Property:Prompt
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A patient has an absolute right to maintain all his medical information confidential. The physician is obligated to respect a patient's privacy and to withhold sharing any private medical information with other individuals, including family members, close friends, or colleagues. Which of the following conditions does not uphold this principle? +
A 70-year-old Caucasian male with a past medical history of hypertension and coronary artery disease was brought to the emergency department (ED) a few hours after he developed sudden, severely worsening epigastric pain and shortness of breath. The pain was stabbing, radiating to the back and was associated with nausea and profuse sweating. He confessed he has not been compliant on his anti-hypertensive medication for the past two months. There is no history of trauma. At presentation his vitals are: temperature is 39.2°C, pulse 110 beats per minute, respiratory rate 32/min, and blood pressure 90/70 mm Hg. On examination his neck veins are distended. Lungs are clear bilaterally. Cardiovascular examination reveals muffled heart sounds. Abdomen is tender to palpation, especially in the epigastrium with associated guarding, and the extremities are cold to touch.
Laboratory results reveal normal parameters. Electrocardiogram showed sinus tachycardia but no acute ischemic changes. Chest x-ray and trans-esophageal echocardiogram reveal enlarged cardiac silhouette and right atrial and ventricular collapse, respectively.
Which of the following is likely to be expected in this patient? +
A 60 year-old female comes to your office complaining of fatigue, lethargy, intolerance of cold and dry skin. These symptoms started gradually over the last month. The patient has a past medical history of hypertension for 15 years which is controlled by Metoprolol and hydrochlorothiazide, thyroiditis which was treated successfully with corticosteroids 3 years ago, and atrial fibrillation 1 year ago which is controlled by amiodarone and warfarin with controlled INR. On examination, all vital signs are normal, no pain or swelling in her neck. Serum TSH is elevated, with low levels of free T4. What is the most probable cause of hypothyroidism in this patient? +
A 60 year-old female comes to your office complaining of fatigue, lethargy, intolerance of cold and dry skin. These symptoms started gradually over the last month. The patient has a past medical history of hypertension for 15 years which is controlled by Metoprolol and hydrochlorothiazide, thyroiditis which was treated successfully with corticosteroids 3 years ago, and atrial fibrillation 1 year ago which is controlled by amiodarone and warfarin with controlled INR. On examination, the patient has a normal vital signs, no pain or swelling in her neck. Serum TSH is elevated, with low levels of free T4. The patient is diagnosed with Amiodarone-induced hypothyroidism (AIH). What is the best next step in managing this patient? +
A 60 year-old female comes to your office complaining of unexplained weight loss, sweating, and tremor. These symptoms started gradually over the last month. The patient has a past medical history of hypertension for 15 years which is controlled by Metoprolol and hydrochlorothiazide, thyroiditis which was treated successfully with corticosteroids 3 years ago, and atrial fibrillation 1 year ago which is controlled by amiodarone and warfarin with controlled INR. On examination, the patient is vitally normal except of recent tachycardia with rate of 100 beat per minute. There is no pain or swelling in her neck. There is marked increase in serum levels of free T4, with undetectable levels of serum TSH. What is the most probable cause of these symptoms? +
A 60-year-old Caucasian male with a past medical history of hypertension and coronary artery disease was brought to the emergency department (ED) a few hours after he developed sudden, severely worsening chest pain and shortness of breath. The pain was stabbing, radiating to the back and was associated with nausea and profuse sweating. He confessed he has not been compliant on his antihypertensive medication for the past two months. At presentation his vitals are: temperature is 39.2°C, pulse 110 beats per minute, respiratory rate 32/min, and blood pressure 90/70 mmHg. On examination his neck veins are distended. Lungs are clear bilaterally. Cardiovascular examination reveals muffled heart sounds. Abdomen is tender to palpation, especially in the epigastrium with associated guarding, and the extremities are cold to touch.
Laboratory results reveal normal parameters. Electrocardiogram showed sinus tachycardia but no acute ischemic changes. Chest x-ray and transesophageal echocardiogram reveal enlarged cardiac silhouette and right atrial and ventricular collapse, respectively. Resuscitative measures were initiated.
