A 65-year-old woman is admitted to the hospital for constant, severe abdominal pain that has worsened over the previous week. She has no other associated symptoms, such as nausea or vomiting, but has noticed that her daily urine output has sharply decreased. She has had a constant desire to urinate, but when she tries, only a small amount of bloody urine is discharged. The patient is a long-time smoker, having smoked 3 packs per day for 45+ years, though she claims to have quit 2 days ago. Bladder ultrasound in the emergency department reveals a large mass consistent with bladder cancer, as well as significant urinary retention.

Which of the following is most likely to be detected upon imaging the patient's genitourinary system?

A 29-year-old man comes to the clinic with a 2-day history of severe left-sided scrotal pain and swelling. He is sexually active and has multiple sexual partners. He has no history of sexually transmitted diseases. His temperature is 38.2°C (100.8°F), blood pressure 120/70 mm Hg, and pulse 80/min. Examination shows unilateral intra-scrotal tenderness and swelling. Raising the testicle makes the pain less intense.

Which of the following is the most likely diagnosis?

A 27-year-old-man with no significant past medical history comes to the health care provider for an infertility evaluation. He and his wife have been trying to conceive for 2 years without success. A complete infertility workup of his wife found no abnormalities. History reveals that the patient had normal childhood development but late puberty. He had problems throughout his life in school secondary to what counselors told him was a moderate learning disability. Physical examination reveals a tall man with long legs and arms that seem out of proportion to the rest of the body. His testes are small, and moderate gynecomastia is present.

Which of the following findings is consistent with this patient's condition?

A 53-year-old woman with no past medical history complains of incontinence. She thinks that she must have "a small bladder capacity" because she has to go to the restroom so frequently. She also complains that she tends to lose her urine when she coughs or laughs. Particularly embarrassing is the fact that when she goes to the gym, she has to wear an undergarment while she does light weightlifting so she does not lose her urine in public. A recent urinalysis and urine culture she had at her employee health center were unremarkable. She denies recent back or head injury, neurologic dysfunction, and renal, bladder/urethral/ureteral disorder. She denies any psychological disorder and appears well-adjusted. She only takes oral contraceptive pills regularly; she does not drink or smoke but admits to drinking 3 cups of coffee a day.

Which of the following is the most likely diagnosis?

Fluid from a thoracentesis is grossly purulent. The effusion from which this fluid was aspired is best described as a(n):

Which of the following is the earliest manifestation of diabetic nephropathy?

A 2-year-old girl is brought to the emergency department because she looked "unwell" and has not wanted to get out of bed for 24 hours. She had a diarrheal illness 1 week ago marked by fever and bloody diarrhea, from which she had recovered. Two days ago, however, she developed reduced appetite and lethargy. She has had only 2 wet diapers in the last 36 hours. She was previously a well child and at the regular clinic visits normal growth and development were noted. Examination shows an irritable, pale child who has petechiae and edema. Vital signs reveal the blood pressure 102/74 mm Hg, pulse 136/min, and respirations 26/min. Lung and abdominal examinations are normal. Laboratory studies show:

Hemoglobin7.1g/dL

WBCs222 x 109/L (normal 5,000-10,000)

Differential:

Polymorphs38%

Lymphocytes52%

Monocytes8%

Platelets80 x 109/L

Blood filmFragmented red blood cells

Prothrombin time12.1 sec

Partial thromboplastin time32 sec

Serum sodium132 mEq/L

Serum potassium6.3 mEq/L

Serum chloride106 mEq/L

Serum bicarbonate16 mEq/L

Blood urea nitrogen32 mg/dL

Serum creatinine3.1 mg/dL

An 8-year-old boy has left leg pain and a high fever, and has been refusing to walk since yesterday. On physical examination, his temperature is 39.8ordmC (103.6ordmF), blood pressure 122/68 mm Hg, pulse 102/min, and respirations 20/min. The left femur is tender to palpation 3 cm above the left knee and there is marked soft-tissue swelling. Radiograph of the left leg is normal. Bone scan shows increased uptake around the metaphysis of the left femur.

