UW 38

37. A 60-year-old physician is admitted to the hospital for jaundice and weight loss. His medical history is noncontributory. After a detailed workup, advanced pancreatic carcinoma is diagnosed. Although the patient is advised to slow down and spend more time with his family, he insists on continuing to work, saying,

"It's a good distraction to think about other people's medical problems." Each day after work, he spends several hours reviewing and analyzing his own diagnostic tests and researching experimental chemotherapy regimens for pancreatic cancer.

I am worried it could be cancer." A few hours later, the patient has another episode of bloody vomitus. When the nurse later cleans up the bedclothes she notices blood on the sheets and a fresh laceration on the patient's forearm. The patient explains,

"l felt so weak and lightheaded that I fell and cut myself on the tray table." No further episodes of hematemesis are reported, and the patient's vital signs and blood counts remain stable. Which of the following is the most likely diagnosis?

Hydrochlorothiazide, lisinopril, omeprazole, atorvastatin, insulin glargine, metformin, and aspirin. Temperature is 37.2 C (98.9 F) and blood pressure is 146/86 mm Hg. Examination shows a mild effusion, tenderness, and decreased range of motion of the left knee.

A fluctuant swelling along the posterior aspect of the knee is palpable. Arthrocentesis with synovial fluid analysis reveals the following: White blood cells 1100/mmz Gram stain Crystals no organisms none

Physical examination is unremarkable. ECG, complete blood count, comprehensive metabolic panel, and urine toxicology screen are normal. The patient is started on olanzapine. Which of the following tests would be most important to obtain at the patient's 3-month follow-up visit?

A. Blood urea nitrogen and creatinine B. Complete blood count C. ECG D. Fasting glucose and lipids E. Liver function tests F. Prolactin level G. Thyroid function tests

postoperatively his platelet count decreases from 240,000/mmz on admission to 65,000/mrna. His vital signs are stable. The surgical wound is healing well. There are no rashes or pitting edema. Which of the following is the most appropriate next step in management of this patient?

A. Continue heparin and obtain a serotonin release assay B. Stop heparin and observe C. Stop heparin and order a platelet transfusion D. Stop heparin and start argatroban E. Stop heparin and start warfarin F. Switch to low molecular weight heparin

Close examination shows greasy-looking, fine yellowish scales on an erythematous base. The trunk and extremities have no lesions. Which of the following is the most likely diagnosis?

A. Acne rosacea B. Psoriasis C. Seborrheic dermatitis D. Systemic lupus erythematosus E. Tinea versicolor

The patient's family members wish he would take time off to rest, but he insists that would make him feel worse. Which ofthe following psychological defense mechanisms is the best explanation for this patient's behavior?

A. Altruism B. Denial C. Displacement D. Intellectualization E. Rationalization F. Reaction formation

He smokes lhpacks of cigarettes daily and does not consume alcohol. His blood pressure is 176/100 mm Hg in the left arm and 180/100 mm Hg in the right. Which of the following is the most likely additional finding in this patient?

A. Continuous bruit in the right periumbilical area B. High aldosterone/renin ratio >20:1 C. Increased 24-hour urinary free cortisol excretion D. Increased urinary excretion of vanillylmandelic acid E. Rib notching on chest x-ray

The infant's head seems large for his body. There is a paucity of subcutaneous fat. The remainder of the physical examination is unremarkable. This infant is at risk for having (or developing) which of the following?

A. Hip subluxation B. Polycythemia C. Hyperglycemia D. Hyperthermia E. Hypercalcemia

36. A 53-year-old man comes to the emergency department complaining of the sudden onset of intense epigastric pain. He also vomited once and noticed a sudden, dull, aching, and diffuse abdominal pain. He has had episodic nonspecific abdominal pain for the past several months.

Abdominal ultrasound performed 2 weeks ago showed small stones in the gallbladder. The patient's other medical problems include constipation, type 2 diabetes mellitus, and hyperlipidemia. He has a 45-pack-year smoking

He does not use tobacco, alcohol, or illicit drugs. His blood pressure is 124/70 mm Hg and pulse is 78/min and regular. Jugular venous pressure is estimated at 5 cm H20. Examination shows no abnormalities. Review of laboratory results from the hospital admission shows normal creatinine level, liver function tests, thyroid studies, and lipid panel.

