Which of the following pathologies most likely underlies this patient’s condition?

Demyelination of neurons in various parts of the brain

Degeneration of the dorsal columns of the spinal cord

Infarction of the posterior limb of the internal capsule

Loss of the pyramidal tract neurons and anterior horn cells of the spinal cord

A 55-year-old man presents with worsening weakness of the left hand and progressive difficulty in walking for the last 2 months.

He says he was previously healthy and active, hiking every weekend, but because of his increasing weakness and incoordination while walking, he stopped his weekly hiking excursion.

His past medical history is unremarkable.

Current medications are a daily multivitamin and occasional acetaminophen for headaches.

The patient denies smoking, recreational drug use, or drinking.

His vitals include: pulse 70/min, respirations 14/min, temperature 37.0°C (98.6°F), and blood pressure 130/80 mm Hg.

Physical examination reveals fasciculations in the tongue and distal extremities.

The left forearm shows significant atrophy, and mild lower limb muscle atrophy is also seen bilaterally.

Hyporeflexia (1+) is present in the left arm, while hyperreflexia (3+) is seen in the legs bilaterally.

Babinski’s sign is positive bilaterally.

The patient's speech is notably slow but no evidence of productive or expressive aphasia is present.


Which of the following is the most likely diagnosis?

Adjustment disorder with mixed anxiety and depressed mood
"

A 21-year-old man comes to the physician because of nervousness and difficulty sleeping over the past 2 weeks.

Three months ago, he started a new team project at his job.

He says that he has trouble falling asleep at night because he thinks about the project.

He insists on checking the work of his teammates and spends several hours each week making elaborate lists and schedules.

He refuses to let others take on more tasks because he thinks that only he can complete them satisfactorily.

The project deadline has already been postponed once.

He says, “My teammates never understand how important it is to do things the right way.” Ever since high school, he has used the majority of his time to plan out assignments and does not have time to regularly participate in social activities.


Which of the following is the most likely cause of her current condition?

Damage to the alveolar capillary endothelium

Bacterial invasion of the pulmonary parenchyma

Two days after undergoing internal fixation of a displaced right femoral fracture sustained during a motor vehicle accident, a 34-year-old woman develops sudden shortness of breath.

On examination, she is oriented only to person.

Her temperature is 38.3°C (100.9°F), pulse is 122/min, respiratory rate is 31/min, and blood pressure is 152/90 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 83%.

There are several scattered petechiae on the anterior chest wall.

Her hemoglobin concentration is 10.3 g/dL, leukocyte count is 9,500/mm3, and platelet count is 140,000/mm3.


A 15-year-old girl comes to the physician for the evaluation of a painless swelling under the left lower jaw for 5 months.

Her 18-year-old sister has a history of acute lymphoblastic leukemia that has been in remission for 11 years.

The patient's temperature is 37°C (98.6°F) Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.

It does not move with swallowing, and forced exhalation against a closed glottis does not increase the size of the swelling.

Ultrasound shows a round mass with uniform low echogenicity and no internal septations.


Which of the following is the most likely cause of this patient’s current condition?

A 70-year-old man is brought to the emergency department by staff of the group home where he resides because of fever, a productive cough, and blood-tinged sputum for 2 days.

The staff report that he developed myalgia, headache, and rhinorrhea 7 days ago, which improved initially before worsening again.

He has hypertension and Alzheimer disease.

Current medications include enalapril and donepezil.

His temperature is 39.8°C (103.6°F), pulse is 120/min, respirations are 22/min and shallow, and blood pressure is 100/60 mm Hg.

Pulse oximetry on 10 L/min of oxygen via nasal cannula shows an oxygen saturation of 92%.

Examination shows scattered crackles and rhonchi throughout both lung fields.

An x-ray of the chest shows bilateral lung opacities and multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma.


Which of the following is the most likely underlying cause of this patient's symptoms?

Obstructive thrombus in the pulmonary artery

A 28-year-old man is scheduled for skin grafting of the right leg.

Four weeks earlier, he underwent open reduction and internal fixation of an open right tibial fracture.

The postoperative period at that time was complicated by necrosis of the overlying skin.

In the operating room, he is placed on continuous hemodynamic monitoring and anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace.

Thirty minutes later, he has severe shortness of breath and lightheadedness and loses consciousness.

His temperature is 37.1°C (98.8°F), pulse is 38/min, respirations are 24/min, and palpable systolic blood pressure is 58 mmHg.

He withdraws the upper extremities to painful stimuli above the navel.


A 73-year-old man is brought to the emergency department 30 minutes after he lost consciousness for 5 minutes while watching a game of summer league football in a seat from the stands in the afternoon.

On arrival, he is lethargic and oriented only to person.

Three weeks ago, he was treated for hepatitis A.

He has type 2 diabetes mellitus and hypothyroidism.

Current medications include metformin and levothyroxine.

His temperature is 41.5 °C (106.7 °F), pulse is 106/min, respirations are 26/min, and blood pressure is 128/70 mm Hg.

The pupils are equal and reactive to light.

Neurologic examination shows no focal findings.

Fundoscopy shows proliferative diabetic retinopathy.

Cardiopulmonary examination shows no abnormalities.

There is no costovertebral angle tenderness.

His serum glucose concentration is 160 mg/dL.


A 3-year-old boy is brought to the physician for a well-child examination.

He was born at 38 weeks' gestation and weighed 2766 g (6 lb 2 oz).

There is no personal or family history of serious illness.

He is at 60th percentile for height and 55th percentile for weight.

A grade 3/6 systolic ejection murmur is heard along the upper left sternal border.

S2 is widely split and does not vary with respiration.

There is a grade 2/6 mid-diastolic murmur along the lower left sternal border.

The abdomen is soft and nontender; there is no organomegaly.


Which of the following is the most likely diagnosis in this patient?

A 19-year-old man is brought to a psychiatrist by his mother.

The patient’s mother has become increasingly concerned about him since his high school graduation.

Although she says that he had been an excellent student in high school, his grades have begun slipping in his second year in college, and he no longer socializes with friends.

When she asked him why he no longer talks to his friends, she states that he told her, “They already know where I am.

They watch me from my bedroom window, so they already know what I’m doing.

We don’t need to talk.” She found this to be bizarre, as nearly all of his friends live hours away.

The patient states that he feels fine and doesn’t understand why everyone thinks he is crazy.

The psychiatrist notices reduced spontaneous movements while the patient is speaking and that he speaks in a monotone with a voice that is soft in volume.

He also appears suspicious and defensive, asking the psychiatrist “why are you asking me that?” after each evaluative question.

His mood is generally flat with little reactivity or engagement during the course of his interview, but he denies any symptoms of depression or psychosis.

Family history is not available as he was adopted.


What disease is the child suffering from?

A 2-year-old Caucasian male presents with recurrent diaper rash and oral thrush.

He has also experienced recurrent episodes of otitis media from repeat Streptoccous pneumoniae.

He notably has reduced T and B cell counts.


Which of the following is most likely this patient’s diagnosis?

A 24-year-old man presents to the office for a physical exam and drug screening requested by his parole officer.

He has a history of multiple run-ins with the law, including theft, destruction of property, and assault and battery.

Patient confesses that he has always been the 'problem child' in his home and always got into trouble with authority figures.

Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting at before 12.

Although a single parent, his mother states there were no stressful changes or issues at home.

Today's urine toxicology screens are negative.


Which of the following is most likely the diagnosis?

A 56-year-old woman presents to her primary care physician for dizziness.

She says that her symptoms began approximately 1 month prior to presentation and are associated with nausea and ringing of the ears.

She describes her dizziness as a spinning sensation that has a start and end and lasts approximately 25 minutes.

This dizziness is severe enough that she cannot walk or stand.

Her symptoms are fluctuating, and she denies any tunnel vision or feelings of fainting.

However, she has abruptly fallen to the ground in the past and denied losing consciousness.

Medical history is significant for a migraine with aura treated with zolmitriptan, type 2 diabetes managed with metformin, and hypertension managed with lisinopril.

Her blood pressure is 125/75 mmHg, pulse is 88/min, and respirations are 16/min.

On physical exam, when words are whispered into her right ear, she is unable to repeat the whispered words aloud; however, this is normal in the left ear.

Air conduction is greater than bone conduction with Rinne testing, and the sound of the tuning fork is loudest in the left ear on Weber testing.


Which of the following is the most likely cause of the patient’s condition?

Microdeletion of the long arm of chromosome 22

Microdeletion of the long arm of chromosome 7

Microdeletion of the short arm of chromosome 5

A 42-year-old primigravida woman goes into labor at 37 weeks.

After several hours of labor, a boy is born with multiple physical abnormalities including cleft palate, micrognathia, and low-set ears.

Imaging reveals an absence of the thymic shadow.


Which of the following is the most likely cause of this patient's disorder?

A 25-year-old woman presents to her primary care physician for her annual physical exam.

Her prior medical history is significant for seasonal allergies and a broken arm at age 12 that was treated in a long arm cast.

She has not had any major illnesses in the previous year and does not currently have any major complaints.

On physical exam her blood pressure is found to be 152/95 mmHg.

Laboratory findings reveal elevated levels of renin and aldosterone.

Given her elevated blood pressure, she is prescribed captopril; however, 1 week later she presents to the emergency department with hypertensive urgency.

At that point captopril is immediately stopped.


A 14-month-old girl is brought to the pediatrician after her parents noticed her being increasingly irritable with frequent vomiting for the past 2 weeks.

They recently immigrated to the country and, unfortunately, the mother did not receive prenatal care during pregnancy due to a lack of health insurance.

Physical examination is unremarkable except for a head circumference over 2 standard deviations larger than the mean for her age, and delay in meeting motor developmental milestones.

A magnetic resonance imaging (MRI) of her brain shows an enlargement of the posterior fossa, cystic dilation of the 4th ventricle, and hypoplasia of the cerebellar vermis (see image).


What is the most likely cause of her recent mental impairment?

A 67-year-old woman with a recently found hepatic carcinoma has been an inpatient for more than a week.

During morning rounds, she was abnormally disoriented to time and place along with a shortened attention span.

The overnight resident reports that she was coming in and out of this state for the past couple nights.

The patient was known to drink often, but reported that she has not consumed alcohol in weeks leading up to her admission.

She is not jaundiced and has no metabolic imbalance upon laboratory tests.


Which of the following is the most likely cause of this patient's symptoms?

Posterior inferior cerebellar artery infarction

A 51-year-old man comes to the physician because of recurrent episodes of dizziness, tinnitus, and hearing loss on the left side for 6 weeks.

These episodes last for hours at a time and are associated with the sensation that the room is spinning.

