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A 68-year-old retired male is accompanied by his son and daughter to a family medicine clinic. They are concerned about their father's health, as they have noticed him becoming gradually more "confused" over the past year. While he had always been capable of managing to live alone, he has not been keeping up with his bills. The patient explains that he needs his bifocals, but both of his children quickly interrupt, stating that he has glasses but misplaces them frequently. He also frequently loses his keys and forgets to shut his door. The management of the condominium has complained because they recently found him wandering around the lobby and pool in the middle of the night while dressed in his underwear. He has no medical problems and takes only an aspirin daily. His MSE is significant for defensiveness to questioning with some irritability. His Mini-Mental State Examination is 19/30, with notable memory deficits and wordfinding difficulties. Which of the following will be the most likely course of his illness?
A 50-year-old woman with a history of essential hypertension presents to the emergency department with sudden onset of a severe headache, nausea and vomiting, and photophobia. On examination, her BP is 160/100 mmHg. She is mildly confused and has nuchal rigidity, without focal neurologic signs. Once the diagnosis has been confirmed, which of the following is the next most important step in patient management?
A 68-year-old retired male is accompanied by his son and daughter to a family medicine clinic. They are concerned about their father's health, as they have noticed him becoming gradually more "confused" over the past year. While he had always been capable of managing to live alone, he has not been keeping up with his bills. The patient explains that he needs his bifocals, but both of his children quickly interrupt, stating that he has glasses but misplaces them frequently. He also frequently loses his keys and forgets to shut his door. The management of the condominium has complained because they recently found him wandering around the lobby and pool in the middle of the night while dressed in his underwear. He has no medical problems and takes only an aspirin daily. His MSE is significant for defensiveness to questioning with some irritability. His Mini-Mental State Examination is 19/30, with notable memory deficits and wordfinding difficulties. An MRI performed would most likely demonstrate which of the following findings?
A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. The initial diagnostic evaluation does not reveal any abnormalities. Which of the following is the best next step in the diagnostic workup?
A 68-year-old retired male is accompanied by his son and daughter to a family medicine clinic. They are concerned about their father's health, as they have noticed him becoming gradually more "confused" over the past year. While he had always been capable of managing to live alone, he has not been keeping up with his bills. The patient explains that he needs his bifocals, but both of his children quickly interrupt, stating that he has glasses but misplaces them frequently. He also frequently loses his keys and forgets to shut his door. The management of the condominium has complained because they recently found him wandering around the lobby and pool in the middle of the night while dressed in his underwear. He has no medical problems and takes only an aspirin daily. His MSE is significant for defensiveness to questioning with some irritability. His Mini-Mental State Examination is 19/30, with notable memory deficits and wordfinding difficulties. A definitive diagnosis of this patient's most likely condition would require which of the following?
A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. Which of the following is the most appropriate initial diagnostic evaluation of this patient?
In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Several weeks later, the child presents to the emergency department with a 4-hour history of irritability. He has had one episode of nonbilious vomiting and has refused to breast-feed. In the emergency department, the infant appears inconsolable. He is afebrile, and his abdomen is mildly distended but soft. On removal of his diaper, the same abnormality is documented (see Figure. Which of the following is the most appropriate management at this time?
The patient is a 25-year-old woman recently released from the hospital after her first manic episode. She is currently taking lithium 1200 mg/day, and her lithium level is 1.1 meq/L. She has a slight, but tolerable, tremor and has gained 5 lbs, but she is otherwise tolerating the medication. She claims her mood is "pretty good." She is sleeping approximately 7 hours per night. Her energy and concentration are adequate, and she denies racing thoughts, talkativeness, or increased activity. She has no major medical problems, and her only other medication is birth control pills. She does not consume alcohol or drugs. She wonders, "How long will I have to take medications for this problem?" How long should she be recommended to continue on maintenance therapy?
A 30-year-old man is seen in the primary care clinic. He complains of 3 months of "feeling down" that began soon after his job loss 6 months ago. His appetite has decreased, and he has noticed his clothes are baggy on him. He has felt extremely distracted and fatigued. He attributes this to waking up at approximately 3:00 a.m. every day and then not falling back to sleep. While he has felt "lower than I've ever been," he denies any suicidal ideation. He does not have any past psychiatric history or current medical problems. He is prescribed mirtazepine (Remeron) 15 mg at bedtime, but he asks, "how long does the medication take to work"? His illness is successfully treated and remits for 1 year. He returns to the clinic wishing to stop the medications. He asks whether he needs to take the medications "for the rest of my life." What should he be counseled regarding his approximate risk of recurrence if he discontinues the medication?
In a 6-month-old previously healthy male infant, an abnormality is revealed during a routine diaper change, as illustrated in Figure. The parents have noted this finding on and off on several occasions over the last month. On each occasion, the child has been feeding well, and is content and playful. Which of the following is the most likely diagnosis?
