USMLE_Diagnosis XV

An elderly diabetic woman with chronic steroid-dependent bronchospasm has an ileocolectomy for a perforated cecum. She is taken to the ICU intubated and is maintained on broad-spectrum antibiotics, renal dose dopamine, and a rapid steroid taper. On postoperative day 2, she develops a fever of 39.2°C (102.5°F), hypotension, lethargy, and laboratory values remarkable for hypoglycemia and hyperkalemia. Which of the following is the most likely explanation for her deterioration?

An elderly man is involved in a rear end automobile collision in which he hyperextends his neck. He develops paralysis and burning pain of both upper extremities, while maintaining good motor function in his legs. Which of the following is the most likely diagnosis?

An ill-appearing 2-week-old baby girl is brought to the emergency room. She is pale and dyspneic with a respiratory rate of 80 breaths per minute. Heart rate is 195 beats per minute, heart sounds are distant, a gallop is heard, and she has cardiomegaly on x-ray. An echocardiogram demonstrates poor ventricular function, dilated ventricles, and dilation of the left atrium. An ECG shows ventricular depolarization complexes that have low voltage. Which of the following is the most likely diagnosis based on this clinical picture?

An infant born at 35 weeks’ gestation to a mother with no prenatal care is noted to be jittery and irritable, and is having difficulty feeding. You note coarse tremors on examination. The nurses report a high-pitched cry and note several episodes of diarrhea and emesis. You suspect which of the following?

An infant is born prematurely and is small for gestational age. At birth, the infant is obviously ill with jaundice, fever, hepatosplenomegaly, myocarditis, and rashes. Neurologic involvement is prominent, with hydrocephalus, intracranial calcifications, and seizures. The mother has a cat and continued to clean the cat's litter box during the pregnancy. Which of the following is the most likely causative agent?

An infant is delivered at full term by a spontaneous vaginal delivery to a 29-year-old primigravida. At delivery, the infant is noted to have subcostal retractions and cyanosis despite good respiratory effort. The abdomen is scaphoid. On bag and mask ventilation, auscultation of the lungs reveals decreased breath sounds on the left, with heart sounds louder on the right. Which of the following is the most likely diagnosis?

An irritable 6-year-old child has a somewhat unsteady but nonspecific gait. Physical examination reveals a very mild left facial weakness, brisk stretch reflexes in all four extremities, bilateral extensor plantar responses (Babinski reflex), and mild hypertonicity of the left upper and lower extremities; there is no muscular weakness. Which of the following is the most likely diagnosis?

An obese 46-year-old G6P1051 with type 1 diabetes since age 12 presents to your office complaining of urinary incontinence. She has been menopausal since age 44. Her diabetes has been poorly controlled for years because of her noncompliance with insulin therapy. She often cannot tell when her bladder is full, and she will urinate on herself without warning. Which of the following factors in this patient’s history has contributed the most to the development of her urinary incontinence?

An obese 50-year-old woman undergoes a laparoscopic cholecystectomy. In the recovery room, she is found to be hypotensive and tachycardic. Her arterial blood gases reveal a pH of 7.29, PaO2 of 60 mm Hg, and PaCO2 of 54 mm Hg. Which of the following is the most likely cause of this patient’s problem?

An older, overweight man complains of disabling, sharp heel pain every time his foot strikes the ground. The pain is worse in the mornings, preventing him from putting any weight on the heel. X-ray films show a bony spur matching the location of his pain, and physical examination shows exquisite tenderness to direct palpation right over that heel spur. Furthermore, when the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation. Which of the following is the most likely diagnosis?

An otherwise healthy 7-year-old child is brought to you to be evaluated because he is the shortest child in his class. Careful measurements of his upper and lower body segments demonstrate normal body proportions for his age. Which of the following disorders of growth should remain in your differential?

An out-of-shape, recently divorced, 42-year-old man is trying to impress a young woman by challenging her to a game of tennis. In the middle of the game, a loud "pop" (like a gunshot) is heard, and the man falls to the ground clutching his ankle. He limps off the court with pain and swelling in the back of the lower leg. Although he can still weakly plantar-flex his foot, he seeks medical help the next day because of persistent pain, swelling, and limping. He can put weight on that foot with no exacerbation of the pain, but the motion of taking a step is painful. Which of the following would be the most likely finding on physical examination?