An echocardiogram shows a mildly dilated left atrium, normal left and right ventricular function, and no major valvular abnormalities. Which of the following is the best additional treatment for this patient?

12. A 64-year-old man comes to the emergency department due to intermittent, burning midline chest pain over the last 2 hours. He has never had similar pain. The patient's medical history includes hypertension and hyperlipidemia.

An immediate ECG shows sinus rhythm with ST-segment elevations in leads II, Ill, and aVF. Temperature is 37.8 C (99.7 F), blood pressure is 115/70 mm Hg, pulse is 65/min, and respirations are 15/min. He is given sublingual nitroglycerin, and the on-call cardiologist is notified.

34. A 31 -year-old motorcyclist is involved in a motor vehicle collision in which he suffered a direct blow to his lower abdomen and pelvis. He reports diffuse abdominal pain and a dull pain in the left shoulder. The patient has no prior medical problems and has been healthy.

Blood pressure is 110/80 mm Hg, pulse is 92/min, and respirations are 16/min. No deformity of the left shoulder is noted and complete range of motion is preserved. Cardiopulmonary examination shows no abnormalities. Diffuse abdominal tenderness with guarding is present. No other injuries are seen.

8. A I-hour-old boy is evaluated in the newborn nursery for microcephaly. He was born via spontaneous vaginal delivery to a 26-year-old woman who did not receive prenatal care. mother has no known chronic medical conditions.

On physical examination, the boy's occipitofrontal circumference is >3 standard deviations below the mean. The anterior fontanelle is closed, and the skull is partially collapsed. Cardiopulmonary examination is Notes The normal.

24. This item has associated media that may require the use of headphones. Please ensure your system/speaker volume is set to an audible level. A 54-year-old male with a past medical history of type 2 diabetes mellitus comes to the emergency department complaining of shortness of breath.

His blood pressure is 146/92 mmHg, respiratory rate is 26/min, and oxygen saturation is 87% on room air. Cardiac auscultation findings over the apex are given below. Based on the physical findings,

A. Administer high-dose erythropoietin and intravenous iron to stabilize blood loss B. Continue intravenous fluids and consult the hospital ethics committee C. Obtain a court order for approval to administer the blood transfusion

D. Proceed with the blood transfusion E. Withhold the blood transfusion because of the patient's religious beliefs

Which one of the following injuries is most likely to be seen on CT scan of the abdomen in this patient? A. Anterior bladder wall rupture B. Bladder dome rupture C. Bladder neck rupture

D. Renal laceration E. Transection of anterior urethra F. Transection of membranous urethra

A. Blood pressure differential between upper and lower extremities B. Late diastolic murmur at cardiac apex C. Prominent capillary pulsations on fingertips

D. Systolic blood pressure drop >10 mm Hg with inspiration E. Systolic blood pressure drop >20 mm Hg upon standing F. Weak and slow-rising carotid pulse

Which of the following is the most appropriate next step in his management? A. Administer hepatitis B immune globulin and hepatitis B vaccine now C. Administer hepatitis B immune globulin now and

D. obtain blood for serological markers of viral hepatitis E. Administer hepatitis B vaccine now and obtain blood for serological markers of viral hepatitis F. Obtain serological markers of viral hepatitis from the volunteer and wait for the results G. Return in 2 weeks for viral hepatitis testing

14. A 64-year-old man is brought to the emergency department after a motor vehicle collision. restrained driver when a truck hit his car on the driver's side at an intersection. He was dazed for several minutes after the collision and subsequently began to experience left chest and leg pain.

His blood pressure is 94/61 mm Hg and pulse is 117/min. Pulse oximetry shows 96% on room air. The patient is conscious and answers questions appropriately. He is wearing a cervical collar. Physical examination shows multiple facial lacerations and bruises on the left chest wall.

18. A 3-year-old boy is brought to the emergency department due to loss of consciousness while playing at a park. The boy was short of breath from running when he appeared blue and went limp for approximately 10 seconds.

His mother caught his fall and says that he regained consciousness quickly. He did not hit his head or experience any trauma. However, the patient has previously lost consciousness during excess crying and temper tantrums.

16. A 2-year-old boy is brought to the physician because he has difficulty keeping up with other children at day care. Over the past couple of months, he has been more fatigued than usual and seems weak. The boy has had some difficulty climbing stairs, which he has never experienced before.

