USMLE 25

57 year old woman had a left modified radical mastectomy for intraductal carcinoma 2 year previously. She presents with lethergy, confusion and thigh pain.X rays reveal a lytic lesion in the shaft of the femur.

Which of the following blood abnormalities is most likely?

a) High magnesium.

b) Low calcium.

c) High glucose.

d) High calcium.

e) High potassium.

Which of the following is the most appropriate initial therapy?

a) Tamoxifen.

b) Vigorous saline infusion.

c) Radiotherapy to the femur.

d) Chemotherapy.

e) Glucocorticoids.

USMLE 23

   A 23 year old woman presents with skipped heartbeats and on cardiac examination is found to have a mid-systolic click followed by a late systolic murmur.

Echo shows prolapse of the mitral valve.

Which of the following is true about this condition?

a) Mitral valve prolapse is present in up to 10 % of the population.

b) Prophylaxis against bacterial endocarditis is never recommended.

c) Mitral valve prolapse is more common in men.

d) Risk of pulmonary embolism is high.

e) Ventricular arrhythmias don't occur.

X ray 42

This 72 year old lady presented with a three month history of colicky lower abdominal pain and rectal bleeding. Rectal and sigmoidoscopic examination were unremarkable. A barium enema was requested. This image is from a barium enema .

What is your clinical diagnosis?

USMLE 22

A 4 year old previously healthy girl presents to the E.R. with a 24-hour history of rectal bleeding & dizziness. She has no other GIT symptoms.

On examination she appears pale. Her heart rate is 140 beats/min, she has a 20 mmHg postural drop in systolic blood pressure. her abdomen is not distended and not tender, and fresh blood and clots are in the rectal vault on rectal examination.

What is your clinical diagnosis?

a)  juvenile rectal polyp.

b) Anal fissure.

c) Bleeding Meckel's diverticulum.

d) Hemorrhoids.

e) Intussusception.

What is the appropriate diagnostic study for her condition?

a) Colonoscopy.

b) Laparoscopy.

c) Technetium scan.

d) UGI contrast study with small bowel follow through.

e) Barium enema.

USMLE 21

A 17 year old girl presents with a 2 day history of lower abdominal discomfort, burn in micturition & increased frequency of urination. She had her first sexual intercourse last week. Her vital signs are stable.

Examination shows supra-pubic tenderness. Urinalysis shows +ve esterase, 50+ WBC and many bacteria.

Which of the following is the most likely mechanism responsible for her clinical condition?

A- Hematogenous spread of infection.

B- Lymphatic spread of infection.

C- Sexual transmission.

D- Poor genital hygiene.

E- Ascending infection.

Medical Case 65

a 1 year old infant is complaining of delayed sitting and repeated chest infection,on examination there is prominent costochondral junction, he is exclusively breast fed, He received multiple injections for treatment of his condition.

All of the following are expected complication for his condition except:
1. anorexia .
2. vomiting .
3. oliguria .
4. nephrocalcinosis .

Medical Case 64

A 30 year old female has been suffering from seasonal nasal obstruction for the last few years. A watery nasal discharge and attacks of sneezing accompanied this nasal obstruction. 2 weeks ago she had an attack of common cold, she refused to have medical treatment and 2 days later she began to develop pain over the forehead and a mild fever. She did not receive any treatment and so recently developed severe headache with a high fever (40 C) and became severely irritable and could not withstand light. On examination there was marked neck and back stiffness.

What is your clinical diagnosis?

Medical Case 32

A 60 year old woman is very worried because she recently had a close family member and friend die, One after the other, First her 85 year old mother died of an ovarian cancer that was diagnosed 4 years ago.

Last week, she lost her best friend to lung cancer that metastasized to brain & liver.

Today, her 53 year old sister learned that she has breast cancer. 

She has regular pap smears and breast examinations. She has read that there are a few ways that have proved to prevent breast cancer.

Which of the following measures has the best evidence of preventing breast CA in high risk woman?

a) BRCA screening.

b) Prophylactic oophorectomy.

c) Tamoxifen.

d) Mammograms every month.

e) Low fat diet.

USMLE 20

A 70 year old man presents to urgent care complaining of a painful, swollen left knee. He previously has had no problems with this knee.

3 days prior to onset, he went out dancing for 3 hours but recalls no specific injury.

**Examination of the knee reveals a moderate sized effusion and mild pain with any range of motion. Plain x-ray shows no fracture.