He has no history of major medical illness and takes no medications.

Examination shows horizontal nystagmus to the left.

Weber test shows lateralization to the right ear.


Which of the following is the most likely diagnosis for this patient?

A 22-year-old woman presents with an episodic history of swelling of the face, hands, and neck and a single episode of difficulty swallowing.

She also has a history of frequent, severe abdominal pain.

At the time of her visit, her blood pressure is 126/84 mm Hg, heart rate is 82/min, and respiratory rate is 15/min.

Physical examination is unremarkable except for a swollen right hand as shown in the image below.

Imaging studies are normal and do not reveal any cause of her pain.

Her C1 inhibitor level is less than 6% of the reference value.


Which of the following is the most likely underlying cause of this patient's condition?

Chronic occlusion of the pulmonary vessels

A 57-year-old man with chronic obstructive pulmonary disease comes to the emergency department because of leg swelling for 2 weeks.

He has smoked 2 packs of cigarettes daily for the past twenty years.

His vital signs are within normal limits.

Physical examination shows jugular venous distention, hepatomegaly, and pitting edema of both lower extremities.

Cardiac examination shows a regular heart rate and normal heart sounds.

Auscultation of the lungs shows scattered wheezing without crackles.

Left ventricular ejection fraction is 60%.


A young Mediterranean teen brings her 4-year-old little brother to the Emergency Room because of a high temperature.

Their parents are on their way to the hospital, but, in the meantime, she provides some of the history.

She explains that he has been running a fever and limping for the past week.

This morning, she had trouble awakening him, and she noticed some swelling and redness around his right ankle.

In terms of his past medical history, she knows he has something wrong with his blood.

He had to receive extra vaccinations as an infant, and he takes an antibiotic everyday.

On exam in the ED, his temperature is 102.4 deg F (39.1 deg C), blood pressure is 90/60 mmHg, pulse is 123/min, and respirations are 22/min.

He is lethargic, and his exam is noteworthy for erythema and edema in an area surrounding his distal shin.


What is the most likely cause of this patient’s condition?

Hypoxanthine-guanine phosphoribosyl transferase (HGPRT) deficiency

Purine nucleoside phosphorylase deficiency

An 8-month-old boy is brought to the office by his mother for recurrent infections.

Over the past 2 months, the boy had multiple visits to the urgent care clinic for respiratory, ear, and skin infections.

His mother is concerned about the health of her child.

Currently, the child had a runny nose for the last 2 days.

There is no fever but the mother adds that the boy is not eating very well.

His mother denies any history of infection during her pregnancy and was tested negative for HIV.

The patient’s heart rate is 90/min, respiratory rate is 14/min, and temperature is 36.7°C (98.0°F).

On physical exam, there are decreased lung sounds in the left lower lobe.

A chest X-ray reveals an absent thymic shadow and fails to show any lung pathology.

There is no history of similar symptoms in the families of either parent.


A 56-year-old man comes to the physician for a routine health maintenance examination.

He has had mild pain in his left groin for 2 weeks.

He was admitted to the hospital 1 month ago for myocardial infarction.

Cardiac catheterization and angiography showed occlusion of the left anterior descending artery and he underwent placement of 2 stents.

He has hypertension and hypercholesterolemia.

There is no family history of serious illness.

He has smoked 2 packs of cigarettes daily for 30 years.

Current medications include aspirin, clopidogrel, rosuvastatin, and enalapril.

His temperature is 36.7°C (98°F), pulse is 88/min, and blood pressure is 130/84 mm Hg.

Examination shows a 3-cm (1.2-in), tender, pulsatile mass in the left thigh, below the inguinal ligament.

There is mild erythema of the overlying skin.

A loud murmur is heard on auscultation of the mass.

Cardiopulmonary examination shows no abnormalities.

Femoral and pedal pulses are palpable bilaterally.

Neurologic examination shows no focal findings.


Which of the following is the most appropriate next step in diagnosis?

A 1-year-old girl is brought to the physician because of fever and crying while passing urine for 2 days.

She was born at term and has been healthy since.

Three months ago, she was treated for a urinary tract infection with oral cefixime.

Her temperature is 39°C (102.2°F), pulse is 144/min, and blood pressure is 85/40 mm Hg.

Physical examination shows no abnormalities.

Urine dipstick shows leukocyte esterase and nitrites; urinalysis shows WBCs and gram-negative rods.

Renal ultrasonography shows hydronephrosis of the left kidney.

Empirical antimicrobial therapy is initiated, following which the patient's symptoms improve.


Which of the following is the most likely cause of this patient’s condition?

An otherwise healthy 27-year-old woman presents to the emergency department because of worsening headaches and nosebleeds.

Her blood pressure is 185/115 mm Hg, pulse is 88/min and temperature is 36.9°C (98.4°F).

She denies the use of nicotine, alcohol, or illicit drugs.

Physical examination is only positive for abdominal bruits.

She is given a calcium-channel blocker and a thiazide diuretic, but her blood pressure did not respond adequately.


Which of the following is the most likely diagnosis?

A 50-year-old farmer from Jamaica presents to his physician with a wart-like lesion on his left foot.

He is a plantain farmer and often farms barefoot because of the pleasant climate.

Physical examination reveals warty, cutaneous nodules that resemble the florets of cauliflower.

On a KOH preparation, irregular, dark brown, yeast-like bodies with septae are noted.

Culture on Sabouraud agar reveals sclerotic bodies.


What was the most likely diagnosis of this patient?

A mother brings her 17-year-old daughter to your office because of a recent onset dull unilateral pelvic pain that started last week.

In addition, the daughter also complains of constipation for which she increased her fiber intake, but the dietary changes are not helping her.

She began menstruating at the age of 13, and her menstrual cycles are regular (about 28 days).

On physical examination, the patient has a large, non-tender, mobile adnexal mass in the left lower quadrant.

The pelvic examination is normal except for the presence of the adnexal mass.

The patient is advised to have an outpatient ultrasound, and then return to the clinic next week.

After 2 weeks, you learned that the patient visited the emergency department for a sudden onset of abdominal pain that required observation after an abdominal ultrasound was performed.

The ultrasound showed a large simple cystic mass with increased internal echoes, having a diameter of 10 cm and hyperechogenic vascular walls on the left ovary with a small intraperitoneal collection in the pouch of Douglas.


Which of the following is the most likely cause of the patient's symptoms?

A 65-year-old man comes to the physician because of progressive shortness of breath and a worsening cough for the past month.

He also reports occasional bloody sputum.

He has lost about 7 kg (15.4 lb) of weight over the past 4 months despite having no change in appetite.

He has smoked 2 packs of cigarettes daily for 15 years but stopped smoking at the age of 55.

Physical examination shows reduced breath sounds throughout both lungs.


Which of the following is the most likely underlying cause of this patient's shoulder pain?

A 13-year-old African-American girl is brought to the physician for right shoulder pain that has worsened over the past month.

She has had many episodes of joint and bone pain and recurrent painful swelling in her hands and feet.

Physical examination shows tenderness of the right anterior humerus without swelling or skin changes.

Active and passive range of motion of the right shoulder is decreased and there is pain with movement.

An x-ray of the right shoulder shows subchondral lucency of the humeral head with sclerosis and joint space narrowing.


A 43-year-old woman presents to the clinic complaining of “spotting.” She states that over the past 5 months she has had intermenstrual bleeding.

Additionally, her menses last more than a week with the first 4 days consisting of heavy bleeding.

She denies abdominal pain but reports feeling an increasing “pressure-like" discomfort.

She denies dysuria, dyspareunia, or dyschezia.

Prior to 5 months ago, her menstrual periods were only 4 days long and consisted of moderate bleeding.

Her periods normally occur every 28 days.

She is frustrated because she feels like she needs to wear a pad all the time.

The patient delivered 3 healthy children vaginally without complications, followed by a tubal ligation.

Her last menstrual period was 1 week ago.

She is sexually active with her husband and denies a history of sexually transmitted diseases.

She has never had an abnormal pap smear.

Her last pap smear and test for human papillomavirus was 4 years ago.

The patient has hypothyroidism treated with levothyroxine.

On physical examination, the thyroid is normal in size without masses or tenderness.

Pelvic examination reveals a firm, mobile, enlarged, irregularly-shaped uterus without adnexal tenderness.


Which of the following is the most likely underlying condition?

Squamous cell carcinoma of the esophagus
"

A 56-year-old woman comes to the emergency department because of severe abdominal pain associated with nausea and vomiting for 12 hours.

The pain extends from the epigastrium to the right upper quadrant and radiates to the right scapula.

The patient has gastroesophageal reflux disease.

She underwent total thyroidectomy for papillary thyroid carcinoma 3 years ago.

She has smoked one pack of cigarettes daily for 35 years.

Current medications include levothyroxine, omeprazole, and a multivitamin.

Her temperature is 38.1°C (100.6°F), pulse is 93/min, and blood pressure is 140/85 mm Hg.

Abdominal examination shows tenderness to deep palpation in the right upper quadrant.

The patient's leukocyte count is 10,300/mm3.

Abdominal ultrasonography shows thickening of the gallbladder wall, without dilatation of the intra- and extrahepatic bile ducts.

Laparoscopic cholecystectomy is performed.

Pathological examination shows acute cholecystitis.

There is an ulcerated 1 x 1.5-cm mass in the fundus of the gallbladder with invasion of the gallbladder wall and lymphatic vessels.


Which of the following is the most likely cause of this patient's symptoms?"

Syndrome of inappropriate antidiuretic hormone

A 58-year-old woman is brought to the emergency department by her husband because of increasing confusion and generalized fatigue over the past week.

During this period, she has had muscle cramps, headaches, nausea, and vomiting.

Six days ago, she underwent resection of a parasagittal meningioma.

She tolerated the procedure well without complications and was discharged two days ago.

She has hypercholesterolemia and hypertension.

Current medications include oxycodone, acetaminophen, atorvastatin, and hydrochlorothiazide.

She is oriented only to person and place.

Her temperature is 37°C (98.6°F), pulse is 89/min, respiratory rate is 14/min, and blood pressure is 142/88 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 97%.

The remainder of the examination shows no abnormalities.

Serum studies show: | Serum | Na+ 126 mEq/L | K+ 3.6 mEq/L | Cl- 107 mEq/L | Urea nitrogen 16 mg/dL | Glucose 87 mg/dL | Creatinine 0.9 mg/dL | Osmolality 255 mOsmol/kg H2O | Urine | Osmolality 523 mOsmol/kg H2O | Sodium 44 mEq/L | .


This patient most likely presents with clinical features of which disease?