He also has difficulty rising from the floor and often has to use his hands to help him stand up. His mother thinks that she had a relative with a disorder that caused weakness but is unsure of the diagnosis.

27. A 60-year-old man is brought to his primary care physician due to worsening insomnia, confusion, and memory loss over the past 3 weeks. He also has muscle twitching and gait problems and this has caused several falls. He has no fever, headache, or urinary problems.

He does not use alcohol or tobacco. His pulse is 82/minI blood pressure is 130/76 mm Hg, and temperature is 37.1 C (98.7 F). He is poorly groomed and disoriented to date and time. On cognitive testing, he misses 3/3 delayed recall items and is unable to draw a clock.

39. A 5-year-old boy is brought to the office by his parents for evaluation of "clumsiness." The patient's fine and gross motor development have been normal at prior visits, but he now frequently runs into doorways or corners of furniture while walking around the house.

He has also begun drinking large amounts ofwater and urinating "all the time." Temperature is 37 C (98.6 F), blood pressure is 95/65 mm Hg, and pulse is 130/min. Physical examination shows dry mucous membranes and loss of bitemporal visual fields. Laboratory results are as follows: Serum studies Sodium Potassium Bicarbonate Blood urea nitrogen Creatinine Blood glucose Urinalysis DEC 145 mEq/L 3.9 rnEq/L 20 rnEq/L 18 mg/dL 0.9 mg/dL 88 mg/dL CT scan of the brain (exhibit) reveals an Abnormality (red arrow).

40. A 48-year-old man comes to the office for evaluation of a facial rash. He first noticed the rash approximately 3 months ago. It started on his forehead and eyebrows and has now progressed to involve his nose down to his chin.

He has also noticed a lot of dandruff in his hair recently. The patient has no other medical problems and takes no medications. Skin examination findings are shown in the image below.

31. A 67-year-old man comes to the emergency department after losing consciousness while shoveling snow near his house. He reports having had a similar episode a month ago while carrying heavy bags from the grocery store. The patient has reduced his physical activity level over the last year due to progressive exertional dyspnea and fatigue.

He has had no chest pain, palpitations, cough, or lower extremity swelling. His other medical problems include type 2 diabetes mellitus and hypercholesterolemia. He is a lifetime nonsmoker. Which of the following physical examination findings is most likely in this patient?

2. A 12-year-old boy is brought to the emergency department due to postprandial, colicky abdominal pain and bilious vomiting. He has not had similar symptoms before and has no other medical issues. The patient had a bicycle accident 2 days ago when he stopped abruptly and fell into the handlebar.

He immediately experienced abdominal pain but started to feel better several hours later. His vital signs are normal. Physical examination shows tenderness in the epigastric area. Bowel sounds are normal.

41. A 6-year-old boy is brought to the office for evaluation of leg pain. The pain has been constant for the last 2 weeks and keeps the patient from playing with his friends. It is worse at night and has made it difficult for the child to fall asleep.

He wakes up several times nightly to void and has had episodes of incontinence as the leg pain prevents him from walking to the bathroom. The patient has had no recent fever or dysuria. Temperature is 36.7 C (98 F).

38. A 28-year-old woman is evaluated for the recent onset of paranoid thinking. For the past 4 months, she has thought that coworkers have been spying on her and talking behind her back. She is afraid to go to work and worries that she might lose her job. She has no hallucinations or depression and no significant medical history.

Her father has coronary artery disease and hypertension, and her mother has a history of depression and hypothyroidism. The patient has a 9-pack-year smoking history and drinks alcohol socially.

25. A 64-year-old white female presents for evaluation of two weeks of decreased appetite and nausea. She also notes occasional palpitations, which have been especially prominent over the past two days.

Her medical history is significant for an anterior wall myocardial infarction one year ago and secondary congestive heart failure with left ventricular systolic dysfunction. Her current medications include aspirin, digoxin, furosemide, enalapril and metoprolol.

11. A 65-year-old man comes to the physician for follow-up on inadequately controlled hypertension. He has no complaints except difficulty walking uphill or climbing stairs due to right thigh pain; he must stop and rest for the pain to go away. His other medical Problems include stable angina that required coronary angioplasty and stenting 2 years ago,

Hypercholesterolemia, a 20-year history of hypertension, and a 10- year history of type 2 diabetes mellitus. His medications include aspirin, metoprolol, valsartan, hydrochlorothiazide, amlodipine, pravastatin, metformin, and glyburide.

