Part III picture

106) A 12-year-old boy notices a scaly, mildly pruritic rash on his arm (see image below). There is no associated fever, muscle pain, nausea, vomiting, diarrhea, or back pain. He recently started taking swimming classes. The rash is most likely to clear with which of the following therapies?

3) A 25-year-old male presents with skin lesions over his elbows, knees and neck. He complains of intense itching and burning sensation over these lesions for the past 10 days. He was advised to follow a gluten-free diet on his previous visit, but was not compliant. His vital signs are stable. On examination, there are flesh-colored to erythematous vesicles distributed over the extensor aspects of elbows, knees, posterior neck and shoulders. Some of these lesions are shown in the picture below. Which of the following is the drug of choice for his skin condition?

6) A 35-year-old woman develops an itchy rash over her back, legs, and trunk several hours after swimming in a lake. Erythematous, edematous papules and plaques are noted. The wheals vary in size. There are no mucosal lesions and no swelling of the lips. What is the best first step in management of her symptomatic rash?

10) A 50-year-old male comes to the office due to an ulcer in his right foot. He has type 2 diabetes, for which he takes glyburide. Laboratory investigations reveal an HbA1c of 9%, and random blood sugar of 180 mg/dL. X-ray of the leg/foot is normal. A picture of the foot ulcer is shown below. Which of the following is the most appropriate management of this patient's foot ulcer?

25) A 25-year-old female comes to the office for a follow-up visit. She was just diagnosed with type 1 diabetes mellitus a few days ago, when she presented at the emergency department with ketoacidosis. After successful management of her diabetic ketoacidosis (DKA), she was sent home on an insulin regimen with the following dosage: Before breakfast 10 units of NPH and 10 units of regular insulin, Before supper 10 units of NPH and 4 units of regular insulin. During this office visit, she shows the record of her fingerstick readings at home. For the last 2 days, her blood glucose levels were (see in pic). What is the most likely explanation for her 7:00 am blood glucose level?

92) A 54-year-old man presents to his primary care provider with the complaint of upper abdominal fullness and pain. He states that he has lost 2.3-4.6 kg (5-10 lb), but denies other symptoms. Physical examination reveals a firm mass in the epigastric area. Ultrasonography reveals a mass in the gastric antrum. A salivary gland biopsy reveals the pathology shown in the image. Which of the following therapies is expected to be part of his treatment plan?

9) A 55-year-old male comes to the physician's office because of fatigue. He denies any other symptoms. His vital signs are stable. Examination shows pallor, massive splenomegaly, and mild hepatomegaly. CBC reveals pancytopenia with striking monocytopenia. His peripheral blood smear is shown below. Bone marrow biopsy shows a dry tap. What is the most appropriate treatment for this patient's condition?

12) A 32-year-old Italian-American man presents to your office for a routine check-up. He works as a business executive and admits to being under a lot of stress recently. He drinks alcohol occasionally and smokes one pack of cigarettes per day. Laboratory analyses reveal: Hemoglobin 10.1 mg/dl, RBC count 4.0 x 10^12/L, MCV 70fl, WBC count 5,500/mm3, Platelets 170,000/mm3, Serum calcium 10.1 mg/dl, Serum potassium 4.5 meq/L, Serum sodium 135 meq/L. Serial fecal occult blood tests are negative. A peripheral blood smear reveals the following: Which of the following is the best treatment for this patient?

55) A 22-year-old female presents to the office with a three-day history of rash, fever, and malaise. There is no burning or itching associated with the rash. Two weeks ago, she had been camping in northern Massachusetts, and noted a tick bite after walking through the woods. She is twelve weeks pregnant. The rash is shown below. The examination is otherwise unremarkable. What is the most appropriate treatment for this patient?