A 24-year-old man presents to his primary care physician with heel pain that has been persistent for 3 weeks now.

He is bothered by the feeling of significant pressure and swelling in his ankle.

He is also having difficulty walking due to pain in his hip.

Upon physical examination, there is evidence of swelling and warmth over his Achilles tendon.

Imaging of his sacroiliac joint reveals soft tissue involvement and narrowing of the joint spaces.

This patient also appears to have a low to moderate kyphosis of his spine.

He has no family history of any bone or rheumatological diseases.


Which of the following is associated with the most likely diagnosis?

A 48-year-old man presents to his primary care physician concerned about his weight.

He states he has been gaining weight though does not feel he has changed his diet.

The patient also states he has felt fatigued lately and not himself.

He denies taking any medications or using any illicit substances at baseline.

His temperature is 99.2°F (37.3°C), blood pressure is 177/108 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.

Physical exam is notable for an obese man with striae on his abdomen.

A 24-hour urine free cortisol is collected and demonstrates an elevated cortisol level; however, a high dose of dexamethasone when administered results in no attenuation of cortisol release.

A CT scan of the abdomen is within normal limits.


What is the most likely cause of this lab abnormality in this patient?

A 24-year-old woman who is 16 weeks pregnant comes to your office requesting a referral for an abortion.

Upon questioning she states that she is scared that her baby will be "deformed" because on routine screening she was found to have an elevated level of alpha-fetoprotein.


Of the following options, which is the most likely diagnosis?

A 63-year-old African American man with a history of hypertension and dyslipidemia presents to the emergency department with facial swelling and difficulty breathing.

Symptoms began suddenly that morning and continued to worsen.

He started taking lisinopril several weeks ago.

His blood pressure is 110/74 mm Hg, heart rate is 94/min, and respiratory rate is 20/min.

Physical examination is notable for swelling of his lips and inspiratory stridor.

Clinical lab results suggest a normal C1 esterase inhibitor level.


A 20-year-old college student is brought to his primary care physician by his parents over the New Years holiday because they are concerned about his behavior since right after high school graduation in May the spring before.

Prior to this year, he was generally an outgoing and social young man, who now reportedly has been spending the majority of his time alone in his dorm room and room at home, where his mother and father have overheard him talking to other people when he has no guests.

When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove that will soon takeover the student union building by setting the trees on fire for all to see.

On exam, his appears to be otherwise healthy and his urine toxicology screen is negative.


A 60-year-old man comes to the physician because of a 3-month history of a slowly enlarging painless ulcer on his lower lip.

One year ago he had a painful rash near his upper lip that resolved completely with acyclovir therapy.

He has a 10-year history of type 2 diabetes mellitus treated with metformin.

He has worked in construction for the past 33 years.

He has smoked one pack of cigarettes daily for 35 years.

Examination shows a 0.5 x 0.5 cm nontender ulcer with everted edges on the midline of his lower lip.

The erythematous ulcer bleeds upon palpation.

He has numerous moles of varying sizes all over his body.

There are no palpable cervical lymph nodes.


Which of the following is the patient most at risk for developing?

A 3-year-old girl is brought to the pediatrician by her father for fever and cough.

The patient’s father states that she had a sore throat and runny nose 2 weeks ago.

Then last night she developed a productive cough and a fever.

The father is worried that this is pneumonia again, and reports that she has been hospitalized 5 times already with pneumonia.

Her medical history is also significant for chronic diarrhea.

The father reports that the patient has 2 older brothers who are both healthy.

The patient’s temperature is 102°F (38.9°C), blood pressure is 102/60 mmHg, pulse is 110/min, and respirations are 28/min with an oxygen saturation of 94% on room air.

On physical examination, decreased breath sounds are appreciated on the right.

A chest radiography shows consolidation in the right upper lobe, consistent with pneumonia.

An antibody panel and flow cytometry are obtained in the setting of the patient’s recurrent infections.

The results show a normal lymphocyte count with low levels of IgA, IgG, and IgE and elevated levels of IgM.


Which of the following is the most likely etiology of his bruises?

Intravascular coagulation with fibrinolysis

An 82-year-old man with Alzheimer disease is brought to the physician by his daughter because of extensive bruising on his arms.

He lives in an assisted living facility.

Physical examination shows large ecchymoses across both forearms and upper arms in varied stages of healing.

His hemoglobin concentration is 11.7 g/dL, mean corpuscular volume is 78 μm3, and platelet count is 180,000/mm3.

Coagulation studies are within normal limits.


Which of the following best describe the primary disorder in this patient?

Obstruction of the lumen of the appendix

Inflammation of the renal parenchyma, calyces and pelvis

Herniation of mucosa and submucosa through the muscular layer of the colon

A 57-year-old woman presents to the emergency department with acute pain in the left lower abdomen associated with nausea and vomiting for the past 24 hours.

Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems except for occasional constipation and indigestion after heavy meals.

She has had hypertension and hypercholesterolemia for the past 7 years.

Her family history is negative for GI disorders.

Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/80 mm Hg, and pulse of 85/min.

On physical examination, there is tenderness in the left lower abdominal quadrant.

Abdominal CT scan shows thickening of the bowel wall and streaky mesenteric fat.


A 35-year-old woman comes to the emergency department because of a 3-day history of pain in the left cheek.

The pain occurs every few hours, lasts 30–60 seconds, and is aggravated by chewing and brushing.

She has a history of pain with a vesicular rash in the right axillary area one year ago.

She had an upper respiratory infection 2 weeks ago.

Physical examination shows no abnormalities.


A 35-year-old is brought into the emergency room after a bicycle vs motored vehicle accident.

He was unconscious after hitting the side of his head on the road, but recovered consciousness after a few minutes.

He started to ride his bicycle again, but then developed a severe headache with nausea and vomiting, at which time he called EMS.

While in the hospital, the patient is confused and cannot provide a history.

He quickly loses consciousness and his CT scan is displayed in Figure 1.


A 42-year-old female presents to the emergency department with two days of severe abdominal pain and fever.

The patient has a history of gallstones, for which she was scheduled to have a cholecystectomy in two weeks.

On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding.

Laboratory evaluation is notable for a leukocytosis and a total bilirubin of 6.4 mg/dL.


What is the most likely cause of this patient’s high blood pressure?

A 25-year-old arrives at a gynecology clinic for a consult as she and her husband plan to conceive a baby soon.

She is currently taking no medications, doesn’t smoke, and drinks alcohol socially.

Her father passed away at the age of 51 due to heart failure.

Her vital signs include blood pressure 150/100 mm Hg, heart rate 67/min, respiratory rate 16/min, and temperature 36.7°C (98.0°F).

When asked about her high blood pressure, the patient says that her primary care physician once told her that her blood pressure was elevated on most of her visits; the physician emphasized that she should exercise and control her diet, but she never followed up with him as she always felt good.

A number of tests are run to find out the etiology of her elevated blood pressure.

Everything is within the normal range except for a renal angiogram shown in the picture.


A 53-year-old man presents to the office complaining of persistent abdominal pain.

He states that he has gained 4.5 kg (10.0 lb) because the pain is only relieved by eating.

The patient also admits that he has had numerous loose, foul-smelling stools over the last few weeks with associated nausea.

He has taken some over the counter antacids without relief or change in symptoms.

His blood pressure is 132/76 mm Hg, respiratory rate is 14/min, and heart rate is 75/min.

Physical examination reveals mild tenderness to palpation of the upper abdomen.


Which of the following etiologies is the most likely cause of this patient’s neurologic findings?

A 56-year-old man presents with severe back pain for the past hour.

He says the pain started about 1 hour ago and has not improved.

The patient describes the pain as sharp, 10/10, and located between his scapula.

Past medical history is significant for hypertension, which he is noncompliant with medication.

His vital signs are a blood pressure of 180/95 mm Hg and a pulse of 108/min.

On physical examination, there is a loss of pain and temperature sensation in the lower trunk and extremities bilaterally.

Strength is 4 out of 5 in all muscle groups in the lower extremities bilaterally.

A contrast CT of the chest reveals findings consistent with a type B aortic dissection.


A 4-year-old girl is seen by her pediatrician for developmental delay.

One year prior, the patient was able to ride a tricycle, stack 3 blocks, and speak in short sentences.

Now, she is unable to feed herself and has recently started to point to objects she wants rather than asking.

Physical exam reveals a well nourished child sitting in a stroller wringing her hands.

The patient's mother reports that her 7-year-old son is doing well, and that they have no family history of mental retardation or other cognitive disorders.


A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor.

Her three children were delivered by lower segment transverse cesarean section.

Her pulse is 98/min, respirations are 15/min, and blood pressure is 130/80 mm Hg.

The abdomen is nontender and contractions are felt.

The fetus is in a cephalic presentation.

The fetal heart rate is reactive with no decelerations.

One hour following vaginal delivery, the placenta is not delivered.

Manual separation of the placenta leads to profuse vaginal bleeding.

A firm, nontender uterine fundus is palpated at the level of the umbilicus.


Which of the following is the most likely cause of this patient's current symptoms?

Six days after admission to the hospital for treatment of infective endocarditis, a 64-year-old woman develops persistent ringing in both ears, lightheadedness, and nausea.

When she turns her head, she sees the light on the ceiling swinging from side to side.

She has congestive heart disease, hypertension, and coronary artery disease.

She was treated for a cerebrovascular accident 7 years ago and has no residual deficits.

Current medications include intravenous vancomycin and gentamicin, as well as oral aspirin, atenolol, furosemide, and lisinopril.

Her vital signs are within normal limits.

Cardiac examination shows a grade 3/6 holosystolic murmur along the left lower sternal border.

While the patient fixates on a target, administration of brisk, horizontal head rotations to both sides results in corrective saccades to refixate back to the target.

Muscle strength and sensation are normal.


Which of the following is the most likely underlying cause of this patient's symptoms?

A 75-year-old woman is brought to the physician by her daughter because of a 1-month history of fatigue and a 3.5-kg (7-lb) weight loss.

The patient has a history of hypertension, hyperlipidemia, and Alzheimer's dementia.

She lives with her daughter and requires assistance with all of her banking and meal preparation.

Her daughter has hypothyroidism but there is no other history of serious illness in the family.

She does not remember the names of her medications but says she takes them every day.

Her pulse is 114/min and blood pressure is 148/101 mm Hg.

Physical examination shows warm skin and a tremor.

The serum thyroid stimulating hormone level is undetectable.

Histological examination of a thyroid biopsy shows follicular atrophy.


What is the most likely explanation for this patient’s presentation?

