IMP2 Block 1 Questions

A 45 year-old female presents to your office with synovitis of her wrists and metacarpophalangeal joints associated with 1 hour of morning stiffness for the last 8 months. She is found to have an elevated rheumatoid factor and positive anti-CCP as well as erosions at her wrist joints. What are two high yield things to note for this diagnosis?

1. Get C-spine XR before elective surgery 2. get quantiferon gold TB screen before TNF-a txmt

Carcinoid syndrome

5-HIAA

A 42-year-old woman who recently emigrated from Guatemala has no history of prior BCG vaccination. She has no cough, fever, or night sweats.

>10

An incarcerated 56-year-old man with COPD presents with a chronic cough.

>10

A 23-year-old man, newly diagnosed HIV positive, is asymptomatic.

>5

A man is arrested for armed robbery in which he assaults a cashier. The cashier has cerebral herniation and has lost all spontaneous respiration, cognitive function, and brainstem reflexes. You are called as an expert witness to advise the court. The defense states the charge should only be assault and battery because the cashier's heart is beating. What should you advise?

A beating heart does not equate to "being alive". Any assault leading to brain death is murder. If you would determine brain death in this case, then the charge should be murder.

A 45 year-old female presents to your office with synovitis of her wrists and metacarpophalangeal joints associated with 1 hour of morning stiffness for the last 8 months. She is found to have an elevated rheumatoid factor and positive anti-CCP as well as erosions at her wrist joints. Which of the following is the first line treatment? A: methotrexate B: massage therapy C: observation D: ibuprofen

A: methotrexate

Hepatocellular carcinoma

AFP; liver

A 19-year-old college student develops a keratitis thought to be secondary to use of disposable soft contact lenses.

Acanthamoeba castellanii

A 67-year old man is admitted with metastatic prostate cancer to the bones. He is in excruciating pain despite your present treatment. He has a history of COPD and the house staff are concerned that increasing his pain medications will decrease his respiratory drive. What should you do?

As long as you are not giving him more pain medication with the intent of ending his life, it is acceptable. The primary ethical duty is to relieve suffering. (doctrine of double effect)

A 29-year-old female reports stiffness in her low back and pelvis for the last several months, worse in the morning and improved after she goes for a run or takes a hot shower after about an hour. She takes ibuprofen and it helps. She has some tenderness at the site where her Achilles tendon inserts into the bone. She feels okay otherwise. Which is the most likely diagnosis? A: systemic lupus erythematosus B: a spondyloarthropathy C: vasculitis D: rheumatoid arthritis

B: a spondylorarthropathy

Ovarian cancer

CA-125

Colon cancer

CEA

One patient just had a baby at 36 weeks. The baby needs a transfusion to survive, but because of religious reasons, the mother refuses. What should you do?

Call the court to get an order for the transfusion

A 15-year old patient wants you to prescribe her contraception. She does not want her parents to know. What should you do?

Contraception does not require parental consent. However, you should encourage her to talk to her parents.

A 37-year-old woman with HIV presents with headache, irritability, and confusion. Funduscopic examination reveals bilateral papilledema. India ink smear of the spinal fluid is positive.

Cryptococcal meningitis

A 42-year old HIV+ man is admitted for hematuria most likely resulting from kidney cancer. He has a DNR. Urology is consulted and they say they would normally advise a kidney biopsy and possible nephrectomy but in this case, since the patient is DNR and preterminal, there is no reason to. What should you advise?

DNR does not mean preterminal. It just means the physician should take cardiopulmonary arrest as the end-point of treatment. Other normal care is independent of the DNR. (However, the patient may not know this and intend something else)

A 57-year old woman with cryptogenic cirrhosis is under your care. She is septic and has severe variceal bleeding and encephalopathy not responding to lactulose. She is hypotensive and on pressors as well as intubated. You expect her to die in a few days. She develops hepatorenal syndrome and uremia. The family is requesting the placement of a fistula for dialysis. What should you do?

Do not start dialysis or place the fistula. Her condition is clearly preterminal and dialysis will only prolong dying, not improve life. Futility of treatment is justification for not providing it.

A 44-year-old man presents with intermittent epigastric pain and is found to have a gastric lymphoma.

H. pylori

A 57-year-old patient presents with right upper quadrant abdominal pain. Serum alpha-fetoprotein level is higher than 1200 ng/mL. The patient does not drink alcohol and has no history of intravenous drug use or blood transfusions. A hepatic mass is present on CT scan of the abdomen.

Hepatitis C infection (hepato-cellular carcinoma)

A 29-year-old patient presents with squamous cell carcinoma of the anus. He is sexually promiscuous and is requesting an HIV test.

Human papillomavirus (HPV)

A 53-year-old woman with a history of resection of the ileum presents with glossitis and a hematocrit of 15%. Her peripheral smear is as shown in the following figure.

Hyper-segmented polymorphonuclear leukocytes

A local law enforcement officer comes to your practice. She shows you proper ID and tells you she is investigating a crime. She wants to see your patient's records for immigration status and medical conditions. What should you do?

If she has a subpoena, then give her the information. If not, refuse.

