USMLE_Diagnosis X

A 56-year-old male comes to the emergency room because of increasing shortness of breath for the last 3 days. He had a cold recently, and since then his symptoms have been worse. He has a mild productive cough but denies fever or chills. He has a several year history of smoking and has been diagnosed with emphysema. He also has a history of diabetes, hypertension, hyperlipidemia, and hypothyroidism. He takes glipizide, metformin, lisinopril, furosemide, aspirin, atorvastatin and levothyroxine. Physical examination shows trace bilateral lower extremity edema and a diffuse decrease in breath sounds along with wheezing. Heart sounds are distant. His arterial blood gas shows the following: Blood pH 7.23, PaO2 88mm Hg, PaCO2 40 mm Hg, HCO3- 16mEq/L. Which of the following best describes the acid-base status of this patient?

A 56-year-old male presents with progressively worsening dyspnea and ankle edema. He denies chest pain syncope or palpitations. He does not smoke or drink alcohol. He denies diabetes mellitus, hypertension, or hyperlipidemia. His temperature is 37.1°C (98.7°F), pulse is 70/min, blood pressure is 136/70mmHg, and respirations are 15/min. Examination shows elevated jugular venous pressure, bilateral ankle edema, and tender hepatomegaly. Chest auscultation shows bibasilar rales. His heat sounds are distant and there is no murmur. Chest x-ray shows mild cardiomegaly and a right-sided pleural effusion. ECG shows low voltage QRS complexes and nonspecific ST-T wave changes. Echocardiography shows normal left ventricular volume with symmetrical thickening of the left ventricular walls and slightly reduced systolic function. Which of the following would represent a potentially reversible cause of this patient’s heat disease?

A 56-year-old male with a history of type-2 diabetes presents for a routine office visit. His blood work from two months ago showed hyperkalemia, and at that time his physician discontinued lisinopril. His repeat blood work done today is shown below: Chemistry panel: Serum sodium 136 mEq/L, Serum potassium 5.6 mEq/L, Chloride 110 mEq/L,Bicarbonate 18 mEq/L, Blood urea nitrogen (BUN) 26 mg/dl, Serum creatinine 1.9 mg/dl. He currently takes glipizide, furosemide, nifedipine and aspirin. His blood pressure is 150/90 mmHg. Examination is unremarkable. Which of the following is the most likely cause of his low bicarbonate and elevated potassium?

A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full-blown paralysis to become obvious, and it has been present now for 3 months. It affects both the forehead and the lower face. He has no pain anywhere, and no palpable masses by physical examination. Which of the following is the most likely diagnosis?

A 56-year-old man has been having bloody bowel movements on and off for the past several weeks. He reports that the blood is bright red, it coats the outside of the stools, and he can see it in the toilet bowl even before he wipes himself. When he does so, there is also blood on the toilet paper. After further questioning, it is ascertained that he has been constipated for the past 2 months and that the caliber of the stools has changed. They are now pencil thin, rather the usual diameter of an inch or so that was customary for him. He has no pain. Which of the following is the most likely diagnosis?

A 56-year-old man has been hospitalized for a myocardial infarction. Two days after admission, he awakens in the middle of the night and screams that there is a man standing by the window in his room. When the nurse enters the room and turns on a light, the patient is relieved to learn that the “man” was actually a drape by the window. This misperception of reality is best described by which of the following psychiatric terms?

A 56-year-old man is brought to the physician’s office by his wife because she has noted a personality change during the past 3 months. While the patient is being interviewed, he answers every question with the same three words. Which of the following symptoms best fits this patient’s behavior?

A 56-year-old man is evaluated for chronic cough. It is present most of the time and is progressively getting worse over the past 3 years. With the cough he usually has white to yellow sputum that he has to expectorate. There is no history of wheezing, asthma, congestive heart failure (CHF), or acid reflux disease. He currently smokes one pack a day for the past 25 years. On examination, his chest is clear. CXR is normal and his forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) on spirometry are normal. Which of the following is the most likely diagnosis?

A 56-year-old white male comes to the office for a health maintenance visit. He feels healthy, and is "enjoying life as much as possible in a stressed environment." He smokes 2-3 packs of cigarettes daily and drinks socially. His temperature is 37°C (98.6°F), blood pressure is 160/94 mm Hg, pulse is 78/min, and respirations are 14/min. Physical examination reveals plethora of the face and moderate splenomegaly. Blood tests show the following: WBC 15,600/mm3, Hemoglobin 17 gm/dl, Hematocrit 52%, Platelets 550,000mm3, RBC count 7.5 million, Sodium 141 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 22 mEq/L, Blood urea nitrogen 16 mg/dl, Creatinine 0.6 mg/dl, Glucose 95 mg/dl. The erythrocyte indices are all within normal range. What is the most probable diagnosis?

A 56-year-old woman has been treated for 3 years for wheezing on exertion, which was diagnosed as asthma. Chest radiograph, shown here, reveals a midline mass compressing the trachea. Which of the following is the most likely diagnosis?