Hereditary defect of amino acid transporter in the kidney

Presence of antibodies to the glomerular basement membrane

Thinning and splitting of the glomerular basement membrane

A 23-year-old man comes to the emergency department complaining of 10/10 abdominal pain.

He describes the pain as sharp, stabbing, intermittent, and concentrated at the left lower quadrant.

It started about 3 hours ago with no obvious precipitating factor.

He reports multiple similar episodes in the past but they have all resolved within 1 hour or so.

He denies fever, weight changes, headaches, nausea/vomiting, or gastrointestinal changes but endorses “red-colored urine” for the past day.

He just returned from an extensive hiking trip in Colorado.

A radiograph of the abdomen was unremarkable.


Which of the following is the most likely cause of these findings?"

Granular subepithelial immune complex deposition

Anti-type IV collagen antibody formation

DNA-anti-DNA antibody immune complex formation

A 6-year-old girl is brought to the physician because of generalized fatigue and dark urine for 4 days.

Four weeks ago, she was treated with cephalexin for a skin infection.

Her temperature is 37°C (98.6°F) and blood pressure is 132/89 mm Hg.

Physical examination shows 1+ pretibial edema bilaterally.

Urine studies show: | Blood 2+ | Protein 2+ | RBC 12–14/hpf with dysmorphic features | RBC casts numerous | .


Which of the following is the most likely diagnosis?

A 15-year-old girl is brought to the physician by her mother because of a 3-day history of lower abdominal pain.

Over the past 9 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days.

Examination shows suprapubic tenderness to palpation.

Pubic hair and breast development are Tanner stage 4.

Pelvic examination shows bulging, bluish tissue 1 cm inside the vaginal introitus.


Which of the following is the most likely explanation of the patient's laboratory findings?"

A 21-year-old man is brought to the emergency department by the police because of altered mental status.

The police found him covering his ears and shouting near a highway rest area.

Upon questioning, he was unable to look directly at the police and answer coherently.

On the way to the hospital, he reported feeling nauseous and vomited twice.

His temperature is 38.2°C (100.8°F), pulse is 100/min, respirations are 28/min, and blood pressure is 110/77 mm Hg.

He is admitted to the hospital for evaluation.

Three hours after admission, he has a tonic-clonic seizure.

Laboratory studies show: | Serum | Na+ 140 mEq/L | Cl- 102 mEq/L | Arterial blood gas analysis on room air: | On admission Three hours later | pH 7.47 7.39 | PaCO2 24 mm Hg 31 mm Hg | PO2 84 mm Hg 82 mm Hg | HCO3- 20 mEq/L 18 mEq/L | .


Which of the following is the most likely explanation for this patient's symptoms?

Infection of the dermis and subcutaneous tissue

A 16-year-old African-American boy is brought to the physician because of a 2-month history of progressive right shoulder pain.

He has had many episodes of joint and bone pain in the past, and as a child, had recurrent painful swelling of his hands and feet.

His brother had a stroke at 6 years of age and now has an intellectual disability.

The patient is at the 60th percentile for height and 55th percentile for weight.

His vital signs are within normal limits.

Physical examination shows tenderness of the right anterior humerus without noticeable swelling or skin changes.

Active and passive range of motion of the right shoulder is decreased and there is pain with movement.

An x-ray of the right shoulder shows subchondral lucency of the humeral head with sclerosis and joint space narrowing.


Which of the following is the most likely cause of this patient's symptoms?

A 50-year-old woman comes to the emergency department after waking up with facial swelling and with difficulties swallowing.

She was recently diagnosed with hypertension and started on an antihypertensive drug.

Her pulse is 110/min and blood pressure is 135/85 mm Hg.

Physical examination shows marked edematous swelling of the face, lips, and tongue.

Serum C4 levels are within the reference range.


Which of the following is the most likely etiology of liver damage in this patient?

Glucose-6-phosphate dehydrogenase deficiency (G6PD deficiency)

A 42-year-old man presents with acute onset jaundice.

Past medical history is significant for COPD diagnosed 4 years ago, managed medically, and admission for acute pancreatitis 6 months ago.

The patient denies any history of smoking, alcohol use or recreational drugs.


A 31-year-old gravida 2 para 2 woman presents to her primary care physician for follow up.

Two weeks ago, she gave birth via vaginal delivery to a 9.5 lb (4.3 kg) male infant.

The delivery was complicated by a vaginal laceration that required extensive suturing once the infant was delivered.

Immediately after delivery of the placenta she experienced intense shaking and chills that resolved within 1 hour.

She has felt well since the delivery but admits to 6 days of malodorous smelling vaginal discharge that is tan in color.

She has a history of vaginal candidiasis and is worried that it may be recurring.

Her temperature is 98.8°F (37.1°C), blood pressure is 122/73 mmHg, pulse is 88/min, respirations are 16/min, and BMI is 33 kg/m^2.

Speculum exam reveals a 1.5 cm dark red, velvety lesion on the posterior vaginal wall with a tan discharge.


Which of the following is the most likely cause of this patient’s respiratory symptoms?

Occlusion of the pulmonary vessels by fat globules

A 50-year-old male presents to the emergency room after getting hit by a car while biking.

He complains of severe pain in both thighs.

His thighs appear swollen, bruised, and angulated.

Radiographic imaging demonstrates bilateral femoral shaft fractures.

He subsequently undergoes surgical fixation of his fractures.

Initially he has an uneventful post-operative course; however, on post-op day 4 he becomes confused and develops chest pain, tachypnea, and dyspnea.

A new petechial rash is seen over his chest and neck.

Electrocardiogram reveals normal sinus rhythm.


Which of the following is the most likely etiology of this patient’s presentation?

Spontaneous rupture of the mitral chordae tendinae

Spontaneous separation in the arterial wall

A 36-year-old male is brought to the emergency department by fire and rescue after being found down in his apartment by his wife.

His wife reports that the patient had been complaining of chest pain for the last few hours but refused to go to the hospital.

She went to the grocery store for about half an hour and found her husband unresponsive on the ground when she returned home.

The patient’s wife reports that his past medical history is significant for a “heart murmur” and that the patient’s father died at age 32 for unknown reasons.

In the trauma bay, the patient’s temperature is 98.8°F (37.1°C), blood pressure is 88/41 mmHg, pulse is 116/min, and respirations are 12/min.

On physical exam, the patient has a Glascow Coma Score (GCS) of 7.

He has a tall stature with long limbs and long, slender fingers.

He is also noted to have a pectus deformity.

On cardiac exam, the patient has a diastolic decrescendo murmur at the left third intercostal space.

He has weak brachial and femoral pulses. |  | .


A 28-year-old woman comes to the physician with her mother because of a 1-week history of feeling unusually energetic.

The mother describes her state as “hyper” and reports that she often paces around her room.

During this period, the patient has not slept.

She had similar episodes 2 months and 5 months ago.

The mother also states that, for the past 8 months, the patient has believed she is a famous singer and is going on a world tour next year.

The patient does not have a partner and has only a few friends.

She was working as a dental technician until 6 months ago, when she started to hear voices telling her to quit.

Physical and neurological examinations show no abnormalities.

On mental status examination, her speech is pressured, but she suddenly stops talking in the middle of sentences and does not finish them.

She occasionally directs her attention to empty corners in the room, as if she were listening to someone.


What could be causing this patient’s newly-discovered dermatologic change?

A 32-year-old obese man visits your dermatology clinic after his barber saw a darkened area on the back of his neck.

He has not seen his primary care physician in many years and does not know if he has diabetes.

A rapid blood glucose test showed a normal glucose level.

Otherwise, he reports recent loss of appetite with slight weight loss.


A 59-year-old man comes to the physician because of a 6-month history of progressive blurry vision in both eyes.

His vision has not improved with the use of reading glasses.

Physical examination shows his visual acuity to be 20/80 in the right eye and 20/60 in the left eye.

A photograph of the fundoscopic examination of the right eye is shown.


A 56-year-old man comes to the physician because of a 2-month history of worsening pain in his left buttock.

The pain is described as a deep, dull ache that is worse at night.

He has smoked one pack of cigarettes daily for the past 30 years and drinks one beer every night.

Physical examination shows tenderness over the left gluteal region.

Neurologic examination shows no focal findings.

An x-ray of the pelvis shows a 4-cm, poorly defined, osteolytic lesion in the left ilium with a moth-eaten pattern of bone destruction, multiple well-defined sclerotic lesions, and an aggressive periosteal reaction.

The remainder of the physical examination, including rectal examination, shows no abnormalities.

Chest x-ray and abdominal ultrasonography show no abnormalities.


Which of the following disorders is most consistent with this patient's presentation?

A 23-year-old woman presents to the emergency department because of nausea.

She has been experiencing severe intermittent nausea and diarrhea for the last year and refuses to leave the emergency department until she is told what is causing her symptoms.

She hates hospitals but has reluctantly undergone numerous workups and imaging studies in order to discern what is wrong.

She says that these symptoms have been causing her severe distress and is impairing her ability to perform her job.

She says that she feels as if the nausea is worse when she is trying to work but says that she will continue to work as an insurance agent despite the physical discomfort.

She has started restricting her diet to only graham crackers because she thinks that helps her symptoms.

She has also started avoiding eating lunch because of the nausea.


These findings support a diagnosis of which of the following?

A 4-month-old adopted infant is brought to the pediatrician because of feeding problems and recurrent fungal and bacterial infections.

Her family has almost no background information about the infant.

They report that she is a little fragile and looks different compared to other infants her age.

Physical evaluation reveals a cleft lip with intact hard and soft palate and mild jaw malformation.

An echocardiogram reveals an interrupted aortic arch.

Further investigation reveals leukopenia and mild hypocalcemia.


A 7-year-old boy is brought in to your clinic by his mother, who is complaining of her son’s “dry scalp and hair loss.” She reports a scaling spot on his scalp developed around 2 months ago, soon after moving to a new school, which then became a larger bald spot.

She denies that anyone in the household is exhibiting similar symptoms, but does recall a note that came home from school warning of a lice outbreak.

Thus far, she has only tried daily baths with little improvement.

The patient denies pain or itchiness, but the mother reports she does notice him scratching his scalp.

The mother also reports that since her son has started at the new school, she has noticed an increase in his tics including excessive blinking and clearing of his throat.

The patient's medical history is significant for asthma, allergic rhinitis, and attention deficient hyperactivity disorder.

His current medications include fluticasone, salmeterol, loratadine, and methylphenidate.

Family history includes obsessive compulsive disorder in his older sister.

The mother also reports her father had a debilitating skin and joint disorder.

On examination, you note swollen lymph glands at the back of the patient's ears and neck, and there are residual black dots within a patch of alopecia.


