A 72-year-old man is brought into clinic by his daughter for increasing confusion. The daughter states that over the past 2 weeks, she has noticed that the patient “seems to stare off into space.” She reports he has multiple episodes a day during which he will walk into a room and forget why. She is also worried about his balance. She endorses that he has had several falls, the worst being 3 weeks ago when he tripped on the sidewalk getting the mail. The patient denies loss of consciousness, pre-syncope, chest pain, palpitations, urinary incontinence, or bowel incontinence. He complains of headache but denies dizziness. He reports nausea and a few episodes of non-bloody emesis but denies abdominal pain, constipation, or diarrhea. The patient’s medical history is significant for atrial fibrillation, diabetes, hypertension, hyperlipidemia, and osteoarthritis. He takes aspirin, warfarin, insulin, lisinopril, simvastatin, and ibuprofen. He drinks a half glass of whisky after dinner every night and smokes a cigar on the weekends. On physical examination, he is oriented to name and place but not to date. He is unable to spell "world" backward. When asked to remember 3 words, he recalls only 2. There are no motor or sensory deficits. Which of the following is the most likely diagnosis?
Q2
A 2-year-old boy is brought to the physician by his parents for the evaluation of an unusual cough, a raspy voice, and noisy breathing for the last 2 days. During this time, the symptoms have always occurred in the late evening. The parents also report that prior to the onset of these symptoms, their son had a low-grade fever and a runny nose for 2 days. He attends daycare. His immunizations are up-to-date. His temperature is 37.8°C (100°F) and respirations are 33/min. Physical examination shows supraclavicular retractions. There is a high-pitched breath sound on inspiration. Which of the following is the most likely location of the abnormality?
Q3
A 66-year-old man is brought into the emergency department by his daughter for a change in behavior. Yesterday the patient seemed more confused than usual and was asking the same questions repetitively. His symptoms have not improved over the past 24 hours, thus the decision to bring him in today. Last year, the patient was almost completely independent but he then suffered a "series of falls," after which his ability to care for himself declined. After this episode he was no longer able to cook for himself or pay his bills but otherwise had been fine up until this episode. The patient has a past medical history of myocardial infarction, hypertension, depression, diabetes mellitus type II, constipation, diverticulitis, and peripheral neuropathy. His current medications include metformin, insulin, lisinopril, hydrochlorothiazide, sodium docusate, atorvastatin, metoprolol, fluoxetine, and gabapentin. On exam you note a confused man who is poorly kept. He has bruises over his legs and his gait seems unstable. He is alert to person and place, and answers some questions inappropriately. The patient's pulse is 90/minute and his blood pressure is 170/100 mmHg. Which of the following is the most likely diagnosis?
Q4
A 30-year-old man comes to the physician for his annual health maintenance examination. The patient has no particular health concerns. He has a history of bilateral cryptorchidism treated with orchidopexy at 8 months of age. This patient is at increased risk for which of the following?
Q5
A 72-year-old man is brought to the physician by his wife for forgetfulness, confusion, and mood changes for the past 4 months. His symptoms started with misplacing items such as his wallet and keys around the house. Two months ago, he became unable to manage their finances as it became too difficult for him. Last week, he became lost while returning home from the grocery store. His wife reports that he shows “no emotion” and that he is seemingly not concerned by his recent symptoms. He has hypertension, type 2 diabetes mellitus, and coronary artery disease. Current medications include aspirin, metoprolol, lisinopril, metformin, and rosuvastatin. His pulse is 56/min and blood pressure is 158/76 mm Hg. Neurologic examination shows loss of sensation on his right leg and an unsteady gait. When asked to stand with his eyes closed and palms facing upward, his right arm rotates inward. An MRI of the brain shows multiple deep white matter lesions. Which of the following is the most likely diagnosis?
Q6
A 57-year-old woman comes to the physician for a routine health maintenance examination. She has well-controlled type 2 diabetes mellitus, for which she takes metformin. She is 163 cm (5 ft 4 in) tall and weighs 84 kg (185 lb); BMI is 31.6 kg/m2. Her blood pressure is 140/92 mm Hg. Physical examination shows central obesity, with a waist circumference of 90 cm. Laboratory studies show:
Fasting glucose 94 mg/dl
Total cholesterol 200 mg/dL
High-density lipoprotein cholesterol 36 mg/dL
Triglycerides 170 mg/dL
Without treatment, this patient is at greatest risk for which of the following conditions?
