(Exam) Part 2 WUKONG 7.1 (455-509) 255-509

78) A 9-year-old boy is brought to the office by his mother because of itching, burning and oozing skin lesions on both of his legs. The boy appears tanned. When asked if he had been spending time outdoors, he replies with great excitement that he just returned yesterday from a camping trip in the woods with his dad. Physical examination of both lower limbs reveals vesicles with erythema arranged in a linear fashion. Weepy and crusted lesions and edema are also present. What type of reaction is responsible for this boy's lesions?

79) A 15-year-old male is brought to the emergency department due to sudden-onset difficulty breathing for the past 45 minutes. He also complains of nausea, colicky abdominal pain and a swollen face. He has been suffering from bronchitis for the past 4 days, and his condition had been improving. His mother says that he had a similar episode when he had a tooth extraction 2 year ago. On examination, there is an edematous swelling of his face including the lips, hands, arms, legs, and genitals. His pulse is 82/min, blood pressure is 120/80 mmHg, respirations are 18/min and temperature is 36.8°C (98.4°F). Which of the following best explains the pathological process of his condition?

80) A 32-year-old Asian female presents to the office with a mole on her foot that recently became darker. She has always had skin that is very sensitive to sunlight. She is unable to tan, and has had several sunburns when she did not use sunscreens. Her past medical history is insignificant. Her mother had 'a kind of skin cancer.' Physical examination reveals a dark mole with irregular borders on the left foot. Which of the following is the strongest risk factor for malignancy in this patient?

81) A 25-year-old complains of fever and myalgias for 5 days and now has developed a macular rash over his palms and soles with some petechial lesions. The patient recently returned from a summer camping trip in Tennessee. Which of the following is the most likely cause of the rash?

82) A 53-year-old female presents to the clinic with an erythematous lesion on the dorsum of her right hand. The lesion has been present for the past 7 months and has not responded to corticosteroid treatment. She is concerned because the lesion occasionally bleeds and has grown in size during the past few months. On physical examination you notice an 11-mm erythematous plaque with a small central ulceration. The skin is also indurated with mild crusting on the surface. Which of the following is true about this process?

84) A 34-year-old homosexual male with a history of HIV presents to the clinic complaining of a wheezing and multiple violaceous plaques and nodules on his trunk and extremities. Physical examination of the oral mucosa reveals similar findings on his palate, gingiva, and tongue. Chest x-ray is also significant for pulmonary infiltrates. What is the most likely pathogenesis of this process?

85) A 40-year-old female presents with altered mental status and confusion. Last year, she was diagnosed with rheumatoid arthritis, for which she is currently using indomethacin and methotrexate. Her temperature is 37°C (98.6°F), pulse is 75/min, blood pressure is 110/70 mmHg, and respirations are 15/min. She is disoriented and irritable. Mucus membranes are moist. There is no jugular venous distention. Lungs are clear to auscultation. Abdomen is soft, nontender and not distended. There is no peripheral edema. Serum chemistry reveals: Sodium 122 mEq/L, Potassium 3.7 mEq/L, Bicarbonate 22 mEq/L, Blood glucose 90 mg/dL, BUN 9.0 mg/dL, Uric acid 3.0 mg/dL. Serum osmolality is 265mOsm/kg, while urine osmolality is 500 mOsm/kg. What is the most likely cause of this patient's hyponatremia?

86) A 25-year-old woman comes into the office with a three-month history of weight loss, irritability, insomnia, and palpitations. Her past medical history is insignificant. She is not taking any current medications and denies drug abuse. Her blood pressure is 155/70 mmHg and heart rate is 110/min. Physical examination reveals lid retraction, fine tremor of the hands, and increased neck circumference. The most probable cause of hypertension in this patient is?

87) A 55-year-old Caucasian male presents to the office for a routine check-up. He has no present complaints. His past medical history is significant for a long history of hypertension. He does not smoke or consume alcohol. His current medications are enalapril and hydrochlorothiazide. His blood pressure is 140/90 mmHg and heart rate is 80/min. Physical examination reveals a moderately overweight man (BMI = 27 kg/m2) with a waist circumference of 41 inches. The laboratory studies show: Fasting blood glucose 112 mg/dl, Total cholesterol 220 mg/dl, LDL cholesterol 140 mg/dl, Triglycerides 240 mg/dl. Which of the following is the most important pathogenic factor for this patient's condition?