A 56-year-old woman is brought to the emergency room with shortness of breath, which she says began suddenly two hours ago while she was enjoying her favorite television show. She also reports the simultaneous onset of sharp, left-sided chest pain. Her previous medical history includes diabetes mellitus for the past 10 years and hypertension for the past 6 years. Her family history is significant for heart disease in her father, who died at age 40. Her medications include enteric-coated aspirin, captopril and glipizide. She has a 30 pack-year smoking history, but does not smoke currently. On physical examination, she is in acute distress and is sweating profusely. Her temperature is 38.0°C (100.5°F), pulse is 140/min and irregular, respiratory rate is 30/min, and blood pressure is 110/60 mm Hg. Her oxygen saturation is 84% on room air by pulse oximetry. Jugular venous pressure is within normal limits and her lungs are clear to auscultation. Serum analysis reveals the following: Hematocrit 40%, WBC count 11,600/mm3, Platelet count 190,000/mm3. Chest x-ray is unremarkable. ECG reveals irregular RR intervals, with no definite P waves and narrow QRS complexes. Which of the following is the most likely cause of her current symptoms?

A 56-year-old woman is complaining of cough for the past 4 months. The cough was dry initially, but only yesterday she was scared-to-death to see phlegm with blood. She is not feeling well and thinks that she has lost "a lot of weight" recently, despite no apparent change in her diet. She swears that she has never smoked a cigarette in her life. There is no history of night sweats nor contact with any person with similar complaints. She is a housewife who rarely drinks, and can't think of using recreational drugs. She is completely faithful to her husband. Her husband is also a "religious non-smoker". Her vitals are stable and lung examination reveals no significant findings. Her chest x-ray shows 1.5cm lesion in the right peripheral lung field and no evidence of any hilar or mediastinal lymph node enlargement. What is the most probable diagnosis?

A 56-year-old woman is referred to you about 3 months after a colostomy subsequent to a sigmoid resection for cancer. She complains that her stoma is not functioning properly. Which of the following is the most common serious complication of an end colostomy?

A 56-year-old woman presents for evaluation of a murmur suggestive of mitral stenosis and is noted on echocardiography to have a lesion attached to the fossa ovalis of the left atrial septum. The mass is causing obstruction of the mitral valve. Which of the following is the most likely diagnosis?

A 56-year-old woman presents to the clinic with a 7-month history of headache and visual disturbance. Her past medical history is unremarkable. She is currently not taking any medications. She admits to smoking a pack of cigarettes daily for the last 15-years, and does not drink. On visual field examination, there is a small field defect noted in both eyes. MRI scan shows a pituitary tumor. Which of the following is the most common type of pituitary tumor?

A 57-year-old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit for 1 week, where he required chest tubes for pleural effusions and was on a respirator for several days. Eventually, he improved sufficiently to be transferred to the floor. Three days after leaving the unit, and about 2 weeks after the onset of the disease, he spikes a fever and develops leukocytosis. Which of the following developments do these recent findings most likely suggest?

A 57-year-old male presents to the emergency department with recent-onset dyspnea and cough. He reports that his symptoms began earlier this morning while he was jogging, when he suddenly started feeling short of breath and very weak. In the emergency department, laboratory analysis reveals a markedly elevated serum b-type natriuretic peptide level. Which of the following clinical signs best correlates with this finding?

A 57-year-old man presents to the emergency department complaining of right arm weakness. He says that he first 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 significant 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 reflex 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 58-year-old G6P4Ab2 diabetic woman who weighs 122.6 kg (270 lb) has her first episode of vaginal bleeding in 5 years. Her physician performs an outpatient operative hysteroscopy and dilatation and curettage (D&C). Which of the following is an indication for the procedure and the most likely diagnosis?

A 58-year-old man presents to the emergency department complaining of fever and chills. The fever started last night and has not subsided, even though he took acetaminophen. He had a successful appendectomy 3 days ago and was discharged from the hospital 2 days ago. His only medication is ibuprofen, which is adequately controlling his pain. He is a 30-pack-year smoker with a chronic cough productive of white sputum. He has noticed increased sputum production, which has become yellowish-green. He denies dysuria, urgency, or frequency. His temperature is 38.4°C (101.1°F), heart rate is 88/min, respiratory rate is 16/min, and blood pressure is 126/74 mm Hg. On examination he appears to be tired but not in acute distress. Pulmonary examination is limited because deep inhalation causes coughing and slight abdominal pain. There is no tactile fremitus or dullness to percussion. He has a slightly erythematous, appropriately tender healing incision in the right lower quadrant without exudates and normal active bowel sounds. Extremities are warm and well perfused without erythema or edema. Pulses are intact. Which of the following most likely could have prevented this condition?

A 58-year-old man presents with pain in the left leg after walking more than one block that is relieved with rest. On physical examination, distal pulses are not palpable in the left foot and there is dry gangrene on the tip of his left fifth toe. An ankle-brachial index on the same side is 0.5. Which of the patient’s symptoms or signs of arterial insufficiency qualifies him for reconstructive arterial surgery of the left lower extremity?

A 58-year-old woman with a chronic mental disorder comes to the physician with irregular choreoathetoid movements of her hands and trunk. She states that the movements get worse under stressful conditions. Which of the following medications is most likely to have caused this disorder?

A 58-year-old woman with stage II epithelial ovarian cancer undergoes successful surgical debulking followed by chemotherapy with carboplatin and radiation therapy. Subsequently, she develops non-pitting edema of both legs and pain and numbness in her legs. Which of the following is the most likely cause of her pain and numbness?

A 59-year-old Caucasian female presents to the emergency department with sudden onset paralysis of her bilateral lower extremities. She has no other symptoms. Physical examination reveals normal tone, normal deep tendon reflexes, and no Babinski sign. Her motor strength is 3/5 in both lower extremities. The remainder of her examination is unremarkable. The patient dramatically improves after she is injected with sodium amytal. What is the most likely diagnosis?