A 50-year-old female comes to you complaining of her hair falling out, a rash on her eyelids and neck after being in the sun and fatigue while washing her hair in the shower. She was recently able to climb stairs but lately she has been so tired and unable to do this. What is diagnosis (2)?

Inflammatory myopathies (dermatomyositis, polymyositosis)

Lymphoma

LDH (lactate DH)

A patient is admitted to the hospital where you are the attending with a first-time seizure. The head CT and EEG are normal. You choose not to start anti-seizure medication. The patient drives to work regularly. What should you do regarding the driving?

Mandatory self-reporting of seizures is required in all 50 states. If there is a USMLE answer that says "encourage patient not to drive", choose that. If that is not an answer, then choose "recommend the patient inform the DMV". You must know your state laws regarding mandatory physician-reporting. Mississippi is "permitted but not required".

A patient with diabetes lives in a small town with only one endocrinologist, who has a full practice and is not accepting new patients. The patient—who has a complicated regimen that her GP says is beyond his scope of understanding—shows up at the office, beseeching to be accepted. What should the endocrinologist do?

No legal obligation to accept patient. This is different from a hospital's mandate to provide emergency treatment. However, once a physician accepts a patient, they cannot suddenly end it, but must help the patient find a new provider

A 30-year old woman is your patient in the ICU for respiratory failure. The patient had a car accident and sustained massive intracranial hemorrhage. She is brain dead and will be removed from the ventilator. You know there are numerous patients in the hospital who need organs. The family is with you and trusts you. Should you ask them about donating her organs?

No. The organ donor network is the only group that should ask and get consent—legally. They have a far higher % success rate than physicians anyway.

A patient has seen you for numerous appointments and procedures. She has not paid her bill in nearly a year. After you insist that she pay, yet again, she says that she is moving to another physician and wants your office to send her medical records over. You say you will not send those records until she has paid her bill.

Nope. She owns the medical record information and you cannot hold them "hostage".

One patient is 36 weeks into a pregnancy. You determine that without an emergency C-section, the fetus will die. The mother refuses because she hates the idea of a C-section. What should you do?

Obey her wishes.

Prostate cancer

PSA

A 15-year old patient wants you to help her get an abortion. She does not want her parents to know. What should you do?

Parental consent laws regarding abortion vary from state to state so there is no set legal answer. You should encourage her to talk to her parents if you think that would not subject her to harm.

A 75-year old man arrives at the emergency department febrile, short-of-breath, and confused. Several family members are with him, including wife and adult children. You want to perform an emergency lumbar puncture. The wife and children refuse. Then a 25-year old grandchild comes up with a document signed by the patient indicating she is his official healthcare proxy. She says perform the puncture. The family says no. What do you do?

Perform the puncture

Hematology and Oncology

Pre-Test

Infectious Diseases

Pre-Test

A 22-year-old man presents with a painless mass in his neck. A biopsy shows the cells as in the following figure.

Reed-Sternberg cells

A 45 year-old female presents to your office with synovitis of her wrists and metacarpophalangeal joints associated with 1 hour of morning stiffness for the last 8 months. She is found to have an elevated rheumatoid factor and positive anti-CCP as well as erosions at her wrist joints. What does this patient have?

Rheumatoid arthritis

A 25-year-old African American female presents to the ED with diffuse joint pain, a red rash on her cheeks and across the bridge of her nose, and is complaining of shortness of breath and chest pain. She has mouth ulcers and alopecia on physical exam and is found to be in kidney failure. What is diagnosis? What antibodies? specific ones?

SLE anti-ANA ds-DNA antibodies

A 10-year-old boy is admitted to the hospital with acute renal failure after a few days of bloody diarrhea. His peripheral smear is as shown in the following figure.

Schistocytes

A 50-year-old female comes to you complaining of her skin thickening on her fingers and her fingers turning white and painful in the cold weather. What is your ddx?

Systemic Sclerosis

A 28-year-old immigrant from Mexico is brought to the emergency room because of new onset of seizures. CT scan of the head reveals several discrete calcified densities throughout the frontal lobe, brainstem, and cerebellum.

Taenia solium

A resident strongly disagrees with the attending physician's management of a patient and believes the course of treatment ordered is wrong. Who should the resident talk to and when?

The USMLE first wants you to answer "discuss" or "confer" or "use evidence-based medicine to achieve consensus". Second, you talk to the local higher authority. Third, you go to the next higher authority. DO NOT go straight to medical board or licensing board. DO NOT inform the patient.

A patient gives you a baked ham worth about $75 as a Christmas gift. A pharmaceutical rep gives you the same thing. A patient gives you a weekend trip to an exclusive golf resort as a gift. A pharmaceutical rep gives you the same. Which do you accept?

The key is whether the intent or effect of the gift is to influence your behavior. With patients, it is unclear, but small gifts are usually acceptable. With industry reps, the assumption is always that the "gift" is an attempt to influence and should be refused.

A 47-year-old woman with HIV presents with new right-sided arm and leg weakness. CT scan of the head reveals multiple ring-enhancing lesions located in both hemispheres and involving the basal ganglia and corticomedullary junction.

