PIC: ULSME-DIAGNOSTIC

A 1-day-old infant with Down syndrome, feeding intolerance, bilious vomiting, and a double bubble on plain radiographs (Figure 6-18). Which one is the most likely diagnostic?

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?

A 10-day-old infant presenting with bilious vomiting, paucity of gas on plain radiographs, and duodenal obstruction on UGI contrast study (Figures 6-15 and 6-16). Which one is the most likely diagnostic?

A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. His abdomen is soft and nondistended, with fullness to palpation in the right upper quadrant. The child passed another stool in the emergency department (see Figure 6-14). Which of the following is the most likely diagnosis?

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?

A 10-year-old patient (pictured below) calls his parents from summer camp to state that he has had fever, muscular pain (especially in the neck), headache, and malaise. He describes the area from the back of his mandible toward the mastoid space as being full and tender and that his earlobe on the affected side appears to be sticking upward and outward. Drinking sour liquids causes much pain in the affected area. When his father calls your office, you remind him that he had refused immunizations for his child on religious grounds. Which of the following preventable diseases has this child acquired?

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?

A 14-year-old black girl has her right breast removed because of a large mass. The tumor weighs 1400 g and has a bulging, very firm, lobulated surface with a whorl-like pattern, as illustrated here. Which of the following is the most likely diagnosis?

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?

A 2-year-old boy is brought to the emergency department by his mother for the evaluation of a productive cough and low-grade fever. He has had ten such infections over the past year, all of which required antibiotics. He was delivered vaginally without any complications. He is an only child. His mother's siblings have a history of similar infections. He is alert and has normal vital signs, except for a mild fever. Auscultation reveals rales and rhonchi in both lungs. The chest x-ray is shown below. What is the most likely diagnosis?

A 2-year-old boy is brought to the emergency department. His mother reports that the patient had been well until 3 days ago, when he developed a fever and nasal congestion. He was diagnosed with otitis media in his right ear, and was started on amoxicillin with clavulanic acid by his pediatrician. He appeared to be improving until this morning, when he began to complain of abdominal pain. The pain has been intermittent, with episodes occurring every 20 minutes for several minutes each time. However, the episodes appear to be worsening and lasting longer with increasing pain. Thirty minutes ago he had an episode of nonbloody, nonbilious emesis that was followed by passage of blood- and mucus-stained stools. He is currently in no acute distress, and his vital signs are normal. A firm sausage-shaped mass is palpable in the RUQ of his abdomen. A rectal examination yields bloody mucus. He does not have any skin lesions or rashes. X-ray of the abdomen is shown in the image. Which of the following is the most likely diagnosis?

A 20-year-old female comes to the office and complains of rough, dry and scaly skin. Her skin was normal at birth, but gradually became dry. The dryness increases during the winter months, despite regular application of body-moisturizing lotion. An image of the patient's skin lesions is shown below. What is the most likely diagnosis?

A 22-year-old female is referred to the dermatology clinic. Over the past few years, she has noticed small areas of depigmentation on her arms and legs. Some of these areas are well-circumscribed, as shown in the picture below. She is otherwise well. Her only medication is the oral contraceptive pill. She is currently sexually active with more than one partner. Which of the following diseases is most likely to be associated with her skin condition?

A 22-year-old male presents to you with feelings of general malaise. He is always tired and has noticed that he has frequent headaches. Exam reveals an elevated arm blood pressure with a radial to femoral delay. ECG shows left ventricular hypertrophy and the chest-x ray is shown below. Close examination of the x-ray reveals a "3" sign. What is the most likely diagnosis in this patient?

A 22-year-old man who was involved in a motor vehicle accident undergoes intravenous fluid resuscitation with 2 L normal saline over 20 minutes. He is in respiratory distress, with a respiratory rate of 40/min. He receives bilateral chest tubes. Endotracheal intubation is performed and mechanical ventilation is initiated due to progressive respiratory failure. His blood pressure is 92/50 mm Hg and pulse is 121/min. The patient is responsive to painful stimuli only. Pulmonary examination shows coarse breath sounds bilaterally. The chest x-ray is shown below. Which of the following most likely contributed to this patient's progressive respiratory failure?

A 22-year-old woman complains of palpitations and has a regular heartbeat at a rate of 170/min, with a blood pressure of 110/70 mmHg. The rate abruptly changes to 75/min after applying carotid sinus pressure. Which of the following is the most likely diagnosis?

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?

A 28-year-old Caucasian woman comes to the office for a routine skin exam. On exam, you encounter a dark-colored lesion. The patient states that she has had a spot there her whole life. She does state that it has recently "been a little itchy and hurts sometimes." She gives a history of sunburns during childhood, and says that she is very "sun-sensitive." A picture of the mole is shown below. Which of the following is the most likely diagnosis?