77) A 68-year-old male presents to the emergency room with cough. Chest x-ray is clear of infiltrates but reveals a right upper lobe lung lesion incidentally. A chest CT scan with IV contrast is performed in the emergency department and reveals a 1 cm x 2cm round lesion in the right upper lobe. The patient is admitted to the hospital, and by day 3 of his hospitalization, he has developed acute renal failure. The patient's past medical history is significant for hypertension, hyperlipidemia, diabetes and coronary artery disease. His medications include aspirin, hydrochlorothiazide, clopidogrel, metoprolol, atorvastatin and lisinopril, all of which he has been taking for several years. He has no known drug allergies. He is a former smoker and does not use alcohol or drugs. His baseline blood pressure is 140/90 mm Hg and has remained in the 140s/90s throughout this admission. Physical examination is otherwise unremarkable. The patient's laboratory values from the time of admission to present are given below. Over the course of the next week, the patient's renal function returns to normal. Which of the following would most likely have prevented his renal failure?

86) A healthy 54-year-old man comes to the physician for a routine health maintenance examination. He has no complaints, but he is requesting for a CT scan of the abdomen. His father died at the age of 60 due to the sudden rupture of an undiagnosed abdominal aortic aneurysm. He has a history of hypertension and gouty arthritis. His social history is not significant. His vital signs are stable. Physical examination shows no abnormalities. ACT scan of the abdomen is shown below. Which of the following is the most appropriate next step in management?

107) A 58-year-old alcoholic is admitted with diagnosis of decompensated liver cirrhosis. The lab panel is shown below on the day of admission and 3 days later. Which of the following best explains the acid-base status change in this patient?

112) A 79-year-old woman presents to her primary care physician complaining of memory loss. She reports increasing difficulty balancing her check book and remembering the names of new acquaintances over the last several months. Her only other complaint is occasional urinary incontinence, which she attributes to old age. She denies headache, vision changes, rash, nausea, or vomiting. Her past medical history is significant for hypertension controlled with felodipine. On exam her vital signs are within normal limits. The heart and lung exams are also unremarkable. The cranial nerves are intact, fundoscopic exam is normal, and no tremor is observed. Her gait is slow and shuffling, there is no dysmetria, and her Folstein mini-mental status score is 24/30. CT scan of her brain is shown below. Which of the following interventions is most likely to relieve her symptoms?

122) A 38-year-old female presents with one week of "shakiness" in her right arm, right leg weakness and unsteady gait. An MRI of her brain is shown below. Which of the following is the best treatment for this patient?

143) A 21-year-old man presents to the ED with a red eye. The patient complains of rhinorrhea and a nonproductive cough but has no eye pain or discharge. He also has no associated ecchymosis, bony tenderness of the orbit, or pain on extraocular eye movement. His vision is normal, extraocular movements are intact, and intraocular pressure (IOP) is 12. A picture of his eye is shown below. What is the most appropriate management of this condition?

16) A 46-year-old man comes to the ER because of weakness and chest tightness. He has had these symptoms for the past one hour. He denies any past medical history. He does not smoke or drink alcohol. His father had a myocardial infarction at 68 years of age and his mother has myasthenia gravis. His EKG is shown on the slide below. The patient should be evaluated for which of the following?

21) The ECG shown in Fig. Was obtained during the initial stages of an acute MI. The patient had just received thrombolytic therapy. What is the rhythm?

25) A 42-year -old male with a past medical history of bladder cancer and recurrent hematuria presents to the emergency room after "passing out" when he got out of bed this morning. The patient says that he was standing up to urinate shortly after waking when he began feeling dizzy. Fortunately he was able to return to his bed before losing consciousness for 7-10 minutes. His EKG at the time of admission is shown below. Which of the following most likely accounts for the observed EKG changes?

38) A 70-year-old man has dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. He has generalized cardiomegaly and pulmonary and systemic venous hypertension. The ECG is shown in Fig.What is the cardiac rhythm?

42) You are called by a surgical colleague to evaluate a 54-year-old woman with ECG abnormalities one day after a subtotal thyroidectomy for a toxic multinodular goiter. Her only medication is fentanyl for postoperative pain control. The patient denies any history of syncope, and has no family history of sudden cardiac death. Physical examination is unremarkable except for a clean postoperative incision at the base of the neck. Her ECG is reproduced below. What is the best next step in evaluation and management of this patient?

45) A 58-year-old man is brought to the ED for a syncopal episode at dinner. His wife states that he was well until she found him suddenly slumping in the chair and losing consciousness for a minute. The patient recalls having some chest discomfort and shortness of breath prior to the episode. His rhythm strip, obtained by EMS, is shown below. Which of the following best describes these findings?