An overweight 12-year-old boy presents with left knee pain that has been going on intermittently for the past three months. Physical activity, especially stair climbing, exacerbates the pain. The boy's mother also points out that he has been limping recently. On physical examination, his anterior left hip is moderately tender to palpation, and when he is asked to stand on his left leg, the right half of his pelvis tilts downward. Which of the following best explains this finding?

An ultrasound is performed on a patient with right upper quadrant pain. It demonstrates a large gallstone in the cystic duct but also a polypoid mass in the fundus. Which of the following is an indication for cholecystectomy for a polypoid gallbladder lesion?

Approximately 6 weeks following a kidney transplant, a 59-year-old woman develops fever, malaise, and myalgias and is found to have a cytomegalovirus (CMV) infection. Which of the following is a potential sequela of CMV infection?

At 38 weeks’ gestation, a 4030-g (8.9-lb) boy is delivered by spontaneous vaginal delivery. During the first minute of life he is limp, cyanotic, lacks respiratory effort, has a heart rate of 95/min, flexes his extremities, and grimaces to nasal suctioning. By 5 minutes, he continues to grimace to nasal suctioning, has a weak cry, is well perfused with a heart rate of 160/min, and is kicking both legs. Based on his Apgar scores, when will the child need to be resuscitated?

At a follow-up routine prenatal visit, the uterine fundus of a healthy 23-year-old pregnant woman is palpated halfway between her symphysis pubis and umbilicus. Which of the following is the most appropriate test to order at this stage of her pregnancy?

At the time of annual examination, a patient expresses concern regarding possible exposure to sexually transmitted diseases. During your pelvic examination, a single, indurated, nontender ulcer is noted on the vulva. Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody (FTA) tests are positive. Without treatment, the next stage of this disease is clinically characterized by which of the following?

During a physical examination for participation in a sport, a 16-year- old girl is noted to have a late apical systolic murmur, which is preceded by a click. The rest of the cardiac examination is normal. She states that her mother also has some type of heart “murmur” but knows nothing else about it. Which of the following is the most likely diagnosis?

During a regular checkup of an 8-year-old child, you note a loud first heart sound with a fixed and widely split second heart sound at the upper left sternal border that does not change with respirations. The patient is otherwise active and healthy. Which of the following heart lesions most likely explains these findings?

During a routine well-child examination a 10-year-old girl reports that she has occasional headache, “racing heart,” abdominal pain, and dizziness. Her mother states that she has witnessed one of the episodes, which occurred during an outing at the mall, and reported the child to be pale and to have sweating as well. Other than some hypertension, she has a normal physical examination. Evaluation of this child is most likely to result in which of the following diagnoses?

During a well-child visit, the grandmother of an 18-month-old patient is concerned because the child’s feet turn inward. She first noticed this when her grandson began to walk. It does not seem to bother the child. On examining his gait, his knees point forward and his feet turn inward. Which of the following is the most likely cause of this condition?

During the evaluation of infertility in a 25-year-old female, a hysterosalpingogram showed evidence of Asherman syndrome. Which one of the following symptoms would you expect this patient to have?

During the performance of a supraclavicular node biopsy under local anesthesia, a hissing sound is suddenly heard, and the patient suddenly dies. At the time of the catastrophic event, the target node was under traction, and the final cut was being made blindly behind it to free it up completely. The patient, an otherwise healthy 24-year-old man, was inhaling at that moment. Which of the following most likely caused this patient's death?

Elizabeth, a 13-year-old girl, comes with complaints of new onset seizures. She has morning headaches that go away after vomiting. She also has history of colonic polyps, for which she is undergoing work-up. Her family history is significant for her mother having problems with polyps. (She underwent proctocolectomy.) Initial non-contrast T1-weighted MRI shows a large, heterogeneous, hypointense mass in the white matter of the right temporal lobe and extending into the parietal and occipital lobes. The lower signal area within the mass suggests tissue necrosis. What is the most likely diagnosis in this patient?