88) A 38-year-old Mexican male presents to the emergency department with a history of weight loss, fever, cough with sputum, nausea, abdominal pain, and postural dizziness for the last three months. Adrenal insufficiency is suspected, and cosyntropin (synthetic ACTH) stimulation test is performed. The rise of serum cortisol following an injection of cosyntropin is grossly subnormal. CT scan of the abdomen shows calcification of both adrenal glands. What is the most likely cause of this patient's adrenocortical insufficiency?

89) A 60-year-old Caucasian male is brought to the emergency department by his daughter due to a 2-day history of confusion and lethargy. According to his daughter, he had been complaining of fatigue, anorexia, polyuria and constipation for the last several weeks. He smokes two packs of cigarettes daily, and consumes alcohol occasionally. His blood pressure is 130/90 mmHg and heart rate is 90/min. Physical examination reveals a somnolent patient who is not oriented in time. His lab values are: Serum Na 140 mEq/L, Serum K 4.0 mEq/L, Serum chloride 100 mEq/L, Serum bicarbonate 22 mEq/L, Serum creatinine 1.6 mg/dl, Serum calcium 13.4 mg/dL, Serum phosphorus 2.2 mg/dL, Blood glucose 100 mg/dL, Alkaline phosphatase 80 U/L. Chest x-ray demonstrates a right middle lobe mass and perihilar adenopathy. What is the most probable cause of this patient's symptoms?

90) A 51-year-old female comes to the office for a routine visit. She is apparently healthy and does not have any complaints. Physical examination reveals a thyroid nodule. She is surprised to hear about the nodule and asks, "How often does this happen? What could have caused this?" Which of the following is the most common cause of thyroid nodules?

91) A 46-year-old male presents with swelling of his face that is especially prominent in the periorbital area. He also complains of bilateral ankle swelling. He denies shortness of breath, fever and discoloration of urine. He is a non-smoker and non-alcoholic. His past medical history is not significant. He is currently not taking any medication. His pulse is 78/min, blood pressure is 130/70mmHg, respirations are 14/min and temperature is 37.1°C (99.0°F). Examination shows bilateral pitting ankle edema. Auscultation reveals clear lungs, normal heart sounds, and no murmurs. Dipstick urinalysis is positive for protein. 24-hour urine collection shows proteinuria of 4.6 g/day. Lab studies show: Total serum calcium 7.5 mg/dL, Albumin 2.2 g/dL, Phosphorus 3.5 mg/dL, Magnesium 2.2 mg/dL, Creatinine 0.8 mg/dL. Which of the following is the most likely cause of his low serum calcium level?

92) A 36-year-old white male is brought to the emergency department because of dyspnea, tachypnea, crampy pain and paresthesias in his extremities. He gives an unclear history about how he "rapidly ascended to a height of 10,000 feet” His pulse is 70/min, blood pressure is 120/80 mmHg, temperature is 36.7°C (98.5°F) and respirations are 24/min. The significant physical finding on examination is carpopedal spasm. At this point, the suspected diagnosis is acute respiratory alkalosis secondary to hyperventilation. Which of the following is true regarding this patient's serum calcium level?

93) A 23-year-old Caucasian male with muscular weakness, vomiting and abdominal pain is brought to the emergency department. He had a minor respiratory illness 2 days ago. His past medical history is significant for diabetes mellitus, type 1. He admits skipping his insulin shots yesterday and today because he had no appetite. His temperature is 37.8°C (100°F), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 27/min. His oral mucosa is dry. The laboratory values are: Serum sodium 132 mEq/L, Serum potassium 5.4 mEq/L, Serum calcium 8.9 mEq/L, Serum chloride 96 mEq/L, Serum bicarbonate 12 mEq/L, Blood glucose 470 mg/dl,BUN 19 mg/dL, Serum creatinine 1.1 mg/dL. Which of the following is the most likely cause of the increased potassium level in this patient?