Q7
A 21-year-old female presents to her first gynecology visit. She states that six months ago, she tried to have sexual intercourse but experienced severe pain in her genital region when penetration was attempted. This has continued until now, and she has been unable to have intercourse with her partner. The pain is not present at any other times aside from attempts at penetration. The patient is distressed that she will never be able to have sex, even though she wishes to do so. She does not recall ever having a urinary tract infection and has never been sexually active due to her religious upbringing. In addition, she has never tried to use tampons or had a Pap smear before. She denies alcohol, illicit drugs, and smoking. The patient is 5 feet 6 inches and weighs 146 pounds (BMI 23.6 kg/m^2). On pelvic exam, there are no vulvar skin changes, signs of atrophy, or evidence of abnormal discharge. The hymen is not intact. Placement of a lubricated speculum at the introitus elicits intense pain and further exam is deferred for patient comfort. Office urinalysis is negative. Which of the following is a risk factor for this patient’s condition?
Q8
A 9-year-old girl is brought to the physician by her mother because of a 3-day history of face and foot swelling, dark urine, and a rash on her hands and feet. The mother reports that her daughter has had a low-grade fever, shortness of breath, and a dry cough for the past 8 days. She has had generalized weakness and pain in her right knee and ankle. She has a ventricular septum defect that was diagnosed at birth. The patient appears lethargic. Her temperature is 38.4 (101.1°F), pulse is 130/min, respirations are 34/min, and blood pressure is 110/60 mm Hg. Examination shows small, non-blanching, purple lesions on her palms, soles, and under her fingernails. There is edema of the eyelids and feet. Funduscopic examination shows retinal hemorrhages. Holosystolic and early diastolic murmurs are heard. Laboratory studies show:
Hemoglobin 11.3 g/dL
Erythrocyte sedimentation rate 61 mm/h
Leukocyte count 15,000/mm3
Platelet count 326,000/mm3
Urine
Blood 4+
Glucose negative
Protein 1+
Ketones negative
Transthoracic echocardiography shows a small outlet ventricular septum defect and a mild right ventricular enlargement. There are no wall motion abnormalities, valvular heart disease, or deficits in the pump function of the heart. Blood cultures grow Streptococcus pyogenes. Which of the following is the most likely diagnosis?
Q9
A 33-year-old woman comes to the physician because of vision impairment in her right eye for the past 2 weeks. During this period, she was unable to distinguish colors with her right eye. She also reports pain with eye movement. She has no double vision. She occasionally has headaches that are relieved by ibuprofen. One year ago, she had a similar episode that affected her left eye and resolved spontaneously. She has no history of serious illness. She works at a library and enjoys reading, even in poor lighting conditions. Her vital signs are within normal limits. The pupils are equal, round, and reactive to light and accommodation. Without correction, visual acuity is 20/50 in the left eye, and 20/100 in the right eye. With spectacles, the visual acuity is 20/20 in the left eye and 20/100 in the right eye. Slit lamp examination shows no abnormalities. A CT scan of the head shows no abnormalities. Which of the following is the most likely diagnosis?
Q10
An 82-year-old male visits his primary care physician for a check-up. He reports that he is in his usual state of health. His only new complaint is that he feels as if the room is spinning, which has affected his ability to live independently. He is currently on lisinopril, metformin, aspirin, warfarin, metoprolol, and simvastatin and says that he has been taking them as prescribed. On presentation, his temperature is 98.8°F (37°C), blood pressure is 150/93 mmHg, pulse is 82/min, and respirations are 12/min. On exam he has a left facial droop and his speech is slightly garbled. Eye exam reveals nystagmus with certain characteristics. The type of nystagmus seen in this patient would most likely also be seen in which of the following diseases?
Age and demographic considerations US Medical PG Practice Questions and MCQs
Question 1: A 72-year-old man is brought into clinic by his daughter for increasing confusion. The daughter states that over the past 2 weeks, she has noticed that the patient “seems to stare off into space.” She reports he has multiple episodes a day during which he will walk into a room and forget why. She is also worried about his balance. She endorses that he has had several falls, the worst being 3 weeks ago when he tripped on the sidewalk getting the mail. The patient denies loss of consciousness, pre-syncope, chest pain, palpitations, urinary incontinence, or bowel incontinence. He complains of headache but denies dizziness. He reports nausea and a few episodes of non-bloody emesis but denies abdominal pain, constipation, or diarrhea. The patient’s medical history is significant for atrial fibrillation, diabetes, hypertension, hyperlipidemia, and osteoarthritis. He takes aspirin, warfarin, insulin, lisinopril, simvastatin, and ibuprofen. He drinks a half glass of whisky after dinner every night and smokes a cigar on the weekends. On physical examination, he is oriented to name and place but not to date. He is unable to spell "world" backward. When asked to remember 3 words, he recalls only 2. There are no motor or sensory deficits. Which of the following is the most likely diagnosis?