Toxoplasmosis

A 41-year-old man presents with periorbital edema, myalgias, and eosinophilia 3 weeks after eating some undercooked pork at an outdoor restaurant.

Trichinella spiralis

Ethics Questions

USMLE Questions

A 50-year-old man with chronic sinusitis comes to the emergency room with shortness of breath and is coughing up blood. He is found to also have kidney failure and a rash on his legs. Here is a picture of his nose and legs. What is diagnosis?

Vasculitides

You inform a patient about the risks and benefits of bone marrow transplantation for leukemia, including the risk of graft versus host disease. After the transplant, the patient develops graft v. host, which is hard to control. The patient learns about another treatment (Gleevec/imitanib) that is inferior regarding curing cancer but does not have the risk of graft v. host disease. Was there an omission in informed consent?

Yes. The physician is obligated to inform the patient about all treatment options, even those disagreed with.

A patient comes to the emergency department with appendicitis. He is informed of all the risks of surgery, but refuses the procedure. He later dies. Did the physician make an error?

Yes. The physician must inform not only of the risks of a procedure but of the risks of not having a procedure and must document both.

You are an intern who has consulted surgery to place a subclavian central venous line. You only know access must be obtained. You do not know why the internal jugular approach is not being used. On the phone, the surgical resident says "Go get consent while I am on my way." What should you do?

You must not do it. You cannot adequately inform the patient about reasons and risks. You should not be in a position to explain risks for procedures you did not decide on

A 40-year old man is undergoing a nasal polypectomy. In the operating room you notice a lesion on the nasal turbinate that the frozen section determines to be cancer. You would have to resect the nasal turbinate to cure it. What should you do?

You must not remove the lesion without the patient's approval. This is true even if the procedure would save the patient's life (unless the illness is an emergency in an unconscious patient).

Dr. Smith is an attending in endocrinology doing a month on general medical service. House staff has seen him out at parties drinking heavily and picking fights. The senior resident tells you this and worries he is reckless. What should you do?

You should tell the resident that there is only a duty to report behavior that affects patient care, not general poor behavior. However, if there is good reason to think that Smith is substance-abusing and this could lead to patient harm, then the resident should report to Smith's supervisor.

Dr. Smith is an attending in endocrinology doing a month on general medical service. House staff has found him lost several times on his way to the bathroom. He also seem to have little knowledge of general medical practice and has trouble remembering cases after residents present them. The senior resident tells you this and wonders if he is developing Alzheimer's. What should you do?

You should tell the resident to report the problem to the department chair. You have as much obligation to report an impaired physician as to report child abuse. You and the resident at mandatory reporters and are protected should the report be untrue as long as made in good faith.

A patient has just tested positive for HIV. His wife does not know and he says he cannot tell her. Should you tell her?

You should try to get the patient to tell her, but if he refuses, yes you can. Breaking confidentiality to prevent harm to others

A 37-year-old woman, G0P0, presents with an eczematous scaly eruption on her right nipple. She recently has taken up running and weight lifting and believes that the exercise has irritated her breast. Physical examination reveals a 1.5-cm erythematous and crusted lesion on her right nipple. The nipple is not inverted, and there are no masses or discharge. There are no axillary nodes, and the other breast is normal. Which of the following is the best next step in diagnosis? a. Biopsy of the lesion b. Mammogram c. Topical steroid therapy d. Topical antifungal therapy e. Suggest the use of an athletic bra

a. Biopsy of the lesion

A 54-year-old man presents with a 2-week history of headache, fever, chills, and night sweats. He complains of myalgias and easy fatigability. He has just returned from a business trip to Africa and the Middle East. Before the trip, the patient received immunizations against poliomyelitis, hepatitis A, hepatitis B, and dengue fever. Throughout the trip, he took chloroquine prophylaxis against malaria. On physical examination, the patient has a temperature of 39.5°C (103.2°F) and is diaphoretic. There is no neck stiffness, photophobia, or lymphadenopathy. Heart and lung examinations are normal. There is mild splenomegaly. Which of the following is the most likely diagnosis in this patient? a. Malaria b. Tuberculosis c. Mononucleosis d. Trypanosomiasis e. Toxoplasmosis

a. Malaria

A 55-year-old man presents with bone pain, especially in the lower back, that is aggravated by movement or weight bearing but tolerable when he is lying down at night. Physical examination is remarkable for pale conjunctivae. Laboratory results show a normocytic anemia and an increased serum globulin level. Peripheral blood smear is significant for rouleaux formation. Osteolytic bone lesions are seen on a radiograph of the spine and pelvis. Bone scan is normal. Which of the following is the most likely diagnosis? a. Multiple myeloma b. Paget disease c. Metastatic bone disease d. Monoclonal gammopathy of unknown significance (MGUS) e. Waldenström macroglobulinemia

a. Multiple myeloma

A 33-year-old woman in her second trimester of her first pregnancy comes to see you in October. She has no prior medical history and no complaints except for rhinitis. So far no one around her has been sick, but she wants to be protected during the upcoming flu season. Her vital signs and the remainder of her physical examination are normal for her stage of pregnancy, other than mildly erythematous nasal mucosa and clear drainage. What is the most appropriate recommendation regarding protection against the flu for this patient? a. She should receive the influenza intramuscular vaccination at this time. b. She should receive the influenza vaccine intranasal mist at this time. c. She should be given prophylaxis with a neuraminidase inhibitor. d. She should not receive flu vaccination until her rhinitis has resolved. e. She should not receive flu vaccination because she is pregnant.