94) A 29-year-old white female presents to the emergency department with nausea, vomiting, severe generalized abdominal pain, and hypotension. She is subsequently admitted to the intensive care unit. Her past medical history is significant for hypothyroidism secondary to Hashimoto's thyroiditis, for which she has been taking levothyroxine. She denies smoking cigarettes, drinking alcohol, and using any intravenous drugs. Her mother also has hypothyroidism. Her blood pressure is 70/50 mmHg, heart rate is 110/min, temperature is 98.4°F (37.0°C) and respiratory rate is 24/min. Physical examination reveals dry and pigmented mucous membranes. The skin creases also show increased pigmentation. Lab studies show: Serum chemistry: Serum Na 130 mEq/L, Serum K 6.1 mEq/L, Chloride 96 mEq/L, Bicarbonate 18 mEq/L, BUN 33 mg/dL, Serum creatinine 1.3 mg/dL, Blood glucose 56 mg/dL. CBC: Hemoglobin 10.8 g/L, Platelets 300,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 70%, Eosinophils 10%, Lymphocytes 20%. The random serum cortisol level is 3.2 mcg/dL (normal=5 to 25 mcg/dL), and ACTH level is 142 pg/mL (normal= 9 to 52 pg/mL). What is the most likely involved pathophysiologic mechanism of this patient's disorder?

95) A 40-year-old male patient presents with a thyroid nodule. His other complaints are episodes of palpitations, anxiety and sweating. He denies heat intolerance. His weight and appetite are normal. He has a family history of thyroid cancer. His pulse is 80/min, and blood pressure is 160/100 mmHg. Examination of the neck shows a 4-cm, hard, non-tender thyroid nodule. The urinalysis, serum sodium, serum potassium, serum calcium, serum creatinine, serum PTH, TSH, T3 and T 4 levels, and the EKG are all normal. The serum calcitonin level is elevated. The urinary levels of metanephrine and norepinephrine are increased as well. FNA biopsy of the thyroid nodule shows malignant cells. Genetic testing shows a mutation in the RETproto oncogene. Which of the following abnormalities is also present in most patients suffering from this disorder?

96) A 45-year-old female presents complaining of constipation and abdominal pain for the past two weeks. She also complains of urinary frequency and constant thirst. Her past medical history is significant for obesity. She tells you that she has been trying very hard to lose weight, and over the past six months has even attempted various fad diets. She assures you that she supplements her intake with numerous over-the-counter vitamins and minerals. She has managed to lose 20 lbs during this time. Her medical history is also significant for atrial fibrillation for the past 4 years, for which she takes diltiazem. On physical examination, her temperature is 36.8°C (98.2°F), blood pressure is 120/70 mmHg, pulse is 90/min, and respirations are 13/min. Her mucous membranes are dry, and her abdomen is soft and non-tender without rebound or rigidity. Bowel sounds are present. Urinalysis is within normal limits. Which of the following is most likely responsible for her current symptoms?

97) A 19-year-old football linebacker is admitted following a motor vehicle accident. He had an extensive cerebral bleed, which led to a deep coma. He also has fractures of the C4 vertebra, pelvis, and right femur. Following admission, he is intubated and central lines are placed. During the next few days, he develops acute renal failure due to rhabdomyolysis. While he is recovering from acute renal failure, he is found to have a serum calcium level of 12.1 mg/dL. Other investigations are: Serum albumin 3.0 g/dL, Serum creatinine 2.8 mg/dL, Serum phosphorus 3.8 mg/dL, Blood glucose 108 mg/dL, PTH 9 pg/mL, PTHrP undetectable, 1, 25-dihyroxy vitamin D 19 pg/mL (normal 20-60 kg/mL). What is the most likely cause of this patient's hypercalcemia?

98) A 28-year-old avid mountain climber and his friend are vacationing in Andes, South America. During their mountain climbing expedition, the pair somehow manages to get lost. It has been over 16 hours since their food supply ran out. Their glycogen stores are becoming depleted, and their bodies are beginning to utilize the process of gluconeogenesis. Which of the following intermediates is alanine being converted into during this process?

99) A 60-year-old Caucasian male presents to your office complaining of decreased hearing on the right side. He also feels that something is wrong with his head because his hat size had increased over the last two years. His past medical history is significant for hypertension and peptic ulcer disease. His current medications are hydrochlorothiazide and enalapril. He also takes ibuprofen for occasional headaches, and ranitidine for infrequent episodes of heartburn. Lab tests showed increased alkaline phosphatase levels. Which of the following is the most likely mechanism underlying this patient's condition?

