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3,531 questions
A30-year-old separated female with borderline personality disorder is brought in by her roommate after she admitted to feeling suicidal and taking several handfuls of "an old prescription" some hours ago. Her vitals demonstrate a slight fever, elevated BP, and tachycardia. On physical examination, her pupils are dilated, she has a tremor, and she complains of "seeing scary faces." She also has noticeably dry mucous membranes. Which of the following medications did this patient most likely ingest?
A 45-year-old man presents to the physician's office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most likely diagnosis?
A 55-year-old lawyer without past psychiatric history presents to her internist with complaints of insomnia. Since her husband suddenly passed away 5 weeks ago, she has had difficulty sleeping, frequently awakening throughout the evening. She subsequently finds herself tired during the day. When asked about her mood, she states that she is "sad" and will often break down in tears when thinking about her husband. Although she feels that her job occupies her mind, she describes being distracted and making minor mistakes at work. Her appetite has diminished, but her weight has not changed. While she feels "lost" and that her life is not enjoyable without him, she denies any suicidal ideation. She reluctantly admits to occasionally hearing her husband calling her name at nighttime. She understands that it is not real but still finds it comforting for her. Which of the following is the most appropriate next step in the management of this patient?
A 62-year-old woman presents to the physician's office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become "pencil thin" in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. Abarium xray is obtained, and one view is shown in Figure. Which of the following is the most appropriate next step in management?
A 29-year-old married male is seen in the emergency room with the chief complaint of, "I'm afraid I'm having a heart attack." He states a 2-month history of experiencing recurrent episodes of chest pain and shortness of breath that last 1020 minutes. He also describes associated tachypnea, lightheadedness, tingling in his extremities, nausea, diaphoresis, anxiety, and fears that he may die. These symptoms are now occurring almost daily but are not provoked by any situations or activities such as exertion or exercise. He is significantly worried about having future episodes and is genuinely concerned that he will suffer a myocardial infarction. He denies having any medical illnesses or taking any medications. He drinks three beers on the weekends only and does not use illicit drugs. His physical examination reveals a slightly elevated BP and pulse. An ECG demonstrates sinus tachycardia Which of the following medications would be most appropriate in the long-term management of this patient's symptoms?
A 29-year-old married male is seen in the emergency room with the chief complaint of, "I'm afraid I'm having a heart attack." He states a 2-month history of experiencing recurrent episodes of chest pain and shortness of breath that last 1020 minutes. He also describes associated tachypnea, lightheadedness, tingling in his extremities, nausea, diaphoresis, anxiety, and fears that he may die. These symptoms are now occurring almost daily but are not provoked by any situations or activities such as exertion or exercise. He is significantly worried about having future episodes and is genuinely concerned that he will suffer a myocardial infarction. He denies having any medical illnesses or taking any medications. He drinks three beers on the weekends only and does not use illicit drugs. His physical examination reveals a slightly elevated BP and pulse. An ECG demonstrates sinus tachycardia. Which of the following medications would be most appropriate in the acute management of this patient's symptoms?
A54-year-old woman presents to her physician for an opinion regarding additional therapy following curative resection of recently diagnosed colon cancer. She underwent uncomplicated sigmoid resection for invasive colon cancer 4 weeks ago. The pathology revealed carcinoma invading into, but not through, the muscularis propria, with one of eight positive mesenteric nodes. There was no evidence of liver metastases at the time of operation. Preoperative chest x-ray and CT scan of the abdomen showed no evidence of distant disease. Preoperative carcinoembryonic antigen (CEA) level was normal. Past history is positive for diabetes and mild hypertension. Examination is unremarkable except for a healing abdominal incision. Which of the following is the most appropriate recommendation regarding adjuvant therapy?
A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/ min, and a pulsatile, tender abdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. On postoperative day 3, the patient develops dark-colored diarrhea but remains normotensive, on full mechanical ventilation, and is awake. Laboratory analysis reveals normal electrolytes, blood urea nitrogen (BUN), and creatinine; hematocrit of 30; and WBC of 15,000. Which is the most appropriate next step in management?
A 48-year-old man with no prior psychiatric history is seen in the acute care clinic because of concerns over having a sexually transmitted disease. He denies any dysuria, penile discharge, or lesions. His physical examination is unremarkable. When informed of this information, he insists on being tested. When inquiries are made regarding his sexual history, he claims to be monogamous with his wife, who happens to be Senator Hilary Clinton. When confronted with the fact that she is already married to someone else and living in another state, he states that he married her 2 years ago in a "secret" ceremony. He adds that she flies in on weekends to have "conjugal visits," but he is afraid that she has been unfaithful to him and has given him a venereal disease. He has no medical problems and is not taking any medications currently. Further history reveals that he holds a steady job as a security guard. He lives alone in an apartment. He denies alcohol or illicit drug use. On MSE, he appears well-dressed and groomed. He is cooperative overall. His mood and affect are anxious. His thoughts are logical. He denies any suicidal or homicidal ideation, or any perceptual disturbances. Which of the following is his most likely diagnosis?