A65-year-old White female presents to the office for her annual gynecologic examination. She has been a patient of yours for many years. She also sees you on a routine basis for treatment of hypertension and hypothyroidism. Her last pap smear was 5 years ago and she has never had an abnormal pap smear. She had a mammogram 1 year ago that was normal. She does not perform self- breast examination. She is without complaint today. Past medical 1. Hypertension for 15 years history: 2. Graves' disease, treated with radioactive iodine thyroid ablation at age 50 OB/GYN history: 1. Menarche at age 14 Four term pregnancies with vaginal deliveries (at age 22, 25, 27, and 32) Total abdominal hysterectomy and bilateral salpingo oophorectomy (TAH/BSO) age 47 for fibroids On estrogen replacement therapy from age 47 to 55 Past surgical 1. Appendectomy at age 16 history: 2. TAH/BSO as noted above Medications: 1. Hydrochlorothiazide 25 mg daily 2. Levothyroxine 0.1 mg daily 3. Potassium chloride 20 meq daily Allergies: None Family history: Parents, siblings unknown as patient was adopted Children are alive and well without known chronic medical conditions Social history: Widowed for 5 years, has not been involved in a sexual relationship since the death of her husband; retired school teacher; college educated; does not smoke cigarettes, drink alcohol, or use drugs; walks 3045 min a day for exercise At this visit you should do which of the following?
A 30-year-old man is seen in the primary care clinic. He complains of 3 months of "feeling down" that began soon after his job loss 6 months ago. His appetite has decreased, and he has noticed his clothes are baggy on him. He has felt extremely distracted and fatigued. He attributes this to waking up at approximately 3:00 a.m. every day and then not falling back to sleep. While he has felt "lower than I've ever been," he denies any suicidal ideation. He does not have any past psychiatric history or current medical problems. He is prescribed mirtazepine (Remeron) 15 mg at bedtime, but he asks, "how long does the medication take to work"? Which of the following symptoms should he be told will most likely improve last?
A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Staging workup and surgery reveal a seminoma of the testicle, with positive inguinal and retroperitoneal nodes. Therapeutic management for this patient is which of the following?
A 28-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Which of the following would help confirm the diagnosis?
A25-year-old woman returns for her well-baby check 1 week after delivery. The baby has been gaining weight adequately and awakens several times per night to breast feed. Although the mother claims she enjoys being a mom overall, she looks sad and does reluctantly admit to feeling "down" quite a bit. While she feels a great deal of support by her husband, she finds herself crying when alone. Her sleep is erratic, and she often feels tired, but she is eating adequately. She denies significant guilt or any thoughts of suicide or infanticide. What is the appropriate treatment approach for this patient?
A42-year-old male presents to the office for a refill of the nasal steroid medication that he uses every spring to control his allergies. You notice on the vital signs taken by the nurse that his blood pressure is 150/95. Except for some sneezing and nasal congestion, the patient has no symptoms. He has no other medical history and his only medication is a nasal steroid. He does not smoke cigarettes, does not drink alcohol, and does not exercise. His body mass index is 24 kg/m2. Initial management at this time should include which of the following?
A 26-year-old divorced woman is brought into the emergency room after being found wandering the streets aimlessly. She is a relatively good historian but gives few spontaneous answers to questions. She describes a 1-year history of the belief that she is being followed by "agents" of the Vatican, who watch her closely to "see if I'm a good Catholic." While they monitor her, they also use radio signals to tell her she is a "whore" and a "slut." Due to these experiences, she has been unable to work. She is afraid to associate with others for fears of being "judged." She enies any medical problems and takes no medications. Her parents were divorced when she was an infant. She does not know anything about her father, but her mother has "manic-depression" and is taking lithium. Her MSE is notable for significant psychomotor slowing, paucity of speech, and a flat affect. Which of the above symptoms or signs is necessary in order to make a diagnosis of schizophrenia?
For each newborn with vomiting and illustrated radiographs, select the most likely diagnosis. A 10- day-old infant presenting with bilious vomiting, paucity of gas on plain radiographs, and duodenal obstruction on UGI contrast study congenital hypertrophic pyloric stenosis annular pancreas duodenal atresia midgut volvulus intussusception
A 26-year-old man is brought into the emergency room via ambulance, minimally responsive to questioning or examination. According to his girlfriend, he has a history of major depressive disorder as well as alcohol dependence. He was found unconscious with a suicide note and many empty beer bottles. She also believes that he had taken "some other drug" that he purchased from a local drug dealer. Which of the following substances found in urine toxicology would be the most dangerous in this patient?
A 35-year-old woman is involved in a motor vehicle crash, sustaining a severe pelvic fracture, with disruption of the pelvic ring. In the trauma resuscitation room, she is confused and tachypneic, with a blood pressure of 90 mmHg systolic and a heart rate of 130/min. Laboratory investigations include serum electrolyte analysis, revealing a sodium of 139, a chloride of 103, and a bicarbonate of 14 meq/L. Which of the following is the most appropriate management of this acid-based derangement?