Pathophysiology Case Studies
A 45-year-old woman presented with fatigue, rapid weight gain with central obesity, fullness and redness of her face, and loss of regular menstrual periods. She was mildly hypertensive, and her family doctor had found her also to be diabetic for which she had received dietary advice. Urinary cortisol was 1000 nmol/24 h (normal < 250 nmol/24 h); serum cortisol was 500 nmol/L at midnight (normal < 50 nmol/L) and her 8:00 AM cortisol was 550 nmol/L after 1 mg of dexamethasone (a potent synthetic glucocorticoid) (normal < 50 nmol/L). Plasma ACTH was 100 ng/L (normal < 80 ng/L). What is the most likely diagnosis?
ACTH secreting tumor
A 54 year-old male with a 30 pack-year history of smoking and small cell lung cancer presents to the oncology outpatient clinic for lab work. Lab results show serum Na+ = 123 mEq/L, serum osmolality = 276 mOsm/kg, and urine osmolality = 559 mOsm/kg. Which of the following is this cancer most likely producing?
ADH
A 46 year-old female arrived to the ER after becoming confused and incoherent and having a syncopal (fainting) episode. Upon arrival to the ER the patient was hypotensive at 75/45, tachycardic at 123, temperature of 100.3 and respirations of 20. Blood glucose was 56. Which of the following disorders could explain both the hypotension and hypoglycemia?
Addison's disease
A 54 year old female patient arrived to the ER after becoming confused and incoherent to family and having a syncopal episode. Upon arrival to the ER the patient was hypotensive at 75/45, tachycardic at 123, temperature of 100.3 and RR of 20. Blood glucose was 56. CBC was within normal limits. BMP results showed K+ 6.0 mM and Na+ 127 mM. Further lab tests showed cortisol was decreased and ACTH was increased, compared with normal. Which of the following is most likely?
Addison's disease
Two weeks after orthopedic surgery, a 62 year-old female presented with uncontrolled pain and purulent drainage from the surgical incision. She was admitted and taken to the OR for irrigation and debridement of the infection site. Additionally, she was started on antibiotics to control the infection. Later that week she started having 3-4 foul smelling watery stools a day, became febrile, and complained of N/V. Which of the following pathogens is most likely causing her abdominal problems?
C. diff
A 76 year old female presented to the emergency department with a complaint of shortness of breath that had become progressively worse over the past two days. The patient had palpitations; labored, shallow and increased rate of breathing with use of accessory muscles; crackles heard over bilateral lung bases; a non-productive cough; ankle edema and anxiety. She confirmed having a past medical history of diabetes, obesity, hypertension, and heart attack one year ago. Initial vital signs were: temp 98.7, HR 111, BP 140/80, RR 30, O2-Sat: 88 on room air. A stat EKG was done, which showed sinus tachycardia. CBC, BMP, and cardiac enzymes were wnl, but BNP was elevated. A stat chest x-ray was also done, which portrayed an enlarged cardiac silhouette and bilateral pleural congestion. Which of the following is most likely the cause of these results?
CHF
A 50 year old male presented to the ER with progressive SOB over the past 4 weeks associated with a productive cough. He stated that he had been very healthy all of his life, except for periodic colds which typically lasted for a similar number of weeks, but never went to the doctor for check-ups. During this episode, however, the persistent cough, fatigue and SOB became a problem for him. He has continually smoked approximately one pack a day since his late teenage years. Vital signs: temperature 99.0F, RR 24, HR 90, BP 150/70, O2-saturation 88% on room air. On physical examination he has rapid shallow breathing; prolonged expiration; a "barrel shaped chest"; occasional wheezing with some rhonchi; diminished breath sounds bilaterally at the bases; peripheral cyanosis; and digital clubbing. Laboratory testing revealed results WNL except for a mild elevation in hemoglobin and a HCO3 of 30. ABG's showed a pH of 7.34, PaO2 of 60 mmHg and PaCO2 of 50 mmHg. Pulmonary function tests revealed decreased FEV1, and decreased FEV1/FVC. Which of the following is most likely the cause of these results?
COPD
A 62 year old female presents to the ER via ambulance. The patient arrived on a CPAP machine, placed by the paramedics en route, due to an on scene oxygen saturation of 76%. The patient's breathing is notably labored and the patient is too fatigued to answer any questions. The patient is tripoding and using accessory muscles to breath. The patient is tachypneic, anxious, diaphoretic, has clubbed fingers, a barrel shaped chest, and grey/blue nail beds. On arrival the patient's oxygen saturation is 86% on CPAP. The patient is transferred from the ambulance stretcher to an ER bed and placed on a non-rebreather (NRB) mask. Initial Vital Signs: BP 160/90, HR 112, RR 32, O2 Sat 84% on NRB, Temp. 98.4. Immediately upon arrival, the patient had an EKG showing sinus tachycardia. Labs, blood cultures, and an i-STAT® ABG were obtained. The patient was placed on a cardiac monitor, pulse oximeter, and NIBP monitor. The patient was placed on BiPAP by the hospital's respiratory therapist, and the patient's O2 Sat rose to 92%, but the patient continued to show signs of severe respiratory distress. A STAT chest x-ray and STAT CT scan of the chest were ordered. The i-STAT® ABG showed critical high PaCO2 (98), critical low PaO2 (46), and low pH (7.19). Which of the following is the most likely diagnosis?