A 3-week-old infant with hypoplastic left heart syndrome comes to the physician for a follow-up visit. The infant was born at term via normal spontaneous vaginal delivery. The patient had the first of 3 palliative heart surgeries shortly after birth. He did well after surgery and was discharged home one week ago. Over the last 24 hours, the infant has difficulty feeding and one episodes of vomiting. On examination, the infant is afebrile, pulse is 160/min, respiratory rate is 55/min, blood pressure is 90/50mmHg, and pulse oximetry is 80% on room air. He is mildly cyanotic, small, but well developed. His cardiovascular exam reveals tachycardia and distant heart sounds with a systolic ejection murmur heard throughout the precordium. His chest radiographs from discharge and today are shown below. What is the most likely diagnosis?

A 30-year-old man presents with coughing up blood and sputum. There is no associated dyspnea, fever, or pleuritic chest pain. His past medical history is significant for recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. The sputum production is usually worse when lying down and in the morning. He quit smoking 5 years ago and started when he was 18 years old. On physical examination, he appears chronically ill with clubbing of the fingers. Wet inspiratory crackles are heard at the lung bases posteriorly. CXR shows scaring in the right lower lobe, which on chest CT scan is identified as airway dilatation, bronchial wall thickening, and grapelike cysts. Which of the following is the most likely diagnosis?

A 31-year-old nurse in your hospital has noticed a lesion in her left eye. She denies change in vision, pain, fevers, or discharge. A picture of her eye is shown below. Which of the following is the most likely diagnosis?

A 34-year-old female presents to the ER with difficulty breathing and dizziness. Blood pressure tracing from an arterial line placed in the ER is depicted below. Which of the following best accounts for these findings?

A 35-year-old male presents to your office with red skin lesions on his back that were first noticed by his wife. His past medical history is not significant. Physical examination reveals the following findings (see the slide below). Which of the following is the most likely diagnosis in this patient?

A 35-year-old man who recently emigrated from Mexico complains of persistent cough. He says that he coughs up yellowish sputum that is occasionally streaked with blood. He also notes occasional fevers and frequent nighttime awakenings with cough and choking. He has a 20 pack-year smoking history but does not use alcohol or drugs. CT of his chest is shown below. What is the most likely diagnosis?

A 35-year-old White man has a long past history of diarrhea, rectal bleeding, crampy abdominal pain, and the passage of mucus. He now presents with a worsening of his symptoms despite taking his medications. A barium enema is performed and is shown in Fig. Which of the following is the most likely diagnosis of this new complication?

A 39-year-old man presents to his physician with the complaint of loss of peripheral vision. Which of the following findings are demonstrated by the subsequent magnetic resonance imaging (MRI) scan, shown here?

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?

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?

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?

A 40-year-old Caucasian male comes to the emergency department because he is having "the worst headache" of his life. The headache is of sudden onset, and associated with nausea and vomiting. He denies any fever and trauma to head. He is not taking any medications. He has a history of migraine headaches. The neurological examination is non-focal. CT scan of the head without contrast is shown below. Which of the following is the most likely cause of this patient's headache?

A 40-year-old man is seen for an insurance assessment. He has no past medical history and feels well. His compete physical examination is normal. His biochemistry, complete blood count (CBC), ECG, and urinalysis are also normal. His CXR is abnormal and presented in Fig. Which of the following is the most likely diagnosis?

A 43-year -old man complains of progressive weakness and shortness of breath over the last two weeks. He denies any chest or muscle pain, nausea, vomiting or weight loss. He had a recent upper respiratory tract infection. His heart rate is 90/min and blood pressure is 110/70 mmHg. Jugular venous pressure is normal. Lungs are clear to auscultation. His chest x-ray is shown below. Which of the following is the most likely additional finding in this patient?

A 43-year-old male (Patient A) is being evaluated for an esophageal disorder. Esophageal manometry tracings after a single swallow of 5 ml of water are shown on the slide below. (UE: upper esophagus, ME: middle esophagus, LES: lower esophageal sphincter). Which of the following is the most likely diagnosis in this patient?

A 43-year-old man presents to your office complaint of nagging left-side chest pain that increases on deep inspiration, plus two weeks of non-productive cough. He denies chills, fever or weight loss. His medical history is significant for Hodgkin's disease treated 20 years ago with chemotherapy and radiation therapy. On physical examination today, his blood pressure is 140/90 mmHg and his heart rate is 90/min. His chest x-ray is shown below. Which of the following is the most likely cause of his chest pain?

A 45-year-old male comes to you with complaints of throbbing pain over the pulp of his right index finger for the last two days. He has been feeling warm for the last three days. He denies ever having any sexually transmitted disease or cold sores in the past. On examination, he has a swollen, soft, and tender distal pulp space of the right index finger with some non-purulent vesicles. A picture of his hand is shown below. Tzanck smear of the vesicles show multinucleated giant cells. Which of the following is most likely the occupation of this patient?