Which of the following is the most likely pathogen?

5-year-old boy is brought to the clinic because his parents have noticed swelling around his eyes for the past 3 days. The child was previously well and was last seen for an annual well-child visit 1 month ago when his weight was 18.5 kg (40.8 lb). He has been urinating less than usual but he is otherwise well. No change in the urine color was noticed and there was no fever, diarrhea, or vomiting. Examination reveals an alert and active child. Blood pressure is 98/66 mm Hg. There is periorbital edema as well as pitting edema of the ankles. Lung and abdominal examinations are normal and there is no skin rash. Laboratory studies show:

A 52-year-old male presents complaining of urinary frequency, with hesitancy, and nocturia for the past few months. During his physical examination, you note a nontender, non-enlarged prostate with an isolated right posterior lobe nodule. Which of the following options is most appropriate?

A 36-year-old man develops rapid mental status deterioration 2 days after sustaining a femoral fracture in a skiing accident. Physical examination shows multiple petechiae in the anterior chest and abdomen. On the third day, the patient lapses into coma and dies. Postmortem examination of the brain reveals numerous petechial hemorrhages in the corpus callosum and centrum semiovale.

Which of the following is the most likely diagnosis?

Which term is used to describe the characteristic concave or "spoon-shaped" nails of iron deficiency anemia?

A 72-year-old man with a history of obesity and hypertension treated with nifedipine comes to the health care provider complaining of worsening right-sided knee pain. He has suffered from this knee pain for 10 years, but it is no longer relieved with nonsteroidal anti-inflammatory drugs as in the past. The knee pain gets progressively worse as the day goes on and the pain improves with rest. When asked about other joint involvement, he reports that he has less severe pain in his right wrist. His temperature is 37°C (98.6°F), blood pressure 160/90 mm Hg, pulse 68/min, and respirations 15/min. Physical examination reveals an obese man in no acute distress. His knee is not swollen or warm, but crepitus can be appreciated. His left knee and right wrist are normal.

Which of the following is consistent with this patient's history?

A 37-year-old woman presents with a swollen and tender left wrist. The symptoms began approximately a day earlier and have become increasingly severe. She has noted a fever and shaking chills last night. She has no past medical history and takes no medications, except for ibuprofen for occasional premenstrual cramps. On physical examination the wrist has decreased ROM and is tender to palpation. The joint space has an obvious effusion and is tender, erythematous, and warm.

Which of the following is the most appropriate next step in management?

A patient describes a history of recurrent bouts of uveitis. Her chemistry panel reveals elevated serum calcium and uric acid levels. Her anergy screen is negative. Her chest x-ray demonstrates bilateral hilar adenopathy. Which diagnosis is most likely?

A 38-year-old woman comes to the office complaining of a new-onset rash on her face, hair loss, malaise, and fatigue that has been worsening over the previous month. She has also noticed that sun exposure makes her rash flare to a great degree. Her medical history is significant for food allergies and acute thyroiditis as a teenager. Her only medication is a daily thyroid hormone supplement. On physical examination, there is ill-defined erythema and edema on the nose and cheeks. There is diffuse thinning of the scalp hair, with short hairs on the anterior hairline. The fingertips are studded with minute, violaceous papules that are tender to touch. Urinalysis shows 4+ protein. Laboratory studies show:

-Red blood cells2.9 x 1012/LWhite blood cells2.0 x -109/LPlatelets220 x 109/L

-Erythrocyte sedimentation rate57 mm/h

-Anti-nuclear antibody1:160

Which of the following antibodies is the most specific serologic test for this disease?

A 38-year-old woman comes to the office complaining of a new-onset rash on her face, hair loss, malaise, and fatigue that has been worsening over the previous month. She has also noticed that sun exposure makes her rash flare to a great degree. Her medical history is significant for food allergies and acute thyroiditis as a teenager. Her only medication is a daily thyroid hormone supplement. On physical examination, there is ill-defined erythema and edema on the nose and cheeks. There is diffuse thinning of the scalp hair, with short hairs on the anterior hairline. The fingertips are studded with minute, violaceous papules that are tender to touch. Urinalysis shows 4+ protein. Laboratory studies show:

-Red blood cells2.9 x 1012/LWhite blood cells2.0 x -109/LPlatelets220 x 109/L

-Erythrocyte sedimentation rate57 mm/h

-Anti-nuclear antibody1:160

Which of the following antibodies is the most specific serologic test for this disease?