Examination of the cerebrospinal fluid (CSF) of an 8-year-old, mildly febrile child with nuchal rigidity and intermittent stupor shows the following: WBCs 85/μL (all lymphocytes), negative Gram stain, protein 150 mg/dL, and glucose 15 mg/dL. A computed tomographic (CT) scan with contrast shows enhancement of the basal cisterns by the contrast material. Which of the following is the most likely diagnosis?

Following a head-on motor vehicle collision, a 21-year-old unrestrained passenger presents to the ER with dyspnea and respiratory distress. She is intubated and physical examination reveals subcutaneous emphysema and decreased breath sounds. Chest x-ray reveals cervical emphysema, pneumomediastinum, and a right-sided pneumothorax. What is the most likely diagnosis?

For the past 6 months, a 32-year-old multiparous woman has complained about intermittent vaginal bleeding between normal menstrual periods. The bleeding is painless and is not associated with cramping. She denies postcoital bleeding. Her last Pap smear, 6 months ago, was negative for dysplasia or malignancy. She underwent a tubal sterilization after her last pregnancy 3 years ago. Pelvic examination reveals normal external genitalia and vulva. Her vagina and cervix are without lesions. Her uterus is asymmetrically enlarged, about 8-week size, and nontender. Results of a qualitative urine –human chorionic gonadotropin (-hCG) test are negative. Which of the following is the most likely diagnosis?

Friends are considering adopting a “special needs” child from another country. The family has few details, but the information they have received so far suggests the 4-year-old child has had surgery for an endocardial cushion defect, is short for his age, and had a history of what sounds like surgically repaired duodenal atresia at birth. You are suspicious this child may have which of the following syndromes?

In the newborn nursery it is noted that a child has uneven gluteal folds. Physical examination of the child's hips reveals that one of them can be easily dislocated posteriorly with a jerk and a "click," and returned to normal position with a "snapping" sound. The family is concerned because a previous child had the same problem. Which of the following is the most likely diagnosis?

Initial examination of a full-term infant weighing less than 2500 g (5 lb, 8 oz) shows edema over the dorsum of her hands and feet. Which of the following findings would support a diagnosis of Turner syndrome?

Last week a 20-year-old college student developed acute wrist pain and swelling. This resolved in four days. Yesterday, he developed pain and swelling in his left knee. Two months ago he went on a backpacking trip in Rhode Island. A week or so later he developed an enlarging circular red spot that persisted for 2 weeks and then resolved. What is the most likely diagnosis?

Ms. Lee, a 62-year-old Chinese woman, comes with yellowness in her eyes for the past 6 weeks. She is generally feeling tired, has lost some weight, and occasionally had some nausea. She denies any altered bowel habits. She is a non-smoker but drinks 2-3 beers each night. Her dad is suffering from high cholesterol and also has had stroke. She had a dilatation and curettage for an abnormal pap smear 15 years ago. Her vitals are stable and she is afebrile. She has marked scleral icterus. An abdominal examination reveals normal bowel sounds and no organomegaly. Her stools were occult blood negative. Her liver function tests and enzymes were ordered and the results are: Total protein 6.1 g/dl, Albumin 3.9 g/dl, AST 67U/L, ALT 52U/L, Alkaline phosphatase 290 U/L, Total bilirubin 9.6 mg/dl, Direct bilirubin 8.9 mg/dl, Serum lipase is 46 U/L, Anti-mitochondrial antibodies negative. Which of the following is the most likely cause of these findings?

On a routine well-child examination, a 1-year-old boy is noted to be pale. He is in the 75th percentile for weight and the 25th percentile for length. Results of physical examination are otherwise normal. His hematocrit is 24%. The answer to which of the following questions is most likely to be helpful in making a diagnosis?

On a routine-screening CBC, a 1-year-old is noted to have a microcytic anemia. A follow-up hemoglobin electrophoresis demonstrates an increased concentration of hemoglobin A2. The child is most likely to have which of the following?