Which of the following best describes the symptoms this patient is expressing?

A 52-year-old man visits his psychiatrist saying he feels sad most of the time.

5 months ago, he lost his daughter in a motor vehicle accident and since then has been unable to cope with this loss.

He spends most of his day thinking about her and this often distracts him from his daily activities.

He also admits to hearing his daughter’s voice in his sleep and sometimes has dreams about her.

During the day, he sometimes gets brief glimpses of her.

He believes this is because he was not able to do anything to help her during the last moments of her life.

Other than this, he is able to get along his daily life and has never contemplated suicide.

But he often wishes he could be close to his daughter again.


A 48-year-old man is brought to the physician by his wife because he has become increasingly restless and anxious.

His wife says that he has seemed sad and irritable for the past 4 months.

He lost his job as a store clerk because he often lied to avoid work, and spent most of his days on the phone placing bets on football games.

He avoids all family-related events because he has borrowed money from most of his relatives.

He is hopeful that his symptoms will improve once he is able to win some of his money back.

He previously smoked 8–10 cigarettes daily but quit 1 month ago.

On examination, he is uncooperative and dismissive.

He is oriented to person, place, and time.


A 66-year-old man comes to the physician with a 4-month history of recurrent crusty lesions on the dorsal surface of his hands.

When he scrapes off the crusts, they reappear after a few days.

The lesions are mildly pruritic and occasionally burn.

A photograph of his right hand is shown.


Which of the following best describes the most likely diagnosis?

A 24-year-old man is brought to the emergency department for bowling at a local bowling alley while inappropriately dressed.

The patient refused to speak with police and was seen conversing with inanimate objects in the back of the police car.

The patient states that his clothes were contaminated by assassins who have been tracking him for years.

The patient refuses to answer any further questions, and continues to whisper toward someone else.

The patient has a past medical history of homelessness, alcohol abuse, marijuana use, and cocaine abuse.

Physical exam is notable for a healthy young man who seems mistrustful of all hospital personnel.

The patient is started on a medication and is transferred to the psychiatric inpatient unit.

The patient’s condition improves, but he still often speaks of a contamination that is on his clothes and skin that is coming from external parties.

The patient is started on a new medication.

He is then sent to group therapy, followed by physical activity in the yard.

The physician is called over when the patient is found down in the recreation yard while he was exercising.

The patient is not responsive, and his limbs seem to resist passive force.

His temperature is 104°F (40°C), pulse is 112/min, blood pressure is 140/90 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air.


A 77-year-old man presents to the emergency department with a change in his mental status.

The patient’s daughter states that he can cook and clean up after himself and only needs help paying bills.

Yesterday the patient seemed fine; however, this morning she noticed that he struggled to perform simple tasks and was forgetful while cooking, leaving the stove on.

They recently returned from a trip to Mexico and admit to drinking unfiltered water and eating local cuisines while abroad.

The patient has a past medical history of hypertension and diabetes.

His temperature is 97.5°F (36.4°C), blood pressure is 187/118 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 100% on room air.


A 37-year-old man presents to his primary care physician with a chief complaint of diarrhea.

The patient states that his symptoms have worsened recently.

He works as a farmer and is dressed in tattered and old denim.

He lives alone, and this is the first time he has come to town in years.

The patient’s diet is mostly dairy products and some meat products.

He denies any systemic symptoms and states that diarrhea tends to occur right after a meal.

He also claims that at times he struggles to fall asleep, and sometimes he feels he lacks energy.

The patient is instructed to avoid consuming dairy products for a week and to return with a report of his symptoms.

As you set up the return appointment with this patient you notice that he is rather emotionless.

He also states that he lacks anybody that he can list as an emergency contact so he leaves that section of his medical forms blank.


Which of the following is the most appropriate next step in diagnosis?"

A 68-year-old man comes to the physician because of constipation and decreased appetite during the past several months.

In the past 2 weeks, he has also noticed an increasing frequency of urination.

He has not had any dysuria or flank pain.

He has a history of hypertension, calcium pyrophosphate crystal arthritis, and alcoholic cirrhosis.

Current medications include hydrochlorothiazide, rifaximin, lactulose, and naproxen as needed for the joint pain.

His vital signs are within normal limits.

Physical examination shows decreased bowel sounds but is otherwise unremarkable.

Serum studies show: | Creatinine 1.1 mg/dL | Calcium 11.8 mg/dL | Phosphorus 2.1 mg/dL | Magnesium 1.6 mg/dL | Total protein 6 g/dL | Albumin 3.1 g/dL | AST 53 U/L | ALT 43 U/L | .


Which of the following is the most likely etiology of this patient’s symptoms?

A 2-year-old boy was rushed to the emergency department in the early morning by his mother because he was unresponsive to deep pain stimuli.

The patient’s mother said that he has been suffering from a fever, cough and runny nose for the last 10 days.

2 days ago, they visited a free clinic and received medication.

When she gave him the medication yesterday, the patient had 3 episodes of vomiting and his condition rapidly worsened.

This morning, the patient did not wake up, even after multiple attempts.

On physical examination, the patient is febrile, hypotensive, and tachycardic.

Peripheral pulses are 1+, and his extremities are pale and cool to touch.

Pupils are equal and slowly reactive to light.


Which of the following is the most likely cause of these findings?

A 2200-g (4-lb 14-oz) newborn is delivered at term to a 37-year-old primigravid woman.

Apgar scores are 6 and 8 at 1 and 5 minutes, respectively.

Examination in the delivery room shows that he is at the 2nd percentile for head circumference and at the 10th percentile for length.

He has a small jaw, small eyes, and low-set ears.

There is a keyhole-shaped defect in the iris of the left eye.

There is an opening in the roof of the mouth extending into the soft and hard palate bilaterally.

A 3/6 holosystolic murmur is heard at the left lower sternal border.

The heels are prominent, with convex-shaped deformity of the plantar surface of the feet.


Of the following, which is the most likely cause of the patient’s symptoms:

Mass in the thoracic region of the spinal cord

A 72-year-old presents to the Emergency Room with hemoptysis.

He has smoked 1 pack of cigarettes a day for the past 30 years.

Physical examination of the face is shown in Image A and is accompanied by left upper extremity edema.


Which of the following diagnostic tests would be the most appropriate?

A 34-year-old woman presents to the office due to a pulmonary embolism confirmed by computed tomography (CT) chest angiogram, which she was recently hospitalized for.

She does not have any recent surgical trauma or travel history.

She complains of having episodes where her fingers become white and then blue, and they are usually accompanied by pain in the same region.

These episodes tend to happen more frequently during winter and have been ongoing for about 2 years now.

She also had a spontaneous abortion at 12 weeks of gestation last year.

She does not have a family history of venous thromboembolic disease.

The vital signs include heart rate 76/min, respiratory rate 18/min, temperature 37.2°C (99.0°F), and blood pressure 120/80 mm Hg.

Physical examination is non-contributory.

The complete blood count (CBC) results are as follows: | Hemoglobin 14.2 g/dL | Hematocrit 39% | Leukocyte count 4,950/mm3 | Neutrophils 59% | Bands 3% | Eosinophils 1% | Basophils 0% | Lymphocytes 31% | Monocytes 4% | Platelet count 120,000/mm3 | The coagulation test results are as follows: | Partial thromboplastin time (activated) 56 seconds | Prothrombin time 15 seconds | Reticulocyte count 1.0% | Thrombin time < 2 seconds deviation from control | .


Which of the following is the most likely underlying diagnosis?

A 33-year-old man presents to his primary care physician for fatigue, weight loss, and diffuse pruritus.

The patient has a past medical history of multiple admissions for severe abdominal pain and bloody diarrhea as well as several episodes of ascending cholangitis which were successfully treated.

He is currently a member of Alcoholics Anonymous.

His temperature is 98.2°F (36.8°C), blood pressure is 124/75 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 99% on room air.

Urinalysis is notable only for a dark urine sample with no red blood cells present.

A rectal exam reveals pale stool and grossly visible blood.

Physical exam is otherwise notable for pruritis, jaundice, and scleral icterus.


Which of the following is the most likely diagnosis?

A 28-year-old G2P1 woman at 29 weeks gestation presents to the obstetrician after noticing red spots on her undergarments over the past week.

Her vaginal bleeding has not been painful; however, she is concerned that it has persisted.

Her previous child was born by cesarean section and she is currently taking folate and a multivitamin.

Her temperature is 98.9°F (37.2°C), blood pressure is 120/84 mmHg, pulse is 88/min, respirations are 17/min, and oxygen saturation is 99% on room air.

Physical exam is notable for a gravid uterus and non-tender abdomen.

Speculum exam reveals a closed cervical os and a small amount of blood.


Which of the following is the most likely cause of this patient's physical findings?

A 57-year-old woman comes to the emergency department 1 hour after experiencing a distressing 10-minute episode of stuttering during a business meeting.

She has smoked 2 packs of cigarettes daily for 30 years.

Current medications include fosinopril and hydrochlorothiazide.

Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 16/min, and blood pressure is 134/88 mm Hg.

She is oriented to person, place, and time.

When she is asked to hold both arms fully extended at shoulder level with palms upwards and eyes closed, her right palm turns inwards and downwards.


Which of the following is the most likely etiology of this patient's condition?

At a routine exam, a 68-year-old female patient is discovered to have a serum calcium level of 11.5 mg/dL.

Follow-up laboratory tests show a high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase.

24-hour urine calcium level is elevated.

Review of symptoms includes complaints of fatigue, constipation, and diffuse bone pain for which she takes vitamin D.

Past medical history is significant for type 2 diabetes mellitus for 25 years and essential hypertension for 15 years.

The patient has a history of kidney stones.


Which of the following is the most likely underlying pathology?

An 11-year-old girl presents to her pediatrician with complaints of headache and rapid leg fatigue with exercise.

Her vital signs are: HR 77, BP in left arm 155/100, RR 14, SpO2 100%, T 37.0 C.

On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse.

Her lower extremities feel slightly cool.

Blood pressure obtained on the left lower extremity is 120/80.


A 34-year-old woman comes to the gynecologist complaining of vaginal swelling and discomfort.

She states that over the past 2 weeks she has noticed swelling of her right labia.

The swelling continued to grow in size and now causes her discomfort when walking.

She denies abnormal discharge or bleeding from the swelling or from the vulva.

She normally shaves the area, but with the recent pain, she has been unable to.

The patient is relatively healthy and takes only a multivitamin.

She never received the vaccine for human papillomavirus (HPV).

On physical exam, there is a fluctuant, swelling of the right labia, most prominently at the posterior vestibule.


Which of the following was the most likely cause of this patient's symptoms?