A 27-year-old woman is admitted to the hospital because of 4 days of joint pain. Initially she had diffuse joint pain that would "travel" from her wrists to her elbows and to her knees. Over the last 24 hours, however, she has had intense pain and swelling localized to her right knee. She denies any trauma to the area. She denies any fevers or chills but admits to mild dysuria that she attributed to a urinary tract infection. Further history reveals that she has had unprotected sex with 4 partners in the last 3 months. Her temperature is 37.0°C (98.6°F), blood pressure 120/70 mm Hg, pulse 113/min, and respirations 18/min. The right knee is swollen and tender. She has scattered necrotic pustules on her palms and soles. Arthrocentesis is performed and a complete blood count and blood cultures are obtained.

-Hemoglobin:14.mg/dL

-Leukocytes:10,000/mm3

-Platelets:170,000/mm3

-Hematocrit:36%

-Gram stain of the synovial fluid is shown.

Which of the following is the most appropriate next step in management?

A 34-year-old female presents complaining of symmetrical redness and swelling of the small joints of her hands (PIPs and MCPs). She has noted that the symptoms are worst in the morning. Her erythrocyte sedimentation rate is elevated and her rheumatoid factor is negative. Which of the following diagnosis is most likely?

A 16-year-old boy comes to the health care provider complaining of a persistent sunburn on his face that started when he was on vacation 2 weeks earlier and does not seem to be improving. He also complains of headache, chills, fever, and joint pains that are most prominent in the hands with the pain being the worst in the morning. Aspirin seems to improve the symptoms somewhat. He has no significant past medical history and does not take any medication on a regular basis. He denies allergies to medications. On physical examination, the patient is a well-developed and well-nourished young man. His temperature is 37.3ordmC (99.1ordmF), blood pressure is 140/90 mm Hg, pulse is 80/min, and respirations are 16/min. Inspection of the skin reveals diffuse erythema and edema of the nose and cheeks in a butterfly distribution and erythema and edema of the skin overlying the interphalangeal part of his fingers. The proximal and distal interphalangeal joints of the fingers are edematous and tender and his fingertips are studded with minute violaceous papules tender to touch. On the hard palate, there are several shallow ulcers up to 1 cm in diameter. Laboratory studies show:

-RBCs 2.8 x 10¹²/L (normal 4.7ndash6.1 million cells)

-WBCs 2.2 x 10⁹/L (normal 5,000-10,000)

-Platelets 200 x 10⁹/L (normal 150,000-400,000)

-Erythrocyte sedimentation rate 57 mm/h (normal <20 mm/h)

-Urine protein 4+ (normal negative)

Which of the following is the most appropriate screening lab test for this patient?

A 27-year-old nulliparous female presents because she's been trying to get pregnant for two years, but has failed. She relates a history of a misdiagnosis of appendicitis that lead to abscess formation when she was 14 years old. Which of the following diagnostic studies would be most helpful at this point in her evaluation?

A 54-year-old woman is admitted to the hospital for pneumonia. The patient presented to the hospital 2 days ago for cough and fever. She reported temperatures to 38.9° C (102° F) and a cough productive of green, copious sputum. She also reported pleuritic chest pain with deep inspiration. The initial examination revealed diminished breath sounds in the left lower lobe with dullness to percussion, and a chest radiograph revealed a dense left lower lobe infiltrate.

Which of the following organisms is most likely responsible for her pneumonia?

A 14-year-old is experiencing a severe asthma attack. Although he is using accessory muscles to breath, auscultation of his chest reveals no audible wheezing. His heart rate is 160 and his respiratory rate is 52. Which of the following arterial blood gases represents the worst prognosis?

