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3,531 questions
A 60-year-old man visits his GP complaining of tiredness. He has noticed weight loss over the last six months and irritation of the tip of his penis which appears inflamed on examination. He mentions he has been visiting the toilet more often than usual and feeling thirsty. The most appropriate investigation would be:
A 61-year-old woman presents to the walk-in clinic with a history of tight, sternal chest pain ''appearing out of the blue''. Such episodes have occurred at different times throughout the day and rarely last longer than a few minutes. They do not correspond to hard exercise. The patient has no cardiac history to date. Her electrocardiogram (ECG) has not detected any abnormalities and 2 days have passed since the last episode. Which of the following is the next best step in her management?
An 81-year-old woman is referred to cardiology out-patients with a history of dizzy episodes and one episode of syncope. She is known to have long-standing atrial fibrillation. A 24-hour tape confirms atrial fibrillation, with rates varying from 30 to 140 bpm. There are several daytime pauses of over 3 seconds. She is listed for a permanent pacemaker. Which of the following would be the most appropriate device?
A first-time mother comes to visit you with her 10-month-old son. At least once every day her son vomits up his entire feed. The vomiting is not projectile but rather the feed returns to the mouth and spills over his top. She stopped breast-feeding him when he was 6 months old. He is otherwise well in himself, with a normal weight for his age. What is the most likely diagnosis?
A 13-year-old girl, who is quiet and withdrawn, comes to see you with her mother. She has a 4-month history of weight loss and secondary amenorrhoea. She has no bowel symptoms. Her body mass index is 16. Apart from being very thin, the examination is otherwise normal. All blood results, including hormone assays, are normal. What is the most likely diagnosis?
4 USMLE IM2e/Diagnostic A 60-year-old man presents with total visual loss in his left eye that developed over 1 day. He says he had a headache on the left side in the 5 days that preceded the visual loss, which was constant and severe, and worse on talkingoreating. On further questioning he said he has been feeling lethargic for the last 2 months and has been having some shoulder aches. There is no relevant past medical history and he has never smoked. On examination, there is no vision in the left eye, there is a relative afferent papillary defect, and the optic disc appears red and swollen on ophthalmoscopy. There is no other cranial nerve defect or neurological defect. Which investigation would confirm the most likely diagnosis?
A 45-year-old woman with type 1 diabetes and rheumatoid arthritis has been admitted after a massive overdose of ibuprofen and has been noted to have acute renal failure with a creatinine level of around 350 µmol/L. The next day, you are called to see her as she is becoming breathless. Her airway is clear. She looks anxious. Her respiratory rate is 28/min and her saturations are 86o/o on air. You hear bibasal crepitations in her chest, which is slightly dull to percussion at both bases. She has a pulse of 110 bpm and blood pressure of 125/80 mmHg. Her urine output has been 120 ml in the last 10 hours, and you note that her jugular venous pressure is high. It appears from the notes that the night house officer was asked to see her due to her low urine output and prescribed aggressive fluid resuscitation. What is the most likely reason for her breathlessness?
pH 7.51, p02 18, pC02 2.3, HC03-24 A 65-year-old man presents to the GP with chest pain, increasing shortness of breath and weight loss. He describes the pain as dull and worse on inhalation. He notices that he has lost 1 stone in 3 weeks. He has never smoked and has no other significant past medical history. He used to work in a shipyard. Observations include temperature 36.8°C, pulse rate 80 bpm, blood pressure 140/95 mmHg and respiratory rate 18/min. On examination, there is dullness to percussion over the left lower lung zone. What is the most likely diagnosis?
A 55-year-old man is referred to haematology with repeated nosebleeds, malaise, weight loss and night sweats. Investigations show a raised white cell count, mainly neutrophils and myelocytes, anaemia, increased urate and increased alkaline phosphatase. On blood film there are no blast cells. Genetic studies show a t(9:22) translocation encoding for the BCR-ABL gene. What is his diagnosis?