A 56-year-old woman is brought to the emergency department by her husband 30 minutes after a generalized tonic-clonic seizure.

Over the past 3 months, she has had recurrent headaches and worsening early-morning vomiting.

She has no personal or family history of a seizure disorder.

An MRI of the brain shows a central mass; surgical resection is planned.

One day before the surgery, the patient has another generalized seizure and, despite resuscitative efforts, she dies.

Gross examination of the brain at autopsy is shown.


This patient’s history is most consistent with which of the following conditions?

A 29-year-old woman presents to her primary care provider for a normal check-up at the prompting of her mother.

When asked how she is doing, she replies that she feels depressed.

Upon further questioning, she states that she feels “worthless” now that her ex-boyfriend left her 2 days ago.

She has been sitting in his bed all day trying to call him but he is not answering her calls.

She says that she will never find another man like him and feels like she should just “disappear” rather than continue living without him.

She also reports that she can hear his voice when he’s not around, especially at night before she goes to bed.

She denies having any other friends and has some social anxiety, particularly in large groups of people.

A review of her medical record indicates that she has endured several episodes of verbal and physical abuse from her prior relationships which she suggested “were all her fault.” She has had 4 prior serious relationships and reports that she has not been single for more than a few days in the last 10 years.

On exam, she is unkempt with poor self-care.


Which of the following is the most likely underlying etiology of this patient's condition?

A 52-year-old homosexual man presents to the emergency department because of sudden right loin pain accompanied by nausea and vomiting.

He has essential hypertension for 3 years for which he takes bisoprolol.

He has a remote history of intravenous drug use.

His temperature is 36.9°C (98.4°F), the blood pressure is 137/92 mm Hg, and the pulse is 95/min.

Physical examination reveals right flank tenderness and 2+ edema of both legs up to the knees.

Doppler ultrasonography shows an enlarged, echogenic right kidney with the absent venous signal.

Laboratory results are shown: | Serum creatinine 2.2 mg/dL | Urine dipstick 4+ protein | Urine analysis 20–25 red cells/high power field | .


Which of the following best describes this cause of the patients symptoms after treatment?

A 65-year-old man with squamous cell carcinoma of the lung presents with a sodium of 118 and an altered mental status.

He is started on 3% normal saline over the next several hours.

The patient’s mental status improves and and a repeat sodium six hours later is 129.

Three days after treatment he demonstrates quadriparesis and dysarthria.


Which of the following is the most likely cause of this patient's anemia?"

A 25-year-old woman comes to the physician for a routine examination.

She is a recreational runner and for the past 3 months she has been training for a marathon.

Menses occur at regular 28-day intervals and last 6 days.

She drinks three to five beers when going out with friends.

Her temperature is 36.6°C (98.0°F), blood pressure is 110/72 mm Hg, pulse is 70/min, and respirations are 14/min.

Physical examination shows no abnormalities.

Laboratory studies show: | Hemoglobin 9.8 g/dL | Mean corpuscular volume 91 fL | Lactate dehydrogenase 400 U/L | Platelet count 250,000/mm3 | Reticulocyte count 3% | Haptoglobin 23 mg/dL (N=41–165 mg/dL) | Serum | Iron 90 μg/dL | Ferritin 170 ng/mL | Total iron binding capacity (TIBC) 220 μg/dL (N=251–406 μg/dL) | Urinalysis shows trace blood but no RBCs.


Which personality disorder is most likely?

A 45-year-old man comes into the ED after a car accident.

After waiting an hour in the waiting room, he begins to berate the receptionist and demands to be seen by a doctor.

During the exam, the patient brags that he recently had to quit his job because they did not appreciate his talent and drive.

After a medical student declines his invitation for a date, he becomes very angry and throws supplies across the room.

The physician manages the patient's physical injuries and begins to suspect the patient has a personality disorder.


Which of the following is the most likely underlying cause of this patient's symptoms?

Degeneration of ganglion cells within the myenteric plexuses

A 52-year-old woman comes to the physician because of a 4-day history of painful swallowing and retrosternal pain.

She was diagnosed with HIV infection 2 months ago; her medications include tenofovir, emtricitabine, and raltegravir.

Physical examination of the oral cavity shows no abnormalities.

The patient's CD4+ T-lymphocyte count is 70/mm3 (N ≥ 500).

Two weeks later, she reports no improvement in symptoms.

Esophagogastroduodenoscopy is performed and shows multiple round superficial ulcers in the distal esophagus.


An 18-year-old girl comes to the emergency room with abdominal pain.

She states that the pain started 6 hours ago, is 8/10, and localizes to the right lower abdomen.

She recalls a similar episode last month.

Her older brother was hospitalized 2 years ago for perforated appendicitis.

The patient got her first menstrual period at age 14.

Her periods occur regularly every 28 days.

Her last menstrual period was 2 weeks ago.

She is sexually active with multiple partners and uses condoms inconsistently.

The patient’s temperature is 99°F (37.2°C), blood pressure is 110/74 mmHg, pulse is 89/min, and respirations are 14/min with an oxygen saturation of 98% on room air.

On physical exam, the patient is in moderate distress.

There is lower abdominal tenderness with guarding.

A pelvic examination reveals clear mucous in the vaginal introitus, a mobile uterus, and tenderness of the right adnexa.

Labs are obtained, as shown below: |  | Leukocyte count: 10,000/mm^3 with normal differential | Hemoglobin: 13.5 g/dL | Platelet count: 200,000/mm^3 | Beta-human chorionic gonadotropin: Pending |  | A pelvic ultrasound demonstrates a small fluid collection in the cul-de-sac posterior to the uterus.


A 26-year-old man presents to the office complaining of persistent back pain for the past 3 months.

You saw the patient previously and prescribed NSAIDs and rest, but he has not improved.

The patient states that his maternal grandfather had ‘back problems his whole life’, and he worries that he might have the same issues.

An X-ray is performed and shows squaring of the vertebrae with longitudinal fibrous bands.


What is the most likely explanation for this patient’s symptoms?

Accumulation of N-acetyl-p-benzoquinone imine in the liver

Malignant overgrowth of glial cells in the brain

Obstruction of the cystic duct by gallstone

A 57-year-old man comes to the clinic complaining of nausea and 1 episode of vomiting during the past day.

He denies any precipitating event except for a headache for which he took some acetaminophen yesterday.

The headache is described as bilateral, dull, and 8/10 in severity.

His past medical history is significant for hypertension, biliary colic, and a past hospitalization for delirium tremens when he “tried to quit alcohol cold turkey.” When asked about his current alcohol intake, the patient looks away and mutters “just a couple of drinks here and there.” The patient reports mild abdominal pain that began this morning but denies vision changes, bowel changes, fever, or weight loss.

Physical examination demonstrates tenderness at the right upper quadrant (RUQ) that does not worsens with inhalation.


Which of the following pathologic findings is she most likely to have?

A 47-year-old G3P2 woman presents to her endocrinologist for a follow-up appointment.

Her last menstrual period was at the age of 35 years.

She now feels fatigued and cannot concentrate on her work or type properly on the keyboard because of an onset of tremor in her hands.

Her symptoms are taking a toll on her quality of life.

The patient’s blood pressure is 124/83 mm Hg, pulse is 91/min, respirations are 17/min, and temperature is 36.7°C (98.1°F).

On physical examination, there is a mild enlargement of the thyroid; the gland is minimally firm in texture and is nontender.


What is the most likely cause of her presentation?

A 45-year-old woman presents to the office with a chief complaint of a cough that has persisted for a month and a half.

She also has night fevers and has lost 5 kg (11 lb) in the last 2 months.

She recently returned from a 6-month trip to Peru.

Her vitals include: heart rate 82/min, respiratory rate 17/min, temperature 38.0°C (100.4°F), and blood pressure 107/80 mm Hg.

On auscultation, she has diminished respiratory sounds at the base of the right lung.

Chest radiography shows an opacity in the right apex.


A 52-year-old homeless man is brought to the urgent care clinic with altered mental status and disorientation for the last day.

His temperature is 37°C (98.6°F), the respiratory rate is 15/min, the pulse is 107/min, and the blood pressure is 92/67 mm Hg.

He has a flapping tremor of the wrists during attempted extension.

He is started on intravenous D5 1/2NS and blood is drawn for further testing.

On re-examination the next morning, he has developed visual disturbances with a new horizontal nystagmus and a staggering gait.

His blood tests show:  | Serum | Albumin 3.2 gm/dL | Alkaline phosphatase 150 U/L | Alanine aminotransferase 76 U/L | Aspartate aminotransferase 155 U/L | Gamma-glutamyl transpeptidase 202 U/L | .


A 6-year-old girl is brought to the physician for a well-child examination.

Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 96/52 mm Hg.

Examination shows a 2/6 continuous, low-pitched murmur over the left upper sternal border that radiates towards the neck.

The murmur disappears when she flexes her neck.

The remainder of the examination shows no abnormalities.


Which of the following is the most likely cause of the patient's symptoms?

Bacterial infection from ethmoidal sinus

A 12-year-old girl is brought to the emergency department because of severe pain and swelling of her right eye for 3 days.

Over the past two weeks, she had nasal congestion and a constant, mild headache.

She did not visit a doctor and instead took over-the-counter naproxen and phenylephrine.

Her nasal congestion has since improved, but the headache persists.

She underwent a dental procedure for caries about ten days ago.

She does not recollect any recent insect bites or trauma.

She appears ill and reports occasional chills.

Her temperature is 38.3°C (101°F), pulse is 89/min, and blood pressure is 110/70 mm Hg.

Examination shows proptosis of the right eye.

Her right upper and lower eyelid are erythematous, swollen, and tender to touch.

Her headache is worsened by leaning forward and improves when the patient is lying on her back.


A 17-year-old girl is brought to the physician for a well-child examination.

She frequents buffet restaurants but feels guilty soon after.

She has a history of burning her extremities with cigarettes.

Her last menstrual period was 3 weeks ago.

She attends high school and plays field hockey on the school team.

She is at the 25th percentile for height, 12th percentile for weight, and 17th percentile for BMI.

Examination shows bilateral parotid gland enlargement.

Oropharyngeal examination shows perimolysis.

The remainder of the examination shows no abnormalities.


A 1-day-old male is seen in the neonatal intensive care unit for respiratory distress.

He was born at 37 weeks to a 24-year-old G3P11011 Rh- mother who had no prenatal care.

On physical examination, temperature is 99°F (37.2°C), blood pressure is 120/85 mmHg, pulse is 120/min, respirations are 26/min, and pulse oximetry is 92% on room air.

There is abdominal distention with a positive fluid wave.