a. She should receive the influenza intramuscular vaccination at this time

A 54-year-old woman presents with a peripheral lung mass. She has no history of tobacco use and has worked as a seamstress all her life. She has no family history of lung cancer.

adenocarcinoma of the lung

what are antibodies for myopathies?

anti-Jo-1

antibodies for systemic sclerosis?

anti-Scl-70

antibodies for limited sclerosis? another name for this disease?

anti-centromere CREST syndrome

A 23-year-old man with sickle cell disease presents with shortness of breath and pleuritic chest pain. His temperature is 38.5°C (101.3°F), and he is tachypneic and tachycardic. Heart examination is normal. Lung examination is notable for right basilar crackles. The patient's arterial saturation is 88%. He has a leukocytosis, and chest radiograph reveals an infiltrate. Which of the following is the most likely diagnosis? a. Acute osteomyelitis b. Acute chest syndrome c. Myocardial infarction d. Congestive heart failure e. Parvovirus B19 infection

b. Acute chest syndrome

A 46-year-old woman with a recent history of sinusitis presents with a severe headache. She complains of neck stiffness and photophobia. On physical examination she has a temperature of 39.7°C (103.4°F). Blood pressure is normal, and heart rate is 110 beats per minute. She has nuchal rigidity with a normal funduscopic examination and no focal neurologic deficit. Brudzinski and Kernig signs are positive. Which of the following is the most likely diagnosis? a. Migraine headache b. Bacterial meningitis c. Torticollis d. Cluster headache e. Cysticercosis

b. Bacterial meningitis

A 47-year-old nurse presents to your office complaining of a poorly healing ulcer of her left second digit. The ulcer started a week ago and is painless. The patient has tried using over-the-counter antibacterial and hydrocortisone creams without improvement. She denies trauma to the hand. The patient has a temperature of 38.4°C (101.1°F) and left-sided epitrochlear and axillary adenopathy. She has a 4-cm ulcer on the dorsal side of the left second digit covered by a black eschar and surrounded by an extensive amount of nonpitting edema. Which of the following is the most likely diagnosis? a. Smallpox infection b. Cutaneous anthrax c. Cat-scratch disease d. Leprosy infection e. Brown recluse spider bite

b. Cutaneous anthrax

A woman with a history of left mastectomy and subsequent radiation therapy for breast cancer 2 years ago presents with a 3-cm mass along the edge of the surgical suture line. She denies fever, chills, night sweats, and weight loss. Physical examination reveals some generalized induration and a tanned appearance of the skin overlying the mastectomy secondary to radiation therapy. There is a nonmobile, nontender mass along the suture line that is not warm or fluctuant. She has no axillary lymphadenopathy. A biopsy specimen of the breast mass is most likely to show which of the following? a. Fibroadenoma b. Malignancy c. Benign cyst d. Abscess e. Lipoma

b. Malignancy

A 28-year-old woman with no significant past medical history complains of easy fatigability, tachypnea, and occasional palpitations. On further history, she reports a bizarre craving for ice chips. She has no other symptoms. On physical examination, she has conjunctival pallor and brittle nails, with a 2/6 systolic ejection murmur at the left sternal border, but no other findings. Her hemoglobin level is 7 g/dL and a peripheral smear shows hypochromic, microcytic cells with target cells and an increased number of platelets. What is the most likely etiology of her anemia? a. Gastrointestinal blood loss b. Menorrhagia c. Hemolysis d. Aplastic anemia e. Hypersplenism

b. Menorrhagia

A 19-year-old previously healthy college student presents with a 5-day history of fever, generalized malaise, and sore throat. He denies cough. He does not use illicit drugs and uses condoms every time with his sole sexual partner. He has been vaccinated against hepatitis B. On physical examination the patient appears jaundiced and has a temperature of 38.7°C (101.7°F). The pharynx is erythematous but has no exudate. There is bilateral tender cervical lymphadenopathy. Liver size is 14 cm in the midclavicular line (MCL), and the spleen tip is palpable 2 cm below the left costal margin. The white blood cell count is elevated, and many atypical forms are reported. Which of the following is the most appropriate confirmatory diagnostic test? a. Blood culture b. Monospot c. Hepatitis B surface antigen d. Hepatitis C antibody e. Sputum culture

b. Monospot

A 16-year-old boy is bitten on the leg by a neighbor's dog. The dog is healthy and has proof of a rabies vaccination. The next day, the patient develops a cellulitis at the site of the bite, accompanied by a purulent, foul-smelling discharge. There is unilateral inguinal lymphadenopathy. Which of the following organisms is most likely responsible for the patient's symptoms? a. Rabies virus b. Pasteurella multocida c. Aeromonas hydrophila d. Pseudomonas aeruginosa e. Vibrio parahaemolyticus