52) A 25-year-old female with blonde hair and fair complexion complains of a mole on her upper back. The lesion is 8 mm in diameter, darkly pigmented, and asymmetric, with an irregular border (see illustration below). Which of the following is the best next step in management?

78) A 30-year-old female complains of palpitations, fatigue, and insomnia. On physical examination, her extremities are warm and she is tachycardic. There is diffuse thyroid gland enlargement and proptosis. There is thickening of the skin in the pretibial area. Mild clubbing of digits is present. Which of the following laboratory values would you expect in this patient?

80) A 17-year-old girl has never had a menstrual period. On physical examination, she has minimal breast development and no axillary or pubic hair. She is color blind and has had a diminished sense of smell since birth. Laboratory evaluation would most likely reveal which of the following?

89) A 14-year-old boy presents at the pediatric clinic for a routine check-up. The patient had developed end-stage renal disease over the previous 2 years, and was successfully treated with a renal transplant 6 months prior. Since his operation, he has developed purple striae on his back and arms, central obesity, and an increasingly round face. During the subsequent blood analysis, which of the following results would be most likely?

133) A 58-year-old white man complains of intermittent rectal bleeding and, at the time of colonoscopy, is found to have internal hemorrhoids and the lesion shown at the splenic flexure. Pathology shows tubulovillous changes. Repeat colonoscopy should be recommended at what interval?

148) A 65-year-old man presents to his physician complaining of difficulty swallowing, occasional chest pain, and regurgitation of food. Over the past 2 months he has lost about 7 kg (15 lb). Results of a barium swallow study are shown in the image. What test should be performed to look for possible causes of his condition?

172) A 74-year -old Caucasian man is evaluated for occasional palpitations and poor exercise tolerance. He has been living alone since his wife died two years ago. His diet consists mainly of precooked food that he heats up in the microwave oven. He has a history of degenerative joint disease and hypertension. He takes a daily aspirin, hydrochlorothiazide, and glucosamine. He quit smoking 20 years ago and occasionally drinks alcohol. His peripheral blood smear is shown below. Which of the following substances is most likely elevated in this patient's blood?

11) A 56-year-old male is being evaluated for increased fatigability. His past medical history is significant for severe aortic stenosis that required aortic valve replacement, diabetes mellitus, and osteoarthritis. Peripheral blood smear findings are shown on the slide below. Which of the following laboratory findings would you most expect to find in this patient?

58) A 69-year-old woman presents with left flank pain and hematuria. Physical examination suggests a left-sided abdominal mass. Computerized tomography (CT) scan of the abdomen reveals a 5-cm mass in the left kidney. Which of the following laboratory abnormalities might also be present (See Fig.)?

98) A 64-year -old African American male presents to you with complaints of a dry cough, weight loss and pain in his right arm. The symptoms started approximately 2 months ago. His past medical history is significant for type 2 diabetes mellitus and hypertension. He smokes 1 pack per day and drinks alcohol occasionally. He denies any drug allergies. Physical examination is unremarkable. ECG reveals normal sinus rhythm. An MRI of his chest is shown below. Which of the following is most likely responsible for this patient's symptoms?

113) A 32-year-old man is intubated and mechanically ventilated after an opioid drug overdose. The ventilator triggers 12 breaths per minute, each delivering 500 ml of tidal volume at a flow rate of 60 L/min. You perform an inspiratory hold for 2 seconds following delivery of the tidal volume, and the airway pressure is measured to be 30 cm H2O. The measured pressure reflects which of the following?

133) A 21-year-old man has a nonproductive cough, shortness of breath, and chest pain, which changes with breathing. He also has pain in the left arm. On examination, there is tender- ness over the left shoulder, heart sounds are normal, and the lungs are clear. CXR reveals a lytic lesion in the left humerus and reticulonodular opacities in the upper and middles lobes. The eosinophil count is normal. Which of the following is the most appropriate initial diagnostic test?

