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A 18 year old boy is brought to the physicians office by his mother, with complains of sweats and headaches during the nights. Initially he was started on NPH insulin, 30 U each morning and 15 U every night. But following a persistent morning glycosuria that did not improve, the evening dose was increased to 20 U during his last visit. His recent lab tests reveal worsening of his morning glycosuria with moderate ketones in his urine. The next step in management of this patient will be +
A 26 year old women comes to ER with complaints of nausea, sweating, dizziness and palpitations. She appears anxious, tremulous and breathes rapidly. She used to be previously in good health. These symptoms appeared suddenly before 30 minutes on her arrival to the ER. Her blood pressure is 110/70 mm Hg, pulse rate 110/minute and temperature is 36.6 C. Acute coronary syndrome and pulmonary embolism have been ruled out. While waiting for the physician, she also began complaining about numbness and a tingling sensation around her mouth and in her fingertips. The most appropriate next step by the physician will be +
A 9 year old girl is brought to the physicians office by her mother who complaints of few recent changes in her daughter. Her daughter has been having episodes of uncontrollable laughter. Her performance in her school has been poor and she often tends to turn aggressive on her classmates and even on her mother. She has also started menstruating recently and her breast development started at the age of 7 years, which is unusual. Which of the following mass lesions might explain her symptoms? +
A 54 year old woman, a known Crohn’s disease patient looking malnourished was admitted following severe diarrhea. She also has a small intestinal fistula. She was then started on parental nutrition. During the second week of parenteral nutrition, she develops spasms in her hands and feet. She also complains of muscle twitching and cramps. Examination reveals extension of interphalangeal joints and adduction and flexion of the metacarpophalangeal joints. The laboratory findings include <br>
Serum calcium 8.2 mg/dL <br>
Serum sodium 135 mEq/L <br>
Serum potassium 3.2 mEq/L <br>
Serum chloride 100 mEq/L <br>
Serum phosphorus 2.6 mg/dL <br>
Serum albumin 2.4 g/dL <br>
Serum bicarbonate 25 meq/L <br>
pH 7.42 <br>
PaCO2 38 mm Hg <br>
<br>
The most likely cause of the her complaint is +
A 52 year old female is complaining of headache, hot flashes, vaginal dryness and irritability. Her symptoms started about a year ago and have been gradually worsening. Her last menstrual period was before 12 months. She currently smokes two packs of cigarettes daily and drinks a glass of wine occasionally. She takes hydrochlorothiazide for her hypertension. Her cardiorespiratory examination is unremarkable. Her physical examination reveals scares pubic hairs with a vaginal dryness and atrophy. She is advised vaginal estrogen replacement and short term combined hormonal replacement therapy for her menopausal symptoms and to prevent osteoporosis. She asks about receiving a transdermal estrogen therapy rather than the oral estrogen therapy. By not using oral estrogen, which of the following complications may be avoided? +
An 85 year old woman with a past medical history of stroke, hypertension and diabetes mellitus is sent to the ER from a nursing home for evaluation of fever and altered mental status. Vital signs revealed a temperature of 101F, BP: 100/60 mmHg, RR: 22 bpm, HR: 110. Physical examination revealed an elderly woman not responding to verbal stimuli but moans in response to deep pain. Ecchymoses are seen on lower extremities. A foley catheter is present draining cloudy urine.