b. Pasteurella multocida

A 52-year-old man presents with a neck mass. He states that after he drinks one to two glasses of wine, the neck mass becomes painful. He also complains of intermittent fever, night sweats, pruritus, and a 10-lb weight loss over the last month. Physical examination reveals a 3-cm mass in the left anterior cervical lymph node chain that is hard and tender to deep palpation. Several other cervical nodes and a left axillary node are palpable. There is no hepatomegaly or splenomegaly. Which of the following is most likely to be found on diagnostic testing? a. Paratrabecular lymphoid aggregates on bone marrow biopsy b. Reed-Sternberg cells on lymph node biopsy c. Auer rod on bone marrow biopsy d. Cells with numerous cytoplasmic projections on bone marrow biopsy e. Noncaseating granulomas on lymph node biopsy

b. Reed-Sternberg cells on lymph node biopsy

A 22-year-old woman with sickle cell disease presents with a painful pretibial ulcer. Physical examination reveals the presence of purulent material draining from the wound site. The patient has a low-grade fever. Radiographs reveal soft tissue swelling and a periosteal reaction. Which of the following is the most likely pathogen responsible for the symptoms? a. Staphylococcus epidermis b. Salmonella c. Shigella d. Streptococcus pyogenes e. Mycobacterium tuberculosis

b. Salmonella

A 40-year-old gardener presents with painless papules that appeared following a puncture wound from a rose thorn a few weeks earlier. Physical examination reveals a chain of erythematous nodules along the dorsal aspect of the arm. Which of the following is the most likely diagnosis? a. Coccidioidomycosis b. Sporotrichosis c. Blastomycosis d. Cutaneous larva migrans e. Histoplasmosis

b. Sporotrichosis

A 56-year-old African American man presents with a 15-lb unintentional weight loss over the last 6 weeks. He states that food "gets stuck" in the middle of his chest. Initially, the patient had difficulty swallowing solids, but the symptoms have since progressed to the point where he has similar problems when swallowing liquids. He also complains of odynophagia. He denies hoarseness and does not have a history of reflux symptoms. He smokes one pack of cigarettes per day and admits to heavily drinking alcohol. Physical examination reveals a left fixed supraclavicular node. Which of the following is the most likely diagnosis? a. Achalasia b. Squamous cell carcinoma of the esophagus c. Adenocarcinoma of the esophagus d. Esophageal stricture e. Schatzki ring

b. Squamous cell carcinoma

A 61-year-old woman presents to the emergency room with dyspnea on exertion and facial swelling for nearly 2 weeks. She has smoked three packs of cigarettes per day for nearly 40 years but does not drink alcohol. Her blood pressure is 120/88 mm Hg, pulse is 90 beats per minute, respirations are 16 breaths per minute, and she is afebrile. Heart and lung examinations are normal. She has dilated veins in the neck and upper chest area. Blood gases are normal. Which of the following is the most likely diagnosis? a. Tumor lysis syndrome b. Superior vena cava syndrome c. Cord compression d. Hypercalcemia e. Cardiac tamponade f. Pancoast syndrome

b. Superior vena cava syndrome

Multiple myeloma

beta-2-microglobulin

A 28-year-old woman presents with her third episode of left lower extremity deep venous thrombosis. She has a history of two second-trimester miscarriages in the past. Laboratory data reveal an elevated activated partial thromboplastin time (PTT) that is not corrected by dilution with normal plasma and an abnormal dilute Russell viper venom. Which of the following is the most likely diagnosis? a. Libman-Sacks disease b. Livedo reticularis c. Antiphospholipid syndrome d. Takayasu arteritis e. Sjögren syndrome

c. Antiphospholipid syndrome

A 52-year-old man presents with fever and leukocytosis. He has splinter hemorrhages and a holosystolic murmur that radiates to the axilla. Transesophageal echocardiogram demonstrates several vegetations located on the mitral valve; there is moderate mitral regurgitation. Blood culture bottles continuously reveal no growth of organisms. Which of the following may be the causal agent of the patient's endocarditis? a. Staphylococcus aureus b. Campylobacter jejuni c. Haemophilus aphrophilus d. Vibrio parahaemolyticus e. Streptococcus viridans

c. Haemophilus aphrophilus

A 79-year-old woman presents to the emergency room with a 1-week history of fever, myalgias, nausea, vomiting, and diarrhea. Her symptoms started shortly after she ate at a Mexican restaurant with her daughter and son-in-law. She did not eat raw foods, and her family members did not become ill. She has no past medical history and takes no medications. She has a temperature of 39.5°C (103.2°F) and appears extremely ill. She is awake and oriented to person and place but not to time. Heart and lung examinations are normal, and she has no focal neurologic deficits. CT scan of the head is normal. Lumbar puncture reveals pleocytosis, increased protein concentration, and normal glucose. Blood and cerebrospinal fluid cultures identify a gram-positive rod organism. Which of the following is the most likely diagnosis? a. Actinomyces infection b. Bacillus cereus infection c. Invasive Listeria infection d. Inhalation anthrax infection e. Clostridium botulinum infection