A 59-year-old G4P4 presents to your office complaining of losing urine when she coughs, sneezes, or engages in certain types of strenuous physical activity. The problem has gotten increasingly worse over the past few years, to the point where the patient finds her activities of daily living compromised secondary to fear of embarrassment. She denies any other urinary symptoms such as urgency, frequency, or hematuria. In addition, she denies any problems with her bowel movements. Her prior surgeries include tonsillectomy and appendectomy. She has adult-onset diabetes and her blood sugars are well controlled with oral Metformin. The patient has no history of any gynecologic problems in the past. She has four children who were all delivered vaginally. Their weights ranged from 8 to 9 lb. Her last delivery was forceps assisted. She had a third-degree laceration with that birth. She is currently sexually active with her partner of 25 years. She has been menopausal for 4 years and has never taken any hormone replacement therapy. Her height is 5 ft 6 in, and she weighs 190 lb. Her blood pressure is 130/80 mmHg. Based on the patient’s history, which of the following is the most likely diagnosis?

A 59-year-old male is brought to the emergency department with severe dyspnea and left-sided chest discomfort. He says that he was driving to work when he began to feel suddenly weak and short of breath. He has a long history of chronic obstructive pulmonary disease, esophageal reflux and chronic pyelonephritis. He smokes one pack of cigarettes per day. His current medications include ranitidine and inhaled ipratropium and albuterol as needed. Physical examination reveals trace ankle edema, decreased breath sounds over the left chest and scattered wheezes over the right chest. ECG shows sinus tachycardia. Arterial blood gas analysis is given below: pH 7.42, pO2 59 mmHg, pCO2 41 mmHg. Which of the following most likely underlies this patient's current condition?

A 59-year-old man goes to a psychiatrist for a 3-month history of panic attacks. He notes for the past 3 months he has experienced “out of the blue,” extreme episodes of fearfulness that last about 20 minutes. During that time he experiences palpitations, sweating, shortness of breath, and trembling. He denies any substance abuse, and has never had symptoms like this before these past 3 months. Which of the following signs or symptoms would likely lead the physicians to expect a diagnosis of anxiety secondary to a general medical condition in this case?

A 59-year-old man is brought to the office by his family due to attitude problems over the last year. He has a history of memory loss and word-finding problems. He has lost interest in golf, which used to be one of his favorite sports. Recently, he has become promiscuous and has started using "dirty language," which he has never used before. He is a non-smoker. He has no significant past medical or surgical history. His uncle had similar features, for which he was admitted into a nursing home, but died soon after admission. The physical examination reveals intact visuospatial functions, intact cranial nerves, and prominent snout and grasp reflexes. What is the most likely diagnosis?

A 59-year-old man presents to his internist for a routine visit. He has no complaints, and review of symptoms is negative. His past medical history is significant for poorly controlled hypertension for 15 years due to noncompliance with antihypertensive medications. He takes hydrochlorothiazide 25 mg orally four times a day. His family history is significant for hypertension, heart failure, and stroke. He has a 30-pack-year smoking history and drinks two beers a day. On physical examination he is a mildly obese man in no acute distress. He has a normal jugular venous pressure. He has a prominent point of maximum impulse, regular rate and rhythm, normal S1, loud S2, and audible S4 with no murmurs. His lungs are clear to auscultation bilaterally, and he has no signs of edema. His abdominal and neurologic examinations are within normal limits. His temperature is 37.0°C (98.6°F), pulse is 81/min, respiratory rate is 12/min, blood pressure is 165/96 mmHg, and oxygen saturation is 100% on room air. His ECG shows normal sinus rhythm with large amplitude of the S wave in V1 and V2 and of the R wave in V5 and V6. Also present are diffuse ST segment/T wave changes, widened bifid P waves, and prolonged QRS waveforms. Which of the following is the most likely diagnosis?

A 59-year-old obese man comes to the office "to make sure everything is okay." Yesterday after lunch, he experienced weakness in his right upper arm and right lower extremity. He was limping, and his right hand was not strong enough to hold some heavy things. His speech was "somewhat faulty”, and he had a light diffuse headache. By dinnertime, his symptoms were resolving, and when he woke up this morning, his weakness was gone. His past medical history is significant for hypertension, for which he takes atenolol. He has been smoking 1 pack of cigarettes a day for the past 40 yrs. His blood pressure is 150/95 mm of Hg and heart rate is 78/min. The neurological examination is normal. There is a mild carotid bruit on his left side. What is the most likely diagnosis?

A 59-year-old woman who had been diagnosed with infiltrating ductal carcinoma 2years prior presents with pain of her right breast. The breast is swollen, tender on palpation, and is diffusely indurated with a “peau d’orange” appearance. Multiple axillary lymph nodes are palpable in the lower axilla. A skin biopsy from her breast reveals extensive invasion of dermal lymphatics. What is the best diagnosis?

A 6-day-old girl who was born at home is being evaluated for bruising and gastrointestinal bleeding. Laboratory findings include partial thromboplastin time and prothrombin time, greater than 2 minutes; serum bilirubin, 4.7 mg/dL; alanine aminotransferase, 18 mg/dL; platelet count, 330,000/mm3; and hemoglobin, 16.3 g/dL. Which of the following is the most likely cause of her bleeding?

A 6-month-old boy is found to have bilateral metaphyseal fractures of both proximal and distal ends of the tibia. The mother says that her boyfriend takes care of the infant while she is at work. Her boyfriend explains the injuries as the result of multiple falls from bed. Which of the following is the most likely diagnosis?

