manifested by tachypnea and grunting. His arterial blood gas results (obtained on room air) upon admission to the NICU are: pH, 7.20; Pco2, 70 mm Hg; Po2, 50 mm Hg, and base deficit 10 mmol/L. Of the following, the MOST common cause for this infant's respiratory distress is

You are asked to see a 14-year-old girl who developed pubic hair at age 11 years and breast buds at age 12 years, but has not reached menarche. She is a gymnast who practices 2 hours a day. Breast tissue is Sexual Maturity Rating (SMR) 2 and pubic hair is SMR 4. She is 57 in tall and weighs 86 lb. The results of gonadotropin laboratory studies are a luteinizing hormone concentration of 18 mIU/ml, (18 IU/L) (normal adult female, 2 to 70 mIU/ml, [2 to 70 IU/L]) and a follicle-stimulating hormone concentration of 40 mIU/mL ( 40 IU/L) (normal adult female, 1 to 30 mIU/mL [1 to 30 IU/L]). Of the following, the MOST likely cause of the primary amenorrhea in this patient is

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?

You are seeing a 6-year-old boy for a health supervision visit. He was born with trisomy 21 and an atrioventricular septal defect for which he underwent complete surgical repair at 2 months of age with an excellent result. His mother reports that he has not been sleeping well, that he snores loudly, and that she believes that he fatigues easily with play. On physical examination, he appears in no distress, his respiratory rate is 24 breaths/min, his heart rate is 100 beats/min, and his blood pressure is 110/70 mm Hg. His precordial impulse is prominent, and there is a loud second heart sound and a 2/6 holosystolic murmur at the cardiac apex with radiation to the left axilla. There is mild hepatomegaly and jugular venous congestion. Of the following, the MOST likely cause of this patient's findings is

A frail 6-year-old child who has cystic fibrosis is transported by ambulance to the emergency department. She has had hemoptysis for the past 4 hours, yielding approximately 10 mL of bright red blood. She has had increased cough over the past 3 days. Physical examination findings include a respiratory rate of 38 breaths/min, heart rate of 90 beats/min, oxygen saturation of 92% on room air, blood pressure of 100/70 mm Hg, and temperature of 98.6°F (37°C). She is awake and alert but seems breathless when she tries to speak. On auscultation, you note diffuse crackles throughout her lung fields. Of the following, the BEST next step in the management of this patient is to

The mother of a 6-month-old girl calls you because the infant has not been feeding well all day and appears pale. You tell her to meet you at the emergency department. Upon arrival, you find an awake, alert, but irritable child who wants to take her bottle but fatigues quickly thereafter. On physical examination, she has no fever, a respiratory rate of 50 breaths/min, heart rate of 250 beats/min, and blood pressure of 80/50 mm Hg. Her oxygen saturation is 98% in room air. Her lungs are clear, with good aeration. Her rapid pulse is palpable in all extremities, and she has a capillary refill time of 2 seconds. You administer oxygen and place the child on a cardiac monitor, which reveals a rapid heart rate with a narrow QRS complex. Of the following, the BEST management plan for this infant is

A 14-year-old overweight girl developed an episode of abdominal pain and jaundice 1 week ago. At that time, total bilirubin measured 8 mg/dL (136.8 mcmol/L) and direct bilirubin measured 5 mg/dL (85.5 mcmol/L). She was admitted to the hospital, where ultrasonography demonstrated a dilated common bile duct and gallbladder stones. She underwent endoscopic retrograde cholangiopancreatography (ERCP), and a gallstone was extracted from her common bile duct. She presents to your office today for follow-up and is asymptomatic. Physical examination demonstrates a normal-size liver and spleen without tenderness. Repeat laboratory studies reveal a total bilirubin of 2.5 mg/dL (42.8 mcmol/L) and direct bilirubin of 1.5 mg/dL (25.7 mcmol/L). Transaminase measurements are normal. Of the following, the MOST appropriate next step is to

A 15-year-old girl presents with diplopia after prolonged reading and ptosis that worsens in the afternoon. On examination, she is noted to have bilateral ptosis, impaired extraocular muscle movements, facial weakness, and generalized hypotonia and weakness increasing with repetition. Which of the following is the best diagnostic test for this disorder?