On postoperative day 3 after an uncomplicated repeat cesarean delivery, the patient develops a fever of 38.2C (100.8F). She has no complaints except for some fullness in her breasts. On examination she appears in no distress; lung and cardiac examinations are normal. Her breast examination reveals full, firm breasts bilaterally slightly tender with no erythema or masses. She is not breast-feeding. The abdomen is soft with firm, nontender fundus at the umbilicus. The lochia appears normal and is nonodorous. Urinalysis and white blood cell count are normal. Which of the following is a characteristic of the cause of her puerperal fever?

On postoperative day 5, an otherwise healthy 55-year-old man recovering from a partial hepatectomy is noted to have a fever of 38.6°C (101.5°F). Which of the following is the most common nosocomial infection postoperatively?

On the first pelvic examination of an 18-year-old nulligravida, a soft, fluctuant mass is found in the superior aspect of the right labia majora. This is asymptomatic. She tells you it has been present for several years and seems to be enlarging slightly. There is no defect in the inguinal ring. Which of the following is the most likely diagnosis?

On the second day after birth, a mother reports that her newborn infant does not move his left hand and his left eyelid droops. On examination, you confirm the findings of the mother and elicit myosis in the left eye. Pregnancy was uneventful, and delivery uncomplicated. Which of the following is the most likely diagnosis?

Parents bring their 17-year-old son to the emergency department due to his strange behavior at times during the past few weeks. The boy is normally polite and soft-spoken, but he has recently become irritable, impatient, and rude. His parents initially dismissed his behavior as a “phase” with the expectatioin that he would grow out of it. However, they became very concerned on discovering that he had stolen money from their wallets and was sleeping erratically. When questioned by his father about his strange behavior, the boy responsed, “I’m on a secret mission. The king of Norway has sent me here to spy on the US government.” His temperature is 36.6 C, BP is 144/94 mmHg, pulse is 118/min, and respirations are 18/min. On physical examination, the patient appears to be irritated. He is sweating profusely and his pupils are dilated. He is observed in the emergency department for several hours, his condition improves, and he is discharged to the care of his parents. Which of the following is the most likely diagnosis?

Physical examination of an infant delivered to a 42-year-old, gravida 3, para 2, woman, is remarkable for slight hypotonia and a poor Moro reflex. Further examination reveals upslanting palpebral fissures, epicanthal folds, excess nuchal skin, an enlarged tongue, clinodactyly of the fifth fingers, and a single transverse palmar crease. Which of the following is the most likely diagnosis?

Select the most likely diagnosis. A. Child abuse B. Foreign body C. Trichomonas vaginitis D. Bacterial vaginosis E. Candidiasis A 25-year-old woman presents to the physician's office for evaluation of foul-smelling vaginal discharge. She has been sexually active with a new partner for the past month. Physical examination reveals a thin, whitish-gray vaginal discharge. There is no discharge from the cervical os, and there is no adnexal or cervical motion tenderness. The remainder of the examination is normal. The pH of the vaginal fluid is 5.0. When KOH is added to vaginal discharge on a slide, an amine-like ("fishy") odor is perceived. A wet mount of the fluid reveals many epithelial cells with adherent bacteria. No polymorphonuclear cells are seen.

Several months after sustaining a crushing injury to his arm, a patient complains bitterly about constant, burning, agonizing pain in that arm, that does not respond to the usual analgesic medications. The pain in his arm is aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves. The arm is cold, cyanotic, and moist, but it is not swollen. Pulses at the wrist are normal, and neurologic function of the three major nerves is intact. Which of the following is most appropriate to provide diagnostic confirmation of the nature of the problem and eventual therapy?

Starting over 9 months ago, a 39-year-old multiparous woman complains about having increasing heavy vaginal bleeding and pain with her menstrual periods. Two years ago, after workup for an abnormal Pap smear reported a low-grade squamous intraepithelial lesion (LSIL), she underwent cryotherapy for biopsy-confirmed cervical intraepithelial neoplasia grade I (CIN 1). Subsequent follow-up Pap smears have been negative. Her present pelvic examination is unremarkable except for a diffusely enlarged, globular, soft, tender uterus. Results of a qualitative urine -human chorionic gonadotropin (-hCG) test are negative. Which of the following is the most likely diagnosis?