100) A 60-year-old man presents to his primary care physician for routine medical care. He has no complaints, takes no medications, and has a family history of DM. Examination is unremarkable. A screening laboratory test reveals a fasting blood glucose level of 152 mg/dL. One week later the test is repeated and a value of 144 mg/dL is obtained. Which of the following is the most likely cause of these findings?

102) A 28-year-old woman presents to her gynecologist for her annual examination. She mentions that she and her husband have been trying to conceive for 9 months without success and that her menstrual cycles have become irregular. Her gynecologist suggests that she and her husband continue to try to conceive and that the woman return in 3 months for some laboratory studies if she still has not become pregnant. In the interim, a routine visit to the ophthalmologist reveals bitemporal hemianopsia. Which of the following is the most likely cause of this woman’s infertility?

103) A 50-year-old obese female is taking oral hypoglycemic agents. While being treated for an upper respiratory infection, she develops lethargy and is brought to the emergency room. Neurological examination is nonfocal; she does not have neck rigidity. Laboratory results are as follows: Na: 134 mEq/L, K: 4.0 mEq/L, HCO3: 25 mEq/L, Glucose: 900 mg/dL, BUN: 84 mg/dL, Creatinine: 3.0 mg/dL, HgA1c: 6.8%, BP: 120/80 mmHg lying down, 105/65 mmHg sitting. Which of the following is the most likely cause of this patient’s coma?

104) An obese 18-year-old woman is brought to the emergency department by her mother, who noted that she had been lethargic all day, and suffered a brief, seizure-like episode. One month earlier, the patient had been started on medication for type 2 DM. Lactic acid levels are normal. Which of the following medications most likely played a role in the patient’s current presentation?

105) A 52-year-old African-American woman with type 2 diabetes mellitus (DM) presents to her physician’s office and states that she has been feeling lousy in the morning. She notes that she reliably checks her blood glucose levels, and is frustrated at the fact that she often has a blood sugar level in the 120s at night, followed by a level in the 170s to 180s the following morning. The patient’s primary care physician increased her nightly dose of neutral protamine Hagedorn insulin 1 month ago, but her morning glucose levels have only become more elevated. She has recently begun to limit her carbohydrate intake at night, with no effect. This patient’s morning hyperglycemia might most likely be alleviated by which of the following?

106) A 26-year-old G1P0 woman at 12 weeks gestation presents to her obstetrician for her first visit. Her pregnancy thus far has been notable only for some mild nausea and vomiting that lasted throughout her first trimester. She reports feeling overly tired lately and very weak. Her past medical history is significant for pernicious anemia. On physical examination she is an anxious-appearing, thin woman. Her blood pressure is 130/85 mmHg, heart rate is 115/ min, and respiratory rate is 18/min. Fetal heart tones are present at 135/min. The uterine fundus is at 12 cm. The woman has a diffuse, non- tender goiter, a resting tremor, and poor global muscle strength. Which is the most likely mechanism underlying this woman’s condition?

107) A 60-year-old woman recently diagnosed with type 2 DM complains of daily headaches and double vision that have gradually worsened over the previous month. An MRI shows a large pituitary adenoma. Which of the following is most likely being secreted by this tumor?

108) A 45-year-old Asian male complains of a progressively worsening sore throat and difficulty swallowing for the past 24 hours. You notice that his voice is muffled and he is drooling. He also has a harsh shrill associated with respiration. His temperature is 39.3°C (103°F), blood pressure is 120/80 mmHg, pulse is 106/min, and respiratory rate is 22/min. On examination, a few cervical lymph nodes are palpable and there is tenderness to palpation over his larynx. Which of the following are the two most common organisms that cause this condition?

109) A 65-year-old female complains of difficulty eating over the last two days. She states that food drops out of her mouth. She has also been having some discharge in her left ear recently. She denies any sore throat, nasal discharge, chest pain, cough, or difficulty breathing. Her past medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. She has been poorly complaint with follow-up appointments. Her temperature is 38.8°C (101.7°F), pulse is 96/min, blood pressure is 140/90 mmHg, and respirations are 18/min. Examination of the left ear canal shows granulations. There is facial asymmetry, and the angle of the mouth on the left is deviated downward. Which of the following is the most likely causative organism for this patient's condition?