A 3-year-old African American boy is brought to the emergency department with sudden onset of difficulty walking. His mother reports that his right hand also seems "clumsy." The boy's past medical history is significant for a hospitalization one year ago for severe upper extremity pain and hand swelling. On physical examination, he has a blood pressure of 90/60 mmHg, heart rate of 120/min, temperature of 36.7°C (98°F), and respiratory rate of 22/min. Which of the following would be most helpful in diagnosing his condition?

A 2-year-old girl is brought to the emergency department with a fever, chills, poor appetite, and vomiting. On examination, she is irritable and diaphoretic. Her temperature is 39.2 C (102.5 F), blood pressure is 80/48 mm Hg, pulse is 88/min, and respirations are 17/min. She is tender at the left costovertebral angle. Initial laboratory tests show the following: Leukocyte count 16,300/mm3, Hemoglobin 12.5 g/dL, Platelet count 245,000/mm3, Blood urea nitrogen 6 mg/dL, Creatinine 0.5 mg/dl. Urinalysis is positive for leukocyte esterase and nitrite, with 150 white blood cells/hpf. After TV antibiotic administration and stabilization, what is the most appropriate diagnostic study?

A 2-year-old boy is brought to the clinic because of a swelling at the base of his neck on the left side. The family indicates that since he was born, they suspected he had some kind of a mass in his left supraclavicular area and behind the sternomastoid on that same side, but the area felt soft and mushy, was not always evident, and seemed to be painless, so they did nothing about it. Two weeks ago the child had an upper respiratory infection, and within a day or two the mass became larger and quite obvious. On physical examination he indeed has a soft, mushy, ill-defined mass occupying the entire left supraclavicular area and extending into the posterior triangle of the neck. He has no enlarged lymph nodes anywhere, and his spleen and liver are not palpable. Which of the following is the most appropriate next step in the evaluation?

A father brings his 3-year-old daughter to the emergency center after noting her to be pale and tired and with a subjective fever for several days. Her past history is significant for an upper respiratory infection 4 weeks prior, but she had been otherwise healthy. The father denies emesis or diarrhea, but does report his daughter has had leg pain over the previous week, waking her from sleep. He also reports that she has been bleeding from her gums after brushing her teeth. Examination reveals a listless pale child. She has diffuse lymphadenopathy with splenomegaly but no hepatomegaly. She has a few petechiae scattered across her face and abdomen and is mildly tender over her shins, but does not have associated erythema or joint swelling. A CBC reveals a leukocyte count of 8,000/μL with a hemoglobin of 4 g/dL and a platelet count of 7,000/μL. The automated differential reports an elevated number of atypical lymphocytes. Which of the following diagnostic studies is the most appropriate next step in the management of this child?

An 11-month-old boy is brought to the emergency department by his parents. The child has a fracture of the right femur. The father reports this was sustained as a result of falling out of the crib. The child is also noted to have bruises on his shoulders and back. The rest of his examination is unremarkable. Which of the following is the most appropriate next step in diagnosis?

A 2-year-old child is brought to the physician for a routine visit. He is growing and developing appropriately. He drinks 3-4 glasses of whole milk each day. He is starting to put words together into short sentences. His mother has no concerns. Physical examination shows mild pallor. Laboratory studies show the following: Hemoglobin 9.5 g/dL, RDW 21%, MCV 70 fl, Platelet count 284,000/mm3, Leukocyte count 6,500/mm3. Which of the following additional findings is most likely in this patient?

A 14-year-old boy is hit by an automobile while walking across the street and is immediately taken to the emergency department. On arrival, he is conscious and complains of shortness of breath and chest pain. Physical examination reveals an ecchymotic area over his right chest and subcutaneous emphysema. Breath sounds are absent on the right side. His trachea is deviated to the left, and his right hemithorax is tympanic to percussion. Which of the following is the most appropriate initial step in management of this patient?

1. An 18-year-old man was traveling at a high speed when his car slammed into a wall. He is brought into the emergency department by ambulance. His blood pressure is 60/40 mmHg, pulse is 115/min and weak, respirations are 18/min, and central venous pressure is 2 cmH2O. He is responsive only to painful stimuli. Breath sounds are equal bilaterally, and cardiac auscultation reveals only tachycardia. The abdomen is soft, nondistended, and nontender with active bowel sounds. A chest x-ray film shows a widened mediastinum. Which of the following is the most likely diagnosis?