COPD exacerbation
A 53 year-old male was in the ICU with viral pneumonia; throughout his ICU stay he steadily declined. He went into respiratory distress two days after admission and was intubated and a central line was placed. Subcutaneous heparin was given prophylactically to prevent thrombus formation. His BP dropped and he was started on a vasopressor medication. His ventilator settings were increased. An arterial line was placed for blood draws. The bedside nurse noticed the patient coughing up large amounts of think frothy bright blood in his endotracheal tube on day six of admission. The patient was also oozing blood from his central line and arterial line puncture sites. Increased ecchymosis (bruising) was noted on extremities. Urine output was 10-20 ml an hour (low). Labs were sent to look for bleeding cause. Significant lab results were: Hbg 6.8 HCT 22.0, WBC count 24,000, ABG: pH 7.1, PaCO2 36, Bicarb 15, platelet count 12,000, INR 5.0, and elevated D-dimer. Which of the following is most likely the immediate cause of these results?
DIC
A 35 year old female develops tingling and weakness of lower extremities. The weakness continued to progress up her torso and upper extremities resulting in paralysis and the inability to breathe on her own. Which of the following events is most likely associated with the trigger for this problem?
GI illness
A 35-year-old woman came to her physician complaining of palpitations, difficulty climbing stairs and general fatigue. She also said that she had lost 4 kg of weight recently despite a good appetite and no attempt at dieting. She also reported occasional diarrhea, and increasingly infrequent and light menstrual bleeds. On examination, her skin was warm and moist and she had a fine tremor of outstretched hands. There was mild weakness of the thigh muscles. She had tachycardia (110/min). She also had a mild thyroid enlargement (goiter) and a bruit over the gland. Thyroid function tests show suppressed TSH level (< 0.05; range 0.4-4 mU/L) and increased thyroxine (T4 = 29; range 9-25 pmol/L) and tri-iodothyronine (T3 = 25; range 3.5-6.5 pmol/L). Thyroid receptor antibodies were detected. What is the most likely diagnosis?
Grave's disease
A 35-year-old woman has had insomnia for the past 4 months. On physical examination, she exhibits bilateral proptosis (mild exophthalmia). Her outstretched hands have a fine tremor. On palpation of her neck, the thyroid gland appears to be enlarged, but no masses are palpable. Laboratory studies show a serum TSH of 0.2 microU/mL (normal 0.4 - 5.0 microU/mL) in association with a serum free thyroxine of 5.1 ng/dL (normal 0.8 - 1.8 ng/dL). Which of the following is the most likely diagnosis?
Grave's disease
An otherwise healthy, 60-year-old man noticed an occasional tremor in his left arm when relaxing and watching television. He also noticed occasional muscle cramping in his left leg, and his spouse noticed that he would occasionally develop a trance-like stare. Which of the following is most likely to help?
L-dihydroxyphenylalanine (L-DOPA)
A 68 year old male presented with new onset chest pain. He reported pain as substernal, and radiating to her shoulders and back. He also complained of shortness of breath and appeared diaphoretic. Vital Signs: Temp 98.8, BP 144/82, Pulse 88, RR 22. BMP and CBC were wnl, but troponin and D-dimer were both elevated. 12 lead EKG revealed ST segment elevation. Which of the following is most likely the cause of these results?
STEMI
A 23 year-old male presented to the ED with complaints of chest pain of 19 months duration. Chest pain was aggravated by strenuous activities and moderately relieved with rest. Patient stated a history of dyspnea on exertion and effort intolerance since childhood. Patient remembered frequent squatting to relieve episodes of breathlessness following exertion. Patient denies history of cough, change in urine or bowels, leg swelling, nocturia or oliguria. General examination showed central cyanosis with digital clubbing. Pulse was regular with a rate of 80 BPM, and BP was 120/70 mmHg. Cardiac examination found a systolic murmur. The lungs were clear and abdomen was non-tender. Chest radiograph showed enlarged heart with pulmonary oligemia with right ventricular hypertrophy. There was no aortic or mitral regurgitation. Patient Hct was 72%. Which scenario is most likely in this patient?
Tetralogy of Fallot
A 19-year-old female presents to the OB/GYN office complaining of amenorrhea. She reports that she has never experienced menstruation or vaginal spotting. Past medical history is significant for a heart murmur discovered in early childhood, delayed growth in development beginning at the age of four and chronic middle ear infections. Physical exam is significant for delayed development of secondary sexual characteristics. Patient's chest is broad; nipples are widely spaced with minimal breast bud elevation. Subtle webbing of the neck with low posterior neckline is noted. Which of the following disorders is most likely?