She also suffers from severe heartburn controlled with high-dose pantoprazole. Family history is not significant. She does not smoke cigarettes or consume alcohol. Blood pressure is 112/72 mm Hg and pulse is 94/min. Pulse oximetry shows 95% on room air. BMI is 23 kg/m2.

Item 1 of 2 Which of the following would be the most expected finding on physical examination? A. Delayed femoral pulses bilaterally B. Ejection-type systolic murmur radiating to the carotids

Walking for 6 minutes causes mild dyspnea, and oxygen saturation drops to 88%. Chest x-ray shows no infiltrates. Pulmonary function testing reveals FEVI at 95% of predicted and a FEVI/FVC ratio of 84%. Pulmonary artery systolic pressure estimated by Doppler echocardiography is 65 mm Hg at rest (normal 15-30 mm Hg).

Item 2 of 2 Lung biopsy will most likely demonstrate which of the following? A. Alveolar spaces filled with fibroblasts B. Arterial intimal hyperplasia C. Bronchial wall thickening and mucus plugs D. Chronic inflammation with noncaseating granulomas E. Septal widening and hemosiderin-loaded macrophages

29. A 25-year-old medical volunteer comes to the occupational health office after accidentally pricking his finger while disposing of sharps from a procedure on a 36-year-old patient. The patient had been admitted to the hospital for anorexia, abdominal pain, and jaundice.

Laboratory results on the source patient 's blood are as follows: HBsAg Anti-HBs HBeAg Anti-HBe Anti-HAV IgM Anti-HAV IgG Anti-HCV HIV ELISA Positive Negative Positive Negative Negative Negative Negative Negative The volunteer admits that he is not vaccinated against hepatitis B.

35. A 62-year-old man comes to the office with a 4-week history of itchy, dry skin on the hands. He has experienced scaly, cracking skin at the dorsum of both hands extending to the fingers. The patient has tried moisturizer lotions with some relief, but the symptoms are persistent.

Medical history is notable for seasonal allergies, hypertension, benign prostatic hyperplasia, and an occasional herpes rash on his upper lip following upper respiratory infections. He works as a dentist and does not use tobacco, alcohol, or illicit drugs.

He has an open gunshot wound in the chest and an exit wound in the back. Intravenous fluids and vasopressors are started, and a blood transfusion is ordered. The patient's fiancé arrives and states that he should not receive a blood transfusion because he is a devout Jehovah's Witness.

No evidence is found in the medical chart of advance directives or a living will documenting the patient's wishes, and examination of his belongings show no blood refusal card. Which of the following is the most appropriate next step in the management of this patient?

cyanotic boy with a systolic ejection murmur along the mid to upper left sternal border. When the child squats, the murmur becomes louder and the cyanosis improves. The abdomen is soft, nontender, and nondistended.

No organomegaly is present. Femoral and brachial pulses are equal and 2+. Deep tendon reflexes are 2 Which of the following is the most likely diagnosis in this patient?

5. You are called to the nursery to evaluate a newborn infant. The mother is a 24-year-old primigravida. Her pregnancy was complicated by preeclampsia. The infant was delivered at 39-weeks gestation via emergent cesarean section due to maternal hypertension and non-reassuring fetal heart tones.

On examination, the infant's weight is 2.6 kg (5 lb 11 oz) placing him in the 5th percentile, height is 18 inches (46 cm) placing him in the 5th percentile, and head circumference is 13 inches (33 cm) placing him in the 10th percentile.

On physical examination, her blood pressure is 120/80 mm Hg, pulse is 106/min and respirations are 15/min. The remainder of her exam is unremarkable. Chest x-ray shows an enlarged cardiac silhouette and normal lung fields.

On laboratory testing, her digoxin level is twice the upper limit of normal. You order an EKG. Which of the following arrhythmias is most specific for digitalis toxicity? A. Atrial flutter B. Atrial fibrillation

1. A 51 -year-old man is admitted to the hospital because of renal failure. His past medical history is significant for recurrent episodes of bilateral flank pain over the past several years as well as nocturia 2 to 3 times per night for the past 10 years. He has no weight loss.