A. Ischemic stroke
B. Subdural hematoma (Correct Answer)
C. Vitamin B12 deficiency
D. Alzheimer disease
E. Normal pressure hydrocephalus
Explanation: ***Subdural hematoma***
- The patient's presentation with **gradual onset of confusion**, increasing forgetfulness, and **balance issues with falls** over a couple of weeks, especially after a fall three weeks prior, is highly suggestive of a subdural hematoma.
- His use of **warfarin** and **aspirin** significantly increases his risk for bleeding, and the **headache and nausea/vomiting** are common symptoms of increased intracranial pressure.
*Ischemic stroke*
- An ischemic stroke typically presents with **acute, focal neurological deficits**, which are not described here.
- While the patient has risk factors for stroke (atrial fibrillation, hypertension, diabetes), the **gradual onset** of symptoms over weeks makes it less likely.
*Vitamin B12 deficiency*
- Vitamin B12 deficiency can cause **cognitive impairment** and neurological symptoms, but it usually develops **insidiously over months to years**, not acutely over 2 weeks.
- It is also associated with **peripheral neuropathy and megaloblastic anemia**, which are not reported.
*Alzheimer disease*
- Alzheimer's disease causes **progressive cognitive decline** over many years, starting with memory issues that gradually worsen.
- The **relatively rapid 2-week progression** of symptoms and the clear precipitating factor of a fall make Alzheimer's less likely in this acute context.
*Normal pressure hydrocephalus*
- Normal pressure hydrocephalus (NPH) classically presents with a triad of **gait disturbance, urinary incontinence, and dementia**.
- While the patient has gait issues and cognitive changes, the **absence of urinary incontinence** and the relatively rapid onset after a fall makes NPH less probable.
Question 2: A 2-year-old boy is brought to the physician by his parents for the evaluation of an unusual cough, a raspy voice, and noisy breathing for the last 2 days. During this time, the symptoms have always occurred in the late evening. The parents also report that prior to the onset of these symptoms, their son had a low-grade fever and a runny nose for 2 days. He attends daycare. His immunizations are up-to-date. His temperature is 37.8°C (100°F) and respirations are 33/min. Physical examination shows supraclavicular retractions. There is a high-pitched breath sound on inspiration. Which of the following is the most likely location of the abnormality?
A. Epiglottis
B. Subglottic larynx (Correct Answer)
C. Supraglottic larynx
D. Bronchioles
E. Bronchi
Explanation: ***Subglottic larynx***
- The symptoms of **barking cough**, **raspy voice**, and **inspiratory stridor** (high-pitched breath sound on inspiration) are classic for **croup (laryngotracheobronchitis)**.
- Croup is characterized by **inflammation and edema of the subglottic larynx**, which is the narrowest part of the pediatric airway, leading to obstruction.
*Epiglottis*
- **Epiglottitis** typically presents with a sudden onset of **high fever**, **dysphagia**, drooling, and a muffled voice, often without a preceding viral prodrome.
- Patients with epiglottitis usually appear severely ill and may adopt a **tripod position** to maximize airway opening, which is not described here.
*Supraglottic larynx*
- While inflammation can occur here, severe **supraglottic edema** leading to the described symptoms (especially the barking cough) is uncommon in typical croup.
- Conditions affecting the supraglottic area, such as **supraglottitis**, often cause a muffled voice and severe dysphagia, rather than a raspy voice and classic croupy cough.
*Bronchioles*
- Inflammation of the bronchioles typically causes **bronchiolitis**, characterized by **wheezing**, tachypnea, and increased work of breathing due to small airway obstruction.
- This condition does not typically present with a **barking cough** or **stridor**, which are indicative of upper airway obstruction.
*Bronchi*
- Inflammation of the bronchi (**bronchitis**) primarily causes a **cough** (often productive) and sometimes wheezing or rhonchi.
- It does not typically result in **stridor** or a **raspy voice**, as these symptoms arise from laryngeal or tracheal involvement.
Question 3: A 66-year-old man is brought into the emergency department by his daughter for a change in behavior. Yesterday the patient seemed more confused than usual and was asking the same questions repetitively. His symptoms have not improved over the past 24 hours, thus the decision to bring him in today. Last year, the patient was almost completely independent but he then suffered a "series of falls," after which his ability to care for himself declined. After this episode he was no longer able to cook for himself or pay his bills but otherwise had been fine up until this episode. The patient has a past medical history of myocardial infarction, hypertension, depression, diabetes mellitus type II, constipation, diverticulitis, and peripheral neuropathy. His current medications include metformin, insulin, lisinopril, hydrochlorothiazide, sodium docusate, atorvastatin, metoprolol, fluoxetine, and gabapentin. On exam you note a confused man who is poorly kept. He has bruises over his legs and his gait seems unstable. He is alert to person and place, and answers some questions inappropriately. The patient's pulse is 90/minute and his blood pressure is 170/100 mmHg. Which of the following is the most likely diagnosis?