168) Over the last six weeks a 45-year-old nurse has developed progressive difficulty getting out of chairs and climbing stairs. She can no longer get in and out of the bathtub. She has no muscle pain and takes no regular medications. She does not use alcohol and does not smoke cigarettes. On examination she has a purplish rash that involves both eyelids (see figure). There is weakness of the proximal leg muscles. What is the best next diagnostic test?

12) A 2-day-old boy in the newborn nursery was born at 39 weeks gestation to a 38-year-old woman by vaginal delivery. The mother received epidural fentanyl for severe painful contractions during labor, but the delivery was uncomplicated. Since birth, the boy has shown little interest in breast or bottle feeding. He spit up the last feed but has not vomited. He has not yet passed meconium. Physical examination shows a newborn with generalized hypotonia, a flat facial profile, low-set folded earlobes, and a single transverse crease on each palm. His abdomen is firm and distended. Digital rectal examination is notable for a tight anal canal and relieves an expulsion of gas and stool. Abdominal x-ray shows markedly distended loops of bowel with no gas in the rectum. What is the mostly likely mechanism for his findings?

111) Shortly after birth, an infant develops abdominal distention and begins to drool. When she is given her first feeding, it runs out the side of her mouth, and she coughs and chokes. Physical examination reveals tachypnea, inter- costal retractions, and bilateral pulmonary rales. The esophageal anomaly that most commonly causes these signs and symptoms is illustrated by which of the following?

114) A 13-year-old male is brought to the physician for evaluation of intermittent left knee pain that arose three months ago. He does not remember any trauma to his knee. The pain worsens after basketball games, but improves some with rest. He has been taking non-steroidal anti-inflammatory medications with some relief. On physical examination, he has edema and tenderness over the proximal tibia at the site of the patellar tendon insertion. Examination of the knee joint is normal and no effusion is present. His knee pain is reproducible by extending the knee against resistance. A lateral radiograph of his knee is shown below. Which of the following is the most likely cause of this patient's knee pain?

151) A 13-year-old develops fever, malaise, sore throat, and a dry, hacking cough over several days. He does not appear to be particularly sick, but his chest examination is significant for diffuse rales and rhonchi. The chest radio- graph is shown below. Which of the following is the most likely pathogen?

176) An otherwise healthy child has on his 1-year-old routine CBC the polymorphonuclear neutrophil shown below. This child likely has which of the following?

10) The newborn pictured below was born at home and has puffy, tense eye- lids; red conjunctivae; a copious amount of purulent ocular discharge; and chemosis 2 days after birth. Which of the following is the most likely diagnosis?

29) The adolescent shown presents with a 14-day history of multiple oval lesions over her back. The rash began with a single lesion over the lower abdomen (Image A); the other lesions developed over the next days (image B). These lesions are slightly pruritic. Which of the following is the most likely diagnosis?

41) A 2-year-old boy is brought into the emergency room with a complaint of fever for 6 days and the development of a limp. On examination, he is found to have an erythematous macular exanthem over his body as shown in (image A), ocular conjunctivitis, dry and cracked lips, a red throat, and cervical lymphadenopa- thy. There is a grade 2/6 vibratory systolic ejection murmur at the lower left sternal border. A white blood cell (WBC) count and differential show predominant neutrophils with increased platelets on smear. Later, he develops the findings as seen in (image B). Which of the following is the most likely diagnosis?

90) The mother of a 3-day-old infant brings her child to your office for an early follow-up visit. The mom notes that the child has been eating well, has had no temperature instability, and stools and urinates well. She notes that over the previous 3 days the child has had a progressive rash on the face as pictured here. Which of the following is the most likely diagnosis?

101) Over the previous 2 to 3 weeks, a very active 13-year-old white boy is noted by his family to have developed deep pains in his leg that awaken him from sleep. The family brings him to your office with a complaint of a swelling over his distal leg, which he attributes to his being kicked while playing soccer about 1 week ago. He has had no fever, headaches, weakness, bruising, or other symptoms. A radiograph of the leg is shown below. Which of the following is the most likely explanation for his pain?

107) A 4-month-old baby boy arrives to the ER cold and stiff. The parents report that he had been healthy and that they put him to bed as usual for the night at the regular time. When they next saw him, in the morning, he was dead. Physical examination is uninformative. A film from a routine skeletal survey is shown below. Which of the following is the most likely diagnosis?