A 65-year-old woman presents to the physician's office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in the figure. Which of the following is the most appropriate next step in management?
A 65-year-old woman presents to the physician's office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in the figure. Which of the following is the most likely diagnosis?
The patient is a 28-year-old female medical student who is referred to the Office of Student Affairs due to receiving an incomplete on her surgery clerkship. Upon questioning, she admits to "sneaking out" of the operating room in order to avoid participating in surgeries. When confronted with her unprofessional behavior and expectations of the rotation, she claims to have significant anxiety revolving around the operating room. She states, "It's not that I mind the surgery itself, just the blood." She proceeds to reveal numerous instances of feeling dizzy, lightheaded, and even fainting when seeing blood. As a result, she has been unable to donate blood while in college or medical school and has, thus far, been able to "work around" drawing blood in other clerkships. Which of the following is her most likely diagnosis?
A32 year-old male presents to the primary care clinic with recurrent episodes of bronchitis. He is otherwise healthy but admits to a 14 packyear history of cigarette smoking. He is prescribed another trial of appropriate antibiotics, but he has "had enough" of smoking and wants to quit. Use of which of the following modalities would most likely give him the best chance of quitting?
A 67-year-old man is seen in the clinic for a scheduled visit. He complains of walking difficulties that have progressively worsened over many months. He also has noticed "shaking" of his hands, resulting in his dropping objects occasionally. He is greatly upset by these problems and admits to frequent crying spells. His only chronic medical illnesses are gastroesophageal reflux disease and hyperlipidemia. He is currently prescribed a proton pump inhibitor and cholesterol-lowering agent. His MSE is notable for little expression or range of affect. His vitals signs are within normal limits. On physical examination, there is a noticeable coarse tremor of his hands, left greater than right. His gait is slow moving and broad-based. Some time after initiation of treatment with the proper medication, he becomes agitated and is noted to be hallucinating. Which of the following medications would be the most appropriate to treat these new symptoms?
While you are working in the community health center, a 40-year-old male presents to you as a referral from the dental clinic. The patient reported on the intake history form at the dental office that he had rheumatic fever at the age of 7. The dentist refused to allow him to have a dental examination and cleaning until he was cleared by a medical doctor. Other than rheumatic fever, the patient has no medical history and does not take any medications. He denies chest pain, palpitations, dyspnea, or any other symptoms. On examination, he has normal vital signs and a normal general examination. On auscultation of his heart, you hear a 2/6 systolic ejection murmur at the left upper sternal border without radiation. Review of his chart shows that he had an echocardiogram approximately 9 months ago that revealed mild mitral valve prolapse without evidence of mitral regurgitation, but otherwise normal valves and cardiac function. Which of the following would be the most appropriate management at this time?
A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Initial management should include which of the following?
A 5-week-old infant presents with a 1-week history of progressive nonbilious emesis, associated with a 24-hour history of decreased urine output. The infant continues to be active and eager to feed. On examination, the infant has a sunken fontanelle and decreased skin turgor. The abdomen is scaphoid, and with a test feed, there is a visible peristaltic wave in the epigastrium. Which of the following is the most appropriate next step in management of this infant?
A 37-year-old multiparous White female, s/p bilateral tubal ligation, reports a family history remarkable for a mother diagnosed with bilateral breast cancer at the age of 43, from which she ultimately died, and a sister diagnosed with epithelial ovarian cancer at the age of 47, for which she is currently undergoing chemotherapy. Secondary to this worrisome family history, the patient elected to undergo genetic testing and was found to be a BRCA1 carrier. In view of her carrier status, you inform her of which of the following?
A27-year-old nulligravid single White female presents to your office for an annual examination. In taking her history, you learn that her mother died of ovarian cancer at the age of 63. There is no other family history ofbreast or ovarian cancer. The patient asks you to tell her what she can do to reduce her own ovarian cancer risk. What is the most effective strategy appropriate for this patient to reduce her risk?
A 29-year-old woman presents to the primary care clinic complaining of frequent headaches for several months. During the interview she appears tearful and withdrawn, with minimal eye contact and reluctance to answer questions. With further encouragement and support, she is able to describe intense feelings of sadness, along with significant insomnia, poor concentration, fatigue, anhedonia, and little appetite with a 20-lb weight loss. Before she leaves the office, what is the most important question to ask her?