110) A 62-year-old male comes to your office for a routine follow-up appointment. He has smoked one pack of cigarettes per day for the past 30 years and adamantly refuses to quit. He also drinks six to ten beers each weekend. His past medical history is significant for type 2 diabetes mellitus and hypertension. His last hemoglobinA1c was 8.3%. He is overweight with a current BMI of 27.5 kg/m2. While examining him, you notice a whitish patch over the anterior floor of his mouth. The lesion appears to have a granular texture and is not removed by scraping with a tongue depressor. Which of the following is most likely cause of his oral lesion?

111) A 51 -year-old obese male presents to your office complaining of difficulty swallowing solids but not liquids. His medical history is significant for GERD. Six months ago he was diagnosed with Barrett's esophagus. He reports that three months after the diagnosis of Barrett's esophagus, his heartburn resolved. Barium swallow now reveals an area of symmetric, circumferential narrowing affecting the distal esophagus. Which of the following best explains this finding?

112) A 23-year-old man comes to the physician because of a two-month history of loose stools, decreased appetite, and weight loss. He has no history of medical problems. He takes no medications. His temperature is 36.7°C (98°F), blood pressure is 120/76 mmHg, pulse is 90/min, and respirations are 16/min. Laboratory studies show: Hemoglobin 11.2 g/dL, MCV 80 fl, Leukocyte count 9,500/cmm, Segmented Neutrophils 65%, Bands 3%, Eosinophils 1%, Basophils 0%, Lymphocytes 25%, Monocytes 6%, Platelets 550,000/cmm, ESR 50 mm/hr, Serum sodium 145 mEq/L, Serum potassium 4.0 mEq/L. Test of the stool for occult blood is positive. Which of the following is the most likely type of diarrhea in this patient?

113) A 66-year-old man presents with a four week history of increasing back pain and severe constipation. He has no weakness or sensory symptoms in his legs. He takes acetaminophen for back pain, metoprolol for high blood pressure, and an over-the-counter fiber supplement for constipation. A screening colonoscopy 5-year ago was unremarkable. Rectal examination shows no abnormalities. Examination of the stool for occult blood is negative. His blood pressure is 135/80 mmHg and heart rate is 80/min. Abdominal examination shows no abnormalities. Laboratory studies show: Hb 9.5 g/dl, WBC 7,000/cmm, Platelets 300,000/cmm, BUN 28 mg/dl, Serum Creatinine 1.9 mg/dl, ESR 80/hr. Which of the following is the best explanation for this patient's constipation?

114) A 12-year-old girl comes to the physician for chronic weight loss and fatigue. She has a history of bulky, floating, foul-smelling stools, flatulence and meteorism. She also has bone pain and easy bruising. Laboratory studies show anemia with serum iron: 25 mg/dl , ferritin: 25 mg/dl and serum total iron binding capacity 600 mg/dl (normal 300-360 mg/dL); PT is 16 sec. Physical examination shows loss of subcutaneous fat, pallor, hyperkeratosis and abdominal distention; bowel sounds are increased. Which of the following is most likely associated with this patient's condition?

115) A 44-year-old male who has had an extensive small bowel resection for Crohn's disease has been on total parenteral nutrition for two years. He presented to the hospital with epigastric and right upper quadrant pain. He has been taking azathioprine. His vital signs are within normal limits. Physical examination shows mild right upper quadrant tenderness. An ultrasonogram shows several gallstones; an ultrasonogram performed two years ago did not demonstrate gall stones. Which of the following is the most likely cause of his gallstones?

116) A 35-year-old Caucasian male presents to the emergency department with two episodes of bloody vomiting which occurred one-half hour ago. He has a history of migraines. For the past two days, he has been having severe headaches and has taken 20 tablets of aspirin without relief. He then resorted to heavy drinking and forgot about the pain. He drinks alcohol "occasionally" and has been smoking 1 pack of cigarettes daily for the past 18 years. Which of the following is the most likely explanation for this patient's hematemesis?

117) A 29-year-old male with a 6-year history of HIV infection presents with chronic, severe diarrhea associated with malaise, nausea, anorexia and abdominal cramps. His last CD4 count was 80cells/mm3. A modified acid-fast stain of a stool specimen shows 4-6 mm oocysts. Which of the following is the most likely microorganism responsible for this condition?