2. A 30-year-old obese woman with no significant past medical history presents to the ED complaining of shortness of breath and coughing up blood-streaked sputum. The patient states that she traveled to Moscow a month ago. Upon returning to the United States, the patient developed a persistent cough associated with dyspnea. She was seen by a pulmonologist, who diagnosed her with bronchitis and prescribed an inhaler. However, over the following weeks, the patient’s symptoms worsened, and she developed pleuritic chest pain. In the ED, she lets you know that she smokes half a pack per day. Her vitals include a temperature of 99°F, BP of 105/65 mmHg, HR of 124 beats per minute, RR of 22 breaths per minute, and an oxygen saturation of 94% on room air. Physical examination is noncontributory, except for rales at the left-mid lung. Her ECG reveals sinus tachycardia with large R waves in V1 to V3 and inverted T waves. Given this patient’s history and presentation, what is the most likely etiology of her symptoms?

You have been asked to see a 72-year-old Caucasian woman who is 52 hours following uncomplicated laparoscopic cholecystectomy for gallstone disease. She was found unconscious on the ward with generalized tonic-clonic seizures, requiring 20 mg diazepam. Her sodium level is 112 mmol/L. During surgery she received 3 L of 5% dextrose with 20 mmol/L potassium chloride. Her potassium and urea and creatinine are within normal limits. There are no signs of heart failure. Her plasma osmolality is 265 mOsm/kg and her urinary osmolality is 566 mOsm/kg. Which of the following is the most likely cause for her low sodium?

A 25-year-old woman presents with lower abdominal pain, fever, and a vaginal discharge. Pelvic examination reveals bilateral adnexal (ovarian) tenderness and pain when the cervix is manipulated. Cultures taken from the vaginal discharge grow Neisseria gonorrhoeae. Which of the following is the most likely cause of this patient’s adnexal pain?

A 19-year-old male college student returns from spring break in Fort Lauderdale, Florida, with complaints of acute pain and swelling of the scrotum. Physical examination reveals an exquisitely tender, swollen right testis that is rather hard to examine. The cremasteric reflex is absent, but there is no swelling in the inguinal area. The rest of his genitourinary examination appears to be normal. A urine dip is negative for red and white blood cells. Which of the following is the appropriate next step in management?

A 12-year-old girl presents to your office for the first time with a swollen, painful, erythematous right knee joint. She tells you that her left knee felt and looked similar yesterday, but now feels normal. She also is easily fatigued and has had fever. On physical examination, she has a temperature of 101.7°F (38.7°C), a heart rate of 125 beats/min, a respiratory rate of 24 breaths/min, and a blood pressure of 120/78 mm Hg. Her lungs are clear. On auscultation, you note a 3/6 holosystolic murmur (Item Q87 A) at the cardiac apex with radiation to the axilla. Of the following, the BEST plan for management of this patient's joint swelling includes

A 10-year-old child is brought to your office for evaluation of a 1-day history of fever, vomiting, diarrhea, and abdominal pain. His mother states that he has vomited five times, and the emesis has been clear. He has had four episodes of nonbloody diarrhea. He describes his abdominal pain as crampy but cannot localize it to any specific part of his abdomen. He denies any symptoms of dysuria. On physical examination, the child is in no acute distress, his temperature is 99.2°F (37.3°C), heart rate is 102 beats/min, respiratory rate is 26 breaths/min, and blood pressure is 105/70 mm Hg. Results of examination of the head, neck, chest, and heart are normal. His abdomen is soft, and there is no guarding. There is no rebound tenderness. He complains of mild discomfort on deep palpation of his entire abdomen. He has hyperactive bowel sounds on auscultation, and he has no flank tenderness. Of the following, the MOST appropriate next step in the management of this patient is to

A 4-year-old girl with sickle cell disease presents to the emergency department with a temperature of 39.6 C (103.2F). Other than irritability, the physical examination is unremarkable. Laboratory evaluations reveal a white blood cell count of 18,200/mm3, with 88% polymorphonuclear neutrophils, 10% lymphocytes, and 2% monocytes, and a hemoglobin of 7.6 g/dL. Which of the following is the most appropriate next step in management?