A 6-month-old infant has poor weight gain, vomiting, episodic fevers, and chronic constipation. Laboratory studies reveal a urinalysis with a pH of 8.0, specific gravity of 1.010, 1+ glucose, and 1+ protein. Urine anion gap is normal. Serum chemistries show a normal glucose and a normal albumin with a hyperchloremic metabolic acidosis. Serum phosphorus and calcium are low. What is the best diagnosis to explain these findings?

A 6-month-old infant is taken to the emergency department because he had a seizure. Physical examination demonstrates premature closure of cranial sutures and markedly bowed legs. Laboratory studies demonstrate low serum phosphate levels, with normal vitamin D and parathyroid hormone levels. Urinalysis shows high phosphate levels, but no increased excretion of glucose, amino acids, or protein. The child's maternal grandfather had crippling bone disease, and his mother has mild bowing of the legs. Which of the following is most likely diagnosis?

A 6-month-old infant presents to the emergency department with the new onset of weak cry, decreased activity, and poor feeding. The mother also states that the infant has been constipated for the past 2 days. On physical examination, the infant has a very weak cry, poor muscle tone, and absent deep tendon reflexes. Which of the following is the most likely diagnosis?

A 6-month-old previously health child is brought to the doctor's office because of sudden onset of lethargy, constipation, generalized weakness and poor feeding. He has been meeting all development milestones and his immunization schedule is up to date. On further questioning, his parents mention that his diet was recently advanced to a homemade formula of evaporated milk and honey. On physical examination, he has stable vital signs, clear lungs, normal skin turgor and full fontanelles. Which of the following is the most likely explanation for the patient's presentation?

A 6-week-old boy is brought to the physician because of a rash involving the diaper area. On examination, there are erythematous, slightly scaly patches covering the buttocks and the lower abdomen. Skin creases appear spared. The baby is otherwise healthy. Physical examination reveals no lymphadenopathy, fever, or other signs of organic illness. Which of the following is the most common cause of this condition?

A 6-year-old boy has insidious development of limping with decreased motion in one hip. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Examination of the knee is normal, but passive motion of the hip is guarded. The child is afebrile, and the parents indicate that his gait and level of activity were completely normal all his life until this recent problem. He has not had a recent febrile illness. Which of the following is the most likely diagnosis?

A 6-year-old boy is brought into the emergency room by his mother for walking with a limp for several weeks. On examination, the patient has tenderness over his right thigh without evidence of external trauma. An x-ray of the pelvis shows a right femoral head that is small and denser than normal. Which of the following is the most likely diagnosis?

A 6-year-old boy is brought to the emergency department (ED) by the paramedics due to nausea, vomiting, diarrhea and abdominal pain over the past hour. His mother found an open multivitamin supplement bottle and some pills scattered on the kitchen floor. After his admission to the ED, he starts hyperventilating and experiences hematemesis. His blood pressure is 90/60 mmHg, pulse is 130/min, respirations are 50/min and temperature is 37.2 C (99F). Abdominal plain x-ray reveals several small opacities in the stomach and duodenum. Lab results are: Hb 13.5 g/dL, Ht 42%, WBC 10,000/mm3, Platelets 300,000/mm3, Blood Glucose 118 mg/dL, Serum Na 135 mEq/L, Serum K 34 mEq/L, Chloride 102 mEq/L, Bicarbonate 16 mEq/L, BUN 16 mg/dL, Serum Creatinine 1.0 mg/dL, pH 7.30, P02: 90 mm Hg, PC02: 29 mm Hg. What is the most likely diagnosis?

A 6-year-old boy is brought to the emergency department because of the acute onset of headache, nausea, and vomiting. On arrival, physical examination reveals marked nuchal rigidity and funduscopic evidence of papilledema. A head CT scan reveals a solid tumor in the posterior fossa, centered in the cerebellar vermis and extending to the fourth ventricle. An emergency craniotomy is performed, during which a small sample of the tumor is sent to the pathologist for a frozen section consultation. 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 6-year-old boy is brought to the office by his mother due to a decreased appetite and irritability for the past three days. He also had an episode of diarrhea yesterday. Lately, he has been sitting close to the television with the volume turned up very loudly. His temperature is 38.1°C (100.5°F), blood pressure is 110/60 mmHg, and heart rate is 110/min. On examination, there is left-sided yellowish ear discharge. His nasal mucosa appears boggy and postnasal drip is present. What is the most likely diagnosis?

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 6-year-old boy is brought to the physician for evaluation of behavior problems. His parents report he is "hyperactive all the time." They cannot get him to sit still. When he does sit, he fidgets and tries to get out of his seat. He is easily distracted and frequently changes from one activity to another. He does not seem to listen when his parents talk to him, and often forgets to do his chores. He talks excessively and often interrupts other people. His parents state that he has been like this for a few years, but they had originally assumed his behavior was normal for his age. His physical examination is unremarkable. Which of the following will be of most help in establishing the diagnosis?

A 6-year-old boy is brought to your practice by his paternal grandmother for his first visit. She has recently received custody of him after his mother entered the penal system in another state; she does not have much information about him. You note that the child is short for his age, has downslanting palpebral fissures, ptosis, low-set and malformed ears, a broad and webbed neck, shield chest, and cryptorchidism. You hear a systolic ejection murmur in the pulmonic region. His grandmother reports that he does well in regular classes, but has been diagnosed with learning disabilities and receives speech therapy for language delay. His constellation of symptoms is suggestive of which of the following?