Turner's syndrome
A 32 y/o female presents with complaints of anxiety accompanied by a "racing heart." She reports a recent job loss and attributes presenting symptoms with this event. A thorough history revealed concerns of weight loss, and missed period. Physical examination reveals: HR 105 with regular rhythm, B.P. 132/90, presence of fine bilateral hand tremor, presence of perspiration, skin is warm to touch, and minimal non- tender enlargement of thyroid gland is detectable upon palpation. A thyroid panel is done and TSH is 9.3 mU/L - Normal Values (0.5-5.0 mU/L), T4 is 12.5 mcg/dl - Normal Values (4.6-11.2mcg/dl), and T3 is 205 ng/dl - Normal Values (75-195ng/dl). Which of the following could most likely cause the current problem? a) antibodies against the TSH receptors on the thyroid gland
a TSH secreting hormone
A 45-year-old businessman had a routine medical examination, at which he was found to have a slightly enlarged liver. Tests revealed bilirubin 15 μ mol/L (0.9 mg/dL), AST 434 U/L, ALT 198 U/L, ALP 300 U/L, γ -glutamyl transpeptidase (γGT) 950 U/L, and albumin 40 g/L (4 g/dL). He seemed perfectly well. Which of the following is most likely to help him?
abstaining from alcohol consumption
A patient presents with severe abdominal pain, nausea and vomiting. Serum amylase is increased and serum calcium is decreased. Which of the following diseases is most likely?
acute pancreatitis
One week after a severe strep throat, a 6 year old female patient presents with oliguria. Which type of glomerular nephritis is most likely in this patient?
acute proliferative (postinfectious) glomerulonephritis
A 52 yr old female was admitted into the MICU with sepsis. The patient slowly became increasing lethargic. Vitals included: BP: 60/30, RR: 6, and HR: 55. Shortly afterwards, the patient lost her pulse and went into cardiopulmonary arrest. After approximately 30 minutes of resuscitation, the patient was intubated, started on vasopressors, and a pulse was established. The patient was stabilized. A few hours post arrest, the patient's urine output started to decrease. Subsequent labs showed: BUN: 34mg/dl, serum creatinine: 2.6mg/dl. Urinalysis was positive for tubular cell casts, and red blood cells, urine sodium concentration was 50 mEq/L. In addition, the patient developed edema around her legs and ankles. The period of severe hypotension most likely caused which of the following?
acute tubular necrosis
A 60-year-old woman is admitted with sudden onset of chest pain and is diagnosed with an acute myocardial infarction. There is difficulty maintaining adequate blood pressure and tissue perfusion for 3 days. Her serum lactate becomes elevated. Her serum urea nitrogen and creatinine are noted to be increasing. Granular and hyaline casts are present on microscopic urinalysis. Which of the following renal lesions is most likely to be present in this situation?
acute tubular necrosis
A 60-year-old woman was admitted with sudden onset of chest pain and is diagnosed with an acute myocardial infarction. There was difficulty maintaining adequate blood pressure and tissue perfusion for 3 days. Her serum lactate became elevated. Her serum urea nitrogen and creatinine were noted to be increased. Granular and hyaline casts were present on microscopic urinalysis. Which of the following renal problems is most likely to be present in this situation?
acute tubular necrosis
A 45-year-old man has a 4 month history of nonfocal, generalized headaches. On physical examination he is found to have a blood pressure of 170/110 mm Hg. Laboratory studies show serum sodium of 146 mmol/L, potassium 2.3 mmol/L, chloride 103 mmol/L, glucose 82 mg/dL, and creatinine 1.2 mg/dL. His plasma renin activity is 0.1 ng/mL/hr (normal 0.5 - 3.3 ng/mL/hr) and his serum aldosterone 65 ng/mL (normal 2 - 9 ng/dL). Which of the following is the most likely cause for his findings?
adrenal cortical adenoma
A 41-year-old man is found in an obtunded state and taken to the hospital. On admission physical examination he is icteric. His abdomen is enlarged with a fluid wave. An abdominal CT scan shows extensive intraperitoneal fluid and a uniformly enlarged liver that has decreased attenuation (decreased brightness). Laboratory studies show total protein 6.5 g/dL, albumin 2.8 g/dL, total bilirubin 4.8 mg/dL, AST of 563 U/L, ALT 317 U/L, alkaline phosphatase 55 U/L, and ammonia 91 micromol/L (normal range 7 - 27 micromol/L). A liver biopsy is performed and microscopically demonstrates abundant Mallory hyaline, neutrophilic infiltrates, hepatocyte necrosis, portal fibrosis, and extensive macrovesicular steatosis (fatty liver). Which of the following is the most likely diagnosis?
alcoholic hepatitis
A 34 y/o female presents to the ED with anxiety, palpitations, and chest pain. She is currently receiving radiation to the chest as a result of breast cancer. She denies fever, chills, SOB, cough, abdominal pain, or N/V/D. Vital signs are: T 98.9, BP 90/60, HR 100, RR 26, SpO2 98% RA. Lungs are clear to auscultation bilaterally. Heart shows regular rhythm with weak S1, S2, and faint rub. Jugular venous distension is present. Peripheral pulses are weak bilaterally. EKG shows normal sinus rhythm with decreased voltage. Chest x-ray shows increased cardiac silhouette. Echocardiogram is positive for effusion. Which scenario is most likely in this patient?