A. Normal aging
B. Lewy body dementia
C. Vascular dementia (Correct Answer)
D. Pseudodementia (depression-related cognitive impairment)
E. Alzheimer's dementia
Explanation: ***Vascular dementia***
- This diagnosis is strongly supported by the patient's **stepwise decline** in cognitive function following a "series of falls" (likely small strokes or transient ischemic attacks) and his extensive history of **vascular risk factors** including hypertension, diabetes, and previous myocardial infarction.
- The acute worsening of confusion over 24 hours, coupled with pre-existing impaired executive function (inability to cook or pay bills), is characteristic of **vascular dementia's fluctuating course** and presentation often linked to new cerebrovascular events.
*Incorrect: Normal aging*
- **Normal aging** involves a very gradual and mild decline in cognitive functions, primarily affecting processing speed and memory recall, without significant impairment in daily activities.
- This patient's rapid, stepwise decline and inability to perform instrumental activities of daily living (IADLs) such as cooking and managing finances go beyond what is considered normal cognitive changes with aging.
*Incorrect: Lewy body dementia*
- **Lewy body dementia** is characterized by prominent **fluctuations in attention and alertness**, recurrent visual hallucinations, and spontaneous parkinsonism, none of which are explicitly mentioned as primary features in this patient's presentation.
- While fluctuations in confusion are present, the history of a clear stepwise decline post-falls and significant vascular risk factors points away from Lewy body dementia as the most likely primary cause.
*Incorrect: Pseudodementia (depression-related cognitive impairment)*
- **Pseudodementia** refers to cognitive impairment that occurs in the context of **major depression**, where patients may exhibit poor concentration, memory difficulties, and psychomotor slowing that mimics dementia.
- While this patient is on fluoxetine for depression, the **stepwise decline** after clear vascular events (falls), multiple vascular risk factors, and impaired executive function point to a true neurodegenerative process rather than depression-induced cognitive changes, which typically improve with treatment of the underlying mood disorder.
*Incorrect: Alzheimer's dementia*
- **Alzheimer's dementia** typically presents with a **gradual and progressive decline** in memory, particularly episodic memory, followed by other cognitive domains over several years.
- The patient's history of a clear **stepwise decline** in function after acute events (falls) and the strong presence of **vascular risk factors** make vascular dementia a more fitting diagnosis than Alzheimer's, which is not typically associated with such a sudden, step-like progression.
Question 4: A 30-year-old man comes to the physician for his annual health maintenance examination. The patient has no particular health concerns. He has a history of bilateral cryptorchidism treated with orchidopexy at 8 months of age. This patient is at increased risk for which of the following?
A. Yolk sac tumor
B. Leydig cell tumor
C. Testicular lymphoma
D. Sertoli cell tumor
E. Teratocarcinoma (Correct Answer)
Explanation: ***Teratocarcinoma***
- Cryptorchidism is a known risk factor for the development of **testicular germ cell tumors**, which includes **teratocarcinoma**. Orchidopexy may make screening easier but does not eliminate the increased risk.
- Testicular germ cell tumors, such as teratocarcinoma, typically present in young men and can derive from **undifferentiated germ cells** that remain in the undescended testis.
*Yolk sac tumor*
- While a type of **germ cell tumor**, yolk sac tumors are more common in infants and young children, and less frequently the primary presentation in an adult with a history of treated cryptorchidism.
- In adults, yolk sac components can be part of a mixed germ cell tumor but are rarely the sole diagnosis in this age group in the context of cryptorchidism risk.
*Leydig cell tumor*
- Leydig cell tumors are **sex cord-stromal tumors**, not germ cell tumors, and are not significantly associated with a history of cryptorchidism.
- These tumors typically present with symptoms related to **hormone production**, such as gynecomastia or precocious puberty.
*Testicular lymphoma*
- Testicular lymphoma is the most common testicular tumor in men over **60 years old** and is not primarily linked to a history of cryptorchidism.
- This is a **hematopoietic neoplasm** that can originate in the testis or metastasize there, rather than a primary testicular tumor associated with developmental abnormalities.
*Sertoli cell tumor*
- Sertoli cell tumors are also **sex cord-stromal tumors** and are not strongly associated with cryptorchidism.
- They are generally rare and can sometimes produce hormones, leading to clinical manifestations like **gynecomastia**.