Laboratory studies:
Hgb : 8.4 mg/dl
WBC: 14,000
Platelets: 15,000
BUN: 50
Creatinine: 3.3
Prothrombin Time: 16.4 (11-15s)
Partial Thromboplastin Time: 60 (25-40s)
LDH level: 478 (45-90 U/L)
Which of the following features would most likely help in identifying the etiology of this patient’s thrombocytopenia? +
A 72-year-old man with a history of chronic obstructive pulmonary disease (COPD), stroke, elevated cholesterol, and dementia is brought to the ER by his wife for fever and shortness of breath during past three days. He underwent an oral surgical procedure 6 weeks ago. Upon examination, the temperature is 36.8°C, the blood pressure is 140/60 mm Hg, and the respiratory rate is 22 breaths per minute. A soft diastolic murmur is heard and gentamicin therapy is initiated. Which of the following tests should have been administered in order to monitor the medication's adverse reactions? +
A 9-year-old boy is brought to the pediatrician's office for persistent pain in his right leg. The mother explains that the patient's symptoms have been progressively worsening for the past 2 months. Upon further investigation, the patient reports recent unintentional weight loss despite normal appetite. Physical examination is remarkable for tenderness over the right femoral diaphyseal area. Additional testing reveals a right femoral bone mass with a histopathological analysis that demonstrates small, round, blue cells that are CD99-positive. What is the most likely radiographic finding of this patient's right femur? +
A 37-year-old diabetic man presents to the emergency department (ED) with severe headache and eye pain. His wife explains that he has been hospitalized a few weeks ago for diabetic ketoacidosis. She states that the patient's past medical history is significant for type 1 diabetes mellitus diagnosed at the age of 23 years; and the patient has recently been non-compliant with his insulin injections. In the ED, initial work-up is remarkable for elevated glucose levels in the urine and serum. Examination of the nasal cavity reveals a black necrotic eschar. Neurological exam is remarkable for facial palsy and ophthalmoplegia. What are the microscopic characteristics of the organism responsible for this patient's condition? +
A 45-year-old HIV-positive man presents to your office with complaints of increasing fatigue, difficulty swallowing, and a 6.8 kg (15 lb) weight loss in the past 2 months. The patient is found to have a CD4+ count of 192 cells/mm<sup>3</sup> and viral load of 52,432 copies/mL. Physical examination reveals a white patch on the right side of the tongue that cannot be scraped off. What is the most likely organism responsible for this finding? +
A 62-year-old woman is brought to the emergency department (ED) by her husband. He reports that one month ago, the patient had complaints of sleep disorder and decrease in appetite. A few days later, she started to become forgetful. At first, the patient was forgetting minor details like the car keys or appointments. The husband is now more concerned that she has lately been forgetting the names of her children, has developed slurred speech, and has experienced progressive difficulty in walking. The patient's temperature is 37 °C (98.6 °F), blood pressure is 122/82 mmHg, and heart rate is 76/min. Physical exam in the ED is remarkable for confusion, muscular hypokinesis, and atrophy. The physician also notes the presence of involuntary intermittent myoclonic jerks of the lower extremities in response to sound or touch. Cerebrospinal fluid analysis demonstrates elevated 14-3-3 proteins. Brain biopsy of this patient would most likely demonstrate which of the following findings? +
A 48 year old male come to the office with a complaint that he experiences gritty and burning sensation in both eyes. He does not wear contact lens. He also says swallowing dry food without water is difficult. He says he had these symptoms for a year and now need some relief of these symptoms. He has been diagnosed with depression and is on fluoxetine. His vitals are normal and reviews of systems are remarkable for muscle pains. Which of the following condition is most likely associated with later stages of the disease? +
A 27-year-old male presents to his primary care physician's office for joint pain over the past several days. The patient denies feeling similar pain in the past. He has tried over the counter ibuprofen but it has not relieved his pain. His past medical history is otherwise unremarkable. He smokes one pack per day and has about 20 drinks per week. He uses marijuana occasionally but denies any injectable drug use. He is sexually active and uses condoms. He denies recent travel outside the country and has no allergies. Physical examinations show mild hyperemia and swelling in the right knee and right ankle. Range of movement is restricted because of pain. No rash is present. Arthrocentesis reveals a turbid fluid with WBC count of 20,000/mm3. What is the best next step to confirm the diagnosis? +