cardiac tamponade
A 43-year-old previously healthy woman has noted bouts of sharp upper abdominal pain along with nausea for 3 weeks. On physical examination she has tenderness to palpation of the right upper quadrant. She has scleral icterus. A liver biopsy is performed and on microscopic examination shows only intracanalicular cholestasis in the centrilobular regions, along with swollen liver cells and portal tract edema. There is no necrosis and no fibrosis. There is no increase in stainable iron. Which of the following is the most likely diagnosis?
choledocholithiasis
A 60-year-old man has a 90 pack year history of smoking. For the past 5 years, he has had a cough productive of copious amounts of mucoid sputum for months at a time. He has had episodes of pneumonia with Streptococcus pneumoniae and E. coli cultured. His last episode of pneumonia is complicated by septicemia and brain abscess and he dies. At autopsy, his bronchi microscopically demonstrate mucus gland hypertrophy. Which of the following conditions is most likely to explain his clinical course?
chronic bronchitis
A 76 year old female presents with a chief complaint of shortness of breath, fatigue, and a 20 lbs weight gain over the last 6 weeks. Vitals include: BP 165/78, HR 118, RR 26, SpO2 94% on 3L NC, and Temp 36.9. Assessment consists of S1, S2, and S3 heart sounds, crackles bilaterally in bases of lungs, and 3+ pitting edema to bilateral upper and lower extremities. X-ray showed cardiomegaly and fluid buildup in the lungs. CT was negative for PE. Echocardiogram showed ventricular hypertrophy with an ejection fraction of 35%. Which of the following best explains these findings?
congestive heart failure
A 59-year-old woman was admitted to the renal unit with recurrent infections and recurrent endocarditis. She had been treated with hemodialysis for 5 years and over a period of 2 years had lost 33% of her body weight. She had a very poor appetite and had been taking two cartons (1.5 kcal/ml) of milkshake sip feeds daily. She was anuric and her fluid intake was restricted to 1000 ml daily. Her height was 1.68 m and she weighted 52.7 kg; BMI was 18. Her most recent biochemistry results revealed persistent hyperkalemia between 5.7 and 6.2 mmol/L. Which of the following treatments is most helpful?
continued nutritional supplementation with decreased K+ intake
A 27-year-old G2 P1 woman has a screening ultrasound performed at 18 weeks gestation. The fetus is appropriate in size for 18 weeks. The fetal kidneys, liver, head, and extremities appear normal. However, the fetus has a heart with a membranous ventricular septal defect, overriding aorta, and marked pulmonic atresia. If the baby were to be liveborn, which of the following characteristics on physical examination would most likely result from these cardiac defects?
cyanosis
The mother of a 2-year old girl brings her daughter to the pediatrician's office. The mother states that the patient has had frequent watery, foul smelling and sometimes greasy stools on and off for the past 3 months. At other times she seems to be constipated. She is noticeably small for her age - in the 50th percentile for height and 25th percentile for weight. The mother also reports that after the patient's last cold, the cough did not subside for several weeks and each cough was producing thick, grayish mucus. Her medical record shows 3 hospitalizations in the past 2 years from respiratory tract infections, all of which were treated with antibiotics. Today, she appears to be in good health with no apparent cough, but she looks malnourished and pale. Abdominal ultrasound showed no obstructions or mechanical blockages, and stool culture revealed normal bacterial growth, without viral infection. Stool sample was positive for fat and vitamins A, E and D. Chloride sweat test on 150mg of sweat revealed 111mEq/L of chloride (high). Which scenario is most likely in this patient?
cystic fibrosis
An 8-year-old girl was referred to a nephrologist after it had been noticed that her face was puffy and her ankles swollen over a period of about 2 weeks. Dipstick test for urine protein yielded a strongly positive (++++) result and measurement in a 24-hour collection showed protein excretion of 7 g/day. The reference value for urinary protein excretion is less than 0.15 g/day. Why are her ankles swollen?
decrease in the plasma oncotic pressure resutling from loss of plasma protein
An 82 year old male was brought to the ED after a syncopal (fainting) episode at his nursing facility. Assessment includes a hematoma above the left eye and the patient reports decreased urine output and blurry vision at times. Vitals include: BP 113/68, HR 118, RR 18, Temp 36.9, and SpO2 96% on room air. Lab results included: Na+ 150, Cl- 112, serum osmolality 303, urine osmolality 1280, all other labs were within normal limits. Orthostatic testing was as follows: supine (lying) BP 116/71 HR 97, sitting BP 102/64 HR 104, standing BP 82/48 HR 121. Stress test and echocardiogram were unremarkable. Which of the following best explains his orthostatic hypotension?
dehydration
A 23 y/o female presents to the ED with general weakness and vomiting. Her PMH includes IDDM. ROS is positive for polyuria, and polydipsia. Pt also reports dysuria that started 3 days prior. Pt denies SOB or cough, chest pain, abdominal pain, bloating, and change in bowel habits. Vitals include: Temp: 101.2, BP: 120/80, HR: 120, RR: 24, SpO2: 98% on RA. She is AAOx3, but drowsy, lungs are CTAB, and heart sounds are normal with tachycardia. Lab tests reveal: Na+: 149 mEq/L; K+: 3.2 mEq/L; HCO3-: 16 mEq/L; pH: 7.2; Anion gap: 18; plasma glucose: 455 mg/dL. Urinalysis was positive for ketones, leukocyte esterase, nitrites, and WBCs. Which of the following best explains the patient's symptoms?
