Question 22

24 year old man comes to the emergency room with history of fever, malaise, and shortness of breath. He has been having fever for last 7 days for which he tried over the counter acetaminophen for symptomatic relief. He appears in moderate distress. He is disheveled, and has smell of alcohol on his clothes. There are some scars on his both forearms. He confesses to be an alcoholic and drug abuser. He has a past history of pulmonary TB treated at the community center about 3 years ago. He has no past histroy of any neurological or psychiatric illnesses. He usually does not visit a doctor, and does not remember about his vaccination status. The veins on his right forearm are thick and cord like but are non tender. He has history of sulfa and penicillin allergy. On examination his Temp is 101.2 degrees, BP is 98/46 mm Hg, and Pulse is 112/min. His chest examination reveals few rhonchis. On cardiac examination the physician hears an abnormal sound in his left lower border of sternum (see media). He does not remember of any childhood cardiac illness. He has no neck stiffness. What is the most likely diagnosis?

a) Rheumatic Heart Disease

b) Ventricular Septal Defect

c) Tuberculous pericarditis

d) Cardiac Tamponade

e) Infective Endocarditis

This vignetter applies to Question 22 to 24

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Question 21

25 year old nurse complaints of dizziness and sweating in the ER. A few days ago she had similar complaints and was adviced to go home from work after stabilizing. She joined work yesterday after leave. This is her third episode of similar complaints. She usually have such complaints whenever she is stressed due to patient overload, and feels better with rest and some juice. Today, her BP is 124/88 mm Hg, pulse is 102/min. She is sweating profusely. The doctor requests for blood chemistry, glucose level, and C- peptide level. The electrolytes levels are as follows, Na 134, K 3.4, Cl 98, Ca 9.2, Mg 2.4, BUN 20, Creat 0.9. Her Glucose level is 54 mg %, and C peptide levels are high. The doctor orders her 5 % Dextrose 100 cc, and she is stabilized subsequently. What is the most likely diagnosis?

A) Factitious disorder
B) Insulinoma
C) Glucagonoma
D) Manchausen Syndrome
E) Hypochondriasis

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Question 20

22 year old male comes to the clinic with complaints of swelling on his back. He says the swelling is cosmetically ugly. It is non tender and has not changed since few years. He also complains of some swelling on his scalp. Occasionally, he has pain in his abdomen, and passes black stools often. Rectal examination is non contributory. Stool shows altered blood. The physician schedules him for a colonoscopy. He is an adopted child of his parents, and does not know anything about his biological parents. On colonoscopy, the physician notes several polyp. What is the most likely diagnosis.

A) Gardener's Syndrome
B) Turcot's Syndrome
C) Diverticulosis
D) HNPCC
E) Colon Ca
F) Angiodysplasia

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Question 19

What vitamin deficiency is linked to the patient's symptoms in question 17?

A) Thiamine
B) Riboflavin
C) Niacin
D) Biotin
E) Cobalamine
F) Folic Acid

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Question 18

The patient in question 17 is stabilized. What cardiac finding is most likely to be present in this patient?

A) Mitral regurgitation
B) Tricuspid regurgitation
C) Aortic Regurgitation
D) Mitral Stenosis
E) Tricuspid Stenosis
F) Aortic Stenosis


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