PIC: USLME-DIAGNOSTIC 1

A 45-year-old man is brought to the office due a sudden onset of skin lesions and fever. He is unable to eat or drink due to the pain in his mouth and throat. His wife says that he was complaining of a headache, malaise, and joint pain prior to developing the skin lesions. Generally, he has been in good health, other than an episode of sinusitis, for which he was prescribed trimethoprim-sulfamethoxazole 5 days ago. His pulse is 92/min, blood pressure is 110/80 mmHg, respirations are 14/min, and temperature is 36.8°C (98.4°F). On examination, both conjunctivae are inflamed. There is erythema, blistering and ulceration over the oral mucosa. There is an erythematous rash over the trunk and cutaneous lesions over the hands, arms and feet. Some of the lesions are shown in the picture below. What is the most likely diagnosis?

A 45-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 6-12. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most likely diagnosis?

A 46-year-old man presents to the emergency department with difficulty breathing and chest discomfort. His pain worsens with inspiration but does not radiate. He says that he has never had symptoms like this before. His past medical history is unremarkable. He works as a long-haul truck driver. On physical examination, his blood pressure is 110/70 mmHg, his heart rate is 110/min, his respiratory rate is 31/min, and his temperature is 36.7°C (98°F). ECG reveals sinus tachycardia but no ischemic ST-segment or T-wave changes. His chest X-ray is shown below. What is the most likely diagnosis in this patient?

A 47-year-old female, who is a chronic alcoholic, is admitted to the hospital with epigastric pain, nausea, and vomiting. Her serum amylase and lipase levels are significantly elevated and the diagnosis of acute pancreatitis is made. She is maintained nothing by mouth (NPO), and receives intravenous hydration and narcotic analgesics. On the second day of hospitalization she develops progressive shortness of breath. Her temperature is 37.2°C (98.9°F), blood pressure is 110/66 mm Hg, pulse is 110/min, and respirations are 24/min. Her oxygenation is measured at 84% on 100% non-rebreather mask and the decision is made to intubate. Since the time of admission, she has received 5 liters of normal saline and has produced 3 liters of urine output. On examination, there is no evidence of jugular venous distention. Chest auscultation reveals diffuse bilateral crackles. Auscultation of the heart reveals normal heart sounds with no murmurs. A chest x-ray from the time of admission and one from the time of intubation are shown below. Based on these findings, what is the most likely diagnosis in this patient?

A 51-year-old woman presents to the physician’s office with a 2-month history of a right breast blood tinged nipple discharge. Past history is unremarkable. Family history is positive for postmenopausal breast cancer in a maternal grandmother. Examination reveals no palpable masses or regional adenopathy, but a serous discharge is easily elicited from a single duct in the right breast. Bilateral mammograms show no abnormalities. Cytology from the discharge was not diagnostic. A ductogram was ordered, and the results are shown: Which of the following is the most likely diagnosis?

A 55-year-old man presents to the ED complaining of mild diffuse abdominal pain. He states that he underwent a routine colonoscopy yesterday and was told “everything is fine.” The pain began upon waking up and is associated with some nausea. He denies fever, vomiting, diarrhea, and rectal bleeding. His BP is 143/71 mm Hg, HR is 87 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. His abdomen is tense but only mildly tender. You order baseline laboratory tests. His chest radiograph is seen below. Which of the following is the most likely diagnosis?

A 55-year-old-woman presents to the physician’s office for evaluation of mammographic findings on a screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for insulin-dependent diabetes. Family history is positive for postmenopausal breast cancer in her mother. She has a normal breast examination and no axillary adenopathy. A mediolateral oblique (MLO) view of the right breast is shown: Which of the following is the most likely diagnosis?

A 58-year-old steam pipe worker presents with a vague ache in the left chest and mild dyspnea of several months’ duration. There is dullness on percussion of the left chest associated with diminished breath sounds. His CXR is shown in Fig. Which of the following is the most likely diagnosis?

A 60-year-old woman presents with the skin lesion shown here. She reports a history of a burn injury to the hand while cooking a few years ago. She reports the wound has never healed completely. You are concerned about the skin lesion and perform a punch biopsy. Which of the following is the most accurate diagnosis given the patient’s history?