On physical examination, his blood pressure is 164/100 mm Hg. The liver is enlarged and a mass is felt at the right flank on deep palpation. Which of the following is the most likely diagnosis?

22. A 44-year-old man comes to the office for follow-up after a recent hospitalization. Two weeks ago, he went to the emergency department with palpitations and was found to have atrial fibrillation with rapid ventricular response.

Overnight, he spontaneously converted to normal sinus rhythm and was discharged home the next day. The patient has no history of hypertension, diabetes mellitus, hypercholesterolemia, or heart disease.

10. A 62-year-old hospitalized woman is evaluated for worsening skin lesions. She was admitted 6 days ago for elective coronary artery bypass grafting due to extensive coronary artery disease. The surgery was uncomplicated, and the patient was extubated on hospital day 2.

She has recovered well, but yesterday she noticed red patches on her abdomen that progressed to purple lesions today. The patient has a history of non-ST elevation myocardial infarction, type 2 diabetes mellitus, hypertension, and hyperlipidemia.

The patient has no chronic medical conditions and has reached all her developmental milestones on time. Her maternal aunt was recently diagnosed with bipolar disorder. The patient has friends at school and gets along well with her 2 older siblings.

She plays basketball, although she worries that she is not a good player because she drops the ball often. On mental status examination, the patient is friendly, cooperative, and responds appropriately to questions.

15. A 6-hour-old girl is evaluated in the newborn nursery due to respiratory distress. She was born at 37 weeks gestation via spontaneous vaginal delivery after induction of labor for preeclampsia with severe features.

Since birth, the baby has not been able to feed due to tachypnea, Birth weight is at <3rd percentile for gestational age. Temperature is 372 C (99 F) and blood pressure is normal. Pulse oximetry is 96% saturation on room air. Examination reveals a plethoric infant.

6. An unconscious 42-year-old man is brought to the emergency department by ambulance after sustaining a gunshot wound to the chest during an attempted robbery at a convenience store. He is bleeding profusely. The patient is minimally responsive to pain and is unable to provide any history.

The ambulance record indicates that his initial blood pressure was 120/70 mm Hg, pulse was 95/min, and respirations were 16/min. The patient's current blood pressure is 70/40 mm Hg, pulse is 130/min, and respirations are 28/min.

He demonstrates prominent agnosia. Pertinent physical findings include nystagmus, hypokinesia, and positive extensor plantar response bilaterally. Laboratory studies are as follows. Hematocrit White blood cells Platelets 40% 6,000/pL A non-contrast head CT scan is normal. The electroencephalogram shows periodic sharp waves.

Which of the following is the most likely diagnosis? A. Amyotrophic lateral sclerosis B. Creutzfeldt-Jakob disease C. Lewy body dementia D. Major neurocognitive disorder (dementia) due to

Examination shows dry, crusted, and irritated skin with erythema at the fingers, finger webs, and dorsum of the hands, as shown in the image. A few vesicles are noted at the finger webs. No other skin lesions are seen.

Which of the following is the most likely diagnosis? A. Contact dermatitis B. Herpetic whitlow C. Psoriasis D. Scabies E. Tinea manuum

prior to pregnancy and she had gotten used to it, but it is getting worse. The patient has no medical conditions. She takes a daily prenatal vitamin and no other medications. Bimanual pelvic examination shows a 15-week-size, mobile uterus with an irregular contour.

Which of the following is the most likely etiology of her size-date discrepancy? A. Adenomyosis B. Complete mole C. Endometriosis

The head is normocephalic with an open and flat anterior fontanelle. Cardiac examination reveals snus tachycardia and no murmurs, Pulmonary examination reveals tachypnea; breath sounds are clear throughout, and there are no retractions.

The infant has normal female infantile genitalia. Chest x-ray shows clear lung fields and a normal cardiac silhouette. Laboratory results are as follows: Complete blood count Hematocrit Platelets Leukocytes 20,500/mm3 Serum chemistry Glucose 35 mg/dL (>50 mg/dL)

Three minutes later, the patient reports ightheadedness and extreme weakness. His repeat blood pressure is 75/50 mm Hg and pulse is 85/min. The patient is diaphoretic and his extremities are cold. Jugular venous pulse is 3 cm above the sternal angle in the semirecumbent position.