118) A 45-year-old Caucasian male presents with a 2-year history of progressive heartburn which is most severe while supine. Over-the-counter antacids have not relieved his symptoms. Endoscopy shows a hiatal hernia. The patient is reluctant to accept any treatment. Which of the following is he at risk for if his condition is left untreated?

119) A 45-year-old male comes to the physician with a 6-month history of periodic abdominal pain. He tried several over-the-counter medications including H2 blockers and proton pump inhibitors with moderate success. Workup, including an upper GI series and endoscopy, showed multiple duodenal ulcers and a single jejunal ulcer. Test of the stool for occult blood is positive. Test of the stool for fat is positive. Which of the following is the best explanation for this patient's impaired fat absorption?

120) A 58-year-old man presents with a one-year history of diarrhea. The stools are watery and accompanied by abdominal cramps. He denies any fever, blood per rectum, or foul-smelling stools. He has also experienced frequent episodes of dizziness, flushing, wheezing, and a feeling of warmth. He has taken herbal medicines, which failed to relieve his symptoms. He is depressed about his illness, and feels hopeless about diagnosis and treatment. He appears ill. Auscultation of the chest shows a 2/6 systolic murmur over the left lower sternal border. Abdominal examination shows hepatomegaly 3cm below the right costal margin, mild shifting dullness, and no abdominal tenderness. Laboratory studies show: Hb 13.0gm/dl, MCV 90fl, WBC 6,100/cmm, Platelets 210,000/cmm, AST101 U/L, ALT 99 U/L, Alkaline phosphatase 400 mg/dl. This patient is at risk of developing a deficiency of which vitamin or mineral?

121) A 65-year-old Caucasian male presents to your office with a several month history of difficulty swallowing. He has noticed a right-sided neck mass which increases in size while drinking fluids. His past medical history is significant for hypertension, gastroesophageal reflux disease, and osteoarthritis of his right knee. His current medications include hydrochlorothiazide, ranitidine, and occasional naproxene. You order a barium examination of the esophagus to visualize the abnormality. Which of the following is the most important pathogenetic factor in the development of this patient's problem?

122) A 20-year-old male university student presents with a one-month history of 4 to 6 loose watery bowel movements per day with occasional tenesmus, urgency, and abdominal cramps. He also describes a two-week history of intermittent bright red blood per rectum. His appetite and energy levels are excellent and his weight is stable. He is otherwise healthy and takes no medications. His family history is unremarkable. He has not recently used antibiotics nor has he traveled outside the country. He does not use tobacco, alcohol or drugs. Sigmoidoscopy demonstrates mild erythema and rectal biopsy confirms acute mucosal inflammation. Which of the following is a potential complication of this condition requiring regular surveillance?

123) A 46-year -old alcoholic man comes to the emergency department because of several episodes of vomiting. The last episode of emesis contained blood. Five hours ago, he had a fatty meal and several alcoholic drinks. Two days ago, he had an upper GI tract endoscopy and abdominal ultrasound for the evaluation of dyspepsia. The endoscopy was unremarkable, and the ultrasound showed a hyperechogenic enlarged liver and stones in the gallbladder. His temperature is 36.6°C (97.9°F), blood pressure is 120/70 mm Hg, pulse is 95/min, and respirations are 15/min. Laboratory studies show: Hb 12.8 g/dl, WBC 5,400/cmm, BUN 26 mg/dl, Creatinine 1.1 mg/dl, AST 100 U/L, ALT 45 U/L, Bilirubin 0.7 mg/dl. Nasogastric suction shows normal stomach contents mixed with bright red blood. The rectal examination shows no melena. Which of the following is the most likely explanation for this patient's bloody vomiting?