What is the next best step in the management of this patient? +
A 46 year old male comes to his primary care physician with complaints of intermittent chest pain and difficulty in swallowing for the past 10 days. He denies any history of radiation of pain, difficulty in breathing, loss of appetite and loss of weight. He has a past medical history of gastroesophageal reflux disease for the past 5 years and is on treatment with proton pump inhibitors. He is also a known hypertensive and diabetic patient who is regular with his medications. He is a known smoker who quit smoking before 2 years and occasionally drinks alcohol. His vital signs are heart rate of 82 beats/min, respiratory rate of 16/minute, blood pressure of 130/80 mm Hg and oral temperature of 37.2 C. The patient is referred for an endoscopy where biopsies are taken from all the four quadrants within every 2 cm epithelium in the lower esophagus. The histopathology of the biopsies revealed a low grade dysplasia of the esophageal epithelium. What is the next best step in management of this patient? +
A 49 year old man presents to his primary care physician with complaints of generalized muscle weakness and pain present all throughout the day for the past three days. It started as a vague neck pain before progressing to generalized muscle weakness. He also complains of drooping of his upper eyelids and inability to open his car doors because of hand weakness. Over-the-counter acetaminophen has not been helpful. He denies any history of fever, difficulty in breathing or swallowing and facial muscle weakness. He has a past medical history of gastroesophageal reflux disease and plantar fasciitis that was diagnosed before 1 week for which he is currently taking methylprednisolone. He has a history of smoking 1 pack of cigarette per day for the past 25 years and denies taking alcohol. On examination, his vital signs are blood pressure of 130/85 mm Hg, pulse rate of 80 beats/min, respiratory rate of 15 breaths/min and temperature of 37.2 °C. Bilateral ptosis is noticed and there is pain on palpation of both the upper and lower extremity. Muscle strength is 2 in both the upper and lower extremities. Handgrip is weak, and he has difficulty standing up from sitting position. Sensations are bilaterally normal and symmetrical. Normal deep tendon reflexes are noted. His complete blood count and basic metabolic profile are normal. His other lab tests revealed the following<br>
ESR : 10 mm/hr<br>
Creatinine phosphokinase: 890 U/L<br>
C-reactive protein : 14 mg/L<br>
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A urine dipstick test is positive for hemoglobin. Muscle biopsy and electromyography are not performed. What is the most likely cause for this patient’s complaints? +
A 74 year old woman with complains of weight loss, progressive malaise, jaw claudication and scalp tenderness for the past 1 month. She also complains of one episode of transient complete loss of vision in her right eye and partial loss of vision in her left eye. On examination, she has a right tender, nodular and non-pulsatile temporal artery. Her lab tests revealed an erythrocyte sedimentation rate of 74 mm/hour and C-reactive protein of 52 mg/liter. She is immediately started on intravenous methylprednisolone 250 mg BD and oral prednisolone 80 mg OD. A following temporal artery biopsy is consistent with arteritis. Her symptoms resolved and her inflammatory markers improved over the next 3 days. She is discharged on oral prednisolone. Three months later she presents to the office with complaints of weakness. She has difficulty in standing up from sitting position and in climbing the stairs. Her lab tests revealed erythrocyte sedimentation rate of 10 mm/hour, C-reactive protein of 3 mg/liter and creatinine phosphokinase of 24 U/L. What is the most likely cause for this patient’s complaints? +
A 18-year-old African american male comes to the office for the evaluation of pain in his right hip that started 7 weeks ago. The pain has gradually progressed, and now it limits his daily activities. He has sickle cell disease and was hospitalized 4 months ago due to a painful crisis that was successfully treated with hydration, oxygen, and analgesics. His temperature is 37.4C (99F), blood pressure is 120/90 mmHg, pulse is 90/min, and respirations are 14/min. Physical examination reveals no local tenderness, but there is restriction of abduction and internal rotation of the hip. What is the most likely diagnosis? +
A previously healthy 3-year-old boy is brought to the emergency department (ED) due to stridor of sudden onset. Last night, he suddenly developed a high fever followed by breathing difficulty. His temperature is 40C (104 F), pulse is 130/min, and respiration rate is 40/min. In the ED, the child is toxic-appearing,sitting up, leaning forward and drooling. His lungs are clear, and oxygen saturation is 85% in room air. What is the most appropriate next step in management? +
A 3.5 year-old boy is brought to the hospital due to a cough and a whistling sound with breathing. Three days ago, he developed fever, a hoarse cry, rhinorrhea and a progressively worsening, barky cough. His immunizations are up-to-date. His 6-year-old brother also as cold symptoms. His temperature is 37.5C (99.5F),pulse is 140/min, and respirations are 36/min. On examination, he is conscious, in mild respiratory distress, has a dry barking cough. His pharynx is reddish and injected, but without enlargement or asymmetry. The lungs auscultation was clear. Lateral neck x-rays reveal a narrowed subglottic region. What is the most likely diagnosis? +
A 16 year old girl comes to the clinic, complaining of irregular vaginal spotting for the last 2 months. She has never had any bleeding between periods in the past. She has been taking oral contraceptive pills for the last two months and occasional pain killers for her ankle strain. She is a professional tennis player and trains daily for more than 4 hours. She reports that she has been stressed for the last month trying to catch up with her schedule for the next national championship. The pelvic examination is unremarkable. Her lab tests does not reveal any abnormality. Her pregnancy test is negative. What is the best next step? +