A 32-year-old man has had asthma for the past 9 years. The symptoms are frequently exacerbated by changes in the weather and household allergens. He has had 2 emergency department visits over the past year, where he was started on oral corticosteroids, but he has not required hospitalization. He uses an albuterol inhaler about 4 times per week for symptom relief and has symptoms at night about 3 times a month.

Which of the following would be the most appropriate therapy to maintain remission between his asthmatic attacks?

A 67-year-old man with emphysema comes to his healthcare provider for a routine checkup. He reports that his symptoms have remained stable, with frequent coughing and dyspnea, despite compliance to his medications, which include oral prednisone, aminophylline, inhaled beta 2 agonists, and rotating courses of antibiotics. On physical examination he has a barrel-chest and distant breath sounds in both lung fields with soft expiratory wheezes. An arterial blood gas reveals an arterial pH of 7.32, a pCO₂ of 47 mm Hg, and a pO₂ of 53 mm Hg.

Which of the following would most likely prolong his survival?

While suturing a wound, you opt to use lidocaine with epinephrine. The rationale for your choice is:

A 79-year-old man weighing 75 kg with emphysema is intubated in the intensive care unit because of respiratory failure after developing adult respiratory distress syndrome secondary to an Escherichia coli bacteremia. This event followed an untreated urinary tract infection. The ventilator is set to a respiratory rate 20/min, tidal volume 450 mL/breath, and pO₂100%.

If these settings are continued for long term use, the patient has increased risk for developing which of the following complications?

An EKG demonstrates a PR interval of 0.16 seconds, a P to QRS relationship of 1:1, a variable heart rate and an R to R interval that is noted to accelerate and decelerate during the respiratory cycle. What is the diagnosis?

Combinations of antimicrobial agents are commonly employed in the treatment of meningitis in infants less than three months old. Ampicillin is commonly an agent included in this regimen. Ampicillin is used empirically for the possible presence of:

A 74-year-old woman, who has been followed for the past 25 years for chronic obstructive pulmonary disease (COPD) comes to the emergency department complaining of 48 hours of temperatures of 38.6° C (101.4° F) and worsening shortness of breath. She has a chronic productive cough, which has become more copious. On physical examination she has rhonchi and increased fremitus in the posterior mid-lung field. Patient has a long-standing history or smoking and continues to smoke. A Gram's stain reveals many epithelial cells and multiple gram-positive and gram-negative organisms; no neutrophils are seen.

Which of the following is the most likely organism causing the symptoms?

A 42-year-old female presents after finding a firm, painless bump in her right eyelid. On examination, you note a 6 mm mass within the tarsus of the right eye. The skin is freely movable over the mass. The remainder of the ophthalmoscopic examination is unremarkable. Which of the following is the most likely diagnosis?

A 3-year-old boy is brought to the office by his parents for a regular health supervision examination. His condition has not changed significantly since his last visit 6 months earlier. He still prefers to play by himself and rocks back and forth constantly. The mother has finally adjusted to the fact that her son shows no signs of emotional attachment to her. On physical examination the boy is noncooperative and utters unintelligible mumbles when the healthcare provider approaches him. The healthcare provider fails to establish any eye contact with him. Suddenly the boy starts screaming and runs over to the wall and repetitively bangs his forehead against it.

Which of the following is the most likely diagnosis?

A 22-year-old patient was involved in an automobile accident and is comatose. Which of the following diagnostic modalities would be least useful in this patient's evaluation?

A 33-year-old woman comes to the healthcare provider because of anxiety and irritability. She states that approximately 10 days before the onset of her menses, she goes from "feeling fine" to "feeling awful." She has frequent angry outbursts toward her husband and children, feels depressed and irritable, and cries easily. She also develops severe breast tenderness during this time. The symptoms resolve soon after the start of her menses and she feels fine until the symptoms start over again as the next menses approach. She has had this constellation of symptoms every cycle over the past year and feels that she can't go on like this anymore, as her job and family relations are suffering greatly. She has no other medical problems and takes no medications. Her physical examination is entirely normal.

Which of the following is the most appropriate management?

Which white blood cell disorder is characterized by the presence of the Philadelphia chromosome in 90% of cases?