Question 5: A 72-year-old man is brought to the physician by his wife for forgetfulness, confusion, and mood changes for the past 4 months. His symptoms started with misplacing items such as his wallet and keys around the house. Two months ago, he became unable to manage their finances as it became too difficult for him. Last week, he became lost while returning home from the grocery store. His wife reports that he shows “no emotion” and that he is seemingly not concerned by his recent symptoms. He has hypertension, type 2 diabetes mellitus, and coronary artery disease. Current medications include aspirin, metoprolol, lisinopril, metformin, and rosuvastatin. His pulse is 56/min and blood pressure is 158/76 mm Hg. Neurologic examination shows loss of sensation on his right leg and an unsteady gait. When asked to stand with his eyes closed and palms facing upward, his right arm rotates inward. An MRI of the brain shows multiple deep white matter lesions. Which of the following is the most likely diagnosis?
A. Vitamin B12 deficiency
B. Frontotemporal dementia
C. Alzheimer disease
D. Lewy body dementia
E. Vascular dementia (Correct Answer)
Explanation: ***Vascular dementia***
- The patient's history of **hypertension, type 2 diabetes mellitus, and coronary artery disease** indicates significant vascular risk factors. The **multiple deep white matter lesions** on MRI are characteristic findings in vascular dementia, resulting from chronic **cerebral ischemia**.
- The **insidious onset** with progressive **cognitive decline** (forgetfulness, confusion, financial difficulties, getting lost) combined with **focal neurological deficits** (loss of sensation, unsteady gait, pronator drift), and "no emotion" or lack of concern, strongly points towards vascular dementia.
*Vitamin B12 deficiency*
- While vitamin B12 deficiency can cause cognitive impairment and neurological symptoms, it typically manifests with **megaloblastic anemia** and **peripheral neuropathy**, which are not noted in this case.
- The MRI findings of **multiple deep white matter lesions** are not characteristic of vitamin B12 deficiency, and the patient's extensive vascular risk factors are more indicative of a cerebrovascular etiology.
*Frontotemporal dementia*
- Characterized primarily by **early and prominent behavioral and personality changes** (e.g., disinhibition, apathy) or **language deficits**. While apathy is present ("no emotion"), the prominent **focal neurological deficits** and MRI findings of deep white matter lesions are less typical.
- Unlike this case, memory impairment is usually not the initial or most prominent symptom in frontotemporal dementia until later stages, which contrasts with the patient's initial presentation of forgetfulness.
*Alzheimer disease*
- Alzheimer disease typically presents with **progressive memory impairment** as the hallmark symptom, often preceding other cognitive or neurological deficits. While memory loss is present here, the rapid progression (4 months), prominent focal neurological signs, and vascular risk factors are less typical.
- MRI would typically show **cortical atrophy**, particularly in the hippocampus and medial temporal lobes, rather than multiple deep white matter lesions without significant atrophy.
*Lewy body dementia*
- Key features include **fluctuating cognition, recurrent visual hallucinations**, and spontaneous **parkinsonism**. None of these core features are explicitly described in the patient's presentation.
- While mood changes and apathy can occur, the presence of **focal neurological deficits** and deep white matter lesions on MRI are not primary characteristics of Lewy body dementia.
Question 6: A 57-year-old woman comes to the physician for a routine health maintenance examination. She has well-controlled type 2 diabetes mellitus, for which she takes metformin. She is 163 cm (5 ft 4 in) tall and weighs 84 kg (185 lb); BMI is 31.6 kg/m2. Her blood pressure is 140/92 mm Hg. Physical examination shows central obesity, with a waist circumference of 90 cm. Laboratory studies show:
Fasting glucose 94 mg/dl
Total cholesterol 200 mg/dL
High-density lipoprotein cholesterol 36 mg/dL
Triglycerides 170 mg/dL
Without treatment, this patient is at greatest risk for which of the following conditions?
A. Osteoporosis
B. Rheumatoid arthritis
C. Subarachnoid hemorrhage
D. Central sleep apnea
E. Liver cirrhosis (Correct Answer)
Explanation: ***Liver cirrhosis***
* This patient has **metabolic syndrome**, characterized by **central obesity** (waist >88 cm in women), **hypertension** (≥130/85 mm Hg), **low HDL cholesterol** (<50 mg/dL in women), **elevated triglycerides** (≥150 mg/dL), and **type 2 diabetes mellitus**.
* Metabolic syndrome is strongly associated with **non-alcoholic fatty liver disease (NAFLD)**, which affects **70-90% of patients** with this condition.