124) A 53-year-old woman presents to your office with right-sided abdominal pain that started two days ago. She describes the pain as constant and burning in nature. There is no associated nausea, vomiting or diarrhea. The patient reports taking over-the-counter antacids and ibuprofen, which brought no relief. Her medical history is significant for breast cancer diagnosed one year ago, for which she underwent a modified radical mastectomy and is receiving chemotherapy, the last course of which was completed two months ago. On physical examination, her temperature is 36.7°C (98°F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 16/min. Her lung fields are clear to auscultation and her abdomen is soft and non-distended. The liver span is 10 cm and the spleen is not palpable. Lightly touching the skin to the right of the umbilicus elicits intense pain. In one week the patient is most likely to develop:

125) A 20-year-old Caucasian male presents with lower abdominal pain for the past few hours. The pain first started around the umbilicus, but then shifted to the right lower abdominal area. He has had one episode of vomiting. Physical examination shows tenderness at McBurney's point. CT scan of the abdomen confirms the diagnosis of acute appendicitis. Which of the following explains the pathophysiology of the shifting of pain from the peri-umbilical area to the right lower quadrant in acute appendicitis?

126) A husband and wife present to the ED with 1 day of subjective fever, vomiting, watery diarrhea, and abdominal cramps. They were at a restaurant a day before for dinner and both ate the seafood special, which consisted of raw shellfish. In the ED, they are both tachycardic with temperatures of 99.8°F and 99.6°F for him and her, respectively. Which of the following is responsible for the majority of acute episodes of diarrhea?

127) A 21-year-old woman presents to the ED complaining of diarrhea, abdominal cramps, fever, anorexia, and weight loss for 3 days. Her BP is 127/75 mm Hg, HR is 91 beats per minute, and temperature is 100.8°F. Her abdomen is soft and nontender without rebound or guarding. WBC is 9200/μL, β-hCG is negative, urinalysis is unremarkable, and stool is guaiac positive. She tells you that she has had this similar presentation four times over the past 2 months. Which of the following extraintestinal manifestations is associated with Crohn disease but not ulcerative colitis?

128) A 67-year-old woman is currently postoperative day 8 after an emergent laparoscopic cholecystectomy for acute cholecystitis. On postoperative day 2 she spiked a temperature of 40°C (101.4°F) and began to complain of some shortness of breath. X-ray of the chest revealed right lower lobe pneumonia, and the patient was started on clindamycin. Today she is experiencing multiple episodes of foul-smelling, watery diarrhea that is green tinged but non-bloody. She also complains of lower abdominal cramping. Her temperature is 37.8°C (100°F), pulse is 90/min, respiratory rate is 15/min, and blood pressure is 110/70 mm Hg. Which of the following is the most likely explanation for these findings?

129) A 73-year-old woman presents to the emergency room with black tarry stools and symptoms of presyncope when standing up. Digital rectal examination confirms the presence of melena. She recently started using ibuprofen for hip discomfort. Upper endoscopy confirms the diagnosis of a gastric ulcer. Which of the following is the most likely explanation for the gastric ulcer?

130) A 77-year-old woman is brought to the emergency room because of nonspecific abdominal discomfort. She has no anorexia, fever, chills, or weight loss. Her abdomen is soft and non-tender on physical examination. Abdominal x-rays show lots of stool in the colon, but no free air or air-fluid levels. The amylase is 150 U/L (25–125U/L), and the rest of her biochemistry and complete blood count are normal. Which of the following conditions can cause a false positive elevation in the serum amylase?

131) A 76-year-old woman with a history of congestive heart failure, coronary artery disease, and an “irregular heart beat” is brought to the ED by her family. She has been complaining of increasing abdominal pain over the past several days. She denies nausea or vomiting and bowel movements remain unchanged. Vitals are HR of 114 beats per minute, BP 110/75 mm Hg, and temperature 98°F. On cardiac examination, her HR is irregularly irregular with no murmur detected. The abdomen is soft, nontender, and nondistended. The stool is heme-positive. This patient is at high risk for which of the following conditions?

132) A 78-year-old man with a history of atherosclerotic heart disease and congestive heart failure presents with increasing abdominal pain. The pain began suddenly a day ago and has progressively worsened since then. He denies nausea, vomiting, and diarrhea, but states that he had black tarry stool this morning. He denies any history of prior episodes of similar pain. Vitals are BP 120/65 mm Hg, HR 105 beats per minute, and temperature 99°F. The patient is at high risk for which of the following conditions?

133) A 29-year-old man with acquired immune deficiency syndrome (AIDS) comes to the emergency department because of progressively increasing abdominal discomfort. Examination shows voluntary guarding in the upper abdomen. His biochemistry is normal except for an elevated amylase at 370 U/L (25–125 U/L). Which of the following infections can trigger this disorder in AIDS patients?