The lungs are clear, and no murmurs are heard on auscultation. Which of the following is the best next step in management of this patient?

19. A 35-year•old African American woman comes to the clinic due to exertional shortness of breath. exercise tolerance a year ago was walking 7 blocks but now she walks less than a block before becoming short of breath. She also feels lightheaded when she forces herself "to go on."

The patient denies any episodes of syncope, chest pain, cough, wheezing, orthopnea, nausea, or lower extremity edema. She has been treated for Raynaud phenomenon and fingertip ulcerations for the last 2 years.

28. A 46-year-old man comes to the emergency department due to intermittent severe right flank pain over the past few days. He has had decreased urination over the last week but has also noted occasional episodes of high urine output along with a feeling of generalized weakness.

The patient has a history of chronic back pain for which he takes oxycodone daily, and he undenvent a left total nephrectomy following a motor vehicle accident 25 years ago, He was recently started on low-dose lisinopril for a new diagnosis of

23. A 76-year-old man with multi-infarct dementia is being evaluated for cough and low-grade fever. He was treated for pneumonia twice in the last year. For the past 6 months, he has had difficulty swallowing and occasionally regurgitates undigested food.

The patient has a long history of hypertension and chronic atrial fibrillation. His body mass index is 22 kg/mz. His temperature is 38.5 C (101.3 F), blood pressure is 150/95 mm Hg, pulse is 102/min, and respirations are 16/min.

21. A 24-year-old woman, gravida 1 para 0, comes to the office for her first prenatal visit after a positive Her last menstrual period was 9 weeks ago. Prior to conception, she had regular 28-day cycles with heavier and longer periods after stopping oral contraceptives last year.

The patient has had some nausea and vomiting, but no cramps or vaginal bleeding. On review of systems, she says that voiding is uncomfortable as she often has the feeling of incomplete bladder emptying. This had been "happening for a while"

but the patient has lower-extremity weakness on gait testing and must use the handrails to support herself when she attempts to walk. Laboratory results are normal except for hemoglobin of 11 g/dL and hematocrit of 34%. Pregnancy test is negative.

The patient is admitted to the hospital and endoscopy is performed. No source of bleeding is identified. When discharge is discussed, she says "l know there is something terribly wrong with me, with all this weakness and bleeding.

26. A 65-year-old man comes to the emergency department due to severe right leg pain and is found to have an acute thrombotic occlusion of the right popliteal artery. He has a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia.

The patient is admitted to the surgical floor and initiated on intravenous unfractionated heparin. The following morning, he undergoes surgical revascularization of the right leg. The patient's hospital course progresses well, but 5 days

The events are brief and accompanied by blue discoloration of his lips. The patient was born full term via normal vaginal delivery, and there was no known history of cyanosis or jaundice in the neonatal period. He has met all developmental milestones.

The patient's father has hypertension and hyperlipidemia, and his paternal uncle has a seizure disorder. Temperature is 37.5 C (99.5 F), pulse is 110/min, and respirations are 45/min. Physical examination shows an alert and mildly

His temperature is 37 C (98.6 F), pulse is 94/min, blood pressure is 90/50 mm Hg, and respirations are 18/min. Examination shows an alert and cooperative child. Auscultation shows normal first and second heart sounds with no murmurs.

The patient's lungs are clear to auscultation and his abdominal examination is within normal limits. Neurologic examination demonstrates 1+ patellar and Achilles reflexes bilaterally. Both calves appear enlarged.

She is receiving low-dose subcutaneous heparin for prophylaxis of deep venous thrombosis and has not received any oral anticoagulation. Temperature is 37.1 C (98.7 F), blood pressure is 130/82 mm Hgt and heart rate is 90/min. Cardiopulmonary examination reveals patchy rales and normal heart sounds.

The sternal surgical site is healing well. Several large purple/black patches are seen in the periumbilical area, surrounded by erythema. Peripheral pulses are normal. Neurologic examination is unremarkable.

33. A 42-year-old woman with severe uterine bleeding and iron-deficiency anemia is receiving a blood transfusion prior to a hysterectomy. Thirty minutes after the transfusion starts, she complains of chills and severe flank pain. The patient's temperature is 39.1 C (102.4 F), blood pressure is 133/80 mm Hg, pulse is 120/min, and respirations are 20/min.