A 50 year old man has been brought to the office by his family for noticeable decrease in his functional status over the last few months. He has a down syndrome and has been semi-independent all his adult life. For the last 6 years, he has been in vocational training, where he has been coping well till 8 months ago, when he started to be so forgetful and losing orientation of time and place around him. He has been rounding around the neighbor’s residence. His family reports that he lost his vocabulary when he speaks. His laboratory tests do not reveal any abnormalities. What is the clinical pattern consistent with the patient symptoms? +
A 30 year old adult male comes to the clinic of progressive weight loss over 10 pounds, the condition started 18 months earlier when he noticed progressive non bloody diarrhea. He reports that he feels malaise and aching in multiple joints allover his body and his energy level is low for the last couple of months. He admits that he has few unprotected sexual relationships. The past medical history is non-relevant. He denies taking any alcohol or cigarette. He works as DJ composer and get used to travel out of United States frequently for business trips. The vital signs shows a temperature of 37.0 C with soft non tender abdomen and negative fecal occult blood stool. The laboratory is negative for antiendomysial antibodies. The small intestine biopsy shows a PAS staining macrophages. Which is the best next step? +
A 30 year old adult male comes to the clinic of progressive weight loss over 10 pounds, the condition started 18 months earlier when he noticed progressive non bloody diarrhea. He reports that he feels malaise and aching in multiple joints allover his body and his energy level is low for the last couple of months. He admits that he has few unprotected sexual relationships. The past medical history is non-relevant. He denies taking any alcohol or cigarette. He works as DJ composer and get used to travel out of United States frequently for business trips. The vital signs shows a temperature of 37.0 C with soft non tender abdomen and negative fecal occult blood stool. The laboratory is negative for antiendomysial antibodies.The HIV serology is negative by ELISA test. The small intestine biopsy shows a PAS staining macrophages. Which is the best next step? +
A 55 year old male came to clinic with a mild headache for the last three months. The headache has been getting worse over time. Recently he noticed a progressive numbness in his left leg. He denies any motor or gait abnormality. He reports falling while playing with grand son 4 months on backyard. He is taking aspirin 80 mg, plavix 75 mg, propranolol 20 mg, insulin lantos injection for the last 1o years. He takes long acting analgesics for chronic back pain. The pin brick test reveals bilateral loss of fine sensation till knee level.His surgical history includes two time retinal laser surgery for retinal detachment and hemorrhage.What would be the underlying lesion? +
A 65 year old man comes to the clinic with a weakness and not feeling well. He has been in a bad mood since he lost his best friend who died of cancer. Since then, he has been worried a lot about his health. He noticed that he has difficulty raising his right eyelid for the last 6 weeks. His medical history is significant for an ischemic brain stroke 5 years ago, with no residual motor or sensory deficits. He drinks a two glass of red wine every night after the dinner. He has been smoking 1 pack per day for the last 30 years. He is treated for COPD by formeterol and tiotropium. The physical examination shows a ptosis of right eye lid, however the extraocular muscles movement is intact. The full neurological examination does not reveal any abnormality. What would be the best next step in management? +
A 45 year old female comes to the clinic with a weakness and not feeling well. She has been in bad mood since he lost her two sons in car accident two months ago. Since then, she has been worrying alot about of issues in her life. She has sought a psychiatric consultation for the frequent nightmares and panic attacks. She also noticed that he has difficulty raising his right eyelid for the last 6 weeks. His medical history is significant for a rheumatoid arthritis has failed to respond to DMARDs for the last 3 years. she drinks a couple beers at weekends. She does not smoke nor take illicit drugs. Her medications are Etanercept, analgesics and Fluxetine. The physical examination shows a ptosis of right eye lid, however the extraocular muscles movement are intact. The full neurological examination does not reveal any abnormality. What would be the best next step in management? +
A 45 year old female comes to the clinic with a weakness and not feeling well. She has been in a bad mood since she has lost her two sons in car accident two months ago. Since then, she has been worried about a lot of issues in her life. She has sought a psychiatric consultation for the frequent nightmares, emotional breakdown and panic attacks. She also noticed that he has difficulty raising his right eyelid for the last 6 weeks. His medical history is significant for a rheumatoid arthritis has failed to respond to DMARDs for the last 3 years. she drinks a couple beers at weekends. She does not smoke nor take illicit drugs. Her medications are etanercept, analgesics and fluxetine. The physical examination shows a ptosis of bilateral eye lids, however the extraocular muscles movement is intact. The full neurological examination does not reveal any abnormality. What would be the best confirmatory test to diagnose the disease ? +