135) A 33-year-old woman develops mild epigastric abdominal pain with nausea and vomiting of 2 days duration. Her abdomen is tender on palpation in the epigastric region, and the remaining examination is normal. Her white count is 13,000/mL, and amylase is 300 U/L (25–125 U/L). Which of the following is the most common predisposing factor for this disorder?

136) A 54-year-old man complains of burning epigastric pain that usually improves after a meal, and is occasionally relieved with antacids. On examination, he appears well and besides some epigastric tenderness on palpation, the rest of the examination is normal. Upper endoscopy confirms a duodenal ulcer. Which of the following statements concerning PUD is most likely correct?

137) A 60-year-old man with no past medical history undergoes upper endoscopy and biopsy for an upset stomach that is worsened by eating. He is found to have inflammation predominantly in the antrum of the stomach. Which of the following is the most likely etiology of this condition?

138) A 23-year-old woman presents to the ED complaining of pain with urination. She has no other complaints. Her symptoms started 3 week ago. During this time, she has been to the clinic twice, with negative urine cultures each time. Her condition has not improved with antibiotic therapy with sulfonamides or quinolones. Physical examination is normal. Wet mount showed epithelial cells. Which of the following organisms is most likely responsible for the patient’s symptoms?

141) A term boy with Apgar scores of 9 and 9 at 1 and 5 minutes has failed to pass meconium at 72 hours. He has had no episodes of emesis, and his abdomen is only mildly distended to palpation. The patient’s mother reports that her older son had the same problem at birth. A plain radiograph of the abdomen shows a small bowel obstruction with numerous air-filled loops of bowel. The patient is treated with a diatrizoate meglumine (Gastrografin) enema, with good results. Which of the following is the most likely mechanism for this infant’s acute intestinal problem?

142) You are working in the ED on a Sunday afternoon when four people present with acute-onset vomiting and crampy abdominal pain. They were all at the same picnic and ate most of the same foods. The vomiting began approximately 4 hours into the picnic. They deny having any diarrhea. You believe they may have “food poisoning” so you place IV lines, administer IV fluids, and observe. Over the next few hours, the patients begin to improve, the vomiting stops, and their abdominal pain resolves. Which of the following is the most likely cause of their presentation?

143) A 43-year-old man feels vaguely unwell. Physical examination is unremarkable except for evidence of scleral icterus. The skin appears normal. Which of the following is the most likely explanation for why early jaundice is visible in the eyes but not the skin?

144) A 56-year-old woman becomes the chief financial officer of a large company and, several months thereafter, develops upper abdominal pain that she ascribes to stress. She takes an over-the-counter antacid with temporary benefit. She uses no other medications. One night she awakens with nausea and vomits a large volume of coffee grounds-like material; she becomes weak and diaphoretic. Upon hospitalization, she is found to have an actively bleeding duodenal ulcer. Which of the following statements is true?

145) A 50-year-old man wants to talk to you about something, "absolutely confidential". After you assure him, he admits, "He is unable to get an erection and just can't have sex." He wants to figure it out quickly because "he simply can't live like this." He has never been diagnosed with diabetes and denies other complaints. He has a 2 pack/day history of smoking for 30 years. On examination, his BP: 158/90mm of Hg; Temperature: 37.1°C (98.8°F); RR 14/min; PR 82/min. There is upper body obesity, rounded face, increased fat around the neck, and thinning of arms and legs. You find his skin to be bruised, fragile and thin. Laboratory reveals the following results. Serum: Glucose 186 mg/dl, Sodium 142 mEq/L, Potassium 2.5 mEq/L, Bicarbonate 38 mEq/L. Chest X ray shows a large mass in left bronchus. What is the most likely cause of patient's condition?

146) A 66-year old female has been your patient for the last 8 years. She was diagnosed with colorectal carcinoma 2 years ago, and eventually underwent an endoscopic resection. Since then, she has been healthy, and has been coming to the office regularly for follow-up visits. She is very grateful, and has stated many times that she owes her life to you. You are currently a co-investigator of a retrospective observational study of patients with colon cancer, and you believe that including her medical information will be extremely beneficial. What course of action must you take so that you can include this patient's data in your study?