Laboratory results are as follows: |  | Serum: | Alkaline phosphatase: 80 U/L | ALT: 33 U/L | AST: 32 U/L | Bilirubin (total): 10 mg/dL | Bilirubin (conjugated): 0.2 mg/dL | Amylase: 76 U/L |  | Leukocyte count: 5,000/mm^3 with normal differential | Hemoglobin: 8 g/dL | Platelet count: 200,000/mm^3 | Mean corpuscular volume: 80 µm^3 | Reticulocyte count: 3% |  | .


A 29-year-old woman comes to the physician with complaints of fever, headache, and rash, which have gradually worsened over the past 6 days.

The patient informs the physician that the rash appeared after 2 days of fever.

The rash started at the wrists and ankles and then gradually spread to the trunk, palms, and soles.

On examination, the physician notes a maculopapular rash as shown in the image below.

Vital signs show a temperature of 39.4°C (103.0°F), a blood pressure of 110/70 mm Hg, and a pulse rate of 86/min.


Which of the following is the most likely cause of these findings?

Obstructed orifice of the Bartholin duct

Allergic reaction to the intrauterine device

An otherwise healthy 23-year-old newly-married woman comes to the physician because of a 6-day history of discomfort in her vaginal area during and after sexual intercourse.

Her last menstrual period was 3 weeks ago.

Two years ago, she was diagnosed with genital herpes which was treated with acyclovir.

She has been in a monogamous relationship for the past year and has been using an intrauterine device for contraception for the past month.

Examination shows a 4-cm, mildly tender mass in the inferior aspect of the left labium minus with no signs of inflammation.

Speculum examination causes her discomfort but shows no abnormalities.


Which of the following is the most likely cause of this infant’s presentation?

A 37-year-old G1P1001 delivers a male infant at 9 pounds 6 ounces after a C-section for preeclampsia with severe features.

The mother has a history of type II diabetes with a hemoglobin A1c of 12.8% at her first obstetric visit.

Before this pregnancy, she was taking metformin, and during this pregnancy, she was started on insulin.

At her routine visits, her glucose logs frequently showed fasting fingerstick glucoses above 120 mg/dL and postprandial values above 180 mg/dL.

In addition, her routine third trimester culture for group B Streptococcus was positive.

At 38 weeks and 4 days gestation, she was found to have a blood pressure of 176/103 mmHg and reported a severe headache during a routine obstetric visit.

She denied rupture of membranes or vaginal bleeding.

Her physician sent her to the obstetric triage unit, and after failure of several intravenous doses of labetalol to lower her blood pressure and relieve her headache, a C-section was performed without complication.

Fetal heart rate tracing had been reassuring throughout her admission.

Apgar scores at 1 and 5 minutes were 7 and 10.

After one hour, the infant is found to be jittery; the infant's temperature is 96.1°F (35.6°C), blood pressure is 80/50 mmHg, pulse is 110/min, and respirations are 60/min.

When the first feeding is attempted, he does not latch and begins to shake his arms and legs.

After 20 seconds, the episode ends and the infant becomes lethargic.


A 65-year-old male presents to his cardiologist to discuss increasing episodes of dyspnea after climbing stairs.

He also now needs three pillows at night to sleep.

Physical examination reveals an early diastolic murmur best appreciated at the left sternal border with bounding peripheral pulses.

The cardiologist is very concerned and immediately refers the patient for a surgical workup.


Which of the following is the most likely cause of this patient's symptoms?

Dysfunction of ATP-binding cassette transporter

Deficiency of lysosomal galactocerebrosidase

A 7-year-old boy is brought to the physician because of decreased vision, hearing, and speaking over the past 3 months.

During this time, he has also had difficulty walking, concentrating, drawing, and feeding himself.

His maternal male cousin had similar complaints and died at the age of 5 years.

Examination shows hyperpigmented skin and nails.

Neurologic examination shows an ataxic gait, spasticity, and decreased muscle strength in all extremities.


Which of the following is the most likely pathology for this presentation?

Depigmented substantia nigra and locus cerulus

Abnormal cleavage of amyloid precursor protein

A 75-year-old man was brought in by his daughter since he was having increased incidences of forgetting things.

His daughter said that he becomes increasingly frustrated searching for his glasses and keys most of the time.

He was helped out a couple of times in the supermarket for forgetting the way out.

He recently lost his driving license when he was spotted by the cops driving in the wrong direction on the interstate.


What is the most likely primary metabolic disturbance?

A 12-year-old female presents to the emergency room difficult to arouse and occasionally vomiting.

On physical exam, her oral mucosa looks dry, her breath has a fruity odor, and her breathing is slow, deep and labored.


Which of the following is the most likely diagnosis?

A 36-year-old man presents to the emergency room with subacute worsening of chronic chest pain and shortness of breath with exertion.

The patient is generally healthy, lifts weights regularly, and does not smoke.

His temperature is 97.8°F (36.6°C), blood pressure is 122/83 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air.

Cardiac auscultation reveals a crescendo-decrescendo murmur heard right of the upper sternal border with radiation into the carotids.

An ECG shows left axis deviation and meets criteria for left ventricular hypertrophy.


Genetic form of hemolytic uremic syndrome

Hemolytic uremic syndrome associated with systemic disease

Escherichia-induced hemolytic uremic syndrome

A 10-year-old boy is brought to the physician because of fever and bloody diarrhea for the past few days.

His parents report that he has become increasingly lethargic and irritable.

His temperature is 38.6°C (101.4°F), pulse is 102/min, and respirations are 22/min.

He has no significant past medical history.

His parents say that he mostly only eats a diet of chicken, hamburgers, fries, cheese, and milk.

On physical examination, pallor and edema in both legs are present.

His laboratory studies show: | Hemoglobin 8.9 gm/dL | Leukocyte count 9,300/mm3 | Platelet count 67,000/mm3 | Blood urea nitrogen 43 mg/dL | Serum creatinine 2.46 mg/dL | Coombs test Negative | .


Which of the following is the most likely cause of these findings?"

A 40-year-old man comes to the physician because of decreased sexual arousal and erectile dysfunction that has put strain on his marriage for the last year.

He has also had fatigue and generalized weakness for the past 9 months.

He has noticed his bowel movements have not been as frequent as usual.

He has occasional dry coughing and back pain.

He has not had fever, headache, or changes in vision.

One year ago, he traveled to South Africa with his wife.

He is 168 cm (5 ft 6 in) tall and weighs 89 kg (196 lb); BMI is 31.6 kg/m2.

His temperature is 36.5°C (97.7°F), pulse is 50/min, and blood pressure is 125/90 mm Hg.

Physical examination shows dry skin and a distended abdomen.

Neurological examination reveals delayed deep tendon reflexes.

Laboratory studies show: | Hemoglobin 11.0 g/dL | Platelet count 380,000/mm3 | Serum | Na+ 130 mEq/L | Cl- 97 mEq/L | K+ 4.5 mEq/L | HCO3- 25 mEq/L | Glucose 95 mg/dL | TSH 0.2 μU/mL | .


Which of the following is most likely to confirm the most likely diagnosis in this patient?

The straight leg test and the clinical presentation

A 25-year-old man presents to his primary care physician with lower back pain.

He states that he has had the pain for the past two years.

The patient works as a butcher, and recently was moving heavy meat carcasses.

The patient states that his pain is worse in the morning and that nothing improves it aside from swimming.

The patient has a past medical history of anabolic steroid abuse, acne, hypertension and obesity.

His current medications are hydrochlorothiazide, ibuprofen, topical benzoyl peroxide, and acetaminophen.

On physical exam there is no tenderness upon palpation of the spine.

There is limited range of motion of the spine in all 4 directions.


A 16-year-old girl is brought to the physician because her mother is concerned about her lack of appetite and poor weight gain.

She has had a 7-kg (15-lb) weight loss over the past 3 months.

The patient states that she should try to lose more weight because she does not want to be overweight anymore.

She maintains a diary of her daily calorie intake.

Menarche was at the age of 13 years, and her last menstrual period was 3 months ago.

She is sexually active with 2 male partners and uses condoms inconsistently.

She is at 50th percentile for height and below the 5th percentile for weight and BMI.

Her temperature is 37°C (98.6°F), pulse is 58/min and blood pressure is 96/60 mm Hg.

Examination shows fine hair over the trunk and extremities.


What is the most likely diagnosis in this patient?

A 25-year-old male presents with progressively worsening headaches over the past two months.

He also feels that he has been losing his balance more often over the past week, but he denies any motor weakness or sensory impairment.

His neurological exam reveals impaired upward gaze, pupils that constrict poorly to light but react to accommodation, and bilateral upper eyelid retraction.

On tandem walking, he tends to fall on both sides.

The remainder of the physical examination is unremarkable.


Pleomorphic replacement of normal bone
"

A 12-year-old girl is brought to the primary physician because of severe ear pain and yellow discharge from her left ear for the past 2 days.

The pain started during her last day of summer camp, where she spent a lot of time outdoors hiking, horseback riding, and swimming.

Her temperature is 37°C (98.6°F), pulse is 76/min, and blood pressure is 110/75 mm Hg.

Examination shows tragal tenderness and a red and edematous external auditory canal.

A diagnostic tuning fork is placed in the middle of the patient's forehead.

The patient reports hearing the sound more loudly in the left ear.

To complete the workup, the tuning fork is placed on the mastoid process of the left ear.

Once she can no longer hear the sound, the tuning fork is placed in front of the auricle, and she reports no longer hearing the sound.

On the right side, once the sound from the mastoid process subsides and the tuning fork is placed in front of the right ear, she reports hearing the sound again.


Which of the following is the most likely diagnosis?"

A 50-year-old man comes to the emergency department because of severe lower chest pain for the past hour.

The pain radiates to the back and is associated with nausea.

He has had two episodes of non-bloody vomiting since the pain started.

He has a history of hypertension and type 2 diabetes mellitus.

He has smoked one pack of cigarettes daily for 30 years.

His medications include enalapril and metformin.

His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm Hg.

Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound; bowel sounds are decreased.

Laboratory studies show: | Hemoglobin 14.5 g/dL | Leukocyte count 5,100/mm3 | Platelet count 280,000/mm3 | Serum | Na+ 133 mEq/L | K+ 3.5 mEq/L | Cl- 98 mEq/L | Total bilirubin 1.0 mg/dL | Amylase 160 U/L | Lipase 880 U/L (N = 14–280) | An ECG shows sinus tachycardia.


Based on these findings, which of the following is the most likely diagnosis?

A 30-year-old woman seeks evaluation at a local walk-in clinic with a week-long history of lightheadedness and palpitations.