The transfusion is stopped, but she continues to complain of symptoms and eventually begins bleeding around her intravenous catheter site. Which of the following is the most likely cause of this patient's transfusion reaction?

13. A 27-year-old woman comes to the emergency department due to abdominal pain, weakness, and vomiting blood. The patient says, "l feel so weak and lightheaded that I can't even walk." She had a similar episode 3 months over the she presented with hematemesis.

The workup was negative and she was discharged after 2 days. Temperature is 37.2 C (99 F), blood pressure is 100/60 mm Hg, pulse is 98/min, and respirations are 14/min. Strength is 5/5 in both upper and lower extremities,

17. A 58-year-old woman comes to the clinic due to a 6-month history of left knee pain that is worse with activity. She initially had pain only with ambulation but has progressively developed rest pain at night. In addition, the patient has had intermittent morning stiffness of 10-15 minutes duration.

There is no associated fever or weight loss. Medical history is significant for hypertension, type 2 diabetes mellitus, gastroesophageal reflux disease, and obstructive sleep apnea. Current medications include

3. A 20-year-old woman comes to the office due to 3 days of malodorous vaginal discharge and severe vulvar pruritus. The patient is sexually active and had a copper-containing intrauterine device placed for contraception last year. She has no chronic medical conditions and has had no surgeries.

Vital signs are normal. Pelvic examination shows a thin, frothy, and green vaginal discharge with marked vulvar and vaginal erythema. Vaginal discharge pH is 5.5. The intrauterine device strings are visualized and protrude through the cervical os.

Bedside ultrasonography does not demonstrate free intraperitoneal fluid. Plain abdominal radiograph shows dilated stomach with scanty distal gas. Laboratory results are as follows: Hemoglobin Leukocytes Total bilirubin Amylase 13.8 g/dL 8000/mmz 1.3 mg/dL 91 IJ/L

Which of the following is the most likely diagnosis for this patient? A. Duodenal hematoma B. Liver laceration C. Pancreatic pseudocyst D. Pyloric stenosis E. Small-bowel perforation

Pupils are equal and reactive to light. Heart sounds are normal. The trachea is midline. Bilateral breath sounds are present. The abdomen is diffusely tender. There is obvious deformity and tenderness of his left thigh.

Which of the following is the best Immediate step in management of this patient? A. Chest CT scan with contrast B. Echocardiography C. Focused bedside ultrasound D. Head CT scan without contrast E. Left femur radiography

Her blood pressure, 5 hours after her home measurement, is 140/90 mm Hg and weight is 70 kg (154.3 lb), a gain of 5 kg (11 lb) in 1 week. Physical examination shows pitting edema to the calves. Laboratory results are as follows: Hemoglobin Platelets Creatinine Aspartate aminotransferase 11.1 g/dL 0.8 mg/dL 12 U/L Urine dipstick shows 1+ protein and 1+ glucose. Fetal heart tracing is reactive.

Which of the following is the best next step for confirming this patient's diagnosis? A. Biophysical profile B. Finger-stick blood glucose test C. Observation of blood pressure for 4 hours D. Urine protein-to-creatinine ratio test E. Urine toxicology

Physical examination is notable for foul-smelling breath and a fluctuant mass in the left neck. Auscultation shows crackles in the right lung base. Chest x-ray shows an infiltrate without cavitation in the right lower lung field. The patient is admitted, sputum and blood cultures are sent, and antibiotics are started.

Which of the following is the most appropriate next step in his management? A. Bronchoscopy B. Contrast esophagram C. Gastric feeding tube placement D. Neck mass biopsy E. Upper gastrointestinal endoscopy

On physical examination, blood pressure is 112/69 mm Hg and pulse is 72/min. BMI is 34 kg/mz. There is tenderness to palpation over the sternum. Cardiac auscultation reveals a normal Sl and S2 without extra sounds or murmurs. ECG and chest x-ray are normal.

Which of the following is the most appropriate next step in management of this patient? A. CT scan of the chest B. Erythrocyte sedimentation rate C. Esophageal pH testing

She says that she can see and hear Mudsie but reports no other auditory or visual hallucinations. At one point in the interview, she looks over her shoulder and says, "Shhh, Mudsie, not now." Her parents are concerned that her behavior is abnormal and will interfere with her ability to make real friends.