diabetic ketoacidosis
A 33-year-old female presents with secondary amenorrhea, hirsutism, significant weight gain of 15 kg within the past 2 months, acne, significant muscle weakness, recurrent headaches, hair loss, wine-colored striae on the abdomen and extremities, facial roundness, a lump over the back of her neck, and feelings of depression. She also complains of a persistent headache, and a neuro exam demonstrates bilateral temporal hemianopsia. Which pattern of lab results is most likely?
elevated ACTH and elevated cortisol
A.F. a, 46 year old female patient arrived to the ER after becoming confused and incoherent to family and having a syncopal episode. Upon arrival to the ER the patient was hypotensive at 75/45, tachycardic at 123, temperature of 100.3 and respirations of 20. Blood glucose was 56. Which additional lab results are most likely for this patient?
elevated renin and ACTH
A 36-year-old woman has had episodes of lower abdominal and pelvic pain for the past 10 years. A bimanual pelvic examination reveals no abnormalities. A Pap smear is negative. She has an abdominal ultrasound scan that reveals no abnormalities. Finally, she undergoes laparoscopy, and her physician notes the presence of several 0.2 to 0.5 cm brown nodular lesions located on serosal surfaces of the uterus, fallopian tubes, and appendix. These lesions are excised. Which of the following microscopic findings is most likely to be present in these lesions?
endometrial glands with stroma
A 45-year-old woman complained of right upper quadrant abdominal pain and vomiting after consuming fatty food. The only biochemical abnormality was a modestly raised alkaline phosphatase at 400 U/L (< 260 U/L). Which of the following is most likely?
gall stones
A baby boy, born of a poorly controlled, chronically hyperglycemic, diabetic mother, was large and chubby (macrosomic) at birth (5 kg) but appeared otherwise normal. He declined rapidly, however, and within 1 h showed all the symptoms of hypoglycemia. Which of the following treatments is most likely to help him?
glucose infusion
A 15-year-old insulin-dependent boy visited a diabetic clinic for a routine check-up. He told the doctor that he followed all the dietary advice and never missed insulin injections. Although his random blood glucose was 108 mg/dL, HbA1c concentration was 11% (adequate control: below 7%). Which of the following best explains the elevated HbA1c value?
he is not following the dietary advice and/or missed multiple insulin injections
A 72 year old male presents to the ED comatose. Vitals are HR 132 (Sinus Tachycardia), BP 87/45. CMP shows blood glucose 2250 (mg/dl), pH 7.41, Na+ 133, K+ 4.6, Cl- 97, HCO3- 23, and serum osmolarity 356 mOsm. Which scenario is most likely in this patient?
hyperosmolar hyperglycemic non-ketotic syndrome
A two year old child, comes into the Pediatric Emergency Room with tachycardia (HR of 125 bpm), tachypnea (respiratory rate of 40), shortness of breath, pallor, and chest retractions. The child had been "kicking a soccer ball and running in the backyard for less than an hour and then began to breathe heavily and started to look pale". Patient's labs were WNL. A chest X-ray ruled out pneumonia. In addition, urine and sputum cultures ruled out all other types of infections. Finally, an echocardiogram was ordered to rule out cardiac defects. The child's echocardiogram showed atrial septal defect (ASD) and auscultation revealed a heart murmur. Which of the following statements is most likely correct?
increase blood flow through the lungs caused pulmonary edema
A 51 year old female, K.W. with a past medical history significant for only HTN, presented to the ER with BP 276/196 and left-sided weakness. A CT scan of the head revealed a right basal ganglia hemorrhage with intra-ventricular extension. One day after K.W.'s initial presentation, her urinary output increases, and labs show serum Na+ 162, serum osmolality 315. Which of the following statements concerning this case is most likely true?
increased ICP has damaged the hypothalamus and is preventing appropriate ADH secretion
A 56 year old female presented to the ER with dry cough for the last month and shortness of breath. Patient has a history of HTN, DM, and breast cancer. EMT found her tachypneic with labored breathing. They immediately placed a non-rebreather on her. When she arrived to the ER she was lethargic. The blood gas showed: PH 7.46, PaO2 59, PaCO2 30, HCO3- 23, on 100% O2. Even on the non-rebreather she was still laboring to breath. Chest x-ray showed her lungs where opaque. Pulmonary function testing showed FEV1 was significantly reduced, approximately 50% of expected, while the FEV1/FVC ratio was WNL. Which of the following is most likely the cause of these results?
interstitial lung disease
A 56 year old male was admitted to the hospital with increased fatigue, weakness, loss of appetite with a 12lb weight loss, dry hackling cough, chest discomfort, and SOB with exertion. The patient had been in and out of the hospital multiple times in the past 3 years with similar symptoms. Pt had an occupational history of working in coal mines for 30 plus years. ABG showed respiratory acidosis. Pulmonary function testing showed FEV1 and FVC were significantly reduced, while the FEV1/FVC ratio was WNL. Which of the following best explains these findings?