c. Invasive Listeria

A 41-year-old woman presents with a maculopapular rash on her soles and palms. Both the VDRL (RPR) and FTA-ABS are positive. Two hours after being treated with penicillin, the patient develops fever, chills, myalgias, tachypnea, tachycardia, and leukocytosis. Which of the following is the most likely diagnosis? a. Neurosyphilis b. Tertiary syphilis c. Jarisch-Herxheimer reaction d. Rocky Mountain spotted fever e. Endocarditis

c. Jarisch-Herxheimer reaction

A 42-year-old man develops fever and chills within a few hours after a blood transfusion. His temperature is 38.7°C (101.6°F), and his blood pressure is 120/80 mm Hg. He is slightly tachycardic, but his respiratory rate is normal. His CBC is normal except for the anemia for which he was receiving the transfusion. Laboratory data including electrolytes, liver function tests, and urinalysis are normal. Which of the following is the most likely diagnosis? a. Anaphylaxis to blood transfusion b. ABO incompatibility c. Leukoagglutinin reaction to blood transfusion d. Transfusion-associated circulatory overload e. Urticarial reaction to blood transfusion

c. Leukoagglutinin reaction to blood transfusion

A 27-year-old man was recently diagnosed HIV positive. As part of his routine workup for his new diagnosis, his CD4 count was 285/μL and his RPR came back positive at a titer of 1:64. On physical examination he does not have a penile chancre or any findings of the cardiovascular, lung, or neurologic systems. What is the most appropriate next step? a. Treatment with benzathine penicillin G intramuscularly once b. Treatment with aqueous penicillin G intravenously c. Lumbar puncture d. Blood cultures e. Repeat nontreponemal serologic tests

c. Lumbar puncture

A 56-year-old man complains of a 10-lb weight loss over a 2-month period. He has no symptoms except nocturia, hesitancy at starting his urinary stream and mid-back pain that is constant and worse at night. He does not smoke cigarettes, use illicit drugs, or drink alcohol, and he has no past medical history. On physical examination, the patient is afebrile with normal blood pressure. The only abnormal finding on heart, lung, abdominal, lymph node, and musculoskeletal examinations is point tenderness over the thoracic spinous processes. Which of the following is the most likely diagnosis? a. Musculoskeletal strain b. Lymphoma c. Metastatic prostate cancer d. Metastatic lung cancer e. Epidural abscess

c. Metastatic prostate cancer

An ill-looking 58-year-old man with a 20-year history of diabetes mellitus presents with severe pain and swelling of his right arm that started 2 days ago after some minor trauma. He has a temperature of 39.8°C (103.6°F). Examination of the arm reveals a 13-cm area of dark red epidermal induration. Large bullae filled with purple fluid are seen in the center of the wound. Some parts of the wound are friable and appear black in color. Crepitus is felt with palpation of the arm. Laboratory data reveal a leukocytosis and an elevated serum creatinine phosphokinase. Which of the following is the most likely diagnosis? a. Bullous pemphigoid b. Folliculitis c. Necrotizing fasciitis d. Cellulitis e. Fournier gangrene

c. Necrotizing fasciitis

A 7-year-old boy with sickle cell disease presents with severe left upper quadrant pain that started suddenly 2 hours before he arrived at the emergency room. He has no previous history of pain in that area. Physical examination reveals a temperature of 37°C (98.6°F) and a normal blood pressure. Heart rate is 108 beats per minute. Heart and lung examinations are normal. There is fullness and tenderness in the left upper quadrant of the abdomen with palpation, but there is no audible rub. There is no hepatomegaly or rebound tenderness, and FOBT is negative. The rest of the physical examination is normal. Hemoglobin is 6.1 g/dL. Which of the following is the most likely diagnosis? a. Vasoocclusive crisis b. Splenic infarction c. Splenic sequestration crisis d. Left pleural effusion e. Pulmonary infarction

c. Splenic sequestration crisis

A 41-year-old woman develops abdominal cramps and diarrhea 2 hours after eating fried rice. Physical examination is normal except for some mild abdominal tenderness with palpation. Examination of the stool reveals no fecal leukocytes. Which of the following is the most likely etiology for the symptoms? a. Shigella b. Salmonella c. Vibrio cholerae d. Bacillus cereus e. Staphylococcus aureus f. Vibrio parahaemolyticus

d. Bacillus cereus

A 26-year-old woman presents with disseminated gonorrhea. She has a past medical history significant for meningococcal meningitis when she was 19 years old. Which of the following complement deficiencies is the most likely cause of her recurrent infections? a. C2 b. C3 c. C3, C4 d. C5, C6, C7, C8, C9 e. C1q, C1r, C1s

d. C5, C6, C7, C8, C9

A 25-year-old heterosexual man develops a urethral discharge and dysuria 5 days after having unprotected sexual intercourse with a new partner. Physical examination reveals meatal erythema. There are no penile lesions and no inguinal lymphadenopathy. A purulent urethral discharge is evident. Gram stain of the discharge reveals neutrophils and intracellular gram-negative diplococci, and the patient is treated for Neisseria gonorrhoeae. Two weeks after antibiotic therapy (ceftriaxone intramuscular injection), the patient returns with a clear urethral discharge and dysuria. Gram stain reveals many neutrophils but no organisms. Which of the following is the most likely diagnosis? a. Resistant strain of N. gonorrhoeae b. Lymphogranuloma venereum c. Chancroid d. Chlamydia trachomatis urethritis e. Syphilis infection