The 7-year-old boy now in your office was last seen 2 weeks ago with a mild viral upper respiratory tract infection. Today, however, he presents with fever, ataxia, weakness, headache, and emesis. In the office he has a 3 minutes left-sided tonic-clonic seizure. You send him to the hospital and order a magnetic resonance imaging (MRI) of the brain, the results of which show disseminated multifocal white matter lesions that enhance with contrast. This boy’s likely diagnosis is which of the following?

The family of a 4-year-old boy has just moved into your area. The child was recently brought to the emergency department (ED) for an evaluation of abdominal pain. Although appendicitis was ruled out in the ED and the child’s abdominal pain has resolved, the ED physician requested that the family follow up in your office to evaluate an incidental finding of an elevated creatine kinase. The family notes that he was a late walker (began walking independently at about 18 months of age), that he is more clumsy than their daughter was at the same age (especially when trying to hold onto small objects), and that he seems to be somewhat sluggish when he runs, climbs stairs, rises from the ground after he sits, and rides his tricycle. A thorough history and physical examination are likely to reveal which of the following?

The local sorority house recently installed a sun-tanning station. Two days later three sorority girls present to the ED with bilateral eye pain, tearing, and photophobia. After ophthalmic anesthesia instillation, a complete eye examination is performed. Visual acuity is normal. Extraocular eye movements are intact and pupils are equal, round, and reactive to light. IOP is normal. Slit-lamp examination is normal, but fluorescein examination under cobalt blue light illuminates small dots throughout the cornea. What is the most likely diagnosis?

The mother of a 2-week-old infant reports that since birth, her infant sleeps most of the day; she has to awaken her every 4 hours to feed, and she will take only an ounce of formula at a time. She also is concerned that the infant has persistently hard, pellet-like stools. On your examination you find an infant with normal weight and length, but with an enlarged head. The heart rate is 75 beats per minute and the temperature is 35°C (95°F). The child is still jaundiced. You note large anterior and posterior fontanelles, a distended abdomen, and an umbilical hernia. This clinical presentation is likely a result of which of the following?

The mother of a 6-month-old infant is concerned that her baby may be teething. You explain to her that the first teeth to erupt in most children are which of the following?

The mother of one of your regular patients calls your office. She reports that her daughter has a 3-day history of subjective fever, hoarseness, and a bad barking cough. You arrange for her to be seen in your office that morning. Upon seeing this child, you would expect to find which of the following?

The parents of a 5-year-old boy come to the physician concerned about their child's recurrent leg pains. The boy has been complaining for several weeks about pain in both legs, usually occurring soon after going to bed. He derives relief from rubbing his legs and knees. He does not limp and is able to participate in sports activities. Which of the following is the most likely diagnosis?

The parents of a 7-day-old infant bring her to your office for a swollen eye. Her temperature has been normal, but for the last 2 days she has had progressive erythema and swelling over the medial aspect of the right lower lid near the punctum. Her sclera and conjunctiva are clear. Gentle pressure extrudes a whitish material from the punctum. Which of the following ophthalmic conditions is the correct diagnosis?

The parents of a 7-month-old boy arrive in your office with the child and a stack of medical records for a second opinion. The boy first started having problems after his circumcision in the nursery when he had prolonged bleeding. Studies were sent at the time for hemophilia, but factor VIII and IX activity were normal. At 2 months he developed bloody diarrhea, which his doctor assumed was a milk protein allergy and changed him to soy; his parents note he still has occasional bloody diarrhea. He has seen a dermatologist several times for eczema, and he has been admitted to the hospital twice for pneumococcal bacteremia. During both admissions, the parents were told that the infant’s platelet count was low, but they have yet to attend the hematology appointment arranged for them. The child’s WBC count and differential were normal. Which of the following is the most likely diagnosis in this child?