A 6-year-old boy presents in clinic for a routine visit. Examination reveals coarse, dark pubic hair, an enlarged penis and testes, and acne of the face and upper back. His mother notes that he has a body odor similar to that of her teenage son after playing sports. The child is in file 99th percentile of height for his age group. Which of the following is the most likely diagnosis?

A 6-year-old boy presents to the emergency department with a cough, sore throat, and malaise of 4 days’ duration. Examination reveals a temperature of 101.5°F, erythematous pharynx, and a tender right neck mass with overlying erythema. Which one is the most likely diagnosis?

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 6-year-old Caucasian male is brought to your office with a two-week history of right shoulder pain. Physical examination reveals localized swelling below the shoulder joint, and x-ray shows a single lytic lesion in the right humeral head. Laboratory analyses show mild hypercalcemia but are otherwise within normal limits. Which of the following is the most likely diagnosis?

A 6-year-old female is brought to the physician with a rash and joint pains. Her mother reports that she has been previously healthy except for a sore throat a few weeks ago. One week ago, the patient developed pain in her knees. The knee pain resolved after a few days, but now her ankles and wrists are tender. She has also developed a pink rash on her trunk that is non-pruritic. Vital signs are temperature 38.3°C (101°F), pulse 85/min, and respiratory rate 20/min. On examination, there is pain and stiffness during manipulation of the wrists and ankles. A faint, erythematous, centrifugal rash on her trunk and proximal limbs is present. Laboratory studies show: Complete blood count: Hemoglobin 12.5 g/dL, MCHC 32%, MCV 85 fl, Reticulocyte count 0.1%, Platelet count 200,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%, C-reactive protein 3.5 mg/dL, Erythrocyte sedimentation rate 38 mm/hr. Which of the following is the most likely diagnosis?

A 6-year-old female is brought to the physician with a rash and joint pains. Her mother reports that she has been previously healthy except for a sore throat a few weeks ago. One week ago, the patient developed pain in her knees. The knee pain resolved after a few days, but now her ankles and wrists are tender. She has also developed a pink rash on her trunk that is non-pruritic. Vital signs are temperature 38.3 c (101 F), pulse 85/min, and respiratory rate 20/min. On examination, there is pain and stiffness during manipulation of the wrists and ankles. A faint, erythematous, centrifugal rash on her trunk and proximal limbs is present. Laboratory studies show: Complete blood count: Hemoglobin 12.5 g/dL, MCHC 32%, MCV 85 fl, Reticulocyte count 0.1%, Platelet count 200,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 56%, Eosinophils 1%, Lymphocytes 33%, Monocytes 10%, C-reactive protein 3.5 mg/dL, Erythrocyte sedimentation rate 38 mm/hr. Which of the following is the most likely diagnosis?

A 6-year-old female with Down syndrome is brought to the physician for behavioral changes. Over the past few weeks, she has begun refusing to do her usual activities. Her parents also report that she seems dizzy and state that she has developed urinary incontinence. On examination, she is hypotonic but hyperreflexic with a positive Babinski reflex. Her gait is ataxic. Which of the following is the most likely diagnosis?

A 6-year-old girl has a low-grade fever, headache, and nasal congestion. She has a flushed face and has developed a lacy reticular rash on the trunk and extensor surface of her arms and legs. Palms and soles are spared. Her mother has been ill with a low-grade fever and some joint stiffness and pain. Which of the following is the most likely diagnosis?

A 6-year-old girl states that she has had vaginal bleeding for the past 3 days. She is brought to the office by her worried mother. The mother states that the child has no medical problems and is not on any medications. She denies headache or visual changes. General physical examination is consistent with a normal 6-year-old female without breast budding. External genitalia are unremarkable with no pubic hair. Which of the following is the most likely diagnosis?

A 6-year-old girl with acute lymphocytic leukemia (ALL) is admitted to the hospital with a generalized vesicular rash and high fever. She has no previous history of chickenpox and has never received immunization for varicella. Her 4-year-old sister recently recovered from chickenpox that started about 10 days ago. On admission, her temperature is 38.4 C (101.1 F), blood pressure is 94/58 mm Hg, pulse is 80/min, and respirations are 20/min. Which of the following is the most serious complication of varicella that might occur in this patient?

A 6-year-old male presents to the physician with eyelid swelling. His mother noted an insect bite on his left cheek yesterday, and states that this morning his left eyelid was completely swollen shut and painful. He has not had a fever, fatigue, headache, or rhinorrhea. On examination, he is afebrile. The left eyelid is erythematous, tender to palpation, and swollen shut. When trying to clinically distinguish between preseptal and orbital cellulitis, which of the following findings is most likely to be seen with preseptal cellulitis?

A 60-year-old Caucasian man comes to the physician because of a productive cough and dyspnea on exertion. He denies hemoptysis, chest pain, and leg swelling. He has smoked one-and-a-half packs of cigarettes daily for 40 years and drinks 2-ounces of alcohol daily. He has worked in a shipyard for 10 years. His temperature is 37.2°C (99°F), blood pressure is 140/80 mmHg, pulse is 80/min, and respirations are 20/min. His chest x-ray shows prominent bronchovascular markings and mild diaphragmatic flattening. His pulmonary function testing shows decreased FEV1/FVC ratio and normal DLCO. Which of the following is the most likely diagnosis?