A 62-year-old woman presents to the physician’s office with complaints of constipation. She has had constipation for the last 6 months, which has worsened over the last month, associated with mild bloating. She noted that her stool has become “pencil thin” in the last month, with occasional blood, but she continues to have bowel movements daily. Past history is unremarkable. Examination reveals normal vital signs and heart and lung examination. Abdominal examination reveals mild fullness, especially in the lower quadrants. Rectal examination shows no rectal masses, but the stool is hematest positive. A barium xray is obtained, and one view is shown in Figure 6-11. Which of the following is the most likely diagnosis?

A 63-year-old man is brought to the ED by EMS complaining of severe abdominal pain that began suddenly 6 hours ago. His BP is 145/75 mm Hg and HR is 105 beats per minute and irregular. On examination, you note mild abdominal distention and diffuse abdominal tenderness without guarding. Stool is heme positive. Laboratory results reveal WBC 12,500/μL, haematocrit 48%, and lactate 4.2 U/L. ECG shows atrial fibrillation at a rate of 110. A CT scan is shown below. Which of the following is the most likely diagnosis?

A 65-year-old male comes to the emergency department with severe shortness of breath. The symptoms started one week ago with fever and a non-productive cough. His past medical history is significant for coronary artery disease with bypass surgery two years ago, hypertension and diabetes mellitus. His temperature is 38.9°C (102°F), blood pressure is 160/70 mm Hg, pulse is 110/min, and respirations are 26/min. Physical examination reveals decreased breath sounds over the right lower lung base. His chest X-ray is shown on the slide below. Which of the following is the most likely cause of this patient's current complaints?

A 65-year-old man presents to the physician’s office for his yearly physical examination. His only complaint relates to early fatigue while playing golf. Past history is pertinent for mild hypertension. Examination is unremarkable except for trace hematest-positive stool. Blood tests are normal except for a hematocrit of 32. A UGI series is performed and is normal. A barium enema is performed, and one view is shown in Figure 6-10. Which of the following is the most likely diagnosis?

A 65-year-old woman presents to the physician’s office for evaluation of an abnormal screening mammogram. She denies any breast masses, nipple discharge, pain, or skin changes. Past history is pertinent for hypertension. Family history is positive for postmenopausal breast cancer in a sister. She has a normal breast examination and no axillary adenopathy. The remainder of her examination is unremarkable. An MLO view of the right breast is shown in Figure 6-6a along with a magnification view of the craniocaudal (CC) film (Figure 6-6b). Which of the following is the most likely diagnosis?

A 65-year-old woman presents to the physician’s office for her yearly physical examination. She has no complaints except for a recent 10-lb weight loss. Past history is pertinent for a 40 pack-year smoking history, hypertension, asthma, and hypothyroidism. Examination reveals a thin woman with normal vital signs and unremarkable heart and abdominal examinations. Lung examination reveals mild wheezing and a few bibasilar rales. A chest x-ray is obtained and is shown in Figure 6-13. A chest x-ray obtained 3 years ago was normal. Yearly laboratory tests including a CBC, electrolytes, and lipid panels are normal. Which of the following is the most likely diagnosis?

A 65-year-old woman presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Past history is pertinent for hypertension, diabetes, a 30 pack-year smoking history, and occasional alcohol intake. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An abdominal ultrasound reveals cholelithiasis, and one view of a UGI x-ray series is shown in Figure 6-8. Which of the following is the most likely diagnosis?

A 69-year-old man with rheumatic heart disease presents to the emergency department complaining of a fever and weakness on his left side. On physical examination the patient is weak in his left upper extremity and he draws only the right half of a clock. Shortly after his presentation, the patient dies, and an autopsy is performed. A gross view of the patient’s heart is shown in the image. Which of the following is a risk factor for the type of lesion pictured?

A 74-year-old man presents to the emergency department with abdominal pain. The pain is deep and aching and is localized to the left lower quadrant. The man reports multiple episodes of diarrhea over the preceding week. He also reports having multiple similar episodes of abdominal pain in the past. On physical examination he is febrile and has tenderness to palpation of the left lower quadrant. His WBC count is 23,000/mm³. Results of CT are shown in the image. Which of the following is the most likely diagnosis?