The parents of a previously healthy 2-year-old child note her to be pale and bring her to your clinic for evaluation. She currently has no fever, nausea, emesis, bone pain, or other complaints. Her examination is significant for pallor, tachycardia, and a systolic ejection murmur, but she has no organomegaly. Her complete blood count (CBC) reveals a hemoglobin of 4 g/dL, normal indices for age, a WBC count of 6.5/μL, and a platelet count of 750,000/μL. Her reticulocyte count is 0%. Coombs test is negative. Her peripheral blood smear shows no blast forms and no fragments. Red blood cell (RBC) adenosine deaminase levels are normal. A bone marrow reveals markedly decreased erythroid precursors. Which of the following is this child’s likely diagnosis?

The physician on call is called to the well-baby nursery because a full-term, African-American boy who is 49 hours old has not passed meconium. The pregnancy was uncomplicated. The neonate’s blood pressure is 70/50 mm Hg, heart rate is 140/min, and respiratory rate is 36/ min. The neonate is crying but is easily consolable. His abdomen is markedly distended. A barium enema is ordered, which shows dilated proximal bowel and a narrowed distal segment. Which of the following would provide a definitive diagnosis in this child?

The physician on call is paged to the well-baby nursery because a full-term, 3-hour-old boy has had green emesis twice, once after each of his feedings. He is being breast-fed. He was born by spontaneous vaginal delivery following a pregnancy complicated by polyhydramnios. His Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. His temperature is 37°C (98.6°F), blood pressure is 70/50 mm Hg, pulse is 150/min, and respiratory rate is 24/ min. His upper abdomen is distended, soft, and without palpable masses. Air is visualized in the duodenum and the stomach on x-ray. Which of the following is the most likely diagnosis?

The police bring a 14-year-old boy to the clinic after he was found setting fire to the neighbor's house. He has been previously arrested and warned by the cops twice. The first time was 15 months ago for stealing his neighbor's motorcycle. The second occasion was 6 months ago for a fight with his peers on the roadside. His parents arrive and tell you that he has been behaving this way for the past 3 years, and often argues at home. He steals money from them and tries to hurt the pets. Although they have not seen him using any drugs, they suspect that his behavior could be due to drugs. What is the most likely diagnosis?

The unrestrained front-seat passenger in a car that crashed at high speed arrives at the emergency department with signs of moderate respiratory distress. Physical examination shows no breath sounds at all on the left hemithorax. Percussion is unremarkable, and his vital signs are normal. A chest x-ray film shows a collapsed left lung and multiple air-fluid levels filling the left pleural cavity. A nasogastric tube that had been placed prior to taking the film shows the tube reaching the upper abdomen and then curling up into the left chest. Which of the following is the most likely diagnosis?

The unrestrained front-seat passenger in a car that crashes sustains closed comminuted fractures of both femoral shafts. Shortly after admission, he develops a blood pressure of 80/50 mm Hg, a pulse rate of 110/min, and a venous pressure of zero. He becomes pale, cold, and clammy, but the rest of his physical examination and x-ray films of the chest and pelvis are unremarkable. A sonogram of the abdomen done in the emergency department is likewise negative. Which of the following is the most likely reason for the low blood pressure?

Three days ago you delivered a 40-year-old G1P1 by cesarean section following arrest of descent after 2 hours of pushing. Labor was also significant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse pages you to come to see the patient on the postpartum floor because she has a fever of 38.8C (102F) and is experiencing shaking chills. Her blood pressure is 120/70 mm Hg and her pulse is 120 beats per minute. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breast-feed, but says her milk has not come in yet. On physical examination, her breasts are mildly engorged and tender bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted. Her pelvic examination reveals uterine tenderness but no masses. Which of the following is the most likely diagnosis?

Two weeks after a viral syndrome, a 2-year-old child develops bruising and generalized petechiae, more prominent over the legs. No hepatosplenomegaly or lymph node enlargement is noted. The examination is otherwise unremarkable. Laboratory testing shows the patient to have a normal hemoglobin, hematocrit, and white blood cell (WBC) count and differential. The plateletcount is 15,000/μL. Which of the following is the most likely diagnosis?

