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3,531 questions
A 40-year-old woman is being evaluated for fever. She started having fever 6 weeks ago. Other symptoms include an erythematous rash, fatigue, and weight loss. Her medical history is significant for hypertension. She takes hydrochlorothiazide. On physical examination, the patient's temperature is found to be 100.6° F (38.1° C), a 3/6 murmur is noted in the mitral area, and an erythematous rash is seen on both legs. A complete blood count shows anemia; the patient's erythrocyte sedimentation rate (ESR) is elevated at 80 mm/hr. A transthoracic echocardiogram shows a 2 cm pedunculated mass in the left atrium. Which of the following is the most likely diagnosis for this patient?
A 56-year-old man with hypertension presents to your clinic for a routine health maintenance visit. He is asymptomatic and takes only hydrochlorothiazide. His blood pressure is 138/78 mm Hg. His total cholesterol level is 190 mg/di, and his high-density liproprotein (HDL) cholesterol level is 36 mg/di. He is a nonsmoker. He tells you he is concerned about IHD and that he has read about new methods to detect early disease, including CT imaging. He is interested in this screening test in hope of detecting any disease he may have before it becomes a problem. How should you advise this patient with regard to electron-beam computed tomography (EBCT)?
A 62-year-old woman presents to accident and emergency with a 1-day history of sudden onset back pain and difficulty walking. She has not opened her bowels or passed urine for the previous day. She has a past medical history of breast cancer, diagnosed two years earlier and staged as T2N1MO disease with oestrogen receptor positive status. She has been treated for her cancer with a wide local excision and axillary node clearance, followed by radiotherapy, chemotherapy and tamoxifen. On examination, there is reduced tone in the lower limbs. Power is diminished throughout the lower limbs, but especially on hip flexion. There is reduced sensation below the Ll dermatome. What is the most appropriate diagnostic investigation?
A previously healthy 52-year-old man presents with complaints of intermittent substernal chest discomfort. The pain does not radiate. The symptoms occur with exercise, and they are not relieved by rest. The patient does not have shortness of breath. The resting ECG is normal. You determine that the patient has an intermediate pretest probability of having significant coronary artery disease, and you elect to have him undergo exercise ECG testing to further evaluate his symptoms. Which of the following findings would be most highly suggestive of significant ischemic heart disease (IHD) on exercise ECG testing?
A 67-year-old man with type 2 diabetes and a long history of cigarette smoking develops severe exertional chest pain. Cardiac catheterization reveals three-vessel disease. Twenty-four hours later, he develops abdominal pain, painful toes, and a rash. On examination, he has purple discoloration of the second and fourth toes on his right foot and a lacy rash on both legs. Laboratory results are as follows: Hb, 13; HCT, 39; WBC, 9.0; BUN, 26; and Cr, 1.8. What is the most likely diagnosis for this patient?
The patient in Question 38 receives thrombolytic therapy with streptokinase within 30 minutes of the onset of his chest pain. Soon after administration of streptokinase, the ECG changes revert to baseline. He is monitored on telemetry for 48 hours without any arrhythmias. He is able to walk around the ward without difficulty. Further diagnostic tests during the immediate discharge period should include which of the following?
A 52-year-old woman presents to the GP with intermittent palpitations and breathlessness that has occurred over the last few weeks. She denies chest pain. Her electrocardiogram (ECG) shows sinus tachycardia and she does not appear to be anaemic. Which blood test would be of most use in confirming the diagnosis?
A 42-year-old woman presents to her GP with a 2-month history of nipple discharge from her left breast. The discharge is milky in colour. No blood is noted. She has a past medical history of hypertension, type 2 diabetes mellitus and depression. She has been taking regular medication for these conditions. She has been a1nenorrhoeic for 6 months. A provisional diagnosis of hyperprolactinaen1ia is made. What of the following is NOT appropriate management?
A 76-year-old woman presents to the emergency department for evaluation of nausea and mild epigastric pain that started suddenly 45 minutes ago. She denies having chest pain. Her medical history includes diabetes mellitus, hypertension, and hyperlipidemia. An electrocardiogram is interpreted as being normal. For this patient, which of the following statements regarding the diagnosis of unstable angina is false?