interstitial lung disease
A 35-year-old man complained of shortness of breath after climbing two flights of stairs. His chest radiograph was normal, as were examination of the heart and the electrocardiogram; blood gases were normal. He was taking a nonsteroidal antiinflammatory agent (NSAID) for joint pain. His blood cell count revealed a hemoglobin value of 10 g/dL (reference range for men 13-18 g/dL) and a reduced mean corpuscular volume of 72 dL (reference range 80-96). Serum ferritin concentration was low at 10 μ g/L (reference range 14-200). Which of the following diagnoses is most likely?
iron deficiency anemia
A 15-year-old African-American boy came to the UK on an exchange visit for 2 months. After 2 weeks in the UK, he complained of abdominal discomfort, a feeling of being bloated, increased passage of urine and, more recently, the development of diarrhea. His only change in diet noted at the time was the introduction of milk. He had developed a considerable liking for milk and was consuming 1-2 large cartons per day. A lactose tolerance test was performed, whereby the young man was given 50 g lactose in an aqueous vehicle to drink. Plasma glucose levels did not rise by more than 1 mmol/L (18 mg/dL) over the next 2 hours, with sampling at 30-minute intervals. Which of the following is most likely?
lactose intolerance
A 44-year-old woman dies as a consequence of a "stroke". At autopsy, she is found to have a large right basal ganglia hemorrhage. She has an enlarged heart with predominantly left ventricular hypertrophy. Her kidneys are small with cortical scarring, and microscopically they demonstrate small renal arterioles that have luminal narrowing from concentric thickening. Which of the following is the most likely diagnosis?
malignant hypertension
A 63 year-old male presents with depression, confusion, vague pains in his bones, and ulcers. He was recently diagnosed with kidney stones. Blood tests reveal that PTH is decreased, while both serum Ca++ and phosphate are increased. Which of the following is most likely?
metastatic bone cancer
A 65 year old male presents to the emergency room with complaints of chest pain. He describes it as a chest pressure radiating into left arm and jaw, and states it feels as though somebody is stepping on his chest and it is hard to breathe. Pain is unrelieved by rest, and increases in severity with even minimal activity. Labs were also drawn; CBC was unremarkable, but serum troponin and D-dimer were both elevated. Which of the following is the most likely cause of his pain?
myocardial infarction
A 73-year-old male, presents to the ED with a primary complaint of chest pain. He has past medical history of type II diabetes, hypertension, hyperlipidemia, stroke, dementia, complete heart block with permanent pacemaker placement, and bladder cancer. Upon admission to the ED, he is alert but confused, and complains of severe pain/heaviness to his chest. Patient is diaphoretic and short of breath. EKG reveals ST segment elevation. Cardiac enzymes are elevated, and serial cardiac enzymes demonstrate a peak in Troponin. Which scenario is most likely in this patient?
myocardial infarction
A 44-year-old woman was admitted to hospital because of weakness, anorexia, recurrent infections, bilateral leg edema, and breathlessness. Her plasma albumin concentration was 1.9 mg/dl and her urinary protein excretion was 10 g/24 h. Which of the following does this patient most likely have?
nephrotic syndrome
A 3 year old presents to the ER with acute left sided facial palsy. Patient's mother states her son has been irritable over the last few weeks. His current VS include: 36.6 degrees C, HR 80 bpm in sinus rhythm, BP 180/110, RR 22, and oxygen saturation of 99% on RA. On assessment, patient has a normal neurologic exam except for his left sided facial palsy. He has no cardiac murmur and has 2+ pulses on both upper and lower extremities. His lungs are clear to auscultation. Patient is placed on a cardiac monitor, which continues to show a normal HR and rhythm. A CT scan is negative for a cranial bleed. The following labs are all normal: CBC, serum electrolytes, BUN, creatinine, urinalysis and urine culture. Patient undergoes an ultrasound of the kidneys and abdomen followed by a magnetic resonance angiography (MRA) of the kidneys. These results indicate a unilateral stenosis of the right renal artery. Which scenario is most likely in this patient?
only the right kidney is producing excessive renin
A 20-year-old primigravida delivers a term baby girl following an uncomplicated pregnancy. No anomalies are noted at the time of birth. Five weeks later, the mother brings the baby to the clinic because she has difficulty breathing and occasionally turns pale. On physical examination a continuous murmur is audible. Which of the following congenital cardiac anomalies is most likely to be present in this infant?
patent ductus arteriosus
A 2 month-old female presents for evaluation of poor feeding. She is in no apparent acute distress, but mom reports that she has difficulty with feeding and get short of breath at times. Mom is concerned that the baby seems to be losing weight and is excessively tired. The baby's weight is below average for age and length. She is alert at this time and does not appear to be in any acute distress. Respiratory rate is 41, and auscultation reveals crackles in bilateral bases. Patient is afebrile and has strong peripheral pulses in upper and lower extremities. Auscultation reveals a HR of 140 with a continuous murmur. Which scenario is most likely in this patient?
patent ductus ateriosus
A 16-year-old healthy adolescent is involved in a schoolyard gang fight and stabbed in the chest with a knife in the left midclavicular line. He is taken to the emergency department and on arrival his blood pressure is barely obtainable. His lungs are clear to auscultation. His heart sounds are barely audible. Which of the following is the most likely acute condition that may preclude his survival?