Two weeks ago, a 5-year-old boy developed diarrhea, which has persisted to the present time despite dietary management. His stools have been watery, pale, and frothy. He has been afebrile. Microscopic examination of his stools is likely to show which of the following?

Which of the following patients has the lowest clinical probability for the diagnosis of pulmonary embolism (PE)?

While bathing her newly-received 2-year-old son, a foster mother feels a mass in his abdomen. A thorough medical evaluation of the child reveals aniridia, hypospadias, horseshoe kidney, and hemihypertrophy. Which of the following is the most likely diagnosis for this child?

While making rounds in the newborn nursery, the nurses ask you to examine a 2-day-old infant who is not feeding well. The nurse reports that the infant is irritable, is not sleeping well, and has had several episodes of vomiting and loose stools today. A review of the maternal history reveals that she had poor prenatal care and the pregnancy was complicated by intrauterine growth restriction. On examination, the infant is diaphoretic and has a high-pitched cry. The infant is also noted to have occasional sneezing and is mildly tachypneic. No dysmorphic features are noted and the remainder of the examination is unremarkable. This infant's symptoms are most likely caused by prenatal exposure to which of the following?

While you are on call at the hospital covering labor and delivery, a 32-year-old G3P2002, who is 35 weeks of gestation, presents complaining of lower back pain. The patient informs you that she had been lifting some heavy boxes while fixing up the baby’s nursery. The patient’s pregnancy has been complicated by diet-controlled gestational diabetes. The patient denies any regular uterine contractions, rupture of membranes, vaginal bleeding, or dysuria. She denies any fever, chills, nausea, or emesis. She reports that the baby has been moving normally. She is afebrile and her blood pressure is normal. On physical examination, you note that the patient is obese. Her abdomen is soft and nontender with no palpable uterine contractions. No costovertebral angle tenderness can be elicited. On pelvic examination her cervix is long and closed. The external fetal monitor indicates a reactive fetal heart rate strip; there are rare irregular uterine contractions demonstrated on the tocometer. The patient’s urinalysis comes back with trace glucose, but is otherwise negative. The patient’s most likely diagnosis is which of the following?

You are an internist making your rounds at a local nursing home. While you are reviewing a medical chart, one of the nurses approaches you to complain about a 62-year-old male patient who frequently masturbates in front of the staff and other nursing home residents. He has been taking olanzapine for years for schizophrenia. Upon interviewing him, you find the patient's thought processes to be devoid of hallucinations or delusions. There are several times when he laughs inappropriately during the interview. His speech is rambling and unpredictably shifts from one topic to another. Based on his clinical presentation, how should his illness be classified?

You are asked to consult on a 31-year-old woman who is at 26 weeks’ gestation and who has had fever for 2 days. She states that she starting feeling fevers and chills approximately 3 days ago. These symptoms have worsened since that time and she has also experienced myalgias, back pain, malaise, and upper respiratory complaints. She was initially diagnosed with the flu, but her condition seems to be worsening. Her prenatal course has been otherwise uncomplicated. She has no past medical or surgical history. Her past obstetric history is significant for a normal spontaneous vaginal delivery 3 years ago. She takes no medications and is allergic to sulfa drugs. Her physical examination is significant for a temperature of 38.3 C (101.0 F) and mild abdominal tenderness. Her urine culture is negative. Her obstetrician performed an amniocentesis yesterday that demonstrated gram-positive rods. Which of the following is the most likely causative organism?

You are asked to evaluate four different patients, all who have presented with cough and progressive dyspnea. Each has a chest x-ray showing diffuse pulmonary infiltrates. In which of the following patients would bronchoscopy with bronchoalveolar lavage be most likely to yield a diagnosis?

You are called to examine a 2-day old male infant due to difficulty in feeding. He becomes cyanotic and short of breath when he feeds, but turns pink when he cries. His prenatal, birth and family histories are unremarkable. His vital signs are normal. Chest auscultation is normal. His peripheral pulses are full and symmetric. What is the most likely diagnosis?