A 60-year-old female comes to your office for progressive exertional dyspnea and new-onset ankle swelling. She has been recently worked up for proteinuria and easy bruisability. Otherwise her past medical history is insignificant. She has a ten pack-year history of smoking and she drinks two to three glasses of wine every day. Her temperature is 37.1°C (98.8°F), blood pressure is 130/70 mmHg, pulse is 80/min and respirations are 14/min. There is mild jugular venous distention on physical examination. Chest auscultation shows scattered bibasilar crackles. Echocardiography reveals symmetrical thickening of the ventricular walls, normal ventricular dimensions and a slightly reduced systolic function. Which of the following is the most likely diagnosis?

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 flaccid 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?

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 60-year-old male is admitted to the hospital because of right lower lobe pneumonia. His medical history is significant for hypertension, diabetes mellitus, severe degenerative disease of the spine, and longstanding lower back pain. He is a chronic smoker with a 40-pack year smoking history. During his hospitalization, the laboratory report shows decreased serum calcium levels and increased phosphate levels. Further evaluation reveals increased serum intact parathyroid hormone levels. Which of the following medical conditions is most likely responsible for this patient's abnormal lab findings?

A 60-year-old male presents to the office and complains of muscle weakness in his extremities. Other accompanying symptoms include progressive difficulty in performing weight-carrying tasks, and a 7 kg (15 lb) weight loss during the last three months. His past medical history is insignificant. He smokes 2 packs of cigarettes daily, and consumes alcohol occasionally. His muscle strength is 3/5 in the proximal muscle groups symmetrically. His reflexes are normal. No sensory abnormality is present. Chest x-ray reveals a right lower lobe ill-defined mass. Which of the following is the most likely localization of the pathologic process in this patient?

A 60-year-old male with a history of hypertension, diabetes, coronary artery disease, asthma, and cigarette smoking undergoes emergent laparotomy for a perforated peptic ulcer. He receives 4 liters of intravenous normal saline intraoperatively. Following the procedure, he is extubated without complication, but subsequently develops respiratory distress. Immediate arterial blood gas analysis on room air shows: PaO2 60mmHg, pH 7.46, PaCO2 37mmHg, HCO3 22mmHg. His temperature is 37.2°C (98.9°F) and blood pressure is 126/76 mm Hg. Lung auscultation reveals bilateral rales. His arterial blood gas fails to improve with administration of 100% oxygen. What is the most likely cause of his respiratory distress?

A 60-year-old man comes to the physician's office because of fatigue and hematuria. His past medical history is significant for fatty liver, gout, and anemia. He has smoked two packs of cigarettes daily for 40 years. He is a heavy alcohol drinker. His last visit to his physician was 1 month agoforthe 'flu'. His temperature is 37.1°C (98.9°F), blood pressure is 145/90mm Hg, pulse is 78/min, and respirations are 14/min. Examination shows no abnormalities. Dipstick testing is positive for hematuria. Laboratory studies show: Urinalysis: Glucose Negative, Ketones Negative, Leukocyte esterase Negative, Nitrites Negative, WBC 1-2/hpf, RBC 1-2/hpf, Casts Epithelial cell. Serum chemistry: Serum Na 140 mEq/L, Serum K 5.0 mEq/L, Bicarbonate 20 mEq/L, BUN 36 mg/dL, Serum creatinine 34 mg/dL. Which of the following is the most likely diagnosis?

A 60-year-old man complains of anal itching and discomfort, particularly toward the end of the day. He works as a salesman in a department store, where he has to be on his feet all day. When he goes home in the evening, he finds himself sitting sideways to avoid the discomfort. He has no fever, rectal bleeding, or soiling of his underwear, and he has never had surgery in that area. Which of the following is the most likely diagnosis?

A 60-year-old man presents to the emergency department after being awoken from sleep by severe pain in his right great toe. He reports that his toe is suddenly swollen and very tender to touch. On review of systems, the patient also describes occasional headaches and pruritus that can be "unbearable" after a hot bath. He does not smoke or drink alcohol. On physical examination, his lungs are normal. The liver span is 10 cm and the spleen is palpable 2 cm below the costal margin. Aspiration of the affected toe joint reveals negatively birefringent crystals. Which of the following is most likely responsible for this patient's symptoms?

A 60-year-old otherwise healthy woman presents to her physician with a 3-week history of severe headaches. A contrast CT scan reveals a small, circular, hypodense lesion with ringlike contrast enhancement. Which of the following is the most likely diagnosis?

A 60-year-old Vietnam war veteran comes for his annual examination. He does not have any complaints, other than getting tired very quickly. Physical examination reveals pallor and an enlarged spleen. CBC reveals: WBC 14,000/cmm, Hemoglobin 9.9 g/dL, Hematocrit 30%, Platelets 100,000/cmm. The lymphocytes have fine, irregular cytoplasmic projections. Cytochemical testing reveals a strong acid phosphatase reaction, which is not inhibited by tartaric acid. What is the most probable diagnosis?

A 60-year-old white male is brought to the physician's office for the evaluation of worsening confusion and memory loss for the past three weeks. His other complaints are muscle twitching and gait problems. He denies any fever, headache or urinary problems. He does not drink nor smoke. His pulse is 82/min, blood pressure is 130/76 mm Hg, and temperature is 37.1°C (98.7°F). He displays poor grooming and is disoriented. The pertinent physical findings are nystagmus and positive extensor plantar response bilaterally. The laboratory studies are as follows: Hematocrit 40%, WBC 6,000/microl, Platelets 160,000/microl. A non-contrast head CT scan is normal. The EEG shows periodic sharp waves. What is the most likely diagnosis of this patient?