A 54-year-old man comes to his health care provider complaining of intermittent palpitations. The patient reports that a few times over the past few months he has had episodes of ''pounding in his chest'' that are associated with shortness of breath and occasional chest pain. He is forced to sit down if he is standing, because of weakness and vertigo. The patient has a history of hypertension and mitral valve prolapse. He takes nifedipine (Procardia, Adalat) and hydrochlorothiazide daily. While sitting in the office, the patient begins to complain of increasing shortness of breath and palpitations. His blood pressure is 85/50 mm Hg and his pulse is 110-130/min and irregularly irregular.

Which of the following is the most appropriate management at this time?

All of the following are factors that predispose a patient to the development of gastroesophageal reflux EXCEPT:

A 71-year-old retired physician complains of increasing calf pain when walking uphill. The symptoms have gradually increased over the past 2 months. His past medical history is significant for a transient ischemic attack 6 months ago. Over the past month, his blood pressure has worsened despite previous control with diltiazem, hydrochlorothiazide, and propranolol. His other medications are isosorbide dinitrate and aspirin. On physical examination, his blood pressure is 152/90 mm Hg and his pulse is 66/min. There is a right carotid bruit. His lower extremities are mildly cool and have diminished pulses at the dorsalis pedis. An ACE inhibitor is added to help control his blood pressure.

Which of the following is the most appropriate in the management of his leg pain?

A patient warrants antihypertensive medication use for the duration of her pregnancy. Which of the following is the antihypertensive recommended for such patients?

A 77-year-old man comes to the health care provider because of decreasing exercise tolerance. Just 1 year earlier he was able to play doubles tennis for 2 hours. Over the past few months, however, he has had progressive dyspnea on exertion and now can walk only 2 blocks on level ground before becoming short-winded. He has also been awaking from sleep with shortness of breath and requires 3 pillows to sleep comfortably. He has a history of rheumatic fever as a teenager. On physical examination his blood pressure is 168/60 mm Hg, pulse 92/min, and respirations 18/min. He is afebrile. He has jugulovenous distention lying supine. He has bibasilar rales extending 1/4 up both posterior lung fields. He has a regular S1 and S2, with a blowing diastolic murmur heard at the aortic area, which is grade II/VI. An S3 is audible. The liver edge is mildly tender, and there is moderate lower extremity edema extending to both knees.

Which of the following medications will most likely be effective in the management of his cardiac disorder?

A 6-year-old child falls onto his right arm. An x-ray demonstrates a buckle in the cortices of the distal radius, proximal to the growth plate, without angulation. What is the term used to describe this fracture?

A 15-month-old boy is brought to the emergency department by his parents because he suddenly turned blue and had difficulty breathing while he was playing in the back yard of their home. The parents have noticed several times in the previous 2-3 months that he had developed a bluish discoloration around the lips but did not think much of it, as it was wintertime. Recently, however, the boy had increasing fatigability and would stop in the middle of playing to catch his breath by sitting down or squatting. This morning when he suddenly turned blue and started behaving in a very flustered manner they rushed him to the emergency department. The parents deny any other significant medical conditions or allergies to medication. They have a 4-year-old daughter who is in good health. On physical examination, the patient is in the fifth percentile for height and weight. His lips and fingertips are bluish in color and he frequently stops to catch his breath while playing in the examination room. There is a hint of clubbing of his fingers. Vital signs are within normal limits, but a complete blood count shows a red blood cell count of 6 x 10¹²/L and a hematocrit of 66%. A chest radiograph shows a boot-shaped heart with an uptilted apex and clear lung fields. On auscultation, there is a harsh systolic ejection murmur and a single S2 is heard.

Which of the following is the most likely diagnosis?

A 55-year-old male presents complaining of "difficulty writing" using his dominant hand and some "slurred" speech. He has a h/o hypertension, DM type II, and hypertriglyceridemia. Which of the following would you anticipate to find on a CT scan of his head, as the explanation for his chief complaint?