She also complains of fatigability and shortness of breath of the same duration.

The past medical history is significant for menarche at 9 years of age, heavy menstrual bleeding for the past several years and abdominal pain that worsens during menses.

She stopped trying to conceive a child after 2 spontaneous abortions in the past 4 years and has been on iron oral supplementation for the last 2 years.

She adds that she feels a dull pressure-like discomfort in her pelvis and constipation.

The physical examination is significant for pale mucous membranes and a grade 2/6 ejection systolic murmur in the area of the pulmonic valve.

Pelvic examination reveals an enlarged, mobile uterus with an irregular contour.

The hemoglobin level is 10 g/dL and the hematocrit is 27%.


A 3-year-old girl is brought by her parents to the office for bloody diarrhea and a seizure.

The parents say she started having fever, abdominal pain, and diarrhea about 3 days ago, but the bloody diarrhea started 12 hours ago.

The seizure was the last symptom to appear 3 hours ago, and it consisted of repetitive movement of arms and legs with loss of consciousness.

Her 4-year-old brother had a similar case with bloody diarrhea 2 weeks ago.

Her vital signs include: blood pressure is 130/85 mm Hg, her respiratory rate is 25/min, her heart rate is 120/min, and her temperature is 39.2°C (102.6°F).

On physical examination, she looks pale and sleepy, the cardiopulmonary auscultation is normal, the abdomen is painful on palpation, and the skin assessment reveals the presence of disseminated pinpoint petechiae.

The complete blood count results are as follows: | Hemoglobin 7 g/dL | Hematocrit 25 % | Leukocyte count 17,000/mm3 | Neutrophils 70% | Bands 2% | Eosinophils 1% | Basophils 0% | Lymphocytes 22% | Monocytes 5% | Platelet count 7,000/mm3 | Her coagulation tests are as follows: | Partial thromboplastin time (activated) 30 seconds | Prothrombin time 12 seconds | Reticulocyte count 1 % | Thrombin time < 2 seconds deviation from control | .


Transfusion related bacterial contamination

A 45-year-old woman presents to the emergency department with hematemesis.

Her son said that the patient had complained of gnawing abdominal pain that worsened before and improved after meals for the past 3 weeks.

She frequently travels for work and is often stressed.

She drinks alcohol socially and does not smoke tobacco or marijuana.

She has not had anything to eat or drink for the past 24 hours due to the pain, but coughed up "several cup of" frank red blood before arrival.

Her temperature is 98°F (37°C), blood pressure is 80/50 mmHg, pulse is 140/min, respirations are 23/min, and oxygen saturation is 96% on room air.

Gastric ultrasound reveals high gastric residual volume.

The patient is empirically started on 3 units of uncrossmatched O-negative blood transfusion and pantoprazole.

The patient's initial laboratory data return in the meantime: |  | Hemoglobin: 5 g/dL | Hematocrit: 18 % | Leukocyte count: 8,000/mm^3 with normal differential | Platelet count: 400,000/mm^3 |  | Serum: | Na+: 140 mEq/L | Cl-: 115 mEq/L | K+: 3.2 mEq/L | HCO3-: 26 mEq/L | BUN: 60 mg/dL | Glucose: 104 mg/dL | Creatinine: 1.1 mg/dL |  | Blood type: AB | Rhesus status: negative |  | After bedside esophageogastroduodenoscopy with stapling of several peptic ulcers, repeat labs are obtained in 2 hours.

The patient now complains of feeling hot with intermittent shivering.

Her temperature is 101°F (38.3°C), blood pressure is 100/55 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air.

Her lungs are clear to auscultation bilaterally, and no accessory respiratory muscle use is observed.


Which of the following genetic conditions is most likely related to these clinical features?

A 1-year-old boy is brought to his pediatrician’s office due to regression of development.

She has observed that he is not progressing as he did during the 1st year of his life.

There seems to be a regression in some behavioral and other milestones.

She is also concerned about his facial development.

On examination, the vital signs are normal.

He has coarse facial features with a bulging frontal bone.

Additionally, his lips are enlarged and corneal clouding is observed.

Urine studies show an increase in dermatan sulfate.


Which of the following is most likely the diagnosis?

A 22-year-old man presents to the emergency department for chest pain.

He says that the chest pain began a few hours prior to presentation and is associated with nausea, abdominal discomfort, and sweating.

He has experienced similar symptoms multiple times in the past, which brings him great concern because he believes he may be having a heart attack.

This concern has persisted for 2 months.

This has caused him to avoid taking long train rides or driving on divided highways.

Approximately 7 months ago his parents divorced.

Medical history is significant for obesity.

He denies any medications or illicit drug use.

An electrocardiogram demonstrates sinus tachycardia with a pulse of 110/min.


An otherwise healthy 52-year-old man comes to the physician because of a 2-month history of palpitations.

He says that he can feel his heart beat in his chest all the time.

For the past 3 weeks, he has shortness of breath on exertion.

He has not had chest pain, orthopnea, or nocturnal dyspnea.

He emigrated from Nepal at the age of 25 years.

His temperature is 36.5°C (97.7°F), pulse is 103/min, and blood pressure is 138/56 mm Hg.


Which of the following is the most likely cause of this patient's seizure?

A 46-year-old woman is brought to the emergency department for respiratory depression.

Routine urine toxicology screening is positive for alcohol, fentanyl, and benzodiazepines.

Naloxone, flumazenil, and lactated Ringer's solution are administered intravenously.

Two hours later, the woman has a tonic-clonic seizure lasting for one minute.

Her pulse is 100/min, blood pressure is 145/90 mm Hg, and respiratory rate is 24/min.

Pulse oximetry on room air shows an oxygen saturation of 98%.

The patient appears drowsy and diaphoretic.

She is not oriented to place or time but responds to her name.

Examination shows a hematoma on her left temple.

Neurological examination shows stiff extremities and a tremor in both hands.

The remainder of the examination shows no abnormalities.


Which of the following is the most likely diagnosis in this patient?

A 45-year-old woman presents with a 2-year history of fatigue, paresthesia, diarrhea, and abdominal pain.

She says she experiences 2–3 episodes of non-bloody diarrhea per month associated with crampy abdominal pain.

She also has the bilateral tingling sensation of her upper and lower limbs in a glove and stocking pattern which is sometimes associated with the burning sensation of her hands and legs.

The patient denies smoking, alcohol consumption, illicit drug use.

Her vital signs include: blood pressure 100/60 mm Hg without postural changes, heart rate 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉).

Laboratory findings are significant for the following: | Hgb 7.2 gm/dL | MCV 110 fL | RBC 3.6 X109/L | Platelets 10,000/mm3 | Total count  4,200/mm3 | Reticulocyte 0.8% | A peripheral blood smear demonstrates hypersegmented neutrophils.

Anti-intrinsic factor and anti-tissue transglutaminase antibodies were negative.

An upper GI series with small bowel follow-through is performed which shows a narrowing of the barium contrast in the lumen of the terminal ileum to the width of a string.


What is the most likely cause of this patient’s condition?

A 35-year-old man attempted to climb Mount Everest.

At an altitude of 7,000 meters, he became short of breath and developed a dusky blue tinge around his face and lips.

A physician in the climbing party performs a rudimentary physical exam which reveals a respiratory rate of 30/min, blood pressure of 130/90 mm Hg, heart rate of 108/min, and temperature of 36.4°C (97.5°F), with few basal crackles on the right side of chest.

No jugular venous distension or dependent edema is noted.

With this information, the mountain climber is sent down the mountain for further evaluation.

Investigation reveals a normal chest X-ray with a normal heart size.


Which of the following is the most likely precipitating factor for this patient's symptoms?

A 56-year-old man is brought to the emergency department by his wife because of increasing confusion and lethargy for the past 12 hours.

His temperature is 37.3°C (99.1°F), pulse is 109/min, respirations are 18/min, and blood pressure is 108/67 mm Hg.

Examination shows abdominal distention and several erythematous, lacy lesions on the chest that blanch with pressure.

His hands make a flapping motion when they are dorsiflexed.


Parents bring an 11-month-old baby to the clinic because the baby has a fever of 39.0°C (102.2°F).

The baby is irritated and crying constantly.

A complete physical examination reveals no significant findings, and all laboratory tests are negative.

Five days after resolution of her fever, she develops a transient maculopapular rash.


Chronic pancreatitis with pseudocyst rupture

A 73-year-old man comes in to the emergency department because of nausea and severe pain in his upper abdomen and right shoulder blade for the past day.

He was able to eat a little for breakfast but vomited up the meal a couple of hours later.

He has type 2 diabetes mellitus treated with metformin.

He has smoked half a pack of cigarettes daily for 40 years and drinks 4 beers every week.

His temperature is 38.8°C (102°F), pulse is 124/min, and blood pressure is 92/68 mm Hg.

Pulse oximetry on room air shows an oxygen saturation of 95%.

The abdomen is soft and there is tenderness to palpation of the right upper quadrant with soft crepitus.

The remainder of the examination shows no abnormalities.

Laboratory studies show: | Hemoglobin 14.3 g/dL | Leukocyte count 18,100/mm3 | Platelet count 216,000/mm3 | Serum | Aspartate aminotransferase (AST, SGOT) 41 U/L | Alanine aminotransferase (ALT, SGPT) 19 U/L | Alkaline phosphatase 110 U/L | Total bilirubin 0.9 mg/dL | Direct bilirubin 0.2 mg/dL | Albumin 4.1 g/dL | Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen.


A 12-month-old girl is brought in by her mother to the pediatrician for the first time since her 6-month checkup.

The mother states that her daughter had been doing fine, but the parents are now concerned that their daughter is still not able to stand up or speak.

On exam, the patient has a temperature of 98.5°F (36.9°C), pulse is 96/min, respirations are 20/min, and blood pressure is 100/80 mmHg.

The child appears to have difficulty supporting herself while sitting.

The patient has no other abnormal physical findings.

She plays by herself and is making babbling noises but does not respond to her own name.

She appears to have some purposeless motions.

A previous clinic note documents typical development at her 6-month visit and mentioned that the patient was sitting unsupported at that time.


A 4-year-old boy is brought to the physician because of a 1-month history of generalized fatigue.

During the past week, he has also had fever and severe leg pain that keeps him awake at night.

Examination shows cervical and axillary lymphadenopathy.

His liver is palpated 4 cm below the right costal margin and the spleen is palpated 3 cm below the left costal margin.

His hemoglobin concentration is 10.2 g/dL, leukocyte count is 64,500/mm3, and platelet count is 29,000/mm3.

A bone marrow aspirate predominantly shows immature cells that stain positive for CD10, CD19, and TdT.