23 year old female presents to the office with 5 day history of joint pain and fever. She says has tried over the counter ibuprofen and had only mild relief of her symptoms. Her past medical history is insignificant. She does not smoke or drink. She is sexually active and uses condoms. Physical examination shows hyperemia and swelling in the left knee. Range of movements is restricted because of pain. No rash is present. Arthrocentesis done shows a turbid fluid with WBC count of 60,000/mm3. You make a diagnosis of infectious arthritis. Which additional finding would help in determining the cause of the condition? +
A 62 year old male is hospitalized following acute myocardial infarction. His other medical problems include type 2 diabetes mellitus, hypertension, emphysema and degenerative joint disease. He admits smoking two packs of cigarettes daily as well as drinking two bottles of beer daily for the past 20 years. His medications include aspirin, glyburide, metoprolol, enalapril, heparin, albuterol and ipratropium inhalers. His blood pressure is 150/90 mm Hg, pulse 86/min, respiratory rate 16/min and temperature is 36.6 C (98 F). During his stay in the hospital, a number of blood tests were ordered including a thyroid function test. Which of the following lab abnormalities is an indication for a thyroid function test in this patient? +
A 66 year old Caucasian male presents to the physicians office with erectile dysfunction that has been over the last few months. He finds difficulty in obtaining erection and also recently noticed a decrease in his nocturnal erections. His past medical history is significant for type 2 diabetes mellitus and benign prostatic hypertrophy. His current medications include glyburide and prazosin. His physical examination is insignificant. His recent HbA1c level measured a week ago was 6.5%. He is asking for a prescription of sildenafil. Which of the following is the best statement concerning the regarding the treatment of erectile dysfunction in this patient? +
A 84 year old man is referred from his nursing home for evaluation of confusion and lethargy. He is a known rheumatoid arthritis patient, who is currently using indomethacin and methotrexate. His temperature is 36.8 C, pulse is 72/min, blood pressure is 110/70 mm Hg and respirations are 16/min. He is disoriented. Mucus membranes are moist. Neck examination reveals no jugular venous distension. Lungs are clear on auscultation. Abdomen is soft, nontender and not distended. His laboratory results are significant for a serum sodium level of 118 mEq/L (Normal 135 mEq/L to 148 mEq/L). Other test results are<br>
Potassium 3.9 mEq/L<br>
Glucose 98 mg/dL<br>
BUN 9 mg/dL<br>
Uric acid 3 mg/dL<br>
Serum osmolality 260 mOsm/Kg of water<br>
Urine osmolality 450 mOsm/Kg of water<br>
Urine sodium 80 meq/L<br>
<br>
What is the most likely cause? +
A 56 year old diabetic male is admitted to the coronary care unit with acute myocardial infarction complicated by cardiogenic shock. His hospital course was complicated by acute renal failure. His thyroid study came out as abnormal. He does not have any previous history of thyroid disease. Physical examination of the thyroid gland is found to be normal. Lab result of the thyroid study is as follows:<br>
Serum T3: 1.1 nmol/L (Normal 1.8 to 2.9 nmol/L)<br>
Serum T4: 8 microg/dL (Normal 5 to 12 microg/dL)<br>
The most likely diagnosis is +
A 58 year old man who was diagnosed with schizophrenia in his early twenties is found wandering around his halfway house confused and disoriented. He is rushed to a local emergency room, where his serum sodium concentration is found to be 123 meq/L (Normal 135 mEq/L to 145 mEq/L). His urine sodium concentration is 5 meq/L (Normal >20 mEq/L). The patient was being treated with risperidone 4 mg per day for the past 3 years. He had been compliant with the medication and had good control over his symptoms. His roommate reports that the patient makes many trips to the nearby water cooler and often complains of being thirsty. What is the most likely cause of this patient’s metabolic disturbance? +
A 35 year old Caucasian male is diagnosed with medullary thyroid carcinoma that is non resectable. His past medical history is insignificant. He does not smoke or consume alcohol. His family history is significant for thyroid cancer and pheochromocytoma in his father. Which of the following could have been most effective in preventing this patient’s non resectable cancer? +