A 10-year-old girl is brought to the office because of fever and chills for 3 days. She had been complaining of a headache and feeling tired for 10 days before she developed fever. The parents had tried giving her acetaminophen, but the child's condition was not improving. Her past medical history is significant for frequent streptococcal throat infections over the past 2 years and a new onset heart murmur detected at her last well child visit 2 months earlier. She is on no medication currently, except for acetaminophen. Otherwise, she has been wearing dental braces for the past year and had a primary tooth extracted 2 weeks earlier in the attempt of liberating space for permanent teeth. On physical examination, the patient is diaphoretic, in moderate distress with a temperature of 39.0° C (102.2° F), blood pressure of 90/60 mm Hg, pulse of 110/min, and respirations of 24/min. On her fingernails, you note several splinter hemorrhages. Auscultation confirms a grade 2/6 high-pitched, blowing, systolic ejection murmur, best heard at the apex that radiates to the left axilla. A chest radiograph is unremarkable, but the electrocardiogram shows signs of left ventricular strain. An echocardiogram reveals vegetations on the mitral valve.

Which of the following microorganisms is the most likely cause of this patient's current condition?

A female in her third trimester of pregnancy developed hypertension, diffuse edema, proteinuria and hyperreflexia. She was treated with intravenous magnesium sulfate and is now hyporeflexic and drowsy. What do you prescribe now?

A 56-year-old smoker with no previous medical history comes to the emergency department complaining of chest pain and shortness of breath with exertion. He is admitted to the hospital for further evaluation. An exercise stress test supports the diagnosis of coronary artery disease, and the patient undergoes a heart catheterization. There is diffuse coronary artery disease but no clearly stentable lesions. The cardiologist decides that medical management of this patient's coronary disease is appropriate at this time. The patient has no allergies and has no other medical conditions.

His blood pressure and pulse over 3 days are as follows:

Day 1 blood pressure 146/96 mm Hg, pulse 80/min

Day 2 blood pressure 150/90 mm Hg, pulse 86/min

Day 3 blood pressure 140/96 mm Hg, pulse 73/min

Which is the most appropriate blood pressure medication for this patient?

This papulosquamous eruption is most common in young adults. A single oval patch is generally noted several days before a more generalized, fawn-colored rash erupts. This rash is most prevalent on the trunk, and the proximal upper and lower extremities. The rash spontaneously disappears over five to six weeks. The diagnosis is:

A 57-year-old man with hypertension and hyperlipidemia comes to the emergency department complaining of crushing substernal chest pain, diaphoresis, and nausea for 3 hours. He denies palpitations or shortness of breath. He has no previous history of angina or myocardial infarction. His temperature is 37.0° C (98.6° F), blood pressure is 82/60 mm Hg, pulse is 103/min, and respirations are 20/min. Physical examination shows jugular venous distention, a tachycardic heart that is without murmurs, and clear lungs. An electrocardiogram is shown.

A right-sided electrocardiogram is also performed that shows ST elevation in V3 and V4.

Which of the following is the most appropriate medical intervention at this time?

A patient presents complaining of generalized swelling. Her urine is positive for protein. Her serum testing reveals hyperlipidemia and hypoalbuminemia. Which of the following is the most likely diagnosis?

A 28-year-old man seeks help for progressive edema affecting his right lower extremity. It first started about 2 years ago but has become much worse in the last 6 months. Physical examination shows pitting edema from the groin to the toes, as well as very prominent varicose veins and an area of chronic cellulitis above the medial malleolus. These findings are confined to the right side and are not present at all on the left. He also is noted to have a palpable thrill and an audible bruit over the right groin. His resting pulse is 115/min. He gives a history of having suffered a gunshot wound to his right groin 3 years ago, for which he had no specific therapy.

Which of the following is the most likely diagnosis?

A 6-year-old female presents complaining of right ear pain. The tympanic membrane cannot be well visualized. She complains of pain when the tragus is manipulated. Several periauricular lymph nodes are easily palpable. Which of the following is the most likely diagnosis?