pericardial tamponade
A 29-year-old primigravida who received no prenatal care has marked vaginal bleeding after the onset of labor at 38 weeks gestation. Cesarean section is performed and a lacerated low-lying placenta is removed. She remains hypotensive for 6 hours and requires transfusion of 12 packed RBC units. Postpartum, she becomes unable to breast-feed the infant. She does not have a resumption of normal menstrual cycles. She becomes more sluggish and tired. Laboratory findings include hyponatremia, hyperkalemia, and hypoglycemia. Which of the following pathologic lesions is she most likely to have had following delivery?
pituitary necrosis
A 31-year-old woman who has two healthy children, notes that she has had no menstrual periods for the past 6 months, but she is not pregnant and takes no medications. Within the past week, she has noted some milk production from her breasts. She has been bothered by headaches for the past 3 months. After nearly hitting a bus while changing lanes driving her vehicle, she is concerned with her vision. An optometrist finds her lateral vision to be reduced. On physical examination she is afebrile and normotensive. Which of the following laboratory test findings is most likely to be present in this woman?
pituitary necrosis
A Thirty year old male presents to his general practitioner for increasing back pain, which he states has become increasingly worse over the past several months. He describes the pain as "sharp and crampy," and indicates to his mid back as the location of the pain. Pt. denies fever, chills, frequent urination, pain on urination or recent trauma. Past medical history is significant only for moderate hypertension, which is well controlled on current medication regimen. Family history is unobtainable. Routine labs were drawn, including CBC, CMP and urinalysis. Upon physical examination pt. is found to have CVA tenderness. Deep palpation of the abdomen elicits pain bilaterally and evidences enlarged kidneys. Based on physical findings pt. is sent for a CT scan. Urinalysis revealed hematuria and proteinuria; BUN= 40 (normal 7-18) Creatinine 2.7(normal 0.6-1.2); CT scan revealed diffuse renal cysts bilaterally. Which of the following is the most likely diagnosis?
polycystic kidney disease
A 42-year-old female presents to her physician complaining of muscle weakness and cardiac abnormalities. Laboratory tests indicate that she is hypokalemic. Which of the following could be the cause of her condition?
primary hyperaldosteronism
A 42-year-old female presents to her physician complaining of muscle weakness, depression, and cardiac abnormalities. Laboratory tests indicate that she is hypercalcemic, with normal serum sodium and potassium. Which of the following could best explain her symptoms?
primary hyperparathyroidism
A 28-year-old female presents to the OB/GYN office complaining of amenorrhea and nipple discharge. Patient reports missing her period 5 months ago; however, she reports that she has taken multiple pregnancy tests since her last menstrual period, all producing negative results. Patient reports having a normal 28-day menstrual cycle starting when she was 13-years-old. Patient describes nipple discharge as "white discharge that leaks from the breast randomly every day". Patient reports a decreased libido and vaginal dryness with intercourse and denies any other sexual dysfunction. Remainder of physical exam is unremarkable. Which of the following disorders is most likely?
prolactinoma
A 56 year-old male presents with no specific complaint. He works as a truck driver and has been in 2 accidents recently and his boss insists that he gets "checked out" by a medical professional before he can drive again. He claims that objects suddenly appear from out of nowhere. He admits to recent loss of libido and erectile dysfunction. Which of the following is most likely?
prolactinoma
A 65 year-old female is post operative day two after a right total knee replacement. After surgery due to her difficulties with pain the patient has refused physical therapy and has been unable to get out of bed. During her morning nursing assessment, the patient complains of moderate chest discomfort with pain level 6/10, some shortness of breath, and quickly thereafter became diaphoretic. Vital signs reveal: BP 152/82, HR 139, RR 26, T: 98.7, O2 sat on RA: 90%. Immediately a 12-lead ECG was ordered and performed revealing sinus tachycardia with ventricular rate of 139 beats per minute. STAT cardiac enzymes were WNL, but D-dimer was elevated. The patient has been placed on the warfarin protocol that began the night after surgery. Her pre-operative INR was 1.01. Her post-op day #2 INR was 1.2 after having received two doses of Coumadin. Her INR goal on the warfarin protocol was 2-3, so the patient was not yet therapeutic. Which of the following is most likely causing this patient's discomfort?
pulmonary embolism
On the 11th postoperative day following a radical prostatectomy for adenocarcinoma of the prostate, a 70-year-old man is recovering uneventfully. He then ambulates to the bathroom, but upon returning to his bed he suddenly becomes extremely dyspneic and diaphoretic, with chest pain, palpitations, and a feeling of panic. Which of the following post-operative complications has he most likely developed?
pulmonary embolism
A 26 year old woman presented to her OBGYN's office complaining of fever, bilateral flank pain, nausea, aches, chills, dysuria, hematuria, and urinary frequency. Her BP was 128/82, pulse was 100, O2-sat was 99% on room air, and temperature was 38.7 degrees Celsius. She rated her bilateral flank pain as 8/10. She reported experiencing urinary frequency with dysuria and hematuria for the past 24 hours and reported nausea, but denied vomiting. A CT scan of her abdomen and pelvis ruled out kidney stones or an obstruction. Urinalysis was positive for leukocyte esterase. CBC showed that both white blood cell count and neutrophil count were elevated. Which of the following renal problems is most likely to be present in this situation?