* NAFLD can progress to **non-alcoholic steatohepatitis (NASH)**, then to **hepatic fibrosis**, and ultimately **cirrhosis**—making this patient's greatest long-term risk without intervention.
* NAFLD is now the **leading cause of chronic liver disease** in developed countries, and the combination of obesity, insulin resistance, and dyslipidemia directly promotes hepatic lipid accumulation and inflammation.
*Incorrect: Osteoporosis*
* While common in post-menopausal women, **obesity is generally protective against osteoporosis** due to increased weight-bearing stress on bones and higher estrogen levels from adipose tissue aromatization.
* No specific risk factors for osteoporosis (e.g., corticosteroid use, smoking, low calcium intake) are present.
*Incorrect: Rheumatoid arthritis*
* This is an **autoimmune condition** not associated with metabolic syndrome.
* The patient has no symptoms of joint pain, morning stiffness, or synovitis that would suggest rheumatoid arthritis.
* Metabolic factors do not increase the risk of developing rheumatoid arthritis.
*Incorrect: Subarachnoid hemorrhage*
* While **hypertension** is a risk factor for hemorrhagic stroke, subarachnoid hemorrhage is more specifically associated with **ruptured aneurysms** or **arteriovenous malformations**.
* The patient's moderately elevated blood pressure poses some cardiovascular risk, but this is not the greatest risk compared to the progressive liver disease associated with metabolic syndrome.
*Incorrect: Central sleep apnea*
* **Central sleep apnea** (cessation of respiratory effort) is primarily associated with **heart failure**, **stroke**, or **opioid use**—not metabolic syndrome.
* **Obstructive sleep apnea** (OSA) is what's associated with obesity and metabolic syndrome, but that is not an option here.
* While this patient may be at risk for OSA, central sleep apnea is not the primary concern in metabolic syndrome.
Question 7: A 21-year-old female presents to her first gynecology visit. She states that six months ago, she tried to have sexual intercourse but experienced severe pain in her genital region when penetration was attempted. This has continued until now, and she has been unable to have intercourse with her partner. The pain is not present at any other times aside from attempts at penetration. The patient is distressed that she will never be able to have sex, even though she wishes to do so. She does not recall ever having a urinary tract infection and has never been sexually active due to her religious upbringing. In addition, she has never tried to use tampons or had a Pap smear before. She denies alcohol, illicit drugs, and smoking. The patient is 5 feet 6 inches and weighs 146 pounds (BMI 23.6 kg/m^2). On pelvic exam, there are no vulvar skin changes, signs of atrophy, or evidence of abnormal discharge. The hymen is not intact. Placement of a lubricated speculum at the introitus elicits intense pain and further exam is deferred for patient comfort. Office urinalysis is negative. Which of the following is a risk factor for this patient’s condition?
A. Low estrogen state
B. Generalized anxiety disorder (Correct Answer)
C. Endometriosis
D. Squamous cell carcinoma of the vulva
E. Body dysmorphic disorder
Explanation: ***Generalized anxiety disorder***
- The patient describes **severe pain upon attempted penetration** and significant distress about her inability to have intercourse, consistent with **genito-pelvic pain/penetration disorder (GPPPD)**, formerly known as dyspareunia, vaginismus, and sexual aversion disorder.
- While GPPPD is multi-factorial, **anxiety and psychological distress** are significant risk factors and often exacerbate the condition, leading to muscle guarding and increased pain perception.
*Low estrogen state*
- This patient is a pre-menopausal 21-year-old with a normal BMI, making a **low estrogen state** highly unlikely.
- Low estrogen typically leads to **vulvovaginal atrophy**, dryness, and pain, which would present with objective findings like vulvar skin changes or atrophy, not observed in this case.
*Endometriosis*
- Endometriosis causes **deep dyspareunia** (pain with deep penetration), often accompanied by chronic pelvic pain, dysmenorrhea, and infertility.
- The patient's pain is described as severe with *attempted penetration at the introitus*, which is more superficial than typical endometriosis-related pain.
*Squamous cell carcinoma of the vulva*
- This condition is typically found in older women and associated with a history of **HPV infection** or chronic inflammation.
- It would present with **visible vulvar lesions**, itching, bleeding, or palpable masses, none of which are described in the patient's exam.
*Body dysmorphic disorder*
- Body dysmorphic disorder involves a **preoccupation with perceived flaws** in physical appearance, leading to significant distress or impairment.
- While it can impact sexual intimacy, the primary symptom described is **physical pain during attempted intercourse**, not distress over her genital appearance.