A 60-year-old woman comes to the emergency department due to a sudden onset of severe pain in her left eye with blurred vision, nausea, and vomiting. The symptoms began a few minutes ago, while she was watching a movie in a nearby theatre. Her blood pressure is 140/90 mm Hg, pulse is 82/min, respirations are 14/min, and temperature is 98.4°F. Examination reveals decreased visual acuity. Her left eye appears red, with a hazy cornea, shallow anterior chamber, and dilated, fixed pupil. Her left eye is stony hard to touch. What is the most likely diagnosis?

A 60-year-old woman comes to the physician for an annual examination. She has no complaints. She had her last menstrual period at age 55 and has had no vaginal bleeding since. She has no medical problems and has never had surgery. She takes no medications and has no allergies to medications. The physical examination is unremarkable. She is concerned about cancer and wants to know which type is the major cause of cancer death in women. Which of the following is the correct response?

A 60-year-old woman complains of decreasing vision and a dull ache over her left eye for the past 12 hours. She had a successful surgical cataract extraction in her left eye five days ago. Her blood pressure is 140/90 mmHg, pulse is 92/min, respirations are 14/min, and temperature is 38.1°C (101.7°F). Examination of the left eye reveals a swollen eyelid, edematous conjunctiva, and exudates in the anterior chamber. Testing with Snellen's chart demonstrates decreased visual acuity in her left eye. What is the most likely diagnosis?

A 60-year-old woman is transferred to a physician from an outside hospital following a motor vehicle collision. Her medical history is notable for Osler-Weber-Rendu syndrome. She is otherwise healthy. Which of the following triads is most likely to characterize her medical history prior to the collision?

A 61-year-old alcoholic man presents with severe epigastric pain radiating to his back. His amylase and lipase are elevated, and he is diagnosed with acute pancreatitis. Over the first 48 hours, he is determined to have 6 Ranson’s criteria, including a PaO2 less than 60 mm Hg. His chest x-ray reveals bilateral pulmonary infiltrates, and his wedge pressure is low. Which of the following criteria must be met to make a diagnosis of adult respiratory distress syndrome (ARDS)?

A 61-year-old man with severe three-vessel coronary disease and diabetes mellitus is scheduled for abdominal surgery. The patient has a long history of coronary disease and had a q-wave myocardial infarction 2 years ago. He has had type 1 diabetes mellitus for 12 years. His medications include atenolol, insulin, and captopril. His last hemoglobin Alc, 3 months ago, was 9.2%. Which of the following is the most predictive of a perioperative complication in this patient?

A 61-year-old woman is brought to the emergency department drowsy and disoriented, able only to follow simple commands. On examination her abdomen is distended and nontender, her skin has a yellow hue, and there are multiple spider nevi on her chest. In her purse, the physician finds prescriptions for peginterferon and ribavirin. When asked to raise her hands, the physician notices a coarse tremor. Laboratory tests show: Blood urea nitrogen: 17 mg/dL Creatinine kinase: 1.1 mg/dL Aspartate aminotransferase: 89 U/L Alanine aminotransferase: 93 U/L Total bilirubin: 3.1 mg/dL Ammonia: 124 μg/dL Which of the following is the most likely diagnosis?

A 62-year-old Caucasian male presents to your office because of a non-productive cough that is 'quite disturbing.' The cough has been present for several weeks. He visited your office two times before for poorly controlled hypertension, and was started on lisinopril. He usually takes aspirin, amlodipine, and metoprolol. He does not smoke or consume alcohol. His blood pressure is 130/90 mmHg and heart rate is 60/min. Physical examination reveals a bruit over the right carotid artery, but is otherwise normal. Which of the following is the most likely cause of this patient's complaint?

A 62-year-old Caucasian man presents to your office with occasional ear pain and a lump in his neck. His past medical history is significant for hypertension treated with hydrochlorothiazide and diabetes mellitus treated with metformin. He smokes two packs of cigarettes per day and consumes alcohol occasionally. He is not sexually active. Physical examination reveals a hard, non-tender submandibular mass that is 3 cm in diameter. Chest examination is unremarkable. Abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. His extremities have no cyanosis, clubbing, or edema. Complete blood count is within normal limits. Which of the following is the most likely cause of this patient's complaint?

A 62-year-old Caucasian woman complains of difficulty remembering important dates and appointments. She also describes poor concentration, daytime sleepiness and easy fatigability. She is concerned about her forgetfulness because her mother suffered from recurrent strokes and had severe memory loss. Her father died of chronic leukemia. Her daughter's recent job loss has caused her a lot of stress. She does not smoke or consume alcohol. Her appetite is decreased but she has gained 4 pounds over the last three months. She visited an otolaryngologist for hoarseness of recent onset. She takes over- the-counter laxatives for constipation and occasional aspirin for knee pain. She denies any other medication use. Which of the following is the most likely diagnosis in this patient?

A 62-year-old male is brought to the ER after passing out at work. He reports having had difficulty walking over the past couple of days due to an infected wound on his right foot. His past medical history is significant for diabetes mellitus. On physical examination, his blood pressure is 80/40 mm Hg and his heart rate is 120/min, regular. His skin is cold and clammy. Right heart catheterization is performed, and the following readings are obtained: Right atrial pressure 18 mmHg, Pulmonary artery pressure 40/20 mmHg, Pulmonary capillary wedge pressure 9 mmHg. Which of the following is the most likely diagnosis?

A 62-year-old male treated for hypertension and hyperlipidemia complains of nagging right knee pain that is worse in the evening. The pain has been present for several months and it seems to limit his physical activities. His blood pressure is 160/100 mmHg and his heart rate is 70/min. His BMI is 32 kg/m2, and palpation of the knee reveals a cool joint with bony tenderness. His blood cholesterol level is 200 mg/dl and his serum uric acid level is 9.0 mg/dl. Which of the following additional findings is likely on further examination of the right knee?