pyelonephritis
A 31 year old female presented to the ED complaining of back pain, nausea, and a fever. She woke up with 9/10 left sided flank pain that radiated to her left lower abdomen. Her BP was 137/76; pulse was 104; pulse ox 100.0% on room air; and a temperature of 38.4 degrees Celsius. She denied dysuria, frequency, or urgency. She was ordered for a renal sonogram to rule out an obstruction or a kidney stone. A CBC showed her WBC's to be 19.3 k/uL. A UA showed positive large leukocyte esterase, 12 WBC, trace RBC, negative nitrites, and many bacteria. A clean catch urine culture showed 10,000-50,000 cfu/ml of staphylococcus aureus. The renal sonogram showed moderate hydronephrosis with mild dilation of the proximal ureter. There were no obvious renal calculi. The left ureteral jet suggested non-obstructive flow into the bladder. Which of the following is the most likely diagnosis?
pyelonephritis
A 72 year old male presents to the Emergency Department complaining of dyspnea, right sided upper chest pain and a non-productive cough for the past three weeks. He is also complaining of shortness of breath at rest and dyspnea on exertion for the past 2-3 months. He also mentions that he has started sleeping sitting up, because it's more comfortable. He denies nausea, vomiting, diarrhea, and fevers. His vital signs were as follows: Temp 35.9, HR 78, RR 28, BP 130/80, SaO2 95%, and 4/10 pain. Physical assessment revealed markedly diminished breath sounds on the right side to mid-lung. Dullness to percussion was also noted on the right side of the chest. The trachea appeared midline. CMP and EKG are unremarkable. What is the most likely cause of these symptoms?
right sided pleural effusion
A 52-year-old woman presented to the accident and emergency department of her local hospital with severe right-sided flank pain. Blood was detected on stick testing of urine and radiography revealed the presence of kidney stones. The pain settled with opiate analgesia. Further questioning revealed a history of recent depression, generalized weakness, recurrent indigestion, and aches in both hands. Serum adjusted calcium was 12.8 mg/dL, serum phosphate 2.0 mg/dL, and PTH 169 pg/mL (normal range 11-69 pg/mL). Which of the following is most likely?
she has a PTH secreting hormone
A 14 year old previously healthy female presents to the ED. She has a 2 day history of increased fatigue, thirst, and frequent urination. She has "fruity" breath odor, and her blood glucose is > 600 mg/dl. Which of the following is expected?
she has elevated anion gap acidosis, urinalysis will show ketones, she has decreased PaCO2, she has dehydration due to polyuria
A 16 year-old female presents to the ED with a 2 day history of polyuria, polydipsia, fatigue, nausea, and disorientation. Blood tests show: Na+ 137 mM, Cl- 96 mM, HCO3- 14 mM, blood glucose 567 mg/dl, serum osmolarity 294 mOsm/L, PaCO2 32 mmHg, pH 7.26. Which of the following statements is LEAST likely to be true?
she has hyperosmolar hyperglycemic nonketotic syndrome
A 56-year-old woman was admitted to a general ward with increasing breathlessness. She had smoked 20 cigarettes a day for the previous 25 years and reported frequent attacks of 'winter bronchitis'. Arterial blood gas measurements revealed a pO2 of 45 mmHg, pCO2 of 53 mmHg, and pH 7.35; bicarbonate concentration was 35 mmol/L. Which of the following statements is LEAST likely to be true?
supplemental oxygen will normalize her blood gas values
A 15 year old female presents to the ED c/o of vomiting on and off over the past 2 days, a headache, and "not feeling well." She decided to come to the hospital when she started to have abdominal pain and was having trouble catching her breath. On initial assessment, she is a thin girl who appears lethargic and to be having Kussmaul respirations. Her breath has a fruity odor. Her vital signs are: 36.5 degrees Celsius, HR 115, BP 90/50, RR 34, O2 saturation 94%. The RN instantly collects a finger stick blood glucose due to the fruity odor of her breath to find a glucose level of >500 mg/dl. Other labs are collected and are notable for large urine ketones, a pH of 7.25 and HCO3 of 12. Which of the following statements is most likely true?
the low BP is the result of hypovolemia
A 72-year-old female patient is in the step-down unit. She is currently being treated for pneumonia with intravenous antibiotics and oxygen therapy but during her stay at the hospital has developed other symptoms. She is now complaining of abdominal cramping, loss of appetite and nausea. Vital signs are as follows: heart rate 85, Blood pressure 130/70, respirations 20, oral temperature 100.7˚F. The patient's abdomen is tender to the touch and hyperactive bowel sounds are auscultated in all four quadrants. Stool is watery and seedy and bowel movements are increasing in frequency, currently at six per day. Which of the following statements is most likely true?
the most likely causative agent for the diarrhea can form spores
A 57-year-old man is found comatose. On physical examination he has decreased skin turgor (he's dehydrated). Laboratory studies show a blood glucose of 780 mg/dl. Urinalysis reveals no ketosis or proteinuria, though there is glucosuria. Which of the following is the most likely diagnosis?
type II diabetes mellitus