A 35-year-old man complains of increasing shortness of breath with exercise. These symptoms have been ongoing for the last year. Previously he has been healthy. He denies any fever, chills, shakes, nausea, vomiting, diarrhea, chest pain, palpitations, hemoptysis, or weight loss. He denies any occupational exposure. He also reports a dry cough. He does not take any medications and has no known drug allergies. He denies a smoking history. His oxygen saturation is 93% on room air. Lungs have a fine crackle pattern. Heart is regular. Examination of the extremities shows clubbing. Chest x-ray reveals diffuse linear capacities. Pulmonary function tests show a restrictive pattern. He has a decreased diffusion capacity. Which of the following is the most likely diagnosis?

You are called to the emergency department to consult on a 34-year-old woman at 22 weeks’ gestation with a skin rash and shortness of breath. She states that the skin rash started 2 days ago on her trunk and has spread to her extremities. Earlier today she developed shortness of breath. She has been feeling like she has fever and chills, but she has not taken her own temperature. She has no other medical problems and has never had surgery. She works as a third-grade teacher. She has not been traveling recently, but one of her students recently had the chicken pox. On physical examination, her temperature is 38.1 C (100.6 F), blood pressure is 100/70 mm Hg, pulse is 116/min, and respirations are 18/min. Her lungs have diminished breath sounds bilaterally. Chest x-ray demonstrates diffuse, nodular, peribronchial infiltrates. Which of the following is the most appropriate next step in management?

A 52-year-old woman returns to the clinic for a followup appointment. She has had fatigue and anorexia for the past 6 months that, despite an extensive workup, including age-appropriate cancer screening, thyroid testing, routine blood studies, and psychiatric screening, has eluded a diagnosis. She now returns with the same complaints of fatigue and diminished appetite, but now is complaining also of lower abdominal bloating and pressure. Before these 6 months, she had been in excellent health. Her past medical history is unremarkable, though she does have an uncle who had diabetes and colon cancer, an aunt with breast cancer, and a mother who died of uterine cancer. Vital signs are within normal limits. Physical examination reveals a mildly distended, nontender abdomen that is increased in size since her last visit. Additionally, the pelvic examination reveals a possible nontender adnexal mass, though it is difficult to palpate. A CA-125 level is within normal limits. Which of the following is the most appropriate next diagnostic study?

A 39-year-old woman is 6 days post-partum and has come back to hospital with shortness of breath. She is struggling to breath at rest, has a respiratory rate of 28, pulse 115, BP 105/60 mmHg, temperature 37 .4 On examination she has an audible wheeze and cough. Investigations reveal a PO2 of 9.5 kPa on arterial blood gas and a PCO2 3.7 kPa, pH 7.36, base excess -3.4. A chest x-ray shows some upper lobe diversion and bilateral diffuse shadowing with an enlarged heart. Her haemoglobin is 8.9 g/dL, white blood count 11.1 x 109/L and C-reactive protein 21 mg/L. What is the most likely cause of her symptoms?

113. A 44-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. Cervical spine is immobilized. His breathing is normal. At the scene of the accident, his blood pressure is 70/30 mm Hg. After receiving two liters of intravenous 􀃓uid, his blood pressure is 80/40 mmHg. Neck veins are collapsed. Lungs are clear to auscultation. Abdomen is mildly distended. There is no obvious source of external bleeding. No intraperitoneal blood or solid organ damage is seen on ultrasonogram or diagnostic peritoneal lavage. Imaging studies reveal a pelvic fracture and fracture of the right fourth rib. Which of the following is the most appropriate next step in management?

119. A 42-year-old man is brought to the emergency department after a motor vehicle accident. He was a restrained driver and hit a car from behind on a highway. He drank one glass of wine before driving. He occasionally uses cocaine. His medical problems include mild intermittent asthma and peptic ulcer disease. On initial evaluation, his blood pressure is 112/92 mm Hg and pulse is 96/min. His pulse oximetry shows 95% on room air. Examination shows bruises on the anterior chest wall and abdominal wall. X-rays reveal a fracture of the eighth left rib but no pneumothorax or pleural e􀃗usion. Cervical C- spine series are negative. An ultrasound does not show free intraperitoneal 􀃓uid. An ECG shows normal sinus rhythm with no ST-segment or T-wave changes. He is treated with intravenous 􀃓uids and analgesics. Eight hours later, he complains of epigastric discomfort, left shoulder pain, and mild nausea. His blood pressure is 97/62 mm Hg and pulse is 112/min. His pulse oximetry shows 96% on room air. Which of the following is most likely to diagnose this patient's current condition?

135. A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following should be performed as part of the preoperative workup and management of this child’s disorder?