You are called to examine a 2-day-old male, newborn after he was noted to be cyanotic. He was born at term. His antenatal and birth histories are unremarkable. Auscultation reveals a holosystolic murmur at the left, lower sternal border and a single S2. No rales or rhonchi are heard. Chest radiograph reveals decreased pulmonary vascular markings and a normal-sized heart. EKG reveals left axis deviation. What is the most likely diagnosis?

You are called to examine a male newborn because his first feeding caused him to choke, cough and regurgitate. He was born at term via normal vaginal delivery. On examination, he has excessive salivation, fine, frothy bubbles in the mouth, abdominal distention and rattling breath sounds. Radiographs of the chest and abdomen reveal bilateral atelectasis and gastric distension. Which of the following can best explain the above findings?

You are called to examine a one-day-old male neonate who gradually developed cyanosis over the past few hours. The infant was delivered vaginally at full term, assisted with forceps, and weighed 9 lbs. The Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Oxygen administration by mask does not relieve the cyanosis. Further examination reveals tachypnea, subcostal retractions, a normal S 1, single and loud S2, and no murmur. Which of the following is the most probable cause of the infant's cyanosis?

You are delivering a 33-year-old G3P2 and encounter a shoulder dystocia. After performing the appropriate maneuvers, the baby finally delivers, and the pediatricians attending the delivery note that the right arm is hanging limply to the baby’s side with the forearm extended and internally rotated. Which of the following is the baby’s most likely diagnosis?

You are examining the pupils of a patient. On inspection, the pupils are 3 mm and equal bilaterally. You shine a flashlight into the right pupil and both pupils constrict to 1 mm. You then shine the flashlight into the left pupil and both pupils slightly dilate. What is this condition called?

You are helping with school sports physicals and see a 16-year-old boy who has had trouble keeping up with his peers. Which of the following auscultatory findings suggests a previously undiagnosed ventricular septal defect?

You examine a 28-year-old woman who is 2 days status post-cesarean delivery for a nonreassuring fetal heart rate tracing in labor. Her prenatal course was complicated by her developing acute tuberculosis in the days immediately before her delivery. When you diagnosed her with tuberculosis, she decided to hold off on therapy until after the baby was born. She was also found to be Group B Streptococcus–positive on a 36-week vaginal culture. She has a past medical history significant for chronic hepatitis B. Her past surgical history is significant for a breast reduction 4 years ago. Postpartum she is doing well, with no complaints, normal vital signs, and a normal postpartum physical examination. She wants to know if she is able to breast feed her infant. Which of the following conditions precludes this patient from breastfeeding?

You find a discrete, whitish polyp that extends through the tympanic membrane in a child with a history of recurrent otitis media. This most likely represents which of the following?

You have diagnosed a healthy, sexually active 24-year-old female patient with an uncomplicated acute urinary tract infection. Which of the following is the likely organism responsible for this patient’s infection?

Your 6-year-old son awakens at 1:00 AM screaming. You note that he is hyperventilating, is tachycardic, and has dilated pupils. He cannot be consoled, does not respond, and is unaware of his environment. After a few minutes, he returns to normal sleep. He recalls nothing the following morning. Which of the following is the most likely diagnosis?

Your older sister, her husband, their 2-day-old infant, and their pet Chihuahua arrive at your door. The parents of the child are concerned because the pediatrician noted the child was “yellow” and ordered some studies. They produce a wad of papers for you to review. Both the mother and baby have O-positive blood. The baby’s direct serum bilirubin is 0.2 mg/dL, with a total serum bilirubin of 11.8 mg/dL. Urine bilirubin is positive. The infant’s white blood cell count is 13,000/μL with a differential of 50% polymorphonuclear cells, 45% lymphocytes, and 5% monocytes. The hemoglobin is 17 g/dL, and the platelet count is 278,000/μL. Reticulocyte count is 1.5%. The peripheral smear does not show fragments or abnormal cell shapes. Which of the following is the most likely explanation for this infant’s skin color?

Your patient has just had twins and wonders if there is any way to determine whether the twins are identical. You correctly tell her which of the following?