128) A patient with hair loss is shown below. The lesion does not fluoresce with a Wood lamp and has not responded well to a variety of topical agents. The lesion is boggy, is spreading, and has tiny pinpoint black dots throughout. Which of the following is the most likely diagnosis?

131) The parents of the child pictured below bring him to the office for evaluation of short stature. At 5 years of age, he is the shortest child in his kindergarten class. His development is normal, and he is reading on a first grade level. Both parents are of normal height, and this child resembles no one in the family. Which of the following is the most likely diagnosis?

134) The 16-month-old male infant pictured below was recently brought from a developing country to the United States. The family history reveals that his father had an eye and a leg removed. Which of the following is the most likely diagnosis?

154) You are called to the delivery room to evaluate an infant born at 28-weeks gestational age. The infant is tachypneic and cyanotic. Examination reveals intercostal and subcostal retractions along with nasal flaring. Lungs have coarse breath sounds bilaterally. After initial resuscitation, the patient is given respiratory support with continuous positive airway pressure and admitted to the neonatal intensive care unit. The patient's respiratory status continues to worsen over the next 24 hours. A chest radiograph from the patient is shown below. In addition to prematurity, which of the following is a risk factor for the development of this disease?

173) A 5-year-old girl is brought to the physician with low grade fever and rhinorrhea. Her symptoms began ten days ago. She has also had persistent purulent rhinorrhea, nasal congestion, and a dry cough during the day that worsens at night. Her symptoms do not seem to be improving. On examination, the child has erythema and swelling of the nasal turbinates with purulent nasal drainage. She has evidence of drainage in the posterior pharynx as well. The remainder of her examination is unremarkable. Computed topography of her face is shown below. Which of the following is the most common predisposing factor for her condition?

174) A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (Image A) and the barium enema done after admission (Image B) are shown. Which of the following is the most likely diagnosis for this patient?

182) The 4-year-old child pictured below is noted to have the tooth decay as shown. This characteristic pattern of tooth decay is caused by which of the following?

192) The delivery of a newborn boy is remarkable for oligohydramnios. The infant (pictured) is also noted to have undescended testes and clubfeet, and to be in respiratory distress. Which of the following is the most likely diagnosis to explain these findings?

204) A 13-year-old asymptomatic girl is shown below. She states that the findings demonstrated began more than a year ago. Which of the following is the most likely diagnosis?

206) A 4-year-old boy presents to the physician with fever and a sore throat. His illness began with rhinorrhea, cough, and congestion one week ago, but in the last 24 hours he has developed fever, a sore throat, and neck pain. His mother also reports that he sounds hoarse. His appetite is decreased and he complains of dysphagia. His temperature is 39.7 C (103.5F), pulse is 100/min, and respiratory rate is 25/min. On examination, the child appears sick. He has cervical lymphadenopathy on the right and decreased range of motion of his neck. His voice is muffled and sounds hoarse. His oropharynx is erythematous and a bulge is noted in the posterior pharyngeal wall. A lateral radiograph of the neck is shown below. Which of the following is the most likely diagnosis?

207) A 10-year-old obese child (shown below) has central fat distribution, arrested growth, hypertension, plethora, and osteoporosis. Which of the following disorders is most likely responsible for the clinical picture that this boy presents?

216) A previously healthy 4-year-old boy is brought to the physician for evaluation of fever and respiratory distress. The patient developed fever three days ago. Since then, he has had increasing fatigue, irritability, and respiratory distress. His temperature is 100 F (38.2C), pulse is 144/min, respiratory rate is 45/min, and blood pressure is 95/60 mm Hg. On examination, the child appears to be in moderate respiratory distress with tachypnea and subcostal retractions. He is tachycardic with an III/IV holosystolic murmur best heard at the cardiac apex. Peripheral pulses are present and capillary refill is three seconds. His liver is palpated three centimeters below the costal margin. A chest radiograph is shown below. Which of the following is the most likely cause of this patient's symptoms?

