PLE Category: Internal Medicine

PLE-2431

A 72-year-old man comes to the physician because of a 6-month history of mild to moderate shortness of breath when climbing stairs. He had a myocardial infarction 2 years ago and has had an ejection fraction of 35% since then. His only medication is a β-adrenergic blocking agent. The lungs are clear to auscultation. Cardiac examination shows an S4 gallop. There is no peripheral edema. Laboratory studies are within normal limits. An ECG shows no acute changes. Which of the following is the most appropriate pharmacotherapy?

PLE-2428

A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of 290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril for hypertension and glyburide for type 2 diabetes mellitus. She also has intermittent episodes of gout. Fasting serum studies show: Total cholesterol: 252 mg/dL, HDL-cholesterol: 80 mg/dL, Triglycerides: 300 mg/dL, Glucose: 118 mg/dL, Thyroid-stimulating hormone: 4.5µU/mL. Which of the following is the most appropriate next step in management?

PLE-2429

A 67-year-old man is brought to the emergency department 4 hours after the onset of severe midlumbar back pain. He is anxious, pale, and diaphoretic. His temperature is 37.1 C (98.8 F), blood pressure is 105/65 mm Hg, and pulse is 120/min. Examination shows no other abnormalities. X-ray films of the lumbar spine show degenerative disc disease with calcifications anterior to the vertebral bodies. What is the most likely diagnosis?

PLE-2426

A 20-year-old man is brought to the emergency department on a summer day, 20 minutes after developing headache, nausea, and unsteady gait while running the last 2 miles of a marathon. On arrival, he is confused and disoriented. His temperature is 40°C (104°F), blood pressure is 100/60 mm Hg, and pulse is 155/min. His skin is warm and dry. Neurologic examination shows no focal findings. What is the most likely mechanism of this patient’s condition?

PLE-2427

A 72-year-old man with hypertension has had increasingly severe back pain over the past 2 months. He had a myocardial infarction 4 years ago. He has marked tenderness over T11, T12, L1, and L2. An x-ray film of the lumbosacral spine shows osteoblastic lesions in these vertebrae. What is the most likely diagnosis?

PLE-2424

A 42-year-old woman comes to the physician for evaluation of persistently increased blood pressures. At her last two office visits during the past 3 months, her blood pressure has ranged between 150-170/105-115 mm Hg. During this period, she has had occasional headaches. In addition, she has had an increased urine output over the past 6 weeks that she attributes to a diet high in sodium. She is otherwise healthy and takes no medications. Her blood pressure today is 168/115 mm Hg, pulse is 68/min, and respirations are 14/min. Funduscopic examination shows mild arteriovenous nicking. The point of maximal impulse is not displaced. There is no edema, abdominal bruits, or masses. Serum studies show Na 144, Cl 90, K 2.9, HCO3 32, BUN 20, Creatinine 1.2. What is the most likely underlying cause of this patient’s hypertension?

PLE-2425

A previously healthy 16-year-old high school wrestler comes to the physician because of a rash on his forearms and the back of his legs for 1 week. He is allergic to pollen and dust. Examination shows patches of erythema with mild lichenification over the antecubital and popliteal fossae. There are clusters of painful, umbilicated vesicles at sites of active skin inflammation. Which of the following is the most likely diagnosis?

PLE-2420

A 27-year-old woman is brought to the physician because of a 3-day history of visual loss and aching discomfort in her right eye. Examination shows markedly reduced visual acuity in the right eye, with full peripheral visual fields to confrontation. Color vision is decreased in the right eye. The right eye does not react to direct light but has a normal consensual response. Fundoscopic examination shows no abnormalities. She also has an ataxic gait and bilateral Babinski sign. What is the most appropriate next step in diagnosis?

PLE-2421

A 52-year-old man comes to the physician because he has had a 14 kg weight loss during the past 6 months. He has noticed oily, floating stools during the past 2 months. He received the diagnosis of acute pancreatitis 2 years ago and has had 1 to 3-hour episodes of severe abdominal pain since then. The patient is a 30-year pack smoker. He is an alcoholic but has been abstinent for the past 2 years. The abdomen is scaphoid with mild diffuse tenderness. The liver edge is firm and is palpated 2 cm below the right costal margin. Laboratories show Amylase 90 (slightly increased), Lipase 43 (normal), alkaline phosphatase 120 (normal), AST 23, ALT 29. What is the most appropriate step in management?

PLE-2422

An asymptomatic 47-year-old woman comes to the physician for a routine health maintenance examination. She has no history of rheumatic fever. She takes no medications. Her pulse is 70 bpm, and blood pressure is 150/60 mmHg. A grade 2/6 decrescendo murmur that begins after S2 is heard at the sternal border. What is the most likely diagnosis?