138. A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6°C (97.9°F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min, and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents and bile but no blood. His bleeding stopped a few hours after admission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again from the rectum. Packed red cells and intravenous 􀃓uid are started. Which of the following is the most appropriate next step in management?

72. A 72-year-old man undergoes an aortobifemoral graft for symptomatic aortoiliac occlusive disease. The inferior mesenteric artery (IMA) is ligated at its aortic attachment. Twenty-four hours after surgery the patient has abdominal distention, fever, and bloody diarrhea. Which of the following is the most appropriate diagnostic study for this patient?

37. A 35-year-old woman has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. The symptoms have been slowly progressive for about 5 years. She looks thin and cachectic, and has atrial 􀃒brillation and a low-pitched, rumbling diastolic apical heart murmur. At age 15, she had rheumatic fever. Surgery has been recommended. Which of the following is the most appropriate management?

86. A 26-year-old, drug-addicted man develops congestive heart failure over a period of a few days. He is febrile, has a loud, diastolic murmur at the right second intercostal space, and has a blood pressure of 120/20 mmHg. A physical examination performed a few weeks ago, when he attempted to enroll in a detoxi􀃒cation program, was completely normal. His blood pressure at that time was 120/80 mm Hg, and no murmurs were noted. In addition to long-term antibiotic therapy, which of the following is the most appropriate next step in management?

178. A 32-year-old, previously healthy man is a victim of a drive-by shooting, sustaining a gunshot wound to the left lower extremity. The entrance wound is located over the medial aspect of the calf, with an exit wound over the anterior pretibial region. Neurovascular examination of the extremity is normal. There is associated soft-tissue injury from the blast e􀃗ect and a severely comminuted tibial fracture demonstrated on radiographs. Appropriate management of this injury includes which of the following?178. A 32-year-old, previously healthy man is a victim of a drive-by shooting, sustaining a gunshot wound to the left lower extremity. The entrance wound is located over the medial aspect of the calf, with an exit wound over the anterior pretibial region. Neurovascular examination of the extremity is normal. There is associated soft-tissue injury from the blast e􀃗ect and a severely comminuted tibial fracture demonstrated on radiographs. Appropriate management of this injury includes which of the following?

16. A 55-year-old woman has been known for years to have mitral valve prolapse. She has now developed exertional dyspnea, orthopnea, and atrial 􀃒brillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back. Because of her deterioration, surgery has been recommended. Which of the following is the most appropriate procedure?

92. A 32-year-old man with a 3-year history of ulcerative colitis (UC) presents for discussion for surgical intervention. The patient is otherwise healthy and does not have evidence of rectal dysplasia. Which of the following is the most appropriate elective operation for this patient?

61. A 3-year-old African American boy is brought to the emergency department with sudden onset of di􀃕culty walking. His mother reports that his right hand also seems "clumsy." The boy's past medical history is signi􀃒cant for a hospitalization one year ago for severe upper extremity pain and hand swelling. On physical examination, he has a blood pressure of 90/60 mmHg, heart rate of 120/min, temperature of 36.7°C (98°F), and respiratory rate of 22/min. Which of the following would be most helpful in diagnosing his condition?

190. 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?

206. A 55-year-old woman comes to the physician for an annual physical examination. She has no new complaints, except fatigue. She has an 8-year history of chronic low back pain; severe degenerative joint disease has been documented on MRI. She had an anterior wall myocardial infarction four years ago. Her current medications include naproxen, acetaminophen, oxycodone, aspirin, atenolol, and simvastatin. Her blood pressure is 130/80 mm Hg and pulse is 72/min. Laboratory studies show: Hb 10 g/dl, WBC 6,000/cmm, Blood sugar 82 mg/dl, BUN 36 mg/dl, Serum creatinine 2.0 mg/dl. Urinalysis : Protein 2+, Glucose Absent, RBC AbsentWBC 10-15/HPF, Nitrite Negative, Esterase Negative, Sediment WBC casts. Serum protein electrophoresis is negative for monoclonal gammopathy. Two years ago, her BUN level was 22 mg/dl, and creatinine level was 1.6 mg/dl. Which of the following is the most likely pathology involved in this patient's renal failure?

238. A 70-year-old retired engineer is brought to the o􀃕ce 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 signi􀃒cant 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?