A 62-year-old man complains of perineal discomfort and reports that there are streaks of fecal soiling in his underwear. Four months ago, he had a perirectal abscess drained surgically. Physical examination shows a perineal opening in the skin lateral to the anus, and a cord-like tract can be palpated going from the opening toward the inside of the anal canal. Brownish purulent discharge can be expressed from the tract. Which of the following is the most likely diagnosis?

A 62-year-old man has been diagnosed by endoscopic biopsy as having a sigmoid colon cancer. He is otherwise healthy and presents to your office for preoperative consultation. He asks a number of questions regarding removal of a portion of his colon. Which of the following is most likely to occur after a colon resection?

A 62-year-old man is brought to the emergency department after being involved in a motor vehicle collision where he suffered serious burns. On physical examination there are second degree burns covering both upper extremities and third degree burns over the anterior aspects of both lower extremities. On day three of his hospitalization, the patient develops tachycardia and decreased urine output. His blood pressure is 90/60 mmHg, pulse is 120/min, temperature is 95°F (35°C), and respirations are 26/min. Laboratory analysis reveals: Blood glucose 230 mg/dL, WBC 16,000/mm3, Platelets 80,000/mm3. Which of the following is the best explanation for this patient's current condition?

A 62-year-old man presents to his primary care physician's office with progressive exertional dyspnea. His past medical history is significant for hypertension treated with hydrochlorothiazide and diabetes mellitus treated with metformin. He was an industrial worker for 30 years and retired one year ago. He smokes one pack of cigarettes per day and consumes alcohol occasionally. His blood pressure is 150/100 mmHg and his heart rate is 80/min. His BMI is 31 kg/m2. Chest x-ray reveals pleural calcifications. Pulmonary function studies show the following: FEV1 70% of predicted, FVC 65% of predicted, Residual volume 70% of predicted, DLCO decreased. Which of the following is the most likely cause of this patient's symptoms?

A 62-year-old man presents with a 3-month history of an enlarged lymph node in the left neck. He is a long-time smoker of cigarettes and denies fevers, night sweats, fatigue, or cough. On physical examination there is a 1.5 cm hard, fixed mass below the angle of the mandible in the left neck. Which of the following is the most likely cause of an enlarged lymph node in the neck?

A 62-year-old man with a history of hypertension presents to the ED with severe constant mid-epigastric pain for the past hour. Over the last several months, he has had intermittent pain shortly after eating, but never this severe. He states he now has generalized abdominal pain that began suddenly about 15 minutes ago. He has no history of trauma, has never had surgery, and takes no medications. His vitals include HR of 115 beats per minute lying supine, increasing to 135 when sitting up, BP of 170/105 mm Hg supine, falling to 145/85 mm Hg when sitting up. He appears pale. His abdomen is rigid and diffusely tender with guarding and rebound. Bowel sounds are absent and stool hemoccult is positive. The white blood cell (WBC) count is 8500/μL, hemoglobin 8.5 mg/dL, hematocrit 27%, and platelets 255/μL. Which of the following is the most likely diagnosis?

A 62-year-old man with chronic schizophrenia is brought to the emergency room after he is found wandering around his halfway house, confused and disoriented. His serum sodium concentration is 123 meq/L and urine sodium concentration is 5 meq/L. The patient has been treated with risperidone 4 mg/day for the past 3 years with good symptom control. His roommate reports that the patient often complains of feeling thirsty. Which of the following is the most likely cause of this patient’s symptoms?

A 62-year-old woman had an abdominal hysterectomy and salpingo-oophorectomy 3 days ago. She had an indwelling bladder catheter during the procedure, which was removed in the recovery room. She has been voiding at will since then. She also had compression pneumatic stockings on both lower extremities during the operation. She began ambulation on the 1st postoperative day, and has been as active as possible under the circumstances, including faithful adherence to a prescribed program of incentive spirometry. On the evening of the 3rd postoperative day, she spikes a fever, with a temperature to 39.4C (103F). Which of the following is the most likely source of the fever?

A 62-year-old woman is seen after a 3-day history of fever, abdominal pain, nausea, and anorexia. She has not urinated for 24 hours. She has a history of previous abdominal surgery for inflammatory bowel disease. Her blood pressure is 85/64 mm Hg, and her pulse is 136. Her response to this physiologic state includes which of the following?

A 62-year-old woman is suffering from advanced colorectal cancer. Despite aggressive surgery and adjuvant chemotherapy, the disease has spread throughout her pelvis and eroded into her left acetabulum. Her pain from the disease has increased dramatically over the last few months. Understandably, her need for pain medications has increased proportionately, and she is now requiring a combination of COX-2 inhibitors, oxycodone and acetaminophen combinations, and gabapentin to take the edge off of her pain. Her pain control plan involves transitioning her to a long-acting sustained-release form of fentanyl. She is extremely worried about her need for increasing doses of narcotics; she has heard that they have awful side effects, and fears becoming “hooked.” Regarding the side effects of narcotic pain medications, she can confidently be told that which of the following is the most common, clinically significant side effect she is likely to experience?

A 62-year-old woman presents for annual examination. Her last spontaneous menstrual period was 9 years ago, and she has been reluctant to use postmenopausal hormone replacement because of a strong family history of breast cancer. She now complains of diminished interest in sexual activity. Which of the following is the most likely cause of her complaint?