A 69-year-old woman comes to the health care provider for a periodic health maintenance examination. She has no complaints. She takes 1,500 mg of calcium daily, a multivitamin, and daily aspirin. She exercises regularly, eats a fairly healthy diet, and does not smoke cigarettes. She drinks a couple of glasses of wine with dinner each evening and smokes marijuana occasionally with a friend who has glaucoma. She is concerned about her risks for breast, ovarian, and colon cancer because she has friends with each of these diseases. Breast and pelvic examination are unremarkable. A mammogram is normal. Findings from a barium enema are shown.

Which of the following is the most common presenting symptom of this condition?

You note polygonal, purple, popular lesions involving the flexor surfaces of a patient’s wrists. The patient has no other lesions. The lesions appear to follow a linear pattern of distribution. What is this phenomenon?

A 42-year-old alcoholic man comes to the emergency department with severe abdominal pain that began 3 hours ago. He is well known to the medical staff because of 3 prior hospitalizations for acute pancreatitis. He says that this time his pain began suddenly and in short order became constant, generalized, and extremely severe. He lies motionless on the stretcher, and on physical examination he has tenderness, rigidity, and rebound in all four abdominal quadrants. Bowel sounds are absent. Initial studies are significant for a serum amylase of 1,200 U/L and free air under both diaphragms on an upright plain film of the abdomen.

Which of the following is the most likely diagnosis?

A female presents complaining of a grayish, watery vaginal discharge. The KOH prep does not reveal any hyphae. Clue cells are identified on the wet mount. A paucity of WBCs are noted. What diagnosis is most likely?

A 63-year-old man in apparent good health is convinced by magazine articles and TV programs that he will live longer if he takes one aspirin tablet every day. After about 3 weeks of doing so (325 mg/day), he begins to notice bright red blood on the toilet paper when he wipes after a bowel movement. This does not occur every time, but only when, for whatever reason, he has to strain more than usual. He has never had any discomfort referable to hemorrhoids or any bowel pathology that he is aware of. Anoscopy and digital rectal examination show external and internal hemorrhoids, none of which are bleeding at the time of the examination.

Which of the following is the most appropriate next step in management?

A 6-year-old male is brought into your office for evaluation of his gait. You note that when ambulatory, the medial aspects of his knees are far apart and his feet are unusually close together. Which of the following best describes this condition?

A 44-year-old woman comes to the clinic after being treated in the emergency department 2 weeks ago for her first episode of diverticulitis. Her condition was diagnosed by CT scan of the abdomen and treated with an outpatient course of ciprofloxacin (Cipro) and metronidazole (Flagyl). She has no previous medical history and takes no medication on a regular basis. The patient's recovery was uneventful, and she is currently without any new complaints. She is now concerned about multiple small gallstones that were incidentally noted on the CT scan. Of note, the gallbladder appeared otherwise normal, and there was an absence of dilated ducts. She denies any problems with cholelithiasis in the past but is worried because her mother had a "gallstone infection" in the past that required surgery and intravenous antibiotics.

Her temperature is 37.0°C (98.6°F),

blood pressure 140/80 mm Hg,

pulse 93/min, and

respirations 18/min.

She is 60 inches tall and weighs 77 kg (169 lb).

Her abdomen is nontender and nondistended with normal bowel sounds. There is no rebound or guarding. Murphy sign is negative. Her liver is normal sized.

Laboratory studies show normal levels for all of the following:

Hemoglobin11 mg/dL

Leukocyte count5700/mm3

Platelets270,000/mm3

Hematocrit31%

Sodium145 mEq/L

Potassium4.5 mEq/L

Chloride100 mEq/L

Bicarbonate 24 mEq/L

Glucose 116 mg/dL

Creatinine 1.0 mg/dL

BUN 10 mg/dL

Total protein 6.0 g/dL

Albuimin 3.5 g/dL

Total bilirubin 0.9 mg/dL

Direct bilirubin 0.4 mg/dL

Alkaline phosphatase 59 U/L

AST 20 U/L

ALT31 U/L

Which of the following is the most appropriate management of this patient?

Which of the following agents has a mechanism of action that does not involve beta-receptors?