d. Chlamydia trachomatis urethritis

A 68-year-old man with endocarditis and bacteremia from Streptococcus bovis infection may have a high incidence of which of the following malignancies? a. Prostate cancer b. Pancreatic cancer c. Lymphoma d. Colon cancer e. Lung cancer

d. Colon cancer

A 23-year-old man presents with the acute onset of fever, skin lesions on his extremities that are papular and erythematous with a hemorrhagic and necrotic center, joint pain, and an acute tenosynovitis of the dorsum of his left foot. He has no past medical history and takes no medications. He does not smoke, drink alcohol, or use illicit drugs. On physical examination, the patient has a temperature of 39.1°C (102.4°F). Passive flexion and extension of the left great toe causes severe pain over the dorsum of the midfoot and ankle. Which of the following is the most likely diagnosis? a. de Quervain tenosynovitis b. Reiter syndrome c. Acute gouty attack d. Disseminated gonococcal infection e. Still disease

d. Disseminated gonococcal infection

A 35-year-old woman presents with fever, diarrhea, and right upper quadrant pain. She recently returned from a 2-month business trip in Mexico. Physical examination reveals no jaundice. She has point tenderness over the liver and has a positive fecal occult blood test. Computed tomography (CT) scan of the abdomen reveals several oval lesions in the liver. Which of the following is the most likely etiology of this patient's symptoms? a. Hepatitis A infection b. Echinococcus granulosus c. Enterobius vermicularis d. Entamoeba histolytica e. Campylobacter jejuni

d. Entamoeba histolytica

A 19-year-old woman in her second trimester of pregnancy presents with a deep venous thrombosis (DVT) of her left lower extremity. She has no previous history of DVT and has no family history of thromboem-bolism. Which of the following is the most likely reason for the patient developing a DVT? a. Protein C deficiency b. Protein S deficiency c. Antithrombin III deficiency d. Factor V Leiden deficiency e. Hyperhomocysteinemia

d. Factor V Leiden deficiency

A 31-year-old African American man presents to the emergency room and is diagnosed as having a community-acquired pneumonia. After 2 days of antibiotics, the patient becomes jaundiced. His hematocrit is 30% (decreased from 40% on admission), reticulocyte count is 6%, and indirect bilirubin value is 4.5 mg/dL (total bilirubin of 6.0 mg/dL). Peripheral blood smear demonstrates Heinz bodies. The patient recalls a similar problem when he was given antibiotics 5 years ago for an acute sinusitis. His three brothers have a similar reaction to antibiotics. Which of the following is the most likely diagnosis? a. Sickle cell anemia b. Sickle cell trait c. Autoimmune hemolytic anemia d. Glucose-6-phosphate dehydrogenase deficiency e. Allergic reaction

d. Glucose-6-phosphate dehydrogenase deficiency

A 37-year-old man who is in excellent health presents for a routine physical examination. Family history reveals that the patient's mother died of colon cancer at the age of 50 years and a brother, who is 44 years old, was recently diagnosed with colon cancer. The patient also has two maternal aunts with ovarian cancer. Physical examination is normal, and fecal occult blood test (FOBT) is negative. Laboratory data are normal. Which of the following statements best describes this patient? a. He most likely has the BRCA2 mutation. b. He needs an annual colonoscopy beginning at age 36. c. He should have a prophylactic colectomy. d. If he develops colon cancer, it would most likely be in the proximal colon. e. If he develops colon cancer, it would most likely be in the distal colon.

d. If he develops colon cancer, it would most likely be in the proximal colon

A 37-year-old postal worker from Atlantic City, New Jersey, presents to the emergency room with the chief complaint of dry cough for several days. He has fever, malaise, dyspnea on exertion, and pleuritic chest pain. He has experienced mild nausea and diffuse abdominal pain. He has been in good health otherwise and has no recent travel history. No contacts have been ill. Physical examination is remarkable for a temperature of 38.5°C (101.4°F) and decreased breath sounds at the lung bases bilaterally. Chest radiograph reveals pleural effusions and a widened mediastinum. Which of the following is the most likely diagnosis? a. Pneumonic plague b. Tularemia c. Hemorrhagic fever d. Inhalation anthrax e. Hantavirus pulmonary syndrome

d. Inhalation anthrax

A neonate develops meningitis, and you suspect that the responsible organism was acquired during passage through the birth canal. Which of the following organisms is most likely responsible for the neonate's illness? a. Staphylococcus aureus b. Pseudomonas c. Rubeola d. Listeria monocytogenes e. Salmonella