241. A 72-year-old woman complains of di􀃕culty "􀃒nding 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 di􀃕culty 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 de􀃒cit, and su􀃗ers from poor sleep, slowness of movement, shu􀃖ing gait and urinary incontinence. Which of the following is the most likely diagnosis?

232. A 65-year-old, obese, white female comes to the o􀃕ce for the evaluation of her progressively worsening memory. She considers herself "very independent," and lives alone; however, the development of her new symptoms is causing her some distress, as she often forgets to pay her bills. A detailed review of systems reveals no other symptoms, except for mild urinary incontinence. She has hypertension controlled with a beta-blocker and type 2 diabetes mellitus controlled with diet. She does not use tobacco, alcohol or drugs. Her blood pressure is 130/90 mmHg, pulse is 72/min, temperature is 36.7°C (98°F) and respirations are 14/min. Lungs are clear to auscultation and percussion. A grade 2/6, systolic ejection murmur is heard. Abdominal examination shows no tenderness or masses. Neurological examination shows broad-based, shu􀃖ing gait and a right-sided carotid bruit. Complete blood count and serum chemistry panel are within normal limits MRI shows enlarged ventricles. What is the most likely diagnosis?

10. 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 signi􀃒cant 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?

24. A 67-year-old Asian male comes to the clinic for the 􀃒rst time. He walks very slowly as he enters the room. His chief complaint is "extreme forgetfulness" for the past 6 months. He tearfully shares that he has been "losing sleep." He used to be a very "bright and sharp" person, but is now unable to focus on his daily activities and feels "really extremely low and useless." His past medical history is signi􀃒cant for hypertension, hypercholesterolemia, diabetes, benign prostatic hyperplasia, and TIA. His family history is insigni􀃒cant, except for Alzheimer's dementia in his father. He does not smoke, and drinks wine only occasionally. He has been living alone for the last 6 months, after his son moved out. His physical exam is normal, except for markedly slow movements. A CT scan of the head is normal. Which of the following is the most likely diagnosis?

27. A 60-year-old Hispanic female is brought to the emergency department due to a sudden onset of worsening, left-sided hemiplegia, which was followed by a headache and altered mental status. She was taking her regular morning walk when she developed these symptoms. Her past medical history is remarkable for uncontrolled essential hypertension. She has been a chronic smoker for the last 30 years. The neurological examination shows 􀃓accid paralysis on the left side, and deviation of eyes towards the right side. The CT scan is consistent with a hemorrhagic stroke. Which of the following is the most likely diagnosis?

31. 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 signi􀃒cant 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?

32. A 76-year-old woman presents for a routine medical check-up. Her medical history is signi􀃒cant 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 di􀃕culties 􀃒nding the right word. She drives herself to the grocery market weekly to do her shopping, and has no di􀃕culty managing her 􀃒nances. She describes her mood as good. She visits her close friends on occasion and often has di􀃕culty 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?

34. A 65-year-old man comes to the physician's o􀃕ce because of frequent falls. For the past 2 months, he has been having increasing di􀃕culty in maintaining balance when walking or standing. He tends to lose his balance on the left side, and feels that his "left body has become weak." He also complains of occasional headaches and nausea for the past 3 months. His other medical problems include hypertension, diabetes mellitus-type 2 and a myocardial infarction 10 years ago. He denies the use of tobacco, alcohol, or drugs. His medications include glyburide, aspirin and enalapril. His vital signs are within normal limits. When asked to get up from the chair and stand with his feet together, he tends to sway to the left, even with his eyes open. When asked to walk a few steps, he walks cautiously and lurches to the left. There is decreased resistance to passive 􀃓exion. Which of the following is the most likely diagnosis?

43. A 65-year-old Caucasian male presents to the emergency department with sudden onset of weakness in his right arm and right leg. He has had episodes of transitory weakness and numbness in his right extremities over the last month, but those episodes used to resolve quickly. He denies headache, nausea, vomiting and loss of consciousness. His past medical history is signi􀃒cant for hypertension, diabetes mellitus, type 2 and myocardial infarction experienced 2 years ago. His current medications are aspirin, metoprolol, enalapril, simvastatin, and glyburide. He does not smoke or consume alcohol. His blood pressure is 160/80 mmHg, pulse is 65/min, temperature is 36.7°C (98°F) and respirations are 14/min. The physical examination reveals right-sided hemiplegia and facial paresis. His speech and praxis do not seem to be impaired. He correctly names his left and right arms. Bedside visual 􀃒eld testing is normal. Head CT without contrast shows no intracranial bleeding Where is the most likely location of the lesion responsible for this patient's condition?