Question 8: A 9-year-old girl is brought to the physician by her mother because of a 3-day history of face and foot swelling, dark urine, and a rash on her hands and feet. The mother reports that her daughter has had a low-grade fever, shortness of breath, and a dry cough for the past 8 days. She has had generalized weakness and pain in her right knee and ankle. She has a ventricular septum defect that was diagnosed at birth. The patient appears lethargic. Her temperature is 38.4 (101.1°F), pulse is 130/min, respirations are 34/min, and blood pressure is 110/60 mm Hg. Examination shows small, non-blanching, purple lesions on her palms, soles, and under her fingernails. There is edema of the eyelids and feet. Funduscopic examination shows retinal hemorrhages. Holosystolic and early diastolic murmurs are heard. Laboratory studies show:
Hemoglobin 11.3 g/dL
Erythrocyte sedimentation rate 61 mm/h
Leukocyte count 15,000/mm3
Platelet count 326,000/mm3
Urine
Blood 4+
Glucose negative
Protein 1+
Ketones negative
Transthoracic echocardiography shows a small outlet ventricular septum defect and a mild right ventricular enlargement. There are no wall motion abnormalities, valvular heart disease, or deficits in the pump function of the heart. Blood cultures grow Streptococcus pyogenes. Which of the following is the most likely diagnosis?
A. Myocarditis
B. Acute lymphoblastic leukemia
C. Hand-Foot-and-Mouth Disease
D. Kawasaki disease
E. Infective endocarditis (Correct Answer)
Explanation: ***Infective endocarditis***
- The patient presents with **fever, new murmurs (holosystolic and early diastolic), Roth spots (retinal hemorrhages), Janeway lesions (non-blanching purple lesions on palms and soles), Osler's nodes (on fingertips/under fingernails), and splenomegaly (implied by elevated WBC and history of infection),** which are classic signs of infective endocarditis. The presence of a **ventricular septal defect (VSD)** is a predisposing cardiac lesion.
- **Positive blood cultures for *Streptococcus pyogenes*** confirms the infection, and the **dark urine with blood and protein** suggests **glomerulonephritis**, a common complication of endocarditis.
*Myocarditis*
- While myocarditis can cause **fever, shortness of breath, and cardiac dysfunction**, it typically does not present with the characteristic peripheral stigmata of endocarditis such as **Janeway lesions, Osler's nodes, or Roth spots**.
- The echocardiogram explicitly states **"no wall motion abnormalities, valvular heart disease, or deficits in the pump function"**, which would be expected in severe myocarditis.
*Acute lymphoblastic leukemia*
- Leukemia could explain **fatigue, fever, elevated WBC, and petechial rash**, but it would not typically cause **new cardiac murmurs, retinal hemorrhages (Roth spots), or positive blood cultures for *Streptococcus pyogenes***.
- The specific signs of endocarditis, and the absence of profound anemia or thrombocytopenia, make leukemia less likely.
*Hand-Foot-and-Mouth Disease*
- This viral illness is characterized by **fever and vesicular rash on the hands, feet, and oral cavity**, primarily affecting young children.
- It does not cause **cardiac murmurs, Roth spots, Osler's nodes, or Janeway lesions**, and would not typically lead to a *Streptococcus pyogenes* bacteremia.
*Kawasaki disease*
- Kawasaki disease presents with **fever, rash, conjunctivitis, oral mucosal changes, lymphadenopathy, and extremity changes (edema, peeling)**.
- It **does not typically feature new cardiac murmurs, Janeway lesions, Osler's nodes, Roth spots, or positive bacterial blood cultures**, and primarily affects younger children.
Question 9: A 33-year-old woman comes to the physician because of vision impairment in her right eye for the past 2 weeks. During this period, she was unable to distinguish colors with her right eye. She also reports pain with eye movement. She has no double vision. She occasionally has headaches that are relieved by ibuprofen. One year ago, she had a similar episode that affected her left eye and resolved spontaneously. She has no history of serious illness. She works at a library and enjoys reading, even in poor lighting conditions. Her vital signs are within normal limits. The pupils are equal, round, and reactive to light and accommodation. Without correction, visual acuity is 20/50 in the left eye, and 20/100 in the right eye. With spectacles, the visual acuity is 20/20 in the left eye and 20/100 in the right eye. Slit lamp examination shows no abnormalities. A CT scan of the head shows no abnormalities. Which of the following is the most likely diagnosis?
A. Narrow-angle glaucoma
B. Retinal detachment
C. Macular degeneration
D. Retinitis pigmentosa
E. Optic neuritis (Correct Answer)
Explanation: ***Optic neuritis***
- This condition presents with **acute monocular vision loss**, **pain with eye movement**, and **dyschromatopsia** (inability to distinguish colors), which are classic symptoms of optic neuritis.