Which of the following is the most appropriate response? A. Having imaginary friends is normal at this age and may help with social relationships. B. Having imaginary friends is normal; however, their presence can adversely affect the development of real friendships.

hypertension. There is no family history of renal disease, On physical examination, blood pressure IS 145/86 mm Hg and heart rate is 861 min, Laboratory results are as follows: Serum chemistry Potassium Creatinine Urinalysis Protein White blood cells Red blood cells Casts

Which of the following is the most likely cause of this patient's symptoms? A. Adrenal tumor B. Glomerulonephritis C. Inherited renal disease D. Interstitial nephritis E. Renal artery stenosis F. Urinary outflow obstruction

Cardiac Examination reveals tachycardia; no murmurs are present. A soft, non-fluctuant, tender, 5-cm (2.5-in) mass over the right anterior distal thigh without overlying erythema is noted. The right knee has full range of motion, and no effusion is noted. An erythematous, papular rash is present over the chest, trunkl and groin. Laboratory results are as follows: Serum chemistry Sodium Potassium 150 mEq/L 3.8 rnEq/L Skeletal survey reveals a single small, well-defined, lytic distal femoral diaphyseal lesion.

Which of the following is the mostlikely diagnosis in this patient? A. Langerhans cell histiocytosis B. Multiple myeloma C. Osteogenesis imperfecta D. Osteoid osteoma E. Osteomyelitis F. Osteosarcoma

The abdomen is soft, nontender, and has no palpable masses. Multiple contractures and a right club foot are noted. The infant has marked hypertonia. Imaging shows thin cerebral cortices and multiple intracranial calcifications within the cerebral cortex.

Which of the following maternal risk factors is most commonly associated with this infant's presentation? A. Consumption of unpasteurized dairy products B. Daily alcohol consumption C. Inadequate folic acid supplementation D. Nonadherence to vaccination schedule E. Travel to a tropical, mosquito-infested region

32. A 38-year-old woman comes to the office due to chest pain. She describes the pain as sharp, localized to an area just left of the sternum, and nonradiating. The pain is constant but worsens somewhat with inspiration and movement. She first noticed the pain while exercising 3 weeks ago,

but has experienced it at rest as well. The patient has no fevers, chills, dyspnea, swelling, or difficulty breathing at night. Her medical history is significant for 2 normal vaginal deliveries. Her father had a myocardial infarction at age 60. She does not use tobacco, alcohol, or illicit drugs.

history and drinks 1 or 2 beers daily. His temperature is 38.00 C (100.40 F), blood pressure is 160/95 mm Hg, pulse is 110/min, and respirations are 26/min. Examination shows a diffusely tender abdomen with rebound tenderness. There is increased pain in the

upper abdomen when palpating after deep inspiration, but there is no guarding or palpable mass. Rectal examination shows an empty vault. Upright chest x-ray is shown below. Which of the following is the most likely diagnosis in this patient?

4. A 6-year-old girl is brought to the clinic for evaluation of "strange behavior." Her parents have noticed that she seems to have conversations with herself when no one else is there, especially when she is alone in her room. In addition,

when the girl dropped a plate at dinner, she said that "Mudsie did it" and that Mudsie was a friend who went to school with her. She states, "Mudsie is my invisible friend who is a bit clumsy, but I am teaching her to go slowly so that she gets better."

7. A 42-year-old woman, gravida 1 para 0, at 36 weeks gestation comes to the labor and delivery unit for evaluation. Her feet were very swollen on awakening, and she has had difficulty ambulating. The patient's blood pressure, which was measured at home by her spouse

who is a cardiologist, was 146/92 mm Hg. She reports good fetal movement with no contractions, vaginal bleeding, or leakage of fluid. The patient has been very tired and has had shortness of breath.

9. A 29-year-old woman at 25 weeks gestation comes to clinic for routine prenatal care. She has a history of chronic hepatitis C infection acquired approximately 10 years ago. Her pregnancy has been otherwise uncomplicated to date. She is married and is monogamous with her husband,

who is aware of her hepatitis infection. Her past medical history is significant only for an appendectomy at age 12. She has not been immunized against hepatitis A or B. She takes no medications, aside from a daily prenatal multivitamin.