242) A 24-year-old woman arrives in the emergency center in active labor. She is at term, but received no prenatal care after 16 weeks of gestation when she lost her insurance coverage. The mother has an uncomplicated vaginal delivery. You are paged shortly after birth when the baby is noted to have respiratory distress. The infant has diminished breath sounds on the left, and the PMI is shifted toward the right. A chest radiograph is shown. The NG tube you placed earlier reveals the stomach to be below the diaphragm. Which of the following is the most likely diagnosis at this point?

244) The 1-year-old boy in the photograph below, who recently had a circumcision, requires an additional operation on his genitalia that will probably eliminate his risk of which of the following?

246) The term infant pictured below weighs 2200 g (4 lb, 14 oz). He is found to have a ventricular septal defect on cardiac evaluation. This infant appears to have features consistent with which of the following?

255) A 15-year-old boy comes to the physician with left shoulder joint pain and swelling. He has had these symptoms for the past 3 months and they are getting progressively worse. He has no fever, weight loss, or night sweats. The patient lifts weights and plays baseball 5 days a week. He has taken acetaminophen and ibuprofen with little relief. Examination shows a tender mass at the left proximal humerus. Range of motion is normal. Laboratory evaluation shows elevated alkaline phosphatase, erythrocyte sedimentation rate, and lactate dehydrogenase. X-ray of the shoulder is shown in the photograph below. Which of the following is the most likely diagnosis?

280) You are called to the newborn nursery to evaluate a term infant with bilious emesis. Although the mother had poor prenatal care, she had a normal vaginal delivery with no complications. The infant began having bilious vomiting several hours after birth. The infant has urinated, but has not had a bowel movement. Vital signs are temperature 36.9 0C (98.4 0F), pulse 150/min, and respiratory rate 40/min. On examination, the abdomen is distended and there are decreased bowel sounds. The remainder of the physical examination is unremarkable. An abdominal radiograph is shown below. Which of the following is the most likely diagnosis?

298) A 7-year-old male is brought to the emergency department for a suspected femur fracture. He has had multiple fractures in the past after minor trauma. Today, his mother states that he was running and fell. He complained of pain in his thigh after he fell. His examination is remarkable for tenderness to palpation and slight deformity of his right proximal thigh. He has decreased muscle tone throughout. His eye examination is shown below. Which of the following is the most likely associated finding?

312) The newborn nursery calls to notify you that a 1-day-old baby boy has developed abdominal distension and bilious emesis. Prenatal history was significant for areas of echogenic bowel seen on ultrasound. You order an abdominal radiograph; based on the results you order a contrast enema. Both are shown here. This infant is most likely to have which of the following?

319) The infant in the following picture presents with hepatosplenomegaly, anemia, persistent rhinitis, and a maculopapular rash. Which of the following is the most likely diagnosis for this child?

337) For the past year, a 12-year-old boy has had recurrent episodes of swelling of his hands and feet, which has been getting worse recently. These episodes occur following exercise and emotional stress, last for 2 to 3 days, and resolve spontaneously. The last episode was accompanied by abdominal pain, vomiting, and diarrhea. The results of routine laboratory workup are normal. An older sister and a maternal uncle have had similar episodes, but they were not given a diagnosis. He presents today with another episode as shown in the photographs on the next page. Which of the following is the most likely diagnosis?

348) Two weeks after a viral syndrome, a 9-year-old boy presents to your clinic with a complaint of several days of weakness of his mouth. In addition to the drooping of the left side of his mouth, you note that he is unable to completely shut his left eye. His smile is asymmetric, but his examination is otherwise normal. Which of the following is the most likely diagnosis?

349) A 4-year-old girl is noticed by her grandmother to have a limp and a some-what swollen left knee. The parents report that the patient occasionally com- plains of pain in that knee. An ophthalmologic examination reveals findings as depicted in the photograph. Which of the following conditions is most likely to be associated with these findings?

368) The child shown below presents with a 3-day history of malaise, fever to 41.1C (106F), cough, coryza, and conjunctivitis. He then develops the erythematous, maculopapular rash pictured. He is noted to have white pinpoint lesions on a bright red buccal mucosa in the area opposite his lower molars. Which of the following is the most likely diagnosis?