A 54-year-old man comes to the health care provider because of "ringing in his ears," a feeling of "spinning," and a progressive loss of hearing in his left ear. He says that this all began "a while ago" with a slight feeling of unsteadiness and this "annoying ringing." He didn't go to the doctor because he thought he was "going crazy," but now his wife is getting worried that the television needs to be much louder and that he constantly says "What?" when she speaks to him on his left side. He has no chronic medical conditions, does not take any medications, and does not drink alcohol. Examination shows nystagmus, but no other abnormalities.

Which of the following is the most likely diagnosis?

The results of a barium esophagram reveal esophageal webbing in a woman with long-standing iron deficiency anemia. Her diagnosis is:

A male infant is born at 40 weeks' gestation to a 25-year-old primigravid woman. Delivery is by primary Cesarean section because of breech presentation. Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. Physical examination is normal. Infant and mother are scheduled to be discharged home on hospital day 4. Before discharge, a nurse performs a heelstick on the infant to collect a blood specimen for the Newborn Screening Program.

Which of the following metabolic disorders is routinely tested for in newborn screening in all states?

Laboratory report: elevated serum free t4; low serum TSH level. Which of the following is the MOST likely diagnosis?

A 50-year-old woman is being treated for longstanding severe rheumatoid arthritis. Screening blood studies demonstrate a moderate anemia with a hemoglobin level of 10 g/dL (normal 12.1-15.1 g/dL). The patient's nutritional status is adequate, and the clinician suspects she has anemia of chronic disease.

Which of the following erythrocyte findings would be most likely to be seen on peripheral blood smear?

Which of the following agents is effective in the treatment of Parkinson's?

Six days after an uncomplicated left nephrectomy, a 42-year-old man complains of moderate abdominal pain and diarrhea. He is stooling approximately 6 times a day with profuse watery diarrhea. The patient also experiences painful cramps during these episodes. In other medical history, the patient has a history of hypertension and elevated cholesterol. His medications include metoprolol (Lopressor) and simvastatin (Zocor). He denies any recent cardiopulmonary history and any history of chronic gastrointestinal disorders. His chart indicates that he received a 2-day regimen of cefazolin (Ancef) for perioperative skin prophylaxis. His temperature is 38.3°C (101.0°F). Stool is positive for fecal leukocytes and occult blood. The diagnosis is established with additional studies and he is given treatment. Unfortunately he fails to respond to therapy and requires surgery. An image of a segment of his colon is shown.

Which of the following is the most likely pathogen?

The most common cause of preventable blindness in the United States is:

Two bewildered parents rush into the emergency department carrying a 3-year-old girl. They tell the health care provider at the door that she ingested multiple acetaminophen pills less than an hour ago. The mother was experiencing a terrible headache over the past 2 days and was taking acetaminophen as a pain reliever. She left the open bottle on her desk to get a glass of water, and when she returned her daughter was putting the tablets in her mouth. Immediately the mother removed whatever pills were still in the child's mouth and checked to insure that all the other medications were safely stored away; when she saw that they were untouched in the medicine cabinet, the family got in the car to rush to the hospital. On route there the girl started vomiting. The mother does not know how many pills her daughter took because it wasn't a full bottle to begin with. At the hospital she takes out the half-empty bottle and spills the contents on the counter. A total of 36 pills is present from an original 100 count, 325 mg of acetaminophen each. The child, crying on the examining table, appears frightened and diaphoretic, and repeats several times that she wants to throw up. Her pulse is 120/min and respirations are 24/min.

Which of the following is the most appropriate next step?

A 44-year-old woman has a 10-year history of progressive dysphagia without pain. The dysphagia affects all kinds of food, without preference for solids. The food sticks in the xiphoid area and can be helped along by drinking large amounts of water and sitting up straight until the whole bolus passes into the stomach. She also describes many episodes of regurgitation of foul-smelling but undigested food, either when she leans forward or when she is asleep at night. She used to be heavier and lost weight as the disease progressed. A barium swallow shows a massively dilated proximal esophagus with a narrow, beak-like appearance in the lower sphincteric area.

Which of the following is the most likely original pathophysiology that explains the development of this problem?