A 77-year-old woman is admitted to hospital with a urinary tract infection. She receives antibiotics and seems to be responding well. On the fourth day she is eating her lunch when she suddenly drops her fork. She calls for the nurse who notices the left side of her face is drooping. What is the best next course of action?
A 31-year-old man presents with a 1-month history of a growing round, flat, erythematous lesion on the left thigh. The border is slightly more erythematous than the rest of the lesion and has some flakiness of the skin.. The lesion itches. The patient also has had long-standing itchy scales between his toes. Which of the following investigations would help confirm the most likely diagnosis?
A 67-year-old man presents for evaluation of worsening dyspnea. The patient reports that his symptoms have been worsening over the past several months. He also mentions that he has developed some swelling in his legs and notes that he is easily fatigued. His medical history is remarkable for type 2 (non-insulin-dependent) diabetes mellitus, presumed cytogenic cirrhosis, and ''arthritis'' in his hands. The patient denies ever using alcohol. On physical examination, the patient's vital signs are normal; examination of the jugular venous pulse shows the height to be 10 cm; no thyromegaly is present; pulmonary examination reveals faint basilar crackles; cardiac examination shows nondisplaced point of maximal impulse and no audible murmur; no hepatosplenomegaly is noted; and 2+ bilateral lower extremity edema is noted. An ECG is unremarkable. An echocardiogram reveals normal ejection fraction and normal valvular function. You order lab work that includes iron studies and make the diagnosis of hemochromatosis. What is the pathogenesis of heart failure in this patient?
You are told that a patient has been admitted to accident and emergency with jaundice and right upper quadrant pain. What levels of plasma bilirubin would this patient have in order for jaundice to be clinically visible:
A 5-year-old girl presents with her parents who have become concerned about the small petechiae and ecchymoses on her skin. An abdominal examination reveals hepatosplenomegaly. You suspect an acute leukaemia. The most appropriate initial investigation for diagnosis is:
peripheral blood smear shows a macrocytic anaemia, a Schilling test shows impaired vitamin B12 absorption and a diagnosis of pernicious anaemia is made. Which of the following antibodies is most closely associated with pernicious anaemia?
A 44-year-old woman presents with recurrent fever, pallor, malaise and shortness of breath. She has noticed a petechial rash on her skin and small bruises on her arms. A blood test reveals a pancytopenia. During examination, you palpate a large spleen. Which investigation would differentiate between hypersplenism and aplastic anaemia?
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. She denied any visual disturbances, hea.dache or head injury. She also complained of fatigue over the past month. She takes only omeprazole and paracetamol. An ECG showed normal sinus rhythm. Blood pressure was 102/50 mmHg with a postural systolic drop of 30 mmHg. Blood test showed revealed Na+ 126 mmol/L, K+ 6.5 mmol/L, urea 10.0 mmol/L, creatinine 139 µmol/L. Which of the following will be most useful in establishing the diagnosis?
A 55-year-old man is being investigated for irregular heart rhythms. He has a medical history of diabetes mellitus. He explains that exercise is difficult for him due to joint pains. During the examination it is noted that he has tan skin pigmentation and hepatomegaly. Which of the following investigations could reveal the aetiology of his symptoms?
A 66-year-old man with a 10-year history of chronic obstructive pulmonary disease is assessed in the respiratory clinic for eligibility for long-term domiciliary oxygen therapy. Which of the following is NOT a criterion for prescription of long-term oxygen therapy?
A 26-year-old woman presents to the emergency department with an oxygen saturation reading of 80o/o on air with a background history of increased breathlessness on exertion over the course of a week. She has not travelled abroad recently and does not have a family history of thromboembolism. On examination, there is elevation of the jugular venous pressure and accentuation of the pulmonary component of the second heart sound. A chest examination is unremarkable. A chest X-ray is normal and a subsequent CT angiography demonstrated a pulmonary embolism. Which of the following management is NOT appropriate?