Clinical Reasoning — MCQs

A 27-year-old woman presents to her primary care physician for minor aches and pains in her bones and muscles. She states that these symptoms have persisted throughout her entire life but have worsened recently when she moved to attend college. The patient is physically active, and states that she eats a balanced diet. She is currently a full-time student and is sexually active with 1 partner. She states that she has been particularly stressed lately studying for final exams and occasionally experiences diarrhea. She has been taking acyclovir for a dermatologic herpes simplex virus infection with minimal improvement. On physical exam, the patient exhibits 4/5 strength in her upper and lower extremities, and diffuse tenderness over her limbs that is non-specific. Laboratory values are ordered as seen below: Serum: Na+: 144 mEq/L Cl-: 102 mEq/L K+: 4.7 mEq/L HCO3-: 24 mEq/L Ca2+: 5.0 Urea nitrogen: 15 mg/dL Glucose: 81 mg/dL Creatinine: 1.0 mg/dL Alkaline phosphatase: 225 U/L Aspartate aminotransferase (AST, GOT): 11 U/L Alanine aminotransferase (ALT, GPT): 15 U/L Which of the following is most likely associated with this patient’s presentation?

A 45-year-old man comes to the physician because of a 6-month history of a slowly enlarging nodule on the left upper eyelid that has persisted despite treatment with warm compresses. He also reports heaviness of the eyelid and mild blurring of vision in the left eye. Vital signs are within normal limits. Visual acuity is decreased in the left eye. Ophthalmic examination shows a solitary, rubbery, nontender nodule on the central portion of the left upper eyelid. The lesion is better seen on eversion of the left eyelid. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old woman presents to the family medicine clinic for evaluation of a sore throat. The patient states that she does not have a runny nose, cough or itchy throat. The patient has no past medical history but she did have an appendectomy when she was 8 years old. She takes acetaminophen when she gets a headache and does not smoke cigarettes. Her vitals include: blood pressure 112/68 mm Hg, heart rate 72/min, respiratory rate 10/min and temperature 39.2°C (102.6°F). Physical examination reveals a patient who is uncomfortable but alert and oriented. Upon palpation, the physician notices swollen anterior cervical nodes. Inspection of the pharynx and tonsils does not reveal any erythema or exudate. Which of the following is the most appropriate next step for this patient?

A 39-year-old man comes to the physician for evaluation of hearing loss. He reports difficulty hearing sounds like the beeping of the microwave or birds chirping, but can easily hear the pipe organ at church. He works as an aircraft marshaller. A Rinne test shows air conduction greater than bone conduction bilaterally. A Weber test does not lateralize. Which of the following is the most likely underlying cause of this patient's condition?

A 33-year-old woman presents to her primary care physician complaining of right jaw pain for the last 3 weeks. She first noticed it while eating a steak dinner but generally feels that it is worse in the morning. She describes the pain as deep and dull, with occasional radiation to the ear and back of her neck. She denies any incidents of jaw locking. The patient also states that her husband has noticed her grinding her teeth in her sleep in the last several months. She has a past medical history of depression, for which she takes fluoxetine, and carpal tunnel syndrome, for which she uses a wrist brace. The patient works as a secretary. Her father passed away from coronary artery disease at the age of 54, and her mother has rheumatoid arthritis. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 135/81 mmHg, pulse is 70/min, and respirations are 14/min. On exam, there is no overlying skin change on the face, but there is mild tenderness to palpation at the angle of the mandible on the right. Opening and closing of the jaw results in a slight clicking sound. The remainder of the exam is unremarkable. Which of the following is the next best step in management?

A 17-year-old girl presents to an urgent care clinic after waking up in the morning with a left-sided facial droop and an inability to fully close her left eye. Of note, she is currently on oral contraceptives and escitalopram and smokes half a pack of cigarettes per day. Her temperature is 98.2°F (36.8°C), blood pressure is 110/68 mmHg, pulse is 82/min, and respirations are 12/min. On exam, she has generalized, unilateral left-sided drooping of her upper and lower face, and an inability to move the left side of her mouth or close her left eye. Her extraocular movements and swallow are intact. She has no other neurologic deficits. Which of the following interventions would most likely address the most likely cause of this patient's symptoms?

A 46-year-old woman comes to the clinic complaining of right eye irritation. The eye is itchy and red. Discomfort has been relatively constant for the last 6 months, and nothing makes it better or worse. Past medical history is significant for hypertension, hyperlipidemia, and aggressive tooth decay, requiring several root canals and the removal and replacement of several teeth. She takes chlorthalidone, fluvastatin, and daily ibuprofen for tooth pain. She has smoked a pack of cigarettes daily since the age of 20 and drinks alcohol on the weekends. She does not use illicit drugs. She cannot provide any family history as she was adopted. Her temperature is 36.7°C (98°F), blood pressure is 135/65 mm Hg, pulse is 82/min, respiratory rate is 15/min, and BMI is 27 kg/m2. A thorough eye exam is performed and shows no foreign objects. Both eyes appear erythematous and infected. Schirmer test is abnormal. Laboratory test Complete blood count: Hemoglobin 9.5 g/dL Leukocytes 12,500/mm3 Platelets 155,000/mm3 ESR 60 mm/hr Antinuclear antibody Positive What is the best next step in the management of this patient?

A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?

A 22-year-old man presents to the emergency department with a fever and a sore throat. He has had these symptoms for the past 2 weeks and has felt progressively more fatigued. His temperature is 102°F (38.9°C), blood pressure is 120/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for tonsillar exudates, posterior cervical lymphadenopathy, and splenomegaly. Which of the following is the most appropriate next step in management for this patient?

A 28-year-old man presents to his physician with a complaint of a 4-week history of headaches that is affecting his academic performance. Over-the-counter medications do not seem to help. He also mentions that he has to raise his head each time to look at the board when taking notes. His blood pressure is 125/75 mm Hg, pulse 86/min, respiratory rate 13/min, temperature 36.8°C (98.2°F). Ophthalmic examination shows an upward gaze palsy, convergence-retraction nystagmus, and papilledema. CT scan of the head reveals a 1.5 x 1.2 cm heterogeneous mass in the epithalamus with dilated lateral and 3rd ventricles. What other finding is most likely to be associated with this patient’s condition?