A 29-year-old woman is concerned about recurrent ulcers she gets in her mouth. Occurring every few months, they are small, grey, shallow ulcers that disappear spontaneously. She has no other gastrointestinal symptoms or weight loss. What is the most likely cause?
A 62-year-old Asian woman presents to the emergency department with increasing shortness of breath for the past 2 weeks. She has a past medical history of breast cancer, ischaemic heart disease, previous myocardial infarction with a stent in her left anterior descending artery, and osteoarthritis. On examination, there are reduced breath sounds on her lung bases, and dullness to percussion. Both legs are swollen. A chest X-ray demonstrates a right-sided pleural effusion. A simple aspiration of the pleural cavity showed a pleural fluid protein:serum protein ratio <0.5. What is the most likely underlying diagnosis?
A 7-year-old boy presents with multiple erythematous patches, over both sides of his face, head, neck, upper chest and left arm and shoulder, which appear to be covered in a honey-coloured crust. His mother says that the lesions have spread, over about a week, starting at the left neck and radiating outwards. The child appears to be upset and the lesions are itchy. There is no past medical history and no history of recent infections. Which of the following diagnoses is most likely?
A 35-year-old man presents to the GP with increasing fatigue for 3 months. He fmds himself waking up choking a few times at night. He was told by his partner that he snores quite loudly most nights. He denies any weight loss. He smokes 30 cigarettes/day, drinks 2 pints of beer every night and bas a body mass index of 32. What is the most likely differential diagnosis?
A 75-year-old man has been recently diagnosed with Parkinson's disease and started on levodopa (L-DOPA), which has helped his tremor and bradyk:inesia significantly. However, in the past week be had a fall shortly after getting out of his chair, during which he briefly blacked out, and afterwards was sweating and felt cold. Which of the following side effects most likely explains the fall?
A 6-year-old boy bas a 1-month history of aching bones and muscle pains. On examination he appears pale and has multiple bruises along his legs. He has extensive lymphadenopathy. Blast cells are seen on the blood film. What is the most likely diagnosis?
A 62-year-old woman presents to the emergency department with collapse. She felt dizzy when she tried to stand up from a sitting position. She did not lose consciousness. Sl1e denied any visual disturbances, headache or head injury. She also complained of fatigue over the past month. She takes only omeprazole and paracetamol. An electrocardiogram (ECG) showed normal sinus rhythm. Her blood pressure was 102/50 mmHg. A blood test revealed the following: Na+ 126 mmol/L, K+ 6.5 mmol/L, urea 10.0 mmol/L, and creatinine 139 µmol/L. What is the most likely diagnosis?
A 32-year-old woman presents to the GP with a 3-month history of non- productive cough and breathlessness on exertion. She also complains of fatigue, weight loss and joint pain. She smokes 15 cigarettes/day. She bas not travelled to any foreign countries recently. On examination, fine interstitial crackles are heard on the anterior chest wall. There are m.ultiple tender red lumps on both shins. What is the most likely diagnosis?
A 78-year-old woman, who bas recently been feeling under the weather and losing some weight, develops a severe left-sided headache with jaw pain on eating. She also complains of USMLE IM2e/Diagnostic blurred vision on the left side. Which of the following investigations is needed to give a defmitive diagnosis?
A 60-year-old Chinese man presents to the GP with a 4-month history of weight loss. He has lost around 1 stone in weight. He also has a cough productive of green sputum without blood. He has a reduced appetite, insomnia and night sweats. His past medical history includes hypertension and ischaemic heart disease. He is a retired 1nanaging director who has just emigrated from Hong Kong to England. He denies a smoking history. His observations include temperature 36.4°C, pulse 67 bpm, blood pressure 152/92 mmHg and respiratory rate 15/min. On examination, there is dullness to percussion over the left upper lung zone. What is the most likely diagnosis?
A 74-year-old man is admitted to hospital with an acute-on-chronically ischaemic leg and started on intravenous heparin. Blood tests taken 5 days later show platelet levels have dropped from 250 to 54 x 109. What is the most likely cause for thrombocytopenia in this patient?