13. A 64-year-old diabetic with a long history of uncontrolled hypertension is admitted for chest pain. ECG reveals elevated ST segments in the anterior wall leads. Cardiac enzymes are elevated and the patient is admitted to the ICU for supportive care. He receives low molecular weight heparin and is placed on a nitroglycerin drip. He continues to have chest pain and requires intravenous morphine. Three days later, the patient is transferred to the 􀃓oor and he remains on bed rest. During the night the nurse on call informs you that the patient has a cold leg. On examination, the left leg is cold and there are no distal pulses. There is minimal swelling and the leg appears mottled. Emergency vascular surgery consult was placed and the appropriate treatment was given. Which of the following should also be considered in this patient?

121. A 46-year-old white male presents with chronic diarrhea, abdominal distention, 􀃓atulence, and weight loss. He also has arthralgias and bulky, frothy stools. He has never had blood transfusions, tattooing or highrisk sexual behaviors. His temperature is 38.3°C (101°F), blood pressure is 130/90 mm Hg, pulse is 84/min, and respirations are 16/min. Physical examination shows generalized lymphadenopathy and skin hyperpigmentation. Which of the following is the most appropriate diagnostic test?

Unconjugated bilirubin 145. A 42-year-old previously well woman presents with pruritus. She is not taking any medications, and only drinks alcohol on a social basis. Her physical examination is entirely normal with no signs of chronic liver disease or jaundice. Laboratory evaluation reveals an alkaline phosphatase level of three times normal, and an ultrasound of the liver and gallbladder is normal. Which of the following is the most appropriate next step in diagnosis?

82. A 29-year-old female is brought to the emergency department due to paraplegia, urinary incontinence and urgency. She denies any trauma. She has a history of trigeminal neuralgia. The neurological examination shows spasticity and hyperre􀃓exia in the lower extremities, and impaired vibration and proprioception in her left forearm. Which of the following is the most likely 􀃒nding in this patient's cerebrospinal 􀃓uid (CSF) examination?

83. A 28-year-old Caucasian female presents to the emergency department (ED) appearing very anxious. She is accompanied by her boyfriend. She woke up this morning with severe weakness over the right side of her body. The weakness came on all of a sudden, but gradually resolved during the day. She denies any sensory symptoms. Her boyfriend reports that her speech was "weird, almost as if she was stuttering or struggling to get her words out." This too has resolved. The patient denies any other symptoms. The only other history of note is that she returned from a holiday in Italy 2 days ago. Vitals signs are unremarkable. The neurological examination is normal. Her chest x-ray is within normal limits. EKG shows normal sinus rhythm with a rate of 82/min. An urgent head CT scan is within normal limits. Which of the following investigations is most likely to reveal the underlying cause of this episode?

85. A 26-year-old white female presents with worsening weakness of her right upper extremity, left lower extremity and ataxia. She also complains of unilateral eye pain and visual loss. The eye pain is worsened by ocular movements. On eye examination, there is a central visual 􀃒eld defect in her right eye. Fundoscopy is normal. Neurological examination shows spastic paraparesis in the right upper extremity and the left lower extremity. What is the most appropriate next step in this patient's management?

87. A 32-year-old female is brought to the clinic by her husband because he believes she is a malingerer and is "just being di􀃕cult." Sometimes, she appears confused and disoriented. Over the past year, she has complained of visual loss, eye pain and inability to do any household chores. Two months ago, she claimed to have lost control of her bladder. Interestingly, she is "her normal self" when it is time to go for summer trips. The wife insists that she does not understand what is happening to her, and adds that she occasionally loses the ability to move her right hand. The physical examination is basically normal. The patient appears, alert, oriented, and is in no distress. Which of the following is the most appropriate next step in management?

89. A 69-year-old comatose man is brought to the emergency department by an ambulance. His wife says that he has been hypertensive for the past twenty years, and he is not compliant with his medication. His pulse is 80/min and blood pressure is 240/140 mm Hg. The physical examination reveals reactive pupils, no oculocephalic re􀃓exes, no nystagmus, positive conjugate gaze deviation to the left, and re􀃓exes of 3/4 on the right and 2/4 on the left side. Which of the following is most likely to be seen on computed tomography?