Which of the following is the best next management?

a) MRI of Knee.

b) Aspiration of effusion fluid.

c) Physical therapy referral.

d) Arthroscopy.

e) Rest, ice and leg elevation.

USMLE 19

A 32 year old woman is visiting you in your primary care office as a new patient.Overall, she is healthy.On taking a a family history , you learn that her mother was diagnosed with colorectal cancer at the age of 52.

When should this patient start being screened for colorectal cancer?

a) There is no proven benefit for colorectal cancer screening.

b) at age of 40

c) at age of 30

d) at age of 60

e) at age of 50

USMLE 16

A 47-year old man with diabetes and hypertension travels with his family to Mexico. The next morning after eating out at local restaurant and despite drinking bottled water, he develops severe crampy abdominal pain and watery, frequent diarrhea. 

Which of the following is the best approach for his care?

a) Penicillin x5 days.

b) Tetracycline x3 days.

c) Ciprofloxacin x3 days.

d) Metronidazole x10 days.

e) Observation of symptoms.

Medical Case 31

Male patient aged 25 years old, Farmer complaining from recurrent attacks of lower abdominal colic and dysentry of 5 years duration, clinical examination revealed pallor, wasting and edema of both lower limbs. On abdominal examination the liver was cirrhotic but of normal size,spleen moderately enlarged without ascites.

Laboratory investigations: 

hemoglobin level 9gm%

marked esinophilia

stool analysis : blood, mucus and undigested food.

After medical treatment the symptoms markedly & gradually improved, the general condition became better, edema lower limbs subsided and the patient became cured.

* What are the questions you want to ask the patient helping in the diagnosis?

* What is the possible diagnosis?

Medical Case 30

 A female patient 55 years old was admitted to the hospital with severe chronic heart failure. Her pulse rate was 120\ min & regular, Investigations were done and treatment was started in the form of:

rest, salt restriction, digitalis, thiazides and vasodialtors.

Would you or would you not prescribe beta-blockers in this case? Why?

USMLE 15

  A 51 year old man complains of difficulty walking and mild right sided foot pain for the past several weeks. His medical history for type 1 DM, hypertension and hyperchlesterolemia. Physical examination reveals a significantly deformed right foot and a mildly deformed left foot. X-ray suggests effusion in several of the tarsometatarsal joints, large osteophytes, and several extraarticular bone fragments.

Which of the following is the most likely cause of the patient's complaints?

A) Hyperuricemia.

B) Poor vascular supply

C) Rheumatoid arthritis.

D) Nerve damage.

E) Bone demineralization.

F) Bacterial infection.

Medical Case 29

A 5-month-old girl presented with history of constipation and delayed developmental milestones. She had prolonged physiological jaundice. On exam, she is hypoactive, has an open mouth with large tongue. Other systemic examinations are within normal.

What is the next step in management?
A) Checking T4 and TSH
B ) Checking serum bilirubin
C ) Doing CT scan of head
D ) Follow up after 4 weeks

MRI 6

A boy with a knee pain. No previous trauma.

T1

ECG 4

A 57 year old woman is seen urgently for chest pain of two hours duration. the pain is mild, continuous, aching and localized to the upper chest and shoulder. No previous cardiovascular problems.

Does the ECG suggest Myocardial ischemia or subendocardial injury?

What appropriate investigation is indicated?

USMLE 14

A 35-year-old alcoholic male is admitted for nausea, vomiting, and abdominal pain that radiates to the back. The laboratory value that suggests a poor prognosis in this patient is

a. Elevated serum lipasae

b. Elevated serum amylase

c. Leukocytosis of 20,000/µm

d. Diastolic blood pressure greater than 90 mmHg

Medical Case 23

       An 85-year-old man is being evaluated for gait difficulties. On examina-

tion it is found that joint proprioception is absent in his toes. People with

impaired position sense will usually fall if they stand with their feet together

and do which of the following?

a. Flex the neck

b. Extend their arms in front of them

c. Flex the knees

d. Turn the head

e. Close their eyes

USMLE 12

A 72-year-old male comes to the office with intermittent symptoms

of dyspnea on exertion, palpitations, and cough occasionally productive of

blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur

is faintly heard toward the apex. The origin of the patient’s problem proba-

bly relates to

a. Rheumatic fever as a youth

b. Long-standing hypertension

c. Silent MI within the past year

d. Congenital origin