- The recurrent nature affecting different eyes (**recurrent episodes in each eye**) and the spontaneous resolution are highly suggestive of **demyelinating disease**, such as **multiple sclerosis**, of which optic neuritis is often the initial presentation.
*Narrow-angle glaucoma*
- **Narrow-angle glaucoma** typically presents with **sudden, severe eye pain**, blurred vision, headache, and halos around lights due to acutely elevated intraocular pressure.
- The examination would reveal a **mid-dilated pupil** and **conjunctival injection**, which are not described in this patient.
*Retinal detachment*
- Patients with **retinal detachment** usually report a sudden onset of **floaters**, **flashes of light**, and a **"curtain" or "shadow" obscuring part of their vision**.
- **Pain with eye movement** and **dyschromatopsia** are not typical features of retinal detachment.
*Macular degeneration*
- **Macular degeneration** primarily affects central vision, causing **blurred or distorted vision**, particularly reading difficulty, and difficulty recognizing faces.
- It usually presents in **older individuals** and is not characterized by pain with eye movement or sudden, recurrent episodes of vision loss with dyschromatopsia.
*Retinitis pigmentosa*
- **Retinitis pigmentosa** is a group of inherited eye diseases that cause progressive vision loss, beginning with **night blindness** and then gradual **peripheral vision loss** (tunnel vision).
- The patient's acute monocular vision loss with pain and dyschromatopsia is not typical of the slow, progressive nature of retinitis pigmentosa.
Question 10: An 82-year-old male visits his primary care physician for a check-up. He reports that he is in his usual state of health. His only new complaint is that he feels as if the room is spinning, which has affected his ability to live independently. He is currently on lisinopril, metformin, aspirin, warfarin, metoprolol, and simvastatin and says that he has been taking them as prescribed. On presentation, his temperature is 98.8°F (37°C), blood pressure is 150/93 mmHg, pulse is 82/min, and respirations are 12/min. On exam he has a left facial droop and his speech is slightly garbled. Eye exam reveals nystagmus with certain characteristics. The type of nystagmus seen in this patient would most likely also be seen in which of the following diseases?
A. Benign paroxysmal positional vertigo
B. Multiple sclerosis (Correct Answer)
C. Meniere disease
D. Vestibular neuritis
E. Aminoglycoside toxicity
Explanation: ***Multiple sclerosis***
- This patient's presentation (acute vertigo, left facial droop, dysarthria, and nystagmus in an elderly patient with vascular risk factors) is most consistent with a **brainstem stroke** affecting the posterior circulation.
- The nystagmus in this case is **central nystagmus**, characterized by being non-fatigable, multidirectional, and not suppressed by visual fixation—typical of **CNS lesions** affecting the brainstem or cerebellum.
- **Multiple sclerosis** also causes **central nystagmus** due to demyelinating plaques in the brainstem, cerebellum, or medial longitudinal fasciculus, making it the condition that would exhibit the same type of nystagmus pattern.
- Both brainstem stroke and MS produce central vestibular dysfunction with similar nystagmus characteristics.
*Benign paroxysmal positional vertigo*
- BPPV causes **peripheral nystagmus** that is fatigable, triggered by specific head positions, and typically resolves within 30-60 seconds.
- The nystagmus is usually **rotatory or torsional** and follows a predictable pattern with the Dix-Hallpike maneuver.
- This patient's persistent symptoms and additional neurological signs (facial droop, dysarthria) indicate a **central, not peripheral**, cause.
*Meniere disease*
- Meniere's disease causes **peripheral nystagmus** associated with episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness.
- The nystagmus in Meniere's is typically **horizontal** during acute attacks but does not present with focal neurological deficits like facial weakness or speech changes.
- This patient lacks the classic auditory symptoms and has clear signs of a **central lesion**.
*Vestibular neuritis*
- Vestibular neuritis results from inflammation of the vestibular nerve, causing **peripheral nystagmus** that is horizontal-torsional, unidirectional, and enhanced without visual fixation.
- It typically presents with acute severe vertigo following a viral illness, without other neurological signs.
- The presence of **facial droop and dysarthria** in this patient rules out a purely peripheral vestibular disorder.
*Aminoglycoside toxicity*
- Aminoglycosides cause **bilateral vestibulotoxicity**, leading to oscillopsia, chronic dysequilibrium, and possible hearing loss, but not acute vertigo with nystagmus.
- When present, the vestibular dysfunction is typically **bilateral and symmetric**, without spontaneous nystagmus at rest.
- This patient is not on aminoglycosides, and his presentation with focal neurological signs points to a **central structural lesion** rather than toxic peripheral vestibulopathy.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
