A 50-year-old female with PMH significant for HTN comes to your clinic for a refill of her lisinopril medication. She is also taking lovastatin and hydrochlorothiazide. Vital signs are: HR 80, BP 150/100, and BMI 40. Physical exam is remarkable for a waist-to-hip ratio of 1.0 and the presence of diffuse dark patches on her skin (see image below). Her fasting lab results are: Sodium: 145 mmol/L, Potassium: 5.0 mmol/L, Chloride: 105 mmol/L, Bicarbonate: 25 mmol/L, BUN: 10 mg/dL, Creatinine: 1.0 mg/dL, Glucose: 200 mg/dL, Triglyceride: 200 mg/dL, LDL: 250 mg/dL, Total cholesterol: 300 mg/dL, HDL: 30 mg/dL, and Hemoglobin A1C: 7.0%.                                                         The patient’s history, physical exam, and laboratory findings are most consistent with which of the following conditions?

A 50-year-old female comes into your office with concerns of falling. She states that over the last few months, she has a feeling of numbness and “tingling” in her feet. She denies any problems with her balance and denies vertigo, but does not feel “sure-footed.” She denies any neurological history. Past medical history is significant for hysterectomy 10 years ago for menorrhagia and a bowel resection for Crohn’s disease. On exam, the patient has decreased reflexes and sensation bilaterally in her lower extremities. CBC shows a Hgb of 9.1 with an MCV of 105. The peripheral blood smear is shown (see image below). The patient’s methylmalonic acid (MMA) level is elevated. What is the most likely cause of this patient’s clinical presentation?              

An 82-year-old man presents to the urology clinic accompanied by his wife, and requests evaluation of “problems down there.” He is a poor historian, but his wife helps with his review of systems. She reports that he does not have any voiding issues and states that he has never had to see a urologist previously. Genitourinary examination is suggestive of phimosis.  Which of the following physical examination findings would support this diagnosis?

A 28-year-old female is brought to the ER by her husband because of bizarre behavior 4 days after the uncomplicated delivery of a full-term healthy boy. Her personal and family history of mental illness is negative. The second day after delivery, she accused her husband of poisoning her food. She has problems falling asleep, generally sleeping only 2-3 hours nightly and complaining of unpleasant smells waking her up. She started arranging toys and the newborn’s things in a specific symmetrical order and became aggressive when someone moved them. She would stop the ongoing activity from time to time with a blank expression and was found several times staring at the wall and silently counting. Even simple tasks require the help of others, and she often forgets what she started doing. This makes her irritable and sometimes tearful. She feels guilty about being a terrible mother and states that she did not deserve to have a baby. The morning when her husband asked for your advice, she told him that she hears voices telling her to take her son and jump out the window. What is the most likely diagnosis?

A 26-year-old male presents to the urology clinic for evaluation of a painless mass in his left testicle. He said he noticed it the other day when he was performing testicular self-examination. You palpate his scrotum and note a ‘bag of worms’ consistency in his left hemiscrotum. Which of the following conditions is the most likely diagnosis for this patient?

You are asked to evaluate a 32-year-old woman who presents complaining of “worsening stress.”  On further questioning, the patient admits that she is developing a severe fear of public places and open areas, and this has started to affect her ability to function.  She left her previous job due to this escalating discomfort, and now rarely leaves her home.  She realizes that her fears are seriously affecting her ability to function, and, despite considerable anxiety, has come to the office today to get help.  Based on this information, which of the following conditions is the most likely diagnosis for this patient?

A 36-year-old male patient presents for initial psychiatric evaluation and is accompanied by his wife.  She explains that her husband’s behavior is negatively affecting their personal relationship and his interactions with co-workers at the office.  She describes her husband’s overwhelming need for order, strong sense of “how things should be done,” perfectionism that interferes with completing tasks, and rigidity about following rules.  Which of the following conditions is the most likely diagnosis for this patient? 

A 36-year-old female presents with a history of gradual onset of nervousness and fatigue. She has lost 15 pounds in the past year despite an increase in appetite.  She reports that she is not sleeping well, because she feels anxious all of the time. Her menses have become scant with frequent intermenstrual spotting, and she feels that she constantly prefers a cooler environment than those around her. On physical examination, she has a heart rate of 100/min with normal blood pressure, and a fine tremor of the fingers is noted. The skin is warm, moist, and has a smooth texture. The thyroid is diffusely enlarged to palpation. A lid-lag sign is easily demonstrable. A common complication of this disease is:

A pregnant woman at 30 weeks gestation reported a flu-like illness to her provider. Suspecting Cytomegalovirus infection, laboratory testing was completed. The results showed positive CMV IgM antibodies with high avidity CMV IgG antibodies. Which of the following statements is true concerning this fetus after delivery?

During your Psychiatry rotation, you are asked to evaluate a 34-year-old male patient with signs and symptoms suggestive of Bipolar I disorder.  The patient is started on lithium and your preceptor asks you to review with the patient the possible common side effects associated with this medication.  Which of the following potential side effects should be included in your discussion with the patient?