d. Listeria monocytogenes

A 62-year-old man presents for his annual health maintenance visit. The review of systems is positive for occasional fatigue and headache. The patient admits to generalized pruritus following a warm bath or shower. He has plethora and engorgement of the retinal veins. A spleen is palpable on abdominal examination. The patient's hematocrit is 63%, and he has a leuko-cytosis and thrombocytosis. Peripheral blood smear is normal. The patient does not smoke. Which of the following is the most likely diagnosis? a. Essential thrombocytosis b. Myelofibrosis c. Spurious polycythemia d. Polycythemia vera e. Secondary polycythemia

d. Polycythemia vera

A 42-year-old woman of Italian descent presents for a preemployment physical examination. She has no symptoms, no past medical problems, and takes no medications. Her physical examination is normal except for pale conjunctivae. Fecal occult blood test (FOBT) is negative. Her complete blood count (CBC) is remarkable for a hemoglobin of 11.4 g/dL, a mean corpuscular volume (MCV) of 60 fL, and a reticulocyte count of 0.6%. Her white blood cell count and platelets are normal. Peripheral smear reveals microcytosis, hypochromia, acanthocytes (cells with irregularly spaced projections), and occasional target cells. Which of the following is the most likely diagnosis? a. Iron-deficiency anemia b. Sideroblastic anemia c. Anemia of chronic disease d. Thalassemia trait e. Alpha thalassemia major

d. Thalassemia trait

A 43-year-old man presents with a 2-month history of diarrhea and abdominal cramping. He has no nausea or vomiting. He denies melena and hematochezia. He has a 10-lb weight loss. Physical examination reveals edema of the head and neck. His face appears to be flushed. He has bilateral expiratory wheezes and a systolic murmur that increases with inspiration. Abdominal examination is normal. Rectal examination is FOBT negative. Which of the following is the best next step in diagnosis? a. CT scan of the chest b. Transthoracic echocardiogram c. CT scan of the abdomen d. Twenty-four-hour urine for 5-HIAA e. Transesophageal echocardiogram

d. Twenty-four-hour urine for 5-HIAA

A 19-year-old woman with a lifelong history of easy bruisability presents with menorrhagia. She also reports occasional nosebleeds. She has no family history of bleeding disorders and takes no medications. Physical examination is normal. Laboratory investigation reveals a normal platelet count but a prolonged bleeding time. Which of the following is the most likely diagnosis? a. Hemophilia A b. Christmas disease c. Type III von Willebrand disease d. Type I von Willebrand disease e. Bernard-Soulier syndrome

d. Type I von Willebrand disease

diff btw derma and poly

derma- skin poly- no skin

A 32-year-old woman presents with the recent onset of petechiae of her lower extremities. She denies menorrhagia and gastrointestinal bleeding. She has no family history of a bleeding disorder and has been in excellent health her entire life. She takes no medications and does not drink alcohol. Physical examination is remarkable for petechiae of both legs. There is no hepatosplenomegaly. The rest of the physical examination is normal. Platelet count is 8000/μL. Hemoglobin and white blood cell count are normal. Peripheral smear reveals reduced platelets and an occasional megathrom-bocyte. Which of the following is the most likely diagnosis? a. Thrombocytopenic thrombotic purpura (TTP) b. Hemolytic-uremic syndrome (HUS) c. Evans syndrome d. Disseminated intravascular coagulopathy (DIC) e. Idiopathic thrombocytopenic purpura (ITP)

e. Idiopathic thrombocytopenic purpura (ITP)

A 34-year-old woman was recently told by another physician that her blood test was positive for Helicobacter pylori. She completed a course of medication but is concerned about this finding. This patient is at risk for which of the following? a. Squamous cell carcinoma of the esophagus b. Adenocarcinoma of the esophagus c. Non-Hodgkin lymphoma of the small intestine d. Gastroesophageal reflux disease e. Mucosa-associated tissue lymphomas (MALT)

e. Mucosa-associated tissue lymphomas (MALT)

A 61-year-old man presents to a Houston emergency room in the summertime with a 3-day history of fever, malaise, sore throat, nausea, and vomiting. While being examined by a medical student, the patient becomes lethargic, then convulses, requiring intravenous benzodiazepam administration. Physical examination is remarkable for a temperature of 38.3°C (101.0°F). There is bilateral papilledema and neck stiffness. Deep tendon reflexes are exaggerated, and spastic paralysis is evident. Which of the following is the most likely diagnosis? a. Mollaret meningitis b. Neurosyphilis c. Herpes simplex virus d. Cerebrovascular accident e. Brain abscess f. West Nile virus g. Heatstroke

f. West Nile virus

Testicular cancer

hCG

A 39-year-old woman with a tobacco history has a centrally located lung mass and a serum sodium of 121 mEq/L.

small cell carcinoma of the lung

A 62-year-old woman presents with jaundice, back pain, and weight loss. CT scan of the abdomen demonstrates a mass at the head of the pancreas.

tobacco use

A previously healthy 49-year-old man presents with fever and night sweats. He has splenomegaly. His peripheral white blood cell count is 22,000 mL, and a peripheral smear shows immature leukocytes with an increase in the number of basophils. Leukocyte alkaline phosphatase score is low, and vitamin B12 level is elevated.

translocation between chromosome 9 and 22 (t9:22) [CML]